Hello everyone, my name is Alan Zhang from the University of California, San Francisco. Today I'm providing a lecture for the ANA toolkit on hip arthroscopy. We're going to focus this segment on medications and prophylaxis after surgery. So in considering postoperative medications and prophylaxis, there's four main areas that we want to plan for. One is patient pain control. Another one includes a common complication or side effect of hip arthroscopy, which is heterotopic ossification. Also DVT risk is a risk after hip arthroscopy and then infection as well. For each of these areas, you can think about what medications may be helpful. For pain control, you can use opioids or NSAIDs. HO prophylaxis, you can also use NSAIDs for that, but also radiation is a classic form for that. And then DVT prophylaxis is usually also chemoprophylaxis with medications such as aspirin or factor Xa inhibitors. And then infection prophylaxis would be with antibiotics, of course. In terms of pain medications, most surgeons will prescribe opioids for their patients after hip arthroscopy. The main ones that are used would be hydrocodone or oxycodone. And typically I would give these with the acetaminophen combination. So that would be Norco with hydrocodone and acetaminophen, and then Percocet, oxycodone and acetaminophen. The Norco is like Vicodin, except it's got 325 milligrams of acetaminophen versus 500 for Vicodin. And then the opioid dosage is 5 or 10 for the hydrocodone, similarly with oxycodone as well. And typically you don't want the patients to take this more than every six to eight hours, which is due to the acetaminophen dosage as well. A less potent opioid would be Tramadol or Ultram. This one can also be used, it may be less effective for the pain receptors, but you can also give this to patients every six to eight hours. Now it is important preoperatively to counsel your patients on limiting postoperative opioid use. So we always talk about this in terms of patient expectations before the actual surgery itself. And when I'm prescribing this, I talk to the patients about the risk of using this too much or overdosing as well. And of course, part of that consultation discusses side effects of opioids, which include constipation and nausea. So typically I'll also prescribe Colace to my patients and then Zofran as well for nausea. But then I tell them, hey, if you're not taking a lot of opioids, then you don't have to worry about the side effects and these other medications. And it helps them kind of think about limiting the use overall. Further things you can do to decrease opioid use include things during the surgery like a pericapsular block. So this is, at the end of the case, you could just put a bunch of local anesthetic around the capsule or in the joint to help decrease postoperative acute pain. And this has been shown to be more effective than peripheral nerve blocks in a randomized control trial. Here at UCSF, we also did a randomized control trial of fascia iliac preoperative block versus a sham block, which is saline. And we found that there's really no difference in pain control with or without that block. So we don't do this preoperatively for patients. Sometimes we'll still do rescue nerve blocks in the recovery room with the patients having a lot of pain, but we don't just do automatic pre-op blocks for patients anymore. And of course, as referenced earlier, there's been good studies on this in other areas of sports medicine where if you discuss preoperative opioid expectations and educate the patients on limiting the use, it's been very effective for decreasing postoperative use for opioids. So in my practice, I give my patients Norco, the 10 milligram dose, and I have them take it one tablet every six hours as needed for pain. But I only prescribe 12 tablets for my hip arthroscopy patients. This is enough for three days if you're taking one every six hours. And I tell my patients, I expect them to not need it after two days, typically sometimes less. And there's plenty of my patients who told me they never end up using this at all. So that's kind of the small dosage I give to them. And I haven't had requests to refill this. So if patients take this, a lot of times they don't use all of it. If they do use all of it, they know they're done after that. So I haven't had people call me to try to refill that either over the years. And then I also give Colace and Zofran as well. This will limit your postoperative phone calls to the office about constipation or nausea if they are taking the Norco. And of course, the preoperative discussion, I just want to reemphasize how important that is for limiting opioid use. Now you can also use NSAIDs, which will help with pain control as well. But also decrease opioid use. So you can give ibuprofen, 6 to 800 milligrams every 6 to 8 hours. You can also do naproxen or Aleve, 500 milligrams every 12 hours. And then this kind of blends into the next section about heterotopic ossification. So you can kind of consider what NSAIDs you want to use in relation to HO prophylaxis. So HO is a risk after hip arthroscopy because during our femoroplasty or osteoplasty parts of the surgery, the little bone dust can get into the muscles or out into the soft tissue. So you want to make sure the HO doesn't form. So the classic treatment for HO prophylaxis has been with endomethicin, which is a very strong NSAID. And you can give that either 75 QDay or 50 milligrams BID, and you can do that for three up to six weeks. And a lot of