PROSPECT final recommendations

The PROSPECT final recommendations are based on short-term pain outcomes (e.g. pain scores and supplementary analgesic use), following total hip arthroplasty. The recommendations do not take into account rehabilitation related to long-term pain. This is because rehabilitation programmes for patients undergoing total hip arthroplasty vary greatly between countries, and there is a lack of data for the effects of different rehabilitation regimes on long-term pain outcomes. Indeed, most studies assessing postoperative pain in total hip arthroplasty do not continue beyond 48 h following surgery. It is considered that adequate postoperative pain control is a prerequisite for successful rehabilitation because it allows early mobilisation and permits a more rapid initiation of physiotherapy.

The PROSPECT final recommendations are presented in the table below and are categorised according to the different anaesthetic techniques used for total hip arthroplasty. The PROSPECT group recommends that the choice of anaesthetic technique should be primarily based on the disposition of the patient rather than the management of their postoperative pain. However, based on postoperative pain outcomes, the continuation of some form of regional analgesia following general anaesthesia is recommended over the use of general anaesthesia alone.

Following surgery, the PROSPECT recommendations for pain management encompass a step-down approach for managing high-intensity pain in the immediate postoperative period to moderate- and low-intensity pain later in the postoperative period. For this step-down approach, PROSPECT recommends opioids (strong opioids initially, followed by weak opioids) in combination with paracetamol and conventional NSAIDs or COX-2-selective inhibitors, administered as appropriate for the level of postoperative pain.

Anaesthetic type Timing		GA alone	Peripheral neural block + GA	Spinal ± GA or IV sedation	Epidural ± GA
Pre-operative		Pre-operative analgesia is not recommended
Intra-operative		Strong long-acting opioids to secure analgesia when the patient wakes	Femoral nerve block or posterior lumbar plexus block	Single shot spinal LA + morphine	Epidural LA + opioid Do not use clonidine
Intra-operative		Surgical drains and wound infiltration are not recommended
Postop	High-intensity pain*	Paracetamol + COX-2-selective inhibitors or conventional NSAIDs + IV strong opioid by PCA or regular injection	Continue nerve block (by continuous infusion or PCRA) + COX-2-selective inhibitors or conventional NSAIDs ± rescue strong opioids IV	Establish systemic pain management as the nerve block regresses, using COX-2-selective inhibitors or conventional NSAIDs ± rescue strong opioids IV	Establish epidural infusion as the nerve block regresses, ± PCEA, + COX-2-selective inhibitors or conventional NSAIDs ± rescue strong opioids IV
Postop	Low- and moderate- intensity pain**	Paracetamol + COX-2-selective inhibitors or conventional NSAIDs ± rescue weak opioid

*High-intensity pain, VAS ? 50, on a scale of 1–100

**Moderate-intensity pain, VAS <50>30, on a scale of 1–100

**Low-intensity pain, VAS ? 30, on a scale of 1–100

IV, intravenous; LA, local anaesthetic; PCA, patient-controlled analgesia; PCEA, patient-controlled epidural analgesia; PCRA, patient-controlled regional analgesia