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Abouali JA, Curd ED, Mei XY, Sheth U, Khan M, de SA D, Tjong VK, Rana J. Attitudes and Practices Surrounding Opioid Prescriptions following Open Reduction Internal Fixation of Distal Radius and Ankle Fractures: A Survey of the Canadian Orthopaedic Association Membership. Adv Orthop 2023; 2023:9968219. [PMID: 37719667 PMCID: PMC10501842 DOI: 10.1155/2023/9968219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/03/2023] [Accepted: 08/23/2023] [Indexed: 09/19/2023] Open
Abstract
Background The past two decades have seen a significant increase in consequences associated with nonmedical misuse of prescription opioids, such as addiction and unintentional overdose deaths. This study aimed to use an electronic survey to assess attitudes and opioid-prescribing practices of Canadian orthopaedic surgeons and trainees following open reduction internal fixation (ORIF) of distal radius and ankle fractures. This study was the first to assess these factors following ORIF of distal radius and ankle fractures using a survey design. Methods A 40-item survey was developed focusing on four themes: respondent demographics, opioid-prescribing practice, patients with substance use disorders, and drug diversion. The survey was distributed among members of the Canadian Orthopaedic Association. Descriptive statistics were used to summarize respondent demographics and outcomes of interest. A Chi-square test was used to determine if proportion of opioid prescriptions between attending surgeons and surgeons in training was equal. Results 191 surveys were completed. Most respondents prescribed 10-40 tabs of immediate-release opioids, though this number varied considerably. While most respondents believed patients consumed only 40-80% of the prescribed opioids (73.6%), only 28.7% of respondents counselled patients on safe storage/disposal of leftover opioids. 30.5% of respondents felt confident in their knowledge of opioid use and mechanisms of addiction. Most respondents desired further education on topics such as procedure-based opioid-prescribing protocols (74.2%), alternative pain management strategies (69.7%), and mechanisms of opioid addiction (49.0%). Conclusions The principle finding of this study is the lack of a standardized approach to postoperative prescribing in distal radius and ankle fractures, illustrated by the wide range in number of opioids prescribed by Canadian orthopaedic surgeons. Our data suggest a trend towards overprescription among respondents following distal radius and ankle ORIF. Future studies should aim to rationalize interventions targeted at reducing postoperative opioid prescribing for common orthopaedic trauma procedures.
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Affiliation(s)
- Jihad A. Abouali
- University of Toronto, Department of Surgery, 200 Elizabeth St, Toronto, ON M5G 2C, Canada
| | | | - Xin Y. Mei
- University of Toronto, Department of Surgery, 200 Elizabeth St, Toronto, ON M5G 2C, Canada
| | - Ujash Sheth
- University of Toronto, Department of Surgery, 200 Elizabeth St, Toronto, ON M5G 2C, Canada
| | - Moin Khan
- McMaster University, Department of Surgery, 280 Main Street West, Hamilton, ON L8S 4K1, Canada
| | - Darren de SA
- McMaster University, Department of Surgery, 280 Main Street West, Hamilton, ON L8S 4K1, Canada
| | - Vehniah K. Tjong
- Northwestern University, Department of Surgery, 676 N. St. Clair St., Suite 2320, Chicago, IL 60611, USA
| | - Jesleen Rana
- University of Toronto, Department of Surgery, 200 Elizabeth St, Toronto, ON M5G 2C, Canada
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Kampitak W, Kertkiatkachorn W, Ngarmukos S, Tanavalee A, Tanavalee C, Tangkittithaworn C. Comparison of Analgesic Efficacies of the iPACK (Interspace Between the Popliteal Artery and Capsule of the Posterior Knee) and Genicular Nerve Blocks Used in Combination With the Continuous Adductor Canal Block After Total Knee Arthroplasty: A Randomized Clinical Trial. J Arthroplasty 2023; 38:1734-1741.e2. [PMID: 36931354 DOI: 10.1016/j.arth.2023.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND The interspace between the popliteal artery and capsule of the posterior knee (iPACK) block and the genicular nerve block (GNB) are motor-sparing nerve blocks used for knee pain relief. We compared the analgesic efficacies of ultrasound-guided iPACK block and GNB when combined with continuous adductor canal block after total knee arthroplasty. METHODS In this randomized control study, 132 total knee arthroplasty patients were assigned to the iPACK, GNB, and iPACK + GNB groups. All patients received combined spinal anesthesia and continuous adductor canal block. The primary outcome was the 8-hour postoperative pain score during movement. Secondary outcomes were pain scores, posterior knee pain, intravenous morphine consumption, and tibial and common peroneal nerve sensorimotor function. All included patients completed the study. RESULTS The 4-hour and 8-hour postoperative pain scores during movement were significantly lower in the iPACK + GNB group than that in the iPACK group (-2.5 [3.6, 1.3]; P < .001 and -2 [-3, -1]; P < .001, respectively). The differences in rating pain scores and posterior knee pain were not clinically relevant. The iPACK group demonstrated a significantly higher intravenous morphine consumption than did the GNB and iPACK + GNB groups during the first 48 hours postoperatively (P < .001) but were not clinically relevant. There was no incidence of complete sensorimotor blockade in any of the groups. CONCLUSION The iPACK-GNB combination relieved pain during movement better than the iPACK block alone during the 8 hours postoperatively after total knee arthroplasty in setting of multimodal analgesia such as adductor canal block.
