Background Total knee replacement (TKR) and total hip replacement (THR) are performed to provide pain relief and restore physical functioning. Several preoperative factors have been associated with poor postoperative pain including a high preoperative pain.
Objectives To develop recommendations for preoperative pharmacological pain management in patients undertaking TKR and/or THR due to osteoarthritis based on the best evidence and experience.
Methods Rrecommendations were generated following nominal group methodology and Delphi technique. A panel of experts as established (5 orthopedics, 1 anesthesiologist) that defined in the first panel meeting the scope and purpose of the consensus document, chapters and preliminary recommendations. Three systematic literature reviews were performed and sent to the panel in order to help define recommendations: 1) efficacy (on postoperative pain) and safety of preoperative analgesia in TKR and THR; 2) efficacy (on postoperative pain) and safety of pre-emptive analgesia in TKR and THR; preoperative predictors of postoperative pain in TKR and THR. A first draft of recommendations was generated and circulated for comments and wording refinements. Then, an electronic Delphi process (2 rounds) was carried out. A total of 38 orthopedics and anesthesiologists took part in the Delphi. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement (GA) if at least 70% voted ≥7. The level of evidence (LE) and grade or recommendation (GR)was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence.
Results A total of 21 recommendations were developed. The recommendations cover the preoperative pharmacological pain management, evaluation and monitoring of treatment and pre-emptive treatment. somerecommendations are: Once the surgery is indicated, a proper treatment to relief disease symptoms and signs should be followed (LE 5; GR D; GA 100%);The panel recommends to carefully evaluate previous pharmacological treatments in patients who will undertake a TKR or THR in order to define the treatment until surgery (LE 5; GR D; GA 95%); It is recommended to encourage patients to lose weight and maintain their weight at a lower level (especially those with obesity) and maintain physical activity as much as possible (LE 2a; GR B; GA 100%); The use of NSAID (oral and topical) to control preopeartive pain (unless is contraindicated) is recommended in patients undergoing TKR or THP (LE 1a; GR A; GA 86%); The panel could not recommend or not recommend the use of acetaminophen or tramadol (LE 1a; GR A; GA 67%); The use of glucosamine, chondroitin sulphate, hyaluronic acid or antiepileptic drugs are not recommended (LE 1b; GR A; GA 86%); Intraarticular injections with corticosteroids can be used (LE 1a; GR A; GA 81%).
Conclusions In patients who will undertake a TKR or THP, a proper evaluation of the surgery indication, pharmacological pain management, and patient and treatment monitoring, could improve postoperative pain.
Disclosure of Interest None declared