Advancing Orthopedic Postsurgical Pain Management .
A Supplement toOctober 2014Volume 43Number 10SAdvancing OrthopedicPostsurgical Pain Management& Multimodal Care Pathways:Improving Clinical &Economic Outcomes
Editorial StaffVice President, Group Editor: Glenn Williams(973) 206-2343gwilliams@frontlinemedcom.comManaging Editor: Joseph Kinsley(973) 206-8971jkinsley@frontlinemedcom.comAssistant Editor: Kellie Irvin(973) rthopedics.com and www.frontlinemedcom.comArtCreative Director: Mary Ellen NiatasArt Director: John J. DeNapoliWeb Production Manager: Allan ChangProduction and ManufacturingProduction Manager: Donna Pituras(973) scription Service: (800) 480-4851quadrantajo@emscirc.comPublishing StaffSenior Vice President/ Group Publisher: Sharon Finch(973) 206-8952sfinch@frontlinemedcom.comSenior Director of Business Development: Toni Haggerty(973) 206-8979thaggerty@frontlinemedcom.com7 Century Drive, Suite 302 Parsippany, NJ 07054-4609Tel: 973-206-3434 Fax: 973-206-9378Stephen Stoneburn, ChairmanDouglas E. Grose, EVP Digital Business Development/CFOMarcy Holeton, President/CEO, Clinical Content DivisionAlan J. Imhoff, President/CEO, Medical News DivisionJoAnn Wahl, President, Custom SolutionsJim Chicca, Executive Director, OperationsCarol Nathan, VP, Custom ProgramsLori Raskin, Corporate Director, Marketing & ResearchDonna Sickles, Corporate Director, Audience DevelopmentIn affiliation with Global Academy for Medical Education, LLC.Sylvia H. Reitman, MBA, Vice President, Medical Education & ConferencesDavid J. Small, MBA, Vice President, Events
Recent Advances in Incorporationof Local Analgesicsin Postsurgical Pain PathwaysAdolph V. Lombardi Jr, MD, FACSAbstractTotal knee and hip replacement surgeriesare highly invasive, and a significant level ofpostoperative pain is commonplace in patientsundergoing these procedures. It is now knownthat postoperative pain can affect hospitalstay, patient satisfaction, postsurgical rehabilitation, and a range of other clinical and administrative outcomes. The need for a multimodalapproach to the control of postoperative pain,using combinations of agents that have synergistic effects, is now widely accepted.There has been increasing interest in localperiarticular and intra-articular injections,which can result in significantly less pain inthe postanesthesiology care unit (PACU),significantly less use of rescue opioids in thePACU, significantly less confusion, significantly less blood loss, and a significantlylower bleeding index. EXPAREL (bupivacaine liposome injectable suspension) is anextended-release anesthetic that is approvedby the US Food and Drug Administration forsingle-dose injection into the surgical siteto produce postsurgical analgesia. Severalphase 2 and phase 3 studies across a rangeof surgical procedures have demonstratedthat the inclusion of EXPAREL in the multimodal regimen can significantly reduce bothpain scores (including cumulative pain scoresat 24 hours) and opioid consumption, as wellas resulting in delayed time to the first use ofopioids and more opioid-free patients at72 hours. Multimodal regimens that includeEXPAREL may have important benefits intotal joint arthroplasty.Orthopedic procedures are reported to be among themost painful surgical procedures, and more than halfof all patients experience suboptimal postoperativepain control.1 Total knee and hip replacement surgeries, inparticular, are invasive, and a significant level of postoperativepain is commonplace in patients undergoing these procedures.The volume of orthopedic surgical procedures makes postoperative pain an issue that not only affects a vast number ofpatients but also has a major impact on health care costs. Morethan 90 million orthopedic surgical procedures are performedin the United States each year, of which approximately 56 million are conducted on an inpatient basis and 35 million are ambulatory.2,3 Around 719,000 total knee replacement proceduresand around 332,000 hip replacements were performed in 2010.4The Need for Improved Managementof Postoperative PainFor