Methylprednisolone taper is an effective addition to multimodal pain regimens after total shoulder arthroplasty: results of a randomized controlled trial: 2022 Neer Award winner.

BACKGROUND: Perioperative corticosteroids have shown potential as nonopioid analgesic adjuncts for various orthopedic pathologies, but there is a lack of research on their use in the postoperative setting after total shoulder arthroplasty (TSA). The purpose of this study was to assess the effect of a methylprednisolone taper on a multimodal pain regimen after TSA. METHODS: This study was a randomized controlled trial (clinicaltrials.gov NCT03661645) of opioid-naive patients undergoing TSA. Patients were randomly assigned to receive intraoperative dexamethasone only (control group) or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course (treatment group). All patients received the same standardized perioperative pain management protocol. Standardized pain journal entries were used to record visual analog pain scores (VAS-pain), VAS-nausea scores, and quantity of opioid tablet consumption during the first 7 postoperative days (POD). Patients were followed for at least one year postoperatively for clinical evaluation, collection of patient-reported outcomes, and observation of complications. RESULTS: A total of 67 patients were enrolled in the study; 32 in the control group and 35 in the treatment group. The groups had similar demographics and comorbidities. The treatment group demonstrated a reduction in mean VAS pain scores over the first 7 POD. Between POD 1 and POD 7, patients in the control group consumed an average of 17.6 oxycodone tablets while those in the treatment group consumed an average of 5.5 tablets. This equated to oral morphine equivalents of 132.1 and 41.1 for the control and treatment groups, respectively. There were fewer opioid-related side effects during the first postoperative week in the treatment group. The treatment group reported improved VAS pain scores at 2-week, 6-week, and 12-week postoperatively. There were no differences in Europe Quality of Life, shoulder subjective value (SSV), at any time point between groups, although American Shoulder and Elbow Surgeons questionnaire scores showed a slight improvement at 6-weeks in the treatment group. At mean follow-up, (control group: 23.4 months; treatment group:19.4 months), there was 1 infection in the control group and 1 postoperative cubital tunnel syndrome in the treatment group. No other complications were reported. CONCLUSIONS: A methylprednisolone taper course shows promise in reducing acute pain and opioid consumption as part of a multimodal regimen following TSA. As a result of this study, we have included this 6-day methylprednisolone taper course in our multimodal regimen for all primary shoulder arthroplasties. We hope this trial serves as a foundation for future studies on the use of low-dose oral corticosteroids and other nonnarcotic modalities to control pain after shoulder surgeries.

Shifts in Prescribers' Initial Postoperative Opioid Prescriptions Following Primary Total Hip Arthroplasty Between 2014 and 2018.

BACKGROUND: The opioid epidemic is a public health crisis impacting the practice of surgeons performing primary total hip arthroplasty (THA). Seeking to evaluate changes in prescribers' practices, we asked the following questions: (1) Have the initial discharge opioids following THA changed and (2) Have initial total oral morphine milligram equivalents (OME) prescribed following THA decreased since 2014? METHODS: We retrospectively reviewed discharge prescriptions for 4233 primary THAs performed between fiscal years (FYs) 2014 and 2018 throughout our healthcare system. Drug, dosing, and total OMEs were recorded. We categorized prescriptions into 3 groups: short-acting narcotics only, short-acting plus long-acting narcotics, and short-acting narcotics plus tramadol. Mean age was 59 and 63% were males. RESULTS: The proportion of patients receiving tramadol increased from 2% (FY14) to 25% (FY18) while long-acting opioid prescriptions decreased from 44% (FY14) to 14% (FY18). Oxycodone (82%) was the most common short-acting narcotic. In total, we observed a 27% decrease in initial OME prescribed to a mean of 683 mg (FY18) (P < .0001). Short-acting only protocols had a 19% OME decrease to 589 mg (FY18). Short plus long-acting protocols haed a 23% OME decrease to 939 mg (FY18). Short-acting plus tramadol had an OME of 849 mg (FY18). CONCLUSION: Despite a 27% observed decrease in initial OME prescription following THA, the 683 mg mean OME in FY18 was high. Substituting tramadol for a long-acting narcotic failed to have a dramatic clinical impact on decreasing OME. These data suggest that decreasing the number of short-acting narcotic pills is a critical factor in decreasing OME.

Intraoperative Ketamine in Total Knee Arthroplasty Does Not Decrease Pain and Narcotic Consumption: A Prospective Randomized Controlled Trial.

