Perfecting Anesthesia and Analgesia for Total Joints Cases

Master management of patients’ pain by combining effective multimodal regimens with precise regional blocks.

Charles Hannon, MD, MBA, an orthopedic surgeon with Mayo Clinic in Rochester, Minn., is a leading researcher on pain management before, during and after hip and knee arthroplasty who has contributed to evidence-based guidelines endorsed by numerous relevant societies such as the American Association of Hip and Knee Surgeons and the American Academy of Orthopaedic Surgeons. He says current research is focused on how best to reduce pain, reduce opioid consumption and enhance recovery with minimal side effects.

“The literature shows a huge shift in how we deal with opioids,” says Dr. Hannon. “We now recommend a much lower amount after surgery, and there’s definitely a benefit for patients to reduce opioid use before surgery because it helps their outcomes after surgery. The data is very clear that, assuming there are no medical contraindications, patients should be discharged with acetaminophen, nonsteroidal anti-inflammatories (NSAIDs), a low-dose opioid like Tramadol if tolerated and very low prescription amounts of regular opioids like oxycodone.”

Research progresses

Chancellor Gray, MD, joined Florida Orthopaedic Institute this summer after spending the previous eight years at the University of Florida in Gainesville, where he served as division chief and William Petty Endowed Professor in Adult Reconstructive Surgery. Beginning in 2016, he dove deeply into anesthesia and analgesia techniques to better enable outpatient hip and knee surgery.

Dr. Gray and his team refined their approaches to multimodal anesthesia and analgesia for total joints for seven years, learning a great deal along the way. “The techniques have evolved,” he says. “Multimodal now looks different than it did seven years ago, and certainly different than it did 15 years ago.”

When Dr. Gray and his partners began, their opioid prescriptions were standard for 2016. That didn’t last long as their research and experience progressed. They established four patient pathways for outpatient joint replacement pain management with different postoperative prescriptions tailored for specific patient needs:

• Opioid-sparing. For patients who purposely wanted to avoid all opioids.
• Narcotic-naïve. For patients who were not trying to avoid narcotics, but had never taken them before.
• Standard. For patients who had been on narcotics at some point to help manage preoperative pain.
• Long-term user. For patients who, for example, took opioids for chronic pain.

In 2017, patients in the opioid-sparing pathway were given 30 Tramadol tablets. Narcotic-naïve and standard patients were prescribed 56 Tramadol pills and 56 hydrocodone tablets. Long-term users received 56 oxycodone tablets. By 2020, the prescriptions were significantly different: 21 Tramadol pills for the opioid-sparing pathway, 28 hydrocodone pills for the narcotic-naïve, and 28 oxycodone pills for standard and long-term users. Acetaminophen and COX-2 or COX-1 anti-inflammatories were included in the mix.

“By being consistent, defining and establishing protocols, and being very clear in our communication with patients and with our team, we found that even without major changes in regional anesthesia, the opioid prescriptions we were giving at the outset were, in retrospect, pretty heavy-handed,” says Dr. Gray. “So we just kept pushing on it — ‘Can we try a little less? Yeah, that seems to work.’ Over time, we found patients did not need nearly as many pills as we thought they would at the outset.”

Dr. Hannon says a key to multimodal pain management success is an awareness of each patient’s previous medical history and opioid use. “Depending upon the amount of opioids the patient is on before surgery, sometimes we engage our pain management colleagues to help the patient with a formal weaning program because weaning opioids is a complex procedure,” he says. “If they’re on a really high dose, we may even have pain management colleagues help with the pain control protocol after surgery.”

Intraoperatively, research is currently focused on corticosteroids such as intravenous dexamethasone that could help reduce pain, inflammation, nausea and vomiting. “That’s a big area right now that’s evolving in terms of how many doses we should be giving,” says Dr. Hannon, noting his involvement in an ongoing multicenter randomized control trial.

Regional anesthesia benefits

Anesthetic techniques are still developing for outpatient total joints. Dr. Hannon describes the use of regional nerve blocks in total knee arthroplasty as critical, and says good data supports the use of adductor canal blocks and periarticular injections to reduce pain and opioid consumption after surgery. He says more research is needed to determine if employing both methods in tandem produces an additive effect.

Over seven years, anesthesia practices changed for Dr. Gray’s patients. “For hips, we switched from using an indwelling nerve catheter to a local periarticular injection with a long-acting anesthetic agent, typically ropivacaine or bupivacaine, in the hip,” he says. Dr. Gray and his surgeon partners performed that injection themselves, with the exact timing varying from surgeon to surgeon. “We found that was just as safe and effective as using a nerve catheter placed by our anesthesia team,” he says.

For knees, the standard was to place a nerve catheter into the adductor canal that the patient would use at home typically for three days to deliver ropivacaine through a small pump. “We liked the adductor canal because it is motor-sparing, so the patient still has function of their quadriceps muscle, which makes it safer from a falls risk perspective,” says Dr. Gray. “Our anesthesia colleagues also placed an iPACK block of a long-acting anesthetic to deal with posterior knee pain. We would generally also apply a little bit of local anesthetic directly through the front of the knee during surgery. Those three things working together really led to effective pain relief and enabled our patients for the most part to not require something like a knee immobilizer because they still had quad function, and could be comfortable and participate in physical therapy right away.”

