A Novel Prescription Method Reduces Postoperative Opioid Distribution and Consumption: A Randomized Clinical Trial.

BACKGROUND: Prescription opioid abuse in the United States has risen substantially over the past 2 decades. Narcotic prescription refill restrictions may paradoxically be contributing to this epidemic. We investigated a novel, refill-based opioid prescription method to determine whether it would alter postoperative narcotic distribution or consumption. METHODS: In this randomized controlled trial, patients undergoing internal fixation of distal radius fractures or thumb carpometacarpal joint arthroplasty received either a single prescription for all postoperative narcotics (control arm) or the same amount of pain medication divided into 3 equal prescriptions to be filled as needed (experimental arm). Outcomes included total narcotics dispensed, measured in morphine milligram equivalents (MME) through a prescription monitoring program, patient-reported opioid consumption versus opioid not consumed, and a satisfaction survey. RESULTS: Forty-eight participants were enrolled; 25 were randomized to the control arm and 23 to the experimental arm. At 8 weeks post-op, fewer opioids had been dispensed to the experimental arm (177 ± 94 vs 287 ± 123 MME, P = .0025). At 6-week follow-up, the experimental arm reported lower narcotic consumption (124 ± 105 vs 214 ± 110 MME, P = .0131). Subanalysis of the independent surgeries yielded similar results. Some patients reported insurance issues when filling subsequent prescriptions. Consequently, although 100% of control arm patients reported good pain control, only 82.6% of experimental arm patients said likewise (P = .0455). CONCLUSIONS: This randomized clinical trial demonstrated that patients obtained and consumed fewer narcotics when postoperative opioids were given in a refill-based prescription method. More research is needed to determine whether this opioid distribution method is reproducible, translatable, and feasible.

Targeted Muscle Reinnervation in the Hand: A Technical Roadmap.

PURPOSE: Targeted muscle reinnervation (TMR) transfers cut the nerve endings to the motor nerves of the nearby muscles to reduce neuroma pain and/or enhance prosthetic function. To guide surgeons, anatomic "roadmaps" describe nerve transfer options for TMR at various locations. This study aimed to landmark and measure motor entry points (MEPs) to the hand interossei muscles in the context of TMR for digital nerve neuroma management. METHODS: Ten fresh-frozen cadaveric hands were dissected to describe the innervation arising from the deep branch of the ulnar nerve to the dorsal interossei (DIs) and palmar interossei (PIs) muscles. The location of MEPs relative to the bone and soft tissue landmarks and the size of the target nerves were measured. RESULTS: The MEPs for the DIs and PIs were found in the central third of the metacarpal. The MEPs to the PIs averaged 23.3-24.7 mm from the median nerve. The length of nerve proximal to the MEP was limited, ranging between 6.5 ± 2.6 mm for the first PI and 10.5 ± 2.7 mm for the second PI. Similarly, minimal nerve proximal to the MEP of the DI was available for mobilization. Access to the first PI innervation required substantial release of the thenar musculature. Motor nerve diameter averaged 0.85-0.97 mm. CONCLUSIONS: In considering TMR for the management or prevention of digital nerve neuromas, the motor branches to the second and third PIs are the most accessible and best approached volarly, whereas motor branches to the DIs take more direct routes into the muscle, making volar exposure difficult. Nerve length proximal to the MEP is short, requiring that most of the nerve length for neurorrhaphy comes from the digital nerve. Size mismatch at the neurorrhaphy site is favorable compared to more proximal TMR. CLINICAL RELEVANCE: Targeted muscle reinnervation in the hand is technically feasible for a patient with a symptomatic neuroma after digital amputation.

Postoperative care via smartphone following carpal tunnel release.

INTRODUCTION: This study explores a novel smartphone application for postoperative care following carpal tunnel release (CTR). We hypothesized that a software-based 'virtual visit' for CTR could be safe, effective and convenient for the patient. METHODS: Our group developed the software application utilized in this study. Interactive steps with video instructions enabled patients to complete dressing and suture removal, capture a wound photo, answer a question about median nerve symptoms and capture a video of finger range of motion. Adult patients undergoing endoscopic or open CTR were enrolled. Prior to their scheduled postoperative visit, patients received and completed the module using their smartphone. Agreement between findings of the virtual visit and the corresponding in-person clinical visit was assessed using kappa values. RESULTS: Twenty-two patients were contacted regarding study enrolment and 17 patients were enrolled (ages 23-63, mean 48.2, 6M, 11F). Of 16 patients who participated, all completed dressing removal. Ten of 16 patients removed their sutures successfully. Fourteen patients captured a clinically adequate wound photo and 15 patients answered a question about median nerve symptoms. Fourteen patients captured a range of motion video. Software assessments of surgical wounds, nerve symptoms and physical exams agreed strongly with clinical assessments. DISCUSSION: Most patients were able to respond to a question about their symptoms, provide clinical assessment of their wound via a photo and record a video of their range of motion. Suture removal was the most difficult task. More investigation is needed to determine which patients can reliably remove their sutures.

