Opioid prescription levels and postoperative outcomes in orthopedic surgery

Predicting postoperative complications after pneumonectomy using machine learning: a 10-year study

BACKGROUND

Reducing postoperative cardiovascular and neurological complications (PCNC) during thoracic surgery is the key to improving postoperative survival.

OBJECTIVE

We aimed to investigate independent predictors of PCNC, develop machine learning models, and construct a predictive nomogram for PCNC in patients undergoing thoracic surgery for lung cancer.

METHODS

This study used data from a previous retrospective study of 16,368 patients with lung cancer (training set: 11,458; validation set: 4,910) with American Standards Association physical statuses I-IV who underwent surgery. Postoperative information was collected from electronic medical records to help build models based on cause-and-effect and statistical data, potentially revealing hidden dependencies between factors and diseases in a big data environment. The optimal model was analyzed and filtered using multiple machine-learning models (Logistic regression, eXtreme Gradient Boosting, Random forest, Light Gradient Boosting Machine and Naïve Bayes). A predictive nomogram was built and receiver operating characteristics were used to assess the validity of the model. The discriminative power and clinical validity were assessed using calibration and decision-making curve analyses.

RESULTS

Multivariate logistic regression analysis revealed that age, surgery duration, intraoperative intercostal nerve block, postoperative patient-controlled analgesia, bronchial blocker use and sufentanil use were independent predictors of PCNC. Random forest was identified as the optimal model with an area under the curve of 0.898 in the training set and 0.752 in the validation set, confirming the excellent prediction accuracy of the nomogram. All the net benefits of the five machine-learning models in the training and validation sets demonstrated excellent clinical applicability, and the calibration curves showed good agreement between the predicted and observed risks.

CONCLUSION

The combination of machine-learning models and nomograms may contribute to the early prediction and reduction in the incidence of PCNC.

Application and Analysis of the Enhanced Recovery After Surgery Opioid Prescription Protocol in Arthroscopy and Arthroplasty Patients

INTRODUCTION

Surgery and postoperative opioid prescriptions are critical periods for potential drug dependence and diversion. Enhanced recovery after surgery (ERAS) pathways aim to improve patient outcomes by leveraging preoperative education, emphasizing nonopioid pain management, and using less invasive surgical techniques. The study hypothesis was that the use of ERAS pathways would decrease postoperative opioid prescribing after arthroscopy and arthroplasty surgeries.

METHODS

A retrospective chart review was conducted on patients treated by 11 orthopaedic surgeons at 9 Iowa hospitals from November 2022 to March 2024. Patients were divided into arthroplasty (n = 67) and arthroscopy (n = 33) cohorts. Opioids prescribed before and after ERAS implementation were measured and converted to morphine milligram equivalents (MMEs). Statistical analyses included the Wilcoxon signed rank test, Mann-Whitney U test, and chi-squared test.

RESULTS

The mean pre-ERAS prescription size was 389 MMEs (range: 140 to 900 MMEs) for the overall cohort postoperatively, with arthroplasty at 451 MMEs (range: 200 to 900 MMEs) and arthroscopy at 264 MMEs (range: 140 to 450 MMEs). After ERAS, the overall mean size dropped to 194 MMEs (range: 38 to 600 MMEs), with arthroplasty at 210 MMEs (range: 38 to 600 MMEs) and arthroscopy at 161 MMEs (range: 45 to 315 MMEs). Both cohorts saw significant reductions, with a mean 47% reduction in arthroplasty and a mean 33% reduction in arthroscopy (both P < 0.001). Statistical analysis found percent reduction of prescription size to be greater in the arthroplasty cohort than in the arthroscopy cohort ( P < 0.001). Arthroscopy patients had a higher mean percentage of MMEs prescribed leftover (60%) compared with arthroplasty patients (27%; P < 0.001).

CONCLUSION

The study hypothesis was upheld as ERAS pathways resulted in a notable reduction in prescribing of opioids postoperatively after both arthroplasty and arthroscopic surgeries. ERAS pathways should continue to be tailored and studied to improve postoperative recovery while decreasing the reliance on opioids postoperatively for pain management.

Optimization of Postoperative Opioids Use Following Spine Surgery

PURPOSE OF REVIEW

The present investigation evaluated the use of opioids for postoperative pain relief in spinal surgery patients.

RECENT FINDINGS

Pain management is a crucial component of postoperative care that greatly impacts patient outcomes. Postoperative pain management has been shown to allow for earlier mobility, discharge, and return to normal life. Opioids are the standard treatment for postoperative pharmacologic pain relief, but they are associated with the same adverse effects that pain management strives to mitigate. Opioids are associated with a large side effect profile, including a higher risk of various postoperative complications. Opioids are potentially highly addictive and postoperative use is associated with dependence, tolerance, and the current opioid epidemic. Some studies indicate that there are similar surgical outcomes amongst patients independent of whether opioids were prescribed opioids for pain relief.

CONCLUSION

Opioids should only be recommended for postoperative pain management under strict guidance and supervision from physicians. All 50 states have acute pain guidelines in place limiting opioid prescribing. One of the strategies of reducing postoperative opioid consumption is the emphasis on opioid alternatives that should be actively considered and explored prior to resorting to opioids. There are pharmacological and non-pharmacological options available for pain relief that can provide similar levels of analgesia as prescription opioid without unwanted effects such as tolerance and dependency. Proper assessment of patient history and risk factors can aid physicians in tailoring a pain management regimen that is appropriate for each individual patient. More research into efficacy and safety of alternative treatments to opioids is warranted.

Administration of a Methylprednisolone Taper and Complication Rates Following Total Knee Arthroplasty: A Multicenter Retrospective Study

Background

Most patients undergoing total knee arthroplasty (TKA) report moderate to severe pain in the acute postoperative period. Recent preliminary data have suggested that a short course of oral corticosteroid may improve early postoperative pain after various orthopedic operations, but the safety of this practice has not been rigorously evaluated in larger patient populations. The purpose of this study was to evaluate complication rates in patients receiving a methylprednisolone taper (MT) vs controls after primary TKA.

Methods

Records were reviewed for patients undergoing primary TKA from 2018 to 2023 by 2 surgeons at different institutions who began routinely prescribing a 6-day MT to patients without a contraindication or poorly controlled diabetes. The primary outcome of periprosthetic joint infection at 90 days and final follow-up was assessed as were secondary outcomes of surgical site infection and wound complications. A total of 930 patients were included in the study, with 641 patients in the control cohort and 289 patients in the methylprednisolone cohort.

Results

There were no significant differences between the methylprednisolone and control cohorts in 90-day periprosthetic joint infection (0.7% vs 0%, P = .1, respectively), surgical site infection (1.0% vs 1.4%, P = .4, respectively), or wound complication (1.0% vs 2.0%, P = .4, respectively). There were no significant differences in any complication at final follow-up.

Conclusions

MT following TKA did not significantly increase rates of wound complications or infections in this multi-institutional retrospective cohort study. This study provides preliminary evidence regarding the safety profile of a short duration of postoperative oral corticosteroids following TKA.

Efficacy of Sodium Channel-Selective Analgesics in Postoperative, Neuralgia, and Neuropathy-Related Pain Management: A Systematic Review and Literature Review

Postoperative pain is a prevalent problem, often lasting from days to years. To minimize opioid use and associated risks of dependency, Enhanced Recovery After Surgery (ERAS) protocols increasingly incorporate multimodal analgesics. Sodium channel-selective blockers are a promising non-opioid alternative, yet their application in postoperative pain remains underexplored. This systematic review evaluates their efficacy in managing postoperative, neuropathic, and neuralgia-related pain. A systematic review was conducted using controlled keywords across multiple databases to identify studies on sodium channel-selective blockers published up to 2024. Eligible studies included clinical trials, observational studies, case series, and reports involving patients aged 18 or older. Data were extracted on therapeutic outcomes, dosages, complications, and comparisons with other analgesics. Five studies met the inclusion criteria, involving 804 patients, 81.58% of whom were women. One study addressed postoperative pain, while the remaining five focused on neuropathy- and neuralgia-related pain. All studies reported significant pain reduction in at least one treatment group compared with placebo. In the study on postoperative pain, the sodium channel-selective blocker significantly reduced pain scores without requiring opioid analgesia. Across all studies, only two patients needed concomitant opioid therapy, and one discontinued treatment due to adverse effects. Dosages varied, with no reports of severe complications. Comparative analyses showed that sodium channel-selective blockers were as effective, if not superior, to traditional pain medications in reducing pain intensity. Sodium channel-selective blockers demonstrate significant potential in pain management with minimal opioid reliance. While effective for neuropathic pain, further studies are essential to validate their role in acute postoperative settings and refine their use in multimodal analgesia regimens.

Effectiveness of Interventions to Reduce Opioid Use After Orthopaedic Surgery: A Systematic Review of Randomised Controlled Trials

BACKGROUND

The prescribing of opioids to patients for postoperative pain can lead to persistent opioid use. This review investigated the effectiveness of interventions aimed at reducing opioid use in patients after orthopaedic surgery.

METHODS

Electronic databases were searched from inception to November 2023. We included randomised controlled trials investigating interventions aimed at reducing opioid use after orthopaedic surgery. Two reviewers conducted the screening and data extraction and assessed the risk of bias (Cochrane Risk of Bias tool) and certainty of evidence (GRADE). The primary outcome was the mean daily dose of opioid analgesic medications in the medium term (1-3 months after randomisation). Results were pooled in a meta-analysis using a random-effects model where appropriate (e.g. I2 < 50%) or summarised narratively.

RESULTS

The search yielded 17,471 records, of which 39 trials were included. High heterogeneity meant that most comparisons could not be pooled. The mean daily dose was lower with multimodal analgesia interventions than with placebo/no intervention/usual care or active control in the medium term. No between-group differences were found between other pharmacological or non-pharmacological interventions and either placebo/no intervention/usual care or active control at the medium-term time point. The certainty of evidence ranged from low to moderate.

CONCLUSIONS

Multimodal analgesic interventions may reduce opioid use compared with placebo/no intervention/usual care or active control in the medium term. However, the high heterogeneity and low certainty of evidence means it is uncertain which interventions are effective in reducing opioid use after orthopaedic surgery.

Pain profiles and opioid consumption following joint replacement surgery: a prospective observational cohort study

PURPOSE

We sought to analyze postoperative discharge opioid prescription, consumption, and pain over three months following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

We conducted a prospective observational study in patients undergoing THA and TKA at two centres in Toronto, ON, Canada. We contacted study participants at two, six, and 12 weeks after discharge to collect data on analgesic satisfaction, pain relief, time point of stopping opioids, quantity of unconsumed opioid pills, quality of pain, and mental health. We also evaluated patient factors that may have contributed to a higher opioid consumption or dissatisfaction with the analgesic prescription at six weeks.

RESULTS

The median [interquartile range] opioid pill count prescribed at the time of discharge for the 443 participants was 60 [50-80]. At 12 weeks after surgery, 33.9% of participants had more than one-third of their prescribed quantity remaining. Three-quarters of the cohort indicated that pain relief after arthroplasty was appropriate at all postoperative follow-ups. The incidence of neuropathic pain reduced from 24.1% before TKA or THA to 4.3% at 12 weeks after arthroplasty. Female sex (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.08 to 2.95; P = 0.03), a history of preoperative opioid use (OR, 2.46; 95% CI, 1.25 to 5.1; P = 0.01), and TKA vs THA (OR, 2.46; 95% CI, 1.47 to 4.17; P = 0.001) were associated with higher opioid consumption at six weeks after arthroplasty.

