O3257: Breaking the Habit: A Multicenter Experience Following Discontinuation of Postoperative Opioid Analgesia for Supracondylar Humerus Fractures

Background: Supracondylar humerus (SCH) fractures are one of the most common elbow injuries in pediatric patients. Typically treated with closed reduction and percutaneous pinning (CRPP), adequate postoperative pain control is an important factor contributing to recovery and ultimately joint function. Previous publications have prospectively compared postoperative pain control after undergoing SCH CRPP and demonstrated equivalent analgesia between opioid and non-opioid prescribed groups. These findings have led multiple institutions to establish protocols in effort to discontinue postoperative opioid prescribing following such procedures. The purpose of this study was to describe the multicenter experience following the implementation of these protocols and explore the challenges associated.

Methods: A retrospective review was conducted identifying patients < 18 years old who underwent CRPP for closed SCH fractures one year after implementation of a non-opioid protocol at two pediatric level 1 trauma centers. Inclusion criteria were patients treated with CRPP along with available preoperative radiographs and operative notes for review. Exclusion criteria were patients treated via open reduction. Demographic information, injury characteristics, and outcomes were collected with specific focus on capturing postoperative opioid prescription and need for rescue prescription for postoperative pain. Univariate analyses were conducted using independent student t-tests, chi-squared, and Fisher exact tests as appropriate.

Results: Study criteria identified 447 patients (51.2% female) with a mean age of 6.2 years (SD= 2.2 years). The most common fracture types per the Gartland classification were Type III (48.1%) followed by Type II (45.4%), Type IV (4.7%), and flexion type (1.8%). Nine total patients had concomitant skeletal injuries requiring CRPP including 7 patients having associated distal radius/ulnar fractures, 1 having a lateral humeral condyle fracture, and 1 having a proximal ulna fracture. A total of 70 patients (15.7%, median of 7 doses) still had opioids prescribed at discharge and 4 patients (0.9%) required opioid prescriptions following discharge for inadequate pain control. No significant differences in opioid prescription patterns were seen across injury characteristics or patient race (p>0.05). Patients who were prescribed opioids postoperatively were slightly older (mean= 6.8 vs 6.1 years, p= 0.007) and had longer postoperative follow up (mean= 85.3 vs 68.2 days, p=0.02). Similarly, patients who received rescue opioids were followed for longer postoperatively (mean= 130.8 vs 55.6 days, p=0.001).

Conclusion: One year after implementing non-opioid analgesia protocols, findings support the continued efficacy of non-opioid pain management in SCH CRPP, with less than 1% of patients requiring rescue opioids. Despite the potential of opioid-free protocols, there remain practical and logistical challenges in widespread adoption and difficulty breaking post-operative opioid prescribing habits. Though there are still opportunities to improve education and awareness on the effectiveness of non-opioid protocols following CRPP, pediatric orthopedic surgeons can be reassured that adequate postoperative pain control and responsible opioid stewardship can coexist effectively.