Published 7/27/2021

FACT SHEET: Clinical Practice Guideline and Appropriate Use Criteria for the Evaluation of Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery

ROSEMONT, Ill. (July 27, 2021)—The American Academy of Orthopaedic Surgeons (AAOS) released a Clinical Practice Guideline (CPG) and an Appropriate Use Criteria (AUC) to help healthcare professionals determine appropriateness of pain alleviation strategies to reduce pain following orthopaedic surgery and traumatic injury, with the intent to minimize the use of opioids in the post-operative period for better patient outcomes.  

The CPG and AUC were developed in collaboration with the Major Extremity Trauma Research Consortium (METRC) and funded by a Department of Defense research grant. 

This CPG is intended to serve as an information resource for decision makers and developers of practice guidelines and recommendations. The guideline evaluates 28 therapeutic interventions for pain alleviation, improved function and opioid reduction after musculoskeletal injury or orthopaedic surgery to improve care.  

CPG highlights include: 

  • Moderate evidence that there is no difference in patient outcomes between local and regional anesthesia for patients undergoing total knee and hip arthroplasty. 
  • Strong evidence for the use of continuous regional anesthesia over local anesthesia in total shoulder arthroplasty to reduce pain and opioid use in the first 24 hours after surgery. 
  • Acetaminophen should be used to improve patient pain and decrease opioid use. 
  • Strong evidence for the use of intravenous ketamine in the peri-operative period to reduce opioid use in the first 24 hours after total hip and knee arthroplasty. 

This AUC is intended to offer guidance on decision factors for adults with musculoskeletal injuries to the extremity and/or pelvis. The treatment scenarios provided by this AUC stem from the recommendation in the CPG issued by AAOS, detailed above. The AUC online tool provides clinicians algorithms on how to optimally evaluate the condition based on a patient’s various indications, including injury severity/type, pain intensity, magnitude of limitations, pain intensity, magnitude of limitation and degree of energy/polytrauma.  

Recommendations, specific next steps, and procedures to ensure optimal recovery include: 

  • Cognitive strategy (virtual reality, mirror therapy, music, aromatherapy, meditation, education, etc.) 
  • Opioids/Tramadol, anti-depressants 
  • NSAIDS/acetaminophen 
  • Gabapentinoids 
  • Ketamine 
  • Relaxants 
  • Physical strategy (cryotherapy, ice, heat, TENS, acupuncture, massage, etc.) 
  • Regional analgesia (field block, peripheral nerve/plexus blocs, etc.)  
  • Exercise 

Each treatment recommendation is ranked by level of appropriateness. 

The new CPG and AUC is intended to be used by all qualified and appropriately trained providers and surgeons involved in the alleviation of patient pain and improve function after musculoskeletal injury or orthopaedic surgery; however, healthcare professionals other than orthopaedic surgeons, including but not limited to adult primary care physicians, adult medicine specialists, physical therapists, hand therapists, occupational therapists, physician assistants, social workers, case managers, psychologists, and nurse practitioners who routinely see this patient population in various practice settings may benefit from this tool. These new tools are not intended for use as a benefits determination document.  

The evidence-based guideline and AUC tools offer accepted approaches to treatment and/or diagnosis and are not intended to be a fixed protocol. Patient care and treatment should always be based on a clinician’s independent medical judgment, given the individual patient’s specific clinical circumstances.  

The full CPG and AUC for the evaluation of pharmacologic, physical and cognitive pain alleviation for musculoskeletal extremity/pelvis surgery is available through AAOS’ OrthoGuidelines website and free mobile app. For more information on the development process for AAOS clinical practice guidelines, please reference the Clinical Practice Guideline Methodology. 

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Contact AAOS Media Relations 

Deanna Killackey 


Lauren Riley