Mary Kay Drummond kept waiting for the pain to come after her Jan. 21 knee replacement surgery. The 59-year-old Pittsburgh woman had her right knee replaced a year ago, and when it was time for her left, she braced herself for the discomfort and immobility she experienced the first time.
That pain never came. Like Drummond, many hip and knee replacement patients at St. Clair Hospital in Mount Lebanon, Pa., are waking up from surgery in less pain and getting back on their feet sooner, thanks to a new cocktail of medication given during surgery.
The combination, which features the anesthetic Exparel, is for patients undergoing total hip and knee replacements. Dr. Brett Perricelli, an orthopedic surgeon at St. Clair, began using the cocktail in October 2013 and said he has seen dramatic improvements in patients' pain levels and recovery time.
"This has changed everything that I have previously learned about hip and knee replacement," he said.
Exparel is a long-acting local anesthetic, and it works much like Novocain used in dentistry.
Perricelli said he has used this method on about 100 patients since he began four months ago, and now uses it on every patient because he is so convinced of its benefits.
The treatment is a multimodal analgesia, or a series of painkillers in various forms. Before surgery, patients receive the painkiller Celebrex and a scopolamine patch to reduce nausea.
During the procedure, Perricelli injects the local anesthetic Exparel, suspended in a fat molecule, into the surgery site. The molecule is genetically modified to slowly release the medication, allowing for pain relief up to 72 hours after surgery. Patients also receive tranexamic acid intravenously to reduce bleeding.
The benefits are twofold: a decreased need for narcotics and increased mobility soon after surgery. When patients wake up with less pain, they are less apt to need narcotics after surgery. Narcotics, though effective in subduing pain, come with various side effects that include grogginess, nausea, urinary retention, confusion and the risk of addiction. After surgery, patients receive the non-narcotic painkiller acetaminophen intravenously for 24 hours or Ultram, another oral pain reliever. Perricelli said patients are still able to take narcotics if needed, but a majority of his patients do not.
Another benefit is the decreased use of nerve blockers during surgery, previously a common practice for hip and knee replacements. The absence of nerve blockers, which relieve pain but delay mobility after surgery, gets patients back on their feet faster. Many patients receiving this treatment are able to walk with assistance the day of surgery. Patients can begin physical therapy sooner. Expedited mobility also decreases the risk of blood clots, which can occur with prolonged inactivity.
For the medical professionals involved, the new treatment was a shift of both procedure and philosophy.
"For years, it was, 'You're in pain; you get narcotics,' and then managing all the adverse effects of narcotics," he said.
Based on early analyses by St. Clair, the new protocol is more cost-effective because patients are taking fewer narcotics and have shorter hospital stays and more effective physical therapy.
Surgeons across the country have also begun to use similar procedures with Exparel for orthopedic surgeries, including doctors in Texas, South Carolina, Maryland and Ohio. Drummond, contrasted her experience with her left knee replacement, using the Exparel cocktail, with her earlier surgery on the right knee, when she received a combination of narcotics and nerve blockers.
She called the difference "amazing." She said, "I am weeks ahead of where I was on the last one."
Following her first surgery, Drummond used a walker for 2 ½ weeks and a cane for several weeks after that. In addition to pain, she experienced limited range of motion. For her second surgery, Drummond left the hospital a day earlier than the last surgery and used the walker for four days before walking unassisted.
She expects to return to work after six weeks, compared with the nine weeks she spent at home last year. Most importantly, she said, is that she hasn't taken narcotics, and is feeling healthier and more aware during recovery.