Opioid abuse has grown tremendously in the United States, and opioid analgesics have led to more fatal overdoses than street drugs.1,2 Furthermore, data have indicated that more than 70% of individuals who are consuming prescription drugs are using drugs that have not been directly prescribed to them.3 In the 2000s, new standards were introduced to improve pain management in health care settings, encouraging the use of pain scales and pain tools. As a result, physicians' prescribing of opioids and the availability of pharmaceutical opioids for nonmedical use increased.4 According to the International Narcotics Control Board, the United States leads in the consumption of opioids, having a rate 5 times that of second place Japan and an increase in addiction and fatal overdoses during the past two decades.1,2 From 1999 to 2009 alone, a 4-fold increase in narcotic consumption was seen.5 In contrast to the United States, patients in Asia and Europe are rarely prescribed opioids after discharge, instead receiving non-narcotic medications such as acetaminophen. These patients indicate that they are satisfied with this pain management.6,7
Orthopedic procedures account for a large portion of the overall narcotic consumption, with orthopedists ranking fifth among prescribers.5 Surgeries involving the foot and ankle are some of the more painful procedures in orthopedics. However, advances in technology have led to the development of percutaneous instrumentation for foot and ankle surgery. Recently approved by the Food and Drug Administration, the instrumentation to perform percutaneous surgery has been gaining popularity across the United States for procedures such as osteotomies of the fore-mid-hindfoot (ie, hallux valgus correction, hammertoe correction, lesser metatarsals osteotomies, calcaneus osteotomies, midfoot osteotomies), as well as joint arthrodesis, cheilectomies, and exostectomies.
The appropriate amount of opioids to prescribe after orthopedic surgery is unknown. Merrill et al8 investigated 171 patients who underwent open foot and ankle procedures, finding that they consumed an average of 27.2 pills before their first postoperative visit. To the current authors' knowledge, there are no studies examining opioid consumption after percutaneous foot and ankle surgery. The goal of this study was to assess total opioid (oxycodone) consumption and time to return to work following percutaneous foot surgery.
Materials and Methods
This study received institutional review board approval. Fifty consecutive patients undergoing outpatient percutaneous foot surgery (bony with or without percutaneous soft tissue work) performed by a single surgeon (E.V.) between February 1 and May 31, 2018, were included in this retrospective review. There were 17 men and 33 women in this cohort. Mean age was 47.2 years (range, 18–76 years) at the time of the procedure. All patients were prescribed 30 tablets of 5-mg oxycodone and 50 tablets of 500-mg acetaminophen for pain. Unless medically contraindicated, all patients also received 9 tablets of 600-mg ibuprofen to be taken 3 times a day for the first 3 days postoperatively. At the time of surgery, all patients were given a sheet on which to record the number of oxycodone tablets they took during the first 14 days postoperatively. Patients were asked to bring this sheet and remaining pills with them to their first postoperative visit at 2 weeks. Patients were asked at each postoperative visit when they had returned to work.
General anesthesia and a long-acting popliteal nerve block administered by an anesthesiologist were used for all procedures. The procedures were performed at the forefoot (n=37; 72%), midfoot (n=2; 4%), hindfoot (n=8; 18%), or combined locations (n=3; 6%).
Forty-four patients brought the oxycodone consumption sheet with them to their first postoperative visit, and 6 patients returned the sheet via email within 48 hours of their postoperative visit. The mean number of oxycodone tablets taken during the first 14 days postoperatively was 3.3 (range, 0–18 tablets). By day 14, no patient was taking any narcotic medication (Figure 1). The mean time to return to work was 18.9 days (range, 1–75 days) (Table 1).
Mean opioid consumption (oxycodone tablets) during postoperative period.
Patient Characteristics by Type of Surgery
The mean number of tablets consumed was 2.2 (range, 0–7 tablets) in forefoot surgeries, 3.5 (range, 1–6 tablets) in midfoot surgeries, 5.3 (range, 3–7 tablets) in hindfoot surgeries, and 11 (range, 7–18 tablets) in combined procedures.
The mean time to return to work was 10.4 days (range, 1–42 days) in forefoot surgeries, 33 days (range, 23–43 days) in midfoot surgeries, 38.9 days (range, 17–63 days) in hindfoot surgeries, and 54.3 days (range, 42–75 days) in combined procedures (Table 1).
In the United States, the opioid epidemic has attracted the attention of the media, the government, and medical societies. Minimally invasive surgery is desirable for improving postoperative pain, complications, and function. It has been shown to be safe and effective in various foot and ankle procedures (eg, hallux valgus correction, metatarsal osteotomies, and calcaneal osteotomies).9,10 Percutaneous foot surgery is widely used in Europe and Australia; however, it has only recently been introduced in the United States. This is the first study to examine opioid consumption and time to return to work after percutaneous foot surgery. The authors found that patients consumed a mean of 3.3 tablets of 5-mg oxycodone during the 2-week postoperative period, and no tablets at 2 weeks. Also, the mean time to return to work was 18.9 days.
