Caution Appropriate as We Investigate New Approaches to Pain Management
The dangers of chronic opioid use have rightly been at the forefront of orthopaedic practice considerations in recent years. The widespread use of regional anesthesia and periarticular-injection cocktails, targeted NSAID utilization, and strict limitations on opioid use have become standard approaches for postoperative pain management.
With the availability of cannabinoids in numerous state jurisdictions, attention has now turned to the potential of these compounds to enhance patient comfort in the postoperative period. However, as we contemplate their use, it’s imperative that we also evaluate the impact of these compounds on clinically important outcomes such as bone-healing and fusion. The track record of nicotine, NSAIDs, and other compounds in terms of the impact on bone-healing is enough to suggest caution.
In the June 2, 2021 issue of JBJS, Yun et al. provide new insight into this topic. Specifically, they evaluated the impact of cannabinoid receptor agonist WIN55 on osteogenic differentiation in vitro and bone regeneration and spinal fusion in a preclinical rat model.
They found that WIN55 had no adverse impact on osteogenic differentiation of primary bone marrow stem cells in vitro. As noted by the authors, “mRNA expression levels of Runx2 and Alp were similar among cells treated with vehicle alone and WIN55. Likewise, exposure to WIN55 did not inhibit ALP [Alkaline phosphatase] activity or bone matrix mineralization.”
In addition, no adverse impact of WIN55 on spinal fusion or bone regeneration was found. Forty-five rats (15 per group) underwent L4-L5 posterolateral spinal fusion with bilateral placement of collagen scaffolds soaked with rhBMP-2. The rats were treated with vehicle alone or 0.5 or 2.5 mg/kg WIN55 by way of daily intraperitoneal injections for 5 days. Radiography, manual palpation-based fusion scoring, microCT, and histology were used for assessment. No significant differences among the groups in the mean fusion score, fusion rate, and new bone volume were demonstrated.
These findings are intriguing, and such research helps set the stage for carefully designed in vivo research projects, eventually moving toward randomized controlled trials, before recommending widespread use of cannabinoids for post-surgical pain management.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Not All Modes in Multimodal Pain Management are Effective
The public health crisis attributed to opioids has placed increasing emphasis on other approaches to pain management, both pharmacologic and nonpharmacologic. Although some people find the term “multimodal pain management” to be ambiguous when used in clinical research or patient care, it emphasizes the need for a broader (and multidisciplinary) approach to pain management.
On the pharmacologic side, pregabalin has been found to be a variably effective adjunctive analgesic in research involving joint arthroplasty. However, its use in adolescents and children has not been adequately explored. In the February 5, 2020 issue of The Journal, Helenius et al. investigate the impact of pregabalin on total opioid consumption and pain scores in a randomized, placebo-controlled trial of 63 adolescents undergoing posterior instrumented spinal-fusion procedures. These operations are quite invasive and often result in ICU admission because of the amount of narcotics required. In this study, induction and maintenance of anesthesia and mobilization protocols were standardized for patients in both the pregabalin and placebo groups, and the authors precisely measured opioid consumption during the first 48 hours after surgery with data from patient-controlled anesthesia systems.
According to the findings from this adequately powered trial, adjunctive pregabalin did not have a positive impact on opioid consumption or postoperative pain scores. Despite these negative findings, it is my hope that this drug and others being investigated as adjunctive “modes” in multimodal pain management will be subjected to similarly designed trials, so we can accurately determine which agents work best in limiting opioid utilization.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
What’s New in Foot and Ankle Surgery 2019
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected the five most clinically compelling findings from among the 60 noteworthy studies summarized in the May 15, 2019 “What’s New in Foot and Ankle Surgery.”
Syndesmotic Injury
–In a Level-II prospective cohort study, 48 patients were reviewed 12 months after transsyndesmotic stabilization with 1 or 2 quadricortically positioned screws.1 Although malreduction of >3 mm or 15° rotation was observed in 30% of the patients, outcome scores were equivalent compared with patients in the anatomically reduced group. Age, obesity, fracture pattern, and screw configuration had no effect on functional outcomes.
Total Ankle Replacement
–A Level-II prospective cohort study compared outcomes of older-generation and newer-generation total ankle replacements (n = 170) with ankle arthrodesis (n = 103). At the 3-year follow-up, both replacement and fusion resulted in improved function and reduced pain, and a pooled comparison of all outcome scores revealed no difference between the 2 procedures. However, subset analyses showed that patients who received newer-generation implants had significantly better outcomes than those who underwent arthrodesis.
