Does the addition of post-operative gabapentin reduce the use of narcotics after orthopedic surgery?

OBJECTIVES: To evaluate the efficacy of post-operative gabapentin administration as an analgesic agent and its effect on narcotic use after orthopedic surgery in an outpatient sports medicine practice by comparing patients prior to and after initiating the routine use of gabapentin as part of a standardized post-operative pain medication regimen. We hypothesized that adding gabapentin to a multimodal post-operative pain regimen would decrease the number of requested pain medication refills and have no detrimental effect on Visual Analogue Scale and Single Assessment Numerical Evaluation scores at these early post-operative visits. METHODS: All outpatient surgical patients, <90 years of age, undergoing outpatient orthopedic surgery by the study's senior author were included between 08/05/2021 and 02/22/2022. Patients were allowed 1 narcotic refill post-operatively and only in the first 3 weeks. The primary outcome was difference in percentage of patients who requested a narcotic refill within 3 weeks post-op. Two- and 6-week Visual Analogue Scale and Single Assessment Numerical Evaluation scores, and baseline health and demographic data. T-tests were run on continuous variables, Chi-Square or Fisher's Exact Test were run on dichotomous variables, and Mann-Whitney U test was run on all other categorical variables. Statistical significance was set at P < .05 for all tests. RESULTS: There was a significant difference in narcotic refills at 3 weeks: 23 pre-gabapentin patients and 9 post-gabapentin patients (22.8% vs 9.0%, respectively: P = .006). There were no differences between 2- and 6-week Visual Analogue Scale and 2-week Single Assessment Numerical Evaluation scores. There was a significant difference in 6-week SANE between groups: mean difference = 6.4 (P = .027) though less than the established MCID. CONCLUSION: Addition of gabapentin to a post-operative multimodal pain regimen reduced the use of narcotics after orthopedic sports medicine surgeries while also providing equivalent pain control.

A Prospective Assessment of Opioid Utilization Post-Operatively in Orthopaedic Sports Medicine Surgeries.

BACKGROUND: The healthcare system is plagued finding the balance between opioid use and abuse. Orthopaedic surgeons are expected to curtail the number of opioids prescribed in order to lower opioid abuse. We sought to prospectively evaluate opioid consumption following a wide range of sports orthopaedic surgical procedures to determine utilization patterns. METHODS: All patients receiving procedures within a one-year period were consented and then called daily for one week followed by weekly for up to two months or until the patients no longer were taking their opioid medication. We studied the number of opioids patient's took postoperatively and also collected information in regards to the patient and the surgical procedure. RESULTS: Included were 223 patients with a mean age of 32.9 years (range, 11 to 82). Surgeons prescribed a mean total of 59.5 pills, and patients reported consuming a mean total of 20.9 pills, resulting in a utilization rate of 40%. 94.4% of patients received no education on how to properly dispose of unused opioids. The mean SANE score was 53.9. The mean Pain Catastrophizing Scale score was 15.1. The mean Opioid Risk Tool was 3.3. The procedures were broken down into: 47.5% ligamentous knee repair, 18.4% shoulder arthroscopy/other shoulder, 7.6% meniscus, 7.6% shoulder arthroplasty, 5.4% distal biceps, 4.0% lower leg (ankle/foot/tibia) and 4.0% shoulder ORIF. CONCLUSION: Over-prescribing opioids after sports orthopaedic surgeries is widespread. In this study, we found that patients are being prescribed 2.48 times greater opioid medications than needed following sports orthopaedic surgical procedures. We recommend surgeons take care when prescribing postoperative pain control and consider customizing their opioid prescriptions on the basis of prior opioid usage, anatomic location and procedure type. We also recommend educating the patients on proper disposal of excess opioids and consider involving pain management for patients likely to require prolonged opioid usage.

Which Anterior Acetabular Fracture Surgical Approach is Preferred? A Survey of the Orthopaedic Trauma Association Active Membership.

OBJECTIVE: The goal of this survey was to determine the current surgeon-preferred anterior surgical approach for the treatment of acetabular fractures in North America. DESIGN: Web-based survey; PARTICIPANTS:: Orthopaedic Trauma Association (OTA) members. METHODS: Active members of the OTA were solicited to participate in an OTA-sponsored survey asking for their preferred standard anterior surgical approach to the acetabulum, along with some general demographic data. The approach choices were: the classic ilioinguinal as described by Letournel, a modified ilioinguinal, the modified Stoppa (Anterior Intrapelvic) with or without a lateral window, the pararectus, and an alternative to be specified by the survey taker. RESULTS: Of the 675 total active OTA membership, 214 (32%) satisfactorily completed the survey. Of the 214 active members, only 32 (15%) prefer the classic ilioinguinal approach and 60 (28%) prefer some type of modified ilioinguinal approach. More than half of the active member respondents (121; 56.5%) prefer the modified Stoppa approach. Statistical analysis of the respondents' demographic data revealed only years in practice to be significantly different among treatment options (P < 0.01) with those with the least time in practice preferring the modified Stoppa. CONCLUSIONS: It seems that the modified Stoppa has become the preferred anterior acetabular fracture surgical approach in North America, being especially favored by those more recently in practice. The exact reasons for this change cannot be determined from this survey and are most likely multifactorial. However, training experience may play an important role.

Current Trends in the Surgical Treatment of Open-Book Pelvic Ring Injuries: An International Survey Among Experienced Trauma Surgeons.

INTRODUCTION: In the open-book, rotationally unstable (OTA/AO type 61-B1.1) pelvic ring injury, the posterior sacroiliac complex is believed to remain intact. