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Terres MT, Machado Assis ML, Lombardi RA, Balthazar da Silveira C, Amaral S. Adding Dexmedetomidine to Intra-articular Local Anesthetics Results in Prolonged Analgesia After Knee Arthroscopy: A Systematic Review and Meta-analysis. Arthroscopy 2024:S0749-8063(24)00493-6. [PMID: 38992512 DOI: 10.1016/j.arthro.2024.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 06/15/2024] [Accepted: 06/27/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE To assess the efficacy and safety of dexmedetomidine as an adjuvant to intra-articular (IA) injections of local anesthetics (LA) in adult patients undergoing knee arthroscopy. METHODS We searched MEDLINE, Embase, and Cochrane Library for randomized controlled trials (RCTs) comparing IA dexmedetomidine plus LA versus LA alone for knee arthroscopy in adults. We used the DerSimonian and Laird random-effects model for all outcomes and conducted a sensitivity analysis with the leave-one-out method, as well as a subgroup analysis for the type of LA. We used R version 4.1.2 for all statistical analyses. RESULTS We included 16 RCTs encompassing 799 patients, of whom 49.8% received IA dexmedetomidine. In the pooled analysis, time to first analgesia rescue was prolonged in almost 4 hours with the use of dexmedetomidine (mean difference [MD] 229 minutes; P < .001). We found statistically significant differences favoring dexmedetomidine in pain scores at rest and movement throughout the first 2, 6, 12, and 24 hours postoperatively (P < .001). Although the MD ranged from -0.3 to -0.9 cm, corresponding to a 3% to 9% reduction in pain scores, this change is not clinically significant compared with the minimal clinically important difference (MCID). Additionally, the intervention group showed a statistically significant reduction in cumulative opioid consumption over 24 hours (MD -4.5 mg; P < .001). However, this reduction did not meet the threshold for the MCID. There was no difference between groups on the incidence of hypotension (P = .190), bradycardia (P = .430), and postoperative nausea and vomiting (P = .550). CONCLUSIONS Adding dexmedetomidine to LA in IA injections for knee arthroscopy significantly extended analgesia duration. Additionally, it lowered pain scores and opioid use, although these effects did not reach the MCID. Furthermore, this addition did not increase the risk of adverse events. LEVEL OF EVIDENCE Level II, meta-analysis of Level I and II studies.
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Affiliation(s)
| | | | - Rafael Arsky Lombardi
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A
| | | | - Sara Amaral
- Department of Anesthesiology, Regional Hospital Deputado Afonso Guizzo, Araranguá, Brazil.
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2
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Herrera GF, Patzkowski JC, Patzkowski MS, Giordano NA, Scott-Richardson M, Kent M, Highland KB. Discharge Opioid Dose Indirectly Associated With Functional Outcomes 2 Weeks After Shoulder and Knee Arthroscopy in a US Military Sample. Mil Med 2024; 189:e1771-e1778. [PMID: 38602453 DOI: 10.1093/milmed/usad495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/13/2023] [Accepted: 12/21/2023] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION Postsurgical opioid utilization may be directly and indirectly associated with a range of patient-related and surgery-related factors, above and beyond pain intensity. However, most studies examine postsurgical opioid utilization without accounting for the multitude of co-occurring relationships among predictors. Therefore, this study aimed to identify factors associated with opioid utilization in the first 2 weeks after arthroscopic surgery and examine the relationship between discharge opioid prescription doses and acute postsurgical outcomes. METHODS In this prospective longitudinal observational study, 110 participants undergoing shoulder or knee arthroscopies from August 2016 to August 2018 at Walter Reed National Military Medical Center completed self-report measures before and at 14 days postoperatively. The association between opioid utilization and both patient-level and surgery-related factors was modeled using structural equation model path analysis. RESULTS Participants who were prescribed more opioids took more opioids, which was associated with worse physical function and sleep problems at day 14, as indicated by the significant indirect effects of discharge opioid dose on day 14 outcomes. Additional patient-level and surgery-related factors were also significantly related to opioid utilization dose and day 14 outcomes. Most participants had opioid medications leftover at day 14. CONCLUSION Excess opioid prescribing was common, did not result in improved pain alleviation, and was associated with poorer physical function and sleep 14 days after surgery. As such, higher prescribed opioid doses could reduce subacute functioning after surgery, without benefit in reducing pain. Future patient-centered studies to tailor opioid postsurgical prescribing are needed.
