Advertisement

Drugs & Aging

, Volume 31, Issue 2, pp 83–91 | Cite as

Postoperative Pain Management After Total Knee Arthroplasty in Elderly Patients: Treatment Options

  • Colin J. L. McCartney
  • Kathleen Nelligan
Therapy in Practice

Abstract

Total knee arthroplasty (TKA) is a common surgical procedure in the elderly and is associated with severe pain after surgery and a high incidence of chronic pain. Several factors are associated with severe acute pain after surgery, including psychological factors and severe preoperative pain. Good acute pain control can be provided with multimodal analgesia, including regional anesthesia techniques. Studies have demonstrated that poor acute pain control after TKA is strongly associated with development of chronic pain, and this emphasizes the importance of attention to good acute pain control after TKA. Pain after discharge from hospital after TKA is currently poorly managed, and this is an area where increased resources need to be focused to improve early pain control. This is particularly as patients are often discharged home within 4–5 days after surgery. Chronic pain after TKA in the elderly can be managed with both pharmacological and non-pharmacological techniques. After excluding treatable causes of pain, the simplest approach is with the use of acetaminophen combined with a short course of non-steroidal anti-inflammatory drugs (NSAIDs). Careful titration of opioid analgesics can also be helpful with other adjuvants such as the antidepressants or antiepileptic medications used especially for patients with neuropathic pain. Topical agents may provide benefit and are associated with fewer systemic side effects than oral administration. Complementary or psychological therapies may be beneficial for those patients who have failed other options or have depression associated with chronic pain.

Keywords

Chronic Pain Total Knee Arthroplasty Neuropathic Pain Gabapentin Pregabalin 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Conflict of Interest Declaration

CJL McCartney and K Nelligan declare no relevant conflicts of interest. No sources of funding were used to support the preparation of this manuscript.

