Enhanced recovery pathways (ERPs) utilise multimodal rehabilitation techniques to reduce post-operative pain and accelerate the rehabilitation process following surgery. Originally described following elective colonic surgery enhanced recovery pathways have gained increasing use following elective hip and knee joint replacement in recent years. Early studies have indicated that enhanced recovery pathways can reduce length of hospital stay, reduce complications and improve cost-effectiveness of joint replacement surgery. Despite this growing evidence base uptake has been slow in certain centres and many surgeons are yet to utilise enhanced recovery pathways in their practice. We look at the process and effects of implementing an enhanced recovery pathway following total hip replacement surgery at a district general hospital in the United Kingdom. A retrospective study was initially undertaken over a four-month period to assess patient demographics, length of stay, time to physiotherapy and complication rates including re-admission within 28 days. Based on national recommendations an enhanced recovery pathway protocol was then implemented for an elective total hip replacement list. Inclusion criteria were elective patients undergoing primary total hip replacement (THR) surgery. The pathway included pre-operative nutrition optimisation, 4mg ondansetron, 8mg dexamethasone and 1g tranexamic acid at induction and 150mL ropivacaine HCL 0.2%, 30mg ketorolac and adrenaline (RKA) mix infiltration to joint capsule, external rotators, gluteus tendon, iliotibial band, soft-tissues and skin around the hip joint. The patient was mobilised four-hours after surgery where possible and aimed to be discharged once mobile and pain was under control. Following implementation a prospective study was undertaken to compare patient demographics, length of stay and complication rates including re-admission within 28 days. 34 patients met the inclusion criteria and were included in each group pre and post-enhanced recovery pathway. Following implementation of an enhanced recovery pathway mean length of stay decreased from 5.4 days to 3.5 days (CI 1.94, p < 0.0001). Sub-group analysis based on ASA grade revealed that this reduction in length of stay was most pronounced in ASA 1 patients with mean length of stay reduced from 5.0 days to 3.2 days (CI 1.83, p < 0.0001). There was no significant change in the number of complications or re-admission rates following enhanced recovery pathway. The enhanced recovery pathway was quick and easy to implement with co-ordination between surgeons, anaesthetist, nursing staff and patients. This observational study of consecutive primary total hip replacement patients shows a substantial reduction in length of stay with no change in complication rates after the introduction of a multimodal enhanced recovery protocol. Both of these factors reduce hospital costs for elective THR patients and may improve patient experiences

Peri-articular injections (PAI) have become an important component in many multimodal pain protocols after total knee arthroplasty (TKA). Liposomal bupivacaine has emerged as a highly marketed and touted ingredient for PAI. However, the true efficacy of this material, particularly compared with less expensive PAI “cocktails” such as traditional bupivacaine or ropivacaine, has not been proven to date. Ropivacaine is considered a long-active local analgesic and in combination with epinephrine, ketorolac and clonidine has been shown to be a very effective PAI in a multimodal pain program. Liposomal bupivacaine has been similarly touted as a long-acting PAI. Initial reports provided support for liposomal bupivacaine PAI's providing similar pain relief as epidurals or femoral nerve blocks. The authors of these studies tout comparable pain control with decreased length of stay attributable to avoiding the side effects of epidurals and regional blocks. However, the ultimate clinical issue relates to how liposomal bupivacaine PAI's compares to traditional PAI cocktail ingredients such as bupivacaine and ropivacaine, which also avoid deleterious effects of regional analgesia, and at a much cheaper price point. Fortunately the highest quality research to date, which includes randomised prospective trials and retrospective controlled cohort studies, have reported consistent results. In a retrospective cohort study comparing a traditional ropivacaine and epinephrine versus liposomal bupivacaine PAI demonstrated no difference between the two groups in inpatient pain scores when used in a comprehensive multimodal pain control program. Further, two prospective randomised trials reported no difference in liposomal bupivacaine PAI compared to a traditional PAI of either bupivacaine or ropivacaine, epinephrine, ketorolac and clonidine. Finally, there have been some authors who contend the efficacy of liposomal bupivacaine PAI's is entirely dependent on a meticulous injection technique, however, comparative studies against traditional PAI ingredients with this recommended technique do not exist. In summary, the existing data supports that liposomal bupivacaine is an effective PAI that can be used to provide comparable pain relief to that achieved by regional blocks. However, liposomal bupivacaine has not been shown to provide superior pain relief when compared to traditional ropivacaine or bupivacaine PAI's in multimodal pain protocols after TKA. Further, liposomal bupivacaine is prohibitively priced at approximately six times that of ropivacaine-based PAI cocktails. Therefore, the “game changer” is likely the implementation of peri-articular injections as an essential component of multimodal pain control programs and NOT liposomal bupivacaine