more than a decade now, there has been growing interestin improving ways to assess, monitor, and control postoperativepain, which continues to be a considerable unmet health careissue.5 Pain is a chief reason for both prolongation of hospitalstay and patient dissatisfaction,6 and poor pain management hasbeen shown to have major personal, organizational, and financial costs.7 Rehabilitation after total knee arthroplasty (TKA) andtotal hip arthroplasty (THA) is tied directly to pain and comfortlevels—how patients feel following surgery influences how wellthey participate in rehabilitation therapy and, ultimately, affectsoutcomes.1 Furthermore, untreated acute pain is a predictor ofchronic pain and disability, which has considerable impact onquality of life and represents a major societal burden.6The incidence of severe, debilitating pain has been reportedto range from approximately 2% to 10% of cases.8 In one surveyof 1490 surgical inpatients, which measured postoperative painusing a visual analog scale from 0 to 100, moderate or severepain was reported by 41% of subjects.9 So today, pain remainsa prevalent problem following orthopedic surgery.There are several factors that can predispose patients to painfollowing surgery, and these factors can be either patient- orprocedure-specific. For example, men tend to experience ahigher level of postoperative pain than women, and youngerAuthor’s Disclosure Statement: The author reports that he is a consultant and/or speaker for Biomet, Inc., Kinamed Inc.,Pacira Pharmaceuticals, Inc., and Stryker.S2 The American Journal of Orthopedics October 2014 www.amjorthopedics.com
Multimodal Analgesiain Joint Replacement SurgeryThe trauma of surgery activates the nociceptor system, including nociceptors in both peripheral nerves and the central nervous system.16 The need for a multimodal approachto the control of postoperative pain, using combinations ofagents that have synergistic effects,17,18 is now widely accepted(Figure 1). Typical multimodal regimens may include: Preemptive analgesia with agents such as celecoxib, oxycodone, pregabalin, or gabapentin; Short-acting spinal anesthesia (hip arthroplasty); Adductor canal block (knee arthroplasty); General anesthesia; Tranexamic acid; Pericapsular injectable cocktail; Intravenous (IV) acetaminophen; IV steroid dexamethasone; and Additional postoperative anti-inflammatory medication.patients may have more pain than older patients.8,10 Someindividuals may have a genetic predisposition to increasedpain susceptibility. There are differences according to race andamong different ethnic groups. Also, individuals who havebeen abusing opioids for some time prior to surgery requiremore vigilance with respect to their postoperative pain.Reliance on Opioids Is a Barrierto Effective Pain ManagementOne major contributor to the high rate of postoperative painis the continued reliance on opioid agents as the treatment ofchoice for postoperative pain.11It is now well established that opioid-related adverse events(ORAEs) are pervasive following surgery. These ORAEs include: Central nervous system effects, such as sedation and respiratory depression; Nausea, vomiting, ileus, which are less serious medically,but still troublesome to patients12,13; and Constipation due to decreased gastrointestinal motility.12,14An exacerbating factor that further inhibits effective controlof postoperative pain using opioids is the multitude of stepsthat are typically required between the patient’s perceptionof returning pain and the administration of analgesic medication.15 These steps delay pain relief and leave the care teamconstantly “chasing the pain.” At one time, it was felt that theintroduction of patient-controlled analgesia represented a solution to this problem. Unfortunately, this approach not onlyfailed to provide adequate pain relief in many instances, butalso led to increased use of opioid medication, together withthe associated side effects.www.amjorthopedics.comThere has been increasing interest in local periarticularand intra-articular injections. As long as 10 years ago, datashowed that periarticular and intra-articular injections canresult in significantly less pain in the postanesthesiology careunit (PACU), significantly less use of rescue opioids in thePACU, significantly less confusion, significantly less blood loss,and a significantly lower bleeding index.19 In patients receivingperiarticular and intra-articular injections, a trend towardsincreased range of motion at discharge and reduced need formanipulation has been observed.19A new option for managing postoperative pain is EXPAREL (bupivacaine liposome injectable suspension; Pacira Pharma-1098Average Pain ScoreFigure 1. Effective control of postoperative pain requires a multimodal approach. Data source: Mallory17; Mallory.18 Reproducedcourtesy of Joint Implant Surgeons, Inc.765434.865.18210EXPAREL Femoral CatheterFigure 2. Average resting pain scores, liposomal bupivacaine vsfemoral nerve catheter with ropivacaine infiltration. Pain ratingscale: 0 no pain, 10 worst possible pain. Reproduced withpermission from Hawkins. 24October 2014 The American Journal of Orthopedics S3
Recent Advances in Incorporation of Local Analgesics in Postsurgical Pain Pathwaysceuticals, Inc., San Diego, California), an extended-releaseanesthetic that is approved by the US Food and Drug Administration (FDA) for single-dose injection into the surgical siteto produce postsurgical analgesia.EXPAREL as a Componentof Multimodal Analgesia RegimensA high degree of collaboration between the surgeon and anesthesiologist is essential for optimal outcomes. EXPAREL can beinfiltrated by the surgeon to block nociceptive pain at the site ofinitiation of surgical trauma, while the anesthesiologist uses other anesthetics and complimentary analgesic modalities to achievemore comprehensive management of perioperative pain.20By considering the time to onset of action and the duration ofeffect for each agent in the multimodal regimen, the surgeonand anesthesiologist can coordinate the administration of eachmedication to achieve the desired synergies.The recommended dose of EXPAREL is based on the surgical site and the volume required to cover the area. Pivotal studies in bunionectomy and hemorrhoidectomy used doses of 106mg (8 mL volume) and 266 mg (20 mL volume), respectively.21The technique used when administering EXPAREL hasa major influence on the effectiveness of this medication. Itmust be injected meticulously into the soft tissues, using asmall needle (25-gauge or larger) and proceeding very slowly,taking care to aspirate frequently, in order to check for bloodand minimize the risk of intravascular injection.Several phase 2 and phase 3 studies were performed to assessthe efficacy of EXPAREL across a range of surgical procedures,including hemorrhoidectomy, inguinal hernia repair, breastaugmentation, and TKA.21 Inclusion of this medication in themultimodal regimen was shown to significantly reduce bothpain scores (including cumulative pain scores at 24 hours) andopioid consumption, as well as resulting in delayed time to thefirst use of opioids and more opioid-free patients at 72 hours.22,23Distance Ambulated (feet)Same-Day Discharge AfterTotal Joint ReplacementOver recent years, there has been a trend towards reducingthe length of hospital stay for patients undergoing arthroplasty,and many patients are now sent home the same day if possible.In June 2013 a new facility was opened with the specific goalof minimizing the need for overnight hospitalization after kneeand hip arthroplasty (White Fence Surgical Suites, New Albany,Ohio). Because reducing pain and improving ambulation byincluding EXPAREL in the multimodal analgesia regimen canenhance the possibility of sending patients home on the sameday as their surgery, this agent is a standard component ofanalgesic regimens at that facility. To date, 1152 arthroplastyprocedures have been performed in the first year by 4 surgeons—387 THAs, 355 TKAs, 379 partial knee replacements,15 total shoulder replacements, and 16 hip and knee revisions.The