SLR - August 2023 - Neelum Patel PGY2 DPM
Title: Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review.Reference: Badin D, Ortiz-Babilonia CD, Gupta A, Leland CR, Musharbash F, Parrish JM, Aiyer AA. Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review. Clin Orthop Relat Res. 2022 Nov 1;480(11):2187-2201. doi: 10.1097/CORR.0000000000002307. Epub 2022 Jul 12. PMID: 35901447.
Level of Evidence: Level 3
Reviewed By: Neelum Patel PGY2 DPM
Residency Program: Hoboken University Medical Center, Hoboken New Jersey
Podiatric Relevance: The article discusses patterns of opioid prescription including quantity and duration, patterns of persistent patient use, and clinical outcomes related to pain management and side effects specifically during the post operative period for ankle and pilon fractures. As rearfoot surgeons, it is important that practitioners adequately manage post operative pain while also being mindful of the addictive qualities of such strong medications.
Methods: The level 3 retrospective study was conducted by searching medical databases for original journal articles reporting on opioid use after ankle or pilon fracture surgery due to traumatic injury published 2010 or later. The outcome measures included only descriptive analyses of: prolonged postoperative opioid usage (3-6 months), pre operative opioid exposure, regional anesthetic usage, tourniquet usage, post operative emergency department visits, re-admission rates, and self-reported pain.
Results: Pre operative opioid exposure had the strongest association with prolonged postoperative opioid use as well as with a higher chance of post operative emergency room visits, re-admission to hospitals, and decreased patient satisfaction with pain control. Multiple studies have found that tourniquet usage is directly associated with increased opioid use. Multimodal approach to pain management including the usage of ketorolac, gabapentin, as well as general and regional nerve blocks decrease opioid consumption.
Conclusions: The prescription patterns of providers for opioids for post operative pain management vary as there is no standardization of prescription practices nor any clinical practice guidelines for foot and ankle surgery. Factors that can contribute to increase or decrease in prolonged opioid usage should be taken into consideration when prescribing narcotics. Surgeons should write only short term (less than one week) opioid prescriptions and employ a multimodal approach to post operative pain management such as limiting tourniquet time, regional blocks such as popliteal blocks, and having patients undergo general anesthesia during the case particularly for patients who have taken opiates in the past. Opioids are generally the most common form of pain management prescribed for foot and ankle surgery, however when prescribing the medication, care must be taken to limit the amount of medication written as well as having other pain management techniques employed. An avenue for further investigation to help decrease opioid prescriptions could be see how other forms of pain control such as coordinating NSAIDS with opioids or Tylenol impact pain management and other outcome measures.