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Managing Pain and Opioids After Surgery

How pain is managed after upper-limb surgery — multimodal pain relief, the role and risks of opioids, nerve blocks, and using the least medication needed.

44 citationsUpdated Oct 2026
Illustration: Managing Pain and Opioids After Surgery

Overview

Postoperative pain management in orthopaedic surgery has shifted toward multimodal, opioid-sparing regimens that integrate pharmacologic and nonpharmacologic agents to optimize outcomes after total joint arthroplasty [6]. This approach is critical for optimizing pain control after total knee arthroplasty [5] and can be achieved with fewer opioids, although postoperative care for adolescents undergoing arthroscopy may still require further improvement [1]. Modern multimodal analgesia has weakened the historical relationship between pain and healing, meaning patients may now feel capable of activities that exceed the biological capacity of healing tissues [17]. While effective pain management is the primary goal, surgery has only a limited role in the management of pain for painful peripheral nerve disorders [4].

Specific intraoperative and perioperative interventions demonstrate variable efficacy. Intraoperative dexamethasone reduces early pain and opioid needs after primary cementless total hip arthroplasty using the direct anterior approach [2]. For total knee arthroplasty, the use of 75 mg pregabalin is advocated as part of a contemporary multimodal analgesic regimen [13], whereas the reduction in pain from tranexamic acid in local infiltration analgesia cocktail did not meet the MCID, indicating limited clinical relevance [18]. In arthroscopic rotator cuff repair, the clinical difference in opioid usage between liposomal bupivacaine and traditional interscalene nerve blocks may not translate to patient benefits or justify the increased cost [14]. Similarly, observed reductions in postoperative opioid consumption and VAS pain scores from preoperative nonopioid analgesia after arthroscopic surgery may not represent clinically meaningful improvements [8].

Long-term opioid use and specific patient populations present distinct challenges. Approximately 39% of preoperative opioid users and 9% of nonchronic opioid users continued use of opioids for 10 to 12 months after elective joint surgery [12]. Patients with preoperative fibromyalgia undergoing hip arthroscopy had significantly higher odds of receiving opioid prescriptions within both 90 days and 1 year postoperatively [7]. Conversely, only 4.8% of patients required opioid medications more than 2 weeks postoperatively following anterior cruciate ligament reconstruction [3]. For patients with low back pain, strategies implementing evidence-based non-opioid alternatives to reduce high-dose opioid therapy are warranted [9]. Regional factors suggest room for more consistent pain management strategies in opioid prescribing following zone II flexor tendon repairs [11], and further research is needed to standardize multimodal analgesic protocols for acute pain management of rib fractures [10].

How It Works

Preoperative Factors and Risk Stratification

Preoperative opioid use and smoking are associated with opioid refills after hip arthroscopy [22]. Patients with preoperative fibromyalgia have significantly higher odds of receiving opioid prescriptions within 90 days and 1 year after hip arthroscopy [7]. In anterior cruciate ligament reconstruction, preoperative risk factors for opioid use predict self-reported health and function up to 6 months postoperatively [3]. Additionally, the use of THC increases the risk of higher morphine milligram equivalents (MMEs) needed in the postoperative spine period, especially in patients also using opiates [27].

Multimodal and Nonopioid Strategies

Preoperative nonopioid analgesia reduces postoperative opioid consumption after arthroscopic surgery, though observed reductions may not represent clinically meaningful improvements [8]. Low-dose pregabalin (75 mg) is advocated as part of a contemporary multimodal analgesic regimen for postoperative pain management after total knee arthroplasty [13]. Tranexamic acid reduces opioid consumption after arthroscopic rotator cuff repair [28]. A nanotechnology-based device is significantly associated with an immediate reduction in postoperative opioid use, postoperative nausea and vomiting, use of rescue antiemetics, and hospital length of stay following total knee arthroplasty [26]. The endogenous opioid system in joint tissues may be targeted and exploited therapeutically to obtain peripheral control of symptoms in joint disorders [34]. The effect of melatonin on postoperative pain is neither supported nor opposed due to low quality of evidence and inconclusive trial sequential analysis [21].

Regional Anesthesia and Intraoperative Interventions

Liposomal bupivacaine after arthroscopic rotator cuff repair moderately decreases early postoperative pain but demonstrates equivocal opioid consumption compared to traditional interscalene nerve blocks [14]. The clinical difference in opioid usage from liposomal bupivacaine may not translate to patient benefits or justify the increased cost [14]. A single epidural analgesia with opioid-free IV-PCA significantly reduces total fentanyl consumption compared with conventional opioid-based IV-PCA in patients undergoing lumbar spine surgery [15]. Despite no clinically important differences in pain control, the epidural opioid-free IV-PCA protocol significantly reduced total fentanyl consumption in lumbar spine surgery [15]. Tranexamic acid in a local infiltration analgesia cocktail for total knee arthroplasty did not meet the minimal clinically important difference for pain reduction [18].

Postoperative Outcomes and Complications

Poor postoperative pain tolerance and increased opioid requirements may serve as early predictive markers for an increased risk of postoperative knee stiffness and subsequent manipulation under anesthesia [35]. Infection following trauma surgery is associated with long-term opiate use in operatively managed orthopaedic patients with fracture-related infections [19]. Modern multimodal analgesia has weakened the historical relationship between pain and healing, meaning patients may feel capable of activities that exceed the biological capacity of healing tissues [17].

Prescribing Patterns and Systemic Factors

Effective pain management can be achieved with fewer opioids following implementation of the Controlled Substance Utilization Review and Evaluation System, though postoperative care for adolescents undergoing arthroscopy could be further improved [1]. Demographic factors associated with MMEs prescribed after zone II flexor tendon repairs suggest different needs for different cohorts, while regional factors suggest room for more consistent pain management strategies [11]. One in six admitted patients with low back pain received high daily opioid dosage in Australian hospitals [9]. Strategies implementing evidence-based non-opioid alternatives are warranted to reduce high-dose opioid therapy [9]. The Strengthen Opioid Misuse Prevention Act (STOP Act) demonstrated effectiveness for decreasing orthopaedic opioid prescriptions [25]. Further studies are needed to understand pathophysiologic and psychosocial effects of opioid disorders on fracture and wound healing [16].

What the Evidence Shows

Opioid Consumption and Prescription Patterns

Orthopaedic surgeons prescribe markedly more opioids than they perceive in the setting of elective total joint arthroplasty [31]. In arthroscopic rotator cuff repair, advancing age modulates postoperative opioid consumption [28]. Preoperative opioid use increases consumption in the first 3 days after this procedure [28], as does the number of anchors used [28]. Following zone II flexor tendon repairs, demographic factors associated with morphine milligram equivalents prescribed may suggest different needs for different cohorts [11]. Regional factors associated with opioid prescribing after these repairs suggest room for more consistent pain management strategies [11]. Infection following trauma surgery is associated with long-term opiate use [19].

Multimodal and Non-Opioid Analgesia Strategies

A modern opioid-free multimodal analgesia regimen is important in optimizing pain management after total knee arthroplasty [5]. A single preoperative dose of methadone (10 mg) in primary total knee arthroplasty reduced postoperative opioid usage while maintaining a similar or better level of pain control compared to a standard pain control regimen [29]. A single epidural analgesia with opioid-free IV-PCA protocol significantly reduced total fentanyl consumption compared with conventional opioid-based IV-PCA in patients undergoing lumbar spine surgery [15].

Liposomal bupivacaine after arthroscopic rotator cuff repair moderately decreases early postoperative pain [14]. However, it demonstrates equivocal opioid consumption compared to traditional interscalene nerve blocks [14]. The clinical difference in opioid usage between these two modalities may not translate to patient benefits or justify the increased cost [14]. Liposomal bupivacaine is a promising component of periarticular injection cocktails for total knee arthroplasty, with some studies showing better pain control, lower opioid use, and higher patient satisfaction [42].

