Suspected gluteal compartment syndrome: Etiology predicts clinical course, outcomes and resource utilization

Background

Gluteal Compartment Syndrome (GCS) is a rare subtype of acute compartment syndrome (ACS), complex to diagnose and potentially fatal if left untreated. The incidence of ACS is estimated to be 7.3 per 100,000 in males and 0.7 per 100,000 in females [1-3]. Given its rare occurrence, the incidence of GCS is not well reported. In the case of GCS, the most common etiologies are surgical positioning, prolonged immobilization secondary to substance use or loss of consciousness, and traumatic injury. Clinical findings are pulselessness, pallor, parasthesia, paralysis, and most notably pain out of proportion. Swift diagnosis and treatment are imperative to reduce morbidity and mortality, however the ideal management of GCS is difficult to ascertain given the rare occurrence and variable presentation.

Methods

Orthopaedic trauma database at a level 1 trauma center was reviewed to identify patients for whom the orthopaedic service was consulted due to suspicion of gluteal compartment syndrome. This yielded 11 patients between 2011 and 2019. Patients with a measured ΔP greater than 30 upon initial consultation and with a concerning exam requiring monitoring were included. Patient demographics, comorbidities, GCS etiology, laboratory values, physical exam findings, pain scores (0-10) and patient outcomes were collected via chart review. Patient demographic and injury characteristics were summarized using descriptive statistics.

Results

Prolonged immobilization patients had worse outcomes including longer hospital stays (40.5 days) compared to trauma patients (4.5 days). All adverse medical outcomes recorded including acute renal failure, prolonged neuropathic pain, cardiopulmonary dysfunction were exclusively experienced by prolonged immobilization patients.

Conclusions

Our descriptive study demonstrates the bimodal distribution of GCS patients based on etiology. Prolonged immobilization patients have a longer hospital course and more complications. Our study confirms prior reports and provides information that can be used to counsel patients and families appropriately about treatment and recovery following GCS.

Level of evidence

IV.

Study type

Epidemiological.

Opioid Prescribing Rate for Nonoperative Distal Radius Fractures and Clinician Response to a Clinical Decision Support Alert

BACKGROUND

Opioids are commonly prescribed for the management of acute orthopedic trauma pain, including nonoperative distal radius fractures.

OBJECTIVES

This prospective study aimed to determine if a clinical decision support intervention influenced prescribing decisions for patients with known risk factors. We sought to quantify frequency of opioid prescriptions for acute nonoperative distal radius fractures treated.

METHODS

We performed a prospective study at one large health care system. Utilizing umbrella code S52.5, we identified all distal radius fractures treated nonoperatively, and the encounters were merged with the Prescription Reporting with Immediate Medication Mapping (PRIMUM) database to identify encounters with opioid prescriptions and patients with risk factors for opioid use disorder. We used multivariable logistic regression to determine patient characteristics associated with the prescription of an opioid. Among encounters that triggered the PRIMUM alert, we calculated the percentage of encounters where the PRIMUM alert influenced the prescribing decision.

RESULTS

Of 2984 encounters, 1244 (41.7%) included an opioid prescription. Age increment is a significant factor to more likely receive opioid prescriptions (p < 0.0001) after adjusting for other factors. Among encounters where the physician received an alert, those that triggered the alert for early refill were more likely to influence physicians' opioid prescribing when compared with other risk factors (p = 0.0088).

CONCLUSION

Over 90% of patients (106/118) continued to receive an opioid medication despite having a known risk factor for abuse. Additionally, we found older patients were more likely to be prescribed opioids for nonoperatively managed distal radius fractures.

Lifetime cost-effectiveness analysis osseointegrated transfemoral versus socket prosthesis using Markov modelling

Aims

Prior cost-effectiveness analyses on osseointegrated prosthesis for transfemoral unilateral amputees have analyzed outcomes in non-USA countries using generic quality of life instruments, which may not be appropriate when evaluating disease-specific quality of life. These prior analyses have also focused only on patients who had failed a socket-based prosthesis. The aim of the current study is to use a disease-specific quality of life instrument, which can more accurately reflect a patient's quality of life with this condition in order to evaluate cost-effectiveness, examining both treatment-naïve and socket refractory patients.

Methods

Lifetime Markov models were developed evaluating active healthy middle-aged male amputees. Costs of the prostheses, associated complications, use/non-use, and annual costs of arthroplasty parts and service for both a socket and osseointegrated (OPRA) prosthesis were included. Effectiveness was evaluated using the questionnaire for persons with a transfemoral amputation (Q-TFA) until death. All costs and Q-TFA were discounted at 3% annually. Sensitivity analyses on those cost variables which affected a change in treatment (OPRA to socket, or socket to OPRA) were evaluated to determine threshold values. Incremental cost-effectiveness ratios (ICERs) were calculated.

Results

For treatment-naïve patients, the lifetime ICER for OPRA was $279/quality-adjusted life-year (QALY). For treatment-refractory patients the ICER was $273/QALY. In sensitivity analysis, the variable thresholds that would affect a change in the course of treatment based on cost (from socket to OPRA), included the following for the treatment-naïve group: yearly replacement components for socket > $8,511; cost yearly replacement parts OPRA < $1,758; and for treatment-refractory group: yearly replacement component for socket of > $12,467.

Conclusion

The use of the OPRA prosthesis in physically active transfemoral amputees should be considered as a cost-effective alternative in both treatment-naïve and treatment-refractory socket prosthesis patients. Disease-specific quality of life assessments such as Q-TFA are more sensitive when evaluating cost-effectiveness.

Perioperative nutritional status thought to be important, but poorly understood

OBJECTIVES

Malnutrition has been shown to increase complications and leads to poor outcomes in surgical patients, but it has not been studied extensively in orthopedic trauma. This study's purpose is to determine the perspective and assessment of nutrition by orthopedic traumatologists.

METHODS

A survey was created and distributed via REDCap to orthopedic traumatologists at 60 U.S. trauma centers. Out of 183 distributed surveys, 130 surgeons completed the survey (71%). The survey focused on the importance of nutrition and practice patterns in orthopedic trauma.

RESULTS

Seventy-five percent of surgeons thought that nutritional status was "very important" to the final outcome of patients with orthopedic trauma injuries, 24% responded "somewhat important" and 1% responded "not important." Furthermore, 88% perform nutritional assessments; most surgeons (77%) utilize nutritional laboratory markers, with the most common markers being albumin, pre-albumin, transferrin and CRP. Additionally, 42% think trending the laboratory markers is important, and 50% are not sure if nutrition markers should be tested at multiple time points. Despite 75% of surgeons believing that nutrition is very important, only 8% discuss it with patients routinely. When asked what is more important for outcomes, nutrition or Vitamin D, almost three times as many surgeons thought nutrition was more important (29% vs 11%, respectively).

CONCLUSIONS

While orthopedic traumatologists believe nutrition is an important determinant of patient outcomes, this study shows a clear lack of consensus and variability in practice regarding nutrition among surgeons. Orthopedic trauma surgeons need specific guidelines on how to assess and treat malnutrition in trauma patients.

Are Orthopaedic Trauma Surgeons Appropriately Compensated for Treating Acetabular Fractures? An Analysis of Operative Times and Relative Value Units

OBJECTIVES

To evaluate the work relative value units (RVUs) attributed per minute of operative time (wRVU/min) in fixation of acetabular fractures, evaluate surgical factors that influence wRVU/min, and compare wRVU/min with other procedures.

METHODS

DESIGN

Retrospective.

SETTING

Level 1 academic center.

PATIENT SELECTION CRITERIA

Two hundred fifty-one operative acetabular fractures (62 A, B, C) from 2015 to 2021.

OUTCOME MEASURES AND COMPARISONS

Work relative value unit per minute of operative time for each acetabular current procedural terminology (CPT) code. Surgical approach, patient positioning, total room time, and surgeon experience were collected. Comparison wRVU/min were collected from the literature.

