Abstract
Background
We sought to determine whether regional nerve block, cryotherapy variant, or patient-specific factors predict postoperative opioid requirements and pain control following hip arthroscopy.
Methods
104 patients underwent hip arthroscopy with (n = 31) or without (n = 73) regional block and received cryotherapy with a universal pad [joint non-specific; no compression (n = 60)] or circumferential hip/groin wrap with intermittent compression (n = 44). Outcomes included total opioid prescription amounts, requests for refills, and unplanned clinical encounters for postoperative pain within 45 days of surgery. Multivariate modeling was used to determine the effect of perioperative regional nerve block and type of cryotherapy device on outcomes after adjusting for patient demographics, previous opioid use, mental health disorder history, and surgery length.
Results
The average amount of 5 mg oxycodone pill equivalents prescribed within 45 days of surgery was 40.5 (SD 14.8); 36% requested refills, 20% presented to another physician, and 21% called the surgeon's office due to pain. Neither the hip-specific cryotherapy pad nor regional block was predictive of opioid amounts prescribed, refill requests, or unplanned clinical encounters due to pain. Refill requests within 45 days were more common with baseline opioid use (p < 0.001), increased age (p = 0.007), and mental health disorder history (p = 0.008). Total opioid amounts prescribed within 45 days were higher with workers compensation (p = 0.03), a larger initial opioid prescription (p < 0.001), baseline opioid use (p < 0.001), history of mental health disorder (p = 0.02), and increased age (p = 0.02). Together, these variables explained 61% of the variance in opioid amounts prescribed.
Conclusion
Patient factors are strong predictors of postoperative opioid requirements after hip arthroscopy. Postoperative opioid prescription amounts, opioid refill requests, and pain-related calls or office visits were not affected by use of a perioperative regional nerve block or type of cryotherapy delivery system.
Level of evidence
III, retrospective cohort study.
Keywords: Hip arthroscopy, FAI, Postoperative opioids, Cryotherapy, Regional block
1. Introduction
Patient reliance on opioid medications for postoperative analgesia following orthopaedic surgery is an area of growing concern, yet orthopaedic surgeons remain among the top prescribers of opioid prescriptions among U.S. physician specialties.1,2 Striking an appropriate balance between pain control and responsible opioid prescription practices poses great challenges in early postoperative pain control following hip arthroscopy.3 In an effort to shift the burden of analgesia away from opioid medications after such procedures, modalities such as regional nerve blocks have been implemented.4 Fascia iliaca, femoral nerve, lumbar plexus, and L1/L2 paravertebral perioperative nerve blocks have been utilized in hip arthroscopy with relatively equal efficacy in decreasing immediate postoperative opioid requirements and pain scores when compared to general anesthesia alone.3, 4, 5, 6 Although it has been suggested that lumbar plexus and quadratus lumborum blocks may decrease opiate consumption in the weeks following hip arthroscopy, it has not been fully elucidated whether use of the various perioperative nerve blocks have any effect on total postoperative opioid requirements.7,8
Cryotherapy has also proven useful as an analgesic adjunct following orthopaedic procedures. It minimizes the inflammation associated with postoperative soft tissue injuries via inhibition of vasodilation, modulation of oxygen usage, alteration of spinal cord-mediated reflex arcs, and reduction in the local metabolism of inflammatory markers such as prostaglandins and tumor necrosis factor-alpha (TNF- α).9, 10, 11 The addition of compression to cryotherapy can act to reduce edema, limit muscle spasm, and improve microcirculation at the site of the therapy.10, 11, 12, 13, 14 Studies investigating the efficacy of continuous cryotherapy systems following knee arthroplasty and knee or shoulder arthroscopy show a benefit to cryotherapy, but those investigating any advantage of concomitant intermittent compression have shown mixed results.9, 10, 11, 12, 13, 14, 15
Previous opioid use been demonstrated as a predictor of patients' postoperative opioid consumption following hip arthroscopy.16,17 It is also established that mental health diagnoses such as depression and anxiety predict with increased opioid use and worse outcomes preceding and following hip arthroscopy.18, 19, 20 However, there is a paucity of literature defining any relationship between patient factors such as work and workers’ compensation status and postoperative opioid use. In addition, existing work has not defined whether these patient characteristics predict the incidence of unplanned pain-related clinical encounters such as office calls, clinic visits, or emergency department (ED) visits.
