Back in the Game

Post-op pain control that avoids opioids and supports rapid ambulation is an essential element of a sought-after sports medicine program… and a smart approach or treating athletes and non-athletes alike.

Whether you’re repairing a torn ACL for a 20-year-old college athlete or a 50-year-old pickleball prodigy, steering clear of opioids for these orthopedic surgeries throughout the continuum of care is the ticket to the patient’s optimal recovery… one that’s not only faster but also more effective.

Plenty of research shows the benefits of avoiding opioids to manage postoperative pain for any surgery, and the benefits of opioid-sparing care continue to be realized.

First and foremost, it’s much easier for patients to achieve early ambulation — an essential step for blood flow, wound healing and stability — when they don’t need to overcome the side effects of opioids, such as grogginess, nausea and vomiting.

Another widely recognized benefit is removing the risk for opioid addiction. This risk is especially concerning for younger patients. Research has demonstrated how young adults with frontal lobes that aren’t fully developed are at increased risk for opioid addiction. For example, a 2022 observational study found that of the 26 collegiate athletes in one university sports department who received an opioid prescription due to orthopedic injury or surgery, 14 used opiates for non-analgesic purposes.

Knock out pain safely

For Gregory V. Hickman, MD, FASA, medical director and anesthesia director at Andrews Institute Ambulatory Surgery Center in Gulf Breeze, Fla., this increased risk for opioid addiction among his younger patients is just one more reason for him to employ a continuous nerve block approach to combat postoperative pain.

Dr. Hickman’s patients, who are primarily athletes, mobilize and begin physical therapy exercises such as quad extensions and leg lifts within one hour after surgery. This is because their pain is controlled from the moment they exit surgery through a continuous catheter nerve block placed preoperatively that goes home with them.

“Blocking the pain until they get on their feet gives my patients a chance to get over the hump from immediate post-op pain in the days after surgery,” says Dr. Hickman. He also uses this post-op nerve block approach for non-athletes to help them mobilize after surgery.

For patients of Anthony Mascioli, MD, an orthopedic and sports medicine surgeon at the multicenter Campbell Clinic in Memphis, Tenn., opioid-free pain management starts before the day of surgery. While his approach depends on several key factors, including surgical approach, to optimize rapid recovery with reduced pain, Dr. Mascioli says an effective opioid-free, multimodal pain control strategy is an essential part of the equation.

Planning ahead for effective pain management

“Postoperative pain is handled on the front end of their surgery and opioids are avoided — period,” says Dr. Mascioli. Several days before surgery, the patient receives a nonsteroidal anti-inflammatory drug (NSAID) and is then dosed with IV acetaminophen preoperatively. Before all knee and some hip procedures, the patient receives a single iPACK block in the posterior of the knee. Intraoperatively, the patient receives spinal anesthesia for hip or knee procedures as well as multimodal, opioid-free pain control that typically includes a mix of ketorolac and IV acetaminophen, dexmedetomidine and ketamine.

“This approach spares the patient from the physical and mental side effects of opioids so they can ambulate within an hour after surgery, once the spinal wears off,” explains Dr. Mascioli. For certain procedures such as total joint replacements, a long-acting analgesic injection is added for pain control.

Overall, Dr. Mascioli’s approach for every patient is to avoid opioids throughout their surgical course of care to facilitate early ambulation, reduce complications and foster a more expedient recovery. This, in turn, reduces the patient’s need for opioid pain control while they recover at home.

Avoiding nasty rebound pain

WALK THIS WAY The earlier patients ambulate after surgery, the faster they ultimately recover.

In addition to the intraoperative multimodal mix of dexamethasone, ketorolac and ketamine, the continuous catheter nerve block that Dr. Hickman’s patients receive stays in for a set amount of time after surgery, averaging around four days based on research that identifies this window as the worst for post-op pain. In certain cases, such as a patient with a frozen shoulder that has rendered them immobile, a continuous catheter nerve block may be left in for seven to 10 days.

The main reason for this extended nerve block is to give patients a chance to get ahead of their post-op pain and immediately start combatting the ill effects of being immobile prior to their surgery. Because so many of Dr. Hickman’s patients are athletes with ACL tears, a common concern for quadricep muscle-wasting must be addressed as soon as a surgical repair is made, he stresses.

Dr. Hickman’s non-athlete patients also benefit from the extended nerve block to simply get upright and start moving. “Being able to prevent wasting in muscles that stabilize is important for athletic activity but also for everyday actives such as walking,” says Dr. Hickman.

Falls are another concern for patients who don’t ambulate immediately under supervision after knee and hip procedures. A 2022 study investigated fall rates for patients immediately after total knee arthroplasty who had either an adductor canal block or femoral nerve block for two to three days postoperatively. Researchers observed no patient falls and found the adductor canal block was associated with significantly less knee buckling.

The days immediately after surgery are critical to build muscle back, but this rehab can come to a standstill when intraoperative pain management medications wear off, cautions Dr. Hickman. Dubbed “rebound pain,” this onset of extreme pain often comes at night and leaves a patient desperate for relief, sometimes making them more likely to turn to opioids if they’re offered. “Getting patients through that four- to five-day period where surgical pain is typically the most acute can help them avoid delayed recovery and the complications that can come with it,” says Dr. Hickman.

Looking at the big picture

Dr. Hickman encourages his colleagues to build their experience in regional anesthesia if they don’t already have this skillset. “Think about every patient through their recovery and overall outcome, not just through the perioperative period,” he says. “This is true for all patients, not just athletes. In fact, recovery for non-athletes can be a tougher road because they don’t have the opportunity to work out in physical therapy for up to eight to 10 hours a day like an athlete does.”

From a business perspective, patient satisfaction and patient throughput are also factors specific to pain control and rapid recovery that any surgical center should consider. Research shows a direct correlation between effective post-op pain control and overall patient satisfaction. Opioid-sparing surgical care also helps patients recover more quickly postoperatively, which can help high-volume centers keep busy surgical schedules running smoothly.

Ultimately, “establishing an effective approach to pain management for your surgical patients shows opioids just aren’t needed,” stresses Dr. Mascioli. Reflecting on the tremendous leaps and bounds made for orthopedic surgery patients over the last decade, he stresses that going opioid-free has played a critical role in this progress. “Taking an entire service line to a surgery center and getting patients home and moving just hours after surgery with an opioid-sparing approach is about as good as it gets,” he says. OSM