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Joo H, Nguyen K, Kolodzie K, Chen LL, Kim MO, Manuel S. Differences in Acute Postoperative Opioid Use by English Proficiency, Race, and Ethnicity After Total Knee and Hip Arthroplasty. Anesth Analg 2024:00000539-990000000-00886. [PMID: 39088836 DOI: 10.1213/ane.0000000000007068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
BACKGROUND There is increasing interest in documenting disparities in pain management for racial and ethnic minorities and patients with language barriers. Previous studies have found differential prescription patterns of opioids for racial and ethnic minority group and patients having limited English proficiency (LEP) after arthroplasty. However, there is a knowledge gap regarding how the intersection of these sociodemographic factors is associated with immediate postoperative pain management. This study aimed to explore language and racial-ethnic disparities in short-term opioid utilization after total hip and knee arthroplasty. METHODS We conducted a retrospective cohort study of adult patients who underwent total hip and knee arthroplasty from 2015 to 2019 at an urban medical center. The primary predictor variables included LEP status and racial-ethnic category, and the primary outcome variables were oral morphine equivalents (OMEs) during 2 distinct postoperative periods: the first 12 hours after surgery and from the end of surgery to the end of postoperative day (POD) 1. Patient characteristics and perioperative metrics were described by language status, race, and ethnicity using nonparametric tests, as appropriate. We performed an adjusted generalized estimating equation to assess the total effect of the intersection of LEP and racial-ethnic categories on short-term postoperative opioid use in mean ratios (MRs). RESULTS This study included a total of 4090 observations, in which 7.9% (323) patients had LEP. Patients reported various racial-ethnic categories, with 72.7% (2975) non-Hispanic White, and minority groups including non-Hispanic Asian and Pacific Islander (AAPI), Hispanic/Latinx, non-Hispanic Black/African American, and Others. Patients self-identifying as non-Hispanic AAPI received fewer OME regardless of LEP status during the first 12 hours postoperatively (MR for English proficient [EP], 0.12 [95% confidence interval, CI, 0.08-0.18]; MR for LEP, 0.22 [95% CI, 0.13-0.37]) and from end of surgery to the end of POD 1 (MR for EP, 0.24 [95% CI, 0.16-0.37]; MR for LEP, 0.42, [95% CI, 0.24-0.73]) than EP non-Hispanic White. Hispanic/Latinx patients with LEP received lower amounts of OME during the first postoperative 12 hours (MR, 0.29; 95% CI, 0.17-0.53) and from end of surgery to the end of POD 1 (MR, 0.42; 95% CI 0.23-0.79) than EP non-Hispanic White. Furthermore, within the non-Hispanic White group, those with LEP received fewer OME within the first 12 hours (MR, 0.33; 95% CI, 0.13-0.83). CONCLUSIONS We identified an association between LEP, racial-ethnic identity, and short-term postoperative OME utilization after total knee and hip arthroplasty. The observed differences in opioid utilization imply there may be language and racial-ethnic disparities in acute pain management and perioperative care.
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Affiliation(s)
- Hyundeok Joo
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Kevin Nguyen
- University of California, San Francisco School of Medicine, San Francisco, California
| | - Kerstin Kolodzie
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California
| | - Lee-Lynn Chen
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Solmaz Manuel
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
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Wang Y, Li Z, Gao X, Lin J. The efficacy and safety of intra-articular injection of corticosteroids in multimodal analgesic cocktails in total knee arthroplasty-a historically controlled study. Front Surg 2024; 11:1279462. [PMID: 38919978 PMCID: PMC11196593 DOI: 10.3389/fsurg.2024.1279462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 05/22/2024] [Indexed: 06/27/2024] Open
Abstract
Background Total knee arthroplasty (TKA) is a common and effective procedure. Optimizing pain control and reducing postoperative discomfort are essential for patient satisfaction. No studies have examined the safety and efficacy of intra-articular corticosteroid injections following TKA. This study aims to examine the safety and efficacy of corticosteroids in intra-articular multimodal analgesic injections. Materials and methods This was a historically controlled study conducted at a single academic institution. Before May 2019, patients received an intra-articular cocktail injection without corticosteroids during surgery, referred to as the non-corticosteroid (NC) group. After June 2019, intraoperatively, patients received an intra-articular cocktail injection containing corticosteroids, referred to as the corticosteroid (C) group. Finally, 738 patients were evaluated, 370 in the C cohort and 368 in the NC cohort. The mean follow-up duration was 30.4 months for the C group and 48.4 months for the NC group. Results The mean VAS scores at rest on postoperative day (POD) 1 (2.35) and POD3 (3.88) were significantly lower in the C group than those in the NC group, which were 2.86 (POD1) and 5.26 (POD3) (p < 0.05). Walking pain in the C group (4.42) was also significantly lower than that (5.96) in the NC group on POD3 (p < 0.05). Patients in the C group had a significantly higher mean range of motion (ROM) (92.55) on POD3 than that (86.38) in the NC group. The mean time to straight leg raise for group C (2.77) was significantly shorter than that (3.61) for the NC group (p < 0.05). The C group also had significantly fewer rescue morphine (1.9) and metoclopramide (0.21) uses per patient than the NC group, which were 3.1 and 0.24, respectively. No significant differences in fever or vomiting rates between groups were found. Patients in neither group developed periprosthetic joint infections or skin necrosis. One patient in the C group suffered from wound dehiscence, and the wound healed well after debridement. No patient died or had a re-operation in either group. Conclusions This pilot trial found that intra-articular injection of multimodal analgesia (including corticosteroids) reduced initial postoperative pain, increased ROM in the early postoperative days (up to POD3), and did not increase wound complications or infection rates in approximately 30 months of follow-up.
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Affiliation(s)
- Yixiong Wang
- Department of Orthopedic Diseases, Jincheng General Hospital, Jincheng, China
| | - Zhichang Li
- Arthritis Clinic & Research Center, Peking University People’s Hospital, Beijing, China
| | - Xuan Gao
- Department of Orthopedic Disease, Luanzhou People’s Hospital, Tangshan, Hebei, China
| | - Jianhao Lin
- Arthritis Clinic & Research Center, Peking University People’s Hospital, Beijing, China
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Karlsen APH, Laigaard J, Pedersen C, Thybo KH, Gasbjerg KS, Geisler A, Lunn TH, Hägi-Pedersen D, Jakobsen JC, Mathiesen O. Minimal important difference in postoperative morphine consumption after hip and knee arthroplasty using nausea, vomiting, sedation and dizziness as anchors. Acta Anaesthesiol Scand 2024; 68:610-618. [PMID: 38380438 DOI: 10.1111/aas.14388] [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: 09/07/2023] [Revised: 01/05/2024] [Accepted: 01/30/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Morphine-sparing effects are often used to evaluate non-opioid analgesic interventions. The exact effect that would warrant the implementation of these interventions in clinical practice (a minimally important difference) remains unclear. We aimed to determine this with anchor-based methods. METHODS This was a post hoc analysis of three studies investigating pain management after hip or knee arthroplasty (PANSAID [NCT02571361], DEX-2-TKA [NCT03506789] and Pain Map [NCT02340052]). The overall population was median aged 70, median ASA 2, 54% female. We examined the correlation between 0 and 24 h postoperative iv morphine equivalent consumption and the severity of nausea, vomiting, sedation and dizziness. The anchor was different severity degrees of these opioid-related adverse events. The primary outcome was the difference in morphine consumption between patients experiencing no versus only mild events. Secondary outcomes included the difference in morphine consumption between patients with mild versus moderate and moderate versus severe events. We used Hodges-Lehmann median differences, exact Wilcoxon-Mann-Whitney tests and quantile regression. RESULTS The difference in iv morphine consumption was 6 mg (95% confidence interval: 4-8) between patients with no versus only mild events, 5 mg (2-8) between patients with mild versus moderate events and 0 mg (-4 to 4) between patients with moderate versus severe events. CONCLUSIONS In populations comparable to this post-hoc analysis (orthopaedic surgery, median age 70 and ASA 2), we suggest a minimally important difference of 5 mg for 0-24 h postoperative iv morphine consumption.
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Affiliation(s)
- Anders Peder Højer Karlsen
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Jens Laigaard
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Casper Pedersen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Kasper Højgaard Thybo
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
| | - Kasper Smidt Gasbjerg
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Denmark
| | - Anja Geisler
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospitals, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Hägi-Pedersen
- Research Centre of Anaesthesiology and Intensive Care Medicine, Department of Anaesthesiology, Næstved-Slagelse-Ringsted Hospitals, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koege, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Bedi GS, Roy SP, Sharma V, Bhagat SV, Sanghavi AP, Muchhala SS, Katare S, Kotak BP, Banerjee R. Assessing the Knowledge, Attitude, and Practice of Orthopedicians for Pain Management by Multimodal Approach: A Prospective, Cross-Sectional, and Observational Survey. Cureus 2024; 16:e59935. [PMID: 38854259 PMCID: PMC11161720 DOI: 10.7759/cureus.59935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND The routine use of multimodal analgesic modality results in lower pain scores with minimum side effects and opioid utilization. MATERIALS AND METHODS A prospective, cross-sectional, observational study was conducted among orthopedicians practicing across India to assess the professional opinions on using analgesics to manage orthopedic pain effectively. RESULTS A total of 530 orthopedicians participated in this survey. Over 50% of the participants responded that tramadol with or without paracetamol was the choice of therapy for acute pain. Nearly 50% of the participants mentioned that multimodal interventions can sometimes help to manage pain. A total of 55.6% of participants mentioned that using Non-steroidal anti-inflammatory drugs was the most common in their clinical practice, while 25.7% of participants mentioned that they used tramadol more commonly in their clinical practice. As per clinical efficacy ranking, the combination of tramadol plus paracetamol (44.3%) was ranked first among analgesic combinations, followed by aceclofenac plus paracetamol (40.0%). The severity of pain (62.6%) followed by age (60.6%) and duration of therapy (52.6%) were the most common factors that should be considered while prescribing tramadol plus paracetamol combination. Gastrointestinal and renal are reported as the most common safety concerns encountered with analgesics. CONCLUSION The combination of tramadol and paracetamol was identified as the most preferred choice of analgesics for prolonged orthopedic pain management.
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Affiliation(s)
| | | | | | - Seema V Bhagat
- Medical Affairs, Dr. Reddy's Laboratories Ltd, Hyderabad, IND
| | - Arti P Sanghavi
- Medical Affairs, Dr. Reddy's Laboratories Ltd, Hyderabad, IND
| | | | - Sagar Katare
- Medical Affairs, Dr. Reddy's Laboratories Ltd, Hyderabad, IND
| | - Bhavesh P Kotak
- Medical Affairs, Dr. Reddy's Laboratories Ltd, Hyderabad, IND
| | - Ritwik Banerjee
- Medical Affairs, Dr. Reddy's Laboratories Ltd, Hyderabad, IND
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5
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Snarskis C, Banerjee A, Franklin A, Weavind L. Systems of Care Delivery and Optimization in the Postoperative Care Wards. Anesthesiol Clin 2023; 41:875-886. [PMID: 37838390 DOI: 10.1016/j.anclin.2023.05.007] [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: 10/16/2023]
Abstract
A third of all patients are at risk for a serious adverse event, including death, in the first month after undergoing a major surgery. Most of these events will occur within 24 hours of the operation but are unlikely to occur in the operating room or postanesthesia care unit. Most opioid-induced respiratory depression events in the postoperative period resulted in death (55%) or anoxic brain injury (22%). A future state of mature artificial intelligence and machine learning will improve situational awareness of acute clinical deterioration, minimize alert fatigue, and facilitate early intervention to minimize poor outcomes.
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Affiliation(s)
- Connor Snarskis
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arna Banerjee
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Andrew Franklin
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Liza Weavind
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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6
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Ramos MS, Pasqualini I, Surace PA, Molloy RM, Deren ME, Piuzzi NS. Arthrofibrosis After Total Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202312000-00001. [PMID: 38079496 DOI: 10.2106/jbjs.rvw.23.00140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» Arthrofibrosis after total knee arthroplasty (TKA) is the new formation of excessive scar tissue that results in limited ROM, pain, and functional deficits.» The diagnosis of arthrofibrosis is based on the patient's history, clinical examination, absence of alternative diagnoses from diagnostic testing, and operative findings. Imaging is helpful in ruling out specific causes of stiffness after TKA. A biopsy is not indicated, and no biomarkers of arthrofibrosis exist.» Arthrofibrosis pathophysiology is multifactorial and related to aberrant activation and proliferation of myofibroblasts that primarily deposit type I collagen in response to a proinflammatory environment. Transforming growth factor-beta signaling is the best established pathway involved in arthrofibrosis after TKA.» Management includes both nonoperative and operative modalities. Physical therapy is most used while revision arthroplasty is typically reserved as a last resort. Additional investigation into specific pathophysiologic mechanisms can better inform targeted therapeutics.
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Affiliation(s)
- Michael S Ramos
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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7
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Farrell N, Greenfield PT, Rutkowski PT, Weller WJ. Perioperative Pain Management for Distal Radius Fractures. Orthop Clin North Am 2023; 54:463-470. [PMID: 37718085 DOI: 10.1016/j.ocl.2023.05.006] [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
Distal radius fractures have a high incidence among both young and elderly patients, and in many instances require operative intervention. When operative intervention is employed, adequate pain management is essential to decrease postoperative complications, such as chronic pain and disability, while minimizing the risk of prolonged opioid use and dependence. Strategies to optimize pain management include regional anesthesia, preoperative dosing of medication, multimodal regimens, long-acting selective opioids at the time of surgery, corticosteroids, and non-pharmacologic therapies.
