Total Hip Arthroplasty

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Summary Recommendations 
The recommendations of the PROSPECT Working Group are graded A–D, based on the level of evidence from the studies, which is in accordance with the Oxford Centre for Evidence-Based Medicine (CEBM website accessed Dec 2003, Sackett 2000). In the context of PROSPECT, recommendations based on procedure-specific evidence are grade A, those based on transferable evidence are grade B, those based on evidence from case series are grade C, and those based on clinical practice are grade D (Click here to see the levels of evidence and grades of recommendation table).

PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

In summary, the PROSPECT recommendations for pre-, intra- and postoperative interventions for the management of postoperative pain in total hip arthroplasty are as follows:

Pre-operative

  • Analgesic medication should be initiated in time to ensure an adequate analgesic effect in the immediate postoperative period (grade D)

Intra-operative

  • The anaesthetic technique should be selected on the basis of minimum impact on the co-morbid state of the patient (grade D). The chosen anaesthetic technique can be continued, or may have a continued effect, for analgesia postoperatively (see Postoperative)
  • Analgesia, other than that required for adequate anaesthesia, is recommended only if the analgesic agent requires time to have maximum effect in the early postoperative recovery period (grade D)
  • For long-term analgesic benefits, cemented prostheses rather than non-cemented prostheses are recommended (grade B)
  • Surgical drains are not recommended because they are associated with an increase in discomfort (grade A), pain scores and risk of infection (grade B)

Postoperative

Systemic analgesia

The following are recommended:

  • COX-2-selective inhibitors (grade A) or conventional NSAIDs (grade B) (depending on patient risk factors) – in combination with strong or weak opioids, as required for pain intensity
  • Strong opioids (grade B) – in combination with non-opioid analgesia for high-intensity pain, preferably administered intravenously by patient-controlled analgesia (grade B) or fixed-interval injection (grade D)
  • Weak opioids for moderate- or low-intensity pain (grade A) if conventional NSAIDs or COX-2-selective inhibitors are not sufficient or are contraindicated
  • Paracetamol (grade A) – for all pain intensities in combination with conventional NSAIDs or COX-2-selective inhibitors (with or without weak opioids)

Regional analgesia

The following are recommended:

  • Peripheral neural block continued after surgery (grade A) in combination with systemic analgesia as required for pain intensity (as above)
  • Spinal LA and opioid as a ‘single shot’ given pre-operatively (grade A) (continuous infusion or repeat bolus spinal is not recommended, grade D), then systemic analgesia as required for pain intensity (as above)
  • Epidural analgesia continued after surgery, only in patients at high cardiopulmonary risk, and then systemic analgesia as required for pain intensity (as above)

See Overall PROSPECT Recommendations for the overall strategy for managing pain after total hip arthroplasty

 

PROSPECT final recommendations

The PROSPECT final recommendations are based on short-term pain outcomes (e.g. pain scores and supplementary analgesic use), following total hip arthroplasty. The recommendations do not take into account rehabilitation related to long-term pain. This is because rehabilitation programmes for patients undergoing total hip arthroplasty vary greatly between countries, and there is a lack of data for the effects of different rehabilitation regimes on long-term pain outcomes. Indeed, most studies assessing postoperative pain in total hip arthroplasty do not continue beyond 48 h following surgery. It is considered that adequate postoperative pain control is a prerequisite for successful rehabilitation because it allows early mobilisation and permits a more rapid initiation of physiotherapy.

The PROSPECT final recommendations are presented in the table below and are categorised according to the different anaesthetic techniques used for total hip arthroplasty. The PROSPECT group recommends that the choice of anaesthetic technique should be primarily based on the disposition of the patient rather than the management of their postoperative pain. However, based on postoperative pain outcomes, the continuation of some form of regional analgesia following general anaesthesia is recommended over the use of general anaesthesia alone.

Following surgery, the PROSPECT recommendations for pain management encompass a step-down approach for managing high-intensity pain in the immediate postoperative period to moderate- and low-intensity pain later in the postoperative period. For this step-down approach, PROSPECT recommends opioids (strong opioids initially, followed by weak opioids) in combination with paracetamol and conventional NSAIDs or COX-2-selective inhibitors, administered as appropriate for the level of postoperative pain. 

 
GA alone Peripheral neural block + GA Spinal ± GA or IV sedation Epidural ± GA
Pre-operative Pre-operative analgesia is not recommended
Intra-operative Strong long-acting opioids to secure analgesia when the patient wakes Femoral nerve block or posterior lumbar plexus block Single shot spinal LA + morphine Epidural LA + opioid
Do not use clonidine
Surgical drains and wound infiltration are not recommended
Postop High-intensity pain* Paracetamol + COX-2-selective inhibitors or conventional NSAIDs + IV strong opioid by PCA or regular injection Continue nerve block (by continuous infusion or PCRA) + COX-2-selective inhibitors or conventional NSAIDs ± rescue strong opioids IV Establish systemic pain management as the nerve block regresses, using COX-2-selective inhibitors or conventional NSAIDs ± rescue strong opioids IV Establish epidural infusion as the nerve block regresses, ± PCEA, + COX-2-selective inhibitors or conventional NSAIDs ± rescue strong opioids IV
Postop

Low- and moderate-
intensity pain**



Paracetamol + COX-2-selective inhibitors or conventional NSAIDs ± rescue weak opioid
 
*High-intensity pain, VAS ³ 50, on a scale of 1–100 mm 
**Moderate-intensity pain, VAS <50>30, on a scale of 1–100 mm 
**Low-intensity pain, VAS £ 30, on a scale of 1–100 mm 


IV, intravenous; LA, local anaesthetic; PCA, patient-controlled analgesia; PCEA, patient-controlled epidural analgesia; PCRA, patient-controlled regional analgesia
 


  

Description of studies

Literature search

Pre-operative analgesia

Data are available from studies that assessed pre-operative analgesia versus pre-operative placebo, as well as those that, to examine the concept of pre-emptive — or preventive — analgesia, assessed pre-operative analgesia versus the same analgesia given postoperatively. However, a previous systematic review of pre-emptive analgesia for acute or chronic postoperative pain relief in a variety of surgical procedures — such as orthopaedic, dental, gynaecological and abdominal — has concluded that there is no benefit of pre-emptive over postoperative administration (Møiniche 2002). Nevertheless, it is considered that analgesic medication needs to be initiated in time to ensure an adequate analgesic effect in the immediate postoperative period. This may necessitate administration prior to the postoperative period.

