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I'm doing a little research for myself before having a knee replacement done. I've heard that there are some surgeons who don't let their patients experience any pain and those patients do the best. It does mean using a lot of drugs but I'm okay with that. What's the procedure for this?

The new pain management protocol for total knee replacement surgery proposed by some surgeons has two parts. The first is called preemptive analgesia. This refers to the fact that it is easier to prevent pain than to try and get rid of it once it starts. Getting control of pain signals in the disrupted soft tissues before the adjacent nerve cells can start firing is important. The second part is called multimodal analgesia. This refers to the use of a variety of different medications to achieve pain control. Using low doses of several drugs helps turn off the multiple pathways pain messages are relayed to the brain. The best approach is to combine both approaches (preemptive analgesia and multimodal analgesia). The program begins two days before surgery when patients are started on an antiinflammatory medication. One hour before surgery, a narcotic (e.g., oxycodone) is given. Then during the surgery, the knee is injected with an antiinflammatory and narcotic. Pain controlling medications and antiinflammatories are continued after surgery. The patient is sent home with pain relievers, sleep aids, and antiinflammatories. Other medications such as Tylenol, gabapentin, clonidine, and ketamine are also used as needed. Sometimes medications are combined together and injected as one. This is referred to as a drug cocktail. The authors of this article are actively researching various combinations of medications in these cocktails. They are trying to find the most effective combination and just the right dosages of each individual drug. The mixture is injected into all four quarters of the knee (front, each side, back). Pain levels, pain intensity, and pain duration are used to measure results. Other measures used to assess outcomes include amount of narcotic needed, any sleep disturbance reported, knee range-of-motion, and nausea/vomiting present. They are finding that the approach reported here is giving superior pain control and much improved functional outcomes. It is not always pain free but the reduced pain is significant. All of this takes some change and cooperation among the many surgical partners. The surgeons, pharmacists, anesthesiologists, nurses, physical therapists, and patient/family must work together to create as pain free of a surgical response possible. Communication and collaboration are the key but the result is worth the effort.

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