Effective postsurgical pain control is critical to the timely recovery of patients undergoing joint arthroplasty.1,2 The physiology of postsurgical pain involves multiple pain pathways; therefore, efficacious pain control requires a combination of medications that work additively and synergistically to interrupt both peripherally and centrally mediated pain signals.3 To ensure optimal postsurgical pain management, current guidelines recommend the use of a multimodal approach to analgesia, which may include opioid and nonopioid systemic agents, regional techniques, and local injections.4-6
Multimodal analgesia involves the administration of two or more drugs that provide analgesia through different modes of action and can be administered by the same or different routes.6 These modalities typically include a central regional blockade with local anesthetics combined with around-the-clock acetaminophen and/or a nonsteroidal anti-inflammatory drug or cyclooxygenase-2 selective inhibitor, with opioids as rescue analgesia.4,6 Multimodal analgesia for pain following arthroplasty should be geared toward enhancing patient outcomes and expediting recovery.4,7 This is especially important with the trend toward outpatient procedures for total joint arthroplasty.8 Local anesthetics provide dynamic pain control (ie, pain relief during movement) and are, therefore, a principal component of a multimodal analgesic approach.4 In contrast, peripheral nerve blocks, such as femoral nerve blocks for total knee arthroplasty, have been considered the “gold standard” for treatment2,9; however, these blocks impair quadriceps muscle function, which can delay ambulation and increase the risk of falls.2,4
A primary goal of multimodal analgesia is to reduce opioid consumption, and thereby decrease opioid-related adverse events,10 some of which (eg, nausea, vomiting, and sedation) may interfere with patients’ ability to participate in physical therapy.9 Periarticular infiltration analgesia, a more recent addition to the therapeutic armamentarium, can provide effective postsurgical pain relief when used as part of a multimodal regimen, with reduced systemic opioid consumption and/or early ambulation observed in some studies.11-16 It should be noted that the success of periarticular infiltration analgesia is technique-dependent4; illustrated reviews of local analgesia infiltration techniques for hip and knee arthroplasty are available.17,18
Well-designed multimodal analgesia regimens can prevent periods of inadequate pain relief (analgesic gaps), a common but avoidable problem after joint arthroplasty.19 An appropriate multimodal regimen for acute postsurgical pain encompasses preoperative, intraoperative, and postoperative periods and is administered on a scheduled basis (not as needed).19 Accumulating research evidence indicates that multimodal analgesia for pain after joint arthroplasty may provide more effective pain relief, increased patient satisfaction, and more rapid functional recovery compared with traditional opioid-based approaches.10,19 Additional research is needed to identify the most effective combinations of agents, modes of administration, and timing of delivery of multimodal analgesia in joint arthroplasty pain management.5
- Anastase DM, Cionac Florescu S, Munteanu AM, Ursu T, Stoica CI. Analgesic techniques in hip and knee arthroplasty: from the daily practice to evidence-based medicine. Anesthesiol Res Pract. 2014;569319.
- Kehlet H, Thienpont E. Fast-track knee arthroplasty – status and future challenges. Knee. 2013;20(Suppl 1):S29-S33.
- Barrington JW, Halaszynski TM, Sinatra RS; Expert Working Group on Anesthesia and Othopaedics Critical Issues in Hip and Knee Replacement Arthroplasty FT. Perioperative pain management in hip and knee replacement surgery. Am J Orthop. 2014;43(4 Suppl):S1-S16.
- Joshi GP, Cushner FD, Barrington JW, et al. Techniques for periarticular infiltration with liposomal bupivacaine for the management of pain after hip and knee arthroplasty: a consensus recommendation. J Surg Orthop Adv. 2015;24(1):27-35.
- Joshi GP, Schug SA, Kehlet H. Procedure-specific pain management and outcome strategies. Best Pract Res Clin Anaesthesiol. 2014:28(2):191-201.
- American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-273.
- Ibrahim MS, Khan MA, Nizam I, Haddad FS. Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review. BMC Med. 2013;11:37.
- Henderson RA, Watters TS, Godin JA, Mather RC III, Berend KR, Bolognesi MP. Outpatient joint arthroplasty is increasing in the United States. Presented at the 2015 Annual Meeting of the American Academy of Orthopaedic Surgeons; March 24-28, 2015; Las Vegas, NV.
- Paul JE, Arya A, Hurlburt L, et al. Femoral nerve block improves analgesic outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology. 2010;113(5):1144-1162.
- Halawi MJ, Grant SA, Bolognesi MP. Multimodal analgesia for total joint arthroplasty. Orthopedics. 2015;38(7):e616-e625.
- Affas F, Nygårds E-B, Stiller C-O, Wretenberg P, Oloffson C. Pain control after total knee arthroplasty: a randomized trial comparing local infiltration anesthesia and continuous femoral block. Acta Orthop. 2011;82(3):441-447.
- Barrington JW, Olugbode O, Lovald S, Ong K, Watson H, Emerson RH Jr. Liposomal bupivacaine: a comparative study of more than 1000 total joint arthroplasty cases. Orthop Clin N Am. 2015;46(4):469-477.
- Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty: a randomized double-blind study involving 48 patients. Acta Orthop. 2010;81(3):354-360.
- Niemeläinen M, Kalliovalkama J, Aho AJ, Moilanen T, Eskelinen A. Single periarticular local infiltration analgesia reduces opiate consumption until 48 hours after total knee arthroplasty: a randomized placebo-controlled trial involving 56 patients. Acta Orthop. 2014;85(6):614-619.
- Surdam JW, Licini DJ, Baynes NT, Arce BR. The use of Exparel (liposomal bupivacaine) to manage postoperative pain in unilateral total knee arthroplasty patients. J Arthroplasty. 2015;30(2):325-329.
- Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tønnesen EK, Søballe K. Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial. Acta Orthop. 2007;78(2):172-179.
- Guild GN III, Galindo RP, Marino J, Cushner FD, Scuderi GR. Peri-articular regional analgesia in total knee arthroplasty. A review of the neuroanatomy and injection technique. Ann Orthop Rheumatol. 2014;2(3 Suppl):1025.
- Cushner F, Joshi G, Barrington J, et al. Best Infiltration Practices: Local Analgesia Infiltration Techniques – Hip and Knee Arthroplasty. Lake Mary, FL: International Guidelines Center; 2014.Available at:http://eguideline.guidelinecentral.com/i/319830.
- Scuderi GR. Closing the gaps in postsurgical pain management. Am J Orthop. 2015;44(10 Suppl):S17-S20.