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Perez HA, Pannu JS, Frank E, Adebowale A, Hebert S, Watson W, Lao W, Tian S, Kidd S, Lee S, Inman JC, Walker PC, Simental AA, Nguyen KK. Patient Satisfaction with Nonopioid Postoperative Analgesia in Head and Neck Surgery: A Prospective Randomized Trial. Otolaryngol Head Neck Surg 2024; 171:1426-1432. [PMID: 38943454 DOI: 10.1002/ohn.885] [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: 10/27/2023] [Revised: 05/16/2024] [Accepted: 06/08/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVE To evaluate patients' satisfaction with opioid versus opioid-sparing postoperative analgesia in patients undergoing outpatient head and neck surgery. STUDY DESIGN Prospective randomized trial. SETTING Tertiary care academic hospital. METHODS Adult patients undergoing outpatient head and neck surgery were randomly assigned to 1 of 3 analgesic regimens. First- and second-line medications were the following by group (1) Hydrocodone-acetaminophen with ibuprofen, (2) ibuprofen with hydrocodone-acetaminophen, and (3) ibuprofen with acetaminophen. Preoperative counseling was provided to patients regarding expected pain and proper medication use. Postoperative questionnaires were administered to assess satisfaction. RESULTS One hundred three patients were enrolled in the study (mean age, 56.5 years; women, 75 [73%]). The mean satisfaction score with the pain regimen assigned was similar between the 3 groups (scale 0-10, [7.7, 8.3, 8.5, P = .46]). A similar percentage of patients in each group reported that surgery was more painful than anticipated (25%, 32%, 26%, P = .978), and a similar percentage of patients reported willingness to utilize the same analgesic regimen following future surgeries (75%, 83%, 76%, P = .682). Additional questions evaluating the side effect profile, maximum and minimum pain scores, and difficulty of recovery were not statistically different between the 3 groups. CONCLUSION In the postoperative population for outpatient head and neck surgeries, there was no significant difference in patient satisfaction and pain control between the opioid and nonopioid arms. Providers should discuss opioid-sparing regimens preoperatively with patients and describe them as effective in providing adequate pain control without a significant impact on patient's perception of care.
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Affiliation(s)
- Hector Andres Perez
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Jaibir Singh Pannu
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Ethan Frank
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Adebimpe Adebowale
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Sara Hebert
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Wayanne Watson
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Wilson Lao
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Sisi Tian
- Division of Otolaryngology-Head and Neck Surgery, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Stephanie Kidd
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Steve Lee
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Jared C Inman
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Paul C Walker
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Alfred A Simental
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, USA
| | - Khanh K Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health, Loma Linda, California, USA
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Mayfield CK, Abu-Zahra MS, Bolia IK, Kotlier JL, Lin EH, Gamradt SC, Weber AE, Liu JN, Petrigliano FA. Preoperative Mental Health Disorders Affect Opioid Consumption and Perioperative Complications After Total Shoulder Arthroplasty. Orthopedics 2024:1-8. [PMID: 39312745 DOI: 10.3928/01477447-20240918-01] [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] [Indexed: 09/25/2024]
Abstract
BACKGROUND Limited evidence exists regarding the influence of mental health disorders (MHDs) on opioid use and complications after total shoulder arthroplasty (TSA). We aimed to identify the prevalence of common MHDs among patients undergoing anatomic TSA (aTSA) and reverse TSA (rTSA). MATERIALS AND METHODS The Premier Healthcare Database was queried for patients undergoing primary aTSA and rTSA from 2016 to 2020. International Classification of Diseases, Tenth Revision, diagnosis codes were used to identify MHDs. Primary outcomes included the prevalence of MHDs, perioperative opioid consumption, and 90-day risk of postoperative complications, revision, and readmission. Bivariate and multivariate regression analyses were performed to assess 90-day risk of primary endpoints while controlling for potential confounders. Statistical significance was defined as P<.05. RESULTS From 2016 to 2020, 49,997 of 144,725 (34.55%) patients undergoing primary TSA had at least one diagnosed MHD. The most prevalent were depression (17.03%), anxiety (16.75%), and substance use disorder (10.20%). Patients with a MHD had higher mean hospital costs ($75,984±$43,129 vs $73,316±$39,046, P<.0001), longer mean length of stay (1.95±2.25 days vs 1.61±1.51 days, P<.0001), and higher mean total postoperative opioid use (72.00±231.55 morphine milligram equivalents [MMEs] vs 59.32±127.31 MMEs, P<.0001). Periprosthetic fractures (odds ratio, 1.20; P=.041), dislocation (odds ratio, 1.12; P=.042), and 90-day readmission rates (odds ratio, 1.26; P<.001) were significantly higher among patients with a MHD. CONCLUSION This study found that MHDs are associated with significantly increased perioperative opioid consumption, medical and surgical complication rates, and risk of readmission after TSA. Recognition and optimization of MHDs is critical to minimizing complications and opioid consumption after TSA. [Orthopedics. 202x;4x(x):xx-xx.].
