Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review

Abstract

Background Pain management after foot and ankle surgery must surmount unique challenges that are not present in orthopaedic surgery performed on other parts of the body. However, disparate and inconsistent evidence makes it difficult to draw meaningful conclusions from individual studies. Questions/purposes In this systematic review, we asked: what are (1) the patterns of opioid use or prescription (quantity, duration, incidence of persistent use), (2) factors associated with increased or decreased risk of persistent opioid use, and (3) the clinical outcomes (principally pain relief and adverse events) associated with opioid use in patients undergoing foot or ankle fracture surgery? Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for our review. We searched PubMed, Embase, Scopus, Cochrane, and Web of Science on October 15, 2021. We included studies published from 2010 to 2021 that assessed patterns of opioid use, factors associated with increased or decreased opioid use, and other outcomes associated with opioid use after foot or ankle fracture surgery (principally pain relief and adverse events). We excluded studies on pediatric populations and studies focused on acute postoperative pain where short-term opioid use (< 1 week) was a secondary outcome only. A total of 1713 articles were assessed and 18 were included. The quality of the 16 included retrospective observational studies and two randomized trials was evaluated using the Methodological Index for Non-Randomized Studies criteria and the Jadad scale, respectively; study quality was determined to be low to moderate for observational studies and good for randomized trials. Mean patient age ranged from 42 to 53 years. Fractures studied included unimalleolar, bimalleolar, trimalleolar, and pilon fractures. Results Proportions of postoperative persistent opioid use (defined as use beyond 3 or 6 months postoperatively) rangedThe authors certify that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

CORR Insights®: Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review

“…In an article in this month’s Clinical Orthopaedics and Related Research ® , Badin et al [1] synthesized current data in a systematic review evaluating opioid use in the setting of foot and ankle trauma surgery. Their findings emphasize the problem: Up to 18% of patients who were opioid-naïve before surgery continue to use opioids persistently after surgery; the percentage is even higher in patients with prior opioid exposure.…”

Opioid and non-opioid analgesic regimens after fracture and risk of serious opioid-related events

“… 4 7 Though intraoperative (eg, spinal and regional anesthesia) and postoperative pain management (eg, ketorolac administration) strategies during hospitalization have shown potential benefits at reducing subsequent opioid-related harms, beneficial outpatient pain management strategies remain less well understood. 8 9 …”

A quadruple peripheral nerve block outside the OR for anterior cruciate ligament reconstruction reduces the OR occupancy time

“…In fact, reducing postoperative pain helps shorten the length of hospital stays [9] and optimize the rehabilitation. RA reduces morphine consumption [10][11][12][13][14][15][16], time spent in the post-anesthesia care unit (PACU) [17], and the hospital readmission rate [18]. However, its impact on the length of stay for outpatient procedures is not clear.…”