Does the type of lower extremity fracture affect long-term opioid usage? A meta-analysis.

INTRODUCTION:  Patients recovering from musculoskeletal trauma have a heightened risk of opioid dependence and misuse, as these medications are typically required for pain management. The purpose of this meta-analysis was to examine the association between fracture type and chronic opioid use following fracture fixation in patients who sustain lower extremity trauma. MATERIALS AND METHODS: A meta-analysis was performed using PubMed and Web of Science to identify articles reporting chronic opioid use in patients recovering from surgery for lower extremity fractures. 732 articles were identified using keyword and MeSH search functions, and 9 met selection criteria. Studies were included in the final analysis if they reported the number of patients who remained on opioids 6 months after surgery for a specific lower extremity fracture (chronic usage). Logistic regressions and descriptive analyses were performed to determine the rate of chronic opioid use within each fracture type and if age, year, country of origin of study, or pre-admission opioid use influenced chronic opioid use following surgery. RESULTS: Bicondylar and unicondylar tibial-plateau fractures had the largest percentage of patients that become chronic opioid users (29.7-35.2%), followed by hip (27.8%), ankle (19.7%), femoral-shaft (18.5%), pilon (17.2%), tibial-shaft (13.8%), and simple ankle fractures (2.8-4.7%).Most opioid-naive samples had significantly lower rates of chronic opioid use after surgery (2-9%, 95% CI) when compared to samples that allowed pre-admission opioid use (13-50%, 95% CI). There were no significant associations between post-operative chronic opioid use and age, year, or country of origin of study. CONCLUSIONS:  Patients with lower extremity fractures have substantial risk of becoming chronic opioid users. Even the lowest rates of chronic opioid use identified in this meta-analysis are higher than those in the general population. It is important that orthopedic surgeons tailor pain-management protocols to decrease opioid usage after lower extremity trauma.

Characterization of knee dysfunction and related risk factors during pregnancy.

BACKGROUND: Knee pain can be a common complaint during pregnancy; however, the severity of symptoms and their associated risk factors have not been described. QUESTIONS/PURPOSES: The aim of this study was to characterize knee-related dysfunction and describe risk factors in a general obstetric population. PATIENTS AND METHODS: Patients in obstetric clinics completed the International Knee Documentation Committee (IKDC) questionnaire to assess their knee function, as well as the Pregnancy Physical Activity Questionnaire (PPAQ), a validated tool to assess physical activity. Age, weeks gestation, height, weight, and history of knee problems prior to pregnancy were analyzed to identify independent associations with IKDC score and determine predictors of knee dysfunction. RESULTS: 310 patients were included in this study, of which 68, 111 and 131 were in their first, second and trimesters, respectively. Mean age of the total study group was 30.3 ± 5.5 years. Knee function decreased with each trimester, from a mean IKDC score of 88.9 ± 13.0 in the first trimester, 84.5 ± 16.8 in the second, and 82.0 ± 20.0 in the third, with corresponding decreases in activity levels of 258.5 ± 141.7, 254.0 ± 141.5, and 246.1 ± 156.6 MET-h/wk. Of the total study group, 26.1% had IKDC scores <75, including 13.2%, 25.2%, and 33.6% in the first, second and third trimesters. Risk factors for knee dysfunction included high activity levels of PPAQ ≥ 500 MET-h/wk (OR 2.8), history of knee problems (OR 2.7), age <25 years (OR 2.6), and BMI ≥ 30 kg/m2 (OR 1.9). CONCLUSION: In our cohort, 26.1% of pregnant women reported severe knee dysfunction, and this was associated with high levels of activity, younger age, greater BMI, and history of knee problems. These findings may have implications for women who wish to maintain training and fitness during pregnancy. Future studies are recommended to assess the need for intervention, as well as to identify optimal methods to prevent and address symptoms in this population. LEVEL OF EVIDENCE: IV, Case Series.