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Affiliation(s)
- Wirinaree Kampitak
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Wannida Kertkiatkachorn
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Srihatach Ngarmukos
- Department of Orthopedics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aree Tanavalee
- Department of Orthopedics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chotetawan Tanavalee
- Department of Orthopedics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chonruethai Tangkittithaworn
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Yalcin S, Joo PY, McLaughlin W, Moran J, Caruana D, Flores M, Grauer J, Medvecky M. Factors Associated With Increased Opioid Prescriptions Following Anterior Cruciate Ligament Reconstruction in Opioid-Naïve Patients. Arthrosc Sports Med Rehabil 2023; 5:100740. [PMID: 37645399 PMCID: PMC10461142 DOI: 10.1016/j.asmr.2023.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/25/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To identify the mean morphine milligram equivalent (MME) opioid prescriptions for opioid-naïve patients undergoing isolated anterior cruciate ligament reconstruction (ACLR) between 4 weeks before surgery and the first 90 days after surgery and to describe opioid prescriptions filled per patient and mean MMEs per year within 90 days following ACLR. Methods Exclusion criteria were patients having concurrent other cruciate or collateral ligament repair or reconstruction, meniscus procedures (repair and debridement), any cartilage procedure, lower-extremity osteotomy, or knee procedures for fracture, infection, or neoplasms; patients with substance use disorder or chronic pain also were excluded. Opioid use between 4 weeks before surgery and the first 90 days after surgery was recorded. Prescribing physician specialty also was tracked. The correlation of patient factors and prescriber specialty of MME were compared using the Student's t-test. Significance was defined at P < .05. Results Opioid-naïve patients undergoing isolated ACLR were included. Isolated arthroscopic ACLRs performed between 2010 and Q3 2020 in opioid-naïve patients were identified within the PearlDiver M91 national database. A total of 37,200 patients were identified. Mean MME per patient was 340.9 ± 198.2, with an average MME per day of 59.9. Factors associated with increased opioid use during the 90 days following ACLR were older age (P < .001) and preoperative diagnosis of depression (P < .001). Orthopaedic surgeons were primarily responsible for the number of opioid prescriptions after ACLR (n = 29,326, 73.0%) but 27% (n = 10,797) of prescriptions came from nonorthopaedic surgeon medical providers who prescribed significantly greater MMEs of opioids than orthopaedic surgeons (456.5 vs 339.2, P < .001) per patient. Lastly, decreasing yearly opioid prescriptions per patient (2.4 to 1.6 prescriptions) and the mean MME per patient (428.4 to 257.1) occurred from 2010 to 2020. Conclusions Older age and preoperative diagnosis of depression are associated with greater opioid doses after ACLR. In addition, the vast majority of opioid prescriptions are written by orthopaedic surgeons on the day of ACLR and decreased considerably by four weeks after surgery. Patients receiving opioid prescriptions by nonorthopaedic surgeon medical providers receive significantly greater doses. Level of Evidence Level IV, retrospective cohort study.
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Affiliation(s)
- Sercan Yalcin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Peter Y Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - William McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Dennis Caruana
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael Flores
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Jonathan Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
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Giordano NA, Highland KB, Nghiem V, Scott-Richardson M, Kent M. Predictors of continued opioid use 6 months after total joint arthroplasty: a multi-site study. Arch Orthop Trauma Surg 2022; 142:4033-4039. [PMID: 34846586 DOI: 10.1007/s00402-021-04261-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Continued opioid use after total knee and hip arthroplasty (TKA/THA) is well-documented and associated with both surgical and patient-reported factors. Research examining the combined effects of a multitude of factors on continued, and even chronic, opioid use in a systematic algorithmic manner is lacking. This study prospectively evaluated the combined effect of patient-related and surgical factors associated with continued opioid use after TKA/THA. METHODS From 2016 to 2018, 198 participants undergoing TKA or THA were recruited from two tertiary care facilities. Participants completed surveys before surgery and at 2 weeks, 1, 3, and 6 months following surgery. A LASSO approach, followed by an exhaustive covariate selection procedure, was used to build a multivariable mixed-effects logistic regression model estimating the odds ratio of continued postoperative opioid use based on surgical factors and patient-reported factors. RESULTS Approximately half of the participants underwent either TKA (49%) or THA (51%). Preoperatively, 15% of participants reported taking opioid medication. Opioid use decreased from 68% at 2-week follow-up to 7% by 6 months. In addition, preoperative opioid use (95% CI 1.07-4.37), increased pain (95% CI 1.21-1.62), elevated preoperative Pain Catastrophizing Scale scores (95% CI 1.01-1.04), lower Physical Function scores (95% CI 0.87-0.95), and participants undergoing TKA, compared to THA, (95% CI 0.25-0.67) were found to be significantly associated with continued postoperative opioid use up to 6 months. CONCLUSION Preoperative opioid use, average pain, reduced physical function, and TKA were significantly associated with continued postoperative opioid use. Findings illustrate the need for preoperative and longitudinal assessment of patient-reported outcomes to mitigate poor postoperative pain outcomes. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Nicholas A Giordano
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA, 30322, USA.
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, 11300 Rockville Pike, Rockville, MD, 20852, USA
- Henry M. Jackson Foundation Inc, 11300 Rockville Pike, Rockville, MD, 20852, USA
| | - Vi Nghiem
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, 11300 Rockville Pike, Rockville, MD, 20852, USA
- 60th Medical Group, David Grant Medical Center, University of California-Davis at Travis Air Force Base, Fairfield, CA, USA
| | - Maya Scott-Richardson
- Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, 11300 Rockville Pike, Rockville, MD, 20852, USA
- Henry M. Jackson Foundation Inc, 11300 Rockville Pike, Rockville, MD, 20852, USA
| | - Michael Kent
- Department of Anesthesiology, Duke University School of Medicine, 134 Research Drive, Durham, NC, 27710, USA
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Huda AU, Ghafoor H. The Use of Pericapsular Nerve Group (PENG) Block in Hip Surgeries Is Associated With a Reduction in Opioid Consumption, Less Motor Block, and Better Patient Satisfaction: A Meta-Analysis. Cureus 2022; 14:e28872. [PMID: 36105907 PMCID: PMC9449447 DOI: 10.7759/cureus.28872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 11/05/2022] Open
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A Time-Driven Activity-Based Costing Analysis of Simultaneous Versus Staged Bilateral Total Hip Arthroplasty and Total Knee Arthroplasty. J Arthroplasty 2022; 37:S742-S747. [PMID: 35093545 DOI: 10.1016/j.arth.2022.01.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/05/2022] [Accepted: 01/18/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although studies have compared the claims costs of simultaneous and staged bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA), whether a simultaneous procedure is cost-effective to the facility remains unknown. This study aimed to compare facility costs and perioperative outcomes of simultaneous vs staged bilateral THA and TKA. METHODS We reviewed a consecutive series of 560 bilateral THA (170 staged and 220 simultaneous) and 777 bilateral TKA (163 staged and 451 simultaneous). Itemized facility costs were calculated using time-driven activity-based costing. Ninety-day outcomes were compared. Margin was standardized to unadjusted Medicare Diagnosis Related Group payments (simultaneous, $18,523; staged, $22,386). Multivariate regression was used to determine the independent association between costs/clinical outcomes and treatment strategy (staged vs simultaneous). RESULTS Simultaneous bilateral patients had significantly lower personnel, supply, and total facility costs compared with staged patients with no difference in 90-day complications between the groups. Multivariate analyses showed that overall facility costs were $1,210 lower in simultaneous bilateral THA (P < .001) and $704 lower in TKA (P < .001). Despite lower costs, margin for the facility was lower in the simultaneous group ($6,569 vs $9,225 for THA; $6,718 vs $10,067 for TKA; P < .001). CONCLUSION Simultaneous bilateral TKA and THA had lower facility costs than staged procedures because of savings associated with a single hospitalization. With the increased Medicare reimbursement for 2 unilateral procedures, however, margin was higher for staged procedures. In the era of value-based care, policymakers should not penalize facilities for performing cost-effective simultaneous bilateral arthroplasty in appropriately selected patients.