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Affiliation(s)
- Nolan Farrell
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Paul T Greenfield
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paul T Rutkowski
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN, USA
| | - William Jacob Weller
- Campbell Clinic, Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN, USA
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8
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Tanaka MJ, Prasad R, Miller LA, Fleck MM, Stiles B, Boyne CJ, Nguyen THE. Team Approach: Improving Orthopaedic Operating Room Efficiency. JBJS Rev 2023; 11:01874474-202308000-00004. [PMID: 37549236 DOI: 10.2106/jbjs.rvw.23.00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
The cost of surgical care accounts for almost one-third of all health care spending in the United States. Within health care spending, the operating room (OR) is one of the largest health care costs during a perioperative episode of care. Efficiency in the OR has been associated with increased productivity, safety, and quality of care. However, multiple sources of delays can contribute to inefficiency, and improving efficiency in the OR requires a systematic approach to identify and address each issue. We report on the case of a process improvement initiative implemented in a large academic institution to improve OR efficiency in outpatient orthopaedic cases, and we discuss the lessons learned through this program. Optimizing workflow in the OR requires a multidisciplinary team approach consisting of clinician leaders with common goals and open discussion regarding the needs of each team member, including circulating nurses, surgical nurses/technologists, and anesthesiologists. Our experience highlights the importance of practical, clinician-driven changes that are supported by administrative engagement, resources for staffing and equipment, and institutional flexibility, which are required to implement systemic changes to address and improve efficiency in the OR.
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Affiliation(s)
- Miho J Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rashmi Prasad
- Department of Anesthesia, Johns Hopkins University, Baltimore, Maryland
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9
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Wang JC, Piple AS, Mayfield CK, Chung BC, Oakes DA, Gucev G, Lieberman JR, Christ AB, Heckmann ND. Peripheral Nerve Block Utilization is Associated With Decreased Postoperative Opioid Consumption and Shorter Length of Stay Following Total Knee Arthroplasty. Arthroplast Today 2023; 20:101101. [PMID: 36891161 PMCID: PMC9988417 DOI: 10.1016/j.artd.2023.101101] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/11/2022] [Accepted: 01/11/2023] [Indexed: 03/10/2023] Open
Abstract
Background This study aims to examine differences in postoperative complications and opioid consumption associated with perioperative peripheral nerve block (PNB) utilization during primary total knee arthroplasty (TKA). Methods The Premier Healthcare Database was queried for adult patients who underwent primary, elective TKA from 2015 to 2020. Patients who received a femoral or adductor canal PNB were compared to patients who did not. PNB utilization was trended from 2015 to 2020. Univariate and multivariate regression analyses were performed to assess differences in the 90-day risk of postoperative complications between groups. The average inpatient opioid consumption in morphine milligram equivalents was assessed as a function of length of stay. Results Overall, 609,991 patients were included. PNB utilization increased from 9.29% in 2015 to 30.3% in 2020. After controlling for confounders, the PNB cohort was more likely to have same-day discharge (adjusted odds ratio [aOR] 1.88) and had a decreased risk of periprosthetic joint infection (aOR 0.87), pulmonary embolism (aOR 0.81), and respiratory failure (aOR 0.78). However, there was an increased risk of seroma (aOR 1.75) and hematoma (aOR 1.22) associated with PNB utilization. Lower average overall opioid exposure was seen in the PNB cohort vs no-PNB cohort (82.1 ± 194.7 vs 89.4 ± 214.1 morphine milligram equivalents, P < .001). Conclusions PNB utilization during primary TKA is associated with a shorter length of stay and decreased risk of multiple postoperative complications, as well as reduced postoperative opioid consumption. These data provide evidence in support of the safety and efficacy of this emerging practice. However, the clinical relevance of an increased risk of seroma and hematoma formation may warrant further investigation.
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Affiliation(s)
- Jennifer C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Amit S Piple
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Cory K Mayfield
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Brian C Chung
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Daniel A Oakes
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Gligor Gucev
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Alexander B Christ
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA
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10
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Hannon CP, Fillingham YA, Gililland JM, Sporer SM, Casambre FD, Verity TJ, Woznica A, Nelson N, Hamilton WG, Della Valle CJ. A Systematic Review of the Efficacy and Safety of Ketamine in Total Joint Arthroplasty. J Arthroplasty 2023; 38:763-768.e2. [PMID: 36328104 DOI: 10.1016/j.arth.2022.10.037] [Citation(s) in RCA: 1] [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: 07/07/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Ketamine is administered intraoperatively to treat pain associated with primary total hip (THA) and knee arthroplasty (TKA). The purpose of this study was to evaluate the efficacy and safety of ketamine in primary THA and TKA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons (AAHKS), American Academy of Orthopaedic Surgeons (AAOS), Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management (ASRA). METHODS The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to 2020 on ketamine in THA and TKA. All included studies underwent qualitative assessment and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of ketamine. After a critical appraisal of 136 publications, 7 high-quality studies were included for analyses. RESULTS High-quality evidence demonstrates that intraoperative ketamine decreases postoperative opioid consumption. Four of 7 studies found that ketamine reduces postoperative pain. Intraoperative ketamine is not associated with an increase in adverse events and may reduce postoperative nausea and vomiting (relative risk [RR] 0.68; 95% CI 0.50-0.92). CONCLUSION High-quality evidence supports the use of ketamine intraoperatively in THA and TKA to reduce postoperative opioid consumption. Most studies found ketamine reduces postoperative pain, nausea, and vomiting. Moderate quality evidence supports the safety of ketamine, but it should be used cautiously in patients at risk for postoperative delirium, such as the elderly.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Yale A Fillingham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jeremy M Gililland
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah
| | - Scott M Sporer
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | - Tyler J Verity
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | - Anne Woznica
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | | | - Craig J Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
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11
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Karlsen APH, Pedersen C, Laigaard J, Thybo KH, Gasbjerg KS, Geisler A, Lunn TH, Hägi-Pedersen D, Jakobsen JC, Mathiesen O. Minimal important difference in opioid consumption based on adverse event reduction-A study protocol. Acta Anaesthesiol Scand 2023; 67:248-253. [PMID: 36428272 PMCID: PMC10107239 DOI: 10.1111/aas.14175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The patient-relevant minimal important difference for opioid consumption remains undetermined, despite its frequent use as primary outcome in trials on postoperative pain management. A minimal important difference is necessary to evaluate whether significant trial results are clinically relevant. Further, it can be used as effect size to ensure that trials are powered to find clinically relevant effects. By exploring the dose-response relationship between postoperative opioid consumption and opioid-related adverse effects, we aim to approximate the minimal important difference in opioid consumption anchored to opioid-related adverse effects. METHODS This is a post-hoc analysis of aggregated data from two clinical trials (PANSAID NCT02571361 and DEX2TKA NCT03506789) and one observational cohort study (Pain Map NCT02340052) on pain management after total hip and knee arthroplasty. The primary outcome is the Hodges-Lehmann median difference in opioid consumption between patients with no opioid-related adverse effects and patients experiencing the mildest degree of one or more opioid-related adverse effects (i.e., mild nausea, sedation and/or dizziness or vomiting). Secondary outcomes include the Hodges-Lehmann median difference in opioid consumption that corresponds to one point on a cumulated opioid-related adverse event 0-10 scale. Further, we will explore the proportion of patients that experience opioid-related adverse effects for consecutive opioid dose intervals of 2 mg iv morphine equivalents. Quantile regression will be used to assess any significant interactions with patient baseline characteristics. CONCLUSIONS This study will hopefully bring us one step closer to determining relevant opioid reductions and thereby improve our understanding of intervention effects and planning of future trials.
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Affiliation(s)
- Anders Peder Højer Karlsen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark.,Department of Anaesthesiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Casper Pedersen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Jens Laigaard
- Department of Orthopaedic Surgery and Traumatology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Kasper Højgaard Thybo
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Kasper Smidt Gasbjerg
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark
| | - Anja Geisler
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Troels Haxholdt Lunn
- Department of Anaesthesiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Hägi-Pedersen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesiology, Research Centre of Anaesthesiology and Intensive Care Medicine, Naestved-Slagelse-Ringsted Hospitals, Ringsted, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Mathiesen
- Department of Anaesthesiology, Centre for Anaesthesiological Research, Zealand University Hospital, Køge, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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12
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Thijssen M, Timmerman L, Koning NJ, Rinia M, van Dijk JFM, Cheuk-Alam J, Olthof K, Rekker S, Steegers MAH, van Boekel RLM. Multimodal analgesia practices for knee and hip arthroplasties in the Netherlands. A prospective observational study from the PAIN OUT registry. PLoS One 2022; 17:e0279606. [PMID: 36548295 PMCID: PMC9778981 DOI: 10.1371/journal.pone.0279606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Different multimodal pain management strategies following total hip arthroplasty(THA) and total knee arthroplasty (TKA) surgery are used in clinical practice. The optimal pain management strategy, however, remains unclear. This study aims to evaluate the differences in perioperative multimodal pain management strategies for THA and TKA in the Netherlands, and studies the associations between patient- and therapy related factors and pain outcomes. METHODS Data from the Dutch hospitals in the PAIN OUT network were used in this study. Demographic data, pain management strategy including perioperative medication use and anesthetic techniques were recorded and used in a multivariable regression analysis to study the association with maximum pain intensity, the duration of severe pain, pain interference in bed and postoperative nausea. RESULTS In 343 hip arthroplasty patients and 301 knee arthroplasty patients in seven hospitals, respectively 28 and 35 different combinations of analgesic regimens were used. The number of different drugs prescribed was not related to postoperative pain intensity. Female sex, younger age and spinal anesthesia were associated with higher postoperative maximum pain scores (Numeric Rating Scale (NRS) > 5). Hip surgery and ketamine use were associated with lower postoperative pain scores. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and gabapentinoids, higher age, higher body mass index (BMI) and male gender were associated with less postoperative nausea (NRS < 3). CONCLUSION In conclusion, our study demonstrated a large diversity of analgesic strategies following total joint arthroplasties in the Netherlands. Although no ideal strategy was identified, the use of NSAIDs, ketamine and dexamethasone were associated with less pain and less side effects.
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Affiliation(s)
- Marloes Thijssen
- Department of Anesthesiology and Pain medicine, Antonius Hospital, Nieuwegein, The Netherlands
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Leon Timmerman
- Department of Anesthesiology and Pain medicine, Antonius Hospital, Nieuwegein, The Netherlands
| | - Nick J. Koning
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Myra Rinia
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jacqueline F. M. van Dijk
- Department of Anesthesiology and Pain medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Juanita Cheuk-Alam
- Department of Anesthesiology and Pain Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Kees Olthof
- Department of Anesthesiology and Pain Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Sjaak Rekker
- Department of Anesthesiology and Pain Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Monique A. H. Steegers
- Department of Anesthesiology and Pain Medicine, VU Medical Center, Amsterdam, The Netherlands
| | - Regina L. M. van Boekel
- Department of Anesthesiology and Pain Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- * E-mail:
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A quadruple peripheral nerve block outside the OR for anterior cruciate ligament reconstruction reduces the OR occupancy time. Knee Surg Sports Traumatol Arthrosc 2022:10.1007/s00167-022-07246-2. [PMID: 36469051 DOI: 10.1007/s00167-022-07246-2] [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: 07/08/2022] [Accepted: 11/22/2022] [Indexed: 12/07/2022]
Abstract
PURPOSE The use of regional anesthesia (RA) for anterior cruciate ligament (ACL) reconstruction reduces morphine consumption, the time spent in the post-anesthesia care unit (PACU) and the hospital readmission rate. However, RA failures due to delays in the induction of anesthesia and its unpredictable success rate (Cuvillon et al. Ann Fr Anesth 29:710-715, 2010; Jankowski et al. Anesth Analg 10.1213/01.ANE.0000081798.89853.E7) can lead to disorganization of the operating room (OR) schedule. The hypothesis is that performing RA outside the OR will significantly reduce the OR occupancy time relative to using general anesthesia (GA). The primary objective was to compare the OR occupancy time between RA and GA when performing ACL reconstruction. METHODS This was a retrospective, single-center study of data collected prospectively from consecutive patients operated by a single surgeon between January 2019 and December 2020. The patients undergoing ACL reconstruction were divided into two groups based on the type of anesthesia they received (GA, RA). RA consisted of a quadruple peripheral nerve block (femoral, sciatic, obturator and lateral femoral cutaneous nerves). The durations of the perioperative stages of the patient's journey in the OR suite were compared between these two groups. RESULTS The analysis involved 469 ACL reconstructions: 356 GA and 113 RA. The two groups were comparable in age, gender and ASA score (American Society of Anesthesiologists). The OR occupancy time for ACL reconstruction with RA was reduced by a mean of 13 min (70 ± 12 SD vs. 83 ± 14 SD; P < 0.0001) and the PACU time by 41 min relative to GA (P < 0.0001). The entry-incision time was reduced by an average of 8 min and the end-exit time by 3 min (P < 0.0001). The care time in the PACU was reduced from 84 ± 35 to 46 ± 26 min (P < 0.0001). However, performing anesthesia outside the OR (i.e., in a RA block room) did not reduce the turnover time (n.s). CONCLUSION Performing RA outside the OR reduced the OR occupancy time by nearly 20% relative to using GA for ACL reconstructions. LEVEL OF EVIDENCE Level IV.