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Madrid AS, Rasmussen JV. Risk of prolonged postoperative opioid use after elective shoulder replacement: a nationwide cohort study of 5,660 patients from the Danish Shoulder Arthroplasty Registry. Acta Orthop 2024; 95:433-439. [PMID: 39145522 PMCID: PMC11325634 DOI: 10.2340/17453674.2024.41090] [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] [Received: 02/16/2024] [Accepted: 05/28/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND AND PURPOSE Several studies from the United States report an increased risk of prolonged opioid use after shoulder replacement. We aimed to determine the incidence and risk factors of prolonged opioid use after elective shoulder replacement in a nationwide Danish population. METHODS All primary elective shoulder arthroplasties reported to the Danish Shoulder Arthroplasty Registry (DSR) from 2004 to 2020 were screened for eligibility. Data on potential risk factors was retrieved from the DSR and the National Danish Patient Registry while data on medication was retrieved from the Danish National Health Service Prescription Database. Prolonged opioid use was defined as 1 or more dispensed prescriptions on and 90 days after date of surgery (Q1) and subsequently 1 or more dispensed prescriptions 91-180 days after surgery (Q2). Preoperative opioid use was defined as 1 or more dispensed prescriptions 90 days before surgery. Logistic regression models were used to estimate risk factors for prolonged opioid use. RESULTS We included 5,660 patients. Postoperatively 1,584 (28%) patients were dispensed 1 or more prescriptions in Q1 and Q2 and were classified as prolonged opioid users. Among the 2,037 preoperative opioid users and the 3,623 non-opioid users, 1,201 (59%) and 383 (11%) respectively were classified as prolonged users. Preoperative opioid use, female sex, alcohol abuse, previous surgery, high Charlson Comorbidity index, and preoperative use of either antidepressants, antipsychotics, or benzodiazepines were associated with increased risk of prolonged opioid use. CONCLUSION The incidence of prolonged opioid use was 28%. Preoperative use of opioids was the strongest risk factor for prolonged opioid use, but several other risk factors were identified for prolonged opioid use.
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Affiliation(s)
- Alexander Scheller Madrid
- Department of Orthopaedic Surgery, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark
| | - Jeppe Vejlgaard Rasmussen
- Department of Orthopaedic Surgery, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark
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4
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Abdel Khalik H, Shanmugaraj A, Ekhtiari S, Horner NS, Gazendam A, Simunovic N, Ayeni OR. Self-defined former smokers consume the highest opioid quantities following knee and shoulder arthroscopy. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39105443 DOI: 10.1002/ksa.12403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 07/25/2024] [Accepted: 07/25/2024] [Indexed: 08/07/2024]
Abstract
PURPOSE To identify risk factors associated with increased postoperative opioid consumption and inferior pain outcomes following knee and shoulder arthroscopy. METHODS Using the data set from the NonOpioid Prescriptions after Arthroscopic Surgery in Canada (NO PAin) trial, eight prognostic factors were chosen a priori to evaluate their effect on opioid consumption and patient-reported pain following arthroscopic knee and shoulder surgery. The primary outcome was the number of oral morphine equivalents (OMEs) consumed at 2 and 6 weeks postoperatively. The secondary outcome was patient-reported postoperative pain using the Visual Analogue Scale (VAS) at 2 and 6 weeks postoperatively. A multivariable linear regression was used to analyse these outcomes with eight prognostic factors as independent variables. RESULTS Tobacco usage was significantly associated with higher opioid usage at 2 (p < 0.001) and 6 weeks (p = 0.02) postoperatively. Former tobacco users had a higher 2-week (p = 0.002) and cumulative OME (p = 0.002) consumption compared to current and nonsmokers. Patients with a higher number of comorbidities (p = 0.006) and those who were employed (p = 0.006) reported higher pain scores at 6 weeks. Patients in the 'not employed/other' category had significantly lower pain scores at 6 weeks postoperatively (p = 0.046). CONCLUSION Former smoking status was significantly associated with increased post-operative opioid consumption following knee and shoulder arthroscopy at 2 and 6 weeks postoperatively. Increased pain was found to be significantly associated with employment status and an increasing number of comorbidities at 6 weeks postoperatively. These findings can aid clinicians in identifying and mitigating increased opioid utilization as well as worse pain outcomes in high-risk patient populations. LEVEL OF EVIDENCE Level III, cohort study.
