Editor's Note: In part 1 of his account of his knee replacement surgery, knee replacement specialist Ira H. Kirschenbaum, MD, chairman of the Department of Orthopedics at Bronx-Lebanon Hospital Center, Bronx, New York, described his experience as a patient up to and including his procedure. Here, in part 2, Dr Kirschenbaum discusses postoperative pain management, including the effectiveness of the multimodal pain management techniques his surgeon prescribed, his need for opioid medication; and the physical aspects of his recovery.
Tired but Good
August 25, 2016
This is postoperative day 3. This has been a good day so far. My pain ranges from a best of 1 to a worst of 3 out of 10 on a visual pain scale. I haven't taken anything but Tylenol® and Aleve® all day. I'm able to stand up pretty nicely for a patient who has had his left knee replaced. I'm a bit surprised, actually. I have always thought that my patients would have been in worse shape by this time in terms of pain, but we've been pretty aggressive with the multimodal pain medicines and ice. It's working.
Last night was the last time I took any narcotics. I only took 10 mg of oxycodone at about 9 PM. I ended up waking up at 2:30 AM with a little bit of discomfort that was well controlled with two Tylenol. That's my pain story.
My knee function is quite good. I'm walking a bit better. I have a knee exercise that I'll be doing more of today. I do get tired a lot sooner than I would have expected. After walking around a lot this morning, I found myself very tired by 10:30 AM. I think a lot of my body energy is being directed toward my knee to heal it, so the rest of my body becomes correspondingly tired.
I'm not getting dizzy or having any imbalance while walking, but I am aware that when I'm starting to get a little tired, I need to sit or lay down and rest. I took a nap this morning for about an hour and a half, something I don't usually do. The key is to be sensitized to my degree of tiredness, keep the fluids going, and keep the multimodal pain medications going. Other than that, it's been a good day.
The Real World
August 26, 2016
Woke up on this fourth day after surgery feeling remarkably well. Some generalized soreness, but I was able to move my knee to 103 degrees. How do I know? Measuring a joint is done with a goniometer. And yes, there is a smartphone app for that.
Today I advanced to a cane. I had been using a walker. A cane felt more natural, and since I did some quadriceps exercises yesterday, my quadriceps strength is improving. As I was instructed in my physical therapy session before the operation, I gripped the cane in my right hand, the hand opposite my new knee, and carefully started walking. I was pumped. I managed to get my clothes on (regular clothes, by the way), climbed into a car (as a passenger), and went out into the real world.
Getting into the car was not hard. I decided to sit in the back seat. I went over to my friend's business office and hung out for a couple of hours. Had lunch, worked on the computer, made some phone calls. As I mentioned yesterday, after major surgery, this kind of mental effort tires you out. My advice to patients is this: Whatever discomfort, pain, or fear you experience in the first few days, have faith that it will subside in a short while.
Thinking About Pain
August 27, 2016
It is now Saturday, the fifth day after my surgery. I am well past the time when most patients and surgeons conventionally feel that patients experience the most pain. I now have minor discomfort only.
In my experience as a surgeon, total knee replacement is an operation in which we traditionally use quite a lot of opioids. Yet my opioid use has been minimal. A lot of it has to do with the adoption of modern multimodal pain techniques by my surgeon, which more and more surgeons are using. These techniques include intravenous acetaminophen (Ofirmev®) on a particular protocol; injections of liposomal bupivacaine (Exparel®) in the operating room mixed with standard bupivacaine; ice therapy; early mobilization; oral Tylenol around the clock; and nonsteroidal anti-inflammatory drugs (NSAIDs) both preop and immediately postop.
I've been on this regimen since last Monday, when I had my procedure. Since then, I've taken oxycodone in 10-mg doses for a total of 30 mg over 4 days. I have taken no other opioids. Partly this is attributable to the success of the multimodal pain techniques. But I also attribute it to the expectations and trust I had that the pain would not be as great as what others who have had this surgery suggested it would be.
My experience raises a number of questions. For example, when did I experience the most pain, how bad was it, and how did I manage it?
I had the surgery on a Monday. I probably had the most pain from Tuesday afternoon to late Tuesday evening. This was a time when I think the standard bupivacaine was wearing off and the liposomal bupivacaine was kicking in—what is called a "bridging" time. The pain drifted to about 4 or 5 out of 10 on the pain scale—never more than that—and then by Wednesday morning the pain diminished to about a 3 as the liposomal bupivacaine started working at its full impact. So the pain was quite manageable using the multimodal techniques.
At many hospitals, knee replacement patients receive two Percocets (two 10-mg tablets of acetaminophen/oxycodone) every 4-6 hours. Some hospitals give 30 mg of oxycodone twice a day in addition to that. My experience belies this approach. We have been stuck in a rut in the way we order opioids. In my case, I was able to use significantly lower amounts of pain medicine. I think the narcotics we give the patients to control pain need to be at a much lower dosage, and they need to be given over greater time periods. We also need to adopt a multilevel pain regimen that includes intravenous acetaminophen and liposomal bupivacaine, which reduce pain in the knee for 24-72 hours.
I have used standard bupivacaine and, separately, standard bupivacaine with liposomal bupivacaine in my practice, and I have seen an absolute improvement in patients' pain on the second and third days from the use of liposomal bupivacaine. Whether this decreased the length of stay is hard to say, because we have a very short length of stay at my hospital (the average is around 2 days). I had my procedure as an outpatient, so length of stay was not my endpoint. Instead, my endpoints were patient satisfaction and patient satisfaction with pain relief, which was significantly better with the liposomal bupivacaine.
I felt the bupivacaine wear off at about 11 PM on Monday, the day of my surgery. I had a short period of discomfort until the liposomal bupivacaine kicked in, which it definitely did, because I had significant pain relief most of Tuesday, when I did a fair amount of exercise. Tuesday night my knee was sore, but the liposomal bupivacaine, continued to work. On Wednesday I had pain of between 1 and 3 on the pain scale. That could only really be explained by the use of bupivacaine/liposomal bupivacaine, which allowed me to severely limit my use of opioids in the first couple of days. It also helped me prevent any dependency I might have developed, which might have caused me to reach for a pill for the pain.
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Cite this: Part 2: When a Knee Replacement Specialist Needs His Own New Knee - Medscape - Oct 05, 2016.