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Affiliation(s)
- Germaine F Herrera
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Rockville, MD 20852, USA
| | - Jeanne C Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200, USA
| | - Michael S Patzkowski
- Department of Anesthesia, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200, USA
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
| | - Nicholas A Giordano
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA 30322, USA
| | | | - Michael Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
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3
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Liu S, Sun Y, Wang Y, Sun C, Zhang Q. Comparison of the effect of dexmedetomidine intrathecal injection and intravenous infusion on subarachnoid blockade during knee arthroscopy procedures: a randomized controlled trial. BMC Anesthesiol 2024; 24:16. [PMID: 38182994 PMCID: PMC10768377 DOI: 10.1186/s12871-023-02401-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/30/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Comparison of whether intrathecal dexmedetomidine prolongs spinal anesthesia-associated sensorimotor blockade more than intravenous infusion during knee arthroscopy procedures performed under subarachnoid blockade. METHODS Ninety patients aged 18-75 years, ASA class I-II, who underwent knee arthroscopy between October 2022 and April 2023 were randomized into intrathecal、intravenous and control groups.Subjects received three modes of administration: an intrathecal group (2 ml of 1% ropivacaine + 1 ml of 5 μg dexmedetomidine, along with intravenous saline infusion), an intravenous group (intrathecal 2 ml of 1% ropivacaine + 1 ml of 0.9% saline, with dexmedetomidine pumped intravenously at a dose of 0.5 μg/kg/h), and a control group (intrathecal 2 ml of 1% ropivacaine + 1 ml of 0.9% saline, along with intravenous saline infusion). Total analgesic duration, duration of sensory and motor blockade, Ramsay sedation score, Visual Analogue Score (VAS) at different postoperative time points, and occurrence of adverse effects were recorded. RESULTS The total analgesia duration was significantly longer in the intrathecal group than in the intravenous and control groups (352.13 ± 51.70 min VS 273.47 ± 62.57 min VS 241.41 ± 59.22 min, P < 0.001).The onset of sensory block was shorter in the intrathecal group than in the intravenous and control groups (4 [3-4]min VS 5 [4-5]min VS 5 [4-5]min; P < 0.001);the onset of motor block was shorter in the intrathecal group than in the intravenous group and the control group (5 [4-5]min VS 5 [5-6]min VS 6[5.5-7]min; P < 0.001).Sedation scores were higher in the intravenous group than in the intrathecal and control groups (P < 0.001). At 5 h postoperatively, the VAS score in the intrathecal group was lower than that in the intravenous and control groups (P < 0.001). At 24 h postoperatively, the VAS score in the intrathecal group was lower than that in the control group (P < 0.001). In addition, the incidence of bradycardia was significantly higher in the intravenous group than in the intrathecal and control groups (30%, 6.5%, and 3.4%, respectively; P = 0.018, P = 0.007). CONCLUSIONS Intrathecal administration of dexmedetomidine did prolong the total analgesia duration, as well as accelerate the onset of sensory-motor blockade compared with intravenous infusion, and did not result in any hemodynamic instability or other adverse events at the doses studied. TRIAL REGISTRATION This single-center, prospective, RCT has completed the registration of the Chinese Clinical Trial Center at 26/09/2023 with the registration number ChiCTR2300076170.
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Affiliation(s)
- Shujiao Liu
- Department of Anesthesiology, Binzhou Medical University Hospital, Binzhou, 256603, China
| | - Yaorui Sun
- Department of Anesthesiology, Binzhou Medical University Hospital, Binzhou, 256603, China
| | - YeWen Wang
- Department of Anesthesiology, Binzhou Medical University Hospital, Binzhou, 256603, China
| | - Chao Sun
- Department of Anesthesiology, Binzhou Medical University Hospital, Binzhou, 256603, China
| | - Quanyi Zhang
- Department of Anesthesiology, Binzhou Medical University Hospital, Binzhou, 256603, China.