BACKGROUND: Multiple studies have demonstrated that ketamine, a glutamate receptor blocker, may decrease postoperative pain in abdominal and orthopedic surgeries. However, its role with spinal anesthesia and total knee arthroplasty (TKA) remains unknown. The purpose of this study is to determine the efficacy of subanesthetic dosing of ketamine during TKA on postoperative pain and narcotic consumption. METHODS: In this prospective, randomized, double-blinded clinical trial, we enrolled 91 patients undergoing primary TKA with spinal anesthesia in a single institution from 2017 to 2018. Patients were randomized to receive intraoperative ketamine infusion at a rate of 6 mcg/kg/min for 75 minutes or a saline placebo. All patients received spinal anesthesia and otherwise identical surgical approaches, pain management, and rehabilitation protocols. Patient-reported visual analog pain scores were calculated preoperatively, postoperative days (POD) 0-7, and 2 weeks. Narcotic consumption was evaluated on POD 0 and 1. RESULTS: There was no difference in average pain between ketamine and placebo at all time points except for at PODs 1 (45 vs 56, P = .041) and 4 (39 vs 49, P = .040). For least pain experienced, patients administered with ketamine experienced a reduction in pain only at POD 4 (22 vs 35, P = .011). There was no difference in maximum pain cohorts at all time points of the study or in-hospital morphine equivalents between the 2 cohorts. CONCLUSION: As part of multimodal pain management protocol, intraoperative ketamine does not result in a clinically significant improvement in pain and narcotic consumption following TKA.

Which patient-specific and surgical characteristics influence postoperative pain after THA in a fast-track setting?

BACKGROUND: In our hospital a fast-track setting including a multimodal pain protocol is used for total hip arthroplasty (THA). Despite this multimodal pain protocol there is still a large range in reported postoperative pain between patients, which hinders mobilization and rehabilitation postoperatively. The goal of this study was to identify which patient-specific and surgical characteristics influence postoperative pain after THA in a fast-track setting. METHODS: All 74 patients with osteoarthritis of the hip who underwent primary THA procedure by anterior supine intermuscular approach between November 2012 and January 2014 were included in this prospective cohort study. The protocol for pain medication was standardized. Postoperative pain determined with the Numeric Rating Score was collected at 17 standardized moments. Linear mixed models were used to examine potential patient-specific and surgical factors associated with increased postoperative pain. RESULTS: Pain patterns differed substantially across individuals. Adjusted for other variables in the model, preoperative use of pain medication (regression coefficient 0.78 (95% CI 0.28-1.26); p = 0.005) and preoperative neuropathic pain scored by DN4 (regression coefficient 0.68 (95% CI 0.15-1.20); p = 0.02) were the only factors significantly associated with higher postoperative pain scores. CONCLUSIONS: The knowledge of which factors are associated with higher postoperative pain scores after THA in a fast-track setting may help optimizing perioperative postoperative pain management and preoperative education of these patients. TRIAL REGISTRATION: The study was retrospectively registered in the ISRCTN registry under identifier ISRCTN15422220 (date of registration: July 25, 2017).

Self-Reported Cannabis Use Is Associated With a Lower Rate of Persistent Opioid Use After Total Joint Arthroplasty.

Background: Legalization of cannabis, along with concern over prescription opiate use, has garnered interest in cannabis for adjuvant pain control. This study examines the relationship between cannabis and opioid consumption after total hip (THA) or knee (TKA) arthroplasty. Methods: Patients undergoing primary THA or TKA with minimum 6-month follow-up who self-reported cannabis use were retrospectively reviewed. A total of 210 patients (128 TKAs and 82 THAs) were matched by age; gender; type of arthroplasty; Charlson Comorbidity Index; and use of nicotine, antidepressants, or benzodiazepines to patients who did not self-report cannabis use. Patients receiving an opioid prescription after 90 days postoperatively were classified as persistent opioid users (POUs). Duration of opioid use (DOU) was calculated for non-POU patients as the time between surgery and their last opioid prescription. Differences in inpatient morphine milligram equivalents (MMEs), outpatient MMEs, POU, and DOU were analyzed. Results: Cannabis users required equivalent inpatient and outpatient MMEs. There was no difference in DOU. There was a significant difference in POU between cannabis users and matched controls (1.4% [n = 3] vs 9.5% [n = 20], P < .001, respectively). Grouping patients by TKA or THA, there remained a difference in POU for TKA (1.5% [n = 2] vs 10.9% [n = 14], P = .002) and THA (1.2% [n = 1] vs 7.3% [n = 6], P = .04). There was no difference in inpatient or outpatient MMEs or DOU for THA and TKA patients. Conclusions: There is a reduced rate of POU in patients who self-report perioperative cannabis use. Prospective studies are needed to clarify the role of cannabis as an adjunct to perioperative pain control.