What Can Surgeons Do to Alleviate Pain in Their Post-TJA Patients?
Dr. Claudette Lajam answers ICJR’s questions about the evolution of a protocol for managing pain in total hip and total knee arthroplasty patients at NYU Langone Health.
ICJR: You and your orthopaedic colleagues at NYU Langone Health implemented an opioid-sparing pain management protocol for primary total joint arthroplasty in 2017. Why did you undertake this effort to standardize the protocol?
Claudette M. Lajam, MD, FAAOS, FAOA, FAAHKS: We are all familiar with the opioid crisis in the US. Orthopaedic surgeons contribute substantially to the number of prescription opioids in circulation. In 2009, for example, 7.7% of opioids prescribed were ordered by orthopedic surgeons.  Although regulatory mandates by state and federal agencies had some impact on duration of prescriptions, there was little change in the number of patients who received opioids after total joint arthroplasty. 
As surgeons and physicians, we are aware that some surgeries are inherently more painful than others and may require distinct types of pain management after surgery. The “one size fits all” regulatory mandates do not address this. Hence, our NYU Langone Orthopedics Arthroplasty Division created a physician-led, multimodal, perioperative protocol to help alleviate pain after total joint arthroplasty while minimizing patient exposure to opioid medication.
ICJR: What are the components of the opioid-sparing protocol, and does it differ between total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients?
Dr. Lajam: Our protocol includes non-pharmacologic and pharmacologic measures, beginning the day before surgery. Education of the patient about the protocol is a key element, where expectations about management of postoperative pain are discussed with the surgeon and team. It is also important to address anxiety about anticipated pain, which can be more problematic than pain itself in some cases.
There is not much distinction between TKA and THA. There are triggers that prompt different treatments depending on the level of pain reported by the patient.
Before surgery, patients take 1 gram of acetaminophen and a COX-2 non-steroidal anti-inflammatory drug (NSAID); they are also encouraged to hydrate. Regional anesthesia is used in most procedures, with the addition of adductor canal blocks for TKA patients.
Intraoperatively, tranexamic acid is used (unless contraindicated) to minimize intraoperative bleeding into the operative space. Periarticular medication, which includes ropivacaine with epinephrine, plus ketorolac if not contraindicated, is injected by the surgeon during the procedure. Intravenous (IV) dexamethasone and short-acting opioids may be given by the anesthesia team, per the current protocol. One gram of acetaminophen is given immediately postoperatively.
Postoperatively, there is a tiered, age-adjusted pain management protocol. All patients receive acetaminophen (1 gram, 3 times a day), and cold therapy with ice packs is applied 5 times per day. In addition, patients may receive:
- An NSAID: IV ketorolac is administered on POD1, with the dose based on patient age. A COX-2 NSAID is administered once daily for 30 days postoperatively.
- Neuromodulators: 50 mg of pregabalin is given every 8 hours for 3 days postoperatively. It is held if the patient is becoming too sedated.
- Opioids: Patients receive 50 mg of tramadol every 4 hours for mild to moderate pain. Pain that is severe, or not alleviated with these medications, triggers a 2.5-mg to 5-mg dose of oxycodone every 4 to 6 hours as required.
There is a separate protocol for patients who are not opioid-naïve. Pain consultation is requested for patients who are opioid dependent.
ICJR: How did the protocol evolve from initial development to implementation? What feedback did you get from surgeons and nurses as the protocol was being refined? Was there pushback about the limits placed on opioids?
Dr. Lajam: Our protocol has evolved since its inception in 2017. Most changes were made based on feedback from stakeholders.
- The recommended maximum daily dose of acetaminophen was changed from 4g/day to 3g/day. Thus, the acetaminophen dose was adjusted from 1 gram every 6 hours to 1 gram every 8 hours.
- Considering value-based principles, we switched from liposomal bupivacaine to standard ropivacaine with epinephrine. Research shows no significant advantage of the substantially more costly liposomal product. [3,4]
- Our anesthesia colleagues have adjusted their perioperative measures. Regional anesthetic blocks (adductor canal) were added to protocols for TKA. In addition, IV dexamethasone is now used to address immediate postoperative inflammation and nausea.
