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Anesthesia and Analgesia Practices in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership
The Journal of Arthroplasty xxx (2019) 1e6
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Anesthesia and Analgesia Practices in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership Charles P. Hannon, MD a, Timothy C. Keating, MD a, Jeffrey K. Lange, MD b, c, Benjamin F. Ricciardi, MD d, Bradford S. Waddell, MD e, Craig J. Della Valle, MD a, * a
Adult Reconstruction Division, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA Harvard Medical School, Boston, MA d Department of Orthopaedic Surgery, Center for Musculoskeletal Research, University of Rochester School of Medicine, Rochester, NY e Adult Reconstruction and Joint Replacement Division, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 9 April 2019 Received in revised form 8 June 2019 Accepted 25 June 2019 Available online xxx
Background: The purpose of this study is to survey the current analgesia and anesthesia practices used by total joint arthroplasty surgeon members of the American Association of Hip and Knee Surgeons (AAHKS). Methods: A survey of 28 questions was created and approved by the AAHKS Research Committee. The survey was distributed to all 2208 board-certified adult reconstruction surgeon members of AAHKS in November 2018. Results: There were 622 responses (28.2%) to the survey. A majority of respondents (93.2%, n ¼ 576) use preemptive analgesia prior to total joint arthroplasty. Most respondents use a spinal for total knee arthroplasty (TKA) (74.4%) and total hip arthroplasty (THA) (72.6%). A peripheral nerve block is routinely used by 68.7% of respondents in primary TKA. Periarticular injection or local infiltration anesthesia is routinely used by 80.3% of respondents for both TKA and THA patients. The average number of opioid pills prescribed postoperatively after TKA is 49 pills (range 0-200) and after THA is 44 pills (range 0-200). Most surgeons (58%) expect that this prescription should last for 2 weeks. A majority of respondents (74.0%) use multimodal analgesics in addition to opioids. Conclusion: There is no consensus regarding the optimal multimodal anesthetic and analgesic regimen for total joint arthroplasty among surveyed board-certified arthroplasty surgeon members of AAHKS. Understanding current practice patterns in anesthesia, analgesia, and opioid prescribing may serve as a platform for future work aimed at establishing best clinical practices of maximizing effective postoperative pain control and minimizing the risks associated with prescribing opioids. © 2019 Elsevier Inc. All rights reserved.
Keywords: total joint arthroplasty total hip arthroplasty total knee arthroplasty multimodal analgesia anesthesia opioids
Each year over 1 million total joint arthroplasty (TJA) procedures are performed in the United States with a goal of relieving pain and restoring function. However, both total knee arthroplasty (TKA) and total hip arthroplasty (THA) can be painful procedures and effective
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.06.055. * Reprint requests: Craig J. Della Valle, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Chicago, IL 60612. https://doi.org/10.1016/j.arth.2019.06.055 0883-5403/© 2019 Elsevier Inc. All rights reserved.
pain control after surgery is critical for success of the procedure. Effective pain control after TJA has been shown to improve outcomes including faster recovery, lower complication rates, reduced costs of care, and improved patient satisfaction [1e8]. Poor pain control after TJA has been associated with longer inpatient hospital stays, increased healthcare costs, increased risk of chronic pain postoperatively, and poorer functional outcomes [9,10]. There are many anesthetic and analgesic options to control pain after TJA. Historically, opioids were a cornerstone of controlling pain after TJA. Opioids are effective analgesics, but are associated with significant side effects and risks [11]. Opioids are associated with increased urinary, gastrointestinal, neurologic, cardiac, and
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respiratory complications postoperatively [12e15]. In addition, they have an addictive potential, which has led to the opioid epidemic the United States is fighting today [16,17]. Heroin is responsible for a majority of opioid-related deaths, but sadly 86% of heroin users say that a previous opioid prescription started their addiction [18]. As a result, there has been a nationwide effort to curb opioid prescriptions. Multimodal analgesic regimens in TJA have garnered significant interest because they limit the use of opioids perioperatively. These regimens use a variety of medications and delivery routes at multiple perioperative time points in order to target several different biologic pathways that may contribute to postoperative pain after TJA [19]. In addition to multiple oral medications, multimodal analgesic regimens may combine the use of regional anesthesia (eg, epidurals), peripheral nerve blocks, periarticular analgesic injections, and cryotherapy to limit opioid use postoperatively. Several studies have demonstrated that multimodal analgesia is effective for controlling pain after TJA, but there is no consensus on the ideal regimen [7,8]. The purpose of this study is to survey the current analgesia and anesthesia practices used by board-certified TJA surgeons that are members of the American Association of Hip and Knee Surgeons (AAHKS). Understanding current practice patterns in anesthesia, analgesia, and opioid prescribing may serve as a platform for future work aimed at establishing best clinical practices of maximizing effective postoperative pain control and minimizing the risks associated with prescribing opioids.
Materials and Methods A survey of 28 questions was created in accordance with the Dillman’s Tailored Design Method. The Dillman’s Tailored Design Method is a validated method of survey design that maximizes the response rate in a professional group that has been used for previous AAHKS Research Committee Surveys [20e24]. The survey was approved by the AAHKS Research Committee and distributed to all 2208 board-certified adult reconstruction surgeon members of AAHKS in November 2018 (Appendix 1). The survey was administered over a 3-month period from November 2018 to January 2019. The descriptive survey was distributed by a singlemode (online) and was self-administered. The survey was distributed via e-mail with a description of the survey followed by a link to an electronic, anonymous survey instrument (SurveyMonkey, Inc, Palo Alto, CA). A reminder to complete the survey with a link to the survey was sent approximately 2 weeks after initial distribution to nonresponders. The survey collected demographic data of the respondents including age, clinical volume, location, and type of practice. Respondents then answered specific questions regarding their analgesia and anesthesia practices including use of preemptive analgesia, regional blocks, peripheral nerve blocks, and periarticular injections (PAIs). In addition, respondents answered questions regarding their use of opioids including the types of opioids utilized, delivery mechanisms, and number of opioid pills prescribed postoperatively. Finally, respondents answered a question regarding how they treat patients who have a history of preoperative opioid use. The survey sample power analysis of Dillman et al states that a 13% response rate is necessary to achieve a 95% confidence level, plus or minus a 5% sample error [23,25]. Responses to all questions were tabulated and descriptive statistics are reported for each question. Analysis was completed using Microsoft Excel (Seattle, WA).
