Hip replacement is a common operative procedure to improve mobility and quality of life. Adequate pain relief is essential in the postoperative period to enable ambulation and initiation of physiotherapy. Patients who undergo this surgery are typically elderly, after falls.

Evidence-based recommendations specific to the condition

For overview of interventions recommended and NOTrecommended see PROSPECT PROSPECT/Total hip arthroplasty/Overall PROSPECT recommendations

Pre-operative

• COX-2-selective inhibitors and non-selective NSAIDs in time to provide sufficient analgesia when the patient wakes PROSPECT/Total hip arthroplasty/Summary PROSPECT recommendations

• FIRST choice: peripheral nerve blocks
  • Femoral nerve block. It can also be administered in a preclinical setting (including accident site) and provides effective analgesia for patient transport. German guidelines 4.6.6.1, p67; French section 10.3.1. p 408
  • Posterior lumbar plexus block (psoas sheath blocks) French section 10.3.2. p 408
• Single-bolus spinal local anaesthetic and morphine.
• Epidural infusion with local anaesthetic plus opioid for patients with cardiopulmonary risk, in time to provide analgesia in the early postoperative recovery period.

Intra-operative

PROSPECT /Total hip arthroplasty/Summary PROSPECT recommendations

• Intra-operative, high-volume, low-concentration wound infiltration (LIA) ¹
  (¹ See also Raeder & Spreng, 2011 in the Supplementary reading)
• IV-cox-2 selective inhibitors and an opioid in time to provide analgesia in the early postoperative recovery period.

Postoperative

PROSPECT /Total hip arthroplasty/Summary PROSPECT recommendations

• Continue nerve block using Patient Controlled Regional (PCRA).
• Whenever possible, patients should be given multimodal pain management therapy.
  • COX-2 selective NSAIDs, nonselective NSAIDs, and calcium channel α-2-δ antagonists (gabapentin and pregabalin) should be considered as part of a postoperative multimodal pain management regimen.
  • Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen. ASA section V Multimodal techniques for Pain Management, p 253-254.
• In absence of nerve block, give strong opioids by IV PCA in combination with non-opioid analgesia to manage high-intensity pain.
• Weak opioids for moderate- or low-intensity pain if conventional NSAIDs or COX-2-selective inhibitors are insufficient or are contraindicated.

Non-pharmacological

Employ physical measures such as cooling and elevation of the operated limb. German section 4.6.1, p 59.

Summary of analgesic protocols depending on the type of anaesthesia

Summary

Peripheral nerve blocks are the choice techniques for providing analgesia after total hip arthroplasty. Local infiltration analgesia (LIA) is another option. If not available, administer systemic opioids and non-opioid analgesia. Multimodal-based analgesia should be given whenever possible. Epidural infusion for patients with cardiopulmonary risk.

Supplementary reading

1. Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev. 2003;(3):CD003071.

2. Kehlet H, Andersen LÖ. Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand 2011;55:778-784

3. Raeder J, Spreng UJ. Local-infiltration anaesthesia (LIA):postoperative pain management revisited and appraised by the surgeons? Acta Anaesthesiol Scand 2011;55:772-774

4. Rawal N. Local Infiltration Analgesia and other multicomponent techniques to improve postoperative outcome- are we comparing oranges and apples? Reg Anesth Pain Med. 2012;36:417-420