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Marmor MT, Mahadevan V, Solans BP, Floren A, Jarlsberg L, Cohen I, Savic R. Inpatient pain alleviation after orthopaedic trauma surgery-are we doing a good job? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:569-576. [PMID: 37650973 DOI: 10.1007/s00590-023-03670-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 08/02/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Poor pain alleviation (PPA) after orthopaedic surgery is known to increase recovery time, readmissions, patient dissatisfaction, and lead to chronic postsurgical pain. This study's goal was to identify the magnitude of PPA and its risk factors in the orthopaedic trauma patient population. METHODS A single-institution's electronic medical records from 2015 to 2018 were available for retrospective analysis. Inclusion criteria included orthopaedic fracture surgery patients admitted to the hospital for 24 h or more. Collected variables included surgery type, basic demographics, comorbidities, inpatient medications, pain scores, and length of stay. PPA was defined as a pain score of ≥ 8 on at least three occasions 4-12 h apart. Associations between collected variables and PPA were derived using a multivariable logistic regression model and expressed in adjusted odds ratios. RESULTS A total of 1663 patients underwent fracture surgeries from 2015 to 2018, and 25% of them reported PPA. Female sex, previous use of narcotics, increased ASA, increased baseline pain score, and younger age without comorbidities were identified as significant risk factors for PPA. Spine procedures were associated with increased risk of PPA, while procedures in the hip, shoulder, and knee had reduced risk. Patients experiencing PPA were less likely to receive NSAIDs compared to other pain medications. CONCLUSIONS This study found an unacceptably high rate of PPA after fracture surgery. While the identified risk factors for PPA were all non-modifiable, our results highlight the necessity to improve application of current multimodal approaches to pain alleviation including a more personalized approach to pain alleviation.
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Affiliation(s)
- Meir T Marmor
- Department of Orthopedic Surgery, University of California, 2550 23rd Street, San Francisco, CA, 94110, USA.
| | - Varun Mahadevan
- Department of Orthopedic Surgery, University of California, 2550 23rd Street, San Francisco, CA, 94110, USA
| | - Belén P Solans
- Department of Bioengineering and Therapeutic Sciences, School of Pharmacy, University of California, San Francisco, CA, USA
| | - Alexander Floren
- Department of Bioengineering and Therapeutic Sciences, School of Pharmacy, University of California, San Francisco, CA, USA
| | - Leah Jarlsberg
- Department of Bioengineering and Therapeutic Sciences, School of Pharmacy, University of California, San Francisco, CA, USA
| | - Isaac Cohen
- Department of Bioengineering and Therapeutic Sciences, School of Pharmacy, University of California, San Francisco, CA, USA
| | - Rada Savic
- Department of Bioengineering and Therapeutic Sciences, School of Pharmacy, University of California, San Francisco, CA, USA
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Cunningham D, LaRose M, Patel P, Zhang G, Morriss N, Paniagua A, Gage M. Regional anesthesia improves inpatient but not outpatient opioid demand in tibial shaft fracture surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2921-2931. [PMID: 36912951 DOI: 10.1007/s00590-023-03504-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/26/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Patients undergoing operative treatment of tibial shaft fractures have considerable pain largely managed with opioids. Regional anesthesia (RA) has been increasingly used to reduce perioperative opioid use. METHODS This was a retrospective study of 426 patients that underwent operative treatment of tibial shaft fractures with and without RA. Inpatient opioid consumption and 90-day outpatient opioid demand were measured. RESULTS RA significantly decreased inpatient opioid consumption for 48 h post-operatively (p = 0.008). Neither inpatient use after 48 h nor outpatient opioid demand differed in patients with RA (p > 0.05). CONCLUSIONS RA may help with inpatient pain control and reduce opioid use in tibial shaft fracture. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Micaela LaRose
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Preet Patel
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Gloria Zhang
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Nicholas Morriss
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA.
| | - Ariana Paniagua
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Mark Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
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Xu AL, Humbyrd CJ. Strategies for Reducing Perioperative Opioid Use in Foot and Ankle Surgery: Education, Risk Identification, and Multimodal Analgesia. Orthop Clin North Am 2023; 54:485-494. [PMID: 37718087 DOI: 10.1016/j.ocl.2023.04.006] [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] [Indexed: 09/19/2023]
Abstract
There remains a high prevalence and substantial risks of opioid utilization amongst orthopedic patients. The goal of this review is to discuss strategies for responsible opioid use in the perioperative setting following foot and ankle orthopedic surgeries. We will highlight 1) education interventions, 2) risk identification, and 3) non-opioid alternatives for postoperative pain management.
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Affiliation(s)
- Amy L Xu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Casey Jo Humbyrd
- Orthopedic Surgery, University of Pennsylvania, 230 West Washington Square, 5th Floor, Philadelphia, PA 19107, USA.
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Broggi MS, Oladeji PO, Spenser C, Kadakia RJ, Bariteau JT. Risk Factors for Prolonged Opioid Use After Ankle Fracture Surgery. Foot Ankle Spec 2023; 16:476-484. [PMID: 34369179 DOI: 10.1177/19386400211029123] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The incidence of ankle fractures is increasing, and risk factors for prolonged opioid use after ankle fracture fixation are unknown. Accordingly, the purpose of this study was to investigate risk factors that lead to prolonged opioid use after surgery. METHODS The Truven MarketScan database was used to identify patients who underwent ankle fracture surgery from January 2009 to December 2018 based on CPT codes. Patient characteristics were collected, and patients separated into 3 cohorts based on postoperative opioid use (no refills, refills within 6 months postoperative, and refills within 1 year postoperatively). The χ2 test and multivariate analysis were performed to assess the association between risk factors and prolonged use. RESULTS In total, 34 691 patients were analyzed. Comorbidities most highly associated with prolonged opioid use include 2+ preoperative opioid prescriptions (odds ratio [OR] = 11.92; P < .001), tobacco use (OR = 2.03; P < .001), low back pain (OR = 1.81; P < .001), depression (OR = 1.48; P < .001), diabetes (OR = 1.34; P < .001), and alcohol abuse (OR = 1.32; P < .001). CONCLUSION Opioid use after ankle fracture surgery is common and may be necessary; however, prolonged opioid use and development of dependence carries significant risk. Identifying those patients at an increased risk for prolonged opioid use can aid providers in tailoring their postoperative pain regimen. LEVELS OF EVIDENCE Prognostic, Level III.
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Affiliation(s)
| | | | - Corey Spenser
- Department of Orthopaedics, Emory University, Atlanta, Georgia
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Badin D, Ortiz-Babilonia CD, Gupta A, Leland CR, Musharbash F, Parrish JM, Aiyer AA. Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review. Clin Orthop Relat Res 2022; 480:2187-2201. [PMID: 35901447 PMCID: PMC10476710 DOI: 10.1097/corr.0000000000002307] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/13/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pain management after foot and ankle surgery must surmount unique challenges that are not present in orthopaedic surgery performed on other parts of the body. However, disparate and inconsistent evidence makes it difficult to draw meaningful conclusions from individual studies. QUESTIONS/PURPOSES In this systematic review, we asked: what are (1) the patterns of opioid use or prescription (quantity, duration, incidence of persistent use), (2) factors associated with increased or decreased risk of persistent opioid use, and (3) the clinical outcomes (principally pain relief and adverse events) associated with opioid use in patients undergoing foot or ankle fracture surgery? METHODS We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for our review. We searched PubMed, Embase, Scopus, Cochrane, and Web of Science on October 15, 2021. We included studies published from 2010 to 2021 that assessed patterns of opioid use, factors associated with increased or decreased opioid use, and other outcomes associated with opioid use after foot or ankle fracture surgery (principally pain relief and adverse events). We excluded studies on pediatric populations and studies focused on acute postoperative pain where short-term opioid use (< 1 week) was a secondary outcome only. A total of 1713 articles were assessed and 18 were included. The quality of the 16 included retrospective observational studies and two randomized trials was evaluated using the Methodological Index for Non-Randomized Studies criteria and the Jadad scale, respectively; study quality was determined to be low to moderate for observational studies and good for randomized trials. Mean patient age ranged from 42 to 53 years. Fractures studied included unimalleolar, bimalleolar, trimalleolar, and pilon fractures. RESULTS Proportions of postoperative persistent opioid use (defined as use beyond 3 or 6 months postoperatively) ranged from 2.6% (546 of 20,992) to 18.5% (32 of 173) and reached 39% (28 of 72) when including patients with prior opioid use. Among the numerous associations reported by observational studies, two or more preoperative opioid prescriptions had the strongest overall association with increased opioid use, but this was assessed by only one study (OR 11.92 [95% confidence interval (CI) 9.16 to 13.30]; p < 0.001). Meanwhile, spinal and regional anesthesia (-13.5 to -41.1 oral morphine equivalents (OME) difference; all p < 0.01) and postoperative ketorolac use (40 OME difference; p = 0.037) were associated with decreased opioid consumption in two observational studies and a randomized trial, respectively. Three observational studies found that opioid use preoperatively was associated with a higher proportion of emergency department visits and readmission (OR 1.41 to 17.4; all p < 0.001), and opioid use at 2 weeks postoperatively was associated with slightly higher pain scores compared with nonopioid regimens (β = 0.042; p < 0.001 and Likert scale 2.5 versus 1.6; p < 0.05) in one study. CONCLUSION Even after noting possible inflation of the harms of opioids in this review, our findings nonetheless highlight the need for opioid prescription guidelines specific for foot and ankle surgery. In this context, surgeons should utilize short (< 1 week) opioid prescriptions, regional anesthesia, and multimodal pain management techniques, especially in patients at increased risk of prolonged opioid use. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Daniel Badin
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Carlos D. Ortiz-Babilonia
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
- Department of Orthopaedic Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Arjun Gupta
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Farah Musharbash
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - James M. Parrish
- Department of Orthopaedic Surgery, Jackson Memorial Hospital, Miami, FL, USA
| | - Amiethab A. Aiyer
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
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Regional anesthesia and analgesia for trauma: an updated review. Curr Opin Anaesthesiol 2022; 35:613-620. [PMID: 36044292 DOI: 10.1097/aco.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW This narrative review is an updated summary of the value of regional anesthesia and analgesia for trauma and the special considerations when optimizing pain management and utilizing regional analgesia for acute traumatic pain. RECENT FINDINGS In the setting of the opioid epidemic, the need for multimodal analgesia in trauma is imperative. It has been proposed that inadequately treated acute pain predisposes a patient to increased risk of developing chronic pain and continued opioid use. Enhanced Regional Anesthesia techniques along with multimodal pain therapies is thought to reduce the stress response and improve patient's short- and long-term outcomes. SUMMARY Our ability to save life and limb has improved, but our ability to manage acute traumatic pain continues to lag. Understanding trauma-specific concerns and tailoring the analgesia to a patient's specific injuries can increase a patient's immediate comfort and long-term outcome as well.
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Letter to the Editor: Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment. J Am Acad Orthop Surg 2022; 31:e461-e462. [PMID: 35944549 DOI: 10.5435/jaaos-d-22-00371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Cunningham DJ, Paniaugua AR, LaRose MA, DeLaura IF, Blatter MK, Gage MJ. Regional anesthesia does not decrease inpatient or outpatient opioid demand in distal femur fracture surgery. Arch Orthop Trauma Surg 2022; 142:1873-1883. [PMID: 33938985 DOI: 10.1007/s00402-021-03892-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 03/31/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Regional anesthesia (RA) is sometimes used to decrease pain and opioid consumption in distal femur fractures. However, the real-world impact of RA on inpatient opioid consumption and outpatient opioid demand is not well known. The hypothesis of this study is that RA would be associated with decreased inpatient opioid consumption and outpatient opioid demand. METHODS This study evaluated inpatient post-operative opioid consumption (0-24 h, 24-48 h, 48-72 h) and outpatient opioid demand (discharge to 2 weeks, 6 weeks, and 90 days) in all patients ages 18 and older undergoing operative treatment of distal femur fractures at a single institution from 7/2013 to 7/2018 (n = 230). Unadjusted and adjusted multivariable models were used to evaluate the impact of RA and other baseline patient and operative characteristics on inpatient opioid consumption and outpatient opioid demand. RESULTS Adjusted models demonstrated a small, significant increase in inpatient opioid consumption in patients with RA compared to no RA (4.7 estimated OE's without RA vs 6.2 OE's with RA from 24- to 48-h post-op, p < 0.05) but otherwise no significant differences at other timepoints (6.7 estimated OE's without RA vs 6.9 OE's with RA from 0- to 24-h post-op and 4.5 vs 4.4 from 48- to 72-h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA from discharge to 6 weeks and to 90 days (55.8 OE's without RA vs 63.9 with RA from discharge to 2 weeks, p > 0.05; 74.9 vs 95.1 OE's to 6 weeks, and 85 vs 113.1 OE's to 90 days, p < 0.05). DISCUSSION In distal femur fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results call into question the routine use of RA in distal femur fractures. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA.
| | - Ariana R Paniaugua
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Isabel F DeLaura
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Michael K Blatter
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
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Hu H, Zhang J, Xie XG, Dai YK, Huang X. Identification of risk factors for surgical site infection after type II and type III tibial pilon fracture surgery. World J Clin Cases 2022; 10:6399-6405. [PMID: 35979296 PMCID: PMC9294882 DOI: 10.12998/wjcc.v10.i19.6399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/05/2022] [Accepted: 05/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND High-energy tibial pilon fractures are complex and severe fractures that are associated with a high risk of infection following open reduction and internal fixation. Infection can negatively impact patient outcomes.
AIM To compare risk factors for postoperative infection after open reduction and internal fixation for a pilon fracture.
METHODS Among the 137 patients included, 67 developed a surgical site infection. Demographic, clinical, and surgical factors were compared between the two groups. A binary logistic regression analysis was used to determine the odds ratio (OR) and corresponding 95%CI for significant risk factors for postoperative infection.
RESULTS The distribution of pathogenic bacteria among the 67 patients who developed a surgical site infection was as follows: Gram-positive, 58.2% (n = 39); Gram-negative, 38.8% (n = 26); and fungal, 2.9% (n = 2). The following factors were associated with postoperative infection (P < 0.05): a Ruedi–Allgower pilon fracture type III (OR = 2.034; 95%CI: 1.109–3.738); a type III surgical incision (OR = 1.840; 95%CI: 1.177–2.877); wound contamination (OR = 2.280; 95%CI: 1.378–3.772); and diabetes as a comorbidity (OR = 3.196; 95%CI: 1.209–8.450).
CONCLUSION Infection prevention for patients with a Ruedi–Allgower fracture type III, surgical incision type III, wound contamination, and diabetes lowers the postoperative infection risk after surgical management of tibial pilon fractures.
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Affiliation(s)
- Hao Hu
- Department of Orthopaedics, Huai’an Second People’s Hospital, Huai’an 223300, Jiangsu Province, China
| | - Jian Zhang
- Department of Orthopaedics, Huai’an Second People’s Hospital, Huai’an 223300, Jiangsu Province, China
| | - Xue-Guan Xie
- Department of Orthopaedics, Huai’an Second People’s Hospital, Huai’an 223300, Jiangsu Province, China
| | - Yan-Kun Dai
- Department of Orthopaedics, Huai’an Second People’s Hospital, Huai’an 223300, Jiangsu Province, China
| | - Xu Huang
- Department of Orthopaedics, Huai’an Second People’s Hospital, Huai’an 223300, Jiangsu Province, China
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Cunningham DJ, LaRose M, Zhang G, Patel P, Paniagua A, Gadsden J, Gage MJ. Regional Anesthesia Associated With Decreased Inpatient and Outpatient Opioid Demand in Tibial Plateau Fracture Surgery. Anesth Analg 2022; 134:1072-1081. [PMID: 35313323 DOI: 10.1213/ane.0000000000005980] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Regional anesthesia (RA) has been used to reduce pain and opioid usage in elective orthopedic surgery. The hypothesis of this study was that RA would be associated with decreased opioid demand in tibial plateau fracture surgery. METHODS Inpatient opioid consumption and 90-day outpatient opioid prescribing in all patients ≥18 years of age undergoing tibial plateau fracture surgery from July 2013 to July 2018 (n = 264) at a single, level I trauma center were recorded. The presence or absence of perioperative RA was noted. Of 60 patients receiving RA, 52 underwent peripheral nerve blockade (PNB) with single-shot sciatic-popliteal (40.0%; n = 24), femoral (26.7%; n = 16), adductor canal (18.3%; n = 11), or fascia iliaca (1.7%; n = 1) block with ropivacaine. Ten patients received epidural analgesia (EA) with either single-shot spinal (11.7%; n = 7) blocks or continuous epidural (5.0%; n = 3). Additional baseline and treatment characteristics were recorded, including age, sex, race, body mass index (BMI), smoking, chronic opioid use, American Society of Anesthesiologists (ASA) score, injury mechanism, additional injuries, open injury, and additional inpatient surgery. Statistical models, including multivariable generalized linear models with propensity score weighting to adjust for baseline patient and treatment characteristics, were used to assess perioperative opioid demand with and without RA. RESULTS RA was associated with reduced inpatient opioid usage from 0 to 24 hours postoperatively of approximately 5.2 oxycodone 5-mg equivalents (0.74 incident rate ratio [IRR]; 0.63-0.86 CI; P < .001) and from 24 to 48 hours postoperatively of approximately 2.9 oxycodone 5-mg equivalents (0.78 IRR; 0.64-0.95 CI; P = .014) but not at 48 to 72 hours postoperatively. From 1 month preoperatively to 2 weeks postoperatively, RA was associated with reduced outpatient opioid prescribing of approximately 24.0 oxycodone 5-mg equivalents (0.87; 0.75-0.99; P = .044) and from 1 month preoperatively to 90 days postoperatively of approximately 44.0 oxycodone 5-mg equivalents (0.83; 0.71-0.96; P = .011), although there was no significant difference from 1 month preoperatively to 6 weeks postoperatively. There were no cases of acute compartment syndrome in this cohort. CONCLUSIONS In tibial plateau fracture surgery, RA was associated with reduced inpatient opioid consumption up to 48 hours postoperatively and reduced outpatient opioid demand up to 90 days postoperatively without an associated risk of acute compartment syndrome. RA should be considered for patients undergoing tibial plateau fracture fixation.
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Affiliation(s)
- Daniel J Cunningham
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Micaela LaRose
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Gloria Zhang
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Preet Patel
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Ariana Paniagua
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey Gadsden
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark J Gage
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Cunningham DJ, Paniagua A, DeLaura I, Zhang G, Kim B, Kim J, Lee T, LaRose M, Adams S, Gage MJ. Regional Anesthesia Decreases Inpatient But Not Outpatient Opioid Demand in Ankle and Distal Tibia Fracture Surgery. Foot Ankle Spec 2022:19386400221088453. [PMID: 35440214 DOI: 10.1177/19386400221088453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Regional anesthesia (RA) is commonly used in ankle and distal tibia fracture surgery. However, the pragmatic effects of this treatment on inpatient and outpatient opioid demand are unclear. The hypothesis was that RA would decrease inpatient opioid consumption and have little effect on outpatient demand in patients undergoing ankle and distal tibia fracture surgery compared with patients not receiving RA. METHODS All patients aged 18 years and older undergoing ankle and distal tibia fracture surgery at a single institution between July 2013 and July 2018 were included in this study (n = 1310). Inpatient opioid consumption (0-72 hours postoperatively) and outpatient opioid prescribing (1 month preoperatively to 90 days postoperatively) were recorded in oxycodone 5-mg equivalents (OEs). Adjusted models were used to evaluate the impact of RA versus no RA on inpatient and outpatient opioid demand. RESULTS Patients without RA had higher rates of high-energy mechanism of injury, additional injuries, open fractures, and additional surgery compared with patients with RA. Adjusted models demonstrated decreased inpatient opioid consumption in patients with RA (12.1 estimated OEs without RA vs 8.8 OEs with RA from 0 to 24 hours postoperatively, P < .001) but no significant difference after that time (9.7 vs 10.4 from 24 to 48 hours postoperatively, and 9.5 vs 8.5 from 48 to 72 hours postoperatively). Estimated cumulative outpatient opioid demand was significantly increased in patients receiving RA at all time points (112.5 OEs without RA vs 137.3 with RA from 1 month preoperatively to 2 weeks, 125.6 vs 155.5 OEs to 6 weeks, and 134.6 vs 163.3 OEs to 90 days, all P values for RA <.001). DISCUSSION In ankle and distal tibia fracture surgery, RA was associated with decreased early inpatient opioid demand but significantly increased outpatient demand after adjusting for baseline patient and treatment characteristics. This study encourages the use of RA to decrease inpatient opioid use, although there was a worrisome increase in outpatient opioid demand. LEVEL OF EVIDENCE Level III: Retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ariana Paniagua
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Isabel DeLaura
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Gloria Zhang
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Billy Kim
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jonathan Kim
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Terry Lee
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Micaela LaRose
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Samuel Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Cunningham DJ, LaRose MA, Zhang GX, Au S, MacAlpine EM, Paniagua AR, Klifto CS, Gage MJ. Regional anesthesia reduces inpatient and outpatient perioperative opioid demand in periarticular elbow surgery. J Shoulder Elbow Surg 2022; 31:e48-e57. [PMID: 34481050 DOI: 10.1016/j.jse.2021.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/31/2021] [Accepted: 08/03/2021] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Regional anesthesia (RA) can be used to manage perioperative pain in the treatment of periarticular elbow fracture fixation. However, the opioid-sparing benefit is not well-characterized. The hypothesis of this study was that RA had reduced inpatient opioid consumption and outpatient opioid demand in patients who had undergone periarticular elbow fracture surgery. METHODS This study retrospectively reviews inpatient opioid consumption and outpatient opioid demand in all patients aged ≥18 years at a single Level I trauma center undergoing fixation of periarticular elbow (distal humerus and proximal forearm) fracture surgery (n=418 patients). In addition to RA vs. no RA, additional patient and operative characteristics were recorded. Unadjusted and adjusted models were constructed to evaluate the impact of RA and other factors on inpatient opioid consumption and outpatient opioid demand. RESULTS Adjusted models demonstrated decreases in inpatient opioid consumption postoperation in patients with RA (13.7 estimated oxycodone 5-mg equivalents or OEs without RA vs. 10.4 OEs with RA from 0 to 24 hours postoperation, P = .003; 12.3 vs. 9.2 OEs from 24 to 48 hours postoperation, P = .045). Estimated cumulative outpatient opioid demand differed significantly in patients with RA (166.1 vs. 132.1 OEs to 6 weeks, P = .002; and 181 vs. 138.6 OEs to 90 days, P < .001). DISCUSSION In proximal forearm and distal humerus fracture surgery, RA was associated with decreased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results encourage utilization of perioperative RA to reduce opioid use.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Gloria X Zhang
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Sandra Au
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Elle M MacAlpine
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Ariana R Paniagua
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Cunningham DJ, Robinette JP, Paniagua AR, LaRose MA, Blatter M, Gage MJ. Regional anesthesia does not decrease opioid demand in pelvis and acetabulum fracture surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1357-1370. [PMID: 34519897 DOI: 10.1007/s00590-021-03114-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 09/02/2021] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Patients with pelvic and acetabular fractures often have considerable pain in the perioperative period. Regional anesthesia (RA) including peripheral nerve blocks and spinal analgesia may reduce pain. However, the real-world impact of these modalities on inpatient opioid consumption and outpatient opioid demand is largely unknown. The purpose of this study was to evaluate the impact of perioperative RA on inpatient opioid consumption and outpatient opioid demand. METHODS This is a retrospective, observational review of inpatient opioid consumption and outpatient opioid demand in all patients ages 18 and older undergoing operative fixation of pelvic and acetabular fractures at a single Level, I trauma center from 7/1/2013-7/1/2018 (n = 205). Unadjusted and adjusted analyses were constructed to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand while controlling for age, sex, race, body mass index (BMI), smoking, chronic opioid use, ASA score, injury mechanism, additional injuries, open injury, and additional inpatient surgery. RESULTS Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (12.6 estimated OE's without RA vs 16.1 OE's with RA from 48 to 72 h post-op, p < 0.05) but no significant differences at other timepoints (17.5 estimated OE's without RA vs 16.8 OE's with RA from 0 to 24 h post-op, 15.3 vs 17.1 from 24 to 48 h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA at discharge to 90 days post-op (and 156.8 vs 207.9 OE's to 90 days, p < 0.05) but did not differ significantly before that time (121.5 OE's without RA vs 123.9 with RA from discharge to two weeks, 145.2 vs 177.2 OE's to 6 weeks, p > 0.05). DISCUSSION In pelvis and acetabulum fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. Regional anesthesia may not be beneficial for these patients.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA.
| | - J Patton Robinette
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Ariana R Paniagua
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Michael Blatter
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
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Yamamoto N, Imaizumi T, Noda T, Inoue T, Kawasaki K, Ozaki T. Postoperative computed tomography assessment of anteromedial cortex reduction is a predictor for reoperation after intramedullary nail fixation for pertrochanteric fractures. Eur J Trauma Emerg Surg 2021; 48:1437-1444. [PMID: 34057554 DOI: 10.1007/s00068-021-01718-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 05/26/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Postoperative radiographs are routinely used to assess fracture reduction following intramedullary nail fixation for pertrochanteric fractures, even though computed tomography (CT) is a superior modality. We aimed to determine the association between reduction quality assessed by CT and rates of reoperation and to evaluate the association of reoperation and reduction quality according to the assessment modality (plain radiographs vs. CT). METHODS A retrospective analysis of 299 consecutive patients treated with intramedullary nail fixation for pertrochanteric fractures was conducted. Fracture reduction measured by postoperative radiographs and CT was categorized as anatomical type, extramedullary type, or intramedullary type. Postoperative data for analysis included reduction status, tip-apex distance (TAD), screw position in the femoral head, sliding distance, and conditions associated with reoperation. RESULTS Of the 299 patients included with a mean age of 83.1 ± 8.2 years, there were six patients who required reoperation (2.0%). According to the CT assessments, there were 42 intramedullary reductions (14.0%). Patients with a non-intramedullary reduction based on postoperative CT images were significantly more likely to have proper placement of the screw, a reduced TAD, a reduced sliding distance, and a lower reoperation rate than those with an intramedullary reduction (P < 0.05). The reduction quality assessed by postoperative CT was significantly associated with reoperation (95% CI, 1.45-29.31). CONCLUSIONS Intramedullary reduction assessed by CT was associated with reoperation. The reduction quality based on CT findings was more predictive for reoperation than that from plain radiographs.
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Affiliation(s)
- Norio Yamamoto
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan.
| | - Takahiro Imaizumi
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Tomoyuki Noda
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Tomoo Inoue
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Keisuke Kawasaki
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Toshifumi Ozaki
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
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