Table 1 Demographics of the American Association of Hip and Knee Surgeons Membership Survey Respondents. Percent of Respondents (Number of Respondents) Type of practice (%, n) Private practice Hospital employee Academics Multispecialty group Solo private practice Military Veterans administration Other Age (mean, range) Years in practice (mean, range) Case volume in 2017 (%, n) <100 100-199 200-299 300-399 400-499 >500 Geographic region Northeast South Midwest West
47.0% (292) 19.0% (118) 16.4% (102) 11.4% (71) 4.8% (30) 0.6% (4) 0.5% (3) 0.3% (2) 51.7 (range 33-81) 18.8 (range 1-47) 4.5% 13.8% 20.0% 22.4% 17.6% 21.6%
(28) (86) (124) (139) (109) (134)
36.5% 23.6% 20.1% 19.8%
(227) (147) (125) (123)
Results The survey was distributed to 2208 adult reconstruction surgeons in AAHKS and there were 622 responses (28.2%). Demographic data regarding the respondents is summarized in Table 1. The average number of years in practice of the respondents is 18.8 years (range 1-47). Most respondents (81.7%) performed more than 200 arthroplasty cases in 2017 and 47.0% of respondents are in private practice. Of the 622 respondents, 29.2% perform cases at an ambulatory surgery center. Of those that do perform surgeries at an ambulatory center, 70.5% use the same anesthesia and analgesia protocol for both their ambulatory patients and inpatients. A majority of respondents (93.2%, n ¼ 576) use preemptive analgesia prior to TJA. Seventeen different medications are reported as used for preemptive analgesia prior to TJA (Table 2). The most common medications used are acetaminophen, celecoxib, gabapentin, and oxycodone extended or controlled release. For TKA, most respondents use a spinal anesthesia (74.4%), while 23.0% of respondents use a general anesthesia. An epidural is used by 1.6% of respondents and a combined spinal epidural with a catheter is used by 1.0% of respondents. A peripheral nerve block is routinely used by 68.7% of respondents in primary TKA. Of those who utilize a peripheral nerve block for primary TKA, 90.9% prefer an adductor canal block (ACB). Of those that utilize an ACB, 19.0% use a catheter while the remaining 81.0% do not use a catheter. Femoral nerve block is utilized by 3.6% of respondents and a popliteal artery and posterior knee capsule interspace block is utilized by 2.2% of respondents. On-Q pumps were only routinely used with peripheral nerve blocks by 17.6% of respondents. For THA, most respondents use a spinal (72.6%), while 24.3% use general anesthesia. An epidural is used by 2.0% of respondents and a combined spinal epidural with a catheter is used by 1.2% of respondents. Only 10.6% of respondents routinely use a peripheral nerve block for primary THA cases. Of those that use a peripheral nerve block, a majority use a fascia iliaca block (71.7%), while the remaining use a lumbar plexus block (18.9%) and a femoral nerve block (9.4%). Periarticular injection or local infiltration anesthesia is routinely used by 80.3% of respondents for both TKA and THA patients. About
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36.1% 10.0% 1.6% 0.5% 0.2% 1.2% 0.5% 0.3%
Percentage of Prescribers
11.4% of respondents use PAI for TKA only, while 1.8% use PAI for THA only. A select group of respondents (6.5%) do not use PAI. Of those who use PAI, 66.1% also use a peripheral nerve block for TKA patients. Ten different medications are used in PAI (Fig. 1). The most common medications utilized include ketorolac (61.9%), epinephrine (59.2%), and bupivacaine (54.8%). Intravenous corticosteroids are routinely administered by 63.2% of respondents for TKA or THA patients. A majority of respondents (91.0%) do not routinely use longacting opioids in their neuraxial anesthesia. In addition, only 1.5% of respondents use patient-controlled anesthesia with intravenous opioids after primary TKA or THA. Seven different opioid medications are used postoperatively after primary TKA or THA including Percocet, Norco, OxyContin IR, OxyContin ER, MS Contin, Dilaudid, and Tramadol (Fig. 2). The average number of opioid pills prescribed postoperatively after TKA is 49 pills (range 0-200; Fig. 3). The average number of opioid pills prescribed after THA is 44 pills (range 0-200; Fig. 3). Most surgeons (58%) expect that this prescription should last for 2 weeks. Less than a quarter of surgeons (22.0%) expect the initial postoperative prescription of opioids to last 2-3 weeks, 10.2% expect it to last 3-4 weeks, and 9.9% expect it to last greater than 1 month. For chronic opioid users, 49.3% of
59.2%
2.67%
0.33%
Fig. 2. Opioid medications prescribed after total joint arthroplasty.
0.5% 0.3% 0.2%
62.9%
2.67%
Morphine (MS-Contin)
40.8% 23.6%
2.83%
Tramadol (Ultram)
Oxycodone Immediate Release (OxyIR)
78.3% 11.3% 1.1%
Hydromorphone (Dilaudid)
88.9%
28.67%
Oxycodone Controlled or Extended Release
Acetaminophen Nonsteroidal anti-inflammatories Celecoxib Ketorolac Ibuprofen Gabapentinoids Gabapentin Pregabalin Opioids OxyContin controlled or extended release Tramadol Oxycodone immediate release Morphine extended release Hydrocodone/acetaminophen Anti-nausea Scopolamine (Patch) Ondansetron Fosaprepitant Other Omeprazole Ketamine Magnesium sulfate
31.00%
Hydrocodone/Acetaminoph en (Norco)
Respondents (%)
32.50%
Oxycodone/Acetaminophe n (Percocet)
Medication
Percentage of Prescribers
Table 2 Preemptive Analgesic Medications Utilized.
