Intra-Articular Opioids vs NSAIDs
Limited evidence suggests there is no difference in patient outcomes between intra-articular opioids and NSAIDs administered intraoperatively for post-operative pain control.
Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery (2021)
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: SOMOS, OTA

Rationale

The Intra-Articular Opioid vs NSAID recommendation has been downgraded one level because of inconsistent evidence.

There are 2 moderate quality studies (Kim 2015, Sanel 2016) with inconsistent evidence suggesting no difference in outcomes in patients who receive intraarticular opioid versus NSAIDs.

Benefits/Harms of Implementation

Uncontrolled pain after total joint arthroplasty can lead to limited post-operative range of motion, poor functional outcomes, and patient’s dissatisfaction. There are many analgesic modalities that can be used in the perioperative period, such as intravenous and oral opioids, epidural analgesia, and peripheral nerve blockade. Each method has its own risks and side effects, intravenous opioids cause nausea, vomiting, and urinary retention. Epidural analgesia is associated with urinary retention, respiratory depression, delayed ambulation and is complicated by perioperative thromboprophylaxis. Peripheral nerve blockade may cause muscle weakness resulting in delayed ambulation. There is also the risk of local anesthetic toxicity and nerve injury. Periarticular injection involves injection of a combination of analgesic drugs into the synovium, joint capsule, and subcutaneous tissues during orthopedic surgery. Periarticular injection after total joint arthroplasty has been reported to have good analgesic efficacy, cost-effectiveness, and few side effects. The main side effects are associated with local anesthetic toxicity. Adherence to dosing guidelines in conjunction with appropriate patient monitoring during and after injection will decrease the potential for harm.

Outcome Importance

Opioid-related side effects such as dizziness, nausea and vomiting can result in delayed ambulation and subsequently delay discharge from the hospital. Using a combination of periarticular local anesthetics, opioids, NSAIDs, and other agents has been shown to decrease opioid use.

Cost Effectiveness/Resource Utilization

Periarticular infiltration is generally performed by the surgeon during the procedure, which other than the medication costs, results in little added expense. It is recommended that these medications are prepared in a controlled, sterile manner. Intra articular opioids alone or in combination require chain of control processes to ensure there is no opioid misuse or abuse potential.

Acceptability

Surgeon training and acceptance of peri articular infiltration is increasing. Anesthesiologists are also learning how to incorporate peri articular infiltration into perioperative multimodal analgesic plans.

Feasibility

The inclusion of periarticular infiltration into practice is feasible. It will require surgeon education, pharmacy preparation of sterile combination of medications, and recognition of side effects associated with its use.

Future Research

Although the analgesic effect of various drug combinations for periarticular infiltration during orthopedic surgery has been well documented, the gold standard for drug combination has not yet been established. Future research should focus on the ideal combination and dose of medications.