vast majority of patients treated at that facility (89.8%)were able to be discharged on the same day as their surgery.Of the 10.2% who stayed overnight, most remained at thefacility either for travel-related convenience or because theyunderwent surgery late in the day. In addition, 97% of patientsatisfaction scores at the facility have been positive.Summary504043302027New approaches to multimodal analgesia that offer improvedpain control can reduce the use of opioid medications andallow earlier weight-bearing and ambulation. Effective newoptions, such as EXPAREL , also have the potential to reduce oreliminate the use of nerve blocks. Safe same-day discharge ofpatients has become a reality, and with it significant cost savings for the surgeon, facility, patient, and health care system.Dr. Lombardi is an orthopedic surgeon and president of Joint Implant Surgeons, Inc., Mount Carmel Health System, The Ohio StateUniversity, New Albany, Ohio.100To determine the benefits of EXPAREL in total joint replacement, a recent study compared the use of femoral nervecatheter with EXPAREL in 200 patients undergoing TKA.24,25The average resting pain score at 72 hours was lower in theEXPAREL group than in the femoral nerve catheter withropivacaine infiltration group (Figure 2). Patients who received EXPAREL also were able to walk farther followingsurgery (Figure 3) and required less assisted ambulationcompared with the femoral catheter group. Whereas allpatients receiving femoral block required the assistance of2 persons, those who received EXPAREL only required moderate assistance from 1 person. In addition, the length ofhospital stay was reduced by half a day with EXPAREL .EXPAREL Femoral CatheterFigure 3. Assisted ambulation, day 0 postoperation, liposomalbupivacaine vs femoral nerve catheter with ropivacaine infiltration.Reproduced with permission from Hawkins. 24Am J Orthop. 2014;43(10 suppl):S2-S5. Copyright Frontline MedicalCommunications Inc. 2014. All rights reserved.References1.S4 The American Journal of Orthopedics October 2014 Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS.Controlling pain after total hip and knee arthroplasty using a multimodalprotocol with local periarticular injections: a prospective randomizedwww.amjorthopedics.com
A. V. Lombardi, Jr.2.3.4.5.6.7.8.9.10.11.12.13.14.study. J Arthroplasty. 2007;22(6 Suppl 2):33-38.Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the UnitedStates, 2006. Natl Health Stat Report. 2009;(11):1-25.Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-540.Centers for Disease Control and Prevention. FastStats: inpatient surgery.2010. htm. AccessedAugust 11, 2014.Pogatzki-Zahn EM, Schnabel A, Zahn PK. Room for improvement:unmet needs in postoperative pain management. Expert Rev Neurother.2012;12(5):587-600.Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey ofchronic pain in Europe: prevalence, impact on daily life, and treatment.Eur J Pain. 2006;10(4):287-333.Mhuircheartaigh RJ, Moore RA, McQuay HJ. Analysis of individual patientdata from clinical trials: epidural morphine for postoperative pain. Br JAnaesth. 2009;103(6):874-881.Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factorsand prevention. Lancet. 2006;367(9522):1618-1625.Sommer M, de Rijke JM, van Kleef M, et al. The prevalence of postoperative pain in a sample of 1490 surgical inpatients. Eur J Anaesthesiol.2008;25(4):267-274.Macrae WA, Davies HTO. Chronic postsurgical pain. In: Crombie IK, ed.Epidemiology of Pain. Seattle, WA: International Association for the Studyof Pain Press; 1999:125-142.Joshi GP, Kehlet H. Procedure-specific pain management: theroad to improve postsurgical pain management? Anesthesiology.2013;118(4):780-782.Oderda GM, Said Q, Evans RS, et al. Opioid-related adverse drug eventsin surgical hospitalizations: impact on costs and length of stay. AnnPharmacother. 