scholarly journals A Prospective Randomized Study Evaluating the Effect of Perioperative NSAIDs on Opioid Consumption and Pain Management After Ankle Fracture Surgery

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0008 ◽  
Author(s):  
Elizabeth McDonald ◽  
Joseph Daniel ◽  
Kristen Nicholson ◽  
Rachel Shakked ◽  
Steven Raikin ◽  
...  
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Bone Healing ◽  
Ankle Fracture ◽  
Drug Regimen ◽  
The United States ◽  
Opioid Consumption ◽  
Ankle Fractures ◽  
Opioid Medication ◽  
Narcotic Analgesia

Category: Trauma Introduction/Purpose: Currently there is an epidemic in the United States regarding opioid abuse. This has resulted in strict government prescribing regulations throughout the country and increasing efforts by orthopaedic surgeons to better manage postoperative narcotic analgesia. Non-steroidal anti-inflammatory drugs (NSAIDs) can serve as a powerful adjunct in managing postoperative pain and in turn minimize the need for opioid medications. It has recently been shown that ketorolac can be used after open reduction and internal fixation (ORIF) of ankle fractures without interfering with bone healing. Therefore, we set out to evaluate whether including ketorolac in the postoperative drug regimen reduces opioid consumption and pain after ORIF of ankle fractures. Methods: 128 patients undergoing ORIF of an ankle fracture were prospectively randomized to treatment with or without ketorolac. Patients also had the option to simultaneously undergo regional anesthesia. Patients assigned to the treatment group were given 30 mg of IV ketorolac intraoperatively; prescribed 20 tablets of ketorolac 10 mg PO Q6 H and 30 tablets of Oxycodone/Acetaminophen 5/325 Q4-6 H PRN. Patients assigned to the control group were given 30 tablets of oxycodone/acetaminophen 5/325 Q4-6 H PRN only. A survey was distributed via Research Electronic Data Capture (REDCap) on postoperative days 1-7. Patients were asked to report their daily opioid consumption, pain level using the Visual Analog Scale (VAS), satisfaction with pain management, and side effects. Intention-to-treat analysis was performed. Normality of data was tested using the Shapiro-Wilk test. Differences between the control and treatment groups were tested using Mann-Whitney U or Student’s t-tests. Results: 105/128 (82%) patients with mean BMI of 29.3 completed all study requirements. 54 received ketorolac with opioid medication and 51 received opioids alone. 43 men (41%) and 62 women (59%) participated with mean age of 48 years. Patients receiving ketorolac required less oxycodone/acetaminophen (p<0.013) and reported less pain (p<0.048) during postoperative days 1 and 2 compared to control patients(Figure 1). While opioid consumption did not significantly differ after day 2, patients treated with ketorolac maintained less pain (days 1-4, p<0.028); better sleep (days 1-5, p<0.037); lower frequency of pain (days 1-3; p<0.017); and greater satisfaction with pain management (days 1-3, p<0.047). Hypersensitivity was significantly less on day 1 (p=0.036) and paresthesias on day 3 (p=0.011). Surprisingly, there was no difference in nausea/constipation between groups (p>0.139). Conclusion: The addition of ketorolac to the postoperative drug regimen significantly reduced pain, while decreasing the use of opioid medication following ORIF of ankle fractures early in the postoperative period. Better pain management during postoperative days 1 and 2 is particularly important because patients on average consume the most opioids during this time. With the assurance that ketorolac does not interfere with bone healing, this NSAID is a valuable tool for helping patients manage postoperative pain with less narcotic analgesia.

scholarly journals Postoperative Pain and Opioid Use Following Surgical Treatment of Ankle Fractures

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0033
Author(s):  
Matthew Pate ◽  
Jacob Hall ◽  
John Anderson ◽  
Donald Bohay ◽  
John Maskill ◽  
...  
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Ankle Fracture ◽  
Management Practices ◽  
Opioid Analgesic ◽  
The United States ◽  
Ankle Fractures ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Opioid Medication

