Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain. Satisfactory perioperative analgesia is essential for a good and predictable surgical outcome. Effective postoperative pain control is a major challenge to the treating surgeon and his team. Old age and multiple comorbidities restrict the choice of analgesics one can offer. Transdermal buprenorphine (TDB), widely used in chronic pain management, has been rarely studied in acute postoperative setting. The purpose of this study was to compare the safety and efficacy of a TDB patch to conventional analgesics after knee arthroplasty surgery. A prospective randomized study was conducted with 200 patients aged 60-75 years undergoing TKA surgery under neuraxial anesthesia. All patients received periarticular local anesthetic infiltration and epidural/femoral nerve block infusion for 72 hours postoperatively. Group A received the TDB patch 5 mcg applied at the end of surgery. Group B received a combination of paracetamol and tramadol. All patients received intravenous diclofenac as rescue analgesia. Pain scores at rest, on movement, and side effects, if any, were compared over 7 days using the numerical rating scale score. Pain scores at rest and on movement were significantly lower in group A (P values .008 and .01). Rescue analgesia requirement was also significantly less in this group. Only one patient had clinically significant respiratory depression, and 3 patients had local erythema. Our data shows that the TDB patch is more efficacious in reducing postoperative pain after TKA surgery and can be safely used with fewer systemic side effects when compared to conventional analgesics.