Pain Control and

rapid rehabilitation

C Dodd

Nuffield Orthopaedic
Centre, Oxford

J Goodfellow, J OConnor, D Murray,

C Dodd, P Mclardy-Smith, R Gundle,
R Gill, D Beard, A Price, J Rees, A Weale,
G Keyes, S White, R Miller, A Short, JN Argenson,
V Psychoyos
 Development

Minimally invasive approach

Mackintosh, Marmor
Popularised by Reppicci
Pain Control - Local infiltration
Reppicci - Day case (23hrs)
Kohan & Kerr - Day case (5hrs)
 Education
What to expect
Pain control
Some pain, less than pre-op
Rehabilitation
Discharge plans
 Pain control - per operative
Day case anaesthetic (no blocks)
Local infiltration
Ropivacaine 300mg (40ml 0.75%)
Ketorolac 30mg
Adrenaline 0.5mg (0.5ml 1:1000)
Saline to 100ml
x2 50ml syringes, 19 gauge spinal needle
Damaged tissues & 3 cm out under skin
Firm bandage (block lasts longer)
Pain Control - Post operative
Regular - prevent pain - 5 days
Ibuprofen 800 mg TDS (or Cox 2)
Paracetamol 1000 mg QDS
Ranitidine 150 mg BD

As necessary - breakthrough pain

Codeine 30-60 mg QDS
Tramadol 50-100 mg QDS
 Pain control - Optional
Epidural catheter
With filter
Inserted in knee at operation (lateral gutter)
Following morning (before block wears off)
Clamp drain
Bupivacaine 20ml 0.5% (or ropivacaine)
Catheter and drain removed
 Post operative care
Drain - remove following morning
Eat & drink - 2hrs
Mobilisation
Walk from 2hrs (helps pain relief)
Splint as necessary for walking, 2 days
Flexion
Day 1 (drain & LA) achieve flexion
Thereafter flex as tolerated - will improve
Physio may aggravate the knee
 Discharge
Day of discharge not critical
Our routine day 4 to 5
Currently undertaking RCT comparing
day case (24hr) with routine
Prior to RCT pilot study (n=8)
Day case - Oxford Experience
Patient selection
Suitable home situation, & location
Good general health, low anaesthetic risk

24hr mobile telephone number

Emergency instructions & protocol
Outpatient 5 days
Wound review, Intensive exercises
Patients - mean age 60, KSS 43/100
 Results
All discharged day 1
Post Op Pain (VAS 0-10)
1 admin error
10 Day
No medical comp. Night
8
Walking
No early readmissions
6
1 late readmissions
4
MUA at 3 months
2
80 to 120 degrees
0
Pain less than pre op 1 2 3 4 5 6 7 8 9 10
Days post op
 Pain - at clinic reviews
up to 6 weeks
At clinic
8
Pain
at clinic 6
VAS 0 to 10
4
Less than pre op
6 weeks - Good relief 2

0
Pre-op 1 wk 2 wks 6 wks
 Results - ROM
160 Flexion Extension
140
125
111
range in degrees

120

100 91
80

60

40

20 4 1.4 1.2
0

pre op 2 weeks 6 weeks

 Summary
Pain control - key element
Less pain than pre-op
Technique evolving
Excellent early clinical results possible
Day case possible for appropriate patients
 Although pain control is

important - dont

compromise on the surgical

technique!

Thank you