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Peripheral Nerve Block for Pain Management after Total Hip Arthroplasty: A Retrospective Study with Propensity Score Matching. J Clin Med 2022; 11:jcm11185456. [PMID: 36143103 PMCID: PMC9505421 DOI: 10.3390/jcm11185456] [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] [Received: 08/13/2022] [Revised: 09/11/2022] [Accepted: 09/13/2022] [Indexed: 11/17/2022] Open
Abstract
This study aimed to evaluate the effect of a peripheral nerve block (PNB) on immediate postoperative analgesia and the early functional outcomes for patients who underwent total hip arthroplasty (THA). From January 2016 to August 2021, 353 patients who underwent THA were divided into two groups: the patient-controlled analgesia (PCA) group (n = 217) who received only intravenous (IV) analgesia, and others who received IV PCA and PNB (PCA + PNB group) (n = 136). After propensity score matching for age and sex, 136 patients from each group were included in the study. Primary outcomes were the visual analogue scale (VAS) at rest, activity status at postoperative 6, 24, 48 h. Secondary outcomes were functional scores by the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, Harris Hip Score (HHS) and rescue medications used. The postoperative VAS at 6, 24, 48 h at rest and 6 h at activity were significantly lower in the PCA + PNB group (p = 0.000, 0.001, 0.000, 0.004 in order). There was no significant difference for postoperative 3-month HHS (p = 0.218), except for 3-month WOMAC index (p = 0.001). There were no significant differences for VAS between the PNB methods except femoral nerve block (FNB) and fascia iliaca compartment block (FICB) at postoperative activity 48 h (p = 0.028). There was no significant difference in the total count and amount of rescue medication (p = 0.091, 0.069) and difference in the quadriceps weakness was not noted. Therefore, PNB is beneficial for patients who undergo THA as it provides sufficient postoperative analgesia, especially during immediate postoperative resting pain without quadriceps weakness.
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Abstract
Perioperative pain management is one of the domains in which Anesthesiologists are intricately involved, and which is immensely important. Adequate postoperative analgesia is central to avoid both the acute as well as chronic complications of uncontrolled postoperative pain. Preventive analgesia has been identified as an approach to mitigate the phenomenon of central sensitization, which plays an important role in the development of chronic pain after surgery. As an over-reliance on opioids for peri- and postoperative pain control is associated with opioid dependence and hyperalgesia, multimodal analgesia has taken center stage. Multimodal analgesia, in theory, will optimize perioperative pain control, reduce the chance of central sensitization, and avoid the detrimental effects of opioid overuse. Multiple classes of systemic analgesic medications have been used to accomplish these tasks, and the aim of this article is to outline these medications, their mechanisms of action, as well as the evidence behind their individual roles in multimodal analgesia. Regional anesthesia has also been embraced as a key component of multimodal analgesia in orthopedic surgery; however, over the past several years, local infiltration analgesia (LIA) emerged as a viable alternative, particularly in total knee arthroplasty.
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Affiliation(s)
- Archana O'Neill
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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16
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Elbashir M, Uzoigwe C, Kurup H. Day case ankle arthroplasty: are they safe and cost effective? A single-centre case-control study. J Clin Orthop Trauma 2022; 30:101919. [PMID: 35755933 PMCID: PMC9214791 DOI: 10.1016/j.jcot.2022.101919] [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: 01/23/2022] [Revised: 03/30/2022] [Accepted: 06/10/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Most patients who have an ankle replacement in the United Kingdom stay in hospital for 2-4 days. This study looked at the safety & cost-effectiveness of a day case ankle replacement pathway. METHODS This was a retrospective case-control study looking at day case pathway for ankle replacements set up in collaboration with anaesthetists, nurses and physiotherapists. Patients practiced mobilization with crutches before surgery. Patients were discharged home with enough analgesia, and reviewed within 2-5 days of discharge. RESULTS Twenty ankle replacements done between November 2017 and November 2019 were reviewed with a mean follow up of 38.4 months. None of these patients required to be readmitted within the first 28 days. No complications were related to the surgery being done as day case. Except one, all patients described the experience as excellent or good. CONCLUSION Per case the cost savings are estimated to be £880 in comparison to 20 matched inpatient ankle replacements. We conclude that ankle replacements can be safely carried out as day case with appropriate patient selection, pre-operative education and a multi-disciplinary approach.
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17
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Layson JT, Markel DC, Hughes RE, Chubb HD, Frisch NB. John N. Insall Award: MARCQI's Pain-Control Optimization Pathway (POP): Impact of Registry Data and Education on Opioid Utilization. J Arthroplasty 2022; 37:S19-S26. [PMID: 35271973 DOI: 10.1016/j.arth.2022.02.109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/25/2022] [Accepted: 02/26/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In 2019, the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) recommended an evidence-based opioid pain pathway to participating physicians and hospitals for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to determine if the education could influence and have lasting effects on the prescribing patterns for TJA patients. METHODS Using the MARCQI database, the number of oral morphine equivalents (OMEs) prescribed at discharge were collected from January 2018 through December 2019 for all primary arthroplasty procedures. Periods compared included before and after July 2018 Michigan opioid laws as well as before and after the March 2019 MARCQI recommendations. The data compared total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients, opioid-naive vs opioid-tolerant patients, individual surgeons, and MARCQI sites. RESULTS The data included 84,998 TJAs: 22,774 opioid-naive THAs, 9124 opioid-tolerant THAs, 40,882 opioid-naive TKAs, and 12,218 opioid-tolerant TKAs. In all the groups and at all time periods there were a significant decrease in prescriptions (P < .001). Individual surgeons and participating sites also demonstrated decreased OMEs on discharge after the recommendations. Between the first and last months of collection, this represented an overall decrease of opioid OMEs for THA by 47.1% for opioid-naive patients and 53.4% for opioid-tolerant patients. For TKA patients, the OME decrease was 48.3% for opioid-naive patients, and 48.4% for opioid-tolerant patients. CONCLUSION The MARCQI pain control optimization pathway (POP) program has been successful in drastically reducing opioid prescribing with lasting effects, which has substantially limited the overall opioid prescription burden for patients undergoing arthroplasty.
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Affiliation(s)
- James T Layson
- Department of Orthopaedic Surgery, Ascension Macomb-Oakland Hospital, Madison Heights, MI
| | - David C Markel
- Department of Orthopaedic Surgery, Ascension Providence Hospital and The Core Institute, Novi, MI
| | - Richard E Hughes
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Heather D Chubb
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Nicholas B Frisch
- Department of Orthopaedic Surgery, Ascension Providence Rochester Hospital, Rochester, MI
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18
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Ekelund A, Peredistijs A, Grohs J, Meisner J, Verity N, Rasmussen S. SABER-Bupivacaine Reduces Postoperative Pain and Opioid Consumption After Arthroscopic Subacromial Decompression: A Randomized, Placebo-Controlled Trial. J Am Acad Orthop Surg Glob Res Rev 2022; 6:e21.00287. [PMID: 35584248 PMCID: PMC10566886 DOI: 10.5435/jaaosglobal-d-21-00287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/23/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Shoulder arthroscopy can result in substantial postoperative pain. Sucrose acetate isobutyrate extended-release bupivacaine (SABER-Bupivacaine; trade name Posimir) is a novel depot formulation of bupivacaine designed to provide analgesia at the surgical site for up to 72 hours. The objective of this study was to evaluate the effect of SABER-Bupivacaine on pain and opioid consumption after arthroscopic subacromial decompression and to assess short-term and long-term safety. METHODS In this double-blind, placebo-controlled trial, 78 subjects were randomized in a 2:1 ratio to SABER-Bupivacaine 5 mL or SABER-placebo 5 mL injected into the subacromial space just before skin closure. Twenty-nine additional subjects were randomized on an exploratory basis to bupivacaine hydrochloride 20 mL, also injected subacromially. Subjects rated pain intensity on a 0 to 10 scale over the first 3 postoperative days and received intravenous or oral morphine for breakthrough pain. The coprimary efficacy end points were pain intensity on 90° shoulder flexion and cumulative morphine intake from 0 to 72 hours after surgery. The time to first use of opioid rescue analgesia was a secondary end point. RESULTS The mean (SD) pain intensity was 5.16 (1.94) for SABER-Bupivacaine and 6.43 (1.77) for placebo (P = 0.012). The median consumption of intravenous morphine equivalents was 4.0 mg for SABER-Bupivacaine and 12.0 mg for placebo (P = 0.010). The median time to first use of morphine rescue was 12.4 hours for SABER-Bupivacaine and 1.2 hours for placebo (P = 0.014). The corresponding values for bupivacaine hydrochloride were 5.16 (2.38), 8.0 mg, and 1.4 hours. The incidence and severity of treatment-emergent adverse events were similar for all treatment groups, and no functional or radiographic differences were noted at the 6-month follow-up. DISCUSSION Compared with placebo, SABER-Bupivacaine reduced pain and opioid analgesic consumption over 72 hours after arthroscopic subacromial decompression and prolonged the time to first use of opioid rescue analgesia. No safety signals were noted during the immediate postoperative period or at 6-month follow-up.
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Affiliation(s)
- Anders Ekelund
- From the Department of Orthopaedics, Capio St Görans Hospital, Stockholm, Sweden (Dr. Ekelund); the Department of Orthopaedics, Clinic of Traumatology and Orthopaedics, Ādaži, Latvia (Dr. Peredistijs); the Department of Orthopaedics, Medical University of Vienna, Vienna, Austria (Dr. Grohs); DURECT Corporation, Cupertino, CA (Dr. Verity); Innocoll Biotherapeutics, Princeton, NJ (Dr. Meisner); and the Orthopaedic Research Unit, Aalborg University Hospital, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark (Dr. Rasmussen)
| | - Andrejs Peredistijs
- From the Department of Orthopaedics, Capio St Görans Hospital, Stockholm, Sweden (Dr. Ekelund); the Department of Orthopaedics, Clinic of Traumatology and Orthopaedics, Ādaži, Latvia (Dr. Peredistijs); the Department of Orthopaedics, Medical University of Vienna, Vienna, Austria (Dr. Grohs); DURECT Corporation, Cupertino, CA (Dr. Verity); Innocoll Biotherapeutics, Princeton, NJ (Dr. Meisner); and the Orthopaedic Research Unit, Aalborg University Hospital, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark (Dr. Rasmussen)
| | - Josef Grohs
- From the Department of Orthopaedics, Capio St Görans Hospital, Stockholm, Sweden (Dr. Ekelund); the Department of Orthopaedics, Clinic of Traumatology and Orthopaedics, Ādaži, Latvia (Dr. Peredistijs); the Department of Orthopaedics, Medical University of Vienna, Vienna, Austria (Dr. Grohs); DURECT Corporation, Cupertino, CA (Dr. Verity); Innocoll Biotherapeutics, Princeton, NJ (Dr. Meisner); and the Orthopaedic Research Unit, Aalborg University Hospital, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark (Dr. Rasmussen)
| | - Jon Meisner
- From the Department of Orthopaedics, Capio St Görans Hospital, Stockholm, Sweden (Dr. Ekelund); the Department of Orthopaedics, Clinic of Traumatology and Orthopaedics, Ādaži, Latvia (Dr. Peredistijs); the Department of Orthopaedics, Medical University of Vienna, Vienna, Austria (Dr. Grohs); DURECT Corporation, Cupertino, CA (Dr. Verity); Innocoll Biotherapeutics, Princeton, NJ (Dr. Meisner); and the Orthopaedic Research Unit, Aalborg University Hospital, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark (Dr. Rasmussen)
| | - Neil Verity
- From the Department of Orthopaedics, Capio St Görans Hospital, Stockholm, Sweden (Dr. Ekelund); the Department of Orthopaedics, Clinic of Traumatology and Orthopaedics, Ādaži, Latvia (Dr. Peredistijs); the Department of Orthopaedics, Medical University of Vienna, Vienna, Austria (Dr. Grohs); DURECT Corporation, Cupertino, CA (Dr. Verity); Innocoll Biotherapeutics, Princeton, NJ (Dr. Meisner); and the Orthopaedic Research Unit, Aalborg University Hospital, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark (Dr. Rasmussen)
| | - Sten Rasmussen
- From the Department of Orthopaedics, Capio St Görans Hospital, Stockholm, Sweden (Dr. Ekelund); the Department of Orthopaedics, Clinic of Traumatology and Orthopaedics, Ādaži, Latvia (Dr. Peredistijs); the Department of Orthopaedics, Medical University of Vienna, Vienna, Austria (Dr. Grohs); DURECT Corporation, Cupertino, CA (Dr. Verity); Innocoll Biotherapeutics, Princeton, NJ (Dr. Meisner); and the Orthopaedic Research Unit, Aalborg University Hospital, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark (Dr. Rasmussen)
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Reduction of Opioid Consumption After Outpatient Orthopaedic Trauma Surgeries Using a Multimodal Pain Protocol. J Am Acad Orthop Surg 2022; 30:e327-e335. [PMID: 34723860 DOI: 10.5435/jaaos-d-20-01417] [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] [Received: 01/02/2021] [Accepted: 09/22/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Because of the dearth of literature in the orthopaedic trauma population, we aimed to analyze how a multimodal pain protocol after outpatient surgery affects opioid consumption, pain scores, and patient satisfaction. METHODS This was a cohort study with a historical control at an urban level 1 trauma center. Forty consecutive outpatients were given a peripheral nerve block and a multimodal pain protocol between September 2019 and March 2020 and compared with 70 consecutive preprotocol patients who received a peripheral nerve block and hydrocodone-acetaminophen. The primary outcome was morphine milligram equivalents (MMEs) consumed. Our secondary aims were pain scores and satisfaction. RESULTS Patients in the protocol were younger (36.45 versus 45.09 years, P = 0.007), butthere was no difference in sex, body mass index, American Society of Anesthesiologists, or surgical duration. There was a 59% reduction in opioids consumed in the first 4 days after surgery (3.83 MME versus 9.29 MME, P < 0.001). At the postoperative day-14 time point, protocol patients consumed a total of 5.59 MMEs, which is 40% less than just the first 4 days of the preprotocol (P = 0.02). Protocol patients assigned a higher rating of "least pain" on postoperative day 1 (1.24 versus 0.52, P = 0.04) but had higher satisfaction scores on day 1 (9.68 versus 8.54, P < 0.001) and day 2 (9.66 versus 8.61, P < 0.001). CONCLUSION Implementation of a multimodal pain management protocol after outpatient orthopaedic trauma surgeries reduced opioid consumption by >50% in the first 4 days postoperatively. Additional studies are needed to refine the multimodal pain protocol used in this study. LEVEL OF EVIDENCE II.
