scholarly journals Postoperative Opioid Dependence following Orthopaedic Foot and Ankle Surgery: A Cohort Study of 448 Patients

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0013
Author(s):  
Daniel D. Bohl ◽  
Emily Hejna ◽  
Nasima Mehraban ◽  
Johnny L. Lin ◽  
George B. Holmes ◽  
...  
Keyword(s):  
Risk Factors ◽  
Opioid Dependence ◽  
Management Strategies ◽  
Monitoring Program ◽  
Current Smoker ◽  
Foot And Ankle ◽  
Opioid Use ◽  
Ankle Surgery ◽  
Antidepressant Use ◽  
Baseline Characteristics

Category: Other Introduction/Purpose: Surgeon prescription of narcotic medications has been identified as a contributor to the nation’s devastating opioid epidemic. The purpose of this study is to identify risk factors for postoperative opioid dependence following orthopaedic foot and ankle surgery. Methods: Four hundred and forty-eight patients undergoing orthopaedic foot and ankle surgery at a single institution over a 6- month period were identified. The Illinois Prescription Monitoring Program was used to track opioid prescriptions filled in the preoperative, perioperative, and postoperative periods. Preoperative use was defined as the filling of a prescription during the six months prior to the procedure, excluding the 30 days prior to the procedure. Postoperative dependence was defined as the filling of opioid prescriptions beyond the initial postoperative prescription. Baseline characteristics, including preoperative opioid use, were tested for association with opioid dependence. Results: The rate of preoperative opioid use was 20.5%. The rate of postoperative opioid dependence was 31.3%. Patients who used opioids during the preoperative period had the highest risk for postoperative opioid dependence, at 59.6% (RR=2.5, 95% confidence interval = 1.9-3.2, p<0.001; Table 1). Other baseline characteristics associated with postoperative opioid dependence included antiepileptic use (RR=1.8, p=0.001), recreational drug use (RR=1.7, p=0.022), Charlson comorbidity index >= 2 (RR=1.6, p=0.002), benzodiazepine use (RR=1.5, p=0.010), current smoker status (RR=1.5, p<0.001), age >=60 years (RR=1.4, p=0.022), body mass index >= 30 kg/m2 (RR=1.4, p=0.027), antidepressant use (RR=1.4, p=0.050), and <1 drink per week (RR=1.3 p=0.045). Conclusion: The single strongest predictor of postoperative opioid dependence was preoperative opioid use, which was associated with more than a doubling in risk. Of note, the chronicity of the foot or ankle condition did not predict postoperative opioid dependence. Preoperative discussion of opiate treatment duration, multimodal pain management strategies and judicious prescription of narcotics should be considered in patients with the above-noted risk factors in an effort to avoid dependence on this potentially addictive and harmful class of medications. [Table: see text]

scholarly journals Incidence and Risk Factors of Symptomatic Venous Thromboembolism Following Foot and Ankle Surgery

2018 ◽  
Vol 40 (1) ◽  
pp. 98-104 ◽  
Author(s):  
Johanna Marie Richey ◽  
Miranda Lucia Ritterman Weintraub ◽  
John M. Schuberth
Keyword(s):  
Risk Factors ◽  
Hormone Replacement ◽  
Case Series ◽  
Foot And Ankle ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Ankle Surgery ◽  
History Of ◽  
Low Incidence ◽  
Predictive Risk

