Implementation and Evaluation of a Remote, Questionnaire-Based Model for Monitoring Patients Following Hip or Knee Replacement Surgery

This issue of TRANSFUSION features two clinical trials on the use of tranexamic acid (TXA) in joint replacement surgery. The first study examines the use of TXA for reducing autologous blood transfusion in total knee or hip replacement surgery.1 The second study reports the effect of TXA on allogeneic blood transfusion for two-staged bilateral total knee replacement surgery.2 The first study is a double-blinded randomized placebo controlled trial in which Oremus and colleagues1 compared TXA with placebo to evaluate the efficacy of TXA to reduce autologous transfusion of shed blood in unilateral primary total knee or hip replacement. Ninety-eight primary hip or primary knee replacement patients were randomly allocated to receive an intraoperative intravenous (IV) dose of 1 g of TXA or placebo 15 minutes before skin incision for total hip replacement or 15 minutes before tourniquet release for total knee replacement. After 3 hours, a second dose of 1 g of TXA or an equivalent volume of placebo (saline) was administered IV. The minimum volume of retransfusion was set at 250 mL and a transfusion trigger of hemoglobin (Hb) level of less than 8 or 8 to 10 g/dL with symptoms of anemia. Only 10.2% in the TXA group versus 85.7% in the placebo group received autologous transfusion. The TXA group had a 75% lower requirement for autologous transfusion than the placebo group. The median total external blood loss during the first 24 hours was 320 mL (80-930 mL) in the TXA group versus 970 mL (100-2600 mL) in the placebo group. This study also examined the safety profile of TXA by measuring hemodynamic changes during administration of TXA and performed postoperative screening for deep vein thrombosis (DVT). Clinical assessment for DVT was performed three times a day and ultrasonography, fibrinogen, and D-dimer measurements were performed in suspected cases. The authors did not find any difference in hemodynamic changes or DVT between both groups. In addition, there was no difference in blood loss between the total knee replacement and total hip replacement surgery. This study provides evidence that using TXA with a restrictive transfusion trigger policy can potentially replace the use of an autologous drain system. This protocol can avoid the autologous blood transfusion related complications such as febrile reactions and possible retrograde infection. The use of closed suction drainage for joint replacement surgery is controversial and there is practice variation in whether surgical drains are used. Although the use of a drain is based on individual or institutional practice, evidence has shown that the use of a closed system suction drainage increases the total blood loss after joint replacement surgery.3 At the same time, a recent meta-analysis has confirmed that autologous shed blood transfusion is an effective method to reduce allogeneic blood transfusion.4 Other techniques used to reduce the blood loss are clamping the drain, retrograde injection of TXA through the drain, and closure without a drain.5 The current study by Oremus and coworkers suggests that TXA could potentially eliminate the need for surgical drains and autologous shed blood transfusion. The cost-effectiveness of using TXA rather than autologous transfusion of shed blood was not analyzed in this study, although the cost of TXA may be lower. Overall this well-designed randomized controlled trial shows the efficacy of TXA on reducing autologous shed blood transfusion. The second study is a retrospective study in which Kelley and coworkers2 determined the effect of TXA on blood transfusion in patients undergoing bilateral total knee replacement staged 3 days apart. Transfusion rates were compared between patients who did not receive TXA (before the routine use of TXA) and after the institution of TXA for bilateral total knee replacement. The TXA group received 1 g of TXA IV 15 minutes before incision and 1 g IV before tourniquet release. The main findings were the TXA group had lower mean blood loss than the non-TXA group (373.8 ± 264.6 mL vs. 871.6 ± 457.7 mL, respectively). The blood transfusion rate was lower (43.1% vs. 71.4%) in the TXA group and the amount of allogeneic blood transfusion was lower (0.64 ± 0.84 units vs. 1.53 ± 1.30 units) in the TXA group. In addition, the TXA group had significantly higher Hb level on Day 1 and Day 2 with each stage of total knee replacement. Otherwise there was no difference in postoperative complications including infection, venous thromboembolism, reoperation, hematoma, or pre- and postoperative Knee Society score and range of movement. Since this study was retrospective, routine screening for venous embolism was not done. The transfusion trigger was 9 g/L for the first surgery and 8 g/L for the second surgery. These two studies add to the growing literature supporting the efficacy of TXA for reducing blood loss6, 7 and blood transfusion in joint replacement surgery. Surgical trauma and the use of a tourniquet have been shown to activate fibrinolysis. TXA is a lysine analog that helps to prevent fibrinolysis in conditions that promote fibrinolysis. TXA is relatively inexpensive, easy to administer, and more cost-effective than transfusion and other blood conservation techniques. Existing studies in the orthopedic surgical literature have not shown an increase in adverse events such as thromboembolic complications with the use of TXA for joint replacement surgery. Although the study designs differ, both current studies used the same total dose of TXA and used closed suction drain systems. The total dose of TXA used in both studies was 2 g, but the timing of administration was different. The timing of administration and dosage of TXA have varied in previous studies. A recent study found a preoperative and intraoperative IV dose of TXA was more effective than a single dose of TXA given intraoperatively or an intraoperative dose followed by a postoperative dose.8 These authors also concluded that a single dose with local application was more effective than a single dose administered IV.8 The optimal dose, timing of administration, mode of administration, and duration of treatment have not been determined. A recent systematic review and meta-analysis concluded that the effect of TXA on blood loss varied with the timing of administration of TXA, but the extent of this variation was small, and the authors questioned the clinical importance of this variation.9 The authors also found a lack of a dose–response relationship of TXA, with a total dose of about 14 mg/kg (approx. 1 g) appearing to be sufficient. However, these authors did not specifically examine joint replacement surgery, but included different types of surgery. Most of the blood loss in total knee replacements occurs during the first few hours after surgery.10 A recent pharmacokinetic study showed that peak fibrinolytic activity occurred at 6 hours from the incision time for both total hip and total knee replacement, and the fibrinolysis activity persisted for 18 hours.11 This finding supports a multiple dose regime or a postoperative infusion as the most effective way to reduce blood loss with use of TXA in joint replacement surgery. However, this protocol must be balanced with the high risk for DVT in this patient population. These studies support the use of TXA to reduce blood loss and transfusion in joint replacement surgery. The optimal timing, dose, duration of treatment, and route of administration of TXA, however, remain uncertain. There is a need for more pharmacokinetics studies to optimize the use of TXA to reduce blood loss and blood transfusion, while minimizing any potential adverse effects in joint replacement surgery. These studies should be encouraged by the transfusion medicine community since TXA appears to be a useful pharmacologic alternative to transfusion in orthopedic surgery. None.

