Pain Management Update for Total Joint Replacement

Pain Management Update for Total Joint Replacement

As I have mentioned in previous blogs, the way that we manage pain has changed significantly over the last five years. We have utilized a combination of different components to come up with our current pain management protocol. These include preoperative education to inform the patient and their family what to expect as far as the procedure, the recovery, physical therapy, and the pain that will be present and how it will be managed.  Surgically, we use smaller exposures to decrease some of the tissue trauma, we use a bipolar sealant which decreases the amount of postoperative blood loss and thereby decreases a component of postoperative pain, and a cooling sleeve is placed on the knee after surgery to help decrease swelling and pain.

William P. Barrett, M.D.

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  1. Marie LaChapelle, R.N.

    I am in charge of updating the way pain management is done for total joint replacement surgeries here at Brookhaven Memorial Hospital Medical Center in Patchogue, New York.

    As the Nurse Manager and Pain Management Manager, I am endeavoring to bring the latest postoperative pain management available to our anesthesiologists and orthopaedic surgeons.

    There is great conflict now and resistance to provide standardized pain management for total hips, knees, etc.
    The use of Duramorph is problematic and not successful in treating postoperative pain until the PCA has been started, extending the patient’s length of stay and causing the first 24 hours to be a painful time. CPM use is avoided at this time due to the ongoing knee pain and/or hip pain, etc.

    What is your recommended Pain Management Formula for total joint replacement to bring our hospital into the 21st century.

    Thank you for your kind attention. I am anxiously awaiting your response.

  2. Dr. William Barrett

    Dear Marie,
    We use a multimodal approach which varies depending on medical co-morbidities. In general, healthy patient we do the following:
    tylenol 1000mg
    oxycontin 10 mg
    celebrex 400 mg
    spinal vs gen anesthetic
    TKA all get femoral nerve blocks
    intra op we inject 40-60 ml 1/4% marcaine 10mg morphine in the periarticular soft tissue
    post op – we do not use PCA rather…
    oxycontin 10mg q12
    tylenol 100mg q6 , celebrex 200mg qd and oxycodone 5mg q4 prn breakthrough pain. Regards, William Barrett

  3. Linda Hightower, RN, ONC

    Have your considered using a continuous infusion of marcaine into total joints post-op? We have been using this approach for about 7 years and get good results. We use less opiods, have fewer falls, less nausea… we like it alot. We also do the Tylenol Q6H, celebrex or other NSAID unless renal problems, cooling sleeves for TKA, and then oxycodone/hydrocodone/hydromorphone for breakthrough. On the day that the marcaine infusion is removed we add oxycontin 10-20 mg once or twice a day for about 3-5 days. Our patients are up walking within hours of surgery and doing 2-3 therapy sessions/day. Our LOS is between 2-3 days for both hips and knees.

  4. Melissa Oswald RN

    Dr. Barrett,
    I’m an RN working on a post surgical orthopedic unit. A project I’m currently working on is “pain control following a total joint replacement”. What is your experience with intrathecal pain pumps (Stryker)? Have you found toradol and vicodin/norco/lortab a good combination? Have you ever worked with patients that wanted to try alternative pain treatments such as acupuncture along with medical modalities?
    Any information you can share would be greatly appreciated.

  5. Dr. William Barrett

    Dear Melissa Oswald, RN
    We have not used intrathecal pumps. We use Toradol for 3-4 doses postop as needed for our patients under 65 years. This is in combination with short and long acting p.o. pain medicine and Celebrex and Tylenol.
    William Barrett

  6. Dr. William Barrett

    Dear Linda Hightower, RN
    We have not used the continuous infusion pumps because of concerns regarding infections. Glad to hear they are working well for you.
    William Barrett

  7. Joan Munroe

    My husband just received a hip replacement and the doctor cancelled his regular Celebrex because “it interfears with the growth and healing of the bone”. Would you please comment?

    Thank you.

  8. Larry Meyer

    Dr. Barrett,
    I noticed your name in a Seattle publication regarding partial knee replacment. I’m 45 yrs old and have a six year old. I’m a police officer and have had both knees reconstructed. My right was done in 1980 acl repair with meniscus removal, I believe removed on the inside of my knee because it appears my knee is collapsing inward and causing me hip pain now. Have you found that you are able to do partials on this old of a repair if my knee fits the bill?
    Thank you

  9. Mary Reynolds

    Dr. Barrett,

    I am an RN working on a project for our orthopedic unit , we are looking at different appoaches to manage post operative pain in patients having total knee/total hip replacements. I am interested in knowing whether the patients received a nerve block to manage post op pain,if so did the patients experience weakness the following 24 hrs due to motor/sensory loss from the block?
    Mary Reynolds

  10. Dr. William Barrett

    Dear Mary,
    We use femoral nerve blocks for TKA but not for UNI’s. Patients do have quad inhibition for first 18-24 hours but pain relief is very good. No nerve blocks for THA.
    William Barrett