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respondents use a different anesthesia and analgesia protocol for patients who are chronic opioid users. A majority (68.2%) of these respondents who use a different postoperative analgesic regimen for chronic opioid users refer these patients to pain management, but several different strategies are utilized (Table 3). A majority of respondents (74.0%) use multimodal analgesics in addition to opioids. The mean number of additional medications utilized in addition to opioids is 2.8 medications. Sixteen additional medications are used by respondents in their postoperative regimen for TKA or THA patients (Fig. 4). The most common additional medications include acetaminophen (74.5%), celecoxib (54.1%), and tramadol (48.3%). Gabapentin or pregabalin is used by 33.1% of respondents. Discussion Postoperative pain control is essential for successful outcomes after TJA. The results from this survey describe the current trends in analgesia and anesthesia regimens among board-certified arthroplasty surgeon members of AAHKS. There are several areas of consensus including the use of preemptive analgesia and PAIs. However, there is significant variability in the use of peripheral nerve blocks in TKA patients, the number of opioid pills prescribed postoperatively, and the approach to patients who use opioids chronically preoperatively. Peripheral nerve blocks and PAI are commonly used by AAHKS arthroplasty surgeons in TJA. Over 80% of respondents use PAI for
55.3%
39.2% 30.0%
26.1%
22.9% 11.2%
6.4%
Fig. 1. Medications utilized in periarticular injections for total joint arthroplasty.
1.2%
4
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Percentage of Prescribers
42% 36%
27%
25% Total Knee Arthroplasty 15%
8%
Total Hip Arthroplasty
8%
7%
8% 4%
1% 1% 1% 1% 0
1-14
15-29
30-49
50-74
75-99
100+
Number of Opioid Pills Prescribed Fig. 3. Number of opioid pills prescribed after total hip and total knee arthroplasty.
both THA and TKA patients and 68.7% of respondents use a peripheral nerve block for TKA patients. An overwhelming majority of surgeons (90.9%) prefer ACBs over other blocks such as femoral or saphenous blocks. By sparing the quadriceps muscle, ACBs confer several advantages over femoral nerve blocks including improved quadriceps strength, improved mobilization, and improved functional recovery with no difference in pain control [26]. However, there appears to be still a debate regarding whether there is a benefit to using ACB in combination with PAI. A third of respondents (33.9%) who use PAI do not use a peripheral nerve block for their TKA patients. A recent randomized controlled trial (RCT) of 155 patients undergoing TKA found that when comparing ACB with PAI to PAI alone there were no differences in opioid consumption or pain scores [27]. In contrast, a meta-analysis of 4 RCTs including 297 patients found that ACB with PAI led to significantly decreased opioid consumption in the first 3 days after TKA compared with PAI alone [28]. With the advent of alternative payment models each step in the arthroplasty clinical pathway is being evaluated for its efficacy and cost. Further research including larger multicenter RCTs is necessary to determine whether there is additional value and efficacy of combining peripheral nerve blocks and PAI. Opioids remain a critical part of multimodal analgesia. The average number of opioid pills prescribed after TKA was 49 pills and after THA was 44 pills. This average is less than previous reports. In a retrospective review of 105 TKAs, Hernandez et al [29] reported that the average number of opioid pills prescribed at discharge after TKA at their institution was 74 pills, with a range of 20-300 pills. Sabatino et al [30] reported the mean number of opioid pills prescribed after TKA including refills at their institution was 176.4 pills with a range of 10-480 pills. This decrease in the number opioid pills prescribed suggests that the publicity regarding the opioid epidemic and adverse events associated with opioid use have curbed postoperative prescribing of opioid pills. However, similar to the studies of Hernandez et al and Sabatino et al there still remains
significant variation in the number of pills prescribed with ranges of 0-200 after both TKA and THA in this survey. Recent level I evidence published by Hannon et al [31] suggests that 30 OxyIR pills may be sufficient for a majority of patients undergoing TJA. In their RCT of 304 patients, patients who received 30 OxyIR pills have on median 58 fewer unused pills at 30 days after discharge compared with patients who received a discharge prescription for 90 OxyIR pills. Further research is warranted to determine the most effective ways to curb opioid prescribing among arthroplasty surgeons. Multimodal analgesia is the standard of care for the majority of survey respondents, with 458 surgeons (74% of respondents) reporting use of multiple medications. Seventeen different analgesic medications were reported as utilized following TJA. These medications can be grouped into 5 major categories: opioids, tramadol, nonsteroidal anti-inflammatories, gabapentinoids, and acetaminophen. However, given that there are so many different medications utilized, it suggests that there remains significant variability in the postoperative analgesic regimens among boardcertified arthroplasty surgeons. Comprehensive evidence-based guidelines are necessary to guide arthroplasty surgeons on the most efficacious and cost-effective postoperative analgesic regimen. There are several limitations to this study. Although we did achieve enough responses to meet the power analysis by Dillman et al, the overall response rate of 28.2% is still relatively low. The survey was administered in only 1 mode (online), which may have limited the response rate. Additionally, this survey was of boardcertified AAHKS members only with an average of 18.8 years of experience and may not be representative of the practices of all orthopedic surgeons who perform TJA. In an attempt to limit the duration of the survey to maximize response rate, we also did not inquire about dosages, timing, and length of therapy for the anesthetics and analgesics survey. There may be wide variation in these variables that is missed in the survey.
Table 3 Management of Patients Taking Opioids Prior to Total Joint Arthroplasty. Management of Patients Taking Opioids Preoperatively
Respondents (%)
Pain management referral with reduction in preoperative opioid use Pain management referral without reduction in preoperative opioid use Preoperative opioid use reduction without pain management referral Increase opioid dosage postoperatively without preoperative opioid use reduction Maintain opioid dosage the same throughout perioperative period Chronic opioid users are not offered surgery
38.2% 30.0% 16.4% 7.9% 0.7% 0.7%
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5
Percentage of Prescribers
74.5%
54.1% 48.3%
28.4%
26.4%
24.5% 14.7% 6.9% 1.1% 0.9% 0.4% 0.4% 0.2% 0.2% 0.2% 0.2%
Fig. 4. Multimodal oral analgesics prescribed after total joint arthroplasty.