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20
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Hippalgaonkar K, Chandak V, Daultani D, Mulpur P, Eachempati KK, Reddy AVG. Analgesic efficacy of single-shot adductor canal block versus adductor canal block combined with intra-articular ropivacaine infusion after total knee arthroplasty. Bone Jt Open 2021; 2:1082-1088. [PMID: 34931538 PMCID: PMC8711661 DOI: 10.1302/2633-1462.212.bjo-2021-0119.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Aims Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone. Methods This study was a prospective double-blinded placebo-controlled randomized controlled trial to compare the efficacy of combined ACB+ IAC-ropivacaine infusion (study group, n = 68) versus single-shot ACB+ intra-articular normal saline placebo (control group, n = 66) after primary TKA. The primary outcome was assessment of pain, using the visual analogue scale (VAS) recorded at 6, 12, 24, and 48 hours after surgery. Secondary outcomes included active knee ROM 48 hours after surgery and additional requirement of analgesia for breakthrough pain. Results The study group (mean visual analogue scale (VAS) pain score of 5.5 (SD 0.889)) experienced significant reduction in pain 12 hours after surgery compared to the control group (mean VAS 6.62 (SD 1.356); mean difference = 1.12, 95% confidence interval (CI) -1.46 to 0.67; p < 0.001), and pain scores on postoperative day (POD) 1 and POD-2 were lower in the study group compared to the control group (mean difference in VAS pain = 1.04 (-1.39 to -0.68, 95% CI, p < 0.001). Fewer patients in the study group (0 vs 3 in the control group) required additional analgesia for breakthrough pain, but this was not statistically significant. The study group had significantly increased active knee flexion (mean flexion 86.4° (SD 7.22°)), compared to the control group (mean 73.86° (SD 7.88°), mean difference = 12.54, 95% CI 9.97 to 15.1; p < 0.014). Conclusion Combined ACB+ ropivacaine infusion via IAC is a safe, reproducible analgesic modality after primary TKA, with superior analgesia compared to ACB alone. Further large volume trials are warranted to generate evidence on clinical significance on analgesia after TKA. Cite this article: Bone Jt Open 2021;2(12):1082–1088.
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Affiliation(s)
- Kushal Hippalgaonkar
- Sunshine Bone and Joint Institute, Department of Orthopaedics, Sunshine Hospitals, Secunderabad, India
| | - Vivek Chandak
- Sunshine Bone and Joint Institute, Department of Orthopaedics, Sunshine Hospitals, Secunderabad, India
| | - Deepesh Daultani
- Sunshine Bone and Joint Institute, Department of Orthopaedics, Sunshine Hospitals, Secunderabad, India
| | - Praharsha Mulpur
- Sunshine Bone and Joint Institute, Department of Orthopaedics, Sunshine Hospitals, Secunderabad, India
| | | | - A V Gurava Reddy
- Sunshine Bone and Joint Institute, Department of Orthopaedics, Sunshine Hospitals, Secunderabad, India
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21
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Zhang S, Kong X, Chai W. [Opioids in primary total joint arthroplasty: Interpretation of 2020 AAHKS/ASRA/AAOS/THS/TKS clinical practice guidelines]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1396-1402. [PMID: 34779164 DOI: 10.7507/1002-1892.202103090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
In 2020, the American Association of Hip and Knee Surgeons (AAHKS), the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Orthopaedic Surgeons (AAOS), the American Hip Society (THS), the American Knee Society (TKS) have worked together to develop clinical practice guidelines on the use of Opioids in primary total joint arthroplasty (TJA). This clinical practice guideline formulates recommendations for common and important questions related to the efficacy and safety of Opioids in primary TJA. This article interprets the guideline to help doctors make clinical decisions.
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Affiliation(s)
- Shuai Zhang
- Medical School of Chinese PLA, Beijing, 100853, P.R.China.,Senior Department of Orthopedics, the Forth Medical Center of Chinese PLA General Hospital, Beijing, 100048, P.R.China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, P.R.China
| | - Xiangpeng Kong
- Senior Department of Orthopedics, the Forth Medical Center of Chinese PLA General Hospital, Beijing, 100048, P.R.China
| | - Wei Chai
- Senior Department of Orthopedics, the Forth Medical Center of Chinese PLA General Hospital, Beijing, 100048, P.R.China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, P.R.China
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22
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Chaturvedi R, Tram J, Chakravarthy K. Reducing opioid usage in total knee arthroplasty postoperative pain management: a literature review and future directions. Pain Manag 2021; 12:105-116. [PMID: 34551582 DOI: 10.2217/pmt-2020-0107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Total knee arthroplasty (TKA) is a common orthopedic surgery performed with a projected 3.5 million procedures to be done by 2030. Current postoperative pain management for TKA is insufficient, as it results in extensive opioid consumption and functional decline postoperatively. This study identifies the best practices for postoperative TKA pain management through a literature review of the last three years. Studies utilizing interventional techniques (local infiltration analgesia, nerve blocks) and pharmacologic options were reviewed on PubMed, Embase, Ovid Medline and Scopus. Primary outcomes analyzed were the effect of different analgesic approaches on pain reduction, opioid use reduction and improvements in functional mobility or quadriceps strength postoperatively. Additionally, this paper explores the use of cooled radiofrequency ablation, a minimally invasive therapy, for preoperative and postoperative TKA pain management.
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Affiliation(s)
- Rahul Chaturvedi
- Department of Anesthesiology, Division of Pain Medicine, University of California San Diego, 9400 Campus Point Dr, La Jolla, CA 92037, USA
| | - Jennifer Tram
- Department of Anesthesiology, Division of Pain Medicine, University of California San Diego, 9400 Campus Point Dr, La Jolla, CA 92037, USA
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Acuña AJ, Mengers SR, Raji Y, Janes JL, Gillespie RJ, Voos JE, Karns MR. Opioid-prescribing patterns among shoulder and elbow surgeons: considerations for future prescription guidelines. J Shoulder Elbow Surg 2021; 30:e531-e538. [PMID: 33421561 DOI: 10.1016/j.jse.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/13/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although the achievement of adequate analgesia is critical to patient comfort and recovery following orthopedic procedures, no standard protocol exists to dictate the appropriate duration and quantity of narcotic prescription in the postoperative period. Therefore, the purpose of this survey was to determine patterns of opioid prescribing among orthopedic shoulder and elbow providers. METHODS In March 2020, a survey was distributed through a LISTSERV to 989 members of the American Shoulder and Elbow Surgeons orthopedic society. Survey recipients were asked to describe their personal and practice characteristics. Additionally, they were asked to list their 3 most commonly performed procedures and, for each operation, to list which narcotic pain medication they most commonly prescribe postoperatively, along with the corresponding number of tablets typically given. Similarly, respondents were asked to record frequently recommended alternative strategies for postoperative pain control, factors influencing the respondents' prescribing practices, and methods of patient counseling regarding opioid use and disposal. RESULTS A total of 177 providers responded to the survey. Across all selected procedures, Percocet (5 mg of oxycodone hydrochloride and 325 mg of acetaminophen) was the most commonly prescribed drug, with 21-30 tablets being the most commonly prescribed amount. The majority of surgeons (82%) indicated that previous opioid prescriptions influence their decision to prescribe opioids. Respondents most frequently reported patient age (48%) and duration of the patient's symptoms (32%) as additional influential factors. Most surgeons (93%) reported counseling their patients regarding the use of opioid medications. However, only 30% of surgeons reported providing information regarding how to dispose of unused opioids. In lieu of opioids, nearly all investigators reported the use of ice as a pain-relief strategy, with rest and the use of nonsteroidal anti-inflammatory drugs reported as other commonly recommended alternatives. Of 137 respondents who were aware of prescription guidelines, 21% reported using recommendations from the American Academy of Orthopaedic Surgeons, 21% used institutional policies, and 20% used personal guidelines, whereas the remaining respondents used other literature findings in their prescription decisions. Of particular concern, 21% of overall respondents were unaware of any type of guidelines. DISCUSSION To prevent both misuse and abuse of opioid prescribing, this analysis serves as a starting point for the establishment of more consistent, evidence-based opioid prescription guidelines for surgical procedures on the shoulder and elbow. In addition to recommending safe, procedure-specific opioid dosages and standardizing pain management strategies, these guidelines should include effective methods of educating both providers and patients regarding the use of opioid medication.
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Affiliation(s)
- Alexander J Acuña
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Sunita R Mengers
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Yazdan Raji
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jessica L Janes
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Robert J Gillespie
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - James E Voos
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Michael R Karns
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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24
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Wignadasan W, Thompson JW, Ibrahim M, Kayani B, Magan A, Haddad FS. Day-case unicompartmental knee arthroplasty: a literature review and development of a novel hospital pathway. Ann R Coll Surg Engl 2021; 104:165-173. [PMID: 34323112 DOI: 10.1308/rcsann.2021.0090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We have seen unparalleled changes in our healthcare systems globally as a result of the COVID-19 pandemic. As we strive to regenerate our full capacity elective services in order to contest the increasing demand for lower limb arthroplasty, this pandemic has allowed us a rare opportunity to revise and develop novel elective arthroplasty pathways intended to improve patient care and advance healthcare efficiency. We present an extensive evidence-based review of the approaches used to achieve day-case unicompartmental arthroplasty (UKA) as well as the development of a day-case UKA care pathway in a UK NHS institution based on the evidence provided in the literature. METHODS An extensive search of the literature was performed for articles that reported on readmission or complication rates ≥30 days postoperatively following day-case UKA. FINDINGS Fifteen manuscripts reporting the results of day-case UKA, defined as discharged on the same calendar day of surgery, were included in our review. Mean reported complication rates for day-case and inpatient UKA within the follow-up periods were 4.05% and 6.52%, respectively. Mean readmission rates were 2.71% and 4.36% for day-case and inpatient UKA, respectively. The mean rate of successful same-day discharge was 92.45%. CONCLUSION We introduce our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) founded upon the evidence presented in the literature. Stringent patient selection complimented by a well-defined day-case arthroplasty pathway is fundamental for successful commencement of day-case UKA in the NHS.
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Affiliation(s)
| | - J W Thompson
- University College London Hospitals, UK.,The Princess Grace Hospital, UK
| | - M Ibrahim
- University College London Hospitals, UK.,The Princess Grace Hospital, UK
| | - B Kayani
- University College London Hospitals, UK.,The Princess Grace Hospital, UK
| | - A Magan
- University College London Hospitals, UK
| | - F S Haddad
- University College London Hospitals, UK.,The Princess Grace Hospital, UK
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25
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Berkowitz RD, Steinfeld R, Sah AP, Anupindi VR, Shah D, DeKoven M, Coyle K, McCallum SW, Mack R, Coyle E, Freyer A, Du W, Black LK. Economic Impact of Preoperative Meloxicam IV Administration in Total Knee Arthroplasty: A Randomized Trial Sub-Study. J Pain Palliat Care Pharmacother 2021; 35:150-162. [PMID: 34280067 DOI: 10.1080/15360288.2021.1883789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We evaluated the economic impact associated with preoperative meloxicam IV 30 mg vs placebo administration among adult total knee arthroplasty (TKA) recipients enrolled in Phase IIIB NCT03434275 trial. Data on total hospital costs and length of stay (LOS) obtained from the trial were compared between meloxicam IV 30 mg and placebo groups. Patients in the meloxicam IV 30 mg vs placebo group (n = 93 vs 88) incurred an adjusted $2,266 (95% CI: -$1,035, $5,116; p = 0.1689) lower total hospital costs and an adjusted 8.6% (95% confidence interval [CI]: -2.0%, 18.1%; p = 0.1082) shorter LOS. While statistically non-significant, based on 95% CIs, the results from this sub-study may suggest a favorable impact associated with meloxicam IV 30 mg on hospital costs and LOS.
