New Knee Surgeries: Less Pain, Opioid Use


blue_totalkneereplacement500wideFresh approaches to managing pain after total knee replacement (TKR) surgery could mean a shorter recovery time, decreased pain and less need for post-surgery opioid painkillers, according to new research.

“This is actually a pretty major issue as recent drug classifications have changed on certain narcotics and prompted the need for more preemptive pain treatments,” Dr. Earl Kilbride, a Ascension Seton orthopedic surgeon who performs about 100 TKR operations at University Medical Center Brackenridge annually, said.

Reducing patients’ dependency on prescription opioid painkillers such as hydrocodone, oxycodone and morphine is a growing health concern. Over the weekend, the National Governors Association committed to creating guidelines limiting the use of these highly addictive, potentially lethal drugs. In 2013, almost two million Americans abused prescription painkillers, according to the Centers for Disease Control and Prevention.

A study in this month’s Journal of the American Academy of Orthopaedic Surgeons shows that using a combination of pain management strategies, plus a team-based care approach, resulted in:

  • Hospital stays shortened by almost a day;
  • Lower pain levels reported by patients;
  • Fewer negative side effects, less use of opioid painkillers; and
  • Easier participation in physical therapy after surgery.

“As total knee replacements are being increasingly moved to outpatient facilities and the length of stay that Medicare is looking at approving is starting to decrease, doctors are going to have to adopt an approach like this,” Kilbride said.

The study shows that more effective pain management tactics involve:

  • Spinal and/or general anesthesia;
  • A pre- and post-operation pain medication approach including a peripheral nerve block, over-the-counter drugs, morphine and prescription pain relievers; and
  • Injecting the knee area during surgery to proactively reduce pain in areas not reached by the nerve block.
Dr. Earl Kilbride

Dr. Earl Kilbride

Currently, pain management for most patients who undergo a TKR uses either a general or spinal anesthesia, and a peripheral nerve block, Kilbride said. But this traditional method has several side effects, including nausea, vomiting, low blood pressure, urinary problems, breathing problems and delirium.

Better pain management is increasingly important since knee replacement surgeries are on the rise. Between 1993 and 2009, TKR rates more than tripled. More than 600,000 total knee replacements now are done every year in America.

The study also suggested a team-based care approach involving the patient, family members, surgeon and other health care providers is associated with better outcomes.

“I think not only does it have to be a team approach, but also a system-wide approach that includes the hospital and other non-providers who are involved in the patient’s care,” Kilbride said.

Knee pain can make simple activities like walking or taking the stairs difficult. The most common sources of knee pain are osteoarthritis, rheumatoid arthritis or arthritis from a serious knee injury.

Doctors consider total knee replacement, also called knee arthroplasty, as a solution when non-invasive options like drugs, walking supports and physical therapy don’t work. A TKR usually involves four steps: removing damaged cartilage and some bone, replacing it with metal parts, resurfacing the kneecap with a plastic part and then inserting a plastic spacer between the metal parts.