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"Stacked Modality" Pain Protocol May Benefit Patients With Total Knee or Hip Arthroplasty

Multiple nonnarcotic medications in a "stacked modality" pain protocol reduce postoperative pain and opioid consumption in patients with total hip arthroplasty (THA) and total knee arthroplasty (TKA), as well as length of hospital stay (LOS) in patients with TKA, new research shows.

To examine the effectiveness of a stacked modality pain protocol (PP) versus conventional pain therapy (NPP) in patients with THA and TKA, Harry B. Skinner, MD, PhD, and Ellen Y. Shintani, PharmD, University of California, Irvine, United States, evaluated 48 patients who underwent THA and 54 with TKA between February 2000 and January 2001.

Four groups were divided according to surgical procedure and treatment received. The PP treatment arm consisted of 16 patients with THA and 24 patients with TKA, the NPP treatment arm, 32 patients with THA and 30 patients with TKA. Because more than 50% of patients who underwent TKA in the NPP group received an intraarticular bupivicaine pump, the authors also conducted an analysis of the subgroups (NPP pump and NPP no pump).

Patients in the PP treatment arm received 1 dose each of acetaminophen (650 mg), tramadol (50 mg), and rofecoxib (50 mg) preoperatively; on-demand, patient-controlled opioid (1 mg morphine sulfate, with a 10-min lockout time) postoperatively; and oral dexamethasone (2 mg every 6 hours) for the first 24 hours postoperatively. Oral acetaminophen, tramadol, and rofecoxib were given around the clock, as needed, for pain. An intraarticular bupivicaine pain pump (0.25% at 2 mL/hr for about 48 hours) was also available to patients who underwent TKA.

Patients in the NPP treatment arm received pain medications "according to physician discretion" and not those used in the PP protocol.

Data was collected on LOS; time on patient-controlled opioid; opioid consumption on postoperative days 1 to 4; pain scores obtained on postoperative day 2 and at discharge; and adverse events and medical complications.

Patients with THA in the PP and NPP groups had similar mean LOS (4.4 ± 2.2 and 4.9 ± 1.7 days, respectively; P = .389). The difference in mean LOS between the PP and NPP groups in patients with TKA was statistically significant (4.0 ± 1.2 and 4.9 ± 1.3 days, respectively; P = .012). LOS for patients with TKA in the NPP pump and NPP no pump subgroups was 5.0 ± 1.5 and 4.7 ± 1.1 days, respectively.

Mean time on patient-controlled opioids was shorter, and mean daily opioid consumption was less, in PP groups than in NPP groups in both THA and TKA groups.

Patients with THA in the PP group showed "only a trend toward less pain" on postoperative day 2 (P = .16) and at discharge (P = .071), whereas a higher proportion of patients with TKA in the PP group had a pain score of 4 or less on postoperative day 2 (P = .019) and at discharge (P = .03).

Three patients with THA (all in the NPP group) and 4 patients with TKA (2 in the NPP no pump group; 1 in the NPP pump group; and 1 in the PP group) developed postoperative medical complications. The overall complication rate was 2.5% in the PP group and 10% in the NPP group.

"The main findings of our retrospective evaluation are that the use of a stacked-modality PP in patients with THA or TKA can potentially reduce postoperative pain, opioid consumption, and (in patients with TKA) LOS," the authors concluded.


Am J Orthop 2004 Feb;33:2:85-92; discussion 92. "Results of a multimodal analgesic trial involving patients with total hip or total knee arthroplasty"

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