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Affiliation(s)
- Richard D Berkowitz
- Richard D. Berkowitz, MD, FAAOS is with University Orthopedic and Joint Replacement Center, University Hospital, Tamarac, FL
| | - Richard Steinfeld
- Richard Steinfeld, MD is with Orthopedic Center of Vero Beach, Vero Beach, FL
| | - Alexander P Sah
- Alexander P. Sah, MD, FAAOS is with Institute for Joint Restoration, Washington Hospital, Fremont, CA
| | - Vamshi Ruthwik Anupindi
- Vamshi Ruthwik Anupindi, MS, Drishti Shah, MS, PhD, Mitch DeKoven, MHSA, and Katharine Coyle, BA are with IQVIA, Falls Church, VA
| | - Drishti Shah
- Vamshi Ruthwik Anupindi, MS, Drishti Shah, MS, PhD, Mitch DeKoven, MHSA, and Katharine Coyle, BA are with IQVIA, Falls Church, VA
| | - Mitch DeKoven
- Vamshi Ruthwik Anupindi, MS, Drishti Shah, MS, PhD, Mitch DeKoven, MHSA, and Katharine Coyle, BA are with IQVIA, Falls Church, VA
| | - Katharine Coyle
- Vamshi Ruthwik Anupindi, MS, Drishti Shah, MS, PhD, Mitch DeKoven, MHSA, and Katharine Coyle, BA are with IQVIA, Falls Church, VA
| | - Stewart W McCallum
- Stewart W. McCallum, MD FACS, Randall Mack, BS, Erin Coyle, BA, BSN, Alex Freyer, PharmD, and Libby K. Black, PharmD are with Baudax Bio, Inc., formerly part of Recro Pharma, Inc, Malvern, PA
| | - Randall Mack
- Stewart W. McCallum, MD FACS, Randall Mack, BS, Erin Coyle, BA, BSN, Alex Freyer, PharmD, and Libby K. Black, PharmD are with Baudax Bio, Inc., formerly part of Recro Pharma, Inc, Malvern, PA
| | - Erin Coyle
- Stewart W. McCallum, MD FACS, Randall Mack, BS, Erin Coyle, BA, BSN, Alex Freyer, PharmD, and Libby K. Black, PharmD are with Baudax Bio, Inc., formerly part of Recro Pharma, Inc, Malvern, PA
| | - Alex Freyer
- Stewart W. McCallum, MD FACS, Randall Mack, BS, Erin Coyle, BA, BSN, Alex Freyer, PharmD, and Libby K. Black, PharmD are with Baudax Bio, Inc., formerly part of Recro Pharma, Inc, Malvern, PA
| | - Wei Du
- Wei Du, PhD is with Clinical Statistics Consulting, Blue Bell, PA
| | - Libby K Black
- Stewart W. McCallum, MD FACS, Randall Mack, BS, Erin Coyle, BA, BSN, Alex Freyer, PharmD, and Libby K. Black, PharmD are with Baudax Bio, Inc., formerly part of Recro Pharma, Inc, Malvern, PA
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26
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Hinther A, Rasool A, Nakoneshny SC, Chandarana SP, Hart R, Matthews TW, Dort JC. Chronic opioid use following surgery for head and neck cancer patients undergoing free flap reconstruction. J Otolaryngol Head Neck Surg 2021; 50:28. [PMID: 33892825 PMCID: PMC8066487 DOI: 10.1186/s40463-021-00508-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 03/08/2021] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Physician opioid-prescribing patterns have significant impacts on the current opioid crisis. Patients who use opioids in the postoperative period are at risk of developing chronic postoperative opioid use. This study determined the rate of chronic postoperative opioid use among head and neck cancer patients undergoing primary surgery with free-flap reconstruction. Additionally, this study identified major risk factors associated with the development of chronic postoperative opioid use. METHODS A retrospective chart review was performed for all adults (age ≥ 18 years) undergoing primary head and neck surgical resection with free-flap reconstruction between January 2008 and December 2015. Patients were identified from a prospectively collected database, Otobase™. Data from the provincial drug insurance program were used to capture drug dispensing information to determine chronic opioid use at 3- and 12-months postoperatively. Data extracted from Otobase™ included patient demographics, social habits, clinical stage, pathological stage, type of surgery, and adjuvant treatment. RESULTS The total cohort was comprised of 212 patients. Chronic opioid use at 3- and 12- months postoperatively was observed in 136 (64%) and 116 (55%) patients, respectively. Of the 212 patients, 85 patients (40%) were identified as preoperative opioid users and 127 were opioid naïve (60%). Of the 85 patients who were preoperative opioid users, 70 (82%) and 63 (77%) patients continued to use opioids 3- and 12-months postoperatively, respectively. The proportion of opioid-naïve patients who were using opioids at 3- and 12-months postoperatively was 52% (66 patients) and 42% (53 patients), respectively. Identified risk factors included preoperative opioid use, prior tobacco use, advanced pathologic T-stage, and adjuvant treatment. CONCLUSIONS Among head and neck cancer patients that have undergone major resection with free-flap reconstruction, the prevalence of chronic postoperative opioid users was considerable. Identified risk factors included preoperative opioid use, prior tobacco use, tumor stage, and adjuvant treatment.
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Affiliation(s)
- Ashley Hinther
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Alysha Rasool
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Steven C Nakoneshny
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shamir P Chandarana
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert Hart
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - T Wayne Matthews
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joseph C Dort
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery, Cumming School of Medicine, University of Calgary, HRIC 2A02 3280 Hospital Dr NW, Calgary, Alberta, T2N 4Z6, Canada.
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Thompson JW, Wignadasan W, Ibrahim M, Plastow R, Beasley L, Haddad FS. The introduction of day-case total knee arthroplasty in a national healthcare system: A review of the literature and development of a hospital pathway. Surgeon 2021; 20:103-114. [PMID: 33766461 DOI: 10.1016/j.surge.2021.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/16/2021] [Accepted: 01/30/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION As we now drive to reinitiate our full capacity elective services in an attempt to tackle an ever-growing demand for lower limb arthroplasty, this pandemic has presented rare opportunities to revise and re-engage elective arthroplasty pathways aimed at improving patient care and healthcare efficiency. AIMS We present the development of an evidence-based multidisciplinary perioperative care pathway for day-case total knee arthroplasty (TKA) in a United Kingdom National Health Service (NHS) institution, in conjunction with a review of the literature upon which the protocol is founded. METHODOLOGY We performed a review of the literature reporting complication or readmission rates at ≥30 day postoperative following day-case TKA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed. RESULTS 13 manuscripts with a total of 3370 day-case TKAs, defined as discharged on the same-calendar-day of surgery, were included in analysis. Mean 90-day complication rates (8.31% [range, 0-16.3%] vs 9.49% [range, 0-13.1%], respectively) and readmission rates (2.71% [range, 0-10.0%] vs 3.41% [range, 0-9.9%], respectively) were equivocal between day-case and inpatient TKA. The overall rate of successful same-calendar-day discharge was 95.8%. Our evaluation and critique of the evidence-based literature identifies day-case TKA to be safe, effective and economical, benefitting both patients and healthcare systems alike. CONCLUSION We further validate the introduction of our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) based on the evidence presented. Careful patient selection paralleled with well-defined care pathways are essential for successful introduction of day-case TKA into the NHS.
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Affiliation(s)
- Joshua W Thompson
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, 250 Euston Road, Fitzrovia, London, NW1 2PG, United Kingdom.
| | - Warran Wignadasan
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, 250 Euston Road, Fitzrovia, London, NW1 2PG, United Kingdom
| | - Mazin Ibrahim
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, 250 Euston Road, Fitzrovia, London, NW1 2PG, United Kingdom
| | - Ricci Plastow
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, 250 Euston Road, Fitzrovia, London, NW1 2PG, United Kingdom
| | - Lucy Beasley
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, 250 Euston Road, Fitzrovia, London, NW1 2PG, United Kingdom
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, 250 Euston Road, Fitzrovia, London, NW1 2PG, United Kingdom
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Albertz M, Whitlock P, Yang F, Ding L, Uchtman M, Mecoli M, Olbrecht V, Moore D, McCarthy J, Chidambaran V. Pragmatic comparative effectiveness study of multimodal fascia iliaca nerve block and continuous lumbar epidural-based protocols for periacetabular osteotomy. J Hip Preserv Surg 2021; 7:728-739. [PMID: 34377516 PMCID: PMC8349585 DOI: 10.1093/jhps/hnab010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/25/2022] Open
Abstract
Perioperative pain management protocols have a significant impact on early surgical outcomes and recovery. We hypothesized that multimodal protocol including fascia iliaca compartment nerve block (MM-FICNB) would decrease the length of hospital stay (LOS) by facilitating earlier mobilization, without compromising analgesia, compared to a traditional lumbar epidural-based protocol (EP). Demographics/comorbidities, surgical/block characteristics and perioperative pain/mobilization data were collected from a prospectively recruited MM-FICNB group (N = 16) and a retrospective EP cohort (N = 16) who underwent PAO using similar surgical techniques, physical therapy/discharge criteria. Association of MM-FICNB group with LOS (primary outcome), postoperative pain, postoperative opioid requirements in morphine equivalent rates (MER) (mcg/kg/h) and time to complete physical therapy were tested using multivariable and survival regression. Patient and surgical characteristics were similar between groups. Median time for FICNB performance was significantly less than epidural (6 versus 15 min; P < 0.001). LOS was significantly decreased in the MM-FICNB group (2.88 ± 0.72 days) compared to the EP group (4.38 ± 1.02 days); P < 0.001. MM-FICNB group had significantly lower MER on POD1 (P = 0.006) and POD2 (P < 0.001), with similar pain scores on all POD. MM-FICNB group was associated with decreased LOS and earlier mobilization (P < 0.001) by covariate-adjusted multivariate regression. Cox proportional hazard regression model showed MM-FICNB subjects had 63 (95% CI 7–571, P < 0.001) times the chance of completing physical therapy goals, compared to EP. Compared to EP, MM-FICNB protocol allowed earlier mobilization and decreased post-surgical hospitalization by 1.5 days, without compromising analgesia, with important implications for value-based healthcare and cost-effectiveness.
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Affiliation(s)
- Megan Albertz
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Patrick Whitlock
- Department of Orthopedics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Fang Yang
- Division of Biostatistics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Lili Ding
- Division of Biostatistics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Molly Uchtman
- Department of Orthopedics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Marc Mecoli
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Vanessa Olbrecht
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - David Moore
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - James McCarthy
- Department of Orthopedics, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA
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Thompson JW, Wignadasan W, Ibrahim M, Beasley L, Konan S, Plastow R, Magan A, Haddad FS. Day-case total hip arthroplasty: a literature review and development of a hospital pathway. Bone Jt Open 2021; 2:93-102. [PMID: 33573396 PMCID: PMC7925215 DOI: 10.1302/2633-1462.22.bjo-2020-0170.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Aims We present the development of a day-case total hip arthroplasty (THA) pathway in a UK National Health Service institution in conjunction with an extensive evidence-based summary of the interventions used to achieve successful day-case THA to which the protocol is founded upon. Methods We performed a prospective audit of day-case THA in our institution as we reinitiate our full capacity elective services. In parallel, we performed a review of the literature reporting complication or readmission rates at ≥ 30-day postoperative following day-case THA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed. Results Our evaluation and critique of the evidence-based literature identifies day-case THA to be safe, effective, and economical, benefiting both patients and healthcare systems alike. We further validate this with our institutional elective day surgery arthroplasty pathway (EDSAP) and report a small cohort of successful day-case THA cases as an example in the early stages of this practice in our unit. Conclusion Careful patient selection and education, adequate perioperative considerations, including multimodal analgesia, surgical technique and blood loss management protocols and appropriate postoperative pathways comprising reliable discharge criteria are essential for successful day-case THA. Cite this article: Bone Jt Open 2021;2(2):93–102.
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Affiliation(s)
- Joshua W Thompson
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Warran Wignadasan
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Mazin Ibrahim
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Lucy Beasley
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Sujith Konan
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Ricci Plastow
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Ahmed Magan
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospital Foundation NHS Trust, London, UK.,The Princess Grace Hospital, London, UK
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Krauss E, Cronin M, Dengler N, Segal A. Interaction Between Low-Dose Aspirin and Nonsteroidal Anti-Inflammatory Drugs Can Compromise Aspirin's Efficacy in Preventing Venous Thrombosis Following Total Joint Arthroplasty. Clin Appl Thromb Hemost 2021; 26:1076029620920373. [PMID: 32453611 PMCID: PMC7370567 DOI: 10.1177/1076029620920373] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Total joint arthroplasty is a rapid recovery procedure with patients optimized quickly in preparation for discharge. Two significant postoperative goals are effective pain management and prevention of postoperative venous thromboembolism (VTE). Low-risk patients receive aspirin 81 mg twice daily for VTE prophylaxis; this dosing regimen has been reduced over the past few years from 325 mg to 162 mg to 81 mg twice daily. Unless contraindications exist, all patients receive multimodal pain management that includes the use of celecoxib or meloxicam. Upon reduction of the aspirin dose to 81 mg twice daily, we rapidly identified 2 patients who developed a pulmonary embolus when celecoxib or meloxicam was administered concurrently with aspirin. The interaction between nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin varies among the different NSAIDs. It is also highly dependent on numerous factors, including time of administration, dose of aspirin, and both pharmacodynamics and dose of the NSAID. Real-world outcomes of concomitant administration of NSAIDs with low-dose aspirin led to increased incidence of VTE, possibly due to competitive inhibition of aspirin at platelet receptor sites. This interaction was mitigated by altering the administration times of both agents.
