What is the most effective approach to pain management after orthopedic (ortho) surgery and how important is participating in physical therapy?

Pain Management After Orthopedic Surgery and Importance of Physical Therapy

Effective pain control after orthopedic surgery requires a multimodal analgesic regimen combining acetaminophen with NSAIDs or COX-2 inhibitors as the foundation, with opioids reserved only for rescue, and pre-operative exercise and education are essential Grade A recommendations that reduce postoperative pain and improve functional outcomes. 1

Multimodal Analgesic Foundation

The cornerstone of postoperative pain management must include:

• Acetaminophen (paracetamol) administered pre-operatively or intra-operatively and continued postoperatively, typically 1g every 6 hours, not exceeding 4g daily 1, 2
• NSAIDs or COX-2 selective inhibitors started pre-operatively or intra-operatively and continued postoperatively 1, 2
• Single intravenous dose of dexamethasone 8-10 mg intra-operatively for analgesic and anti-emetic effects 1, 2

This combination provides superior pain control compared to opioids alone while minimizing opioid-related side effects including constipation, nausea, vomiting, and respiratory depression. 3, 4, 5

Regional Analgesia Techniques

For procedures like total hip arthroplasty:

• Single-shot fascia iliaca block or local infiltration analgesia is recommended, especially when contraindications to basic analgesics exist or in patients with high expected postoperative pain 1, 2
• Femoral nerve block is recommended for total knee arthroplasty based on reduction in pain scores and supplemental analgesic requirements 1
• Avoid femoral nerve block, lumbar plexus block, and epidural analgesia for hip arthroplasty as adverse effects outweigh benefits 1

Opioid Management Strategy

Opioids should be reserved strictly as rescue analgesics in the postoperative period, not as first-line therapy. 1, 2

• When IV opioids are necessary, patient-controlled analgesia (PCA) is preferred over intramuscular administration due to improved pain control and higher patient satisfaction 1, 2
• Multimodal regimens reduce total opioid consumption by approximately 60% (from 7.0 to 2.4 total pills) compared to opioid-only regimens 3
• The intramuscular route should be avoided entirely 2

Critical Importance of Pre-operative Exercise and Education

Pre-operative exercise and education are Grade A recommendations that directly reduce postoperative pain and improve functional outcomes. 1

This is not merely supportive care but an evidence-based intervention that:

• Reduces postoperative pain intensity 1
• Improves functional recovery 1
• Facilitates early postoperative rehabilitation 1
• Enhances overall surgical outcomes 1

The evidence demonstrates that adequate pain control enables early postoperative mobility, which is essential for optimal functional recovery and decreased postoperative morbidity. 1

Participation in Physical Therapy

Active participation in physical therapy is fundamental to recovery, as pain control exists primarily to facilitate early mobilization and rehabilitation. 1, 6

• Pain management should be optimized specifically to enable physical therapy participation 1, 4
• Multimodal analgesia that minimizes opioid-related sedation and central nervous system effects allows patients to engage more effectively in rehabilitation 4, 5
• Shorter hospital stays and improved quality of life are directly linked to adequate pain control enabling therapy participation 4

Procedure-Specific Considerations

For Total Hip Arthroplasty:

• Paracetamol + NSAIDs/COX-2 inhibitors + dexamethasone 8-10 mg IV + fascia iliaca block or local infiltration analgesia 1, 2
• If spinal anesthesia is used, intrathecal morphine 0.1 mg could be considered, though adequate analgesia may be achieved without it 1

For Total Knee Arthroplasty:

• Same basic regimen plus femoral nerve block 1
• Strong opioids (if needed) should be combined with non-opioid analgesia for high-intensity pain 1

Common Pitfalls and Caveats

• Never use gabapentinoids routinely for hip arthroplasty as procedure-specific evidence shows side effects outweigh benefits despite multiple peri-operative doses 1
• Avoid NSAIDs in patients with colon or rectal anastomoses due to potential correlation with dehiscence 2
• Exercise caution with NSAIDs in elderly patients due to increased risk of gastrointestinal, platelet, and nephrotoxic effects 1
• Do not exceed acetaminophen 4g daily and use cautiously in liver disease 1, 2
• Reduce opioid use maximally in patients with obstructive sleep apnea to prevent cardiopulmonary complications 2
• Younger age and female gender are risk factors for increased acute postoperative pain requiring more aggressive multimodal management 2

Monitoring and Reassessment

• Regular pain assessment using validated scales at appropriate intervals after each intervention 2
• When significant worsening pain is reported, reevaluate for possible postoperative complications rather than simply escalating analgesia 2
• Combined nurse service with clinician supervision provides superior outcomes in acute postoperative pain management 2