Joint replacement pain management — new trends, techniques

Laura Dyrda -   Print  |

Future demand for hip and knee surgery will drive innovation in the future. Over the next 20 years, there is a projected 400 percent to 600 percent growth in these joint replacement procedures, and due to new innovations surgeons are able to expand indications to younger patients as well.

The expanded indications can help a younger population return to work and daily activities quicker, which has a dramatic economic impact. Physicians are performing less invasive procedures — even sometimes on an outpatient basis — and patients are experiencing the benefit of better pain management to ambulate sooner after surgery and begin the recovery process.


In joint replacement procedures, some surgeons have begun using a liposomal bupivacaine product injected into the surgical site after surgery to help control patient pain up to 72 hours.


"In joint replacement surgery there are huge changes that impact how fast patients are recovering," says Bryan Springer, MD, Fellowship Director at OrthoCarolina Hip and Knee Center in Charlotte, N.C. "We are better able to control pain and then patients can ambulate quicker and leave the hospital sooner."


As a result, associated costs are going down as well. When Dr. Springer first began practicing, joint replacements required a five-day stay at the hospital; now with less invasive procedures and pain control, patients are able to return home the same day or the day after surgery.


"We are making great strides in determining what works and what doesn't," says Dr. Springer. "We need evidence that new products work to show the quality and cost-effectiveness of our solutions."


According to data presented at the 39th Annual Meeting of the American Society of Regional Anesthesia and Pain Management, the liposomal bupivacaine injection demonstrated effectiveness. The randomized, double-blind, placebo controlled study of 278 patients who received either femoral nerve blocks with liposomal bupivacaine or a placebo found:


•    24 percent reduction in total opioid use in the liposomal bupivacaine group
•    55 percent of the patients who were "extremely satisfied" with pain control in the liposomal bupivacaine group, compared to 43 percent in the control group at day seven after surgery
•    Higher percentage of patients were "pain free" in the liposomal bupivacaine group
•    Safety was comparable between the two groups


Dr. Springer has replaced peripheral nerve blocks with periarticular injections for hip and knee arthroplasty patients, which he found:


•    Significantly reduced the risk of falls
•    Allows for early mobilization
•    Reduces rebound pain and many sequela of peripheral nerve blocks


He also reviewed best infiltration practices as determined by a group of high-volume liposomal bupivacaine users and recommended the standard doses be 20 ML of liposomal bupivacaine with 30 mL of 0.25 percent Marcaine with epinephrine, with the opportunity to add 10 mL to 20 mL of normal free preservative saline for higher volume if necessary.


He also found liposomal bupivacaine demonstrated no significant interaction with epinephrine, corticosteroids, antibiotics, tranexamic acid, NSAIDs, opioids and Marcaine. He recommended surgeons use a moving needle technique to ensure liposomal bupivacaine is deposited in multiple areas around the surgical site while avoiding vascular areas.


"Our biggest struggle is keeping our costs down while still providing value to our patients," says Dr. Springer. "We want to provide good quality care at a lower cost, which will be our biggest push over the next decade."


Pacira Pharmaceuticals currently produces a liposomal bupivacaine product.


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