Methylprednisolone taper is an effective addition to multimodal pain regimens after total shoulder arthroplasty: results of a randomized controlled trial: 2022 Neer Award winner.

BACKGROUND: Perioperative corticosteroids have shown potential as nonopioid analgesic adjuncts for various orthopedic pathologies, but there is a lack of research on their use in the postoperative setting after total shoulder arthroplasty (TSA). The purpose of this study was to assess the effect of a methylprednisolone taper on a multimodal pain regimen after TSA. METHODS: This study was a randomized controlled trial (clinicaltrials.gov NCT03661645) of opioid-naive patients undergoing TSA. Patients were randomly assigned to receive intraoperative dexamethasone only (control group) or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course (treatment group). All patients received the same standardized perioperative pain management protocol. Standardized pain journal entries were used to record visual analog pain scores (VAS-pain), VAS-nausea scores, and quantity of opioid tablet consumption during the first 7 postoperative days (POD). Patients were followed for at least one year postoperatively for clinical evaluation, collection of patient-reported outcomes, and observation of complications. RESULTS: A total of 67 patients were enrolled in the study; 32 in the control group and 35 in the treatment group. The groups had similar demographics and comorbidities. The treatment group demonstrated a reduction in mean VAS pain scores over the first 7 POD. Between POD 1 and POD 7, patients in the control group consumed an average of 17.6 oxycodone tablets while those in the treatment group consumed an average of 5.5 tablets. This equated to oral morphine equivalents of 132.1 and 41.1 for the control and treatment groups, respectively. There were fewer opioid-related side effects during the first postoperative week in the treatment group. The treatment group reported improved VAS pain scores at 2-week, 6-week, and 12-week postoperatively. There were no differences in Europe Quality of Life, shoulder subjective value (SSV), at any time point between groups, although American Shoulder and Elbow Surgeons questionnaire scores showed a slight improvement at 6-weeks in the treatment group. At mean follow-up, (control group: 23.4 months; treatment group:19.4 months), there was 1 infection in the control group and 1 postoperative cubital tunnel syndrome in the treatment group. No other complications were reported. CONCLUSIONS: A methylprednisolone taper course shows promise in reducing acute pain and opioid consumption as part of a multimodal regimen following TSA. As a result of this study, we have included this 6-day methylprednisolone taper course in our multimodal regimen for all primary shoulder arthroplasties. We hope this trial serves as a foundation for future studies on the use of low-dose oral corticosteroids and other nonnarcotic modalities to control pain after shoulder surgeries.

Preoperative Depression Is Associated With Increased Complications Following Distal Radius Fracture Surgery.

BACKGROUND: Depression is a known risk factor for inferior outcomes after orthopedic procedures, but its specific relationship with distal radius fractures remains unknown. This study investigates the relationship between preoperative diagnosed depression and common postoperative complications occurring within the first year after open reduction internal fixation (ORIF) for distal radius fractures. METHODS: This retrospective study used Truven MarketScan database and the Current Procedural Terminology (CPT) codes to identify distal radius fracture patients who underwent ORIF in the United States between January 1, 2009, and December 31, 2019. International Classification of Diseases (ICD) codes were used to identify patients with and without a diagnosis of preoperative depression. Univariate, multivariate, t test, and χ2 analyses were performed to determine the association between preoperative depression and postoperative complications following a distal radius fracture surgery. RESULTS: Of the 75 098 eligible patients, 9.9% had at least one ICD code associated with preoperative depression. Preoperative depression was associated with increased odds for surgical site infection (odds ratio [OR] 1.25, confidence interval [CI] 1.14-1.37), emergency department visits for postoperative pain (OR 1.28, CI 1.15-1.36), hardware complication (OR 1.18, CI 1.07-1.30), removal of hardware within 1 year (OR 1.16, CI 1.09-1.27), wound complication (OR 1.17, CI 1.08-1.27), and 30-day readmission (OR 1.21, CI 1.07-1.31). CONCLUSIONS: Preoperative diagnosed depression is associated with increased complications following distal radius fracture surgery. These results can help guide preoperative and postoperative protocols in these higher risk patients. More research is needed to investigate if depression is a modifiable risk factor, as depression treatment could potentially improve postsurgical outcomes.

The impact of prior authorization review on orthopaedic subspecialty care: a prospective multicenter analysis.

BACKGROUND: Prior authorization review (PAR), in the United States, is a process that was initially intended to focus on hospital admissions and costly high-acuity care. Over time, payors have broadened the scope of PAR to include imaging studies, prescriptions, and routine treatment. The potential detrimental effect of PAR on health care has recently been brought into the limelight, but its impact on orthopedic subspecialty care remains unclear. This study investigated the denial rate, the duration of care delay, and the administrative burden of PAR on orthopedic subspecialty care. METHODS: A prospective, multicenter study was performed analyzing the PAR process. Orthopedic shoulder and/or sports subspecialty practices from 6 states monitored payor-mandated PAR during the course of providing routine patient care. The insurance carrier (traditional Medicare, managed Medicare, Medicaid, commercial, worker's compensation, or government payor [ie, Tricare, Veterans Affairs]), location of service, rate of approval or denial, time to approval or denial, and administrative time required to complete process were all recorded and evaluated. RESULTS: Of 1065 total PAR requests, we found a 1.5% (16/1065) overall denial rate for advanced imaging or surgery when recommended by an orthopedic subspecialist. Commercial and Medicaid insurance resulted in a small but statistically significantly higher rate of denial compared to traditional Medicare, managed Medicare, worker's compensation, or governmental insurance (P < .001). The average administrative time spent on a single PAR was 19.5 minutes, and patients waited an average of 2.2 days to receive initial approval. Managed Medicare, commercial insurance, worker's compensation, and Medicaid required approximately 3-4 times more administrative time to process a PAR than to traditional Medicare or other governmental insurance (P < .001). After controlling for the payor, we identified a significant difference in approval or denial based on geographic location (P < .001). An appeal resulted in a relatively low rate of subsequent denial (20%). However, approximately a third of all appeals remained in limbo for 30 days or more after the initial request. CONCLUSIONS: This is the largest prospective analysis to date of the impact of PAR on orthopedic subspecialty care in the United States. Nearly all PAR requests are eventually approved when recommended by orthopedic subspecialists, despite requiring significant resource use and delaying care. Current PAR practices constitute an unnecessary process that increases administrative burden and negatively impacts access to orthopedic subspecialty care. As health care shifts to value-based care, PAR should be called into question, as it does not seem to add value but potentially negatively impacts cost and timeliness of care.

Upper extremity firearm injuries: epidemiology and factors predicting hospital admission.

INTRODUCTION: Civilian gun violence is a public health crisis in the USA that will be an economic burden reported to be as high as $17.7 billion with over half coming from US taxpayers dollars through Medicaid-related costs. The purpose of this study is to review the epidemiology of upper extremity firearm injuries in the USA and the associated injury burden. METHODS: The Inter-university Consortium for Political and Social Research's Firearm Injury Surveillance Study database, collected from the National Electronic Injury Surveillance System, was queried from 1993 to 2015. The following variables were reviewed: patient demographics, date of injury, diagnosis, injury location, firearm type (if provided), incident classification, and a descriptive narrative of the incident. We performed chi-square testing and complex descriptive statistics, and binomial logistic regression model to predict factors associated with hospital admission. RESULTS: From 1993 to 2015, an estimated 314,369 (95% CI: 291,528-337,750; 16,883 unweighted) nonfatal firearm upper extremity injuries with an average incidence rate of 4.76 per 100,000 persons (SD: 0.9; 03.77-7.49) occurred. The demographics most afflicted with nonfatal gunshot wound injuries were black adolescent and young adult males (ages 15-24 years). Young adults aged 25-34 were the second largest estimate of injuries by age group. Hands were the most commonly injured upper extremity, (55,014; 95% CI: 75,973-89,667) followed by the shoulder, forearm, and upper arm. Patients who underwent amputation (OR: 28.65; 95% CI: 24.85-33.03) or with fractures (OR: 26.20; 95% CI: 23.27-29.50) experienced an increased likelihood for hospitalization. Patients with a shoulder injury were 5.5× more likely to be hospitalized than those with a finger injury (OR:5.57; 95% CI:5.35-5.80). The incidence of upper extremity firearm injuries has remained steady over the last decade ranging between 4 and 5 injuries per 100,000 persons. Patients with proximal injuries or injuries involving the bone were more likely to require hospital admission. This study should bring new information to the forefront for policy makers regarding gun violence.

