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Older Age, Female Sex, Anxiety, Substance Use Disorder, Osteoarthritis, Tibial Tubercle Osteotomy, and Opioid Familiarity Are Risk Factors for Prolonged Opioid Use Following Medial Patellofemoral Ligament Reconstruction
Address correspondence to Austin V. Stone, M.D., Ph.D., Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, 2195 Harrodsburg Rd., Lexington, KY 40504.
To determine which preoperative factors are associated with prolonged opioid use after medial patellofemoral ligament reconstruction (MPFLR).
Methods
The M151Ortho PearlDiver database was queried for patients who underwent MPFLR between 2010 and 2020. Inclusion criteria included patients who underwent MPFLR using Current Procedural Terminology codes 27420, 27422, and 27427 and had a patellar instability diagnosis. Prolonged opioid use was defined as opioid use greater than 1 month after surgery. Postoperative opioid use from 1 month to 6 months was assessed. Multivariable logistic regression was used to evaluate the association between patient-related risk factors (age, sex, Charlson Comorbidity Index, anxiety, depression, substance use disorder, osteoarthritis, tibial tubercle osteotomy [TTO], and previous opioid use within 3 months to 1 week of surgery) with prolonged postoperative opioid use. Odds ratios (OR) and their associated 95% confidence intervals (CI) were calculated for each risk factor.
Results
A total of 23,249 patients were included. There was a higher proportion of female patients compared to male patients (67.8% vs 32.2%) in our cohort, as well as a large proportion of patients who had preoperative opioid use (23.9%). In total, 14.3% of patients had a concomitant TTO. Three months post-MPFLR, male patients were at a decreased risk of opioid usage (OR 0.75; CI 0.67-0.83; P ≤ .001). Older age (OR 1.01, CI 1.00-1.01; P ≤ .001), patients with pre-existing anxiety (OR 1.30, CI 1.15-1.47; P ≤ .001), substance use disorder (OR 2.04, CI 1.80-2.31; P ≤ .001), knee osteoarthritis (OR 1.70, CI 1.49-1.94; P ≤ .001), concomitant TTO (OR 1.91, CI 1.67-2.17; P ≤ .001), and opioid familiarity (OR 7.68, CI 6.93-8.52; P ≤ .001) were at a significantly increased risk of postoperative opioid usage.
Conclusions
Older age, female sex, anxiety, substance use disorder, osteoarthritis, tibial tubercle osteotomy, and opioid familiarity are risk factors for prolonged opioid use following MPFLR.
Level of Evidence
Level III, retrospective cohort study.
In the field of orthopaedic surgery, the use and prescription of opioids has been an important topic of discussion.
Older, heavier, arthritic, psychiatrically disordered, and opioid-familiar patients are at risk for opioid use after medial patellofemoral ligament reconstruction.
Older, heavier, arthritic, psychiatrically disordered, and opioid-familiar patients are at risk for opioid use after medial patellofemoral ligament reconstruction.
analyzed postoperative opioid use after common outpatient orthopaedic surgeries at a single institution, some of which being rotator cuff repair, anterior cruciate ligament reconstruction (ACLR), and Achilles tendon repair, finding that more than 11% of patients continued using opioids after 6 months.
Previous studies have investigated factors that lead to prolonged opioid use after multiple orthopaedic procedures, such as ACLR and total joint arthroplasty
to better understand which patients are at an increased risk. Our study uses a large database over multiple years to assess which risk factors influence prolonged opioid use (hydrocodone, oxycodone, morphine, and tramadol) following MPFLR.
The MPFL is a commonly injured ligament in the knee,
Prevalence and site of medial patellofemoral ligament injuries in patients with acute lateral patellar dislocations: A systematic review and meta-analysis.
In the general population, the incidence of lateral patellar dislocations ranges from 5.8 to 7 cases per 100,000 person-years to 29 cases per 100,000 person-years in those aged 10-17 years.
Prevalence and site of medial patellofemoral ligament injuries in patients with acute lateral patellar dislocations: A systematic review and meta-analysis.
