The Journal of Arthroplasty Vol. 22 No. 7 Suppl. 3 2007

Pain Management and Accelerated Rehabilitation forTotal Hip and Total Knee Arthroplasty

Amar S. Ranawat, MD,*y and Chitranjan S. Ranawat, MDyz

Abstract: Improved pain management techniques and accelerated rehabilitationprograms are revolutionizing our patients' postoperative experience after total hipand knee arthroplasty. The process involves regional anesthesia with multimodalpain control using local periarticular injections in combination with enhanced patienteducation and accelerated rehabilitation provided by a dedicated team of surgeons,physicians, anesthesiologists, physician assistants, physical therapists, and socialworkers. With this system, it is now possible to achieve a painless recovery after totalhip arthroplasty and total knee arthroplasty. Although this is not always the case, itwas unheard of in prior years. It is our hope that future research into this area willmake painful, difficult recoveries after total hip arthroplasty and total kneearthroplasty a distant memory. Key words: pain management, rehabilitation.© 2007 Elsevier Inc. All rights reserved.

Few would argue the incredible impact total hiparthroplasty (THA) and total knee arthroplasty(THA, TKA) have had on the quality of life ofpeople with degenerative joint disease of the hip andknee. They are, arguably, the 2 best elective surgicalprocedures available to man. Nonetheless, they areboth underused procedures. The main reason forthis is the overwhelming fear of severe postopera-tive pain and a prolonged recovery [1]. Althoughthis was certainly the norm in years past, it is nowbecoming more of an exception. This is because ourunderstanding of the pain-generating process isimproving, and our ability to control postoperativepain is also improving.

From the *Lenox Hill Hospital, New York, New York; yThe RanawatOrthopaedic Center; and zThe Department of Orthopaedic Surgery,LHH, New York, NY.

Submitted May 2, 2007; accepted May 24, 2007.No funds were received in support of this article. Chitranjan S.

Ranawat and Amar S. Ranawat are consultants for DePuyOrthopaedics, Inc., Warsaw, Ind and Stryker Corp., Mahwah, NJ.Institutional Review Board approval was not obtained for thisarticle because there were no human participants.

Reprint requests: Amar S. Ranawat, MD, Lenox Hill Hospital,11th Floor, 130 East 77th Street, New York, NY 10021.

© 2007 Elsevier Inc. All rights reserved.0883-5403/07/1906-0004$32.00/0doi:10.1016/j.arth.2007.05.040

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Any presurgical evaluation regarding informedconsent in anticipation of THR or TKR shouldnow include a detailed discussion of the risks, benefits,and alternatives of the various pain managementprotocols currently available. General anesthesia withintravenous patient-controlled analgesia with a short-acting narcotic has been the gold standard. Newerpainmanagement strategies aim to control pain withoutrelying on narcotics and its attendant side effects suchas nausea, vomiting, ileus, pruritis, urinary retention,confusion, and respiratory depression.

This article will outline our current understandingof the role regional anesthesia, preemptive analge-sia, nerve blocks, local periarticular injections,patient education, and accelerated rehabilitationprograms have in controlling postoperative pain,reducing deep venous thrombosis (DVT), andfacilitating an earlier recovery of function.

What is Pain?

Pain remains a poorly understood, complexphenomenon most likely controlled by neural,cellular, and humeral mechanisms, with a strongemotional/psychologic component. Any effective

Table 1. Preoperative

Preemptive Analgesia Given Preoperatively

1. Celecoxib 400 mg orally2. Acetaminophen 1000 mg orally3. Tramadol 50 mg4. Oxycodone 20 mg orally5. Pantoprazole 40 mg orally6. Warfarin 5 mg orally

Pain Management and Accelerated Rehabilitation � Ranawat and Ranawat 13

postoperative pain control program for total jointsurgery should address all of these influences.Therefore, a multimodal approach is logical andhas been supported by numerous authors [2].Not only does the fear of pain limit the number of

patients who seek total joint surgery, but uncon-trolled postoperative pain has many deleteriouseffects. It has a profound impact on the recovery offunction, and it is the leading cause of delayeddischarge from the hospital [3]. For all thesereasons, it is the opinion of the senior author thatthe next great advance in the practice of total jointsurgery will be further improvements in postopera-tive pain management.