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Steinmetz RG, Hamilton JM, Moritz BW, Algan SM. Opioid Use After Knee Arthroscopy in Adolescent Patients: A Prospective Evaluation. Orthop J Sports Med 2023; 11:23259671231169192. [PMID: 37255945 PMCID: PMC10226294 DOI: 10.1177/23259671231169192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/27/2023] [Indexed: 06/01/2023] Open
Abstract
Background There is a relative paucity of literature on how to best treat postoperative pain after knee arthroscopy in the adolescent population. Purpose To evaluate the use of opioid medication after knee arthroscopy in adolescent patients. Study Design Case series; Level of evidence, 4. Methods We prospectively enrolled 50 patients aged 10 to 18 years who underwent 1 of the following procedures: diagnostic arthroscopy; plica excision; loose body removal; debridement; chondroplasty; meniscal repair; and/or partial meniscectomy. Patients already taking chronic pain medication and those undergoing revision knee arthroscopy, ligamentous reconstruction, or bony osteotomy procedures were excluded. Postoperatively, the patients were prescribed 15 tablets of hydrocodone/acetaminophen (5 mg/325 mg) every 6 hours as needed for pain. The patients were given a diary to record the number of postoperative opioid pills taken, days the pills were taken, pain level, and nonopioid pills taken. The data were collected and used to identify the mean number of opioid pills needed as well as the number of days opioid medication was needed postoperatively. Results Of the 50 enrolled patients, 35 patients adequately completed the diary and were included in the study. The mean age in this cohort was 14.2 years. The total number of pills taken ranged from 0 to 14, with an overall mean of 5.41. Therefore, on average, patients utilized 36% of their postoperative prescriptions. In our cohort, 74.3% of patients had stopped taking opioids by postoperative day 3, with a mean of 3.8 pills, and 97.1% of patients had stopped taking opioids by postoperative day, 5 with a mean of 5.3 pills. No postoperative refills of opioid medication were necessary. Conclusion After knee arthroscopy, the adolescents in our study consumed a mean of 5.41 opioid pills postoperatively, and over 97% of patients stopped opioid use by postoperative day 5. The results of this study should help in guiding physicians to avoid overprescribing opioid medication while treating postoperative pain after knee arthroscopy in this vulnerable patient population.
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Affiliation(s)
| | - John M. Hamilton
- Department of Orthopedic Surgery,
Baylor Scott and White Hospital, Temple, Texas, USA
| | - Brandon W. Moritz
- Department of Orthopedic Surgery,
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Sheila M. Algan
- Department of Orthopedic Surgery,
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Liddy N, Kamdar PM, Quintana JO, Talamo M, Vadasdi KB, Greene T, Kowalsky MS, Delos D, Sethi PM. Opioid Requirement After Anterior Cruciate Ligament Surgery: Opioid Use After Anterior Cruciate Ligament Surgery Is Low With a Multimodal Approach, and Fifteen Oxycodone 5-mg Tablets Are Sufficient. Arthrosc Sports Med Rehabil 2023; 5:e415-e421. [PMID: 37101876 PMCID: PMC10123425 DOI: 10.1016/j.asmr.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 12/22/2022] [Accepted: 01/05/2023] [Indexed: 02/22/2023] Open
Abstract
Purpose To prospectively determine opioid consumption in patients undergoing anterior cruciate ligament (ACL) repair and reconstruction and to develop evidence-based prescription guidelines following ACL surgery. Methods This multicenter prospective study enrolled patients undergoing ACL reconstruction and repair. Subject demographics and opioid prescriptions were recorded at enrollment. All patients were given education on opiate use and followed the same perioperative, multimodal analgesic regimen. Following surgery, patients were given postoperative "pain journals" to document visual analog scale pain scores and daily opioid consumption for the first 7 postoperative days and on postoperative visit at 14 days. Results In total, 50 patients were included in this analysis between the ages of 14 and 65 years. Patients were prescribed a median of 15 oxycodone 5-mg pills and consumed a median of 2 pill postoperatively (range 0-19 pills). 38% of patients consumed 0 opioid pills, 74% of patients consumed ≤5 opioid pills, and 96% of patients consumed ≤15 opioid pills. Patients reported a mean daily visual analog scale value of 2.8 of 10; mean satisfaction with pain management was high at 4.1/5 on a Likert satisfaction score. Overall, patients consumed a mean 34% of their opioid prescriptions, leaving 436 opioid pills not consumed. Conclusions This study suggests that current expert panels may be recommending an excessive volume of opioids. Based on our findings, we recommend that patients be prescribed no more than 15 Oxycodone 5-mg tablets following ACL surgery. Despite this lower volume prescription, mean pain scores remained below 3 of 10, patient satisfaction with pain control remained high, and 66% of opiate medication prescribed was not used. Level of Evidence II, prospective prognostic cohort investigation.
