1. The Journal of Arthroplasty Vol. 22 No. 7 Suppl. 3 2007
Pain Management and Accelerated Rehabilitation for
Total Hip and Total Knee Arthroplasty
Amar S. Ranawat, MD,*y and Chitranjan S. Ranawat, MDyz
Abstract: Improved pain management techniques and accelerated rehabilitation
programs are revolutionizing our patients' postoperative experience after total hip
and knee arthroplasty. The process involves regional anesthesia with multimodal
pain control using local periarticular injections in combination with enhanced patient
education and accelerated rehabilitation provided by a dedicated team of surgeons,
physicians, anesthesiologists, physician assistants, physical therapists, and social
workers. With this system, it is now possible to achieve a painless recovery after total
hip arthroplasty and total knee arthroplasty. Although this is not always the case, it
was unheard of in prior years. It is our hope that future research into this area will
make painful, difficult recoveries after total hip arthroplasty and total knee
arthroplasty a distant memory. Key words: pain management, rehabilitation.
© 2007 Elsevier Inc. All rights reserved.
Few would argue the incredible impact total hip Any presurgical evaluation regarding informed
arthroplasty (THA) and total knee arthroplasty consent in anticipation of THR or TKR should
(THA, TKA) have had on the quality of life of now include a detailed discussion of the risks, benefits,
people with degenerative joint disease of the hip and and alternatives of the various pain management
knee. They are, arguably, the 2 best elective surgical protocols currently available. General anesthesia with
procedures available to man. Nonetheless, they are intravenous patient-controlled analgesia with a short-
both underused procedures. The main reason for acting narcotic has been the gold standard. Newer pain
this is the overwhelming fear of severe postopera- management strategies aim to control pain without
tive pain and a prolonged recovery [1]. Although relying on narcotics and its attendant side effects such
this was certainly the norm in years past, it is now as nausea, vomiting, ileus, pruritis, urinary retention,
becoming more of an exception. This is because our confusion, and respiratory depression.
understanding of the pain-generating process is This article will outline our current understanding
improving, and our ability to control postoperative of the role regional anesthesia, preemptive analge-
pain is also improving. sia, nerve blocks, local periarticular injections,
patient education, and accelerated rehabilitation
From the *Lenox Hill Hospital, New York, New York; yThe Ranawat
programs have in controlling postoperative pain,
Orthopaedic Center; and zThe Department of Orthopaedic Surgery, reducing deep venous thrombosis (DVT), and
LHH, New York, NY. facilitating an earlier recovery of function.
Submitted May 2, 2007; accepted May 24, 2007.
No funds were received in support of this article. Chitranjan S.
Ranawat and Amar S. Ranawat are consultants for DePuy
Orthopaedics, Inc., Warsaw, Ind and Stryker Corp., Mahwah, NJ. What is Pain?
Institutional Review Board approval was not obtained for this
article because there were no human participants.
Reprint requests: Amar S. Ranawat, MD, Lenox Hill Hospital, Pain remains a poorly understood, complex
11th Floor, 130 East 77th Street, New York, NY 10021. phenomenon most likely controlled by neural,
© 2007 Elsevier Inc. All rights reserved.
0883-5403/07/1906-0004$32.00/0 cellular, and humeral mechanisms, with a strong
doi:10.1016/j.arth.2007.05.040 emotional/psychologic component. Any effective
12

2. Pain Management and Accelerated Rehabilitation Ranawat and Ranawat 13
postoperative pain control program for total joint Table 1. Preoperative
surgery should address all of these influences.
Preemptive Analgesia Given Preoperatively
Therefore, a multimodal approach is logical and
has been supported by numerous authors [2]. 1. Celecoxib 400 mg orally
2. Acetaminophen 1000 mg orally
Not only does the fear of pain limit the number of 3. Tramadol 50 mg
patients who seek total joint surgery, but uncon- 4. Oxycodone 20 mg orally
trolled postoperative pain has many deleterious 5. Pantoprazole 40 mg orally
6. Warfarin 5 mg orally
effects. It has a profound impact on the recovery of
function, and it is the leading cause of delayed
discharge from the hospital [3]. For all these
reasons, it is the opinion of the senior author that The bottom line is that pain must be controlled
the next great advance in the practice of total joint from the onset for any pain management program to
surgery will be further improvements in postopera- work, and secondly, the anesthetic choice should act
tive pain management. to minimize rebound pain, which commonly occurs
with the discontinuation of 24-hour epidurals.