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Affiliation(s)
- Hassaan Abdel Khalik
- Department of Surgery, Division of Orthopaedics, McMaster University, Hamilton, Ontario, Canada
| | - Ajaykumar Shanmugaraj
- University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Seper Ekhtiari
- Department of Surgery, Division of Orthopaedics, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nolan S Horner
- Genesis Orthopedics and Sports Medicine, Chicago, Illinois, USA
| | - Aaron Gazendam
- Department of Surgery, Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nicole Simunovic
- Department of Surgery, Division of Orthopaedics, McMaster University, Hamilton, Ontario, Canada
| | - Olufemi R Ayeni
- Department of Surgery, Division of Orthopaedics, McMaster University, Hamilton, Ontario, Canada
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Root KT, Hones KM, Hao KA, Brolin TJ, Wright JO, King JJ, Wright TW, Schoch BS. A Systematic Review of Patient Selection Criteria for Outpatient Total Shoulder Arthroplasty. Orthop Clin North Am 2024; 55:363-381. [PMID: 38782508 DOI: 10.1016/j.ocl.2023.12.002] [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: 05/25/2024]
Abstract
The utilization of total shoulder arthroplasty (TSA) is increasing, driving associated annual health care costs higher. Opting for outpatient over inpatient TSA may provide a solution by reducing costs. However, there is no single set of accepted patient selection criteria for outpatient TSA. Here, the authors identify and systematically review 14 articles to propose evidence-based criteria that merit postoperative admission. Together, the studies suggest that patients with limited ability to abmluate independently or a history of congestive heart failure may benefit from postoperative at least one night of hospital based monitoring and treatment.
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Affiliation(s)
- Kevin T Root
- College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Keegan M Hones
- Department of Orthopaedics and Sports Medicine, University of Florida, 3450 Hull Road # 3341, Gainesville, FL 32607, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, 1211 Union Avenue # 500, Memphis, TN 38104, USA
| | - Jonathan O Wright
- Department of Orthopaedics and Sports Medicine, University of Florida, 3450 Hull Road # 3341, Gainesville, FL 32607, USA
| | - Joseph J King
- Department of Orthopaedics and Sports Medicine, University of Florida, 3450 Hull Road # 3341, Gainesville, FL 32607, USA
| | - Thomas W Wright
- Department of Orthopaedics and Sports Medicine, University of Florida, 3450 Hull Road # 3341, Gainesville, FL 32607, USA
| | - Bradley S Schoch
- Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Jennewine BR, Marois AJ, West EJ, Murphy J, Throckmorton TW, Bernholt DL, Azar FM, Brolin TJ. Outpatient versus inpatient shoulder arthroplasty outcomes using an updated patient-selection algorithm: minimum 2-year follow-up. J Shoulder Elbow Surg 2024:S1058-2746(24)00458-0. [PMID: 38942227 DOI: 10.1016/j.jse.2024.05.012] [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] [Received: 09/28/2023] [Revised: 05/03/2024] [Accepted: 05/04/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day outcomes and complications. Patient selection algorithms have helped appropriately choose patients for an outpatient TSA setting. This study aimed to determine the outcomes of TSA between outpatient and inpatient cohorts with at least a 2-year follow-up. METHODS A retrospective review identified patients older than 18 years who underwent a TSA with a minimum of 2-year follow-up in either an inpatient or outpatient setting. Using a previously published outpatient TSA patient-selection algorithm, patients were allocated into three groups: outpatient, inpatient due to insurance requirements, and inpatient due to not meeting algorithm criteria. Outcomes evaluated included visual analog scale pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, range of motion (ROM), strength, complications, readmissions, and reoperations. Analysis was performed between the outpatient and inpatient groups to demonstrate the safety and efficacy of outpatient TSA with midterm follow-up. RESULTS A total of 779 TSA were included in this study, allocated into the outpatient (N = 108), inpatient due to insurance (N = 349), and inpatient due to algorithm (N = 322). The average age between these groups was significantly different (59.4 ± 7.4, 66.5 ± 7.5, and 72.5 ± 8.7, respectively; P < .0001). All patient groups demonstrated significant improvements in preoperative to final patient-outcomes scores, ROM, and strength. Analysis between cohorts showed similar final follow-up outcome scores, ROM, and strength, with few significant differences that are likely not clinically different, regardless of surgical location, insurance status, or meeting patient-selection algorithm. Complications, reoperations, and readmissions between all three groups were not significantly different. CONCLUSION This study reaffirms prior short-term follow-up literature. Transitioning appropriate patients to outpatient TSA results in similar outcomes and complications compared to inpatient cohorts with midterm follow-up.
