Revamping Recovery Protocols with Non-Opioid for TKA Procedures


How Novel Technologies and Opioid Alternatives Can Improve Patient Outcomes

Total knee arthroplasty (TKA) procedures are one of the most common surgeries in the United States and the demand for TKA procedures continues to increase every year. Annually, approximately 790,000 knee replacement surgeries are performed, and that number is projected to be 3.48 million by the year 2030. While recovery protocols have evolved over the years, surgeons are taking a closer look at how they can improve different aspects of the recovery process with new technology, research, and medications, including non-opioids.

Dr. Vinod Dasa, Professor of Clinical Orthopaedics and Director of Research at LSU Health in New Orleans, is sharing a new analysis about rapid recovery protocols (RRPs) that can enhance and improve patient outcomes following TKA procedures. His goal is to educate clinicians about innovative approaches and medical advancements related to multimodal pain management protocols including using NSAIDs, acetaminophen, local anesthetics, cryotherapy, physical therapy and more.

The Need for A New Knee Recovery Process

Like many surgeons, Dr. Dasa and his team were using standard recovery protocols (SRP) to treat patients after total knee replacement surgeries. The SRP included using a femoral nerve block, spinal anesthesia, multimodal analgesia and limited patient education prior to surgery. After considering new advancements in the field, Dr. Dasa and his team set out to revamp the TKA recovery process and develop a protocol that would allow their patients to get back to their day-to-day activities sooner.

A vital component to the new RRP was implementing a coordinated effort from every person involved in the surgical and recovery journey including surgeons, physical therapists, operating room staff, and nurses. Further, the new process included engaging and educating patients about the procedure, technology, and pain management options used throughout the perioperative period. Communication from all of these people throughout the surgical journey was a crucial component of the process.

The team also needed to determine how to measure success for patients following TKA. Two main factors that were evaluated as part of the RRP were range of motion (ROM) of the knee and length of stay (LOS) in the hospital. ROM is measured both before and after surgery using a goniometer, or a compass used by surgeons to calculate precise angles. LOS is determined by the number of calendar days a patient remains in the hospital after the completion of their surgery.

Advances in Pain Management Techniques Prior to Surgery

While Dr. Dasa and his team implemented basic changes (e.g., team approach, improved communication) they also incorporated more technical ones. Recently, attention has turned to the use of presurgical techniques to reduce pain and opioid use associated with knee arthroplasty. Novel platforms, such as cryoneurolysis also known as iovera°, have been applied to prospective TKA patients to reduce pain and opioid use. One-to-two weeks before surgery, Dr. Dasa’s team uses this cryotherapy treatment to treat peripheral nerves and immediately reduce pain by using the body’s natural response to cold. This step freezes the sensory nerves prior to surgery and helps patients feel more confident about pain management throughout the surgical process.

Techniques to Manage Pain Intraoperatively

Local infiltration anesthesia (LIA) has become a standard practice for a number of joint procedures over the years. Dr. Dasa and his team use EXPAREL® (bupivacaine liposome injectable suspension), a long-acting local anesthetic injected near the surgical site, which slowly releases a numbing medication to provide pain relief for the first couple days after surgery. LIA like EXPAREL have improved enhanced recovery pathways for Dr. Dasa’s patients. After surgery, he encourages clinicians to quickly enroll patients in postoperative physical therapy. Additionally, he reassesses the multimodal pain management strategy by limiting or eliminating the use of opioids to manage pain after surgery.

Results of Rapid Recovery Protocol

When using a multimodal approach, including the use of cryoneurolysis, NSAIDs, acetaminophen, local anesthetics, and physical therapy to manage postsurgical pain, Dr. Dasa and his team found that patients’ overall LOS in the hospital decreased. Historically, patients undergoing knee replacements with a standard recovery protocol would stay in the hospital for a few days; however, with the RRP group the LOS decreased to less than one day for most patients. In addition, Dr. Dasa noted the RRP was associated with a higher flexion, or range of motion, in the 12 weeks after the procedure. Dr. Dasa has also seen many patients in the last year reduce their opioid consumption, only taking mild pain relievers following TKA using this novel, multimodal, team-based approach.

The findings from this latest research are encouraging as it points to a multimodal pain management approach enhancing recovery for patients after TKA procedures. Dr. Dasa is dedicated to continuing sharing information about the latest medical advancements, including the use of non-opioid options, with his peers to continue to provide optimal results for his patients.

iovera° Indication

The iovera° system is used to destroy tissue during surgical procedures by applying freezing cold. It can also be used to produce lesions in peripheral nervous tissue by the application of cold to the selected site for the blocking of pain. It is also indicated for the relief of pain and symptoms associated with osteoarthritis of the knee for up to 90 days. The iovera° system is not indicated for treatment of central nervous system tissue. The iovera° system’s “1x90” Smart Tip configuration (indicating one needle which is 90 mm long) can also facilitate target nerve location by conducting electrical nerve stimulation from a separate nerve stimulator.

Important Safety Information


The iovera° system is contraindicated for use in patients with the following:

Cryoglobulinemia, paroxysmal cold hemoglobinuria, cold urticaria, Raynaud’s disease, and open and/or infected wounds at or near the treatment site

Potential Complications

As with any surgical treatment that uses needle-based therapy and local anesthesia, there is a potential for site-specific reactions, including, but not limited to:

  • Ecchymosis, edema, erythema, local pain and/or tenderness, and localized dysesthesia

Proper use of the device as described in the User Guide can help reduce or prevent the following complications:

  • At the treatment site(s): injury to the skin related to application of cold or heat, hyper- or hypopigmentation, and skin dimpling
  • Outside the treatment site(s): loss of motor function

EXPAREL Indication

EXPAREL is indicated for single-dose infiltration in adults to produce postsurgical local analgesia and as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information

  • EXPAREL is contraindicated in obstetrical paracervical block anesthesia
  • Adverse reactions reported with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported with an incidence greater than or equal to 10% following EXPAREL administration via interscalene brachial plexus nerve block were nausea, pyrexia, and constipation
  • If EXPAREL and other non-bupivacaine local anesthetics, including lidocaine, are administered at the same site, there may be an immediate release of bupivacaine from EXPAREL. Therefore, EXPAREL may be administered to the same site 20 minutes after injecting lidocaine
  • EXPAREL is not recommended to be used in the following patient population: patients <18 years old and/or pregnant patients
  • Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease

Warnings and Precautions Specific to EXPAREL

  • Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL
  • EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, or intravascular or intra-articular use
  • The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials

Warnings and Precautions for Bupivacaine-Containing Products

  • Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression
  • Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability which may lead to dysrhythmias, sometimes leading to death
  • Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients
  • Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use
  • Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use

Please refer to full Prescribing Information.

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