Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty

BACKGROUND

Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA.

METHODS

This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use.

DISCUSSION

The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making.

TRIAL REGISTRATION

Prospectively registered in Clinicaltrials.gov (NCT04968132).

Persisting pain after endovascular treatment of a symptomatic aortic aneurysm

INTRODUCTION

Usually patients are admitted to hospital with a single diagnosis, but if complaints persist it is important to consider a synchronous secondary diagnosis.

PRESENTATION OF CASE

A 74-year-old woman presented with severe abdominal and back pain. On physical examination, a tender abdominal aortic aneurysm (AAA) was noted. Following endovascular treatment of the AAA, pain in the right lower abdomen persisted. Review of the pre-EVAR CT images revealed a foreign body in the terminal ileum, which was surgically removed.

DISCUSSION

Patients with foreign-body-related intestinal pain present with complaints of abdominal pain at initial presentation. The accompanied back pain and abdominal tenderness of the abdominal aorta in our case could indicate another diagnosis.

CONCLUSION

Persisting complaints post-intervention should not only arouse suspicion of an intervention-related complication, but also of a synchronous second diagnosis.