Abstract
Introduction: The world’s opioid epidemic has gotten increasingly severe over the last several decades and projects to continue worsening. Orthopedic surgery is the largest contributor to this epidemic, accounting for 8.8% of postoperative opioid dependence cases. Total knee arthroplasty (TKA) and anterior cruciate ligament (ACL) reconstruction are commonly performed orthopedic operations heavily reliant on opioids as the primary analgesic in the peri- and immediate postoperative period. These downfalls highlight the pressing need for an alternate, non-pharmacologic analgesic to reduce postoperative opioid use in orthopedic patients. The presented systematic review aimed to analyze and compare the most promising non-pharmacologic analgesic interventions in the available literature to guide future research in such a novel field. Methods: A systematic search of PubMed, MEDLINE, Embase, Cochrane, and Web of Science was performed for studies published before July 2020 based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, and the obtained manuscripts were evaluated for inclusion or exclusion against strict, pre-determined criteria. Risk-of-bias and GRADE (grades of recommendation, assessment, development, and evaluation) assessments were then performed on all included studies. Results: Six studies were deemed fit for inclusion, investigating three non-pharmacologic analgesics: percutaneous peripheral nerve stimulation, cryoneurolysis, and auricular acupressure. All three successfully reduced postoperative opioid use while simultaneously maintaining the safety and efficacy of the procedure. Discussion: The results indicate that all three presented non-pharmacologic analgesic interventions are viable and warrant future research. That said, because of its slight advantages in postoperative pain control and operational outcomes, cryoneurolysis seems to be the most promising. Further research and eventual clinical implementation of these analgesics is not only warranted but should be a priority because of their vast potential to reduce orthopedics surgeries’ contribution to the opioid epidemic.
Highlights
Total knee arthroplasty (TKA) and anterior cruciate ligament (ACL) reconstruction surgeries are two of the most performed orthopedic operations in the world [1,2,3,4]
A systematic search of the published literature was performed based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies published before July 9th, 2020
Studies were included that focused on (1) analyzing the efficacy of a non-pharmacologic peri- or immediate postoperative intervention for TKA or ACL reconstruction operations, (2) analyzing the effect of said interventions on short and long-term postoperative opioid use, (3) analyzing the clinical and functional outcomes of procedures in patients treated with said interventions, and (4) used human patients
Summary
Total knee arthroplasty (TKA) and anterior cruciate ligament (ACL) reconstruction surgeries are two of the most performed orthopedic operations in the world [1,2,3,4]. TKA cases, revisions, and revisions per surgeon have all significantly increased in the last 10 years [2, 5]; ACL reconstruction has become more prevalent over the last 30 years, in the pediatric population, corresponding with the United States’ increase in youth sports injuries [1, 3, 6] While both procedures are considered highly efficacious, with TKA having shown a 10- to 15-year implant survivorship rate of over 90% [2], and up to 92% of ACL reconstruction patients receiving “A” or “B” outcome scores in a 2018 systematic review by Sarraj et al [6], they are both operations consistently associated with moderate to severe postoperative pain [1, 4]. This approach subjects the patient to a wide variety of
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