PROSPECT Recommendations

  • There is no procedure-specific evidence that pre-operative administration of COX-2-selective inhibitors is more effective than postoperative administration
  • As with all analgesics it is recommended that COX-2-selective inhibitors should be administered in enough time to provide sufficient analgesia when the patient wakes (grade D)
  • It is recommended that the use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (cardiovascular morbidity, actual or recent gastroduodenal ulcer history, bone healing, renal function and hepatic function [grade B] or aspirin-sensitive asthma [grade D])
  • Although there is concern about impairment of bone-healing with COX-2-selective inhibitors, there are no conclusive clinical studies to show that they have detrimental effects

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • COX-2-selective inhibitors given pre-operatively significantly reduced postoperative pain scores compared with placebo following spinal fusion Reuben et al 2000 Click here for more information
  • COX-2-selective inhibitors given pre-operatively had a significant postoperative opioid-sparing effect compared with placebo following spinal fusion Reuben et al 2000 Click here for more information
  • Pre-operative administration of oral rofecoxib 25 mg once daily, oral rofecoxib 50 mg or oral celecoxib 200 mg, did not increase intra- or postoperative blood loss when compared with placebo, in patients undergoing total knee arthroplasty or spinal fusion Reuben et al 2000
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation Greenberg et al 2000
  • A randomised clinical trial showed that the COX-2-selective inhibitor rofecoxib was associated with significantly less intra-operative blood loss than the conventional NSAID diclofenac in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function Bavbek et al 2004
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following non-cardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062) (in press, Anesthesiology)
  • Two clinical trials showed that in patients who had undergone CABG surgery, COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo Nussmeier et al 2005
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents EMEA 2004a
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting Blomme et al 2003
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2003

Total Hip Arthroplasty-Specific Evidence

  • [No data found within the parameters of the systematic review]

PROSPECT Recommendations

  • Pre-operative conventional NSAIDs are not recommended, despite their analgesic efficacy, because they are associated with an increased risk of intra- and postoperative bleeding (grade A)
  • There is no procedure-specific evidence that pre-operative administration of conventional NSAIDs is more effective than postoperative administration

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Intravenous diclofenac 75 mg or ketorolac 60 mg given pre-operatively significantly reduced pain scores compared with pre-operative placebo in the immediate postoperative period and at 8 h after total hip or knee arthroplasty Alexander et al 2002
  • Intravenous diclofenac 75 mg or ketorolac 60 mg given pre-operatively had a significant opioid-sparing effect compared with pre-operative placebo after hip or knee arthroplasty (for both drugs versus placebo: time 0, p = 0.009 and 8 h, p = 0.026; n =1 02) Alexander et al 2002
  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo Bricker et al 1987
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo Greer et al 1999
  • Meta-analyses of randomised controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls Marret et al 2003
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction Niemi et al 1997
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery Forrest et al 2002
  • A randomised clinical trial showed that the conventional NSAID diclofenac was associated with significantly greater intra-operative blood loss than the COX-2-selective inhibitor rofecoxib in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease Stevenson 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2003

Total Hip Arthroplasty-Specific Evidence

  • Pre-operative administration of ketorolac 60 mg intravenously was superior to administration of ketorolac at closure for pain scores in the immediate postoperative period (p=0.03 at rest, p=0.0002 on movement), but the effect was not significant at all other times (6–48 h) Fletcher et al 1995
  • Pre-operative administration of ketorolac was superior to administration of ketorolac at closure for reducing the requirement for supplementary analgesia up to 6 h postoperatively (p<0.01), but not from 6–48 h Fletcher et al 1995
  • Pre-operative ibuprofen, 600 mg orally three times per day two weeks before surgery, showed no significant benefit in reducing postoperative pain scores or morphine consumption and produced a similar incidence of PONV compared with placebo, for 0–24 h (n=50) Bugter et al 2003
  • Pre-operative ibuprofen, 600 mg orally three times per day two weeks before surgery, significantly increased the median total peri-operative blood loss compared with placebo (1161 ml versus 796 ml; p<0.01; n=50) Bugter et al 2003
  • Pre-operative conventional NSAIDs significantly increased peri-operative blood loss in patients undergoing total hip arthroplasty compared with other analgesic agents in four out of five studies An et al 1991 Click here for more information
 

PROSPECT Recommendations

  • Gabapentin cannot be recommended at this time due to a lack of procedure-specific evidence, although analgesic data from other procedures are promising.

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Studies of gabapentin and pregabalin in mastectomy, abdominal surgery, laparoscopic cholecystectomy and spinal surgery showed reductions in postoperative pain and supplementary analgesic requirements for at least 24 h Dahl et al 2004

 Total Hip Arthroplasty-Specific Evidence

  • [None cited]

PROSPECT Recommendations

  • Pre-operative ketamine cannot be recommended at this time (grade D) due to a lack of procedure-specific evidence, and due to associated side-effects that may hinder early ambulation, despite some evidence of analgesic efficacy in other procedures

Clinical Practice

  • Ketamine is associated with a risk of adverse effects on the central nervous system

Transferable Evidence from Other Procedures

  • Studies of ketamine in abdominal, orthopaedic, gastric, hepatic and renal surgery showed a reduction in postoperative pain and opioid use when used as an adjuvant to morphine, either epidurally or intravenously Subramaniam et al 2004

Total Hip Arthroplasty-Specific Evidence

  • [None cited]