Conclusion There remains no consensus regarding the optimal multimodal anesthetic and analgesic regimen for TJA. Preemptive analgesia and PAIs are nearly universally utilized by board-certified AAHKS arthroplasty surgeons surveyed. Peripheral nerve blocks are still used by a majority of surgeons. Seventeen different adjunctive medications are utilized as part of multimodal analgesia, and opioids are utilized by most surgeons. The number of opioid pills prescribed postoperatively and how to treat patients who are on chronic opioids prior to surgery vary significantly among the AAHKS membership. Further work is necessary in order to establish best practices for the specific elements of multimodal analgesic regimens surrounding TJA.
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Appendix 1. Distributed Survey on Anesthesia and Analgesia Practices in Primary Total Hip and Knee Arthroplasty 1 Which of the following descriptions best describes your current practice setting? a Solo private practice b Private practice group c Multi-specialty group d Hospital employee e Academic medical center f Veterans Administration (Full-Time) g Military h Other i Please specify 2 What is your current age? a Free text 3 How many years have you been in practice? a Free text 4 In what state is your practice located? a Drop down of all states 5 Approximately how many hip & knee arthroplasty cases did you perform in 2016? a Free text 6 Do you do hip & knee arthroplasty cases at an ambulatory (eg, outpatient) surgery center? a Yes i Do you use a different anesthesia or analgesia protocol for your ambulatory patients and your inpatients? b No 7 Do you use preemptive analgesia prior to surgery? (eg, medications administered in preoperative area 1 e 2 hours prior to incision) a Yes b No 8 Which of the following type of medications do you utilize for preemptive analgesia? Select all that apply. a Acetaminophen (Tylenol) b Paracetamol (Perfalgan) c Gabapentin (Neurontin) d Pregabalin (Lyrica) e Meloxicam (Mobic) f Celecoxib (Celebrex) g Ibuprofen (Advil or Motrin) h Ketorolac (Toradol) i Oxycodone controlled-release or extended release (OxyCONTIN CR or ER) j Other 9 For your primary knee arthroplasty cases, do you use a peripheral nerve block? (eg, adductor canal block or femoral nerve block) a Yes b No 10 Which of the following peripheral nerve blocks do you utilize for your primary total knee arthroplasty cases? a Adductor canal block without catheter b Adductor canal block with a catheter c Femoral nerve block without catheter d Femoral nerve block with a catheter e Other (Free text) 11 What type of anesthesia do you utilize for your primary total knee arthroplasty cases? (please select all that apply) a General anesthesia b Spinal c Epidural d Combined spinal & epidural with catheter
6.e1
12 Do you utilize peripheral nerve blocks for your primary total hip arthroplasty cases? a Yes b No 13 What peripheral nerve block do you use for your primary total hip arthroplasty cases? Free text 14 What type of anesthesia do you utilize for your primary total hip arthroplasty cases? a General anesthesia b Spinal c Epidural d Combined spinal & epidural with catheter 15 Do you utilize a form of periarticular injection (PAI) or local infiltration anesthesia (LIA) for your primary total knee OR total hip arthroplasty cases? a Yes, I use it for both hips & knees b Yes, I use it only for knees c Yes, I use it only for hips d No, I do not use it at all 16 Which of the following medications are included in your PAI or LIA for primary total hip or knee arthroplasty cases? Please select all that apply. a Liposomal bupivacaine b Ropivacaine c Bupivacaine d Ketorolac e Epinephrine f Clonidine g Opioids (eg, morphine) h Corticosteroids i Antibiotics 17 Do you use any type of long acting narcotic in your neuraxial anesthesia? a Yes b No 18 Do you use patient-controlled anesthesia (PCA) with intravenous narcotics (eg, morphine, hydromorphone) after primary total knee or hip arthroplasty? a Yes b No 19 Which of the following narcotic pill medications do you provide patients post-operatively? a Oxycodone & Acetaminophen (Percocet) b Hydrocodone & Acetaminophen (Norco) c Oxycodone immediate-release (OxyCONTIN IR or Oxy IR) d Oxycodone controlled-release or extended release (OxyCONTIN CR or ER) e Other i Please specify 20 How many narcotic pills do you prescribe postoperatively for your primary total knee and total hip arthroplasty patients? Free text 21 For how long do you expect this prescription of narcotic pills to last for your primary total knee and total hip arthroplasty patients postoperatively? Free text 22 Do you use any of these additional medications in your postoperative regimen for either your total knee or total hip arthroplasty patients? a Acetaminophen (Tylenol) b Paracetamol (Perfalgan) c Gabapentin (Neurontin) d Pregabalin (Lyrica)
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e Meloxicam (Mobic) f Celecoxib (Celebrex) g Ibuprofen (Advil or Motrin) h Ketorolac (Toradol) i Other 23 Do you utilize a different anesthesia & analgesia protocol for patients who are chronic opioid users? Chronic opioid users are defined as patients taking 30 mg or more of morphine equivalents daily for at least 4 weeks prior to surgery? a Yes
i I refer all chronic opioid users to a physician who specializes in pain and request that the patient wean off or cut back their opioid use prior to surgery ii I refer all chronic opioid users prior to surgery to a physician who specializes in pain, but do not require the patient to wean or cut back their opioid use prior to surgery iii I make all of my chronic opioid use patients wean off or cut back their opioid use prior to surgery and handle the wean myself iv I do not operate on chronic opioid users b No
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Anesthesia and Analgesia Practices in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership Charles P. Hannon, MD a, Timothy C. Keating, MD a, Jeffrey K. Lange, MD b, c, Benjamin F. Ricciardi, MD d, Bradford S. Waddell, MD e, Craig J. Della Valle, MD a, * a
Adult Reconstruction Division, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA Harvard Medical School, Boston, MA d Department of Orthopaedic Surgery, Center for Musculoskeletal Research, University of Rochester School of Medicine, Rochester, NY e Adult Reconstruction and Joint Replacement Division, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 9 April 2019 Received in revised form 8 June 2019 Accepted 25 June 2019 Available online xxx
Background: The purpose of this study is to survey the current analgesia and anesthesia practices used by total joint arthroplasty surgeon members of the American Association of Hip and Knee Surgeons (AAHKS). Methods: A survey of 28 questions was created and approved by the AAHKS Research Committee. The survey was distributed to all 2208 board-certified adult reconstruction surgeon members of AAHKS in November 2018. Results: There were 622 responses (28.2%) to the survey. A majority of respondents (93.2%, n ¼ 576) use preemptive analgesia prior to total joint arthroplasty. Most respondents use a spinal for total knee arthroplasty (TKA) (74.4%) and total hip arthroplasty (THA) (72.6%). A peripheral nerve block is routinely used by 68.7% of respondents in primary TKA. Periarticular injection or local infiltration anesthesia is routinely used by 80.3% of respondents for both TKA and THA patients. The average number of opioid pills prescribed postoperatively after TKA is 49 pills (range 0-200) and after THA is 44 pills (range 0-200). Most surgeons (58%) expect that this prescription should last for 2 weeks. A majority of respondents (74.0%) use multimodal analgesics in addition to opioids. Conclusion: There is no consensus regarding the optimal multimodal anesthetic and analgesic regimen for total joint arthroplasty among surveyed board-certified arthroplasty surgeon members of AAHKS. Understanding current practice patterns in anesthesia, analgesia, and opioid prescribing may serve as a platform for future work aimed at establishing best clinical practices of maximizing effective postoperative pain control and minimizing the risks associated with prescribing opioids. © 2019 Elsevier Inc. All rights reserved.
