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New: Total Hip Arthroplasty

Summary Recommendations

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 judgments based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

Postoperative pain following elective THA is a major challenge that can hinder early mobilisation, rehabilitation, and patient satisfaction, while increasing opioid use and the risk of postoperative complications (Memtsoudis 2021). These issues are particularly relevant as enhanced recovery and outpatient THA pathways become more widespread, highlighting the need for effective motor-sparing analgesic techniques.

Pain is typically most severe during the first 24 hours after surgery, a critical period that influences early ambulation, opioid consumption, and functional recovery (Panzenbeck 2021). Optimising multimodal analgesia during this window is essential to support recovery and improve postoperative outcomes.

New evidence has emerged since publication of the previous PROSPECT recommendations for postoperative pain management after elective primary THA (Anger 2021), particularly on motor-sparing regional techniques. This review (Carella 2026) aimed to assess the available literature and update the previous PROSPECT recommendations, with focus on evaluating evidence regarding regional anaesthesia techniques, local infiltration analgesia (LIA), neuraxial adjuvants, and systemic ‘non-basic analgesic’ pharmacological interventions.

The PROSPECT group performed the systematic review and formulated the recommendations using the unique PROSPECT methodology, available at https://esraeurope.org/prospect-methodology/. This methodology was first published in Joshi 2019 and updated in Joshi 2023.

Literature databases (MEDLINE, Embase, and the Cochrane Library) were searched from 1 January 2020 to 1 June 2024 to identify randomised controlled trials (RCT), systematic reviews or meta-analyses of adult patients undergoing elective primary THA, that investigated perioperative analgesic, anaesthetic, or surgical interventions aimed at improving postoperative pain management. Studies had to report pain outcomes using a linear scale, such as the Visual Analogue Scale or Numerical Rating Scale, and could include secondary endpoints such as opioid consumption, functional recovery, or adverse events. Only articles published in English and registered in a recognised clinical trial database were considered.

From the literature search, 71 RCT and 32 systematic reviews or meta-analyses met the inclusion criteria. Evidence was evaluated according to PROSPECT methodology, focusing on pain within 24 hours, opioid consumption, functional recovery, and adverse effects.

The included studies were interpreted in the context of standard multimodal analgesia (paracetamol with NSAIDs or COX-2 inhibitors), and recommendations were based on the balance between analgesic efficacy, adverse effects, and clinical applicability.

This review is registered on PROSPERO: CRD42024572651.

Summary of recommendations and key evidence for pain management in patients undergoing primary THA

Basic analgesia (recommended for all patients)
Paracetamol combined with NSAIDs or COX-2-selective inhibitors is recommended, administered either preoperatively or intraoperatively, unless contraindicated

  • In accordance with PROSPECT methodology (Joshi 2023), RCTs representing basic analgesics (paracetamol, NSAIDs, COX-2 specific inhibitors) were not included in this updated review. These components are considered essential to all multimodal analgesic regimens.
A single IV dose of dexamethasone (≤10 mg) is recommended for its analgesic, anti-inflammatory, and antiemetic effects

  • RCTs in the updated review reinforced the analgesic, anti-inflammatory, and antiemetic properties of dexamethasone, while clarifying optimal dosing and timing regimens (Mo 2024; Li 2022; Lei 2020; Lei 2020; Nielsen 2023).

Regional analgesia

Single shot supra-FICB is recommended as an effective component of multimodal analgesia.*

OR

Preoperative single shot PENG block is recommended as an alternative motor-sparing technique with comparable efficacy.

Supra-FICB

  • High-quality RCTs evaluating preoperative supra-FICB demonstrated consistent and clinically relevant benefits for pain scores, opioid consumption, and functional recovery in patients undergoing THA with a posterolateral approach, without evidence of clinically relevant motor impairment (Carella 2022; Gola 2021; Bravo 2020).
  • The updated findings strengthen and extend previous evidence supporting the efficacy of longitudinal supra-FICB (Desmet 2017).
  • A volume of approximately 40 mL was typically used to achieve adequate supra-inguinal spread with the longitudinal technique (Desmet 2017; Vermeylen 2019).

PENG block

Comparative evidence

  • Evidence suggests that preoperative PENG and supra-FICB offer comparable clinical benefit (Carella 2023; Aliste 2021).
Single-shot LIA may be considered as an alternative when regional blocks are not feasible or contraindicated.