References

  1. 1.
    Puolakka PAE, Rorarius MGF, Roviola M, Puolakka TJS, Nordhausen K, Lingren L. Persistent pain following knee arthroplasty. Eur J Anaesthesiol. 2010;27:455–60.PubMedCrossRefGoogle Scholar
  2. 2.
    Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. Br Med J Open. 2012. doi: 10.1136/bmjopen-2011-000435.Google Scholar
  3. 3.
    Ilfeld BM, Le LT, Meyer RS, Mariano ER, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Berry LF, Spadoni EH, Gearen PF. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiol. 2008;108(4):703–13.CrossRefGoogle Scholar
  4. 4.
    Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d’Athis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiol. 1999;91:8–15.CrossRefGoogle Scholar
  5. 5.
    Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiol. 2000;93:1123–33.CrossRefGoogle Scholar
  6. 6.
    Hip and knee replacements in Canada: 2011 annual statistics (clinical data). In: Canadian joint replacement registry. Canadian Institute for Health Information. 2012. http://www.cihi.ca/CIHI-ext-portal/internet/EN/TabbedContent/types+of+care/specialized+services/joint+replacements/cihi021359. Accessed 22 Sept 2013.
  7. 7.
    Singh JA, Lewallen DG. Predictors of use of pain medications for persistent knee pain after primary total knee arthroplasty: a cohort study using an institutional joint registry. Arthr Res Ther. 2012;14:R248.CrossRefGoogle Scholar
  8. 8.
    Macrae WA. Chronic pain after surgery. Br J Anaesth. 2011;87:88–98.CrossRefGoogle Scholar
  9. 9.
    Brander VA, Stulberg D, Adams AD, Harden RN, Bruehl S, Stanos SP, Houle T. Predicting total knee replacement pain. A prospective, observational study. Clin Orthop Relat Res. 2003;416:27–36.PubMedCrossRefGoogle Scholar
  10. 10.
    Forsythe ME, Dunbar MJ, Hennigar AW, Sullivan MJ, Gross M. Prospective relation between catastrophizing and residual pain following knee arthroplasty: a two-year follow-up. Pain Res Manag. 2008;13(4):335–41.PubMedCentralPubMedGoogle Scholar
  11. 11.
    Carmichael NM, Katz J, Clarke H, Kennedy D, Kreder HJ, Gollish J, McCartney CJ. An intensive perioperative regimen of pregabalin and celecoxib reduces pain and improves physical function scores six weeks after total hip arthroplasty: a prospective randomized controlled trial. Pan Res Manag. 2013;18:127–32.Google Scholar
  12. 12.
    Buvanendran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, Moric M, Rosenberg AG. Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor or pain management and recovery of function after knee replacement: a randomized controlled trial. J Am Med Assoc. 2003;290:2411–8.CrossRefGoogle Scholar
  13. 13.
    Amin AK, Patton JT, Cook RE, Gaston M, Brenkel IJ. Unicompartmental or total knee arthroplasty? Clin Orthop Relat Res. 2006;451:101–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Essving P, Axelsson K, Otterborg L, Spännar H, Gupta Am Magnuson A, Lundin A. Minimally invasive surgery did not improve outcome compared to conventional surgery following unicompartmental knee arthroplasty using local infiltration analgesia A randomized controlled trial with 40 patients. Acta Orthop. 2012;83:634–41.PubMedCrossRefGoogle Scholar
  15. 15.
    McAllister CM, Stepanian JD. The impact of minimally invasive surgical techniques on early range of motion after primary total knee arthroplasty. J Arthroplast. 2008;23:10–8.CrossRefGoogle Scholar
  16. 16.
    Leopold SS. Minimally invasive total knee arthroplasty for osteoarthritis. N Engl J Med. 2009;360:1749–58.PubMedCrossRefGoogle Scholar
  17. 17.
    Kissin I. Preemptive analgesia at the crossroad. Anesth Analg. 2005;100:754–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Gordon S, Brahim J, Rowan J, Kent A, Dionne R. Peripheral prostanoid levels and nonsteroidal levels and anti-inflammatory drug analgesia: replicate clinical trials in a tissue injury model. Clin Pharmacol Ther. 2002;72:175–83.PubMedCrossRefGoogle Scholar
  19. 19.
    Jain P, Jolly A, Bholla V, Adatia S, Sood J. Evaluation of efficacy of oral pregabalin in reducing postoperative pain in patients undergoing total knee arthroplasty. Indian J Orthop. 2012;46:646–52.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Memtsoudis SG, Sun X, Chiu Y, Stundner O, Liu SS, Banerjee S, Mazumdar M, Sharrock NE. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiol. 2013;118:1046–58.CrossRefGoogle Scholar
  21. 21.
    Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. Br Med J. 2000;321:1493–7.CrossRefGoogle Scholar
