Posted on in Category 1

Making Orthopedic Procedures Outpatient

Making Orthopedic Procedures Outpatient

Making Orthopedic Procedures Outpatient and Less Painful with Continuous Peripheral Nerve Block 

By Dr. Gregory V. Hickman, Medical Director and Anesthesia Director of the Andrews Institute and Dr. Lonnie Paulos, Medical Director of the Andrews-Paulos Research and Education Institute

A patient’s overall satisfaction and comfort after surgery can affect their entire recovery and for most patients, pain is a concern following surgery. However, post-surgical pain control has traditionally relied on pill or IV narcotics, which can come with a host of side effects, such as nausea, vomiting, confusion and grogginess. Some patients claim that the side effects are worse than coping with the pain itself.

In our experience, we have found that our patients’ recoveries are more comfortable and they can become active faster, when we alleviate their post-operative pain with a continuous peripheral nerve block (CPNB). Because their pain is so well managed, we are able to be more aggressive in their physical therapy activities and can discharge them as outpatients, many of whom leave within an hour or two after the end of surgery.

The product we use, called ON-Q C-bloc, is a disposable delivery pump that provides a continuous infusion of a numbing agent through tiny catheters. It uses no electronics and is easy for patients to use without worry. They take the pump home with them in a small carrying pouch they can wear around their waist, providing them with days of pain relief following surgery.

The concept is similar to epidurals, which have been used for decades in labor and delivery. Instead of placing the catheter in the patient’s lower back, it is placed near specific nerves affected by the planned surgery and only a local anesthetic is used. An ultrasound machine provides an image to guide the placement of the pump catheter. This allows us to place the catheter very close to the nerves numbing the affected area. With this continuous infusion technique, patients don’t suffer from breakthrough pain as with some other methods and generally experience significant pain relief until the catheter is removed, usually by the third day after surgery.

By minimizing pain post-operatively with CPNB, patients are more likely to avoid many of the consequences often associated with traditional pain medications such as urinary retention, sedation, constipation, nausea and vomiting. They can remain virtually pain-free up to several days after surgery. Also, consequences of severe and poorly controlled post-operative pain such as prolonged muscle weakness, regional pain syndrome, muscle spasms and joint history contractions are all minimized.

Surgical procedures that have traditionally required hospitalization that can now be performed in an outpatient setting include open surgical procedures around the shoulder, such as rotator cuff repair and reconstruction, fixation of fractures and joint replacement or resurfacing procedures.

Surgical procedures on the lower extremity include open reduction and internal fixation of fractures, corrective osteotomies of the tibia; patella-femoral realignment procedures, cartilage restoration and joint replacement procedures.

Other recognized risks associated with these surgical procedures such as compartment syndromes, post-operative bleeding, urinary retention or break-through pain can be avoided by careful attention to surgical technique, recovery room monitoring, proper patient/caregiver instructions, and a well designed home visiting nurse program, when indicated.

About Dr. Greg Hickman

An early adopter and pioneer of acute post-operative pain management, Dr. Gregory Hickman played an instrumental role in launching the world class Andrews Institute, ASC. There, he also led a specialized program designed to enhance pain management techniques for ambulatory surgery that benefit patients in their homes as well as throughout rehabilitation.

Dr. Hickman has held several positions including: clinical instructor and medical director, PACU and Holding at the University of Alabama at Birmingham (UAB) from 1990-1991; staff anesthesiologist at Mercy Hospital in Charlotte, NC from 1991-1992; staff anesthesiologist and director of Acute Pain Service at HealthSouth Medical Center in Birmingham from 1992-2007 and was the Chairman of the Department of Anesthesia at HealthSouth from 1993-1997. He has served as Medical Director and Anesthesia Director at the Andrews Institute since March 2007.

Dr. Hickman is an alumnus of Tennessee Technological University and the University of Tennessee, College of Pharmacy where he earned his B.S. in pharmacy. He went on to East Tennessee State University College of Medicine, where he obtained his medical degree and was given the Lange Medical Publications Award, for outstanding achievement as a medical student. He interned in Internal Medicine at the Medical University of South Carolina and completed his residency in Anesthesiology at UAB.

About Dr. Lonnie Paulos

Dr. Paulos is dedicated to educating others in the field of orthopaedic medicine. He has held several faculty and visiting professor positions at numerous academic institutions and clinical facilities across the United States, Europe and North and South America. Positions include associate clinical professor for the University of Utah School of Medicine Department of Surgery, division of orthopaedic surgery from 1983-92; clinical assistant professor and co-director for the University of Utah Department of Orthopaedic Surgery from 1983-92; assistant professor from 1979-81 and assistant clinical professor from 1981-1983 for the University of Cincinnati Department of Orthopaedic Surgery; co-director of the Cincinnati Sports Medicine and Orthopaedic Institute from 1982-83; adjunct professor for the University of Utah School of Physical Therapy from 1983-87; and professor for the Baylor College of Medicine from 2005-07.

In addition to his research efforts, Dr. Paulos has been recognized for his clinical expertise and is an active member of the Herodicus Society as well as 19 other professional medical associations. The American Orthopaedic Society for Sports Medicine (AOSSM) awarded him the European Traveling Fellowship in 1986 followed by the O’Donoghue Research Award for “Biomechanics of Lateral Knee Bracing” in 1987. In 2000, he received the President’s Challenge Award from the National Athletic Trainers’ Association.

Dr. Paulos is an alumnus of the University of Utah, earning his Doctor of Medicine and completing his orthopaedic surgical residency with the School of Medicine, division of Orthopaedic Surgery. Following his residency, he completed a two-part fellowship -- the first half at the Atlanta Sports Medicine Foundation and the second half at the University of Cincinnati Medical Center. In addition, Dr. Paulos earned his Bachelor of Science in Zoology at the University of Utah. During this time, he played five years of football and was recognized as an outstanding academic student athlete. He was named to the All-Western Athletic Conference Academic Team, received Honorable Mention for the Academic All American Team, and was Outstanding Student Athlete for three consecutive years.

Web address: