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Review
. 2019 Feb;15(1):57-65.
doi: 10.1007/s11420-018-9652-2. Epub 2018 Dec 7.

Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review

Ellen M Soffin  1   2 , Christopher L Wu  1   2   3
Affiliations
Review

Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review

Ellen M Soffin et al. HSS J. 2019 Feb.

Abstract

Background: Elective total joint arthroplasty may be a gateway to long-term opioid use.

Questions/purpose: We sought to review the literature on multimodal and regional analgesia as a strategy to minimize perioperative opioid use and control pain in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).

Methods: We conducted a narrative review to assess the state of the evidence informing opioid-sparing analgesics for THA and TKA. A PubMed search was conducted for English-language articles published before April 2018. We preferentially included well-designed randomized controlled trials, systematic reviews, and meta-analyses. Where the highest levels of evidence were not yet apparent, we evaluated retrospective and/or observational studies.

Results: Multimodal analgesia emphasizing nonsteroidal anti-inflammatory agents and acetaminophen is associated with decreases in perioperative opioid use for THA and TKA. Regional analgesia, including peripheral nerve blocks and local infiltration analgesia, is also associated with decreased perioperative opioid use for THA and TKA. Emerging topics in post-arthroplasty analgesia include (1) the value of nonsteroidal anti-inflammatory drugs, (2) the use of peripheral nerve catheters and extended-release local anesthetics to prolong the duration of opioid-free analgesia, and (3) novel peripheral nerve blocks, exemplified by the IPACK (interspace between the popliteal artery and posterior capsule of the knee) block for TKA.

Conclusions: The use of multimodal analgesia with regional techniques may decrease perioperative opioid use for patients undergoing THA and TKA. These techniques should be part of a comprehensive perioperative plan to promote adequate analgesia while minimizing overall opioid exposure.

Keywords: multimodal analgesia; opioid crisis; orthopedic surgery; peripheral nerve block; regional analgesia; total joint arthroplasty.

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Conflict of interest statement

Ellen M. Soffin, MD, PhD, and Christopher L. Wu, MD, declare that they have no conflicts of interest.N/AN/ADisclosure forms provided by the authors are available with the online version of this article.

Figures

Fig. 1
Fig. 1
An opioid-sparing approach to total joint arthroplasty. Multimodal, nonopioid analgesics form the basis of the protocol. Note that opioids are not introduced until the postoperative phase, and then only after other nonopioid analgesics have been maximized, and sufficient analgesia has not been achieved. All eligible patients should receive regularly scheduled acetaminophen and NSAID; continue gabapentin as tolerated; add dextromethorphan as tolerated, while monitoring for adequate analgesia and side effects. ACB adductor canal block, IPACK interspace between the popliteal artery and posterior capsule of the knee, LIA local infiltration analgesia, PRN as needed, PONV postoperative nausea and vomiting.
See this image and copyright information in PMC

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