  22. 22.
    Frassanito L, Vergari A, Zanghi F, Messina A, Bitondo M, Antonelli M. Post-operative analgesia following total knee arthroplasty: comparison of low-dose intrathecal morphine and single-shot ultrasound-guided femoral nerve block: a randomized, single-blinded, controlled study. Eur Rev Med Pharmacol Sci. 2010;14:589–96.PubMedGoogle Scholar
  23. 23.
    Sites BD, Beach M, Gallagher JD, Jarrett RA, Sparks MB, Lundberg CJF. A single injection ultrasound-assisted femoral nerve block provides side effect-sparing analgesia when compared with intrathecal morphine in patients undergoing total knee arthroplasty. Anesth Analg. 2004;99:1539–43.PubMedCrossRefGoogle Scholar
  24. 24.
    Gehling M, Tryba M. Risks and side-effects of intrathecal morphine combined with spinal anaesthesia: a meta analysis. Anaesth. 2009;64:643–51.CrossRefGoogle Scholar
  25. 25.
    Fischer HBJ, Simanski CJP, Bonnet F, Camu F, Neugebauer EAM, Rawal N, Joshi GP, Schug SA, Kehlet H. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty. Anaesth. 2008;63:1105–23.CrossRefGoogle Scholar
  26. 26.
    Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg. 1998;87:88–92.PubMedGoogle Scholar
  27. 27.
    Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg. 2005;101:1634–42.PubMedCrossRefGoogle Scholar
  28. 28.
    Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011;113:904–25.PubMedCrossRefGoogle Scholar
  29. 29.
    Salinas FV, Liu SS, Mulroy MF. The effect of single-injection femoral nerve block versus continuous femoral nerve block after total knee arthroplasty on hospital length of stay and long-term functional recovery within an established clinical pathway. Anesth Analg. 2006;102:1234–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Bingham AE, Fu R, Horn JL, Abraham MS. Continuous peripheral nerve block compared with single-injection peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med. 2012;37:583–94.PubMedCrossRefGoogle Scholar
  31. 31.
    Paul JE, Arya A, Hurlburt L, Cheng J, Thabane L, Tidy A, Murthy Y. Femoral nerve block improves analgesia outcomes after total knee arthroplasty. Anesthesiol. 2010;113:1144–62.CrossRefGoogle Scholar
  32. 32.
    Ilfeld BM, Hadzic A. Walking the tightrope after knee surgery: optimizing postoperative analgesia while minimizing quadriceps weakness. Anesthesiol. 2013;118:248–50.CrossRefGoogle Scholar
  33. 33.
    Andersen HL, Gyrn J, Moller L, Christensen B, Zaric D. Continuous saphenous nerve block as supplement to single-dose local infiltration analgesia for postoperative pain management after total knee arthroplasty. Reg Anesth Pain Med. 2013;38:106–11.PubMedCrossRefGoogle Scholar
  34. 34.
    Perlas A, Kirkham KR, Billing R, Tse C, Brull R, Gandhi R, Chan VWS. The impact of analgesic modality on early ambulation following total knee arthroplasty. Reg Anesth Pain Med. 2013. doi: 10.1097/AAP.0b013e318296b6a0.Google Scholar
  35. 35.
    Jæger P, Zaric D, Fomsgaard JS, Hilsted KL, Bjerregaard J, Gyrn J, Mathiesen P, Larsen TK, Dahl JB. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty. Reg Anesth Pain Med. 2013;28:526–32.CrossRefGoogle Scholar
  36. 36.
    Scott NB. Wound infiltration for surgery. Anaesth. 2010;65:67–75.CrossRefGoogle Scholar
  37. 37.
    Kehlet H, Andersen LO. Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand. 2011;55:778–84.PubMedCrossRefGoogle Scholar
  38. 38.
    McCartney CJ, Choi S. Does anaesthetic technique really matter for total knee arthroplasty? Br J Anaesth. 2013;111:331–3.PubMedCrossRefGoogle Scholar
  39. 39.
    Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg. 1993;77:1048–56.PubMedCrossRefGoogle Scholar
  40. 40.
    Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, Hanssen AD, Horlocker TT. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med. 2008;33:510–7.PubMedGoogle Scholar
  41. 41.
    McCartney CJL, Sinha A, Katz J. A qualitative systematic review of the role of N-methyl-d-aspartate receptor antagonists in preventive analgesia. Anesth Analg. 2004;98:1385–400.PubMedCrossRefGoogle Scholar
  42. 42.
    Adam F, Chauvin M, Du Manoir B, Langlois M, Sessler DI, Fletcher D. Small-dose ketamine infusion improves postoperative analgesia and rehabilitation after total knee arthroplasty. Anesth Analg. 2005;100:475–80.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Edwards ND, Fletcher A, Cole JR, Peacock JE. Combined infusions of morphine and ketamine for postoperative pain in elderly patients. Anaesth. 1993;48:124–7.CrossRefGoogle Scholar