2007;41(3):400-406.Veterans Health Administration/Department of Defense Clinical PracticeGuideline for the Management of Postoperative Pain. Version 1.2. USDepartment of Veterans Affairs website. p/pop fulltext.pdf. Published July 2001. Updated May2002. Accessed August 11, 2014.Chou R, Fanciullo GJ, Fine PG, et al; for the American Pain .22.23.24.25.American Academy of Pain Medicine Opioids Guidelines Panel. Clinicalguidelines for the use of chronic opioid therapy in chronic noncancerpain. J Pain. 2009;10(2):113-130.Sinatra RS, Torres J, Bustos AM. Pain management after major orthopaedic surgery: current strategies and new concepts. J Am Acad OrthopSurg. 2002;10(2):117-129.Dalury DF, Lieberman JR, MacDonald SJ. Current and innovative painmanagement techniques in total knee arthroplasty. J Bone Joint SurgAm. 2011;93(20):1938-1943.Mallory TH, Lombardi AV Jr, Fada RA, Dodds KL. Anesthesia options:choices and caveats. Orthopedics. 2000;23(9):919-920.Mallory TH, Lombardi AV Jr, Fada RA, Dodds KL, Adams JB. Painmanagement for joint arthroplasty: preemptive analgesia. J Arthroplasty.2002;17(4 Suppl 1):129-133.Lombardi AV Jr, Berend KR, Mallory TH, Dodds KL, Adams JB. Softtissue and intra-articular injection of bupivacaine, epinephrine, andmorphine has a beneficial effect after total knee arthroplasty. Clin OrthopRelat Res. 2004;(428):125-130.Barrington JW, Halaszynski TM, Sinatra RS; for the Expert WorkingGroup On Anesthesia and Orthopaedics Critical Issues In Hip AndKnee Replacement Arthroplasty. Perioperative pain management in hipand knee replacement surgery. Am J Orthop. 2014;43(4 Suppl):S1-S16.Exparel [prescribing information]. San Diego, CA: Pacira Pharmaceuticals, Inc; 2011.Gorfine SR, Onel E, Patou G, Krivokapic ZV. Bupivacaine extendedrelease liposome injection for prolonged postsurgical analgesia in patientsundergoing hemorrhoidectomy: a multicenter, randomized, double-blind,placebo-controlled trial. Dis Colon Rectum. 2011;54(12):1552-1559.Golf M, Daniels SE, Onel E. A phase 3, randomized, placebo-controlledtrial of DepoFoam bupivacaine (extended-release bupivacaine localanalgesic) in bunionectomy. Adv Ther. 2011;28(9):776-788.Hawkins RJ. EXPAREL care pathway drug utilization evaluation inorthopedic surgery. Paper presented at: International Congress for JointReconstruction Symposium; March 22, 2013; Chicago, IL.Broome CB, Burnikel B. Novel strategies to improve early outcomesfollowing total knee arthroplasty: a case control study of intra articularinjection versus femoral nerve block [published online ahead of print June14, 2014]. Int Orthop. doi:10.1007/s00264-014-2392-0.October 2014 The American Journal of Orthopedics S5
Transition From Nerve Blocks toPeriarticular Injections and EmergingTechniques in Total Joint ArthroplastyBryan D. Springer, MDAbstractThe emergence of procedure-specific multimodalpain management regimens that provide effectivecontrol of postoperative pain, while markedly reducing the amount of opioid medication required,has been one of the most important advances inhip and knee replacement in recent years. Whenperipheral nerve blockade first became widelyavailable for inclusion in multimodal regimens, itwas viewed as a revolution in the managementof postoperative pain. This approach, however,is costly and has some important limitations,including an increased incidence of falls.For many patients, peripheral nerve blockscan now be replaced by a periarticular injectionwith EXPAREL (bupivacaine liposome injectableThe last decade has brought several remarkable advances injoint replacement surgery. Highly cross-linked polyethylene, for example, has significantly reduced the amountof wear and osteolysis that occurs over time following total jointarthroplasty.1,2 A multitude of studies have demonstrated theability of tranexamic acid to reduce perioperative blood loss andtransfusion requirements following total hip arthroplasty (THA)and total knee arthroplasty (TKA).3,4 Rapid rehabilitation protocols have produced a dramatic reduction in recovery and thetime required for patients to achieve goals for discharge following THA and TKA.5,6 And the emergence of procedure-specificmultimodal pain management regimens has made it possible toprovide effective control