A novel method of pain management following knee replacement surgery

For better postoperative pain management during knee replacement surgery, Houston Methodist researchers recently published clinical evidence that supports the efficacy and safety of injecting painkillers directly into the tibia.

According to a double-blind, randomised trial published in The Journal of Arthroplasty, patients who had a combination of morphine and the antibiotic vancomycin injected into their knee joint’s tibia (also known as the shin bone) experienced less pain after surgery than those who had received the infusion without morphine.

According to Kwan “Kevin” Park, M.D., an orthopaedic surgeon at Houston Methodist, “despite many technological advancements, controlling pain after total knee arthroplasty can be challenging; most patients experience considerable pain and discomfort, especially in the first couple of weeks into their recovery.”

We can prevent patients from needing as much pain medication later on by using intraosseous infusion, which entails injecting medicines straight into the bone marrow.”

The suggested course of action for treating persistent pain brought on by damage to the knee joint from arthritis or injury is total knee replacement. Primary knee replacement surgeries made up 54.5% of the approximately two million hip and knee replacement procedures carried out between 2012 and 2020, according to the 2021 American Joint Replacement Registry Annual Report.

The manipulation of soft tissue and resurfacing of damaged bones during knee replacement produce discomfort in the early postoperative periods, despite the high frequency and positive outcomes of the surgical treatment.

After surgery, patients used to spend many days in the hospital and get extraordinarily high doses of narcotics to treat their postoperative pain, according to Park. However, there has been a paradigm shift; patients are now frequently released the same day as knee replacement surgery, and we use multimodal pain management strategies that are considerably more effective at controlling pain and use fewer drugs.

He continued by saying that these multimodal regimens frequently combine different medications that are given both before and after surgery, such as nonsteroidal anti-inflammatory drugs, opioids, and neurogenic substances that have an effect on the neurological system. Opioid drugs have recognised adverse effects such constipation and nausea, and some people are allergic to opiates despite the fact that they are quite effective at treating pain. Additionally, opioid drugs have a high potential for addiction. Furthermore, there is a lack of agreement on the best preoperative pain management approach.

Prior to surgery, the researchers showed that injecting the antibiotic vancomycin directly into the tibia increased the drug’s concentration in the knee, which helped to reduce infection. Inspired by this achievement, they looked into whether morphine added to a conventional antibacterial solution in the tibial bone could enhance postoperative pain control.

The team included 48 patients who required total knee replacement surgery in the trial. Vancomycin and morphine were delivered directly into the bone marrow of half of these individuals using an infusion device that was implanted near the tibial tubercle. Vancomycin was the only medication given to the others.

For up to 14 days following surgery, the researchers tracked patient reports of pain, nausea, and opiate use. The Center for Musculoskeletal Regeneration at Houston Methodist Hospital and Francesca Taraballi, Ph.D., assistant professor of orthopaedic surgery, worked together to monitor the serum levels of morphine and interleukin-6 in all study participants for 10 hours following surgery.

The patients who received morphine in the tibial bone had lower pain scores following knee replacements than those who did not, according to the researchers’ analysis of their data. This worked for two weeks following surgery. Furthermore, despite having comparable amounts of the inflammatory marker interleukin-6 to the control group, these patients also claimed to have experienced reduced discomfort for several days.

Together, the individuals who got pain medication pumped directly into their tibias experienced equivalent inflammation but required less pain medication to recover from surgery.

According to Park, the direct injection of opiates into the bone marrow after surgery may even speed up the knee joint’s recuperation.

“We’re able to lessen postoperative discomfort for up to two weeks, the quantity of pain medications patients need, and even maybe improve the function of the knee over time by injecting pain medicine intraosseously,” he said. The multimodal pain treatment approach we have been utilising for knee replacement throughout the years may also be improved by our technology.


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