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Luo W, Liang J, Wu J, Luo Q, Wu H, Ou Y, Li Y, Ma W. Effects of pericapsular nerve group (PENG) block on postoperative recovery in elderly patients with hip fracture: study protocol for a randomised, parallel controlled, double-blind trial. BMJ Open 2022; 12:e051321. [PMID: 35351697 PMCID: PMC8966559 DOI: 10.1136/bmjopen-2021-051321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Hip fracture is a common and serious emergency in the elderly, and it is associated with severe pain, significant morbidity and mortality. The use of peripheral nerve block can relieve pain effectively and reduce opioid requirements, which may accelerate patient's recovery. The pericapsular nerve group (PENG) block has been found to provide an effective blockade to the hip joint with a potential motor-sparing effect, so we hypothesised that the PENG block may be an effective tool to enhance the recovery in elderly patients after hip fracture surgery. METHODS AND ANALYSIS This study is a single-centred, randomised, parallel controlled, double-blind trial. A total of 92 elderly patients scheduled for hip fracture surgery will be divided into two groups at random to receive either ultrasound-guided femoral nerve block or ultrasound-guided PENG block. The primary outcome will be to compare the Quality of Recovery-15 scores at 24 hours postoperatively between the two groups. The secondary outcomes will include measuring and comparing the strength of the quadriceps, the visual analogue scale at rest and on movement, the total morphine consumption, the rescue analgesic, the first time of postoperative out-of-bed mobilisation and complications. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Board of the Ethics Committee of The First Affiliated Hospital of Guangzhou University of Chinese Medicine on 15 December 2020 (reference K2020-110). The results of this study will be published in peer-reviewed international journals. TRIAL REGISTRATION NUMBER ChiCTR2100042341.
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Affiliation(s)
- Wei Luo
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Jianhui Liang
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Jieting Wu
- Department of Anesthesiology, The Third People's Hospital of Guangzhou Baiyun District, Guangzhou, Guangdong, China
| | - Quehua Luo
- Department of Anesthesiology, Guangdong Provincial People's Hospital, and Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Huiyi Wu
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yanhua Ou
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yuhui Li
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - WuHua Ma
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
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Chen CHM, Yun AG, Fan T. Efficacy of Liposomal Bupivacaine versus Ropivacaine in Adductor Canal Block for Total Knee Arthroplasty. J Knee Surg 2022; 35:96-103. [PMID: 32583397 DOI: 10.1055/s-0040-1713114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Adductor canal block (ACB) is advantageous for postoperative analgesia in total knee arthroplasty (TKA) because it results in minimal motor block. Liposomal bupivacaine (LB) is Food and Drug Administration-approved extended-release formulation of bupivacaine for interscalene peripheral nerve blocks. Its use is increasing in the TKA setting, mainly as a local infiltration agent. We compared the efficacy of ACB using LB versus ropivacaine in TKA. Two cohorts of patients were retrospectively analyzed at a single institution receiving ropivacaine and LB ACB for TKA. Duration of LB ACB, time to first opioid use postrecovery room, amount of opioid use postrecovery room, length of stay (LOS), and average and highest pain scores were collected. A total of 91 and 142 TKA patients received ropivacaine and LB for ACB, respectively. At 8 hours postrecovery room, more patients in the LB group required no opioids compared with the ropivacaine group (p = 0.026). Mean opioid consumption was lower in the LB group than in the ropivacaine group at 8 and 24 hours postrecovery room, although statistical significance was only observed at 8 hours (p = 0.022). The highest pain score for patients in the two groups was not statistically different. The average pain score for patients with a 2-day LOS was higher in the LB group, but average pain scores were similar for patients with 1- and 3-day LOS. Median LOS for the LB and ropivacaine groups was 1 and 2 days, respectively (p < 0.0001). Significantly lower opioid use at 8 hours postrecovery room was seen in the LB group compared with the ropivacaine group. There was no difference in opioid use at 24 and 48 hours. There was also no advantage with LB ACB in decreasing pain scores. However, the LB ACB group demonstrated a significantly shorter LOS compared with the ropivacaine ACB group.
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Affiliation(s)
| | - Andrew G Yun
- Department of Surgery, St. John's Health Center, Santa Monica, California
| | - Teresa Fan
- Department of Pharmacy, St. John's Health Center, Santa Monica, California
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Kampitak W, Tanavalee A, Ngarmukos S, Cholwattanakul C, Lertteerawattana L, Dowkrajang S. Effect of ultrasound-guided selective sensory nerve blockade of the knee on pain management compared with periarticular injection for patients undergoing total knee arthroplasty: A prospective randomized controlled trial. Knee 2021; 33:1-10. [PMID: 34536763 DOI: 10.1016/j.knee.2021.08.024] [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: 11/24/2020] [Revised: 04/12/2021] [Accepted: 08/25/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Ultrasound-guided selective sensory nerve blockade (SSNB) of the knee, including an adductor canal block (ACB), anterior femoral cutaneous nerve block, and infiltration between the popliteal artery and posterior capsule of the knee may provide effective motor-sparing knee analgesia for total knee arthroplasty (TKA). We hypothesized that the SSNB would manage pain better on ambulation 24 hours postoperatively compared to periarticular infiltration (PAI), when combined with postoperative continuous ACB. METHODS Seventy-two patients undergoing elective TKA under spinal anesthesia were randomly assigned to either SSNB (SSNB group) or intraoperative PAI (PAI group). All patients received postoperative multimodal analgesia, including continuous ACB. The primary outcome was pain on ambulation 24 hours postoperatively. Secondary outcomes included rest and dynamic numerical rating scale pain score, intravenous morphine requirement, functional performance measures, adverse events, satisfaction, and length of stay. RESULTS There was no difference in pain score during movement between the groups (mean difference -0.48 [-1.38 to 0.42], p = 0.3) and other immediate overall pain scores 24 hours postoperatively. Patients in the SSNB group had significantly lower intravenous morphine requirement than the PAI group for 48 hours postoperatively (0 [0, 0] vs. 0 [0, 2]; p = 0.008). There was no intergroup difference in the performance-based measures, satisfaction, and length of stay. CONCLUSIONS The SSNB did not provide superior postoperative analgesia, or improvement in immediate functional performance. However, it may result in lower opioid consumption postoperatively when compared with the intraoperative PAI.
