Education, Guidelines, Willingness: Keys to Changing Opioid-Prescribing Habits

When planning for any type of surgical procedure, the orthopaedist considers many patient and injury-specific variables. With a distal radius fracture, for example, the main goal of the surgery—anatomic reconstruction of the distal radius—remains constant. However, there are numerous other variables (fracture morphology and patient age, just to name 2) that have to be considered to achieve that goal. Yet, when it comes to postoperative pain control, I imagine that most orthopaedic surgeons prescribe the same amount of opioids to almost every patient undergoing an open reduction/internal fixation of a distal radius fracture, regardless of unique patient characteristics. Our medical mantra that “no two patients are the same” seems to fall by the wayside when it comes to postoperative pain control.

This disconnect is what I thought about while reading the article by Stepan et al. in the January 2, 2019 issue of The Journal. The authors’ institution developed and disseminated to all prescribers a 1-hour opioid education program and consensus-based postoperative opioid prescription guidelines. They then compared the number of opioid pills and total oral morphine equivalents prescribed after 9 ambulatory procedures within 3 subspecialty services (sports medicine, hand, and foot and ankle) prior to and after implementation of the guidelines. Stepan et al. found a significant decrease  in the amount of narcotics prescribed after 6 of the 9 surgery types after implementation of the guidelines. Over the course of a year, those decreases would have equaled about 30,000 fewer opioid pills!

Interestingly, there was no significant post-guideline decrease in opioid prescribing after any of the 3 foot-and-ankle procedures. The authors attribute that finding to the slow adoption of the guidelines due to adherence to previously developed pain-management recommendations in this subspecialty.

It has become apparent that we tend to overprescribe opioids postoperatively (see related OrthoBuzz post). This study supports previous data showing that prescription guidelines can be useful in decreasing the amount of postoperative narcotics prescribed to patients, while maintaining adequate pain management and good levels of patient satisfaction.  While further work in developing educational tools and procedure-specific “standards” to help surgeons guide their postoperative prescribing practices would be useful, a surgeon’s mindfulness is equally important. We need first to recognize that orthopaedic surgeons tend to overprescribe postoperative opioids—and second, we must be willing to change our habits. Without both awareness and willingness, the best guidelines and recommendations will be ignored, and an opportunity for us to help curb the opioid crisis in our country will be wasted.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Bundled Payments for Hip and Knee Replacement: Working as Planned?

When Medicare’s Comprehensive Care for Joint Replacement (CJR) program was implemented in 2016, the health care community—especially orthopaedic surgeons— had 2 major concerns. First, would the program actually demonstrate the ability to decrease the costs of total joint replacements while maintaining the same, or improved, outcomes? Second, would CJR promote the unintended consequence of participating hospitals and surgeons ”cherry picking” lower-risk patients and steering clear of higher-risk (and presumably higher cost) patients?  Both of these questions were at the heart of the study by Barnett et al. in a recent issue of the New England Journal of Medicine.

The authors evaluated hip and knee replacements at 75 metropolitan centers that were mandated to participate in the CJR program and compared the costs, complication rates, and patient demographics to similar procedures at 121 control centers that did not participate in CJR. The authors found significantly greater decreases in institutional spending per joint-replacement episode in institutions participating in the CJR compared to those that did not. Most of these savings appeared to come from CJR-participating institutions sending fewer patients to post-acute care facilities after surgery. Furthermore, the authors did not find differences between centers participating in the CJR and control centers in terms of composite complication rate or the percentage of procedures that were performed on high-risk patients.

While this 2-year evaluation does not provide the level of detail necessary to make far-reaching conclusions, it does address two of the biggest concerns related to CJR implementation from a health-systems perspective. There may be individual CJR-participating centers that are not saving Medicare money or that are cherry picking lower-risk patients, but overall the program appears to be doing what it set out to do—successfully motivating participating hospitals and healthcare facilities to look critically at what they can do to decrease the costs of a joint-replacement episode while simultaneously maintaining a high level of patient care. The Trump administration shifted CJR to a partly voluntary model in March 2018, and I hope policymakers consider these findings if further changes to the CJR model are planned.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

Full-Thickness Cartilage Defects More Predictive of Future TKA than Joint-Space Narrowing

Many older patients present to orthopaedic surgeons with clinical knee pain suggestive of osteoarthritis (OA) but with little or no radiographic evidence of disease. And a substantial proportion of those patients do not respond adequately to the recommended, first-line nonsurgical treatment approaches to knee OA. A prognostic study by Everhart et al. in the January 2, 2019 issue of The Journal of Bone & Joint Surgery helps explain why that might be.

