Jørgensen C C, Petersen M, Kehlet H, Aasvang E K
The Lundbeck Centre for Fast-track Hip and Knee Arthroplasty, Rigshospitalet, Copenhagen, Denmark.
Section for Surgical Pathophysiology, 7621, Rigshospitalet, Copenhagen University, Denmark.
Eur J Pain. 2018 Apr 20. doi: 10.1002/ejp.1232.
Persistent or increased long-term opioid consumption has previously been described following total hip- (THA) and knee arthroplasty (TKA). However, detailed information on postoperative analgesic consumption trajectories and risk factors associated with continued need of analgesics in fast-track THA and TKA is sparse.
This is a descriptive multicentre study in primary unilateral fast-track THA or TKA with prospective data on patient characteristics and information on reimbursement entitled dispensed prescriptions of paracetamol, non-steroidal anti-inflammatory drugs, opioids, anticonvulsants and antidepressants 1 month preoperatively and 1 year postoperatively. Patients were stratified according to preoperative opioid use. Postoperative analgesic consumption trajectories were stratified as increased, decreased or no use compared to the preoperative period.
Of 8975 patients (4849 THA/4126 TKA), 33.9% had relevant reimbursed prescriptions 9-12 months postoperatively. Of 2136 (23.8%) patients with preoperative opioid use, 3.4% had unchanged opioid consumption at 9-12 months postoperatively. However, increased opioid consumption after 9-12 months occurred in 17.6 (TKA) and 10.2% (THA) compared to 9.9 and 6.3% in opioid-naive TKA and THA patients, respectively. Increased NSAID and paracetamol use was seen in 11.5 and 12.4% of all patients. Preoperative analgesic use (any), TKA, psychiatric disorder, tobacco abuse, cardiac disease and use of walking aids were associated with increased opioid consumption.
Continued and increased opioid and other analgesic use occur in a clinically significant proportion of fast-track TKA and THA patients 9-12 months postoperatively, suggesting treatment failure and need for early intervention. Preoperative risk assessment may allow identification of patients in risk of increased postoperative opioid consumption.
We found a considerable fraction of patients with continued or increased opioid consumption 9-12 months after fast-track THA and TKA. Increase in opioid consumption was more frequent in preoperative opioid users than opioid-naive patients, but a pattern of increased analgesic consumption was present across all analgesics. Our data demonstrate a need for increased focus on long-term analgesic strategies and postoperative follow-up after THA and TKA, especially in preoperative opioid users.
全髋关节置换术（THA）和全膝关节置换术（TKA）后长期阿片类药物持续或增加使用的情况此前已有描述。然而，关于快速康复THA和TKA术后镇痛药物使用轨迹以及与持续镇痛需求相关的危险因素的详细信息却很匮乏。
这是一项描述性多中心研究，纳入原发性单侧快速康复THA或TKA患者，前瞻性收集患者特征数据以及术前1个月和术后1年有关对乙酰氨基酚、非甾体抗炎药、阿片类药物、抗惊厥药和抗抑郁药的报销处方信息。患者根据术前阿片类药物使用情况进行分层。术后镇痛药物使用轨迹根据与术前相比增加、减少或未使用进行分层。
在8975例患者（4849例THA/4126例TKA）中，33.9%在术后9至12个月有相关报销处方。在2136例（23.8%）术前使用阿片类药物的患者中，3.4%在术后9至12个月阿片类药物使用量未变。然而，与未使用阿片类药物的TKA和THA患者分别为9.9%和6.3%相比，术后9至12个月阿片类药物使用量增加的在TKA患者中占17.6%，在THA患者中占10.2%。在所有患者中，11.5%和12.4%的患者非甾体抗炎药和对乙酰氨基酚使用量增加。术前使用镇痛药物（任何一种）、TKA、精神障碍、烟草滥用、心脏病和使用助行器与阿片类药物使用量增加相关。
在快速康复TKA和THA患者中，术后9至12个月有相当比例的患者持续且增加使用阿片类药物和其他镇痛药物，这表明治疗失败且需要早期干预。术前风险评估可能有助于识别术后阿片类药物使用量增加风险的患者。
我们发现快速康复THA和TKA术后9至12个月有相当一部分患者持续或增加使用阿片类药物。术前使用阿片类药物的患者比未使用阿片类药物的患者阿片类药物使用量增加更频繁，但所有镇痛药物均存在镇痛药物使用量增加的情况。我们的数据表明需要更加关注THA和TKA后的长期镇痛策略和术后随访，尤其是在术前使用阿片类药物的患者中。
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