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Affiliation(s)
- Wirinaree Kampitak
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Aree Tanavalee
- Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Srihatach Ngarmukos
- Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chanida Cholwattanakul
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Lalita Lertteerawattana
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Supreeda Dowkrajang
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Kutlu Yalcin E, Araujo-Duran J, Turan A. Emerging drugs for the treatment of postsurgical pain. Expert Opin Emerg Drugs 2021; 26:371-384. [PMID: 34842026 DOI: 10.1080/14728214.2021.2009799] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Postoperative pain is a distressful experience and remains to be a significant concern after surgery. Current agents either fail to prevent or minimize postoperative pain or cause a series of adverse effects, addiction, or abuse. Opioids have been the gold standard in the treatment of postoperative pain despite their well-described adverse effects. Many new agents with different mechanisms of action have been recently introduced to address this issue. AREAS COVERED This current review summarizes the list of new and emerging drugs investigated for their efficacy in controlling the postoperative pain and decreasing the need for rescue opioid use, adverse effect profile, abuse, and addiction potential. EXPERT OPINION Opioids have unrivaled analgesic efficacy. However adverse effects of opioids led to the search for better options. In mild pain most of the emerging drugs have been shown to control postoperative pain and decrease the use of rescue opioid, however fail to control pain after major surgeries causing severe pain. Specific agents such as Oliceridine, new local anesthetics, etc., are effective in controlling severe pain and hold a promise to replace opioids in the near future.
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Affiliation(s)
- Esra Kutlu Yalcin
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | | | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.,Department of General Anaesthesia, Cleveland Clinic, Cleveland, OH, USA
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de Rezende MU, Varone BB, Martuscelli DF, Ocampos GP, Freire GMG, Pinto NC, de Sousa MVP. Pilot study of the effect of therapeutic photobiomodulation on postoperative pain in knee arthroplasty. Braz J Anesthesiol 2021; 72:159-161. [PMID: 34800495 PMCID: PMC9373348 DOI: 10.1016/j.bjane.2021.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 07/06/2021] [Accepted: 07/12/2021] [Indexed: 11/18/2022] Open
Abstract
Nine participants undergoing primary TKA submitted to spinal anesthesia, sedation, ultrasound-guided obturator and Femoral nerve Block analgesia, and photobiomodulation Therapy (FBMT) were evaluated regarding postoperative pain and morphine consumption. FBMT sessions were performed in the Immediate Postoperative period (IPO) and after 24 hours. Participants received 16.7±15 mg of morphine up to the third postoperative day. At IPO, mean pain score was 4.8±3.2 and 5.6±3.5, at rest and on movement, respectively. Photo biomodulation therapy can be considered an option for mitigating pain for patients undergoing TKA.
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Affiliation(s)
- Marcia Uchoa de Rezende
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Instituto de Ortopedia e Traumatologia, Grupo de Doenças Osteometabólicas, São Paulo, SP, Brazil.
| | - Bruno Butturi Varone
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Diego Ferreira Martuscelli
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Instituto de Ortopedia e Traumatologia, São Paulo, SP, Brazil
| | - Guilherme Pereira Ocampos
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Instituto de Ortopedia e Traumatologia, Grupo de Doenças Osteometabólicas, São Paulo, SP, Brazil
| | - George Miguel Goes Freire
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Instituto Central, Divisão de Anestesia, Equipe de Controle da Dor, São Paulo, SP, Brazil
| | - Nathali Cordeiro Pinto
- Bright Photomedicine Ltd., São Paulo, SP, Brazil; Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Instituto do Coração, São Paulo, SP, Brazil
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Harrison AE, Kozarek JDB, Yeh J, MacDonald JH, Ruiz-Pelaez JG, Barengo NC, Turcotte JJ, King PJ. Postoperative outcomes of total knee arthroplasty across varying levels of multimodal pain management protocol adherence. J Orthop 2021; 28:26-33. [PMID: 34744378 DOI: 10.1016/j.jor.2021.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/17/2021] [Accepted: 10/10/2021] [Indexed: 01/08/2023] Open
Abstract
We examined the effect of varying multimodal pain management (MMPM) combinations on oral morphine milligram equivalents (OMME) and length of stay (LOS) after total knee arthroplasty (TKA). Five groups were compared based on the combination of multimodal analgesics ranging from no MMPM to full MMPM with acetaminophen, gabapentinoids, and celecoxib. After risk adjustment, MMPM was associated with decreased odds of LOS ≥2 days and OMME ≥75th percentile. MMPM protocols are effective at reducing LOS and postoperative narcotic requirements post-TKA. Patients appear to derive similar benefit from receiving all three medications, as well as various combinations of these drugs.