  44. 44.
    Andersen LO, Gaarn-Larsen L, Kristensen BB, Husted H, Otte KS, Kehlet H. Subacute pain and function after fast-track hip and knee arthroplasty. Anaesth. 2009;64:508–13.CrossRefGoogle Scholar
  45. 45.
    Ramlall Y, Archibald D, Robinson Pereira SJ, Sawhney M, Ramlall S. Post-discharge pain management following elective primary total hip and total knee arthroplasty on patients discharged to home on pod 5 or earlier from an acute care facility. Int J Orthop Trauma Nurs. 2010;14:185–92.CrossRefGoogle Scholar
  46. 46.
    Chan EY, Blyth FM, Nairn L, Fransen M. Acute postoperative pain following hospital discharge after total knee arthroplasty. Osteoarthr Cartil. 2013;21:1257–63.PubMedCrossRefGoogle Scholar
  47. 47.
    Bremner S, Webster F, Katz J, Watt-Watson J, McCartney C. Older adults’ postoperative pain medication usage after total knee arthroplasty: a qualitative descriptive study. J Opioid Manag. 2012;8:145–52.PubMedCrossRefGoogle Scholar
  48. 48.
    Sale JE, Gignac M, Hawker G. How “bad” does the pain have to be? A qualitative study examining adherence to pain medication in older adults with osteoarthritis. Arthr Rheum. 2006;55:272–8.CrossRefGoogle Scholar
  49. 49.
    Ibrahim MS, Alazzawi S, Nizam I, Haddad FS. An evidence-based review of enhanced recovery interventions in knee replacement surgery. Ann R Coll Surg Engl. 2013;95:386–9.PubMedCrossRefGoogle Scholar
  50. 50.
    Moore RA. What works for whom? Determining the efficacy and harm of treatments for pain. Pain. 2013;154:S77–86.CrossRefGoogle Scholar
  51. 51.
    Schroer WC, Diesfeld PJ, LeMarr AR, Reedy ME. Benefits of prolonged postoperative cylcooxygenase-2 inhibitor administration on total knee arthroplasty recovery. J Arthroplast. 2011;26:2–7.CrossRefGoogle Scholar
  52. 52.
    Buvanendran A, Kroin JS, Della Valle CJ, Kari M, Moric M, Tuman KT. Perioperative oral pregabalin reduces chronic pain after total knee arthroplasty: a prospective, randomized, controlled trial. Anesth Analg. 2010;110:199–207.PubMedCrossRefGoogle Scholar
  53. 53.
    American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57:1331–46.CrossRefGoogle Scholar
  54. 54.
    Derry S, Moore RA, Rabbie R. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2012;9:CD007400.PubMedGoogle Scholar
  55. 55.
    Pergolizzi J, Böger RH, Budd K, Dahan A, Erdine S, Hans G, Kress HG, Langord R, Likar R, Raffa RB, Sacerdote P. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract. 2008;8:287–313.PubMedCrossRefGoogle Scholar
  56. 56.
    Mercadante S, Ferrera P, Villari P, Casuccio A. Opioid escalation in patients with cancer pain: the effect of age. J Pain Sympt Manage. 2006;32:413–9.CrossRefGoogle Scholar
  57. 57.
    Liu WQ, Kanungo A, Toth C. Equivalency of tricyclic antidepressants in open-label neuropathic pain study. Acta Neurol Scand. 2013. doi: 10.1111/ane.12169.Google Scholar
  58. 58.
    Boyle J, Eriksson ME, Gribble L, Gouni R, Johnsen S, Coppini DV, Kerr D. Randomized, placebo-controlled comparison of amitriptyline, duloxetine, and pregabalin in patients with chronic diabetic peripheral neuropathic pain: impact on pain, polysomnographic sleep, daytime functioning, and quality of life. Diabetes Care. 2012;35:2451–8.PubMedCrossRefGoogle Scholar
  59. 59.
    Argoff CE. Topical analgesics in the management of acute and chronic pain. Mayo Clin Proc. 2013;88:195–205.PubMedCrossRefGoogle Scholar
  60. 60.
    Lin EB, Katon W, Von Korff M, Tang L, Williams JW Jr, Kroenke K, Hunkeker E, Harpole L, Hegel M, Arean P, Hoffing M, Della Penna R, Langston C, Unutzer J, IMPACT Investigators. Effect of improving depression care on pain and functional outcomes among older adults with arthritis. A randomized controlled trial. J Am Med Assoc. 2003;290:2428–9.CrossRefGoogle Scholar
  61. 61.
    Berman BM, Singh BB, Lao L, Langenberg P, Li H, Hadhazy V, Bareta J, Hochberg M. A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatol (Oxford). 1999;38:346–54.CrossRefGoogle Scholar
  62. 62.
    Breit R, Van der Wall H. Transcutaneous electrical nerve stimulation for postoperative pain relief after total knee arthroplasty. J Arthroplast. 2004;19:45–8.CrossRefGoogle Scholar
  63. 63.
    Nnoaham KE, Kumbang J. Transcutaneous electrical nerve stimulation (TENS) for chronic pain (review). Cochrane Database Syst Rev. 2008;3:CD003222.PubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  1. 1.Department of Anaesthesia, Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada

Personalised recommendations