A reduction in opioid prescription size after total joint arthroplasty can be safely performed without an increase in complications

BACKGROUND

Excessive opioid prescriptions after total joint arthroplasty increase risks for adverse opioid related events, chronic opioid use, and unlawful opioid diversion. Decreasing postoperative prescriptions may improve quality after TJA. Concerns exist that a decrease in opioids prescribed may increase complications such as readmissions, emergency department (ED) visits, or worsened patient reported outcomes (PROs). The purpose of this study was to explore whether a reduction in opioids prescribed after TJA resulted in increased complications.

METHODS

Data originated from a statewide database prospectively abstracted including oral morphine equivalents prescribed at discharge, readmissions, ED visits, and PROs. Data was collected from 84,998 TJA occurring one year before and after the creation of an opioid-prescribing protocol that had decreased prescriptions by approximately 50%. Trends were monitored using Shewhart control charts. Regression models were used to determine statistically significant changes over time.

RESULTS

All groups showed a reduction in opioids prescribed by almost 50% without an increase in ER visits or readmissions, and without a detrimental effect on PROs. Compared to baseline data before opioid reduction, opioid-naïve TKA had significant improvements in all outcomes (p=0.03, p=0.02, p<0.001, p<0.001). Opioid tolerant TKAs and THAs had no worsened outcomes and significant improvement in KOOSJR(p=0.03) and HOOSJR (p=0.03). Opioid-naïve THA had significant improvements in HOOSJR (p=0.003) and PROMIS (p=0.001).

CONCLUSIONS

Postoperative opioid prescription recommendations from a statewide registry decreased prescribing by approximately 50% without decreasing PROs or increasing ED visits or readmissions. A reduction in opioids prescribed after TJA can be accomplished safely and without increased complications.

Delayed Diagnosis and Management of Traumatic Cervical Spine Subluxation

Introduction

Traumatic cervical instability, which includes bilateral facet dislocation, unilateral facet dislocation, and bilateral facet perch or subluxation, is generally treated expeditiously. Treatment is focused on providing stability of the cervical spine and mitigating sequelae such as spinal cord injury, nerve injury, cervical deformity, chronic pain, and even death. Surgical stabilization of traumatic bilateral cervical facet subluxation is the norm. There is not much-published literature concerning late treatment of neglected cervical facet subluxations or dislocations.

Case Report

We present the case of a 53-year-old female who sustained cervical spine injury in 2010 after a single car motor vehicle accident. She did not seek immediate medical care but rather self-medicated with heroin, non-prescribed oral opiates and alcohol. She also wore a store-bought soft collar for support. She presented to our office in 2016 with persistent severe neck pain along with neck stiffness, fixed cervical flexion deformity, dysphagia, and left C6 radiculopathy. Plain radiographs demonstrated regional cervical kyphosis from C4 to C6 measuring 50°as well as autofusion at the C5/6 level. Cervical computed tomography (CT) confirmed traumatic ankylosis of C5/6 and anterolisthesis at C4/5. Cervical magnetic resonance imaging revealed multilevel cervical disc degeneration, moderate central stenosis at C4/5, and multilevel foraminal stenosis. We performed circumferential surgery: Anterior C5 and C6 corpectomy, placement of an expandable cage, and anterior C4 to C6 plating. This was followed by posterior decompression, lateral mass instrumentation, and fusion from C4-7. We were able to restore forward gaze, eliminate her dysphagia and the left C6 radiculopathy, and diminish the global neck pain.

Conclusions

Neglect of unstable cervical injuries portends poor clinical results. In this case, the neglect was self-induced in part from the patient's lifestyle, social situation, and lack of early access to healthcare. Despite the delayed treatment, surgical intervention was able to improve her quality of life and decrease her deformity.

A 30-year-old Male with Delayed Diagnosis and Management of Chronic Post-traumatic Atlantoaxial Rotatory Subluxation

Introduction:

Atlantoaxial rotatory subluxation (AARS) is an uncommonly encountered diagnosis within the adult population. The rare nature of this dislocation within the adult population often results in delayed diagnosis and treatment.

Case Report:

A 30-year-old male presented following a low-speed motor vehicle accident. The patient had been involved in a work-related accident 1-year prior and had experienced fixed leftward gaze and tenderness of the cervical spine following this incident, but exhibited no focal neurologic deficits. Imaging demonstrated a Fielding Type 1 AARS of approximately 45°. The subluxation was reduced; and posterior C1–C2 instrumentation and fusion were performed, with no complications. Post-operative imaging revealed maintained reduction and alignment. The patient regained acceptable alignment and relief from his pre-operative symptoms.

Conclusions:

Our case is an illustration of a chronic post-traumatic AARS in an adult patient with delayed diagnosis and definitive management. This diagnosis is rare within the adult population and is frequently overlooked. A high index of suspicion must exist when evaluating adult patients with clinical presentations of chronic neck pain, torticollis, or “cock robin” head positioning as delayed diagnosis.