Background Venous thromboembolism (VTE) is a frequent acute cardiovascular disease, leading to significant morbidity and mortality worldwide. Major trauma, surgery, immobilisation and joint replacements are major provoking factors for VTE. In particular, patients undergoing knee and hip joint replacement surgery are at high risk of developing VTE perioperatively, even in the era of established pharmacological thromboprophylaxis. Without thromboprophylaxis, as many as 20–60% of patients may develop perioperative VTE. Purpose As recent studies indicate an increasing number of total knee and hip replacement surgeries in European countries and the United States, aims of our study were to investigate a) total burden and temporal trends of VTE complications following knee (KJR) and hip joint replacement (HJR) in Germany 2005–2016 and to identify b) predictors of VTE during hospitalization. Methods In an analysis of the nationwide German inpatient sample, we included all hospitalized patients with elective primary KJR and HJR in Germany between 2005 and 2016 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2016, own calculations). We analyzed temporal trends of surgical procedure, mortality, and VTE, and identified predictors of VTE. Results A total of 1,804,496 hospitalized patients underwent KJR (65.1% women, 53.4% aged ≥70 years) and 1,885,839 received HJR (59.1% women, 51.4% ≥70 years). VTE was documented in 23,297 (1.3% of total) KJR patients and in 11,554 HJR patients (0.6%). The number of primary KJR (129,832 in 2005 to 167,881 in 2016 [β-(slope)-estimate 1978 per year; 95% CI 1951 to 2004, P<0.001]) and primary HJR (145,223 in 2005 to 171,421 in 2016 [β-estimate 1818 per year; 95% CI 1083 to 2553, P<0.001]) increased during this twelve-year period. In-hospital VTE decreased from 1.9% to 0.9% (β-estimate −0.77 [95% CI: −0.81 to −0.72], P<0.001) after KJR and from 0.9% to 0.5% (β-estimate −0.71 (95% CI: −0.77 to −0.65), P<0.001) after HJR. In parallel, in-hospital death rate dropped from 0.14% (184 deaths) to 0.09% (146 deaths) (β-estimate −0.44 [95% CI: −0.59 to −0.30], P<0.001) after KJR and from 0.33% to 0.29% (β-estimate −0.11 (95% CI: −0.20 to −0.02), P=0.018) after HJR. Infections during hospitalization were associated with a higher VTE risk. VTE events were associated with in-hospital death in KJR (OR 20.86 [95% CI: 18.78–23.15], P<0.001) and HJR (OR 15.19 [95% CI: 14.19–16.86], P<0.001) independently from age, sex and comorbidities. Conclusions While total numbers of KJR and HJR interventions increased in Germany between 2005 and 2016, the rate of VTE decreased substantially. VTE complications were associated with 15-to 21-fold increase of in-hospital case-fatality rate. Perioperative infections increased the risk for VTE substantially. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503), institutional grant for the Center for Thrombosis and Hemostasis. The authors are responsible for the contents of this publication.

