When pain is a problem

following orthopedic surgery

How the restorative intent of orthopedic surgery can be inhibited by pain management options

With orthopedic procedures in particular, ambulation and functional movement are key to helping patients return to their everyday lives. Because postoperative pain can make it difficult for patients to move around, it is important to manage it effectively. Local anesthetics can be part of a strong foundation for postoperative care. They are generally regarded as safe when dosed and administered correctly. However, generic products are not designed to manage pain beyond 8 to 12 hours, and even long-acting formulations struggle to last beyond 24 hours in part because the inflammatory process inhibits their ability to penetrate the nerve cell membrane.1-4

The overuse of opioids

Due in part to the limitations of local anesthetics, opioid therapy is crucial to many surgeons’ multimodal strategies. However, opioid-related adverse events are associated with many risks, including increased hospital stays.5,6

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Body with diagram of brain leading down to CNS in one leg, close-up of TKA incision with local anesthetic application.

Body with CNS leading down one leg. Close-up of TKA postoperative scar. Callout of opioids next to brain.

Local anesthetics stop pain at the source, blocking the pain signals at the site of injury. However, generic local anesthetics are not designed to provide pain relief beyond 8 to 12 hours, and even longer-acting local anesthetics exhibit limited and inconsistent efficacy beyond 24 hours in part because the inflammatory process inhibits their ability to penetrate the nerve cell membrane.1-4

Top Procedures

  • Knee arthroplasty
  • Spinal fusion
  • Laminectomy, Foraminotomy, Discectomy

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References: 1. Berde CB, Strichartz GR. Local anesthetics. In: Miller RD, Cohen NH, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL, eds. Miller’s Anesthesia. Vol 2. 8th ed. Philadelphia, PA: Saunders; 2015:1012-1054.e4. 2. Carvalho B, Clark DJ, Yeomans DC, Angst MS. Continuous subcutaneous instillation of bupivacaine compared to saline reduces interleukin 10 and increases substance P in surgical wounds after cesarean delivery. Anesth Analg. 2010;111(6):1452-1459. doi:10.1213/ANE.0b013e3181f579de. 3. Kim J, Burke SM, Kryzanski JT, et al. The role of liposomal bupivacaine in reduction of postoperative pain after transforaminal lumbar interbody fusion: a clinical study. World Neurosurg. 2016;91:460-467. 4. Becker DE, Reed KL. Essentials of local anesthetic pharmacology. Anesth Prog. 2006;53(3):98-109. doi:10.2344/0003-3006(2006)53[98:EOLAP]2.0.CO;2. 5. Oderda GM, Evans RS, Lloyd J, Lipman A, et al. Cost of opioid-related adverse drug events in surgical patients. J Pain Symptom Manage. 2003;25(3):276-283. doi:10.1016/S0885-3924(02)00691-7. 6. Pizzi LT, Toner R, Foley K, et al. Relationship between potential opioid-related adverse effects and hospital length of stay in patients receiving opioids after orthopedic surgery. Pharmacotherapy. 2012;32(6):502-514. doi:10.1002/j.1875-9114.2012.01101.x.