A previous study of open foot and ankle surgery reported that an average of 27.2 opioid pills were consumed during the first 3 months postoperatively, with 37% of the patients being unable to stop.8 Similar findings were reported by Saini et al11 (20 tablets of 5-mg oxycodone), but the median number of pills prescribed was 40, indicating an over-prescription rate of approximately 50%. Lai et al12 directly compared percutaneous Chevron-Akin with open scarf osteotomies, reporting similar clinical and radiographic outcomes but superior pain control in the percutaneous group. Similarly, in a randomized controlled trial of minimally invasive vs open Chevron osteotomy hallux valgus correction, Kaufmann et al13 found improved patient satisfaction at 12 weeks in the minimally invasive cohort compared with the open cohort. Compared with values for open procedures reported in the literature, the current study indicated that percutaneous procedures lead to a significant reduction in and cessation of narcotic consumption postoperatively. In the current study, patients undergoing percutaneous procedures had minimal narcotic consumption overall, with no patient using narcotics at the 2-week postoperative visit. This may be due to the fact that percutaneous techniques in the foot and ankle have smaller incisions and minimal disruption of the surrounding soft tissue, potentially leading to significantly less perioperative pain.14,15 This is consistent with other surgical procedures such as arthroscopic vs open rotator cuff repair, Bankart repair, and carpal tunnel release.16–18
This is the first study to report the time to return to work for either the open or the percutaneous technique with bony involvement. Wander19 retrospectively compared 68 patients who underwent endoscopic vs open plantar fasciotomy with heel spur resection, documenting a faster return to work for the endoscopic procedure (28.65 vs 83.85 days). To the current authors' knowledge, that is the only study that has investigated time to return to work in foot surgery. However, because only patients without any bony osteotomy procedures were examined, that study was significantly different from the current study. Atroshi et al20 reported a faster return to work after a minimally invasive procedure for the treatment of carpal tunnel syndrome. Return to work is an indicator of patient satisfaction.21 The current study demonstrated that the percutaneous technique offers a potential benefit in this regard compared with the traditional open approach.
Multimodal analgesia in foot and ankle surgery is advocated as a method to improve pain control, limit hospital stay, and decrease complications associated with opioid consumption.22 In the current study, the long-acting popliteal block and concomitant use of ibuprofen and acetaminophen may have affected the overall number of opioids consumed per patient. Figure 1 shows that most opioids were consumed within the first 3 days postoperatively, and that no patients were using opioids at the 2-week postoperative visit. This indicated that, despite the use of a peripheral nerve block, overall opioid use after percutaneous foot and ankle procedures is still minimal.
More importantly, these data are of value in practicing “prescribing” stewardship. As highlighted by Rodgers et al,23 knowledge of how many pills to prescribe will be a powerful tool that physicians can use to avoid instances of abuse and diversion. Although minimizing postoperative pain alone will not solve the opioid crisis, all physicians must be vigilant in their prescribing habits.
This study had some limitations. This retrospective review involved a small number of patients and no control group. In addition, patients were only broadly stratified by region of the foot undergoing surgery—no specific procedure was investigated. Also, the nurses in the recovery room routinely recommend that patients “stay ahead” of the pain by taking oxycodone prior to experiencing full-blown postoperative pain, which could possibly explain the oxycodone tablets taken within the first 24 hours after discharge to home. Larger studies with a control group are needed to further delineate the outcomes of percutaneous surgeries of the foot and ankle. A comparison group must have similar baseline characteristics because postoperative pain intensity has been linked to preoperative pain severity.24
Overall, this study demonstrated that patients undergoing foot and ankle surgery with percutaneous techniques required significantly less opioid medication postoperatively compared with the average amount reported in the literature. No patient required narcotics 2 weeks after surgery. Patients had rapid recovery and return to work. The authors suggest that only a 2-week supply of narcotics be prescribed for percutaneous techniques in foot surgery.