RESULTS

The mean wRVU per surgical minute for each CPT code was (1) CPT 27226 (isolated wall fracture): 0.091 wRVU/min, (2) CPT 27227 (isolated column or transverse fracture): 0.120 wRVU/min, and (3) CPT 27228 (associated fracture types): 0.120 wRVU/min. Of fractures with single approaches, anterior approaches generated the least wRVU/min (0.091 wRVU/min, P = 0.0001). Average nonsurgical room time was 82.1 minutes. Surgeon experience ranged from 3 to 26 years with operative time decreasing as surgeon experience increased ( P = 0.03). As a comparison, the wRVU/min for primary and revision hip arthroplasty have been reported as 0.26 and 0.249 wRVU/min, respectively.

CONCLUSIONS

The wRVUs allocated per minute of operative time for acetabular fractures is less than half of other reported hip procedures and lowest for isolated wall fractures. There was a significant amount of nonsurgical room time that should be accounted for in compensation models. This information should be used to ensure that orthopaedic trauma surgeons are being appropriately supported for managing these fractures.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Humerus Nonunion Surgery in Patients With Initial Operative Fracture Fixation

OBJECTIVES

To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population.

METHODS

DESIGN

Retrospective case series.

SETTING

Eight, academic, level 1 trauma centers.

PATIENTS SELECTION CRITERIA

Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019.

OUTCOME MEASURES AND COMPARISONS

Success rate of nonunion surgery.

RESULTS

Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate.

CONCLUSIONS

This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patients with glenohumeral arthritis are more likely to be prescribed opioids in the emergency department or urgent care setting

OBJECTIVE

The objective is to quantify the rate of opioid and benzodiazepine prescribing for the diagnosis of shoulder osteoarthritis across a large healthcare system and to describe the impact of a clinical decision support intervention on prescribing patterns.

DESIGN

A prospective observational study.

SETTING

One large healthcare system.

PATIENTS AND PARTICIPANTS

Adult patients presenting with shoulder osteoarthritis.

INTERVENTIONS

A clinical decision support intervention that presents an alert to prescribers when patients meet criteria for increased risk of opioid use disorder.

MAIN OUTCOME MEASURE

The percentage of patients receiving an opioid or benzodiazepine, the percentage who had at least one risk factor for misuse, and the percent of encounters in which the prescribing decision was influenced by the alert were the main outcome measures.

RESULTS

A total of 5,380 outpatient encounters with a diagnosis of shoulder osteoarthritis were included. Twenty-nine percent (n = 1,548) of these encounters resulted in an opioid or benzodiazepine prescription. One-third of those who received a prescription had at least one risk factor for prescription misuse. Patients were more likely to receive opioids from the emergency department or urgent care facilities (40 percent of encounters) compared to outpatient facilities (28 percent) (p < .0001). Forty-four percent of the opioid prescriptions were for "potent opioids" (morphine milliequivalent conversion factor > 1). Of the 612 encounters triggering an alert, the prescribing decision was influenced (modified or not prescribed) in 53 encounters (8.7 percent). All but four (0.65 percent) of these encounters resulted in an opioid prescription.

CONCLUSION

Despite evidence against routine opioid use for osteoarthritis, one-third of patients with a primary diagnosis of glenohumeral osteoarthritis received an opioid prescription. Of those who received a prescription, over one-third had a risk factor for opioid misuse. An electronic clinic decision support tool influenced the prescription in less than 10 percent of encounters.

Adherence to legislation limiting opioid prescription duration following musculoskeletal injury

OBJECTIVES

North Carolina had implemented legislation (Strengthen Opioid Misuse Prevention (STOP) Act) limiting opioid prescriptions to 5 days for acute pain and 7 days for post-operative pain. This study aimed to identify patient, prescriber, and facility characteristics associated with STOP Act adherence for patients with acute or post-surgical musculoskeletal (MSK) conditions.

DESIGN

A three-level hierarchical logistic regression model was used to predict odds of adherence with STOP Act duration limits, accounting for fixed and random effects at the patient, prescriber, and facility levels.

SETTING

A large healthcare system in North Carolina.

PATIENTS AND PARTICIPANTS

Patients (N = 6,849) presenting from 2018 to 2020 with a diagnosis of an acute MSK injury.

INTERVENTIONS

The STOP Act limited the duration of opioid prescriptions in North Carolina.

MAIN OUTCOME MEASURE

Prescriptions adhering to the STOP Act duration limits of 5 days (nonoperative) or 7 days (operative) were the primary outcome.

RESULTS

Opioids were compliant with STOP Act duration limits in 69.3 percent of encounters, with 33 percent of variation accounted for by clinician and 29 percent by facility. Patients prescribed >1 opioid (odds ratio (OR) 0.46, 95 percent confidence interval (CI): 0.36, 0.58) had reduced odds of a compliant prescription; surgical patients had increased odds of a compliant prescription (outpatient surgery: OR 5.89, 95 percent CI: 2.43-14.29; inpatient surgery: OR 7.71, 95 percent CI: 3.04-19.56). Primary care sports medicine clinicians adhered to legislation less frequently than orthopedic surgeons (OR 0.38, 95 percent CI: 0.15, 0.97).

CONCLUSIONS

Most prescriptions adhered to STOP Act legislation. Tailored interventions to improve adherence among targeted groups of prescribers, eg, those treating nonoperative injuries and sport medicine clinicians, could be useful.

Impact of clinical decision support on controlled substance prescribing

BACKGROUND

Prescription drug overdose and misuse has reached alarming numbers. A persistent problem in clinical care is lack of easy, immediate access to all relevant information at the actionable time. Prescribers must digest an overwhelming amount of information from each patient's record as well as remain up-to-date with current evidence to provide optimal care. This study aimed to describe prescriber response to a prospective clinical decision support intervention designed to identify patients at risk of adverse events associated with misuse of prescription opioids/benzodiazepines and promote adherence to clinical practice guidelines.

METHODS

This study was conducted at a large multi-center healthcare system, using data from the electronic health record. A prospective observational study was performed as clinical decision support (CDS) interventions were sequentially launched (January 2016-July 2019). All data were captured from the medical record prospectively via the CDS tools implemented. A consecutive series of all patient encounters including an opioid/benzodiazepine prescription were included in this study (n = 61,124,172 encounters; n = 674,785 patients). Physician response to the CDS interventions was the primary outcome, and it was assessed over time using control charts.

RESULTS

An alert was triggered in 23.5% of encounters with a prescription (n = 555,626). The prescriber decision was influenced in 18.1% of these encounters (n = 100,301). As the number of risk factors increased, the rate of decision being influenced also increased (p = 0.0001). The effect of the alert differed by drug, risk factor, specialty, and facility.

CONCLUSION

The delivery of evidence-based, patient-specific information had an influence on the final prescription in nearly 1 in 5 encounters. Our intervention was sustained with minimal prescriber fatigue over many years in a large and diverse health system.

Opioid Prescribing for Chronic Musculoskeletal Conditions: Trends over Time and Implementation of Safe Opioid-Prescribing Practices

OBJECTIVES

This study aimed (1) to determine the impact of a clinical decision support (CDS) tool on rate of opioid prescribing and opioid dose for patients with chronic musculoskeletal conditions and (2) to identify prescriber and facility characteristics associated with adherence to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain in this population.We conducted an interrupted time series analysis to assess trends in percentage of patients from 2016 to 2020, receiving an opioid and the average opioid dose, as well as the change associated with implementation of the CDS toolkit. We conducted a retrospective cohort study to assess the association between prescriber and facility characteristics and safe opioid-prescribing practices.

METHODS

We assessed the impact of the CDS intervention on percent of patients receiving an opioid and average opioid dose (morphine milligram equivalents). We operationalized safe opioid prescribing as a composite score of several behaviors (i.e., prescribing naloxone, initiating a pain agreement, prescribing <90 MME, avoiding extended-release prescriptions for opioid-naïve patients, and avoiding coprescribing opioids and benzodiazepines) and used a hierarchical linear regression model to assess associations between prescriber and facility characteristics and safe opioid prescribing.

RESULTS

This CDS intervention had a modest but statistically significant 1.6% reduction on the percent of patients (n = 1,290,746) receiving an opioid (mean: 15% preintervention; 10% postintervention). The average dose of opioid prescriptions did not significantly change. Advanced practice providers and prescribers with higher percentages of patients aged 18 to 64 exhibited safer opioid prescribing, while prescribers with higher percentages of white patients and larger numbers of patients on opioids exhibited less safe opioid prescribing.

