Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty

Publication Date: March 1, 2020


An oral NSAID administered either preoperatively and/or in the early postoperative period reduces pain and opioid consumption following primary TJA. (Strong)

Administration of an oral selective cyclooxygenase-2 (COX-2) NSAID immediately preoperatively, compared to early postoperative administration, provides improved postoperative pain control and reduced opioid consumption following primary TJA. (Moderate)

Administration of an oral selective COX-2 NSAID after discharge reduces pain and opioid consumption during the six-week period following a primary total knee arthroplasty (TKA). (Moderate)

In the absence of reliable evidence, it is the opinion of the workgroup that oral selective COX-2 NSAIDs may be used after discharge as part of a multimodal pain regimen to reduce postoperative pain and opioid consumption in patients undergoing primary total hip arthroplasty (THA). ()

Administration of IV ketorolac preoperatively, intraoperatively, or within 24 hours postoperatively reduces pain and opioid consumption postoperatively (within the first 48 hours) following primary TJA. (Strong)

Low-dose (15 mg) and high-dose (30 mg) administration of IV ketorolac immediately postoperatively are equivalent at reducing pain and opioid consumption postoperatively (within the first six hours) following primary TJA. (Moderate)

Oral or IV NSAIDs administered preoperatively, intraoperatively, or postoperatively do not appear to increase the risk of medical complications following primary TJA. However, providers should consider patient comorbidities, the type of NSAID administered, dose, and duration of administration. (Limited)

Recommendation Grading




Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty

Authoring Organization

Publication Month/Year

March 1, 2020

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

The purpose of these guidelines is to improve the treatment of orthopaedic surgical patients and reduce practice variation by promoting a multidisciplinary evidenced-base approach on the use of NSAIDs following primary TJA

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Operating and recovery room, Outpatient

Intended Users

Psychologist, occupational therapist, addiction treatment specialist, nurse, nurse practitioner, physician, physician assistant



Diseases/Conditions (MeSH)

D010146 - Pain, D019643 - Arthroplasty, Replacement


nonsteroidal anti-inflammatory drugs (NSAIDs), joint pain, total joint arthroplasty (TJA)

Source Citation

Fillingham YA, Hannon CP, Roberts KC; AAHKS Anesthesia & Analgesia Clinical Practice Guideline Workgroup, Hamilton WG, Della Valle CJ. Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty. 2020 Oct;35(10):2704-2708. doi: 10.1016/j.arth.2020.05.043. Epub 2020 May 29. PMID: 32571593.


