Tramadol use before total shoulder arthroplasty: patients have lower risk of complications and resource utilization than those using traditional opioids

Abstract

Evidence continues to mount for the deleterious effects of preoperative opioid use in the setting of total shoulder arthroplasty (TSA). Tramadol, a synthetic opioid with concomitant neurotransmitter effects, has become a popular alternative to traditional opioids, but it has not been well studied in the preoperative setting of TSA. The purpose of this study is to evaluate postsurgical outcomes in TSA for patients with preoperative tramadol use compared to patients using traditional opioids and those who were opioid naïve. Utilizing the IBM Watson Health Marketscan databases, a retrospective cohort study was performed for patients undergoing TSA from 2009-2018. Filled pain prescriptions were collected and prescribing trends were analyzed. Outcomes were compared between four patient cohorts defined by preoperative analgesia use-opioid naïve, tramadol, traditional opioids, and combination (opioids and tramadol). Multivariate analysis was used to account for small variations in cohort demographics and comorbidities. Analysis focused on resource utilization and complications. Revision rates at 1- and 3-years postoperative were also compared. 29,454 TSA patients were studied, with 8,959 available for 3-year postoperative follow-up. 10,462 (35.5%) were prescribed traditional opioids and 2,214 (7.5%) tramadol only. From 2009-2018, prescribing trends in the United States demonstrated a significant decrease in the number of patients prescribed preoperative narcotics, whereas patients prescribed preoperative tramadol and those who were opioid naïve significantly increased. Compared to opioid naïve patients, the traditional opioid cohort had significantly increased odds of resource utilization and complications, whereas the tramadol cohort did not. Specifically, the traditional opioid cohort had an increased risk of prosthetic joint infection compared to both opioid naïve and tramadol cohorts. The traditional opioid cohort had higher revision rates than opioid naïve patients at 1- and 3-years, whereas the tramadol cohort did not. Despite a decrease in opioid prescriptions over the study period, many patients in the United States remain on opioids. While tramadol is not without its own risks, our results suggest that patients taking preoperative tramadol as an alternative to traditional opioids for glenohumeral arthritic pain had a lesser postoperative risk profile, comparable to opioid naïve patients.