A Multimodal Pain Management Protocol Including Preoperative Cryoneurolysis for Total Knee Arthroplasty to Reduce Pain, Opioid Consumption, and Length of Stay

Joshua A Urban, Kandice Dolesh, Erin Martin, Joshua A Urban, Kandice Dolesh, Erin Martin

Abstract

Background: A retrospective analysis was conducted to determine if cryoneurolysis of superficial genicular nerves combined with standard care decreased postoperative opioids and pain after total knee arthroplasty (TKA).

Methods: Data from patients who underwent TKA at a single center were analyzed. Patients who received standardized cryoneurolysis before TKA were compared with a historical control group including patients who underwent TKA without cryoneurolysis. Both groups received a similar perioperative multimodal pain management protocol. The primary outcome was opioid intake at various time points from hospital stay to 6 weeks after discharge. Additional outcomes included pain, length of stay, and range of motion.

Results: The analysis included 267 patients (cryoneurolysis group: n = 169; control group: n = 98). During the hospital stay, the cryoneurolysis group had 51% lower daily morphine milligram equivalents (MMEs) (47 vs 97 MMEs; ratio estimate, 0.49 [95% confidence interval (CI), 0.43-0.56]; P < .0001) and 22% lower mean pain score (ratio estimate, 0.78 [95% CI, 0.70-0.88]; P < .0001) vs the control group. The cryoneurolysis group received significantly fewer cumulative MMEs, including discharge prescriptions, than the control group at week 2 (855 vs 1312 MMEs; ratio estimate, 0.65 [95% CI, 0.59-0.73]; P < .0001) and week 6 (894 vs 1406 MMEs; ratio estimate, 0.64 [95% CI, 0.57-0.71]; P < .0001). The cryoneurolysis group had significant 44% reduction in overall length of stay (P < .0001) and greater flexion degree at discharge (P < .0001).

Conclusions: Addition of preoperative cryoneurolysis to a multimodal pain management protocol reduced opioids and in-hospital pain and optimized outcomes during the 6-week recovery period after TKA.

Keywords: Cryoanalgesia; Knee replacement; Multimodal analgesia; Orthopedic surgery; Pain management.

© 2021 The Authors.

References

    1. Trasolini N.A., McKnight B.M., Dorr L.D. The Opioid crisis and the orthopedic surgeon. J Arthroplasty. 2018;33:3379.
    1. Oderda G.M., Said Q., Evans R.S. Opioid-related adverse drug events in surgical hospitalizations: impact on costs and length of stay. Ann Pharmacother. 2007;41:400.
    1. Hansen C.A., Inacio M.C.S., Pratt N.L., Roughead E.E., Graves S.E. Chronic use of opioids before and after total knee arthroplasty: a retrospective cohort study. J Arthroplasty. 2017;32:811.
    1. Namba R.S., Inacio M.C.S., Pratt N.L. Persistent opioid use following total knee arthroplasty: a signal for close surveillance. J Arthroplasty. 2018;33:331.
    1. Hadlandsmyth K., Vander Weg M.W., McCoy K.D. Risk for prolonged opioid use following total knee arthroplasty in veterans. J Arthroplasty. 2018;33:119.
    1. Goesling J., Moser S.E., Zaidi B. Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain. 2016;157:1259.
    1. Cook D.J., Kaskovich S.W., Pirkle S.C. Benchmarks of duration and magnitude of opioid consumption after total hip and knee arthroplasty: a database analysis of 69,368 patients. J Arthroplasty. 2019;34:638.
    1. Cancienne J.M., Patel K.J., Browne J.A., Werner B.C. Narcotic use and total knee arthroplasty. J Arthroplasty. 2018;33:113.
    1. Steiner S.R.H., Cancienne J.M., Werner B.C. Narcotics and knee arthroscopy: trends in use and factors associated with prolonged use and postoperative complications. Arthroscopy. 2018;34:1931.
    1. Politzer C.S., Kildow B.J., Goltz D.E. Trends in opioid utilization before and after total knee arthroplasty. J Arthroplasty. 2018;33:S147.
    1. Exposing a silent gateway to persistent opioid use – a choices matter status report. 2018. [accessed 01.04.20]
    1. Gan T.J. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017;10:2287.
    1. Memtsoudis S.G., Poeran J., Zubizarreta N. Association of multimodal pain management strategies with perioperative outcomes and resource utilization: a population-based study. Anesthesiology. 2018;128:891.
    1. Parvizi J., Bloomfield M.R. Multimodal pain management in orthopedics: implications for joint arthroplasty surgery. Orthopedics. 2013;36:7.
    1. Dasa V., Lensing G., Parsons M. Percutaneous freezing of sensory nerves prior to total knee arthroplasty. Knee. 2016;23:523.
    1. Mihalko W.M., Kerkhof A., Guyton J.L. Cryoneurolysis prior to total knee arthroplasty reduces postoperative pain and opioid use. Orthop Proc. 2019;101-B:69.
    1. Radnovich R., Scott D., Patel A. Cryoneurolysis to treat the pain and symptoms of knee osteoarthritis: a multicenter, randomized, double-blind, sham-controlled trial. Osteoarthritis Cartilage. 2017;25:1247.
    1. Ilfeld B.M., Preciado J., Trescot A.M. Novel cryoneurolysis device for the treatment of sensory and motor peripheral nerves. Expert Rev Med Devices. 2016;13:713.
    1. Ilfeld B.M., Gabriel R.A., Trescot A.M. Ultrasound-guided percutaneous cryoneurolysis providing postoperative analgesia lasting many weeks following a single administration: a replacement for continuous peripheral nerve blocks?: a case report. Korean J Anesthesiol. 2017;70:567.
    1. Ilfeld B.M., Finneran I.V.J.J. Cryoneurolysis and percutaneous peripheral nerve stimulation to treat acute pain: a narrative review. Anesthesiology. 2020;133:1127.
    1. Brat G.A., Agniel D., Beam A. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018;360:j5790.
    1. Hsia H.L., Takemoto S., van de Ven T. Acute pain is associated with chronic opioid use after total knee arthroplasty. Reg Anesth Pain Med. 2018;43:705.
    1. Brummett C.M., England C., Evans-Shields J. Health care burden associated with outpatient opioid use following inpatient or outpatient surgery. J Manag Care Spec Pharm. 2019;25:973.
    1. Gordon T. Peripheral nerve regeneration and muscle reinnervation. Int J Mol Sci. 2020;21:8652.
    1. Bedard N.A., Pugely A.J., Westermann R.W. Opioid use after total knee arthroplasty: trends and risk factors for prolonged use. J Arthroplasty. 2017;32:2390.

Source: PubMed

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