4.7 Postoperative management: general considerations

10.1055/b-0038-160837

4.7 Postoperative management: general considerations

Liu Fan, John Arraf

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1 Introduction

The overall care plan for a trauma patient should cover the preoperative management, the surgical procedures, and postoperative care ( Table 4.7-1 ). All too often, it is following surgical intervention that vigilance is relaxed and complications may occur. These, at best, deprive the patient of the full benefit of the procedure and, at worst, may seriously reduce a patient′s quality of life.

**Table 4.7-1** Guidelines for postoperative treatment of specific adult fractures according to AO principles. The aim of operative fracture treatment is functional restitution and early pain-free active mobilization. Surgery followed by immobilization is a poor combination.
Fracture type and fixation	Postoperative positioning	Additional limb support	Exercise, weight bearing	Comment
Humerus, proximal: “dynamic“, unstable splinting by K-wire	Orthopedic sling, Gilchrist′s bandage, abduction frame, etc	Immobilization for 3 weeks	Pendulum exercises starting at once, active-assisted mobilization after week 2 Partial functional use: week 3–6 Full functional use: week 6–10	Note: associated injuries (eg, rotator cuff)
Humerus, proximal: “stable“ fixation: PHILOS, PHN	Arm placed on a cushion, orthopedic sling	Orthopedic sling for 2 weeks	Active-assisted mobilization starting at once Partial functional use: week 3–6 Full functional use: week 6–10	More details in Table 6.2.1-1 Shoulder rehabilitation protocol
Humerus, shaft: “stable“ fixation: intramedullary nail, plate	Arm placed on a cushion, elevated position	Orthopedic sling for 1 week	Active-assisted mobilization starting at once Partial functional use and limited rotation: week 4–6 Full functional use: week 6–10	Mobilization of the shoulder and elbow
Humerus, distal: stable ORIF	Arm placed on a cushion, elevated position	Upper arm splint or sling	Active-assisted mobilization starting at once Partial functional use and limited rotation: week 4–6. Full functional use: week 6–10	Mobilization of the shoulder, no forced passive manipulation
Olecranon: tension band	Arm placed on a cushion, elevated position	None	Active-assisted mobilization starting at once Partial functional use and limited rotation: week 4–6 Full functional use: week 6–12	Mobilization of the shoulder
Radial head: stable ORIF	Arm placed on a cushion, elevated position	Sling, exceptionally removable splint	Limited rotation: week 0–4 Partial functional use: week 4–6 Full functional use: week 6–8	Note: associated ligament injuries, mobilization of the shoulder
Forearm, shaft: stable plate fixation	Arm placed on a cushion, elevated position	None or light splint	Active-assisted mobilization starting at once Partial functional use: week 4–6 Full functional use: week 6–10	Note: mobilization of hand, wrist, elbow, and shoulder, splint for associated neurological injuries
Radius, distal: “stable” fixation: plate	Elevated position	Positioning splint	Active-assisted mobilization starting at once Partial functional use: week 4–6 Full functional use: week 6–10	Mobilization of adjacent joints (including shoulder)
Radius, distal: “unstable” fixation: K-wire	Elevated position	Palmar splint or cast	Mobilization of adjacent joints	–
Radius, distal: external fixation	Elevated position	Sling	Active exercises for mobile fingers	Release of distraction after 3–4 weeks, mobilization of the elbow and shoulder
Femur, neck: screw fixation or DHS	Leg extended in slight abduction (cushion between legs)	None	Young patients (< 60 years of age): 30 kg week 0–4; 50 kg week 4–6, then full weight bearing Older patients: full weight bearing	If stable: full weight bearing, consider compliance of the patient and bone quality