Little is known about whether rural-urban differences exist in patients after hip and knee joint replacement surgery. We compared patient characteristics, pain and functional outcomes of rural and urban patients undergoing joint replacement surgery in a single high-volume metropolitan centre. Prospective cohort study conducted in patients who underwent primary elective hip (THJR) or knee replacement (TKJR) between 1 January 2006 and 31 December 2009. A university-affiliated tertiary referral centre situated in the central metropolitan region of Melbourne, Australia. One thousand nine hundred fifty-five consecutive patients undergoing primary total joint replacement. Pain and function were assessed preoperatively and 12 and 24 months postoperatively. The main independent variable was geographic location specifically comparing patients residing in rural/regional compared with urban communities. A total of 2193 primary joint replacements were performed (981 THJR and 1212 TKJR) in 1955 patients. Rural patients presented at a younger age and with earlier radiographic disease than their urban counterparts. There was a higher rate of rheumatoid arthritis among rural patients presenting for TKJR. There was no difference in pain and function scores between groups at 12 and 24 months post-surgery. In our series of 1955 patients undergoing total hip and knee joint replacement surgery, rural patients presented at a younger age and an earlier stage of disease progression. At 24 months, rural patients had pain and functional outcomes as good as their urban counterparts. More research is required to determine which factors lead to the early presentation of rural patients.

Routine thromboprophylaxis represents the current standard of care in the management of patients following total hip or knee replacement. Legacy agents used to address the issue of risk of venous thromboembolism present barriers to use, either by the need for monitoring and dose adjustment (warfarin) or the need for injection (low molecular weight heparins and fondaparinux), or pose a risk of upper gastrointestinal bleeding (acetylsalicylic acid and all antithrombotic agents). The introduction of new pharmacologic agents in recent years has sought to address the issues of not only efficacy, but also safety, ease of use, and patient compliance. New orally administered agents, ie, apixaban, dabigatran, and rivaroxaban, have demonstrated various degrees of efficacy over enoxaparin while preserving safety. Indirect comparisons of the relative efficacies of apixaban, dabigatran, and rivaroxaban have shown rivaroxaban to be more efficacious than dabigatran and apixaban in reducing symptomatic and total venous thromboembolism following total hip or knee replacement surgery. A pooled analysis of the four RECORD (Regulation of Coagulation in Orthopedic Surgery to Prevent deep vein thrombosis and pulmonary embolism) trials (two in total hip replacement and two in total knee replacement) demonstrated rivaroxaban to be the first and only antithrombotic agent ever to demonstrate superiority in reducing symptomatic venous thromboembolism and all-cause mortality compared with another antithrombotic agent (enoxaparin). New oral antithrombotic agents have demonstrated efficacy in prophylaxis against venous thromboembolism following total hip or knee replacement surgery while preserving safety, with increased ease of administration of thromboprophylaxis for both the patient and the physician, which may contribute to improved compliance.