PROSPECT Recommendations

  • Pre-operative strong opioids are not recommended because of inconsistent evidence of their postoperative analgesic efficacy (grade A)
  • As with all analgesia, strong opioids should be administered in time to provide sufficient analgesia in the early postoperative recovery period (grade D)

Clinical Practice

  • As with all types of analgesia for postoperative pain, strong opioids should be instituted in time to secure sufficient analgesia when the patient wakes

Transferable Evidence from Other Procedures

  • Pre-operative oral administration of morphine sulphate 20 mg reduced supplementary analgesia requirements compared with pre-operative placebo, in a group of patients undergoing total hip or knee arthroplasty (p<0.05; n=98) Reiter et al 2003
  • Pre-operative oral administration of morphine sulphate 20 mg did not reduce postoperative pain scores compared with pre-operative placebo, in a group of patients undergoing total hip or knee arthroplasty (n=98) Reiter et al 2003

Total Hip Arthroplasty-Specific Evidence

  • Pre-operative morphine or pre-operative buprenorphine were not significantly different from placebo for the incidence of nausea or vomiting O'Sullivan et al 1983
  • Pre-operative morphine or pre-operative buprenorphine were not significantly different from placebo for postoperative pain scores O'Sullivan et al 1983
  • Oral sustained-release morphine 20 mg every 12 h, starting at premedication, did not significantly decrease VAS scores compared with IM morphine 10 mg every 6 h postoperatively Bourke et al 2000
  • Study details O'Sullivan et al 1983 Click here for more information

PROSPECT Recommendations

  • The choice of anaesthetic should be based on the co-morbid state of the patient and the contraindications of the proposed anaesthetic technique (grades A and B) rather than on the management of postoperative pain
  • Depending on the pharmacokinetic profile of the analgesic drugs, it may be necessary to initiate analgesia intra-operatively to allow sufficient time for the analgesia to reach maximum effect in the early postoperative recovery period (grade D)
  • For recommendations on epidural, peripheral nerve block and spinal techniques, see Postoperative section

Clinical Practice

  • Spinal anaesthesia and postoperative analgesia using LA and strong opioid is widely used in clinical practice, although the effects on the incidence of postoperative nausea and vomiting, and on urine retention, should be carefully considered before administration
  • Long-acting opioids, such as morphine, are preferred to short-acting opioids for a long duration of analgesia postoperatively
  • Both the lumbar plexus block and the femoral nerve block can be used to inject a single bolus of local anaesthetic for short duration of analgesia; or by infusion or PCA via a nerve catheter for a prolonged effect
  • Epidural analgesia is associated with a risk of bladder complaints and neurological impairment, therefore patients should be assessed for this method of pain relief on an individual basis
  • Clonidine is not used routinely in postoperative epidural analgesia, despite its analgesic efficacy, because of the risk of hypotension, sedation and bradycardia
  • It is considered that analgesic drugs should be instituted in time to secure sufficient pain relief when the patient wakes

Transferable Evidence from Other Procedures

  • Combined spinal epidural block or spinal block were superior to epidural block (0.5% bupivacaine plus 0.2 or 0.4 mg morphine for spinal, or 0.5% bupivacaine plus 4 mg morphine for epidural) for surgical analgesia and for reducing consumption of perioperative sedatives and other analgesics in major orthopaedic surgery Holmstrom et al 1993
  • Epidural anaesthesia reduces the frequency of deep vein thrombosis and pulmonary embolism, and reduces intra-operative and postoperative blood loss, compared with general anaesthesia, particularly in total hip arthroplasty patients, as shown in a review Modig 1989
  • Epidural infusion of bupivacaine and meperidine (1 mg/ml) had a significantly slower regression of sensory anaesthesia and slower development of pain, in contrast to infusions of bupivacaine alone (control) or bupivacaine and fentanyl (3 µg/ml) following total knee arthroplasty (p<0.05; n=48) Ferrante et al 1993
  • A systematic review of different methods of anaesthesia for hip fracture surgery showed that regional anaesthesia was associated with reduced short-term mortality compared with general anaesthesia but there was no significant difference for other outcome measures Parker et al 2004 Click here for more information
  • Bolus spinal morphine (300 µg) was significantly more effective than saline placebo for reducing postoperative pain scores after total knee arthroplasty (p<0.05; n=60) Tan et al 2001
  • Peripheral neural blocks are associated with a lower risk of side-effects compared with neuraxial opioids Sinatra et al 2002
  • Femoral nerve block is associated with a lower risk of serious complications than spinal anaesthesia (using bupivacaine or lidocaine) Auroy et al 2002
  • In a systematic review of seven randomised trials in hip fracture, nerve blocks administered pre- or peri-operatively resulted in a reduction in pain score and supplementary analgesia requirement compared with control (n=269) Parker et al 2001a
  • 'Single shot' or continuous peripheral nerve block was significantly more effective than placebo for reducing the requirement for supplementary analgesia following total knee or hip arthroplasty (n=242) Allen JG et al 1998
  • 'Single shot' femoral nerve block reduced pain scores for up to 8 h and reduced morphine consumption following total knee arthroplasty Allen JG et al 1998
  • The posterior approach to the lumbar plexus (psoas sheath block) produces more reliable analgesia to the hip joint than the distal approach (femoral nerve or 3-in-1 blocks). However, the lumbar plexus block has the potential for more serious complications than the femoral nerve block Auroy et al 2002
  • Addition of epinephrine did not alter the duration of analgesia with a 'single shot' 3-in-1 femoral nerve block (20 ml ropivacaine 0.5% [~11–12 h] or 0.2% [~7 h]) following total knee arthroplasty (n=41) Weber et al 2001
  • In a systematic review, spinal morphine in patients undergoing caesarean section was shown to increase the relative risk of postoperative pruritis, nausea and vomiting compared with control; increasing the dose of morphine increased the relative risk of postoperative nausea and vomiting Dahl et al 1999
  • Spinal administration of bolus clonidine or morphine produced a high incidence of bladder distension in patients undergoing hip surgery, but there was a greater incidence with spinal morphine than clonidine (p<0.001) Gentili and Bonnet 1996

