The Ramifications of Opioid Utilization and Outcomes of Alternative Pain Control Strategies for Total Knee Arthroplasties

Abstract

Morbidity and mortality related to opioid use has generated a public health crisis in the United States. Total knee arthroplasty (TKA) is an increasingly common procedure and is often accompanied by post-operative opioid utilization. Unfortunately, post-operative opioid usage after TKA has been shown to lead to higher rates of complications, longer hospital stays, increased costs, and more frequent need for revision surgery. Pre-operative opioid utilization has been shown to be one of the most important predictors of post-operative opioid usage. Additional risk factors for continued post-operative opioid utilization after TKA include pre-operative substance and tobacco use as well as higher post-operative prescription dosages, younger age, female gender, and Medicaid insurance. One method for mitigating excessive post-operative opioid utilization are Enhanced Recovery After Surgery (ERAS) protocols, which include a multidisciplinary approach that focuses on perioperative factors to optimize patient recovery and function after surgery. Additional strategies include multimodal pain regimens with epidural anesthetics, extended duration local anesthetics and adjuvants, and ultrasound guided peripheral nerve blocks. In recent years, opioid prescribing duration limitations have also been put into place by state and federal government, hospital systems, and ambulatory surgery centers making effective acute pain management imperative for all stakeholders. In this regard, as rates of TKA continue to increase across the United States, multidisciplinary efforts by all stakeholders are needed to ensure adequate pain control while preventing the negative sequalae of opioid medications.

Turning baby steps into big leaps: shifting paradigms in fast‐track joint replacement surgery

“…At our own institution, for example, patients that have been extensively optimised in the pre-operative setting undergo robot-guided joint replacement and are walking comfortably at home the same day following short-acting spinal anaesthesia and ultrasound-guided adductor canal, genicular and popliteal plexus blocks [1][2][3][4]. Such fast-tracking of orthopaedic patients through their surgical journey has been shown to pay off in terms of shorter length of stay; better satisfaction; reduced cost of care; improved resource utilisation; and lower complication rates [5][6][7][8]. The logical endpoint of fasttracking is day-case joint replacements.…”