Differential Use of Narcotics in Total Hip Arthroplasty: A Comparative Matched Analysis Between Osteoarthritis and Femoral Neck Fracture

Opiate use after total hip arthroplasty for metastatic bone disease

OBJECTIVES

To investigate post-operative opioid use following a total hip arthroplasty (THA) in metastatic bone disease (MBD) patients and identify factors associated with post-operative opioid use at 6 weeks and 90 days.

BACKGROUND

MBD commonly affects the hip, and surgical intervention including THA may be indicated for pain relief or to improve function. Following THA, patients are often prescribed short courses of opioids for post-operative pain relief. No study has evaluated opiate use following THA in patients for MBD.

METHODS

This was a retrospective review of patients using opioids preoperatively who underwent primary THA for MBD at two institutions between 2009 and 2022. Preoperative and post-operative opioid usages, respectively, at 6 weeks and 90 days were quantified through calculating daily morphine milligram equivalents (MMEs) and compared using the sign test. Factors associated with post-operative opioid use at 6 weeks and 90 days were compared using χ2 test or Fisher's exact test as appropriate.

RESULTS

Nineteen THA and 11 THA with complex acetabular reconstruction were included. At 6 weeks, 26 (86.7 percent) patients were utilizing opiates, and at 90 days, 23 (76.7 percent) patients were utilizing opiates. There was a statistically significant difference between median daily preoperative MME compared to daily MME at 90 days (p < 0.001). The only statistically significant association with opioid use at 90 days was opioid use at 6 weeks.

CONCLUSION

To our knowledge, this is the first paper evaluating post-operative opioid use following primary THA in MBD patients. After THA in the setting of MBD, patients exhibit decreased post-operative opioid use. Future studies with larger cohorts should be conducted to characterize post-operative opioid use following joint arthroplasty in MBD patients.

Cannabis use disorder is associated with shorter length of stay and increased home discharge after primary total joint arthroplasty: a propensity-weighted analysis

INTRODUCTION

Increased legalization of cannabis use across the United States has been correlated with increased cannabis use in the clinical setting. However, little is known regarding the characteristics and postoperative outcomes after primary joint arthroplasty (TJA) for patients with cannabis use disorder (CUD).

METHODS

This retrospective cohort study used data from the National Inpatient Sample of patients undergoing primary TJA between 2006 to 2015. Patients were grouped based on presence of concomitant CUD. Patient demographic characteristics and outcome data between groups were analyzed. Propensity score methodology was used to compare immediate in-hospital complications and economic outcomes.

RESULTS

A total of 8,740,798 TJAs were included. The prevalence of CUD increased nearly five-fold from 0.05% to 0.26% during this time (P < 0.0001). CUD patients were significantly younger, more likely to be male, most frequently of non-Hispanic Black race, and had higher rates of Medicaid insurance. Patients with CUD had a significantly shorter length of hospital stay (3.04 vs. 3.24 days, P = 0.0297), while incurring significantly higher daily ($22,614 vs. $17,955, P < 0.0001) and total charges during admission ($58,507 vs. $50,924, P < 0.0001), compared to patients without CUD. When compared with the control group, CUD was associated with significantly greater odds of home discharge (odds ratio (OR): 1.45, P = 0.0007), and significantly lower odds of rehab discharge (OR: 0.70, P = 0.0013). There were no differences in overall complication profile or in the vast majority of individual in-hospital complications between groups.

CONCLUSION

While CUD is correlated to shorter length of stay and increased home discharge after TJA, it does not show a strong effect on complications in an inpatient postoperative setting. It is important for clinicians to appreciate the demographic profile and expected clinical and economic outcomes for patients with CUD undergoing TJA, particularly in the context of evolving laws surrounding cannabis use.

The effect of skin traction on pain relief in patients with isolated intertrochanteric fractures, a randomized clinical trial

BACKGROUND

Hip fractures are common in elderly patients. The surgery is usually delayed due to underlying conditions, and pain control is crucial while the patient is cleared for surgery. In this randomized controlled trial (RCT) study, we hypothesized that the application of skin traction in patients with intertrochanteric fracture does not significantly change the Visual Analogue Score (VAS) of pain.