A nanotechnology-based device following total knee arthroplasty is significantly associated with an immediate reduction in postoperative opioid use [26]. This device is also significantly associated with a reduction in postoperative nausea and vomiting [26], a reduction in the use of rescue antiemetics [26], and a reduction in hospital length of stay [26]. The reduction in pain from adding tranexamic acid to a local infiltration analgesia cocktail after total knee arthroplasty did not meet the minimal clinically important difference [18]. Conversely, use of tranexamic acid reduces opioid consumption after arthroscopic rotator cuff repair [28].

Subjective pain levels and the amount of supplementary pain medication used were both lower in the group receiving patient-controlled lidocaine analgesia for acromioplasty surgery [40]. A multidisciplinary approach is effective for reducing inpatient opioid consumption in operatively treated upper extremity fracture patients [32]. The greatest reduction in inpatient opioid consumption for these patients using a multidisciplinary approach was seen on postoperative day 1 and 2 [32]. Modified forearm intravenous regional analgesia for hand surgery requires a much lower dose of local anesthetic agent and greatly diminishes the chances of complications from overdose [20]. Preoperative nonopioid analgesia reduces postoperative opioid consumption after arthroscopic surgery [8].

The effect of melatonin on postoperative pain is neither supported nor opposed due to low quality of evidence, minor degree of VAS score reduction, and inconclusive trial sequential analysis of postoperative opioid consumption [21]. No significant differences in Visual Analog Scale scores at 12, 24, 36, and 48 hours after surgery were observed between groups receiving ketorolac, acetaminophen, and gabapentin versus control in femoral shaft fractures [41].

Regional and Neuraxial Techniques

Opioid consumption and pain scores obtained with a surgeon-performed iliac fascia catheter were similar to those obtained with epidural analgesia after anterior acetabular fracture surgery [30]. A single epidural analgesia with opioid-free IV-PCA protocol showed no clinically important differences in pain control compared with conventional opioid-based IV-PCA in patients undergoing lumbar spine surgery [15].

Risk Factors and Patient Characteristics

Patients with preoperative fibromyalgia undergoing hip arthroscopy demonstrated similar 2-year reoperation rates compared to matched controls [7]. Levels of preoperative anxiety in opioid-naive patients undergoing primary arthroscopic rotator cuff repair had no significant effect on total postoperative opioid usage [45]. These anxiety levels also had no significant effect on the number of days opioid medication was taken [45] or on adjusted daily opioid usage [45]. Opioids, prescription nonsteroidal anti-inflammatory drugs, and corticosteroid injections were reported as most effective by patients for hip and knee arthritis [44].

Outcomes, Safety, and Systemic Considerations

Effective pain management can be achieved with fewer opioids following implementation of the Controlled Substance Utilization Review and Evaluation System [1]. Postoperative care of adolescents undergoing arthroscopy could be further improved despite effective pain management with fewer opioids [1]. Strategies that ensure equity in pain management are needed such that all patients have equitable access to early and adequate pain control after injury [23]. Further research is needed to standardize multimodal analgesic protocols and to assess their impact on long-term, patient-centred outcomes for rib fractures [10]. Following ePHR, patients demonstrate significant improvement in pain and function [24].

Practical Considerations

Preoperative Risk Stratification and Counseling

Preoperative opioid use and smoking are associated with opioid refills after hip arthroscopy and should be addressed during preoperative counseling [22]. Patients with preoperative fibromyalgia have significantly higher odds of receiving opioid prescriptions within 90 days and 1 year postoperatively compared to matched controls [7]. Furthermore, patients using opioids preoperatively for total joint arthroplasty are more likely to have a social determinant of health deficit compared to opioid-naïve patients [36].