Pain Management
–A prospective study analyzing opioid utilization among 988 patients following an outpatient foot and ankle surgical procedure found that only 50% of prescribed opioids were utilized.2 Risk factors for increased opioid consumption included continuous infusion catheter or regional-block anesthesia, age <60 years, high preoperative pain levels, and surgery involving the ankle or hindfoot.
Hallux Rigidus
–Authors of a prospective multicenter series followed 80 patients who underwent a first metatarsophalangeal joint arthroplasty with a 3-component, unconstrained, cementless implant.3 They reported significant improvement in AOFAS Ankle-Hindfoot Scale scores and range of motion at a median follow-up of 11.5 years, with 91.5% implant survival at 15 years. Two patients had periprosthetic cysts on the metatarsal side and 13 patients had phalangeal cysts, but the presence of cysts did not influence clinical results. Multivariate analysis showed a correlation between reduced AOFAS scores and arthrosis of the metatarsosesamoid junction, prompting the authors to suggest that the sesamoid should be enucleated in the presence of substantial arthrosis, fracture, or chondromalacia.
Clubfoot
–Deformity recurrence following Ponseti casting is often treated surgically. However, a comparative cohort study of 35 patients found that repeat casting and bracing for recurrent clubfoot resulted in acceptable 7-year outcomes in 26 (74%) of the patients. The authors suggest that in many children repeat casting should be the first-line intervention in relapsed deformity.
References
- Cherney SM, Cosgrove CT, Spraggs-Hughes AG, McAndrew CM, Ricci WM, Gardner MJ. Functional outcomes of syndesmotic injuries based on objective reduction accuracy at a minimum 1-year follow-up. J Orthop Trauma.2018 Jan;32(1):43-51.
- Saini S, McDonald EL, Shakked R, Nicholson K, Rogero R, Chapter M, Winters BS, Pedowitz DI,Raikin SM, Daniel JN. Prospective evaluation of utilization patterns and prescribing guidelines of opioid consumption following orthopedic foot and ankle surgery. Foot Ankle Int.2018 Nov;39(11):1257-65. Epub 2018 Aug 19.
- Kofoed H, Danborg L, Grindsted J, Merser S. The Rotoglide™ total replacement of the first metatarso-phalangeal joint. A prospective series with 7-15 years clinico-radiological follow-up with survival analysis. Foot Ankle Surg.2017 Sep;23(3):148-52.
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.
Adductor Canal Block Compared with Periarticular Bupivacaine Injection for Total Knee Arthroplasty
In the last decade, the widespread use of regional anesthesia in total knee arthroplasty has led to improvements in pain control, more rapid functional recovery, and reductions in the length of the hospital stay. #JBJS #JBJSInfoGraphics #visualabsrtact
Full article: https://bit.ly/2zrZvJW
JBJS Webinar: Managing Knee-Arthritis Pain Before and After Surgery
Early on, patients with knee osteoarthritis (OA) often get sufficient pain relief with nonsteroidal anti-inflammatory drugs. But as the condition progresses, many opt for knee replacement. Although knee replacement shows remarkable long-term results, immediate postsurgical pain management is a crucial consideration for orthopaedists and patients.
On Tuesday, December 13, 2016 at 12:30 PM EST, The Journal of Bone & Joint Surgery (JBJS) and PAIN, the official journal of the International Association for the Study of Pain, will host a complimentary webinar focused on relieving pain before and after surgery for knee arthritis.
- Sachiyuki Tsukada, MD, coauthor of a study in JBJS, will compare pain relief and side effects from intraoperative periarticular injections versus postoperative epidural analgesia after unilateral knee replacement.
- PAIN author Lars Arendt-Nielsen, Dr.Med.Sci, will delve into findings from a study examining biomarker and clinical outcomes associated with the COX-2 inhibitor etoricoxib in patients with knee OA.
Moderated by JBJS Associate Editor Nitin Jain, MD, the webinar will include an additional perspective from musculoskeletal pain-management expert Michael Taunton, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all three panelists.
Seats are limited, so register now!
AAOS Issues Statement on Opioids in Orthopaedics
The current prescription-opioid/heroin epidemic in the US has been much publicized of late. According to a recent AAOS information statement, the nearly 100-percent increase in the number of narcotic pain-medication prescriptions between 2008 and 2011 corresponds to an increase in opioid diversion to nonmedical users as well as a resurgence in heroin use.