Medicaid payer status is associated with increased 90-day morbidity and resource utilization following primary shoulder arthroplasty: a propensity score-matched analysis.

BACKGROUND: Medicaid payer status has been shown to affect risk-adjusted patient outcomes and health care utilization across multiple medical specialties and orthopedic procedures. However, there is a paucity of data regarding the impact of Medicaid payer status on 90-day morbidity and resource utilization following primary shoulder arthroplasty (reverse total shoulder arthroplasty [rTSA], anatomic total shoulder arthroplasty [aTSA], and hemiarthroplasty [HA]). The purpose of this study was to examine 90-day readmission and reoperation rates, hospital length of stay (LOS), and direct cost following primary shoulder arthroplasty in the Medicaid population. METHODS: The National Readmission Database was queried for all patients undergoing primary aTSA, rTSA, and HA from 2011 to 2016. Medicaid or non-Medicaid payer status was determined. Patient demographic characteristics and comorbidities, along with 90-day readmission, 90-day reoperation, LOS, and inflation-adjusted cost, were queried. Propensity score matching was used to control for baseline differences in cohorts that could be acting as confounders in the exposure-outcome relationship. This was achieved with 1-to-1 propensity score matching between Medicaid and non-Medicaid patients. Odds ratios (ORs) and 95% confidence intervals (CIs) for 90-day readmission and reoperation rates were calculated, and a comparison of LOS and cost was performed between the propensity score-matched cohorts. RESULTS: A total of 4667 Medicaid and 161,147 non-Medicaid patients were identified from the 2011-2016 National Readmission Databases. Propensity score analysis was performed, and 4637 Medicaid patients were matched to 4637 non-Medicaid patients; each group comprised 1504 rTSAs (32.4%), 1934 aTSAs (41.7%), and 1199 HAs (25.9%). Patients with Medicaid payer status yielded significant increases in the 90-day all-cause readmission rate of 11.6% vs. 9.3% (P < .001; OR, 1.28 [95% CI, 1.12-1.46]), 90-day shoulder-related readmission rate of 3.3% vs. 2.3% (P = .004; OR, 1.44 [95% CI, 1.12-1.85]), and 90-day reoperation rate of 2.0% vs. 1.3% (P = .008; OR, 1.54 [95% CI, 1.12-1.94]). Furthermore, there was an increased risk of an extended LOS (ie, LOS > 2 days) (28.4% vs. 25.7%; P = .004; OR, 1.14 [95% CI, 1.04-1.25]) along with increased direct cost (median, $17,612 vs. $16,775; P < .001). DISCUSSION: This study demonstrates that Medicaid payer status is independently associated with increased 90-day readmission and reoperation rates, LOS, and direct cost following primary shoulder arthroplasty. Providers may have a disincentive to treat patient populations who require increased resource utilization following surgery. Risk adjustment models accounting for Medicaid payer status will be necessary to ensure good access to care for this patient population by avoiding penalties for physicians and hospital systems.

Porous 3D Printed Titanium Cages in Anterior Cervical Discectomy and Fusion are Associated With Less Subsidence, Improved Maintenance of Segmental Lordotic Correction, and Similar Clinical Outcomes as Allograft.