Keywords: total joint arthroplasty total hip arthroplasty total knee arthroplasty multimodal analgesia anesthesia opioids
Each year over 1 million total joint arthroplasty (TJA) procedures are performed in the United States with a goal of relieving pain and restoring function. However, both total knee arthroplasty (TKA) and total hip arthroplasty (THA) can be painful procedures and effective
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.06.055. * Reprint requests: Craig J. Della Valle, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Chicago, IL 60612. https://doi.org/10.1016/j.arth.2019.06.055 0883-5403/© 2019 Elsevier Inc. All rights reserved.
pain control after surgery is critical for success of the procedure. Effective pain control after TJA has been shown to improve outcomes including faster recovery, lower complication rates, reduced costs of care, and improved patient satisfaction [1e8]. Poor pain control after TJA has been associated with longer inpatient hospital stays, increased healthcare costs, increased risk of chronic pain postoperatively, and poorer functional outcomes [9,10]. There are many anesthetic and analgesic options to control pain after TJA. Historically, opioids were a cornerstone of controlling pain after TJA. Opioids are effective analgesics, but are associated with significant side effects and risks [11]. Opioids are associated with increased urinary, gastrointestinal, neurologic, cardiac, and
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respiratory complications postoperatively [12e15]. In addition, they have an addictive potential, which has led to the opioid epidemic the United States is fighting today [16,17]. Heroin is responsible for a majority of opioid-related deaths, but sadly 86% of heroin users say that a previous opioid prescription started their addiction [18]. As a result, there has been a nationwide effort to curb opioid prescriptions. Multimodal analgesic regimens in TJA have garnered significant interest because they limit the use of opioids perioperatively. These regimens use a variety of medications and delivery routes at multiple perioperative time points in order to target several different biologic pathways that may contribute to postoperative pain after TJA [19]. In addition to multiple oral medications, multimodal analgesic regimens may combine the use of regional anesthesia (eg, epidurals), peripheral nerve blocks, periarticular analgesic injections, and cryotherapy to limit opioid use postoperatively. Several studies have demonstrated that multimodal analgesia is effective for controlling pain after TJA, but there is no consensus on the ideal regimen [7,8]. The purpose of this study is to survey the current analgesia and anesthesia practices used by board-certified TJA surgeons that are members of the American Association of Hip and Knee Surgeons (AAHKS). Understanding current practice patterns in anesthesia, analgesia, and opioid prescribing may serve as a platform for future work aimed at establishing best clinical practices of maximizing effective postoperative pain control and minimizing the risks associated with prescribing opioids.
Materials and Methods A survey of 28 questions was created in accordance with the Dillman’s Tailored Design Method. The Dillman’s Tailored Design Method is a validated method of survey design that maximizes the response rate in a professional group that has been used for previous AAHKS Research Committee Surveys [20e24]. The survey was approved by the AAHKS Research Committee and distributed to all 2208 board-certified adult reconstruction surgeon members of AAHKS in November 2018 (Appendix 1). The survey was administered over a 3-month period from November 2018 to January 2019. The descriptive survey was distributed by a singlemode (online) and was self-administered. The survey was distributed via e-mail with a description of the survey followed by a link to an electronic, anonymous survey instrument (SurveyMonkey, Inc, Palo Alto, CA). A reminder to complete the survey with a link to the survey was sent approximately 2 weeks after initial distribution to nonresponders. The survey collected demographic data of the respondents including age, clinical volume, location, and type of practice. Respondents then answered specific questions regarding their analgesia and anesthesia practices including use of preemptive analgesia, regional blocks, peripheral nerve blocks, and periarticular injections (PAIs). In addition, respondents answered questions regarding their use of opioids including the types of opioids utilized, delivery mechanisms, and number of opioid pills prescribed postoperatively. Finally, respondents answered a question regarding how they treat patients who have a history of preoperative opioid use. The survey sample power analysis of Dillman et al states that a 13% response rate is necessary to achieve a 95% confidence level, plus or minus a 5% sample error [23,25]. Responses to all questions were tabulated and descriptive statistics are reported for each question. Analysis was completed using Microsoft Excel (Seattle, WA).
