LIMITED RECOMMENDATION One moderate quality study (Mochizuki 2016) looking at combo tramadol/acetaminophen vs NSAID in 1551 TKA patients demonstrated decreased VAS scores and independence from the need for walker in the tramadol/acetaminophen group.
Benefits/Harms of Implementation
Tramadol causes less respiratory depression, cardiac depression, dizziness, and drowsiness than morphine; therefore, it has been used as a first-line analgesic for postoperative pain. Combination therapy with acetaminophen and Tramadol results in less pain than when the medications are used alone.
Outcome Importance
Targeting multiple pain pathways with multimodal analgesics including Tramadol, acetaminophen and NSAIDs will decrease parenteral opioid use and side effects. In addition, using Tramadol in conjunction with acetaminophen may decrease the dose of Tramadol required, subsequently decreasing side effects.
Cost Effectiveness/Resource Utilization
Tramadol is a centrally acting, oral analgesic that contains an opioid and is therefore considered a controlled substance. Side effects such as nausea, vomiting and dizziness are associated with Tramadol, although unlike other opioids, respiratory depression is rare.
Acceptability
Tramadol, acetaminophen and NSAIDs are all commonly used medications for postoperative orthopedic pain.
Feasibility
This recommendation does not significantly change clinical practice as all of these medications are widely used.
Future Research
Future research should focus on determining the most effective combination and dose of medications.