Opioid Use for Operative Foot and Ankle Fractures: A Systematic Review

Abstract

Category: Ankle; Trauma Introduction/Purpose: Patients treated operatively for foot and ankle fractures may be at higher risk of undertreated pain as well as overuse of opioid medications. We sought to synthesize the recent literature investigating use of opioids for analgesia following foot and ankle fracture surgery. To accomplish this, we aimed to determine the patterns of opioid use and prescription (e.g., quantity, duration, incidence of persistent use), risk or protective factors for persistent opioid use, and clinical outcomes (e.g., relief of pain, adverse events) associated with opioid use in this population. Methods: We followed PRISMA guidelines for our review. We systematically searched PubMed, Embase, Scopus, Cochrane, and Web of Science. We included studies published from 2010 to present that assessed patterns of opioid use, risk factors for increased opioid use, and outcomes associated with opioid use following foot/ankle fracture surgery. Two reviewers performed title/abstract screening and full-text review. The quality of included studies was evaluated using MINORS criteria. Results: In our review, 1713 articles were assessed and 18 were included (Figure 1). MINORS scores ranged from 13 to 18, indicating moderate study quality. Overall, there was wide variability in opioid use between and within studies. Rates of postoperative persistent opioid use ranged from 7-39%. Risk factors for increased opioid use included preoperative opioid exposure, mental health disorders, tobacco consumption, and certain injury patterns. Protective factors were spinal anesthesia, peripheral nerve block, and postoperative ketorolac. Opioid use was not associated with decreased pain or improved satisfaction. Opioid use was associated with increased rates of pain-related emergency department visits and readmission. Preoperative opioid use was associated with the greatest odds of increased postoperative use. Conclusion: There is a high incidence of persistent opioid use after foot and ankle fracture surgery. Opioid use was associated with negative health outcomes without decreasing pain levels or increasing patient satisfaction after foot/ankle fracture surgery. The wide variability of reported opioid use emphasizes the need for standardized guidelines for postoperative opioid use in this patient population, and our findings suggest that lower opioid prescription may be advisable.