PROSPECT guideline for total hip arthroplasty: updated systematic review and procedure‐specific postoperative pain management recommendations

INTRODUCTION: The Procedure Specific Postoperative Pain Management (PROSPECT) collaboration develops evidence-based recommendations integrating analgesic efficacy, safety and functional recovery. Since publication of the 2021 PROSPECT guidelines for total hip arthroplasty, new evidence, particularly on motor-sparing regional techniques, has emerged. This systematic review updates the 2021 recommendations for postoperative pain management after elective primary total hip arthroplasty. METHODS: Databases were searched systematically for randomised controlled trials and systematic reviews published between January 2020 and June 2024 evaluating peri-operative analgesic or surgical interventions for total hip arthroplasty. Studies involving non-randomised designs or lacking validated pain outcomes were not included. Evidence was synthesised according to PROSPECT methodology, focusing on pain within 24 h; opioid consumption; functional recovery; and adverse effects. Recommendations were graded by expert consensus. RESULTS: A total of 103 studies were included. Core recommendations remain unchanged: scheduled paracetamol and non-steroidal anti-inflammatory drugs, combined with a single intravenous dose of dexamethasone (≤ 10 mg). Low-dose intrathecal morphine (0.1 mg) may be considered with spinal anaesthesia in hospitalised patients. Among regional techniques, supra-inguinal fascia iliaca compartment block and pre-operative pericapsular nerve group block provided the most consistent analgesia. Quadratus lumborum and lumbar erector spinae plane blocks showed inconsistent efficacy and increased risk of motor weakness and are not recommended. Single-shot local infiltration analgesia remains an alternative when regional techniques are unavailable. DISCUSSION: In addition to previous recommendations, supra-inguinal fascia iliaca compartment block and pre-operative pericapsular nerve group block are recommended as preferred regional techniques for total hip arthroplasty, with single-shot local infiltration analgesia as an alternative when regional anaesthesia is not feasible.