Can we offer a Total Knee Replacement, free of Opioids use?
Advances in the field of Orthopedic Surgery have instilled new improved surgical techniques and have allowed surgical teams to expose the patient undergoing a total knee replacement to a faster recovery in an almost post-operative Opioid-free atmosphere. The length of stay has diminished over the years to a point that many centers offer presently this surgical procedure in an outpatient setting. This has become the state-of-art for many hospitals eager to implement such new “fast-tracks” protocols.
We know well that a total knee replacement is a very common procedure. More than 765,000 TKA’s are performed in the United States annually and many believed that the number may almost double to 1.5 million by the year 2030. While so many joint replacement are being done, it adds to this opioid epidemic seen in the country. Better surgical techniques with specialized cuts by robots have allowed a perfect prosthetic fitting, providing a stable joint reconstruction. Pain management has become a problem for the patients and the surgeons involved in the procedures.
Post-surgical opioids are regularly prescribed to almost all patients undergoing a total knee replacement. It was proven as well that half of the same patients were still receiving narcotics six months after the surgical procedure. The need to search for a more potent medication or more specialized techniques to minimize the use of Opioids, was discussed.
Recent studies have investigated how a non-opioid, long-lasting local analgesic (bupivacaine liposome injectable suspension) injected in the surgical wounds can provide pain control. This is why we will see why the “Phase 4 PILLAR Study” has shown promising hope in reducing the need for opioids in a patient undergoing Total Knee Replacement.
Pain management after surgery has a significant impact on the post-op recovery. It is encouraged to discuss these issues with a patient undergoing surgical treatment. The local effect of EXPAREL in the surgical site has also provided analgesia. Many who have benefited from such procedure in the past have shown their fear in a long hospitalization with possibly a higher risk of infections and complications in the peri or post-operative period like bleeding with or without the use of a tourniquet.
Over the years, we have taken in consideration these facts, in an effort to minimize the loss of blood and to control pain. Pain management in the last decade has also contributed to newer approaches in facilitating a faster recovery. Different techniques in epidural or regional anesthesia as well as General anesthesia have enhanced the use of peripheral nerve blocks.
We have certainly overprescribed opioids after such procedure in order to control pain to a point that we, as orthopedists. have definitely contributed to this crisis of dependence and addiction in the United States. We looked for a way the decrease the need for opioid in increasing our interest on a non-opioid post-surgical pain management strategy. We will deliberately review the post-operative management used by many leading institutions in the country.
May the lector remember the way we addressed this opioid epidemic in one of our past AMHE newsletter. One surgeon has to ask himself how to avoid using Opioid in his practice and review the alternatives.
Most institutions have used the LIA Approach which has provided a satisfactory pain management response in the first 48 hours during the post-operative period of a Total Knee Replacement. A mixture of local anesthetic agent usually “Ropivacaine” combined with a corticosteroid like “Betamatasone”, Epinephrine, Morphine and antibiotics have been used to reduce the need for opioids alone or in combination with local or regional anesthesia. It becomes difficult to show differences in the pain management when many protocols are being used.
The LIA protocols have facilitated an early 48 hours free of pain to patients during their rehabilitation on the “fast track” and has not increased the rate of infection or other complications like bleeding. It was found to be a safe way to insuring early pain control, avoiding anesthetic blocks or Opioid medication. Institutions have used a mixture of 50 cc of saline mixed to 300 micrograms of Epinephrine with 10 mg of Morphine sulfate, 6 mg of Betamethasone sodium phosphate sulfate, 100 mg of Tobramycin and 200 mg of Ropivacaine injected in the joint and the soft tissue around the knee like the Pes Anserine, the posterior capsule, the quadriceps tendon, the collateral ligaments after a through irrigation of the knee joint itself and the placement of the desired prosthetic components.
This cocktail was used in all the cases for years while epidural anesthesia has been preferred to a general anesthesia with a blood loss prevention protocol. Optimization of the orthopedic patient to keep a hemoglobin (Hb) at 13g.L, Hypotensive anesthesia with the use of a tourniquet during the procedure, Plugging the femoral canal with autologous bone grafts after proper bone cut and tunneling to fit the prosthesis at the femoral site have contributed enormously to this successful approach. Finally, Tranexamic acid (TXA) has been used, mixed with saline in different protocols in one or two doses intravenously or intra-articularly assuring a successful outcome to a Primary or a revision knee replacement. This was also used successfully in hemophilic patients with satisfactory results.
In this protocol, patients undergoing joint replacement are able to be mobile on the first day post op with crutches or walker. Anti-thrombolytic prophylaxis is performed additionally with a low weight molecular heparin (LWMH) for a four week-period. No opioids are used after the first day after surgery until discharge on acetaminophen or non-steroidal anti-inflammatory medications.
This is the way orthopedist have learned in the eve of this opioid epidemic, a way to eliminate the abuse of narcotics in search for pain control following Total Knee Replacement. More institutions are adopting such protocols.
Maxime Coles MD
1- Barlow T, Griffin D, Barlow D, Realpe A. Patients’ decision making in total knee arthroplasty: a systematic review of qualitative research. Bone Joint Res. 2015; 4(10): 163-169.
2- Goesling J, Moses SE, Zaidi B, et al Trends and predictors of Opioid use following total knee and total hip arthroplasty. Pain 2016; 157(6): 1259-1265.
3- Mont MA, Beaver WB, Dysart SH, Barrington JW, Del Gaizo DJ Local infiltration analgesia with liposomal bupivacaine improves pain scores and reduces opioid use after total knee arthroplasty: results of randomized controlled trial. J Arthroplasty 2017:1-7, doi: 10.1016/ j arth 2017.07.924.
4- Breindahl T, Simonsen O, Hindersson P, Brodsgaard Dencker B, Brouw Jorgensas a post-operative analgesia en M, Rasmussen S. Autologous Blood Transfusion after local infiltration analgesia with Ropivacaine in Total Knee and Total Hip Replacement. Anesthesiol Res Pract: 2012: 458795
5- Essving P, Axxalson K, Kjelberg, Wallgreen O, Gupta P, Dhanevar R, Lundin A: Reduced Morphine consumption and pain intensity with local infiltration analgesia (LIA) following Total Knee Arthroplasty: Acta Orthop2010; 81:354-360.
6- Inacio MCS, Paxton EW, Graves SC, Namba RS, Nemes S, Projective increase in Total Knee Replacement in the United States, an alternative projection model: Osteoarthritis Cartilage 2017: (25): 797-1803.
7- Ma LP, qi YM, Zhao D X: Comparison of local infiltration anesthesia of sciatic nerve block for pain control after total knee arthroplasty: a systematic review and meta-analysis.
8- Train J, Schwarzkopf R: Local infiltration anesthesia with steroids in total knee arthroplasty: a systematic review of randomized control trials. J Orthop. 2015; 12: S44-50.