PRACTICE PEARLS: Optimizing Perioperative Pain Management in Knee Replacement

    Although there have been many improvements in total knee arthroplasty (TKA) in the last 15 years, Douglas E. Padgett, MD, from Hospital for Special Surgery in New York, believes advances in perioperative patient management – particularly in pain control measures – have been a “game-changer” in helping primary and revision TKA patients recover from their procedure.

    At ICJR’s Revision Hip & Knee Course, Dr. Padgett reviewed his perioperative pain management protocol for TKA patients.

    Traditionally, pain control meant general anesthesia and postoperative morphine. This caused nausea and light-headedness, which prolonged recovery and led to longer lengths of stay and decreased patient satisfaction.

    In contrast, current multimodal protocols encompass preoperative, intraoperative, and postoperative measures that optimize pain management while minimizing side effect of the medications used. This has encouraged more rapid mobilization of patients after surgery, Dr. Padgett said, and contributed to quicker discharge from the hospital.

    Dr. Padgett orders the following drugs for his patients preoperatively: [1]

    • COX-2 inhibitors
    • Pregabalin
    • Opioids
    • Scopolamine patch
    • Stool softener

    Intraoperatively, Dr. Padgett avoids opioids, relying instead on an adductor canal block. This block is performed in the operating room under ultrasound guidance with the patient in the supine position. An injection of 15 mL of 25% bupivacaine is used. Dr. Padgett showed a video demonstrating how a skilled anesthesiologist can perform this block in less than a minute.

    Dr. Padgett also orders the following for his patients intraoperatively:

    • Dexamethasone
    • Intravenous (IV) acetaminophen
    • IV ketorolac

    Patients are hydrated aggressively, kept warm, and given preemptive anti-emetics.

    Dr. Padgett uses intraoperative pericapsular injection as part of his multimodal pain management protocol. [3,4] The injection is performed in 2 steps:

    • Step 1: A combination of bupivacaine with epinephrine, morphine, methylprednisolone, cefazolin, and normal saline is injected into the deep capsule posteriorly and anteromedially.
    • Step 2: 20 mL of 0.5% bupivacaine is injected subcutaneously around the incision.

    The postoperative pain protocol consists of:

    • Oxycodone – 10 mg every 12 hours for 48 hours, plus 5 mg as needed for breakthrough pain
    • Acetaminophen – 1 gram every 8 hours
    • Ketorolac – 15 to 30 mg IV every 6 hours for 24 hours, after which the patient is switched to meloxicam

    Using these multimodal protocols, Dr. Padgett has not had any postoperative pain problems on day 1, and most patients are ready to be discharged on day 2.

    Click the image above to watch Dr. Padgett’s presentation.


    1. Sanders S, Buchheit K, Deirmengian C, Berger RA. Perioperative protocols for minimally invasive total knee arthroplasty. J Knee Surg. 2006;19:129–132.
    2. Buvanendran A, Tuman KJ, McCoy DD, BMatusic B, Chelly JE. Anesthetic Techniques for Minimally Invasive Total Knee Arthroplasty. J Knee Surg 2006; 19(2): 133-136.
    3. Busch CA, Shore BJ, Bhandari R, et al. Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. J Bone Joint Surg [Am] 2006;88-A:959–963.
    4. Vendittoli PA, Makinen P, Drolet P, et al. A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study. J Bone Joint Surg [Am] 2006;88-A:282–289.