The Ohio State University Wexner Medical Center, Columbus, Ohio.
Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
J Bone Joint Surg Am. 2019 Mar 6;101(5):384-391. doi: 10.2106/JBJS.18.00502.
Preoperative opioid use results in adverse outcomes and higher costs after elective surgery. However, duration thresholds for higher risk are not entirely known. Therefore, the purpose of our study was to determine the number and duration of preoperative opioid prescriptions in order to estimate the risk of postoperative adverse events after major joint replacement and lumbar fusion.
National insurance claims data (2007 to September 30, 2015) were used to identify primary total knee arthroplasties (TKAs), total hip arthroplasties (THAs), and 1 or 2-level posterior lumbar fusions (PLFs) performed for degenerative disease. The effect of preoperative opioid burden (naive, ≤3 months, >3 to 6 months, >6 months but stopped 3 months before surgery, and >6 months of continuous use) on the risks of various adverse outcomes was studied using Cox proportional hazards analysis with adjustment for demographic and clinical covariates.
A total of 58,082 patients stratified into 3 cohorts of 32,667 with TKA, 14,734 with THA, and 10,681 with 1 or 2-level PLF were included for this analysis. A duration of preoperative opioids of >3 months was associated with a higher risk of 90-day emergency department (ED) visits for all causes and readmission after TKA. Preoperative opioid prescription for >6 months was associated with a higher risk of all-cause and pain-related ED visits, wound dehiscence/infection, and hospital readmission within 90 days as well as revision surgery within 1 year after TKA, THA, and PLF. Stopping the opioid prescription 3 months preoperatively for chronic users resulted in a significant reduction in the risk of adverse outcomes, with the greatest impact seen after THA and PLF.
Patients with a preoperative opioid prescription for up to 3 months before a major arthroplasty or a 1 or 2-level lumbar fusion had a similar risk of adverse outcomes as opioid-naive patients. While >6 months of opioid use was associated with a higher risk of adverse outcomes, a 3-month prescription-free period before the surgery appeared to mitigate this risk for chronic users.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
择期手术后，术前使用阿片类药物会导致不良后果和更高的成本。然而，高风险的持续时间阈值尚不完全清楚。因此，我们研究的目的是确定术前阿片类药物处方的数量和持续时间，以估计主要关节置换和腰椎融合术后术后不良事件的风险。
使用国家保险索赔数据（2007 年至 2015 年 9 月 30 日）来确定因退行性疾病而行初次全膝关节置换术（TKA）、全髋关节置换术（THA）和 1 或 2 级后路腰椎融合术（PLF）。使用 Cox 比例风险分析，调整人口统计学和临床协变量，研究术前阿片类药物负担（无、≤3 个月、>3-6 个月、>6 个月但在手术前 3 个月停止使用、>6 个月连续使用）对各种不良结局风险的影响。
共纳入 58082 例患者，分为 3 组：32667 例 TKA、14734 例 THA 和 10681 例 1 或 2 级 PLF。术前阿片类药物使用时间超过 3 个月与所有原因的 90 天急诊就诊和 TKA 后再入院风险增加相关。术前阿片类药物处方超过 6 个月与所有原因和与疼痛相关的 ED 就诊、伤口裂开/感染以及 90 天内住院再入院以及 TKA、THA 和 PLF 后 1 年内翻修手术的风险增加相关。慢性使用者术前停止阿片类药物处方 3 个月可显著降低不良结局的风险，THA 和 PLF 术后影响最大。
在主要关节置换术或 1 或 2 级腰椎融合术前使用阿片类药物处方长达 3 个月的患者与阿片类药物无使用史的患者不良结局风险相似。虽然 >6 个月的阿片类药物使用与不良结局风险增加相关，但手术前 3 个月的无处方期似乎减轻了慢性使用者的这种风险。
治疗性 II 级。请参阅作者说明，以获取完整的证据水平描述。