- Paulozzi LJ. Prescription drug overdoses: a review. J Safety Res. 2012;43(4):283–289. doi:10.1016/j.jsr.2012.08.009 [CrossRef] PMID:23127678
- Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15(9):618–627. doi:10.1002/pds.1276 [CrossRef] PMID:16862602
- 2016 National Survey on Drug Use and Health: methodological summary and definitions. https://www.samhsa.gov/data/sites/default/files/NSDUHMethodSummDefs-2016/NSDUH-MethodSum-mDefs-2016.htm
- Davis WR, Johnson BD. Prescription opioid use, misuse, and diversion among street drug users in New York City. Drug Alcohol Depend. 2008;92(1–3):267–276. doi:10.1016/j.drugalcdep.2007.08.008 [CrossRef] PMID:17913395
- Calcaterra S, Glanz J, Binswanger IA. National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999–2009. Drug Alcohol Depend. 2013;131(3):263–270. doi:10.1016/j.drugalcdep.2012.11.018 [CrossRef] PMID:23294765
- Carragee EJ, Vittum D, Truong TP, Burton D. Pain control and cultural norms and expectations after closed femoral shaft fractures. Am J Orthop (Belle Mead NJ).1999;28(2):97–102. PMID:10067712
- Lindenhovius AL, Helmerhorst GT, Schnellen AC, Vrahas M, Ring D, Kloen P. Differences in prescription of narcotic pain medication after operative treatment of hip and ankle fractures in the United States and The Netherlands. J Trauma. 2009;67(1):160–164. doi:10.1097/TA.0b013e31818c12ee [CrossRef] PMID:19590328
- Merrill HM, Dean DM, Mottla JL, Neufeld SK, Cuttica DJ, Buchanan MM. Opioid consumption following foot and ankle surgery. Foot Ankle Int. 2018; 39(6):649–656. doi:10.1177/1071100718757527 [CrossRef] PMID:29506395
- Lui TH. Percutaneous posterior calcaneal osteotomy. J Foot Ankle Surg. 2015; 54(6):1188–1192. doi:10.1053/j.jfas.2015.04.027 [CrossRef] PMID:26190778
- Magnan B, Bonetti I, Negri S, Maluta T, Dall'Oca C, Samaila E. Percutaneous distal osteotomy of lesser meta-tarsals (DMMO) for treatment of metatarsalgia with metatarsophalangeal instability. Foot Ankle Surg. 2018; 24(5):400–405. doi:10.1016/j.fas.2017.04.012 [CrossRef] PMID:29409206
- Saini S, McDonald EL, Shakked R, et al. Prospective evaluation of utilization patterns and prescribing guidelines of opioid consumption following orthopedic foot and ankle surgery. Foot Ankle Int. 2018;39(11):1257–1265. doi:10.1177/1071100718790243 [CrossRef] PMID:30124084
- Lai MC, Rikhraj IS, Woo YL, Yeo W, Ng YCS, Koo K. Clinical and radiological outcomes comparing percutaneous Chevron-Akin osteotomies vs open scarf-Akin osteotomies for hallux valgus. Foot Ankle Int. 2018; 39(3):311–317. doi:10.1177/1071100717745282 [CrossRef] PMID:29241361
- Kaufmann G, Dammerer D, Heyenbrock F, Braito M, Moertlbauer L, Liebensteiner M. Minimally invasive versus open chevron osteotomy for hallux valgus correction: a randomized controlled trial. Int Orthop. 2019;43(2):343–350. doi:10.1007/s00264-018-4006-8 [CrossRef] PMID:29869014
- Bauer T. Percutaneous first metatarsophalangeal joint fusion. Open Orthop J. 2017;11(1): 724–731. doi:10.2174/1874325001711010724 [CrossRef] PMID:28979586
- Roukis TS. Percutaneous and minimum incision metatarsal osteotomies: a systematic review. J Foot Ankle Surg. 2009;48(3):380–387. doi:10.1053/j.jfas.2009.01.007 [CrossRef] PMID:19423043
- Atroshi I, Larsson GU, Ornstein E, Hofer M, Johnsson R, Ranstam J. Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial. BMJ. 2006;332(7556):1473. doi:10.1136/bmj.38863.632789.1F [CrossRef] PMID:16777857
- Buess E, Steuber KU, Waibl B. Open versus arthroscopic rotator cuff repair: a comparative view of 96 cases. Arthroscopy. 2005;21(5):597–604. doi:10.1016/j.arthro.2005.01.002 [CrossRef] PMID:15891728
- Green MR, Christensen KP. Arthroscopic versus open Bankart procedures: a comparison of early morbidity and complications. Arthroscopy. 1993;9(4):371–374. doi:10.1016/S0749-8063(05)80308-1 [CrossRef] PMID:8216566
- Wander DS. A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome. J Foot Ankle Surg. 1996;35(2):183–184. doi:10.1016/S1067-2516(96)80046-9 [CrossRef] PMID:8722893
- Atroshi I, Johnsson R, Ornstein E. Patient satisfaction and return to work after endoscopic carpal tunnel surgery. J Hand Surg Am. 1998;23(1): 58–65. doi:10.1016/S0363-5023(98)80090-7 [CrossRef] PMID:9523956
- Vestling M, Tufvesson B, Iwarsson S. Indicators for return to work after stroke and the importance of work for subjective well-being and life satisfaction. J Rehabil Med. 2003;35(3):127–131. doi:10.1080/16501970310010475 [CrossRef] PMID:12809195
- Kohring JM, Orgain NG. Multi-modal analgesia in foot and ankle surgery. Orthop Clin North Am. 2017;48(4):495–505. doi:10.1016/j.ocl.2017.06.005 [CrossRef] PMID:28870309
- Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am. 2012;37(4):645–650. doi:10.1016/j.jhsa.2012.01.035 [CrossRef] PMID:22410178
- Chou LB, Wagner D, Witten DM, et al. Postoperative pain following foot and ankle surgery: a prospective study. Foot Ankle Int. 2008;29(11):1063–1068. doi:10.3113/FAI.2008.1063 [CrossRef] PMID:19026197
Patient Characteristics by Type of Surgery
|Age, mean, y||47.2||47.3||59||44.3||46.3|
|Opioid tablets consumed, mean, No.||3.3||2.2||3.5||5.3||11|
|Time to return to work, mean, d||18.9||10.4||33||38.9||54.3|