Preoperative opioid use is a risk factor for complication following revision total hip arthroplasty

Abstract

Background:

The demand for revision total hip arthroplasty (THA) procedures continues to increase. A growing body of evidence in primary THA suggests that preoperative opioid use confers increased risk for complication. However, it is unknown whether the same is true for patients undergoing revision procedures. The purpose of this study was to investigate whether or not there was a relationship between preoperative opioid use and surgical complications, medical complications, and healthcare utilisation following revision THA.

Methods:

This is a retrospective cohort study using the Truven Marketscan database. Patients undergoing revision THA were identified. Preoperative opioid prescriptions were queried for 1 year preoperatively and were used to divide patients into cohorts based on temporality and quantity of opioid use. This included an opioid naïve group as well as an “opioid holiday” group (6 months opioid naïve period after chronic use). Demographic and complication data were collected and both univariate and multivariate analysis was then performed.

Results:

62.5% of patients had received an opioid prescription in the year preceding surgery. Patients with continuous preoperative opioid use had higher odds of the following: infection (superficial or deep surgical site infection; OR 1.29; 95% CI, 1.03–1.62, p = 0.029), wound complication (OR 1.36; 95% CI, 1.02–1.82, p = 0.037), sepsis (OR 1.90; 95% CI 1.08–3.34, p = 0.026), and revision surgery (OR 1.54, 95% CI, 1.28–1.85, p < 0.001). This group also had higher care utilisation including extended length of stay, non-home discharge, 90-day readmission, and emergency room visits (p < 0.001). An opioid holiday mitigated some of this increased risk as this cohort has baseline (i.e. same as opioid naïve) risk (p > 0.05 for all comparison).

Conclusions:

Opioid use prior to revision THA is common and is associated with increased risk of postoperative complication. Given that risk was reduced by a preoperative opioid holiday, this represents a modifiable risk factor which should be discussed and addressed preoperatively to optimise outcomes.

Keywords

Arthroplasty complications narcotic opioid revision total hip

Get full access to this article

View all access options for this article.

References

Kurtz

Lau

Ong

, et al. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res 2009; 467: 2606–2612.

Keswani

Lovy

Robinson

, et al. Risk factors predict increased length of stay and readmission rates in revision joint arthroplasty. J Arthroplasty 2016; 31: 603–608.

Liodakis

Bergeron

Zukor

, et al. Perioperative complications and length of stay after revision total hip and knee arthroplasties: an analysis of the NSQIP database. J Arthroplasty 2015; 30: 1868–1871.

Pugely

Martin

Gao

, et al. The incidence of and risk factors for 30-day surgical site infections following primary and revision total joint arthroplasty. J Arthroplasty 2015; 30(Suppl. 9): 47–50.

American Society of Addiction Medicine. Opioid addiction: 2016 facts and figures, https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf (2016, accessed 20 August 2019).

Seth

Scholl

Rudd

, et al. Overdose deaths involving opioids, cocaine, and psychostimulants - United States, 2015-2016. MMWR Morb Mortal Wkly Rep 2018; 67: 349–358.

Vowles

McEntee

Julnes

, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain 2015; 156: 569–576.

Frieden

Houry

. Reducing the risks of relief–the CDC opioid-prescribing guideline. N Engl J Med 2016; 374: 1501–1504.

Namba

Paxton

Inacio

. Opioid prescribers to total joint arthroplasty patients before and after surgery: the majority are not orthopedists. J Arthroplasty 2018; 33: 3118–3124.e3.

10.

Bell

Shohat

Goswami

, et al. Preoperative opioids increase the risk of periprosthetic joint infection after total joint arthroplasty. J Arthroplasty 2018; 33: 3246–3251.e1.

11.

Peratikos

Weeks

Pisansky

AJB

, et al. Effect of preoperative opioid use on adverse outcomes, medical spending, and persistent opioid use following elective total joint arthroplasty in the United States: a large retrospective cohort study of administrative claims data. Pain Med 2020; 21: 521–531.

12.

Jain

Brock

Malik

, et al. Prediction of complications, readmission, and revision surgery based on duration of preoperative opioid use: analysis of major joint replacement and lumbar fusion. J Bone Joint Surg Am 2019; 101: 384–391.

13.

Nguyen

LCL

Sing

Bozic

. Preoperative reduction of opioid use before total joint arthroplasty. J Arthroplasty 2016; 31(Suppl. 9): 282–287.

14.

Rozell

Courtney

Dattilo

, et al. Preoperative opiate use independently predicts narcotic consumption and complications after total joint arthroplasty. J Arthroplasty 2017; 32: 2658–2662.

15.

Weick

Bawa

Dirschl

, et al. Preoperative opioid use is associated with higher readmission and revision rates in total knee and total hip arthroplasty. J Bone Joint Surg Am 2018; 100: 1171–1176.

16.

Ben-Ari

Chansky

Rozet

. Preoperative opioid use is associated with early revision after total knee arthroplasty: a study of male patients treated in the Veterans affairs system. J Bone Joint Surg Am 2017; 99: 1–9.

17.

Starr

Rozet

Ben-Ari

. A risk calculator using preoperative opioids for prediction of total knee revision arthroplasty. Clin J Pain 2018; 34: 328–331.

18.

Goplen

Verbeek

Kang

, et al. Preoperative opioid use is associated with worse patient outcomes after total joint arthroplasty: a systematic review and meta-analysis. BMC Musculoskelet Disord 2019; 20: 234.

19.

Smith

Bido

Collins

, et al. Impact of preoperative opioid use on total knee arthroplasty outcomes. J Bone Joint Surg Am 2017; 99: 803–808.

20.

Cook

Kaskovich

Pirkle

, et al. Benchmarks of duration and magnitude of opioid consumption after total hip and knee arthroplasty: a database analysis of 69,368 patients. J Arthroplasty 2019; 34: 638–644.e1.

21.

Truven Health Analytics. The truven health marketscan databases for health services researchers: thought leadership white paper. 2019.

22.

Padilla

Gabor

Schwarzkopf

, et al. A novel opioid-sparing pain management protocol following total hip arthroplasty: effects on opioid consumption, pain severity, and patient-reported outcomes. J Arthroplasty 2019; 34: 2669–2675.

23.

Cozowicz

Olson

Poeran

, et al. Opioid prescription levels and postoperative outcomes in orthopedic surgery. Pain 2017; 158: 2422–2430.

24.

Plein

Rittner

. Opioids and the immune system - friend or foe. Br J Pharmacol 2018; 175: 2717–2725.

25.

Khosrow-Khavar

Kurteva

Cui

, et al. Opioids and the risk of infection: a critical appraisal of the pharmacologic and clinical evidence. Expert Opin Drug Metab Toxicol 2019; 15: 565–575.

26.

Shanmugam

Couch

McNish

, et al. Relationship between opioid treatment and rate of healing in chronic wounds. Wound Repair Regen 2017; 25: 120–130.

27.

Herskovitz

MacQuhae

Dickerson

Jr , et al. Opioids’ effect on healing of venous leg ulcers. J Invest Dermatol 2017; 137: 2646–2649.

28.

Gibran

Jang

Isik

, et al. Diminished neuropeptide levels contribute to the impaired cutaneous healing response associated with diabetes mellitus. J Surg Res 2002; 108: 122–128.

29.

Wainwright

Gill

McDonald

, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: enhanced recovery after surgery (ERAS^®) Society recommendations. Acta Orthop 2020; 91: 3–19.