Category: Ankle, Bunion, Trauma Introduction/Purpose: Chronic opioid abuse is one of the greatest public health challenges in the United States. The most common first exposure to opioids comes from acute care prescriptions, such as those after surgery. Moreover, opioids are often prescribed excessively, with current estimates suggesting ˜75% of the pills prescribed are unused. Ankle fractures are the most common operatively treated fracture in orthopaedic surgery, and management of acute pain following surgery is challenging. The optimal perioperative pain regimen is still a point of controversy, as there is limited data available regarding appropriate amount of opioid to prescribe. This study evaluates opioid prescribing techniques of multiple foot and ankle surgeons, and associated patient outcomes. We aim to help surgeons improve their pain management practices and to limit opioid overprescription. Methods: Chart review and phone survey were performed on forty two adult patients within three to six months of ankle fracture fixation at our institution. These patients were offered to voluntarily participate in a standardized questionnaire regarding pain scores, opioid use, non-opioid analgesic use, pain management satisfaction, and patient prescription education. Results: 57% of patients reported that they were given “more” or ”much more” opioid medication than needed, 38% stated that they were given the “right amount”, and 5% reported that they were given ”less” or “much less” than needed. 40.0% were on opioids prior to operation. 53.5% did not require refill of discharge opioid prescriptions, 30.2% of patients did not fill any posteroperative opioid prescription. 16.3% of patients filled their discharge prescription and at least one additionall refill (mean refill = 2.22). Mean number of reported opioid pills taken after surgery was 17.4. Mean satisfaction with overall pain management at phone follow up was 8.6/10. Conclusion: While postoperative pain and management vary substantially, a majority of patients feel that they are given more opioid medication than necessary following ankle fracture repair, and a majority of opioid prescriptions are not completely used. Going forward, it is likely that a majority of patients could experience the same beneficial results with less prescription opioid pain medication, which would reduce overpresciption and potential misuse.

scholarly journals Opioid Consumption Patterns and the Risk of Prolonged Opioid Use Among Opioid-Naïve Patients Following Ankle Fracture Surgery

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0006
Author(s):  
Hope Skibicki ◽  
Sundeep Saini ◽  
Ryan Rogero ◽  
Kristen Nicholson ◽  
Rachel J. Shakked ◽  
...  
Keyword(s):  
Ankle Fracture ◽  
The United States ◽  
Opioid Consumption ◽  
Consumption Patterns ◽  
Opioid Use ◽  
Index Procedure ◽  
Factors Associated ◽  
Tibial Plafond ◽  
Significant Difference ◽  
Fracture Surgery

Category: Ankle Introduction/Purpose: Over the past two decades, the number of opioids dispensed in the United States has nearly tripled. Previous literature has demonstrated an association between acute opioid exposure and the risk of long-term opioid use. Statewide Prescription Drug Monitoring Programs (PDMPs) have been implemented to deter overprescribing and help monitor information pertaining to suspected abuse. The purpose of this study was to assess the immediate postoperative opioid consumption patterns as well as the incidence of new prolonged opioid use among opioid naïve patients following ankle fracture surgery. Methods: This was a retrospective review of prospectively collected data. Patients were included if they underwent outpatient open reduction and internal fixation of an ankle or tibial plafond fracture between October 2016 and September 2017. Patients were excluded if they received any narcotic prescriptions prior to the date of the initial injury. Patient demographics, medical history, fracture pattern, and opioid prescription and consumption details were collected. The morphine equivalent dose was calculated for each prescription and then converted to the equivalent of a 5-mg oxycodone “pill”. The New Jersey PDMP was used to determine all prescriptions of controlled substances filled up to 1 year postoperatively. Prolonged use was defined as filling a postoperative prescription for a controlled substance 90 days after the index procedure. Linear regression analysis was performed to identify independent factors associated with immediate postoperative opioid consumption and repeated to identify factors associated with prolonged use. Results: One-hundred seventy-one patients were included in this study. At the first postoperative visit, patients consumed a median of 24 pills, whereas the median number prescribed was 40. This resulted in an initial utilization rate of 60% and 2,736 pills left unused. Additionally, we found that 18.7% (n=32) of patients required a narcotic prescription after 90 days from the index procedure. There was no statistically significant difference found between specific fracture type (isolated distal fibula, bimalleolar, trimalleolar) and prolonged opioid consumption, however tibial plafond fractures could not be included due to insufficient sample size (n=5). Patients with a self-reported history of depression (p=.094) or diabetes (p=.097) demonstrated marginal correlation with prolonged narcotic use. Conclusion: Our study demonstrated that patients who underwent outpatient surgical fixation of an ankle or tibial plafond fracture were initially overprescribed narcotics by nearly 67%, leaving a significant quantity of pills unused for potential abuse or diversion. 18.7% of originally opioid naïve patients required continued analgesia 90 days after the index procedure, however large variations in consumption rates make it difficult for physicians to predict prolonged narcotic use.

scholarly journals Outcome Following Lower Extremity Nerve Block during Foot and Ankle Surgery: A Systematic Review

