Easing Knee Replacements

New anesthesia techniques minimize pain and maximize recovery.

Three years ago, Laura Breton escaped the bone-chilling winters of Western New York and moved to Florida, where she enjoys the balmy weather and her retirement. The Buffalo native couldn’t escape all her aches and pains. She’s had knee problems since she was a teen, and she brought those problems with her.

Photo by Fred Bellet.

Laura can put weight on her right knee Again after the surgery.

“I recall my knees bothering me back when I was in high school,” she confides. “I didn’t have an injury; knee problems run in my family. I have two sisters who have the same thing as me. My problem was an ongoing thing. As I got older, the pain got worse.
“I had a knee replacement on my left knee in 2004 in Buffalo, and it was very painful. In the hospital, the nurses wanted me to stand, and I couldn’t for the life of me. The pain was absolutely horrible; it was just so sharp. It was a ten out of ten or maybe beyond. I could not put pressure on my knee. It was ridiculously painful.”
After Laura was discharged from the hospital, she was sent for rehabilitation for two weeks. They gave her medication for the pain, but still she suffered.
“It was just unbelievably painful,” she laments. “My knee even got infected. It was really a bad situation, so I didn’t press the issue of getting my other knee done until it got so bad I just had to do it.
“My right knee got to the point that when I went up and down stairs, I could feel the bones grinding on each other. I guess there was no cartilage left in my knee. It was painful just to walk around.”
When Laura could no longer handle the agony in her right knee, she sought out the orthopaedic surgeon she’d seen for a previous injury, David V. Cashen, MD, of Coastal Orthopaedics & Sports Medicine. Coastal Orthopaedics is a group of physicians who work closely with Lakewood Ranch Medical Center in Bradenton.
“When Laura came to see me, she had severe, end-stage, degenerative arthritis in her right knee,” reports Dr. Cashen. “I initially attempted conservative treatments, including physical therapy, strengthening and anti-inflammatories. These did not give her relief from her pain. Eventually, she decided to proceed with a right knee replacement.”
“Dr. Cashen told me about this new medicine they now use,” states Laura. “He encouraged me to have the knee replacement done, so I trusted him and said okay. I had the surgery in August 2016.”

Multimodal Approach

Not only did Dr. Cashen use a minimally invasive technique for Laura’s second surgery, he also employed an advanced method for pain reduction that provided a huge improvement over her first procedure.
“The biggest difference in this surgery from her first knee replacement is the use of a multimodal pain management approach,” notes Dr. Cashen. “This approach involves taking steps to limit patients’ use of narcotics, which helps to mobilize them more efficiently and effectively.
“Initially, as part of the surgical process through Lakewood Ranch’s Orthopaedic Spine and Joint Center, we do extensive pre-operative education. During that education, we focus very heavily on explaining what a knee replacement is, how much pain patients may experience and ways they can deal with that pain.”
The Orthopaedic Spine and Joint Center is Lakewood Ranch Medical Center’s dedicated orthopaedic surgery unit, and Dr. Cashen is its medical director. The center is a 21-bed facility devoted to the care of people having spine and joint surgery, including knee replacement. The Orthopaedic Spine and Joint Center staff follows specific guidelines and protocols designed to quickly initiate rehabilitation and enhance patient recovery.
“As part of the process, surgeons provide multiple means of pain management, not just the traditional patient-controlled morphine pumps and oral narcotics,” explains Dr. Cashen. “We still use those when needed, but as little as possible. Instead, we use different types of anesthesia during surgery.”
Neuraxial anesthesia is an injection into the spine that numbs the leg, so the patient can’t feel any pain. When patients who receive neuraxial anesthesia wake up from surgery, they’re comfortable and don’t need high doses of narcotics for initial pain control.
“Giving patients narcotics early after surgery can lead to confusion and uncomfortable symptoms,” informs the doctor. “Then, it is harder to get them up and moving around to begin the second part of treatment, physical therapy and rehabilitation.
“The next phase of the multimodal approach is a saphenous nerve block, which affects approximately seventy percent of the pain receptors in the knee. This block can last anywhere from six to eighteen hours, and again, the patients need less narcotics for pain relief. The saphenous nerve block affects sensory, or feeling, nerves only. Function is not disturbed, so patients can walk and do physical therapy safely.”
The saphenous nerve block doesn’t provide 100 percent relief, however, so surgeons supplement it with a medication cocktail containing a long-acting anesthetic called EXPAREL®.
“The effects of the EXPAREL cocktail can last up to and sometimes longer than three days,” observes
Dr. Cashen. “The biggest benefit is that it provides another way to eliminate the knee pain. These medications eventually wear off, and the patients will experience some pain, but by that time, it is typically manageable with Tylenol®, low-dose narcotics and ice therapy.”

Second Time Around

From the time Laura woke up from surgery, she noticed her recovery was significantly easier and less painful than it had been with her first knee procedure.
“The contrast was wonderful,” she marvels. “Right after I had the second surgery, my pain was maybe a four or five. This time, I could walk on my knee right away. I had to use a walker, but I could put pressure on it.
“I was in the hospital for only a couple of days, and I didn’t even go to rehab. I went home, and my sister was there to help me for a week or two. Within a couple of weeks, I was doing absolutely fine and not taking pain medications. My knee’s been fine ever since.”

“Being at Lakewood Ranch Medical Center is like a breath of fresh air compared to the hospitals I’ve been in before, and I’ve been in hospitals quite a few times in my life.” -Laura

For Laura, Dr. Cashen’s multimodal pain management approach made a significant difference in her postoperative discomfort, making her recovery much easier and quicker than her first experience. She also credits the staff and facilities at Lakewood Ranch Medical Center’s Orthopaedic Spine and Joint Center for making her time there exceptional.
“The Orthopaedic Spine and Joint Center is great. I loved it,” she enthuses. “It’s like a hotel. I had my own room, and it was more like a bedroom. It was beautiful. It had wallpaper and pictures on the walls.
“The staff is very nice and caring. Being at Lakewood Ranch Medical Center is like a breath of fresh air compared to the hospitals I’ve been in before, and I’ve been in hospitals quite a few times in my life.
“My sister needs to have her knees done, and she keeps going back and forth about it. I’ve told her how much better my second surgery was as far as recovery, pain, everything. I definitely recommend the new approach to anybody. And I absolutely recommend Lakewood Ranch Medical Center. It’s great!”

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    • David V. Cashen, MD

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