CONCLUSION

A discharge prescription of 60 opioid pills may be excessive for patients undergoing THA or TKA. Identifying patients with risk factors for higher postoperative opioid consumption may result in more appropriate analgesic regimens.

High inpatient-opioid consumption predicts extended length of hospital stay in patients undergoing spinal fusion for adolescent idiopathic scoliosis

OBJECTIVES

Opioids are common medications used following spine surgery. However, few studies have assessed the impact of increased inpatient-opioid consumption on outcomes following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). The aim of this study was to determine the impact of increased inpatient-opioid consumption on hospital length of stay (LOS) following PSF for AIS.

METHODS

A retrospective cohort study was performed using the Premier Healthcare Database (2016-2017). Adolescent patients (11-17 years old) who underwent PSF for AIS, identified using ICD-10-CM coding, were stratified by inpatient MME (morphine milligram equivalent) consumption into Low (< 25th percentile for the cohort), Medium (25-75th percentile), and High (> 75th percentile) cohorts. Demographics, comorbidities, intraoperative procedures, perioperative adverse events (AEs), length of hospital stay (LOS), non-routine discharge rates, cost of admission, and 30-day readmission rates were assessed. A logistic multivariate regression analysis was performed to determine the association between inpatient MME consumption and extended LOS.

RESULTS

Of the 1042 study patients, 260 (24.9%) had Low-MME consumption, 523 (50.2%) had Medium-MME consumption, and 259 (24.9%) had High-MME consumption. A greater proportion of patients in the High cohort identified as non-Hispanic white (Low: 46.5% vs Medium: 61.4% vs High: 65.3%, p < 0.001), while the proportion of patients reporting any comorbidity did not vary across the cohorts (p = 0.940). The number of post-operative AEs experienced also did not vary across the cohorts (p = 0.629). A greater proportion of patients in the High cohort had an extended LOS (Low: 6.5% vs Medium: 8.6% vs High: 19.7%, p < 0.001), while a greater proportion of patients in the Low cohort had an increased cost of admission (Low: 33.1% vs Medium: 20.3% vs High: 26.6%, p < 0.001). The High cohort had increased 30-day readmission rates relative to the Low and Medium cohorts (Low: 0.8% vs Medium: 0.2% vs High: 1.5%, p = 0.049). Non-routine discharge rates did not vary among the cohorts (p = 0.441). On multivariate analysis, High-MME consumption was significantly associated with extended LOS, while Medium-MME consumption was not [Medium: aOR: 1.48, CI (0.83, 2.74), p = 0.193; High: aOR: 4.43, CI (2.47, 8.31), p < 0.001].

CONCLUSIONS

Our study showed that high post-operative-MME consumption was significantly associated with extended LOS in patients undergoing PSF for AIS. In light of these findings, changes to existing protocols that decrease the reliance on opioids for post-operative analgesia are merited to improve patient outcomes and reduce health-care expenditures.

The impact of multimodal analgesia in coronary artery bypass graft surgery-a population-based analysis

OBJECTIVE

Multimodal pain management aims to concurrently target several pain pathways for improved treatment efficacy and recovery. We investigated associations between multimodal analgesia use and postoperative complications, length of hospital stay (LOS), and opioid consumption among patients undergoing coronary artery bypass graft surgery.

METHODS

This retrospective cohort study included 349,940 adult patients undergoing elective coronary artery bypass graft surgery (January 2006 to December 2019), from the national Premier Healthcare claims dataset. The study intervention was multimodal analgesia, defined as opioid use with the addition of nonopioid analgesic modalities. These included, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, paracetamol/acetaminophen, neuraxial anesthesia, steroids, gabapentin/pregabalin, and ketamine. Analgesic management was stratified into 4 categories: opioids only and multimodal analgesia with the addition of 1, 2 or ≥3 nonopioid analgesic modalities. Mixed-effects regression models measured associations between multimodal analgesia and postoperative complications, LOS, and opioid consumption measured in milligram oral morphine equivalents.

RESULTS

Multimodal analgesia was associated with a beneficial dose response pattern. With increasing nonopioid analgesic modalities added to opioid analgesia, a stepwise decrease in complication risk was consistently observed, eg, with the addition of 1, 2, or ≥3 nonopioid modalities the odds for any complication decreased by 8% (odds ratio [OR], 0.92; confidence interval [CI], 0.90-0.94), 17% (OR, 0.83; CI, 0.81-0.86), and 22% (OR, 0.78; CI 0.69-0.79), respectively. This stepwise pattern was consistent in respiratory, cardiac, and renal complications individually. Similarly, LOS decreased stepwise with added analgesic modalities.

CONCLUSIONS

These nationally representative data indicate that enhanced pain management by multiple pain pathways is associated with significant reductions in postoperative complications and shortened patient recovery.

Opioid consumption in the first 30 days after surgery was independently associated with new persistent opioid use

INTRODUCTION

Previous studies suggest that new persistent opioid use (NPOU) after surgery was associated with larger perioperative opioid prescriptions, but the association between NPOU and postoperative opioid consumption is unknown.

METHODS

This retrospective study included opioid naïve individuals aged 18-64 who underwent surgical procedures across 70 Michigan hospitals between July 1, 2018 and November 15, 2021 and were prescribed opioids at discharge. We used clinical and patient-reported opioid consumption data from the Michigan Surgical Quality Collaborative, a statewide surgical registry, linked with the state Prescription Drug Monitoring Program. Multivariable logistic regression modeling was used to assess the association between patient-reported opioid consumption during the 30 days after discharge and NPOU, defined as having an opioid fill during both 31-120 days and 121-210 days after discharge.

RESULTS

Among 36,271 patients included, 482 (1.3%) developed NPOU. These patients consumed more opioid pills in the first 30 days postoperatively than those without NPOU (mean (SD): 7.3 (8.4) 5 mg oxycodone equivalent pills vs 4.1 (5.5), SMD=-0.41). In adjusted analyses, each additional opioid pill consumed in the 30-day postoperative period was associated with a 0.05 percentage-point increase in the predicted probability of NPOU (95% CI 0.04 to 0.07 percentage points). Thus, holding all other variables constant, a 10-pill increase in consumption would be associated with a 0.5 percentage-point increase in the probability of NPOU, or a 38.4% increase relative to the baseline rate of 1.3%.

CONCLUSION

Demonstrating that opioid consumption in the first 30 days after surgery was independently associated with NPOU underscores the importance of perioperative opioid prescribing on long-term outcomes.

Analysis of Opioid Prescribing Trends Following Thyroidectomy and Parathyroidectomy Before and After the 2021 American Academy of Otolaryngology-Head and Neck Surgery Opioid Prescribing Clinical Practice Guidelines

OBJECTIVE

To evaluate the trends in opioid and nonopioid prescribing for thyroidectomy and parathyroidectomy before and after the publication of guidelines by the American Academy of Otolaryngology-Head and Neck Surgery in April 2021.

STUDY DESIGN

Retrospective.

SETTING

Eighty-three health care organizations in the United States that contribute to the TriNetX database.

METHODS

Deidentified patient data were retrieved from the TriNetX. Patients who were prescribed either opioids or nonopioid analgesic within 1 to 5 days following thyroid surgery and parathyroidectomy were included. Evaluation of the prescription trends was performed by interrupted time series analysis in Statistical Analysis System 9.4 with significance set at P < .05 to assess trends before and after the new opioid prescription guidelines.

RESULTS

For thyroid surgery, there was an immediate effect of the guideline change indicated by a 3.3% decrease in the opioid prescription trend (P = .03) and a significant increase in nonopioid use of overtime by 0.13% every 3 months (P < .0001). The opioid prescription trend following parathyroidectomy significantly decreased over time by 0.28% every 3 months (P < .0001), while the nonopioid prescription trend increased by 0.14% (P < .0001).

CONCLUSION

There was an associated immediate reduction in the opioid prescribing trend for thyroidectomy, but the change was not sustained overtime. There was an associated decrease in the opioid prescribing trend for parathyroidectomy, but not immediately after the initial publication of the prescription guidelines.

LEVEL OF EVIDENCE

Level III.

Enhanced recovery after surgery (ERAS) improves outcomes in elderly patients undergoing short-level lumbar fusion surgery: a retrospective study of 333 cases

BACKGROUND

Degenerative lumbar disease significantly impairs the quality of life in elderly individuals, with short-segment lumbar degenerative disease being particularly prevalent. When conservative treatment proves ineffective, surgical intervention becomes the optimal choice for managing lumbar disease. The implementation of Enhanced Recovery After Surgery (ERAS) in spinal surgery has been progressively refined, leading to greater patient benefits. However, age and the associated decline in physiological function remain critical factors influencing surgical decision-making. Currently, there is a paucity of research focused on elderly patients undergoing lumbar fusion surgery to substantiate that advanced age does not diminish the benefits derived from ERAS in this demographic.

METHODS

This is a retrospective cohort study of prospectively collected data. Patients who underwent short-segment (1 or 2 segments) transforaminal lumbar interbody fusion (TLIF) under the care of the same surgical team at our institution were recruited, and divided into no-ERAS-elder, ERAS-elder, and ERAS-younger groups. Subsequently, time to physiological function recovery and other outcomes were compared.

RESULTS

The outcomes of the ERAS-elder group (n = 113) and the no-ERAS-elder group (n = 120) were compared. The overall physiological function recovery was significantly faster (6.71 ± 2.6 days vs. 8.6 ± 2.67 days, p = 0.01) in the ERAS-elder group. Next, the outcomes of the ERAS-elder group (n = 113) were compared with those of the ERAS-younger group (n = 100), and no significant difference in total physiological function recovery was found between the two groups (6.71 ± 2.6 days vs. 6.14 ± 1.63 days, p = 0.252).

CONCLUSIONS

This study shows that the implementation of the ERAS program can effectively shorten the recovery time of physiological function in elderly patients after short-segment lumbar surgery, reduce the incidence of some complications, alleviate pain, and significantly shorten the length of hospital stay. ERAS enables elderly patients to achieve outcomes comparable to those of younger patients.

Methylprednisolone taper is an effective addition to multimodal pain regimens after total shoulder arthroplasty: results of a randomized controlled trial: 2022 Neer Award winner

BACKGROUND

Perioperative corticosteroids have shown potential as nonopioid analgesic adjuncts for various orthopedic pathologies, but there is a lack of research on their use in the postoperative setting after total shoulder arthroplasty (TSA). The purpose of this study was to assess the effect of a methylprednisolone taper on a multimodal pain regimen after TSA.

METHODS

This study was a randomized controlled trial (clinicaltrials.gov NCT03661645) of opioid-naive patients undergoing TSA. Patients were randomly assigned to receive intraoperative dexamethasone only (control group) or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course (treatment group). All patients received the same standardized perioperative pain management protocol. Standardized pain journal entries were used to record visual analog pain scores (VAS-pain), VAS-nausea scores, and quantity of opioid tablet consumption during the first 7 postoperative days (POD). Patients were followed for at least one year postoperatively for clinical evaluation, collection of patient-reported outcomes, and observation of complications.

