Taking the Pain Out of Total Joints


Regional anesthesia is improving outcomes in facilities where providers are placing advanced blocks to help patients recover.

Regional anesthesia has evolved into a game-changer for performing joint replacement procedures. The improved ability to block pain signals around the surgical area for a few hours with a single injection or for a longer duration through continuous infusions allows surgeons to perform these complex surgeries in the outpatient setting. It can also help to improve patient satisfaction.

Employing regional anesthesia is particularly helpful for patients who are likely to suffer from more intense pain due to medical issues or the type of surgery they’re undergoing, according to Edward Mariano, MD, MAS, FASA, a professor of anesthesiology and perioperative pain medicine at Stanford (Calif.) University School of Medicine and chair of the American Society of Anesthesiologists’ Committee on Regional Anesthesia and Pain Medicine. He says joint replacement patients will experience significant discomfort after surgery if their pain is not effectively managed.

Improvements in regional anesthesia practices over the past decade, including the development of new blocks that target nerves closer to the surgical site, allow providers to deliver effective pain relief without the use of opioids and enable patients to be active sooner after surgery. That increased mobility goes hand in hand with Enhanced Recovery After Surgery (ERAS) protocols, which are increasingly being used to improve patient care.

LINE OF SIGHT Ultrasound machines with larger, high-resolution screens give providers clear and detailed views of targeted nerve bundles.  |  Mike MacKinnon

“The thought process is that the more active patients are after joint replacement surgery, the less likely they are to suffer complications such as deep vein thrombosis,” says Dr. Mariano. “Plus, pain management can improve with activity.”

He adds that many total joint patients have had declining activity in the months or years before their surgery, making it even more important to get them moving on their own and start physical therapy sooner so they can redevelop needed muscle tone. In some cases, patients can even begin physical therapy on the day of surgery. Patients who receive regional anesthesia are also less likely to end up back in the surgeon’s clinic for unexpected follow-up care or in an emergency department because of uncontrolled pain.

Regional anesthesia, as beneficial as it is, hasn’t yet become the standard at outpatient facilities, according to Dr. Mariano, who notes that it’s still underutilized for many common procedures. “For example, more than one million primary knee arthroplasty surgeries are performed each year and our best estimates for the use of nerve blocks is somewhere between one in four and one in five patients, which is incredibly low,” he says.

Dr. Mariano adds that nerve blocks are performed only about half the time for patients who undergo shoulder arthroscopy — one of the most painful outpatient procedures. “Before we can call regional anesthesia the standard of care, I think we must make sure more patients have access to it,” he says. “We’re making a lot of progress in this area but, at least for now, it’s still a work in progress.”

Advancing techniques

Regional anesthesia still might be generally underutilized, but Dr. Mariano says blocks are beginning to be used more frequently thanks in part to numerous improvements in block techniques. For example, there’s been a steady uptick in the use of interscalene brachial plexus blocks during shoulder replacements, distal peripheral blocks for upper limb surgeries, and popliteal sciatic blocks for foot and ankle procedures and arthroscopic surgeries for the treatment of sports injuries.

These developing blocks are placed more easily and accurately thanks to ultrasound machines with larger screens, clearer images and user-friendly controls. “The clarity and sharpness of the image as well as the imaging processing power create a more defined image, which makes the procedure easier,” says Mike MacKinnon, DNP, FNP-C, CRNA, an anesthesia provider at Northeastern Anesthesia in Show Low, Ariz. “Looking for differences in nerve patterns on old snowy screens compared with now actually seeing the fascicles of the nerves is a tremendous advantage.”

He adds that larger screens and intuitive controls found on newer ultrasound units help with efficiency and ease of use, but other functions such as automated image enhancement technology allow providers to visualize needles “in-plane,” even when inserting them at a steep angle. “That would otherwise be much harder to do,” says Dr. MacKinnon. “These upgrades have made it easier to visualize the needle, danger zones and target nerves, making placing a block with ultrasound guidance safer, more effective and easier.”

Innovations in ultrasound guidance are also leading to the continued development of emerging blocks that are likely to play a larger role in the future of patient care. Many of them are allowing more patients to undergo surgeries at outpatient facilities. For example, placing the pericapsular nerve group (PENG) block in total hip patients is a technique Dr. MacKinnon frequently uses. “This block involves depositing local anesthetics in the fascial plane between the psoas muscle and the upper pubic branch, effectively targeting the anterior hip capsule by blocking the articular branches of the femoral nerve and accessory obturator nerve,” he says. The PENG block is a better option than the femoral nerve block or lumbar plexus block because it avoids quadriceps weakness and allows patients to ambulate much more quickly, according to Dr. MacKinnon.

Dr. Mariano expects to see more “personalization” of regional anesthesia moving forward. “We know there are certain surgeries that hurt more, but we also know each individual patient might experience pain from the same surgery in a different way,” he says. “We’re only just scratching the surface of understanding how many inter-individual differences there are.”

Although providers don’t yet have the information they need to make accurate predictions about which blocks would work best on individual patients, Dr. Mariano thinks providers will be better able to predict trajectories of pain based on patients’ genotypic differences as more outcomes data is collected. “Once we can account for those differences, we’ll be able to better understand, for example, which patients would benefit the most from shorter or longer blocks,” he says. “Some patients might also need higher- or lower-intensity blocks. I think that will help to contribute to a more personalized approach to pain management.”

Gradual implementation

Dr. Mariano considers nerve blocks best practice for any patients who qualify for them. He says patients expect to experience the highest quality of care, regardless of where they recover from surgery, so their recovery at home after outpatient procedures should be at least as good as what they would experience in a hospital. “In my mind, that means prioritizing efforts to ensure patients can be as independent as possible,” he says. “You want patients to take fewer sedating opioids or pain medicines with side effects, sleep better and be better able to manage their daily activities. Those things are very well facilitated by regional anesthesia.” Dr. Mariano adds that by not relying on opioids to manage post-op pain, patients avoid side effects that can delay or impede recoveries such as brain fog, constipation and nausea or vomiting.

He says surgical leaders looking to increase their facility’s use of regional blocks, especially for total joint procedures, must first have a broader discussion with the clinicians who provide direct patient care to ensure that all stakeholders are on board with the concept and understand that doing so can improve patient outcomes and satisfaction.

Introducing regional anesthesia is also likely to require some investment in training for clinicians and the equipment needed to place blocks effectively. Surgeons will also need to buy into the program and realize that anesthesia providers who are just beginning to administer regional blocks will face a learning curve. “The first time you do anything is usually not the fastest,” says Dr. Mariano. “You’re going to need a little bit of time in order to develop proficiency.”

He calls for rethinking how providers approach regional anesthesia in general practice. “That means trying to focus on administering a set of core blocks,” he says. “Simulation training has a significant role in teaching providers basic skills and how to use ultrasound guidance as the means to localize nerves for local anesthetic injection. I think there also needs to be a minimum amount of patient care experience that providers meet for placing common blocks.”

Dr. Mariano adds, “It’s okay for providers to learn specific types of blocks as long as they feel comfortable using those techniques to benefit patients.”

When facilities are ready to begin offering regional anesthesia, patient communication and preparation need to become part of the equation. “The messaging for patients should include setting their expectations for how pain is managed, so the placement of regional blocks is brought up well in advance of the day of surgery,” says Dr. Mariano.

He believes having this conversation helps patients understand why blocks are an important aspect of how facilities are providing excellent patient care. OSM

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