Multimodal and Nonopioid Analgesic Strategies

Preoperative interventions: A single preoperative dose of methadone (10 mg) in primary total knee arthroplasty reduces postoperative opioid usage while maintaining similar or better pain control compared to a standard regimen [29]. Preoperative nonopioid analgesia reduces postoperative opioid consumption and VAS pain scores after arthroscopic surgery, though these reductions may not represent clinically meaningful improvements [8].

Intraoperative and regional techniques: A single epidural analgesia with opioid-free IV-PCA significantly reduces total fentanyl consumption compared with conventional opioid-based IV-PCA in lumbar spine surgery, despite no clinically important differences in pain control [15]. Modified forearm intravenous regional analgesia for hand surgery is effective and safe, requiring a much lower dose of local anesthetic agent and diminishing the chances of complications from overdose [20].

Multidisciplinary care: A multidisciplinary approach is effective for reducing inpatient opioid consumption in operatively treated upper extremity fracture patients, with the greatest reduction seen on postoperative days 1 and 2 [32].

Opioid Prescription Patterns and Utilization

Demographic factors associated with morphine milligram equivalents prescribed after zone II flexor tendon repairs suggest different needs for different cohorts, while regional factors suggest room for more consistent pain management strategies [11]. Perioperative regional nerve blocks during thumb carpometacarpal arthroplasty increased episode-of-care cost without reducing the numbers of short-term emergency department visits or postoperative opioid prescriptions [39]. The use of THC increases the risk of more morphine milligram equivalents needed in the postoperative spine period, especially if patients were also on opiates [27].

Systemic and Regulatory Considerations

The Strengthen Opioid Misuse Prevention Act (STOP Act) is effective for decreasing orthopaedic opioid prescriptions, although optimal reduction is a multimodal endeavor not limited to regulatory legislation [25]. Strategies implementing evidence-based non-opioid alternatives are warranted to reduce high-dose opioid therapy, as one in six admitted patients with low back pain received high daily opioid dosage in Australian hospitals [9]. Strategies that ensure equity in pain management are needed so that all patients have equitable access to early and adequate pain control after injury [23]. Further research is needed to standardize multimodal analgesic protocols and to assess their impact on long-term, patient-centred outcomes for acute pain management of rib fractures [10].