METHODS

This is a prospective, single institution, parallel randomized controlled trial. Two hundred and twenty-nine patients with isolated intertrochanteric fractures were enrolled in the study. Patients with neurologic issues, drug addiction, scars or swelling, or vascular issues at the site of skin traction application were excluded from the study. Patients were divided into two groups: group A included 97 patients, and group B included 95 patients. Skin traction was applied for group A, while only a soft pillow was put beneath the patients' knees in the other group. The VAS score was measured after the diagnosis, two hours before the operation, and 24 h after the surgery. The morphine dosage administered per day was documented for both groups.

RESULTS

After excluding patients with postoperative delirium, 154 patients (55 males and 99 females) with isolated intertrochanteric fractures (69 right-sided and 85 left-sided), and a mean age of 70 ± 10 remained in the study. There were no significant differences between the two groups regarding age, gender, and mean time from injury to admission (P > .05). The mean VAS score measures and morphine dosage administered per day were not significantly different between the two groups (P > .05). Both groups experienced significant pain relief 24 h postoperatively (P < .001).

CONCLUSION

Pre-operative skin traction application affected neither the patients' VAS scores nor the mean morphine dosage per day in patients with isolated intertrochanteric fractures. Our data does not support the routine application of pre-operative skin traction in patients with intertrochanteric fractures.

TRIAL REGISTRATION

The project was registered in the Iranian Registry of Clinical Trials (registration reference: IRCT20180729040636N3, registration date: 01/07/2020).

LEVEL OF EVIDENCE: 1

Prevalence of Chronic Opioid Use in the Elderly After Hip Fracture Surgery

BACKGROUND

While interest has focused on opioid use after total hip arthroplasty, little research has investigated opioid use in elderly patients after hip fracture. We hypothesize that a substantial number of opioid-naïve elderly patients go on to chronic opioid use after hip fracture surgery.

METHODS

We reviewed a consecutive series of 219 patients 65 years and older who underwent surgical fixation between January 1, 2016 and February 28, 2019 for a native hip fracture. Patients were excluded for polytrauma, periprosthetic or pathologic fractures, recent major surgery, or death within 90 days of their hip surgery. The state prescription monitoring database was used to determine opioid use.

RESULTS

Overall, 58 patients (26%) were postoperative chronic opioid users. Of the initial 188 opioid-naïve patients, 43 (23%) became chronic users. Of the 31 preoperative opioid users, 15 (48%) continued as chronic users. Chronic postoperative users were more likely to be White (76% vs 91%, P = .04), younger (78 vs 82 years, P = .003), and preoperative opioid users (odds ratio 3.3, P = .007). Arthroplasty vs fixation did not affect the rate of chronic opioid use (P = .22).

CONCLUSION

Chronic opioid use is surprisingly common after hip fracture repair in the elderly. Twenty-three percent of opioid-naïve hip fracture patients became chronic users after surgery. Continued vigilance is needed by orthopedic surgeons to limit the amount and duration of postoperative narcotic prescriptions and to monitor for continued use.

Cannabis Use Disorder in the Setting of Primary Total Hip Arthroplasty: Understanding the Epidemiology, Demographic Characteristics, and Inpatient Postoperative Outcomes

INTRODUCTION

Cannabis use is expected to increase in the context of its decriminalization and legalization in several states. The purpose of this study was to report on the epidemiologic and demographic characteristics and inpatient postoperative outcomes of patients with cannabis use disorder (CUD) undergoing primary total hip arthroplasty (THA).

METHODS

The National Inpatient Sample registry was used to identify patients undergoing THA between 2006 and 2015. Patients were stratified into groups with and without CUD. Epidemiology, comorbidity, and outcomes data were comparatively analyzed between these two groups.

RESULTS

A total of 2,838,742 THAs were performed during the study period. The prevalence of CUD significantly increased from 0.10% in 2006 to 0.39% in 2015 (P < 0.0001). Patients with CUD were significantly younger, more likely to be male, had higher rates of Medicaid insurance and were more likely to be non-Hispanic Black and less likely to be non-Hispanic White when compared with the control group. When comparing patients with and without CUD, there was no significant difference in the composite any complication variable and no significant difference in seven of eight individual in-hospital complications assessed, with the exception being higher genitourinary complications in the CUD group. There were no significant differences in discharge disposition or length of stay.

