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American Association of Hip and Knee SurgeonsOrthopaedic Surgery2020advanced

Opioids in Total Joint Arthroplasty

Published by American Association of Hip and Knee Surgeons (AAHKS), American Society of Regional Anesthesia and Pain Medicine (ASRA), American Academy of Orthopaedic Surgeons (AAOS), Hip Society, and Knee Society · AAOS Clinical Practice Guidelines and Systematic Review Methodology

7Recommendations

36References

Summary

AI-generated

This clinical practice guideline provides evidence-based recommendations regarding the use of opioids before, during, and after primary total joint arthroplasty (TJA). It highlights the risks of preoperative opioid use, advocates for prescribing the lowest effective quantity at discharge, and details the effects of perioperative opioids.

opioidstotal joint arthroplastyAAHKSASRAAAOSorthopaedic surgerypain managementguidelines

Key Takeaways

1
Preoperative opioid use is linked to poorer patient outcomes and higher complication risks.
2
Reducing preoperative opioid consumption can yield better postoperative results.
3
Pre-emptive and intraoperative opioids lower early postoperative opioid needs but carry risks of respiratory depression if compounded with other doses.
4
Scheduled postoperative opioid administration is discouraged due to risks like sedation and respiratory depression.
5
Prescribing 30 versus 90 opioid pills at discharge offers equivalent pain control while minimizing unused medication.
6
Tramadol may help reduce postoperative pain and opioid usage, though it brings increased risks of dizziness and dry mouth.

Key Recommendations

Guideline Question 1

1
Preoperative opioid use is associated with inferior patient reported outcomes, increased opioid consumption after surgery, an increased risk for chronic opioid use, and an increased risk of complications after TJA.
ModerateEvidence: Low

Guideline Question 2

2
Reduction of opioid use prior to TJA may lead to improved patient reported outcomes after TJA compared to patients who do not reduce opioid consumption prior to surgery.
LimitedEvidence: Low

Guideline Question 3

3
An opioid administered immediately prior to surgery reduces postoperative pain and opioid consumption within the first 72 hours after TJA, but may increase the risk of complications, such as respiratory depression or sedation, especially if combined with other opioids administered intraoperatively or postoperatively.
StrongEvidence: Moderate to High

Guideline Question 4

4
An opioid administered intraoperatively reduces opioid consumption, but does not affect postoperative pain within 72 hours after surgery. An opioid administered intraoperatively may increase the risk of complications, such as respiratory depression or sedation, especially if combined with other opioids administered preoperatively or postoperatively.
ModerateEvidence: High

Guideline Question 5

5
Scheduled opioid administration without multimodal analgesia within 72 hours after primary TJA reduces the need for additional opioid pain medications for breakthrough pain and may reduce postoperative pain within 72 hours after surgery, but providing scheduled opioids is discouraged. Scheduled opioid administration postoperatively may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other opioids administered during the perioperative period.
ModerateEvidence: Moderate to High

Guideline Question 6

6
Prescribing lower quantities of opioid pills at discharge may lead to equivalent patient reported outcomes, pain relief, reduced opioid consumption, and fewer unused opioid pills after TJA.
ModerateEvidence: High

Guideline Question 7

7
Tramadol administered within 24 hours after surgery may reduce postoperative pain and opioid consumption after TJA within 72 hours after surgery, but may be associated with adverse events such as dizziness and dry mouth.
ModerateEvidence: High

Scope & Objectives

Clinical Topic

Opioids in Total Joint Arthroplasty

Objectives

To improve the treatment of orthopaedic surgical patients and reduce practice variation by promoting a multidisciplinary evidenced-base approach on the use of opioids following primary TJA.

Target Patient Population

Patients undergoing primary total joint arthroplasty (TJA)

Target Providers

Orthopaedic SurgeonsAnesthesiologistsPain Management Specialists

Patient Criteria & Setting

Therapeutic Area

Pain Management

Guideline Scope

TreatmentManagement

Care Settings

PerioperativePostoperative

Special Populations

Opioid naïve patientsPatients with chronic opioid use

Evidence Grading

System: AAOS Clinical Practice Guidelines and Systematic Review Methodology

Safety & Contraindications

Contraindications

Extended release opioids

Monitoring Guidance

The cumulative dose of opioids administered as well as the timing between opioid doses must be carefully monitored in TJA patients.

Authors & Contributors

Charles P. HannonYale A. FillinghamDenis NamP. Maxwell CourtneyBrian M CurtinJonathan M. VigdorchikAAHKS Anesthesia & Analgesia Clinical Practice Guideline WorkgroupAsokumar BuvanendranWilliam G. HamiltonCraig J. Della Valle

Guideline Features

Dosing informationBased on systematic reviewMultidisciplinaryDrug interactions discussed

Learning Context

Difficulty

advanced

Learning Paths

OpioidsTotal Joint ArthroplastyPain ManagementOrthopaedic SurgeryPerioperative Care

AI Podcast

Deep-dive audio (~10 min)

Study Guide

Structured study document

Infographic

Visual overview of key points

Slide Deck

Presentation-ready slides

Managing Pain Safely: New Evidence-Based Guidelines for Opioids in Hip and Knee Replacements

Read the full blog article

Guideline Info

SocietyAmerican Association of Hip and Knee Surgeons

Full nameAmerican Association of Hip and Knee Surgeons (AAHKS), American Society of Regional Anesthesia and Pain Medicine (ASRA), American Academy of Orthopaedic Surgeons (AAOS), Hip Society, and Knee Society

SpecialtyOrthopaedic Surgery

Year2020

Evidence systemAAOS Clinical Practice Guidelines and Systematic Review Methodology

RegionUSA

LanguageEnglish

Key Figures

Recommendations7

References36

Clinical Areas

Orthopaedic SurgeryAnesthesiologyPain Medicine

American Association of Hip and Knee Surgeons

USA

American Association of Hip and Knee Surgeons (AAHKS), American Society of Regional Anesthesia and Pain Medicine (ASRA), American Academy of Orthopaedic Surgeons (AAOS), Hip Society, and Knee Society

All American Association of Hip and Knee Surgeons guidelines