Key Evidence

  • [L3] The hypothesis was upheld in part, suggesting that effective pain management can be achieved with fewer opioids, but that the postoperative care of adolescents undergoing arthroscopy could be further improved. [1] (10.1177/23259671261450619)
  • [L5] The authors commend the original trial's evidence that intraoperative dexamethasone reduces early pain and opioid needs but highlight limitations including fixed dosing, lack of power for secondary outcomes, and insufficient safety monitoring, advocating for future work to refine dosing, ensure adequate power, and monitor safety endpoints over a longer recovery period. [2] (10.1016/j.arth.2025.07.051)
  • [L3] Only 4.8% of patients required opioid medications more than 2 weeks postoperatively. [3] (10.1016/j.asmr.2025.101294)
  • [L4] These figures emphasize that surgery has only a limited role in the management of pain in this context. [4] (10.1016/0266-7681(84)90008-1)
  • [L3] This study highlights the importance of a modern opioid-free multimodal analgesia regimen in optimizing pain management after TKA. [5] (10.1016/j.arth.2025.09.011)
  • [L4] Multimodal, opioid-sparing regimens that incorporate both pharmacologic and nonpharmacologic agents offer the most balanced approach to pain management after TJA. [6] (10.1016/j.arth.2026.03.068)
  • [L3] However, patients with fibromyalgia had significantly higher odds of receiving opioid prescriptions within both 90 days and 1 year postoperatively. [7] (10.1002/arj.70003)
  • [L1] Despite statistically significant findings, observed reductions in postoperative opioid consumption and VAS pain scores may not represent clinically meaningful improvements. [8] (10.1177/03635465251396164)
  • [L4] Strategies implementing evidence-based non-opioid alternatives to reduce high-dose opioid therapy are warranted. [9] (10.1186/s12891-026-09882-y)
  • [Paper] Further research is needed to standardize multimodal analgesic protocols and to assess their impact on long-term, patient-centred outcomes. [10] (10.1016/j.injury.2025.112857)
  • [L2] Demographic factors associated with MMEs prescribed may suggest different needs for different cohorts, but regional factors suggest room for more consistent pain management strategies. [11] (10.1016/j.jhsg.2026.100971)
  • [L3] Approximately 39% of preoperative opioid users and 9% of nonchronic opioid users continued use of opioids for 10 to 12 months after surgery. [12] (10.1016/j.arth.2025.06.053)
  • [L1] Therefore, the authors advocate for the use of 75 mg pregabalin as part of a contemporary multimodal analgesic regimen for postoperative pain management after TKA. [13] (10.1016/j.arth.2025.06.068)
  • [L1] However, the clinical difference in opioid usage may not translate to patient benefits or justify the increased cost. [14] (10.1016/j.otsr.2025.104190)
  • [L1] Despite no clinically important differences in pain control, the epidural opioid-free IV-PCA protocol significantly reduced total fentanyl consumption compared with conventional opioid-based IV-PCA in patients undergoing lumbar spine surgery. [15] (10.1097/corr.0000000000003891)
  • [L3] Further studies are needed to understand pathophysiologic and psychosocial effects of opioid disorders on fracture and wound healing. [16] (10.1016/j.injury.2025.112926)
  • [L5] Modern multimodal analgesia has weakened the historical relationship between pain and healing, meaning patients may now feel capable of activities that exceed the biological capacity of healing tissues. [17] (10.1016/j.otsr.2026.104865)
  • [L1] However, the reduction in pain did not meet the MCID, indicating limited clinical relevance in terms of analgesia. [18] (10.1186/s42836-026-00385-8)
  • [L3] Infection following trauma surgery is associated with long term opiate use. [19] (10.1016/j.injury.2025.112566)
  • [L4] This technique is very effective and safe, requiring a much lower dose of local anesthetic agent and greatly diminishing the chances of complications from overdose. [20] (10.1016/s0363-5023(89)80103-0)
  • [L1] Given the low quality of evidence, minor degree of VAS score reduction, and inconclusive trial sequential analysis of postoperative opioid consumption, this metaanalysis neither supports nor opposes the effect of melatonin on postoperative pain. [21] (10.1111/papr.12948)
  • [L3] These findings suggest that smoking and preoperative opioid use may be topics to address during preoperative counseling of these patients. [22] (10.1177/23259671261472200)
  • [L3] Strategies that ensure equity in pain management are needed such that all patients have equitable access to early and adequate pain control after injury. [23] (10.1016/j.injury.2026.113065)