Background: The incidence rate of venous thrombotic events (VTEs) following foot and ankle surgery is low. Currently, there is no consensus regarding postoperative prophylaxis or evidence to support risk stratification. Methods: A 2-part study assessing the incidence and factors for the development of VTE was conducted: (1) a retrospective observational cohort study of 22 486 adults to calculate the overall incidence following foot and/or ankle surgery from January 2008 to May 2011 and (2) a retrospective matched case-control study to identify risk factors for development of VTE postsurgery. One control per VTE case matched on age and sex was randomly selected from the remaining patients. Results: The overall incidence of VTE was 0.9%. Predictive risk factors in bivariate analyses included obesity, history of VTE, history of trauma, use of hormonal replacement or oral contraception therapy, anatomic location of surgery, procedure duration 60 minutes or more, general anesthesia, postoperative nonweightbearing immobilization greater than 2 weeks, and use of anticoagulation. When significant variables from bivariate analyses were placed into the multivariable regression model, 4 remained statistically significant: adjusted odds ratio (aOR) for obesity, 6.1; history of VTE, 15.7; use of hormone replacement therapy, 8.9; and postoperative nonweightbearing immobilization greater than 2 weeks, 9.0. The risk of VTE increased significantly with 3 or more risk factors ( P = .001). Conclusion: The overall low incidence of VTE following foot and ankle surgery does not support routine prophylaxis for all patients. Among patients with 3 or more risk factors, the use of chemoprophylaxis may be warranted. Level of Evidence: Level III, retrospective case series.

scholarly journals Combating escalating harms associated with pharmaceutical opioid use in Australia: the POPPY II study protocol

BMJ Open ◽  
2018 ◽  
Vol 8 (12) ◽  
pp. e025840 ◽  
Author(s):  
Natasa Gisev ◽  
Sallie-Anne Pearson ◽  
Timothy Dobbins ◽  
David C Currow ◽  
Fiona Blyth ◽  
...  
Keyword(s):  
Risk Factors ◽  
Opioid Dependence ◽  
Service Use ◽  
Population Level ◽  
Ethics Committee ◽  
Adverse Outcomes ◽  
Opioid Use ◽  
Research Committee ◽  
Services Research ◽  
Wide Range

IntroductionOpioid prescribing has increased 15-fold in Australia in the past two decades, alongside increases in a range of opioid-related harms such as opioid dependence and overdose. However, despite concerns about increasing opioid use, extramedical use and harms, there is a lack of population-level evidence about the drivers of long-term prescribed opioid use, dependence, overdose and other harms.Methods and analysisWe will form a cohort of all adult residents in New South Wales (NSW), Australia, who initiated prescribed opioids from 2002 using Pharmaceutical Benefits Scheme dispensing records. This cohort will be linked to a wide range of other datasets containing information on sociodemographic and clinical characteristics, health service use and adverse outcomes (eg, opioid dependence and non-fatal and fatal overdose). Analyses will initially examine patterns and predictors of prescribed opioid use and then apply regression and survival analysis to quantify the risks and risk factors of adverse outcomes associated with prescribed opioid use.Ethics and disseminationThis study has received full ethical approval from the Australian Institute of Health and Welfare Ethics Committee, the NSW Population and Health Services Research Committee and the ACT Health Human Research Ethics Committee. This will be the largest postmarketing surveillance study of prescribed opioids undertaken in Australia, linking exposure and outcomes and examining risk factors for adverse outcomes of prescribed opioids. As such, this work has important translational promise, with direct relevance to regulatory authorities and agencies worldwide. Project findings will be disseminated at scientific conferences and in peer-reviewed journals. We will also conduct targeted dissemination with policy makers, professional bodies and peak bodies in the pain, medicine and addiction fields through stakeholder workshops and advisory groups. Results will be reported in accordance with the REporting of studies Conducted using Observational Routinely collected Data (RECORD) Statement.

Incidence of and Risk Factors for Venous Thromboembolism After Foot and Ankle Surgery

2018 ◽  
Vol 12 (3) ◽  
pp. 218-227 ◽  
Author(s):  
Samuel R. Huntley ◽  
Eildar Abyar ◽  
Eva J. Lehtonen ◽  
Harshadkumar A. Patel ◽  
Sameer Naranje ◽  
...  
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Female Gender ◽  
Risk Groups ◽  
Foot And Ankle ◽  
Improvement Program ◽  
True Incidence ◽  
Ankle Surgery ◽  
Data Files ◽  
Retrospective Comparative Study