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Affiliation(s)
- Nicole Liddy
- New York Medical College, Valhalla, New York, U.S.A
- Orthopaedic & Neurosurgery Specialists (ONS) Foundation for Clinical Research and Education, Greenwich, Connecticut, U.S.A
- Address correspondence to Nicole Liddy, M.S., Orthopaedic & Neurosurgery Specialists, ONS Foundation for Clinical Research and Education, 6 Greenwich Office Park, Greenwich, CT 06831.
| | - Parth M. Kamdar
- New York Medical College, Valhalla, New York, U.S.A
- Orthopaedic & Neurosurgery Specialists (ONS) Foundation for Clinical Research and Education, Greenwich, Connecticut, U.S.A
| | - Julio O. Quintana
- Orthopaedic & Neurosurgery Specialists (ONS) Foundation for Clinical Research and Education, Greenwich, Connecticut, U.S.A
| | - Michael Talamo
- Orthopaedic & Neurosurgery Specialists (ONS) Foundation for Clinical Research and Education, Greenwich, Connecticut, U.S.A
| | - Katherine B. Vadasdi
- Orthopaedic & Neurosurgery Specialists (ONS) Foundation for Clinical Research and Education, Greenwich, Connecticut, U.S.A
| | - Timothy Greene
- Orthopaedic & Neurosurgery Specialists (ONS) Foundation for Clinical Research and Education, Greenwich, Connecticut, U.S.A
| | - Marc S. Kowalsky
- Orthopaedic & Neurosurgery Specialists (ONS) Foundation for Clinical Research and Education, Greenwich, Connecticut, U.S.A
| | - Demetrios Delos
- Orthopaedic & Neurosurgery Specialists (ONS) Foundation for Clinical Research and Education, Greenwich, Connecticut, U.S.A
| | - Paul M. Sethi
- Orthopaedic & Neurosurgery Specialists (ONS) Foundation for Clinical Research and Education, Greenwich, Connecticut, U.S.A
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He Y, He H, Li X, Lei G, Xie D, Wang Y. Intra-Articular Magnesium Plus Bupivacaine Is the Most Effective and Safe Postoperative Analgesic Option Following Knee Arthroscopy: A Network Meta-analysis. Arthroscopy 2022; 38:2897-2908.e18. [PMID: 35346774 DOI: 10.1016/j.arthro.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 03/02/2022] [Accepted: 03/02/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the comparative efficacy and safety of single-dose intra-articular injection of commonly used analgesics after knee arthroscopy. METHODS A systematic literature review was done to search for randomized controlled trials (RCTs) published from database inception to October 1, 2020, that compared analgesics (i.e., morphine, bupivacaine, ropivacaine, and magnesium alone or in combination) with placebo or each other after knee arthroscopy. The primary outcomes were postoperative pain intensity at 2 hours and 24 hours. Secondary outcomes included the time to first analgesic request, number of patients requiring supplementary analgesics and side effects. We estimated summary standardized mean differences (SMDs) or odds ratios with 95% credible intervals (95% CrIs) using Bayesian network meta-analysis with random effects. RESULTS In total, 78 randomized controlled trials comprising 4,425 participants were included. Compared with placebo, magnesium plus bupivacaine was most likely to be effective in relieving pain at both 2-hour (SMD = -3.81, 95% CrI -5.28 to -2.35) and 24-hour after surgery (SMD = -2.81, 95% CrI: -4.29 to -1.30). Following was morphine plus bupivacaine (2-hour: SMD = -2.19, 95% CrI -3.05 to -1.31; 24-hour: SMD = -1.44, 95% CrI -2.14 to -0.73) and bupivacaine alone (2-hour: SMD = -1.66, 95% CrI -2.33 to -0.98; 24-hour: SMD = -0.67, 95% CrI -1.22 to -0.07); ropivacaine alone and magnesium alone were not effective on pain relief. The interval time to first analgesic request was significantly extended compared with placebo except for ropivacaine alone and magnesium alone. The number of patients requiring supplementary analgesics was reduced in all groups except ropivacaine alone. No statistically significant difference was found between any studied analgesics or placebo with regard to side effects. CONCLUSIONS Of 6 common postoperative intra-articular analgesics, magnesium plus bupivacaine provides the most effective pain relief without increasing short-term side effects after knee arthroscopy. LEVEL OF EVIDENCE Level II, meta-analysis of Level I and II studies.