RESULTS

A total of 67 patients were enrolled in the study; 32 in the control group and 35 in the treatment group. The groups had similar demographics and comorbidities. The treatment group demonstrated a reduction in mean VAS pain scores over the first 7 POD. Between POD 1 and POD 7, patients in the control group consumed an average of 17.6 oxycodone tablets while those in the treatment group consumed an average of 5.5 tablets. This equated to oral morphine equivalents of 132.1 and 41.1 for the control and treatment groups, respectively. There were fewer opioid-related side effects during the first postoperative week in the treatment group. The treatment group reported improved VAS pain scores at 2-week, 6-week, and 12-week postoperatively. There were no differences in Europe Quality of Life, shoulder subjective value (SSV), at any time point between groups, although American Shoulder and Elbow Surgeons questionnaire scores showed a slight improvement at 6-weeks in the treatment group. At mean follow-up, (control group: 23.4 months; treatment group:19.4 months), there was 1 infection in the control group and 1 postoperative cubital tunnel syndrome in the treatment group. No other complications were reported.

CONCLUSIONS

A methylprednisolone taper course shows promise in reducing acute pain and opioid consumption as part of a multimodal regimen following TSA. As a result of this study, we have included this 6-day methylprednisolone taper course in our multimodal regimen for all primary shoulder arthroplasties. We hope this trial serves as a foundation for future studies on the use of low-dose oral corticosteroids and other nonnarcotic modalities to control pain after shoulder surgeries.

Risks associated with chronic cannabis use on opioid use, length of stay, and revision rate for patients undergoing posterior lumbar interbody fusion

BACKGROUND CONTEXT

Opioids are commonly prescribed to treat spinal pain, especially those undergoing surgery. Cannabis has been suggested as an agent that can modulate opioid needs in these patients.

PURPOSE

To investigate the effect of cannabis use on perioperative opioid requirement and revision surgery rate in patients undergoing lumbar fusion.

STUDY DESIGN

Retrospective cross-sectional study.

PATIENT SAMPLE

A total of 48,499 patients from PearlDiver national database who underwent posterior lumbar interbody fusion.

OUTCOME MEASURES

Opioid-use rates, MME, length of stay, and revision rates.

METHODS

Using PearlDiver, we identified patients for posterior lumbar interbody fusion (PLIF), cannabis use disorder, revision lumbar fusion, demographics, and comorbidities. Cannabis users and non-users were propensity matched for age, sex, and tobacco use. Pre and postoperative cumulative morphine milli equivalence (MME) were calculated. Opioid-use rates, MME, length of stay (LOS), and revision rates were compared using univariate analysis. Revision rates were compared using Kaplan-Meyer log-rank analysis, and logistic and cox regression.

RESULTS

Of 48,499 patients undergoing PLIF, 3.4% were identified as chronic cannabis users. They were younger, and more likely to be male and use tobacco. They had a higher rate and amount of opioid use within 90-days preoperatively, and 90- and 365-days postoperatively, after controlling for age, sex, and tobacco use. Cannabis users had longer LOS (4.4 vs 4.0 days), and a higher rate of revision surgery (6.9% vs 3.2%). Log-rank analysis, as well as logistic and cox regression confirmed an increased revision rate. Concurrent tobacco and cannabis use also had an additive effect on revision rate to 8.1%, compared with those who used only cannabis (5.4%) or tobacco (4.5%).

CONCLUSIONS

Chronic cannabis use is associated with an increased preoperative and long-term postoperative opioid use, a longer length of stay, and an increased revision rate.

The impact of perioperative opioid use on postoperative outcomes following spinal surgery: a meta-analysis of 60 cohort studies with 13 million participants

BACKGROUND CONTEXT

An important factor for the prognosis of spinal surgery is the perioperative use of opioids. However, the relationship is not clear.

PURPOSE

The purpose of this study was to evaluate the effect of perioperative opioid use on the prognosis of patients following spinal surgery.

STUDY DESIGN/SETTING

Systematic review and meta-analysis.

OUTCOME MEASURES

A meta-analysis was conducted using the random-effects method to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs).

METHODS

The PubMed, Embase, and Cochrane Library databases were systematically searched to find relevant articles that were published until September 2, 2022. The primary outcome was prolonged postoperative opioid use, and secondary outcomes included the length of stay (LOS), reoperation, the time to return to work (RTW), postoperative complications, gastrointestinal complications, new permanent disability, central nervous system events and infection. In addition, subgroup analysis of the primary outcome was conducted to explore the main sources of heterogeneity, and sensitivity analysis of all outcomes was performed to evaluate the stability of the results.

RESULTS

A total of 60 cohort studies involving 13,219,228 individuals met the inclusion criteria. Meta-analysis showed that perioperative opioid use was specifically related to prolonged postoperative opioid use (OR 6.91, 95% CI 6.09 to 7.84, p<.01). Furthermore, the results also showed that perioperative opioid use was significantly associated with prolonged LOS (OR 1.74, 95% CI 1.39 to 2.18, p<.01), postoperative complications (OR 1.72, 95% CI 1.26 to 2.36, p<.01), reoperation (OR 2.38, 95% CI 1.85 to 3.07, p<.01), the time to RTW (OR 0.45, 95% CI 0.39 to 0.52, p<.01), gastrointestinal complications (OR 1.39, 95% CI 1.30 to 1.48, p<.01), central nervous system events (OR 1.99, 95% CI 1.21 to 3.27, p=.07) and infection (OR 1.22, 95% CI 1.09 to 1.36, p=.01). These results were corroborated by the trim-and-fill procedure and leave-one-out sensitivity analyses.

CONCLUSIONS

Based on the current evidence, patients with perioperative opioid use, in comparison to controls, appear to have prolonged postoperative opioid use, which may increase the risk of poor outcomes including prolonged LOS, complications, reoperation, RTW and so on. However, these results must be carefully interpreted as the number of studies included was small and the studies were statistically heterogeneous. These findings may help clinicians to realize the harmfulness of perioperative use of opioids, reduce the use of prescription opioids, necessarily withdraw before operation or significantly wean to the lowest tolerable preoperative amount, and provide some inspiration for standardizing the use of opioids in the future.

Impact of opioid dependence on outcomes following total shoulder arthroplasty

INTRODUCTION

The opioid epidemic is a well-established problem encountered in orthopedic surgery in the United States. Evidence in lower extremity total joint arthroplasty and spine surgery suggests a link between chronic opioid use and increased expense and rates of surgical complications. The purpose of this study was to study the impact of opioid dependence (OD) on the short-term outcomes following primary total shoulder arthroplasty (TSA).

METHODS

A total of 58,975 patients undergoing primary anatomic and reverse TSA were identified using the National Readmission Database from 2015 to 2019. Preoperative opioid dependence status was used to divide patients into 2 cohorts, with 2089 patients being chronic opioid users or having opioid use disorders. Preoperative demographic and comorbidity data, postoperative outcomes, cost of admission, total hospital length of stay (LOS), and discharge status were compared between the 2 groups. Multivariate analysis was conducted to control for the influence of independent risk factors other than OD on postoperative outcomes.

RESULTS

Compared to nonopioid-dependent patients, OD patients undergoing TSA had higher odds of postoperative complications including any complications within 180 days (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.3-1.7), readmission within 180 days (OR 1.2, 95% CI 1.1-1.5), revision within 180 days (OR 1.7, 95% CI 1.4-2.1), dislocation (OR 1.9, 95% CI 1.3-2.9), bleeding (OR 3.7, 95% CI 1.5-9.4), and gastrointestinal complication (OR 14, 95% CI 4.3-48). Total cost ($20,741 vs. $19,643), LOS (1.8 ± 1.8 days vs. 1.6 ± 1.7 days), and likelihood for discharge to another facility or home with home health care (18 vs. 16% and 23% vs. 21%, respectively) were higher in patients with OD.

CONCLUSION

Preoperative opioid dependence was associated with higher odds of postoperative complications, rates of readmission and revision, costs, and health care utilization following TSA. Efforts focused on mitigating this modifiable behavioral risk factor may lead to better outcomes, lower complications, and decreased associated costs.

Development and Internal Validation of the Postoperative Analgesic Intake Needs Score: A Predictive Model for Post-Operative Narcotic Requirement after Spine Surgery

STUDY DESIGN

Retrospective Cohort.

OBJECTIVE

The aim of this study was to develop a clinical tool to pre-operatively risk-stratify patients undergoing spine surgery based on their likelihood to have high postoperative analgesic requirements.

METHODS

A total of 1199 consecutive patients undergoing elective spine surgery over a 2-year period at a single center were included. Patients not requiring inpatient admission, those who received epidural analgesia, those who had two surgeries at separate sites under one anesthesia event, and those with a length of stay greater than 10 days were excluded. The remaining 860 patients were divided into a derivation and validation cohort. Pre-operative factors were collected by review of the electronic medical record. Total postoperative inpatient opioid intake requirements were converted into morphine milligram equivalents to standardize postoperative analgesic requirements.

RESULTS

The postoperative analgesic intake needs (PAIN) score was developed after the following predictor variables were identified: age, race, history of depression/anxiety, smoking status, active pre-operative benzodiazepine use and pre-operative opioid use, and surgical type. Patients were risk-stratified based on their score with the high-risk group being more likely to have high opioid consumption postoperatively compared to the moderate and low-risk groups in both the derivation and validation cohorts.

CONCLUSION

The PAIN Score is a pre-operative clinical tool for patients undergoing spine surgery to risk stratify them based on their likelihood for high analgesic requirements. The information can be used to individualize a multi-modal analgesic regimen rather than utilizing a "one-size fits all" approach.

Risk Factors for Prolonged Opioid Use After Ankle Fracture Surgery

BACKGROUND

The incidence of ankle fractures is increasing, and risk factors for prolonged opioid use after ankle fracture fixation are unknown. Accordingly, the purpose of this study was to investigate risk factors that lead to prolonged opioid use after surgery.

METHODS

The Truven MarketScan database was used to identify patients who underwent ankle fracture surgery from January 2009 to December 2018 based on CPT codes. Patient characteristics were collected, and patients separated into 3 cohorts based on postoperative opioid use (no refills, refills within 6 months postoperative, and refills within 1 year postoperatively). The χ2 test and multivariate analysis were performed to assess the association between risk factors and prolonged use.

RESULTS

In total, 34 691 patients were analyzed. Comorbidities most highly associated with prolonged opioid use include 2+ preoperative opioid prescriptions (odds ratio [OR] = 11.92; P < .001), tobacco use (OR = 2.03; P < .001), low back pain (OR = 1.81; P < .001), depression (OR = 1.48; P < .001), diabetes (OR = 1.34; P < .001), and alcohol abuse (OR = 1.32; P < .001).

CONCLUSION

Opioid use after ankle fracture surgery is common and may be necessary; however, prolonged opioid use and development of dependence carries significant risk. Identifying those patients at an increased risk for prolonged opioid use can aid providers in tailoring their postoperative pain regimen.

LEVELS OF EVIDENCE

Prognostic, Level III.

Systemic Diclofenac Sodium Reduces Postoperative rhBMP-2 Induced Neuroinflammation: A Rodent Model Study

STUDY DESIGN

This is a basic science, animal research study.

OBJECTIVE

This study aims to explore, in rodent models, the effectiveness of systemic nonsteroidal anti-inflammatory drugs in reducing recombinant human bone morphogenetic protein-2 (rhBMP-2) induced neuroinflammation.

