Postoperative Pain Management in Orthopedic Surgery

Multimodal Analgesic Regimens

The American Society of Anesthesiologists recommends a multimodal analgesic regimen combining acetaminophen with NSAIDs or COX-2 inhibitors as the foundation, with opioids reserved only for rescue, to reduce postoperative pain and improve functional outcomes 1, 2
Acetaminophen should be administered pre-operatively or intra-operatively and continued postoperatively, typically 1g every 6 hours, not exceeding 4g daily, as recommended by the American College of Surgeons 1, 3, 4
NSAIDs or COX-2 selective inhibitors should be started pre-operatively or intra-operatively and continued postoperatively, according to the American Pain Society 1, 2, 3, 4
A single intravenous dose of dexamethasone 8-10 mg intra-operatively provides analgesic and anti-emetic effects, as suggested by the American Society of Anesthesiologists 1, 2, 3, 4

For total hip arthroplasty, a single-shot fascia iliaca block or local infiltration analgesia is recommended, especially when contraindications to basic analgesics exist or in patients with high expected postoperative pain, according to the American Academy of Orthopaedic Surgeons 1, 3, 5, 4
Femoral nerve block is recommended for total knee arthroplasty based on reduction in pain scores and supplemental analgesic requirements, as stated by the American Society of Regional Anesthesia and Pain Medicine 6

Opioids should be reserved strictly as rescue analgesics in the postoperative period, not as first-line therapy, as recommended by the Centers for Disease Control and Prevention 1, 2, 3, 4, 5
When IV opioids are necessary, patient-controlled analgesia (PCA) is preferred over intramuscular administration due to improved pain control and higher patient satisfaction, according to the American Society of Anesthesiologists 6, 4

Pre-operative exercise and education are Grade A recommendations that directly reduce postoperative pain and improve functional outcomes, as stated by the American College of Sports Medicine 1, 2
Pre-operative exercise reduces postoperative pain intensity, improves functional recovery, facilitates early postoperative rehabilitation, and enhances overall surgical outcomes, according to the National Institutes of Health 1, 2

For total hip arthroplasty, a regimen of paracetamol + NSAIDs/COX-2 inhibitors + dexamethasone 8-10 mg IV + fascia iliaca block or local infiltration analgesia is recommended, as suggested by the American Association of Hip and Knee Surgeons 1, 2, 3, 4
For total knee arthroplasty, the same basic regimen plus femoral nerve block is recommended, according to the American Academy of Orthopaedic Surgeons 6

Gabapentinoids should not be used routinely for hip arthroplasty due to potential side effects, as recommended by the American Society of Anesthesiologists 1, 2, 5
NSAIDs should be avoided in patients with colon or rectal anastomoses due to potential correlation with dehiscence, as stated by the American Society of Colon and Rectal Surgeons 4
Acetaminophen should not exceed 4g daily and should be used cautiously in liver disease, according to the American Association for the Study of Liver Diseases 7, 4