Total Hip Arthroplasty-Specific Evidence

  • Spinal morphine 0.1 mg was superior to a posterior lumbar plexus block using ropivacaine 0.475% for reducing postoperative pain scores for 6–18 h (p<0.05) and reducing supplementary analgesic consumption for 48 h, but there was no significant difference for the incidence of nausea, vomiting or pruritis (n=53) Souron et al 2003
  • Continuous spinal bupivacaine analgesia (and anaesthesia) was superior to IV PCA morphine analgesia (plus 'single shot' spinal anaesthesia) for reducing VAS scores for 3–24 h (p<0.05) and the incidence of PONV (n=68) Maurer et al 2003
  • Spinal analgesia was superior to epidural analgesia in one study for pain scores Mollmann et al 1999 Click here for more information
  • A range of morphine doses (0.025, 0.05, 0.1 and 0.2 mg), administered with bupivacaine 20 mg for spinal anaesthesia, were similar for VAS pain scores Slappendel et al 1999
  • Two studies showed that continuous epidural anaesthesia/analgesia was superior to general anaesthetic plus intravenous morphine analgesia for reducing postoperative pain scores Møiniche et al 1994 Click here for more information
  • Epidural ropivacaine produced a greater proportion of patients with recovered motor function (Bromage score <1) than epidural levobupivacaine and epidural bupivacaine groups immediately postoperatively (p<0.05). However, there were no differences at 6 h (n=45) Casati et al 2003 Click here for more information
  • Epidural anaesthesia was associated with less intra-operative blood loss than neuroleptoanaesthesia, halothane, phenoperidine or general anaesthesia in four studies Chin et al 1982
  • Epidural catheter insertion with the tip of the Tuohy needle rotated 45° toward the operative side was superior to catheter insertion with the tip of the Tuohy needle in the conventional position (90° cephalad) for reducing postoperative local anaesthetic consumption for 12–48 h (p=0.001), but there was no significant difference for pain scores (n=48) Borghi et al 2004
  • Posterior lumbar plexus block 'single shot' given pre- or postoperatively was superior to placebo for reducing postoperative pain scores and supplementary analgesic consumption Stevens et al 2000 Click here for more information
  • Femoral nerve block ('single shot' 40 ml bupivacaine 0.5% plus epinephrine after induction of general anaesthesia) increased the time to first analgesic request by approximately 4 h compared with placebo (p<0.05) (n=40) Fournier et al 1998
  • Postoperative lumbar plexus block was superior to femoral nerve block for reducing postoperative pain scores at rest and supplementary analgesic consumption Biboulet et al 2004 Click here for more information
  • Addition of a lumbar plexus block to general anaesthesia was associated with less intra-operative blood loss compared with general anaesthesia alone, in one study (n=30) Stevens et al 2000
  • Continuous spinal bupivacaine demonstrated a significant reduction in mean arterial pressure during anaesthetic induction compared with 'single shot' spinal bupivacaine (21 ± 11 mmHg versus 29 ± 14; p<0.05) (n=68) Maurer et al 2003
  • Femoral nerve block did not significantly reduce postoperative pain scores, and there was inconclusive evidence for the effect on supplementary analgesic consumption, compared with placebo Fournier et al 1998 Click here for more information
  • Posterior lumbar plexus block provided no significant benefit over femoral nerve block or control (no nerve block) for postoperative pain scores on movement, PONV or articular mobility during rehabilitation (n=45) Biboulet et al 2004
  • Posterior lumbar plexus block using ropivacaine 0.475% was less effective than spinal morphine 0.1 mg for reducing pain scores during 6–18 h (p<0.05) and supplementary analgesic consumption during 48 h, and there was no significant difference in the incidence of nausea, vomiting or pruritis (n=53) Souron et al 2003
  • There are no studies examining the effects of intra-operative wound infiltration on postoperative pain during total hip arthroplasty
  • Study details Chin et al 1982 Click here for more information

PROSPECT Recommendations

  • It is recommended that surgical requirement rather than pain management should be the main consideration in choosing the surgical procedure (grade D)
  • Cemented prostheses have not been shown to confer any short-term analgesic benefit over non-cemented prostheses, but they are associated with better long-term pain outcomes (>1 year) (grade B)
  • Drains are not recommended because they are associated with increased pain scores, do not confer a clinical benefit, and increase the risk of infection (grade B)

Clinical Practice

  • Surgical need rather than postoperative pain management should drive the choice of surgical approach

Transferable Evidence from Other Procedures

  • Cemented prostheses have been shown to be superior to non-cemented prostheses for long-term reduction of pain and for increasing mobility in patients with fractured neck of femur Parker et al 2001b Click here for more information
  • Wound drains without suction produced less postoperative pain intensity on removal compared with drains with suction in intra-articular procedures (n=126; p<0.05) Brandner et al 1991
  • No benefit of bipolar hemiarthroplasty over unipolar hemiarthroplasty (review of six trials, n=742) was demonstrated for postoperative pain in a range of arthroplasty procedures Parker et al 2001b
  • There was no significant benefit of drained compared with un-drained wounds for a range of postoperative pain outcomes, including postoperative pain scores Parker et al 2003 Click here for more information

Total Hip Arthroplasty-Specific Evidence

  • There was no difference between two surgical methods – the modified Hardinge approach and transtrochanteric lateral approach — in postoperative pain scores in one study (n=100) Horowitz et al 1993
  • Wound drains were associated with higher pain scores than no drains (no statistical analysis) in one study of patients undergoing total hip arthroplasty (n=23) Ravikumar et al 2001

PROSPECT Recommendations

  • COX-2-selective inhibitors are recommended for their analgesic and opioid-sparing effect (grade A). They should be given in combination with strong opioids for high-intensity pain (grade A), or with weak opioids for moderate- or low-intensity pain (grade D)
  • COX-2-selective inhibitors may be preferred to conventional NSAIDs in the peri-operative setting, in patients who have an increased risk of bleeding, or who are at risk of gastroduodenal ulcer/erosion (grade B)
  • The use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (cardiovascular morbidity, actual or recent gastroduodenal ulcer history, renal function and hepatic function [grade B] or aspirin-sensitive asthma [grade D])
  • Although there is concern about impairment of bone-healing with COX-2-selective inhibitors, there are no conclusive clinical studies to show that they have detrimental effects 

