Savannah R. Smith

Impact of Preoperative Opioid Use on Total Knee Arthroplasty Outcomes

Background: There is growing concern about the use of opioids prior to total knee arthroplasty (TKA), and research has suggested that preoperative opioid use may lead to worse pain outcomes following surgery. We evaluated the pain relief achieved by TKA in patients who had and those who had not used opioids use before the procedure. Methods: We augmented data from a prospective cohort study of TKA outcomes with opioid-use data abstracted from medical records. We collected patient-reported outcomes and demographic data before and 6 months after TKA. We used the Pain Catastrophizing Scale and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to quantify the pain experiences of patients treated with TKA who had had a baseline score of ≥20 on the WOMAC pain scale (a 0 to 100-point scale, with 100 being the worst score), who provided follow-up data, and who had not had another surgical procedure within the 2 years prior to TKA. We built a propensity score for preoperative opioid use based on the Pain Catastrophizing Scale score, comorbidities, and baseline pain. We used a general linear model, adjusting for the propensity score and baseline pain, to compare the change in the WOMAC pain score 6 months after TKA between persons who had and those who had not used opioids before TKA. Results: The cohort included 156 patients with a mean age of 65.7 years (standard deviation [SD] = 8.2 years) and a mean body mass index (BMI) of 31.1 kg/m2 (SD = 6.1 kg/m2); 62.2% were female. Preoperatively, 36 patients (23%) had had at least 1 opioid prescription. The mean baseline WOMAC pain score was 43.0 points (SD = 12.8) for the group that had not used opioids before TKA and 46.9 points (SD = 15.7) for those who had used opioids (p = 0.12). The mean preoperative Pain Catastrophizing Scale score was greater among opioid users (15.5 compared with 10.7 points among non-users, p = 0.006). Adjusted analyses showed that the opioid group had a mean 6-month reduction in the WOMAC pain score of 27.0 points (95% confidence interval [CI] = 22.7 to 31.3) compared with 33.6 points (95% CI = 31.4 to 35.9) in the non-opioid group (p = 0.008). Conclusions: Patients who used opioids prior to TKA obtained less pain relief from the operation. Clinicians should consider limiting pre-TKA opioid prescriptions to optimize the benefits of TKA. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cost-effectiveness of nonsteroidal anti-inflammatory drugs and opioids in the treatment of knee osteoarthritis in older patients with multiple comorbidities

OBJECTIVE To evaluate long-term clinical and economic outcomes of naproxen, ibuprofen, celecoxib or tramadol for OA patients with cardiovascular disease (CVD) and diabetes. DESIGN We used the Osteoarthritis Policy Model to examine treatment with these analgesics after standard of care (SOC) - acetaminophen and corticosteroid injections - failed to control pain. NSAID regimens were evaluated with and without proton pump inhibitors (PPIs). We evaluated over-the-counter (OTC) regimens where available. Estimates of treatment efficacy (pain reduction, occurring in ∼57% of patients on all regimens) and toxicity (major cardiac or gastrointestinal toxicity or fractures, risk ranging from 1.09% with celecoxib to 5.62% with tramadol) were derived from published literature. Annual costs came from Red Book Online(®). Outcomes were discounted at 3%/year and included costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios (ICERs). Key input parameters were varied in sensitivity analyses. RESULTS Adding ibuprofen to SOC was cost saving, increasing QALYs by 0.07 while decreasing cost by

Projecting Lifetime Risk of Symptomatic Knee Osteoarthritis and Total Knee Replacement in Individuals Sustaining a Complete Anterior Cruciate Ligament Tear in Early Adulthood.

800. Incorporating OTC naproxen rather than ibuprofen added 0.01 QALYs and increased costs by

Cost‐effectiveness of tramadol and oxycodone in the treatment of knee osteoarthritis

300, resulting in an ICER of

The Value of History, Physical Examination, and Radiographic Findings in the Diagnosis of Symptomatic Meniscal Tear among Middle-Age Subjects with Knee Pain.

54,800/QALY. Using prescription naproxen with OTC PPIs led to an ICER of

Financial incentives and health coaching to improve physical activity following total knee replacement: a randomized controlled trial

76,700/QALY, while use of prescription naproxen with prescription PPIs resulted in an ICER of

Cost-effectiveness of generic celecoxib in knee osteoarthritis for average-risk patients: A model-based evaluation

252,300/QALY. Regimens including tramadol or celecoxib cost more but added fewer QALYs and thus were dominated by several of the naproxen-containing regimens. CONCLUSIONS In patients with multiple comorbidities, naproxen- and ibuprofen-containing regimens are more effective and cost-effective in managing OA pain than opioids, celecoxib or SOC.

Disparities in Total Knee Replacement: Population Losses in Quality-Adjusted Life-Years Due to Differential Offer, Acceptance, and Complication Rates for African Americans

To estimate the lifetime risk of knee osteoarthritis (OA) and total knee replacement (TKR) in persons sustaining anterior cruciate ligament (ACL) tear by age 25 years.

Comparative pain reduction of oral non-steroidal anti-inflammatory drugs and opioids for knee osteoarthritis: systematic analytic review

To evaluate the cost‐effectiveness of incorporating tramadol or oxycodone into knee osteoarthritis (OA) treatment.

Association of MRI findings and expert diagnosis of symptomatic meniscal tear among middle-aged and older adults with knee pain

To evaluate the utility of clinical history, radiographic findings, and physical examination findings in the diagnosis of symptomatic meniscal tear (SMT) in patients over age 45 years, in whom concomitant osteoarthritis is prevalent.