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Management of postoperative pain after total hip arthroplasty

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


  • FIRST choice: peripheral nerve blocks
  • 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.


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.


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.


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

Anaesthesia GA and peripheral block General anaesthesia Spinal anaesthesia Epidural +/- GA
Preoperative analgesia Femoral nerve block None None None
Intraoperative analgesia Femoral nerve block or posterior lumbar plexus block Non opiod analgesic and/or strong long-acting opioid to secure analgesia when the patient wakes Local infiltration analgesia (LIA) High risk patients: Epidural LA + opioid
Postoperative analgesia Continue nerve block (by continuous infusion or PCRA Analgesia) + COX-2-selective inhibitors or conventional NSAIDs ± opioids, weak or strong depending on intensity of pain. Paracetamol + COX-2-selective inhibitors or conventional NSAIDs + IV strong opioid by PCA Systemic analgesia as the nerve block regresses, using COX-2-selective inhibitors or conventional NSAIDs ± strong opioids IV Continue epidural infusion + COX-2-selective inhibitors or conventional NSAIDs ± strong opioids IV
Non-pharmacological Non-pharmacological


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