The right pain control
In addition to administering hydrocortisone before and after, our multi-
modal protocol includes preemptive pain medications, anti-inflamma-
tories before and after, regional blocks and patient-controlled anesthe-
sia for roughly 36 hours after surgery. I prefer adductor canal blocks
supplemented by saphenous blocks, which our anesthesia team admin-
ister under ultrasound. We rarely use general anesthesia.
Preemptive pain medications include acetaminophen or, in some
cases, oxycontin, though currently we're studying the efficacy and
practicality of using IV acetaminophen. We also administer anti-inflam-
matory drugs before and after surgery, continuing for a couple of
weeks after patients are home. I prefer meloxicam (Mobic), a COX-2
inhibitor that, unlike NSAIDs, doesn't affect platelets and clotting. I'm
not a big proponent of injecting local long-acting anesthetics like bupi-
vacaine around the incision and deep structures before closing the
wound, but many of my colleagues are, and it can be very effective.
Finally, we equip our patients with pain pumps, which they typically
love, because all they have to do is push a button for relief from
breakthrough pain, and the anesthetic doesn't affect their cognitive
function.
Naturally, we're trying to minimize the need for opioids, and we've
been able to document that using hydrocortisone along with the rest
of the protocol greatly reduces opioid use. There was a time when
patients were often using opioids for 6 weeks or more, particularly at
night. Now, most of our patients are able to cast them aside in 2 or 3
weeks and control their pain mostly with Tylenol.
Incidentally, I'm often asked whether I use perioperative hydrocorti-
sone when I'm doing just one knee. The short answer is no, though
I'm expanding my use a little bit with more complex cases. We may
move to using hydrocortisone on all total knees, but first we want to
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