Femur: intertrochanteric/pertrochanteric: DHS/PFNA	Leg extended in slight abduction (cushion between legs)	None	Young patients (< 60 years of age): par tial weight bearing (toe-touch): 15 kg week 0–4, 30 kg week 4–6, then full weight bearing when pain has dissipated Elderly patients (> 60 years of age): full weight bearing	With intramedullary implant, full weight bearing can star t immediately
Femur: subtrochanteric: PFNA, AFN, DCS, angled blade plate	Leg extended	None	Partial weight bearing: 15 kg week 0–6, 30 kg week 4–10 Elderly patients (> 60 years of age): full weight bearing
Femur, shaft: stable fixation with locked intramedullary nail	Leg extended	None	Partial weight bearing: 15 kg week 3–4 All femurs nailed are full weight bearing. If plated, full weight bearing with active hip and knee movements	Dynamization is rarely indicated
Femur, shaft: stable plate fixation	90°–90° positioning or CPM Note: protect common fibular nerve	None	Partial weight bearing: 15 kg week 3–6, 30 kg week 6–8 Full weight bearing: af ter week 8 Knee should be exercised without restrictions	Consider compliance of the patient and fracture pattern/MIPO
Femur, distal: LISS/DCS angled blade plate	90°–90° positioning, (CPM) Note: protect the fibular nerve	Knee brace in case of associated ligamental lesions	Partial weight bearing: 15 kg week 0–6, 30 kg week 6–10 Full weight bearing: week 10–12 Knee should be moved without restrictions	“Stable” situation: full weight bearing from week 6–8
Tibia, proximal: LCP/L-plate LISS plate	Elevated position, (CPM)	(Dorsal splint or knee brace in extension)	Partial weight bearing: 15 kg week 3–6, 30 kg week 6–10 Full weight bearing: week 10–14 After 2–3 weeks in full ex tension, splint should be removed and knee flexion is begun but ex tension must be emphasized	Avoid resting knee flexion to prevent loss of knee extension
Patella: tension band	Elevated position, (CPM)	–	Isometric quadriceps exercises at once Partial weight bearing on fully ex tended leg: 30 kg week 0–6 Full weight bearing: week 6–8	Active-assisted flexion of the knee starting at once (to a maximum of 90°)
Tibia, shaft: intramedullary nailing	Elevated position	None	Partial weight bearing: 15 kg week 0–2, 30 kg week 2–4 Full weight bearing: when comfor table	Prevention of pes equinus
Tibia, shaft: plate fixation LC-DCP, LCP absolute stability	Elevated position	None	Partial weight bearing: 15 kg week 0–6, 30 kg week 6–10 Full weight bearing: week 10–12	Prevention of pes equinus, watch for clinical and radiological signs of instability
Tibia, shaft: plate fixation LC-DCP, LCP Relative stability	Elevated position	None	Partial weight bearing: 15 kg week 0-6 followed by progressive weight bearing as healing dictates	Prevention of pes equinus, watch for clinical and radiological signs of instability
Tibia, distal: pilon: different pilon plates	Elevated position, CPM	Postoperative U-splint to prevent pes equinus	Partial weight bearing (toe-touch): 15 kg week 0–6, 30 kg week 6–12 Full weight bearing: week 12–14	Active-assisted mobilization at once
Malleoli	Elevated position, (CPM)	Postoperative U-splint Associated ligamental injuries: cast for 6 weeks	Immediate full weight bearing as tolerated unless contraindication such as diastasis, diabetes, alcohol abuse, or neuropathy	In case of a position screw, dorsal extension and full weight bearing should be restricted until screw removal (week 12–16)
Calcaneus	Elevated position	Removable splint to prevent pes equinus	Nonweight bearing for 6 weeks then par tial weight bearing 6–10 weeks Full weight bearing: af ter week 10–16	Active-assisted mobilization at once of the ankle, subtalar joint, and toes Diabetics with neuropathy should be splinted and have restricted weight bearing for 8–12 weeks
Abbreviations: AFN, antegrade femoral nail; DCS, damage-control surgery; DHS, dynamic hip screw; ORIF, open reduction and internal fixation; PFNA, proximal femoral nail antirotation; PHILOS, proximal humerus internal locked system; PHN, proximal humeral nail.

Postoperative management is not limited to the time spent in hospital but must be continued at home and later at work and at leisure. To achieve this, three postoperative phases are recognized:

In the first phase, immediately after surgery, emphasis is on pain control, mobilization, prevention, and early recognition of complications.
In the second phase, after hospitalization, attention is centered upon integration into the social environment and mobilization.
The final phase concludes treatment and returns the patient to his/her preoperative capabilities including work, education, and leisure activities.

2 First phase—immediate postoperative phase

2.1 Postoperative pain management

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” [1]. In addition to being an unpleasant experience for the patient, poorly controlled pain may have deleterious physiological consequences for the patient leading to increased morbidity [2].

With adequate analgesia the orthopedic patient will be able to mobilize and perform physical therapy better and recover more quickly.

The simplest and most common methods used to quantify pain are scales that measure the intensity of the pain. Among the most commonly used is the Visual Analog Scale (VAS), which consists of a straight line with the words “no pain at all” on one end and “worst pain imaginable” on the other ( Fig 4.7-1 ). Patients quantify the severity of their pain by placing a mark along the scale [3]. Measurement can be improved by using a standard 10 cm line and then quantifying the pain from 0 to 10 for later comparison. By quantifying pain on VAS, pain can be classified as mild (VAS 1–4), moderate (VAS 4–7), or severe (VAS 7–10). However, surgeons should be aware that pain scores can be affected by anxiety, with more anxious patients reporting higher pain scores [4] and a significant correlation between high anxiety and high reported pain. This emphasizes the close interaction of psychosocial factors and pain. The World Health Organization′s Analgesic Ladder can be adapted to suit the needs of the orthopedic patient ( Table 4.7-2 ).

**Fig 4.7-1** Numerical Visual Analog Scale.

**Table 4.7-2** World Health Organization Analgesic Ladder for pain in orthopedics.
Mild pain	Acetaminophen*, acetylsalicylic acid, or other NSAIDs +/− coanalgesics†
Moderate pain	Weak opioid analgesics such as oxycodone, codeine, or tramadol with acetaminophen +/− NSAIDs +/− coanalgesics
Severe pain	Potent opioid analgesics such as morphine or hydromorphone +/− acetaminophen +/− NSAIDs +/− coanalgesics +/− regional anesthesia techniques‡
^*Acetaminophen = paracetamol ^†Coanalgesics include antidepressants, anticonvulsants ^‡Regional anesthesia techniques include epidural analgesia, plexus catheters or single injection nerve blocks Abbreviations: NSAID, nonsteroidal antiinflammatory drug.

2.1.1 Analgesics

Acetaminophen has no antiinflammatory effect; it is an effective analgesic and antipyretic. Doses are 10–15 mg/kg orally every 4–6 hours. For adults, these may be doses of 500–1,000 mg (depending on availability) every 4–6 hours. Rectal suppositories may be given in doses of 15–20 mg/kg every 4 hours and it is now available for intravenous administration. The total daily dose of acetaminophen for adults from all sources must not exceed 4 g to prevent liver toxicity.

Nonsteroidal antiinflammatory drugs (NSAIDs) given even as a single dose preoperatively can significantly decrease morphine requirements by up to 29% over 24 hours [5]. This translates into a lower incidence of opioid-induced adverse effects, such as pruritus, nausea and vomiting. Unlike opioids, which exert their effect predominantly on rest pain, NSAIDs have shown considerable efficacy in minimizing pain associated with movement, thereby facilitating postoperative physiotherapy and minimizing postoperative physiological impairment [6]. Reducing postoperative opioid requirements may also decrease the likelihood of sedation and opioid requirements may also decrease the likelihood of sedation and opioid-induced respiratory depression. In addition to single preoperative doses, NSAIDs may also be given at regular scheduled intervals as appropriate ( Table 4.7-3 ).

**Table 4.7-3** Nonsteroidal antiinflammatory drugs dosing [7, 8].
Drug	Adult dose	Pediatric dose
Ibuprofen	Oral: 200–400 mg every 4–6 h, max 3.2 g/d	Oral: 4–10 mg/kg every 6–8 h to max 40 mg/kg/d
Indomethacin	Oral, rectal: 25–50 mg/dose, 2–3 times daily, max 200 mg/d	Oral: 1–2 mg/kg/d in 2–4 separate doses, max 4 mg/kg/d
Acetylsalicylic acid (ASA)	Oral: 650–975 mg every 4–6 h, max 4 g/d	Oral: 10–15 mg/kg every 4–6 h, max 60–80 mg/d
Naproxen	Oral: 500 mg initial dose, then 250 mg every 6–8 h, max 1,250 mg/d	Oral: 5–7 mg/kg every 8–12 h max 1,000 mg/d
Diclofenac	Oral: 50 mg, 3 times daily, max 200 mg/d	Oral: 2–3 mg/kg/d in 2–4 separate doses
Ketorolac	Intravenous: 10–30 mg every 6 h, max 120 mg/d Oral: 10 mg every 6 h, max 40 mg/d	Intravenous: 0.5 mg/kg every 6 h

Some of the more common adverse effects of NSAIDs include gastric bleeding and ulceration, bleeding from the operative site, nephrotoxicity, bronchospastic hypersensitivity reactions, and the suppression of heterotopic bone formation. Nonsteroidal antiinflammatory drugs should be used with care in geriatric patients and avoided in patients with impaired renal function.

Of special interest is the effect of NSAIDs on bone healing. Although there is evidence from animal studies that NSAIDs inhibit bone healing via their antiinflammatory effect [9], there is increasing evidence that their short-term use in humans does not affect fracture healing [10].

COX-2 inhibitors are well known for their analgesic efficacy. Their lower potential to induce gastrointestinal bleeding and minimal effect on platelet function make them seem an attractive choice in the elderly orthopedic patient. However, their propensity for harm in patients at risk for cardiovascular disease precludes their use in this population [11].

Because of concerns about cardiovascular problems, many COX-2 inhibitors have been withdrawn.

Neuromodulating drugs, such as amitriptyline, gabapentin, and pregabalin have been explored for their coanalgesic effect in the setting of postoperative pain. Turan et al [12] found that in the setting of spine surgery, a single oral dose of 1,200 mg gabapentin preoperatively decreased not only early postoperative pain scores but also resulted in a large reduction in morphine requirements and a significant reduction in opioid-related adverse effects postoperatively. Anticonvulsant drugs exert their diverse pharmacological effects on both ascending and descending pain pathways through a variety of mechanisms, including sodium and calcium channel blocking [13]. The dose of gabapentin for chronic pain ranges from 900–1,800 mg/day. These drugs may also have a place in the management of phantom pain following amputation and in the setting of elective amputation may be started a few days before surgery.

N-methyl-D-aspartate antagonists receptor antagonists, such as ketamine, magnesium and dextromethorphan, potentiate opioid analgesia through their modulation of pain pathways. Their use results in decreased morphine consumption and significantly decreased postoperative pain [14].

Opioid analgesics are a cornerstone of treatment for moderate to severe postoperative pain. Opioids exert their analgesic effects in the central nervous system at the µ-, κ-, and δ-receptors. All pure opioid analgesics cause a dose-dependent sedation and respiratory depression that is similar at equianalgesic doses. This phenomenon is exacerbated by the concomitant use of benzodiazepines, sedating antiemetics, and antihistamines.

Codeine is a weak opioid frequently used in conjunction with acetaminophen for the treatment of mild to moderate pain. Codeine is a prodrug that undergoes hepatic O-de-methylation to morphine, which is primarily responsible for its analgesic effect. Approximately 7–10% of Caucasians lack the enzyme cytochrome CYP2D6 that is necessary to convert codeine to morphine, and it is likely that this sizable segment of the population will not obtain pain relief from this drug. Conversely, in some populations up to 30% of patients have duplicate copies of the gene resulting in much higher and potentially dangerous serum morphine levels [15]. For this reason, codeine should not be used as a first-line analgesic unless the patient has a favorable history with this drug ( Table 4.7-4 ).