SUMMARY OF BACKGROUND DATA

rhBMP-2 is increasingly used to augment fusion in lumbar interbody fusion surgeries, although it can cause complications including postoperative radiculitis.

MATERIALS AND METHODS

Eighteen 8-week-old Sprague-Dawley rats underwent Hargreaves testing to measure the baseline thermal withdrawal threshold before undergoing surgical intervention. The L5 nerve root was exposed and wrapped with an Absorbable Collagen Sponge containing rhBMP-2. Rats were randomized into 3 groups: (1) Low dose (LD), (2) high dose (HD) diclofenac sodium, and (3) saline, receiving daily injection treatment. Hargreaves testing was performed postoperatively on days 5 and 7. Seroma volumes were measured by aspiration and the nerve root was then harvested for hematoxylin and eosin, immunohistochemistry, Luxol Fast Blue staining, and real-time quantitative polymerase chain reaction. The Student t test was used to evaluate the statistical significance among groups.

RESULTS

The intervention groups showed reduced seroma volume, and a general reduction of inflammatory markers (MMP12, MAPK6, GFAP, CD68, and IL18) compared with controls, with the reduction in MMP12 being statistically significant ( P = 0.02). Hematoxylin and eosin and immunohistochemistry of the nerve roots showed the highest macrophage density in the saline controls and the lowest in the HD group. Luxol Fast Blue staining showed the greatest extent of demyelination in the LD and saline groups. Lastly, Hargreaves testing, a functional measure of neuroinflammation, of the HD group demonstrated a minimal change in thermal withdrawal latency. In contrast, the thermal withdrawal latency of the LD and saline groups showed a statistically significant decrease of 35.2% and 28.0%, respectively ( P < 0.05).

CONCLUSION

This is the first proof-of-concept study indicating that diclofenac sodium is effective in alleviating rhBMP-2-induced neuroinflammation. This can potentially impact the clinical management of rhBMP-2-induced radiculitis. It also presents a viable rodent model for evaluating the effectiveness of analgesics in reducing rhBMP-2-induced inflammation.

The Effects of Opioid Dependency Use on Postoperative Spinal Surgery Outcomes: A Review of the Available Literature

There is a lack of evidence to support the effectiveness of long-term opioid therapy in patients with chronic, noncancer pain. Despite these findings, opioids continue to be the most commonly prescribed drug to treat chronic back pain and many patients undergoing spinal surgery have trialed opioids before surgery for conservative pain management. Unfortunately, preoperative opioid use has been shown repeatedly in the literature to negatively affect spinal surgery outcomes. In this review article, we identify and summarize the main postoperative associations with preoperative opioid use that have been found in previously published studies by searching on PubMed, Google Scholar, Medline, and ScienceDirect; using keywords: Opioid dependency, postoperative, spinal surgery, specifically (1) increased postoperative chronic opioid use (24 studies); (2) decreased return to work (RTW) rates (8 studies); (3) increased length of hospital stay (LOS) (9 studies); and (4) increased healthcare costs (8 studies). The conclusions from these studies highlight the importance of recognizing patients on opioids preoperatively to effectively risk stratify and identify those who will benefit most from multidisciplinary counseling and guidance.

Opioid Use Disorder in Patients Undergoing Primary 1- to 2-Level Anterior Cervical Discectomy and Fusion Is Associated With Longer In-Hospital Lengths of Stay and Higher Rates of Readmissions, Complications, and Costs of Care

STUDY DESIGN

Retrospective study.

OBJECTIVE

To determine whether opioid use disorder (OUD) patients undergoing 1- to 2-level anterior cervical discectomy and fusion (1-2ACDF) have higher rates of: 1) in-hospital lengths of stay (LOS); 2) readmissions; 3) complications; and 4) costs.

METHODS

OUD patients undergoing primary 1-2ACDF were identified within the Medicare database and matched to a control cohort in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 80,683 patients who underwent 1-2 ACDF with (n = 13,448) and without (n = 67,235) OUD. Outcomes analyzed included in-hospital LOS, 90-day readmission rates, 90-day medical complications, and costs. Multivariate logistic regression analyses were used to calculate odds-ratios (OR) for medical complications and readmissions. Welch's t-test was used to test for significance for LOS and cost between the cohorts. An alpha value less than 0.002 was considered statistically significant.

RESULTS

OUD patients were found to have significantly longer in-hospital LOS compared to their counterparts (3.41 vs. 2.23-days, P < .0001), in addition to higher frequency and odds of requiring readmissions (21.62 vs. 11.57%; OR: 1.38, P < .0001). Study group patients were found to have higher frequency and odds of developing medical complications (0.88 vs. 0.19%, OR: 2.80, P < .0001) and incurred higher episode of care costs ($20,399.62 vs. $16,812.14, P < .0001).

CONCLUSION

The study can help to push orthopaedic surgeons in better managing OUD patients pre-operatively in terms of safe discontinuation and education of opioid drugs and their effects on complications, leading to more satisfactory outcomes.

The role of preoperative opioid use in shoulder surgery-A systematic review

Background

Emerging evidence suggests preoperative opioid use may increase the risk of negative outcomes following orthopedic procedures. This systematic review evaluated the impact of preoperative opioid use in patients undergoing shoulder surgery with respect to preoperative clinical outcomes, postoperative complications, and postoperative dependence on opioids.

Methods

EMBASE, MEDLINE, CENTRAL, and CINAHL were searched from inception to April, 2021 for studies reporting preoperative opioid use and its effect on postoperative outcomes or opioid use. The search, data extraction and methodologic assessment were performed in duplicate for all included studies.

Results

Twenty-one studies with a total of 257,301 patients were included in the final synthesis. Of which, 17 were level III evidence. Of those, 51.5% of the patients reported pre-operative opioid use. Fourteen studies (66.7%) reported a higher likelihood of opioid use at follow-up among those used opioids preoperatively compared to preoperative opioid-naïve patients. Eight studies (38.1%) showed lower functional measurements and range of motion in opioid group compared to the non-opioid group post-operatively.

Conclusion

Preoperative opioid use in patients undergoing shoulder surgeries is associated with lower functional scores and post-operative range of motion. Most concerning is preoperative opioid use may predict increased post-operative opioid requirements and potential for misuse in patients.

Level of evidence

Level IV, Systematic review.

The use of liposomal bupivacaine in fracture surgery: a review

Historically, opioids have played a major role in the treatment of postoperative pain in orthopedic surgery. A multitude of adverse events have been associated with opioid use and alternative approaches to pain relief are being investigated, with particular focus on multimodal pain management regimens. Liposomal bupivacaine (EXPAREL) is a component of some multimodal regimens. This formulation of bupivacaine encapsulates the local anesthetic into a multivesicular liposome to theoretically deliver a consistent amount of drug for up to 72 hours. Although the use of liposomal bupivacaine has been studied in many areas of orthopedics, there is little evidence evaluating its use in patients with fractures. This systematic review of the available data identified a total of eight studies evaluating the use of liposomal bupivacaine in patients with fractures. Overall, these studies demonstrated mixed results. Three studies found no difference in postoperative pain scores on postoperative days 1-4, while two studies found significantly lower pain scores on the day of surgery. Three of the studies evaluated the quantity of narcotic consumption postoperatively and failed to find a significant difference between control groups and groups treated with liposomal bupivacaine. Further, significant variability in comparison groups and study designs made interpretation of the available data difficult. Given this lack of clear evidence, there is a need for prospective, randomized clinical trials focused on fully evaluating the use of liposomal bupivacaine in fracture patients. At present, clinicians should maintain a healthy skepticism and rely on their own interpretation of the available data before widely implementing the use of liposomal bupivacaine.

Association of inpatient opioid consumption on postoperative outcomes after open posterior spinal fusion for adult spine deformity

INTRODUCTION

Opioids are the most commonly used analgesic in the postoperative setting. However, few studies have analyzed the impact of high inpatient opioid use on outcomes following surgery, with no current studies assessing its effect on patients undergoing spinal fusion for an adult spinal deformity (ASD). Thus, the aim of this study was to investigate risk factors for high inpatient opioid use, as well as to determine the impact of high opioid use on outcomes such as adverse events (AEs), hospital length of stay (LOS), cost of hospital admission, discharge disposition, and readmission rates in patients undergoing spinal fusion for ASD.

METHODS

A retrospective cohort study was performed using the Premier healthcare database from the years 2016 and 2017. All adult patients > 40 years old who underwent thoracic or thoracolumbar fusion for ASD were identified using the ICD-10-CM diagnostic and procedural coding system. Patients were then categorized into three cohorts based on inpatient opioid use: Low MME (morphine milligram equivalents), Medium MME, and High MME. Patient demographics, comorbidities, treating hospital characteristics, intraoperative variables, postoperative AEs, LOS, discharge disposition, and total cost of hospital admission were assessed in the analysis. Multivariate regression analysis was done to determine independent predictors of high inpatient MME, prolonged LOS, and increased hospital cost.

RESULTS

Of 1673 patients included, 417 (24.9%) were classified as Low MME, 840 (50.2%) as Medium MME, and 416 (24.9%) as High MME. Age significantly decreased with increasing MME (Low: 71.0% 65 + years vs Medium: 62.0% 65 + years vs High: 47.4% 65 + years, p < 0.001), while the proportions of patients presenting with three or more comorbidities were similar across the cohorts (Low: 20.1% with 3 + comorbidities vs Medium: 18.0% with 3 + comorbidities vs High: 24.3% with 3 + comorbidities, p = 0.070). With respect to postoperative outcomes, the proportion of patients who experienced any AE (Low: 60.2% vs Medium: 68.8% vs High: 70.9%, p = 0.002), extended LOS (Low: 6.7% vs Medium: 20.7% vs High: 45.4%, p < 0.001), or non-routine discharge (Low: 66.6% vs Medium: 73.5% vs High: 80.1%, p = 0.003) each increased along with total MME. In addition, rates of 30-day readmission were greatest among the High MME cohort (Low: 8.4% vs Medium: 7.9% vs High: 12.5%, p = 0.022). On multivariate analysis, medium and high MME were associated with prolonged LOS [Medium: OR 4.41, CI (2.90, 6.97); High: OR 13.99, CI (8.99, 22.51), p < 0.001] and increased hospital cost [Medium: OR 1.69, CI (1.21, 2.39), p = 0.002; High: OR 1.66, CI (1.12, 2.46), p = 0.011]. Preadmission long-term opioid use [OR 1.71, CI (1.07, 2.7), p = 0.022], a prior opioid-related disorder [OR 11.32, CI (5.92, 23.49), p < 0.001], and chronic pulmonary disease [OR 1.39, CI (1.06, 1.82), p = 0.018] were each associated with a high inpatient MME on multivariate analysis.

CONCLUSION

Our study demonstrated that increasing inpatient MME consumption was associated with extended LOS and increased hospital cost in patients undergoing spinal fusion for ASD. Further studies identifying risk factors for increased MME consumption may provide better risk stratification for postoperative opioid use and healthcare resource utilization.

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.

