I wanted to write a post about postoperative pain. However, the only prior experience I’d had was a few knee arthroscopies – which, while not nothing, do not rank very high on my orthopedic procedure pain scale. So, as my children would say, I had no “street cred.” And then I underwent knee replacement. Oh, mama! All of a sudden, I had more street cred than I’d bargained for.
As surgeons, we try to prepare you for your surgery. For those of you undergoing joint replacement, we even have a nifty “joint camp” we give in the lead up to your procedure, during which we spend a fair amount of time on multimodal pain management, among other topics. I’m not going to go into much detail regarding the protocols we use, other than to make a few basic points. Instead, I wanted to write a more personal overview of surgical pain and the strategies I used to deal with it that I thought might be helpful for you as well.
First a caveat: every procedure we perform is different. Even the same procedure in the same patient is at least a little different. Some people just have more wrong with their surgical joint and it takes us a little more work to fix it. For those of you keeping score at home, when a surgeon says “a little more work” you can be assured that will likely translate into more pain after. As patients, we often have a selective memory when it comes to traumatic events. We tend to “misremember” the bad stuff, at least a little. How else do you explain a mother having more than one child? So, when you speak to someone who had your planned surgery some years ago, they often gloss over the bad parts and boast that they were “golfing 3 days after their hip replacement” or “playing catch a week after their shoulder procedure” – unlikely, both of these. Also, if you’re not hitting whatever you’ve expected your recovery milestones to be, it may be simply that you had more wrong with your joint than did your Uncle Monty. If you are truly behind, believe me, your surgeon will make you aware that you need to up your game.
Another caveat: even exactly the same pain stimulus can create a different pain perception in different individuals. In other words, the same pain hurts some people more than others. Other factors can make pain better or worse. It’s not just hardwiring or the extent of the insult to your body. There are both physical and mental factors involved. I will confess something here. As a surgeon, when someone tells me they have a “high pain threshold,” I usually think the opposite might be the case. Despite my skepticism, I too thought I had a high pain threshold, after breezing through what were admittedly fairly minor procedures. And then I had knee replacement. Ha! But as I’ve had time to reflect on this a little, I now find when a person tells me they have a “high pain threshold” what they’re really saying to me is that they are resilient. This is key because resilience is how you overcome adversity.
A final caveat: unfortunately there is no magic bullet when it comes to alleviating pain. However, there are a number of things you can do to help. Even though each measure that I will describe later in this post may only help partially to relieve your pain, if you stack enough of them together, well, then you’re getting somewhere. The more things you’re able to do to help your pain, the sooner you’ll be able to leave the narcotic medication behind and move on with your recovery.
I’ll be honest: your surgery is going to hurt. Depending on your medical history and the extent of your procedure, it may hurt more than anything you’ve ever experienced before. And yet, you will get through it. This too shall pass and one day, maybe sooner than you think, you can make up a whopper about how fast you recovered that will put Uncle Monty to shame.
So, onto the good stuff. I’m going to give you my experience and what I did to make it through in hopes that you might find something that helps you too. After coming out of anesthesia, I was pretty groggy for several hours. I’m what our anesthesiologists affectionately refer to as a “cheap date.” As I would become sleepy, I’d notice my oxygen saturation was drifting downwards. My first piece of advice is: remember to breathe. Big deep breaths fill up your lungs with air, opening the small lung sacs called alveoli that can fill with fluid after surgery and help prevent pneumonia. You’ll have enough on your plate with your operation – you don’t need a debilitating lung infection on top of it.
A brief word about the hospital. Many of you will have procedures that do not require a hospitalization afterwards. Some of you will have procedures that due to the significance of the surgery, your general medical health, or other social factors, mandate a stay in the hospital. However, for some of you, hospitalization, at least for a night, is an option. My advice: go home if you have the chance and your medical team thinks you will be safe to do so. I had a perfectly lovely team of nurses and health care providers that did their job to perfection. It was still an unpleasant experience and one best avoided if possible. It’s simply not possible to rest in that environment because those lovely people have their jobs to do and that entails waking you up regularly (invariably just as you’ve managed to drift off to sleep) to take vital signs or blood or what have you. You’re also surrounded by super bacteria, the likes of which are never seen around your home. Plus, hospital food deserves its reputation. Enough said.
Let’s talk narcotics. First, I think most of us are aware of the opioid addiction crisis in this country. In the last twenty years, it is no secret that they have been over-prescribed. There are now rules in place limiting the number of pills we can prescribe and the frequency with which we can issue these prescriptions. That said, they do play their role early in your recovery to help you get on top of your pain. It took me a day to figure out that I needed 10 mg of oxycodone to help with the pain and I needed to take it regularly. Once I was able to get on top of my pain, then I was able to decrease my dose and frequency. Opioids are addictive – and can cause wicked constipation, among other unpleasant side effects – but if you use them judiciously, and wean off them as you no longer need them, your risk of addiction is minimal. So use them, early.
