Adult Reconstruction

With the advances in total joint arthroplasty, there has been a great deal of attention directed toward perioperative multimodal pain management since postoperative pain remains a significant concern for patients and impacts their functional recovery. Numerous strategies have been devised to reduce the consumption of opioids and narcotics due to their associated untoward side effects. Prior to surgery, patient education has been helpful in reducing the anxiety of the procedure and enlightening the patient to the postoperative care and rehabilitation. In addition, it is becoming common practice to try and prevent the pain before it starts. Therefore, with a multimodal approach, patients typically receive pre-emptive medications, including a long-acting narcotic, acetaminophen, a Cox-2 inhibitor, and antinausea medication followed by regional anesthesia for the procedure. Periarticular injections at the time of surgery, along with a postoperative multimodal analgesia protocol, have been shown to be a viable alternative to peripheral nerve blocks, but this is not without some controversy. The advantage of periarticular injections is that it provides excellent pain control and functional recovery following joint arthroplasty with a reduction in the side effects and complications associated with narcotics and muscle weakness associated with peripheral nerve blocks. The article by Guild and coauthors reviews the neural anatomy of the knee and describes a technique for infiltration of the periarticular tissues at the time of total knee arthroplasty. It appears that concentrating the periarticular injections in the areas of the knee with increased innervation is necessary to maximize the benefits of the injection and thereby improve postoperative pain control.

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