Implementing Evidence-Based, Phase-Specific Multimodal Analgesia for Total Joint Arthroplasty: An Interprofessional...

This review aims to synthesize current evidence on perioperative multimodal analgesia within enhanced recovery after surgery (ERAS) pathways for total joint arthroplasty (TJA). The primary objective is to translate this evidence into clear, actionable insights for nursing management and interprofessional collaboration, emphasizing the pivotal role of nursing professionals in orchestrating patient-centered pain management to optimize outcomes.

A structured narrative review was conducted to provide a clinically relevant synthesis of current evidence on perioperative multimodal analgesia within ERAS pathways for TJA. The review methodology was informed by established recommendations for rigorous narrative reviews, including the SANRA framework. PubMed and MEDLINE were searched for English-language publications available up to June 2025. Studies were screened for relevance and prioritized according to methodological quality, clinical significance, and implications for nursing management and interprofessional practice, with particular emphasis on randomized controlled trials, cohort studies, clinical practice guidelines, systematic reviews, meta-analyses, and landmark studies.

Multimodal analgesia, which synergistically combines pharmacologic and nonpharmacologic techniques, is the standard of care for TJA. Evidence supports phase-specific protocols: preemptively, combining analgesics (e.g., COX-2 inhibitors) 24-48 h preoperatively and tailoring regimens to patient risk profiles (e.g., duloxetine for central sensitization); intraoperatively, using local infiltration analgesia (LIA) as a cornerstone technique; and postoperatively, implementing a structured, nursing-led "non-opioid-first" strategy with scheduled NSAIDs/acetaminophen and monitored opioid rescue protocols. For total knee arthroplasty (TKA), the combination of adductor canal block (ACB), IPACK block, and LIA is an evidence-based strategy for optimizing analgesia while preserving motor function. Intravenous glucocorticoids are also recommended during surgery. Successful implementation is critically dependent on nursing management, including proactive patient education and expectation management, vigilant interpretive pain assessment, systematic monitoring for medication-specific adverse effects, and coordination of mobilization with analgesic peaks. The heterogeneity of evidence underscores the need for standardized, institution-specific protocols, implementation tools, and governance frameworks to support nursing-led ERAS practice. Ultimately, effective analgesia functions within an interprofessional collaborative framework, in which nurses act as central coordinators facilitating communication among surgeons, anesthesiologists, and therapists to dynamically personalize care.

The evolution toward personalized multimodal analgesia elevates the nursing role from protocol administration to essential clinical decision-making and care coordination. Nursing leadership is indispensable for bridging evidence-to-practice gaps, minimizing practice variation, and ensuring patient safety. Key to success is the adoption of standardized pathways that empower nurses to lead patient education, assessment, and cross-disciplinary communication. Future efforts should focus not only on refining analgesic evidence but also on implementation science, protocol governance, workforce competency development, and quality improvement strategies that facilitate sustainable integration into nursing workflows and consistently achieve superior analgesia, enhanced functional recovery, and minimized complications within ERAS programs.