To block or not to block?

Abstract

Contemporary joint replacement surgery has shown dramatic technical development in recent years. It is one of the most commonly performed procedures and is predicted to increase exponentially over the next decade. This has led to the development of enhanced recovery after surgery (ERAS) consisting of multimodal, multidisciplinary perioperative care pathways designed to reduce hospital length of stay through reduced morbidity and early ambulation. An essential prerequisite for the success of an accelerated care pathway is early ambulation facilitated by the provision of dynamic pain relief (i.e. pain relief during movement). To achieve a shorter hospital length of stay, it is necessary that the pathway includes optimization and standardization of the preoperative, intraoperative, and postoperative pain management components. An optimal multimodal pain therapy should be initiated in the preoperative period by the identification of patients who are at risk of greater pain intensity. Patient counselling and expectation management has been shown to improve pain relief and patient satisfaction [1]. Patients with high severity of preoperative pain are more likely to report chronic pain after both total hip and knee replacement and this association is five times stronger in patients undergoing total knee arthroplasty (TKA) compared to total hip arthroplasty (THA) [2]. Preoperative pain-on-movement is the strongest predictor of chronic pain-on-movement at 12 months in patients undergoing TKA. Preoperative pain-at-rest is weakly predictive of chronic pain-at-rest at 12 months in patients undergoing THA. Interestingly, acute postoperative pain-on-movement has not been associated with chronic pain after TKR or THR after adjusting for preoperative pain; however, acute painat-rest was associated with chronic pain after THR but not TKR after adjusting for preoperative pain [2]. Intraand postoperative analgesia: the requirement for procedure specificity is now well recognized and universally accepted. DOI: http://dx.doi.org/10.21454/rjaic.7518.242.ioh