Opioids in primary total joint arthroplasty: Interpretation of 2020 AAHKS/ASRA/AAOS/THS/TKS clinical practice guidelines_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Shuai ^1,2,3 , KONG Xiangpeng ^2,3 ^△ ,  CHAI Wei ^2,3

1. Medical School of Chinese PLA, Beijing, 100853, P.R.China;
2. Senior Department of Orthopedics, the Forth Medical Center of Chinese PLA General Hospital, Beijing, 100048, P.R.China;
3. National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, P.R.China;

Corresponding author：

CHAI Wei, Email: chaiwei301@163.com

Keywords：

Opioids; total joint arthroplasty; multimodal analgesia

DOI：

10.7507/1002-1892.202103090

Video：

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In 2020, the American Association of Hip and Knee Surgeons (AAHKS), the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Orthopaedic Surgeons (AAOS), the American Hip Society (THS), the American Knee Society (TKS) have worked together to develop clinical practice guidelines on the use of Opioids in primary total joint arthroplasty (TJA). This clinical practice guideline formulates recommendations for common and important questions related to the efficacy and safety of Opioids in primary TJA. This article interprets the guideline to help doctors make clinical decisions.

Citation： ZHANG Shuai, KONG Xiangpeng, CHAI Wei. Opioids in primary total joint arthroplasty: Interpretation of 2020 AAHKS/ASRA/AAOS/THS/TKS clinical practice guidelines. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(11): 1396-1402. doi: 10.7507/1002-1892.202103090 Copy

