Preop Valium or Xanax Raises TKA Adverse Event Risk

New research shows that “Mother’s Little Helpers”—benzodiazepines, a type of tranquilizer better known as Valium or Xanax, among the most commonly prescribed medications in the United States—increase adverse event risk for total knee arthroplasty (TKA) patients.

A new study “Are Patients Taking Benzodiazepines at Increased Risk for Complications Following Primary Total Knee Arthroplasty” was published in the December 5, 2020 issue of The Journal of Arthroplasty.

Nicholas Hernandez, M.D. is an orthopedic surgeon at Brigham and Women’s Hospital and Harvard Medical School in Boston, Massachusette. A co-author on this work, he told OTW, “Benzodiazepine use appears to be increasing in the United States, and many patients that undergo elective total knee arthroplasty are taking benzodiazepines preoperatively.”

“Despite the increased use of benzodiazepines nationwide,” says Dr. Hernandez, “there is scant literature in the scientific community on whether preoperative benzodiazepine use leads to more complications following total knee arthroplasty.”

Using a national database, the researchers looked at individuals who underwent primary TKA from 2010 to 2019. Some patients did and some did not have a preop history of benzodiazepine use.

Benzos=Elevated Risk for Nearly Everything

“Patients with more than one preoperative benzodiazepine prescription had increased odds for revision, early resection, femur fracture fixation, and delirium following total knee arthroplasty. Interestingly, these same patients had decreased odds of undergoing manipulation under anesthesia for knee stiffness.”

If Combined With Opioids, Even Worse

“Benzodiazepines have known side effects, including the development of medication tolerance, withdrawal symptoms and interactions with other medications,” Dr. Hernandez told OTW. “An example of a dangerous drug interaction is the interaction between benzodiazepines and opioids.”

“Benzodiazepines and opioids in combination is common, and the combination promotes respiratory depression and raises mortality risk overall.”

“Much attention has been given to the current crisis of opioid misuse, overdose, opioid use disorder and prescribing protocols, rightfully so, and its adverse effects and complications, but less on benzodiazepine use. This present study considers the impact that preoperative and likely persistent benzodiazepine use has on the surgical outcomes of patients—an underreported condition that warrants more attention.”

“There is need for further research to aid healthcare providers in decision making. An interesting finding in this present study is the association between benzodiazepines and a decreased rate of manipulation under anesthesia (MUA). While this association is a favorable finding, it does not overshadow the adverse outcomes related to benzodiazepine use. Accordingly, future studies can assess the use of other muscle relaxants with less adverse effects in the prevention of knee stiffness and MUA.”

“For patients and clinical providers, this study showed that preoperative use of benzodiazepines may be associated with adverse events following total knee arthroplasty. This study equips healthcare providers with data to counsel benzodiazepine users about the adverse outcomes that may be associated with their TKA. This study encourages providers to pause and prescribe thoughtfully, evaluate for drug interactions, and emboldens surgeons and healthcare teams to optimize patients before surgery, with counseling and support to safely wean down or off these medications as much as possible.”