You are here
Management of postoperative pain after total knee arthroplasty
Version 1, February 2013
Total knee arthroplasty is a common operative procedure to improve mobility and quality of life in patients with end-stage knee osteoarthritis. Adequate pain relief is essential in the postoperative period to enable ambulation and initiation of physiotherapy.
Evidence-based recommendations specific to the condition
For overall recommendations see: PROSPECT/total knee arthroplasty/OVERALL Prospect recommendations
For overview of treatments NOTrecommended see: PROSPECT/total knee arthroplasty /OVERALL Prospect recommendations/NOT recommended
Pre-operative and intra-operative
PROSPECT /total knee arthroplasty/Summary recommendations/pre-&intra-operative
Local anaesthetic techniques
- First choice: Femoral nerve block French section 10.3.2, p 408
- Femoral block is advantageous over epidural; both provide similar levels of analgesia but the femoral block is associated with fewer side effects and patient monitoring is less intensive. French section 10.3.1, p 408.
- Femoral block provides better analgesia compared to paraenteral-opioid based analgesia ANZAC chapter 7.5.1, p 196.
- Second choice: spinal anaesthesia, local anaesthetic with an opioid, preferably morphine. ANZCA chapter 5.2.1, ‘Intrathecal opioids’, p 127.
- Continuous epidural. Associated with increased side effects, particularly hypotension. German chapter 4.6.9.3., p 71-72.
Postoperative
PROSPECT PROSPECT /total knee arthroplasty/Summary recommendations/postoperative
Local anaesthetic techniques
Continue.
Systemic-based techniques
- Opioids will form the mainstay of systemic analgesia.
- Strong for severe pain and weak for moderate to weak pain.
- 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.
Non-pharmacological
Use physical measures such as cooling, compression techniques and elevation of operated limb. German section 4.6.1, p 59; PROSPECT /total knee arthroplasty/non-pharmacological/techniques
Analgesia protocol proposal depending on the type of anaesthesia
| Anaesthesia | General anaesthesia | GA and peripheral block | Spinal anaesthesia | Epidural +/- GA |
|---|---|---|---|---|
| Preoperative analgesia | None | Femoral nerve block | None | None |
| Intraoperative analgesia | Systemic non- opiod analgesic and/or strong long-acting opioids to secure analgesia when the patient wakes | Femoral nerve block | Intrathecal morphine | Epidural LA + opioid |
| Postoperative analgesia | Paracetamol + COX-2-selective inhibitors OR conventional NSAIDs + IV strong opioid by PCA | Continue nerve block (by continuous infusion or PCRA) + COX-2-selective inhibitors OR ns NSAIDs ± strong opioids IV | Establish systemic pain management as the nerve block regresses, using COX-2-selective inhibitors or ns NSAIDs ± strong opioids IV | PCEA, + COX-2-selective inhibitors or conventional NSAIDs ± strong opioids IV |
| Non-pharmacological | Cooling, compression techniques and elevation of operated limb. | |||
Summary
Regional anaesthesia-based techniques are the choice techniques for providing analgesia after total knee arthroplasty. If not available, provide systemic opioids and non-opioid analgesia. The general practice guidelines for multimodal analgesia should be applied.
Supplementary Reading
- Buvanendran A, Kroin JS, Della Valle CJ, Kari M, Moric M, Tuman KJ. Perioperative oral pregabalin reduces chronic pain after total knee arthroplasty: a prospective, randomized, controlled trial. Anesth Analg. 2010 Jan 1;110(1):199-207.
- Kehlet H, Andersen LÖ. Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand 2011;55:778-784
- Raeder J, Spreng UJ. Local-infiltration anaesthesia (LIA):postoperative pain management revisited and appraised by the surgeons? Acta Anaesthesiol Scand 2011;55:772-774
- 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