Multimodal techniques slash postoperative knee pain.

Charles Uhlinger, 68, hails from western New York but plied his trade in Detroit, Michigan, where he worked for the Ford Motor Company. Charles retired from the automaker after a long career and eventually found his way to the Sunshine State, where he currently resides.

Photo by Jordan Pysz.

Photo by Jordan Pysz.

“At Ford, I was a quality engineer, which involved graphing quality information, checking product quality and other similar tasks,” Charles describes. “I did that job for twenty years, but I worked for Ford for thirty-eight years.

“I was born in Buffalo, New York, but lived in Detroit for nearly forty years. I retired from Ford in 2009 and moved to Florida at the end of 2017. We moved because both of our sons moved to Florida, and my grandkids are down here.”

Three years ago, while still living in Michigan, Charles underwent joint replacement surgery on his right knee. At that time, the doctor told him his left knee was deteriorating rapidly and would likely require replacement surgery in the near future.

“There was a lot of pain in my left knee,” Charles reports. “It was bone on bone inside that knee, so it was causing intense pain. After we moved to Florida, I contacted Coastal Orthopedics, and Dr. Cashen became my doctor. He took care of me for about a year before I finally had my left knee replaced.

“I’m a big softball player, and I was still playing, but I was taking a lot of ibuprofen to be able to play. By January 2019, the pain in my left knee was so bad that I had to stop playing softball. That’s when I knew I needed to get the knee replaced. The surgery was performed in early February of this year.”

David V. Cashen, MD, is an orthopedic surgeon that specializes in joint replacement surgery, performed Charles’ left knee replacement at Lakewood Ranch Medical Center.

“I first met Charles in January 2018,” Dr. Cashen remembers. “At that time, he had been having pain in his left knee for three years. He admitted that the pain rated a nine on a scale of one to ten, and he had trouble going up and down stairs.

“What forced him to seek surgery on that knee, however, was when he began experiencing severe pain while playing softball, which he loves doing. The pain became so intense, he could not run the bases. He needed a pinch runner. That’s when we opted to move forward with joint replacement surgery on his left knee.”

Multimodal Approach

Traditionally, knee replacement surgery and its recovery were a painful process. But today, many orthopedic surgeons take specific steps before and during surgery to improve postoperative pain control. Reducing postoperative pain assists with quick initiation of joint rehabilitation and more rapid achievement of recovery goals.

“Because of the discomfort that patients experience after knee replacement surgery, surgeons do whatever we can to manage pain,” Dr. Cashen confirms. “We follow what’s called a multimodal approach to pain management.

“As part of this approach, we begin by using non-narcotic pain medications, including anti-inflammatories, ibuprofen and steroids, around the time of surgery. Anesthesia is another important part of pain management. That includes spinal anesthesia and nerve blocks that are delivered right before surgery.”

One type of nerve block that is used is the adductor canal block. With this technique, the nerves to the knee are numbed for 12 to 18 hours, which is very beneficial for pain control immediately following surgery.

“Then during surgery, we inject the knee with a medication, a local, long-acting anesthetic,” Dr. Cashen describes. “Instead of wearing off in an hour or two, this anesthetic is effective over a three- to four-day period. That allows the patient to begin therapy prior to severe postoperative pain. It lands them gently into the rehabilitation process.

“The anesthetic is liposomal bupivacaine, and we’ve seen good results with it. It has definitely affected how patients rate their pain after surgery. And it helps them avoid high-dose narcotics, which avoids constipation, nausea and grogginess, and helps decrease patients’ dependence on narcotics in the long run.”

Following surgery, patients spend time in The Orthopaedic Spine and Joint Center, Lakewood Ranch Medical Center’s dedicated orthopedic surgery unit. The center is a 21-bed facility devoted to the care of people having spine and joint surgery, including knee replacement.

“We start rehabilitation right away,” Dr. Cashen states. “Our goal is to get patients up out of bed the day of surgery. If we achieve that, we see lower complication rates and higher patient satisfaction because getting patients on their feet right away has proven to be helpful. And with better pain control, convincing them to stand up and move around is much easier.

Photo by Jordan Pysz.

Charles Uhlinger

“Three to four days post-op, patients may begin to feel severe pain. At that point, we focus on ice therapy for pain control. This helps minimize the amount of narcotics we use. We rely instead on anti-inflammatories and ibuprofen. By the time the pain becomes a problem, we can use a much weaker narcotic that doesn’t have as many side effects.”

Improved Response

Charles recalls being in Lakewood Ranch’s Orthopaedic Spine and Joint Center following his surgery.

“I spent three days and two nights there,” he relates. “It was fantastic. I had a nice, beautiful, private room. The nurses and the care were great. They did some really good in-hospital therapy while I was there, and the food was really good, which is a plus.

“Knee replacement is a painful surgery, but the injection Dr. Cashen gave me during surgery helped. The surgery on my right knee was more painful, and my left knee responded better than my right knee.”

Charles reports that the surgery on his left knee went well. His scar looks good, and he’s healing well.

“I have very little pain now,” he says. “Every once in a while, I get a pain that rates a one or two, but that’s normal. And I’m back to hitting and pitching and playing softball again. I’m golfing again, too, and playing eighteen holes with no problem.

“I’ve already recommended Dr. Cashen to one of my neighbors, and one of my buddies just had his shoulder replaced at Lakewood Ranch Medical Center. He also thought it was a great place. I definitely recommend it. I tell everybody how good my experience was at Lakewood Ranch Medical Center.”

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    • David V. Cashen, MD

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