Opioid prescribing and pain trajectories after periacetabular osteotomy

Aims Periacetabular osteotomy (PAO) is performed in young, opioid-naive patients and is associated with postoperative pain. Optimizing perioperative analgesia while limiting opioid exposure remains a priority. This study evaluated postoperative pain trajectories, hospital length of stay (LOS), and opioid-prescribing patterns associated with an institutional transition from epidural-based to periarticular injection (PAI)-based analgesia after PAO. Secondary aims were to assess the influence of preoperative opioid exposure and compare outcomes between ropivacaine-based and bupivacaine PAI formulations. Methods The study included 724 patients who underwent PAO between January 2010 and December 2022 at a single academic institution, with epidural use replaced by PAI in 2016. Patients were stratified by postoperative analgesia strategy: epidural catheter (n = 333) or PAI (n = 391). Outcomes included daily postoperative pain scores, LOS, discharge opioid prescriptions (morphine milligram equivalents (MMEs)), total opioid exposure, and 30-day refill rates. Statistical comparisons were performed using chi-squared, Fisher’s exact, and Kruskal–Wallis tests. Results Baseline characteristics were similar between groups. Epidural analgesia was associated with lower pain scores during the first 48 hours (last pain postoperative day 0 to 1: mean 2.9 (SD 2.0) vs 4.7 (SD 2.1); p < 0.001), whereas the PAI group had a shorter LOS (mean 2.2 days (SD 1.0) vs 3.4 days (SD 0.9); p < 0.001) and higher pain scores at discharge (mean 4.8 (SD 1.9) vs 4.0 (SD 1.9); p < 0.001). Median discharge opioid prescriptions (313 (IQR 225 to 388) vs 825 (IQR 600 to 1,000) MMEs) and total 30-day opioid exposure (360 (IQR 275 to 575) vs 900 (IQR 638 to 1,100) MMEs) were lower in the PAI group (both p < 0.001), while refill rates were higher (34.0% vs 19.2%; p < 0.001). Within the PAI cohort, ropivacaine-based and bupivacaine injections showed similar pain trajectories and refill rates. Conclusion Epidural analgesia provided superior early postoperative pain control, whereas PAI-based pathways enabled earlier discharge and lower overall opioid prescribing but with higher refill rates. These findings highlight trade-offs in contemporary perioperative pathways and support individualized analgesic strategies after PAO. Cite this article: Bone Jt Open 2026;7(11):1410–1418.