- Opioid dosing was adjusted based on patient and nursing feedback. Initially, tramadol was given every 8 hours, but it is now given every 4 to 6 hours, with a maximum daily dose of 400 mg. As the protocol evolved, “severe pain” was added as a trigger for the use of oxycodone, as tramadol would not always adequately alleviate pain in some patients.
ICJR: What about patients: Has there been pushback from those who thought they needed more opioids at discharge? How do you deal with that? Is preoperative counseling the answer?
Dr. Lajam: Until 2018, the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) patient surveys focused on “pain alleviation” as a metric for determining quality of care.  This created tremendous pressure on physicians and institutions to manage pain aggressively, frequently with opioids. In 2018, the questions were changed to focus on “communication.”
Nonetheless, postoperative pain remains central to patient experience after TKA and THA.
Pain catastrophizing can be a substantial barrier to postoperative pain alleviation. [6,7] Consistent education about postoperative expectations is a key element of the success of any postoperative pain alleviation protocol. All members of the surgical team must reinforce this concept during the preoperative process. It is important to ensure that patients understand the goal of postoperative pain medication: to control, but not eliminate, postoperative pain. Surgeons should explain of the value of some postoperative pain, which is a signal for the patient to slow down or stop a particular activity while the body heals.
Of course, there has been pushback from patients with anxiety about their postoperative pain. Identification of this anxiety is an important step towards improvement in postoperative pain alleviation. If patients are assured that their pain will be a focus of postoperative care and that it will be addressed appropriately, most are quite reasonable about adherence to their plan.
Further, it is important to identify preoperatively any patients who are opioid-tolerant or who have a history of substance abuse or addiction. These patients may require a pain management consultation to help manage medications appropriately. Communication between the surgical team and any existing addiction professional or pain physician is encouraged so that the patient and the surgeon understand and agree about the plan to manage postoperative pain.
Claudette M. Lajam, MD, FAAOS, FAOA, FAAHKS, is an Associate Professor of Orthopedic Surgery, NYU Langone Grossman School of Medicine, NYU Langone Orthopedics, in New York, New York.
Disclosures: Dr. Lajam has no disclosures relevant to this article.
- Volkow ND, McLellan TA, Cotto JH, et al. Characteristics of opioid prescriptions in2009. JAMA 2011;305:1299-1301.
- Lott A, Hutzler LH, Bosco JA 3rd, Lajam CM. Opioid prescribing patterns in orthopaedic surgery patients: the Effect of New York state regulations and institutional initiatives. J Am Acad Orthop Surg. 2020 Dec 15;28(24):1041-1046. doi: 10.5435/JAAOS-D-20-00050. PMID: 32301820.
- Bravin LN, Ernest EP, Dietz MJ, Frye BM. Liposomal bupivacaine offers no benefit over ropivacaine for multimodal periarticular injection in total knee arthroplasty. Orthopedics. 2020 Mar 1;43(2):91-96. doi: 10.3928/01477447-20191223-01. Epub 2019 Dec 31. PMID: 31881086.
- Danoff JR, Goel R, Henderson RA, Fraser J, Sharkey PF. Periarticular ropivacaine cocktail is equivalent to liposomal bupivacaine cocktail in bilateral total knee arthroplasty. J Arthroplasty. 2018 Aug;33(8):2455-2459. doi: 10.1016/j.arth.2018.02.083. Epub 2018 Mar 6. PMID: 29599033.
- Thompson CA. HCAHPS survey to measure pain communication, not management. Am J Health Syst Pharm. 2017 Dec 1;74(23):1924-1926. doi: 10.2146/news170084. PMID: 29167127.
- Riddle DL, Jensen MP, Ang D, Slover J, Perera R, Dumenci L. Do pain coping and pain beliefs associate with outcome measures before knee arthroplasty in patients who catastrophize about pain? A cross-sectional analysis from a randomized clinical trial. Clin Orthop Relat Res. 2018 Apr;476(4):778-786. doi: 10.1007/s11999.0000000000000001. PMID: 29543659; PMCID: PMC6260056.
- Wright D, Hoang M, Sofine A, Silva JP, Schwarzkopf R. Pain catastrophizing as a predictor for postoperative pain and opiate consumption in total joint arthroplasty patients. Arch Orthop Trauma Surg. 2017 Dec;137(12):1623-1629. doi: 10.1007/s00402-017-2812-x. Epub 2017 Oct 3. PMID: 28975493.