Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Symposium: Perioperative Pain Management in Orthopaedic Surgery 16 articles


Fewer Postoperative Fevers: An Unexpected Benefit of Multimodal Pain Management?

Joseph A. Karam MD, Benjamin Zmistowski BS, Camilo Restrepo MD, William J. Hozack MD, Javad Parvizi MD

Elevated temperatures after total joint arthroplasty (TJA) are common and can be a source of anxiety both for the patient and the surgical team. Although such fevers rarely are caused by acute infection, many patients are subjected to extensive testing for elevated body temperature after surgery. We recently implemented a multimodal pain management regimen for TJA, which includes acetaminophen, pregabalin, and celecoxib or toradol, and because some of these medications have antipyrexic properties, it was speculated that this protocol might influence the frequency of postoperative pyrexia.

Lateralizing Epidural Catheter Placement as Evidenced by Electrical Stimulation

Nigel E. Sharrock BMedSci, MB, ChB, George Go BS

Epidural steroids are more effective if administered in the anterolateral epidural space. It follows that the ability to administer local anesthetics in the ipsilateral anterolateral epidural space should likewise improve their efficacy for postoperative epidural analgesia.

Is L2 Paravertebral Block Comparable to Lumbar Plexus Block for Postoperative Analgesia After Total Hip Arthroplasty?

Richa Wardhan MD, Anne-Sophie M. Auroux PharmD, Bruce Ben-David MD, Jacques E. Chelly MD, PhD, MBA

Continuous lumbar plexus block (LPB) is a well-accepted technique for regional analgesia after THA. However, many patients experience considerable quadriceps motor weakness with this technique, thus impairing their ability to achieve their physical therapy goals.

Pain Trajectories Identify Patients at Risk of Persistent Pain After Knee Arthroplasty: An Observational Study

Patricia M. Lavand’homme MD, PhD, Irina Grosu MD, Marie-Noëlle France RN, Emmanuel Thienpont MD, MBA

Persistent postsurgical pain is a major source of dissatisfaction after knee arthroplasty. Postoperative pain trajectories allow a dynamic view of pain resolution after surgery and might help to identify patients at risk for persistent pain.

The Influence of Anesthesia and Pain Management on Cognitive Dysfunction After Joint Arthroplasty: A Systematic Review

Michael G. Zywiel MD, Atul Prabhu MD, Anthony V. Perruccio PhD, Rajiv Gandhi MSc, MD

Despite the overall success of total joint arthroplasty, patients undergoing this procedure remain susceptible to cognitive decline and/or delirium, collectively termed postoperative cognitive dysfunction. However, no consensus exists as to whether general or regional anesthesia results in a lower likelihood that a patient may experience this complication, and controversy surrounds the role of pain management strategies to minimize the incidence of postoperative cognitive dysfunction.

Peripheral Nerve Blocks in Shoulder Arthroplasty: How Do They Influence Complications and Length of Stay?

Ottokar Stundner MD, Rehana Rasul MA, MPH, Ya-Lin Chiu MS, Xuming Sun MS, Madhu Mazumdar MA, MS, PhD, Chad M. Brummett MD, Reinhold Ortmaier MD, Stavros G. Memtsoudis MD, PhD, FCCP

Regional anesthesia has proven to be a highly effective technique for pain control after total shoulder arthroplasty. However, concerns have been raised about the safety of upper-extremity nerve blocks, particularly with respect to the incidence of perioperative respiratory and neurologic complications, and little is known about their influence, if any, on length of stay after surgery.

Intraarticular Analgesia Versus Epidural Plus Femoral Nerve Block After TKA: A Randomized, Double-blind Trial

Keith R. Reinhardt MD, Shivi Duggal BS, MBA, Ben-Paul Umunna BA, Gregory A. Reinhardt MSPT, Denis Nam MD, Michael Alexiades MD, Charles N. Cornell MD

Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic.

Is Regional Anesthesia Associated With Reduced PACU Length of Stay?

John M. Corey MD, Catherine M. Bulka MPH, Jesse M. Ehrenfeld MD, MPH

Postanesthesia care is a costly component of overall surgical care. In the ambulatory setting, regional anesthesia has been shown for multiple surgical procedures to either decrease postanesthesia care unit (PACU) length of stay (LOS) or completely bypass it altogether. This has not been demonstrated in a large hospital setting with a complex surgical case mix.

