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What would you recommend for Pain Control for ACI/TTT?

Epidural
3 (27.3%)
Nerve Block
4 (36.4%)
Other
4 (36.4%)

Total Members Voted: 11


Author Topic: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?  (Read 9631 times)

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Offline MegTX

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #15 on: July 22, 2008, 02:15:52 AM »
Julie, thanks for the info... when you say "nerve catheter"... is that something like the On-Q system?  There is a decent chance I'm going to have to have ACI/TTT or TTT/Microfracture on my other leg in a year or two, once we get this leg completely stable, and I never want to go through the HELL I did with days 2 and 3 post-op.  My OS only does outpatient, so I'm limited to a degree in what I can request, but I have GOT to have another option besides OD'ing on hydrocodone if I dance this dance again.  I'm trying to get as educated as possible about all the pain management techniques so I can argue them with my OS.  He's highly competent with the surgical techniques, I'm just getting the impression he's a bit cavalier about pain control post-op.  He thought that the nerve block and washing the surgical sites with an opiate would give me a few days relatively pain-free and wear off gradually.  He was dead wrong.  They had to give me more morphine post-op than I've ever had on board before, just to get me to the point I could stand to be moved and put in a wheelchair to go out to the car.  My pain was never completely under control until at least day 4 post-op.  To me, that's just completely unacceptable.
Lateral Release, Medial "Reef" - '91
{16 years of grinding, pain, swelling and lots of ice}
'scope 7/07 - .7cm2 tibial plateau microfracture, 2.5cm2 grade4 patellar CP debridement
ACI & Fulkerson TTT 2/08 (patella lesion then 4.5cmx3cm)

Offline KW

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #16 on: July 22, 2008, 02:24:20 AM »
Meg,  I have had 1 TTT w/out and 2 with the On-Q and I will never have another major knee surgery without it again.  For me the system did a great job controling my pain through the 1st 3 to 4 days when it is the worst.

Karen
Right Knee
2000 - 2002 - Scope,LR,TTT,Unscrewed
01-10-12 - PFJR

Left Knee
04/07 TTT/LR
08/07 Bone Grth Stim
10/07 Loose/Bent Screw
1/08 Unscrewed/MRI~NON-UNION
02/19/08 Lt  TTT Revision W/Graft
12/09/08 Scope
05/15/09 Scope
09/04/09 PFJR/Unscrewed

Offline Julie P

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #17 on: July 23, 2008, 09:02:45 PM »
Meg,

The OnQ system is a "brand name".  The hospitals that I work at we use the ON-Q systems on open heart patients and some big thoracic and abdominal procedures.  We use different pumps that can be manipulated more for the orthopaedic procedures.  The surgeon places them intraop for the general and CV/Thoracic cases in the subcutaneous tissue and it only gives local coverage.  It does not cover the whole area. 
Now for the orthopaedic procedures, the anesthesia staff place the catheters and confirm it is by the nerve before stitching it in place. We use a different kind of pump that can be more set and individualized than the ONQ.  This is done in the preop holding area before the surgeons even make incision....thus "blocking" the brain from even getting the pain signal and if your leg reads the studies they will know that they should have a lot less pain long term cause your brain never recevied a lot of the pain signals. :) :D  Sounds weird, but the research supports it.

Now with that being said, obviously reading others posts that some institutions may be using them as a slow delivery device for nerve infusions.  If that is the case, it IS being used as a nerve catheter.  The limitations will be depending on who places it (surgeon vs anesthesia) and if they place it near the nerve or in the joint space.  Near the nerve will give you much much better pain control.   The infusion goes at a certain baseline that is set and you can give yourself a bolus dose of up to 5mL. 

Not sure why your surgeon did not admit you overnight for pain control.  One of the indications for admission is intractable pain.  Even if your insurance initially did not approve overnight, this is one reason that is then allowed.  As far as planning for next time, ask for a continuous femoral nerve catheter infusion if you have to go home that day.  If you get to stay for a few days, you can also consider an epidural.

Hope that helps.  I will keep an eye on this post if you have any other questions.  I too will be having ACI to trochlea and patella along with Fulkerson in January.  So I like reading other people experiences with their rehab.

