The Efficacy and Safety of Opioids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundOpioids are frequently used to treat pain after total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of opioids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management.MethodsThe MEDLINE, EMBASE, and Cochrane Central Register of controlled trials were searched for studies published before November 2018 on opioids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of opioids.ResultsPreoperative opioid use leads to increased opioid consumption and complications after TJA along with a higher risk of chronic opioid use and inferior patient-reported outcomes. Scheduled opioids administered preemptively, intraoperatively, or postoperatively reduce the need for additional opioids for breakthrough pain. Prescribing fewer opioid pills after discharge is associated with equivalent functional outcomes and decreased opioid consumption. Tramadol reduces postoperative opioid consumption but increases the risk of postoperative nausea, vomiting, dry mouth, and dizziness.ConclusionModerate evidence supports the use of opioids in TJA to reduce postoperative pain and opioid consumption. Opioids should be used cautiously as they may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other central nervous system depressants or used in the elderly.     

Opioids in the management of persistent non-cancer pain

The medical use of opioids to treat pain and illness predates historic record. Opioids have a well-defined role in the treatment of acute and cancer pain, and most clinicians are comfortable prescribing opioids in these contexts. However, in persistent non-cancer pain (PNCP) there remains considerable controversy. While there is evidence of short-to-medium-term benefit, concerns exist over long-term efficacy, side effects, safety, and the potential for opioid misuse. Guidelines published to date emphasize the importance of patient selection, opioid preparation, monitoring of therapy, and a multimodal treatment package including other disciplines and non-pharmacological therapies. Worldwide, the use of opioids for PNCP has increased significantly over the past decade and with it, concerns of increases in opioid-related harm.     

Chronic Use of Opioids Before and After Total Knee Arthroplasty: A Retrospective Cohort Study

Background

Opioids are commonly used for the management of preoperative and postoperative pain among patients undergoing total knee arthroplasty (TKA). There is limited literature on the chronic use of opioids pre-TKA and post-TKA. The aim of this study was to characterize the use of opioids in TKA patients before and after surgery and identify risk factors of chronic opioid use.

Efficacy of Opioids in Preemptive Multimodal Analgesia for Total Knee Arthroplasty: A Prospective,Double-Blind,Placebo-Controlled,Randomized Trial

BackgroundPreemptive multimodal analgesia is a commonly used technique to control pain following total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of pre-emptive opioids for pain management in patients who underwent TKA.MethodsIn this prospective, double-blind, placebo-controlled, randomized trial, 100 patients who underwent TKA at our hospital were randomized to the oxycodone or control group. At 2 hours before surgery, patients in the oxycodone group received 400 mg celecoxib, 150 mg pregabalin, and 10 mg extended-release oxycodone hydrochloride. Patients in the control group received 400 mg celecoxib, 150 mg pregabalin, and placebo. The primary outcome was postoperative consumption of morphine hydrochloride as rescue analgesia. Secondary outcomes were time to first rescue analgesia, postoperative pain assessed by the visual analogue scale, functional recovery assessed by range of knee motion and ambulation distance, time until hospital discharge, indicators of liver function, and complication rates.ResultsThe 2 groups were similar in mean postoperative 0 to 24 hour morphine consumption (11.4 mg for control versus 12.4 mg for oxycodone group, P = .419) and mean total morphine consumption (18.2 versus 19.8 mg, P = .227). There were no statistical differences in secondary outcomes.ConclusionsIn our study, preemptive opioid administration did not provide clinical benefits over placebo. Orthopaedic surgeons should consider not using pre-operative opioids in patients undergoing TKA.     

Effect of Obesity on Total Ankle Arthroplasty: A Systematic Review of Postoperative Complications Requiring Surgical Revision

Total ankle arthroplasty has become an increasingly used alternative to ankle arthrodesis for the treatment of end-stage ankle arthritis. However, despite progressive technological advances and the advent of multiple commercial implant systems, some concern remains for the relatively high complication and failure rates. The objective of the present investigation was to perform a systematic review of the incidence of complications in obese patients undergoing total ankle arthroplasty. We performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses, and prospective clinical trials with ≥15 total participants, a mean follow-up period of ≥12 months, ≥1 defined cohort with a body mass index of ≥30?kg/m², and a reported incidence rate of complications requiring revisional surgery at the final follow-up point. Four studies met our inclusion criteria, with a total of 400 implants analyzed. Of these, ≥71 (17.8%) developed a complication requiring a revisional surgical procedure. The most commonly reported surgeries were revision of the metallic components and ankle gutter debridement. It is our hope that our investigation will allow foot and ankle surgeons to more effectively communicate the perioperative risk to their patients during the education and consent process.     