  • [L4] Following ePHR, patients demonstrate significant improvement in pain and function. [24] (10.1016/j.arthro.2020.12.159)
  • [L4] Ultimately, although optimal reduction in opioid prescriptions is a multimodal endeavor that is by no means limited to mere regulatory legislation, this study does demonstrate the effectiveness of the STOP Act for decreasing orthopaedic opioid prescriptions. [25] (10.5435/jaaosglobal-d-20-00006)
  • [L1] This randomized placebo-controlled study demonstrates that the use of NBD is significantly associated with an immediate reduction in postoperative opioid use, PONV, use of rescue antiemetics, and hospital LOS. [26] (10.1016/j.arth.2026.04.083)
  • [L3] The use of THC increases the risk of more morphine milligram equivalents (MMEs) needed in the postoperative spine period, especially if those patients were on opiates as well together. [27] (10.5435/jaaosglobal-d-23-00206)
  • [L1] Advancing age modulated postoperative opioid consumption, whereas preoperative opioid use and number of anchors used increased opioid consumption in the first 3 days after ARCR. [28] (10.1016/j.jse.2025.07.023)
  • [L1] This study demonstrated the effectiveness and safety of a single preoperative dose of methadone (10 mg) in primary TKA in reducing postoperative opioid usage while maintaining a similar or better level of pain control when compared to a standard pain control regimen. [29] (10.1016/j.arth.2025.06.058)
  • [L3] Opioid consumption and pain scores were similar to those obtained with epidural analgesia. [30] (10.1016/j.injury.2026.113708)
  • [L4] Orthopaedic surgeons prescribe markedly more opioids than they perceived in the setting of elective total joint arthroplasty. [31] (10.5435/jaaosglobal-d-24-00152)
  • [L3] A multidisciplinary approach is effective for reducing inpatient opioid consumption in operatively treated upper extremity fracture patients, with the greatest reduction seen on POD 1 and 2. [32] (10.1016/j.jseint.2026.101685)
  • [Paper] Routine pharmacological analgesia is not required for office-based K-wire removal in either paediatric or adult populations. [33] (10.1016/j.injury.2026.113434)
  • [Paper] The endogenous opioid system now demonstrated might be targeted and exploited therapeutically to obtain peripheral control of symptoms in joint disorders. [34] (10.1002/jor.20132)
  • [L3] Poor postoperative pain tolerance and increased opioid requirements may serve as early predictive markers that portend an increased risk of postoperative knee stiffness and subsequent MUA. [35] (10.1016/j.arth.2026.03.042)
  • [L3] Patients using opioids preoperatively are more likely to have a social determinant of health deficit compared to opioid-naïve patients, which may indicate differences in pathways of care and highlights the influence of social determinants of health on patient outcomes following total joint arthroplasty. [36] (10.1016/j.arth.2025.08.033)
  • [L3] In this matched national cohort, perioperative regional nerve blocks during CMC arthroplasty increased episode-of-care cost without reducing the numbers of short-term ED visits or postoperative opioid prescriptions. [39] (10.1016/j.jhsg.2026.101089)
  • [L3] Subjective pain levels and the amount of supplementary pain medication used were both lower in the group receiving patient-controlled lidocaine analgesia at statistically significant levels. [40] (10.1067/mse.2000.104092)
  • [L2] The study observed no significant differences in Visual Analog Scale scores at 12, 24, 36, and 48 hours after surgery between the experimental and control groups. [41] (10.5435/jaaosglobal-d-25-00027)
  • [L1] The LB is a promising component, with some studies showing better pain control, lower opioid use, and higher patient satisfaction. [42] (10.1016/j.arth.2026.09.034)
  • [L5] They highlight concerns regarding the reported pain score trends, the definition of block failure, and the injury severity score (ISS) documentation in the index study. [43] (10.1016/j.injury.2025.112632)
  • [L4] Opioids, prescription nonsteroidal anti-inflammatory drugs, and corticosteroid injections were reported as most effective by patients. [44] (10.5435/jaaosglobal-d-20-00046)
  • [L2] Levels of preoperative anxiety in opioid-naive patients undergoing primary ARCR had no significant effect on total postoperative opioid usage, the number of days opioid medication was taken, or the adjusted daily opioid usage. [45] (10.1177/23259671261427788)
  • [L4] The study defines a management protocol for residuum pain after osseointegration, categorizing pain into mechanical, neuropathic, and infectious processes. [46] (10.1016/j.injury.2025.112881)