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Affiliation(s)
- Brenton R Jennewine
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center - Campbell Clinic, Memphis, TN, USA
| | - Anthony J Marois
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center - Campbell Clinic, Memphis, TN, USA
| | - Eric J West
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center - Campbell Clinic, Memphis, TN, USA
| | - Jeff Murphy
- Murphy Statistical Services, Warsaw, IN, USA
| | - Thomas W Throckmorton
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center - Campbell Clinic, Memphis, TN, USA
| | - David L Bernholt
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center - Campbell Clinic, Memphis, TN, USA
| | - Frederick M Azar
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center - Campbell Clinic, Memphis, TN, USA
| | - Tyler J Brolin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center - Campbell Clinic, Memphis, TN, USA.
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Kishan A, Pearson ZC, Li SS, Pressman Z, Ahiarakwe U, Pathiravasan CH, Srikumaran U. How low can we go? A randomized controlled trial of low-quantity initial opioid prescriptions for shoulder surgery. J Shoulder Elbow Surg 2024; 33:1211-1218. [PMID: 38461934 DOI: 10.1016/j.jse.2024.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Orthopedic surgeons are the third most frequent prescribers of opioid medications. Given the current opioid addiction crisis, it is critical to limit opioid prescriptions to the lowest effective dose. In this study, we investigated how the initial opioid prescription after shoulder surgery affects maximum possible opioid consumption. We hypothesized that fewer pills in the initial opioid prescription would lead to less opioid consumption, a lower refill request rate, and fewer post-surgery office contacts for pain. METHODS In this single-center, prospective, randomized controlled clinical trial, 74 adults who underwent shoulder arthroplasty, rotator cuff repair, or other arthroscopic shoulder procedures were enrolled from December 2020 to July 2022. Follow-up was completed by February 2023. Participants were randomly assigned to receive postoperative prescriptions of seven 5-mg oxycodone pills (n = 20), 15 pills (n = 29), or 23 pills (n = 25). The primary outcome was maximum possible opioid consumption within 2 weeks after surgery, calculated by assuming consumption of all pills in the initial prescription, as well as any refills. Secondary outcomes were the opioid prescription refill request rates, post-surgery pain-related telephone calls or messages to the provider's office ("office contacts") within 2 weeks after surgery, and American Shoulder and Elbow Surgeons pain scores 2 weeks after surgery. Baseline characteristics did not differ among groups except for mean age, which was younger in the 7-pill group (P = .047). RESULTS Maximum possible opioid consumption increased with the number of pills initially prescribed, with means of 78 morphine milligram equivalents (MME) for the 7-pill group, 118 MME for the 15-pill group, and 199 MME for the 23-pill group (P < .001). None of the secondary outcome measures differed among groups. Refill request rates were 20% for the 7-pill group, 3.4% for the 15-pill group, and 12% for the 23-pill group (P = .20). The proportions of patients with at least 1 office contact were 35% in the 7-pill group, 45% in the 15-pill group, and 28% in the 23-pill group (P = .43). Mean American Shoulder and Elbow Surgeons pain scores were 49 in the 7-pill group, 44 in the 15-pill group, and 40 in the 23-pill group (P = .20). CONCLUSION After shoulder surgery, an initial prescription of fewer opioid pills was associated with less maximum possible opioid consumption without an increase in the percentage of patients requesting opioid refills or contacting the provider's office for pain-related concerns. An initial postoperative prescription of fewer 5-mg oxycodone pills may be equally or more effective compared with larger quantities for most patients.