Among the strategies the AAOS statement calls for to stem the tide of opioid abuse and manage patient pain more safely and effectively are the following:
- Opioid-prescription policies at the practice level that
- set ranges for acceptable amounts and durations of opioids for various musculoskeletal conditions,
- limit opioid prescription sizes to only the amount of medication expected to be used,
- strictly limit prescriptions for extended-release opioids, and
- restrict opioid prescriptions for nonsurgical patients with chronic degenerative conditions.
- Tools (such as the opioid risk tool at MDCalc) that identify patients at risk for greater opioid use.
- Empathic communication with patients, who “use fewer opiates when they know their doctor cares about them as individuals,” according to the statement.
- An interstate tracking system that would allow surgeons and pharmacists to see all prescriptions filled in all states by a single patient.
- CME standards that require periodic physician CME on opioid safety and optimal pain management strategies.
Noting that stress, depression, and ineffective coping strategies tend to intensify a person’s experience of pain, the statement concludes that “peace of mind is the strongest pain reliever.”
JBJS Editor’s Choice—Patient Pain: A Hurdle for All Orthopaedists
Ev
ery clinician treating musculoskeletal injury or disease knows that pain perception among patients is highly subjective and variable. Given the same objective magnitude of a pain stimulus, one person will grade it a 2 on the visual analog scale (VAS), while another will rate it an 8. I am sure that every dentist experiences similar patient variability! What is behind this, and what can we do with our decision making related to pain management to ensure compassionate and effective orthopaedic care?
We know that cultural and social factors play a role in pain perception, as do smoking and opiate-abuse history. Now, in a prognostic study in the August 5, 2015 edition of The Journal of Bone & Joint Surgery, Ernat et al. identify an association between pharmacologic treatment for anxiety and depression and poor outcomes, including higher postoperative pain scores, following primary surgery for femoroacetabular impingement (FAI) among members of the US military. The between-group difference in pain scores was significant only for antidepressant use, but 33 of the 37 patients in the study who took mental-health medications were on antidepressants.
I wonder whether the anxiety and depressive response to situational or relational stimuli that prompt an individual to seek mental-health treatment may be closely related to the same person’s response to painful musculoskeletal stimuli. Alternatively, incompletely treated anxiety or depression may influence a patient’s pain response to surgical treatment of FAI.
Either way, we need more research in this area so we can better manage our patients. An interesting study by Kane et al. that tested various approaches to standardizing patient pain reports showed how difficult normalizing pain scores is, but we still need to encourage further research into responses to painful stimuli, whether they be psychological or physical.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Did you know that JBJS is an accredited CME provider?
For over 125 years, the Journal of Bone & Joint Surgery (JBJS) has been the premier journal for orthopaedic surgeons. Today, our publication portfolio has grown to 4 peer-reviewed, evidence-based journals. Two of these journals offer continuing medication education (CME) for orthopaedic generalists, specialists and allied health personnel. The development of the CME activities is overseen by a committee consisting of editors from The Journal and JBJS Reviews.
The JBJS CME program is designed to enhance the knowledge, competence and performance of orthopaedic surgeons worldwide, and to improve musculoskeletal health for their patients. Our CME program addresses a range of clinical topics including: adult hip and knee reconstruction, foot and ankle surgery, spine surgery, shoulder and elbow surgery, pain management, sports medicine, pediatrics, and trauma. After successful completion of the period of Provisional Accreditation, JBJS received full accreditation for our CME program in March of 2015.
The Journal of Bone and Joint Surgery, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The Journal of Bone & Joint Surgery offers two CME activities: The Quarterly CME Activity and the Subspecialty CME Activity. Each of these CME activities is an interactive educational experience of examination questions based on articles published in the Journal of Bone & Joint Surgery. The Quarterly CME Activity contains 50 questions and is also designated for a maximum of 10 AMA PRA Category 1 Credits™. The Subspecialty CME activity contains 10 questions and is designated for a maximum of 5 AMA PRA Category 1 Credits™.
The Quarterly CME activity is approved by the American Board of Orthopaedic Surgery (ABOS) as a Self-Assessment Examination (SAE) that qualifies for SAE CME under the Board’s Maintenance of Certification (MOC) Program. Each Quarterly activity grants 5 SAE credits and must be submitted in pairs for maintenance of certification
JBJS Reviews, our newest journal, offers a journal-based CME activity with each article. Each article contains 5 CME assessment questions that can be completed and submitted after reading the article for 1 AMA PRA Category 1 Credit™.
JBJS is committed to providing timely, relevant CME to orthopaedic surgeons and allied health providers worldwide, promoting effective decision-making and clinical practice based on the gold-standard of peer-reviewed, scientific information contained within our publications.
You can access JBJS CME activities by visiting the JBJS Orthopaedic Education Center.
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