patients may have some stomach issues or gastric upset with that because that's a very strong medication. You can also use naproxen, 500 milligrams BID for two to three weeks, and we'll talk a little bit about that in a second. And of course, you can also use radiation, which is really uncommon when we're doing this in an outpatient setting. We're not going to send the patients to get irradiated at the hospital right afterwards. So in terms of the naproxen use for HO prophylaxis, Steve Aoki at Utah did a really nice study back in 2015, randomized double-blinded controlled trial, giving patients naproxen, 500 milligrams BID for three weeks. And the patients that got the naproxen had much lower HO rates, down from 46% for the placebo group, down to 4%. And then subsequently, he did a follow-up study on this where he just did naproxen BID for two weeks, and that showed to have the same effect, only 3% HO risk after the surgery. So I've really adopted that. This is really good literature on that. So for my pain control and HO prophylaxis in my practice, I'll give naproxen, 500 milligrams BID for two weeks. I give them 28 tablets and I tell them to finish that off, even if they're not having any pain. This is still good for HO prophylaxis. Now, in terms of DVT or PE, after hip arthroscopy, the risk is relatively low, 1% to 5%. It's been shown to be a lower risk than knee arthroscopy in the literature, but it depends on certain factors, definitely patient factors such as obesity, older age, if they're on oral contraceptives, and then also medical or family history can affect this as well. Obesity, what their weight-bearing status is, if they're very limited on their weight-bearing status and very limited with a restrictive brace, this may also increase their risk for the DVT. And then in terms of prevention, you can use chemoprophylaxis, and the medications for that can be used for two to three weeks, typically while they're on crutches or in a brace. You can use aspirin, which you can do 81 milligrams as a baby aspirin once a day, that would be the bare minimum, or you could do twice a day for baby aspirin, or you can use a full dose aspirin, 325 milligrams a day. The literature on what type of aspirin you want to use or how frequent is all over the place, but it shows that pretty much any of those could be good options for using aspirin. If you want to do something stronger, there's the factor Xa inhibitors, so the oral ones are the ones that are more popular nowadays with Xarelto or Eliquis, which is shown there, and then also the subcutaneous injections with Lobinox or Heparin, those are less likely to be used now with the effective oral inhibitors. However, we did do a large database study looking at risk for DVT after hip arthroscopy, and we showed that this was a very low rate overall, so 0.5% for DVT, 0.6% for any type of venous thromboembolism that would include PE or DVT. We also show that in this large cohort, thromboprophylaxis with aspirin or Lobinox was not really associated with decreasing the risk because the inherent risk was so low. Now, patients with obesity, oral contraceptive pills, or history of malignancy did have much higher risks, so those populations may need to be targeted a little bit more, but you have to think about routinely giving aspirin along with your NSAIDs such as naproxen. This is going to really lead to high risk for gastritis because you're giving a high dose of NSAIDs and aspirin at the same time, especially if the patient has any history of gastric upset or ulcers. It's definitely going to irritate that, so if you do do DVT prophylaxis, you're going to also want to give a proton pump inhibitor. The most common one is Omeprazole, and Prilosec is over-the-counter these days as well for that. So in my practice, I don't routinely give DVT prophylaxis for my hip arthroscopy patients. However, if they do have certain risk factors like age over 40, they're on an oral contraceptive pill, obese, or a family history of DVT, then I'll give them a full dose of aspirin once a day for two weeks. And then if the patient has a personal history of DVT after prior surgery, then we're going to really increase our prophylaxis on this, and I'll just give them Apixaban or Eliquis 5mg BID for four weeks after surgery. And of course, if I add aspirin or Apixaban, I'm going to also give them Omeprazole during that time course, whether it's two weeks or four weeks, as long as they're on the prophylaxis as well. Infection, finally, this is a very low rate after hip arthroscopy. This area of skin is not like the shoulder where there's C. acnes, so it's a relatively low bacterial burden. We just give IV Cefazolin before skin incision during the surgery, but I don't give any oral antibiotics after surgery. There's really not much literature on needing to do that, unless the patient has had multiple skin infections or something like that before, I wouldn't do this. Wrapping this up, this is my medication slash prophylactic protocol after my hip arthroscopy. For pain control, I'll give them Norco 10 over 325, 12 tablets. I'll give them Colace, 30 tablets of that, and I'll give them Zofran, 10 tablets of that. I'll also give Naproxen 500 BID for two weeks, 28 tablets for that, and then I don't give anything for DVT or infection unless there's some previous history or significant risk factors. All right, that's all I have for this. Thanks so much for your time.

hip arthroscopy

postoperative care

heterotopic ossification

deep vein thrombosis

Alan Zhang