Pain Management Strategies To Reduce Opioid Use Following Total Knee Arthroplasty

Due to the rising concern regarding excessive opioid use, several alternative pain control options have been developed for total knee arthroplasty (TKA). Therefore, the purpose of this article was to review non-narcotic treatments to manage pain after TKA. Specifically, we evaluated: 1) acetaminophen; 2) cyclooxygenase-2 (cox-2) inhibitors; 3) gabapentinoids; 4) dexmedetomidine, 5) nerve blocks; 6) local analgesic infiltration; 7) transcutaneous electrical nerve stimulation (TENS); and 8) perioperative bracing.

A literature search was conducted using the PubMed and EBSCO host electronic databases. All available studies between 1998 and 2018 were evaluated. Searches were performed using the following terms: total knee arthroplasty (title), acetaminophen (title), cyclooxygenase-2 inhibitors (title), gabapentinoids (title), nerve blocks (title), local analgesic infiltration (title), transcutaneous electrical nerve stimulation (title), knee (title), postoperative outcome (title), opioids (title), analgesics (title), alternative (title), heroin (title), chronic pain (title), opioid overdose (title), and cost (title). After full-text analysis of 273 reports that satisfied the search criteria, 58 studies were included in this review.

There is conflicting evidence on acetaminophen and gabapentinoids, with some studies reporting opioid use reduction with their use; whereas, others found no difference. Cox-2 inhibitors can potentially reduce opioid requirements and improve pain scores following TKA; however, they are associated with several side effects. Dexmedetomidine has been associated with reduced postoperative opioid consumption, but it has limited applications as it is associated with several major side effects. Neuraxial anesthesia can potentially help control postoperative pain; however, there is a limited effective window and identifying the specific nerve can be challenging. Local infiltrating analgesia have been found to help relieve pain in the early postoperative period. Multiple studies have identified substantial reductions in pain with knee braces. The non-invasive and non-pharmacologic nature of this treatment option makes it very safe and effective for the generalized TKA population.

The optimal solution for postoperative TKA pain management has yet to be determined. Although several options exist, many of them have been associated with adverse effects limiting their generalizability. Knee braces, however, have been identified as one potentially successful option. Importantly, knee braces are safe for the majority of patients and should be widely recommended for patient use.