The primary aim of the current study is to determine the variables that most influence opioid requirements following hip arthroscopy among regional nerve block, type of cryotherapy pad, and patient-specific factors. The secondary aims are to determine whether regional nerve block, type of cryotherapy device, or patient demographic or historical factors influence the quantity of postoperative medication refills or unplanned clinical encounters to due to pain. It is hypothesized that the use of both regional nerve blocks and intermittent compression cryotherapy with a hip-specific pad in the weeks following hip arthroscopy will decrease patients' opioid requirements, pain medication refills, and unplanned clinical encounters. It is also hypothesized that pre-existing mental health diagnosis, unemployment status, workers’ compensation status, and increasing age will predict increased postoperative opioid requirements.
2. Methods
A total of 105 consecutive patients (age range 15–50) underwent outpatient hip arthroscopy between January 4, 2018 and August 31, 2018. All surgeries were performed for intraarticular pathology secondary to femoroacetabular impingement (FAI) syndrome as confirmed by physical exam and diagnostic magnetic resonance imaging (MRI). No surgeries for debridement of osteoarthritis were performed; all patients had minimal to no degenerative changes (Tönnis grade 1 or 0) on hip radiographs. Surgeries were performed by one of 2 sports medicine fellowship-trained surgeons with additional training and expertise specific to hip arthroscopy. One patient was excluded due to an unexpected admission for a medical complication, which left 104 patients for the final analysis.
All hip arthroscopies were performed on a traction bed using a protocol generalized between the two surgeons. Three standardized portals were utilized for treatment of acetabular and femoral sided intraarticular pathology. These included an anterolateral portal for initial access followed by establishment of mid-anterior and distal anterolateral accessory portals. Both surgeons performed a complete capsulotomy closure at the completion of the case. The implementation and modality of a regional block was largely dependent upon the individual practice of the staffing attending anesthesiologist. Among anesthesiologists at the study's institution that do provide regional anesthesia, some preferentially block all patients postoperatively but prior to leaving the operating room, others selectively block patients in the postoperative recovery area, and others perform alternative blocks for the hip. Anesthesiologists practicing the latter instead target individual nerves (e.g. L1/L2 nerve roots) or the articular branches of the femoral and accessory obturator nerves (i.e. pericapsular nerve group block) to provide complete analgesia for the hip joint.
All patients received a cryotherapy device postoperatively. The standard cryotherapy device provided is the Iceman (DJO, Vista, CA) with a universal (hip joint-specific) cold delivery pad; all patients were offered the option to rent the GameReady GRPro 2.1 system with a hip/groin specific wrap (Coolsystems, Concord, CA). The rental unit required out of pocket payment by the patient. Both devices deliver continuous cryotherapy, though the GameReady system also delivers intermittent compression.
The primary study outcome was the assessment of any correlation between regional blocks or continuous cryotherapy and the total amount of opioids prescribed within 45 days of surgery. The study was conducted in a state which has a comprehensive pharmacy database, the Ohio Automatic Rx Reporting System; this allows for exact determination of the total quantity of opioids prescribed to a patient by any medical provider within the state during this defined time period. Opioid amounts were converted to morphine milligram equivalents (MME) to allow for direct comparison of various opioid medications and then reported as equivalent quantities of 5-mg (mg) oxycodone pills (a commonly utilized opioid medication and strength for postoperative pain). The most common initial postoperative prescription was oxycodone-acetaminophen (n = 88), followed by oxycodone (n = 8), hydrocodone-acetaminophen (n = 5), acetaminophen with codeine (n = 1), tramadol (n = 1), and immediate release morphine sulfate (n = 1).