Introduction. Pain control following total knee arthroplasty (TKA) heavily influences timing of mobilization and rehabilitation postoperatively as well as length of hospital stay. Recently, periarticular injection of liposomal bupivacaine (EXPAREL®; Pacira Pharmaceuticals, Inc., San Diego, California) has demonstrated pain relief comparable to femoral nerve block for postoperative analgesia in TKA with earlier mobilization and shortened hospital stay. In order to better explore the use of EXPAREL® in TKA, we standardized the postoperative analgesia to intraoperative periarticular injection of multimodal pain management, which is a recommended postoperative method of pain control in TKA. We studied the effectiveness of periarticular EXPAREL® in TKA postoperative pain control, including impact on early mobilization and length of hospital stay, compared to another local analgesic (Ropivacaine) when both are used as part of a multimodal pain management approach. Methods. We performed a double blind, randomized, controlled, prospective, IRB-approved study that enrolled 96 participants who underwent a unilateral TKA by one surgeon between May 2014 and March 2015. The two randomized groups were as follows: group 1 (control group) was given the standard intra-articular “pain cocktail” injection, consisting of ropivacaine, ketorolac, morphine, and epinephrine mixed with saline into a 100cc preparation and group 2 (study group) was given a similar intra-articular injection consisting of bupivacaine, ketorolac, morphine, and epinephrine mixed with saline into an 80cc preparation as well as an injection of EXPAREL®, 20cc of 1.3% EXPAREL®, to total 100cc. All patients included in the study were determined to be opioid naïve as described by the Food and Drug Administration criteria. Patients were treated with the same postoperative pain management protocol as well as the same post-operative physical therapy program. The consumption of oral and intravenous narcotics at specific time points as well as total use was recorded during hospital stay. We recorded Visual Analog Pain scores, hours to ambulate 100 feet and length of hospital stay (hours). Both the investigator and the patient were blinded as to which group the patient was randomized, making this a double blind study. Results. On a per hour basis, the mean use of narcotics of the two groups differed by only 0.1mg. For total narcotic use during hospital stay, the weighted sum used by patients in the EXPAREL® group, 97.7mg of hydrocodone ±42.84 mg, exceeded the weighted sum, 89.6 mg of hydrocodone ± 58.57 mg, used by patients in the control group. The difference between the two groups was not significant. The means for length of stay differed by only 26 minutes and the difference was not significant. Similarly insignificant, the means for the time to ambulate 100 feet differed by 53 minutes, with the EXPAREL® group actually taking the longer time. The two groups did not differ for Visual Analog Score for pain on day 1 or day 2 post-operatively. Conclusion. When comparing the use of EXPAREL® to another multimodal pain management approach using ropivacaine, there is no difference in post-operative opioid consumption, Visual Analong Scores for pain, amount of time to ambulate or length of hospital stay

