Introduction
Post-operative pain management in orthopedic surgery should be viewed as part of a recovery pathway rather than as an isolated attempt to minimize pain scores. Nearly half of adults undergoing surgery experience moderate or severe post-operative pain, and inadequate pain management may impair recovery and function [1]. Contemporary perioperative guidance emphasizes assessment of pain in relation to function, multimodal analgesia, regional anesthesia where appropriate, non-pharmacological measures and safe opioid use [1,2].
In orthopedic practice, the relevant functional endpoint varies with the procedure. After total knee arthroplasty, early knee movement and mobilization are priorities; after fracture fixation, analgesia must coexist with limb elevation, weight-bearing or range-of-motion restrictions and, where relevant, serial neurological and vascular assessment; after hip arthroplasty, early mobilization is usually central to recovery. Thus, the analgesic regimen should be judged not only by pain intensity but also by whether it enables the required rehabilitation task without introducing clinically important adverse effects.
Multimodal analgesia is widely used, but its individual components do not have interchangeable evidence or identical clinical value. Recent evidence-based guidance supports combining interventions with complementary mechanisms while avoiding interventions that add little benefit or interfere with recovery [2,3,4,5,6,7]. Procedure-specific recommendations are particularly informative because the background analgesic regimen changes the incremental effect of a block, local infiltration technique, or rescue opioid.
The updated PROSPECT recommendation for total hip arthroplasty retained scheduled paracetamol and an NSAID or COX-2 inhibitor plus a single perioperative dose of dexamethasone as the core regimen, while recommending selected motor-sparing regional techniques and not routinely recommending techniques with inconsistent efficacy or undesirable motor effects [7]. This review therefore takes a critical, procedure-specific approach rather than treating multimodal analgesia as a fixed bundle. The orthopedic surgeon contributes knowledge of tissue injury, fixation or reconstruction, fracture biology, limb assessment and rehabilitation, whereas the anesthesiologist contributes expertise in regional techniques, systemic analgesia and perioperative risk.
Their shared objective is a strategy that provides sufficient analgesia for recovery without obscuring complications or creating avoidable treatment-related harm. The overall framework is shown in Fig. 1.
Review Methodology and Scope
This article is intended as a narrative review with a structured literature search rather than a systematic review or meta-analysis. PubMed/MEDLINE was searched using combinations of terms related to orthopedic surgery, post-operative pain, multimodal analgesia, regional anesthesia, opioids, NSAIDs, fracture healing, arthroplasty, persistent post-surgical pain and enhanced recovery. Priority was given to recent systematic reviews and meta-analyses, randomized controlled trials, consensus statements and procedure-specific guidelines; earlier high-quality studies were retained when they provided foundational evidence.
Searches and reference verification were updated through September 2026. Evidence was not pooled quantitatively because the procedures, interventions, and outcomes were heterogeneous. Findings were synthesized according to procedure, functional objective, analgesic benefit, adverse effects, and limitations of the available evidence.
This makes the evidentiary basis and limitations of the review explicit.
Pain management should be planned around recovery
The most useful question after orthopedic surgery is not simply whether pain is present, but whether pain is preventing an important activity or signaling an unexpected problem. Pain at rest, pain during movement and pain severe enough to disturb sleep have different clinical implications. A moderate pain score during supervised physiotherapy may be acceptable if the patient can participate, whereas a similar score at rest with inability to sleep may require a different response.
Conversely, a low pain score accompanied by sedation, hypotension or weakness is not necessarily a successful outcome. The 2024 multidisciplinary consensus recommends assessing pain to facilitate function and extending the analgesic plan across the perioperative pathway [1]. The evidence therefore supports recovery-oriented analgesia, but the strength of evidence for individual interventions varies considerably.
Analgesia should be linked to the rehabilitation plan from the beginning, including the expected time of mobilization, weight-bearing status, need for neurological assessment and anticipated discharge pathway.
The orthopedic–anesthesia interface
The operation is the starting point for analgesic planning because tissue injury, surgical approach, expected movement and the consequences of excessive motor block differ substantially between procedures. Patient factors then modify that baseline. Previous opioid exposure, chronic pain, renal or hepatic dysfunction, gastrointestinal or cardiovascular disease, anticoagulation, frailty, sleep-disordered breathing and previous adverse reactions may change which components of a multimodal regimen are appropriate [1,2].