CONCLUSION

A CDS intervention was associated with a small improvement in percent of patients receiving an opioid, but not on average dose. Clinicians are not prescribing opioids for chronic musculoskeletal conditions frequently, when they do, they are generally adhering to guidelines.

Persistent opioid and benzodiazepine use after radical cystectomy in enhanced recovery after surgery (ERAS) patients

OBJECTIVES

Opioid use, misuse, and diversion is of paramount concern in the United States. Radical cystectomy is typically managed with some component of opioid pain control. We evaluated persistent opioid and benzodiazepine use after radical cystectomy and assessed the impact of their preoperative use on this outcome. We also explored associations between preoperative use and perioperative outcomes.

METHODS AND MATERIALS

We used prospectively maintained data from our enhanced recovery after surgery (ERAS) cystectomy database and the Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM) database to identify controlled substance prescriptions for radical cystectomy patients. We separated patients by frequency of preoperative opioid and/or benzodiazepine prescriptions (0, 1, 2+) and used these cohorts to explore persistent use (prescription 3-12 months after surgery) alongside perioperative outcomes.

RESULTS

Our cohort included 257 patients undergoing cystectomy at a single institution from 2017 to 2021. Preoperative opioid and benzodiazepine prescriptions were documented for 120 (46.7%) and 26 (10.1%) patients, respectively. Persistent opioid use was observed in 20 (14.6%) of opioid-naive patients (no prescriptions in 9 months prior to surgery) while 13 (19.7%) patients with 1 preoperative prescription and 28 (51.9%) patients with 2 or more preoperative prescriptions demonstrated persistent use. New persistent benzodiazepine use occurred in 6 (2.6%) patients. Overall persistent benzodiazepine use was present in 11 (4.3%) patients. In a multivariable model, preoperative opioid and benzodiazepine prescriptions were associated with persistent opioid use (P < 0.001; P = 0.027 respectively). No association was identified between preoperative opioid or benzodiazepine usage and perioperative outcomes including length of stay, return of bowel function, inpatient opioid usage, inpatient or discharge complications, readmissions, or emergency department visits. Inpatient pain scores were noted to be higher in patients with ≥ 2 preoperative opioid prescriptions (P = 0.037).

CONCLUSIONS

Persistent opioid use was present in 23.7% of patients, with a new persistent use rate of 14.6%. Benzodiazepine use was less frequent than opioids, with a small number demonstrating new persistent use. Preoperative opioid and benzodiazepine use is associated with persistent opioid use postoperatively. Preoperative opioid and benzodiazepine use did not affect perioperative outcomes in our cohort.

Changes in opioid prescription duration for musculoskeletal injury associated with the North Carolina Strengthen Opioid Misuse Prevention (STOP) Act

OBJECTIVES

To assess whether implementation of the Strengthen Opioid Misuse Prevention (STOP) Act was associated with an increase in the percentage of opioid prescriptions written for 7 days or fewer among patients with acute or postsurgical musculoskeletal conditions.

DESIGN

An interrupted time-series study was conducted to determine the change in duration of opioid prescriptions associated with the STOP Act.

SETTING

Data were extracted from the electronic health record of a large health care system in North Carolina.

SUBJECTS

Patients presenting from 2016 to 2020 with an acute musculoskeletal injury and the clinicians treating them were included in an interrupted time-series study (n = 12 839).

METHODS

Trends were assessed over time, including the change in trend associated with implementation of the STOP Act, for the percentage of prescriptions written for ≤7 days.

RESULTS

Among patients with acute musculoskeletal injury, less than 30% of prescriptions were written for ≤7 days in January of 2016; by December of 2020, almost 90% of prescriptions were written for ≤7 days. Prescriptions written for ≤7 days increased 17.7% after the STOP Act was implemented (P < .001), after adjustment for the existing trend.

CONCLUSIONS

These results demonstrate significant potential for legislation to influence opioid prescribing behavior.

The use of xenogenic dermal matrices in the context of open extremity wounds: where and when to consider?

Optimal treatment of orthopaedic extremity trauma includes meticulous care of both bony and soft tissue injuries. Historically, clinical scenarios involving soft tissue defects necessitated the assistance of a plastic surgeon. While their expertise in coverage options and microvascular repair is invaluable, barriers preventing collaboration are common. Acellular dermal matrices represent a promising and versatile tool for orthopaedic trauma surgeons to keep in their toolbox. These biological scaffolds are each unique in how they are used and promote healing. This review explores some commercial products and offers guidance for selection in different clinical scenarios involving traumatic wounds.

Impact of Anesthesia selection on Post-Op Pain Management in Operatively treated Hip Fractures

OBJECTIVES

To determine if the use of Peripheral Nerve Block (PNB) versus Local Infiltration Analgesia (LIA) for hip fracture patients, affected opioid consumption in the early post-operative period.

DESIGN

Retrospective cohort study SETTING: Two level 1 trauma centers PATIENTS/INTERVENTION: 588 patients with surgically treated AO/OTA 31A and 31B fractures between February 2016-October 2017 were included. 415 (70.6%) received general anesthesia (GA) alone, 152 received GA plus perioperative PNB (25.9%), and 21 had GA plus LIA intra-operatively (3.6%). Median age was 82 years; predominantly female (67%) and AO/OTA 31A fractures (55.37%).

MAIN OUTCOME MEASURES

Morphine Milligram Equivalents (MME) at 24 and 48 hours postoperatively, length of stay (LOS) and the occurrence of any complication after surgery RESULTS: The PNB cohort was less likely to use any opioid than the GA group at 24 and 48 hours postoperatively (OR: 0.36, 95% CI: 0.22-0.61 and OR: 0.56, 95% CI: 0.35-0.89 respectively). LOS ≥ 10 days had 3.24 times the odds of 24- and 48-hour opioid administration compared to LOS ≤ 10 days (OR: 3.24, 95% CI 1.11-9.42; OR: 2.98, 95% CI 1.38-6.41, respectively). The most common complication was post-operative delirium, with PNB more likely to present with any complication compared to GA (OR= 1.88, 95% CI 1.09-3.26). There was no difference when comparing LIA to general anesthesia.

CONCLUSIONS

Our findings suggest PNB for hip fracture can help limit the use of post-operative opioids with adequate pain relief. Regional analgesia does not seem to avoid complications such as delirium.

Implementation of required sedation assessment in nursing workflow to address naloxone utilization

OBJECTIVE

Opioid-related adverse drug events continue to occur. This study aimed to characterize the patient population receiving naloxone to inform future intervention efforts.

DESIGN

We describe a case series of patients who received naloxone in the hospital during a 16-week time frame in 2016. Data were collected on other administered medications, reason for admission to the hospital, pre-existing diagnoses, comorbidities, and demographics.

SETTING

Twelve hospitals within a large healthcare system.

PATIENTS

46,952 patients were admitted during the study period. 31.01 percent (n = 14,558) of patients received opioids, of which 158 received naloxone.

INTERVENTION

Administration of naloxone. Main outcome of interest: Sedation assessment via Pasero Opioid-Induced Sedation Scale (POSS), administration of sedating medications.

RESULTS

POSS score was documented prior to opioid administration in 93 (58.9 percent) patients. Less than half of patients had a POSS documented prior to naloxone administration with 36.8 percent documented 4 hours prior. 58.2 percent of patients received multimodal pain therapy with other nonopioid medications. Most patients received more than one sedating medication concurrently (n = 142, 89.9 percent).

CONCLUSIONS

Our findings highlight areas for intervention to prevent opioid oversedation. Investing in electronic clinical decision support mechanisms, such as sedation assessment, could detect patients at risk for oversedation and ultimately prevent the need for naloxone. Coordinated order sets for pain management can reduce the percentage of patients receiving multiple sedating medications and promote the use of multimodal pain management in efforts to reduce opioid reliance while optimizing pain control.

How Many Patients Do We Need? Predictors of Consent to Participate in Clinical Research Studies in Orthopaedic Trauma

OBJECTIVES

To characterize the recruitment rates at a Level I trauma center enroling for multiple prospective orthopaedic trauma research studies and identify patient-related and study-related predictors of consent.

DESIGN

We conducted a case-control study to identify predictors of study consent. The authors categorized studies based on intensity of the study intervention (low, intermediate, or high). A 2-level generalized linear model with random intercept for study was used to predict study consent.