At our institution, preemptive analgesia begins pre-
Anesthesia operatively with most patients receiving 1000 mg of
acetaminophen, 400 mg of celecoxib, 50 mg of tra-
It has now been well documented that regional madol, and 20 mg of extended-release oxycodone in the
anesthesia offers significant advantages over general holding area. In addition, patients are given a proton-
anesthesia with regard to intraoperative blood loss, pump inhibitor, an antiemetic, and warfarin (Table 1).
DVT, and postoperative pain management [4]. As a
result, single-shot spinal anesthesia is our preferred
method. To minimize the DVT risk in THA specifi- Nerve Blocks
cally, this is supplemented with 500 U of IV heparin
during femoral preparation [5]. The use of nerve blocks with and without cathe-
There are many other regional anesthetic options ters has been proven to be very effective at
besides spinal anesthesia, such as hypotensive, controlling pain and minimizing narcotic require-
epidural anesthesia with or without indwelling ments after THA and TKA. There are, however,
catheters for 24 or 48 hours; combined spinal/ several drawbacks, including the increased time it
epidurals; intrathecal morphine (Duramorph, Baxter takes to place the blocks; the availability of skilled
Heathcare Corporation, Deerfield, IL); and most anesthesiologists to place them; and, perhaps most
recently, extended-release epidural morphine (Depo- importantly, the associated motor blockade that
dur, Skyepharma, London, England) [6]. Although limits functional recovery and delays rehabilitation.
they all offer the aforementioned benefits of regional Nonetheless, several specialized centers have made
anesthesia, they have different risk profiles and femoral nerve blocks for TKA and “3-in-1” blocks
require different levels of postoperative monitoring. for THA routine for all patients because of its
The use of epidural catheters also precludes the use of excellent pain-relieving capability [8].
certain anticoagulants such as the low-molecular-
weight heparins. Unfortunately, because many of
Local Periarticular Injections
these other modalities also use narcotics as part of the
anesthetic, they are not immune from its attendant
At our center, we have been focused on using
side effects, as previously described.
local, periarticular injections as part of our overall
pain management protocol. It is our belief that the
Preemptive Analgesia right cocktail in the right patient offers the most
effective pain control with the least amount of side
The idea of preemptive analgesia is not a new one; effects (Tables 1 and 2). We have demonstrated the
nonetheless, it is rarely used. More often than not, safety and efficacy of this program with a rando-
patients are only given pain medications well after mized, prospective study, which has been duplicated
the onset of symptoms. It is now known that by other authors as well [9]. The results of our study
continuous, around-the-clock dosing of pain med- are pending publication in this journal.
ications is far more effective at alleviating pain than Ultimately, we believe that most surgeons across
the standard “as-needed or prn” dosing [7]. the country will be using local, periarticular injec-
Furthermore, it creates a lower narcotic require- tions for their arthroplasties because of their
ment, which has obvious benefits. excellent pain-relieving ability, their low side-effect

3. 14 The Journal of Arthroplasty Vol. 22 No. 7 Suppl. 3 October 2007
Table 2. Intraoperative satisfaction. Most high-volume centers use a variety
teaching aids such as audiovisuals, booklets, web-
Intraoperative Injection
based learning, as well as individual and group
1. 0.5% Bupivacaine 200-400 mg classes to educate patients preoperatively and post-
2. Morphine sulphate (0.4-1.0 cc) 4-10 mg
3. Epinephrine 1/1000 (0.3 cc) 300 μg operatively [10]. To do this effectively requires a
4. Methylprednisolone acetate 40 mg tremendous allocation of time and resources. It
5. Cefuroxime (10 cc) 750 mg usually necessitates a full-time, dedicated, and
6. Normal saline 22 cc
No steroids in diabetic/immunocompromised patients experienced nurse to appropriately handle the
Vancomycin if allergic to penicillin barrage of patient-generated questions that inevi-
Clonidine transdermal patch applied in operating tably arise. It is also a good idea to revisit these
room—100 μg/24 h
Injection sites for intraoperative periarticular injection classes on a regular basis to ensure proper teaching
and training of staff members.
THA
Before final reduction
Anterior capsule Accelerated Rehabilitation
Iliopsoas tendon and insertion site
After final reduction (before irrigation and closure)
Abductors There are 2 factors that permit patients to participate
Fascia lata in an accelerated rehabilitation program. The first, and
Gluteus maximus and its insertion
Posterior capsule and short external rotators perhaps most important, is the motivated patient.
