Regional Anesthesia Associated With Decreased Inpatient and Outpatient Opioid Demand in Tibial Plateau Fracture Surgery

Abstract

BACKGROUND: Regional anesthesia (RA) has been used to reduce pain and opioid usage in elective orthopedic surgery. The hypothesis of this study was that RA would be associated with decreased opioid demand in tibial plateau fracture surgery. METHODS: Inpatient opioid consumption and 90-day outpatient opioid prescribing in all patients ≥18 years of age undergoing tibial plateau fracture surgery from July 2013 to July 2018 (n = 264) at a single, level I trauma center were recorded. The presence or absence of perioperative RA was noted. Of 60 patients receiving RA, 52 underwent peripheral nerve blockade (PNB) with single-shot sciatic-popliteal (40.0%; n = 24), femoral (26.7%; n = 16), adductor canal (18.3%; n = 11), or fascia iliaca (1.7%; n = 1) block with ropivacaine. Ten patients received epidural analgesia (EA) with either single-shot spinal (11.7%; n = 7) blocks or continuous epidural (5.0%; n = 3). Additional baseline and treatment characteristics were recorded, including age, sex, race, body mass index (BMI), smoking, chronic opioid use, American Society of Anesthesiologists (ASA) score, injury mechanism, additional injuries, open injury, and additional inpatient surgery. Statistical models, including multivariable generalized linear models with propensity score weighting to adjust for baseline patient and treatment characteristics, were used to assess perioperative opioid demand with and without RA. RESULTS: RA was associated with reduced inpatient opioid usage from 0 to 24 hours postoperatively of approximately 5.2 oxycodone 5-mg equivalents (0.74 incident rate ratio [IRR]; 0.63–0.86 CI; P < .001) and from 24 to 48 hours postoperatively of approximately 2.9 oxycodone 5-mg equivalents (0.78 IRR; 0.64–0.95 CI; P = .014) but not at 48 to 72 hours postoperatively. From 1 month preoperatively to 2 weeks postoperatively, RA was associated with reduced outpatient opioid prescribing of approximately 24.0 oxycodone 5-mg equivalents (0.87; 0.75–0.99; P = .044) and from 1 month preoperatively to 90 days postoperatively of approximately 44.0 oxycodone 5-mg equivalents (0.83; 0.71–0.96; P = .011), although there was no significant difference from 1 month preoperatively to 6 weeks postoperatively. There were no cases of acute compartment syndrome in this cohort. CONCLUSIONS: In tibial plateau fracture surgery, RA was associated with reduced inpatient opioid consumption up to 48 hours postoperatively and reduced outpatient opioid demand up to 90 days postoperatively without an associated risk of acute compartment syndrome. RA should be considered for patients undergoing tibial plateau fracture fixation.

Analysis of Risk Factors and Surgical Strategy of Knee Traumatic Arthritis after Internal Plate Fixation in the Treatment of Tibial Plateau Fracture

“…If the patient has the symptoms of joint swelling and limitation of movement, the joint, joint space, and meniscus feel tenderness during physical examination, MRI examination shows meniscus grade III signal changes; combined with arthroscopy, the existence of meniscus injury can be comprehensively determined. (2) Determination of ligament injury [ 12 ]: ligament injury can be divided into two types: collateral ligament injury and cruciate ligament injury. (3) Determination of osteoporosis [ 13 ]: the existence of osteoporosis was determined by whole body bone mineral density (BMD).…”

Pro-Con Debate: Peripheral Nerve Blockade Should Be Provided Routinely in Extremity Trauma, Including in Patients At Risk for Acute Compartment Syndrome

“…The targeted pain relief improves pain scores while decreasing opioid use, side effects from systemic medications, lengths of stay, and health care costs. 14 Many enhanced recovery after surgery (ERAS) and injury protocols include regional anesthetics in multimodal care. 25 In patients at risk for ACS, PNB may provide added benefits by limiting catecholamine release and enhancing blood flow through the extremity via sympathetic blockade.…”

“…13 Traditionally, systemic opioid analgesia has been used for severe trauma-related pain despite numerous side effects and the risk of creating opioid dependence when pain is uncontrolled. 14 Alternative analgesic modalities have been introduced with PNB providing superior analgesia and improved range of motion tolerance with minimal to no side effects. 1 High-energy injuries, fractures (particularly tibial plateau, tibial shaft, and radial fractures), or vascular trauma also predispose the patient to a greater likelihood of developing ACS.…”

Regional anesthesia and analgesia for trauma: an updated review

“…When determining how to manage acute orthopedic trauma pain, one must tailor it to the type of injury and intervention as it has been shown that fracture location, tissue involvement, and operative fixation have significant effects on pain intensity [32]. Elective orthopedic surgeries utilizing RA have reduced opioid consumption and postoperative pain; however, traumatic fractures are commonly associated with bone and soft tissue trauma which may be associated with increased inflammation and pain patterns [ ].…”