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Affiliation(s)
- Yuchen He
- Department of Orthopaedics, Changsha, Hunan, China
| | - Hongyi He
- Department of Orthopaedics, Changsha, Hunan, China
| | - Xiaoxiao Li
- Xiangya Hospital, Central South University, Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China
| | - Guanghua Lei
- National Clinical Research Center for Geriatric Disorders, Changsha, Hunan, China; Xiangya Hospital, Central South University, Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan, China; Hunan Engineering Research Center for Osteoarthritis, Changsha, Hunan, China
| | - Dongxing Xie
- Department of Orthopaedics, Changsha, Hunan, China.
| | - Yilun Wang
- Department of Orthopaedics, Changsha, Hunan, China
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7
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Sutherland TN, Wunsch H, Newcomb C, Hadland S, Gaskins L, Neuman MD. Trends in Routine Opioid Dispensing After Common Pediatric Surgeries in the United States: 2014-2019. Pediatrics 2022; 149:186699. [PMID: 35373305 PMCID: PMC9386619 DOI: 10.1542/peds.2021-054729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 11/24/2022] Open
Abstract
Using Joinpoint regression, our study revealed substantial decreases in postoperative opioid dispensing after outpatient pediatric surgeries beginning in 2017.
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Affiliation(s)
- Tori N. Sutherland
- Department of Anesthesiology and Critical Care,Centers for Perioperative Outcomes Research and
Transformation,Leonard Davis Institute of Health Economics, University
of Pennsylvania, Philadelphia, Pennsylvania,Address correspondence to Tori N. Sutherland, MD, MPH, Department
of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia,
University of Pennsylvania, CHOP Research Institute, 2716 South St, Suite
11.242, Philadelphia, PA 19146. E-mail:
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health
Sciences Centre, Toronto, Canada,Department of Anesthesia and Interdepartmental Division
of Critical Care Medicine, University of Toronto, Toronto, Canada
| | | | - Scott Hadland
- Division of Adolescent and Young Adult Medicine,
MassGeneral Hospital for Children,Department of Pediatrics, Harvard Medical School, Boston,
Massachusetts
| | - Lakisha Gaskins
- Department of Anesthesiology and Critical Care,Centers for Perioperative Outcomes Research and
Transformation
| | - Mark D. Neuman
- Department of Anesthesiology and Critical Care,Centers for Perioperative Outcomes Research and
Transformation,Pharmacoepidemiology Research and Training, Perelman
School of Medicine,Leonard Davis Institute of Health Economics, University
of Pennsylvania, Philadelphia, Pennsylvania
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8
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Rossi MJ. Editorial Commentary: Opioid Sparing Through Patient Education Programs Is the Future for Sports Medicine and Arthroscopic Surgery to Optimize Outcome. Arthroscopy 2021; 37:1573-1576. [PMID: 33896509 DOI: 10.1016/j.arthro.2021.02.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
Opioid research in sports medicine and arthroscopic surgery has exploded in the last few years. The literature definitively shows that preoperative opioid usage-in so-called opioid exposed, tolerant, and familiar patients-increases postoperative usage, readmission rates, and medical complications, yielding poorer outcome. Strategies to combat the deleterious effects of preoperative opioid use should be used to include ownership and acknowledgment of the problem, adherence to opioid prescribing protocols, and use of a multimodal anesthesia program that can mitigate the adverse effects by limiting abuse and preventing potential poor outcome. Adding patient education programs to change patient modifiable risk factors shows promise while simultaneously optimizing appropriate patient expectations that are linked to increased outcome. Thus, opioid mitigation, sparing, or altogether avoidance through improved education programs and opioid prescribing protocols will likely be the future of sports medicine and arthroscopic surgery to optimize patient outcome.
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