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Affiliation(s)
- Anna E Harrison
- Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Jason D B Kozarek
- Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Justin Yeh
- Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | | | - Juan G Ruiz-Pelaez
- Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Noël C Barengo
- Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA.,Florida International University, Robert Stempel College of Public Health and Social Work, Department of Health Policy and Management, Miami, FL, USA
| | | | - Paul J King
- Luminis Health Anne Arundel Medical Center, Annapolis, MD, USA
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13
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Tangtiphaiboontana J, Figoni AM, Luke A, Zhang AL, Feeley BT, Ma CB. The effects of nonsteroidal anti-inflammatory medications after rotator cuff surgery: a randomized, double-blind, placebo-controlled trial. J Shoulder Elbow Surg 2021; 30:1990-1997. [PMID: 34174448 DOI: 10.1016/j.jse.2021.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 05/11/2021] [Accepted: 05/16/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used for postoperative pain management. However, animal studies have demonstrated negative effects of NSAIDs on bone and tendon healing after commonly performed procedures such as rotator cuff repair. The purpose of this study was to evaluate the effects of postoperative NSAID use on opioid use, pain control, and shoulder outcomes after arthroscopic rotator cuff repair. METHODS A randomized, double-blind, placebo-controlled trial of postoperative NSAID use was performed in patients undergoing primary arthroscopic rotator cuff surgery at a single institution. Patients were randomized to receive ibuprofen or placebo for 2 weeks postoperatively, in addition to opioid medication. They were instructed to keep a daily pain diary for the first week after surgery, which was returned at their first postoperative visit for analysis. Visual analog scale (VAS) pain scores, shoulder range of motion, and 12-item Short Form Survey, Disabilities of the Arm, Shoulder and Hand, and American Shoulder and Elbow Surgeons (ASES) scores were collected. Assessment of rotator cuff healing was performed using ultrasound at 1 year postoperatively. RESULTS A total of 50 patients in the placebo group and 51 patients in the ibuprofen group were included for analysis. There were no differences in age, race, sex, history of preoperative NSAID or opioid use, or operative findings between groups. The amount of mean total morphine milligram equivalents (MMEs) used in the first postoperative week was lower in the ibuprofen group than in the placebo group (168 MMEs vs. 211 MMEs, P = .04). Early VAS scores on postoperative days 3, 4, 5, and 6 were lower in the ibuprofen group, but there was no difference in mean VAS scores between groups by 6 weeks after surgery. At 6 months, mean forward flexion and the mean ASES score were higher in the ibuprofen group than in the placebo group: 162° vs. 153° (P = .03) and 86 vs. 78 (P = .02), respectively. There were no differences in shoulder motion or 12-item Short Form Survey, Disabilities of the Arm, Shoulder and Hand, or ASES scores at 1 year. At 1 year after surgery, 7 patients in the ibuprofen group had evidence of tendon retear diagnosed on ultrasound (5 partial and 2 full thickness) compared with 13 patients in the placebo group (5 partial and 8 full thickness), but this difference was not statistically significant (P = .20). CONCLUSION Postoperative ibuprofen use reduces opioid requirements and decreases patient pain levels in the first week after arthroscopic rotator cuff repair. In addition, ibuprofen use after rotator cuff repair does not lead to an increased risk of tendon retear.
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Affiliation(s)
| | - Andrew M Figoni
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Anthony Luke
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - C Benjamin Ma
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
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AbdelRady MM, Ali WN, Younes KT, Talaat EA, AboElfadl GM. Analgesic efficacy of single- shot adductor canal block with levobupivacaine and dexmedetomidine in total knee arthroplasty: A randomized clinical trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1968713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Marwa Mahmoud AbdelRady
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Wesam Nashat Ali
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Khaled Tolba Younes
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Esraa Ahmed Talaat
- Rheumatology & Rehabilitation Department, Faculty of Medicine, Assiut University, Assiut, Egypt
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Kampitak W, Tanavalee A, Tansatit T, Ngarmukos S, Songborassamee N, Vichainarong C. The analgesic efficacy of anterior femoral cutaneous nerve block in combination with femoral triangle block in total knee arthroplasty: a randomized control trial. Korean J Anesthesiol 2021; 74:496-505. [PMID: 34182749 PMCID: PMC8648511 DOI: 10.4097/kja.21120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/27/2021] [Indexed: 11/10/2022] Open
Abstract
Background Ultrasound-guided femoral triangle block (FTB) can provide motor-sparing anterior knee analgesia. However, it may not completely anesthetize the anterior femoral cutaneous nerve (AFCN). We hypothesized that an AFCN block (AFCNB) in combination with a FTB would decrease pain during movement in the immediate 12-hour postoperative compared with a FTB alone. Methods Eighty patients scheduled to undergo total knee arthroplasty (TKA) were randomized to receive either FTB alone (FTB group) or AFCNB with FTB (AFCNB + FTB group) as a part of the multimodal analgesic regimen. The primary outcome was pain during movement 12 hours postoperatively. Secondary outcomes included numeric rating scale (NRS) pain scores, incidence of surgical incision site pain, intravenous morphine consumption, immediate functional performance, patient satisfaction, and length of hospital stay. Results The NRS pain scores on movement 12 hours postoperatively were significantly lower in patients of AFCNB + FTB group compared to those in patients of FTB group (mean difference, -2.02 [95% confidence interval: -3.14, -0.89], P < 0.001). Incidence of pain at the site of surgical incision in 24 hours postoperatively and morphine consumption in 48 hours postoperatively were significantly lower (P < 0.001) and quadriceps muscle strength at 0 degree immediately after the surgery was significantly greater in patients of AFCNB + FTB group (P = 0.04). Conclusions The addition of ultrasound-guided AFCNB to FTB provided more effective analgesia and decreased opioid requirement compared to FTB alone after TKA and may enhance immediate functional performance on the day of surgery.
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Affiliation(s)
- Wirinaree Kampitak
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aree Tanavalee
- Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Tanvaa Tansatit
- Department of Anatomy, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Srihatach Ngarmukos
- Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattaporn Songborassamee
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chutikant Vichainarong
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Do Patient Point of Entry and Medicaid Status Affect Quality Outcomes Following Total Knee Arthroplasty? J Arthroplasty 2020; 35:1761-1765. [PMID: 32146111 DOI: 10.1016/j.arth.2020.02.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/21/2020] [Accepted: 02/11/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The effect of surgeon practice and patient care setting have not been studied in the Medicaid population undergoing total knee arthroplasty (TKA). This study aims to evaluate whether point of entry and Medicaid status affect outcomes following TKA. METHODS The electronic medical record at our urban, academic, tertiary care hospital system was retrospectively reviewed for all primary, unilateral TKA during January 2016 and January 2018. Outpatient visits within the 6-month preoperative period categorized TKA recipients as either Hospital Ambulatory Clinic Centers patients with Medicaid insurance or private office patients with non-Medicaid insurers. RESULTS There were 174 Medicaid patients and 317 non-Medicaid patients for 491 total patients. Medicaid patients were significantly younger (62.6 ± 1.6 vs 65.4 ± 1.1 years, P < .01), of "other' ethnicity (43.1% vs 25.6%, P < .01), and to be a current smoker (9.3% vs 6.6%, P = .02). There was no difference in gender, body mass index, and American Society of Anesthesiologists score. After controlling for patient factors, the Medicaid effect was insignificant for surgical time (exponentiated β 0.93, 95% confidence interval [CI] 0.86-1.01, P = .076) and facility discharge (odds ratio 1.58, 95% CI 0.71-3.51, P = .262). Medicaid status had a significant effect on length of stay (LOS) (rate ratio 1.21, 95% CI 1.02-1.43, P = .026). CONCLUSION Multivariable analysis controlling for patient factors demonstrated that Medicaid coverage had minimal effect on surgical time and facility discharge. Medicaid patients had significantly longer LOS by one-half day. These results indicate that comparable outcomes can be achieved for Medicaid patients following TKA provided that the surgeon and care setting are similar. However, increased care coordination and preoperative education may be necessary to normalize disparities in hospital LOS. LEVEL OF EVIDENCE III, retrospective observational analysis.