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Affiliation(s)
- Arman Kishan
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Zachary C Pearson
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Steve S Li
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Zachary Pressman
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Uzoma Ahiarakwe
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Chathurangi H Pathiravasan
- Department of Biostatistics, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Uma Srikumaran
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA.
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Brandner GT, Guareschi AS, Eichinger JK, Friedman RJ. Impact of opioid dependence on outcomes following total shoulder arthroplasty. J Shoulder Elbow Surg 2024; 33:82-89. [PMID: 37422130 DOI: 10.1016/j.jse.2023.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/22/2023] [Accepted: 05/28/2023] [Indexed: 07/10/2023]
Abstract
INTRODUCTION The opioid epidemic is a well-established problem encountered in orthopedic surgery in the United States. Evidence in lower extremity total joint arthroplasty and spine surgery suggests a link between chronic opioid use and increased expense and rates of surgical complications. The purpose of this study was to study the impact of opioid dependence (OD) on the short-term outcomes following primary total shoulder arthroplasty (TSA). METHODS A total of 58,975 patients undergoing primary anatomic and reverse TSA were identified using the National Readmission Database from 2015 to 2019. Preoperative opioid dependence status was used to divide patients into 2 cohorts, with 2089 patients being chronic opioid users or having opioid use disorders. Preoperative demographic and comorbidity data, postoperative outcomes, cost of admission, total hospital length of stay (LOS), and discharge status were compared between the 2 groups. Multivariate analysis was conducted to control for the influence of independent risk factors other than OD on postoperative outcomes. RESULTS Compared to nonopioid-dependent patients, OD patients undergoing TSA had higher odds of postoperative complications including any complications within 180 days (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.3-1.7), readmission within 180 days (OR 1.2, 95% CI 1.1-1.5), revision within 180 days (OR 1.7, 95% CI 1.4-2.1), dislocation (OR 1.9, 95% CI 1.3-2.9), bleeding (OR 3.7, 95% CI 1.5-9.4), and gastrointestinal complication (OR 14, 95% CI 4.3-48). Total cost ($20,741 vs. $19,643), LOS (1.8 ± 1.8 days vs. 1.6 ± 1.7 days), and likelihood for discharge to another facility or home with home health care (18 vs. 16% and 23% vs. 21%, respectively) were higher in patients with OD. CONCLUSION Preoperative opioid dependence was associated with higher odds of postoperative complications, rates of readmission and revision, costs, and health care utilization following TSA. Efforts focused on mitigating this modifiable behavioral risk factor may lead to better outcomes, lower complications, and decreased associated costs.
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Affiliation(s)
- Gabriel T Brandner
- Department of Orthopaedics & Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Alexander S Guareschi
- Department of Orthopaedics & Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Josef K Eichinger
- Department of Orthopaedics & Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Richard J Friedman
- Department of Orthopaedics & Physical Medicine, Medical University of South Carolina, Charleston, SC, USA.
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Werner BC, Burrus MT, Denard PJ, Romeo AA, Lederman E, Griffin JW, Sears B. Stemless anatomic total shoulder arthroplasty is associated with less early postoperative pain. JSES Int 2024; 8:197-203. [PMID: 38312271 PMCID: PMC10837735 DOI: 10.1016/j.jseint.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background Improvements in pain control after shoulder arthroplasty with a reduction in narcotic use continues to be an important postoperative goal. With the increased utilization of stemless anatomic total shoulder arthroplasty (aTSA), it is relevant to compare between stemmed and stemless arthroplasty to assess if there is any association between this implant design change and early postoperative pain. Methods Patients from a multicenter, prospectively-maintained database who had undergone a stemless aTSA with a minimum of two year clinical follow-up were retrospectively identified. Patients who underwent aTSA with a short stem were identified in the same registry, and matched to the stemless aTSA patients by age, sex and preoperative pain score. The primary study outcome was the Visual Analog Scale pain score. Secondary pain outcomes were the American Shoulder and Elbow