More than two-thirds of patients recover from knee replacement surgery without opioids

A retrospective case series study led by Dr. Vinod Dasa, professor of clinical orthopedics at LSU Health New Orleans School of Medicine, reports that more than two-thirds of patients who underwent total knee replacement surgery did not require opioids for postoperative pain. The results are published in the Journal of Orthopedic Experience and Innovation.

A multimodal analgesia regimen, which targets many pain pathways, provided adequate pain relief for 27 of the 40 patients studied. The regimen included preoperative cryoneurolysis (freezing of the nerves); perioperative oral and intravenous analgesics, neuraxial (spinal) block and regional adductor canal and local infiltration of liposomal bupivacaine (Exparel); intraoperative periarticular infiltration of bupivacaine hydrochloride (Marcaine); and postoperative oral nonopioid analgesics.

Twenty percent of patients in the case series had filled at least one opioid prescription within three months prior to total knee arthroscopy (TKA). All eight required opioids for three months after surgery. Although pain scores improved over time for all patients, patients who used opioids after TKA reported higher pain levels at each assessment time point compared to those who had an opioid-free TKA.

The authors write that prolonged opioid use after TKA is associated with higher rates of infection, stiffness, and aseptic revision. Additionally, overprescription of opioids after TKA increases the risk of misuse, abuse, addiction, and overdose, and contributes to the national opioid crisis. This pilot study aimed to demonstrate that opioid-free TKA was possible; however, the results indicate that the majority of patients who used opioids in the three months prior to TKA required opioids for pain control after TKA. How to mitigate prolonged opioid use after TKA for this high-risk subgroup remains an area ripe for investigation.

The authors conclude that “although there is no consensus on the optimal multimodal pain protocol to use in TKA, a growing body of evidence indicates that modalities that target a variety of pain pathways can produce additive or synergistic benefits Future research should seek to determine which elements of the protocol are most critical to effectively manage pain and minimize opioid use after TKA and investigate new approaches to achieving opioid-free status in TKA patients who receive preoperative opioids.

Improving recovery after knee replacement surgery has been a long-standing challenge. Thanks to recent innovations and improved surgical techniques, we are now able to achieve results that many have found difficult.”

Dr. Vinod Dasa, Professor of Clinical Orthopedics, LSU Health New Orleans School of Medicine

Co-authors include Amy B. Bronstone, PhD, assistant research professor in the Department of Orthopedics; Rocio Crabb, MD, fourth-year orthopedic resident; Jarrod Brown, BS, fourth-year medical student, all at LSU Health New Orleans School of Medicine; as well as Claudia Leonardi, PhD, assistant professor within behavioral and community health at LSU Health New Orleans School of Public Health.

Dr. Dasa is a paid speaker for Bioventus, Swiftpath and Pacira; consultant for Bioventus and Pacira; owns stock or stock options in SIGHT Medical, My Medical Images and Goldfinch Health; and has received research support from SKK, Cartiheal and OREF and NIH. The other authors have no competing interests to disclose.


Journal reference:

Bronstone, AB, et al. (2022) Opioid-sparing multimodal analgesia for total knee arthroplasty: results from a retrospective case series of 40 patients. Journal of Orthopedic Experience and Innovation.

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