1.	Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg (Am), 2007, 89(4): 780-785.
2.	Halawi MJ, Grant SA, Bolognesi MP. Multimodal analgesia for total joint arthroplasty. Orthopedics, 2015, 38(7): e616-625.
3.	Parvizi J, Miller AG, Gandhi K. Multimodal pain management after total joint arthroplasty. J Bone Joint Surg (Am), 2011, 93(11): 1075-1084.
4.	Tali M, Maaroos J. Lower limbs function and pain relationships after unilateral total knee arthroplasty. Int J Rehabil Res, 2010, 33(3): 264-267.
5.	Menendez ME, Ring D, Bateman BT. Preoperative opioid misuse is associated with increased morbidity and mortality after elective orthopaedic surgery. Clin Orthop Relat Res, 2015, 473(7): 2402-2412.
6.	Wyles CC, Hevesi M, Trousdale ER, et al. The 2018 Chitranjan S. Ranawat, MD Award: Developing and implementing a novel institutional guideline strategy reduced postoperative opioid prescribing after TKA and THA. Clin Orthop Relat Res, 2019, 477(1): 104-113.
7.	Moucha CS, Weiser MC, Levin EJ. Current strategies in anesthesia and analgesia for total knee arthroplasty. J Am Acad Orthop Surg, 2016, 24(2): 60-73.
8.	Sah AP, Liang K, Sclafani JA. Optimal multimodal analgesia treatment recommendations for total joint arthroplasty: A critical analysis review. JBJS Rev, 2018, 6(6): e7. doi: 10.2106/JBJS.RVW.17.00137.
9.	Hannon CP, Keating TC, Lange JK, et al. Anesthesia and analgesia practices in total joint arthroplasty: A survey of the American association of hip and knee surgeons membership. J Arthroplasty, 2019, 34(12): 2872-2877.
10.	Hannon CP, Fillingham YA, Nam D, et al. Opioids in total joint arthroplasty: The clinical practice guidelines of the American Association of Hip and Knee Surgeons, American society of regional anesthesia and pain medicine, American academy of orthopaedic surgeons, hip society, and knee society. J Arthroplasty, 2020, 35(10): 2709-2714.
11.	Hannon CP, Fillingham YA, Nam D, et al. The efficacy and safety of opioids in total joint arthroplasty: Systematic review and direct meta-analysis. J Arthroplasty, 2020, 35(10): 2759-2771.e13.
12.	Aasvang EK, Lunn TH, Hansen TB, et al. Chronic pre-operative opioid use and acute pain after fast-track total knee arthroplasty. Acta Anaesthesiol Scand, 2016, 60(4): 529-536.
13.	Hansen CA, Inacio MCS, Pratt NL, et al. Chronic use of opioids before and after total knee arthroplasty: A retrospective cohort study. J Arthroplasty, 2017, 32(3): 811-817.
14.	Inacio MC, Hansen C, Pratt NL, et al. Risk factors for persistent and new chronic opioid use in patients undergoing total hip arthroplasty: a retrospective cohort study. BMJ Open, 2016, 6(4): e010664. doi: 10.1136/bmjopen-2015-010664.
15.	Sing DC, Barry JJ, Cheah JW, et al. Long-acting opioid use independently predicts perioperative complication in total joint arthroplasty. J Arthroplasty, 2016, 31(9Suppl): 170-174.
16.	Hernandez NM, Parry JA, Taunton MJ. Patients at risk: Large opioid prescriptions after total knee arthroplasty. J Arthroplasty, 2017, 32(8): 2395-2398.
17.	Pivec R, Issa K, Naziri Q, et al. Opioid use prior to total hip arthroplasty leads to worse clinical outcomes. Int Orthop, 2014, 38(6): 1159-1165.
18.	Zywiel MG, Stroh DA, Lee SY, et al. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg (Am), 2011, 93(21): 1988-1993.
19.	Hansen LE, Stone GL, Matson CA, et al. Total joint arthroplasty in patients taking methadone or buprenorphine/naloxone preoperatively for prior heroin addiction: A prospective matched cohort study. J Arthroplasty, 2016, 31(8): 1698-1701.
20.	Manalo JPM, Castillo T, Hennessy D, et al. Preoperative opioid medication use negatively affect health related quality of life after total knee arthroplasty. Knee, 2018, 25(5): 946-951.
21.	Nguyen LC, Sing DC, Bozic KJ. Preoperative reduction of opioid use before total joint arthroplasty. J Arthroplasty, 2016, 31(9Suppl): 282-287.
22.	Hadlandsmyth K, Vander Weg MW, McCoy KD, et al. Risk for prolonged opioid use following total knee arthroplasty in veterans. J Arthroplasty, 2018, 33(1): 119-123.
23.	Politzer CS, Kildow BJ, Goltz DE, et al. Trends in opioid utilization before and after total knee arthroplasty. J Arthroplasty, 2018, 33(7S): S147-S153.
24.	Rubenstein W, Grace T, Croci R, et al. The interaction of depression and prior opioid use on pain and opioid requirements after total joint arthroplasty. Arthroplast Today, 2018, 4(4): 464-469.
25.	Smith SR, Bido J, Collins JE, et al. Impact of preoperative opioid use on total knee arthroplasty outcomes. J Bone Joint Surg (Am), 2017, 99(10): 803-808.