Lisfranc Fixation Techniques and Postoperative Functional Outcomes: A Systematic Review

The optimal method of fixation of acute Lisfranc injuries is yet to be established. We aim to systematically review the literature to identify the impact of fixation method on postoperative functional outcomes. A systematic review was undertaken using the PRISMA framework to identify all studies reporting postoperative functional outcomes in patients who underwent open-reduction internal fixation of acute Lisfranc injuries. Studies reporting outcomes of numerous fixation methods were divided into fixation subcohorts. Studies comparing bridge plate with transarticular screw fixation were included for meta-analysis, conducted using a random-effects model. Seventeen studies (20 subcohorts) with 462 patients were included. Mean patient age was 29.6 (rang, 15-81) years. Mean follow-up was 38.7 (range 11 to 287) months. American Academy of Orthopaedic Surgeons midfoot score (AOFAS-MF) was the most frequently reported functional outcome (16/20 subcohorts). Overall weighted mean AOFAS-MF was 76.3 ± 9.4 for all cases, with 74.2 ± 9.4 for transarticular screws and 79.2 ± 8.3 for bridge plates. The mean difference between screw and plate was not statistically significant (mean difference = 5.0, 95% confidence interval, -4.8 – 14.8, p = .3). A single study reported AOFAS-MF mean of 92 using suture button fixation. Meta-analysis of the 2 available comparative studies revealed higher postoperative AOFAS-MF with bridge plate fixation (pooled standardized mean difference, 0.51; 95% confidence interval, 0.15-0.87, p = .006). There is scarcity of literature examining the impact of fixation method on postoperative functional outcomes in acute Lisfranc injuries. A small number of studies have reported superior functional outcomes with use of bridge plate fixation. Further evidence is needed to ascertain which injuries are best managed with each fixation method or whether 1 fixation construct is universally superior.     

Intraoperative opioid dosing in children with and without cerebral palsy

Objective: To describe the differences in intraoperative opioid dosing and associated outcomes in children with and without cerebral palsy (CP). Background: Previous work on children with cognitive impairment has suggested that they receive less intraoperative opioid than children without cognitive impairment. This finding may be due to a common concern that impaired children are hypersensitive to the adverse effects of opioids. Patterns in intraoperative opioid dosing have yet to be studied in children with motor impairment (e.g. CP). Methods: We examined the medical records of pediatric patients with CP who underwent orthopedic surgery over the last decade at our institution, as well as the records of a randomly selected group of pediatric orthopedic patients without CP (non‐CP). Outcome variables were intraoperative opioid dosing, postoperative intensive care unit (ICU) admission, and postoperative oxygen desaturation. We collected demographic, surgical, and medical data for covariate analysis. A stepwise multivariate regression was used for each outcome. Results: Seventy‐one (71) CP and 77 non‐CP charts were included in the study. CP children received significantly less intraoperative opioid (3.26 ± 3.01 μg·kg^?1 fentanyl dose equivalents) than non‐CP children (4.58 ± 3.79 μg·kg^?1) (P = 0.02), and this difference was corroborated by the regression analysis, which significantly associated CP with decreased opioid dosing (P < 0.001). In addition, intraoperative opioid dosing, but not CP, predicted ICU admission (odds ratio: 1.463, 95% CI: 1.042–2.054, P = 0.03) and postoperative oxygen desaturation (odds ratio: 1.174, 95% CI: 1.031–1.338, P = 0.02). Conclusions: Similar to prior research on children with cognitive impairment, a reduction in intraoperative opioid dosing was found in children with CP. Given the discrepant doses of intraoperative opioid between groups, it is unclear whether children with CP are at any greater risk for untoward opioid‐related events.     

Microdialysis in Postoperative Monitoring of Gastrointestinal Organ Viability: A Systematic Review

World Journal of Surgery - Microdialysis is a technique for continuous measurement of extracellular substances. It may be used to monitor tissue viability. The clinical implications of using...