Based upon an a priori power analysis, the resulting sample of 104 patients (n = 60 universal cryotherapy pad without intermittent compression, n = 44 hip/groin specific wrap with intermittent compression; n = 31 regional block, n = 73 no regional block) is sufficient to evaluate the primary study aim. Currently, no clinically significant difference in outpatient opioid usage following hip arthroscopy has been established. For the present study, a difference of 187.5 MME in the total amount of opioids prescribed throughout the postoperative period was considered clinically meaningful, which is equivalent to 25 pills of 5 mg oxycodone. The power analysis indicated the ability to detect a 187.5 MME (25 pills of 5 mg oxycodone) difference in opioid amounts, assuming a standard deviation of 400 MME (53.3 pills of 5 mg oxycodone) per group, at 89% power (α = 0.05) for the universal versus hip/groin specific cryotherapy pads and 82% power (α = 0.05) for regional block versus no regional block.
Secondary outcome measures included the assessment of any correlation between regional block, continuous cryotherapy, patient demographic/historical factors, and whether or not patients visited an ED or an outside physician for a pain-related complaint, whether they visited, called, or messaged their surgeon's clinic concerning pain management, or if they requested an opioid refill within 45 days of surgery. Patient factors of interest included age, preoperative baseline opioid use, workers compensation status, employment status, and history of a mental health diagnosis. The primary opioid analgesic prescribed for use at home following surgery was a combination oxycodone-acetaminophen (5–325 mg) pill, though an opioid without acetaminophen is occasionally prescribed either due to patient preference or a medical contraindication to acetaminophen. Patients without a medical contraindication or intolerance to non-steroidal inflammatory drugs (NSAIDs) were routinely prescribed either meloxicam 15 mg daily, indomethacin 75 mg daily, or ibuprofen 600 mg every 8 h, depending upon provider and patient preference. Neither gabapentin nor a selective cyclooxygenase-2 (COX-2) inhibitor was routinely prescribed postoperatively.
2.1. Statistical analysis
Analyses were performed using JMP 14.0 by the SAS institute (Cary, NC). Descriptive statistics were prepared for the entire sample, where appropriate. Bivariate analyses were performed comparing opioid usage rates as well as opioid-related outcomes (refill requests, ED or clinic visits for pain, and clinic calls for pain) between patients who did versus did not receive a perioperative nerve block and patients who received a standard cryotherapy pad versus the hip/groin specific pad. Chi-square analysis was performed on categorical variables; either student's t-tests or Wilcoxon rank-sum tests were performed for non-normally distributed and normally distributed continuous variables, respectively.
Non-normal distributions of outpatient postoperative opioid usage rates and distance traveled necessitated Johnson's-SU transformations prior performing multivariate analysis in order to achieve more normal distributions of the data. Independent risk factors for requiring a pain medication refill, unplanned ED visits, or outpatient visits to another provider for pain, and calls to the surgeon's clinic for a pain-related complaint were determined utilizing a series of logistic regression models. Independent risk factors for increased total outpatient postoperative opioid prescription amounts were elucidated through multivariate linear regression modeling. Multivariate models considered the potential covariates of age, sex, distance between home address and surgical provider's office, employment status, workers compensation status, insurance status, disability status, previous opioid use, mental health disorder history, length of procedure, use of regional anesthesia, type of cryotherapy device, amount of opioids on initial postoperative prescription for home, and inclusion of acetaminophen in the postoperative prescriptions for home. The outcome variables of interest, use of a regional block and type of cryotherapy device, were included in all multivariate models regardless of significance level.