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Sheth U, Mehta M, Huyke F, Terry MA, Tjong VK. Opioid Use After Common Sports Medicine Procedures: A Systematic Review. Sports Health 2020; 12:225-233. [PMID: 32271136 PMCID: PMC7222661 DOI: 10.1177/1941738120913293] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
CONTEXT The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America. OBJECTIVE To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures. DATA SOURCES A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018. STUDY SELECTION Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies. RESULTS A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill. CONCLUSION Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.
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Affiliation(s)
- Ujash Sheth
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Mitesh Mehta
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Fernando Huyke
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Michael A. Terry
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Vehniah K. Tjong
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
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18
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Schlosser MJ, Korwek KM, Dunn R, Poland RE. Reduced post-operative opioid use decreases length of stay and readmission rates in patients undergoing hip and knee joint arthroplasty. J Orthop 2020; 21:88-93. [PMID: 32255987 DOI: 10.1016/j.jor.2020.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/22/2020] [Indexed: 02/02/2023] Open
Abstract
Background While adequate pain relief is central to patient recovery and satisfaction, opioid use is associated with side effects, adverse drug events and opioid use disorder and therefore is under increased scrutiny. Enhanced surgical recovery protocols include multimodal pain management as a key process, but the impact of opioid dose as an independent variable has not been examined. Methods Retrospective analysis of 51,824 hip and knee arthroplasty encounters in a large healthcare system. Results Overall, patients receiving treatment with lower doses of opiates had shorter median length of stay (p < 0.001); this earlier discharge had no negative consequences on readmission rates. In particular, patients discharged on day 1 received a lower median morphine milligram equivalent (MME) per day than those who were not discharged (32.5 [IQR: 19.0-50.0] versus 45.0 [26.7-71.2], respectively, p < 0.001). The probability of discharge on day 1 was 41.2% and 19.6% for those patients on lower versus higher MME/day, respectively. Similarly, there was a reduction in odds of readmission of 15.2% (95% CI 5.8-23.6%) for patients on lower doses of MME/day. Conclusion Lower MME/day following joint arthroplasty is linked to the probability of discharge on both days 1 and 2 post-surgery as well as reduced odds of readmission. These findings persisted even when adjusting for all other factors, including participation in the enhanced surgical recovery program, the use of a multi-modal analgesic regimen, the presence of complications, patient demographics, and other baseline characteristics. Efforts to reduce opioid use in the peri- and immediate post-operative period, regardless of the mechanism, demonstrated a significant effect on patient outcomes.
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Affiliation(s)
| | | | - Reginald Dunn
- Clinical Services Group, HCA Healthcare, Nashville, TN, USA
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19
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Reid DBC, Shapiro B, Shah KN, Ruddell JH, Cohen EM, Akelman E, Daniels AH. Has a Prescription-limiting Law in Rhode Island Helped to Reduce Opioid Use After Total Joint Arthroplasty? Clin Orthop Relat Res 2020; 478:205-215. [PMID: 31389888 PMCID: PMC7438153 DOI: 10.1097/corr.0000000000000885] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 06/17/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND In the United States, since 2016, at least 28 of 50 state legislatures have passed laws regarding mandatory prescribing limits for opioid medications. One of the earliest state laws (which was passed in Rhode Island in 2016) restricted the maximum morphine milligram equivalents provided in the first postoperative prescription for patients defined as opioid-naïve to 30 morphine milligram equivalents per day, 150 total morphine milligram equivalents, or 20 total doses. While such regulations are increasingly common in the United States, their effects on opioid use after total joint arthroplasty are unclear. QUESTIONS/PURPOSES (1) Are legislative limitations to opioid prescriptions in Rhode Island associated with decreased opioid use in the immediate (first outpatient prescription postoperatively), 30-day, and 90-day periods after THA and TKA? (2) Is this law associated with similar changes in postoperative opioid use among patients who are opioid-naïve and those who are opioid-tolerant preoperatively? METHODS Patients undergoing primary THA or TKA between January 1, 2016 and June 28, 2016 (before the law was passed on June 28, 2016) were retrospectively compared with patients undergoing surgery between June 1, 2017 and December 31, 2017 (after the law's implementation on April 17, 2017). The lapse between the pre-law and post-law periods was designed to avoid confounding from potential voluntary practice changes by physicians after the law was passed but before its mandatory implementation. Demographic and surgical details were extracted from a large multi-specialty orthopaedic group's surgical billing database using Current Procedural Terminology codes 27130 and 27447. Any patients undergoing revision procedures, same-day bilateral arthroplasties, or a second primary THA or TKA in the 3-month followup period were excluded. Secondary data were confirmed by reviewing individual electronic medical records in the associated hospital system which included three major hospital sites. We evaluated 1125 patients. In accordance with the state's department of health guidelines, patients were defined as opioid-tolerant if they had filled any prescription for an opioid medication in the 30-day preoperative period. Data on age, gender, and the proportion of patients who were defined as opioid tolerant preoperatively were collected and found to be no different between the pre-law and post-law groups. The state's prescription drug monitoring program database was used to collect data on prescriptions for all controlled substances filled between 30 days preoperatively and 90 days postoperatively. The primary outcomes were the mean morphine milligram equivalents of the initial outpatient postoperative opioid prescription after discharge and the mean cumulative morphine milligram equivalents at the 30- and 90-day postoperative intervals. Secondary analyses included subgroup analyses by procedure and by preoperative opioid tolerance. RESULTS After the law was implemented, the first opioid prescriptions were smaller for patients who were opioid-naïve (mean 156 ± 106 morphine milligram equivalents after the law's passage versus 451 ± 296 before, mean difference 294 morphine milligram equivalents; p < 