of postoperative pain, while markedlyreducing the amount of opioid medications.7,8The Evolution of PerioperativeMultimodal AnalgesiaThere are now ample data demonstrating that patient outcomes following total joint arthroplasty are heavily influenced by how well the patient’s postoperative pain is controlled.9 Effective pain control can enable patients to get outsuspension), an extended-release anestheticinfiltrated by the surgeon as part of a multimodalpain regimen. EXPAREL offers some importantclinical and administrative benefits over nerveblocks. Preliminary data from a pilot study comparing the relative effectiveness of EXPAREL versus sciatic nerve blockade has shown anoticeable reduction in average pain scores atrest with EXPAREL following both hip and kneearthroplasty, as well as a reduction in the 6- to12-hour pain score following hip arthroplasty.There was also a significant reduction in opioiduse with EXPAREL , as well as a 411 reductionin the cost of total knee arthroplasty and a 348reduction in the cost of total hip arthroplasty.of bed and move about sooner, which reduces their risk ofvenous thromboembolism following surgery. Earlier ambulation also facilitates more rapid discharge, and there are datashowing that shortening the length of time patients spend inthe hospital not only has economic benefits but also reducesthe likelihood that they will develop an infection.10The initiation, development, and transmission of perioperative pain, as well as potential wind-up that can lead to chronicpain, are known to involve multiple distinct pathways. Therefore, effective control of postoperative pain requires a combination of agents and techniques that work independently andsynergistically in both the peripheral and central nervous systems. Many analgesic and anesthetic agents are now available forinclusion in such multimodal regimens (Figure 1), and they arecombined in various ways. Experts believe that multimodal regimens should be tailored according to the surgical procedure.7Peripheral Nerve Blockadein Multimodal AnalgesiaWhen peripheral nerve blockade first became widely available for inclusion in multimodal regimens, it was viewed as aAuthor’s Disclosure Statement: The author reports that he is on the speakers bureau of Pacira Pharmaceuticals, Inc., and is a speaker/consultantto CeramTec, ConvaTec, DePuy, Wright Medical, and Zimmer.S6 The American Journal of Orthopedics October 2014 www.amjorthopedics.com
revolution in the management of postoperative pain. Patientcontrolled analgesia could be eliminated in many cases and,with a femoral nerve block, a catheter, and a single-shotsciatic block, patients who would previously have been in asignificant amount of pain were experiencing no pain at allduring the immediate postoperative period.The absence of postoperative pain with nerve blocks,however, is also associated with significant motor blockadeleading to weakness in the leg. This has been shown to increase the risk of falls following surgery. Two recent studies found that, despite the implementation of multiple fallprevention protocols, use of femoral nerve catheters for TKAwas associated with a significant risk of falls and associatedmorbidity.11,12 In addition, the goals of rapid rehabilitationprotocols involve early mobilization. The resulting weaknessfrom nerve blocks, however, often prevents or limits patientmobility following surgery.Another important limitation of peripheral nerve blockade is the occurrence of rebound pain when the block wearsoff. Patients often feel sufficiently pain-free during the immediate postoperative period that they neither need nor requestpain medication. Once the effects of the block subside, thepatient often has a sudden increase in pain, and the care teamis suddenly playing “catch-up” with opioid pain medicationsto get the problem under control. Patients who have received NSAIDs TramadolOPIOIDS IV acetaminophen OxycodoneNSAIDs Pregabalin Dexamethasone Peripheralnerve blockAPAPSelectiveNSAIDsAntidepressantsMIS, LocalAnestheticsPatient