Background: Venous thromboembolism (VTE) is a rare but potentially lethal complication after orthopaedic foot and ankle surgery. The true incidence of VTE after orthopaedic foot and ankle surgery stratified by specific procedure has yet to be examined. The purpose of this study is to report the incidence of and identify risk factors for VTE in a large sample of patients receiving orthopaedic foot and ankle surgery. Methods: In this study, we retrospectively analyzed data from the National Surgical Quality Improvement Program 2006 to 2015 data files. The incidence of VTE was calculated for 30 specific orthopaedic foot and ankle surgeries and for 4 broad types of foot and ankle surgery. Demographic, comorbidity, and complication variables were analyzed to determine associations with development of VTE. Results: The overall incidence of VTE in our sample was 0.6%. The types of procedures with the highest frequency of VTE were ankle fractures (105/15 302 cases, 0.7%), foot pathologies (28/5466, 0.6%), and arthroscopy (2/398, 0.5%). Female gender, increasing age, obesity, inpatient status, and nonelective surgery were all significantly associated with VTE. Conclusion: Although VTE after orthopaedic foot and ankle surgery is a rare occurrence, several high-risk groups and procedures may be especially indicated for chemical thromboprophylaxis. Levels of Evidence: Level III: Retrospective, comparative study

scholarly journals Postoperative Tourniquet Pain in Patients Undergoing Foot and Ankle Surgery

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0042
Author(s):  
Ashish Shah ◽  
Eva Lehtonen ◽  
Samuel Huntley ◽  
Harshadkumar Patel ◽  
John Johnson ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Postoperative Pain ◽  
Length Of Stay ◽  
Systolic Blood Pressure ◽  
Foot And Ankle ◽  
Opioid Use ◽  
Tourniquet Time ◽  
Pain Scores ◽  
Regional Nerve Block ◽  
Ankle Surgery

Category: Other Introduction/Purpose: The tourniquet is commonly used in orthopedic surgeries on the upper and lower extremities to reduce blood loss, improve visualization, and expedite the surgical procedure. However, tourniquets have been associated with multiple local and systemic complications, including postoperative pain. Guidelines vary regarding ideal tourniquet pressure and duration, while the practice of fixed, high tourniquet pressures remains common. The relationship between tourniquet pressure, duration, and postoperative pain has been studied in various orthopaedic procedures, but these relationships remain unknown in foot and ankle surgery. The purpose of this study was to assess for correlation between excessive tourniquet pressure and duration and the increased incidence of tourniquet pain in foot and ankle surgery patients. Methods: Retrospective chart review was performed for 132 adult patients who underwent foot and ankle surgery with concomitant use of intraoperative tourniquet at a single institution between August and December of 2015. Patients with history of daily opioid use of 30 or more morphine oral equivalents for greater than 30 days, patients who underwent foot and ankle surgery without regional nerve block, patients deemed to have failed regional nerve block, and patients who underwent foot and ankle surgery without tourniquet use were excluded. Patient’s baseline systolic blood pressure, tourniquet pressure and duration, tourniquet deflation time, tourniquet reinflation pressure and duration, intraoperative blood pressure and heart rate changes, intra-operative opioid consumption, PACU pain scores, PACU opioid consumption, and PACU length of stay were collected. Statistical correlation between tourniquet pressure and duration and postoperative pain scores, pain location, narcotic use, and length of stay in PACU was assessed using linear regression in SPSS. Results: Average age of patients was 47.6 years (Range: 16 - 79). Tourniquet pressure was 280 mmHg in 90.6% of patients (Range: 250-300 mmHg). Only 3.8% percent of patients had tourniquet pressures 100-150 mmHg above systolic blood pressure. Mean tourniquet time was 106.2 ± 40.1 min. Tourniquet time showed significant positive correlation with morphine equivalents used in the perioperative period (N = 121; r = 0.406; p < 0.001). Long tourniquet times (= 90 minutes) were associated with greater intraoperative opioid use than short tourniquet times (= 90 minutes) (19 mg ± 22 mg vs. 5 mg ± 11.6 mg; p <0.001). Tourniquet duration and PACU length of stay had a positive association (R2 = 0.4). Conclusion: The majority of cases of foot and ankle surgery at our institution did not adhere to current tourniquet use guidelines, which recommend tourniquet pressure between 100 and 150 mmHg above patient’s systolic blood pressure. Prolonged tourniquet times at high pressures not based on limb occlusion pressure, as observed in our study, lead to increased pain and opioid use and prolonged time in PACU. Basing tourniquet pressures on limb occlusion pressures could likely improve the safety margin of tourniquets, however randomized studies need to be completed to confirm this.

