From the Guidelines
Effective post-operative pain management for total knee arthroplasty (TKA) requires a multimodal approach combining pharmacological and non-pharmacological strategies, with the most recent evidence from 2016 suggesting the use of spinal anesthesia with a supplemental adductor canal block for perioperative pain control and to minimize opiate usage 1.
Key Components of Post-Operative Pain Management
- Preemptive analgesia with acetaminophen and NSAIDs
- Intraoperative use of regional anesthesia techniques such as adductor canal blocks or femoral nerve blocks
- Postoperative use of scheduled acetaminophen and NSAIDs, with opioids used judiciously for breakthrough pain
- Cryotherapy and early mobilization to reduce local inflammation and improve outcomes
Recommended Medications and Doses
- Acetaminophen 1000mg every 6 hours (maximum 4g daily)
- Celecoxib 200mg twice daily for 2-5 days if not contraindicated
- Immediate-release oxycodone 5-10mg every 4-6 hours as needed for breakthrough pain
- Tramadol 50-100mg every 6 hours as pain decreases
Non-Pharmacological Strategies
- Cryotherapy applied for 20 minutes every 2-3 hours
- Early mobilization beginning the day of surgery or first postoperative day
- Use of a continuous passive motion machine if necessary
Importance of Multimodal Approach
A multimodal approach to post-operative pain management can minimize opioid use, reduce side effects, and improve patient outcomes, including earlier mobilization, shorter hospital stays, and improved patient satisfaction 1.
Considerations for Patient Care
- Patient comorbidities and overall health status should be taken into account when selecting an anesthesia and analgesia regimen
- The choice of anesthesia technique should be based on the individual patient's needs and medical history
- A comprehensive pain management plan should be developed in collaboration with the patient and their healthcare team 1.
From the Research
Postoperative Pain Management Strategies in Total Knee Arthroplasty
- Total knee arthroplasty (TKA) is a common surgery that can result in moderate to severe postoperative pain, affecting patient rehabilitation and satisfaction 2.
- Historically, opioids have been used for perioperative pain management, but they have undesirable side effects, such as nausea and respiratory depression, which limit their use 2.
- Multimodal analgesia is considered the optimal regimen for perioperative pain management in TKA, combining various medications and delivery routes, including preemptive analgesia, neuraxial anesthesia, and local infiltration analgesia 2, 3.
- This approach provides superior pain relief, promotes knee recovery, and reduces opioid consumption and related adverse effects 2, 3.
Comparison of Pain Management Techniques
- A study comparing epidural, femoral block, and adductor canal block techniques found that peripheral nerve blocks with perineural dexamethasone improved postoperative analgesia for TKA 4.
- The addition of dexamethasone to adductor canal block showed promise as an alternative to femoral nerve block 4.
- Another study found that single and continuous femoral nerve block, intrathecal morphine, and local infiltration analgesia demonstrated significant analgesic effects 5.
Management of Postoperative Pain in Elderly Patients
- Elderly patients undergoing TKA are at risk of severe postoperative pain and chronic pain, emphasizing the importance of good acute pain control 6.
- Multimodal analgesia, including regional anesthesia techniques, can provide effective pain control in elderly patients 6.
- Chronic pain after TKA can be managed with pharmacological and non-pharmacological techniques, including acetaminophen, non-steroidal anti-inflammatory drugs, and opioid analgesics 6.