Prescribing and Consumption of Opioids After Primary, Unilateral Total Hip and Knee Arthroplasty in Opioid-Naive Patients

BACKGROUND

This cohort study was designed to determine the discrepancy between the quantity of opioid prescribed vs that which was consumed after total knee arthroplasty (TKA) and total hip arthroplasty (THA) in opioid-naive patients.

METHODS

Seven hundred twenty-three opioid-naive patients (426 TKAs and 297 THAs) from 7 hospitals in Michigan were contacted within 3 months of their surgery. Opioid prescribing and self-reported consumption was calculated in oral morphine equivalents (OMEs). Secondary outcomes included opioid refill in the first 90 days, pain in the first 7 days post-operatively, and satisfaction with pain care.

RESULTS

For TKA, the mean prescribing was 632 mg OME (±229), and the mean consumption was 416 mg (±279). For THA, the mean prescribing was 584 mg OME (±335), and the mean consumption was 285 mg (±301). There were no associations between the amount of opioid prescribed and the likelihood of refill, post-operative pain, or satisfaction with pain control. The amount of opioid prescribed was associated with increased consumption, such that each increase of 1 pill was associated with approximately an additional half pill consumed after adjusting for other covariates. Moreover, 48.2% felt that they received "More" or "Much more" opioid than they needed.

CONCLUSION

We recommend no more than 50 tablets of 5 mg oxycodone or its equivalent after TKA and 30 tablets after THA. Although dose reductions in other surgeries have not resulted in harm, continued assessment is needed to ensure that there are no unintended effects of opioid reduction, including worsened pain, decreased satisfaction, emergency department visits, or hospital readmissions.

LEVEL OF EVIDENCE

Level III; Retrospective, cohort study.

Aspirin prophylaxis and surveillance of pulmonary embolism and deep vein thrombosis in total hip arthroplasty

This is a prospective study of aspirin prophylaxis and thromboembolism surveillance in 159 patients having total hip arthroplasty by one surgeon at one institution. All patients had preoperative venous Doppler examination of the lower extremities and a ventilation-perfusion lung scan. Aspirin (650 mg) was given the night prior to surgery and continued at that dose twice per day. Venous Doppler examination was performed 10-14 days after operation. Asymptomatic pulmonary embolism was treated with oral anticoagulation only. There was a 12.6% incidence of pulmonary embolism, but only 1.9% of all patients developed a symptomatic pulmonary embolus. No patient had a fatal pulmonary embolus. No patient had a clinically evident deep vein thrombosis, and venous Doppler examination detected only nine patients with deep vein thrombosis (5.7%). The venous Doppler examination could not predict which patients would develop a pulmonary embolism. The authors could not determine a group of patients at high risk for the development of pulmonary embolism. There was no correlation between well-established "risk factors" and the development of pulmonary embolism. There was no correlation between the use of cemented or uncemented components and the development of pulmonary embolism. There were few complications of this prophylactic regimen of aspirin and surveillance. The authors believe this may be an acceptable prophylactic regimen for patients having total hip arthroplasty. However, the value of venous Doppler examination in the detection of deep vein thrombosis following total hip arthroplasty is uncertain.

Kirschner wire migration from the pelvis to the heart and a new method of fixation of articular fracture fragments, acetabular reconstruction

Fixation of comminuted, articular fracture fragments is frequently difficult. This can be accomplished with Kirschner wires (K-wires), but the risk of migration of smooth K-wires is well known. A case of migration of such a wire from the acetabulum, through the great vessels, and into the heart is presented. The Herbert screw is designed to be "buried" and, thus, allows firm fixation and congruent reduction of overlying fragments. The variation in thread pitch between the two ends of the Herbert screw should prevent migration once the screw is seated. A use of the Herbert screw in the fixation of articular fracture fragments in acetabular reconstruction is presented.