scholarly journals Opioid Consumption after Foot and Ankle Surgery: The Influence of Payer Status

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0008
Author(s):  
Joshua Acebo ◽  
Kenrick Lam ◽  
Shamis Khan ◽  
Rishabh Jain ◽  
Vinod Panchbhavi
Keyword(s):  
Monitoring Program ◽  
Foot And Ankle ◽  
Inclusion Criteria ◽  
Commercial Insurance ◽  
Post Operative Pain ◽  
Ankle Surgery ◽  
History Of ◽  
Medicare Patients ◽  
Morphine Equivalent ◽  
Insured Patient

Category: Ankle, Hindfoot, Midfoot/Forefoot Introduction/Purpose: Opioid utilization after foot and ankle surgery has received more attention recently with several papers publishing guidelines on the number of opioids to prescribe following surgery. To our knowledge the patient populations that have been studied in all of these papers are all private payer mixes, with a low amount of indigent patients. Social factors often have a large influence over surgical outcomes and therefore we aimed to see if this held true for post-operative opioid utilization as well. In this study we investigated differences in opioid utilization among patients with either Medicaid, Medicare or commercial insurance. Methods: All bony foot and ankle procedures performed by a single foot and ankle surgeon were reviewed between the dates of 7/1/2017 - 6/30/2018. Inclusion criteria were age over 18, did not have a history of chronic pain, and not incarcerated. Bony procedures included any osteotomy, fracture fixation, or arthrodesis. The number of narcotic prescriptions filled by the patient within 6 months following surgery was retrieved via the Texas Prescription Monitoring Program Database. Patients were also called and surveyed about their post-operative pain. The patients were then divided into 3 groups by payer status: commercial insurance including workman’s compensation, Medicaid including county insurance and self pay patients, and Medicare. Results: 92 patients met inclusion criteria, 22 Medicare, 26 Medicaid, and 44 commercial. Medicaid patients filled more narcotic prescriptions than commercial and medicare patients (870 mg morphine equivalent vs 781 mg morphine equivalent for commercial and 649 mg morphine equivalent for medicare) however this difference was not statistically significant (Medicaid vs Medicare p = 0.07). Medicaid patients also needed a greater number of refills per patient (0.27 for Medicaid vs 0.20 and 0.09 for commercial and Medicare, p = 0.22) and had a larger number of telephone encounters for pain (p = 0.02) than the other payer types. Conclusion: Although not statistically significant, there was a trend toward greater opioid utilization within the Medicaid and county insured patient population.

scholarly journals Subsequent Pain or Injury After Foot and Ankle Surgery in Patients Receiving Workers’ Compensation

2019 ◽  
Vol 41 (1) ◽  
pp. 17-24
Author(s):  
Gabrielle Bui ◽  
Yubo Gao ◽  
Natalie Glass ◽  
Christopher Cychosz ◽  
John Lawrence Marsh ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Retrospective Chart Review ◽  
Anatomical Location ◽  
Workers Compensation ◽  
Foot And Ankle ◽  
Chi Square ◽  
Level Of Evidence ◽  
Legal Representation ◽  
Ankle Surgery

