Multimodal Pain Management in Orthopedic Surgery

Surgeon Prescribing Patterns And Perioperative Risk Factors Associated With Prolonged Opioid Use After Total Shoulder Arthroplasty

INTRODUCTION

The opioid epidemic in the United States has contributed to a notable economic burden and increased mortality. Total shoulder arthroplasty (TSA) has become more prevalent, and opioids are commonly used for postoperative pain management. Prolonged opioid use has been associated with adverse outcomes, but the role of surgeons in this context remains unclear. This study aims to investigate the incidence and risk factors of prolonged opioid utilization after primary TSA.

METHODS

After obtaining institutional review board approval, a retrospective review of 4,488 primary total shoulder arthroplasties from 2014 to 2022 at a single academic institution was conducted. Patients were stratified by preoperative and postoperative opioid use, and demographic, clinical, and prescription data were collected. Prescriptions filled beyond 30 days after the index operation were considered prolonged use. Multivariate analysis was conducted to determine the independent risk factors associated with prolonged opioid utilization.

RESULTS

Among 4,488 patients undergoing primary TSA, 22% of patients developed prolonged opioid use with 70% of prolonged users being opioid-exposed preoperatively. Independent risk factors of prolonged use include patient age younger than 65 years (Odds Ratio (OR) 1.02, P < 0.001), female sex (OR 1.41, P < 0.001), race other than Caucasian (OR 1.36, P = 0.003), undergoing reverse TSA (OR 1.28, P = 0.010), residing in an urban community (OR 1.33, P = 0.039), preoperative opioid utilization (OR 6.41, P < 0.001), preoperative benzodiazepine utilization (OR 1.93, P < 0.001), and increased postoperative day 1-30 milligram morphine equivalent (OR 1.003, P < 0.001).

DISCUSSION

Nearly 22% of patients experienced prolonged opioid use, with preoperative opioid exposure being the most notable risk factor in addition to postoperative prescribing patterns and benzodiazepine utilization. Surgeons play a crucial role in opioid management, and understanding the risk factors can help optimize benefits while minimizing the associated risks of prolonged opioid use. Additional research is needed to establish standardized definitions and strategies for safe opioid use in orthopaedic surgery.

Exploring the Potential of a Smart Ring to Predict Postoperative Pain Outcomes in Orthopedic Surgery Patients

Poor pain alleviation remains a problem following orthopedic surgery, leading to prolonged recovery time, increased morbidity, and prolonged opioid use after hospitalization. Wearable device data, collected during postsurgical recovery, may help ameliorate poor pain alleviation because a patient's physiological state during the recovery process may be inferred from sensor data. In this study, we collected smart ring data from 37 inpatients following orthopedic surgery and developed machine learning models to predict if a patient had postsurgical poor pain alleviation. Machine learning models based on the smart ring data were able to predict if a patient had poor pain alleviation during their hospital stay with an accuracy of 70.0%, an F1-score of 0.769, and an area under the receiver operating characteristics curve of 0.762 on an independent test dataset. These values were similar to performance metrics from existing models that rely on static, preoperative patient factors. Our results provide preliminary evidence that wearable device data may help control pain after orthopedic surgery by incorporating real-time, objective estimates of a patient's pain during recovery.

Acupoint Stimulation for Pain Control in Enhanced Recovery After Surgery: Systematic Review and Meta-Analysis

Introduction: Postoperative pain control is a challenge in enhanced recovery after surgery (ERAS). The current study reviewed the efficacy and safety of incorporating acupoint stimulation for postoperative pain control in ERAS. Methods: Ten databases for relevant randomized controlled trials (RCTs) published in English or Mandarin Chinese were searched from 1997 to 2022. The quality of each article was appraised using the Cochrane Collaboration Risk of Bias Criteria and the modified Jadad Scale. The primary outcome was pain control, measured using the visual analog scale 24 h after surgery. Results: Eleven trials met the eligibility criteria and were included in the study. Acupoint stimulation was found more effective than control treatments in terms of pain intensity (standardized mean difference [SMD] -0.94; 95% confidence interval [CI] -1.35 to -0.53), analgesic drug consumption (SMD -1.87; 95% CI -2.98 to -0.75), postoperative nausea (PON; SMD 0.31; 95% CI 0.13 to 0.73), postoperative vomiting (POV; SMD 0.57; 95% CI 0.11 to 2.92), and PON and POV (PONV; SMD 0.29; 95% CI 0.16 to 0.53). The Zusanli (ST36) and Neiguan (PC6) were the most-used acupoints in the included trials (8/11). The reported adverse reaction was only one case of bruising. Discussion: Acupoint stimulation improved pain control in patients undergoing ERAS more than control treatments. The findings provide an evidence-based premise for incorporating acupoint stimulation into ERAS strategies. More rigorous RCTs are needed in the future.

Effects of a Modified Long-Acting Cocktail on Analgesia and Enhanced Recovery After Total Hip Arthroplasty: A Double-Blinded Randomized Clinical Trial

BACKGROUND

We compared the efficacy and safety of a modified cocktail for postoperative analgesia and early functional rehabilitation in patients undergoing total hip arthroplasty (THA).