SETTING

This analysis includes data from 10 federally funded studies conducted as part of a large, national consortium that were enroling patients in 2013-2014.

PATIENTS/PARTICIPANTS

Three hundred thirty-four patients were approached for at least 1 study and included in the analysis.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

Consent to participate in the research study.

RESULTS

A total of 315 patients consented to be in a study (71% of approached patients). Consent rate varied by study (45%-95%). No patient characteristics (race, age, or sex) were associated with consent. Patients approached for studies of intermediate intensity were 83% less likely to consent (odds ratio = 0.17; 95% confidence interval: 0.04-0.67), and those approached for studies of high intensity were 91% less likely to consent (odds ratio = 0.09; 95% confidence interval: 0.03-0.32).

CONCLUSION

Patient factors were not associated with consent. Study intensity is a major driver of consent rates. Studies of higher intensity will require the study team to approach up to twice as many patients as the target enrolment. This study provides a framework that can be used in study planning and determination of feasibility.

Opioid and benzodiazepine use in gynecologic oncology patients

OBJECTIVE

The goals of this study were to describe opioid and benzodiazepine prescribing practices in the gynecologic oncology patient population and determine risks for opioid misuse in these patients.

METHODS

Retrospective study of opioid and benzodiazepine prescriptions for patients treated for cervical, ovarian (including fallopian tube/primary peritoneal), and uterine cancers within a single healthcare system from January 2016 to August 2018.

RESULTS

A total of 7643 prescriptions for opioids and/or benzodiazepines were dispensed to 3252 patients over 5754 prescribing encounters for cervical (n=2602, 34.1%), ovarian (n=2468, 32.3%), and uterine (n=2572, 33.7%) cancer. Prescriptions were most often written in an outpatient setting (51.0%) compared with inpatient discharge (25.8%). Cervical cancer patients were more likely to have received a prescription in an emergency department or from a pain/palliative care specialist (p=0.0001). Cervical cancer patients were least likely to have prescriptions associated with surgery (6.1%) compared with ovarian cancer (15.1%) or uterine cancer (22.9%) patients. The morphine milligram equivalents prescribed were higher for patients with cervical cancer (62.6) compared with patients with ovarian and uterine cancer (46.0 and 45.7, respectively) (p=0.0001). Risk factors for opioid misuse were present in 25% of patients studied; cervical cancer patients were more likely to have at least one risk factor present during a prescribing encounter (p=0.0001). Cervical cancer was associated with a higher number of risk factors (p<0.001).

CONCLUSIONS

Opioid and benzodiazepine prescribing patterns differ for cervical, ovarian, and uterine cancer patients. Gynecologic oncology patients are overall at low risk for opioid misuse; however, patients with cervical cancer are more likely to have risk factors present for opioid misuse.

Orthopaedic Trauma Never Sleeps: Resource Allocation Even During a Non-trauma Crisis

This study aimed to describe hospital resource utilization of an orthopaedic trauma service and the injury epidemiology during the 2019-2020 coronavirus pandemic to help plan future non-trauma crises. A retrospective chart review was performed on adult patients > 18 years of age who presented to our Level I Trauma Center for musculoskeletal trauma from March 30, 2020 to May 8, 2020 (stay-at-home order) and from March 30, 2019 to May 8, 2019 (comparison group). There were 182 patient encounters and 274 fractures in the 2020 stay-at-home period, and there were 210 patient encounters and 337 fractures in the 2019 control group. There was no statistical difference found comparing the proportion of patient encounters in the stay-at-home period to the control period (p > 0.05). The similar volume of consultations and surgeries justifies maintenance of standard resource allocation. (Journal of Surgical Orthopaedic Advances 32(2):102-106, 2023).

Balancing Safety, Comfort, and Fall Risk: An Intervention to Limit Opioid and Benzodiazepine Prescriptions for Geriatric Patients

Introduction

This study reports on the impact of a clinical decision support tool embedded in the electronic medical record and characterizes the demographics, prescribing patterns, and risk factors associated with opioid and benzodiazepine misuse in the older adult population.

Significance

This study reports on prescribing patterns for patients ≥65 years-old who presented to Emergency Departments (ED) or Urgent Care (UC) facilities across a large healthcare system following a fall (n = 34,334 encounters; n = 25,469 patients). This system implemented a clinical decision support intervention which provides an alert when the patient has an evidence-based risk factor for prescription drug misuse; prescribers can continue, amend or cancel the prescription.

Results

Of older adults presenting with a fall, 31.4% (N = 7986) received an opioid or benzodiazepine prescription. Women and younger patients (65-74) had a higher likelihood of receiving a prescription (P < .0001). 11% had ≥1 risk factor. Women were more likely to receive an early refill (P = .0002) and younger (65-74) men were more likely to have a past positive toxicology (P < .0001). A prescription was initiated in 8,591 encounters, and 946 (9.0%) triggered an alert. In 58 cases, the alert resulted in a prescription modification, and in 80 the prescription was canceled.

Conclusions

Documented risk for opioid misuse in the elderly was 10% among patients presenting to the ED/UC after a fall. The dangers associated with opioid/benzodiazepine use increase with age as does fall risk. Awareness of risk factors is an important first step; more work is needed to address potentially hazardous prescriptions in this population.

Depression Screening and Behavioral Health Integration in Musculoskeletal Trauma Care

OBJECTIVES

To report our experiences in implementing a behavioral health integration pathway, including a validated depression screening and referral to care.

DESIGN

Retrospective case series.

SETTING

Single surgeon's musculoskeletal trauma outpatient practice during calendar year 2019.

PATIENTS

All patients presenting to the practice during 2019 were included (n = 573).

INTERVENTION

We piloted the usage of Patient Health Questionnaire (PHQ)-2 and PHQ-9 screening. An evidence-based, real-time treatment protocol embedded in the electronic health record was triggered when a patient screened positive for depression including an automated behavioral health integration pathway.

MAIN OUTCOME MEASUREMENTS

The percentage of patients screened, the results of the PHQ screening, and the number of patients referred and enrolled in behavioral health programs were collected.

RESULTS

Of the 573 patients, 476 (83%) received the PHQ-2 screening, 80 (14%) had a current screening on file (within 1 year), and 17 (3.0%) were not screened. One hundred seventy-two patients (36%) had a PHQ-2 score of 2 or greater and completed the PHQ-9; of them, 60 (35% of patients screened with full PHQ-9, 13% of patients screened) screened positive for symptoms of moderate depression (PHQ-9 score ≥10), and 19 (4.0%) reported passive suicidal ideation (PHQ-9 item 9). Fifty of these patients were referred to behavioral health through the pathway, and 8 patients enrolled in the program. Ten patients were not referred because of a technical error that was quickly resolved. Patients reporting suicidal ideation were managed with psychiatric crisis resources including immediate virtual consult in the examination room.

CONCLUSIONS

This case series demonstrates the feasibility of screening patients for depressive symptoms and making necessary referrals to behavioral health in outpatient musculoskeletal trauma care. We identified 50 patients with depression and appropriately triaged them for further care in our community.

Opioid Prescribing Risk Factors in Nonoperative Ankle Fractures: The Impact of a Prospective Clinical Decision Support Intervention

Opioids are frequently used for acute pain management of musculoskeletal injuries, which can lead to misuse and abuse. This study aimed to identify the opioid prescribing rate for ankle fractures treated nonoperatively in the ambulatory and emergency department setting across a single healthcare system and to identify patients considered at high risk for abuse, misuse, or diversion of prescription opioids that received an opioid. A retrospective cohort study was performed at a large healthcare system. The case list included nonoperatively treated emergency department, urgent care and outpatient clinic visits for ankle fracture and was merged with the Prescription Reporting With Immediate Medication Mapping (PRIMUM) database to identify encounters with prescription for opioids. Descriptive statistics characterize patient demographics, treatment location and prescriber type. Rates of prescribing among subgroups were calculated. There were 1,324 patient encounters identified, of which, 630 (47.6%) received a prescription opioid. The majority of patients were 18-64 years old (60.3%). Patients within this age range were more likely to receive an opioid prescription compared to other age groups (p < .0001). Patients treated in the emergency department were significantly more likely to receive an opioid medication (68.3%) compared to patients treated at urgent care (33.7%) or in the ambulatory setting (16.4%) (p < .0001). Utilizing the PRIMUM tool, 14.2% of prescriptions were provided to patients with at least one risk factor. Despite the recent emphasis on opioid stewardship, 14.2% of patients with risk factors for misuse, abuse, or diversion received opioid analgesics in this study, identifying an area of improvement for prescribers.