STUDY-DESIGN: Retrospective chart review. OBJECTIVES: Investigate radiographic and clinical outcomes of 3D printed titanium cages (3DTC) vs allograft in patients undergoing Anterior cervical discectomy and fusion (ACDF). METHODS: Consecutive series of patients undergoing ACDF with 3DTC were compared to patients using corticocancellous allograft. Cage subsidence, fusion status, sagittal alignment, and patient-reported-outcomes. Radiographic evaluation was performed on the closing intraoperative x-ray and compared to films at 6-weeks, 6-months, and 1-year. Cage subsidence was calculated based on the amount of settling into superior and inferior endplates compared to the intraoperative x-ray. Fusion was assessed based on < 1 mm of flexion/extension motion. Sagittal alignment parameters and patient-reported-outcomes were measured. RESULTS: Seventy six-patients/(120 levels) in 3DTC group and 77-patients/(115 levels) in allograft group were evaluated. No significant differences were noted in patient demographics, level fused or the number of levels fused between the groups. The most common level fused was C5-6. 3DTC had a significantly lower subsidence rate at all-time points as compared to allograft (P < .001). 3DTC maintained segmental lordosis better than allograft at all-time points including 1-year postop (P < .001). No significant differences were noted in fusion rate for 3DTC vs allograft at 6-months (P > .05). There were no significant differences in patient-reported-outcomes. CONCLUSION: 3D printed titanium cages had similar patient-reported outcomes and fusion rates as allograft, but less subsidence at all-time points. 3D printed titanium cages better maintained the segmental lordosis at the operative level at all-time points. Although longer term evaluation is needed, based on these results, 3DTC appear to be viable graft options for ACDF that better maintain disc space height and improve segmental lordotic interbody correction.

A Prospective Randomized Controlled Trial of Methylprednisolone for Postoperative Pain Management of Surgically Treated Distal Radius Fractures.

PURPOSE: Perioperative glucocorticoids have been effectively used as a pain management regimen for reducing pain after hand surgery. We hypothesize that a methylprednisolone taper (MPT) course following surgery will reduce pain and opioid consumption in the early postoperative period. METHODS: This study was a randomized controlled trial of patients undergoing surgical fixation for distal radius fracture. Before surgery, patients were randomly assigned to receive preoperative dexamethasone only or preoperative dexamethasone followed by a 6-day oral MPT. Patient pain and opioid consumption data were collected for 7 days after surgery using a patient-reported pain journal. RESULTS: Our study consisted of 56 patients enrolled from November 2018 to March 2020. Twenty-eight patients each were assigned to the control and treatment groups. Demographic characteristics such as age, body mass index, the dominant side affected, smoking status, diabetes status, and current narcotic use were similar between the control and treatment groups. With a noticeable, significant reduction starting on postoperative day 2, patients who received an MPT course consumed substantially less opioids during the first 7 days (7.8 ± 7.2 pills compared with 15.5 ± 11.5 pills, a 50% reduction). These patients also consumed significantly fewer oral morphine equivalents than the control group (81.2 vs 41.2). A significant difference in the pain visual analog scale scores between the 2 groups was noted starting on postoperative day 2, with 48% of the treatment group reporting no pain by postoperative day 6. No adverse events, including infection or complications of wound or bone healing, were seen in either group. CONCLUSIONS: There was an early improvement in pain and reduction in early opioid consumption with a 6-day MPT following surgical fixation for distal radius fracture. With no increased risk of adverse events in our sample, MPT may be a safe and effective way to reduce postoperative pain. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Predictive Factors Associated with the Need for Simultaneous Carpal Tunnel and Ulnar Nerve at the Elbow Releases.