26.	Abrisham SM, Ghahramani R, Heiranizadeh N, et al. Reduced morphine consumption and pain severity with transdermal fentanyl patches following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2014, 22(7): 1580-1584.
27.	Hendolin H, Nuutinen L, Kokki H, et al. Does morphine premedication influence the pain and consumption of postoperative analgesics after total knee arthroplasty? Acta Anaesthesiol Scand, 1996, 40(1): 81-85.
28.	Minville V, Lubrano V, Bounes V, et al. Postoperative analgesia after total hip arthroplasty: patient-controlled analgesia versus transdermal fentanyl patch. J Clin Anesth, 2008, 20(4): 280-283.
29.	Sathitkarnmanee T, Tribuddharat S, Noiphitak K, et al. Transdermal fentanyl patch for postoperative analgesia in total knee arthroplasty: a randomized double-blind controlled trial. J Pain Res, 2014, 7: 449-454.
30.	Reiter A, Zulus E, Hartmann T, et al. Preoperative oral administration of fast-release morphine sulfate reduces postoperative piritramide consumption. Wien Klin Wochenschr, 2003, 115(12): 417-420.
31.	Kiliçkan L, Toker K. The effects of preemptive intravenous versus preemptive epidural morphine on postoperative analgesia and surgical stress response after orthopaedic procedures. Minerva Anestesiol, 2000, 66(9): 649-655.
32.	中华医学会骨科学分会关节外科学组. 骨关节炎诊疗指南 (2018年版). 中华骨科杂志, 2018, 38(12): 705-715.
33.	Pico L, Hernot S, Nègre I, et al. Peroperative titration of morphine improves immediate postoperative analgesia after total hip arthroplasty. Can J Anaesth, 2000, 47(4): 309-314.
34.	Smith TW, Binning AR, Dahan A. Efficacy and safety of morphine-6-glucuronide (M6G) for postoperative pain relief: a randomized, double-blind study. Eur J Pain, 2009, 13(3): 293-299.
35.	陶坤明, 袁红斌. 阿片类药物的围术期应用: 当前的关注和争议. 上海医学, 2020, 43(2): 89-93.
36.	Dahl V, Raeder JC, Drøsdal S, et al. Prophylactic oral ibuprofen or ibuprofen-codeine versus placebo for postoperative pain after primary hip arthroplasty. Acta Anaesthesiol Scand, 1995, 39(3): 323-326.
37.	Joppich R, Richards P, Kelen R, et al. Analgesic efficacy and tolerability of intravenous morphine versus combined intravenous morphine and oxycodone in a 2-center, randomized, double-blind, pilot trial of patients with moderate to severe pain after total hip replacement. Clin Ther, 2012, 34(8): 1751-1760.
38.	Manoir BD, Bourget P, Langlois M, et al. Evaluation of the pharmacokinetic profile and analgesic efficacy of oral morphine after total hip arthroplasty. Eur J Anaesthesiol, 2006, 23(9): 748-754.
39.	Jove M, Griffin DW, Minkowitz HS, et al. Sufentanil sublingual tablet system for the management of postoperative pain after knee or hip arthroplasty: A randomized, placebo-controlled study. Anesthesiology, 2015, 123(2): 434-443.
40.	Musclow SL, Bowers T, Vo H, et al. Long-acting morphine following hip or knee replacement: a randomized, double-blind, placebo-controlled trial. Pain Res Manag, 2012, 17(2): 83-88.
41.	Ahdieh H, Ma T, Babul N, et al. Efficacy of oxymorphone extended release in postsurgical pain: a randomized clinical trial in knee arthroplasty. J Clin Pharmacol, 2004, 44(7): 767-776.
42.	McCormack JP, Warriner CB, Levine M, et al. A comparison of regularly dosed oral morphine and on-demand intramuscular morphine in the treatment of postsurgical pain. Can J Anaesth, 1993, 40(9): 819-824.
43.	Ashburn MA, Lind GH, Gillie MH, et al. Oral transmucosal fentanyl citrate (OTFC) for the treatment of postoperative pain. Anesth Analg, 1993, 76(2): 377-381.
44.	Matsumoto S, Matsumoto K, Iida H. Transdermal fentanyl patch improves post-operative pain relief and promotes early functional recovery in patients undergoing primary total knee arthroplasty: a prospective, randomised, controlled trial. Arch Orthop Trauma Surg, 2015, 135(9): 1291-1297.
45.	Hannon CP, Calkins TE, Li J, et al. The James A. Rand young investigator’s award:Large opioid prescriptions are unnecessary after total joint arthroplasty: A randomized controlled trial. J Arthroplasty, 2019, 34(7S): S4-S10.
46.	Stiller CO, Lundblad H, Weidenhielm L, et al. The addition of tramadol to morphine via patient-controlled analgesia does not lead to better post-operative pain relief after total knee arthroplasty. Acta Anaesthesiol Scand, 2007, 51(3): 322-330.
47.	Stubhaug A, Grimstad J, Breivik H. Lack of analgesic effect of 50 and 100 mg oral tramadol after orthopaedic surgery: a randomized, double-blind, placebo and standard active drug comparison. Pain, 1995, 62(1): 111-118.
48.	Pang WW, Mok MS, Lin CH, et al. Comparison of patient-controlled analgesia (PCA) with tramadol or morphine. Can J Anaesth, 1999, 46(11): 1030-1035.

1. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg (Am), 2007, 89(4): 780-785.
2. Halawi MJ, Grant SA, Bolognesi MP. Multimodal analgesia for total joint arthroplasty. Orthopedics, 2015, 38(7): e616-625.
3. Parvizi J, Miller AG, Gandhi K. Multimodal pain management after total joint arthroplasty. J Bone Joint Surg (Am), 2011, 93(11): 1075-1084.
4. Tali M, Maaroos J. Lower limbs function and pain relationships after unilateral total knee arthroplasty. Int J Rehabil Res, 2010, 33(3): 264-267.
5. Menendez ME, Ring D, Bateman BT. Preoperative opioid misuse is associated with increased morbidity and mortality after elective orthopaedic surgery. Clin Orthop Relat Res, 2015, 473(7): 2402-2412.
6. Wyles CC, Hevesi M, Trousdale ER, et al. The 2018 Chitranjan S. Ranawat, MD Award: Developing and implementing a novel institutional guideline strategy reduced postoperative opioid prescribing after TKA and THA. Clin Orthop Relat Res, 2019, 477(1): 104-113.
7. Moucha CS, Weiser MC, Levin EJ. Current strategies in anesthesia and analgesia for total knee arthroplasty. J Am Acad Orthop Surg, 2016, 24(2): 60-73.
8. Sah AP, Liang K, Sclafani JA. Optimal multimodal analgesia treatment recommendations for total joint arthroplasty: A critical analysis review. JBJS Rev, 2018, 6(6): e7. doi: 10.2106/JBJS.RVW.17.00137.
9. Hannon CP, Keating TC, Lange JK, et al. Anesthesia and analgesia practices in total joint arthroplasty: A survey of the American association of hip and knee surgeons membership. J Arthroplasty, 2019, 34(12): 2872-2877.
10. Hannon CP, Fillingham YA, Nam D, et al. Opioids in total joint arthroplasty: The clinical practice guidelines of the American Association of Hip and Knee Surgeons, American society of regional anesthesia and pain medicine, American academy of orthopaedic surgeons, hip society, and knee society. J Arthroplasty, 2020, 35(10): 2709-2714.
11. Hannon CP, Fillingham YA, Nam D, et al. The efficacy and safety of opioids in total joint arthroplasty: Systematic review and direct meta-analysis. J Arthroplasty, 2020, 35(10): 2759-2771.e13.
12. Aasvang EK, Lunn TH, Hansen TB, et al. Chronic pre-operative opioid use and acute pain after fast-track total knee arthroplasty. Acta Anaesthesiol Scand, 2016, 60(4): 529-536.
13. Hansen CA, Inacio MCS, Pratt NL, et al. Chronic use of opioids before and after total knee arthroplasty: A retrospective cohort study. J Arthroplasty, 2017, 32(3): 811-817.
14. Inacio MC, Hansen C, Pratt NL, et al. Risk factors for persistent and new chronic opioid use in patients undergoing total hip arthroplasty: a retrospective cohort study. BMJ Open, 2016, 6(4): e010664. doi: 10.1136/bmjopen-2015-010664.
15. Sing DC, Barry JJ, Cheah JW, et al. Long-acting opioid use independently predicts perioperative complication in total joint arthroplasty. J Arthroplasty, 2016, 31(9Suppl): 170-174.
16. Hernandez NM, Parry JA, Taunton MJ. Patients at risk: Large opioid prescriptions after total knee arthroplasty. J Arthroplasty, 2017, 32(8): 2395-2398.
17. Pivec R, Issa K, Naziri Q, et al. Opioid use prior to total hip arthroplasty leads to worse clinical outcomes. Int Orthop, 2014, 38(6): 1159-1165.
18. Zywiel MG, Stroh DA, Lee SY, et al. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg (Am), 2011, 93(21): 1988-1993.
19. Hansen LE, Stone GL, Matson CA, et al. Total joint arthroplasty in patients taking methadone or buprenorphine/naloxone preoperatively for prior heroin addiction: A prospective matched cohort study. J Arthroplasty, 2016, 31(8): 1698-1701.
20. Manalo JPM, Castillo T, Hennessy D, et al. Preoperative opioid medication use negatively affect health related quality of life after total knee arthroplasty. Knee, 2018, 25(5): 946-951.
21. Nguyen LC, Sing DC, Bozic KJ. Preoperative reduction of opioid use before total joint arthroplasty. J Arthroplasty, 2016, 31(9Suppl): 282-287.
22. Hadlandsmyth K, Vander Weg MW, McCoy KD, et al. Risk for prolonged opioid use following total knee arthroplasty in veterans. J Arthroplasty, 2018, 33(1): 119-123.
23. Politzer CS, Kildow BJ, Goltz DE, et al. Trends in opioid utilization before and after total knee arthroplasty. J Arthroplasty, 2018, 33(7S): S147-S153.
24. Rubenstein W, Grace T, Croci R, et al. The interaction of depression and prior opioid use on pain and opioid requirements after total joint arthroplasty. Arthroplast Today, 2018, 4(4): 464-469.
25. Smith SR, Bido J, Collins JE, et al. Impact of preoperative opioid use on total knee arthroplasty outcomes. J Bone Joint Surg (Am), 2017, 99(10): 803-808.
26. Abrisham SM, Ghahramani R, Heiranizadeh N, et al. Reduced morphine consumption and pain severity with transdermal fentanyl patches following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2014, 22(7): 1580-1584.