Screws-Only Primary Subtalar Arthrodesis for Calcaneus Fractures

BACKGROUND

The management of displaced intraarticular calcaneus fractures (DIACFs) is a difficult problem with disappointing results from open reduction internal fixation (ORIF). Alternatively, ORIF with primary subtalar arthrodesis (PSTA) has gained increasing popularity. The purpose of this study is to review patient-centered and radiographic outcomes of ORIF plus PSTA using only screws through a sinus tarsi approach.

METHODS

A retrospective study of patients who underwent ORIF+PSTA for DIACFs was conducted. The same surgical technique was used in all cases consisting of only screws; no plates were used. Delayed surgeries past 8 weeks were excluded. Demographic and radiographic data were collected including worker's compensation claims. Plain radiographs were used to characterize injuries and review outcomes.

RESULTS

Seventy-nine DIACFs underwent PSTA with a median follow-up of 200 days (n = 69 patients). Median time to weightbearing was 57.5 days postoperatively. Ten fractures were documented as Sanders II, 36 as Sanders III, and 32 as Sanders IV. Sixty-eight fractures (86.1%) achieved fusion on radiographs at a median of 126.5 (range, 54-518) days. Thirty-nine fractures (57.3%) demonstrated radiographic fusion in all 3 predefined locations. Nine of the 14 worker's compensation patients returned to work within the period of observation. There were 8 complications: 3 requiring a secondary operation. Eleven of 79 fractures treated did not go on to achieve radiographic union.

CONCLUSION

In this retrospective case series, we found that screws-only primary subtalar arthrodesis for the treatment of DIACFs through a sinus tarsi approach was associated with relatively high rates of return to work and radiographic fusion.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Impact of an opioid prescribing alert system on patients with posttraumatic stress disorder

BACKGROUND AND OBJECTIVES

Posttraumatic stress disorder (PTSD) is associated with higher rates of chronic pain and increased risk of developing Opioid use disorder. This paper evaluates the impact of PRIMUM, an electronic health record-embedded (EHR) clinical decision support intervention on opioid prescribing patterns for patients with diagnosis of PTSD.

METHODS

Inpatient, emergency department (ED), urgent care, and outpatient encounters with ICD-10 codes F43.1 (PTSD), F43.10 (PTSD, unspecified), F43.11 (PTSD, acute), and F43.12 (PTSD, chronic) at Atrium Health between 1/1/2016 and 12/29/2018 were included in the study.

RESULTS

A total of 3121 patients with a diagnosis of PTSD were seen in 37,443 encounters during the study period. Ten percent (n = 3761) of the encounters resulted in prescriptions for opioids and PRIMUM alerts were triggered in 1488 of these encounters. These alerts resulted in "decision influenced" for 17% of patients (n = 255) or no prescriptions for opioids or benzodiazepines for 5.8% (n = 86). The majority of the prescriptions were below 50 Morphine milligram equivalents (MME)/day, but there were 570 (15.5%) prescriptions for doses of 50-90 MME and 721 (19.6%) prescriptions for >90 MME/day.

DISCUSSION AND CONCLUSION

The PRIMUM alert system helps improve patient safety. PRIMUM affected clinician decisions 17% of the time, and the effect was greater in patients with opioid overdose history and those presenting for early refills.

SCIENTIFIC SIGNIFICANCE

The effectiveness of clinical support interventions for opioid prescribing for patients with PTSD has not been documented previously. Our findings provide novel evidence that the EHR can be used to improve patient safety among patients with PTSD in the context of substance use.

Resident Education and Wellness: A Strategy for Future Pandemics

The Coronavirus Disease 2019 (COVID-19) pandemic presented a novel challenge to modern healthcare systems and medical training. Resource allocation and risk mitigation dramatically affected resident training. The objective of this article is to develop new strategies to maintain a healthy, competent residency program while combating the unique challenges to resident education and wellness. In 2020, our institution implemented a revolving 3-Team system. While the "Inpatient-Team" delivered direct care, the "Back-up Team" and "Quarantine-Team" managed the telemedicine virtual clinic and education-wellness strategy, respectively. Our 3-Team system allowed delivery of safe, high-quality patient care while optimizing resident education, research, and wellness. The efficient use of technology led to both improved virtual education outside of the hospital and intentional wellness opportunities despite social distancing restrictions. Utilization of virtual platforms for patient care, education, research, and wellness grew out of necessity in this pandemic, yet represent an opportunity for lasting improvement. (Journal of Surgical Orthopaedic Advances 31(3):150-154, 2022).

Promoting Bone Formation and Healing in Segmental Defects Through Ectopic Induced Membrane

We aimed to determine whether addition of an in vivo ectopic induced membrane (EM) to the Masquelet Technique enhanced angiogenesis and bone formation in a segmental defect. After generating and stabilizing a diaphyseal femur defect, 10 rats received a polymethylmethacrylate (PMMA) spacer within the defect (control); 10 received another PMMA spacer implanted subcutaneously (EM). We removed the spacers and added autograft; the excised EM was added to their autograft (EM group). Post-mortem x-rays assessed bone formation and bridging. Osteogenesis in the proximal defect was significantly more uniform (p < 0.01), and there was greater amount of bone remodeling distally in the EM group (p < 0.05). There was no difference in bone formation (p = 0.19) but greater degrees of bridging in the EM group (2.20 vs. 1.20, p = 0.09). The EM resulted in more homogeneous proximal osteogenesis and increased bone remodeling distally. These findings could lead to more consistent and predictable bone healing. (Journal of Surgical Orthopaedic Advances 31(3):161-165, 2022).

Orthopaedic Implant Coatings: Recent Approaches and Clinical Translation

Despite improved surgical techniques and prophylactic procedures, orthopaedic implant-associated infections remain high with complications that can lead to devastating outcomes for the patient. Implant coatings and associated surface modification techniques represent a promising means to prevent infections. Various approaches have emerged to address the challenges associated with implant infections, such as antibacterial resistance, biofilm prevention, and appropriate efficacy kinetics. Methods including antibiotic and antimicrobial peptide surface tethering, use of osteo-conductive and -inductive materials, and altering hydrophobicity and hydrophilicity of the implant surface, have all demonstrated efficacy toward diminished infection risk. Though many of these techniques have shown great potential in in vitro and in vivo studies, clinical translation remains limited with very few commercially available implant coatings globally. This review summarizes recent advancements in orthopaedic implant coatings, pre-clinical studies, and clinical translation, as well as potential future marketed products. (Journal of Surgical Orthopaedic Advances 31(3):169-176, 2022).

Treatment Order and Risk of Surgical Site Infection in Patients Undergoing Concurrent Operative Fixation of Closed and Open Fractures

This study aimed to characterize postoperative infection rate among patients undergoing definitive fixation of both open and closed fractures during the same surgery. Outcomes between patients with open fractures (OF) treated first were compared to those with closed fractures (CF) treated first. We identified 303 adult patients with multiple (≥ 2) pelvis and extremity fractures who presented to our Level 1 Trauma hospital in 2017. Forty patients with at least one open and one closed fracture treated with operative fixation during the same surgery were included in analysis. Eight surgical site infections (SSI) developed in seven patients. There was no significant difference between treatment order groups (OF = 4 patients (5 fractures), CF = 3 patients (3 fractures); p > 0.99). This is the first study comparing different chronologies of operative fixation in coexisting open and closed fractures. Our study shows that the choice of treatment order does not influence SSI risk. (Journal of Surgical Orthopaedic Advances 31(3):181-186, 2022).

Traumatic Arthrotomies: Do They All Need the Operating Room?

OBJECTIVES

To compare complications and cost of care in patients with traumatic arthrotomies (TAs) treated with surgical debridement, irrigation, and closure to those treated with nonoperative treatment and local wound care.

DESIGN

This is a prospective observational multicenter study.

SETTING

This study was conducted at multiple Level I trauma centers.

PATIENTS

Patients with TAs.

INTERVENTION

Patients were treated with operative versus nonoperative management decided by the attending surgeon. Nonoperative treatment of TAs included bedside irrigation, primary closure, antibiotics, and discharge from the emergency department with close follow-up unless admission was otherwise indicated.