Perioperative trends in neck and leg fluid volume in surgical patients: a prospective observational proof-of-concept study

PURPOSE

The severity of obstructive sleep apnea (OSA) may increase postoperatively. The changes in segmental fluid volume, especially neck fluid volume, may be related to increasing airway collapsibility and thus worsening of OSA in the postoperative period. Our objective was to evaluate the feasibility of performing bioelectrical impedance analysis (BIA) and to describe the trend and predictors of changes in segmental fluid volumes in patients receiving general anesthesia for noncardiac surgery.

METHODS

We conducted a prospective observational proof-of-concept cohort study of adult patients undergoing elective inpatient noncardiac surgery. Patients underwent a portable sleep study before surgery, and segmental fluid volumes (neck fluid volume [NFV], NFV phase angle, and leg fluid volume [LFV]) were measured using BIA at set time points: preoperative period (preop), in the postanesthesia care unit (PACU), the night following surgery at 10 pm (N 0), and the following day at 10 am (POD 1). Linear regression models were constructed to evaluate for significant predictors of overall segmental fluid changes. The variables included in the models were sex, preoperative apnea-hypopnea index (AHI), fluid balance, body mass index (BMI), cumulative opioids, and the timepoint of measurement.

RESULTS

Thirty-five adult patients (20/35 females, 57%) were included. For the feasibility outcome, measure of recruitment was 50/66 (76%) and two measures of protocol adherence were fluid measurements (34/39, 87%) and preoperative sleep study (35/39, 90%). There was a significant increase in NFV from preop to N 0 and in LFV from preop to PACU. Neck fluid volume also increased from PACU to N 0 and PACU to POD 1, while LFV decreased during the same intervals. The overall changes in NFV were associated with the preop AHI, BMI, and opioids after adjusting for body position and pneumoperitoneum.

CONCLUSIONS

This proof-of-concept study showed the feasibility and variability of segmental fluid volumes in the perioperative period using BIA. We found an increase in NFV and LFV in the immediate postoperative period in both males and females, followed by the continued rise in NFV and a simultaneous decrease in LFV, which suggest the occurrence of rostral fluid shift. Preoperative AHI, BMI, and opioids predicted the NFV changes.

STUDY REGISTRATION

ClinicalTrials.gov; NCT02666781, registered 25 January 2016; NCT03850041, registered 20 February 2019.

Does Preoperative Opiate Choice Increase Risk of Postoperative Infection and Subsequent Surgery?

BACKGROUND

Opioids are commonly prescribed for chronic pain before spinal surgery and research has shown an increased rate of postoperative adverse events in these patients.

OBJECTIVE

This study compared the incidence of 2-year subsequent surgical procedures and postoperative adverse events in patients undergoing lumbar fusion with or without 90-day preoperative opioid use. We hypothesized that patients using preoperative opioids would have a higher incidence of subsequent surgery and adverse outcomes.

METHODS

A retrospective cohort study was performed using the Optum Pan-Therapeutic Electronic Health Records database including adult patients who had their first lumbar fusion between 2015 and 2018. The daily average preoperative opioid dosage 90 days before fusion was determined as morphine equivalent dose and further categorized into high dose (morphine equivalent dose >100 mg/day) and low dose (1-100 mg/day). Clinical outcomes were compared after adjusting for confounders.

RESULTS

A total of 23,275 patients were included, with 2112 patients (10%) using opioids preoperatively. There was a significantly higher incidence of infection compared with nonusers (12.3% vs. 10.1%; P = 0.01). There was no association between subsequent fusion surgery (7.9% vs. 7.5%; P = 0.52) and subsequent decompression surgery (4.1% vs. 3.6%; P = 0.3) between opioid users and nonusers. Regarding postoperative infection risk, low-dose users showed significantly higher incidence (12.7% vs. 10.1%; P < 0.01), but high-dose users did not show higher incidence than nonusers (7.5% vs. 10.1%; P = 0.23).

CONCLUSIONS

Consistent with previous studies, opioid use was significantly associated with a higher incidence of 2-year postoperative infection compared with nonuse. Low-dose opioid users had higher postoperative infection rates than did nonusers.

Opioid Dose, Pain, and Recovery following Abdominal Surgery: A Retrospective Cohort Study

Background: The optimal dosage for opioids given to patients after surgery for pain management remains controversial. We examined the association of higher post-surgical opioid use with pain relief and recovery. Methods: We retrospectively enrolled adult patients who underwent elective abdominal surgery at our hospital between August 2021 and April 2022. Patients were divided into the “high-intensity” or “low-intensity” groups based on their post-surgical opioid use. Generalized estimating equation models were used to assess the associations between pain scores at rest and during movement on days 1, 2, 3, and 5 after surgery as primary outcomes. The self-reported recovery and incidence of adverse events were analyzed as secondary outcomes. Results: Among the 1170 patients in the final analysis, 293 were in the high-intensity group. Patients in the high-intensity group received nearly double the amount of oral morphine equivalents per day compared to those in the low-intensity group (84.52 vs. 43.80), with a mean difference of 40.72 (95% confidence interval (CI0 38.96−42.48, p < 0.001) oral morphine equivalents per day. At all timepoints, the high-intensity group reported significantly higher pain scores at rest (difference in means 0.45; 95% CI, 0.32 to 0.58; p < 0.001) and during movement (difference in means 0.56; 95% CI, 0.41 to 0.71; p < 0.001) as well as significantly lower recovery scores (mean difference (MD) −8.65; 95% CI, −10.55 to −6.67; p < 0.001). A post hoc analysis found that patients with moderate to severe pain during movement were more likely to receive postoperative high-intensity opioid use. Furthermore, patients in the non-high-intensity group got out of bed sooner (MD 4.31 h; p = 0.001), required urine catheters for shorter periods of time (MD 12.26 h; p < 0.001), and were hospitalized for shorter periods (MD 1.17 days; p < 0.001). The high-intensity group was at a higher risk of chronic postsurgical pain (odds ratio 1.54; 95% CI, 1.14 to 2.08, p = 0.005). Conclusions: High-intensity opioid use after elective abdominal surgery may not be sufficient for improving pain management or the quality of recovery compared to non-high-intensity use. Our results strengthen the argument for a multimodal approach that does not rely so heavily on opioids.

The Association of Postoperative Opioid Prescriptions with Patient Outcomes

OBJECTIVE

To compare outcomes after surgery between patients who were not prescribed opioids and patients who were prescribed opioids.

SUMMARY OF BACKGROUND DATA

Postoperative opioid prescriptions carry significant risks. Understanding outcomes among patients who receive no opioids after surgery may inform efforts to reduce these risks.

METHODS

We performed a retrospective study of adult patients who underwent surgery between January 1, 2019 and October 31, 2019. The primary outcome was the composite incidence of an emergency department visit, readmission, or reoperation within 30 days of surgery. Secondary outcomes were postoperative pain, satisfaction, quality of life, and regret collected via postoperative survey. A multilevel, mixed-effects logistic regression was performed to evaluate differences between groups.

RESULTS

In a cohort of 22,345 patients, mean age (standard deviation) was 52.1 (16.5) years and 13,269 (59.4%) patients were female. About 3175 (14.2%) patients were not prescribed opioids, of whom 422 (13.3%) met the composite adverse event endpoint compared to 2255 (11.8%) of patients not prescribed opioids ( P = 0.015). Patients not prescribed opioids had a similar probability of adverse events {11.7% [95% confidence interval (CI) 10.2%-13.2%] vs 11.9% (95% CI 10.6%-13.3%]}. Among 12,872 survey respondents, patients who were not prescribed an opioid had a similar rate of high satisfaction [81.7% (95% CI 77.3%-86.1%) vs 81.7% (95% CI 77.7%- 85.7%)] and no regret [(93.0% (95% CI 90.8%-95.2%) vs 92.6% (95% CI 90.4%-94.7%)].

CONCLUSIONS

Patients who were not prescribed opioids after surgery had similar clinical and patient-reported outcomes as patients who were prescribed opioids. This suggests that minimizing opioids as part of routine postoperative care is unlikely to adversely affect patients.

A Multimodal Pain Management Regimen for Open Treatment of Distal Radius Fractures: A Randomized Blinded Study

BACKGROUND

Adequate pain control is critical after outpatient surgery where patients are not as closely monitored. A multimodal pain management regimen was compared to a conventional pain management method in patients undergoing operative fixation for distal radius fractures. We hypothesized that there would be a decrease in the amount of narcotics used by the multimodal group compared to the conventional pain management group, and that there would be no difference in bone healing postoperatively.

METHODS

Forty-two patients were randomized into 2 groups based on pain protocols. Group 1, the control, received a regional block, acetaminophen, and oxycodone. Group 2 received a multimodal pain regimen consisting of daily doses of pregabalin, celecoxib, and acetaminophen up until postoperative day (POD) #3. They also received a regional block with oxycodone for breakthrough pain.

RESULTS

From POD#3 to week 1, there was a significant increase in oxycodone use in the study group correlating with the point in time when the multimodal regimen was discontinued. The shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) scores taken at 2 weeks postoperation showed a significantly lower average score in the study group compared to the control. There was no difference in bone healing.

CONCLUSIONS

The 2 regimens yielded similar pain control after surgery. The rebound increase in narcotic use after the multimodal regimen was discontinued, and significant difference in QuickDASH scores seen at 2 weeks postoperatively supported that multimodal regimens may not necessarily lead to decreased narcotic use in outpatient upper extremity surgery, but in the short term are shown to improve functional status.

Preoperative Opioid Use Is Associated With Inferior Patient-Reported Outcomes Measurement Information System Scores Following Rotator Cuff Repair

PURPOSE

To determine the influence of preoperative opioid use on Patient-Reported Outcomes Measurement Information System (PROMIS) scores pre- and postoperatively in patients undergoing arthroscopic rotator cuff repair (RCR).

METHODS

A retrospective review of all RCR patients aged >18 years old was performed. PROMIS pain interference ("PROMIS PI"), upper extremity function ("PROMIS UE"), and depression ("PROMIS D") scores, were reviewed. These measures were collected at preoperative, 6-month, and 1-year postoperative time points. A prescription drug-monitoring program was queried to track opioid prescriptions. Patients were categorized as chronic users, acute users, and nonusers based on prescriptions filled. Comparison of means were carried out using analysis of variance and least squares means. Effect sizes and 95% confidence intervals were calculated.

RESULTS

In total, 184 patients who underwent RCR were included. Preoperatively, nonusers (n = 92) had superior PROMIS UE (30.6 vs 28.9 vs 26.1; P < .05) and PI scores (61.5 vs 64.9 vs 65.3; P < .001) compared with acute users (n = 65) and chronic users (n = 27), respectively. At 6 months postoperatively; nonusers demonstrated significantly greater PROMIS UE (41.7 vs 35.6 vs. 33.5; P < .001), lower PROMIS D (41.6 vs 45.8 vs 51.1; P < .001), and lower PROMIS PI scores (50.7 vs 56.3 vs 58.1; P < .01) when compared with acute and chronic users, respectively. Nonusers had lower PROMIS PI (47.9 vs 54.3 vs 57.4; P < .0001) and PROMIS D (41.6 vs 48.3 vs 49.2; P = .0002) scores compared with acute and chronic users at 1-year postoperatively. Nonusers experienced a significantly greater magnitude of improvement in PROMIS D 6 months postoperatively compared with chronic opioid users (-5.9 vs 0.0; P < .01).

CONCLUSIONS

Patients undergoing RCR demonstrated superior PROMIS scores pre- and postoperatively if they did not use opioids within 3 months before surgery.