Table 1 Demographics of the American Association of Hip and Knee Surgeons Membership Survey Respondents. Percent of Respondents (Number of Respondents) Type of practice (%, n) Private practice Hospital employee Academics Multispecialty group Solo private practice Military Veterans administration Other Age (mean, range) Years in practice (mean, range) Case volume in 2017 (%, n) <100 100-199 200-299 300-399 400-499 >500 Geographic region Northeast South Midwest West
47.0% (292) 19.0% (118) 16.4% (102) 11.4% (71) 4.8% (30) 0.6% (4) 0.5% (3) 0.3% (2) 51.7 (range 33-81) 18.8 (range 1-47) 4.5% 13.8% 20.0% 22.4% 17.6% 21.6%
(28) (86) (124) (139) (109) (134)
36.5% 23.6% 20.1% 19.8%
(227) (147) (125) (123)
Results The survey was distributed to 2208 adult reconstruction surgeons in AAHKS and there were 622 responses (28.2%). Demographic data regarding the respondents is summarized in Table 1. The average number of years in practice of the respondents is 18.8 years (range 1-47). Most respondents (81.7%) performed more than 200 arthroplasty cases in 2017 and 47.0% of respondents are in private practice. Of the 622 respondents, 29.2% perform cases at an ambulatory surgery center. Of those that do perform surgeries at an ambulatory center, 70.5% use the same anesthesia and analgesia protocol for both their ambulatory patients and inpatients. A majority of respondents (93.2%, n ¼ 576) use preemptive analgesia prior to TJA. Seventeen different medications are reported as used for preemptive analgesia prior to TJA (Table 2). The most common medications used are acetaminophen, celecoxib, gabapentin, and oxycodone extended or controlled release. For TKA, most respondents use a spinal anesthesia (74.4%), while 23.0% of respondents use a general anesthesia. An epidural is used by 1.6% of respondents and a combined spinal epidural with a catheter is used by 1.0% of respondents. A peripheral nerve block is routinely used by 68.7% of respondents in primary TKA. Of those who utilize a peripheral nerve block for primary TKA, 90.9% prefer an adductor canal block (ACB). Of those that utilize an ACB, 19.0% use a catheter while the remaining 81.0% do not use a catheter. Femoral nerve block is utilized by 3.6% of respondents and a popliteal artery and posterior knee capsule interspace block is utilized by 2.2% of respondents. On-Q pumps were only routinely used with peripheral nerve blocks by 17.6% of respondents. For THA, most respondents use a spinal (72.6%), while 24.3% use general anesthesia. An epidural is used by 2.0% of respondents and a combined spinal epidural with a catheter is used by 1.2% of respondents. Only 10.6% of respondents routinely use a peripheral nerve block for primary THA cases. Of those that use a peripheral nerve block, a majority use a fascia iliaca block (71.7%), while the remaining use a lumbar plexus block (18.9%) and a femoral nerve block (9.4%). Periarticular injection or local infiltration anesthesia is routinely used by 80.3% of respondents for both TKA and THA patients. About
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36.1% 10.0% 1.6% 0.5% 0.2% 1.2% 0.5% 0.3%
Percentage of Prescribers
11.4% of respondents use PAI for TKA only, while 1.8% use PAI for THA only. A select group of respondents (6.5%) do not use PAI. Of those who use PAI, 66.1% also use a peripheral nerve block for TKA patients. Ten different medications are used in PAI (Fig. 1). The most common medications utilized include ketorolac (61.9%), epinephrine (59.2%), and bupivacaine (54.8%). Intravenous corticosteroids are routinely administered by 63.2% of respondents for TKA or THA patients. A majority of respondents (91.0%) do not routinely use longacting opioids in their neuraxial anesthesia. In addition, only 1.5% of respondents use patient-controlled anesthesia with intravenous opioids after primary TKA or THA. Seven different opioid medications are used postoperatively after primary TKA or THA including Percocet, Norco, OxyContin IR, OxyContin ER, MS Contin, Dilaudid, and Tramadol (Fig. 2). The average number of opioid pills prescribed postoperatively after TKA is 49 pills (range 0-200; Fig. 3). The average number of opioid pills prescribed after THA is 44 pills (range 0-200; Fig. 3). Most surgeons (58%) expect that this prescription should last for 2 weeks. Less than a quarter of surgeons (22.0%) expect the initial postoperative prescription of opioids to last 2-3 weeks, 10.2% expect it to last 3-4 weeks, and 9.9% expect it to last greater than 1 month. For chronic opioid users, 49.3% of
59.2%
2.67%
0.33%
Fig. 2. Opioid medications prescribed after total joint arthroplasty.
0.5% 0.3% 0.2%
62.9%
2.67%
Morphine (MS-Contin)
40.8% 23.6%
2.83%
Tramadol (Ultram)
Oxycodone Immediate Release (OxyIR)
78.3% 11.3% 1.1%
Hydromorphone (Dilaudid)
88.9%
28.67%
Oxycodone Controlled or Extended Release
Acetaminophen Nonsteroidal anti-inflammatories Celecoxib Ketorolac Ibuprofen Gabapentinoids Gabapentin Pregabalin Opioids OxyContin controlled or extended release Tramadol Oxycodone immediate release Morphine extended release Hydrocodone/acetaminophen Anti-nausea Scopolamine (Patch) Ondansetron Fosaprepitant Other Omeprazole Ketamine Magnesium sulfate
31.00%
Hydrocodone/Acetaminoph en (Norco)
Respondents (%)
32.50%
Oxycodone/Acetaminophe n (Percocet)
Medication
Percentage of Prescribers
Table 2 Preemptive Analgesic Medications Utilized.
3
respondents use a different anesthesia and analgesia protocol for patients who are chronic opioid users. A majority (68.2%) of these respondents who use a different postoperative analgesic regimen for chronic opioid users refer these patients to pain management, but several different strategies are utilized (Table 3). A majority of respondents (74.0%) use multimodal analgesics in addition to opioids. The mean number of additional medications utilized in addition to opioids is 2.8 medications. Sixteen additional medications are used by respondents in their postoperative regimen for TKA or THA patients (Fig. 4). The most common additional medications include acetaminophen (74.5%), celecoxib (54.1%), and tramadol (48.3%). Gabapentin or pregabalin is used by 33.1% of respondents. Discussion Postoperative pain control is essential for successful outcomes after TJA. The results from this survey describe the current trends in analgesia and anesthesia regimens among board-certified arthroplasty surgeon members of AAHKS. There are several areas of consensus including the use of preemptive analgesia and PAIs. However, there is significant variability in the use of peripheral nerve blocks in TKA patients, the number of opioid pills prescribed postoperatively, and the approach to patients who use opioids chronically preoperatively. Peripheral nerve blocks and PAI are commonly used by AAHKS arthroplasty surgeons in TJA. Over 80% of respondents use PAI for
55.3%
39.2% 30.0%
26.1%
22.9% 11.2%
6.4%
Fig. 1. Medications utilized in periarticular injections for total joint arthroplasty.
