Minimal Opioid Use After Total Hip Replacement (THR)

Long acting narcotics or scheduled doses of narcotics are often used as part of a multimodal pain regimen. In this study, this is eliminated. Instead, it uses a cocktail of different drugs including intraoperative Ketamine use (NMDA receptor antagonist), intra-op Benadryl (to decrease excitation of nociceptors) and IV Tylenol. The narcotic free regimen starts preoperatively with the use of Aspirin,Clonidine patch, Cymbalta (Duloxetine), and is maintained both intraoperatively and post operatively. Baby ASA (81mg) is being used as an anti-inflammatory agent. A number of studies including the one by Morris et al. (2009), have shown via in vitro experiments that low dose aspirin decreases polymorphonuclear leukocyte and macrophage accumulation. It inhibits thromboxane making it an antithrombotic agent as well. The concern with aspirin has been major bleeding. Several studies in the orthopedic patient population using ≤81 mg of aspirin have shown that it does not increase bleeding (Cuellar, Mantz). At HSS, patients are routinely continued on baby aspirin when needed for its cardio protective effect. Devereaux in the POISE trial did show an increased risk of bleeding when ASA was given preoperatively at a dose of 200 mg. In our study, all patients will be given intravenous tranexamic acid which should mitigate against the risk of bleeding. Duloxetine is also being added. In a recent study done at HSS. Duloxetine was found to decrease the amount of opioid use and nausea. If found to be more effective with the use of EPCA vs. PAI or combination of the two, a new way of managing postop pain while minimizing Nnartcuoreti co fu Ssetu adsy per CDC recommendation will be helpful in managing patients post-operatively.

Inclusion criteria

• Any patient with osteoarthritis scheduled for primary total hip arthroplasty with a participating surgeon
• Planned use of regional anesthesia
• Planned posterolateral surgical approach
• Age Range 45-80
• Ability to follow study protocol

Exclusion criteria

• Any patient with age <45 or >80
• Any patient with planned anterior surgical approach
• Any patient with prior major ipsilateral hip surgery
• Any patient intending to receive general anesthesia
• Any patient with an ASA of IV
• Any patient with insulin-dependent diabetes
• Any patient with hepatic (liver) failure (history of cirrhosis or elevated LFT's)
• Any patient with chronic renal (kidney) failure (formal diagnosis of renal disease of elevated creatinine)
• Any patient with history of gastric (stomach) ulcer
• Chronic opioid use (taking opioids for >3 mo duration on a daily basis)
• Chronic analgesic use (i.e. lyrica, gabapentin) for >3 mo duration
• Stress dose steroids
• Use of antidepressants
• Contraindications to aspirin
• Allergy to any of the medications (or adhesives) involved in the study protocol
• Dementia
• Non-English speakers.