With MPFLR being a common treatment option for patients with patellar instability, how to best achieve postoperative pain control is an important consideration for surgeons. Aside from the physical pain arising from MPFL injury, psychological factors may also influence pain perception. Corey et al.
found that patients who had lower baseline Veterans RAND 12-item Health Survey Mental Component Scores had higher baseline Knee Injury and Osteoarthritis Outcome Score Pain scores.
The purpose of this study was to determine which preoperative factors are associated with prolonged opioid use following MPFLR. We hypothesized that older age, previous opioid use, depression, anxiety, knee osteoarthritis (OA), concomitant tibial tubercle osteotomy (TTO), female sex, and substance use disorder would be associated with prolonged opioid use following MPFLR.
Methods
Database
Data were obtained from the M151Ortho PearlDiver database,
which contains records from more than 151 million distinct patients between 2010 and 2020. PearlDiver has both International Classification of Diseases (ICD) Ninth and Tenth Revision diagnosis codes, as well as Current Procedural Terminology (CPT) codes. All information in the database is deidentified. Inclusion criteria included patients who underwent MPFLR using CPT codes 27420, 27422, and 27427 and had a patellar instability diagnosis (Appendix Table 1, available at www.arthroscopyjournal.org). Patients who underwent a concomitant TTO were identified using the CPT codes 27418, 27455, 27457, and 27705.
Risk Factors
Prolonged opioid use was defined as using opioids for greater than 1-month postoperatively. Age, sex, Charlson Comorbidity Index, history of anxiety, depression, substance use disorder (alcohol, opioid, cannabis, sedatives, hypnotics, anxiolytics, cocaine, stimulants, hallucinogens, inhalants, psychoactive substances), knee OA, concomitant TTO, and previous opioid use within 3 months to 1 week of MPFLR was assessed. Patients with a previous diagnosis of depression, anxiety, substance use disorder, and knee OA were identified using the ICD codes in Appendix Table 2, Appendix Table 3, Appendix Table 4, Appendix Table 5, available at www.arthroscopyjournal.org, respectively.
Postoperative Opioid Prescriptions
Multiple formulations of hydrocodone, oxycodone, morphine, and tramadol were included in the queries. Patients who received a prescription of these medications within 6 months postoperatively were identified. Patients were stratified based on the timing of their prescriptions. The same opioid formulations were included in our query of preoperative opioid use. Patients with an opioid prescription within 3 months to 1 week before their surgery were identified and placed into the opioid-familiar group. All other patients in the population were placed into the opioid-naïve group.
Data Analysis
Demographic variables and comorbidities were tabulated and reported. Multivariable logistic regression was performed to independently analyze patient demographics and comorbid conditions. Odds ratios (ORs) and their associated 95% confidence intervals (CIs) were calculated for each risk factor, with P < .05 being considered statistically significant. R software (R Foundation for Statistical Computing, Vienna, Austria) that was embedded within PearlDiver was used for all statistical analysis.
Results
In total, 23,249 patients met inclusion criteria for analysis. There was a much higher proportion of female patients compared with male patients (67.8% vs. 32.2%), as well as a large proportion of patients who had preoperative opioid use (23.9%, of whom 68.8% were female and 31.2% were male). The majority of patients had a Charlson Comorbidity Index score of mild (93.2%), and 14.3% of patients had a concomitant TTO. Complete patient demographics are included in Table 1.
When stratifying patients by opioid familiarity, the percentage of patients who had opioid prescriptions within 3 months to 1 week of surgery substantially required more opioids compared with those who did not at all timepoints measured (Fig 1).
Fig 1Percentage of patients using opioids. Orange line represents the percentage of opioid familiar patients who continued using opioids up to 6 months postoperatively. Blue line represents the percentage of opioid naïve patients who continued using opioids up to 6 months postoperatively
On multivariable analysis, older age, female sex, anxiety, substance use disorder, knee OA, concomitant TTO, and preoperative opioid use were found to have statistically significant associations with prolonged opioid use following MPFLR (Table 2).