Can Regional Anesthesia and Analgesia Prolong Cancer Survival After Orthopaedic Oncologic Surgery?

Juan P. Cata MD, Mike Hernandez MS, Valerae O. Lewis MD, Andrea Kurz MD

The perioperative period of major oncologic surgery is characterized by immunosuppression, angiogenesis, and an increased load of circulating malignant cells. It is a window period in which cancer cells may seed, invade, and proliferate. Thus, it has been hypothesized that the use of regional anesthesia with the goal of reducing surgical stress and opioid and volatile anesthetic consumption would avoid perioperative immune suppression and angiogenesis and ultimately cancer recurrence.

Association of Obesity With Inflammation and Pain After Total Hip Arthroplasty

Roja Motaghedi MD, James J. Bae MSc, Stavros G. Memtsoudis MD, PhD, David H. Kim MD, Jonathan C. Beathe MD, Leonardo Paroli MD, PhD, Jacques T. YaDeau MD, PhD, Michael A. Gordon MD, Daniel B. Maalouf MD, MPH, Yi Lin MD, PhD, Yan Ma PhD, Susanna Cunningham-Rundles PhD, Spencer S. Liu MD

The prevalence of obesity is increasing, and obesity often leads to degenerative joint disease requiring total hip arthroplasty (THA). Obesity is a proinflammatory state associated with an increase in chronic, low-grade inflammatory response. As such, it may augment the postoperative inflammatory response, which has been associated with postoperative pain and complications.

Burden Incurred by Patients and Their Caregivers After Outpatient Surgery: A Prospective Observational Study

Asha Manohar MD, Kristin Cheung MD, Christopher L. Wu MD, Tracey S. Stierer MD

The burden of patients and their caregivers after outpatient surgery has not been fully examined. The number of outpatient surgeries has dramatically increased in the last several years, particularly in the orthopaedic sector. Patients undergoing outpatient orthopaedic procedures may be expected to have more postdischarge pain than those undergoing nonorthopaedic outpatient procedures. In light of this, assessment of patient and caregiver expectations and actual burden after discharge is of importance.

Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA

Seshadri C. Mudumbai MD, MS, T. Edward Kim MD, Steven K. Howard MD, J. Justin Workman MD, Nicholas Giori MD, Steven Woolson MD, Toni Ganaway BA, Robert King BS, Edward R. Mariano MD, MAS (Clinical Research)

Femoral continuous peripheral nerve blocks (CPNBs) provide effective analgesia after TKA but have been associated with quadriceps weakness and delayed ambulation. A promising alternative is adductor canal CPNB that delivers a primarily sensory blockade; however, the differential effects of these two techniques on functional outcomes after TKA are not well established.

Single-injection or Continuous Femoral Nerve Block for Total Knee Arthroplasty?

Eric Albrecht MD, DESA (Fellow), Dorothea Morfey BSc, MBBS, Vincent Chan MD, Rajiv Gandhi MD, Arkadiy Koshkin MD, Ki Jinn Chin MD, MBBS, Sylvie Robinson BSc, Philippe Frascarolo PhD, Richard Brull MD

The ideal local anesthetic regime for femoral nerve block that balances analgesia with mobility after total knee arthroplasty (TKA) remains undefined.

Continuous Femoral Nerve Block Using 0.125% Bupivacaine Does Not Prevent Early Ambulation After Total Knee Arthroplasty

Michael J. Beebe MD, Rachel Allen MD, Mike B. Anderson MS, ATC, Jeffrey D. Swenson MD, Christopher L. Peters MD

Continuous femoral nerve block has been shown to decrease opioid use, improve postoperative pain scores, and decrease length of stay. However, several studies have raised the concern that continuous femoral nerve block may delay patient ambulation and increase the risk of falls during the postoperative period.

Does Limb Preconditioning Reduce Pain After Total Knee Arthroplasty? A Randomized, Double-blind Study

Stavros G. Memtsoudis MD, PhD, Ottokar Stundner MD, Daniel Yoo MS, Alejandro Gonzalez Della Valle MD, Friedrich Boettner MD, Anna Maria Bombardieri MD, PhD, Kethy Jules-Elysee MD, Lazaros Poultsides MD, MS, PhD, Yan Ma PhD, Thomas P. Sculco MD

Total knee arthroplasty (TKA) can be associated with considerable postoperative pain. Ischemic preconditioning of tissue before inducing procedure-related underperfusion may reduce the postoperative inflammatory response, which further may reduce associated pain.