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Preoperative pain management protocol may reduce arthrofibrosis in primary TKA

Multimodal analgesia seen as reason for significant decrease in risk of postoperative complication.

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ASHEVILLE, N.C. — The use of a multimodal pain management protocol that includes preemptive analgesia has shown to possibly reduce the incidence of arthrosis following primary total knee arthroplasty, according to a Miami investigator.

"I think that pain management may be one of the most important advances in arthroplasty since the introduction of sterilizing plastics," said Carlos J. Lavernia, MD. "I remember making the rounds 5 years ago, seeing half of my knee patients contorting in pain, really hurting, and the first 2 postop days were the worst."

Lavernia presented his data and pain management protocol during the Special Emphasis Poster session during the 120th annual meeting of the American Orthopaedic Association, held here.

In the abstract for the poster, Lavernia and colleagues wrote, "Pain response has been postulated to contribute to the development of arthrofibrosis following primary total knee arthroplasty (TKA). A balanced program of multimodal analgesia significantly reduces the incidence of arthrofibrosis after primary TKA."

In a prospective analysis of 1,136 patients undergoing primary TKA, the investigators compared 358 consecutive patients who received a multimodal pain management regimen, including a pre-emptive course, to 778 patients who did not receive these modalities. Patient-oriented outcomes were collected before and after surgery. All patients received a femoral nerve block during surgery. Manipulation under anesthesia was performed on all patients whose knees did not bend more than 85° at the 6-week postop milestone.

The multimodal pain protocol included a preoperative course of OxyContin [oxycodone, Purdue Pharma], Tylenol [acetaminophen, McNeil], Celebrex [celecoxib, Pfizer] and Zofran [ondansetron, GlaxoSmithKline].

The perioperative pain cocktail included: Xylocaine [lidocaine, AstraZeneca], Toradol [ketorolac, Roche], Duramorph [morphine injection, Baxter Healthcare] and Marcaine [bupivacaine, AstraZeneca]. Postoperatively, patients had a daily dose of oxycodone, acetaminophen and celecoxib.

Overall, in this patient group, who had an average age of 68 years and consisted of 72.5% women, Lavernia and colleagues found that seven patients underwent manipulation in the multimodal pain group compared to 39 patients in the nonmultimodal pain group. "The incidence in the number of manipulations was significantly associated with this new pain protocol in a regression model," the investigators wrote in their abstract.

There were no reported complications due to the multimodal pain management protocol.

Patients who had the multimodal pain protocol were able to begin straight leg raises on postoperative day 1, Lavernia said. "I can really tell you that this has changed my life and the lives of the patients in my practice."

For more information:

• Lavernia CJ, D'apuzo M, Hernandez V, Hernandez R. Multimodal pain management and arthrofibrosis after primary TKA. Poster # AR3. Presented at the 120th Annual Meeting of the American Orthopaedic Association. June 15, 2007. Asheville, N.C.