Lindsey Wurster and Sarah Brandt are Physician Assistants, Patricia Mecum is a Family Nurse Practitioner, Kenneth Gundle and Lucas Anissian are Attending Orthopedic Surgeons, all at US Department of Veterans Affairs Portland Health Care System in Oregon. Erik Woelber is an Orthopedic Surgery Resident, and Kenneth Gundle is an Attending Physician, both in the Orthopedic Department at Oregon Health and Sciences University in Portland. Correspondence: Lindsey Wurster (lindsey.wurster@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Background: For decades, opioids have been the mainstay in pain management after total joint arthroplasty despite evidence that their use should be curtailed. To limit unnecessary prescribing of opioids, the US Department of Veterans Affairs (VA) Portland Health Care System Total Joints Service implemented the Minimizing Opioids After Joint Operation (MOJO) postoperative pain protocol in 2018 to reduce opioid use following total knee arthroplasty (TKA). This protocol included reductions of inpatient and outpatient opioid prescribing, preoperative optimization, use of perioperative nerve blocks, and surgery without a tourniquet.
Methods: We performed a retrospective chart review that compared the first 20 consecutive patients undergoing TKA using the MOJO protocol with the last 20 patients using the prior routine. Outcomes included total inpatient opioid use, daily opioid use, emergency department (ED) visits or readmissions within 90 days, phone calls for pain or medication refills, length of stay (LOS), and pain during inpatient hospital stay.
Results: There were significant differences between the pre-MOJO and the MOJO groups with regard to daily inpatient morphine equivalent dose (MED) (82 mg vs 31 mg, P < .01) and total inpatient MEDs (306 mg vs 33 mg, P < .01) . There was less self-reported pain on postoperative day 1 in the MOJO group (5.5 vs 4.1, P = .01), decreased LOS (4.4 days vs 1.1 days, P < .01), fewer total ED visits (6 vs 2, P < .07), and fewer discharges to skilled nursing facilities (12 vs 0, P < .01).
Conclusions: The MOJO protocol reduced postoperative opioid use after TKA in the VA setting without compromising pain control or increasing ED visits. The framework and routines described are potentially applicable to other institutions and surgical specialties.
For decades, opioids have been a mainstay in the management of pain after total joint arthroplasty. In the past 10 years, however, opioid prescribing has come under increased scrutiny due to a rise in rates of opioid abuse, pill diversion, and opioid-related deaths.1,2 Opioids are associated with adverse effects, including nausea, vomiting, constipation, apathy, and respiratory depression, all of which influence arthroplasty outcomes and affect the patient experience. Although primary care groups account for nearly half of prescriptions written, orthopedic surgeons have the third highest per capita rate of opioid prescribing of all medical specialties.3,4 This puts orthopedic surgeons, particularly those who perform routine procedures, in an opportune but challenging position to confront this problem through novel pain management strategies.
Approximately 1 million total knee arthroplasties (TKAs) are performed in the US every year, and the US Department of Veterans Affairs (VA) health system performs about 10,000 hip and knee joint replacements.5,6 There is no standardization of opioid prescribing in the postoperative period following these procedures, and studies have reported a wide variation in prescribing habits even within a single institution for a specific surgery.7 Patients who undergo TKA are at particularly high risk of long-term opioid use if they are on continuous opioids at the time of surgery; this is problematic in a VA patient population in which at least 16% of patients are prescribed opioids in a given year.8 Furthermore, veterans are twice as likely as nonveterans to die of an accidental overdose.9 Despite these risks, opioids remain a cornerstone of postoperative pain management both within and outside of the VA.10
In 2018, to limit unnecessary prescribing of opioid pain medication, the total joint service at the VA Portland Health Care System (VAPHCS) in Oregon implemented the Minimizing Opioids after Joint Operation (MOJO) postoperative pain protocol. The goal of the protocol was to reduce opioid use following TKA. The objectives were to provide safe, appropriate analgesia while allowing early mobilization and discharge without a concomitant increase in readmissions or emergency department (ED) visits. The purpose of this retrospective chart review was to compare the efficacy of the MOJO protocol with our historical experience and report our preliminary results.
Methods
Institutional review board approval was obtained to retrospectively review the medical records of patients who had undergone TKA surgery during 2018 at VAPHCS. The MOJO protocol was composed of several simultaneous changes. The centerpiece of the new protocol was a drastic decrease in routine prescription of postoperative opioids (Table 1). Other changes included instructing patients to reduce the use of preoperative opioid pain medication 6 weeks before surgery with a goal of no opioid consumption, perform daily sets of preoperative exercises, and attend a preoperative consultation/education session with a nurse coordinator to emphasize early recovery and discharge. In patients with chronic use of opioid pain medication (particularly those for whom the medication had been prescribed for other sources of pain, such as lumbar back pain), the goal was daily opioid use of ≤ 30 morphine equivalent doses (MEDs). During the inpatient stay, we stopped prescribing prophylactic pain medication prior to physical therapy (PT).
We encouraged preoperative optimization of muscle strength by giving instructions for 4 to 8 weeks of daily exercises (Appendix). We introduced perioperative adductor canal blocks (at the discretion of the anesthesia team) and transitioned to surgery without a tourniquet. Patients in both groups received intraoperative antibiotics and IV tranexamic acid (TXA); the MOJO group also received topical TXA.
Further patient care optimization included providing patients with a team-based approach, which consisted of nurse coordinators, physician assistants and nurse practitioners, residents, and the attending surgeon. Our team reviews the planned pain management protocol, perioperative expectations, criteria for discharge, and anticipated surgical outcomes with the patient during their preoperative visits. On postoperative day 1, these members round as a team to encourage patients in their immediate postoperative recovery and rehabilitation. During rounds, the team assesses whether the patient meets the criteria for discharge, adjusting the pain management protocol if necessary.
Changes in surgical technique included arthrotomy with electrocautery, minimizing traumatic dissection or resection of the synovial tissue, and intra-articular injection of a cocktail of ropivacaine 5 mg/mL 40 mL, epinephrine 1:1,000 0.5 mL, and methylprednisolone sodium 40 mg diluted with normal saline to a total volume of 120 mL.
The new routine was gradually implemented beginning January 2017 and fully implemented by July 2018. This study compared the first 20 consecutive patients undergoing primary TKA after July 2018 to the last 20 consecutive patients undergoing primary TKA prior to January 2017. Exclusion criteria included bilateral TKA, death before 90 days, and revision as the indication for surgery. The senior attending surgeon performed all surgeries using a standard midline approach. The majority of surgeries were performed using a cemented Vanguard total knee system (Zimmer Biomet); 4 patients in the historical group had a NexGen knee system, cementless monoblock tibial components (Zimmer Biomet); and 1 patient had a Logic knee system (Exactech). Surgical selection criteria for patients did not differ between groups.