Dexmedetomidine, an alpha 2 agonist, has been approved for providing sedation in the intensive care unit. Along with sedative properties, it has analgesic activity through its highly selective action on alpha 2 receptors. Recent studies have examined the use of dexmedetomidine as an adjuvant to prolong the duration of peripheral nerve blocks. Studies showing effectiveness of dexmedetomidine for adductor canal block in knee surgery are small. Also, its effectiveness has not been compared to Epinephrine which is a strong alpha and beta receptor agonist. In a previous study, we showed that motor sparing knee blocks significantly increased the duration of analgesia compared with periarticular knee infiltration using local anesthetic mixture containing Epinephrine following total knee arthroplasty (TKA). In this study, we compared two local anesthetic mixtures: one containing Dexmedetomidine and the other Epinephrine for prolongation of motor sparing knee block in primary TKA patients. After local ethics board approval and gaining Notice of Compliance (NOC) from Health Canada for use of Dexmedetomidine perineurally, 70 patients between the ages 18 – 95 of ASA class I to III undergoing unilateral primary total knee arthroplasty were enrolled. Motor sparing knee block − 1) Adductor canal continuous catheter 2) Single shot Lateral Femoral Cutaneous Nerve block 3) Single shot posterior knee infiltration was performed in all patients using 60 ml mixture of 0.5% Ropivacaine, 10 mg Morphine, 30 mg Ketorolac. Patients randomized into the Dexmedetomidine group (D) received, in addition to the mixture, 1mcg/kg Dexmedetomidine and the Epinephrine (E) group received 200mcg in the mixture. The primary outcome was time to first rescue analgesia as a surrogate for duration of analgesia and secondary outcomes were NRS pain scores up to 24 hours and opioid consumption. The time to first rescue analgesia was not significantly different between Epinephrine and dexmedetomidine groups, Mean and SD 18.45 ± 12.98 hours vs 16.63 ± 11.80 hours with a mean difference of 1.82 hours (95% CI −4.54 to 8.18 hours) and p value of 0.57. Pain scores at 4, 6, 12, 18 and 24 hours were comparable between groups. Mean NRS pain scores Epinephrine vs Dexmedetomidine groups were 1.03 vs 0.80 at 4 hours, 1.48 vs 3.03 at 6 hours, 3.97 vs 4.93 at 12 hours, 5.31 vs 6.18 and 6.59 v 6.12 at 24 hours. Opioid consumption was also not statistically significant between both groups at 6, 12 18, 24 hours (p values 0.18, 0.88, 0.09, 0.64 respectively). Dexmedetomidine does not prolong the duration of knee motor sparing blocks when compared to Epinephrine for total knee arthroplasty. Pain scores and opioid consumption was also comparable in both groups. Further studies using higher dose of dexmedetomidine are warranted

Pain management following surgery continues to challenge patients, physician-extenders, and surgeons. A recent survey of 300 patients following surgery found that 86% experienced pain following surgery with 75% describing moderate or severe pain. Pain management in 2017 has to better address patient's needs as Pain has become the “5th Vital Sign” and is used in many patient reported outcomes (for better or worse). Multimodal therapy has been defined as “Synchronous administration of ≥ 2 pharmacological agents or approaches, each with a distinct mechanism of action”. Mounting evidence supports the use of a multimodal approach to peri-operative pain management in all surgical subspecialties. A recent systematic review of intravenous ketamine showed a reduction total opioid consumption and an increase in the time to first analgesic dose needed across all studies. Gabapentin and pregabalin have both been shown to dramatically reduce the use of opioid consumption by 30%. We have worked with our anesthesia team and developed a multimodal analgesia program that includes ketorolac 10mg 3 tabs po qd × 3 days, then 10mg 2 tabs po × 2 days; gabapentin 300mg (<65 year old) or 100mg (>65 year old) 3 tabs po × 3 days; oxycodone 5mg po q 4–6 hours prn breakthrough pain and Tylenol 500mg 1–2 tabs po q 6 hours prn

Refinement of surgical techniques, anesthesia protocols, and patient selection has facilitated this transformation to same day discharge for arthroplasty care, most notably Partial Knee Arthroplasty (PKA). The trend for early discharge has already happened for procedures formerly regarded as “inpatient” procedures such as upper extremity surgery, arthroscopy, ACL reconstruction, foot and ankle procedures, and rotator cuff repair. Our program began focused on PKA and has now expanded to primary TKA and THA, and select revision cases. Over the past few years we have performed 1,230 knee arthroplasty procedures with no readmissions for pain control. Average age and age range is identical to our inpatient cohort for our partial knee cases. Patient selection is based on medical screening criteria and insurance access. PKA is the ideal procedure to begin your transition to the outpatient space. We currently perform medial PKA, lateral PKA, and patellofemoral arthroplasty as an outpatient. The program centers on the patient, their family, home recovery, preoperative education, efficient surgery, and represents a shift in the paradigm of arthroplasty care. It can be highly beneficial to patients, surgeons, anesthesia, facility costs, and payors as arthroplasty procedures shift to the outpatient space. Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay in the inpatient hospital environment opening the opportunity for cost savings and even outpatient joint replacement surgery for appropriately selected patients. The hallmark of this program is meticulous protocol execution. Preemptive pain control with oral anti-inflammatory agents, gabapentin, regional anesthetic blocks that preserve quad function for TKA (adductor canal block) and pericapsular long acting local anesthetics with the addition of injectable ketorolac and IV acetaminophen are key adjuncts. Over the past two years utilizing this type of program over 60% of our partial knee replacement patients are now returning home the day of surgery. Concerns over readmission are appropriate. The rates of complications and readmissions are less than our inpatient cohort in appropriately selected cases with a standardised care map. We believe this brings the best VALUE to the patients, surgeons, and the arthroplasty system