The authors evaluated baseline knee radiographs and MRIs from >1,300 older adults (mean age of 61 years) who were enrolled in the Osteoarthritis Initiative, a multicenter observational cohort study with a median of 9 years of follow-up data. They sought to determine independent risk factors for progression to total knee arthroplasty (TKA) among this cohort, all of whom showed Kellgren-Lawrence grade 0 to 3 OA on knee radiographs. MRIs taken at baseline revealed that 38% of those patients had a full-thickness knee-cartilage defect. After the authors adjusted for various confounders (including age, weight, and symptom severity), they found that regardless of radiographic grade, the presence of a full-thickness cartilage defect was a strong independent risk factor for subsequent TKA. Moreover, patients with a defect ≥2 cm2 had twice the risk of arthroplasty compared with patients with defects <2 cm2.

According to the authors, the findings highlight the “greater importance of full-thickness cartilage loss over radiographic OA grade as a determinant of OA severity, specifically regarding the risk of future knee arthroplasty in older adults.” In his commentary on this study, Drew A. Lansdown, MD emphasizes that Everhart et al. “do not advocate for the routine use of MRI in the diagnosis of knee osteoarthritis,” but he says the findings “do suggest that early MRI may have a diagnostic role for patients who are not responding as expected to nonoperative measures.” Noting that the patients in this cohort would probably not be ideal candidates for current cartilage-restoration procedures, Dr. Lansdown encourages further research focused on identifying “patient-specific factors that can match patients with the treatment…that will provide the greatest likelihood of symptom relief and functional improvement.”

Unexplained Pain After TKA? Duloxetine Might Help

Somewhere between 10% and 15% of patients are unsatisfied with their outcome after primary total knee arthroplasty (TKA). In some cases, dissatisfaction is related to poor range of motion, but more often it is related to residual—or even intensified—pain in the knee several weeks after surgery.

In the January 2, 2019 issue of The Journal, Koh et al. report the results of a prospective randomized trial assessing the effects of duloxetine (Cymbalta) in TKA patients who were screened preoperatively for “central sensitization.” In central sensitization, a hyperexcitable central nervous system becomes hypersensitive to stimuli, noxious and otherwise.

Koh et al. randomized 80 centrally sensitized patients (mean age of 69 years), 40 of whom received a multimodal perioperative pain management protocol plus duloxetine, and 40 of whom received the multimodal protocol without duloxetine. During postoperative weeks 2 through 12, patients taking duloxetine reported better results in terms of pain and functional and emotional outcome measures than those not receiving the drug. Patients in the duloxetine group expressed greater satisfaction with pain control (77% vs 29%) and daily activity (83% vs 52%) at postoperative week 12, compared with those in the control group.

This research represents an important advance in identifying and treating patients who are prone to poor outcomes after TKA. The concept of central sensitization is relatively new to the orthopaedic community, and this pharmacologic intervention is likely to be just the first among many that will help these patients. I think it is probable that other, nonpharmacological interventions will eventually be as or even more successful in helping TKA patients with central sensitization. Koh et al. make a valuable  contribution in this article by educating us as to the neurophysiologic basis of this condition, and their work should pave the way for more important research in this area.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Self-Reported Marijuana Use Is Associated with Increased Use of Prescription Opioids Following Traumatic Musculoskeletal Injury

Full Article
Cannabinoids are among the psychoactive substances considered as alternatives to opioids for the alleviation of acute pain. We examined whether self-reported marijuana use was associated with decreased use of prescription opioids following traumatic musculoskeletal injury.

Complications Following Overlapping Orthopaedic Procedures at an Ambulatory Surgery Center

Full Article
Overlapping surgery occurs when a single surgeon is the primary surgeon for >1 patient in separate operating rooms simultaneously. The surgeon is present for the critical portions of each patient’s operation although not present for the entirety of the case. While overlapping surgery has been widely utilized across surgical subspecialties, few large studies have compared the safety of overlapping and nonoverlapping orthopaedic surgery.


Questionnaire Helps Identify Lumbar Patients Who Need Surgeon Consult

Only about 10% to 15% of patients with low back pain who are referred to a spine surgeon actually require a surgical procedure. And because low back pain is such a common presenting complaint, many such patients often wait a long time for a surgery consult. In the December 19, 2018 issue of JBJS, Coyle et al. demonstrate that a simple, 3-item patient-administered questionnaire can identify those better suited for nonoperative management—and thus increase the likelihood that surgical candidates are seen by spine surgeons in an acceptable time frame.

All 227 of the Canadian patients enrolled in this randomized controlled trial received the questionnaire, which elicited information to distinguish between patients with leg-dominant radicular pain and those with back-dominant pain. Evidence-based guidelines recommend nonoperative management for most back-dominant pain, while patients with leg-dominant pain are more likely to need surgery. Researchers randomized 116 patients into an intervention group; these patients were triaged by a spine surgeon and then had their triage status upgraded if responses to the questionnaire indicated leg-dominant symptoms. The 111 patients in the control group were triaged only by a spine surgeon.

After triage, 33 of the 227 patients (15%) were recommended for a surgical procedure—16 from the intervention group and 17 from the control group. Of the 16 surgical candidates identified from the intervention group, 9 (56%) were re-prioritized on the basis of questionnaire results.

