Multimodal Pain Management and Arthrofibrosis

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Abstract

Pain control after arthroplasty has been a key concern for orthopedic surgeons. After total knee arthroplasty (TKA), a small group of patients developed a painful joint with suboptimal range of motion. Manipulation under anesthesia increases flexion and extension while decreasing pain in most cases. The objective of the present investigation is to asses the effect of a multimodal pain management protocol on arthrofibrosis in primary TKAs. A cohort of 1136 patients who underwent primary TKA was selected. Patients were divided into 2 groups: group A had 778 procedures performed using a traditional approach to pain control; group B included 358 procedures that received multimodal pain management. Group A had an incidence of manipulation of 4.75% (37/778). Of 357 patients, 8 required manipulation in group B, which is an incidence of 2.24%. We recommend that orthopedic surgeons consider using a multimodal pain management protocol for TKA.

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Materials and Methods

The implant registry at the Orthopedic Institute at Mercy Hospital (Miami, Fla) was used to select all patients with a minimum follow-up of all cases being 2 years (range, 2-9 years). The patients were divided into 2 groups. Group A consisted of 778 procedures performed using a traditional approach to pain control that consisted of contemporary techniques used at the time, including patient-controlled analgesia pumps and opioid medications on demand. Patients received cruciate-retaining devices

Statistics

We used descriptive statistics to examine our results and describe incidence of manipulation and time to manipulation. An independent t test was used to assess for differences between groups with respect to incidence of manipulation. We also used independent t tests to compare active and passive knee flexion and extension range of motion between those who had manipulation after having the traditional pain protocol and those who had manipulation while previously having the multimodal pain

Results

Group A had an incidence of manipulation of 4.75%: 37 of 778 cases required manipulation within the first 6 weeks postoperatively (Fig. 1). Thirty (78.9%) were female, and 7 (21.1%) were male. The average age of this group was 63.2 years (range, 31-93 years), and their mean BMI (weight in kilograms divided by the square of height in meters) was 31.2 kg/m2 (range, 23.2-40.2 kg/m2). Twenty-six were Hispanics (70.2%), 9 (24.3%) were white, and 2 (5.4%) were African American. The average time

Discussion

Arthrofibrosis after TKA continues to be a significant complication for orthopedic surgeons [4]. In some series of revision TKA, arthrofibrosis has been present in almost 17% of cases [4]. The reported incidence of manipulation after TKA shows inconsistent rates 10, 11, 12. The threshold for manipulation, on the other hand, is relatively consistent with most authors manipulating the knees that do not bend past 90° at 4 to 6 weeks. Our study showed 37 manipulations in the group of 778 patients

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Financial support has been received by the corresponding author. Institutional support: Mercy Hospital, Miami, Fla; Zimmer, Inc, Warsaw, Ind; and the Arthritis Surgery Research Foundation, Inc, Miami, Fla. Royalties: Zimmer, Inc, Warsaw, Ind.

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