Factors associated with perioperative opioid demand in lower extremity fractures: Does consumption vary by anatomic location?

INTRODUCTION

Perioperative opioid pain management protocols should reflect anticipated patient need. Fracture location and external fixation may be related to post-operative pain. The purpose of this study is to evaluate the impact of fracture location, articular injury, and pre-operative external fixation, and articular injury on perioperative opioid demand following definitive fixation.

METHODS

1-month pre-operative to 1-year post-discharge opioid demand in oxycodone 5-mg equivalents in 23,441 patients undergoing fracture fixation of the femoral shaft through ankle between 2007 and 2017 was evaluated using a national database. Opioid demand was compiled over several timeframes: 1-month pre-op to 90-days post-discharge, 3 months post-discharge to 1-year post-discharge, and 1-month pre-op to 1-year post-discharge. Multivariable main effects linear and logistic regression models were constructed to evaluate the increased opioids filled, increased opioid prescriptions, and odds of refills in these timeframes with adjustment for fracture location, external fixator placement, and baseline patient and injury characteristics.

RESULTS

Lower extremity anatomic location and pre-operative external fixation were significantly associated with increased 1-month pre-op to 1-year post-discharge opioid filling (17.6-54.7 additional oxycodone 5-mg equivalents, all p<0.05) and number of filled prescriptions (0.28-0.54 additional prescriptions, all p<0.05). Pilon fractures and pre-operative external fixation, specifically, were associated with increased odds of two or more opioid prescriptions within the 1-month pre-op to 1-year post-discharge time frame (1.25-1.32 odds ratio, all p<0.05).

DISCUSSION

Fracture location and pre-operative external fixator placement predicted perioperative opioid demand. Articular zone (pilon, plateau, and distal femur) fracture fixation was associated with the largest increases in opioid demand after lower extremity fracture fixation. Patients with these injuries may be at highest risk of extensive opioid consumption.