The median wait time for a consultation among the 16 surgical candidates in the intervention group was 2.5 months, compared with 4.5 months for the 17 surgical candidates in the control group. A significantly greater percentage of patients in the intervention group than in the control group were seen for a consult with a spine surgeon within the “acceptable” time frame of 3 months. Another benefit of the questionnaire approach evaluated in this study is that it helps identify nonsurgical candidates early, so they can be directed toward more appropriate treatment (such as physical therapy) rather than delaying treatment while waiting for a consult with a spine surgeon.

Although this study was conducted in the setting of the “nationalized” Canadian health care system, wait times to see orthopaedic surgeons and neurosurgeons are also long for many patients in many regions of the US. This questionnaire enhancement to triage could therefore be viable throughout North America, and perhaps beyond.

Keeping Your Bones Pumped Up

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson. 

While a reasonable amount of “pumping iron” exercise has proven beneficial for musculoskeletal health, long-term use of acid-suppressing proton pump inhibitors (PPIs) may have the opposite effect on bone. Many people are currently taking PPIs, most commonly for gastrointestinal disorders such as heartburn and gastroesophageal reflux. Fortunately, many are occasional PPI users, taking the drugs only when symptoms arise. However, PPIs are often prescribed long term for preventive reasons.1

The same proton-pump mechanism present in the GI tract is seen in the vacuolar H+-ATPases that are present in high concentrations on the ruffled border of osteoclasts.2 Years of PPI use may therefore interfere with normal and essential bone remodeling. PPIs are also prescribed in the pediatric population for reflux symptoms. The effect of PPIs on future fracture or long-term osteoporosis in these very young patients is not clear.

The consequences for adult and elderly patients are clearer. Femoral bone mineral density is significantly decreased in PPI users. Also, patients with peptic ulcer disease using PPIs have a higher risk for osteoporosis than peptic ulcer patients not using PPIs. Among younger adults, the risk of fracture was significantly higher in those using PPIs than in those not using PPIs.

In 2010, the FDA issued a communication alerting healthcare professionals that users of PPIs have a possible increased risk of fractures of the hip, wrist, and spine, and that they should weigh the known benefits against the potential risks when recommending use of these medications. In 2011, the FDA refined its language somewhat: “Following a thorough review of available safety data, FDA has concluded that fracture risk with short-term, low dose PPI use is unlikely.” Still, when fractures are the outcome of interest, the data implicates long-term use of PPIs in having deleterious effects on bone.

Although data on human fracture healing in association with PPI use are sparse, animal studies do show that PPIs have a negative impact on normal fracture healing, with a decrease in the expression of important markers of bone formation, including bone morphogenetic protein (BMP)-2, BMP-4, and cysteine-rich angiogenic inducer (CYR)61.

It is time to question the need for chronic use of PPIs by our patients. Orthopaedists should encourage their patients who take PPIs to discuss this matter with their primary care physician.

References

  1. Eom CS, Park SM, Myung SK, Yun JM, Ahn JS. Use of acid-suppressive drugs and risk of fracture: a meta-analysis of observational studies. Ann Fam Med. 2011 May-Jun;9(3):257-67. doi: 10.1370/afm.1243. PMID: 21555754
  1. Wagner SC. Proton Pump Inhibitors and Bone Health: What the Orthopaedic Surgeon Needs to Know. JBJS Rev. 2018 Dec 18. doi: 10.2106/JBJS.RVW.18.00029. [Epub ahead of print] No abstract available. PMID: 30562209

Epiphyseal Etiology for Juvenile Osteochondritis Dissecans?

Most patients with clinically apparent juvenile osteochondritis dissecans (JOCD) are between 12 and 19 years of age. Often the disease can be treated successfully with nonoperative modalities, but even in cases where the initial lesion resolves, patients may be predisposed to osteoarthritis later in life. While repetitive microtrauma is suspected to be involved in the development of JOCD, the exact etiology remains poorly understood, even 130 years after the condition was first described.

In the December 19, 2018 issue of The Journal, Toth et al. histologically examined 59 biopsy samples from the central condyles of 26 pediatric cadavers to look for areas of epiphyseal cartilage necrosis. Hypothesizing that such evaluation would reveal some lesions similar to those found in animals, the authors did indeed identify 6 samples with 1 or more areas of necrotic cartilage, which were either incorporated into subchondral bone or associated with focal failure of endochondral ossification. Those characteristics are consistent with a similar disease process called osteochondrosis manifesta seen in pigs and horses.  While the clinical significance of these findings remains to be determined, the authors suggest that they may help explain an epiphyseal etiology of JOCD, and the data suggest that these microscopic changes (some of which are rendered in this article as whole-slide images) are probably present in young people 5 to 10 years prior to the clinical manifestations of JOCD.

These findings lend credence to the theory that the underlying etiology of JOCD primarily involves the epiphyseal growth plate rather than subchondral bone. Furthermore, the similarities between these cadaveric specimens and osteochondrosis manifesta lesions in porcine and equine femoral condyles may help us develop improved models to better diagnose, prevent, and treat this pathology.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media