Multimodal Pain Management in Orthopedic Surgery

Abstract

Background: Orthopedic surgery typically results in moderate to severe pain in a majority of patients. Opioids were traditionally the primary medication to target mechanisms of pain transmission. Multimodal analgesia has become a preferred method of pain management in orthopedic practice. Utilizing more than one mode to address post-surgical pain by recruiting multiple receptors through different medications accelerates the recovery process and decreases the need for opioids. By implementing effective analgesic techniques and interventions, this practice, in turn, decreases the usage of perioperative opioids, and in the long term, prevents addiction to pain medications and risk of opioid overdose. In orthopedic surgeries, previous studies have found that multimodal analgesia has reduced early opioid usage in the postoperative course. Pain is the result of direct injury to the nervous system, with a wide variety of chemicals directly stimulating or sensitizing the peripheral nociceptors. The pathophysiology behind the mechanism of post-surgical pain, along with the importance of preoperative, perioperative, and postoperative pain regimens are emphasized. A brief overview of pain medications and their properties is provided. These medications are further categorized, with information on special considerations and typical dosage requirements. Pain management should address both neuropathic and subjective types of pain. Effective pain control requires constant reassessment with individualized strategies. Conclusion: By focusing on multimodal analgesia, anesthesiologists can now utilize newer techniques for postoperative pain relief from orthopedic surgery, with better short-term and long-term outcomes for the patient.

Femoral–Obturator–Sciatic (FOS) Nerve Block as an Anesthetic Triad for Arthroscopic ACL Reconstruction: Is This the Magic Trick We Were Missing?

“…Nowadays, the proliferation of Enhanced Recovery After Surgery (ERAS) protocols, the concept of preemptive multimodal analgesia [9], and the "opioid epidemic" [24] have all contributed to the increased use of regional anesthesia techniques, including PNB. In terms of time management, PNB, when performed in the context of a pre-anesthesia block room, can significantly reduce operating room and post-anesthesia care unit occupancy [25].…”

“…According to the current literature, "orthopaedic procedures are amongst of the most painful procedure a patient can undergo" [9], resulting in moderate-to-severe postoperative pain. Accordingly, following arthroscopic ACL reconstruction, acute postoperative pain is one of the most common postoperative complications, followed by hemarthrosis [5,10].…”

“…Performing PNBs before the surgical incision, as part of the concept of pre-emptive multimodal analgesia, leads to improved pain control after surgery, and the success of this treatment has been well documented in joint arthroplasty, resulting in lower pain scores up to 12 months postoperatively [5]. Although multimodal pain management protocols have not yet been established for arthroscopic ACL reconstruction, it appears that the application of PNBs as an anesthetic technique may be the answer we have been missing for optimal postoperative analgesia in these procedures [5,9].…”

Rehabilitation Strategies Following Posterolateral Corner Repair for Left Knee Dislocation With Multiligament Injury: A Case Report

“…Pain management strategies, including multimodal approaches such as cryotherapy, compression, and manual therapy, have played a pivotal role in reducing pain intensity and improving functional recovery post-surgery. Studies by Lewis et al [ 14 ], Quesnot et al [ 15 ], and Chunduri and Aggarwal [ 16 ] have demonstrated the effectiveness of multimodal pain management strategies in knee surgery. These studies have shown that the combination of cryotherapy, compression, and manual therapy not only reduces pain but also facilitates an earlier return to functional activities and improves patient satisfaction.…”

A Comprehensive Review of Postoperative Analgesics Used in Orthopedic Practice

“…For instance, some may wish to avoid opioids due to concerns about sedation and constipation. In contrast, others may have had positive experiences with opioids in the past and feel more comfortable with this type of medication [ 12 , 13 ].…”