MAIN OUTCOME MEASUREMENTS

Primary outcomes included adverse outcomes and cost. VR-12 was captured at the time of injury and 3 months postinjury.

RESULTS

Of 189 major joint TAs, 64 arthrotomies were treated nonoperatively and 125 operatively. Seventy percent of the arthrotomies in the nonoperative group were small (less than 50 mm in size) and 95% had minimal/no gross contamination, whereas the operative group (OG) had significantly more arthrotomies greater than 50 mm in size and with moderate/severe gross contamination. There was one septic joint in the nonoperative group (1.5%) and 7 in the OG (5.6%). Nonoperative treatment was associated with significantly lower total charges when compared with the OG.

CONCLUSIONS

Although further study may still be needed, this study suggests that small, minimally contaminated TAs with no associated fracture have a low risk of adverse complications, can safely be treated nonoperatively, and are associated with a significantly decreased cost of care.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Dental pain management with prescription opioids by nondental healthcare professionals in a healthcare system network

OBJECTIVES

Patients with dental pain seek treatment in Urgent and Emergency Care settings by physicians and advanced practice practitioners (APPs) unable to provide definitive care, often relying on prescriptions for pain management including opioids. In the face of an opioid epidemic, this study assessed the impact of an electronic health record (EHR) clinical decision support tool to identify patients at high risk for opioid misuse using objective, evidence-based criteria, and guide safer prescribing.

METHODS

Dental pain encounters occurring between January 2016 and June 2018 within our healthcare system were identified and linked to the database supporting a real-time clinical decision support intervention, Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM), to characterize opioid prescribing patterns and prescribers' response to alert. Descriptive analysis of the data was performed.

RESULTS

There were 30,649 dental pain encounters of which opioids were written in 45.5 percent (N = 13,957) encounters. A total of 16.6 percent of patients prescribed an opioid had a risk factor for misuse and triggered the PRIMUM alert at the point of care. In response to the PRIMUM alert (N = 2,501 encounters), clinician decision-making was influenced in 9.5 percent (N = 237) of encounters, which was defined by cancelation of the original opioid prescription. Of those 9.5 percent encounters, 48.1 percent (N = 114) resulted in no opioid prescription written.

CONCLUSIONS

There is potential for a clinical decision support tool embedded in the EHR to guide safer prescribing practice by alerting providers to objective, evidence-based risk characteristics at the point of care.

Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial

Importance

Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist.

Objective

To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections.

Design, Setting, and Participants

This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers.

Interventions

A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder.

Main Outcomes and Measures

The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence.

Results

The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections.

Conclusions and Relevance

Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin.

Trial Registration

ClinicalTrials.gov Identifier: NCT02227446.

Surgical Re-entry Strategy Following COVID-19 Pandemic: A Tiered and Balanced Approach

Following the Presidential declaration of a national emergency, many health care organizations adhered to recommendations from the Centers for Medicare and Medicaid (CMS) as well as the American College of Surgeons (ACS) to postpone elective surgical cases. The transition to only emergent and essential urgent surgical cases raises the question, how and when will hospitals and surgery centers resume elective cases? As a large health care system providing multispecialty tertiary/quaternary care with across the Southeast United States, a collaborative approach to resuming elective surgery is critical. Numerous surgical societies have outlined a tiered approach to resuming elective surgery. The majority of these guidelines are suggestions which place the responsibility of making decisions about re-entry strategy on individual health care systems and practitioners, taking into account the local case burden, projected case surge, and availability of resources and personnel. This paper reviews challenges and solutions related to the resumption of elective surgeries and returning to the pre-COVID-19 surgical volume within an integrated health care system that actively manages 18 facilities, 111 operating rooms, and an annual operative volume exceeding 123,000 cases. We define the impact of COVID-19 across our surgical departments and outline the staged re-entry approach that is being taken to resume surgery within the health care system.

Is There Value in Early Postoperative Visits Following Hip Fracture Surgery?

Introduction

Despite the recommendation for postoperative orthopedic follow-up after a hip fracture in elderly patients, many patients do not return for these visits. In this study, we attempt to determine if early follow-up (<4 weeks post-discharge) changes orthopedic post-operative management.

Materials and Methods

1232 patients aged > 55 years old who underwent operative fixation for hip fractures were enrolled into an orthopedic trauma registry and followed from hospitalization through one year. Demographics, comorbidities, injury severity, and hospital course data were collected. Need for readmission and orthopedic follow-up were ascertained through chart review.

Results

417 patients (33.8%) patients did not return for any follow-up and 30 (2.4%) patients died <30 days from discharge. 370 (45.5%) patients had early orthopedic follow-up ≤28 days after discharge. 317 (38.9%) patients were seen ≥29 days after discharge (late follow-up). 127 (15.6%) patients returned for isolated non-orthopedic care. There were 23 (6.2%) readmissions in the early group, 17 (5.4%) in the late group, and 24 (18.9%) in the no follow-up group (p < 0.001). Patients discharged home were more likely to present for early follow-up compared to those with late and non-orthopedic follow-up (p = 0.002), however there was no difference in readmission rates between those discharged home vs. SNFs/SARs.

Discussion

Patients who received isolated non-orthopedic follow-up within 4 weeks of surgery experienced more hospital readmissions than those with follow-up in that time period; however, these readmissions were primarily due to medical issues. There was no difference in orthopedic-related readmissions and changes in orthopedic management between groups. Patients discharged to SNFs/SARs did not present for early orthopedic as often as those discharged home.

Conclusion

Early orthopedic follow up after hip fracture care does not change post-operative management in these patients and has implications for value-based care.

Level of Evidence

Prognostic Level III.

Prevalence of Prescription Opioids for Nonoperative Treatment of Rotator Cuff Disease Is High

Purpose

To quantify the prevalence of opioid and benzodiazepine prescriptions for patients with rotator cuff disease across a large health care system and to describe evidence-based risk factors for opioid use within this population.

Methods

We conducted a retrospective cohort study at a major health care system of all patients with qualifying diagnostic codes. Emergency department, urgent care, and outpatient encounters between January and December 2016 for an acute rotator cuff tear, listed as the primary diagnosis, were included. Encounters with prescriptions for opioids or benzodiazepines were identified using the Prescription Reporting With Immediate Medication Utilization Mapping (PRIMUM) system. Descriptive statistics and the rate of controlled-substance prescribing were calculated for the population as a whole and among subgroups.

Results

We identified 9,376 encounters meeting the inclusion criteria. Of these encounters, 1,559 (16.6%) resulted in 1 or more prescriptions for an opioid or benzodiazepine that were issued during the visit. A total of 2,007 opioid and/or benzodiazepine prescriptions were issued for the 1,559 encounters (rate of 1.29 prescriptions per prescribing encounter). This represented 5,310 patients, of whom 1,096 (20.6%) received a prescription for an opioid or benzodiazepine during at least 1 of their encounters. Of patients who received a prescription, 20.9% had at least 1 risk factor for prescription misuse; 3.6% of patients had more than 1 risk factor. There were no demographic differences between patients with risk factors and patients without them.

Conclusions

The prescribing of opioids for the treatment of pain in patients with rotator cuff disease remains high across multiple locations and specialties within a large health care system. Using alternative pain management pathways as primary prevention for opioid misuse and abuse in high opioid-prescribing locations-and especially for patients identified as having a high risk of opioid misuse-is an important practice to continue in our shift away from opioid use as a health care system.

Level of Evidence

Level IV, case series.

Why Make the Cut? Trochanteric Slide Osteotomy Can Improve Exposure to the Anterosuperior Acetabulum

OBJECTIVE

To define relative increases in visual bony surface area and access to critical landmarks with the addition of a trochanteric slide osteotomy to a Kocher-Langenbeck approach.

METHODS

A Kocher-Langenbeck approach followed by a trochanteric slide osteotomy was sequentially performed on 10, fresh-frozen, hemipelvectomy cadaveric specimens. Visual and palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J.