0.001) and those who were opioid-tolerant (263 ± 265 morphine milligram equivalents after the law's passage versus 534 ± 427 before, mean difference 271 morphine milligram equivalents; p < 0.001); however, for cumulative prescriptions in the first 30 days postoperatively, this was only true among patients who were previously opioid-naïve (501 ± 416 morphine milligram equivalents after the law's passage versus 796 ± 597 before, mean difference 295 morphine milligram equivalents; p < 0.001). Those who were opioid-tolerant did not have a decrease in the cumulative number of 30-day morphine milligram equivalents (1288 ± 1632 morphine milligram equivalents after the law's passage versus 1398 ± 1274 before, mean difference 110 morphine milligram equivalents; p = 0.066). CONCLUSIONS The prescription-limiting law was associated with a decline in cumulative opioid prescriptions at 30 days postoperatively filled by patients who were opioid-naïve before total joint arthroplasty. This may substantially impact public health, and these policies should be considered an important tool for healthcare providers, communities, and policymakers who wish to combat the current opioid epidemic. However, given the lack of a discernible effect on cumulative opioids filled from 30 to 90 days postoperatively, further investigations are needed to evaluate more effective policies to prevent prolonged opioid use after total joint arthroplasty, particularly in patients who are opioid-tolerant preoperatively. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Daniel B C Reid
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Benjamin Shapiro
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Kalpit N Shah
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Jack H Ruddell
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Eric M Cohen
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Edward Akelman
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
| | - Alan H Daniels
- D.B.C. Reid, B. Shapiro, K.N. Shah, J.H. Ruddell, E.M. Cohen, E. Akelman, A.H. Daniels, Warren Alpert Medical School and the Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI
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Anastasio AT, Farley KX, Boden SD, Bradbury TL, Premkumar A, Gottschalk MB. Modifiable, Postoperative Risk Factors for Delayed Discharge Following Total Knee Arthroplasty: The Influence of Hypotension and Opioid Use. J Arthroplasty 2020; 35:82-88. [PMID: 31500913 PMCID: PMC7194191 DOI: 10.1016/j.arth.2019.07.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/29/2019] [Accepted: 07/31/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We sought to identify independent modifiable risk factors for delayed discharge after total knee arthroplasty (TKA) that have been previously underrepresented in the literature, particularly postoperative opioid use, postoperative laboratory abnormalities, and the frequency of hypotensive events. METHODS Data from 1033 patients undergoing TKA for primary osteoarthritis of the knee between June 2012 and August 2014 at an academic orthopedic specialty hospital were reviewed. Patient demographics, comorbidities, inpatient opioid medication, postoperative hypotensive events, and abnormalities in laboratory values, all occurring on postoperative day 0 or 1, were collected. Multivariate logistic regression analysis was performed to identify independent risk factors for a prolonged length of stay (LOS) >3 days. RESULTS The average age of patients undergoing primary TKA in our cohort was 65.9 (standard deviation, 9.1) years, and 61.7% were women. The mean LOS for all patients was 2.64 days (standard deviation, 1.14; range, 1-9). And 15.3% of patients had a LOS >3 days. On multivariate logistic regression analysis, nonmodifiable risk factors associated with a prolonged LOS included nonwhite race (odds ratio [OR], 2.01), single marital status (OR, 1.53), and increasing age (OR, 1.47). Modifiable risk factors included every 5 postoperative hypotensive events (OR, 1.31), 10-mg increases in oral morphine equivalent consumption (OR, 1.04), and postoperative laboratory abnormalities (hypocalcemia: OR, 2.15; low hemoglobin: OR, 2.63). CONCLUSION This study identifies potentially modifiable factors that are associated with increased LOS after TKA. Doubling down on efforts to control the narcotic use and to use opioid alternatives when possible will likely have efficacy in reducing LOS. Attempts should be made to correct laboratory abnormalities and to be cognizant of patient opioid use, age, and race when considering potential avenues to reduce LOS.
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Affiliation(s)
- Albert T. Anastasio
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Kevin X. Farley
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Scott D. Boden
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Thomas L. Bradbury
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Ajay Premkumar
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Michael B. Gottschalk
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA,Reprint requests: Michael B. Gottschalk, MD, Department of Orthopaedic Surgery, Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA 30307
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21
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Battista C, Harmon E, Patel S, Ghoddoussi F, Lynch B, Nabavighadi K, Krishnan S. Ultrasound-guided out-of-plane (OOP) adductor canal continuous catheter placement compared to in-plane (IP) placement in total knee arthroplasty: Arandomized, single blinded, pilot clinical trial. J Clin Anesth 2019; 61:109692. [PMID: 31826830 DOI: 10.1016/j.jclinane.2019.109692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 11/17/2019] [Accepted: 12/01/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Carter Battista
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Elliot Harmon
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Samir Patel
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Farhad Ghoddoussi
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Brendan Lynch
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Kaveh Nabavighadi
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | - Sandeep Krishnan
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA; Department of Anesthesiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA.
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A Goal-directed Quality Improvement Initiative to Reduce Opioid Prescriptions After Orthopaedic Procedures. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 3:e109. [PMID: 31773081 PMCID: PMC6860138 DOI: 10.5435/jaaosglobal-d-19-00109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Orthopaedic surgeons are increasingly aware of deleterious effects of the opioid epidemic and the association between overprescription and diversion toward nonmedical opioid use or substance abuse. Opiate prescriptions at the time of hospital discharge have been identified as target for intervention. This study describes the successful outcome of a goal-directed intervention aimed at decreasing opioid overprescription by providing routine feedback to providers regarding their prescribing patterns.