LEVEL OF EVIDENCE

III, retrospective comparative trial.

The effect of a quality improvement project on post-operative opioid use following outpatient spinal surgery

BACKGROUND

Prescribing opioids upon discharge after surgery is common practice; however, there are many inherent risks including dependency, diversion, and medical complications. Our prospective pre- and post-intervention study investigates the effect of a standardized analgesic prescription on the quantity of opioids prescribed and patients' level of pain and satisfaction with pain control in the early post-operative period.

METHODS

With the implementation of an electronic medical record, a standardized prescription was built employing multimodal analgesia and a stepwise approach to analgesics based on level of pain. Patients received an education handout pre-operatively explaining the prescription. Consecutive patients over a three-month period undergoing elective spine surgery as day or overnight stay cases who received usual care were compared to a similar cohort who received the standardized prescription and education. Patient satisfaction with post-operative pain control, post-operative pain scores, number of refills required, and opioids prescribed in oral morphine equivalents (OMEs) were compared before and after implementation of the standardized analgesic prescription.

RESULTS

Twenty-six patients received usual care (Control group) and 26 patients received the standardized prescription and education handout (Intervention group). There were significantly fewer OMEs prescribed in the Intervention group compared to the Control group. There was no difference between groups in: patient post-operative pain intensity score, post-operative satisfaction score, or number of refills required.

CONCLUSIONS

This study demonstrates that a standardized prescription consisting of an appropriate amount of opioid and non-opioid analgesics is effective in reducing the OMEs prescribed post-operatively in elective spine surgery procedures, without compromising patient pain control or satisfaction or increasing the number of refills required.

Chronic Opioid Use Prior to ACDF Surgery Is Associated with Inferior Postoperative Outcomes: A Propensity-Matched Study of 17,443 Chronic Opioid Users

OBJECTIVE

Candidates for anterior cervical discectomy and fusion (ACDF) have a higher rate of opioid use than does the public, but studies on preoperative opioid use have not been conducted. We aimed to understand how preoperative opioid use affects post-ACDF outcomes.

METHODS

The MarketScan Database was queried from 2007 to 2015 to identify adult patients who underwent an ACDF. Patients were classified into separate cohorts based on the number of separate opioid prescriptions in the year before their ACDF. Ninety-day postoperative complications, postoperative readmission, reoperation, and total inpatient costs were compared between opioid strata. Propensity score-matched patient cohorts were calculated to balance comorbidities across groups.

RESULTS

Of 81,671 ACDF patients, 31,312 (38.3%) were nonusers, 30,302 (37.1%) were mild users, and 20,057 (24.6%) were chronic users. Chronic opioid users had a higher comorbidity burden, on average, than patients with less frequent opioid use (P < 0.001). Chronic opioid users had higher rates of postoperative complications (9.1%) than mild opioid users (6.0%) and nonusers (5.3%) (P < 0.001) and higher rates of readmission and reoperation. After balancing opioid nonusers versus chronic opioid users along with demographic characteristics, preoperative comorbidity, and operative characteristics, postoperative complications remained elevated for chronic opioid users relative to opioid nonusers (8.6% vs. 5.7%; P < 0.001), as did rates of readmission and reoperation.

CONCLUSIONS

Chronic opioid users had more comorbidities than opioid nonusers and mild opioid users, longer hospitalizations, and higher rates of postoperative complication, readmission, and reoperation. After balancing patients across covariates, the outcome differences persisted, suggesting a durable association between preoperative opioid use and negative postoperative outcomes.

Larger Perioperative Opioid Prescriptions Lead to Prolonged Opioid Use After Hand and Upper Extremity Surgery: A Multicenter Analysis

INTRODUCTION

The opioid epidemic remains an ongoing public health crisis. The purpose of this study was to investigate whether surgeons' prescribing patterns of the initial postoperative opioid prescription predispose patients to prolonged opioid use after upper extremity surgery.

METHODS

This multicenter retrospective study was done at three academic institutions. Patients who underwent carpal tunnel release, basal joint arthroplasty, and distal radius fracture open reduction and internal fixation over a 1.5-year period were included. Opioid prescription data were obtained from the Pennsylvania Prescription Drug Monitoring Program website.

RESULTS

Postoperatively, 30.1% of the patients (191/634) filled ≥1 additional opioid prescription, and 14.0% (89/634) experienced prolonged opioid use 3 to 6 months postoperatively. Patients who filled an additional prescription postoperatively were initially prescribed significantly more pills (P = 0.001), a significantly longer duration prescription (P = 0.009), and a significantly larger prescription in total milligram morphine equivalents (P = 0.002) than patients who did not fill additional prescriptions. Patients who had prolonged opioid use were prescribed a significantly longer duration prescription (P = 0.026) than those without prolonged use.

CONCLUSION

Larger and longer duration of initial opioid prescriptions predisposed patients to continued postoperative opioid use. These findings emphasize the importance of safe and evidence-based prescribing practices to prevent the detrimental effects of opioid use after orthopaedic surgery.

Postoperative Pain Management Following Orthopedic Spine Procedures and Consequent Acute Opioid Poisoning: An Analysis of New York State From 2009 to 2018

OBJECTIVE

Considering the high rates of opioid usage following orthopedic surgeries, it is important to explore this in the setting of the current opioid epidemic. This study examined acute opioid poisonings in postoperative spine surgery patients in New York and the rates of poisonings among these patients in the context of New York's 2016 State legislation limiting opioid prescriptions.

METHODS

Claims for adult patients who received specific orthopedic spine procedures in the outpatient setting were identified from 2009 to 2018 in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Patients were followed to determine if they presented to the emergency department for acute opioid poisoning postoperatively. Multivariable logistic regression was performed to evaluate the effect of patient demographic factors on the likelihood of poisoning. The impact of the 2016 New York State Public Health Law Section 3331, 5. (b), (c) limiting opioid analgesic prescriptions was also evaluated by comparing rates of poisoning prelegislation and postlegislation enactment.

RESULTS

A total of 107,456 spine patients were identified and 321 (0.3%) presented postoperatively to the emergency department with acute opioid poisoning. Increased age [odds ratio (OR)=0.954, P <0.0001] had a decreased likelihood of poisoning. Other race (OR=1.322, P =0.0167), Medicaid (OR=2.079, P <0.0001), Medicare (OR=2.9, P <0.0001), comorbidities (OR=3.271, P <0.0001), and undergoing multiple spine procedures during a single operative setting (OR=1.993, P <0.0001) had an increased likelihood of poisoning. There was also a significant reduction in rates of postoperative acute opioid poisoning in patients receiving procedures postlegislation with reduced overall likelihood (OR=0.28, P <0.0001).

CONCLUSION

There is a higher than national average rate of acute opioid poisonings following spine procedures and increased risk among those with certain socioeconomic factors. Rates of poisonings decreased following a 2016 legislation limiting opioid prescriptions. It is important to define factors that may increase the risk of postoperative opioid poisoning to promote appropriate management of postsurgical pain.

A Prospective Randomized Controlled Trial of Methylprednisolone for Postoperative Pain Management of Surgically Treated Distal Radius Fractures

PURPOSE

Perioperative glucocorticoids have been effectively used as a pain management regimen for reducing pain after hand surgery. We hypothesize that a methylprednisolone taper (MPT) course following surgery will reduce pain and opioid consumption in the early postoperative period.

METHODS

This study was a randomized controlled trial of patients undergoing surgical fixation for distal radius fracture. Before surgery, patients were randomly assigned to receive preoperative dexamethasone only or preoperative dexamethasone followed by a 6-day oral MPT. Patient pain and opioid consumption data were collected for 7 days after surgery using a patient-reported pain journal.

RESULTS

Our study consisted of 56 patients enrolled from November 2018 to March 2020. Twenty-eight patients each were assigned to the control and treatment groups. Demographic characteristics such as age, body mass index, the dominant side affected, smoking status, diabetes status, and current narcotic use were similar between the control and treatment groups. With a noticeable, significant reduction starting on postoperative day 2, patients who received an MPT course consumed substantially less opioids during the first 7 days (7.8 ± 7.2 pills compared with 15.5 ± 11.5 pills, a 50% reduction). These patients also consumed significantly fewer oral morphine equivalents than the control group (81.2 vs 41.2). A significant difference in the pain visual analog scale scores between the 2 groups was noted starting on postoperative day 2, with 48% of the treatment group reporting no pain by postoperative day 6. No adverse events, including infection or complications of wound or bone healing, were seen in either group.

CONCLUSIONS

There was an early improvement in pain and reduction in early opioid consumption with a 6-day MPT following surgical fixation for distal radius fracture. With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Impact of Postoperative Opioid Use on 2-Year Patient-Reported Outcomes in Knee Surgery Patients

The purposes of this study were to identify the patient characteristics associated with refilling a postoperative opioid prescription after knee surgery and to determine whether refilling opioids is associated with 2-year patient-reported outcomes. We hypothesized that postoperative refill of opioids would be associated with worse 2-year patient-reported outcomes. We studied 192 patients undergoing knee surgery at a single urban academic institution. Patients completed multiple patient-reported outcome measures preoperatively and 2 years postoperatively, including six Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the International Knee Documentation Committee (IKDC) questionnaire, numeric pain scale scores for the operative knee and the rest of the body, Marx Activity Rating Scale, as well as measures of met expectations, improvement, and satisfaction. Total morphine equivalents (TMEs) were calculated from a regional prescription monitoring program. Patients who refilled a postoperative opioid prescription were compared with those who did not, and TMEs were calculated for those who refilled (Refill TMEs). One hundred twenty-nine patients (67%) refilled at least one postoperative opioid prescription. Black race, older age, higher average body mass index (BMI), smoking, greater medical comorbidities, preoperative opioid use, lower income, government insurance, and knee arthroplasty were associated with refilling opioids. Greater Refill TMEs was associated with black or white race, older age, higher average BMI, smoking, greater medical comorbidities, preoperative opioid use, government insurance, and unemployment. Refilling opioids and greater Refill TMEs were associated with worse postoperative scores on most patient-reported outcome measures 2 years after knee surgery. However, refilling opioids and greater Refill TMEs did not have a significant association with improvement after surgery. Multivariable analysis controlling for potential confounding variables confirmed that greater postoperative Refill TMEs independently predicted worse 2-year PROMIS Physical Function, 2-year PROMIS Pain Interference, and 2-year IKDC knee function scores. Postoperative refill of opioids was associated with worse 2-year patient-reported outcomes in a dose-dependent fashion. These findings reinforce the importance of counseling patients regarding opioid use and optimizing opioid-sparing pain management postoperatively.

Interpectoral-pectoserratus plane (PECS II) block in patients undergoing trans-axillary thoracic outlet decompression surgery; A prospective double-blind, randomized, placebo-controlled clinical trial

STUDY OBJECTIVE

To investigate if an interpectoral-pectoserratus plane (PECS II) block decreases postoperative pain, postoperative nausea and vomiting and improves quality of recovery in patients with neurogenic thoracic outlet syndrome (NTOS) undergoing trans-axillary thoracic outlet decompression surgery.

DESIGN

A prospective single center double blinded randomized placebo-controlled trial.

SETTING

Perioperative period; operating room, post anesthesia care unit (PACU) and hospital ward.

PATIENTS

Seventy patients with NTOS, undergoing trans-axillary thoracic outlet decompression surgery.

