Early rehab incorporating pain control may lead to better postoperative outcomes

Protocol using IV Toradol or morphine resulted in early hospital discharge, more patient satisfaction

Accelerated rehabilitation programs with a focus on pain management may provide better function after total knee replacement.

In a study of 200 consecutive total knee arthroplasty patients who received either a rotating platform or fixed-bearing implant, researchers found that 15% of patients who underwent a traditional pain protocol had significant pain at six weeks postop.

Chitranjan S. Ranawat, MD, and colleagues found better results after adopting a new rehab program centered on pain management.

“This new protocol, combined with a reduction in overall tourniquet time [and] reduced tissue trauma surgery, has made early discharge of the patient from the hospital, straight leg raising, range of motion, ambulation and patient satisfaction higher than in periods experienced,” Ranawat, the chairman of orthopedics at Lenox Hill Hospital in New York, said during his presentation at the 7th Annual Current Concepts in Joint Replacement Spring 2006 Meeting.

In their original pain management protocol, patients wore compression dressings and suction drains, which were removed after 24 hours. Patients also wore mechanical compression boots for 3 days. They started continuous passive motion and physical therapy 1 day after surgery. Their physical therapy included walking with a cane and range-of-motion exercises. “[For] pain control at that time, we were using epidural anesthesia, femoral nerve block, morphine PCA and hydrocodone,” Ranawat said. Patients also received deep vein thrombosis prophylaxis.

Researchers followed patients 6 weeks, 3 months and 1 year. “By 6 weeks, 83% could ambulate without cane, 59% had range of motion greater than 90° and 34% had some flexion contracture,” Ranawat said. Yet, 15% of patients had pain that needed prolonged Vicodin (acetaminophen and hydrocodone). Less than 3% of these also required postop manipulation. “So pain is the main reason for getting less motion in the postop period,” Ranawat said.

To prevent limited range of motion and pain, the researchers developed a new protocol. “We use Celebrex (celecoxib, Pfizer) before surgery, [oxycodone] before surgery and Protonix (pantoprazole sodium, Wyeth) and, if Toradol (ketorolac tromethamine, Roche) failed, they get morphine.” Physicians also prescribed acetaminophen and injected patients periodically with medications including marcaine, depomedrol or morphine.

Ranawat said that the research highlights the importance of pain control and accelerated rehab. “It appears that controlling pain after total joint surgery, patient education and advanced physical therapy are more important variables in early recovery of knee function and length of stay,” he said. “The length of incision and soft tissue trauma plays a role, but to a smaller degree.”

For more information:
Ranawat CS. Optimizing postop performance: Be all you can be. Presented at the 7th Annual Current Concepts in Joint Replacement Spring 2006 Meeting. May 21-24, 2006. Las Vegas.