INTRODUCTION: Carpal tunnel syndrome and ulnar nerve compression at the elbow (e.g., cubital tunnel syndrome) are the most common upper extremity compressive neuropa- thies treated by hand surgeons. The aim of this study was to determine demographic factors and comorbidities that can help predict those patients most likely to undergo concurrent release of both the carpal tunnel and ulnar nerve at the elbow. We hypothesized that certain comorbidities, such as diabetes, would be associated with an increased risk for the necessity of concomitant procedures. METHODS: Using Truven Marketscan® database, all patients who underwent carpal tunnel release were identified from 2010 to 2017 using Current Procedural Terminology (CPT) codes. Patients were only included if they had continuous enrollment in the database for 12 months preoperatively. Preoperative comorbidities and concurrent procedures were collected us- ing CPT and ICD-9 and 10 codes. Patients who underwent simultaneous carpal tunnel and ulnar nerve at the elbow release on the same day were compared to those patients who underwent carpal tunnel release alone. Additionally, patients who underwent either procedure initially and then went on to have the other procedure at a later date were compared. Univariate analysis and binomial logistic regression were performed to assess the contribution of patient demographics and comorbidities on the necessity of simultaneous release. RESULTS: 259,574 patients underwent carpal tunnel release surgery and were included in the study. 24,401 (7.9%) of pa- tients also underwent simultaneous ulnar nerve release at the elbow on the same day. Significant risk factors associated with the need for simultaneous release, were male gender [(Odds Ratio (OR): 2.05, Confidence Interval (CI): 2.00-2.11, p < 0.001)], chronic pain (OR: 1.78, CI: 1.68-1.87, p < 0.001), diabetes (OR: 1.29, CI: 1.25-1.33, p < 0.001), history of al- coholism (OR: 1.23, CI: 1.10-1.38, p < 0.001), chronic renal disease (OR: 1.26, CI: 1.18-1.34, p < 0.001), tobacco use (OR: 1.49, CI: 1.42-1.56, p < 0.001), and patients with congestive heart failure (OR: 1.26, CI: 1.17-1.35, p < 0.001). Patients with consumer driven health plans and high deductible health plans (HDHP) were 1.5 times more likely to have simultane- ous release compared to those with comprehensive plans (OR: 1.46, CI: 1.37-1.56, p < 0.001; OR: 1.45, CI: 1.34-1.57, p < 0.001; respectively). For necessity of subsequent carpal or ulnar nerve release after either primary procedure, patients with a minimum of 3 years enrollment in the database were analyzed. Of the 113,505 patients who underwent initial carpal tunnel release, 1,746 (1.5%) went on to undergo release of the ulnar nerve at the elbow. Of the 12,673 patients who had initial ulnar nerve releases at the elbow, 721 (5.7%) required additional release of the carpal tunnel. CONCLUSION: Identification of patient demographic factors and comorbidities that can help predict the likelihood of si- multaneous release of both the carpal tunnel and ulnar nerve at the elbow can help direct management of these patients. Combining the two procedures can help save resources, minimize patient burden, and help reduce excess health care utilization.

Racial Disparities in the Utilization of Shoulder Arthroplasty in the United States: Trends from 2011 to 2017.

As the incidence of shoulder arthroplasty rises at exponential rates, race is an important consideration, as racial disparities have been reported in lower-extremity arthroplasty in the United States. Our study sought to examine these disparities. Methods: Using the National Inpatient Sample (NIS) database, all anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (RSA) procedures from 2011 to 2017 were analyzed. The patients were divided into the Black, Hispanic, and White groups. Results: Overall, 91.4% of the patients undergoing any shoulder arthroplasty procedure were White, 4.75% were Black, and 3.85% were Hispanic. Age and sex-standardized RSA utilization rates (per 100,000) in White patients increased by 139% from 6.94 in 2011 to 16.60 in 2017. The disparity for Black patients, compared with White patients, was 118% in 2011 and 124% in 2017; the disparity for Hispanic patients was 112% in 2011 and 103% in 2017. Similar disparities in aTSA utilization rates were seen; when compared with White patients, there was a 150% disparity in 2011 and a 197% disparity in 2017 for Black patients, and a 169% disparity in 2011 and a 262% disparity in 2017 for Hispanic patients. Finally, Blacks had a higher rate of non-home discharge, longer length of stay, and higher overall costs, while Hispanics had a longer length of stay and higher cost than Whites. Conclusions: Despite many efforts to reduce racial disparities in health-care utilization, the chasm in shoulder arthroplasty in the United States appears to be large and widening further. The exponential increase in utilization of shoulder arthroplasty has not been shared equally among races, and the disparities are larger than those reported in lower-extremity arthroplasty.

Off-label usage of RhBMP-2 in posterior cervical fusion is not associated with early increased complication rate and has similar clinical outcomes.