A fixed “orthopedic analgesia protocol” therefore has important limitations. A regimen designed for uncomplicated elective arthroplasty should not automatically be transferred to an older patient with hip fracture, a patient undergoing complex fracture reconstruction, or a patient after ligament reconstruction.
This distinction is clinically important because analgesic choices may affect not only comfort but also mobilization, fall risk, neurological examination and discharge readiness. The anesthetic consultation should identify previous analgesic use and factors associated with difficult post-operative pain, while the surgeon should define the functional and biological priorities of the operation. The resulting plan should specify the baseline non-opioid regimen, whether regional or local techniques are appropriate, how rescue opioids will be used, and what constitutes unexpected pain requiring reassessment rather than simply another dose of medication.
Fig. 2 summarize these shared determinants.
The anesthetic consultation is an opportunity to identify these differences before surgery. Previous analgesic use and the likelihood of difficult post-operative pain should be recorded, while the surgeon can define the functional and biological priorities of the procedure. The resulting plan should specify the baseline non-opioid regimen, whether regional or local techniques are appropriate, how rescue opioids will be used, and what constitutes unexpected pain requiring reassessment rather than simply another dose of medication.
The key determinants of perioperative analgesic planning and their relationship to post-operative recovery are summarized in Fig. 3.
Regional analgesia: Effective, but not in isolation
Regional anesthesia can provide strong early analgesia and reduce opioid exposure, but the evidence is procedure-specific and the benefit is not necessarily sustained. In distal radius fracture surgery, a meta-analysis of randomized trials found lower pain scores in the early post-operative period and lower early opioid consumption with regional compared with general anesthesia, but the early advantage diminished and opioid use increased after discharge, consistent with possible rebound pain [8]. In operative tibia and ankle fracture patients, peripheral nerve blocks improved satisfaction, time spent in severe pain, and 24-h quality of recovery, but the benefit was not maintained at 48 h in that cohort [9].
These findings illustrate two limitations: The effect of regional techniques depends on the background analgesic regimen, and early analgesic superiority does not necessarily translate into better longer-term recovery. Motor weakness, fall risk, and interference with serial neurological examination must also be considered [9,10]. Regional techniques should therefore be selected for their fit with the procedure and recovery pathway, not simply because they produce the largest reduction in pain scores.
The same principle applies to lower-limb surgery. Motor weakness may interfere with mobilization or increase fall risk, while dense analgesia can complicate the clinical assessment of a limb when neurological or vascular findings remain important. Regional techniques should therefore be selected for their fit within the recovery pathway rather than for analgesic intensity alone [9,10].
The updated 2026 PROSPECT recommendation for total hip arthroplasty illustrates this principle. It retained scheduled paracetamol and an NSAID or COX-2 inhibitor with a single intravenous dose of dexamethasone as core therapy and identified supra-inguinal fascia iliaca and pre-operative pericapsular nerve group blocks as the regional techniques with the most consistent analgesic evidence. Quadratus lumborum and lumbar erector spinae plane blocks were not recommended because efficacy was inconsistent and motor weakness was a concern; local infiltration analgesia remained an alternative when regional anesthesia was not feasible [7].
In primary total knee arthroplasty, PROSPECT similarly recommends a baseline non-opioid regimen combined with a single-shot adductor canal block and peri-articular local infiltration, while reserving opioids for rescue [11]. These recommendations demonstrate why procedure-specific pathways are preferable to a generic “multimodal bundle.” The relevant question is which component adds clinically meaningful benefit to the established regimen without compromising mobilization or safety.
Procedure-specific analgesic priorities
Procedure-specific guidance is particularly useful because analgesic priorities differ across common orthopedic operations. Elective total hip and knee arthroplasty generally emphasizes rapid mobilization within an enhanced recovery pathway, whereas fracture fixation may require preservation of neurological assessment, attention to swelling and compartment syndrome, and a more cautious approach to NSAID exposure when fracture healing is a major concern. Ligament reconstruction and other sports procedures often involve substantial early pain but rapid functional rehabilitation, making motor-sparing techniques attractive when they do not compromise examination or rehabilitation.
