Risks of Preoperative Opioid Therapy on Forefoot and Hindfoot Surgery Success

CATEGORY: Hindfoot; Midfoot/Forefoot INTRODUCTION/PURPOSE: Past studies in total joint arthroplasty and orthopaedic trauma have found that preoperative opioid therapy correlates with increased postoperative opioid use and lesser surgical outcomes. To date, these trends have not been studied in cases of forefoot or hindfoot foot and ankle surgery. We hypothesized that patients with preoperative chronic opioid use would have increased likelihood of postoperative opioid use, complications, and re-operation. METHODS: A retrospective review was conducted of forefoot, midfoot and hindfoot surgeries performed from January 2015- September 2020 by a fellowship trained foot and ankle surgeon at an academic medical center. Pre- and postoperative opioid and other analgesic use, medical history, demographic data, operative treatment, and surgical outcomes were reviewed. Records of preoperative opioid use were limited to 50 patients, 90-day postoperative opioid use to 60 patients, and 180-day postoperative opioid use to 69 patients. A total of 149 patients (female=102, male=47) with a mean BMI of 30.87 and mean follow-up up of 1.2 years were included. Of the patients undergoing hindfoot, midfoot, or forefoot arthrodesis, 71/79 joints went on to union, while there were 8 non-unions (3 sub-talar, 2 metatarsophalangeal, 1 tibiotalar, 1 talo-navicular, and 1 calcaneocuboid). The most common procedures were hammertoe correction and Achilles tendon repair. Statistical analysis was performed using correlation, linear multivariate regression, and one-way ANOVA. RESULTS: Preoperative opioid use was statistically significantly associated with loss to follow-up (users=10.0%, non-users=0.0%; p=.044) and continued postoperative opioid use at 90 (92%; p<.001) and 180 days (94%; p<.001). Preoperative benzodiazepine use was significantly associated with continued postoperative benzodiazepine use at 90 (20%; p<.001) and 180 days (26%; p<.001). Of comorbidities, diabetes (p=.007) and psychiatric disease (p=.025) were significant predictors of postoperative opioid use. Psychiatric disease was also a significant predictor of postoperative benzodiazepine use (p=.026). Postoperative opioid use significantly differed by surgical indication (post-traumatic=20.52 MME, prior procedure(s)=232.51 MME, instability=7.64 MME, osteomyelitis=4.67 MME; p<.001), but postoperative benzodiazepine use did not. Additionally, follow-up duration significantly differed by operated area (hindfoot=1.48 years, forefoot=0.92 years, both=3.02 years; p<.001). CONCLUSION: We found that patients with preoperative opioid use have statistically significantly higher rates of loss to follow-up and continued postoperative opioid use. We also found that on average, patients with a history of prior procedures on the forefoot and/or hindfoot require statistically significantly more narcotics than those with a history of post-traumatic injuries, instability, or osteomyelitis. Patients and surgeons should be aware of this data to help appropriately council patients on post- operative expectations.