BACKGROUND CONTEXT: Arthrodesis is important for the success of posterior cervical fusion (PCF), however, there exists limited data regarding the safety and efficacy of bone morphogenic protein (BMP) in PCF. PURPOSE: The primary objective was to evaluate early postoperative complications associated with BMP in PCF and determine whether BMP leads to adverse early clinical outcomes. A secondary objective was to determine the optimal location for BMP sponge placement, within the facet joint (IF) or elsewhere, and the optimal dosage/level. DESIGN: Retrospective, consecutive case-control study. PATIENT SAMPLE: Seven hundred sixty-five patients who underwent PCF OUTCOME MEASURES: Patient-reported outcomes (PROs), complications, arthrodesis, optimum dose/level of BMP METHODS: Surgical data, including preoperative diagnosis, levels fused, type of bone graft, BMP dose (when used), and fusion technique were recorded. Complications were assessed by reviewing the medical record encompassing the first 6-weeks postoperative. These included medical, neurological, and wound-related complications and reoperation. Neurological complications were defined as any new weakness, radicular pain, or numbness. PROs were collected, including SF36, VAS, EQ-5D, and NDI scores. To determine the optimal dosage and location for BMP placement, a sub-analysis was performed. RESULTS: There were no significant differences between the BMP and no BMP group with regards to wound complications, neurological complications, or reoperation. There were no differences in PROs between BMP and no BMP. Placement of BMP for IF and at a dose of 0.87 mg/level minimized wound-related complications. The BMP group had a higher fusion rate compared to the no BMP group (96% vs. 91%, p=.02) when assessed 1 year post-operatively. CONCLUSION: BMP was not associated with a higher rate of early complications after PCF when the dose was minimized. Complications thought to be associated with BMP, such as compressive seroma, radiculitis, and wound-related complications were not seen at a higher rate. PROs at early follow-up were similar. Placement of BMP for IF and at lower doses than previously reported may minimize complications.

The Preoperative Cost of Carpal Tunnel Syndrome.

PURPOSE: Carpal tunnel syndrome is a common condition, with well-defined diagnostic and treatment guidelines. Despite these guidelines, continued variation in care exists, with providers variably using diagnostic tests and nonsurgical treatment modalities prior to surgery. The purpose of this study was to evaluate the variation and cost associated with the diagnosis and nonsurgical treatment of patients prior to undergoing carpal tunnel release. METHODS: We queried the Truven MarketScan database to identify patients who underwent carpal tunnel release from 2010 to 2017. Patients were identified using common current procedural terminology codes and included if they were enrolled in the database for a minimum of 12 months prior to surgery to allow all preoperative data to be captured. All associated current procedural terminology codes during the 1-year preoperative period were refined to codes related to median neuropathy and categorized as office visits, diagnostic imaging (x-ray, ultrasound, and magnetic resonance imaging), electrodiagnostic testing, injections, occupational or physical therapy, durable medical equipment, and preoperative laboratory tests. RESULTS: In total, 378,381 patients were included in the study. A per-patient average cost of $858.74 was spent on preoperative workup and nonsurgical treatment. Electrodiagnostic testing represented 44.6% of the cost, and office visits represented 31.9%. Regarding nonsurgical treatment, 16.1% of the patients received an injection during the 1-year preoperative period, 26.8% received a medical brace, and 6.6% used physical therapy. When analyzed based on age group, the per-patient average cost for patients aged 70 years or older was significantly less than those younger than 70 years ($723.92 vs $878.76). CONCLUSIONS: Despite robust clinical practice guidelines and high volumes, significant variation in presurgical care exists. These data are useful to begin to critically analyze the causes of variation in the diagnosis and treatment of carpal tunnel syndrome and move toward a more effective, efficient, and informed treatment strategy. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/decision analysis II.

Opioid use following a total shoulder arthroplasty: who requires refills and for how long?