Expectations, Behavioral andNonpharmacological ModalitiesFigure 1. Rationale for a multimodal approach to the managementof postoperative pain. Abbreviations: APAP, acetaminophen; IV,intravenous; MIS, minimally invasive surgery; NSAID, nonsteroidalanti-inflammatory drug.Comparison of Femoral and Sciatic Nerve Blocks (Control) With EXPAREL as Componentsof Multimodal Perioperative Pain Regimens for Total Hip or Total Knee ArthroplastyTable 1.Total Hip ArthroplastyTotal Knee ArthroplastyControl(n 16)EXPAREL(n 14)PControl(n 32)EXPAREL (n 26)PMean (SD) Age, y61.63 (11.25)62.64 (9.52)0.792664.94 (11.38)63.04 (13.33)0.5607Sex, female, n (%)10 (63%)8 (57%)0.765122 (69%)21 (81%)0.228729.99 (4.85)31.44 (9.57)0.607432.57 (6.44)35.14 (6.08)0.1325Mean (SD) LOS, d2.44 (0.51)2.71 (0.91)0.30703.31 (1.64)3.19 (1.13)0.7518Mean (SD) 6-12 hPO pain score5.25 (2.34)1.8 (2.10)0.00184.29 (2.23)3.5 (2.04)0.2657Mean (SD) painscore at rest5.01 (1.66)3.11 (2.31)0.01404.70 (2.05)3.57 (1.99)0.0386Mean (SD) opioids,mg/d MEDD, DOS87.94 (44.69)77.5 (55.45)0.730883.44 (97.92)72.50 (33.06)0.7144Mean (SD) opioids,mg/d MEDD, POD 182.97 (68.30)74.96 (43.08)0.708878.28 (79.99)67.12 (43.85)0.5264Mean (SD) opioids,mg/d MEDD, POD 268.59 (91.28)51.79 (39.99)0.529651.31 (49.79)64.13 (59.97)0.3773210.53 (175.06)159.25 (82.60)0.3253193.03 (179.89)176.06 (101.11)0.66978 (50%)10 (71%)0.232017 (53%)14 (54%)0.9556224.91 (61.47)260.08 (123.27)0.4000388.81 (320.7)426.42 (593.51)0.8172Mean (SD) BMIMean (SD) opioids,mg MEDD, 3 days totalPCA used, n (%)Mean (SD) time to firstopioid use, min Abbreviations: BMI, body mass index; DOS, day of surgery; LOS, length of stay; MEDD, morphine-equivalent daily dose; PCA, patient-controlled analgesia;PO, postoperative; POD, postoperative day.www.amjorthopedics.comOctober 2014 The American Journal of Orthopedics S7
Transition From Nerve Blocks to Periarticular Injections and Emerging Techniques in Total Joint Arthroplastya peripheral nerve block for TKA have also been reportedto experience increased incidence of neuropathic pain andneurologic sequelae from the nerve block.13administering the nerve block or other indirect costs.The preliminary analysis of data from the pilot studycomparing EXPAREL with sciatic nerve blockade revealed a 411 reduction in the cost of TKA and a 348 reduction inthe cost of THA (Table 3). Furthermore, it has been possibleto eliminate 1 full-time employee position (anesthesiologyEXPAREL —An Alternative to NerveBlockade for Some ProceduresFor many patients, the use of peripheral nerveblocks has now been superseded by EXPAREL (bupivacaine liposome injectable suspension;Pacira Pharmaceuticals, Inc., San Diego, California), an extended-release anesthetic that can beinjected into the surgical site to produce effectivepostoperative analgesia. EXPAREL is infiltratedby the surgeon, as part of a multimodal regimen, to block nociceptive pain at the site ofinitiation of surgical trauma.8 EXPAREL offerssome important clinical and economic benefitsover nerve blocks.Direct Costs of Elastomeric, Continuous PeripheralNerve Blockade (CPNB), Single-Shot Sciatic Nerve Block,and EXPAREL Table 2.CostOn Q BallElastomericCPNBSelectiveFemoral NerveCatheter PlusSingle-ShotSciatic Block0 25 250AnesthesiaEXPAREL Ball 171.5 265 2650Tubing 58.6 26.35 26.350Clinical BenefitsMedication 22.92 94.51 94.51 299EXPAREL is an attractive alternative to peripheral nerve blocks because it produces no motor blockade, and patients are therefore able tomobilize faster and participate fully in physical therapy immediately after surgery.14 Furthermore, in clinical trials, EXPAREL has beenshown to provide continuous and effective analgesia for up to 72 hours, and to reduce opioidrequirements.14The relative effectiveness of EXPAREL versussciatic nerve blockade is currently being compared in a pilot study (OrthoCarolina, Charlotte,North Carolina). A preliminary analysis of thedata from that study has shown a noticeable reduction in the average pain score at rest withEXPAREL , compared with sciatic nerve blockade, following both THA