Next a little about multimodal pain management. This simply means addressing your pain from multiple angles. We do use medication – both oral and injectable – but we also use ice and elevation and compression and rest. You might have a pain pump or a regional block. We ask that you also take a role in your pain management. This means being resilient and believing you will get through this because you will. Try not to “catastrophize” your pain. It will improve – and if you’re anything like me – sooner than seems possible. Why, I was playing pickle ball the next day after my surgery! Well, maybe not.
As soon as I got home, I began taking a prescription anti-inflammatory (celecoxib in my case) regularly along with a dose of Tylenol every 6-8 hours. I also strapped on my beautiful, glorious, fantastic ice machines. I’ll take a moment here to reflect on how much I love my ice machines. You see, in the hospital I had bags of ice that were actually in two separate plastic bags plus a pillow case that each weighed about 300 pounds, or so it seemed at the time. And unfortunately, they were just sort of cool rather than cold because of all the layers. So, it felt like I had a sumo wrestler sitting on my knees – and since their back end is, shall we say, somewhat exposed to the elements – their bum was a bit on the cool side. The ice machine is infinitely better – colder, lighter, more comfortable, more stable, longer lasting, less restrictive. We sell one model the “Polar Care Cube” by Breg in our office, but you can also find them on line. I highly recommend you get one for your surgery. If you borrow from someone else, be advised that the pads you place on your surgical extremity are site specific, so a knee pad wouldn’t work as well for a shoulder surgery. Generally speaking, I would advise you get your own pad, which are sold separately, for the sake of infection prevention. One clever trick a patient of mine shared with me is instead of over-taxing your ice maker at home, you can freeze plastic bottles of water and reuse these over and over to cool your circulating water. Also, I should note that you can get a significant “freezer burn” if you leave the pad on too long or on your bare skin. I advise a layer of ACE wrap or clothing between the pad and your skin. Check your skin under the pad periodically to be sure it’s not too cold.
So that was my first couple of days – narcotic fairly regularly, regular doses of celecoxib and Tylenol, and many fine hours with my ice machine. For the first 24 hours, I took the narcotic every 3-4 hours. By day two, a dose every 4-6. By day three or four, every 12. After that I took it mostly at bed time, although I probably didn’t need to do so after the first week. I continued fairly regularly with the Tylenol for the first 3-4 weeks and then gradually phased it out, using it mostly episodically for flares of pain or in anticipation of a bout with my physical terrorist (erm, therapist). I continued the celecoxib for several months.
I also had pain pumps, which are clever devices full of a local anesthetic that dripped the numbing medicine on nerves, supplying my knees at a constant rate for 3-4 days post surgery via small catheters. This regional long-acting anesthesia can also be accomplished by a single shot block. The pumps are a bit cumbersome to lug around, but as I found when after they came out, they do help. Despite this, my pain was only elevated for a day or so after the pumps came out and then returned more or less to baseline.
These timelines will vary for everyone. I put them out there as sort of a roadmap. I was fortunate in that the narcotic didn’t make me nauseous or somnolent. So I wasn’t forced to quit them early because of side effects. I just didn’t need them anymore. I do think the regular use of celecoxib, Tylenol, and ice was key to getting off the narcotics early. That, and focusing on what I could do and not on what I couldn’t.
A few words about activity. Get into physical therapy as soon as your surgeon clears you to do so. Also, do your exercises at home. Joints need to move – in particular knees and shoulders. Otherwise, stiffness sets in that can be difficult to overcome. My knees felt like they were encased in concrete (even after the sumo had departed). Moving them was not fun but got easier as time went on. I found that frequent, short duration stretches worked best for me. Warming them up first in the shower, with a heating pad, or after a few minutes on the bike helped as well. After, I would often have a session with my beloved ice machine. Shoulders are a challenge too. We often ask you to move them passively, using your non-operative extremity to drive them around. Pace yourself. We like you to start the process early but ease into it. It will get easier as the days pass, and as it does, you can step up the intensity. As the saying goes, a journey of a thousand miles begins with a single step.
Sleeping is a challenge. As a side sleeper, it was several weeks before I could comfortably sleep on my side. At least I was able to sleep in bed. Poor shoulder patients often sleep best upright or in a recliner for weeks after their surgery. My advice is to find a comfortable position, use pillows to hold you there, take your pain medication at bedtime, and do the best you can. For those of you undergoing knee replacement, try to keep from having pillows directly under your knee because it tends to create a flexion contracture, making it difficult to straighten the knee fully. Better to keep the pillows under the lower part of your legs.
And that’s about it. So, in review, what did I learn from my experience? Go home after your surgery as soon as it’s deemed safe to do so. Use your medications wisely and wean off the narcotic expediently. Get an ice machine and banish the sumo wrestler. Get going in PT. Do your exercises, gently at first, then more as you recover. Be resilient. Know that you are going to get through this. Because before you know it, you will able to come up with a story of your recovery that will give Uncle Monty a run for his money.