Background and Aims:The patients undergoing total knee and hip replacement surgeries are mostly obese, more than 50 years of age with osteophytic spine and spine deformities making the blind conventional technique of regional anaesthesia more difficult. The aim of the study was to compare the role of preprocedural ultrasound scan to conventional blind technique in obese patients with osteophytic spines undergoing total knee or hip replacement surgeries in terms of technical difficulty, clinical efficacy, safety and patient comfort.Methods:A prospective, randomised controlled trial was conducted in which 210 consenting American Society of Anesthesiologists (ASA) grade III patients, age >50 years, Body Mass Index (BMI) ≥30 kg/m2 with osteophytic spines including abnormalities undergoing joint replacement surgeries were randomised in two groups. Ultrasound group (“B”) received Combined Spinal Epidural Anaesthesia (CSEA) after preprocedural lumbar ultrasound scan. In control group (“A”), CSEA was given by blind conventional technique. The primary objective was to compare the rate of successful epidural block on 1st needle insertion attempts in both the groups. The secondary objectives were to compare both groups in terms of ease, success, comfort and safety of epidural block.Results:Ultrasound improved success of CSEA at 1st attempt from 74.3% in control group (“A”) to 85.7% in Ultrasound group (“B”) (P = 0.038). Fewer needle insertion attempts, passes and anaesthesiologist were required in ultrasound group. Pearson correlation coefficient was 0.976 using both views.Conclusion:Preprocedural ultrasound scan is a useful adjunct to lumbar epidural blocks in obese patients with osteophytic abnormal spines.

Hip and Knee Arthroplasty Alternative Payment Model Successes and Challenges.

Background: Dedicated joint replacement programs are being developed to determine their efficacy in decreasing costs and overall demand on the medical system. This study aimed to determine if a dedicated multidisciplinary joint replacement program can reduce postoperative length of stay while maintaining acceptable levels of safety and patient satisfaction, reducing the overall demand and burden on the medical system. Methods: A prospective cohort study was performed on 318 selected patients who had total knee or hip replacement surgery as part of a dedicated multidisciplinary program. The program used a multidisciplinary best practice approach for the patient process. Results: For the 150 patients who had total hip replacement and 168 who had total knee replacement, the mean length of stay was 2.14 (1-11) days and 1.87 (0-8), respectively. Being female, having a hip replacement, increasing age, and higher body mass index were all associated with a length of stay over 2 days. Conclusions: This program was effective at reducing postoperative length of stay for both hip and knee replacement surgeries. This analysis suggests that a dedicated multidisciplinary program is appropriate to decrease length of hospital stay in face of increasing demand. Therefore, it has the potential to serve as a model for other centers to develop similar multidisciplinary programs to help reduce the burden of joint replacements on the health care system.

To explore the lived experiences of patients with severe osteoarthritis (OA) of the hip or knee joint while awaiting joint replacement surgery. An exploratory qualitative approach using phenomenology was adopted for the purpose of the study. Unstructured interviews were carried out on a sample of six patients who had been referred to the National Health Service waiting list for a primary hip or knee replacement. The participants were invited to share their experiences and concerns relating to how they were coping with end-stage OA of their hip or knee joint. Interviews were digitally recorded and transcribed verbatim. Narrative data were analysed using Giorgi's (1985) procedural steps to reveal themes which recurred in the participants' stories. Six themes emerged from the data, central to the experience of living with severe OA. They were: coping and living with pain; not being able to walk; coping with everyday activities; body image; advice and support available; and the effect of their disease upon family, friends and helpers. There were also a number of sub-themes associated with each major theme. This study suggests that there is an absence of generic support, guidance and information relating to the management of symptoms of OA for individuals awaiting hip and knee replacement surgery. Patients awaiting hip and knee joint replacement surgery often have difficulty in managing their symptoms. Support in general appears to be dependent on the availability of resources in the primary care setting. Potential patients who are fortunate to know or meet someone who has undergone a similar procedure learn from the experience of exchanging information between themselves, along with coping strategies in the management of their symptoms.

Does Exercise Reduce Pain and Improve Physical Function Before Hip or Knee Replacement Surgery? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Ochronosis or black joints disorder is a rare autosomal recessive disorder caused by deficiency of homogentisic acid oxidase. Orthopaedic manifestations are common and mostly involve spine and large joints such as knee and hip. Arthropathy is progressive and will eventually leads to arthroplasty. Not being familiar with this disorder might lead to devastating complications. We present a 57 year-old woman with Ochronosis who successfully underwent cemented cruciated substituted knee replacement and cementless hip replacement. Proper orthopaedic and anesthetic pre-operative preparation, soft tissue specially patella tendon management throughout operation and meticulous bleeding control during surgery are crucial. The results of the knee and the hip replacement surgery in this patient are satisfactory, after 24 months and 18 months follow-up, respectively. If Orthopaedic surgeons and anesthesiologists are well prepared, the outcome of joint replacement in Ochronosis patients will be as satisfactory as patients with primary osteoarthritis.