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Affiliation(s)
- Eugene Krauss
- Syosset Hospital, Northwell Health, New York Orthopaedic and Spine Center, Great Neck, NY, USA.,Zucker School of Medicine at Hofstra/Northwell, Hofstra University School of Medicine, New York Orthopaedic and Spine Center, Great Neck, NY, USA.,Syosset Hospital, Northwell Health, Syosset, NY, USA
| | | | - Nancy Dengler
- Syosset Hospital, Northwell Health, Syosset, NY, USA
| | - Ayal Segal
- Syosset Hospital, Northwell Health, New York Orthopaedic and Spine Center, Great Neck, NY, USA.,Syosset Hospital, Northwell Health, Syosset, NY, USA
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Financial and Clinical Ramifications of Introducing a Novel Pediatric Enhanced Recovery After Surgery Pathway for Pediatric Complex Hip Reconstructive Surgery. Anesth Analg 2021; 132:182-193. [PMID: 32665473 DOI: 10.1213/ane.0000000000004980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Enhanced recovery after surgery pathways confer significant perioperative benefits to patients and are currently well described for adult patients undergoing a variety of surgical procedures. Robust data to support enhanced recovery pathway use in children are relatively lacking in the medical literature, though clinical benefits are reported in targeted pediatric surgical populations. Surgery for complex hip pathology in the adolescent patient is painful, often requiring prolonged courses of opioid analgesia. Postoperative opioid-related side effects may lead to prolonged recovery periods and suboptimal postoperative physical function. Excessive opioid use in the perioperative period is also a major risk factor for the development of opioid misuse in adolescents. Perioperative opioid reduction strategies in this vulnerable population will help to mitigate this risk. METHODS A total of 85 adolescents undergoing complex hip reconstructive surgery were enrolled into an enhanced recovery after surgery pathway (October 2015 to December 2018) and were compared with 110 patients undergoing similar procedures in previous years (March 2010 to September 2015). The primary outcome was total perioperative opioid consumption. Secondary outcomes included hospital length of stay, postoperative nausea, intraoperative blood loss, and other perioperative outcomes. Total cost of care and specific charge sectors were also assessed. Segmented regression was used to assess the effects of pathway implementation on outcomes, adjusting for potential confounders, including the preimplementation trend over time. RESULTS Before pathway implementation, there was a significant downward trend over time in average perioperative opioid consumption (-0.10 mg total morphine equivalents/90 days; 95% confidence interval [CI], -0.20 to 0.00) and several secondary perioperative outcomes. However, there was no evidence that pathway implementation by itself significantly altered the prepathway trend in perioperative opioid consumption (ie, the preceding trend continued). For postanesthesia care unit time, the downward trend leveled off significantly (pre: -5.25 min/90 d; 95% CI, -6.13 to -4.36; post: 1.04 min/90 d; 95% CI, -0.47 to 2.56; Change: 6.29; 95% CI, 4.53-8.06). Clinical, laboratory, pharmacy, operating room, and total charges were significantly associated with pathway implementation. There was no evidence that pathway implementation significantly altered the prepathway trend in other secondary outcomes. CONCLUSIONS The impacts of our pediatric enhanced recovery pathway for adolescents undergoing complex hip reconstruction are consistent with the ongoing improvement in perioperative metrics at our institution but are difficult to distinguish from the impacts of other initiatives and evolving practice patterns in a pragmatic setting. The ERAS pathway helped codify and organize this new pattern of care, promoting multidisciplinary evidence-based care patterns and sustaining positive preexisting trends in financial and clinical metrics.
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Previtali D, Di Laura Frattura G, Filardo G, Delcogliano M, Deabate L, Candrian C. Peri-operative steroids reduce pain, inflammatory response and hospitalisation length following knee arthroplasty without increased risk of acute complications: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2021; 29:59-81. [PMID: 31494685 DOI: 10.1007/s00167-019-05700-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/28/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE There is no consensus regarding the risks and benefits of peri-operative steroid supplementation in total knee arthroplasty (TKA). The aim of this meta-analysis is to compare TKA protocols implemented with or without steroids in terms of pain, inflammatory response, hospitalisation length, and complications. METHODS A systematic literature search was performed on July 2019 in PubMed, Medline, Embase, Web of Science, Cochrane library, and the grey literature for a meta-analysis of RCTs comparing peri-operative analgesia protocols implemented with or without steroids. Sub-analyses considering the administration route, steroid type, and dosage were performed. The inverse variance method and the Mantel-Haenszel test were used for pooling continuous variables and for dichotomous variables, respectively. Risk of bias and quality of evidence were defined according to the Cochrane guidelines. RESULTS Twenty articles were included. Steroid supplementation provides significantly lower post-operative pain from day 1 to day 4 (p < 0.05), with less opioid consumption (p = 0.05), less nausea and vomiting (p < 0.05), and greater knee range of motion (p < 0.001), thus resulting in a shorter hospitalisation length (p = 0.01). Moreover, lower C-reactive protein (p < 0.05), and IL-6 (p < 0.05) levels, but a higher blood glucose level at day 1 (p = 0.004), were documented. No significant differences were documented in all the outcomes after 4 days of follow-up. These results were achieved without an increased incidence of complications. According to the results of the sub-analyses, the intravenous administration of 200 steroid equivalents of a long-acting steroid was associated with better results. CONCLUSION Steroid supplementation of peri-operative drug protocols is effective in decreasing post-operative pain, opioid consumption, nausea and vomiting, range of motion limitation, and inflammatory markers without increasing short- and mid-term complications. Although these benefits last only the peri-operative period, steroid supplementation can reduce the length of hospitalisation after TKA. LEVEL OF EVIDENCE Systematic review and meta-analysis, level II.
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Affiliation(s)
- Davide Previtali
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Giorgio Di Laura Frattura
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland.
| | - Giuseppe Filardo
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
- ATRC, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Delcogliano
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Luca Deabate
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
| | - Christian Candrian
- Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Via Tesserete 46, 6900, Lugano, Switzerland
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Hannon CP, Fillingham YA, Browne JA, Schemitsch EH, Mullen K, Casambre F, Visvabharathy V, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Gabapentinoids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2020; 35:2730-2738.e6. [PMID: 32586656 DOI: 10.1016/j.arth.2020.05.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Gabapentinoids are commonly used as an adjunct to traditional pain management strategies after total joint arthroplasty (TJA). The purpose of this study is to evaluate the efficacy and safety of gabapentinoids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. METHODS The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched for studies published prior to November 2018 on gabapentinoids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of gabapentinoids. RESULTS In total, 384 publications were critically appraised to provide 13 high-quality studies regarded as the best available evidence for analysis. In the perioperative period prior to discharge, pregabalin reduces postoperative opioid consumption, but gabapentinoids do not reduce postoperative pain. After discharge, gabapentin does not reduce postoperative pain or opioid consumption, but pregabalin reduces both postoperative pain and opioid consumption. CONCLUSION Moderate evidence supports the use of pregabalin in TJA to reduce postoperative pain and opioid consumption. Gabapentinoids should be used with caution, however, as they may lead to an increased risk of sedation and respiratory depression especially when combined with other central nervous system depressants such as opioids.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Emil H Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Kyle Mullen
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Francisco Casambre
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Vidya Visvabharathy
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - William G Hamilton
- Department of Orthopaedic Surgery, Anderson Orthopedic Research Institute, Alexandria, VA
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Hannon CP, Fillingham YA, Nam D, Courtney PM, Curtin BM, Vigdorchik J, Mullen K, Casambre F, Riley C, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Opioids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2020; 35:2759-2771.e13. [PMID: 32571589 DOI: 10.1016/j.arth.2020.05.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Opioids are frequently used to treat pain after total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of opioids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. METHODS The MEDLINE, EMBASE, and Cochrane Central Register of controlled trials were searched for studies published before November 2018 on opioids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of opioids. RESULTS Preoperative opioid use leads to increased opioid consumption and complications after TJA along with a higher risk of chronic opioid use and inferior patient-reported outcomes. Scheduled opioids administered preemptively, intraoperatively, or postoperatively reduce the need for additional opioids for breakthrough pain. Prescribing fewer opioid pills after discharge is associated with equivalent functional outcomes and decreased opioid consumption. Tramadol reduces postoperative opioid consumption but increases the risk of postoperative nausea, vomiting, dry mouth, and dizziness. CONCLUSION Moderate evidence supports the use of opioids in TJA to reduce postoperative pain and opioid consumption. Opioids should be used cautiously as they may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other central nervous system depressants or used in the elderly.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Denis Nam
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - P Maxwell Courtney
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | | | - Jonathan Vigdorchik
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Kyle Mullen
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Francisco Casambre
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Connor Riley
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Preoperative Gabapentin Administration and Its Impact on Postoperative Opioid Requirement and Pain in Sinonasal Surgery. Otolaryngol Head Neck Surg 2020; 164:889-894. [DOI: 10.1177/0194599820952805] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objective To determine the efficacy of preoperative gabapentin on patient-reported pain levels and postoperative opioid requirements following sinonasal surgery. Study Design Retrospective review. Setting Academic institution. Methods Patients undergoing sinonasal surgery between July 2019 and January 2020 were followed. Groups were divided into those that received 600 mg of oral gabapentin 1 hour preoperatively (gabapentin) and those that did not (control). Postoperatively, each patient was counseled to use acetaminophen, ibuprofen, and oxycodone as needed for pain control. Patients completed a daily postoperative pain and medication log. Pain was measured by the visual analog scale (VAS) and opioid use by morphine equivalent dose (MED). Chi-square test and Wilcoxon test were used for data analysis. Results Fifty-seven patients were included (control, n = 28; gabapentin, n = 29). There was no significant difference in age, sex, or baseline Sinonasal Outcome Test–22 scores between the groups. The total MED, postoperative day (POD) 1-2 MED, POD 3-4 MED, and POD 5-6 MED did not differ significantly between the control (17.9, 12.2, 4.6, 1.5) and gabapentin (19.0, 8.9, 7.2, 3.5) groups ( P = .98, .25, .16, .44). The mean daily VAS score did not differ significantly between the control (3.1) and gabapentin (2.8) groups ( P = .81). The mean daily VAS score decreased significantly in both groups with each successive POD ( P = .004). Conclusion Preoperative gabapentin did not significantly reduce postoperative pain or opioid use. Postoperative discomfort following sinonasal surgery is mild, and opioid intake is minimal.
