Hold the opioids if you do not want to experience revision surgery.
Opioid Use Increases Revision Surgery Risk?!
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Secondary
Maria C.S. Inacio, Ph.D, of the University of South Australia, Adelaide, and colleagues in a retrospective cohort study found that older patients who were still taking opioids 3 months after a total hip arthroplasty (THA) were more likely to need revision surgery at 1 year and 5 years than those who stopped opioid use within 90 days of their surgery.
Revision was more than twice as likely at 1 year and nearly twice as likely at 5 years in those patients who used 400 to 1, 119 mg of opioids (morphine equivalents) in the second 90-day period after undergoing THA
Inacio wrote in the journal BMC Musculoskeletal Disorders that in their cohort, 42% of patients who went on to be revised were being treated for pain with opioids at 1 year post-operatively. “In our study we also found the amount of opioid use, and not just whether opioids were being used, in the days 91-180, to be associated with a higher risk of revision.”
Inacio and colleagues evaluated 9, 943 THAs performed in Australian patients from 2001 to 2012. The mean age of the patients was 81.1 years. About 80% of the cohort had a diagnosis of primary coxarthrosis. Two percent had a revision within 1 year and 4.2% underwent revision within 5 years.
The amount of morphine equivalents used in the first 90 days after surgery was not associated with a higher risk of revision within 1 or 5 years. However, in the second 90-day period, after their THA, patients who used medium to high amounts of morphine equivalents had a significantly higher risk of revision at 1 year and again at 5 years than did patients not taking any opioids. During the same period, patients taking the highest amounts of morphine equivalents had 2 times the risk of 1-year revision and 2.11 times the risk of 5-year revision than those not taking opioids.
In the third 90-day postoperative period, they found no association between levels of morphine equivalents and revision.
According to the investigators, “The observation that patients with revision procedures always had higher opioid consumption than patients that did not go on to be revised, including in the preoperative period, offers a window of opportunity for surgeons to address opioid use and its possible postoperative impact pre-surgery, when more frequent contact and surgical counseling is occurring.”
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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