Clinical Practice

  • [None cited}

Transferable Evidence from Other Procedures

  • COX-2-selective inhibitors significantly reduced postoperative pain and the requirement for supplementary analgesia compared with placebo following knee arthroplasty Hubbard et al 2003 Click here for more information
  • Parecoxib (20 or 40 mg) was as effective as ketorolac (30 mg) administered intravenously for postoperative pain scores (for level, onset and duration of analgesia) following total knee arthroplasty (n=208) Rasmussen et al 2002
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation Greenberg et al 2000
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function Bavbek et al 2004
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following non-cardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062) (in press, Anesthesiology)
  • Two clinical trials showed that in patients who had undergone CABG surgery, COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo Nussmeier et al 2005
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents EMEA 2004a
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting Blomme et al 2003
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2005a

Total Hip Arthroplasty-Specific Evidence

  • Oral valdecoxib was effective in reducing postoperative pain scores at two doses (20 mg or 40 mg) compared with placebo when administered pre-operatively and then postoperatively (p<0.05 for 6, 12 and 18 h) Camu et al 2002
  • Oral valdecoxib was effective in reducing the requirement for supplementary analgesia compared with placebo (p<0.001) Camu et al 2002
  • Oral valdecoxib is not associated with a significant increase in the incidence of nausea or vomiting compared with placebo Camu et al 2002
  • Study details Camu et al 2002 Click here for more information

PROSPECT Recommendations

  • Conventional NSAIDs are recommended for their analgesic and opioid-sparing effect (grade A). They should be given in combination with strong opioids for high-intensity pain (grade A), or with weak opioids for moderate- or low-intensity pain (grade D)
  • Conventional NSAIDs are not recommended in patients who have an increased risk of bleeding, or who are at risk of gastroduodenal ulcer/erosion (grade B)
  • The use of conventional NSAIDs should depend upon assessment of individual patient risks (bleeding complications including epidural haematoma, cardiovascular morbidity, actual or recent gastroduodenal ulcer history, aspirin-sensitive asthma, renal function and hepatic function) (grade B)
  • Although there is concern about impairment of bone-healing with conventional NSAIDs, there are no conclusive clinical studies to show that they have detrimental effects

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Ketorolac (10 mg orally or 30 mg intravenously) was significantly more effective than placebo for reducing pain scores as shown in a number of studies of orthopaedic surgery (including knee, hip and spinal procedures) Kinsella et al 1992
  • Ketoprofen 100 mg orally significantly reduced VAS scores compared with placebo following spinal fusion (p<0.001; n=50) Aubrun et al 2000
  • Oral keterolac 10 mg was as effective as intramuscular morphine 5 mg or 10 mg for reducing postoperative pain scores after orthopaedic procedures DeAndrade et al 1994
  • Intravenous ketorolac 30 mg was more effective than intravenous morphine 4 mg for reducing postoperative pain scores in one study of total knee replacement surgery (n=196) Rasmussen et al 2002
  • Ketoprofen significantly reduced supplementary analgesia requirements compared with placebo following spinal fusion (p=0.002; n=50) Aubrun et al 2000
  • Ketorolac (30 mg bolus, then 5 mg/h infusion for 24 h) reduced the duration of myocardial ischaemic episodes — compared with placebo — for 24 h following the operation in patients undergoing total hip or knee arthroplasty Beattie et al 1997
  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo Bricker et al 1987
  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo Greer et al 1999
  • Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls Marret et al 2003
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction Niemi et al 1997
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery Forrest et al 2002
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease Stevenson 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2005a

Total Hip Arthroplasty-Specific Evidence

PROSPECT Recommendations

  • Ketamine cannot be recommended at this time due to a lack of procedure-specific evidence, although analgesic data from other procedures are promising

Clinical Practice

  • Ketamine is associated with a risk of adverse effects on the central nervous system

Transferable Evidence from Other Procedures

  • Studies of ketamine in abdominal, orthopaedic, gastric, hepatic and renal surgery showed a reduction in postoperative pain and opioid use when used as an adjuvant to morphine, either epidurally or intravenously Subramaniam et al 2004

Total Hip Arthroplasty-Specific Evidence

  • [None cited]

PROSPECT Recommendations

  • Strong opioids are recommended in combination with non-opioid analgesia for managing high-intensity pain following total hip arthroplasty (grade B)
  • Intravenous patient-controlled analgesia (grade A) or fixed-interval intravenous administration titrated for pain intensity (grade D), is recommended over 'on-demand' administration
  • Intramuscular administration of strong opioids is not recommended because of injection-associated pain (grade D)

Clinical Practice

  • Strong opioids in equipotent doses are considered to give a similar level of analgesia
  • Intramuscular administration of strong opioids is considered to be more painful than intravenous administration. However, the size and speed of intravenous dose should be assessed to minimise the risk of respiratory depression

Transferable Evidence from Other Procedures

  • Meperidine significantly reduced postoperative pain scores compared with placebo following hip or knee arthroplasty Tarradell et al 1996 Click here for more information
  • Morphine 4 mg was superior for reducing pain scores and reducing the time to onset of analgesia compared with placebo following total knee arthroplasty Rasmussen et al 2002
  • Oral flupirtine maleate 100–200 mg and pentazocine 50–100 mg had similar effects on pain scores and on the requirement for supplementary analgesia after total hip or knee arthroplasty (n=66) Galasko et al 1985
  • Morphine administered by PCA device had a similar effect to continuous infusion on postoperative pain scores following total hip or knee arthroplasty (n=32) Smythe et al 1996
  • Opioids administered by PCA improved analgesia and decreased the risk of pulmonary complications, and patients preferred them compared with conventional intramuscular, intravenous or subcutaneous opioid treatment, as determined in a quantitative systematic review of randomised trials of postoperative pain management following various surgical procedures Walder et al 2001
  • Meperidine induced significantly higher sedation and respiratory depression compared with tramadol (both 100 mg intravenously) (n=48) Tarradell et al 1996