On stratified analysis, breaking down opioid-familiar and -naïve patients by sex, female patients were found to be at greater risk of prolonged postoperative opioid use regardless of opioid familiarity. For both opioid-familiar and opioid-naïve patients, ORs were greatest 2 months postoperatively (1.46 and 1.56, respectively) (Table 3). Similarly, opioid familiar patients were at higher risk of prolonged postoperative opioid use regardless of sex. For both male and female patients, ORs were highest 3 months postoperatively (10.84 and 9.25, respectively) (Table 4).
Our study found that multiple preoperative factors were associated with prolonged opioid use following MPFLR. Specifically, older age, patients who are female, have anxiety, substance use disorder, knee osteoarthritis, concomitant TTO, and opioid familiar appear to be at an increased risk according to our data. Interestingly, a preoperative diagnosis of depression was not associated with prolonged opioid use. Age was identified by our study as a significant quantitative predictor, with an estimated 1% to 2% increase in the odds of prolonged opioid use per additional year of age.
Previous studies have determined risk factors for prolonged opioid use after orthopaedic conditions. Castle et al
Older, heavier, arthritic, psychiatrically disordered, and opioid-familiar patients are at risk for opioid use after medial patellofemoral ligament reconstruction.
performed a retrospective review of 102 patients undergoing MPFLR at a single institution, finding that age >30 years and body mass index (BMI) >30, cartilage damage, preoperative opioid use, smoking history, and history of psychiatric disorders were associated with prolonged opioid use postoperatively. Baron et al
analyzed the Humana administrative claims database between 2007-2017 for patients undergoing patellofemoral stabilization surgery. From a sample of 1,316 patients, preoperative opioid use, obesity, and preexisting anxiety or depression were significant risk factors for prolonged opioid use postoperatively. Our study builds upon the literature by using the PearlDiver database from 2010 to 2020, sampling more than 23,000 patients. Three of the main findings in our study that differentiate it from the aforementioned 2 studies are treating age as a quantitative value, showing the increase in odds per year of increased age instead of grouping patients into categories of <30 years old and >30 years old. Also, we found that although preexisting anxiety was a significant risk factor for prolonged opioid use after MPFLR, depression was not. Finally, we found that patients who undergo a concomitant TTO are at an increased risk for prolonged opioid use following MPFLR. In a sample of 21,202 patients who underwent ACLR, 17.7% used ≥2 opioid prescriptions 0 to 90 days postoperatively, dropping to 2.7% between 91 and 360 days postoperatively. Risk factors for prolonged opioid use were preoperative opioid use, age ≥20 years, substance use, other activity at time of injury, chondroplasty, chronic pulmonary disease, and American Society of Anesthesiologists classification ≥3.
Our study showed similar results, where at 3 months, 26.8% of opioid familiar patients and 3.7% of opioid-naïve patients were using opioids.
Male patients had a decreased risk of prolonged opioid use following MPFLR compared with female patients. This has been seen in previous orthopaedic literature, as following both ACLR and total hip arthroplasty (THA), female patients were at an increased risk for prolonged opioid use.
There can be a multitude of factors as to why this is the case. Although there have not been many studies assessing sex differences in opioid use, Serdarevic et al
assessed 8,525 participants from a community outreach program based out of the University of Florida Clinical and Translational Science Institute, finding that women were more likely to report a lifetime use of use prescription opioids than men. Similarly, Back et al
interviewed 24 participants from their community (12 male and 12 female) who had prescription opioid dependence, finding that while men were significantly more likely to crush and snort prescription opioids (75% vs 17%), women were significantly more likely to use opioids to cope with interpersonal stress, and use them in the morning.