  • LIA, performed intraoperatively by the surgeon, represents a pragmatic and technically simple option, particularly when regional anaesthesia is not feasible or contraindicated.
  • Available evidence indicates that LIA provides transient analgesic benefit confined to the early postoperative period, particularly when regional blocks or optimal multimodal analgesia are not used (Xiao 2021; Bernaus 2022).
  • However, its overall benefit appears modest and context-dependent, and it does not consistently improve pain, opioid use, or functional recovery beyond what can be achieved with preferred motor-sparing regional techniques (Ye 2023; Bravo 2023; Et 2023).
  • There is currently no good evidence supporting the combination of regional techniques with LIA. The combination does not enhance postoperative analgesic outcomes and may expose patients to higher and potentially toxic concentrations of local anaesthetic.

Neuraxial analgesia
Low-dose intrathecal morphine (≤0.1 mg) may be considered, if the patient has received spinal anaesthesia for the surgery and the procedure is performed in an inpatient setting

  • The use of intrathecal morphine is supported by consistent procedure-specific evidence in THA. In the updated review, findings of two additional studies (Vitola 2022; Albrecht 2020) reinforced the role of low-dose intrathecal morphine (0.1 mg) as an effective and safe adjunct in in-hospital settings, while higher doses should be used with caution due to dose-dependent side effects.
  • It may be considered as an alternative to peripheral regional techniques in selected inpatient settings, although its use in ambulatory pathways may be limited by monitoring requirements and side effects.

Rescue analgesia
Opioids should be reserved for rescue analgesia

  • In accordance with PROSPECT methodology (Joshi 2023), RCTs investigating opioids were not included in this updated review.

*In the previous PROSPECT review (Anger 2021), “FICB” referred to all approaches (infra- and supra-inguinal) without distinction. This revision from the previous guidance reflects accumulating clinical evidence of inconsistent analgesia with infra-FICB.

COX, cyclooxygenase; IV, intravenous; LIA, local infiltration analgesia; NSAID, non-steroidal anti-inflammatory drug; PENG, pericapsular nerve group; RCT, randomised controlled trial; supra-FICB, supra-inguinal fascia iliaca compartment block; THA, total hip arthroplasty.

Analgesic interventions that are not recommended for pain management in patients undergoing primary THA.

Intervention

Reason for not recommending
Regional analgesia techniques
Infra-inguinal fascia iliaca block Lack of procedure-specific evidence
Postoperative PENG block Lack of procedure-specific evidence
Lumbar erector spinae plane block Inconsistent procedure-specific evidence
Ilio-psoas block Lack of procedure-specific evidence
Circum-psoas block Limited procedure-specific evidence
Quadratus lumborum block
Anterior (transmuscular)		 Procedure-specific evidence, but side effects
Quadratus lumborum block
Posterior or lateral		 Lack of procedure-specific evidence
Continuous quadratus lumborum block Lack of procedure-specific evidence
Obturator nerve block Lack of procedure-specific evidence
Lateral femoral cutaneous nerve block Lack of procedure-specific evidence
Postoperative lateral femoral cutaneous nerve block Lack of procedure-specific evidence
Paravertebral block Lack of procedure-specific evidence
Lumbar plexus block Procedure-specific evidence, but side effects
LIA adjuncts to local anaesthetics Inconsistent procedure-specific evidence
LIA in combination with other blocks Inconsistent procedure-specific evidence
Continuous LIA Lack of procedure-specific evidence and potential side effects
Intrathecal drugs
Intrathecal dexmedetomidine Limited procedure-specific evidence
Intrathecal oxytocin Lack of procedure-specific evidence
Systemic drugs
Methylprednisolone Limited procedure-specific evidence
Postoperative dexamethasone Inconsistent procedure-specific evidence
Duloxetine Limited procedure-specific evidence
IV dexmedetomidine Lack of procedure-specific evidence
Melatonin Lack of procedure-specific evidence
Gabapentinoids Inconsistent evidence and side effects
Surgical techniques
Super-PATH approach Lack of procedure-specific evidence
Direct anterior approach Lack of procedure-specific evidence
3D immersive reality Lack of procedure-specific evidence

LIA, local infiltration analgesia; PENG, pericapsular nerve group; super-PATH, supercapsular percutaneously-assisted total hip.

COX, cyclooxygenase; IV, intravenous; LIA, local infiltration analgesia; NSAID, non-steroidal anti-inflammatory drug; PENG, pericapsular nerve group; supra-FICB, supra-inguinal fascia iliaca compartment block; THA, total hip arthroplasty.

PROSPECT recommendations for THA – Infographic