Not recommended for total knee arthroplasty

Pre-operative not recommended	·         Systemic analgesia: –       Alpha-2-delta subunit ligands (gabapentinoids) (Grade D), due to a lack of procedure-specific evidence –       Conventional NSAIDs (Grade B) because of limited procedure-specific evidence and increased risk of bleeding –       Corticosteroids (Grade D) due to a lack of procedure-specific evidence (may be used for reasons other than postoperative analgesia) –       NMDA antagonists o        Dextromethorphan (Grade D) due to inconsistent evidence of analgesic effects o        Ketamine (Grade D) because of limited procedure-specific evidence –       Strong opioids (Grade D) due to a lack of evidence for analgesic benefit over postoperative administration ·         Peripheral nerve blocks: –       Combination femoral and obturator block (Grade D) because of limited procedure-specific evidence –       Combination femoral and sciatic nerve block (Grade D) because of limited and inconsistent procedure-specific evidence –       Lumbar plexus block (posterior approach) (Grade D), as femoral nerve block is equally effective and is associated with fewer complications –       Alpha-2-adrenoceptor agonists (clonidine, epinephrine), as part of the LA solution in peripheral nerve blocks (Grade A) due to a lack of efficacy in procedure-specific studies ·         Epidural: –       LA and/or opioid (Grade B) due to an increased risk of adverse events and no improvement in analgesia compared with femoral nerve block –       Ketamine (as adjuvant to epidural) (Grade B) due to side-effects and inconclusive analgesic efficacy –       Tramadol (as adjuvant to epidural) (Grade B) because of insufficient analgesia ·         Spinal: –       Neostigmine (Grade D) because of side-effects and limited procedure-specific evidence –       Clonidine (Grade D) because of limited and inconsistent procedure-specific evidence ·         Intra-articular techniques (Grade D) because of inconsistent evidence ·         Physical therapy (Grade D) based on postoperative analgesic effects alone
Intra-operative not recommended	·         Systemic analgesia: –       NMDA antagonists o        Dextromethorphan (Grade D) because of inconsistent analgesia o        Ketamine (Grade D) due to limited procedure-specific evidence –       Weak opioids (Grade D) due to lack of evidence for analgesic benefit over postoperative administration ·         Peripheral nerve blocks administered intra-operatively (Grade D) ·         GA or spinal anaesthesia without any local or regional analgesic technique (Grade D) ·         Epidural anaesthesia (Grade D) because postoperative epidural analgesia is not recommended ·         Intra-articular techniques (Grade D) because of inconsistent analgesia ·         Drains (Grade A) due to lack of analgesic and other recovery benefits
Postoperative not recommended	·         Systemic analgesia: –       Alpha-2-delta subunit ligands (gabapentinoids) (Grade D) due to lack of procedure-specific evidence –       Clonidine (Grade D) because of limited procedure-specific evidence –       IV ketamine infusion (Grade D) because of limited procedure-specific evidence –       IM administration of strong opioids (Grade B) due to unfavourable pharmacokinetics, injection-associated pain and patient dissatisfaction –       Weak opioids for high intensity pain (Grade D) due to insufficient analgesic efficacy –       Paracetamol alone for high intensity pain (Grade D) due to insufficient analgesic efficacy ·         Peripheral nerve blocks: –       Combination femoral and obturator block (Grade D) because of limited procedure-specific evidence –       Combination femoral and sciatic nerve block (Grade D) because of limited and inconsistent procedure-specific evidence –       Lumbar plexus block (posterior approach) (Grade D), as femoral nerve block is equally effective and is associated with fewer complications –       Alpha-2-adrenoceptor agonists (clonidine, epinephrine), as part of the LA solution in peripheral nerve blocks (Grade A) due to a lack of efficacy ·         Epidural: –       LA and/or opioid (Grade B) due to an increased risk of adverse events and no improvement in analgesia compared with femoral nerve block –       Ketamine (as adjuvant to epidural) (Grade B) due to side-effects and inconsistent analgesic efficacy –       Tramadol (as adjuvant to epidural) (Grade B) because of insufficient analgesia ·         Intra-articular techniques (Grade D) because of inconsistent analgesia ·         TENS (Grade B) due to limited procedure-specific evidence suggesting a lack of benefit