Refinement of surgical techniques, anaesthesia protocols, and patient selection have facilitated this transformation to same day discharge for arthroplasty care, most notably Partial Knee Arthroplasty (PKR). The trend for early discharge has already happened for procedures formerly regarded as “inpatient” procedures such as upper extremity surgery, arthroscopy, ACL reconstruction, foot and ankle procedures, and rotator cuff repair. Our program began focused on Partial Knee Arthroplasty (PKA) and has now expanded to primary TKA and THA, and select revision cases. Over the past few years we have performed 1,230 Knee Arthroplasty procedures with no readmissions for pain control. Average age and age range is identical to our inpatient cohort for our partial knee cases. Patient selection is based on medical screening criteria and insurance access. PKA is the ideal procedure to begin your transition to the outpatient space. We currently perform medial PKA, lateral PKA, and patellofemoral arthroplasty as outpatient cases. The program centers on the patient, their family, home recovery, pre-operative education, efficient surgery, and represents a shift in the paradigm of arthroplasty care. It can be highly beneficial to patients, surgeons, anaesthesia, facility costs, and payors as arthroplasty procedures shift to the outpatient space. Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay in the inpatient hospital environment opening the opportunity for cost savings and even outpatient joint replacement surgery for appropriately selected patients. The hallmark of this program is meticulous protocol execution. Pre-emptive pain control with oral anti-inflammatory agents, gabapentin, regional anesthetic blocks that preserve quad function for TKA (adductor canal block) and pericapsular long acting local anesthetics with the addition of injectable ketorolac and IV acetaminophen are key adjuncts. Over the past two years utilizing this type of program over 60% of our partial knee replacement patients are now returning home the day of surgery. Concerns over readmission are appropriate. The rates of complications and readmissions are less than our inpatient cohort in appropriately selected cases with a standardised care map. We believe this brings the best VALUE to the patients, surgeons, and the arthroplasty system

Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay and opened the opportunity for cost savings and even outpatient joint replacement surgery for appropriately selected patients. The hallmark of this program is preemptive pain control with oral anti-inflammatory agents, gabapentin, regional anesthetic blocks that preserve quad function for TKA (adductor canal block) and long acting local anesthetics with the addition of injectable ketorolac and acetaminophen. Over the past two years utilising this type of program over 60% of our partial knee replacement patients are now returning home the day of surgery. We currently utilise a long acting local anesthetic delivery medication consisting of microscopic, spherical, lipid-based particles composed of a honeycomb-like structure of numerous nonconcentric internal aqueous chambers containing encapsulated bupivacaine separated from adjacent chambers by lipid membranes. Bupivacaine is released from the particles with diffusion of the drug over an extended period of time that more closely matches the time course of postsurgical pain following joint replacement surgery. Trials have demonstrated that a single dose administered via deep tissue infiltration is effective at reducing pain up to 72 hours

Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay in the inpatient hospital environment opening the opportunity for cost savings and even outpatient joint replacement surgery for appropriately selected patients. The hallmark of this program is pre-emptive pain control with oral anti-inflammatory agents, gabapentin, regional anesthetic blocks that preserve quad function for TKA (adductor canal block) and pericapsular long acting time release local anesthetics with the addition of injectable ketorolac and IV acetaminophen. Over the past two years utilising this type of program over 60% of our partial knee replacement patients are now returning home the day of surgery. We currently utilise a long acting local anesthetic delivery medication consisting of microscopic, spherical, lipid-based particles composed of a honeycomb-like structure of numerous nonconcentric internal aqueous chambers containing encapsulated bupivacaine separated from adjacent chambers by lipid membranes. Bupivacaine is released from the particles with diffusion of the drug over an extended period of time that more closely matches the time course of postsurgical pain following joint replacement surgery. Trials have demonstrated that a single dose administered via deep tissue infiltration is effective at reducing pain up to 72 hours. This has been trialed in TKA as well

Pain control is critical in the management of TKA patients and is crucial to allow for early ambulation and accelerated physical therapy. Currently data suggests that 19% of patients are not satisfied with their results following TKA, and failure to control pain may result in prolonged hospitalization, worse outcomes, and increased patient dissatisfaction. Studies suggest that local analgesics coupled with both pre- and post-operative multimodal pain management may result in improved pain control and increased patient satisfaction. Minimization of opioid use is helpful in decreasing complications, accelerating physical therapy milestones, minimizing length of stay and increasing discharge to home. Femoral nerve blocks (FNB) can reduce pain scores for up to 48 hours post-operatively, but may delay ambulation and result in an increased rate of falls. Periarticular injection (PAI) with local analgesics can provide significant short term relief comparable to FNB and can also facilitate decreased opioid consumption. One commonly used local anesthetic is bupivacaine, but the average half-life of this drug is only 2.7 hours. An alternative to this for PAI during TKA is liposomal bupivacaine (LB). LB is a multivesicular drug designed for rapid absorption, prolonged release of bupivacaine, and analgesia that is maintained for up to 72 hours with a single injection. LB exhibits a bimodal peak of distribution, one immediate associated with extra-liposomal bupivacaine, and a second 10–36 hours later associated with the release of liposomal encapsulated bupivacaine. The safety profile of LB has been investigated and adverse events are similar to standard bupivacaine and demonstrate acceptable tolerability. Multiple studies have demonstrated efficacy of this drug compared to other pain control modalities. LB is highly technique dependent and only one piece of a multimodal pain management protocol. Our study consisted of 1808 consecutive primary TKA patients from Sept 2013 to Sept 2015. Three patient cohorts were compiled by date, from Sept 2013 to May 2014 was cohort 1, consisting of FNB and PCA. Department wide adoption of LB began in May 2014 and became routinely used in all patients undergoing total joint arthroplasty at our institution. Cohort 2 entailed a PCA along with LB injection from May 2014 through Feb 2015. Cohort 3 consisted of LB injection only and was from Feb 2015 through Sept 2015. All patients undergoing TKA were eligible and there were no exclusion criteria as long as the protocols were followed. The standard multi-modal analgesia protocol was provided to all patients in all three cohorts. Prior to entering the operating room, patients received preemptive oral analgesics, consisting of: 200 mg celecoxib, 1000 mg acetaminophen, and 50 mg pregabalin. Intra-operative analgesia was chosen at the discretion of the anesthesiologist and preferentially consisted of spinal anesthesia with general anesthesia as an alternate. For all three cohorts, a peri-incisional analgesic cocktail was injected prior to closure consisting of: 40 cc 0.25% Marcaine, 5 cc of (1 mg/cc) morphine, and 1 cc of (30 mg/cc) ketorolac. Cohorts 1 and 2 received PCA post-operatively for pain control post-operatively with prn oral narcotic administration as well. Cohort 3 did not receive a PCA. The cohort treated without FNB and without a PCA using a multimodal pain management protocol including a short acting periarticular injection and a longer acting periarticular injection with LB, had equivalent pain control, less narcotic use, faster achievement of physical therapy milestones, earlier and more frequent discharge home, less complications and a lower cost of the episode of care

Aims

Currently, there is no single, comprehensive national guideline for analgesic strategies for total joint replacement. We compared inpatient and outpatient opioid requirements following total hip arthroplasty (THA) versus total knee arthroplasty (TKA) in order to determine risk factors for increased inpatient and outpatient opioid requirements following total hip or knee arthroplasty.