Multimodal Pain Management after Total Hip and Knee Arthroplasty at the Ranawat Orthopaedic Center

TLDR

Recent advances in pain management for total hip and knee arthroplasty have shifted toward multimodal regional anesthesia, yet no gold standard exists and protocols aim to improve pain control, reduce narcotic use, shorten hospital stay, and enhance patient satisfaction. The authors employed a decade‑long regimen of intravenous patient‑controlled analgesia, femoral nerve blocks, and continuous epidural infusions, with and without FNB, to manage postoperative pain. Despite shortcomings of PCA, FNB, and epidural infusions, the authors transitioned to a multimodal protocol centered on local periarticular injections that reduces narcotic use and improves pain control, patient satisfaction, and function. This expert‑opinion study is classified as Level V evidence, as detailed in the Guidelines for Authors.

Abstract

Improvements in pain management techniques in the last decade have had a major impact on the practice of total hip and knee arthroplasty (THA and TKA). Although there are a number of treatment options for postoperative pain, a gold standard has not been established. However, there appears to be a shift towards multimodal approaches using regional anesthesia to minimize narcotic consumption and to avoid narcotic-related side effects. Over the last 10 years, we have used intravenous patient-controlled analgesia (PCA), femoral nerve block (FNB), and continuous epidural infusions for 24 and 48 hours with and without FNB. Unfortunately, all of these techniques had shortcomings, not the least of which was suboptimal pain control and unwanted side effects. Our practice has currently evolved to using a multimodal protocol that emphasizes local periarticular injections while minimizing the use of parenteral narcotics. Multimodal protocols after THA and TKA have been a substantial advance; they provide better pain control and patient satisfaction, lower overall narcotic consumption, reduce hospital stay, and improve function while minimizing complications. Although no pain protocol is ideal, it is clear that patients should have optimum pain control after TKA and THA for enhanced satisfaction and function. Level of Evidence: Level V, expert opinion. See the Guidelines for Authors for a complete description of levels of evidence.