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Sodhi N, Anis HK, Acuña AJ, Vakharia RM, Gold PA, Garbarino LJ, Mahmood BM, Ehiorobo JO, Grossman EL, Higuera CA, Roche MW, Mont MA. Opioid Use Disorder Is Associated with an Increased Risk of Infection after Total Joint Arthroplasty: A Large Database Study. Clin Orthop Relat Res 2020; 478:1752-1759. [PMID: 32662956 PMCID: PMC7371033 DOI: 10.1097/corr.0000000000001390] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 06/09/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent studies have shown that patients with opioid use disorder have impaired immunity. However, few studies with large patient populations have evaluated the risks of surgical site infection (SSI) and prosthetic joint infection (PJI) with opioid use disorder after total joint arthroplasty (TJA), and there is a lack of evidence for revision TJA in particular. QUESTIONS/PURPOSES Are patients with opioid use disorder who undergo (1) primary THA, (2) primary TKA, (3) revision THA, or (4) revision TKA at a higher risk of experiencing SSIs 90 days after surgery or PJIs 2 years after surgery than those who do not have opioid use disorder? METHODS All primary and revision TJAs performed between 2005 and 2014 were identified from the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is one of the largest nationwide databases; it comprehensively and longitudinally tracks patients based on all insurance claims rather than particular hospital visits, and has a low error rate (estimated at 1.3%). Boolean command operators were used to form a study group of patients with a history of opioid use disorder before surgery. ICD-9 diagnosis codes 304.00 to 304.02 and 305.50 to 305.52 were used to identify patients with opioid use disorder. Study group patients were matched 1:1 to control participants without opioid use disorder undergoing TJA, according to age, sex, and comorbidity burden (Elixhauser comorbidity index [ECI]). The ECI is comprised of 31 different comorbidities and can be used for large administrative databases. The query yielded a study population of 54,332 patients: 14,944 undergoing primary THA (opioid use disorder: n = 7472), 23,680 undergoing primary TKA (opioid use disorder: n = 11,840), 8116 undergoing revision THA (opioid use disorder: n = 4058), and 7592 undergoing revision TKA (opioid use disorder: n = 3796). The primary outcomes analyzed were SSI at 90 days and PJI at 2 years postoperatively, which were identified with ICD-9 codes. Logistic regression analyses were performed to calculate the risk that an infection would develop in a patient with opioid use disorder compared with the matched control patients without opioid use disorder. RESULTS Patients with opioid use disorder undergoing primary THA had an increased risk of SSI at 90 days (OR 1.85 [95% CI 1.51 to 2.25]; p < 0.001) and PJI at 2 years (OR 1.66 [95% CI 1.42 to 1.93]; p < 0.001). Compared with matched controls, opioid use disorder patients undergoing primary TKA had an increased risk of SSI at 90 days (OR 1.72 [95% CI 1.46 to 2.02]; p < 0.001) and PJI at 2 years (OR 1.31 [95% CI 1.16 to 1.47]; p < 0.001). Similarly, for revision THAs, there was an increase in 90-day SSIs (OR 1.89 [95% CI 1.53 to 2.32]; p < 0.001) and 2-year PJIs (OR 4.24 [95% CI 3.67 to 4.89]; p < 0.001). The same held for revision TKAs for 90-day SSIs (OR 1.88 [95% CI 1.53 to 2.29]; p < 0.001) and 2-year PJIs (OR 4.94 [95% CI 4.24 to 5.76]; p < 0.001). CONCLUSIONS After accounting for age, sex, and comorbidity burden, these results revealed that patients with opioid use disorder undergoing TJA were at increased risk of having SSIs and PJIs. Based on these findings, healthcare systems and/or administrators should recognize the increased associated PJI and SSI risks in patients with opioid use disorder and enact clinical policies that reflect these associated risks. Additionally, these findings should encourage surgeons to pursue multidisciplinary approaches to help patients reduce their opioid consumption before their arthroplasty procedure. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Nipun Sodhi
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Hiba K Anis
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alexander J Acuña
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rushabh M Vakharia
- R. M. Vakharia, M. W. Roche, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Peter A Gold
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Luke J Garbarino
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Bilal M Mahmood
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Joseph O Ehiorobo
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
| | - Eric L Grossman
- E. L. Grossman, Rothman Orthopaedic Institute, New York, NY, USA
| | - Carlos A Higuera
- H. K. Anis, A. J. Acuña, B. M. Mahmood, C. A. Higuera, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Martin W Roche
- R. M. Vakharia, M. W. Roche, Holy Cross Hospital, Fort Lauderdale, FL, USA
| | - Michael A Mont
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA
- N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Long Island Jewish Medical Center, New York, NY, USA
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Pedersen C, Troensegaard H, Laigaard J, Koyuncu S, Schrøder HM, Overgaard S, Mathiesen O, Karlsen APH. Differences in patient characteristics and external validity of randomized clinical trials on pain management following total hip and knee arthroplasty: a systematic review. Reg Anesth Pain Med 2020; 45:709-715. [DOI: 10.1136/rapm-2020-101459] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/24/2020] [Accepted: 05/28/2020] [Indexed: 12/24/2022]
Abstract
BackgroundThe external validity of randomized controlled trials (RCTs) is critical for the relevance of trial results in a clinical setting. We aimed to assess the external validity of RCTs investigating postoperative pain treatment after total hip and knee arthroplasty (THA and TKA) by comparing patient characteristics in these trials with a clinical cohort. Further, we assessed the use of exclusion criteria of the included RCTs.MethodsWe searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for relevant RCTs up to June 2019. Data on patient characteristics from this research population were compared with an unselected clinical cohort from the Danish Hip and Knee Arthroplasty Registries in the period 2005–2019. Trends in patient characteristics and the use of exclusion criteria were assessed with control charts.ResultsIn total, 550 RCTs with 48 962 participants were included in the research cohort. The clinical cohort included 101 439 THA patients and 90 505 TKA patients. Patient characteristics (age, body mass index (BMI), American Society of Anesthesiologists (ASA) score and sex distribution) in the research cohort resembled those of the clinical cohort. Age, BMI and ASA scores did not change over time in the research cohort. In the clinical cohort, age increased among both THA and TKA patients, and BMI and ASA scores increased among TKA patients. Most commonly used exclusion criteria in the RCTs were high ASA score (62%), older age (45%), obesity (32%) and chronic opioid use (41%). Exclusion of chronic opioid users and individuals with obesity increased over time.ConclusionPatient characteristics in research trials investigating postoperative pain management after THA and TKA currently resemble those of a clinical cohort. However, individuals in the clinical cohort are getting older, and TKA patients more obese with increasing ASA scores. Concomitantly, RCTs increase the tendency to exclude patients with older age, obesity, chronic pain and/or opioid use. This trending discrepancy can hinder the generalizability of future research results, and therefore increased focus on pragmatic trials resembling real-world conditions are needed.PROSPERO registration numberCRD42019125691
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Sodhi N, Anis HK, Acuña AJ, Vakharia RM, Piuzzi NS, Higuera CA, Roche MW, Mont MA. The Effects of Opioid Use on Thromboembolic Complications, Readmission Rates, and 90-Day Episode of Care Costs After Total Hip Arthroplasty. J Arthroplasty 2020; 35:S237-S240. [PMID: 32197965 DOI: 10.1016/j.arth.2020.02.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/04/2020] [Accepted: 02/07/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate whether opioid use disorder (OUD) patients are at greater odds than non-opioid use disorder (NUD) patients in developing (1) thromboembolic complications; (2) readmission rates; and (3) costs of care. METHODS All patients with a 90-day history of OUD before total hip arthroplasty (THA) were identified from a national database. Patients were matched 1:5 to controls by age, gender, Elixhauser Comorbidity Index scores, and high-risk medical comorbidities, yielding 38,821 patients with (n = 6398) and without (n = 31,883) OUD. Multivariate logistic regression analyses were performed to compare the risks of developing venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) 90 days after the index procedure, 90-day readmission rates, and total global 90-day episode of care costs. RESULTS Patients with a history of OUD were found to be at greater risk for 90-day venous thromboembolisms (2.38 vs. 1.07%; OR: 2.25, 95% CI: 1.86-2.73, P < .0001) compared with matched NUD patients. Specifically, OUD patients were at greater risk for both deep vein thromboses (2.13 vs. 0.87%; OR: 2.46, 95% CI: 2.00-3.03, P < .001) and pulmonary embolism (0.61 vs. 0.27%; OR: 2.24, 95% CI: 1.53-3.27, P < .0001). In addition, patients with OUD were at an increased risk for 90-day readmission (28.68 vs. 22.62%; OR: 1.37, 95% CI: 1.29-1.46, P < .0001) compared with controls. Primary THA patients with OUD incurred a 14.72% higher cost of care ($20,610.65 vs. $17,964.58) compared with NUD patients. CONCLUSION These findings demonstrate that primary THA patients with a history of OUD are at greater risks for thromboembolic complications, readmissions, and higher costs of care in the 90-day postoperative period.
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Affiliation(s)
- Nipun Sodhi
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Northwell Health, New York, NY
| | - Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Rushabh M Vakharia
- Department of Orthopaedic Surgery, Holy Cross Hospital, Ft. Lauderdale, FL
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Martin W Roche
- Department of Orthopaedic Surgery, Holy Cross Hospital, Ft. Lauderdale, FL
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
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Clarke HA, Manoo V, Pearsall EA, Goel A, Feinberg A, Weinrib A, Chiu JC, Shah B, Ladak SSJ, Ward S, Srikandarajah S, Brar SS, McLeod RS. Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery. Can J Pain 2020; 4:67-85. [PMID: 33987487 PMCID: PMC7951150 DOI: 10.1080/24740527.2020.1724775] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 12/12/2022]
Abstract
This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers (surgeons, anesthesiologists, nurses/nurse practitioners, pain teams, pharmacists, allied health professionals, and trainees) to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain. These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients. A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence.
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Affiliation(s)
- Hance A. Clarke
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anaesthesia, University of Toronto, Toronto, Ontario, Canada
- University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, Ontario, Canada
| | - Varuna Manoo
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Emily A. Pearsall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Akash Goel
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anaesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Adina Feinberg
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Aliza Weinrib
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jenny C. Chiu
- Department of Pharmacy, North York General Hospital, Toronto, Ontario, Canada
| | - Bansi Shah
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Salima S. J. Ladak
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Transitional Pain Service, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Ward
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Sanjho Srikandarajah
- Department of Anaesthesia, North York General Hospital, Toronto, Ontario, Canada
| | - Savtaj S. Brar
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Robin S. McLeod
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Lee BH, Wu CL. Educating Patients Regarding Pain Management and Safe Opioid Use After Surgery. Anesth Analg 2020; 130:574-581. [DOI: 10.1213/ane.0000000000004436] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Ohnuma T, Raghunathan K, Moore S, Setoguchi S, Ellis AR, Fuller M, Whittle J, Pyati S, Bryan WE, Pepin MJ, Bartz RR, Haines KL, Krishnamoorthy V. Dose-Dependent Association of Gabapentinoids with Pulmonary Complications After Total Hip and Knee Arthroplasties. J Bone Joint Surg Am 2020; 102:221-229. [PMID: 31804238 DOI: 10.2106/jbjs.19.00889] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Gabapentinoids are commonly prescribed in perioperative multimodal analgesia protocols. Despite widespread use, the optimal dose to reduce opioid consumption while minimizing risks is unknown. We assessed dose-dependent effects of gabapentinoids on opioid consumption and postoperative pulmonary complications following total hip or knee arthroplasty (THA or TKA). We hypothesized that use of a gabapentinoid on the day of THA or TKA is associated with an increased risk of postoperative pulmonary complications in a dose-response fashion compared with the risk for patients who did not receive the drug. METHODS Using the Premier Database, we identified adults who underwent elective primary THA or TKA from 2009 to 2014. The exposure was receipt of a gabapentinoid (gabapentin or pregabalin) on the day of surgery. Gabapentin dose was categorized into 5 groups: none, 1 to 350, 351 to 700, 701 to 1,050, and >1,050 mg per day. Pregabalin dose was categorized into 4 groups: none, 1 to 110, 111 to 250, and >250 mg per day. The primary outcome was a composite of postoperative pulmonary complications, defined as respiratory failure, pneumonia, reintubation, pulmonary edema, noninvasive ventilation, or invasive mechanical ventilation. RESULTS Of 858,306 patients who underwent THA or TKA, 11.0% received gabapentin and 10.2% received pregabalin. The mean age (and standard deviation) of the patients was 65.6 ± 10.7 years, 39.6% were male, 78.2% were Caucasian, and 55.2% were covered by Medicare. In multilevel regression analysis, receipt of gabapentinoid at any dose on the day of surgery was associated with increased odds of postoperative pulmonary complications. Compared with no exposure to the drug being used by the particular group, all dose ranges of gabapentin and pregabalin were associated with greater odds of postoperative pulmonary complications (odds ratio, 95% confidence interval = 1.51, 1.40 to 1.63, for >1,050 mg of gabapentin and 1.81, 1.57 to 2.09, for >250 mg of pregabalin). We found no clinically meaningful associations between exposure to either gabapentin or pregabalin and perioperative opioid consumption or the length of the hospital stay. CONCLUSIONS Exposure to gabapentinoids at any dose on the day of THA or TKA was associated with increased odds of postoperative pulmonary complications in a dose-response fashion, with minimal effects on perioperative opioid consumption. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tetsu Ohnuma
- Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, North Carolina.,CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Karthik Raghunathan
- Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, North Carolina.,CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Sean Moore
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Soko Setoguchi
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Alan R Ellis
- Department of Social Work, North Carolina State University, Raleigh, North Carolina
| | - Matthew Fuller
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - John Whittle
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Srinivas Pyati
- Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, North Carolina.,CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - William E Bryan
- Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, North Carolina
| | - Marc J Pepin
- Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, North Carolina
| | - Raquel R Bartz
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Krista L Haines
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
| | - Vijay Krishnamoorthy
- CAPER Unit, Department of Anesthesiology (T.O., K.R., S.M., M.F., J.W., S.P., R.R.B., K.L.H., and V.K.), Department of Biostatistics and Clinical Outcomes (M.F.), and Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery (K.L.H.), Duke University Medical Center, Durham, North Carolina
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Achieving discharge within 24 h of robotic unicompartmental knee arthroplasty may be possible with appropriate patient selection and a multi-disciplinary team approach. J Orthop 2020; 19:223-228. [PMID: 32071518 DOI: 10.1016/j.jor.2020.01.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 01/31/2020] [Indexed: 12/30/2022] Open
Abstract
Aims There has been significant interest in day-case and rapid discharge pathways for unicompartmental knee replacements (UKR). Robotic-assisted surgery has the potential to improve surgical accuracy in UKR. However, to date there are no published studies reporting results of rapid-discharge pathways in patients receiving UKR using the NAVIO ◊ robotic system. Methods A retrospective analysis identified 19 patients who were safely discharged within 24 h following UKR using the NAVIO ◊ robotic system between June 2017 and October 2019. All patients went through a standardised UKR pathway protocol. Pre-operatively patients underwent education sessions and anaesthetic assessment, with selected patients undergoing occupational/physiotherapy assessment prior to surgery. All patients received a general anaesthetic with local anaesthetic infiltration prior to closure; nerve blocks were not used routinely. A multi-modal analgesic regime was utilised. Patients were discharged home once they were safe to mobilise on ward, had normal vital signs and pain was adequately controlled. Patients were discharged with outpatient physiotherapy referral and consultant follow up at 6 weeks. Results All patients were discharged within 24 h; there were no post-operative complications and no readmissions to hospital. The mean length of stay was 19.5 h (SD = 6.8), with patients seen twice on average by physiotherapy post-operatively. Active range of motion at 6 weeks was 105.8°, with all patients mobilising independently. The median 6-month post-operative Oxford Knee Score was 44 out of 48. Conclusion This initial feasibility study suggests that patients may be safely discharged within 24 h of UKR using the NAVIO robotic system. Appropriate patient selection will ensure successful discharge. Further prospective studies are needed.
