Pain Control After Total Knee Arthroplasty (Replacement) – How Are We Improving?

A patient recently submitted this comment:

“I have heard that recovery after a total knee is VERY painful. What has been done in the last 5-10 years to improve on this problem?”

This is an excellent question and fortunately the answer is “a lot.”

Pain control after total knee replacement has improved by leaps and bounds over the last decade as surgeons and hospital staff recognized the critical role that pain management plays in patient outcomes. Think of it this way, if your knee hurts too much to stand then physical therapy is going to become rather worthless.

In short, controlling pain not only leads to a more pleasant experience for the patient but also leads to better outcomes with earlier mobilization, less risk of DVT (blood clot), lower rate of urinary tract infection/pneumonia/etc. As the medical community realized this, there was a concerted effort by orthopedic surgeons, anesthesiologists, nurses, and hospital management to develop an effective and regimented protocol to control patients’ pain after knee replacement.

So what has been changed and what is being done? At Johnston-Willis, there has been significant improvement in control of postoperative pain and nausea after joint replacement surgery.

Let’s start with anesthesia. Spinal blocks are now quite common for joint replacement. Most total knees are done under spinal anesthesia with less pain and nausea postop. Furthermore, total knee patients also have a femoral nerve block catheter placed preoperatively which significantly reduces pain in the first 48 hours after surgery.

From a surgical perspective, I use a minimally invasive approach to the knee, often i do not use a tourniquet on the leg, and I inject the posterior (back) of the knee with a combination of long-acting local anesthetic and morphine during the surgery. In the immediate postoperative period patients are started on narcotic medications by mouth with strong IV options available for any excess pain.

Nursing is very aware of the need to stay “ahead of the pain” with the medications. We have tried to move away from IV medications for pain as much as possible and focus on oral pain control medications which often have fewer side effects. In addition to narcotic medications, there are also several anti-inflammatory medications ordered which can significantly reduce pain and symptoms without the many side effects of narcotics. Finally, we are very aggressive with treatment of nausea including the use of scopolamine patches preoperatively and the use of multiple anti-nausea medications postop.

Since starting in orthopedics in 2002, I have witnessed a marked shift in the treatment of pain after knee replacement. Patients are typically relatively comfortable postop, which was not the case for many patients a decade ago. There is still clearly some pain associated with knee replacement. However, that pain is now significantly more tolerable and does not prevent patients from proceeding with physical therapy and other parts of recovery. I hope this helps to answer or clarify this issue for any patients (and/or family members of patients) who are considering knee replacement.

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