Total Hip Arthroplasty-Specific Evidence

  • Morphine (0.15 mg/kg intramuscularly) was superior to nalbuphine (0.3 mg/kg intramuscularly) for postoperative pain scores (p<0.02) and for the use of supplementary analgesia (p<0.05; n=80) Fee et al 1989
  • Morphine (2 mg bolus) was superior to meptazinol (20 mg bolus) — each given by PCA — for 8 h postoperative pain scores (p<0.05), and for the incidence of nausea and vomiting (p<0.05; n=49) Frater et al 1989
  • Morphine 2 mg and diamorphine 1 mg — given by PCA — were equally effective for reducing postoperative pain scores (n=40) Robinson et al 1991
  • IV PCA morphine 1 mg 8-min lockout was superior to 4-hourly intramuscular morphine 0.1 mg/kg for postoperative pain scores at rest (p<0.01) and on movement (p<0.05) at 24 and 48 h. There was no significant difference between groups for PONV (n=40) Keita et al 2003
  • Oral morphine (20 mg every 4 h) was superior to IM morphine (5–10 mg on demand) for postoperative pain scores (p<0.05; n=47) McCormack et al 1993
  • Oral sustained-release morphine 20 mg every 12 h, starting at premedication, and IM morphine 10 mg every 6 h postoperatively, were similar for VAS pain scores Bourke et al 2000
  • Study details Fee et al 1989 Click here for more information

PROSPECT Recommendations

  • Weak opioids are not recommended for controlling pain <6 h following total hip arthroplasty (grade A)
  • Weak opioids are recommended for moderate- or low-intensity pain after 6 h if conventional NSAIDs or COX-2-selective inhibitors, are insufficient or are contraindicated (grade D)

Clinical Practice

  • It is considered that weak opioids are ineffective as a single therapy for postoperative pain following total hip arthroplasty

Transferable Evidence from Other Procedures

  • Tramadol (100 mg bolus intravenously) provided no benefit over placebo for postoperative pain scores after total hip or knee arthroplasty (n=48) Tarradell et al 1996

 Total Hip Arthroplasty-Specific Evidence

  • Tramadol (50 or 100 mg orally) provided no benefit over placebo for postoperative pain scores up to 5 h after total hip arthroplasty (n=137) Stubhaug et al 1995
  • Codeine (60 mg orally) provided no benefit over placebo for postoperative pain scores up to 6 h after total hip arthroplasty (n=121) Dahl et al 1995

PROSPECT Recommendations

  • Paracetamol is recommended for all pain intensities because it reduces supplementary analgesic requirements immediately following total hip arthroplasty (grade A)
  • Paracetamol is recommended in combination with conventional NSAIDs or COX-2-selective inhibitors, with or without rescue opioids (grade D)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

Total Hip Arthroplasty-Specific Evidence

  • Parenteral propacetamol 2 g (intravenous infusion) had a significant benefit over placebo in reducing postoperative morphine consumption (p<0.001; n=97) Peduto et al 1998
  • Oral paracetamol 1 g plus codeine 60 mg was superior to placebo and to tramadol (50 or 100 mg) for reducing postoperative pain scores at 2–6 h £ 0.01, all comparisons) and supplementary analgesic use (p<0.01, all comparisons) (n=137) Stubhaug et al 1995
  • Parenteral propacetamol 2 g (intravenous infusion) had no benefit over placebo for reducing postoperative pain scores after total hip arthroplasty (n=97) Peduto et al 1998

PROSPECT Recommendations

  • Epidural infusion with local anaesthetic plus opioid is recommended for cardiopulmonary risk patients (grade A) because of the reduction in cardiopulmonary morbidity associated with epidural analgesia
  • Despite the analgesic benefits of epidural clonidine, it is not recommended for the control of postoperative pain following total hip arthroplasty because of the risk of hypotension, sedation and bradycardia (grades A and D)

Clinical Practice

  • Epidural analgesia is associated with a risk of bladder complaints and neurological impairment, therefore patients are assessed for this method of pain relief on an individual basis
  • Clonidine is not used routinely in postoperative epidural analgesia, despite its analgesic efficacy, because of the risk of hypotension, sedation and bradycardia

Transferable Evidence from Other Procedures

  • Epidural analgesia was superior to systemic analgesia for postoperative pain outcomes Singelyn et al 1998 Click here for more information
  • Epidural analgesia was associated with a lower incidence of pulmonary complications, sedation, urinary retention, pruritis and hypotension compared with systemic analgesia Ballantyne et al 1998 Click here for more information
  • Ropivacaine epidural infusion was superior to placebo (no epidural infusion) for reducing postoperative pain scores (all groups received rescue IV morphine) Turner et al 1996 Click here for more information
  • A combination of epidural local anaesthetic plus opioid produced superior analgesic benefits compared with either drug administered alone Lorenzini et al 2002 Click here for more information
  • Epidural morphine (bolus 4 mg, infusion 12.5 mg/h over 13 h) was similar to epidural ketoprofen (200 mg over 30 min, 12.5 mg/h over 13 h) for postoperative pain scores following total hip or knee arthroplasty Hommeril et al 1994
  • The addition of epidural clonidine (bolus of 150 µg) to epidural bupivacaine (bolus of 50 mg) significantly prolonged the duration of analgesia in patients undergoing hip surgery for traumatic fracture (p<0.05; n=40) Klimscha et al 1995
  • Combined spinal epidural block or spinal block were superior to epidural block (0.5% bupivacaine plus 0.2 or 0.4 mg morphine for spinal, or 0.5% bupivacaine plus 4 mg morphine for epidural) for surgical analgesia and for reducing consumption of perioperative sedatives and analgesics in major orthopaedic surgery Holmstrom et al 1993
  • There was no significant difference between epidural fentanyl (3 µg/ml) plus bupivacaine and bupivacaine alone in the rate of regression of sensory anaesthesia or the development of postoperative pain (n=48) Ferrante et al 1993
  • Epidural infusion of ropivacaine (2 mg/ml) plus sufentanil (1 µg/ml) produced a significantly higher incidence of adverse events (pruritus, nausea and vomiting) than ropivacaine alone following major knee surgery (n=115) Lorenzini et al 2002
  • Neuraxial and parenteral opioids are associated with a greater risk of side-effects compared with continuous plexus and peripheral neural blockades after major orthopaedic surgery Sinatra et al 2002