1.2%
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Percentage of Prescribers
42% 36%
27%
25% Total Knee Arthroplasty 15%
8%
Total Hip Arthroplasty
8%
7%
8% 4%
1% 1% 1% 1% 0
1-14
15-29
30-49
50-74
75-99
100+
Number of Opioid Pills Prescribed Fig. 3. Number of opioid pills prescribed after total hip and total knee arthroplasty.
both THA and TKA patients and 68.7% of respondents use a peripheral nerve block for TKA patients. An overwhelming majority of surgeons (90.9%) prefer ACBs over other blocks such as femoral or saphenous blocks. By sparing the quadriceps muscle, ACBs confer several advantages over femoral nerve blocks including improved quadriceps strength, improved mobilization, and improved functional recovery with no difference in pain control [26]. However, there appears to be still a debate regarding whether there is a benefit to using ACB in combination with PAI. A third of respondents (33.9%) who use PAI do not use a peripheral nerve block for their TKA patients. A recent randomized controlled trial (RCT) of 155 patients undergoing TKA found that when comparing ACB with PAI to PAI alone there were no differences in opioid consumption or pain scores [27]. In contrast, a meta-analysis of 4 RCTs including 297 patients found that ACB with PAI led to significantly decreased opioid consumption in the first 3 days after TKA compared with PAI alone [28]. With the advent of alternative payment models each step in the arthroplasty clinical pathway is being evaluated for its efficacy and cost. Further research including larger multicenter RCTs is necessary to determine whether there is additional value and efficacy of combining peripheral nerve blocks and PAI. Opioids remain a critical part of multimodal analgesia. The average number of opioid pills prescribed after TKA was 49 pills and after THA was 44 pills. This average is less than previous reports. In a retrospective review of 105 TKAs, Hernandez et al [29] reported that the average number of opioid pills prescribed at discharge after TKA at their institution was 74 pills, with a range of 20-300 pills. Sabatino et al [30] reported the mean number of opioid pills prescribed after TKA including refills at their institution was 176.4 pills with a range of 10-480 pills. This decrease in the number opioid pills prescribed suggests that the publicity regarding the opioid epidemic and adverse events associated with opioid use have curbed postoperative prescribing of opioid pills. However, similar to the studies of Hernandez et al and Sabatino et al there still remains
significant variation in the number of pills prescribed with ranges of 0-200 after both TKA and THA in this survey. Recent level I evidence published by Hannon et al [31] suggests that 30 OxyIR pills may be sufficient for a majority of patients undergoing TJA. In their RCT of 304 patients, patients who received 30 OxyIR pills have on median 58 fewer unused pills at 30 days after discharge compared with patients who received a discharge prescription for 90 OxyIR pills. Further research is warranted to determine the most effective ways to curb opioid prescribing among arthroplasty surgeons. Multimodal analgesia is the standard of care for the majority of survey respondents, with 458 surgeons (74% of respondents) reporting use of multiple medications. Seventeen different analgesic medications were reported as utilized following TJA. These medications can be grouped into 5 major categories: opioids, tramadol, nonsteroidal anti-inflammatories, gabapentinoids, and acetaminophen. However, given that there are so many different medications utilized, it suggests that there remains significant variability in the postoperative analgesic regimens among boardcertified arthroplasty surgeons. Comprehensive evidence-based guidelines are necessary to guide arthroplasty surgeons on the most efficacious and cost-effective postoperative analgesic regimen. There are several limitations to this study. Although we did achieve enough responses to meet the power analysis by Dillman et al, the overall response rate of 28.2% is still relatively low. The survey was administered in only 1 mode (online), which may have limited the response rate. Additionally, this survey was of boardcertified AAHKS members only with an average of 18.8 years of experience and may not be representative of the practices of all orthopedic surgeons who perform TJA. In an attempt to limit the duration of the survey to maximize response rate, we also did not inquire about dosages, timing, and length of therapy for the anesthetics and analgesics survey. There may be wide variation in these variables that is missed in the survey.
Table 3 Management of Patients Taking Opioids Prior to Total Joint Arthroplasty. Management of Patients Taking Opioids Preoperatively
Respondents (%)
Pain management referral with reduction in preoperative opioid use Pain management referral without reduction in preoperative opioid use Preoperative opioid use reduction without pain management referral Increase opioid dosage postoperatively without preoperative opioid use reduction Maintain opioid dosage the same throughout perioperative period Chronic opioid users are not offered surgery
38.2% 30.0% 16.4% 7.9% 0.7% 0.7%
C.P. Hannon et al. / The Journal of Arthroplasty xxx (2019) 1e6
5
Percentage of Prescribers
74.5%
54.1% 48.3%
28.4%
26.4%
24.5% 14.7% 6.9% 1.1% 0.9% 0.4% 0.4% 0.2% 0.2% 0.2% 0.2%
Fig. 4. Multimodal oral analgesics prescribed after total joint arthroplasty.
Conclusion There remains no consensus regarding the optimal multimodal anesthetic and analgesic regimen for TJA. Preemptive analgesia and PAIs are nearly universally utilized by board-certified AAHKS arthroplasty surgeons surveyed. Peripheral nerve blocks are still used by a majority of surgeons. Seventeen different adjunctive medications are utilized as part of multimodal analgesia, and opioids are utilized by most surgeons. The number of opioid pills prescribed postoperatively and how to treat patients who are on chronic opioids prior to surgery vary significantly among the AAHKS membership. Further work is necessary in order to establish best practices for the specific elements of multimodal analgesic regimens surrounding TJA.
