What are the postoperative pain management strategies in Total Knee Arthroplasty (TKA)?

From the Guidelines

Post-operative pain management for total knee arthroplasty (TKA) should prioritize a multimodal approach, combining general anesthesia with a femoral nerve block or spinal anesthesia with local anesthetic plus spinal morphine, supplemented with paracetamol, conventional non-steroidal anti-inflammatory drugs (NSAIDs) or COX-2-selective inhibitors, and intravenous strong opioids for high-intensity pain or weak opioids for moderate- to low-intensity pain. This approach is supported by evidence from systematic reviews and consensus recommendations 1.

Key Components of Post-Operative Pain Management

• Preemptive analgesia with paracetamol and NSAIDs or COX-2-selective inhibitors
• Intraoperative use of regional anesthesia techniques such as femoral nerve blocks or spinal anesthesia with local anesthetic plus spinal morphine
• Postoperative use of scheduled paracetamol and NSAIDs or COX-2-selective inhibitors, with intravenous strong opioids for break-through high-intensity pain or weak opioids for moderate- to low-intensity pain
• Use of cooling and compression techniques to reduce local inflammation
• Early mobilization starting day 0-1 post-surgery and proper patient education about pain expectations and management strategies

Rationale for Recommendations

The use of general anesthesia combined with a femoral nerve block or spinal anesthesia with local anesthetic plus spinal morphine is supported by evidence from systematic reviews, which show a reduction in pain scores and supplemental analgesic requirements 1. The addition of paracetamol and conventional NSAIDs or COX-2-selective inhibitors provides further pain relief and reduces the need for opioid analgesics 1. The use of intravenous strong opioids for high-intensity pain or weak opioids for moderate- to low-intensity pain is recommended, with the goal of minimizing opioid requirements and their associated side effects 1.

Considerations for Clinical Practice

In clinical practice, the choice of anesthesia technique and post-operative pain management strategy should be individualized based on patient comorbidities and the overall requirements of the surgery. Optimal post-operative pain management should account for the choice of anesthesia technique, offering different clinical pathways to ensure effective pain control and minimize adverse events. Further research is needed to evaluate the benefits and risks of different regional anesthesia techniques, such as continuous femoral nerve infusions and combination blocks 1.

From the Research

Postoperative Pain Management Strategies in Total Knee Arthroplasty

• The current postoperative pain management regimens for total knee arthroplasty (TKA) involve multimodal analgesia, which is considered the optimal regimen for perioperative pain management of TKA 2.
• Multimodal analgesia provides superior pain relief, promotes recovery of the knee, and reduces opioid consumption and related adverse effects in patients undergoing TKA 2.
• The administration of nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, gabapentinoids, and corticosteroids resulted in shorter hospital length of stay (LOS) and decreased postoperative pain and opioid consumption 3.
• A spinal anesthetic block provided benefits over general anesthesia, including decreased 30-day mortality rates, hospital LOS, blood loss, and complications 3.
• The use of peripheral nerve blocks for postoperative pain management resulted in lower pain scores, decreased opioid consumption, fewer complications, and shorter hospital LOS 3.

Effective Pain Control Strategies

• A multimodal approach to pain management, which involves basic analgesic treatment in combination with glucocorticoids and local infiltration analgesia, is supported by evidence 4.
• Effective pain control can reduce postoperative pain, lower opioid consumption, and its associated adverse effects, and enhance postoperative rehabilitation and patient satisfaction 4.
• Single and continuous femoral nerve block (FNB), intrathecal morphine, local infiltration analgesia, intraarticular injection of local anaesthetics, non-steroidal anti-inflammatory drugs, and gabapentinoids demonstrated significant analgesic effects 5.

Predicting Prolonged Analgesic Use

• The duration of postoperative analgesic use after total knee arthroplasty and nomogram for predicting prolonged analgesic use can be used to identify patients at risk of prolonged analgesic use 6.
• Gender, preoperative Numeric Rating Scale (NRS) movement pain scores, duration of surgery, postoperative days three (POD3) moderate to severe movement pain, and POD3 pain rescue medication were significant prognostic predictors of prolonged analgesic use after discharge 6.