Acupuncture’s Role in Reducing Pain, Opioid Use After TKA
Add acupuncture to the list of modalities that can be used effectively in a multimodal pain management protocol for total knee arthroplasty (TKA) patients.
At the ANESTHESIOLOGY 2021 annual meeting, researchers from Hospital for Special Surgery presented data demonstrating the value of acupuncture in this patient population: In their study, patients who had acupuncture during TKA reported less pain and needed fewer opioids to manage pain than patients who had not received acupuncture.
“Total knee replacement is one of the most common operative procedures in the United States and often very painful, so there’s a great need to explore non-opioid pain relief techniques for this type of surgery,” said Stephanie Cheng, MD, DABMA, lead author of the study. She is an anesthesiologist at Hospital for Special Surgery and an assistant professor of clinical anesthesiology at Weill Cornell Medicine in New York City.
“Acupuncture is extremely safe and can help reduce pain with few unwanted side effects, but it has not been well researched as part of surgical anesthesia.”
Acupuncture Applied to the Ear
The study presented at ANESTHESIOLOGY 2021 included 41 patients undergoing primary TKA at the Hospital for Special Surgery. All patients received the institution’s standard opioid-sparing multimodal analgesic protocol plus electroauricular acupuncture — a modified form of traditional acupuncture that applies a small electric current to thin needles that are inserted at known acupuncture points of the ear.
This type of auricular therapy has been shown to reduce postoperative analgesic requirements in other types of surgery. When Dr. Cheng, board-certified in medical acupuncture, suggested the use of electroauricular acupuncture during TKA to orthopaedic surgeon Michael P. Ast, MD, he was intrigued and agreed to participate in the study.
“I am always looking for methods to benefit our patients and assist with the potential effects of surgery and anesthesia, including pain and nausea/vomiting,” said Dr. Ast, who specializes in adult reconstruction. He is also the Chief Medical Innovation Officer and Vice Chair, Innovation, at Hospital for Special Surgery.
“When [Dr. Cheng] proposed this idea to me 3 years ago, I was fascinated by the notion that it would attempt to reduce those effects without another medication or any potential disruption to our normal perioperative protocols.
“After our initial safety pilot, the response from the patients was so overwhelmingly positive – even just to the idea of the acupuncture – that I was really excited to study it more scientifically.”
No Change in Workflow
For this study, Dr. Cheng applied the electroauricular acupuncture after induction of regional anesthesia, using 8 specific points on the ear to provide targeted pain relief in the knee. She then discontinued acupuncture after 60 minutes, before the patient left the OR. Of note, no opioids were administered intraoperatively.
Dr. Ast said that the use of intraoperative electroauricular acupuncture had no effect on the surgical workflow because it’s done above the sterile field, usually during the prepping and draping process.
“It’s not in close proximity to the surgical field, so it doesn’t interfere with or change the surgery in any way,” he said. “The patient can benefit from the acupuncture without impacting the procedure before, during, or after the surgery.”
Reduced Opioid Usage
While still in the hospital, patients could receive 5 mg to 10 mg of oral oxycodone for intractable pain. On discharge, they received a prescription for 42 5-mg oxycodone pills or the equivalent hydromorphone or tramadol. No refills were provided.
The researchers found that most patients who received acupuncture had a significant reduction in opioid use. Sixty-five percent of patients maintained a low-dose opioid regimen of 15 or fewer oxycodone pills (57.5%) or remained completely opioid-free (7.5%) from induction of anesthesia to 30 days after surgery.
This was not the case with the historical controls: Only 9% of those patients had maintained a low-dose or opioid-free regimen post-surgery.
All patients in the acupuncture group discontinued opioid use after 30 days postoperatively.
The results achieved in this study could have important implications for opioid consumption in hip and knee arthroplasty patients, which is a concern in the context of the ongoing opioid epidemic in the US. The study authors said that, “in this prospective cohort study, we present a feasible approach to integrating intraoperative electroauricular acupuncture into an existing multimodal analgesia regimen for patients undergoing TKA to minimize postoperative opioid usage.”
That’s a perspective too often lacking in the discussion of opioid consumption after surgery, Dr. Cheng said. “Our study shows that if a trained medical acupuncturist is available to perform acupuncture in the operating room, it can help patients with postoperative pain recovery,” she said. “Most studies fail to incorporate non-traditional techniques, such as acupuncture, to help decrease the dependance on opioid medications for postoperative pain control.”
With this study, Dr. Ast has observed the benefits of a non-traditional technique and believes it has a role in joint replacement.
“As noted in the results of this study, we have seen incredibly positive outcomes for this intervention,” he said, “and we have sought to make this a standard part of our perioperative rapid recovery protocol for joint replacements.”
Cheng S, Kelleher DC, Demeo D, Zhong H, Ast MP. Incorporating intraoperative acupuncture to reduce opioid usage after total knee arthroplasty: a prospective cohort trial (Abstract 2078). Presented at ANESTHESIOLOGY 2021, the annual meeting of the American Society of Anesthesiologists, October 8-11, San Diego, California.
Ear photo on home page by Heptal, licensed under the Creative Commons Attribution-Share Alike 4.0 International license; image cropped for size.