Dr. James Van Horne: The role of pain management in successful outpatient total joint replacements

James Van Horne, MD, is an orthopedic surgeon focused exclusively on total joint replacements. He performs around 500 to 600 cases per year and one-third of his patients are commercial insurance beneficiaries; the remaining are Medicare or Medicaid beneficiaries.

Most of the replacements Dr. Van Horne performs are outpatient, either in an ASC or at a rural hospital. He developed an arthritis conservative care program to address not only degenerative joint disease but modifiable risk factors such as diabetes, obesity and chronic narcotic use before surgery to optimize outcomes.

Here, Dr. Van Horne describes his total joint replacement program and the critical role pain management has in successful outpatient procedures.

Question: Describe your process for preparing patients for outpatient total joint replacements. What makes it possible for you to provide total joint cases in the ASC and hospital?

Dr. Van Horne: My team and I developed a program to optimize patients for joint replacement and achieve better outcomes. The program includes a JointCoach, usually a family member or friend, who assists the patient peri-operatively. The JointCoach helps them prepare pre-operatively, manages their medications post-operatively and provides support for at least three days after surgery.

In addition we help patients develop a strong social support net and create a personalized pain control program for when they undergo surgery. About 85 percent to 90 percent of my Medicare patients go home the same day. Nearly everyone goes home within 24 hours of surgery. Our complication rate is 25% below the national average, and we get patients off narcotics rapidly. We aren't sending patients to nursing homes, they aren't returning to the ER, nor being re-admitted to hospital due to complications.

Our outcomes are in part due to patient education and the JointCoach program, but also due to our multimodal pain strategy, which includes liposomal bupivacaine. It's amazing to see that by getting patients beyond the first 2 days of pain they require a week or less of narcotic pain medications.

Q: What is your technique for pain management protocol?

JVH: I find out what narcotic and non-narcotic pain medications work well for each individual patient BEFORE surgery. The bottom line is, I don't want to take my patients to surgery, cut them open and then have to find out what narcotic works for them. I would be doing the patient a great disservice by not knowing what controls their pain BEFORE SURGERY without side effects.
The pain management protocol for my patients begins with optimizing a non-narcotic pain control program while treating their arthritis. Once determined, this non-narcotic program is used as the mainstay of their post-surgery pain control program.

The major reasons why my patients used to stay in the hospital after surgery included poor pain control, nausea/vomiting or sedation caused by narcotics; the main reasons they returned to the ER after discharge were poor pain control, urinary retention and constipation. By finding out what works before surgery, we avoid these complications and are able to discharge to home the same day.

As soon as my patients decide it's time to move ahead with a joint replacement, we enlist them in our narcotic pain program to identify which narcotic and anti-nausea medications are best for each individual patient before surgery. Tramadol, hydromorphone, or oxycodone are the most common narcotics. Scheduled anti-nausea medication four times per day and a constipation prevention program are trialed. That way we can determine the best combination without igniting side effects.

The non-narcotic medication program is started one week before surgery and the narcotic program the morning of surgery. They generally take the narcotic for a week or less after surgery. We track narcotic use by our patients and have data on over 400 patients. We track exact pill count use and document refill requests after surgery. The anti-constipation program is started 3 days before surgery. Patients continue the non-narcotic program for 6 to 12 weeks after surgery.

Q: What is the value of advanced multimodal pain management protocol for outpatient total joint replacements?

JVH: By preventing the pain cycle from starting, we are able reduce the need for narcotics post-operatively. In addition to the oral medication regimen, I do field blocks intraoperatively. Adductor canal blocks and femoral Ilioischial blocks are not utilized. We use EXPAREL® (bupivacaine liposome injectable suspension) for hip and knee patients to help with pain control for 2 to 3 days after surgery. When I first started performing outpatient total joint replacements, I had trouble discharging patients because blocks caused weakness limiting participation with physical therapy and then their pain medications wore off before they left the surgery facility. Now, with the multimodal pain management protocol including EXPAREL, we can help them get past the first 2 to 3 days of incision pain; the non-narcotic will do the job as well as opioids.

In the United States today still close to one-third patients continue to take narcotics 2 months after total knee replacements. In our patients, 84% to 90% of knee replacement patients are not requesting additional narcotic prescriptions one week after surgery; the numbers are better for hip replacements. CMS and CDC recommend not prescribing acute pain medication to narcotic naïve patients for more than 5 to 7 days. As physicians, we need to use non-narcotic pain relievers as much as possible.

Q: How is pain management linked to patient satisfaction?

JVH: When patients can rapidly come off narcotics, and return home the same day, they have fewer complications and hurt less during recovery. We meet the Triple Aim of Healthcare (increased patient satisfaction, lowered complication rates and reduced cost) in our total joint replacement program.

Patients are our partners throughout the care process. They need to have skin in the game. My joint educators and I sit down with patients and their JointCoach for more than an hour pre-surgery to review my educational program with them. We make sure they are ready for surgery and will be safe when they return home. Sometimes they aren't ready. We postpone the procedure and make sure they are SAFE before proceeding.

When I came out of my fellowship over 20 years ago, I learned rapidly that unless patients are engaged with me and have someone that can help them like the JointCoach, it doesn't matter how good I am, they won't do well. Disengaged patients will have complications and end up back in the ER. You have to get them involved as an active participant and then they become satisfied patients.

Contact your Pacira or DePuy Synthes representative for more information on EXPAREL and how to use it in joint arthroplasty.





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.

Full Prescribing Information is available at www.EXPAREL.com

117806-190702 DSUS 07/19

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