Julie
L hardware removal and scar revision 6/4/9
Left AMZ and medial release 1/8/09
ACI biopsy 11/4/08 and bilateral scopes
12-22-06  L -Microfracture lateral trochlea, LR, and removal of loose bodies
1999-Right knee Loose body removal chondromalacia

Offline MegTX

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #18 on: July 24, 2008, 04:03:42 AM »
Julie, thanks again for the info.  I'll definitely be better armed if I have to go through this again.

My OS doesn't do this operation in a hospital, he has a surgical center with his orthopedic practice partners and there are no overnight facilities or provisions.  So overnight and all the pain control mechanisms that go along with that aren't an option.  I'm not sure what he does with other patients that are going to have to have overnight, like hip replacements & such.  I know he has privileges at the local hospital, but it was never even discussed as an option for me.

I completely understand what you're saying about it being best if the pain signal doesn't even get to the brain.  It makes perfect sense.  (I have a bit of a medical background, so I get the anatomy & physiology... it also makes me a bitch of a patient ::wink:: )  I know that when I'm managing pain, I cannot let the pain "get ahead of me" or it's like fighting up a waterfall to get it back under control, and the longer I hurt it seems like the lower my pain threshhold gets.

I'd dearly love for our surgeons to have had to have the surgery they're doing on us, or something similar.  I don't think they really "get it" until they've experienced it themselves.  We have to so often educate ourselves and push for the things that we know aren't negotiable.
Lateral Release, Medial "Reef" - '91
{16 years of grinding, pain, swelling and lots of ice}
'scope 7/07 - .7cm2 tibial plateau microfracture, 2.5cm2 grade4 patellar CP debridement
ACI & Fulkerson TTT 2/08 (patella lesion then 4.5cmx3cm)

Offline courtem10

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #19 on: February 10, 2009, 03:15:21 PM »
Julie,

I was reading your info on the nerve catheter- i will be having patella ACI/HTO this spring and need to prepare for pain. when do they finally take the catheter out and what is the pain like as they are removing the device?? i don't think i can deal with the epidural- i have serious needle phobia
7/08 Left knee microfracture
12/08 Left knee ACI biopsy
4/09 Left knee ACI/AMZ

dileigh

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #20 on: February 10, 2009, 11:07:01 PM »
I took the catheter out at home and it didn't hurt except for where the tape grabbed some hairs  ;D


Diana

Offline Julie P

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #21 on: February 10, 2009, 11:49:38 PM »
Removing the catheters are not a big deal at all.  It is similar to taking out an IV, except the tubing is even smaller in diameter.  You shouldn't feel anything at all, except for the tape coming off your skin.  As far as epidural, it is a good option and shouldn't be concerned about needle phobias for it.  When placing the epidural you should be very sedated and possibly may not even remember them placing it.  Also local anesthetic is used on the area prior to placing the epidural catheter so it really doesn't hurt.  I wouldn't even let that be a determining factor in the decision making process. 

HTOs are pretty painful, if it was me, I would seriously consider the epidural if you are staying overnight for awhile.  If you are going home then do the nerve catheter. 

Hope that helps.
Julie
L hardware removal and scar revision 6/4/9
Left AMZ and medial release 1/8/09
ACI biopsy 11/4/08 and bilateral scopes
12-22-06  L -Microfracture lateral trochlea, LR, and removal of loose bodies
1999-Right knee Loose body removal chondromalacia

Offline courtem10

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #22 on: February 11, 2009, 05:02:41 PM »
i am planning on spending 1 night in the hospital following ACI/HTO so i guess the epidural would be the better option. i just need to discuss this first with my os. pain management is a top concern for me heading into this procedure
7/08 Left knee microfracture
12/08 Left knee ACI biopsy
4/09 Left knee ACI/AMZ

Offline Julie P

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #23 on: February 11, 2009, 07:42:25 PM »
If you are only staying 1 night an epidural may not be the best choice then.  Epidurals are better is you are staying for 2 or more days.  The reason being, you will need time once they take it out to start walking on your crutches and prove that you can pee.  You can't do that when you are numb from the epidural.  A nerve catheter or block would be a better option due to your short stay.  Also many OS have a certain way they want it done so they may not really give you a choice, unless he/she has already told you it is your choice.  Regardless pain management is also a top concern to them so they will make sure you are comfy.  Good Luck. 
L hardware removal and scar revision 6/4/9
Left AMZ and medial release 1/8/09
ACI biopsy 11/4/08 and bilateral scopes
12-22-06  L -Microfracture lateral trochlea, LR, and removal of loose bodies
1999-Right knee Loose body removal chondromalacia

Offline SarahMN

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #24 on: February 11, 2009, 10:18:41 PM »
I like epidurals.  But I have not had the Q--.  You feel nothing until it wears off.  Usually you have a cath for urinating, which would have been great for my and my dh after my last surgery.  I had to get up and potty all night long.  I ended up using a male/female bottle thing that I had at home, sitting on the end of the couch.  I couldn't get up on my knee any more, and it was 5:30 a.m.  My dh and I had been up all night. 