Although the physical stress of surgery is demanding, the psychological stresses than surround it can be as well. Harris et al
Are preoperative depression and anxiety associated with patient-reported outcomes, health care payments, and opioid use after anterior discectomy and fusion?.
found that a preoperative diagnosis of depression or anxiety resulted in greater odds of multiday hospitalization, 90-day readmission, revision surgery, and chronic postoperative opioid use following anterior cervical discectomy and fusion. Likewise, a randomized control trial performed by Kurkis et al
found that in patients undergoing THA, depression was correlated with increased opioid use and preoperative education on opioid use did not affect opioid use or disposal frequency 6 weeks postoperatively. In the sports medicine literature, patients with a history of depression report lower self-reported functional scores at baseline and 1-year postoperatively following ACLR.
assessed patients undergoing lower-extremity fracture fixation, finding that those with alcohol abuse had increased perioperative opioid demand. Cannabis use has variable results, where a study found no increase in opioid use following hip arthroscopy
Bowers NL, Hao KA, Trivedi S, et al. Self-reported cannabis use is not associated with greater opioid use in elective hand surgery patients [published online August 20, 2022]. Eur J Orthop Surg Traumatol. doi:10.1007/s00590-022-03321-z.
Our study builds upon these, as we combined multiple substance use disorders into one category, with findings indicating that there may be an increased risk for opioid use among these patients.
The biggest risk factor found in our study was opioid familiarity. It was found that 23.9% of patients were opioid familiar prior to their surgery. Patients with previous opioid use had a staggering 668% increase in the odds of prolonged use at 3 months. This leveled out and decreased slightly from 4 to 6 months. Similar results have been seen following other orthopaedic procedures. Kunkel et al
found a 5-fold and 4-fold increase in the percentage of patients with chronic opioid use following THA and total knee arthroplasty (TKA), respectively. Rogers et al
analyzed hip arthroscopy patients, finding that those who used opioids before the procedure needed more refills following the procedure. Also, patients with a formal opioid use disorder diagnosis had significantly greater risk for revision hip arthroscopy. Khazi et al
had similar findings, where preoperative opioid use was associated with prolonged opioid use following anatomic and reverse total shoulder arthroplasty. Our study is in line with this as preoperative opioid use was seen to be a large risk factor for prolonged opioid use following MPFL, adding to the established literature.
Overall, our study found multiple risk factors that have the potential to cause prolonged opioid use following MPFLR. Future prospective studies can be performed to determine the effect of these risk factors, allowing for the control of confounding variables. Specifically, a more detailed breakdown could be performed to determine which substance use disorders are associated with increased opioid use following MPFLR.
Limitations
This study was not without limitations. Since we used PearlDiver, the extracted data have the potential for coding errors. Also, preoperative opioid use may be due to other health issues, which can affect outcomes. We attempted to account for this by assessing the Charlson Comorbidity Index, and it was not associated with prolonged opioid use. In addition, we were not able to control for postoperative physical therapy. This may influence outcomes due to improved function leading to better pain control. We were unable to account for BMI due to the large number of pediatric patients in our sample. Pediatric BMI is measured in percentiles while adult BMI is not, which could lead to heterogeneity and inaccurate reporting. Patients were not able to be separated based on receiving/filling one prescription versus multiple pre- and postoperatively. Finally, we assumed that opioid prescriptions were indicative of opioid use, but we cannot determine if patients ingested the medications based on data available in PearlDiver.
Conclusions
Older age, female sex, anxiety, substance use disorder, osteoarthritis, tibial tubercle osteotomy, and opioid familiarity are risk factors for prolonged opioid use following MPFLR.
Older, heavier, arthritic, psychiatrically disordered, and opioid-familiar patients are at risk for opioid use after medial patellofemoral ligament reconstruction.
Prevalence and site of medial patellofemoral ligament injuries in patients with acute lateral patellar dislocations: A systematic review and meta-analysis.
Are preoperative depression and anxiety associated with patient-reported outcomes, health care payments, and opioid use after anterior discectomy and fusion?.
Bowers NL, Hao KA, Trivedi S, et al. Self-reported cannabis use is not associated with greater opioid use in elective hand surgery patients [published online August 20, 2022]. Eur J Orthop Surg Traumatol. doi:10.1007/s00590-022-03321-z.
The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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