JOT - 2026-06-01 - Journal Article
Trends in Utilization of Multimodal Pain Management After Pilon Fracture Open Reduction and Internal Fixation.
Ratnasamy PP, Aron A, Slevin J, Grauer JN, Fram BR
Topics
Key Takeaway
Opioid prescriptions after pilon fracture ORIF fell 61.8% (434 to 166 per 1,000 surgeries) from 2010–2021, with MME per 1,000 surgeries dropping 91.3%, while nonopioid analgesic prescriptions declined only 29.4%.
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Summary
This study queried the PearlDiver M170Ortho national administrative database to characterize trends in postoperative analgesic prescribing after pilon fracture ORIF (AO-OTA 43A/B/C) from 2010–2021, excluding patients with preinjury opioid use, polytrauma, substance abuse, or malignancy. Opioid prescriptions dropped 61.8% and MME per 1,000 surgeries dropped 91.3% over the study period, with 97% of opioids prescribed within the first 2 postoperative weeks. Younger age (OR 1.29 per decade decrease), male sex (OR 1.54), and lower Elixhauser Comorbidity Index (OR 1.28) independently predicted opioid prescribing.
Key Limitation
Inpatient opioid and nonopioid analgesic administration is not captured, making it impossible to determine whether reduced outpatient opioid prescribing reflects genuine multimodal substitution or simply a shift of analgesic burden to the inpatient setting.
Original Abstract
OBJECTIVES
To evaluate trends in pain medication prescriptions after pilon fracture open reduction and internal fixation (ORIF) in the context of recent initiatives to reduce opioid use and promote multimodal pain management.
DESIGN
Retrospective database study.
SETTING
US national administrative data set (PearlDiver M170Ortho database).
PATIENT SELECTION CRITERIA
Included were patients undergoing pilon fracture (AO-OTA 43A/B/C) ORIF from 2010 to 2021 without history of preinjury narcotic use, polytrauma, substance abuse, or neoplasm.
OUTCOME MEASURES AND COMPARISONS
This study captured prescriptions for pain medications within 90 days postoperatively after definitive pilon fracture fixation, categorized by drug category. Annual prescriptions and morphine milligram equivalents per 1000 surgeries were trended during the study interval. Timing of opioid prescriptions postoperatively was determined. Multivariable analysis was performed to determine factors independently associated with opioid prescriptions.
RESULTS
Included were 13,108 patients with pilon fracture ORIF, of whom the average age was 50 years (range 18-84 years (49.9%) female). Discretely billed outpatient opioid prescriptions decreased from 434.1 per 1000 surgeries in 2010 to 165.7 in 2021 (-61.8%). Prescriptions of other pain management drugs on aggregate decreased less drastically from 276.6 in 2010 to 195.3 in 2021 (-29.4%). The proportion of all analgesic medications prescribed postoperatively that were opioids decreased from 60.3% in 2010 to 45.9% in 2021. Among patients who received opioids within 90 days postoperatively, morphine milligram equivalents prescribed per 1000 pilon fracture ORIF surgeries decreased from 589,486 in 2010 to 59,795 in 2021 (-91.3%). The 97% of opioids were prescribed in the first 2 weeks postoperatively. Predictors of postoperative opioid prescriptions by multivariate analysis included younger age (odds ratio [OR] 1.29 per decade decrease), male sex (OR 1.54), and lower Elixhauser Comorbidity Index (OR 1.28) ( P < 0.0001 for all). Patients who had repair of tibia and fibula fractures did not have greater odds of postoperative opioid prescriptions than those who had repair of the tibia alone.
CONCLUSIONS
Opioid prescriptions after pilon fracture ORIF decreased substantially from 2010 to 2021. Prescriptions for nonopioid analgesic medications also decreased but to a lesser extent. Younger age, male sex, and lower comorbidity burden were associated with higher postoperative opioid prescribing.
LEVEL OF EVIDENCE
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.