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total knee arthroplasty. J Bone Joint Surg Am 2018;100:1141e6. https:// doi.org/10.2106/jbjs.17.01177. Xing Q, Dai W, Zhao D, Wu J, Huang C, Zhao Y. Adductor canal block with local infiltrative analgesia compared with local infiltrate analgesia for pain control after total knee arthroplasty. Medicine 2017;96:e8103. https://doi.org/ 10.1097/md.0000000000008103. Hernandez NM, Parry JA, Taunton MJ. Patients at risk: large opioid prescriptions after total knee arthroplasty. J Arthroplasty 2017;32:2395e8. https://doi.org/10.1016/j.arth.2017.02.060. Sabatino MJ, Kunkel ST, Ramkumar DB, Keeney BJ, Jevsevar DS. Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures. J Bone Joint Surg Am 2018;100:180e8. https://doi.org/ 10.2106/jbjs.17.00672. Hannon CP, Calkins TE, Li J, Culvern C, Darrith B, Nam D, et al. Large opioid prescriptions are unnecessary after total joint arthroplasty: a randomized controlled trial. J Arthroplasty 2019;34:S4e10. https://doi.org/10.1016/ j.arth.2019.01.065.
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Appendix 1. Distributed Survey on Anesthesia and Analgesia Practices in Primary Total Hip and Knee Arthroplasty 1 Which of the following descriptions best describes your current practice setting? a Solo private practice b Private practice group c Multi-specialty group d Hospital employee e Academic medical center f Veterans Administration (Full-Time) g Military h Other i Please specify 2 What is your current age? a Free text 3 How many years have you been in practice? a Free text 4 In what state is your practice located? a Drop down of all states 5 Approximately how many hip & knee arthroplasty cases did you perform in 2016? a Free text 6 Do you do hip & knee arthroplasty cases at an ambulatory (eg, outpatient) surgery center? a Yes i Do you use a different anesthesia or analgesia protocol for your ambulatory patients and your inpatients? b No 7 Do you use preemptive analgesia prior to surgery? (eg, medications administered in preoperative area 1 e 2 hours prior to incision) a Yes b No 8 Which of the following type of medications do you utilize for preemptive analgesia? Select all that apply. a Acetaminophen (Tylenol) b Paracetamol (Perfalgan) c Gabapentin (Neurontin) d Pregabalin (Lyrica) e Meloxicam (Mobic) f Celecoxib (Celebrex) g Ibuprofen (Advil or Motrin) h Ketorolac (Toradol) i Oxycodone controlled-release or extended release (OxyCONTIN CR or ER) j Other 9 For your primary knee arthroplasty cases, do you use a peripheral nerve block? (eg, adductor canal block or femoral nerve block) a Yes b No 10 Which of the following peripheral nerve blocks do you utilize for your primary total knee arthroplasty cases? a Adductor canal block without catheter b Adductor canal block with a catheter c Femoral nerve block without catheter d Femoral nerve block with a catheter e Other (Free text) 11 What type of anesthesia do you utilize for your primary total knee arthroplasty cases? (please select all that apply) a General anesthesia b Spinal c Epidural d Combined spinal & epidural with catheter
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12 Do you utilize peripheral nerve blocks for your primary total hip arthroplasty cases? a Yes b No 13 What peripheral nerve block do you use for your primary total hip arthroplasty cases? Free text 14 What type of anesthesia do you utilize for your primary total hip arthroplasty cases? a General anesthesia b Spinal c Epidural d Combined spinal & epidural with catheter 15 Do you utilize a form of periarticular injection (PAI) or local infiltration anesthesia (LIA) for your primary total knee OR total hip arthroplasty cases? a Yes, I use it for both hips & knees b Yes, I use it only for knees c Yes, I use it only for hips d No, I do not use it at all 16 Which of the following medications are included in your PAI or LIA for primary total hip or knee arthroplasty cases? Please select all that apply. a Liposomal bupivacaine b Ropivacaine c Bupivacaine d Ketorolac e Epinephrine f Clonidine g Opioids (eg, morphine) h Corticosteroids i Antibiotics 17 Do you use any type of long acting narcotic in your neuraxial anesthesia? a Yes b No 18 Do you use patient-controlled anesthesia (PCA) with intravenous narcotics (eg, morphine, hydromorphone) after primary total knee or hip arthroplasty? a Yes b No 19 Which of the following narcotic pill medications do you provide patients post-operatively? a Oxycodone & Acetaminophen (Percocet) b Hydrocodone & Acetaminophen (Norco) c Oxycodone immediate-release (OxyCONTIN IR or Oxy IR) d Oxycodone controlled-release or extended release (OxyCONTIN CR or ER) e Other i Please specify 20 How many narcotic pills do you prescribe postoperatively for your primary total knee and total hip arthroplasty patients? Free text 21 For how long do you expect this prescription of narcotic pills to last for your primary total knee and total hip arthroplasty patients postoperatively? Free text 22 Do you use any of these additional medications in your postoperative regimen for either your total knee or total hip arthroplasty patients? a Acetaminophen (Tylenol) b Paracetamol (Perfalgan) c Gabapentin (Neurontin) d Pregabalin (Lyrica)
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e Meloxicam (Mobic) f Celecoxib (Celebrex) g Ibuprofen (Advil or Motrin) h Ketorolac (Toradol) i Other 23 Do you utilize a different anesthesia & analgesia protocol for patients who are chronic opioid users? Chronic opioid users are defined as patients taking 30 mg or more of morphine equivalents daily for at least 4 weeks prior to surgery? a Yes
i I refer all chronic opioid users to a physician who specializes in pain and request that the patient wean off or cut back their opioid use prior to surgery ii I refer all chronic opioid users prior to surgery to a physician who specializes in pain, but do not require the patient to wean or cut back their opioid use prior to surgery iii I make all of my chronic opioid use patients wean off or cut back their opioid use prior to surgery and handle the wean myself iv I do not operate on chronic opioid users b No