Knee and Hip Replacement Pain: A New Approach to Pain Management

Patients undergoing knee or hip replacements recover more quickly when treated with targeted pain-blocking medications that may eliminate the need for general anesthesia during surgery and intravenous narcotics drugs after surgery.

A decade ago, patients undergoing hip or knee replacements were almost exclusively given general anesthesia during surgery and intravenous narcotic pain medications afterward. This approach works for most people and still is commonly practiced. But both general anesthesia and intravenous narcotic drugs can cause nausea, vomiting, grogginess, decreased bowel function and other side effects.

In the early 2000s, Mayo Clinic anesthesiologists began developing new anesthesia protocols for joint replacement surgery that used known anesthetic and pain relief techniques in new combinations. Their goal was to eliminate the need for general anesthesia and intravenous narcotics and the resulting side effects.

The new procedures may vary but typically involve:

A choice: Even with the new protocols, patients may choose regional anesthesia, where the lower half of the body is numbed, or general anesthesia.

Oral pain medications early on: A combination of oral narcotic pain medications are given prior to surgery. Oral narcotics have fewer side effects than narcotics given intravenously. This technique is helpful for recovery whether general or regional anesthesia is used.

Sedation: Sedative drugs given before surgery help patients using regional anesthesia nap during the procedure, but not lose consciousness.

Nerve blocks: Through a catheter, a continuous infusion of numbing medicine is pumped near the surgery site for 48 hours. Nerve blocks are performed in conjunction with general or regional anesthesia.

Oral pain medications after surgery: For more than 95 percent of patients, pain that occurs after the nerve blocks are removed can be managed with oral pain medications such as acetaminophen (Tylenol, others), tramadol (Ultram, others) or oxycodone. Intravenous narcotic medications are used as a last resort.

Patients who receive regional anesthesia report significantly less pain after surgery than those receiving general anesthesia and intravenous narcotics. These patients are out of bed sooner, begin physical therapy sooner and leave the hospital one to two days before patients who were given general anesthesia and intravenous narcotics. With the newer protocols, patients may still experience typical side effects including nausea and vomiting, but to a lesser degree than with the older anesthesia methods.

Another benefit is that regional anesthesia protocols make surgery an option for older adults with more complicated conditions. A decade ago, older adults often were not considered candidates for surgery because they would have fared poorly with older anesthesia techniques.

Doctors report few downsides to these newer pain management approaches. Nerve injury is a rare potential complication. For most people, the regional anesthesia protocols are a change for the better, resulting in less pain, fewer complications and a quicker recovery.

Source: Mayo Clinic (2/10/2010)

Fractured Shoulder May Lead to Higher Incidence of Broken Hip in Older Women

Older women who suffer a broken shoulder (proximal humerus fracture) have a high risk for also breaking a hip within a year after the shoulder injury.

A new study presented today at the 75th Annual Meeting of the American Academy of Orthpaedic Surgeons (AAOS), found that after a shoulder fracture a woman’s risk of fracturing a hip within the following year was five times greater. The risk decreased after the first year but still remained elevated.

Understanding the connection between these injuries is important to preventing hip fractures. Hip fractures account for more than 350,000 hospital admissions in the United States and more than 60,000 nursing home admissions each year. Women have greater risk because of their higher susceptibility to osteoporosis.

Statistics show:

  • about 70 percent of hip fracture patients are women
  • more than 4 percent of hip fracture patients die during their initial hospitalization
  • 24 percent die within a year of the injury
  • about half of women who sustain hip fractures lose the ability to walk independently

Preventing hip fracture poses s a significant quality-of-life issue. "Earlier studies have shown that there is an increased risk of hip fracture after a proximal humerus fracture, but our study found that there is a defined window of time in which the risk is much greater than previously thought. Additionally, other research has shown that interventions within the first three months can reduce the risk of subsequent fractures," said Jeremiah Clinton, MD, co-author of the study and acting clinical instructor at the University of Washington, Department of Orthopaedics. "If we maximize our hip-fracture prevention efforts up front, we may have a much better chance of helping the patient avoid a life-changing and potentially life-ending injury."

The study followed a group of older, Caucasian women for nearly 10 years and found that, while 8 percent of women who did not break a shoulder suffered hip fractures, approximately 14 percent of those who suffered a shoulder fracture later sustained a hip fracture.

The strongest risk factors for hip fracture were age and hip bone mineral density. Other factors included:

  • self-reported health status
  • height at 25 years of age
  • history of recent falls
  • impaired depth perception
  • history of prior fractures

Even when controlling these factors, the researchers still found the increased risk for hip fracture in the first year after a proximal humerus fracture. The reasons for the connection between humerus fracture and hip fracture are still unclear. "It may be associated medical problems, limited use of the injured shoulder, or there could be something about the treatment for the first fracture, such as narcotic pain medications, which could have caused the patient to fall and break a hip," Dr. Clinton said. "Now that we are aware of the relationship between these types of fractures, we can take precautions, intervene early and hopefully help to prevent some hip fractures from occurring."