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Ross TD, Dvorani E, Saskin R, Khoshbin A, Atrey A, Ward SE. Temporal Trends and Predictors of Thirty-Day Readmissions and Emergency Department Visits Following Total Knee Arthroplasty in Ontario Between 2003 and 2016. J Arthroplasty 2020; 35:364-370. [PMID: 31732370 DOI: 10.1016/j.arth.2019.09.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is the second most common surgery performed in Canada. Understanding and improving quality metrics associated with such high-volume procedures is of utmost importance to maximize value within the healthcare system, which is a balance between cost and quality. Although rates and predictors of hospital readmission and emergency department (ED) visits following TKA have previously been described in privatized healthcare settings, few studies have evaluated trends in length of stay (LOS), hospital readmissions, and ED visits following TKA in a universal single-payer system. METHODS Using data from a provincially held and validated registry, the Institute for Clinical and Evaluative Sciences, we undertook a review of all 205,152 TKAs performed in the province of Ontario, Canada, between 2003 and 2016. We determined temporal trends in utilization, LOS, readmissions, and ED visits and evaluated patient and provider predictors of hospital readmissions and ED visits using multivariate logistic regression modeling. We also grouped and described the most common reasons for readmission and ED visits based on the available International Classification of Diseases, Ninth Revision and Tenth Revision coding information. RESULTS LOS decreased significantly over the study period (P < .0001), from a median of 5 days (10th percentile 3 days, 90th percentile 8 days) in 2003 to a median of 3 days (10th percentile 2 days, 90th percentile 4 days) in 2016. All-cause 30-day readmissions did not change significantly over the study period, but the rate of ED visits increased significantly over time. Predictors of 30-day readmission following TKA included older age, male gender, lower income quartile, not having a postoperative visit with a primary care physician (PCP), increased comorbidities, longer LOS, urgent or revision surgery, admission to a teaching hospital, and discharge to an inpatient rehabilitation facility. Variables that predicted increased odds of an ED visit included older age, male gender, lower income quartile, not having a postop visit with a PCP, increasing comorbidities, year of surgery, longer LOS, and revision surgery. Admission to a teaching hospital and discharge to an inpatient rehabilitation facility showed a trend toward increased odds of an ED visit. CONCLUSIONS We identified a significant increase in ED visits following TKA in Ontario between 2003 and 2016, with no corresponding increase in hospital readmissions despite a significant temporal trend toward shorter LOS. Predictors of ED visits and readmissions were similar, including male gender, lower income, higher comorbidities, and lacking a PCP visit postoperatively. Increased rates of ED visits following TKA in Ontario represent a quality problem, as they are associated with increased cost to the public healthcare system without any substantial benefit. Interventions aimed at redirecting patients from the ED for minor postoperative concerns should be investigated, as this is likely to improve care by reducing costs, improving efficiency, and enhancing patient experience.
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Affiliation(s)
- Tayler D Ross
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Erind Dvorani
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amir Khoshbin
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Amit Atrey
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sarah E Ward
- Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Yu S, Eftekhary N, Wiznia D, Schwarzkopf R, Long WJ, Bosco JA, Iorio R. Evolution of an Opioid Sparse Pain Management Program for Total Knee Arthroplasty With the Addition of Intravenous Acetaminophen. J Arthroplasty 2020; 35:89-94. [PMID: 31521446 DOI: 10.1016/j.arth.2019.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Perioperative pain management for patients undergoing total knee arthroplasty (TKA) improves patient outcomes and facilitates recovery. In this study, we compared the effects of preoperative oral acetaminophen vs intravenous (IV) acetaminophen administered once intraoperatively and once postoperatively. METHODS Two standardized, multimodal analgesia protocols were compared in patients undergoing primary, unilateral TKA. The oral acetaminophen cohort (OA) received doses of oral acetaminophen preoperatively and an as-needed basis postoperatively (n = 698). The IV acetaminophen cohort (IA) received 2 doses of IV acetaminophen, one intraoperative and one 6 hours postoperatively, with no oral acetaminophen given (n = 318). No other variables were significantly changed during the study period. RESULTS The IV acetaminophen group demonstrated less narcotic usage on postoperative day 0 (OA: 13.3 mme [morphine mg equivalents], IA: 6.2 mme, P < .001) and overall usage (OA: 66.1 mme, IA: 48.5 mme, P < .001). Pain scores were statistically and clinically significantly decreased in the immediate postoperative (the first 8 hours) for the IA group (OA: patient-reported pain scores of 4.0; IA: patient-reported pain scores of 2.0, P < .001). Both groups progressed and completed their physical therapy similarly for each postoperative day. Length of stay and percent discharge home were slightly improved in the IA group as well, however did not reach statistical difference. CONCLUSION An iterative approach to multimodal pain management after TKA led to improvements in narcotic usage, pain scores, and several quality measures. IV acetaminophen is an integral and effective part of our opioid-sparing multimodal pain regimen in TKA.
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Affiliation(s)
- Stephen Yu
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Nima Eftekhary
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Daniel Wiznia
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - William J Long
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, NYU Langone Health, NYU Langone Orthopaedic Hospital, New York, NY
| | - Richard Iorio
- Department of Orthpaedic Surgery, Brigham Health, Brigham and Women's Hospital, Boston, MA
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Leas DP, Connor PM, Schiffern SC, D'Alessandro DF, Roberts KM, Hamid N. Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway. J Shoulder Elbow Surg 2019; 28:1716-1722. [PMID: 31072655 DOI: 10.1016/j.jse.2019.01.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Opioid therapy has been a cornerstone of perioperative pain control for decades in the United States, despite our increased understanding of the morbidity and mortality linked to opioids. The purpose of this study is to explore the safety, efficacy, and feasibility of an entirely opioid-free perioperative pathway in patients undergoing elective shoulder arthroplasty. METHODS Thirty-five patients undergoing elective total shoulder arthroplasty with a mean age of 71 (range, 50-87) years elected into a comprehensive opioid-free, multimodal pain management protocol. Opioid use was completely eliminated for all points in the perioperative period including during regional and general anesthesia. Data were collected regarding patient-reported pain, opioid consumption in the perioperative period, postoperative delirium, nausea, constipation, and falls. RESULTS Pain level at the primary outcome point of 24 hours or discharge was rated at 2.5 on the numeric rating scale. Stable, low pain scores were demonstrated at all time points postoperatively. Low rates of nausea, falls, and constipation were reported. Only 1 patient required "rescue" opioid medications during the in-patient stay, and an additional patient was given a low-dose opioid prescription at the 2-week postoperative appointment. CONCLUSIONS An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids. This study is the first such study to present a surgical protocol entirely free of opioids at all portions of the patient care pathway.
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Affiliation(s)
- Daniel P Leas
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, NC, USA
| | - Patrick M Connor
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA; OrthoCarolina Sports Medicine Center, Charlotte, NC, USA
| | | | - Donald F D'Alessandro
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA; OrthoCarolina Sports Medicine Center, Charlotte, NC, USA
| | | | - Nady Hamid
- OrthoCarolina Shoulder and Elbow Center, Charlotte, NC, USA.
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Jandali DB, Vaughan D, Eggerstedt M, Ganti A, Scheltens H, Ramirez EA, Revenaugh PC, Al‐Khudari S, Smith RM, Stenson KM. Enhanced recovery after surgery in head and neck surgery: Reduced opioid use and length of stay. Laryngoscope 2019; 130:1227-1232. [DOI: 10.1002/lary.28191] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 06/19/2019] [Accepted: 07/02/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Danny B. Jandali
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Deborah Vaughan
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Michael Eggerstedt
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Ashwin Ganti
- Rush Medical CollegeRush University Medical Center Chicago Illinois U.S.A
| | - Holly Scheltens
- College of NursingRush University Medical Center Chicago Illinois U.S.A
| | - Emily A. Ramirez
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Peter C. Revenaugh
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Samer Al‐Khudari
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Ryan M. Smith
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
| | - Kerstin M. Stenson
- Department of Otorhinolaryngology–Head and Neck SurgeryRush University Medical Center Chicago Illinois U.S.A
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Thompson R, Novikov D, Cizmic Z, Feng JE, Fideler K, Sayeed Z, Meftah M, Anoushiravani AA, Schwarzkopf R. Arthrofibrosis After Total Knee Arthroplasty: Pathophysiology, Diagnosis, and Management. Orthop Clin North Am 2019; 50:269-279. [PMID: 31084828 DOI: 10.1016/j.ocl.2019.02.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Arthrofibrosis is the pathologic stiffening of a joint caused by an exaggerated inflammatory response. As a common complication following total knee arthroplasty (TKA), this benign-appearing connective tissue hyperplasia can cause significant disability among patients because the concomitant knee pain and restricted range of motion severely hinder postoperative rehabilitation, clinical outcomes, and basic activities of daily living. The most effective management for arthrofibrosis in the setting of TKA is prevention, including preoperative patient education programs, aggressive postoperative physical therapy regimens, and anti-inflammatory medications. Operative treatments include manipulation under anesthesia, arthroscopic debridement, and quadricepsplasty.
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Affiliation(s)
- Ryan Thompson
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Surgery, Chicago Medical School, North Chicago, IL, USA
| | - David Novikov
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Zlatan Cizmic
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - James E Feng
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Kathryn Fideler
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Orthopaedic Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Zain Sayeed
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Surgery, Chicago Medical School, North Chicago, IL, USA
| | - Morteza Meftah
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA
| | - Afshin A Anoushiravani
- Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA; Department of Orthopaedic Surgery, Albany Medical Center, Albany, NY, USA
| | - Ran Schwarzkopf
- Division of Adult Reconstructive Surgery, Department of Orthopaedic Surgery, NYU Langone Orthopedics, NYU Langone Health, 301 East 17th Street, New York, NY 10003, USA.
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Wilke BK, Foster DT, Roberts CA, Shi GG, Lesser ER, Heckman MG, Whalen JL, Clendenen SR. Early In-Hospital Pain Control Is a Stronger Predictor for Patients Requiring a Refill of Narcotic Pain Medication Compared to the Amount of Narcotics Given at Discharge. J Arthroplasty 2019; 34:1354-1358. [PMID: 30928332 DOI: 10.1016/j.arth.2019.02.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/17/2019] [Accepted: 02/26/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The United States is combating an opioid epidemic. Orthopedic surgeons are the third highest opioid prescribers and therefore have an opportunity and obligation to assist in the efforts to reduce opioid use and abuse. In this article, we evaluate risk factors for patients requiring an opioid refill after primary total knee arthroplasty, with the goal to reduce opioid prescriptions for those patients at low risk of requiring a refill in order to reduce the amount of unused medication. METHODS We retrospectively reviewed narcotic-naïve patients who underwent total knee arthroplasty from December 2017 to May 2018. We performed multivariable analysis on demographics and preoperative, operative, and postoperative characteristics to determine risk factors for requiring a prescription refill following hospital discharge. RESULTS One-hundred fifty-seven patients were included in the analysis. Sixty percent of patients required a prescription refill. Risk factors included younger age (P = .003) and increased pain on postoperative day one (P < .001). The amount of narcotic medication given at discharge did not independently affect the refill rate (P = .21). CONCLUSION There is strong evidence that elderly patients and those with good pain control on postoperative day 1 are at a lower risk of requiring a narcotic refill postoperatively. With this information, physicians may begin to tailor narcotic prescriptions based on patient risk factors for requiring a prescription refill rather than provide patients with the same number of pills for a given surgery in an effort to reduce unused narcotic medication.
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Affiliation(s)
- Benjamin K Wilke
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
| | - Devon T Foster
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
| | | | - Glenn G Shi
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
| | - Elizabeth R Lesser
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
| | - Joseph L Whalen
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL
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Fleischman AN, Tarabichi M, Foltz C, Makar G, Hozack WJ, Austin MS, Chen AF. Cluster-Randomized Trial of Opiate-Sparing Analgesia after Discharge from Elective Hip Surgery. J Am Coll Surg 2019; 229:335-345.e5. [PMID: 31176028 DOI: 10.1016/j.jamcollsurg.2019.05.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/10/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Surgeons have traditionally relied on opiates after hip replacement, despite a growing epidemic of abuse. This study assessed the efficacy of multimodal analgesia and impact of conservative opiate prescribing after discharge from hip surgery. STUDY DESIGN In this cluster-randomized trial, 235 patients undergoing hip replacement (5 surgeons) received 1 of 3 discharge pain regimens: scheduled-dose multimodal analgesia with a minimal opiate supply (group A), scheduled-dose multimodal analgesia with a traditional opiate supply (group B), or a traditional pro re nata (as needed) opiate regimen alone (group C). Each of the surgeons comprised a distinct cluster and alternated in a randomized sequence between interventions. The multimodal regimen comprised fixed-schedule doses of acetaminophen, meloxicam, and gabapentin. Primary outcomes were daily visual analogue scale pain and opiate use for 30 days. Secondary outcomes included satisfaction, sleep quality, opiate-related symptoms, hip function, and adverse events. The primary intent-to-treat analysis was performed using linear mixed models. RESULTS Daily pain was significantly lower in group A (coefficient [Coeff] -0.81; p = 0.003) and group B (Coeff -0.61; p = 0.021) relative to group C. Although daily opiate use in group A (Coeff -0.77; p < 0.001) and group B (Coeff -0.30; p = 0.04) was lower than group C, opiate use for group A was also lower than group B (Coeff -0.46; p = 0.002). Duration of opiate use was significantly shorter for group A (1.14 weeks) and group B (1.39 weeks) compared with group C (2.57 weeks). There were fewer opiate-related symptoms, most commonly fatigue, in group A compared with C, but groups B and C were not significantly different. Both multimodal regimens improved satisfaction and sleep, and there were no differences in hip function or adverse events. CONCLUSIONS Multimodal analgesia with minimal opiates improved pain control while significantly decreasing opiate use and opiate-related adverse effects. It is time to rethink our reliance on opiates after elective operations.
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Affiliation(s)
| | | | | | | | | | | | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Hinther A, Abdel-Rahman O, Cheung WY, Quan ML, Dort JC. Chronic Postoperative Opioid Use: A Systematic Review. World J Surg 2019; 43:2164-2174. [DOI: 10.1007/s00268-019-05016-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Indexed: 11/28/2022]
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