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

Abstract and Introduction

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.

Introduction

The opioid epidemic in the United States has called into question our reliance on these medications for pain management. Patients are often first exposed to opioids in the perioperative period, and prescription opioids are now the leading cause of drug overdose deaths.[1] There have been appropriate institutional, state, and federal efforts to limit exposure to opioids,[2] yet rates of opioid-involved overdose deaths continue to rise despite reductions in prescribing.[3] Trauma patients are at risk for increased opioid demand and mental health indicators, and substance use and abuse seem to modulate this risk for opioid demand.[4,5] Replacement of opioids with other efficacious analgesics represents a reasonable objective for reducing harm to patients. One strategy that has been advocated is multimodal analgesia or the use of multiple medications with different mechanisms of action to provide additive or synergistic pain control.[6]

The use of regional anesthesia (RA) as part of multimodal pain management has increased in orthopedic surgery.[7] Several studies have demonstrated that RA may reduce pain in the early postoperative period after orthopedic surgery,[8,9] with some techniques demonstrating decreased early opioid demand.[10] While these findings are encouraging, little is known about the impacts of RA on long-term opioid use. Furthermore, much of the literature on RA in orthopedic trauma focuses on more common fractures such as the hip, distal radius, and ankle. However, analgesic efficacy can vary depending on the surgical procedure performed, and procedure-specific multimodal pain management has been shown to improve pain management.[11,12] Therefore, it is important to study the effects of RA in a location-specific manner.

Tibial plateau fractures account for 1% of all fractures and represent a wide range of fracture patterns often associated with high-energy mechanisms and severe pain.[13] Plateau fractures also frequently have associated soft tissue compromise, including injuries to the menisci, collateral, and cruciate ligaments.[14,15] Patient-specific risk factors for increased and/or prolonged postoperative opioid use include patients with bicondylar tibial plateau fractures,[16] external fixation, and intra-articular fracture.[17]

There is currently a dearth of literature evaluating the impact of RA on longitudinal perioperative and postoperative opioid demand in tibial plateau fractures. Our institution uses RA in tibial plateau fractures, most commonly with single-shot sciatic-popliteal, femoral, or femoral/adductor canal blocks, though sometimes with epidural analgesia (EA) or spinal analgesia. Given this knowledge gap, this study retrospectively evaluated inpatient opioid usage up to 72 hours postoperatively and outpatient opioid prescribing from 1 month preoperatively to 90 days postoperatively in patients undergoing tibial plateau fracture surgery with and without RA. The study hypothesis is that RA will be associated with a decrease in inpatient opioid consumption but not outpatient opioid demand.

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