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Chronic Opioid Use Prior to Total Knee Arthroplasty
Michael G. Zywiel, MD1; D. Alex Stroh, BS2; Seung Yong Lee, MD3; Peter M. Bonutti, MD4; Michael A. Mont, MD2
1 Division of Orthopaedic Surgery, University of Toronto, 100 College Street, Room 302, Toronto, ON M5G 1L5, Canada
2 Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address for M.A. Mont: mmont@lifebridgehealth.org
3 Hallym University Medical Center, 445 Kildong, Kangdonggu, Seoul, South Korea
4 Bonutti Clinic, 1303 West Evergreen Avenue, Effingham, IL 62401
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at the Rubin Institute for Advanced Orthopedics, Baltimore, Maryland, and the Bonutti Clinic, Effingham, Illinois
A commentary by Thomas Parker Vail, MD, is linked to the online version of this article at jbjs.org.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Nov 02;93(21):1988-1993. doi: 10.2106/JBJS.J.01473
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Chronic use of opioid medications may lead to dependence or hyperalgesia, both of which might adversely affect perioperative and postoperative pain management, rehabilitation, and clinical outcomes after total knee arthroplasty. The purpose of this study was to evaluate patients who underwent total knee arthroplasty following six or more weeks of chronic opioid use for pain control and to compare them with a matched group who did not use opioids preoperatively.


Forty-nine knees in patients who had a mean age of fifty-six years (range, thirty-seven to seventy-eight years) and who had regularly used opioid medications for pain control prior to total knee arthroplasty were compared with a group of patients who had not used them. Length of hospitalization, aseptic complications requiring reoperation, requirement for specialized pain management, and clinical outcomes were assessed for both groups.


Knee Society scores were significantly lower in the patients who regularly used opioid medications at the time of final follow-up (mean, three years; range, two to seven years); the opioid group had a mean of 79 points (range, 45 to 100 points) as compared with a mean of 92 points (range, 59 to 100 points) in the non-opioid group. A significantly higher prevalence of complications was seen in the opioid group, with five arthroscopic evaluations and eight revisions for persistent stiffness and/or pain, compared with none in the matched group. Ten patients in the opioid group were referred for outpatient pain management, compared with one patient in the non-opioid group.


Patients who chronically use opioid medications prior to total knee arthroplasty may be at a substantially greater risk for complications and painful prolonged recoveries. Alternative non-opioid pain medications and/or earlier referral to an orthopaedic surgeon prior to habitual opioid use should be considered for patients with painful degenerative disease of the knee.

Level of Evidence: 

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    David Ring, MD PhD
    Posted on November 20, 2011
    Stuck in the Biomedical Model
    Massachusetts General Hospital

    Dr. Lack's comment reflects what has been termed the biomedical model of illness, where symptoms and disability can always be reduced to specific pathophysiologies or impairments. Orthopaedic surgeons know well that symptoms and disability do not correlate with radiographic arthrosis, diminished motion, or other measures of pathophysiology or impairment and our scientific literature is consistent on this. For instance, the use of opioid pain medications varies by an order of magnitude between countries based on cultural differences alone (e.g. same fracture, same surgery, same implant). Studies like those of Zwyiel and colleagues represent that orthopaedic surgeons are becoming more comfortable with the biopsychosocial model of human illness. In the biopsychosocial model, pathophysiology is only one component of illness, with psychological and sociological components playing an important role. For many musculoskeletal pain/quality of life issues pathophysiology is actually much less important to the patient's health and wellness than mood, effective coping strategies, social supports, and other resources. These considerations are not academic. If one assumes that a patient's struggles with the pain of knee arthritis are entirely due to the arthritis itself, the result may be the prescription of greater opioids, which are known correlates of greater symptoms and disability--in other words, they will make the patient more ill. Perhaps more importantly, an opportunity will be lost to talk to the patient about big events in their life and whether they feel they'll be able to rely on their knee--opportunities to develop adaptation and resiliency that will serve them as well or better than a prosthetic knee.

