Brandon Broome, MD, Steadman Hawkins Clinic of the Carolinas

Rapid recovery pain pathway for total knee arthroplasty results in improved
pain management, decreased length of stay, and significant cost savings
Brandon Broome, MD, Steadman Hawkins Clinic of the Carolinas; Ian Backlund, Hawkins Foundation
BACKGROUND
RESULTS
CLINICAL IMPLICATIONS
Effective pain management was recently ranked as the second most important factor in
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determining patient satisfaction with surgery. Achieving effective pain management in patients
undergoing total knee arthroplasty (TKAs) requires a careful, evidence-based approach to
ensure patient pain is minimized while allowing for early mobilization, rehabilitation, and recovery
activities. Pain management in TKAs has changed over time, with clinical pathways changing
from use of epidural and spinal anesthesia in combination with opioids to femoral nerve blocks.
The problems associated with the aforementioned pain management clinical pathways are well
documented, including nausea, vomiting, orthostasis, pruritus, bowel obstructions, quadriceps
muscle weakness, and falls.2-4 These complications can impair patient rehabilitation and
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recovery, decrease patient satisfaction, and increase hospital length of stay.
This before-after study revealed patients in Group B experienced better pain management, improved knee flexion
on follow up, shorter length of stay, and decreased overall costs. It should be noted, the patients in Group B did
not experience quadriceps weakness whereas patients in Group A experienced quadriceps weakness due to the
nature of the femoral nerve block. None of the patients in Group A experienced discharge to home the day after
surgery; however, 12% of patients in Group B were discharged to home the day after surgery. A subgroup analysis of patients who received Group A interventions for one knee (n=19) and Group B interventions for the other
knee (n=21) demonstrated mean daily ambulation of 89.6 feet for Group A compared with 138.8 feet for Group B
(P<0.01).
The clinical implications of this before-after analysis revealed improved patient
outcomes in patients who received Group B interventions compared with Group
A interventions. As a result, additional benefits were realized:
Orthopedic surgeons in the United States health care system are constantly seeking methods
for improving patient pain relief after TKA, minimizing complications associated with pain
management, expediting patient rehabilitation and recovery, and shortening patient length of
stay. A before and after comparison between two similar patient cohorts was conducted to
compare two different clinical pathways for pain management in patients undergoing TKA.
METHODS
Patient cohort:
N=200 matched cohort of patients undergoing TKA (n=100
receiving femoral block pain management [group A]; n=100
receiving bupivacaine liposome injectable suspension* pain
management [group B]).
• Average Pain Scores
• Increased patient satisfaction.
• Increased nurse and therapist satisfaction.
• Fewer opiates resulted in decreased possible side effects.
• Cost savings; positive indicator for organizations shifting to bundled payment
system or accountable care organization.
REFERENCES
1.Hamilton DF, Lane JV, Gaston P, Patton JT, Macdonald D, Simpson AH,
Howie CR. What determines patient satisfaction with surgery? A prospective
cohort study of 4709 patients following total joint replacement. BMJ Open.
2013;3(4):1-8.
2.Ayalon O, Liu S, Flics S, Cahill J, Juliano K, Cornell CN. A multimodal clinical pathway can reduce length of stay after total knee arthroplasty. HSS J.
2011;7(1):9-15.
3.Beaupre LA, Johnston DB, Dieleman S, Tsui B. Impact of a preemptive multimodal analgesia plus femoral nerve blockade protocol on rehabilitation, hospital
length of stay, and postoperative analgesia after primary total knee arthroplasty:
a controlled clinical pilot study. Scientific World Journal. 2012:273821.
• Knee Flexion
• Assisted Ambulation
• Length of Stay
• Cost Analysis
* EXPAREL® (Pacira Pharmaceuticals, Inc)
4.Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity
continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg. 2010;111(6):1552-4.
Disclosure: Poster development was supported by Pacira Pharmaceuticals, Inc.