Association of a Physician-Nurse Collaborative Multimodal Analgesic Pathway with Early Pain Trajectories and Institution-Recorded Opioid Use After Total Knee Arthroplasty: A Propensity Score-Matched Retrospective Cohort Study.

BACKGROUND: Multimodal analgesia is widely used after total knee arthroplasty (TKA), but evidence regarding the real-world effectiveness of bundled opioid-sparing pathways remains limited. This study compared a standardized physician-nurse collaborative pathway with conventional care delivered during an earlier historical period. METHODS: This single-center retrospective cohort study included adults undergoing primary unilateral TKA. The modified pathway combined physician-prescribed scheduled celecoxib and tramadol/paracetamol rescue analgesia with nurse-delivered cryotherapy, limb elevation, relaxation training, and perioperative pain education. Propensity score matching was used to balance measured baseline and perioperative characteristics. Primary outcomes were longitudinal resting Visual Analog Scale (VAS) scores and cumulative institution-recorded opioid exposure within 90 days, expressed as oral morphine milligram equivalents (MME). Secondary outcomes included continued institution-recorded opioid prescribing at 90 days, opioid-induced adverse events, functional scores, and length of stay. RESULTS: After matching, 101 patient pairs were analyzed. The group-by-time interaction for resting VAS scores was significant (Wald χ2 = 17.92, P = 0.003). After Bonferroni correction, VAS scores were lower in the Modified Protocol Group at 24 hours, 48 hours, 72 hours, and 1 week, but not at 1 or 3 months. Median 90-day institution-recorded MME was 50.0 [25.0-95.0] mg versus 130.0 [75.0-205.0] mg (P < 0.001). No continued opioid prescription was documented at 90 days in 93.1% versus 81.2% of patients (P = 0.012). Opioid-induced adverse events were less frequent (19.8% vs 38.6%, P = 0.003), and mean length of stay was shorter (5.4 vs 6.8 days, P < 0.001). Assignment to the modified pathway was associated with lower odds of continued prescribing (adjusted OR = 0.39, 95% CI: 0.15-0.99). CONCLUSION: The bundled physician-nurse collaborative pathway was associated with lower early pain scores, reduced institution-recorded opioid exposure, and less continued opioid prescribing after TKA. Prospective studies with concurrent controls are needed to confirm these findings and determine the contribution of individual pathway components.