Surgeons shoulder pain subscore, Western Ontario Osteoarthritis of the Shoulder physical symptoms subscore, and the Single Assessment Numeric Evaluation score. Finally, the percentage of patients who could sleep on the affected shoulder was assessed for each group. These pain-related clinical outcomes were assessed and compared preoperatively, and postoperatively at 9 weeks, 26 weeks, one year and two years. For all statistical comparisons, P > .05 was considered significant. Results 124 patients were included in the study; 62 in each group. At 9 weeks after surgery, statistically significantly improved pain control was reported by patients undergoing stemless aTSA, as assessed by the Visual Analog Scale (stemless: 1.5, stemmed: 2.5, P = .001), American Shoulder and Elbow Surgeons pain subscore (stemless: 42.4, stemmed: 37.3, P < .001), Western Ontario Osteoarthritis of the Shoulder Physical Symptoms (stemless: 80.3, stemmed: 73.1, P = .006) and Single Assessment Numeric Evaluation (stemless: 58.1, stemmed: 47.4, P = .011). Patients who underwent a stemless aTSA were significantly more likely to be able to sleep on the affected shoulder at 9 weeks (29% vs. 11%, odds ratio 3.2, 95% confidence interval 1.2-8.4, P = .014). By 26 weeks postoperatively, there were no differences in all pain-specific outcomes. At two years postoperatively, patient-reported outcomes, range of motion, and strength measures were all similar between the two cohorts. Conclusion Stemless aTSA provides earlier improvement in postoperative shoulder pain compared to matched patients undergoing short-stem aTSA. Additionally, earlier return to sleeping on the affected shoulder was reported in the stemless aTSA group. The majority of these differences dissipate by 26 weeks postoperatively and there were no differences in pain, patient-reported outcomes, range of motion or strength measures between stemless and short-stem aTSA at 2 years postoperatively.
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Affiliation(s)
- Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | | | | | | | - Evan Lederman
- Department of Orthopaedic Surgery, Banner Health, Phoenix, AZ, USA
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Kim HM, Hsu JE, Ricchetti ET. What's New in Shoulder and Elbow Surgery. J Bone Joint Surg Am 2023; 105:1567-1573. [PMID: 37616391 DOI: 10.2106/jbjs.23.00649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- H Mike Kim
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Jason E Hsu
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington
| | - Eric T Ricchetti
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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11
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Turk R, Hamid N. Postoperative Pain Control Following Shoulder Arthroplasty: Rethinking the Need for Opioids. Orthop Clin North Am 2023; 54:453-461. [PMID: 37718084 DOI: 10.1016/j.ocl.2023.04.005] [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
The use of opioid pain medication regimens to control perioperative pain has led to significant patient and societal consequences. There are several alternative, opioid-sparing and opioid-minimizing pain regimens that have been shown to provide equal, if not superior, pain relief with fewer secondary consequences. This article provides an in-depth review of the current evidence regarding efficacy, safety, and feasibility of a perioperative opioid-sparing clinical pathway for patients undergoing shoulder arthroplasty.
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Affiliation(s)
- Robby Turk
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA; Atrium Health, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
| | - Nady Hamid
- Atrium Health Musculoskeletal Institute, Charlotte, NC, USA; Atrium Health, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA; OrthoCarolina, Charlotte, NC, USA
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Sabesan V, Lapica H, Fernandez C, Fomunung C. Evolution of Perioperative Pain Management in Shoulder Arthroplasty. Orthop Clin North Am 2023; 54:435-451. [PMID: 37718083 DOI: 10.1016/j.ocl.2023.04.004] [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
Historically, opioids have been used as a primary conservative treatment for pain related to glenohumeral osteoarthritis (GHOA). However, this practice is concerning as it often leads to overuse, which has contributed to the current epidemic of addiction and overdoses in the United States. Studies have shown that preoperative opioid use is associated with higher complication rates and worse outcomes following surgery, particularly for shoulder arthroplasty. To address these concerns, perioperative pain management for shoulder arthroplasty has evolved over the years to the use of multimodal analgesia.