Anesthesia

It has now been well documented that regionalanesthesia offers significant advantages over generalanesthesia with regard to intraoperative blood loss,DVT, and postoperative pain management [4]. As aresult, single-shot spinal anesthesia is our preferredmethod. To minimize the DVT risk in THA specifi-cally, this is supplemented with 500 U of IV heparinduring femoral preparation [5].There are many other regional anesthetic options

besides spinal anesthesia, such as hypotensive,epidural anesthesia with or without indwellingcatheters for 24 or 48 hours; combined spinal/epidurals; intrathecal morphine (Duramorph, BaxterHeathcare Corporation, Deerfield, IL); and mostrecently, extended-release epiduralmorphine (Depo-dur, Skyepharma, London, England) [6]. Althoughthey all offer the aforementioned benefits of regionalanesthesia, they have different risk profiles andrequire different levels of postoperative monitoring.The use of epidural catheters also precludes the use ofcertain anticoagulants such as the low-molecular-weight heparins. Unfortunately, because many ofthese other modalities also use narcotics as part of theanesthetic, they are not immune from its attendantside effects, as previously described.

Preemptive Analgesia

The idea of preemptive analgesia is not a new one;nonetheless, it is rarely used. More often than not,patients are only given pain medications well afterthe onset of symptoms. It is now known thatcontinuous, around-the-clock dosing of pain med-ications is far more effective at alleviating pain thanthe standard “as-needed or prn” dosing [7].Furthermore, it creates a lower narcotic require-ment, which has obvious benefits.

The bottom line is that pain must be controlledfrom the onset for any painmanagement program towork, and secondly, the anesthetic choice should actto minimize rebound pain, which commonly occurswith the discontinuation of 24-hour epidurals.

At our institution, preemptive analgesia begins pre-operatively with most patients receiving 1000 mg ofacetaminophen, 400 mg of celecoxib, 50 mg of tra-madol, and20mgof extended-releaseoxycodone in theholding area. In addition, patients are given a proton-pump inhibitor, an antiemetic, and warfarin (Table 1).

Nerve Blocks

The use of nerve blocks with and without cathe-ters has been proven to be very effective atcontrolling pain and minimizing narcotic require-ments after THA and TKA. There are, however,several drawbacks, including the increased time ittakes to place the blocks; the availability of skilledanesthesiologists to place them; and, perhaps mostimportantly, the associated motor blockade thatlimits functional recovery and delays rehabilitation.Nonetheless, several specialized centers have madefemoral nerve blocks for TKA and “3-in-1” blocksfor THA routine for all patients because of itsexcellent pain-relieving capability [8].

Local Periarticular Injections

At our center, we have been focused on usinglocal, periarticular injections as part of our overallpain management protocol. It is our belief that theright cocktail in the right patient offers the mosteffective pain control with the least amount of sideeffects (Tables 1 and 2). We have demonstrated thesafety and efficacy of this program with a rando-mized, prospective study, which has been duplicatedby other authors as well [9]. The results of our studyare pending publication in this journal.

Ultimately, we believe that most surgeons acrossthe country will be using local, periarticular injec-tions for their arthroplasties because of theirexcellent pain-relieving ability, their low side-effect

Table 2. Intraoperative

Intraoperative Injection

1. 0.5% Bupivacaine 200-400 mg2. Morphine sulphate (0.4-1.0 cc) 4-10 mg3. Epinephrine 1/1000 (0.3 cc) 300 μg4. Methylprednisolone acetate 40 mg5. Cefuroxime (10 cc) 750 mg6. Normal saline 22 ccNo steroids in diabetic/immunocompromised patientsVancomycin if allergic to penicillinClonidine transdermal patch applied in operatingroom—100 μg/24 h

Injection sites for intraoperative periarticular injection

THABefore final reductionAnterior capsuleIliopsoas tendon and insertion siteAfter final reduction (before irrigation and closure)AbductorsFascia lataGluteus maximus and its insertionPosterior capsule and short external rotatorsSynovium

TKABefore insertion of liner and reductionPosterior capsulePosteromedial and posterolateral structuresAfter reductionExtensor mechanismSynoviumCapsulePes anserinus, anteromedial capsule, and periosteumIliotibial bandCollateral ligaments and origins

14 The Journal of Arthroplasty Vol. 22 No. 7 Suppl. 3 October 2007

profile, and their ease of use. Further research in thisarea will produce improved cocktails with longer-acting agents.