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Edwards DA, Hedrick TL, Jayaram J, Argoff C, Gulur P, Holubar SD, Gan TJ, Mythen MG, Miller TE, Shaw AD, Thacker JKM, McEvoy MD, Geiger TM, Gordon DB, Grant MC, Grocott M, Gupta R, Hah JM, Hurley RW, Kent ML, King AB, Oderda GM, Sun E, Wu CL. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy. Anesth Analg 2019; 129:553-566. [DOI: 10.1213/ane.0000000000004018] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Finney FT, Gossett TD, Hu HM, Waljee JF, Brummett CM, Talusan PG, Holmes JR. New Persistent Opioid Use Following Common Forefoot Procedures for the Treatment of Hallux Valgus. J Bone Joint Surg Am 2019; 101:722-729. [PMID: 30994590 DOI: 10.2106/jbjs.18.00793] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Orthopaedic surgeons are the fourth highest on the list of top prescribers of opioid analgesics by specialty and have a direct impact on opioid-related morbidity in the United States. Operative bunion correction is one of the most commonly performed elective foot surgical procedures in this country. We sought to determine the rate of new persistent opioid use following exposure to opioids after surgical treatment of hallux valgus (bunionectomy) and to identify associated risk factors. METHODS A nationwide U.S. insurance claims database, Truven Health MarketScan, was used to identify opioid-naïve patients who underwent surgical treatment of hallux valgus employing 3 common procedures from January 2010 to June 2015. The rate of new persistent opioid use (i.e., fulfillment of an opioid prescription between 91 and 180 days after the surgical procedure) among patients who filled a perioperative opioid prescription was then calculated. A logistic regression model was used to examine the relationship between new persistent use and risk factors, including surgical procedure, patient demographic characteristics, and patient comorbidities. RESULTS A total of 36,562 patients underwent surgical treatment of hallux valgus and filled a perioperative opioid prescription. The rate of new persistent opioid use among all patients who filled a perioperative opioid prescription was 6.2%. Patients who underwent treatment with a first metatarsal-cuneiform arthrodesis were more likely to have new persistent opioid use compared with the distal metatarsal osteotomy control group (adjusted odds ratio, 1.19 [95% confidence interval, 1.03 to 1.39]; p = 0.021). Factors independently associated with new persistent opioid use included prescribing patterns, coexisting mental health diagnoses, and certain pain disorders. CONCLUSIONS New persistent opioid use following surgical treatment of hallux valgus affects a substantial number of patients. Understanding factors associated with persistent opioid use can help clinicians to identify and counsel at-risk patients and to mitigate this public health crisis. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Fred T Finney
- Departments of Orthopaedic Surgery (F.T.F, T.D.G., P.G.T., and J.R.H.), Surgery (H.M.H. and J.F.W.), and Anesthesiology (C.M.B.), University of Michigan, Ann Arbor, Michigan
| | - Timothy D Gossett
- Departments of Orthopaedic Surgery (F.T.F, T.D.G., P.G.T., and J.R.H.), Surgery (H.M.H. and J.F.W.), and Anesthesiology (C.M.B.), University of Michigan, Ann Arbor, Michigan
| | - Hsou Mei Hu
- Departments of Orthopaedic Surgery (F.T.F, T.D.G., P.G.T., and J.R.H.), Surgery (H.M.H. and J.F.W.), and Anesthesiology (C.M.B.), University of Michigan, Ann Arbor, Michigan
| | - Jennifer F Waljee
- Departments of Orthopaedic Surgery (F.T.F, T.D.G., P.G.T., and J.R.H.), Surgery (H.M.H. and J.F.W.), and Anesthesiology (C.M.B.), University of Michigan, Ann Arbor, Michigan
| | - Chad M Brummett
- Departments of Orthopaedic Surgery (F.T.F, T.D.G., P.G.T., and J.R.H.), Surgery (H.M.H. and J.F.W.), and Anesthesiology (C.M.B.), University of Michigan, Ann Arbor, Michigan
| | - Paul G Talusan
- Departments of Orthopaedic Surgery (F.T.F, T.D.G., P.G.T., and J.R.H.), Surgery (H.M.H. and J.F.W.), and Anesthesiology (C.M.B.), University of Michigan, Ann Arbor, Michigan
| | - James R Holmes
- Departments of Orthopaedic Surgery (F.T.F, T.D.G., P.G.T., and J.R.H.), Surgery (H.M.H. and J.F.W.), and Anesthesiology (C.M.B.), University of Michigan, Ann Arbor, Michigan
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Gabriel RA, Swisher MW, Sztain JF, Furnish TJ, Ilfeld BM, Said ET. State of the art opioid-sparing strategies for post-operative pain in adult surgical patients. Expert Opin Pharmacother 2019; 20:949-961. [DOI: 10.1080/14656566.2019.1583743] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Rodney A. Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
- Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Matthew W. Swisher
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Jacklynn F. Sztain
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
| | - Timothy J. Furnish
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
| | - Brian M. Ilfeld
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Engy T. Said
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
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Phillips JLH, Rondon AJ, Gorica Z, Fillingham YA, Austin MS, Courtney PM. No Difference in Total Episode-of-Care Cost Between Staged and Simultaneous Bilateral Total Joint Arthroplasty. J Arthroplasty 2018; 33:3607-3611. [PMID: 30249405 DOI: 10.1016/j.arth.2018.08.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/22/2018] [Accepted: 08/27/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Due to concerns about higher complication rates, surgeons debate whether to perform simultaneous bilateral total joint arthroplasty (BTJA), particularly in the higher-risk Medicare population. Advances in pain management and rehabilitation protocols have called into question older studies that found an overall cost benefit for simultaneous procedures. The purpose of this study was to compare 90-day episode-of-care costs between staged and simultaneous BTJA among Medicare beneficiaries. METHODS We retrospectively reviewed a consecutive series of 319 simultaneous primary TJAs and 168 staged TJAs (336 procedures) at our institution between 2015 and 2016. We recorded demographics, comorbidities, readmission rates, and 90-day episode-of-care costs based upon Centers for Medicare and Medicaid Services claims data. To control for confounding variables, we performed a multivariate regression analysis to identify independent risk factors for increased costs. RESULTS Simultaneous patients had decreased inpatient facility costs ($19,402 vs $23,025, P < .001), increased post-acute care costs ($13,203 vs $10,115, P < .001), and no difference in total episode-of-care costs ($35,666 vs $37,238, P = .541). Although there was no difference in readmissions (8% vs 9%, P = .961), simultaneous bilateral patients were more likely to experience a thromboembolic event (2% vs 0%, P = .003). When controlling for demographics, procedure, and comorbidities, a simultaneous surgery was not associated with an increase in episode-of-care costs (P = .544). Independent risk factors for increased episode-of-care costs following BTJA included age ($394 per year increase, P < .001), cardiac disease ($4877, P = .025), history of stroke ($14,295, P = .010), and liver disease ($12,515, P = .016). CONCLUSION In the Medicare population, there is no difference in 90-day episode-of-care costs between simultaneous and staged BTJA. Surgeons should use caution in performing a simultaneous procedure on older patients or those with a history of stroke, cardiac, or liver disease.
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Affiliation(s)
- Jessica L H Phillips
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Alexander J Rondon
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Zylyftar Gorica
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Yale A Fillingham
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Matthew S Austin
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - P Maxwell Courtney
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Halawi MJ, Lieberman JR. Opioids in Total Joint Arthroplasty: Moving Forward. J Arthroplasty 2018; 33:2341-2343. [PMID: 29903460 DOI: 10.1016/j.arth.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/01/2018] [Accepted: 06/04/2018] [Indexed: 02/01/2023] Open
Affiliation(s)
- Mohamad J Halawi
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
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