    Michael A. Mont, M.D., Michael G. Zywiel, M.D.
    Posted on November 15, 2011
    The Authors Respond
    Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore; Division of Orthopaedic Surgery, University of Toronto

    We did make specific efforts to control for a number of potential confounding factors to try to ensure that the two groups had a minimal selection bias. The two groups were matched by age, gender, bilaterality, body mass index, and Knee Society scores, and a post hoc analysis of various other possible confounding factors (insurance type, previous knee arthroscopy, chronic back pain and/or back surgery, neuroleptic/antidepressant/anxiolytic medication use, alcohol abuse, and systemic corticosteroid use) was performed. While we found a statistically higher (p = 0.014) number of patients with antidepressant/anxiolytic medication use in the opioid group, all other factors were similar. We did match the opioid and non-opioid groups by Knee Society scores in an attempt to control for differences in pre-operative disease severity, and these were similar between the two groups with mean scores of 38 and 37 points respectively (p=0.513). We did not specifically evaluate joint pathology, and it is certainly possible that patients who received opioid medications pre-operatively did have greater tissue damage. One method that could have been used is a comparison of pre-operative radiographic grade of arthritic changes. However, it is not clear that higher-grade pre-operative arthritic changes are associated with worse post-operative outcomes. In fact, Valdes et al. recently reported that lower pre-operative radiographic osteoarthritis grade is associated with significantly worse outcomes in total knee arthroplasty[1], suggesting that greater pre-operative tissue damage does not, in and of itself, explain the poorer outcomes in the chronic opioid group. Nevertheless, the Dr. Lack’s comment does raise the point that there may be one or more underlying factors related to chronic opioid use not controlled for in our analysis that account for some of all of the difference in outcomes between the two groups. For example, while recent evidence suggests that higher pre-operative pain levels are not associated with residual post-operative pain following total knee arthroplasty[2], pain catastrophizing has been associated with poorer outcomes[3-5]. While not controlled for specifically in our study, it is possible that patients with high levels of catastrophizing are more likely to use opioid medications pre-operatively. We appreciate the comment and do hope that it stimulates additional work to further clarify the complex relationship between osteoarthritic pain, oral opioid medication use, psychological factors, and the outcomes of total knee arthroplasty, and ultimately to help improve outcomes in the higher risk population addressed in our report. REFERENCES [1] Valdes AM, Doherty SA, Zhang W, Muir KR, Maciewicz RA, Doherty M. Inverse Relationship Between Preoperative Radiographic Severity and Postoperative Pain in Patients with Osteoarthritis who Have Undergone Total Joint Arthroplasty. Semin Arthritis Rheum. 2011;Epub Aug 27. [2] Bonnin MP, Basiglini L, Archbold HA. What are the factors of residual pain after uncomplicated TKA? Knee Surg Sports Traumatol Arthrosc. 2011;19:1411-7. [3] Edwards RR, Haythornthwaite JA, Smith MT, Klick B, Katz JN. Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement. Pain Res Manag. 2009;14:307-11. [4] Sullivan M, Tanzer M, Stanish W, Fallaha M, Keefe FJ, Simmonds M, Dunbar M. Psychological determinants of problematic outcomes following Total Knee Arthroplasty. Pain. 2009;143:123-9. [5] Riddle DL, Wade JB, Jiranek WA, Kong X. Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clin Orthop Relat Res. 2010;468:798-806.

    Dorothea Z. Lack, Ph.D.
    Posted on November 04, 2011
    RE: Preoperative Opioid Use in Arthroplasty Patients 11/2/11
    Independent Practice, San Francisco, CA

    Is this a case of Logical Fallacy?--Post Hoc Ergo Propter Hoc???? Is it possible that patients who were given opioids preoperatively had worse joint pathology than those who were not given opioids, and that their postoperative differences can be attributed to the fact that there was more tissue damage to begin with?

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