Sulfasalazine Resolves Joint Stiffness in a Rabbit Model of Arthrofibrosis.

Joint stiffness due to fibrosis/capsule contracture is a seriously disabling complication of articular injury that surgical interventions often fail to completely resolve. Fibrosis/contracture is associated with the abnormal persistence of myofibroblasts, which over-produce and contract collagen matrices. We hypothesized that intra-articular therapy with drugs targeting myofibroblast survival (sulfasalazine), or collagen production (ß-aminopropionitrile and cis-hydroxyproline), would reduce joint stiffness in a rabbit model of fibrosis/contracture. Drugs were encapsulated in poly[lactic-co-glycolic] acid pellets and implanted in joints after fibrosis/contracture induction. Capsule α-smooth muscle actin (α-SMA) expression and intimal thickness were evaluated by immunohistochemistry and histomorphometry, respectively. Joint stiffness was quantified by flexion-extension testing. Drawer tests were employed to determine if the drugs induced cruciate ligament laxity. Joint capsule fibroblasts were tested in vitro for contractile activity and α-SMA expression. Stiffness in immobilized joints treated with blank pellets (control) was significantly higher than in non-immobilized, untreated joints (normal) (p = 0.0008), and higher than in immobilized joints treated with sulfasalazine (p = 0.0065). None of the drugs caused significant cruciate ligament laxity. Intimal thickness was significantly lower than control in the normal and sulfasalazine-treated groups (p = 0.010 and 0.025, respectively). Contractile activity in the cells from controls was significantly increased versus normal (p = 0.001). Sulfasalazine and ß-aminopropionitrile significantly inhibited this effect (p = 0.005 and 0.0006, respectively). α-SMA expression was significantly higher in control versus normal (p = 0.0021) and versus sulfasalazine (p = 0.0007). These findings support the conclusion that sulfasalazine reduced stiffness by clearing myofibroblasts from fibrotic joints. Statement of clinical significance: The results provide proof-of-concept that established joint stiffness can be resolved non-surgically. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:629-638, 2020.

Intercarpal Ligament Injuries Associated With Distal Radius Fractures.

Injuries to the scapholunate (SL) and lunotriquetral (LT) interosseous ligaments occur in approximately one third of distal radius fractures. The diagnosis of these injuries is challenging because plain radiographs are not reliably diagnostic. Wrist arthroscopy may be the most accurate way to examine and diagnose soft-tissue injuries of the carpus adjacent to a distal radius fracture. Treatment options for SL and LT ligament injuries include open repair and/or percutaneous pinning. Because the natural history of these injuries is unclear, the necessity of diagnosing and treating these SL and LT interosseous ligament defects remains speculative.

Simultaneous Fractures of the Ipsilateral Scaphoid and Distal Radius.

Background Ipsilateral fractures of the distal radius and scaphoid are rare, with few reports describing mechanisms of injury, fracture patterns, and treatment approaches. Purpose This article describes the clinical and radiographic features of ipsilateral distal radius and scaphoid fractures occurring simultaneously. Materials and Methods Electronic databases from 2007 to 2017 at a single Level 1 trauma center were reviewed for patients with concurrent fractures of the distal radius and scaphoid. Patient demographics, injury mechanism, scaphoid and distal radius fracture pattern, treatment approach, and radiographic healing were studied. Results Twenty-three patients were identified. Nineteen of the 23 (83%) were males, and 19 of 23 (83%) of the injury mechanisms were considered high energy. Twenty-two of the 23 (96%) scaphoid fractures were nondisplaced, all treated with screw fixation. Most distal radius fractures were displaced and comminuted, 17 of 23 (74%) were intra-articular. All distal radius fractures were treated surgically with internal and/or external fixation. Three patients were lost to follow-up. Average follow-up of the remaining 20 was to 19.8 weeks. Nineteen of the 20 (95%) scaphoids healed, one scaphoid went on to nonunion with avascular necrosis. All 20 radius fractures healed, 16 of 20 (80%) in anatomic alignment. Conclusion Ipsilateral fractures of the distal radius and scaphoid are rare and are usually result of high-energy mechanisms. The scaphoid fracture is usually a nondisplaced fracture at the waist. The distal radius fracture pattern varies but most are displaced and comminuted. The union rate of the scaphoid is high, even if subjected to radiocarpal distraction required for distal radius management. Level of Evidence Therapeutic level IV study.

Brucella osteomyelitis of the proximal tibia: a case report.

Brucellosis is a disease of domestic and wild animals that is transmittable to humans. Although endemic in some parts of the world, brucellosis is an uncommon human pathogen in the United States. The clinical presentation of brucellosis is nonspecific, and brucella osteomyelitis can produce lytic lesions on radiographs that resemble neoplasm. Diagnosis can therefore be difficult unless a high index of suspicion is maintained. We present a case of brucella osteomyelitis of the proximal tibia that demonstrates these features.