Total Hip Arthroplasty-Specific Evidence

  • Two studies showed that continuous epidural anaesthesia/analgesia was superior to general anaesthetic plus intravenous morphine analgesia for reducing postoperative pain scores Møiniche et al 1994 Click here for more information
  • Epidural bolus (pethidine hydrochloride 60 mg) was superior to IM bolus (pethidine hydrochloride 1 mg/kg) administered postoperatively for pain scores at 0.5 and 1 h (p<0.05), but non-significant for 2–4 h pain scores and supplementary analgesic consumption (n=14) Gustafsson et al 1986
  • Postoperative epidural infusions of bupivacaine, ropivacaine or levobupivacaine were similar for postoperative pain scores, supplementary analgesia and PONV in two studies Bertini et al 2001 Click here for more information
  • Epidural infusion of bupivacaine (0.125 mg/ml) combined with morphine (0.05 mg/ml) was similar to combination with fentanyl (0.005 mg/ml) for postoperative pain scores after total hip arthroplasty (n=30) Berti et al 1998
  • Different epidural sufentanil doses (0.5 µg/ml, 0.75 µg/ml or 1.0 µg/ml) administered with ropivacaine 0.1% by continuous epidural infusion, were similar for VAS scores, supplementary analgesic consumption, pain-mobility-and-ability-to-walk scores and adverse events within 0–44 h (n=32) Kampe et al 2003
  • Epidural clonidine was superior to epidural local anaesthetic or morphine for a number of postoperative analgesia outcomes Carabine et al 1992a Click here for more information
  • Addition of clonidine to local anaesthetic or opioid was superior to local anaesthetic or opioid alone for a variety of postoperative analgesia outcomes Carabine et al 1992a Click here for more information
  • The addition of ropivacaine (1 mg/ml, 3 ml/h) to an infusion of fentanyl (10 µg/ml, 3 ml/h) conferred no benefit over fentanyl alone for postoperative pain scores (n=39) Kostamovaara et al 2001
  • Epidural clonidine reduced mean arterial pressure and heart rate compared with epidural morphine but did not increase the incidence of sedation and did not consistently reduce arterial pressure compared with epidural local anaesthetic Carabine et al 1992b Click here for more information

PROSPECT Recommendations

  • Femoral nerve blocks are recommended (grade B) based on their analgesic efficacy in hip fracture surgery and knee arthroplasty. They are recommended over neuraxial techniques and parenteral opioids based on a reduced risk of side-effects in major orthopaedic surgery (grade B). Supplementary obturator and lateral cutaneous nerve of thigh blocks may be required for analgesia in hip arthroplasty
  • Posterior lumbar plexus blocks (psoas sheath blocks) have a greater efficacy than distal lumbar plexus blocks (femoral nerve blocks) in total hip replacement, and are recommended (grade A). However, they have a potential for more serious complications than the femoral block and the risk/benefit balance should be determined for individual patients.
  • Continuous infusion, patient-controlled or 'on-demand' femoral nerve blocks are recommended over a 'single shot' approach as they provide an extended height of block and a greater duration of analgesia (grade D)  

Clinical Practice

  • 'On-demand', patient-controlled or continuous administration are preferred over a 'single-shot' peripheral neural block for longer-acting pain relief

Transferable Evidence from Other Procedures

  • In a systematic review of seven randomised trials in hip fracture, nerve blocks administered pre- or peri-operatively resulted in a reduction in pain score and supplementary analgesic requirement compared with control (n=269) Parker et al 2001a
  • 'Single shot' femoral nerve block reduced pain scores for up to 8 h and reduced morphine consumption following total knee arthroplasty Allen JG et al 1998
  • 'Single shot' or continuous peripheral nerve block was significantly more effective than placebo for reducing the requirement for supplementary analgesia following total knee or hip arthroplasty (n=242) Allen JG et al 1998
  • The posterior approach to the lumbar plexus block produces more reliable analgesia to the hip joint than the distal approach (femoral nerve or 3-in-1 blocks); however, the lumbar plexus block has the potential for more serious complications than the femoral nerve block Auroy et al 2002
  • Continuous plexus and peripheral neural blocks are associated with a reduced risk of side-effects compared with neuraxial and parenteral opioids, in pain management after major orthopaedic surgery Sinatra et al 2002
  • Femoral nerve block is associated with a lower risk of serious complications than spinal anaesthesia (using bupivacaine or lidocaine) Auroy et al 2002
  • Addition of epinephrine did not alter the duration of analgesia with a 'single shot' 3-in-1 femoral nerve block (20 ml ropivacaine 0.5% or 0.2%) following total knee arthroplasty (n=41) Weber et al 2001
  • Continuous 3-in-1 femoral block 10 ml/h (0.125% bupivacaine plus sufentanil 0.1 µg/ml and clonidine 1 µg/ml) provided no benefit over IV PCA morphine for the incidence of nausea and vomiting although a reduction in catheter problems was noted Singelyn et al 1998
  • As with all regional anaesthetic techniques, peripheral neural blockade has a failure rate and can cause neural injury and local anaesthetic toxicity Cox et al 2003