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0022
Author(s):  
Arianna L. Gianakos ◽  
Filippo Romanelli ◽  
Malaka Badri ◽  
Naina Rao ◽  
Bart Lubberts ◽  
...  
Keyword(s):  
Systematic Review ◽  
Pain Management ◽  
Postoperative Pain ◽  
Continuous Infusion ◽  
Nerve Block ◽  
Opioid Consumption ◽  
Foot And Ankle ◽  
Complication Risk ◽  
Prospective Comparison ◽  
Ankle Surgery

Category: Ankle; Other Introduction/Purpose: The purpose of this study was to perform a systematic review of the current literature assessing the management of pain with various block techniques in the perioperative period during elective foot and ankle surgery. Methods: A review of the literature was performed according to the PRISMA guidelines. Medline, Embase, and Cochrane databases were searched on October 1, 2019. Studies were identified by using synonyms for ‘foot’, ‘ankle’, ‘pain management’, ‘opioid’ and ‘nerve block’. Inclusion criteria were studies that 1) reported and compared the outcomes following various types of peripheral nerve blocks in in foot and ankle surgery, 2) were published in the English language, and 3) were published within the last 10 years. Results: Twenty-four articles evaluating 4,640 patients were included. Sixty-seven percent were randomized controlled trials, 17% were prospective comparison studies, and 17% were retrospective comparison studies. Nerve block techniques included: femoral, adductor canal, sciatic, popliteal, saphenous, and ankle. Ropivacaine and bupivacaine were most commonly utilized. Postoperative opioid consumption and postoperative pain levels were reduced with use of PNB when compared with systemic/local anesthesia, in patients receiving combined popliteal/femoral block, and in patients receiving continuous infusion popliteal block [Table 1, Table 2]. Studies demonstrated higher satisfaction with PNB, continuous infusion, and dual injections [Table 3]. One study reported 7% neurologic related complication risk and demonstrated a higher complication rate when with popliteal versus ankle block. All other studies were equivocal or failed to mention complications. Conclusion: Optimal pain management for elective foot and ankle surgery remains controversial and an ideal protocol from a risk-benefit perspective regarding use of PNB has yet to be established. Our study demonstrates improvements in postoperative pain levels, opioid consumption, and length of stay in patients receiving a PNB when compared with systemic anesthesia. Combined PNB and dual catheter administration may improve outcomes. Unfortunately, little data has been published on risks and tradeoffs in order to help guide patients and surgeons with a well informed shared decision making model. Future studies are needed to better clarify any respective tradeoffs to these options. [Table: see text]

scholarly journals How Does Perioperative Ketorolac Affect Opioid Consumption and Pain Management After Ankle Fracture Surgery?

2020 ◽  
Vol 478 (1) ◽  
pp. 144-151 ◽  
Author(s):  
Elizabeth L. McDonald ◽  
Joseph N. Daniel ◽  
Ryan G. Rogero ◽  
Rachel J. Shakked ◽  
Kristen Nicholson ◽  
...  
Keyword(s):  
Pain Management ◽  
Ankle Fracture ◽  
Opioid Consumption ◽  
Fracture Surgery

scholarly journals Does Patient Self-Awareness Predict Ankle Fractures?

2021 ◽  
Vol 8 ◽  
Author(s):  
Shaza Aouthmany ◽  
Tymon Horn ◽  
Michelle Howe ◽  
Edward Kakish ◽  
Alana Kakish ◽  
...  
Keyword(s):  
Ankle Fracture ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
The United States ◽  
Ankle Fractures ◽  
Ankle Injuries ◽  
Self Awareness ◽  
Self Assessment ◽  
X Ray ◽  
Decision Making Processes

Introduction: Ankle injuries represent one of the most common sports and extremity related complaints presented in emergency departments (ED) with over five million ankle injuries annually arising in the United States. The 2007 US National Health Statistics Report stated that lower limb and ankle complaints accounted for 4.1% of all reported body sites undergoing injury in the ED. The purpose of this study was to examine how frequently a sample of ED patients’ perception of having a possible ankle fracture was predictively associated with results of their X-ray evaluation results. Methods: After 2017 IRB approval, a sample of consented adult patients receiving care at the authors’ two Ohio and Michigan ED were asked, “Do you think you broke your ankle?” Regardless of each patient’s answer, they received an X-ray to evaluate for an ankle fracture that was interpreted by a radiologist. Results: A total of 69 eligible patients received an ankle X-ray. The total number of ankle fractures confirmed by X-ray was 20 (29.4% of sample) while 48 (70.5%) of ankles that were X-rayed were not fractured. Six (28.5%) out of 21 males and 14 (30.4%) out of 46 females were found to have a confirmed ankle fracture. The sensitivity of the perceived ankle fracture question was at or below 50% in all sample subgroups except for smokers at 67%. Conclusion: These findings support the importance of an ED clinician’s intuition when considering a patient’s own self-assessment during their clinical decision-making processes

scholarly journals Expanding the Perisurgical Home to Improve Postoperative Pain Management and Reduce Opioid Consumption

