A Collaborative Approach to Pain Control Reduces In-hospital Opioid Use and Improves Range of Motion following Total Knee Arthroplasty

Total Knee Arthroplasty With and Without Schedule II Opioids: A Randomized, Double-Blinded, Placebo-Controlled Trial

INTRODUCTION

Orthopedic surgeons are the third highest prescribers of narcotics. Previous work demonstrated that surgeons prescribe three times the narcotics required, and most patients do not properly dispose of leftover medication following surgery. This has prompted the creation of multimodal pain regimens to reduce reliance on narcotics. It is unknown if these pathways can effectively eliminate opioids following total knee arthroplasty (TKA). Our purpose was to evaluate a multimodal regimen without schedule II narcotics following TKA, in a randomized, blinded fashion. We hypothesized that there would be no difference in pain scores between groups.

METHODS

A total of 43 narcotic-naïve patients participated in a randomized, double-blinded, placebo-controlled trial. Postoperative protocols were identical between cohorts, except for the study medication. The narcotic group received an encapsulated 5 mg oxycodone, whereas the control group received an encapsulated placebo. Perioperative outcomes were compared with routine statistical analysis.

RESULTS

Four patients withdrew early secondary to pain: three in the placebo group and one in the narcotic group (p=1.00). We found no difference in hospital length of stay (p=0.09) or pain scores at all time points between cohorts (all p>0.05). There was a higher proportion of patients using a narcotic in the opioid treatment arm at day 30 (40% vs. 21.4%, p=0.29) and day 60 (20% vs. 7.1%, p=0.32), although this was not statistically significant.

CONCLUSION

A multimodal regimen without schedule II narcotics demonstrates equivalent pain scores and may reduce the risk of long-term opioid dependence following TKA.

Peripheral Nerve Catheter Reduces Postoperative Opioid Consumption and Pain in Revision Total Knee Arthroplasty

Background

Patients undergoing revision total knee arthroplasty (rTKA) have historically received high doses of opioids during the perioperative period. As awareness of opioid use has heightened, opioid administration has continuously decreased. This study aimed to evaluate if peripheral nerve catheter (PNC) use in rTKA reduces opiate consumption while maintaining similar pain control and postoperative function levels.

Methods

A retrospective review of 354 patients who underwent rTKA between July 2019 and January 2022 was conducted. Fifty total patients who received an adductor canal PNC were propensity-matched 1:1 to a control group of 50 patients that did not receive a PNC. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalents per 24-hour interval. Postoperative pain and functional status were assessed using the verbal rating scale for pain and the Activity Measure for Post-Acute Care scores, respectively.

Results

Compared to the control group, the PNC group demonstrated significantly lower overall inpatient opiate consumption (98.68 ± 117.03 vs 176.69 ± 203.47 morphine milligram equivalents; 44.15% decrease, P = .021) and lower verbal rating scale pain scores at 60 to 72 hours postoperatively (4.85 ± 1.24 vs 5.83 ± 1.35; 16.81% decrease, P = .038). There was no significant difference in Activity Measure for Post-Acute Care scores postoperatively (raw score: 19.41 ± 3.61 vs 19.46 ± 3.18; 0.26% decrease, P = .952). Finally, the PNC cohort was significantly less likely to be readmitted within 90 days after surgery (0.0% vs 12.0%; P = .012).

Conclusions

In rTKA patients, PNC can significantly reduce inpatient opioid consumption while maintaining a comparable functional recovery and superior pain control.

Level III Evidence

Retrospective Cohort Study.