RESULTS

The acetabular surface area exposed was 27.66 (±6.67) cm2 for a Kocher-Langenbeck approach. This increased to and 41.82 (±7.97) cm2 with the addition of a trochanteric osteotomy. The exposed surface area was increased by 51.2% for the trochanteric osteotomy (P < 0.001). The superior margin of the acetabulum could be visualized and palpably accessed in both exposures. Access to the more anterosuperior portions of the acetabulum was consistently possible in the trochanteric osteotomy but not with the Kocher-Langenbeck approach.

CONCLUSIONS

A trochanteric osteotomy may visually improve access to the most anterosuperior acetabulum but does not significantly improve surgical access to relevant portions of the superior acetabulum when compared with a Kocher-Langenbeck approach.

Pilot randomized trial of pre-hospital advanced therapies for the control of hemorrhage (PATCH) using pelvic binders

BACKGROUND

Pelvic fractures represent a small percent of all skeletal injuries but are associated with significant morbidity and mortality secondary to hemodynamic instability from bleeding bone surfaces and disrupted pelvic vasculature. Stabilization of the pelvis prior to arrival at a treatment facility may mitigate the hemodynamic consequences of pelvic ring injuries and improve morbidity and mortality. Whether pelvic compression devices such as pelvic binders or sheets can be safely applied in the prehospital setting has not been well-studied. This study aims to evaluate the safety of applying a pelvic binder to at-risk patients in the field after scalable training and the feasibility of conducting a randomized trial evaluating this practice in the prehospital setting.

METHODS

A pilot study (prospective randomized trial design) was conducted in the pre-hospital environment in an urban area surrounding a level-one trauma center. Pre-hospital emergency medical (EMS) personnel were trained to identify patients at high-risk for pelvic fracture and properly apply a commercial pelvic binder. Adult patients with a high-energy mechanism, suspected pelvic fracture, and "Priority 1" criteria were prospectively identified by paramedics and randomized to pelvic binder placement or usual care. Medical records were reviewed for safety outcomes. Secondary outcomes were parameters of efficacy including interventions needed to control hemorrhage (such as angioembolization and surgical control of bleeding) and mortality.

RESULTS

Forty-three patients were randomized to treatment (binder: N=20; nonbinder: N=23). No complications of binder placement were identified. Eight patients (40%) had binders placed correctly at the level of the greater trochanter. Two binders (10%) were placed too proximally and 10 (50%) binders were not visualized on x-ray. Two binder group patients and three nonbinder group patients required angioembolization. None required surgical control of pelvic bleeding. Two nonbinder group patients and one binder group patient were readmitted within 30 days and one nonbinder group patient died within 30 days.

CONCLUSION

Identification of pelvic fractures in the field remains a challenge. However, a scalable training model for appropriate binder placement was successful without secondary injury to patients. The model for conducting prospective, randomized trials in the prehospital setting was successful.

Virtual Reality and Augmented Reality-Translating Surgical Training into Surgical Technique

PURPOSE OF REVIEW

As immersive learning outside of the operating room is increasingly recognized as a valuable method of surgical training, virtual reality (VR) and augmented reality (AR) are increasingly utilized in orthopedic surgical training. This article reviews the evolving nature of these training tools and provides examples of their use and efficacy. The practical and ethical implications of incorporating this technology and its impact on both orthopedic surgeons and their patients are also discussed.

RECENT FINDINGS

Head-mounted displays (HMDs) represent a possible adjunct to surgical accuracy and education. While the hardware is advanced, there is still much work to be done in developing software that allows for seamless, reliable, useful integration into clinical practice and training. Surgical training is changing: AR and VR will become mainstays of future training efforts. More evidence is needed to determine which training technology translates to improved clinical performance. Volatility within the HMD industry will likely delay advances in surgical training.

The Orthopaedic Trauma Service and COVID-19: Practice Considerations to Optimize Outcomes and Limit Exposure

The COVID-19 pandemic has presented challenges to healthcare systems, including the cancellation and then staged resumption of elective procedures. The orthopaedic trauma community has continued to provide care to patients with acute musculoskeletal injuries that cannot be delayed in all scenarios. This article summarizes and provides relevant information (orthopaedic trauma service, outpatient fracture clinic, inpatient surgery) to the practicing orthopaedic traumatologist on maximizing outcomes while limiting exposure during the pandemic. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Prevalence of Opioid and Benzodiazepine Prescriptions for Osteoarthritis

OBJECTIVE

Opioids and benzodiazepines are commonly used for management of osteoarthritis, despite evidence-based recommendations to the contrary. This study aimed to quantify the prevalence of opioid and benzodiazepine prescribing for osteoarthritis. Additionally, we aimed to characterize risk factors for prescription drug misuse, abuse, and diversion among this population.

METHODS

We conducted a descriptive analysis of adult outpatient encounters with a primary diagnosis of osteoarthritis during a 1-year period at a large health care system, excluding cancer and outpatient procedures. Demographic data, prescription data, and patient-specific risk factors were collected. Descriptive analysis was conducted to characterize arthritis patients who received and did not receive prescription opioids.

RESULTS

During 1 year, our system had 31,123 outpatient encounters for osteoarthritis. Opioids and benzodiazepines were prescribed for nearly 27% of the encounters (n = 8,420). In all, 43% of the encounters involved patients age ≥65 years. Hydrocodone-acetaminophen was the most common medication prescribed (34.3%). Most prescriptions were written by pain specialists (53%). A total of 35.5% of patients had a risk factor for prescription misuse, the most prevalent being early refill and a history of receiving ≥3 prescriptions in the past month.

CONCLUSION

Prescriptions for opioids and benzodiazepines continue to be written for osteoarthritis. These prescriptions may pose a risk for adverse outcomes since >1 in 5 patients receiving prescriptions had a risk factor for misuse. Continued efforts to improve compliance with evidence-based guidelines as well as multimodal and alternative pain management pathways are critical to help curb the use of opioids for management of osteoarthritis-related pain.

LEVEL OF EVIDENCE

level IV.

Tiered team research: A novel concept for increasing research productivity in the academic setting

BACKGROUND

Research has become a key pillar of academic medicine and a cornerstone of residency training; however, there continues to be significant barriers to ensuring research productivity for residents. We implemented a novel tiered team approach which aimed to increase research productivity and promote collaboration during residency training.

METHODS

This was a retrospective study that evaluated the implementation of a novel tiered team research approach at a single institution between 2009 and 2013. Analytical software was used to visualize and display the research interconnections among the authors of the captured publications. In addition to using Gephi to determine the research interconnections, the growth in research capability of the tiered team and its individual members were also graphically depicted.

RESULTS

The research team produced a total of 77 publications during the study period (2009-2013). Significant and frequent collaboration and coauthorship was noted as the years progressed following implementation of tiered team research.

DISCUSSION

Tiered team research can be readily implemented at most institutions and can lead to increases in productivity of published research. It can also promote collaboration and peer mentorship among those involved.

The synergistic effect of preoperative opioid use and many associated preoperative predictors of poor outcome in the trauma patient population

OBJECTIVE

The purpose of this study is to investigate if preoperative opioid use is associated with other predictors of poor outcome and the effect of these factors on complications. We hypothesized that preoperative opioid use (POU) is associated with increased rates of postoperative complications.

DESIGN

Retrospective case control study.

SETTING

Academic level-1 trauma center.

PATIENTS/PARTICIPANTS

Patients with long bone, lower extremity fractures requiring operative fixation.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

Postoperative hospital admissions, emergency room (ER) visits, and reoperations.

RESULTS

399 patients (opioid naïve [ON] 80.2%, Age 38, 95% CI 35.9-39.6) were reviewed. Patients who had POU were older (P = 0.004), had higher BMI (P = 0.03), proportion of females (P < 0.001), tobacco use (P < 0.001), proportion of American Society of Anesthesiologist (ASA) class ≥ 3 (P < 0.001), and rates of substance use disorder (SUD) (P < 0.001). POU was associated with prolonged opiate use at 6 months (60.8%), 1 year (43.0%), higher rates of postoperative readmissions (18.1%), ER visits (17.2%), reoperations (17.5%), and complications (Odds Ratio [OR]: 2.4, P < 0.01). The risk of complication increased synergistically with the addition of other predictors: less than a high school education (OR: 4.6, P = 0.001); ASA class ≥3 (OR: 5.6, P < 0.001). All three factors combined also increased risk of complication synergistically (OR: 9.1, P = 0.003).

