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Johns WL, Hanna AJ, Destine H, Sonnier JH, Dodson C, Tucker B, Pepe M, Freedman KB, Tjoumakaris F. Lower Opioid Prescription Quantity Does Not Negatively Impact Pain Control or Patient Satisfaction After ACL Reconstruction: A Randomized, Prospective Trial. J Bone Joint Surg Am 2024; 106:435-444. [PMID: 38285761 DOI: 10.2106/jbjs.23.00657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND The purpose of this study was to evaluate the effects of different quantities of prescribed opioid tablets on patient opioid utilization, postoperative pain and function, and satisfaction after anterior cruciate ligament reconstruction (ACLR). METHODS This was a prospective, randomized trial enrolling patients undergoing primary ACLR. Patients were assigned to 1 of 3 prescription groups: 15, 25, or 35 tablets containing 5-mg oxycodone. Patients completed visual analog scale (VAS) pain and medication logs, opioid medication satisfaction surveys, and International Knee Documentation Committee (IKDC) questionnaires postoperatively. RESULTS Among the 180 patients included in the analysis, there was no significant difference in VAS pain scores (p > 0.05), IKDC scores (p > 0.05), morphine milligram equivalents (MMEs) (p = 0.510) consumed, or patient satisfaction with regard to pain control (p = 0.376) between treatment groups. Seventy-two percent of opioids were consumed in the first 3 days postoperatively, and 83% of patients in the 15-tablet cohort felt that they received the "right amount" of or even "too many" opioids. CONCLUSIONS The prescription of 15 opioid tablets resulted in equivalent pain control, patient satisfaction, and short-term functional outcomes as prescriptions of 25 or 35 opioid tablets after ACLR. Lower prescription quantities of opioid medication may provide equivalent postoperative pain and help to minimize the number of unused opioid doses at risk for possible diversion after ACLR. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- William L Johns
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Nazzal EM, Reddy RP, Haley RM, Wilson JM, Lamplot JD, Musahl V, Xerogeanes JW. Standardized Opioid Counseling Is Underperformed Before and After Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:100782. [PMID: 37554768 PMCID: PMC10404863 DOI: 10.1016/j.asmr.2023.100782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/25/2023] [Indexed: 08/10/2023] Open
Abstract
PURPOSE To characterize contemporary pain management strategies after anterior cruciate ligament reconstruction (ACLR) within the US and international orthopaedic community. METHODS This was a cross-sectional survey-based study disseminated to a consortium of expert orthopaedic surgeons in the management of anterior cruciate ligament injuries. The survey was a 27-question, multiple choice-style questionnaire with question topics ranging from demographic characteristics and practice characteristics to surgeon-specific pain management strategies in the postoperative period after ACLR. Specific topics of interest included the use of preoperative opioid education and/or counseling sessions, implementation of standardized pain management regimens, use of pain tracking systems, and use of any adjunct non-narcotic analgesic modalities. RESULTS A total of 34 completed surveys were collected, representing a 73.9% response rate. Over 85% of respondents reported prescribing opioids as a standardized postoperative regimen after ACLR. Surgeons reported prescribing 5- to 10-mg doses, with the tablet count ranging anywhere from fewer than 10 tablets to more than 20 tablets, often instructing their patients to stop opioid use 2 to 4 days postoperatively. Prescribed dosages remained stable or decreased over the past 6 months with increased use of non-narcotic adjuncts. Only one-third of respondents reported using standardized preoperative opioid counseling, with even fewer discussing postoperative discontinuation protocols. CONCLUSIONS Over 85% of respondents prescribe opioids as a standardized postoperative regimen after ACLR, with only 15% providing non-narcotic pain regimens. However, prescribed dosages have remained stable or decreased over the past 6 months with increased use of non-narcotic adjuncts. Only one-third of respondents use standardized preoperative opioid counseling, with even fewer discussing postoperative discontinuation protocols. CLINICAL RELEVANCE The ongoing opioid epidemic has created an urgent need to identify the most effective pain management strategies after orthopaedic procedures, especially ACLR. This study provides important information about current pain management practices for patients who have undergone ACLR.
