Pain Management in Total Joint Replacement

Many patients express their concerns regarding pain management leading up to total joint

replacement surgery. The surgery causes significant local trauma to the soft tissues and bones,

which results in inflammation and pain. Surgeons have continued to search for the best pain

management protocols and have gradually turned towards non-opioid treatments given the

large opioid epidemic in the United States. Most surgeons use a variety of medicines,

injections, and treatments to target pain from many different angles, which has led to the term

multi-modal pain control. Each surgeon has their own regimen of medicines for most patients,

but that frequently must be personalized for each patient depending on factors such as medical

comorbidities, insulin-dependent diabetes, or poor kidney function. Below, we will discuss the

components that may be included in your personalized regimen.

Pre-operative Medications

Surgical pain management actually starts prior to any incisions being made. An early goal is to

limit the stimulation of nerves throughout the procedure by having medications already on

board before your surgery begins. Surgeons and anesthesia providers work in conjunction to

begin this process as soon as you check in for surgery. Below is a description of the most

common medications given and treatments utilized even before surgery.

Acetaminophen

Although acetaminophen is thought of as a relatively weak pain medication by many patients, it

plays an important role around the time of surgery. Acetaminophen functions by limiting the

production of prostaglandins in the pain pathway and works synergistically with narcotic pain

medications in a way that makes both medications better. Both oral and intra-venous versions

are available and may be used around the time of surgery, but oral acetaminophen has been

found to be just as effective as the intra-venous version in controlling pain.

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) are another very important class of

medications. As their name describes, these medicines help with pain by limiting inflammation,

which is likely the biggest contributor to post-operative pain and limitations in range of motion.

Many medicines fall within the class of NSAIDs, but they are further broken down into two

classes called COX-1 or COX-2 inhibitors. The COX-2 inhibitor Celebrex has a lower risk of

gastrointestinal side effects as compared to the COX-1 inhibitors and is commonly used in the

setting of total joint replacements.

Dexamethasone

Along the same lines as NSAIDs, corticosteroid medications are also potent anti-inflammatory

medications. Dexamethasone is commonly used around the time of surgery for this reason. It

has been shown to decrease post-operative nausea, vomiting, post-op fatigue, and the amount

of time patients spend in the hospital for recovery. It also reduces the risk of many

complications that can occur around the time of surgery, such as stroke, heart attack, blood

clots, respiratory failure, and total joint infections.

Nerve blocks

Another pre-operative consideration for controlling pain is to block the stimulation of the

nerves around the surgical site. Nerve blocks use a variety of numbing medicines injected

around the nerves themselves and are typically completed by the anesthesia provider under

ultra-sound guidance. The medicine used and duration of relief varies, but some nerve blocks

can last several days after surgery. Many nerve blocks are given as a single injection, but others

use a small piece of IV tubing that is left in place through the skin so that the medicine can

continue to be delivered after surgery.

Intra-operative Medications

Once patients are in the operating room and under the care of the anesthesia provider, pain

management remains a mainstay of treatment. Although many medicines are given by the

anesthesia provider throughout the surgery to manage pain, we will focus on a couple of

additional treatments that your surgeon may use to help as well.

Joint Cocktail

As the joint replacement surgery is completed, a common practice is to inject medicines

directly into the tissue surrounding the implants. These injections are frequently referred to as

joint cocktails because mixtures of several medicines are used, including NSAIDs, numbing

medicines, narcotics, and medications designed to decrease bleeding. As with nerve blocks

discussed above, the duration of pain relief varies depending on exactly which medicines are

used; however, they typically last at least twelve hours after surgery.

Exparel

Another type of injection that may be used during surgery is Exparel, which is a slow-release

version of the numbing medicine called bupivacaine. Patients have reported pain relief for as

long as 3-5 days after surgery with the use of this medication, but some studies have not shown

any significant improvement of Exparel injections over joint cocktails.

Post-operative Medications

Narcotics

Narcotic pain medications remain one of the most common treatments for acute post-

operative pain. The opioid epidemic has led to many surgeons limiting the number of narcotic

pills prescribed to patients, all in the attempt to maintain patient safety and decrease the

likelihood of narcotic addiction. Regardless, narcotic pain medication will likely be prescribed

post-operatively for a short period of time. The most common narcotic medicines used today

are oxycodone, hydrocodone, and tramadol.

Acetaminophen

As was discussed above, acetaminophen used in combination with narcotic pain medications

makes them more effective. Some surgeons will prescribe acetaminophen separately from the

narcotic pain medicines, while others will use combination pills such as Percocet or Norco that

contain both the narcotic and acetaminophen.

Anti-inflammatories

Swelling after surgery can be significant and results in considerable post-operative pain.

NSAIDs, such as Celebrex, continue to be used post-operatively for this reason. Other

medicines in this class, such as ibuprofen or naproxen, may be used instead. Lastly,

corticosteroid medications, such as dexamethasone or prednisone, are potent anti-

inflammatories used after surgery as well.

Muscle relaxers

In addition to inflammation as a major source of pain after surgery, muscle spasms occur in a

relatively significant number of patients. Muscle relaxers, such as cyclobenzaprine or

tizanidine, can be quite helpful in those patients and may be prescribed by your surgeon in case

these occur.

Post-operative Treatments

Outside of the medications prescribed for post-operative pain control, there are many other

treatments and activities that can be used to decrease discomfort. R-I-C-E (rest, ice,

compression, and elevation) therapy is a mainstay in that treatment algorithm. Icing,

compression, and elevation all aid in limiting the amount of swelling that occurs. Regarding

elevation, you will want your “toes above the nose” for elevation to be the most successful,

which may require lying down and having the leg on several pillows or cushions. Next,

performing your daily prescribed exercises may also improve pain. These may include early

exercises such as range of motion, heel slides, quadriceps sets, etc. Speak with your surgeon

regarding the exercises you should be performing after surgery. Additionally, walking on a

regular basis may help with decreasing tightness in the replaced joint while also decreasing the

risk for blood clots as well. However, during the first few weeks after surgery, the frequency of

short distance walking is more important that the number of steps taken. In fact, a large step

count after surgery can actually make swelling and pain significantly worse. Instead, focus on

short walks, such as to the kitchen or bathroom, every one to two hours as opposed to long

walks outside. The number of steps and distance of walking should be gradually increased over

the course of 6-8 weeks after surgery.

Conclusions

Joint replacement surgery results in significant discomfort after surgery despite many years of

dedicated research on this topic. Ultimately, each surgeon decides on the specific medications,

modalities, and exercises that they want their patients to utilize in the attempt to minimize

discomfort and maximize the potential for a great outcome. If this is of particular concern to

you leading up to surgery, definitely discuss the treatment plan with your surgeon and their

team throughout the course of treatment. By doing so, you will ensure understanding of the

medications to be prescribed, how they should be taken, and what other activities you can

perform to optimize your personal recovery.