INTERVENTIONS

Patients were randomized to an interventional arm, receiving the block with 40 ml ropivacaine 0.5% (concentration was adjusted if the patient's weight was <66 kg), and a placebo group, receiving a sham block with 40 ml NaCl 0.9%. The interpectoral-pectoserratus plane block was performed ultrasound guided; the first injection below the pectoral minor muscle and the second below the pectoral major muscle. The hospitals' pharmacist prepared the study medication and was the only person able to see the randomization result. The study was blinded for patients, researchers and medical personnel.

MEASUREMENTS

Primary outcome parameters were postoperative pain, measured by numeric rating scale on the PACU (start and end) and on the ward on postoperative day (POD) 0 and 1, and postoperative morphine consumption, measured on the PACU and on the ward during the first 24 h. Secondary outcome parameters were postoperative nausea and vomiting, and quality of recovery.

MAIN RESULTS

There was no statistically significant difference in NRS on the PACU at the start (ropivacaine 4.9 ± 3.2 vs placebo 6.2 ± 3.0, p = .07), at the end (ropivacaine 4.0 ± 1.7 vs placebo 3.9 ± 1.7, p = .77), on the ward on POD 0 (ropivacaine 4.6 ± 2.0 vs placebo 4.6 ± 2.0, p = 1.00) or POD 1 (ropivacaine 3.9 ± 1.8 vs placebo 3.6 ± 2.0, p = .53). There was no difference in postoperative morphine consumption at the PACU (ropivacaine 11.0 mg ± 6.5 vs placebo 10.8 mg ± 4.8, p = .91) or on the ward (ropivacaine 11.6 mg ± 8.5 vs placebo 9.6 mg ± 9.4, p = .39).

CONCLUSIONS

The interpectoral-pectoserratus plane block is not effective for postoperative analgesia in patients with NTOS undergoing trans-axillary thoracic outlet decompression surgery.

The pericapsular nerve group block: a step towards outpatient total hip arthroplasty?

INTRODUCTION

A new regional anaesthetic technique, coined the pericapsular nerve group (PENG) block, targets the anterior hip capsule by blocking the articular branches of the femoral nerve and accessory obturator nerve. In this study, we evaluated: (1) patient outcomes; (2) postoperative pain scores; and (3) postoperative opioid consumption in total hip arthroplasty (THA) patients who received a PENG block in comparison to a control group.

METHODS

A retrospective chart review was performed for patients who underwent primary THA and met criteria at a single institution (n = 48), with an additional cohort of patients collected as controls (n = 48). Postoperative pain scores were measured by obtaining the cumulative visual analogue scores (VAS) at 12-hour intervals until the 48-hour benchmark. All administered opioids were collected from postoperative day (POD) 0 to POD2 and converted to morphine milligram equivalents (MME).

RESULTS

In the PENG group, length of stay was significantly shorter (p < 0.001) and the initial postoperative distance walked was significantly farther (p = 0.001). The PENG group consistently demonstrated significantly lower mean cumulative pain scores until the 48-hour mark (p < 0.001 for all). Patients receiving the PENG block also experienced a significantly longer therapeutic window before requiring their first opioid (p < 0.002). The PENG group required significantly less opioid MMEs on POD1, POD2, and cumulatively over the entire stay (p < 0.022 for all).

CONCLUSIONS

Our findings suggest that the PENG block has the potential of impacting THA recovery pathways and contributing to cost savings. Thus, its use further supports the transition to the outpatient setting and drives us towards achieving value-driven healthcare.

Preoperative opioid use is a risk factor for complication following revision total hip arthroplasty

BACKGROUND

The demand for revision total hip arthroplasty (THA) procedures continues to increase. A growing body of evidence in primary THA suggests that preoperative opioid use confers increased risk for complication. However, it is unknown whether the same is true for patients undergoing revision procedures. The purpose of this study was to investigate whether or not there was a relationship between preoperative opioid use and surgical complications, medical complications, and healthcare utilisation following revision THA.

METHODS

This is a retrospective cohort study using the Truven Marketscan database. Patients undergoing revision THA were identified. Preoperative opioid prescriptions were queried for 1 year preoperatively and were used to divide patients into cohorts based on temporality and quantity of opioid use. This included an opioid naïve group as well as an "opioid holiday" group (6 months opioid naïve period after chronic use). Demographic and complication data were collected and both univariate and multivariate analysis was then performed.

RESULTS

62.5% of patients had received an opioid prescription in the year preceding surgery. Patients with continuous preoperative opioid use had higher odds of the following: infection (superficial or deep surgical site infection; OR 1.29; 95% CI, 1.03-1.62, p = 0.029), wound complication (OR 1.36; 95% CI, 1.02-1.82, p = 0.037), sepsis (OR 1.90; 95% CI 1.08-3.34, p = 0.026), and revision surgery (OR 1.54, 95% CI, 1.28-1.85, p < 0.001). This group also had higher care utilisation including extended length of stay, non-home discharge, 90-day readmission, and emergency room visits (p < 0.001). An opioid holiday mitigated some of this increased risk as this cohort has baseline (i.e. same as opioid naïve) risk (p > 0.05 for all comparison).

CONCLUSIONS

Opioid use prior to revision THA is common and is associated with increased risk of postoperative complication. Given that risk was reduced by a preoperative opioid holiday, this represents a modifiable risk factor which should be discussed and addressed preoperatively to optimise outcomes.

Multiple Opioid Prescribers During the Perioperative Period Increases Opioid Consumption Following Upper Extremity Surgery: A Multicenter Analysis

Background

Opioid prescribing practices have been an area of interest for orthopedic surgeons in the wake of the opioid epidemic. Previous studies have investigated the effects of a multitude of patient-specific risk factors on prolonged opioid use postoperatively. However, to date, there is a lack of studies examining the effects of multiple prescribers during the perioperative period and their potential contribution to prolonged opioid use postoperatively. This study aimed to investigate if multiple unique opioid prescribers perioperatively predispose patients to prolonged opioid use following upper extremity surgery. Second, we compared opioid prescribing patterns among different medical specialties.

Methodology

This retrospective study was conducted at three academic institutions. Between April 30, 2018, and August 30, 2019, 634 consecutive patients who underwent one of three upper extremity procedures  were included in the analysis: carpal tunnel release (CTR), basal joint arthroplasty (BJA), or distal radius fracture open reduction and  internal fixation (DRF ORIF). Prescription information was collected using the state Prescription Drug Monitoring Program (PDMP) online database  from a period of three months preoperatively to six months postoperatively. A Google search was performed to group prescriptions by medical specialty.  Dependent outcomes included whether patients filled an additional opioid prescription postoperatively and prolonged opioid use (defined as opioid use three to six months postoperatively).

Results

In total, 634 patients were identified, including 276 CTRs, 217 DRF ORIFs, and 141 BJAs. This consisted of 196 males (30.9%) and 438 females (69.1%) with an average age of 59.4 years (SD: 14.7 years). By six months postoperatively, 191 (30.1%) patients filled an additional opioid prescription, and 89 (14.0%) experienced prolonged opioid use. In total, 235 (37.1%) patients had more than one unique opioid prescriber during the study period (average 2.5 prescribers). Patients with more than one unique opioid prescriber were significantly more likely to have received overlapping opioid prescriptions (15.7% vs. 0.8%, p<.001), to have filled an additional opioid prescription postoperatively (63.8% vs 10.3%, p<.001), and to have experienced prolonged opioid use postoperatively (35.3% vs 1.5%, p<.001) compared to patients with only one opioid prescriber. Patients with multiple unique prescribers filled more opioid prescriptions compared to those with a single prescriber (2.8 refills vs 1.8 refills, p=.035). Within six months postoperatively, 71.4% of opioid refills were written by non-orthopedic providers. Opioid refills written by non-orthopedic prescribers were written for a significantly greater number of pills (68.4 vs. 27.9, p<.001), for a longer duration (22.2 vs. 6.2 days, p<.001), and for larger total morphine milligram equivalents per prescription (831.4 vs. 169.8, p<.001) compared to those written by orthopedic prescribers.

Conclusions

Patients with multiple unique opioid prescribers during the perioperative period are at a higher risk for prolonged opioid use postoperatively. Non-orthopedic providers were the highest prescribers of opioids postoperatively, and they prescribed significantly larger and longer prescriptions. Our findings highlight the value of utilizing PDMP databases to help curtail opioid overprescription and potential adverse opioid-related outcomes following upper extremity surgery.

Impact of Preoperative Opioid Use on 2-Year Patient-Reported Outcomes in Knee Surgery Patients

The objectives of this study are to assess perioperative opioid use in patients undergoing knee surgery and to examine the relationship between preoperative opioid use and 2-year postoperative patient-reported outcomes (PROs). We hypothesized that preoperative opioid use and, more specifically, higher quantities of preoperative opioid use would be associated with worse PROs in knee surgery patients. We studied 192 patients undergoing knee surgery at a single urban institution. Patients completed multiple PRO measures preoperatively and 2-year postoperatively, including six patient-reported outcomes measurement information system (PROMIS) domains; the International Knee Documentation Committee (IKDC) questionnaire, numeric pain scale (NPS) scores for the operative knee and the rest of the body, Marx's knee activity rating scale, Tegner's activity scale, International Physical Activity Questionnaire, as well as measures of met expectations, overall improvement, and overall satisfaction. Total morphine equivalents (TMEs) were calculated from a regional prescription monitoring program. Eighty patients (41.7%) filled an opioid prescription preoperatively, and refill TMEs were significantly higher in this subpopulation. Opioid use was associated with unemployment, government insurance, smoking, depression, history of prior surgery, higher body mass index, greater comorbidities, and lower treatment expectations. Preoperative opioid use was associated with significantly worse 2-year scores on most PROs, including PROMIS physical function, pain interference, fatigue, social satisfaction, IKDC, NPS for the knee and rest of the body, and Marx's and Tegner's scales. There was a significant dose-dependent association between greater preoperative TMEs and worse scores for PROMIS physical function, pain interference, fatigue, social satisfaction, NPS body, and Marx's and Tegner's scales. Multivariable analysis confirmed that any preoperative opioid use, but not quantity of TMEs, was an independent predictor of worse 2-year scores for function, activity, and knee pain. Preoperative opioid use and TMEs were neither independent predictors of met expectations, satisfaction, patient-perceived improvement, nor improvement on any PROs. Our findings demonstrate that preoperative opioid use is associated with clinically relevant worse patient-reported knee function and pain after knee surgery.

Vancomycin during delivery hospitalizations for women with group B streptococcus

OBJECTIVE

Vancomycin use for intrapartum GBS prophylaxis is not well characterized. The objective of this study was to describe trends in the use of vancomycin among women undergoing vaginal delivery with group B Streptococcus (GBS) colonization.

METHODS

An administrative inpatient database that includes medications was analyzed to evaluate antibiotic use in women undergoing vaginal delivery hospitalizations complicated by GBS colonization from January 2006 to March 2015. Patients with other obstetric or infectious indications for antibiotics were excluded. Frequency of use of individual antibiotic agents was determined. The Cochran-Armitage test was used to assess temporal trends. An adjusted log-linear regression model accounting for demographic and hospital factors with vancomycin receipt as the outcome was performed with adjusted risk ratios (aRR) and 95% confidence intervals (CI) as the measure of effect. Hospital level variation in administration of vancomycin was also evaluated.