PROSPECT provides defined pathways for total hip and knee arthroplasty [7,11], while systematic review evidence in anterior cruciate ligament reconstruction demonstrates differences among regional techniques, spinal anesthesia, and local analgesic strategies [12]. A concise procedure-based framework is provided in Table 1.
Non-opioid analgesia and the NSAID–bone healing question
Paracetamol remains a practical baseline component of multimodal analgesia, although its individual analgesic effect is modest. NSAIDs and COX-2 inhibitors can provide opioid-sparing analgesia after many orthopedic procedures, but fracture surgery raises a distinct concern about bone healing. The evidence is conflicting and is substantially influenced by study design, indication, drug, dose, and duration.
A 2024 systematic review and meta-analysis of 20 studies involving 523,240 patients found no statistically significant difference in delayed union or non-union between NSAID users and non-users (adjusted odds ratio [OR] 1.11, 95% confidence interval [CI] 0.99–1.23), but the evidence was largely observational and individual drug and dose effects were incompletely characterized [13]. A meta-analysis restricted to randomized trials reported an increased overall non-union signal, with risk concentrated in longer exposure, whereas short courses of <2 weeks were not associated with a statistically significant increase [14]. A 2025 critical review similarly concluded that adult clinical studies frequently identify NSAID exposure as a risk factor, but emphasized substantial heterogeneity and insufficient evidence to define a universally safe drug, dose, or duration [15].
The 2026 umbrella review and reconstructed meta-analysis found an overall association with non-union (OR 1.56, 95% CI 1.18–2.11), particularly in adults and long-bone fractures, while no increased risk was detected with exposure of 14 days or less; importantly, the authors judged much of the underlying evidence to be low or critically low [16]. Thus, the literature does not justify either blanket avoidance or unrestricted use. In a patient at high risk of non-union, prolonged or high-dose NSAID exposure should be weighed carefully against alternative analgesic strategies.
Conversely, a short, clinically justified course in a lower-risk setting may be reasonable. This distinction should be discussed jointly by the surgeon and anesthesiologist.
For clinical practice, these findings argue against both blanket avoidance and indiscriminate prescribing. The decision should consider fracture type, mechanical and biological risk, patient comorbidity, NSAID choice, dose and duration, and available alternatives. This is an area where the anesthesiologist’s analgesic objective and the orthopedic surgeon’s concern about healing need to be considered together.
Opioids: Rescue treatment, not a measure of failure
Opioids remain appropriate for patients with significant post-operative pain despite an adequate multimodal regimen. Opioid-sparing care should not be confused with an opioid-free rule. A small randomized double-blind trial in opioid-naive patients undergoing total knee arthroplasty found no significant differences in pain scores or length of stay when a Schedule II opioid was omitted from an otherwise multimodal regimen, although the trial was small and four patients withdrew early because of pain [17,18].
This supports selective opioid reduction but cannot establish that opioids are unnecessary for all patients. Repeated rescue dosing should prompt review of the baseline regimen, block duration, pain trajectory, and possibility of a surgical complication. Opioid consumption is also an imperfect surrogate for recovery because a lower dose may reflect undertreatment, while a higher dose may be appropriate in an individual with severe tissue injury or opioid tolerance [19].
The clinically relevant endpoint is adequate analgesia with the lowest exposure that remains compatible with function and safety.
When severe pain should trigger a clinical review
Unexpectedly severe or escalating post-operative pain should not automatically be interpreted as a requirement for stronger analgesia. Depending on the procedure, it may indicate bleeding, hematoma, infection, vascular compromise, nerve injury, compartment syndrome, implant-related problems or another surgical complication. This point is especially important in fracture surgery.
Analgesia must coexist with appropriate assessment of the operated limb. Regional techniques can be valuable, but the decision to use them should take account of the clinical circumstances and the need for serial examination [9,10]. The practical rule is simple, when the severity or pattern of pain is unexpected, the first response should sometimes be “Why is this patient in so much pain?” rather than “How much more analgesia can be given?” A practical approach to unexpected or escalating post-operative pain is shown in Fig.