**Table 4.7-4** Opioid analgesics **[8]**.*
Drug	Equianalgesic parenteral adult dose, mg	Equianalgesic oral adult dose, mg	Duration of action, hours
Codeine	120	200	3–4
Oxycodone	5–10	30	2–4
Hydrocodone	—	5–10	2–4
Morphine	10	30–60*	3–4
Meperidine	100	300	2–3
Hydromorphone	1.5	6	2–4
Fentanyl	0.1	—	0.5
*60 mg morphine for acute dosing, 30 mg for chronic dosing due to accumulation of metabolites.

Oxycodone and hydrocodone are oral opioid analgesics used in the treatment of moderate to severe pain. Unlike codeine, neither drug undergoes extensive metabolism prior to exerting their analgesic effect. Both oxycodone and hydrocodone are commonly used in conjunction with acetaminophen for the treatment of pain. Oxycodone, like morphine, is commonly used as a sustained-release preparation for around-the-clock dosing.

Morphine is the drug to which other opioids are compared. It penetrates the blood-brain barrier poorly, so that peak analgesic effects do not occur for 15–30 minutes after intravenous injection. It is hepatically conjugated and renally excreted as morphine-6-glucuronide. Because this metabolite can accumulate in renal failure and cause respiratory depression, morphine should be avoided in patients with renal insufficiency.

Meperidine is a synthetic opioid with 1/10 the potency of morphine. Its onset is significantly faster than morphine and it exerts a potent effect on the κ-receptor, which makes it useful in low doses to treat shivering. Its major drawback, however, is its hepatic metabolism to normeperidine, which can induce seizures. For this reason, many institutions discourage its use and limit its dosage to 10 mg/kg daily. Normeperidine is renally excreted, making meperidine an unsuitable choice for patients with a history of either epileptic seizures or renal failure.

Hydromorphone is 6–7 times as potent as morphine and is indicated for moderate to severe pain. It has a slightly faster onset than morphine and like morphine undergoes glucuronidation in the liver. Unlike morphine and meperidine, however, it is relatively devoid of toxic metabolites that depend on renal excretion making it a more appropriate drug in patients with renal insufficiency.

Fentanyl is a synthetic opioid analgesic with approximately 100 times the potency of morphine. It is also indicated in the treatment of moderate to severe pain. The onset of action is less than 30 seconds with a peak effect of 2–3 minutes when given intravenously. It has a relatively short duration of action. Like hydromophone, its lack of toxic metabolites makes it a suitable drug for patients with renal failure. However, its short duration of action makes it difficult to maintain a steady state of analgesia in patients using fentanyl as a patient-controlled analgesia (PCA).

Fear of causing addiction has traditionally been one of the major reasons that physicians avoid prescribing opioid analgesics and by 2015, overdoses attributed to opioid analgesics outnumbered deaths from trauma in the US [16].

The incidence of addiction when prescribing opioids appropriately for the treatment of pain is remarkably low, likely far lower than the incidence of untoward cardiopulmonary adverse effects when pain is not adequately treated. However, surgeons should also be aware of the natural recovery period following trauma and prolonged, outpatient prescription of opioids (more than 3–4 weeks) during the recovery period should be discouraged and is rarely required to treat pain from acute trauma.

Another common reason for under prescribing opioid analgesics is the fear of inducing respiratory depression. This risk can be minimized by using PCA to deliver opioids, instead of larger intramuscular or intravenous injections. When PCA is compared with intramuscular administration of opioids, PCA is found to provide better analgesia with fewer pulmonary and cognitive complications [17]. Smaller, more frequent PCA doses will result in more consistent blood levels with fewer and smaller peaks and troughs in drug levels. Other keys to avoiding oversedation in these patients are to minimize the use of unnecessary sedating medications. Benzodiazepines or sedatives should not be used unnecessarily and, even then, only in smaller doses. Opioid consumption is greatest during the first 24 hours and patients require closer monitoring during this time. In many institutions, patients will routinely be administered oxygen by nasal prongs once therapy with PCA is started.

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