27. Hendolin H, Nuutinen L, Kokki H, et al. Does morphine premedication influence the pain and consumption of postoperative analgesics after total knee arthroplasty? Acta Anaesthesiol Scand, 1996, 40(1): 81-85.
28. Minville V, Lubrano V, Bounes V, et al. Postoperative analgesia after total hip arthroplasty: patient-controlled analgesia versus transdermal fentanyl patch. J Clin Anesth, 2008, 20(4): 280-283.
29. Sathitkarnmanee T, Tribuddharat S, Noiphitak K, et al. Transdermal fentanyl patch for postoperative analgesia in total knee arthroplasty: a randomized double-blind controlled trial. J Pain Res, 2014, 7: 449-454.
30. Reiter A, Zulus E, Hartmann T, et al. Preoperative oral administration of fast-release morphine sulfate reduces postoperative piritramide consumption. Wien Klin Wochenschr, 2003, 115(12): 417-420.
31. Kiliçkan L, Toker K. The effects of preemptive intravenous versus preemptive epidural morphine on postoperative analgesia and surgical stress response after orthopaedic procedures. Minerva Anestesiol, 2000, 66(9): 649-655.
32. 中华医学会骨科学分会关节外科学组. 骨关节炎诊疗指南 (2018年版). 中华骨科杂志, 2018, 38(12): 705-715.
33. Pico L, Hernot S, Nègre I, et al. Peroperative titration of morphine improves immediate postoperative analgesia after total hip arthroplasty. Can J Anaesth, 2000, 47(4): 309-314.
34. Smith TW, Binning AR, Dahan A. Efficacy and safety of morphine-6-glucuronide (M6G) for postoperative pain relief: a randomized, double-blind study. Eur J Pain, 2009, 13(3): 293-299.
35. 陶坤明, 袁红斌. 阿片类药物的围术期应用: 当前的关注和争议. 上海医学, 2020, 43(2): 89-93.
36. Dahl V, Raeder JC, Drøsdal S, et al. Prophylactic oral ibuprofen or ibuprofen-codeine versus placebo for postoperative pain after primary hip arthroplasty. Acta Anaesthesiol Scand, 1995, 39(3): 323-326.
37. Joppich R, Richards P, Kelen R, et al. Analgesic efficacy and tolerability of intravenous morphine versus combined intravenous morphine and oxycodone in a 2-center, randomized, double-blind, pilot trial of patients with moderate to severe pain after total hip replacement. Clin Ther, 2012, 34(8): 1751-1760.
38. Manoir BD, Bourget P, Langlois M, et al. Evaluation of the pharmacokinetic profile and analgesic efficacy of oral morphine after total hip arthroplasty. Eur J Anaesthesiol, 2006, 23(9): 748-754.
39. Jove M, Griffin DW, Minkowitz HS, et al. Sufentanil sublingual tablet system for the management of postoperative pain after knee or hip arthroplasty: A randomized, placebo-controlled study. Anesthesiology, 2015, 123(2): 434-443.
40. Musclow SL, Bowers T, Vo H, et al. Long-acting morphine following hip or knee replacement: a randomized, double-blind, placebo-controlled trial. Pain Res Manag, 2012, 17(2): 83-88.
41. Ahdieh H, Ma T, Babul N, et al. Efficacy of oxymorphone extended release in postsurgical pain: a randomized clinical trial in knee arthroplasty. J Clin Pharmacol, 2004, 44(7): 767-776.
42. McCormack JP, Warriner CB, Levine M, et al. A comparison of regularly dosed oral morphine and on-demand intramuscular morphine in the treatment of postsurgical pain. Can J Anaesth, 1993, 40(9): 819-824.
43. Ashburn MA, Lind GH, Gillie MH, et al. Oral transmucosal fentanyl citrate (OTFC) for the treatment of postoperative pain. Anesth Analg, 1993, 76(2): 377-381.
44. Matsumoto S, Matsumoto K, Iida H. Transdermal fentanyl patch improves post-operative pain relief and promotes early functional recovery in patients undergoing primary total knee arthroplasty: a prospective, randomised, controlled trial. Arch Orthop Trauma Surg, 2015, 135(9): 1291-1297.
45. Hannon CP, Calkins TE, Li J, et al. The James A. Rand young investigator’s award:Large opioid prescriptions are unnecessary after total joint arthroplasty: A randomized controlled trial. J Arthroplasty, 2019, 34(7S): S4-S10.
46. Stiller CO, Lundblad H, Weidenhielm L, et al. The addition of tramadol to morphine via patient-controlled analgesia does not lead to better post-operative pain relief after total knee arthroplasty. Acta Anaesthesiol Scand, 2007, 51(3): 322-330.
47. Stubhaug A, Grimstad J, Breivik H. Lack of analgesic effect of 50 and 100 mg oral tramadol after orthopaedic surgery: a randomized, double-blind, placebo and standard active drug comparison. Pain, 1995, 62(1): 111-118.
48. Pang WW, Mok MS, Lin CH, et al. Comparison of patient-controlled analgesia (PCA) with tramadol or morphine. Can J Anaesth, 1999, 46(11): 1030-1035.

Chinese Journal of Reparative and Reconstructive Surgery

Opioids in primary total joint arthroplasty: Interpretation of 2020 AAHKS/ASRA/AAOS/THS/TKS clinical practice guidelines

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