and TKA, as well as areduction in the 6- to 12-hour pain score following THA (Table 1; OrthoCarolina, Charlotte,North Carolina; unpublished data). The studyalso found a significant reduction in overallopioid use, measured in morphine equivalents,compared with other modalities.Ultrasound0 100 1000 16.36 16.36 16.360 269.38 527.22 527.22 299 Economic BenefitsThe replacement of nerve blockade withEXPAREL has also resulted in substantial costsavings. The direct cost of medication andequipment required to perform a sciatic nerveblock totals approximately 527 (Table 2). Incomparison, the cost of a vial of EXPAREL alone—no additional equipment is needed—isapproximately 299. This difference representsa direct saving of around 47%, and does notinclude anesthesiologist costs associated withImmobilizerTotal CostsaaDoes not include anesthesia charges ( 900- 1200).Comparison of the Total Cost of Total Knee andTotal Hip Arthroplasty Using Femoral and Sciatic NerveBlocks (Control) Versus Using EXPAREL Table 3.Total Knee ArthroplastyControlEXPAREL Average total charges 58,222
Senior Director of Business Development: Toni Haggerty (973) 206-8979 thaggerty@frontlinemedcom.com 7 Century Drive, Suite 302 Parsippany, NJ 07054-4609 Tel: 973-206-3434 Fax: 973-206-9378 Stephen Stoneburn, Chairman Douglas E. Grose, EVP Digital Business Development/CFO Marcy Holeton, President/CEO, Clinical Content Division
the growing awareness of chronic postsurgical pain [6-9]. For example, a prospective study of approximately 5000 patients estimated the incidence of acute neuropathic pain in the days after surgery to be between 1 and 3% [10]. A 1-year follow-up showed that 56% of the patients with acute neuropathic pain continued to have pain [10]. Other .
pain”, “more pain” and “the most pain possible”. Slightly older children can also say how much they are hurting by rating their pain on a 0-10 (or 0-100) scale. Zero is no pain and 10 (or 100) is the worst possible pain. What a child is doing Often children show their pain by crying, making a “pain” face, or by holding or rubbing .
General discussions of pain often refer simply to three types: 1) Acute (brief that subsides as healing takes place) 2) Cancer 3) Chronic non-malignant pain - "persistent pain" Classification of pain by inferred pathology: 1) Nociceptive Pain 2) Neuropathic Pain (McCaffery & Pasero, 1999) Nociceptive Pain A. Somatic Pain B. Visceral Pain
Short-term pain, such as when you suffer a sprained ankle, is called 'acute' pain. Long-term pain, such as back pain that persists for months or years, is called 'chronic' pain. Pain that comes and goes, like a headache, is called 'recurrent' pain. It is not unusual to have more than one sort of pain or to have pain in several places
Knee Pain 1 Knee Pain 2 Knee Pain 3 Knee Pain 4 Knee Pain 5 Lateral Knee Pain Medial Knee Pain Patella Pain 1 Patella Pain 2 Shin Splint. 7 Section 6 Ankle/Foot Big Toe 89 . For additional support, wrap another tape around the last finger joint. Step 3. No stretch is applied during application. 30 Step 1 Step 2 Finger Pain. 31 Requires;
Orthopedic Associates is a collection of talented, highly trained Orthopedic Surgeons and staff dedicated to serving Ocean County and beyond. Ocean Orthopedic Associates was founded in 1969 by some of the original Orthopedic Surgeons to practice in Ocean County and their commitment to excellence and dedica
The modern orthopedic hospitalist is an inpatient orthopedic specialist, devoting his or her time and knowledge to the fractures, injuries, and other issues that present to emergency departments as well as among the inpatient floors. An orthopedic hospitalist can address all acute care orthopedic needs. Some of the most commonly
What Does That Have To Do With Technology? An Orthopedic Practice can not exist without a properly educated, trained and licensed Orthopedic Surgeon. An Orthopedic Practice can not persist itho tpersist without a properly ed catededucated, trained and equipped Staff to convert the Orthopedic Surgeon's training and abilities