See Also

References

[1] Changes in Opioid Prescription Patterns Following Implementation of the Controlled Substance Utilization Review and Evaluation System. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261450619

[2] Comment on “A Randomized, Double-Blind, Placebo-Controlled Trial on the Efficacy of Dexamethasone Combined With Neuraxial Anesthesia in Reducing Pain and Opioid Consumption After Primary Cementless Total Hip Arthroplasty Using the Direct Anterior Approach”. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.07.051

[3] Preoperative Risk Factors for Opioid Use Predict Self-Reported Health and Function Up to 6 Months Following Anterior Cruciate Ligament Reconstruction. Arthroscopy, Sports Medicine, and Rehabilitation. 2025. DOI: 10.1016/j.asmr.2025.101294

[4] The Management of Painful Peripheral Nerve Disorders. Journal of Hand Surgery. 1984. DOI: 10.1016/0266-7681(84)90008-1

[5] In-Hospital Exposure and Opioids Prescribed after Total Knee Arthroplasty. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.09.011

[6] Emerging Nonopioid Analgesic Strategies in Total Joint Arthroplasty: Mechanisms, Evidence, and Practical Implementation. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.068

[7] Patients With Preoperative Fibromyalgia Undergoing Hip Arthroscopy Demonstrated Increased Odds of Postoperative Opioid Prescriptions Within 90 Days and 1 Year but Similar 2‐Year Reoperation Rates Compared to Matched Controls. Arthroscopy. 2026. DOI: 10.1002/arj.70003

[8] Preoperative Nonopioid Analgesia Reduces Postoperative Opioid Consumption After Arthroscopic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465251396164

[9] One in six admitted patients with low back pain received high daily opioid dosage in Australian hospitals: a cross-sectional study. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09882-y

[10] Acute pain management of rib fractures: a narrative review. Injury. 2025. DOI: 10.1016/j.injury.2025.112857

[11] Opioid Prescription Patterns Following Zone II Flexor Tendon Repairs: A National Database Study. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.100971

[12] Opioid Consumption Patterns Before and After Elective Joint Surgery. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.06.053

[13] Analgesic Efficacy and Side Effects of Low-Dose Pregabalin As a Modern Multimodal Agent for Postoperative Pain Control After Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.06.068

[14] Liposomal bupivacaine after arthroscopic rotator cuff repair moderately decreases early postoperative pain and demonstrates equivocal opioid consumption compared to traditional interscalene nerve blocks: A systematic review and meta-analysis of level 1 studies. Orthopaedics & Traumatology: Surgery & Research. 2026. DOI: 10.1016/j.otsr.2025.104190

[15] Single Epidural Analgesia With Opioid-free IV-PCA Reduces Opioid Consumption in Lumbar Spine Surgery: A Randomized, Multicenter Trial. Clinical Orthopaedics & Related Research. 2026. DOI: 10.1097/corr.0000000000003891

[16] Perioperative opioid related disorders on outcomes following lower extremity fracture fixation: Comparative analysis from a multicenter national database. Injury. 2026. DOI: 10.1016/j.injury.2025.112926

[17] When pain is no longer the limiting factor: Adapting postoperative activity to tissue healing. The success of modern analgesia has created a new challenge. Orthopaedics & Traumatology: Surgery & Research. 2026. DOI: 10.1016/j.otsr.2026.104865

[18] Tranexamic acid in local infiltration analgesia cocktail for pain and swelling after total knee arthroplasty: a randomized controlled trial. Arthroplasty. 2026. DOI: 10.1186/s42836-026-00385-8

[19] Long-term opioid use in operatively managed orthopaedic patients with fracture-related infections: A data linkage study. Injury. 2025. DOI: 10.1016/j.injury.2025.112566

[20] Modified forearm intravenous regional analgesia for hand surgery. The Journal of Hand Surgery. 1989. DOI: 10.1016/s0363-5023(89)80103-0

[21] Effect of Melatonin on Postoperative Pain and Perioperative Opioid Use: A Meta‐analysis and Trial Sequential Analysis. Pain Practice. 2020. DOI: 10.1111/papr.12948

[22] Association of Preoperative Opioid Use and Smoking With Opioid Refill After Hip Arthroscopy. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261472200

