Better pain control can shorten hospital stay, aid ambulation after TKA

ORLANDO, Fla. — Controlling postoperative pain following total knee arthroplasty (TKA) is a key to improving patient satisfaction and reducing length of hospital stay, according to a New York orthopedic surgeon.

Chitranjan S. Ranawat, MD, of the Hospital for Special Surgery, detailed his experience managing postoperative pain at the 25th Annual Current Concepts in Joint Replacement Winter Meeting, here.

“I have been doing total joints for 45 years,” Ranawat said. “One thing that has the biggest impact on the quality of function is pain control. I have learned this over the last 3 to 4 years. If you control the pain, the quality and the return of function after total hip and knee [arthroplasty] are different.”

For his patients undergoing TKA, Ranawat preoperatively injects a cocktail consisting of Celebrex (celecoxib, Pfizer), OxyContin (oxycodone, Purdue Pharma) and two other medications into the periarticular tissues.

“I inject 50 cc in total volume into the posterior capsule, medical capsule, medial ligament and the periarticular tissues of the femur,” he said. He also injects 20 cc of 150-mg Marcaine into the quad-arthrotomy.

Postoperatively he administers Toradol (ketorolac, Roche Laboratories), Tylenol (acetaminophen, McNeil) and morphine only as needed, “which is only occasionally,” he said.

“This protocol, combined with a reduction in overall tourniquet time, which I only use for cementation, has promoted early discharge from the hospital, early range of motion and ambulation,” Ranawat said during his presentation.

He presented data on 200 patients treated with his protocol and followed for 1 year. Half of the patients received mobile-bearing implants and the other half received fixed-bearing knees. All patients were interviewed by social workers, visiting nurses and physical therapists during rehabilitation.

Suction drains and compression dressings were removed postoperatively after 24 hours. Continuous passive motion began the next day and increased according to patients’ tolerance, he said.

The postoperative rehabilitation protocol included ambulation with a walker, which was switched to a cane as tolerated.

“Pain control was appropriate for the postoperative period and included epidural anesthesia and femoral nerve block,” Ranawat said.

Patients were discharged on the fourth day. Half of the patients went to rehabilitation, half went directly home for physical therapy, and all were followed up at 6 weeks, 3 months and 1 year, he said.

“At 6 weeks, 83% were walking without a cane, 60% had 90° of flexion and one-third had a flexion contracture of less than 10°,” Ranawat reported.

He said some recent studies noted that 85% of all patients will recover knee function after knee arthroplasty no matter what you do. In his study, 15% of the patients at 6 weeks required continuous support from the support team, pain medications and other drugs.

“It is this 15% who will give you trouble, and it is these patients who require all the help,” Ranawat said.

For more information:
Ranawat CS. A rapid recovery protocol: The happy patient. Paper #89. Presented at the 25th Annual Current Concepts in Joint Replacement Winter Meeting. Dec. 11-13, 2008. Orlando, Fla.