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Management of postoperative pain after total knee arthroplasty

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


PROSPECT PROSPECT /total knee arthroplasty/Summary recommendations/postoperative

Local anaesthetic techniques


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.


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.


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

  1. 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.
  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