Minimizing pain after total knee arthroplasty (TKA) is the driving principle of the recovery process at Shelbourne Knee Center. “One of the most important aspects of patient recovery is being able to get around after surgery and tolerate physical therapy. If we don’t get patients comfortable enough to be able to participate in physical therapy, it’s an uphill battle,” says Rodney Benner, MD, orthopedic surgeon at Shelbourne Knee Center.
Lessons Learned from ACL Reconstruction
The pain management protocol is based on lessons learned from Shelbourne Knee Center’s research on pain after ACL reconstruction, Dr. Benner’s research on TKA patients, and general advances in post-op pain management. The ACL research program tracks patient outcomes and studies factors related to those outcomes for more than 7,000 ACL surgeries.
“Our protocol uses multiple tactics to make pain as controllable as possible after ACL reconstruction,” says Dr. Benner. “We took many of those same principles and applied them to our knee replacement patients. This has made a big difference for them.”
Key tactics from the ACL reconstruction pain management protocol used in the TKA pain management protocol are:
• Prevention of post-op swelling
• Rest during the first seven days post-op
• Use of a continuous passive motion machine (CPM)
• Use of a Cryo/Cuff.
7 Days of Bedrest
Walking soon after TKA increases swelling and pain, says Dr. Benner. That’s why Shelbourne Knee Center puts patients on bedrest for the first week post-op, with walking limited to going to the bathroom and back.
Use of a CPM machine and a Knee Cryo/Cuff during the first week also reduces swelling and pain. The CPM keeps the knee elevated above the heart and gently flexes and extends the knee, eliminating stiffness. Patients use the CPM except when they are eating, doing physical therapy or using the bathroom. The Knee Cryo/Cuff, developed by Dr. Shelbourne in collaboration with Aircast, provides compression and cold therapy to help control swelling.
Better Pain Medicines
Another pain management tactic based on Dr. Benner’s experience and advances in post-op pain management include limited or no use of narcotics.
In the hospital, TKA patients receive a low-dose continuous infusion of Toradol (ketorolac) to control inflammatory pain. A study by Dr. Benner and colleagues of 191 patients who received ketorolac (n = 116) or opioids (n = 75) found that post-op ketorolac improved pain control while reducing the use of opioids and adverse effects1.
“We found an 85% reduction in the amount of narcotic pain medication patients needed while in the hospital and statistically significant pain reduction,” says Dr. Benner.
Patients also take Tylenol, and after completing Toradol they take the NSAID Mobic (meloxicam). As needed, they can also take Tramadol or Norco (a combination of acetaminophen and hydrocodone, an opioid). “Very seldom do our patients need IV opioid pain medications,” says Dr. Benner. That’s critical, since even short-term use of opioids can lead to overuse and addiction.
Patient Education
Dr. Benner also teaches patients about what to expect after TKA, and the pain medications that Shelbourne Knee Center uses. “The more educated patients are about what to expect, the easier it will be to control their pain,” he says. At the hospital, specific staff members take care of Shelbourne Knee Center TKA patients, following these protocols.
For more information about TKA, call 888-FIX-KNEE.
References
- Schwinghammer AJ, Isaacs AN, Benner RW, et al. Continuous Infusion Ketorolac for Postoperative Analgesia Following Unilateral Total Knee Arthroplasty. Ann Pharmacother. 2017 Jun;51(6):451-456. doi: 10.1177/1060028017694655. Epub 2017 Feb 1.