Backwards selection was utilized for the multivariate models with an exit criterion of α > 0.05 for the covariates that remained. Provided that the exclusion resulted in a greater than 10% change in the estimate effect size for regional block or type of cryotherapy device, covariates were kept in the model regardless of p-value. The use of a change in estimate criterion has been demonstrated as a robust method of controlling confounders in multivariate modeling.21,22
3. Results
3.1. Descriptive statistics and bivariate statistical analysis
The mean age was 34.2 years (SD 10.8) with more females (70%) than males (30%) in the sample population (Supplemental Table 1). A total of 38% of patients were unemployed and 47% of patients had government insurance at the time of data collection. Previous opioid use and a mental health disorder history were reported by 14% and 33% of patients, respectively. The average length of surgery was 140 min (SD 33). Hip-specific cryotherapy with intermittent compression was chosen by 42% of patients, and 30% of patients received a perioperative regional block. The mean number of 5 mg oxycodone pill equivalents initially prescribed postoperatively was 40.5 (SD 14.8), while the total amount prescribed within 45 days postoperatively was 54.7 (SD 132). A total of 36%, 20%, and 21% of the sample population needed an opioid refill, had an ED/other physician visit for pain, and made an unplanned clinic call for pain, respectively. Among baseline opioid users (n = 15), 93% (n = 14/15) requested at least one opioid refill; among 89 baseline non-users, 27% (n = 24) requested at least one refill.
In the bivariate analysis, without adjustment for potentially confounding variables, patients who received the cryotherapy system with hip-specific wrap and intermittent compression were more likely to have private insurance (p = 0.007), a larger quantity of opioids on the initial postoperative prescription (p = 0.005), and a shorter length of surgery (p = 0.007), with no other differences in patient characteristics or outcomes (Table 1). Patients who did not receive a regional block were more likely to have an opioid-acetaminophen combination prescription versus an opioid alone (p = 0.04). Otherwise, there were no differences in patient characteristics between patients who did versus did not receive a regional block.
Table 1.
Adjusted risk of requiring an opioid refill.
| Independent risk factor | Adjusted Odds Ratio, 95% Confidence Interval | P-value |
|---|---|---|
| Baseline opioid use | 12.9 CI 2.55, 65.8 | <0.001 |
| Age | Per five-year increase in age: 1.38 CI 1.08, 1.77 |
0.007 |
| History of mental health disorder | 4.18 CI 1.40, 12.5 | 0.008 |
| Use of a regional nerve block | 0.50 CI 0.16, 1.59 | 0.23 |
| Use of hip/groin specific cryotherapy pad with intermittent compression | 1.09 CI 0.41, 2.94 | 0.86 |
∗All postoperative and perioperative factors (Table 1) other than regional block and type of cryotherapy were considered for inclusion in the multivariate model and were excluded if not independently associated with the outcome (p > 0.05) and there was no evidence of confounding with use of regional nerve block or type of cryotherapy pad.
3.1.1. Independent risk factors for requiring an opioid medication refill
Independent risk factors for requiring an opioid refill (Table 2) were baseline opioid use (adjusted Odds Ratio [aOR] 12.9, 95% Confidence Interval [CI] 2.55, 65.8; p < 0.001), increased patient age (per 5-year increase: aOR 1.38, CI 1.08, 1.77; p = 0.007), and history of a mental health disorder (aOR 4.18, CI 1.40, 12.5; p = 0.008). Use of a hip-specific cryotherapy device with intermittent compression (p = 0.86) and regional block (p = 0.23) were not predictive of the need for an opioid refill.
Table 2.
Adjusted risk of ED visit or outpatient visit with another medical provider for pain.