DISCUSSION

Although CUD is significantly associated with various demographic, comorbidity, and hospital characteristics, it is not significantly associated with in-hospital complications, discharge disposition, and length of stay outcomes in the immediate in-hospital, postoperative period. It is critical for clinicians and public health professionals to understand the characteristics and expected inpatient outcomes of this evolving population of patients with CUD undergoing THA, particularly in the context of widespread legalization.

LEVEL OF EVIDENCE

Level III.

Preoperative and Postoperative Opioid Prescription Rates in the Total Hip Replacement Surgical Patient

The United States is facing an opioid epidemic that has only worsened with the COVID-19 pandemic. There is little evidence regarding patterns of opioid use among patients with total hip replacement (THR). Although the Centers for Disease Control and Prevention has put forward guidelines for prescribing opioids, it does not include guidance specifically for THR patients suffering from presurgical and postsurgical pain. The purpose of this study was to (1) compare presurgical and postsurgical opioid rates, (2) compare presurgical and postsurgical morphine milligram equivalents (MME), and (3) determine whether having a presurgical opioid prescription predicts the receipt of postsurgical opioid prescriptions among patients undergoing THR surgery. Retrospective cohort analysis of 4,405 patients undergoing THR at a major academic medical center in the United States from April 30, 2015, to April 30, 2018, was done. Patient characteristics, opioid rates, and average MME/day/person were described. Logistic regression was used to determine whether presurgical opioid prescription and opioid risk level predicted postsurgical opioid prescribing. Median age was 64 years (range = 18-85 years); patients were primarily Caucasian/White (78.8%) and female (54.7%). Opioid prescription rates in this sample for the 12-month presurgical and postsurgical periods were 66.1% and 95.6%, respectively. Oxycodone was the most common opioid prescribed in both periods. Among those prescribed an opioid, moderate/high risk for overdose and/or death was 6.3% presurgery and 19.8% postsurgery. Patients with a comorbidity were two times more likely to receive an opioid prescription in the postsurgical period. The median average MME/day/person was 26.5 (range = 0.3-180.0) for patients with an opioid prescribed during the presurgery period and 40.4 (range = 1.5-270.0) during the postsurgery period. Opioid use, regardless of strength, in the presurgical period as well as having one or more comorbidities predicted opioid use in the postsurgical period.

Opioids and Spinal Cord Stimulators: Pre- and Postoperative Opioid Use Patterns and Predictors of Prolonged Postoperative Opioid Use

Objective

The aim of the study was to compare trends and differences in preoperative and prolonged postoperative opioid use following spinal cord stimulator (SCS) implantation and to determine factors associated with prolonged postoperative opioid use.

Methods

A database of private-payer insurance records was queried to identify patients who underwent a primary paddle lead SCS placement via a laminectomy (CPT-C3655) from 2008–2015. Our resulting cohort was stratified into those with prolonged postoperative opioid use, opioid use between 3- and 6-month postoperation, and those without. Multivariate logistic regression was used to determine the effect preoperative opioid use and other factors of interest had on prolonged postoperative opioid use. Subgroup analysis was performed on preoperative opioid users to further quantify the effect of differing magnitudes of preoperative opioid use.

Results

A total of 2,374 patients who underwent SCS placement were identified. Of all patients, 1,890 patients (79.6%) were identified as having prolonged narcotic use. Annual rates of preoperative (p = 0.023) and prolonged postoperative narcotic use (p < 0.001) decreased over the study period. Significant independent predictors of prolonged postoperative opioid use were age < 65 years (odds ratio [OR], 1.52; p = 0.004), male sex (OR, 1.33; p = 0.037), preoperative anxiolytic (OR, 1.55; p = 0.004) and muscle relaxant (OR, 1.42; p = 0.033), and narcotic use (OR, 15.04; p < 0.001). Increased number of preoperative narcotic prescriptions correlated with increased odds of prolonged postoperative use.

Conclusion

Patients with greater number of preoperative opioid prescriptions may not attain the same benefit from SCSs as patients with less opioid use. The most significant predictor of prolonged narcotic use was preoperative opioid use.