Total Knee Arthroplasty 2020

TKA-specific evidence

Data table: Paracetamol for pain management after TKA

Study details:

• 6 meta-analyses were identified that assessed the analgesic effect of oral and IV paracetamol for patients undergoing TKA, THA or total joint arthroplasty (Guo 2018; Liang 2017; Shi 2018; Sun 2018; Yang 2017; Fillingham 2020). These included 22 studies, of which two RCTs in TKA met PROSPECT inclusion criteria (O’Neal 2017; Murata-Ooiwa 2017).

Arguments for…

• One of two RCTs showed a benefit of paracetamol vs placebo for reducing pain scores (O’Neal 2017; Murata-Ooiwa 2017). No side effects related to treatment were reported.

PROSPECT Recommendations

• Paracetamol and NSAIDs or COX-2-specific inhibitors are recommended, administered either preoperatively or intra-operatively, for management of postoperative pain after TKA.
• The recommendation for paracetamol is based on evidence in TKA from two RCTs of paracetamol (Murata-Ooiwa 2017; O’Neal 2017).
• A meta-analysis concluded that although paracetamol alone has limited analgesic and opioid-sparing efficacy, moderate evidence supports its use for peri-operative pain management after TKA (Fillingham 2020). It is a low-cost and low-risk option and it demonstrates an interesting opioid-sparing effect when combined with NSAIDs (Martinez 2017; Ong 2010).

TKA-specific evidence

Data table: NSAIDs/COX-2-specific inhibitors for pain management after TKA

Study details:

• Two meta-analyses assessed the efficacy and safety of NSAIDs or COX-2-specific inhibitors for patients undergoing TKA (Du 2018; Fillingham 2020). From these, six RCTs evaluating peri-operative COX-2-specific inhibitors were included in the PROSPECT review (Zhu 2014; Essex 2018; Gong 2013; Munteanu 2016; Reynolds 2003; Meunier 2007).

Arguments for…

• Six RCTs showed reduced postoperative pain scores at rest and during mobilisation, and reduced opioid requirements, with use of COX-2-specific inhibitors (Zhu 2014; Essex 2018; Gong 2013; Munteanu 2016; Reynolds 2003; Meunier 2007).
• The benefits of COX-2-specific inhibitors were observed even with concomitant administration of paracetamol or LIA.

Arguments against…

• Results showed no decrease in opioid-related adverse effects like PONV with use of COX-2-specific inhibitors (Zhu 2014; Essex 2018; Gong 2013; Munteanu 2016; Reynolds 2003).

PROSPECT Recommendations

• Paracetamol and NSAIDs or COX-2-specific inhibitors are recommended, administered either preoperatively or intra-operatively, for management of postoperative pain after TKA.
• Recommendations for NSAIDs or COX-2-specific inhibitors are based on evidence in TKA from six studies of COX-2-specific inhibitors, showing analgesic and opioid-sparing effects (Zhu 2014; Essex 2018; Gong 2013; Munteanu 2016; Reynolds 2003; Meunier 2007).
• This is in agreement with the strong recommendation for NSAIDs and COX-2-specific inhibitors in a meta-analysis by Fillingham 2020.
• COX-2-specific inhibitors possess similar analgesic efficacy to NSAIDs but with no effects on platelet function, and thus, could be administered preoperatively.
• A meta-analysis found that NSAIDs are unlikely to be the cause of postoperative bleeding complications (Bongiovanni 2021).
• No safety concerns were reported with NSAIDs and COX-2-specific inhibitors but prescribers need to remain vigilant as the typical older TKA population may be at a higher risk of adverse effects (Fillingham 2020).