Editorial comment: This piece is sponsored by Pacira BioSciences, Inc. as part of a sponsored content program.
Editor’s Note: Innovative pain management is, we think, the most impactful yet underappreciated technology in total joint arthroplasty today. Not only can a multimodal pain management approach cut opioid use, it ALSO delivers better patient outcomes while reducing days in the hospital and other costs. In this guest editorial, we invited Steven M. Dellose, an orthopedic surgeon specializing in total joint reconstruction, trauma, and fracture management at the Christiana Health Care System in Delaware, to detail the innovative products and strategies he employed to, literally, transform his practice. Thank you Dr. Dellose. – Robin R. Young, Editor Orthopedics This Week
Over the past 20 years, 14 million Americans have been diagnosed with knee osteoarthritis (OA), one of the most common joint disorders in the United States. OA is caused by the progressive loss of articular cartilage which in turn causes pain, swelling, stiffness and decreased ability to move. Given that more than half of all persons with symptomatic knee OA are younger than 65, there is a significant risk for greater disability to develop over time.
Additionally, total knee arthroplasty (TKA) continues to be a popular surgery recommended for those living with OA, as well as other knee problems or injuries. In fact, about 790,000 knee replacements are performed each year, and studies show that the number of TKAs performed annually is expected to increase to 3.48 million by 2030. With all of this in mind, and the knowledge that a knee replacement is an inevitable surgery for many people, being aware of medical advancements and the treatment options available to manage pain, including non-opioids, can help ensure OA and TKA patients have a better recovery and experience.
Opioids, a Tragic Record of Overuse and Addiction
The advent of time-released opioids gave physicians a new tool to manage pain following surgery, including knee replacements and other orthopedic procedures. While opioids were effective in managing post-operative pain, they also proved to be significantly more addictive than expected and set in motion a pattern of overuse, addiction and, tragically, death. The resulting opioid crisis affected both patients and their physicians.
One study revealed that in 2009, orthopedic surgeons were the third highest prescribers of opioids. As orthopedic surgeons at Delaware Orthopaedic Specialists practicing at Delaware Outpatient Center for Surgery and Christiana Care Health System, we believe it is our responsibility as physicians to use innovations that can allow us to minimize opioids in our practices.
Unfortunately, surgery has a history of being an unintentional gateway to opioid dependence due to prescribing in an effort to manage postsurgical pain. A 2018 survey noted that 8 to 12% of patients who had a soft tissue or orthopedic procedure reported that they had become addicted to or dependent on opioids following surgery. In consideration of this data, my practice has been on a mission to implement multimodal pain management strategies, including many different non-opioid options, that allow us to minimize our patients’ exposure to opioids before, during and after surgery.
Innovation: Cryoanalgesia Before Surgery
Whether a patient is wanting to delay a TKA surgery, not a candidate for surgery, or preparing for a scheduled TKA, there is an effective non-opioid treatment available that can provide immediate, targeted, and sustained pain relief prior to surgery. We use cryoanalgesia through iovera°, which delivers a localized, nonpharmacologic nerve block to provide immediate, long-lasting relief of pain. In the past, cryotherapy treatments have been complex and invasive; however, this system utilizes a handheld device to deliver focused cold therapy directly to the nerve. The effect on the nerve is temporary and full function is restored over a period of time.
At times, we see patients who need knee replacements but may be delaying surgery due to events, or until certain modifiable risk factors, such as smoking, obesity or existing medical conditions are optimized. iovera° can effectively help these patients delay surgery, as one treatment with the system can provide pain relief for up to 90 days, allowing patients to function more comfortably and experience a reduction in pain until their procedure.
iovera° administered days or weeks prior to surgery as a “prehab” approach allows patients to immediately feel reduced pain. With pain reduced, patients often feel more confident and comfortable with their upcoming surgery. It can also provide sustained pain relief after the procedure. Additionally, I also use iovera° for chronic knee OA sufferers to help minimize the pain they experience from the condition, especially if they are not a candidate for surgery due to age or existing health conditions.
Innovation: Long-Acting Pain Management Following Surgery
For patients undergoing TKA, we use a non-opioid option called EXPAREL® (bupivacaine liposome injectable suspension) during surgery. EXPAREL is a long-acting local anesthetic that is injected into the surgical site and releases a local numbing medication for the first few days following the procedure, providing postsurgical pain relief. Since using this approach, we have noticed that our patients are ambulating sooner, starting rehabilitation earlier, and recovering more quickly. Most patients can go home the same day as surgery.
Benefits: Continue During Recovery
Perhaps most importantly, since incorporating a multimodal pain management protocol, including non-opioid options, regional blocks, spinal anesthesia, and regularly scheduled acetaminophen, among other medications, our practice has reduced postsurgical opioid prescribing among our TKA patients without compromising patient satisfaction or overall pain control. In fact, some of our repeat TKA patients have received one surgery with iovera° and one without and these patients have shared that they experienced noticeably reduced pain with the use of iovera°. Given that a multimodal pain management pathway reduces both pain and opioid consumption, we have implemented it into all our TKA cases.
As orthopedic surgeons, we realize the effects that the overreliance on opioids can have on patients, not to mention side effects such as nausea, constipation, dizziness, or drowsiness, etc. We have the opportunity to really make a difference for our patients while simultaneously helping to combat this crisis.
Note, Dr Dellose is a consultant for Pacira BioSciences, Inc.
Please visit www.iovera.com/safety for full safety and prescribing information.
Indication
EXPAREL® (bupivacaine liposome injectable suspension) is indicated for single-dose infiltration in patients aged 6 years and older to produce postsurgical local analgesia and in adults as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.
Important Safety Information
EXPAREL is contraindicated in obstetrical paracervical block anesthesia.
Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via interscalene brachial plexus nerve block were nausea, pyrexia, and constipation.
Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritis, and tachycardia.
If EXPAREL and other non-bupivacaine local anesthetics, including lidocaine, are administered at the same site, there may be an immediate release of bupivacaine from EXPAREL. Therefore, EXPAREL may be administered to the same site 20 minutes after injecting lidocaine.
EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for interscalene brachial plexus nerve block, and/or pregnant patients.
Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.
Warnings and Precautions Specific to EXPAREL
Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL.
EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, or intravascular or intra-articular use.
The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.
Warnings and Precautions for Bupivacaine-Containing Products
Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.
Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability, which may lead to dysrhythmias, sometimes leading to death.
Allergic Reactions: Allergic-type reactions (e.g., anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.
Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.
Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.
Full Prescribing Information is available at www.EXPAREL.com.
