Though considered among the most beneficial of surgical procedures -- in terms of restoring quality of life and mobility -- total hip or knee replacement-related post-operative pain may leave some patients initially questioning why they underwent the operation. This perception, coupled with patient anxiety pre-surgery and recent manufacturer withdrawals of certain prescription pain relievers, has prompted physicians to explore alternatives to enhance patient care. At the 73rd Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), a panel of orthopaedic experts discussed the efficacy of pain management options after joint replacement and their impact on bone healing.

"All patients undergoing total hip or knee replacement will experience significant pain; our challenge is to reduce pain to an acceptable level in the early post-operative period," according to Chitranjan S. Ranawat, MD, chairman of the department of orthopaedic surgery at Lenox Hill Hospital in New York City. "Pain control plays a key role in joint-replacement patients' recovery; patients' perception of pain most notably impacts the time it takes them to regain mobility."

Nonsteroidal anti-inflammatory drugs (NSAIDs), including over-the-counter aspirin and ibuprofen, are the most prescribed medications to relieve pain and reduce inflammation post-surgery. A lesser prescribed -- and more potent -- set of pain relievers are COX-2 inhibitors, a special category of NSAIDs. Unlike COX-2 inhibitors, NSAIDs prevent blood from clotting, so patients are required to stop taking these medications one to two weeks prior to surgery to prevent excessive bleeding.

"While over-the-counter or narcotic pain medications are more frequently used to alleviate patients' pain post-joint replacement, COX-2 inhibitors are the next round of alternatives available to manage pain that does not subside after initial treatment," explained Thomas A. Einhorn, MD, chairman of the department of orthopaedic surgery at Boston University School of Medicine and chief of orthopaedic surgery at Boston Medical Center. "But really unless there's a surgical complication, most patients' post-operative pain is effectively managed within about a week or ten days. Sometimes the need for pain medication may persist for several weeks after surgery when patients are undergoing aggressive physical therapy to improve function."

Post-operative pain is the leading cause for delay of discharge from the hospital; one of the reasons behind Dr. Ranawat's call for a more aggressive, multi-modal approach to pain management. He emphasized the need to help patients receive optimal pain control, reduce or eliminate the need for narcotic medication. Narcotic medications are known to create significant side effects and delay in patients' return to function after total hip or knee replacement.

"Prevention of pain is easier and more effective than control of established pain," stressed Dr. Ranawat. "In certain patients, administering analgesia two hours prior to surgery -- followed by a combination of COX-2 inhibitors and sustained release oral narcotics -- have proven to be effective in reducing the pain and inflammation that goes hand in hand with surgical trauma, specifically in the case of joint replacement."

Recent studies have indicated that both NSAIDs and COX-2 inhibitors may have a delaying effect on bone healing. However, according to Dr. Einhorn, research has proven that short-term use of NSAIDs after joint replacement, spinal fusion or fracture care is generally safe.

"COX-2 inhibitors and NSAIDs do inhibit bone healing," Dr. Einhorn explained. "We have learned, however, that because these medications are administered for relatively short periods of time after surgery, once the medication is stopped, the bone healing process recovers to where it should be."

The use of NSAIDs and COX-2 inhibitors involve a risk/benefit ratio, and should be assessed by physicians on a case by case basis in light of each patient's specific conditions.

An orthopaedic surgeon is a physician with extensive training in the diagnosis and non-surgical as well as surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves.

With more than 29,000 members, the American Academy of Orthopaedic Surgeons ( or ( is the premier not-for-profit organization that provides education programs for orthopaedic surgeons and allied health professionals, champions the interests of patients and advances the highest quality musculoskeletal health. Orthopaedic surgeons and the Academy are the authoritative sources of information for patients and the general public on musculoskeletal conditions, treatments and related issues. An advocate for improved patient care, the Academy is participating in the Bone and Joint Decade ( -- the global initiative in the years 2002-2011 -- to raise awareness of musculoskeletal health, stimulate research and improve people's quality of life. The Academy's Annual Meeting is being held March 22-26, 2006 at McCormick Place in Chicago.

American Academy of Orthopaedic Surgeons