Table 3. Postoperative

Postoperative Analgesia/Medications

Recovery room1. Ketorolac IV every 6 h (15mg if age N65 y, 30mg if b65 y, hold

if with renal impairment)2. If ketorolac ineffective, morphine 2-4 mg IV every 15 min3. Metoclopramide 10 mg IV PRNOrthopedic floor1. Ketorolac IM every 6 h PRN (15 mg if age N65 y, 30 mg if

b65 y, hold if with renal impairment)2. If ketorolac ineffective, morphine 2-4 mg IM every 2-4 h3. Celecoxib 200 mg orally daily for 10 d4. Oxycodone SR 10/20 mg orally every 12 h for 48 h5. Oxycodone 5 mg orally every 6 h PRN6. Acetaminophen 1000 mg orally every 6 h7. Pantoprazole 40 mg orally daily

PRN, as needed; SR, sustained release.

Other Pain-Reducing Adjuvants

As the industry becomes more aware of theimportance of controlling postoperative pain, moreadjuvant therapies and devices will become avail-able (Table 3). Recently, patient-activated transder-mal analgesic patches, which obviate the need forintravenous lines, have been released. Other strate-gies have focused on using anesthetic-coated suturesand implants as carriers. Newer hemostatic agentsand drain systems are also now available to helpminimize the risk of developing postoperativehematomas, which are a significant cause of painand wound complications.

Patient Education

Managing patients' expectations and preparingthem for total joint surgery has been shown to bevery effective at improving outcomes and patient

satisfaction. Most high-volume centers use a varietyteaching aids such as audiovisuals, booklets, web-based learning, as well as individual and groupclasses to educate patients preoperatively and post-operatively [10]. To do this effectively requires atremendous allocation of time and resources. Itusually necessitates a full-time, dedicated, andexperienced nurse to appropriately handle thebarrage of patient-generated questions that inevi-tably arise. It is also a good idea to revisit theseclasses on a regular basis to ensure proper teachingand training of staff members.

Accelerated Rehabilitation

There are 2 factors that permit patients to participatein an accelerated rehabilitation program. The first, andperhaps most important, is the motivated patient.Even with some pain that most patients wouldconsider unbearable, the motivated patient canpower through. By extension, the second necessaryfactor for most patients is achieving adequate post-operative pain control. The focus of any rehabilitationprotocol should be to control pain because this is thevariable the surgeon canmanipulate [11]. No amountof encouragement or education can convert unmoti-vated patients into motivated ones, especially if theyare experiencing pain.

The fact is that many patients, especially younger,active males, could and should participate in arehabilitation program on the day of surgery,provided they are medically stable. The limitingfactor for most institutions, however, will be the lackof skilled physiotherapists needed to accomplish thisfeat. The benefits include immediate, direct psycho-logic feedback to the motivated patient, with theultimate potential of reducing his or her length-of-stay. The long-term benefits of an accelerated

Pain Management and Accelerated Rehabilitation � Ranawat and Ranawat 15

program are probably negligible; however, the samecould be said for the use of continuous, passivemotion machines, which have become a part of thecommunity standard despite little evidence tosupport its use.

Conclusions

Achieving the painless THA or TKA is withinreach using regional anesthesia and multimodalpain control techniques that avoid the unnecessaryuse of narcotics. This has been documented byseveral prospective, randomized studies, includingour own. The use of local, periarticular injectionswill be a major player in these programs in the yearsto come. Further research is still necessary toidentify longer-acting injectable agents.Although patient education and accelerated reha-

bilitation programs are important in facilitating apatient's recovery, it cannot be overemphasized thatthe focus of any total joint program should be incontrolling postoperative pain.

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