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Affiliation(s)
- Ehab M. Nazzal
- University of Pittsburgh Medical Center Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, U.S.A
| | - Rajiv P. Reddy
- University of Pittsburgh Medical Center Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, U.S.A
| | - Rebecca M. Haley
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A
| | - Jacob M. Wilson
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Joseph D. Lamplot
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Volker Musahl
- University of Pittsburgh Medical Center Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, U.S.A
| | - John W. Xerogeanes
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A
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Yalcin S, Joo PY, McLaughlin W, Moran J, Caruana D, Flores M, Grauer J, Medvecky M. Factors Associated With Increased Opioid Prescriptions Following Anterior Cruciate Ligament Reconstruction in Opioid-Naïve Patients. Arthrosc Sports Med Rehabil 2023; 5:100740. [PMID: 37645399 PMCID: PMC10461142 DOI: 10.1016/j.asmr.2023.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/25/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To identify the mean morphine milligram equivalent (MME) opioid prescriptions for opioid-naïve patients undergoing isolated anterior cruciate ligament reconstruction (ACLR) between 4 weeks before surgery and the first 90 days after surgery and to describe opioid prescriptions filled per patient and mean MMEs per year within 90 days following ACLR. Methods Exclusion criteria were patients having concurrent other cruciate or collateral ligament repair or reconstruction, meniscus procedures (repair and debridement), any cartilage procedure, lower-extremity osteotomy, or knee procedures for fracture, infection, or neoplasms; patients with substance use disorder or chronic pain also were excluded. Opioid use between 4 weeks before surgery and the first 90 days after surgery was recorded. Prescribing physician specialty also was tracked. The correlation of patient factors and prescriber specialty of MME were compared using the Student's t-test. Significance was defined at P < .05. Results Opioid-naïve patients undergoing isolated ACLR were included. Isolated arthroscopic ACLRs performed between 2010 and Q3 2020 in opioid-naïve patients were identified within the PearlDiver M91 national database. A total of 37,200 patients were identified. Mean MME per patient was 340.9 ± 198.2, with an average MME per day of 59.9. Factors associated with increased opioid use during the 90 days following ACLR were older age (P < .001) and preoperative diagnosis of depression (P < .001). Orthopaedic surgeons were primarily responsible for the number of opioid prescriptions after ACLR (n = 29,326, 73.0%) but 27% (n = 10,797) of prescriptions came from nonorthopaedic surgeon medical providers who prescribed significantly greater MMEs of opioids than orthopaedic surgeons (456.5 vs 339.2, P < .001) per patient. Lastly, decreasing yearly opioid prescriptions per patient (2.4 to 1.6 prescriptions) and the mean MME per patient (428.4 to 257.1) occurred from 2010 to 2020. Conclusions Older age and preoperative diagnosis of depression are associated with greater opioid doses after ACLR. In addition, the vast majority of opioid prescriptions are written by orthopaedic surgeons on the day of ACLR and decreased considerably by four weeks after surgery. Patients receiving opioid prescriptions by nonorthopaedic surgeon medical providers receive significantly greater doses. Level of Evidence Level IV, retrospective cohort study.
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Affiliation(s)
- Sercan Yalcin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Peter Y Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - William McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Dennis Caruana
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael Flores
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Jonathan Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
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Berk AN, Piasecki DP, Fleischli JE, Trofa DP, Saltzman BM. Trends in Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review. Orthop J Sports Med 2023; 11:23259671231174472. [PMID: 37284137 PMCID: PMC10240869 DOI: 10.1177/23259671231174472] [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: 01/05/2023] [Accepted: 02/08/2023] [Indexed: 06/08/2023] Open
Abstract
Background Despite the prevalence of patient-reported outcomes (PROs) to evaluate results after anterior cruciate ligament (ACL) reconstruction, there exists little standardization in how these metrics are reported, which can make wider comparisons difficult. Purpose To systematically review the literature on ACL reconstruction and report on the variability and temporal trends in PRO utilization. Study Design Systematic review. Methods We queried the PubMed Central and MEDLINE databases from inception through August 2022 to identify clinical studies reporting ≥1 PRO after ACL reconstruction. Only studies with ≥50 patients and a mean 24-month follow-up were considered for inclusion. Year of publication, study design, PROs, and reporting of return to sport (RTS) were documented. Results Across 510 studies, 72 unique PROs were identified, the most common of which were the International Knee Documentation Committee score (63.3%), Tegner Activity Scale (52.4%), Lysholm score (51.0%), and Knee injury and Osteoarthritis Outcome Score (35.7%). Of the identified PROs, 89% were utilized in <10% of studies. The most common study designs were retrospective (40.6%), prospective cohort (27.1%), and prospective randomized controlled trials (19.4%). Some consistency in PROs was observed among randomized controlled trials, with the most common PROs being the International Knee Documentation Committee score (71/99, 71.7%), Tegner Activity Scale (60/99, 60.6%), and Lysholm score (54/99, 54.5%). The mean number of PROs reported per study across all years was 2.89 (range, 1-8), with an increase from 2.1 (range, 1-4) in studies published before 2000 to 3.1 (range, 1-8) in those published after 2020. Only 105 studies (20.6%) discretely reported RTS rates, with more studies utilizing this metric after 2020 (55.1%) than before 2000 (15.0%). Conclusion There exists marked heterogeneity and inconsistency regarding which validated PROs are used in studies related to ACL reconstruction. Significant variability was observed, with 89% of measures being reported in <10% of studies. RTS was discretely reported in only 20.6% of studies. Greater standardization of outcomes reporting is required to better promote objective comparisons, understand technique-specific outcomes, and facilitate value determination.
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Affiliation(s)
- Alexander N. Berk
- OrthoCarolina Sports Medicine Center, Charlotte, North Carolina, USA
- OrthoCarolina Research Institute, Charlotte, North Carolina, USA
- Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - Dana P. Piasecki
- OrthoCarolina Sports Medicine Center, Charlotte, North Carolina, USA
- OrthoCarolina Research Institute, Charlotte, North Carolina, USA
- Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - James E. Fleischli
- OrthoCarolina Sports Medicine Center, Charlotte, North Carolina, USA
- OrthoCarolina Research Institute, Charlotte, North Carolina, USA
- Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, USA
| | - David P. Trofa
- Department of Orthopaedics, NewYork–Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Bryan M. Saltzman
- OrthoCarolina Sports Medicine Center, Charlotte, North Carolina, USA
- OrthoCarolina Research Institute, Charlotte, North Carolina, USA
- Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, 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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