| Independent risk factor for ED or outpatient provider (other than surgeon) for pain | Adjusted Odds Ratio, 95% Confidence Interval | P-value |
|---|---|---|
| Baseline opioid use | 7.37 CI 1.88, 29.0 | 0.004 |
| Unemployed (not student or minor) | 3.57 CI 1.14, 11.2 | 0.03 |
| Length of surgery | Per additional 10 min: 1.20 CI 1.01, 1.44 |
0.04 |
| Use of a regional nerve block | 0.60 CI 0.16, 2.22 | 0.43 |
| Use of hip/groin specific cryotherapy pad with intermittent compression |
1.55 CI 0.47, 5.13 |
0.47 |
|
Independent risk factor for surgeon clinic call for pain |
Adjusted Odds Ratio, 95% Confidence Interval |
P-value |
| Age | Per 5-year increase in age: 1.08 CI 1.02, 1.14 |
0.006 |
| Baseline opioid use | 4.23 CI 1.22, 14.7 | 0.02 |
| History of mental health disorder | 3.89 CI 1.13, 13.4 | 0.03 |
| Use of regional nerve block | 0.52 CI 0.15, 1.83 | 0.29 |
| Use of hip/groin specific cryotherapy pad with intermittent compression | 1.55 CI 0.55, 4.96 | 0.36 |
∗All postoperative and perioperative factors (Table 1) other than regional block and type of cryotherapy were considered for inclusion in the multivariate model and were excluded if not independently associated with the outcome (p > 0.05) and there was no evidence of confounding with use of regional nerve block or type of cryotherapy pad.
3.1.2. Independent risk factors ED visit or outpatient visit with other medical provider for pain
Baseline opioid use (aOR 7.37, CI 1.88, 29.0; p = 0.004), unemployment (aOR 3.57, CI 1.14, 11.2; p = 0.03), and longer length of surgery (per additional 10 min: aOR 1.20, CI 1.01, 1.44; p = 0.04) were independent risk factors for an unplanned ED visit or outpatient visit to another medical provider (other than the surgeon) for postoperative pain (Table 3). Use of a regional block (p = 0.43) or the groin/hip specific cryotherapy wrap with intermittent compression (p = 0.47) did not affect risk of this outcome.
Table 3.
Independent predictors of total outpatient opioids prescribed within 45 days of surgery.
| Independent predictor | Effect size (beta estimate) and standard error (SE)∗∗ | P-value |
|---|---|---|
| Workers compensation | 0.58 SE 0.27 | 0.03 |
| Total equivalents of 5 mg oxycodone pills in initial postoperative prescription | 0.54 SE 0.08 | <0.001 |
| Baseline opioid use | 0.52 SE 0.10 | <0.001 |
| History of mental health disorder | 0.17 SE 0.07 | 0.02 |
| Age (per 5-year increase) | 0.07 SE 0.03 | 0.02 |
| Use of hip/groin specific cryotherapy pad with intermittent compression | 0.07 SE 0.07 | 0.32 |
| Use of regional nerve block | −0.06 SE 0.07 | 0.40 |
| Total model R-square= 0.61; p<0.001 | ||
∗All postoperative and perioperative factors (Table 1) other than regional block and type of cryotherapy were considered for inclusion in the multivariate model and were excluded if not independently associated with the outcome (p > 0.05) and there was no evidence of confounding with use of regional nerve block or type of cryotherapy pad. ∗∗A positive value for the beta estimate indicates that the presence of the risk factor increases the predicted quantity of opioids prescribed.
3.2. Independent risk factors for surgeon clinic call for pain related complaint
Increased age (per 5-year increase: aOR 1.08, CI 1.02, 1.14; p = 0.006), baseline opioid use (aOR 4.23, CI 1.22, 14.7; p = 0.02), and mental health disorder history (aOR 3.89, CI 1.13, 13.4; p = 0.03) were all independent risk factors for a clinic call for postoperative pain-related complaint (Table 2). Use of a regional nerve block (p = 0.29) or the groin/hip specific cryotherapy wrap with intermittent compression (p = 0.36) did not affect risk of this outcome.
3.2.1. Independent predictors of total opioids prescribed
Workers compensation, a larger initial postoperative opioid prescription, previous opioid use, mental health disorder history, and increased patient age were all independently associated with a greater total amount of outpatient opioids prescribed in the 45-day postoperative period [p < 0.05 (Table 3)]. Neither the use of a regional nerve block (p = 0.40) nor the hip-specific cryotherapy wrap with intermittent compression (p = 0.32) affected the total amount of opioids prescribed in the postoperative period. These variables together accounted for 62% of the variance in total outpatient opioid amounts prescribed.
