Pain control after total knee arthroplasty (TKA) remains challenging. Tramadol is a weak opioid with potentially lower side effects and risk for dependency than stronger opioids. The purpose of this study was to evaluate efficacy and safety of tramadol after TKA in opioid-naïve patients compared with stronger opioids.A retrospective review of patients who underwent primary TKA was performed. In September 2018, opioid-naïve patients were prescribed tramadol instead of oxycodone. Patients receiving tramadol (low-opioid group) were matched to patients discharged with oxycodone before this transition (high-opioid group). We compared morphine milligram equivalent (MME) consumption and outcomes up to 3 months postoperatively.Two-hundred and five patients underwent TKA, with 126 receiving tramadol. Fourteen patients were converted to stronger opioid (11.2% conversion rate). Seventy patients from the low-opioid group were matched to 70 patients in the high-opioid group. Average daily inpatient MME consumption was higher in the high-opioid group (40.0 ± 27.4 vs 16.3 ± 10.9, P = .000). Outpatient prescribed MME was significantly higher in the high-opioid group (135.5 ± 71.5 vs 75.3 ± 51.3, P = .000) along with a higher number of refills (0.53 ± 1.1 vs 0.886 ± 0.94, P = .041). Knee range of motion was not statistically different at any timepoint postoperatively. There was higher adverse event rate in the low-opioid group (8.6% vs 5.7%) but not statically significant.Low opioid regimen following TKA showed lower MME consumption than high opioid regimen with no effect on outcomes up to 3 months. Use of low opioid regimen should be considered for TKA surgery.