Total Hip Arthroplasty-Specific Evidence

  • Posterior lumbar plexus block 'single shot' given pre- or postoperatively was superior to placebo for reducing postoperative pain scores and supplementary analgesic consumption Stevens et al 2000 Click here for more information
  • Femoral nerve block ('single shot' 40 ml bupivacaine 0.5% plus epinephrine after induction of general anaesthesia) increased the time to first analgesic request by approximately 4 h compared with placebo (p<0.05) (n=40) Fournier et al 1998
  • Postoperative lumbar plexus block was superior to femoral nerve block for reducing postoperative pain scores at rest and supplementary analgesic consumption Biboulet et al 2004 Click here for more information
  • Femoral nerve block did not significantly reduce postoperative pain scores, and there was inconclusive evidence for the effect on supplementary analgesic consumption, compared with placebo Fournier et al 1998 Click here for more information
  • Posterior lumbar plexus block provided no significant benefit over femoral nerve block or control (no nerve block) for postoperative pain scores on movement, PONV or articular mobility during rehabilitation (n=45) Biboulet et al 2004
  • Posterior lumbar plexus block using ropivacaine 0.475% was less effective than spinal morphine 0.1 mg for reducing pain scores during 6–18 h (p<0.05) and supplementary analgesic consumption during 48 h, and there was no significant difference in the incidence of nausea, vomiting or pruritis (n=53) Souron et al 2003
  • Femoral nerve block delivered by PCA provided no benefit over delivery by continuous infusion for postoperative pain scores (n=45) Singelyn et al 2001

PROSPECT Recommendations

  • Where appropriate, single bolus spinal morphine (0.1–0.2 mg) plus local anaesthetic is recommended, administered before surgery, as it provides pain relief for up to 24 h (grade A). The decision to use a spinal technique should be based on the overall benefits of spinal anaesthesia/analgesia to each individual patient
  • Spinal clonidine is not recommended because it is less effective than spinal morphine for analgesia (grade A)
  • Short-acting opioids are not recommended because of their shorter duration of effect compared with morphine at appropriate doses (grade D)
  • Continuous spinal administration of morphine following total hip arthroplasty is not recommended due to safety concerns (grade D)

Clinical Practice

  • Spinal local anaesthetics combined with morphine are widely used for postoperative analgesia in clinical practice, although their effects on the incidence of postoperative nausea and vomiting, and on the bladder, should be carefully considered before administration
  • Long-acting opioids, such as morphine, are preferred to short-acting opioids for a long duration of analgesia postoperatively

Transferable Evidence from Other Procedures

  • Bolus spinal morphine (300 µg) was significantly more effective than saline placebo for reducing postoperative pain scores after total knee arthroplasty (p<0.05; n=60) Tan et al 2001
  • Combined spinal epidural block or spinal block were superior to epidural block (0.5% bupivacaine plus 0.2 or 0.4 mg morphine for spinal, or 0.5% bupivacaine plus 4 mg morphine for epidural) for surgical analgesia and for reducing consumption of perioperative sedatives and other analgesics in major orthopaedic surgery Holmstrom et al 1993
  • In a systematic review, spinal morphine in patients undergoing caesarean section was shown to increase the relative risk of postoperative pruritis, nausea and vomiting compared with control; increasing the dose of morphine increased the relative risk of postoperative nausea and vomiting Dahl et al 1999
  • Spinal administration of bolus clonidine or morphine produced a high incidence of bladder distension in patients undergoing hip surgery, but there was a greater incidence with spinal morphine than clonidine (p<0.001) Gentili and Bonnet 1996
  • Neuraxial opioids are associated with a higher risk of side-effects compared with peripheral neural blocks Sinatra et al 2002
  • Spinal anaesthesia (using bupivacaine or lidocaine) is associated with a higher risk of serious complications than femoral nerve block Auroy et al 2002

Total Hip Arthroplasty-Specific Evidence

  • Spinal morphine 0.1 mg was superior to a posterior lumbar plexus block using ropivacaine 0.475% for reducing postoperative pain scores for 6–18 h (p<0.05) and reducing supplementary analgesic consumption for 48 h, but there was no significant difference for the incidence of nausea, vomiting or pruritis (n=53) Souron et al 2003
  • Continuous spinal bupivacaine analgesia (and anaesthesia) was superior to IV PCA morphine analgesia (plus 'single shot' spinal anaesthesia) for reducing VAS scores for 3–24 h (p<0.05) and the incidence of PONV (n=68) Maurer et al 2003
  • Spinal analgesia was superior to epidural analgesia in one study for pain scores Mollmann et al 1999 Click here for more information
  • Strong opioid plus local anaesthetic was superior to local anaesthetic alone for postoperative pain scores, requirement for supplementary analgesia and time to first analgesia request, when administered by the spinal route Fernandez-Galinski et al 1996 Click here for more information
  • Different spinal strong opioids or local anaesthetics were similar for postoperative pain scores  Fournier et al 2000a Click here for more information
  • Spinal morphine 1 mg was superior to clonidine 75–100 µg in combination with isobaric bupivacaine 2.75 ml 0.5% for pain scores up to and including 10 h after the operation (p<0.01), time to first analgesia request and use of supplementary analgesia (p<0.05; n=90) Fogarty et al 1993
  • Patient-controlled spinal analgesia was superior to spinal bolus doses on demand in one study for pain Rundshagen et al 1997 Click here for more information
  • A combination of bupivacaine and morphine may cause a greater incidence of vomiting compared with bupivacaine alone Grace et al 1995 Click here for more information
  • Continuous spinal bupivacaine demonstrated a significant reduction in mean arterial pressure during anaesthetic induction compared with 'single shot' spinal bupivacaine (21 ± 11 mmHg versus 29 ± 14; p<0.05) (n=68) Maurer et al 2003
  • Spinal clonidine provided no significant benefit over placebo in two of three studies Grace et al 1995 Click here for more information

PROSPECT Recommendations

  • Postoperative continuous wound infusion with local anaesthetic cannot be recommended at this time (grade D) due to lack of procedure-specific evidence, although analgesic data from other procedures are promising
  • Wound infiltration at the drain site is not recommended (grade D) because drains are not recommended

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

Total Hip Arthroplasty-Specific Evidence