[23] An evaluation of the association between patient sociodemographic factors and delayed time to analgesia in the trauma bay. Injury. 2026. DOI: 10.1016/j.injury.2026.113065

[24] Significant Variability in Opioid Prescribing Practices after Common Orthopaedic Procedures. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2020.12.159

[25] The Effect of the Strengthen Opioid Misuse Prevention Act on Opiate Prescription Practices Within the Orthopaedic Surgery Department of an Academic Medical Center. JAAOS: Global Research and Reviews. 2020. DOI: 10.5435/jaaosglobal-d-20-00006

[26] Nanotechnology-Based Device Reduces Pain and Immediate Opioid Requirements and Facilitates Earlier Discharge From the Hospital Following Total Knee Arthroplasty: A Randomized Placebo-Controlled Trial. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.04.083

[27] The Effect of Marijuana on Postoperative Spine Patients' Emergency Department Visits, Readmission Rates, and Opioid Consumption. JAAOS: Global Research and Reviews. 2024. DOI: 10.5435/jaaosglobal-d-23-00206

[28] Use of tranexamic acid reduces opioid consumption after arthroscopic rotator cuff repair. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.07.023

[29] Optimizing Postoperative Pain Management in Total Knee Arthroplasty With Preoperative Methadone: A Prospective, Randomized Study. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.06.058

[30] Surgeon-performed iliac fascia catheter versus epidural analgesia versus no regional analgesia after anterior acetabular fracture surgery: a retrospective comparative study of 85 patients. Injury. 2026. DOI: 10.1016/j.injury.2026.113708

[31] Disparity Between Perceived and Actual Opioid Prescriptions by Orthopaedic Surgeons After Total Joint Arthroplasty. JAAOS: Global Research and Reviews. 2025. DOI: 10.5435/jaaosglobal-d-24-00152

[32] The role of a multidisciplinary approach to opioid reduction for patients with operatively treated upper extremity fractures. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101685

[33] Analgesia for Kirschner wire removal in paediatric and adult populations: a narrative review. Injury. 2026. DOI: 10.1016/j.injury.2026.113434

[34] Opioid peptides and receptors in joint tissues: Study in the rat. Journal of Orthopaedic Research. 2006. DOI: 10.1002/jor.20132

[35] Increased Opioid Consumption Following Total Knee Arthroplasty Is Associated With an Increased Risk of Manipulation Under Anesthesia. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.03.042

[36] Patients Utilizing Opioids Before Total Joint Arthroplasty Have Greater Social Determinants of Health Deficits than Opioid-Naïve Patients. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.08.033

[39] Regional Anesthesia in Thumb Carpometacarpal Arthroplasty: Increased Costs Without Differences in Early Emergency Department Visits or Opioid Prescriptions. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.101089

[40] Patient-controlled lidocaine analgesia for acromioplasty surgery. Journal of Shoulder and Elbow Surgery. 2000. DOI: 10.1067/mse.2000.104092

[41] Postoperative Pain Management With Ketorolac, Acetaminophen, and Gabapentin in Femoral Shaft Fractures: A Prospective Cohort Study. JAAOS: Global Research and Reviews. 2025. DOI: 10.5435/jaaosglobal-d-25-00027

[42] Periarticular Injection Cocktails for Pain Management After Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2026.09.034

[43] Comment on “Ultrasound-guided erector spinae plane block for analgesia of traumatic rib fractures”. Injury. 2026. DOI: 10.1016/j.injury.2025.112632

[44] Which Nonsurgical Treatments Do Patients Believe Are Most Effective for Hip and Knee Arthritis?. JAAOS: Global Research and Reviews. 2020. DOI: 10.5435/jaaosglobal-d-20-00046

[45] Preoperative Anxiety Levels and Postoperative Opioid Use in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Prospective Cohort Study. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671261427788

[46] Stump pain management in patients with lower limb osseointegration. Injury. 2025. DOI: 10.1016/j.injury.2025.112881

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Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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