A comprehensive three-phase opiate sparing multimodal pain protocol for hip arthroscopy: a retrospective review

Risk factors for prolonged opioid consumption following hip arthroscopy: A secondary analysis of the Femoroacetabular Impingement RandomiSed controlled Trial and embedded cohort study

PURPOSE

The purpose of the study was to identify prognostic risk factors for prolonged opioid use at 2 and 6 weeks after hip arthroscopy using data from the Femoroacetabular Impingement RandomiSed controlled Trial and its external validation cohort study.

METHODS

Opioids were prescribed for postoperative pain management at the surgeon's discretion, with a majority being prescribed a combination of oxycodone and paracetamol (5/325 mg). Prolonged opioid use was defined as the ongoing use of any dosage of opioids reported at either 2 or 6 weeks after surgery to treat femoroacetabular impingement, as recorded in the patient's study medication log. Multivariable logistic regressions were performed to evaluate patient and surgical characteristics, such as preoperative opioid use, type of surgical procedure and intraoperative cartilage state that may be associated with prolonged opioid use at either 2 and 6 weeks postoperatively.

RESULTS

A total of 265 and 231 patients were included for analysis at 2 and 6 weeks postoperatively, respectively. The median age of participants was 35 years (interquartile range [IQR]: 27-42) and 33% were female. At 2 weeks postoperatively, female sex (odds ratio [OR]: 2.56; 95% confidence interval: [CI] 1.34-4.98, p = 0.005), higher body mass index (BMI) (OR: 1.10; 95% CI: 1.02-1.18, p = 0.009), active tobacco use (OR: 4.06; 95% CI: 1.90-8.97, p < 0.001), preoperative opioid use (OR: 10.1; 95% CI: 3.25-39.1, p < 0.001) and an Outerbridge classification of ≥3 (OR: 2.33; 95% CI: 1.25-4.43, p = 0.009) were significantly associated with prolonged opioid use. At 6 weeks postoperatively, only preoperative opioid use was significantly associated with prolonged opioid consumption (OR: 10.6; 95% CI: 3.60-32.6, p < 0.001).

CONCLUSION

Preoperative opioid use was significantly associated with continued opioid use at 2 and 6 weeks postoperatively. Specific patient factors including female sex, higher BMI, active tobacco use and more severe cartilage damage should be considered in developing targeted strategies to limit opioid use after surgery.

LEVEL OF EVIDENCE

Level III.

Efficacy of regional anesthesia in hip preservation surgeries: a systematic review

The purpose of this study was to review the current literature on perioperative pain management in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation. A systematic review of the literature published from January 2000 to December 2022 was performed. Selection criteria included published randomized controlled trials, prospective reviews and retrospective reviews of all human subjects undergoing hip preservation surgery. Exclusion criteria included case reports, animal studies and studies not reporting perioperative pain control protocols. Thirty-four studies included hip arthroscopy in which peripheral nerve blocks were associated with a significant reduction in pain score (P = 0.037) compared with general anesthesia alone. However, no pain control modality was associated with a significant difference in postanesthesia care unit opioid use (P = 0.127) or length of stay (P = 0.251) compared with general anesthesia alone. Falls were the most common complication reported, accounting for 37% of all complications. Five studies included periacetabular osteotomy and surgical hip dislocation in which peripheral nerve blocks were associated with an 18% reduction in pain on postoperative Day 2, a 48% reduction in cumulative opioid use on postoperative Day 2 and a 40% reduction in hospital stay. Due to the low sample size of the periacetabular osteotomy and surgical hip dislocation studies, we were unable to determine the significant difference between the means. Due to significant between-study heterogeneity, additional studies with congruent outcome measures need to be conducted to determine the efficacy of regional anesthesia in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation.

The impact of fascia iliaca nerve blockade on early postoperative pain and recovery after hip arthroscopy for femoroacetabular impingement syndrome

Fascia iliaca nerve blockade (FIB) has been previously described as an effective technique for reducing postoperative pain and opioid consumption after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). We hypothesize that an FIB will significantly reduce opioid consumption, pain scores and recovery time in our population. A retrospective observational study of 326 consecutive patients undergoing hip arthroscopy for FAIS at a single institution was performed. Patients were classified based on whether or not they received an FIB. Patient demographics, surgical details, medication details and 6-month postoperative outcomes were collected. The primary endpoint was the amount of narcotics required intraoperatively and in the postanesthesia care unit (PACU). Of the 326 patients included in the study, 37 received an FIB. No differences in sex, age or other surgical details were observed between groups. Patients receiving an FIB were more likely to receive celecoxib (P < 0.001), pregabalin (P = 0.001) and methocarbamol (P = 0.002). The FIB group received lower doses of narcotics intraoperatively (P = 0.001), postoperatively (P < 0.001) and in total (P < 0.001). The FIB group also self-reported lower first pain scores upon arrival to PACU (P = 0.001) and experienced shorter PACU recovery times (P < 0.001). After controlling for differences between groups, patients who received an FIB required significantly lower amounts of narcotics, had shorter PACU times and lower first PACU pain score than those who did not (P < 0.001). No differences in complication rates were noted between groups. The use of FIB resulted in lower pain scores, reduced recovery time and decreased early postoperative narcotic requirements for patients undergoing hip arthroscopy for femoroacetabular impingement. Further study is required to validate these findings and determine the optimal approach to regional analgesia in this patient population.

Opioid overprescription in adolescents and young adults undergoing hip arthroscopy

Few studies have examined factors related to the increased consumption of opioids after hip arthroscopy in adolescents and young adults. This study sought to determine prescription patterns following hip arthroscopy in this population, and to determine clinical or surgical factors associated with increased post-operative opioid use. Daily post-operative opioid intake was obtained from pain-control logbooks of adolescents and young adults who underwent hip arthroscopy between January 2017 and 2020. Study outcomes were defined as the median total number of opioid tablets consumed, total days opioids were consumed, mean daily opioid consumption and the ratio of opioids prescribed post-operatively to consumed. Clinical and surgical factors were analyzed to determine any association with opioid consumption. Fifty-eight (20%) patients returned completed logbooks. Most patients (73%) were prescribed 30 oxycodone tablets. The median number of tablets consumed was 7 (range 0–41) over a median duration of 7 days (range 1–22). The median ratio of tablets consumed to prescribed was 20%. Increasing patient age at surgery was associated with increased total number of tablets consumed (r = 0.28, P = 0.04) and to the ratio of tablets consumed to prescribed (r = 0.30, P = 0.03). Patients who were prescribed more than 30 tablets consumed on average 7.8 more tablets than patients prescribed fewer (P = 0.003). Patients who underwent regional anesthesia consumed tablets for longer compared with those who did not (median, 10 versus 4 days; P = 0.03). After undergoing hip arthroscopy, adolescents and young adult patients are commonly overprescribed opioids, consuming on average only one-fifth of the tablets prescribed.