Number of Source Documents
Literature Search Start Date
January 1, 1987
Literature Search End Date
December 31, 2018
Description of External Review Process
AAHKS (AAOS methodology) offers external review to Partner Societies prior to Endorsement Determination. Following the committee’s formulation of the Clinical Practice Guideline draft, it underwent a peer review by the board of directors from AAHKS, ASRA, and the Hip and Knee Societies. The AAOS Evidence-Based Quality and Value Committee reviewed the Clinical Practice Guideline draft for endorsement. Additionally, the publication of the systematic review and meta-analysis on opioids in primary hip and knee arthroplasties that supported the formulation of the Clinical Practice Guideline has undergone peer review for publication.
Specialties Involved
Family Medicine, Hepatology, Internal Medicine General, Orthopaedic Surgery, Pain Medicine, Surgery General
Description of Systematic Review
Resources used to develop the Randomized Quality Appraisal System: • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from The following domains are evaluated to determine the study quality of randomized study designs. • Guyatt, G. H., Oxman, A. D., Sultan, S., et al. (2011). GRADE guidelines: 9. Rating up the quality of evidence. Journal of Clinical Epidemiology, 64(12), 1311–1316.
List of Questions
4 PICO Questions
Description of Study Criteria
A priori article inclusion criteria are constructed for all CPGs. These criteria are our “rules of evidence” and articles that did not meet them are, for the purposes of this guideline, not evidence. To be included in our CPGs an article had to meet the following criteria: Work Group Defined Criteria 1. Study must be of an injury or prevention thereof. 2. Study must be published in or after for surgical treatment, rehabilitation, bracing, prevention and MRI 3. Study must be published in or after for x rays and nonoperative treatment 4. Study must be published in or after for all others non specified 5. Study should have 30 or more patients per group 6. For surgical treatment a minimum of N days/months/year (refer to PICO questions for detailed follow up duration) 7. For nonoperative treatment a minimum of N days/months/year (refer to PICO questions for detailed follow up duration) 8. For prevention studies a minimum of N days/months/year (refer to PICO questions for detailed follow up duration) Standard Criteria for all CPGs • Article must be a full article report of a clinical study. • Retrospective non-comparative case series, medical records review, meeting abstracts, meta-analyses, systematic reviews, historical articles, editorials, letters, and commentaries are excluded. Bibliographies of meta-analyses and systematic reviews will be examined to ensure inclusion of all relevant literature. • Confounded studies (i.e. studies that give patients the treatment of interest AND another treatment) are excluded. Case series studies that have non-consecutive enrollment of patients are excluded. • Controlled trials in which patients were not stochastically assigned to groups AND in which there was either a difference in patient characteristics or outcomes at baseline AND where the authors did not statistically adjust for these differences when analyzing the results are excluded. • All studies evaluated as “very low quality” will be excluded. • Composite measures or outcomes are excluded even if they are patient-oriented. • Study must appear in a peer-reviewed publication • For any included study that uses “paper-and-pencil” outcome measures (e.g., SF36), only those outcome measures that have been validated will be included • For any given follow-up time point in any included study, there must be ≥ 50% patient follow-up (if the follow-up is >50% but <80%, the study quality will be downgraded by one Level) • Study must be of humans • Study must be published in English • Study results must be quantitatively presented • Study must not be an in vitro study • Study must not be a biomechanical study • Study must not have been performed on cadavers • We will only evaluate surrogate outcomes when no patient-oriented outcomes are available.
Description of Search Strategy
We begin the systematic review with a comprehensive search of the literature. Articles we consider were published prior to the start date of the search in a minimum of three electronic databases; PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. The medical librarian conducts the search using key terms determined from the guideline development group’s PICO questions. A CQV methodologist will review/include only primary literature but will supplement the electronic search with a manual search of the bibliographies of secondary literature sources, such as systematic reviews, as available. The methodologist will then evaluate all recalled articles for possible inclusion based on the study selection criteria and will summarize the evidence for the guideline work group who assist with reconciling possible errors and omissions.
Description of Study Selection
A study attrition diagram is provided in the appendix of each document that details the numbers of identified abstracts, recalled and selected studies, and excluded studies that were evaluated in the CPG. The search strategies used to identify the abstracts is also included in the appendix of each CPG document.
Description of Evidence Analysis Methods
All articles included from our systematic literature search are appraised by a CQV methodologist for quality. Depending on the type of study encountered, different quality forms are utilized to determine the quality rating of a study. The quality forms used by staff are described below.
Description of Evidence Grading
The process for determining strength of evidence also considers the following domains: 1. Consistency/heterogeneity of results between studies. Do the results vary widely between studies in terms of strength of effect and direction of effect? 2. Indirectness/generalizability a. Indirectness of patient population. Is the population of the studies applicable to general clinical practice? b. Indirectness of interventions. That is, are the interventions in the studies applied in the same way as they would be in general clinical settings, and are they available in all clinical settings? c. Indirectness of outcomes. Are all relevant outcomes and follow up times evaluated in the included studies? Or, does the evidence only consist of surrogate or intermediate outcomes? 3. Imprecision of results. Are effect estimates from the studies, or the pooled effect in a meta-analysis, highly imprecise, with very wide confidence intervals? For example, if confidence intervals include what might be considered a strong effect, even though the outcome is not statistically significant, the strength of evidence would be downgraded. 4. Tradeoff between benefits and harms. A moderate or strong recommendation can only be made if the benefits of implementing the recommendation clearly outweigh the harms. For example, if multiple high quality RCTs showed that a treatment improves patient reported outcomes, but also greatly increased the risk of serious adverse events, the strength of evidence would be downgraded to limited. The physician work group also applies GRADE’s Evidence to Decision (EtD) framework to determine the final strength of recommendation (appendix 1). The EtD form (appendix 1) is filled out as applicable by the work group member(s) assigned to the PICO question before the meeting, and is used to facilitate discussion about the following issues that may warrant a lower or higher recommendation grade: 1. Certainty of evidence 2. Is there uncertainty over how people value the main outcomes? 3. Are the desirable effects large? 4. Are the undesirable effects small? 5. Are the desirable effects large relative to the undesirable effects? 6. Are resources required to implement the recommendation small? 7. Are the incremental costs small relative to the net benefits? 8. Is the recommendation likely to be acceptable to key stakeholders? 9. Is the option feasible to implement? The EtD allows the workgroup to apply their clinical experience to determine the feasibility and appropriateness of CPG recommendations in real world health care settings. The EtD is a balance between the rigid evidence rules of the systematic review and the real-world clinical expertise of the work group, which allows for a richer perspective, and results in recommendations that are more appropriate. The EtD allows the workgroup to consider possible harms of implementation that may not be well studied in RCTs. It also provides a structured and transparent way to describe how they arrived at the final strength of recommendation and allows readers to be better able to determine how the recommendation applies to their own clinical setting. For example, if high quality studies show that a new imaging modality is good at diagnosing joint infection, but the technology is very expensive and is unlikely to be available at most community medical centers. After filling out the EtD form, the work group may decide that the recommendation should be downgraded from high to moderate because it is not feasible to implement in smaller hospitals due to cost. A reader from a small community hospital is now better able to decide if the recommendation can be implemented at his/her own institution. Conversely, a reader from a high-volume academic medical center that has the imaging technology may decide to apply the recommendation in his/her clinical practice. Furthermore, if low quality studies show that not performing a certain intervention, yields exponentially higher mortality in patients, the work group may decide that the recommendation should be upgraded from limited to moderate because of the potential to prevent loss of life.
Description of Recommendation Grading
Judging the quality of evidence is only a steppingstone towards arriving at the strength of a CPG recommendation. The strength of recommendation also takes into account the quality, quantity, and the trade-off between the benefits and harms of a treatment, the magnitude of a treatment’s effect, and whether data exists on critical outcomes. Strength of recommendation expresses the degree of confidence one can have in a recommendation. As such, the strength expresses how possible it is that a recommendation will be overturned by future evidence. It is very difficult for future evidence to overturn a recommendation that is based on many high quality randomized controlled trials that show a large effect. It is much more likely that future evidence will overturn recommendations derived from a few small retrospective comparative studies. Consequently, recommendations based on the former kind of evidence are given a “strong” strength of recommendation and recommendations based on the latter kind of evidence are given a “limited” strength. To develop the strength of a recommendation, AAOS staff first assigned a preliminary strength for each recommendation that took only the final quality and the quantity of evidence (see Table 1). The recommendations can be further downgraded or upgraded based on the GRADE and Evidence to Decision framework criteria described above.
Description of Funding Source
AAHKS provides funding for Guideline Development.
Company/Author Disclosures
All authors or contributors to the Clinical Practice Guideline have provided a disclosure statement in accordance with the publicly available AAOS Orthopaedic Disclosure Program. All authors and contributors attest none of the disclosures present are relevant to the Clinical Practice Guidelines
Percentage of Authors Reporting COI