CONCLUSIONS

Our study demonstrates that many predictors of poor outcome frequently accompany POU. POU combined with many of these predictors synergistically increases the risk of complication. Outcomes-based payment models should reflect this expected rate of readmissions, ER visits and complications in this group. Patients with POU should be targeted with multi-disciplinary interventions aimed to modify these risk factors.

Lateral External-fixation Adjacent to Radial Nerve

Introduction The aim of our study was to describe the injury pattern and outcomes of active-duty subjects that underwent humeral external fixation and to determine if the placement of external fixator pins outside of the radial nerve safe zones is correlated with injury to the radial nerve. Materials and methods We examined all US Service members treated with humeral external fixation at our facility from June 2005 through June 2015. The mechanism of injury, injury pattern, location of external fixation application, pre- and postoperative radial nerve function, presence or absence of radial nerve transection from injury or external fixation, anatomic location of pins in relation to the radial nerve safe zone, and final radial nerve outcomes were recorded. We defined the proximal safe zone as 5 cm distal to the acromion to 14.8 cm proximal to the lateral epicondyle, and we defined the distal safe zone as the proximal 70% of the transepicondylar width of the humerus when projected proximally from the lateral epicondyle. Results  For our study, 123 patients were identified over our date range, and 16 subjects were included with documentation regarding nerve function/injury characteristics, appropriate radiographs, and active duty status. Around 80% of injuries resulted from a blast mechanism, and 80% of injury patterns included either an intraarticular or open fracture. The radial nerve safe zone was violated in 15 of the 16 subjects (94%). The one subject with a safe construct did not sustain a nerve injury. Complete preoperative documentation on nerve function was only available for half of the subjects. Two of five subjects known to have intact function prior to external fixation had a postoperative neurologic deficit (40%). Of eight subjects with unknown radial nerve function prior to external fixation, seven subjects had full nerve function at the final follow up, and one subject had partial sensory function only. Of the three subjects with impaired preoperative radial nerve function, two made a full recovery, and the third recovered sensory function only. Around 50% of all subjects required medical retirement. Conclusion External fixation of upper extremity injuries in combat is rarely absolutely indicated, often results in the placement of pins outside of the radial nerve safe zone, and is associated with up to a 40% incidence of radial nerve injury.

Opioid Prescribing and Patient Satisfaction Scores Across Practice Types

US physicians prescribe opioids at a high rate relative to other countries. Of the US physicians surveyed, almost half report having prescribed an inappropriate opioid due to concerns about patient satisfaction scores. We investigated patterns in controlled substance prescribing practices, patient risk factors, and associated Press Ganey patient satisfaction scores at a sample of orthopaedic surgery and primary care clinics over a 6month time period. Primary care practices had higher proportions of prescriptions, and patient risk profiles varied across sites. However, overall satisfaction was high, with little variation between sites (78.3 81.3%). Satisfaction with pain control was lower and more varied (67.1 78.0%). A total of 4,229 Press Ganey survey responses were received, including 7,232 comments, of which only 10 (0.1%) expressed frustration for not receiving opioids. Opioid prescriptions had minimal association with Press Ganey scores among varied practices and patient populations. Prescribers should prescribe opioids appropriately without fear that this will negatively impact their satisfaction scores. (Journal of Surgical Orthopaedic Advances 29(1):59, 2020).

Confronting the Opioid Crisis: Practical Pain Management and Strategies: AOA 2018 Critical Issues Symposium

The United States is in the midst of an opioid crisis. Clinicians have been part of the problem because of overprescribing of narcotics for perioperative pain management. Clinicians need to understand the pathophysiology and science of addiction to improve perioperative management of pain for their patients. Multiple modalities for pain management exist that decrease the use of narcotics. Physical strategies, cognitive strategies, and multimodal medication can all provide improved pain relief and decrease the use of narcotics. National medical societies are developing clinical practice guidelines for pain management that incorporate multimodal strategies and multimodal medication. Changes to policy that improve provider education, access to naloxone, and treatment for addiction can decrease narcotic misuse and the risk of addiction.

Advanced Functional Bracing in Lower Extremity Trauma: Bracing to Improve Function

There are many bracing options for patients with functional limitations of the lower extremity following trauma. The first question that the provider must ask when evaluating a patient with a foot and ankle functional limitation because of weakness or pain is, "what are the patient's expectations?" One option for the patient who desires to return to a higher level of function is a novel, custom dynamic orthosis (CDO) that, when coupled with an advanced rehabilitation program, has improved outcomes in patients following lower extremity trauma who have plateaued after traditional rehabilitation pathways. Although this CDO and rehabilitation program has demonstrated success following lower extremity trauma in heterogenous patient populations, research is ongoing to identify both ideal referral diagnoses or injury characteristics, and to further optimize outcomes with the use of the CDO.

Teaching Cortical-Screw Tightening: A Simple, Affordable, Torque-Directed Training Protocol Improves Resident Performance

BACKGROUND

Cortical-screw insertion is a fundamental skill in orthopaedic surgery, yet, to our knowledge, no standardized method of teaching this skill exists. The purpose of this study was to evaluate a training protocol that was designed to teach residents how to tighten a cortical screw without causing any stripping.

METHODS

Twenty-five residents and 8 attending surgeons from an orthopaedic residency program tightened cortical screws in a synthetic bone model with a digital torque screwdriver using 3 different techniques: percutaneous; open, dominant hand; and open, nondominant hand. The residents then participated in a training protocol during which each tightened additional screws while receiving real-time torque feedback. During training, the residents targeted 50% to 70% of the stripping torque for each screw. They were assessed at baseline, immediately after training, and at 12 to 15 weeks after training. During each assessment, the percentage of screws that were tightened in the target range and the percentage of stripped screws were recorded. The costs of the training protocol were assessed.

RESULTS

After training, all of the residents tightened screws with lower insertional torque compared with their baseline, but only the senior residents tightened more screws in the target range and stripped fewer screws. The attending surgeons, when compared with the residents at baseline, tightened more screws in the target range and tended to strip fewer screws, but these differences were absent at final testing. Costs included $1,927 for durable equipment and an estimated $74 per resident per training session for consumable goods.

CONCLUSIONS

The senior residents inserted more screws in the target range and stripped fewer screws after participating in this training protocol, but the junior residents did not show significant improvement. Implementation of this training protocol for all residents may improve clinical performance but, because our sample size was limited, additional study is required to assess skill transfer to clinical practice.

CLINICAL RELEVANCE

Cortical-screw tightening is a fundamental skill in orthopaedics, and completion of this torque-directed training protocol may accelerate residents' skill acquisition.

Does formal vs home-based physical therapy predict outcomes after ankle fracture or ankle fracture-dislocation?

Background

Ankle fractures are among the most common injuries treated by orthopaedic surgeons. Various postoperative rehabilitation strategies have been promoted, but the ability to improve patient-reported functional outcome has not been clearly demonstrated. We aim to evaluate outcomes associated with clinic-based, physical therapist-supervised rehabilitation (Formal-PT) compared to surgeon-directed rehabilitation (Home-PT).

Methods

This prospective observational study included patients with operative bimalleolar or trimalleolar ankle fractures with or without dislocation (n = 80) at a Level I trauma center. Patients were prescribed PT per the surgeon's practice pattern. Patient-reported functional outcomes at 6 months and complication rates were compared between groups.

Results

Of the 80 patients, 38 (47.5%) patients received Formal-PT; the remaining received Home-PT. Thirty-four patients (89.5%) attended ≥1 PT session. Number of sessions attended ranged from 1 to 36 (mean = 16). Receipt of Formal-PT did not differ by injury characteristics or demographics. Of patients with private insurance, 57% were prescribed Formal-PT vs 7% of uninsured patients (P = .033). FAAM and Combination SMFA scores at 6 months were similar between groups (Formal-PT: 69.7, 20.1; Home-PT: 70.9, 24.4; P = .868, .454, respectively). Postoperative complications were rare and equivalent between groups.

Conclusions

Comparison of outcomes between patients with operatively treated displaced ankle fractures/dislocations with Formal-PT vs Home-PT showed no difference in SMFA and FAAM scores. These findings suggest patients receiving supervised PT produced a similar outcome to those under routine physician-directed rehabilitation at 6 months. The cost for therapy averaged $2012.96 per patient receiving Formal-PT.