Background: Workers’ compensation (WC) has been associated with poor outcomes following a variety of injuries and surgeries, but rates of subsequent pain or injury (SPI) following surgery have not been studied. The purpose of this study was to investigate the rates, locations, and risk factors of SPI in WC patients and non-WC patients who underwent the same surgeries. Methods: With institutional review board approval, records from foot or ankle surgery performed by author P.P. from 2009 to 2015 were obtained. A retrospective chart review was performed on all WC and non-WC patients with at least 1 Current Procedural Terminology code of interest. SPI was defined as a new injury at a different anatomical location occurring 2 months to 2 years after the index surgery. Chi-square and 2-tailed t tests were used to compare risk factors and rates of SPI in both groups. Results: The WC population had higher rates of SPI than the non-WC population. Specifically, 13 of 56 WC patients (23.2%) vs 12 of 165 non-WC patients (7.3%) reported SPI ( P = .001). The hip, knee, and contralateral foot and ankle were common areas of SPI in both groups. Legal representation and increased age were risk factors for SPI in the WC population. Specifically, 10 of 13 WC patients with SPI had legal representation vs 16 of 43 WC patients without SPI ( P = .02). Female sex was a risk factor for SPI in the non-WC population. Conclusions: WC patients had higher rates of subsequent pain or injury than non-WC patients. Legal representation was a risk factor for SPI in the WC population. Level of Evidence: Level III, comparative series.

Prospective Evaluation of Opioid Use After Adoption of a Prescribing Guideline for Outpatient Foot and Ankle Surgery

2019 ◽  
Vol 40 (11) ◽  
pp. 1260-1266
Author(s):  
Abhiram R. Bhashyam ◽  
Cornelia Keyser ◽  
Christopher P. Miller ◽  
Jennifer Jacobs ◽  
Eric Bluman ◽  
...  
Keyword(s):  
Opioid Consumption ◽  
Prescription Opioid ◽  
Foot And Ankle ◽  
Opioid Use ◽  
Level Of Evidence ◽  
Opioid Prescription ◽  
Provider Group ◽  
Use Patterns ◽  
Ankle Surgery ◽  
Pill Counts

Background: In 2016, our provider group adopted an initial prescription opioid maximum guideline to reduce overprescription of opioids. The purpose of this study was to prospectively assess opioid consumption patterns following implementation of this guideline in patients undergoing outpatient foot and ankle surgery. Methods: Over a 1-year period, we prospectively analyzed opioid prescription and use patterns of 303 consecutive patients. Opioid consumption was verified by pill counts completed at the 2- and 6-week postoperative visits. The morphine equivalent dose was calculated for each prescription and converted to the equivalent 5-mg oxycodone “pill.” We used the regression coefficients from a regression model of opioid consumption to create a revised guideline for maximum initial opioid prescriptions based on patient age, bony vs nonbony procedure, and anatomic location (forefoot/midfoot/hindfoot/ankle). Results: On average, 37.4 pills were prescribed and 18.9 pills used (47.6% utilization). Only 17.2% of patients used their full prescription quantity. By 2 weeks, 88% of patients no longer used opioids. Only 1.3% of patients used prescription opioids beyond 6 weeks. Independent risk factors for increased opioid consumption were younger age ( P = .003), male sex ( P = .007), recent preoperative opioid use ( P = .019), bony procedures ( P < .001), and ankle/hindfoot procedures ( P = .016 and P < .001). Conclusion: This study showed the amount of opioid consumption for patients undergoing foot and ankle procedures. We present a modified guideline for the maximum initial prescription of opioids following outpatient foot and ankle procedures that can be used as a benchmark for further study in decreasing overprescribing. Level of Evidence: Level II, prospective observational cohort study.

scholarly journals Opioid Consumption Rate After Foot and Ankle Surgery

2019 ◽  
Vol 4 (2) ◽  
pp. 2473011419S0000
Author(s):  
Peter Kvarda ◽  
Noortje Hagemeijer ◽  
Gregory R. Waryasz ◽  
Daniel Guss ◽  
Christopher W. DiGiovanni ◽  
...  
Keyword(s):  
Risk Factors ◽  
Postoperative Pain ◽  
Soft Tissue ◽  
Consumption Rate ◽  
Opioid Consumption ◽  
Foot And Ankle ◽  
Soft Tissue Procedure ◽  
Ankle Surgery ◽  
Ed Visits ◽  
Telephone Calls