4. Discussion
This study sought to determine whether postoperative opioid consumption, pain medication refills, or pain-related clinical encounters following hip arthroscopy are associated with use of regional nerve block or cryotherapy (with or without intermittent compression). While these interventions were not found to substantially affect overall postoperative opioid consumption or other pain-related outcomes, they do provide benefits in the immediate postoperative period.3, 4, 5, 6,9, 10, 11, 12, 13, 14 Perioperative regional blocks have been shown to improve patient outcomes such as opioid consumption and pain scores in the postoperative recovery unit. Although demonstrated to increase fall risk after hip arthroscopy, regional blocks do offer immediate postoperative benefit in select patients.23 Although the potential benefit of cryotherapy following hip arthroscopy is not extensively studied, these devices remain widely used, have low associated risk, and likely decrease swelling.3
The current study does demonstrate that a subset of patients at risk for high postoperative opioid requirements and/or uncontrolled pain can be predictably identified preoperatively. Consistent with previous literature, multiple patient factors including previous opioid use, history of health seeking behavior, insomnia, mental health disorder and substance abuse history, workers compensation status, and unemployment increase the likelihood that patients will obtain 3 or more opioid prescriptions postoperatively.24,25 These patients also had an increased likelihood of seeking prescription opioids at 1 or more years postoperatively. For every additional 10 min spent in the operating room, patients had a 20% increase in the odds of having unplanned ED or office visits for pain. However, increasing the quantity of prescribed opioids was not protective against unplanned ED visits, office visits, or clinic calls related to pain indicating that patient factors may be the primary driver of postoperative analgesia efficacy and tolerance to pain.
With essentially no disadvantages to doing so, the authors propose prescribing a significantly lower quantity of opioids to patients who do not possess the aforementioned risk factors. Moreover, the authors maintain that providers should continue to explore non-opioid methods for pain control such as acetaminophen, gabapentin, NSAIDs, and muscle relaxants.
Future work should seek to better define the benefit and optimal timeline associated with synchronous use of cryotherapy and regional blocks after hip arthroscopy. In addition, given the newfound associations between patient factors and pain-related outcomes, it should be determined whether such patient factors correlate similarly with successful implementation of nerve blocks, cryotherapy, or other pain relief adjuncts.
4.1. Limitations
The present manuscript is not without limitations. As with any retrospective cohort study, the present study was unable to precisely collect and control for all factors affecting patients and the collection of data. The quantity of opioids consumed by each patient was estimated by the number of opioid pills prescribed in the postoperative prescription and in any subsequent refills. Thus, the actual quantity of ingested opioids is truly unknown. The specifics of the anesthesia blockades were not recorded; the delivery of blocks was solely at the discretion of the attending anesthesiologists who cite relatively equivocal results among the varying modalities for the hip. The dose and analgesic for any intraoperative local infiltration analgesia were also not recorded. In addition, any correlation between patient demographic/historical factors and receipt of regional anesthesia was not investigated. Although patients were prescribed cryotherapy devices, their length and frequency of use is not known. Furthermore, the requirement of renting a GameReady system biased the study towards patients with the ability to spend more money out of pocket. Patient self-reported subjective and objective measures of pain, satisfaction, and function were not collected as part of this analysis. Consequently, any generalizations or specific conclusions should be made with caution.
5. Conclusion
Postoperative opioid prescription amounts, opioid refill requests, and pain-related calls or office visits were not affected by use of a perioperative regional nerve block or type of cryotherapy delivery system had no effect on. However, patient demographic and historical factors are strong predictors of postoperative opioid requirements after hip arthroscopy. By continuing to refine the benefits, indications, and ideal timeline for implementation of postoperative analgesics and adjuncts, the patient experience following hip arthroscopy can be better understood and managed.
Declaration of competing interest
None.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jcot.2022.101848.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
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