INTRODUCTION: Pain control following a total shoulder arthroplasty (TSA) is multifactorial. The current standard of care includes the utilization of a multimodal analgesic approach including breakthrough prescription opioid medication in an effort to provide postoperative analgesia. While this original opioid prescription is sufficient for the majority of patients, some go on to require prolonged opioid use. Our study investigated patient risk factors associated with opioid refill postsurgery. METHODS: The Truven Marketscan® database was queried for all patients who underwent either a primary anatomic TSA or primary reverse TSA from 2010 to 2017. Opioid data were collected using National Drug Codes (NDC) from outpatient pharmacy claims. Only opioid-naïve patients were included. Patients were then grouped into 1 of 3 cohorts based on postoperative opioid use: 1) Patients with no additional refills, 2) patients with a minimum of one additional refill up through 6 months postoperatively, and 3) patients with additional refills and continued opioid use past 6 months. RESULTS: Of the total of 17,706 opioid-naïve patients that underwent a TSA, 10,882 (61.5%) did not have any additional refills, 4473 (25.3%) required an additional prescription within 6 months after surgery, and 2351 (13.3%) had prolonged opioid use beyond 6 months postoperatively. A dose-dependent relationship was identified between initial opioid prescription quantity and risk for refill and prolonged use. The prolonged use group was prescribed an equivalent of 20.0 more 5 mg oxycodone pills than the no refill group and 12.7 more than the refill group (P < .001). On multivariate analysis, younger age, female gender, and tobacco use, along with the comorbidities of coronary artery disease, clinical depression, diabetes, and rheumatic disease were all found to be predictive factors of prolonged opioid use. DISCUSSION: The dose-dependent relationship observed between original opioid prescription data and number of additional refills needed, suggests that initially overprescribing opioids may lead to prolonged dependency. This study also identified several independent risk factors for prolonged opioid use, including younger age, depression, and tobacco use. This study will hopefully help recognize high-risk patient populations and serve as the foundation for future studies into opioid prescription standardization and preoperative opioid education.

Telehealth Can Be Implemented Across a Musculoskeletal Service Line Without Compromising Patient Satisfaction.

Background: The COVID-19 pandemic has led to changes to in-office orthopedic care, with a rapid shift to telemedicine. Institutions' lack of established infrastructure for these types of visits has posed challenges requiring attention to confidentiality, safety, and patient satisfaction. Purpose: The aim of this study was to analyze the feasibility of telemedicine in orthopedics during the pandemic and its effect on efficiency and patient satisfaction. Methods: Patients seen by the Emory University Department of Orthopaedics Sports Medicine and Upper Extremity Divisions via telemedicine from March 23 to April 24, 2020, were contacted by telephone. Each patient was asked to respond to questions on satisfaction, ease of use, and potential future use; satisfaction with telemedicine and previous clinical visits were measured using a modified 5-point Likert scale. Results: Of the 762 patients seen, 346 (45.4%) completed the telemedicine questionnaire. Satisfaction varied by visit type, with average scores of 4.88/5 for in-office clinic visits versus 4.61/5 for telemedicine visits. There was no significant difference among age groups for satisfaction ratings. Patients 65 years old or older reported significantly longer visit times and decreased ease of use with the telemedicine platform. Conclusion: Telemedicine in a large orthopedics department was successfully implemented without compromising patient satisfaction. The use of telemedicine allows many patients to be seen quickly and efficiently without diminishing their musculoskeletal clinical experience.

Management of Proximal Pole Scaphoid Nonunions: A Critical Analysis Review.

¼: Optimal management of nonunions of the proximal pole of the scaphoid is controversial and dependent on many patient and pathophysiologic considerations. ¼: If the proximal pole subchondral bone support is sufficient, options include open reduction and internal fixation, either alone or in combination with autologous nonvascularized or vascularized bone graft. ¼: If the proximal pole is not salvageable, replacement with osteochondral autografts or osteochondral flaps is the only option for reconstruction of the native anatomy.

Management of Acute Distal Radioulnar Joint Instability Following a Distal Radius Fracture: A Systematic Review and Meta-Analysis.