Synovium Even with some pain that most patients would
consider unbearable, the motivated patient can
TKA
Before insertion of liner and reduction power through. By extension, the second necessary
Posterior capsule factor for most patients is achieving adequate post-
Posteromedial and posterolateral structures operative pain control. The focus of any rehabilitation
After reduction
Extensor mechanism protocol should be to control pain because this is the
Synovium variable the surgeon can manipulate [11]. No amount
Capsule of encouragement or education can convert unmoti-
Pes anserinus, anteromedial capsule, and periosteum
Iliotibial band vated patients into motivated ones, especially if they
Collateral ligaments and origins are experiencing pain.
The fact is that many patients, especially younger,
active males, could and should participate in a
profile, and their ease of use. Further research in this rehabilitation program on the day of surgery,
area will produce improved cocktails with longer- provided they are medically stable. The limiting
acting agents. factor for most institutions, however, will be the lack
of skilled physiotherapists needed to accomplish this
Other Pain-Reducing Adjuvants feat. The benefits include immediate, direct psycho-
logic feedback to the motivated patient, with the
As the industry becomes more aware of the ultimate potential of reducing his or her length-of-
importance of controlling postoperative pain, more stay. The long-term benefits of an accelerated
adjuvant therapies and devices will become avail-
able (Table 3). Recently, patient-activated transder- Table 3. Postoperative
mal analgesic patches, which obviate the need for
Postoperative Analgesia/Medications
intravenous lines, have been released. Other strate-
gies have focused on using anesthetic-coated sutures Recovery room
1. Ketorolac IV every 6 h (15 mg if age N65 y, 30 mg if b65 y, hold
and implants as carriers. Newer hemostatic agents if with renal impairment)
and drain systems are also now available to help 2. If ketorolac ineffective, morphine 2-4 mg IV every 15 min
minimize the risk of developing postoperative 3. Metoclopramide 10 mg IV PRN
Orthopedic floor
hematomas, which are a significant cause of pain 1. Ketorolac IM every 6 h PRN (15 mg if age N65 y, 30 mg if
and wound complications. b65 y, hold if with renal impairment)
2. If ketorolac ineffective, morphine 2-4 mg IM every 2-4 h
3. Celecoxib 200 mg orally daily for 10 d
Patient Education 4. Oxycodone SR 10/20 mg orally every 12 h for 48 h
5. Oxycodone 5 mg orally every 6 h PRN
6. Acetaminophen 1000 mg orally every 6 h
Managing patients' expectations and preparing 7. Pantoprazole 40 mg orally daily
them for total joint surgery has been shown to be
very effective at improving outcomes and patient PRN, as needed; SR, sustained release.

4. Pain Management and Accelerated Rehabilitation Ranawat and Ranawat 15
program are probably negligible; however, the same length of hospital stay after total joint arthroplasty.
could be said for the use of continuous, passive J Arthroplasty 2006;21(6 Suppl 2):132.
motion machines, which have become a part of the 3. Horlocker TT, Kopp SL, Pagnano MW, et al. Analgesia
community standard despite little evidence to for total hip and knee arthroplasty: a multimodal
pathway featuring peripheral nerve block. J Am Acad
support its use.
Orthop Surg 2006;14:126.
4. Indelli PF, Grant SA, Nielsen K, et al. Regional
Conclusions anesthesia in hip surgery. Clin Orthop Relat Res
2005;441:250.
Achieving the painless THA or TKA is within 5. DiGiovanni CW, Restrepo A, Gonzalez Della Valle AG,
et al. The safety and efficacy of intraoperative heparin
reach using regional anesthesia and multimodal
in total hip arthroplasty. Clin Orthop Relat Res 2000;
pain control techniques that avoid the unnecessary
379:178.
use of narcotics. This has been documented by 6. Viscusi ER, Parvizi J, Tarity TD. Developments in
several prospective, randomized studies, including spinal and epidural anesthesia and nerve blocks for
our own. The use of local, periarticular injections total joint arthroplasty: what is new and exciting in
will be a major player in these programs in the years pain management. AAOS ICL 2007;56:139.
to come. Further research is still necessary to 7. Skinner HB, Shintani EY. Results of a multimodal
identify longer-acting injectable agents. analgesic trial involving patients with total hip or total
Although patient education and accelerated reha- knee arthroplasty. Am J Orthop 2004;33:85.
bilitation programs are important in facilitating a 8. Pagnano MW, Hebl J, Horlocker T. Assuring a
patient's recovery, it cannot be overemphasized that painless total hip arthroplasty: a multimodal approach
emphasizing peripheral nerve blocks. J Arthroplasty
the focus of any total joint program should be in
2006;21(4 Suppl 1):80.
controlling postoperative pain.
9. Parvataneni HK, Ranawat AS, Ranawat CS. The use of
local peri-articular injections in the management of
postoperative pain after total hip and knee replace-
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