RESULTS

469,717 deliveries met inclusion criteria and were included in this analysis. Use of vancomycin increased from 0.8% of patients in 2006 to 3.8% of patients in the first quarter of 2015. Comparing 2015 to 2006 both the unadjusted (relative risk 4.89 95% CI 4.26-5.60) and adjusted (aRR 4.52 95% 3.94-5.19) models demonstrated significantly increased likelihood of vancomycin administration. In evaluating hospital level vancomycin use, variation was noted with 8.0% of centers administering vancomycin to ≥6.0% of patients.

CONCLUSIONS

Vancomycin is becoming increasingly commonly used for intrapartum GBS prophylaxis. Further research and quality improvements initiatives are indicated to optimize intrapartum GBS antibiotic prophylaxis.

The Impact of Perioperative Multimodal Pain Management on Postoperative Outcomes in Patients (Aged 75 and Older) Undergoing Short-Segment Lumbar Fusion Surgery

Background

Due to the presence of multimorbidity and polypharmacy, patients aged 75 and older are at a higher risk for postoperative adverse events after lumbar fusion surgery. More effective enhanced recovery pathway is needed for these patients. Pain control is a crucial part of perioperative management. The objective of this study is to determine the impact of multimodal pain management on pain control, opioid consumption, and other outcomes.

Methods

This is a retrospective review of a prospective collected database. Consecutive patients who underwent elective posterior lumbar fusion surgery (PLF) from October 2017 to April 2021 in our hospital were reviewed. Perioperative multimodal pain management (PMPM) group (from January 2019 to April 2021) in which patients received multimodal analgesia was case-matched to the control group (from October 2017 to December 2018) in which patients were treated under the conventional patient-controlled analgesia (PCA) method. Postoperative visual analogue scale (VAS), opioid consumption, complications within 3 months, and other outcomes were collected and compared between groups.

Results

A total of 122 consecutive patients (aged 75 and older) were included in the PMPM group and compared with previous 122 patients. The PMPM group had a lower maximal VAS score (3.0 ± 1.7 vs. 3.7 ± 2.0, p < 0.001) and frequency of additional opioid consumption (6.6% vs. 19.7%, p=0.001) on POD3 than the control group. The rates of postoperative complications were lower in the PMPM group compared with the control group (25% vs. 49%, p=0.006) during a 3-month follow-up period.

Conclusions

This study demonstrates that the PMPM protocol is effective in pain control and reducing additional opioid consumption when compared with conventional analgesia, even for patients aged 75 and older. Moreover, these improvements occur with a lower incidence of postoperative complications within three months after PLF surgery.

Cerebral mechanism of opposing needling for managing acute pain after unilateral total knee arthroplasty: study protocol for a randomized, sham-controlled clinical trial

Background

Opposing needling is a unique method used in acupuncture therapy to relieve pain, acting on the side contralateral to the pain. Although opposing needling has been used to treat pain in various diseases, it is not clear how opposing needling affects the activity of the central nervous system to relieve acute pain. We herein present the protocol for a randomized sham-controlled clinical trial aiming to explore the cerebral mechanism of opposing needling for managing acute pain after unilateral total knee arthroplasty (TKA).

Methods

This is a randomized sham-controlled single-blind clinical trial. Patients will be allocated randomly to two parallel groups (A: opposing electroacupuncture group; B: sham opposing electroacupuncture group). The Yinlingquan (SP9), Yanglingquan (GB34), Futu (ST32), and Zusanli (ST36) acupoints will be used as the opposing needling sites in both groups. In group A, the healthy lower limbs will receive electroacupuncture, while in group B, the healthy lower limbs will receive sham electroacupuncture. At 72 h after unilateral TKA, patients in both groups will begin treatment once per day for 3 days. Functional magnetic resonance imaging will be performed on all patients before the intervention, after unilateral TKA, and at the end of the intervention to detect changes in brain activity. Changes in pressure pain thresholds will be used as the main outcome for the improvement of knee joint pain. Secondary outcome indicators will include the visual analogue scale (including pain during rest and activity) and a 4-m walking test. Surface electromyography, additional analgesia use, the self-rating anxiety scale, and the self-rating depression scale will be used as additional outcome indices.

Discussion

The results will reveal the influence of opposing needling on cerebral activity in patients with acute pain after unilateral TKA and the possible relationship between cerebral activity changes and improvement of clinical variables, which may indicate the central mechanism of opposing needling in managing acute pain after unilateral TKA.

Trial registration

Study on the brain central mechanism of opposing needling analgesia after total kneearthroplasty based on multimodal MRI ChiCTR2100042429. Registered on January 21, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06066-6.

Decreasing Post-Operative Opioid Prescriptions Following Orthopedic Trauma Surgery: The "Lopioid" Protocol

OBJECTIVE

To assess the effectiveness of a multimodal analgesic regimen containing "safer" opioid and non-narcotic pain medications in decreasing opioid prescriptions following surgical fixation in orthopedic trauma.

DESIGN

Retrospective cohort study.

SETTING

One urban, academic medical center.

SUBJECTS

Traumatic fracture patients from 2018 (848) and 2019 (931).

METHODS

In 2019 our orthopedic trauma division began a standardized protocol of post-operative pain medications that included: 50 mg of tramadol four times daily, 15 mg of meloxicam once daily, 200 mg gabapentin twice daily, and 1 g of acetaminophen every 6 hours as needed. This multimodal regimen was dubbed the "Lopioid" protocol. We compared this protocol to all patients from the prior year who followed a standard protocol that included Schedule II narcotics.

RESULTS

Greater mean MME were prescribed at discharge from fracture surgery under the standard protocol compared to the Lopioid protocol (252.3 vs 150.0; p < 0.001) and there was a difference in the type of opioid medication prescribed (p < 0.001). There was a difference in the number of refills filled for patients discharged with opioids after surgical treatment between standard and Lopioid cohorts (0.31 vs 0.21; p = 0.002). There was no difference in the types of medication-related complications (p = 0.710) or the need for formal pain management consults (p = 0.199), but patients in the Lopioid cohort had lower pain scores at discharge (2.2 vs 2.7; p = 0.001).

CONCLUSIONS

The Lopioid protocol was effective in decreasing the amount of Schedule II narcotics prescribed at discharge and the number of opioid refills following orthopedic surgery for fractures.

Analgesic effects of Phα1β toxin: a review of mechanisms of action involving pain pathways

Phα1β is a neurotoxin purified from spider venom that acts as a high-voltage-activated (HVA) calcium channel blocker. This spider peptide has shown a high selectivity for N-type HVA calcium channels (NVACC) and an analgesic effect in several animal models of pain. Its activity was associated with a reduction in calcium transients, glutamate release, and reactive oxygen species production from the spinal cord tissue and dorsal ganglia root (DRG) in rats and mice. It has been reported that intrathecal (i.t.) administration of Phα1β to treat chronic pain reverted opioid tolerance with a safer profile than ω-conotoxin MVIIA, a highly selective NVACC blocker. Following a recent development of recombinant Phα1β (CTK 01512-2), a new molecular target, TRPA1, the structural arrangement of disulphide bridges, and an effect on glial plasticity have been identified. CTK 01512-2 reproduced the antinociceptive effects of the native toxin not only after the intrathecal but also after the intravenous administration. Herein, we review the Phα1β antinociceptive activity in the most relevant pain models and its mechanisms of action, highlighting the impact of CTK 01512-2 synthesis and its potential for multimodal analgesia.

The Association of Preoperative Opioid Use With Revision Surgery and Complications Following Carpometacarpal Arthroplasty

PURPOSE

Preoperative opioid use has been shown to be associated with poor outcomes following different upper-extremity surgeries. We aimed to examine the relationship between preoperative opioid use and outcomes following carpometacarpal (CMC) arthroplasty. We hypothesized that patients prescribed higher daily average numbers of preoperative oral morphine equivalents (OMEs) would show higher rates of complications and revision surgery.

METHODS

In the Truven Health MarketScan Database, we identified all patients who underwent CMC arthroplasty from 2009 to 2018. We separated them into cohorts based on average daily OMEs prescribed in the 6 months prior to the surgery: opioid naïve, <2.5, 2.5 to 5, 5 to 10, and >10 OMEs per day. We retrieved 90-day complications and 3-year revision surgery data, and we compared these outcomes by opioid-use groups.

RESULTS

We identified 40,141 patients. The majority (55.9%) were opioid naïve, with the next most common group receiving a daily average of <2.5 OMEs (19.2%). Complications increased with increased preoperative OMEs. Multivariable analysis revealed that patients taking >10 OMEs per day had a 1.45% increase in 3-year revision surgery compared with opioid-naïve patients, which equated to 2.12 (confidence interval [CI]: 1.33-3.36) times increased odds. Additionally, patients taking >10 OMEs had increased odds of an emergency department visit (odds ratio [OR]: 1.60, CI: 1.43-1.78), a 90-day hospital admission (OR: 2.34, CI: 1.97-2.79), and surgical site infection (OR, 2.02, CI: 1.59-2.54) compared with opioid-naïve patients, with absolute differences of 4.53%, 2.78%, and 1.22% compared with opioid-naïve patients, respectively. Additionally, preoperative opioid use predicted both number of prescriptions filled in the short term and long term continued opioid use.

CONCLUSIONS

Preoperative opioid use of >10 OMEs per day is associated with a higher risk for complications and revision surgery following CMC arthroplasty. Our findings demonstrate a dose-dependent relationship between opioid use and postoperative complications. Further study is necessary to determine if reducing opioid use prior to CMC arthroplasty may reduce the likelihood of these negative outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Preoperative Opioid Use Is Associated With Higher Revision Rates in Total Joint Arthroplasty: A Systematic Review

BACKGROUND

Although preoperative opioid use has been associated with poor postoperative patient-reported outcome measures and delayed return to work in patients undergoing total joint arthroplasty, direct surgery-related complications in patients on chronic opioids are still not clear. Thus, we sought to perform a systematic review of the literature to evaluate the influence of preoperative opioid use on postoperative complications and revision following primary total joint arthroplasty.

METHODS

Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we queried PubMed, EMBASE, the Cochrane Library, and the ISI Web of Science for studies investigating the influence of preoperative opioid use on postoperative complications following total hip arthroplasty and total knee arthroplasty up to May 2020.

RESULTS

After applying exclusion criteria, 10 studies were included in the analysis which represented 87,165 opioid users (OU) and 5,214,010 nonopioid users (NOU). The overall revision rate in the OU group was 4.79% (3846 of 80,303 patients) compared to 1.21% in the NOU group (43,719 of 3,613,211 patients). There was a higher risk of aseptic loosening (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.11-1.53, P = .002), periprosthetic fractures (OR 1.89, 95% CI 1.53-2.34, P < .00001), and dislocations (OR 1.26, 95% CI 1.14-1.39, P < .00001) in the OU group compared to the NOU group. Overall, 5 of 6 studies reporting on periprosthetic joint infection (PJI) rates showed statistically significant correlation between preoperative opioid use and higher PJI rates.

CONCLUSION

There is strong evidence that preoperative opioid use is associated with a higher overall revision rate for aseptic loosening, periprosthetic fractures, and dislocation, and an increased risk for PJI.

LEVEL OF EVIDENCE

Level III, systematic review.