Purpose: We sought to review the clinical outcomes of conservative and operative treatment options for acute distal radioulnar joint (DRUJ) instability associated with distal radius fractures in adult patients. Methods: A systematic search of PubMed, MEDLINE, and EMBASE for articles published between 1990 and 2020 involving DRUJ instability associated with distal radius fractures was performed. The primary outcomes analyzed included clinical grip strength; range of motion; the disability of the arm, shoulder and hand (DASH) score; and the modified Mayo wrist score (MMWS). Results: Of the 531 articles identified in the literature search, 8 met our defined criteria and were included in the final analysis. The cumulative sample size was 258 patients at a mean follow-up of 11.1 months (range, 3-16.9 months). Treatment groups included cast immobilization in supination, K-wire stabilization, and triangular fibrocartilage complex (TFCC) repair. Statistical analysis revealed no difference across groups in active flexion-extension or DASH scores. A significant decrease in grip strength was found in patients who underwent TFCC repair compared with that in those who underwent both cast immobilization (P = .04) and K-wire stabilization (P = .02). Furthermore, we found a significant decrease in active pronation-supination between patients who underwent TFCC repair and those who underwent cast immobilization (P = .03). Patients who underwent TFCC repair were also found to exhibit decreased MMWS as compared with those who underwent K-wire stabilization (P = .05). Overall, persistent DRUJ instability was only found in 4 patients (1.5%), without a significant difference between treatment groups. Conclusions: This study suggests functional advantages of certain treatment modalities over others, with the range of motion being highest in patients who underwent cast immobilization and grip strength being highest in patients who underwent K-wire stabilization. However, the mean DASH scores showed no difference across all groups, calling into question the clinical need to pursue operative treatment via K-wire stabilization or TFCC repair over conservative treatment via cast immobilization. This study will hopefully serve as a foundation for future prospective studies to help improve and standardize treatment algorithms in patients with DRUJ instability and distal radius fractures.Type of study/level of evidence: Therapeutic II.

Intra-Articular Laser Treatment Plus Platelet Rich Plasma (PRP) Significantly Reduces Pain in Many Patients Who Had Failed Prior PRP Treatment.

Background: In our practice, Platelet Rich Plasma (PRP) injections effectively reduce pain in most, but not all, arthritic patients. When PRP treatment fails, joint replacement surgery is often the only good alternative. Surface Low-Level-Laser-Therapy (LLLT) has not been helpful for osteoarthrosis in our experience. We hypothesized that intra-articular laser (IAL) treatment combined with PRP would improve results in patients with prior ineffective PRP treatment. Methods: We offered Intra-articular Low-Level-Laser-Therapy (IAL) treatment simultaneously with repeat PRP injection to patients who had received no benefit from PRP alone. They were the treatment and also historical control group since all had failed PRP treatment alone. Thirty joints were treated: 22 knees, 4 hips, 2 shoulder glenohumeral joints and 2 first carpo-metacarpal (1st CMC). Results: No adverse events were seen at any time after treatment in any patient. Twenty-eight joints were available for re-evaluation: ≥ 40% improvement was seen in 46% (6 months), 32% (12 months) and 32% (24 months) post-treatment. Mean SANE scores improved significantly at 1 and 2 years. Thirteen patients failed treatment and had joint replacement. Conclusions: PRP with IAL allowed avoidance of surgery and good pain control at least two years post-treatment in nearly half of patients who had failed PRP treatment alone.

Treatment of Type Two Slap Lesion With Anatomic Suture Anchor Repair Without Biceps Tenotomy Or Tenodesis.

BACKGROUND: Poor results after repair of type 2 SLAP tears are relatively common and some have reported better results after biceps tenodesis or tenotomy than repair. In addition, some believe that the long head of the biceps is expendable. Therefore, many now favor biceps tenotomy or tenodesis over biceps anchor repair either in all patients or in older patients, reserving SLAP lesion repair only for young athletes. HYPOTHESIS: We hypothesized that repair of the biceps anchor of the labrum would be effective in all patients regardless of age provided that care was taken not to overtighten the labrum and that rotator cuff pain as the primary pain generator had been ruled out. METHODS: All patients with type 2 SLAP lesion repair by the senior author since he began repairing them with suture anchors were prospectively evaluated. Patients with more than one other concomitant procedure, simultaneous rotator cuff repair or worker's compensation status were excluded. RESULTS: 77% of patients were available for minimum two year followup. No patient had subsequent surgery or manipulation under anesthesis as a result of their SLAP repair. Standardized shoulder test score increased by 4 points. Mean SANE score decreased from 53 pre-op to 14 post-op. Results were the same in those over versus under 40 years of age. CONCLUSION: Anatomic repair of Type 2 SLAP lesions at the biceps anchor without biceps tenodesis or tenotomy can produce good results in patients of all ages.