Category: Opioid consumption rate and risk factors investigation after foot and ankle surgery Introduction/Purpose: The rapid increase in the consumption of prescription opioids has become one of the leading medical, economical, and sociological burdens in North America. In the United States, orthopedic surgery is the fourth leading specialty in the number of opioids prescribed, and the largest among surgical specialties. There is insufficient evidence to guide surgeons about appropriate opioid prescription amounts after orthopaedic foot and ankle (F&A) procedures. The aim of this study was to determine the opioid consumption rate after foot and ankle procedures, and to identify patient risk factors associated with higher use. Methods: A total of 535 patients who underwent a F&A surgery performed by one orthopedic surgeon from August 2016 to March 2018 were investigated. The study was approved by our IRB. Each patient received a preoperative discussion about postoperative pain and expectations alongside a standardized handout. At the two-week postoperative visit, the patient-reported amount of consumed opioids was recorded. Prescription details, the amount of opioids taken, refill requests, pain-issue related telephone calls, and additional MD/ED visits were also documented. Patient demographics and co-morbidities, use of regional anesthesia, postoperative inpatient hospitalization, surgery type and severity, and pre-operative opioid use were collected retrospectively. Total amounts of morphine equivalents were calculated and converted into oxycodone 5 mg pills for standardization. P-values of <0.05 were considered significant. Results: Two hundred forty-four patients with a mean age of 50 years (±16.3) and a BMI of 29 (±6.1) were included. Sixty-six (27%) patients underwent a soft tissue procedure alone and 178 (73%) underwent a bony procedure. 225 (92.2%) patients received regional block. Patients reported that they consumed only 51.2% of prescribed pills after a bony procedure and 42.4% after a soft tissue procedure, respectively, which resulted in a total of 4,496.2 left over pills that derived from this study amongst only 244 patients enrolled. There were 11 refill requests (4.5%), two (0.8%) additional MD/ED visits, and 19 (7.8%) telephone calls related to pain. BMI, procedure type, and number of opioids prescribed were positively correlated with the consumption rate (P =.002, P<.001, P<0.001, respectively). Conclusion: BMI, surgery type (bony vs. soft tissue), and a higher number of pills dispensed were correlated with higher use in the postoperative period. After an educative discussion on postoperative pain, patients took 42.4% of the prescribed opioid after soft tissue procedures and 51.2% after bony procedures, resulting in a significant number of unused pills now available to the community. Future guidelines are necessary to improve our postoperative pain management, but this study suggests that current amounts of dispensed pills after orthopaedic F&A procedures are approximately twice as high as necessary.

Venous Thromboembolic Prophylaxis in Foot and Ankle Surgery: A Review of Current Literature and Practice

2017 ◽  
Vol 10 (4) ◽  
pp. 343-351 ◽  
Author(s):  
Martin H. S. Weisman ◽  
James R. Holmes ◽  
Todd A. Irwin ◽  
Paul G. Talusan
Keyword(s):  
Risk Factors ◽  
Survey Study ◽  
Foot And Ankle ◽  
Thromboembolic Prophylaxis ◽  
Vte Prophylaxis ◽  
Perioperative Phase ◽  
Ankle Surgery ◽  
Significant Difference ◽  
Venous Thromboembolic ◽  
Low Incidence

Venous thromboembolism (VTE) is a well-known and feared complication following foot and ankle surgery, as it is a source of morbidity and mortality in the perioperative phase. The most recent CHEST guidelines recommended against the use of chemoprophylaxis and the majority of the literature has found a low incidence of VTE following foot and ankle surgery. Some authors prefer screening patients for risk factors and recommend the use of chemoprophylaxis on a case-by-case basis. Interestingly, studies that found high incidence of VTE were unable to determine a statistically significant difference between the prophylaxis and placebo groups. Major limitations of retrospective reviews is they are only able to study symptomatic VTE because no routine screening is typically performed. In a survey study, up to 98% of foot and ankle surgeons responded that they use prophylaxis in high-risk patients. Despite evidence-based recommendations, a significant number of foot and ankle surgeons are routinely using some form of VTE prophylaxis without taking risk factors into account. Levels of Evidence: Clinical, Level IV: Review Article

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