2019 ◽  
Vol 19 (2) ◽  
pp. 68-69
Author(s):  
Ivan Urits ◽  
Omar Viswanath ◽  
Vwaire Orhurhu ◽  
Viet Cai ◽  
Musa Aner
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Postoperative Pain Management ◽  
Opioid Consumption

Prospective, Double-blind Evaluation of Perioperative Intravenous Acetaminophen and Ketorolac for Postoperative Pain and Opioid Consumption After Endoscopic Carpal Tunnel Release

Hand ◽  
2020 ◽  
pp. 155894472090650
Author(s):  
Elizabeth C. Truelove ◽  
Eva Urrechaga ◽  
Carmella Fernandez ◽  
John R. Fowler
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Carpal Tunnel ◽  
Carpal Tunnel Release ◽  
Opioid Consumption ◽  
Controlled Study ◽  
Opioid Use ◽  
Double Blind ◽  
Pain Scores ◽  
Endoscopic Carpal Tunnel Release

Background: The current opioid epidemic highlights the need for pain management strategies to decrease or eliminate postoperative use of opioid medications. The purpose of this study was to determine if perioperative administration of intravenous (IV) acetaminophen and/or IV ketorolac decreases postoperative pain and opioid consumption after endoscopic carpal tunnel release. Methods: In all, 44 subjects were enrolled in this randomized, double-blind, placebo-controlled study from October 2015 to April 2017 and divided into 4 treatment arms: placebo, IV acetaminophen, IV ketorolac, or both IV acetaminophen and IV ketorolac. Patients recorded pain at 8-hour intervals on an 11-point scale and daily opioid use for 7 days after surgery. Analysis of variance and Kruskal-Wallis tests were used to compare mean pain scores and opioid consumption. Results: Mean pain scores over the 7-day study period were lower in the placebo and IV acetaminophen groups. Patients in the placebo and acetaminophen groups reported less pain than those in the ketorolac and combination groups on postoperative days 6 and 7. Patients administered IV acetaminophen had lower daily mean opioid usage. In all, 50% of the patients did not take any opioids after surgery. Conclusions: There are small, statistically significant differences in postoperative pain and opioid consumption supporting the use of IV acetaminophen for pain control after endoscopic carpal tunnel release, though these results are likely not clinically relevant. We recommend continued investigation into multimodal pain management in upper extremity surgery as well as limiting the number and quantity of opioid prescriptions provided to patients postoperatively.

scholarly journals Current Trends in Pediatric Spine Deformity Surgery: Multimodal Pain Management and Rapid Recovery

2019 ◽  
Vol 10 (3) ◽  
pp. 346-352
Author(s):  
Sagar A. Shah ◽  
Richard Guidry ◽  
Abhishek Kumar ◽  
Tyler White ◽  
Andrew King ◽  
...  
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Recovery Time ◽  
Postoperative Pain Management ◽  
Opioid Consumption ◽  
Rapid Recovery ◽  
Spine Deformity ◽  
Pediatric Spine ◽  
Pubmed Database ◽  
Scoliosis Correction

Study Design: Narrative review. Objectives: The purpose of this article is to perform a review of the literature assessing the efficacy of opioid alternatives, multimodal pain regimens, and rapid recovery in pediatric spine surgery. Methods: A literature search utilizing PubMed database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease postoperative pain and expedite recovery after posterior spinal fusion in adolescent idiopathic scoliosis patients have been provided based on results of studies with the highest level of evidence. Results: Refining perioperative pain management to lessen opioid consumption with multimodal regimens may be useful to decrease recovery time, pain, and complications. Nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentin, neuraxial blockades, and local anesthesia alone offer benefits for postoperative pain management, but their combination in multimodal regimens and rapid recovery pathways may contribute to faster recovery time, improved pain levels, and lower reduction in total opioid consumption. Conclusion: A rapid recovery pathway using the multimodal approach for pediatric scoliosis correction may offer superior postoperative pain management and faster recovery than traditional opioid only pain protocols.

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