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Affiliation(s)
- Vani Sabesan
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA.
| | - Hans Lapica
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
| | - Carlos Fernandez
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
| | - Clyde Fomunung
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
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Degen RM, Firth A, Sehmbi H, Martindale A, Wanlin S, Chen C, Marsh JD, Willits K, Bryant D. Multimodal analgesia did not improve post-operative pain scores, reduce opioid consumption or reduce length of stay following hip arthroscopy. Knee Surg Sports Traumatol Arthrosc 2023; 31:4016-4026. [PMID: 37170015 DOI: 10.1007/s00167-023-07445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE To determine whether different regimens of multimodal analgesia will reduce postoperative pain scores, opioid consumption, costs and hospital length-of-stay following hip arthroscopy. METHODS From 2018 to 2021, 132 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) were included in this prospective, single-center randomized controlled trial. Patients were randomized into four treatment groups: (1) Group 1-Control: opioid medication (oxycodone-acetaminophen 5 mg/325 mg, 1-2 tabs q6H as needed), Heterotopic ossification prophylaxis-Naprosyn 500 mg twice daily × 3 weeks); (2) Group 2-Control + postoperative sleeping aid (Zopiclone 7.5 mg nightly × 7 days); (3) Group 3-Control + preoperative and postoperative Gabapentin (600 mg orally, 1 h preoperatively; 600 mg postoperatively, 8 h following pre-op dose); (4) Group 4-Control + pre-medicate with Celecoxib (400 mg orally, 1 h preoperatively) The primary outcome was pain measured with a visual analog scale, monitored daily for the first week and every other day for 6 weeks. Secondary outcomes included opioid consumption, healthcare resource use, and hospital length of stay. RESULTS Patient characteristics were similar between groups. There were no statistically significant differences in pain scores between groups at any timepoint after adjusting for intra-operative traction time, intra-operative opioid administration and preoperative pain scores (p > 0.05). There were also no significant differences in the number of days that opioids were taken (n.s.) and the average daily morphine milligram equivalents consumed (n.s.). Similarly, there were no statistically significant differences in length of stay in the experimental groups, compared with the control group (n.s.). Finally, there were no differences in cost between groups (n.s.). CONCLUSION The routine use of Zopiclone, Celecoxib and Gabapentin did not improve postoperative pain control or reduce length-of-stay following hip arthroscopy. Therefore, these medications are not recommended for routine postoperative pain control following hip arthroscopy. LEVEL OF EVIDENCE l.
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Affiliation(s)
- Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada.
- Bone and Joint Institute, Western University, London, ON, Canada.
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
| | - Andrew Firth
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
| | - Herman Sehmbi
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
- Department of Anesthesia, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Ashley Martindale
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
| | - Stacey Wanlin
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
| | - Clara Chen
- Faculty of Health Sciences, Western University, London, Canada
| | | | - Kevin Willits
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
- Bone and Joint Institute, Western University, London, ON, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Dianne Bryant
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
- Bone and Joint Institute, Western University, London, ON, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Faculty of Health Sciences, Western University, London, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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Prince EJ, Pecker LH, Lanzkron S, Carroll CP. The Complex Association of Daily Opioid Dose with Visits for Pain in Sickle Cell Disease: Tolerance or Treatment-Refractory Pain? PAIN MEDICINE (MALDEN, MASS.) 2023; 24:703-712. [PMID: 36458906 PMCID: PMC10501470 DOI: 10.1093/pm/pnac187] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Opioids are used for acute and chronic pain in patients with sickle cell disease. How outpatient opioid regimens relate to acute care visits is of interest given the risks of high opioid doses and high hospital utilization. A prior study by our group suggested that outpatient opioid treatment for chronic pain could contribute to a vicious cycle of treatment-refractory acute pain, greater acute care utilization, and escalating opioid doses. The present larger naturalistic observational study was undertaken to determine whether the results were reliable across multiple acute care settings. METHODS One year of clinical data on patients (n = 291) followed in the Sickle Cell Center for Adults (August 2018 to July 2019) were extracted, including visits to the emergency department, visits to the infusion center, and inpatient admissions. Outpatient opioid dosage was used to predict acute care treatment in generalized linear models that were controlled for patient, disease, and treatment characteristics. RESULTS Outpatient opioid dosage predicted dosage during visits but did not predict visit length or pain relief. Higher outpatient opioid dosage was associated with greater number of visits. However, in post hoc analyses, this relationship was nonlinear, with a clear positive association only for those prescribed the lowest 50% of dosages. DISCUSSION Higher outpatient opioid dosage predicted higher dosages during acute care visits to achieve the same pain score improvement, which is more consistent with opioid tolerance than with treatment-refractory pain. The relationship of outpatient opioid dosage with number of acute care visits was more complex, which suggests that opioid consumption at lower levels is driven by intermittent acute pain and opioid consumption at higher levels is driven by chronic pain.
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Affiliation(s)
| | | | - Sophie Lanzkron
- Medicine and Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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