Dr. Gray says in terms of the patient experience during surgery, two options work just as well depending on the patient. “They could get a general anesthetic, typically TIVA (total intravenous anesthesia), not necessarily with a gas inhalation agent but usually propofol, which minimizes nausea and vomiting,” he says. “A separate group of patients, about 30%, elected for spinal anesthesia with a low dose of propofol on top so they were sedated. We did have a group of patients who chose to go through this wide awake under spinal; they feel nothing, but can communicate with you. They liked participating, so to speak — asking how things are going, what you’re finding. The patient had a choice with the anesthesia provider, and could dial the level of propofol up or down to whatever level of sedation they wanted.”

Dr. Gray says anesthesia and analgesia protocols should be developed to avoid nausea and keep blood pressure at acceptable levels so patients can stand and get moving an hour or so after surgery. He says switching from a long-acting spinal like bupivacaine — which makes patients fairly hypotensive and may make ambulation difficult for three or four hours postoperatively — to a shorter-acting spinal like mepivacaine or chloroprocaine also has benefits. “The patient is comfortable, but they’re not hypotensive, don’t have urinary retention and can stand up and walk around 90 minutes or two hours after the operation,” he says. That quicker ambulation boosts patient satisfaction as well. “They’re pretty amazed by that,” he says. “It is a night and day difference from 10 years ago.”

Dr. Hannon says there is some controversy currently regarding anesthesia methods. “There are some surgeons whose default is a short-acting spinal anesthetic with a medication like mepivacaine,” he says. “During those procedures, the patient is not intubated, technically awake and breathing on their own. At the same time, particularly in the outpatient setting, some surgeons are using a general anesthetic because the recovery when they wake up can be really short, and you’re not waiting for the spinal to wear off. I think either is definitely a reasonable option in 2023. Most are doing a spinal anesthetic but in certain populations or patient care settings, general may be appropriate.”

Collaborating with patients and multiple disciplines

“A lot of this is about engaging the patient appropriately and setting yourself up for success,” says Dr. Gray. “You need to understand your patient and communicate clearly with them at the outset — not only to help them feel reassured that their pain will be well-managed, but also to understand where they lie historically, because people will process this stuff very differently depending on their history and expectations. Actively understand patients’ use patterns and communicate with them very clearly.”

EDUCATE AND ENGAGE Providers and other staff should be consistent in their communications with patients regarding their pain management strategy throughout the episode of care.

Dr. Gray and his team developed detailed handouts for each patient pathway. “This is what we expect you will need, this is how and when to use these medications, when you should call us, when you should take one of your oxycodone pills instead of Tramadol, when to use ice and how much, and reminding them that a big portion of the pain control is other things like Tylenol and Celebrex,” says Dr. Gray. “We gave them all those things in writing so they would understand what their pathway should look like.”

Dr. Gray emphasizes getting patients engaged and involved as active partners in their pain management strategy, and ensuring they remain connected to you at home. “Providing open access to and good communication with your team is so key because a lot of patient pain needs are driven by anxiety,” he says. “Just by you and your team being available, it alleviates a lot of that anxiety, and they get less pills in the end.”

Dr. Gray says it is critical to form an aligned team around the surgeon encompassing anesthesiology, nursing and physical therapy. “If everybody is on the same page about why this is a good idea and how the protocols work, it minimizes confusion and anxiety for the patient,” he says. “Having pathways that everybody can fall back on and be able to communicate and execute makes the whole experience very smooth for everybody involved.”

“A strong collaborative relationship with your anesthesia team is absolutely critical for a successful multimodal program in 2023,” says Dr. Hannon. “You really want to work with your anesthesiologist to develop a program that best fits the needs of your patient and the patient population you’re treating, and you need consistency across your team with the messaging to patients about minimizing opioid use after surgery. If one member of your team is telling the patient, ‘No, you should take as much opioids as you can,’ it can completely destroy the messaging your practice is trying to create.”

Dr. Gray says an engaged, familiar anesthesia team is essential because they’ll play a major role in the success of the pain management protocol. “They meet the patient at that key time right before surgery where they explain what they’re going to do from a regional standpoint, why it’s going to work and what the patient should expect,” he says. “If they’re consistent with your messaging ­— ‘we expect you to be comfortable, you’re going to have some pain but it shouldn’t be something you can’t deal with’ — that really sets you up for success.”

Quicker, less painful recoveries

Pain management for total joints will continue to evolve. “There’s a significant need for future research in this area,” says Dr. Hannon. “We definitely still have room to improve. My hope is that in 10 to 15 years, we’re not doing a one-size-fits-all approach, and we’ll be able to individualize it to each patient.” The good news, says Dr. Hannon, is that more patients are open to opioid-sparing techniques. “There’s been a shift not only in practice, but also in patient perception,” he says. “Back in the day, patients thought, ‘I need opioids after surgery.’ Many patients now say, ‘I don’t want opioids after surgery. How do you treat pain so I don’t have to take any of these medications?’” OSM