Patients with end-stage renal disease (ESRD) are at a higher risk of needing hip or knee replacement (joint replacement) surgery due to the high prevalence of degenerative joint disease and other conditions. However, there remains a large debate about the timing of joint replacement surgery and whether it should be pre- vs post-transplant. We conducted a retrospective study analyzing all adult kidney transplant recipients (KTRs) at our university hospital who had undergone subsequent joint replacement between 2001 and 2017. Transplant-specific outcomes of acute rejection, death censored graft failure (DCGF), and patient death post-joint replacement surgery were outcomes of interest. Controls were selected at a 1:3 ratio based on the incidence density sampling of post-transplant interval. There were 101 KTRs in the joint replacement group and were compared with 281 controls. In the multivariate analysis, the need for joint replacement was not associated with acute rejection (HR: 1.59; 95% CI: 0.77-3.29; P=0.21); DCGF (HR: 0.89; 95% CI: 0.49-1.60; P=0.70) or patient death (HR: 0.84, 95% CI: 0.55-1.38, P=0.42). In selected KTRs, joint replacement surgery was not associated with detrimental transplant-specific outcomes.

The demand for elective joint replacement (EJR) surgery for degenerative joint disease continues to rise in Australia, and relative to earlier practices, patients are discharged back to the care of their general practitioner (GP) and other community-based providers after a shorter hospital stay and potentially greater post-operative acuity. In order to coordinate safe and effective post-operative care, GPs rely on accurate, timely and clinically-informative information from hospitals when their patients are discharged. The aim of this project was to undertake an audit with GPs regarding their preferences about the components of information provided in discharge summaries for patients undergoing EJR surgery for the hip or knee.GPs in a defined catchment area were invited to respond to an online audit instrument, developed by an interdisciplinary group of clinicians with knowledge of orthopaedic surgery practices. The 15-item instrument required respondents to rank the importance of components of discharge information developed by the clinician working group, using a three-point rating scale.Fifty-three GPs and nine GP registrars responded to the audit invitation (11.0% response rate). All discharge information options were ranked as 'essential' by a proportion of respondents, ranging from 14.8-88.5%. Essential information requested by the respondents included early post-operative actions required by the GP, medications prescribed, post-operative complications encountered and noting of any allergies. Non-essential information related to the prosthesis used. The provision of clinical guidelines was largely rated as 'useful' information (47.5-56.7%).GPs require a range of clinical information to safely and effectively care for their patients after discharge from hospital for EJR surgery. Implementation of changes to processes used to create discharge summaries will require engagement and collaboration between clinical staff, hospital administrators and information technology staff, supported in parallel by education provided to junior medical staff.

Incidence rates for thromboembolic, bleeding and hepatic outcomes in patients undergoing hip or knee replacement surgery

Background: Joint replacement surgery is one of the most cost-effective interventions leading to considerable improvements in function and quality of life. The rise in multimorbidity in the UK is leading to an increasing number of patients with long-term conditions (LTCs) undergoing joint replacement surgery. Financially stretched commissioners of health services are seeking to restrict access to routine elective surgery, including hip and knee replacements, despite a lack of evidence to support these decisions. It is therefore important to understand the factors that limit the safety and effectiveness of surgery and how LTCs might have an impact on access to and outcomes of joint replacement. Methods: In this thesis, national patient-level datasets and both quantitative and qualitative research methods were used to investigate the access to and outcomes of hip and knee replacement surgery for patients with 11 different comorbidities. This involved three components: a literature review, methodological work, and empirical work. The literature review explored the outcomes for patients with different comorbidities. The methodological work assessed the agreement between patient-report and administrative data derived comorbidities. Finally, the empirical work explored the severity of joint problems before surgery and the safety and effectiveness outcomes for patients with comorbidities. Semi-structured interviews with healthcare professionals that are involved in the referral and selection of patients for joint replacement surgery were undertaken to provide insight into the factors that influence the access to surgery for patients with comorbidities. Results: The systematic review on outcomes to hip and knee replacement surgery showed that there was limited evidence of the impact of comorbidities on patient-reported outcomes related to effectiveness of joint replacement surgery. Patients with comorbidities reported more severe joint problems before surgery compared to patients without comorbidities, suggesting that patients with comorbidities may be undergoing hip and knee replacement surgery later in the course of their joint disease. This was further supported by the findings from the qualitative study that patients with comorbidities who were considered unsuitable for surgery were ‘lost to the system’ and left to self-manage their comorbidities before being reconsidered for joint replacement surgery. With regards to outcomes, patients with comorbidities have a moderately increased risk of adverse outcomes after hip and knee replacement surgery but benefit almost to the same extent as patients without comorbidities. Patients with comorbidities reported only slightly smaller improvements in severity of joint problems and no difference in quality of life after surgery compared to patients without comorbidities. Patients with multiple comorbidities (two or more comorbidities) reported more severe joint problems before surgery and a slightly higher increased risk of adverse outcomes but nevertheless benefitted considerably from the surgery. Conclusions: This thesis demonstrates that patients with comorbidities may experience inequalities in access to hip and knee replacement surgery even though they benefit almost as much as patients without comorbidities. This finding indicates that the restriction of access to joint replacement surgery based on the presence of comorbidities alone is difficult to justify considering the beneficial impact of the surgery on patients’ lives.