They gave me some form of cortisteroids during the surgery, plus the lidocaine type drug to numb my knee area.  The steroids cause the frequent urination, and any of the marcaine/novacaine stuff makes me wakeful.

So I would opt for an epidural, with my prior experiences.  My epidurals were in my back, and I couldn't see it going in.  Felt nothing.

I did have a nerve block for my shoulder surgery, and it did wear off.  The oral meds made me vomit.  So pain plus vomiting was a drag.

Some sort of pump to a nerve sounds great, if it works as advertised for several days, or would work in me.  I know that an experienced anesthesiologist is key in placing any sort of nerve block, epidural or otherwise.  I did have a tube left in my shoulder, catheter type that I could press to shoot in marcaine.  Darn near useless as far as I could tell.

I agree that the pain gate is something you don't want to cross post op.  Once the pain starts it is hard to shut down.  I usually end up vomiting from most narcotics, IV or pills.  But once the pain starts, from what a few MD/OSs have said, in the knee, you are at risk of having the quads do some sort of protective shutdown. 

After my last knee surgery, which was done arthro, I had conscious sedation, and then marcaine shot into the knee.  It was not a good set up.  It was day surgery, I came home, the marcaine had already worn off in the RR and I was asking for IV pain meds.  Then I came home with oral narcotics, and the vomiting and potty problem while crying in pain was not ideal.  Nightmare.

Also, my quad muscles "shut down" due to the pain.  I don't understand it, so cannot explain it well.  But the self defense mechanism of the knee pain post op overload made them stop responding.  They did not show up until day 19.  So the quads just atrophy.  I was going to get some EMS to restart/train them, but they were back by then. 

I would hope that on my next surgery I could have an epidural, and avoid the first day/s of major pain.  Maybe my quads will keep working that way.  Also the epidurals I have had have worn off gradually, even after they take the cath/needle out.  I loved not having the pain, and would go with one again.  I will beg for it actually.  I don't like general anesthetics, due to my own reactions with lots of nausea, and a depression.

I hope I didn't confuse anyone.  I am only sharing my own preference.  I am sorry for anyone who experiences any major pain post op.

Good luck, Sarah MN

Give me an epidural any day.
3/25/09: R Knee: Arthofibrosis (LOA), chrondoplasty, excise plica, anterior interval release.
11/12/08:  L Knee: LR, Chrondoplasty of patella & MFC, Excise Plica, Synovectomy - 2005-2008: 12-16 weeks bi liateral knee injections with steroids. 
---& tried Synvisc, nothing but cost & 9-10 pain.

Offline courtem10

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #25 on: February 18, 2009, 05:47:35 PM »
i was reading somewhere that a patient had 2 different types of nerve blocks- one with the sciatic and i can't remember the 2nd. is there actually more than 1 type of nerve block? and is one stronger than the other?
7/08 Left knee microfracture
12/08 Left knee ACI biopsy
4/09 Left knee ACI/AMZ

Offline Peg Leg

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Re: Best pain Control for ACI/TTT surgery: Epidural or Nerve Block+why?
« Reply #26 on: February 23, 2009, 02:37:12 AM »
Hi,

I had some major pain issues with my ACI surgery, so when I needed a Fulkerson AMZ 10 months later, we decided on a Femoral nerve block and a Sciatic nerve block.  It worked really well and I had very little pain; I also had a morphine pump (they weren't taking any chances!!).

Good luck!

Peg Leg
10/06  Miicrofracture Rt knee on mfc
defect was 1.3x2, small defect under patella
04/07 Arthroscopy/Cell harvest for Carticel
06/28/07 Carticel surgery ,Rt. Knee
12/27/07  Scope to debride Patella lesion,Rt. Knee
4/17/08  Fulkerson AMZ, Rt. Knee
6/25/09 ConforMis BiCompartmental Knee Replacement















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