Date of Award

12-2017

Degree Name

Doctor of Philosophy

Department

Interdisciplinary Health Sciences

First Advisor

Dr. Amy B. Curtis

Second Advisor

Dr. Eric Vangsnes

Third Advisor

Dr. Hobie Summers

Keywords

Nerve block, pain, orthopædic trauma, fracture, lower extremity, anesthesia

Abstract

This research explores current approaches to managing pain control in patients undergoing operative fixation of lower extremity fractures. As opioid use in the U.S. and abroad increases, alternative methods of treating and preventing opioid requirements are being examined. Patients with lower extremity fractures are susceptible to nonunion when anti-inflammatories are consumed, so alternative approaches are warranted. One such alternative, a peri-operative regional nerve block (PNB), is accomplished by injecting local anesthetic adjacent to one or more peripheral nerves supplying the area of the fracture to decrease pain (Fowler, Symons, Sabato, & Myles, 2008). The goal of this research was to determine effectiveness of PNB on decreasing the amount of opioids following surgery, during the hospital admission, and long-term for those undergoing lower extremity surgery as well as on hospital length of stay and readmission. Demographic and anthropometric data were also assessed. This work was conducted to potentially identify additional options to decrease and anticipate post-surgical pain requirements in order to reduce opioid use in the short term and, potentially, opioid addiction in the long term.

This study of those undergoing tibial plateau fracture repair at one level 1 trauma hospital in the Midwest between 2006-2015 revealed statistically significant lower post- operative day zero opioid requirements and shorter hospital admissions in patients who received single shot PNB compared to those with no PNB for tibial plateau fracture repair. However, it was noted that elevations in opioid requirements on post-operative day one should be controlled for when utilizing PNB. A follow-up study of the same sample identified that those of White race and those who smoke had an increased risk of still being prescribed opioids long term (3 months and 6 months for White patients compared to Black patients, and at 6 months for smokers compared to non-smokers). When all lower extremity fractures were examined over the last 10 years (2006-2015), PNB rate of use continued to increase, with the largest increase associated with implementation of a dedicated PNB team. Hospital length of stay was also significantly shorter among those receiving PNB compared to those with no PNB.

PNB should be considered as a tool for decreasing post-operative opioid requirements in patients undergoing operative repair of tibial plateau fractures. PNB should also be considered for decreasing hospital length of stay in those undergoing operative fixation of all lower extremity fractures and tibial plateau fractures, specifically. Hospitals should evaluate prescribing practices with regard to long-term opioid prescriptions and create protocols to ensure the objective management of pain in all race/ethnicities, and be aware of the increased risk for long-term use among smokers and White patients. Lastly, dedicated PNB teams should be considered at institutions that perform orthopaedic trauma surgery in order to increase the use of PNB.

Access Setting

Dissertation-Open Access

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