Background:Osteoarthritis of the hip and knee is one of the most common causes of reduced mobility. It also causes stiffness and pain. Opioids can offer pain relief but is usually used for severe acute pain caused by major trauma or surgery. The use of opioids for relief of chronic pain caused by arthritis has increased over the last few decades.[1]Objectives:This study aims to investigate the use of strong opiates for patients with hip and knee osteoarthritis before and after joint replacement surgery, over a 13 years period in New Zealand.Methods:This study included patients with osteoarthritis who underwent publicly funded primary hip and knee replacement surgeries in 2005-2017 in New Zealand. These records were identified from the National Minimum Dataset (NMD). They were cross referenced with the NZJR data to exclude the admissions not for primary hip or knee replacement surgeries. Patients without a diagnosis of osteoarthritis were excluded.The PHARMS dataset was linked to the NMD to identify the use of strong opiates before and after surgeries. The strong opiates available for community dispensing in New Zealand and included in this study are: dihydrocodeine, fentanyl, methadone, morphine, oxycodone and pethidine. Use of opiate within three months prior to surgery and within 12 months post-surgery were examined by gender, age group, ethnicity, Charlson Comorbidity Index score and year of surgery. Differences by subgroup was examined with Chi- square test. Logistic regression model was used to calculate the adjusted odds ratios of strong opiate use before and after surgery compared with no opiate use.Results:We identified 53,439 primary hip replacements and 50,072 primary knee replacements with a diagnosis of osteoarthritis. Of patients with hip osteoarthritis, 6,251 (11.7%) had strong opiate before hip replacement surgeries and 11,939 (22.3%) had opiate after surgeries. Of patients with knee osteoarthritis, 2,922 (5.8%) had strong opiate before knee replacement surgeries and 15,252 (30.5%) had opiate after surgeries.The probability of patients with hip and knee osteoarthritis having opiate decreased with age, increased with Charlson comorbidity index score, and increased over time both before and after surgeries. Male patients with hip and knee osteoarthritis were less likely to have opiate than female patients both before and after surgeries. New Zealand Europeans with hip and knee osteoarthritis were more likely to receive opiate than other ethnic groups prior to surgeries, but were less likely to have opiate than Asians post-surgeries.Patients who had opiate before surgeries were more likely to have opiate after surgeries than those who did not have opiate before surgeries. The odds ratio was 8.34 (95% confidence interval (CI): 7.87-8.84) for hip osteoarthritis and 11.94 (95% CI: 10.84-13.16) for knee osteoarthritis after adjustment for age, gender, ethnicity, year of surgery and Charlson comorbidity index score. Having opiate prior to surgeries also increased the probability of having opiate for 6 weeks or more after surgeries substantially. The adjusted odds ratio was 21.46 (95% CI: 19.74-23.31) for hip osteoarthritis and 27.22 (95% CI: 24.95-29.68) for knee osteoarthritis.Conclusion:Preoperative opiate holidays should be encouraged. Multiple strategies need to be used to develop analgesic plans that allow adequate rehabilitation, without precipitating a chronic opiate dependence. Clinicians would also benefit from clear guidelines for prescribing strong opiates.