METHODS

Magnesium sulfate and sodium bicarbonate were added to a cocktail of ropivacaine, epinephrine, and dexamethasone. Primary outcome measures were visual analog scale (VAS) pain scores at various intervals after surgery, morphine consumption for rescue analgesia after surgery, and time to first rescue analgesia. Secondary outcomes were hip function after surgery, daily walking distance, quadriceps muscle strength, and the incidence of postoperative adverse reactions.

RESULTS

Morphine consumption was significantly lower in the modified cocktail group than in the control group in the first 24 hours after surgery (6.2 ± 6.0 versus 14.2 ± 6.4 mg, P < .001), as was total morphine consumption (10.0 ± 8.6 versus 19.2 ± 10.1 mg, P < .001). The duration of the first rescue analgesia was significantly prolonged (23.7 ± 10.3 versus 11.9 ± 5.8 mg, P < .001). Morphine consumption was also reduced in the magnesium sulfate and sodium bicarbonate groups over a 24-hour period compared to the control group (P < .001). The modified cocktail group had significantly lower resting VAS pain scores than the control group within 24 hours after surgery (P < .050). The VAS pain scores during movement within 12 hours after surgery were also lower (P < .050). The experimental groups showed better hip range of motion (P < .050) and longer walking distance (P < .050) on the first postoperative day, and levels of inflammatory markers were significantly reduced. The incidence of postoperative adverse reactions was similar among the 4 groups.

CONCLUSIONS

The modified cocktail with a new adjuvant can prolong the duration of postoperative analgesia, reduce the dosage of rescue analgesics, and accelerate early postoperative functional recovery in patients undergoing THA.

Rehabilitation Strategies Following Posterolateral Corner Repair for Left Knee Dislocation With Multiligament Injury: A Case Report

This case report describes the rehabilitation of a 54-year-old female patient with a left knee dislocation and multiligament injury after surgery. The patient experienced persistent pain and difficulty with weight-bearing, leading to the need for surgical repair. The rehabilitation protocol included three phases: pain management, range-of-motion (ROM) restoration, muscle strength improvement, proprioception, and equilibrium promotion. Modalities like cryotherapy, compression, manual therapy, and a tailored exercise regimen were used. The patient's outcomes showed significant improvements post-rehabilitation, emphasizing the importance of structured physiotherapy interventions in recovery and functional restoration. The aim of the case report is to highlight the efficacy of a structured physiotherapy intervention protocol in facilitating recovery and functional restoration for patients with knee dislocation and multiligament injury post-surgery. Further research and evidence-based rehabilitation strategies are needed to improve outcomes in similar cases.

Femoral-Obturator-Sciatic (FOS) Nerve Block as an Anesthetic Triad for Arthroscopic ACL Reconstruction: Is This the Magic Trick We Were Missing?

Arthroscopic anterior cruciate ligament (ACL) reconstruction with hamstring grafting is a common orthopedic procedure that is associated with moderate-to-severe pain. Peripheral nerve blockade as an anesthetic technique is an appealing option in the era of modern anesthesia. The aim of this narrative review is to document the efficacy and safety of the combination of femoral, obturator, and sciatic (FOS) nerve blocks as an exclusive method for anesthesia in patients undergoing ACL reconstruction. An electronic search of the literature published up to October 2023 was conducted in the Medline, Embase, Cochrane, Web of Science, and Google Scholar databases to find studies on ACL reconstruction and peripheral obturator nerve block. Overall, 8 prospective studies-with a total of 315 patients-published between 2007 and 2022 were included in this review. Ultrasound-guided peripheral FOS nerve blockade is an effective anesthetic technique for ACL reconstruction, offering good perioperative pain management, minimal opioid consumption, and an excellent safety profile. Further well-designed prospective studies are needed to determine the best approach for obturator nerve blockade and the appropriate type and dosage of local anesthetic.

Novel Techniques for Musculoskeletal Pain Management after Orthopedic Surgical Procedures: A Systematic Review

Effective postoperative pain management is critical for recovery after orthopedic surgery, but often remains inadequate despite multimodal analgesia. This systematic review synthesizes evidence on innovative modalities for enhancing pain control following major orthopedic procedures. Fifteen randomized controlled trials and comparative studies evaluating peripheral nerve blocks, local anesthetic infiltration, cryotherapy, transcutaneous electrical stimulation, adjunct medications, and other techniques are included. Thematic analysis reveals that peripheral nerve blocks and local anesthetic infiltration consistently demonstrate reduced pain scores, opioid consumption, and side effects versus conventional analgesia alone. Oral multimodal medications also show promise as part of opioid-sparing regimens. Adjunctive approaches like cryotherapy, music, and dexmedetomidine require further research to optimize protocols. Despite promising innovations, critical knowledge gaps persist regarding comparative effectiveness, optimal interventions and dosing, combination strategies, cost-effectiveness, and implementation. High-quality randomized controlled trials using standardized protocols are essential to guide the translation of enhanced multimodal regimens into clinical practice. This review provides a framework for pursuing research priorities and advancing evidence-based postoperative pain management across orthopedic surgeries.