2.
Persistent pain after orthopedic surgery
Good acute analgesia is important, but it should not be presented as a proven method of preventing chronic pain. A 2025 systematic review and meta-analysis of 49 randomized trials found no perioperative analgesic intervention that clearly reduced pain 3–24 months after total hip or knee arthroplasty; duloxetine reduced movement pain statistically, but the difference was smaller than the pre-defined threshold for clinical importance [20]. Persistent pain is also influenced by factors that precede surgery [21].
A systematic review and meta-analysis of 81 studies involving 171,354 patients identified pre-operative pain and psychological factors among variables associated with persistent pain after hip or knee replacement, although substantial heterogeneity limited quantitative synthesis [22]. A 2026 systematic review after hip replacement similarly identified pre-operative pain, functional disability, sleep disturbance, anxiety, depressive symptoms, central sensitization, and pain catastrophizing as relevant biopsychosocial factors [23]. These findings support risk stratification and early recognition rather than assuming that more intensive perioperative analgesia will prevent persistent pain.
When pain persists after arthroplasty, structural causes must also be considered. A 2025 systematic review of painful hip arthroplasty identified diagnoses, including loosening, infection, iliopsoas impingement, referred lumbar pain and greater trochanteric pain [24]. Persistent pain should therefore trigger appropriate clinical evaluation, rehabilitation and, where indicated, targeted pain management rather than automatic escalation of analgesic medication.
Where the evidence is still unsettled
Several areas remain uncertain and should temper strong clinical claims. First, the incremental benefit of an analgesic intervention depends on the background regimen and the procedure, so results from one operation cannot automatically be generalized to another. Second, regional techniques may improve early pain and opioid consumption without demonstrating durable effects on persistent pain or overall recovery [8,9,25].
Third, opioid consumption is an important stewardship outcome but is not synonymous with quality of recovery. Fourth, the NSAID-bone healing literature remains inconsistent, with recent reviews reaching different conclusions and the newest evidence suggesting that any risk is likely to be modified by drug, dose, duration, patient age, and fracture context [13,14,15,16]. Finally, persistent pain after arthroplasty is common enough to justify proactive assessment, but prevalence estimates vary because definitions, time points and assessment methods differ [26].
These uncertainties are not weaknesses of the clinical framework; rather, they define where individualized decision-making is necessary.
A Practical Shared Model
A perioperative analgesic plan is most effective when established collaboratively around the surgical procedure, patient-specific risk profiles, and post-operative functional milestones. Rather than repeating specific pharmacological dosages throughout the text, Table 2 provides an operational decision-making framework structured around five core perioperative questions, in keeping with enhanced recovery and practice-pathway approaches to multimodal analgesia and regional anesthesia after arthroplasty [27,28,29].
Limitations of the evidence
This review has limitations. The literature is heterogeneous, with procedure-specific guidelines, randomized trials, observational studies, and systematic reviews addressing different interventions and outcomes. The review was not designed as a formal systematic review, and no quantitative meta-analysis was undertaken.
Consequently, the framework should be interpreted as an evidence-informed clinical synthesis rather than a graded guideline. Some recommendations, particularly around regional techniques and NSAID exposure after fracture surgery, remain sensitive to the quality and applicability of the underlying studies.
Conclusion
Orthopedic pain management should not be reduced to a choice between opioids, non-opioid drugs or regional anesthesia. The evidence supports a procedure-specific multimodal strategy, but the strength of evidence differs across interventions and operations. The relevant decision is whether the overall strategy provides sufficient analgesia for mobilization, sleep and rehabilitation while respecting fracture biology, neurological assessment and patient-specific safety.
Regional techniques should be selected for demonstrated procedure-specific benefit and acceptable motor and examination effects; NSAIDs should be prescribed with attention to dose, duration and fracture-healing risk; and opioids should remain available as appropriately monitored rescue therapy. Unexpected or escalating pain should prompt clinical reassessment rather than reflex analgesic escalation. The most defensible model is therefore collaborative, recovery-focused and explicitly responsive to uncertainty in the evidence.
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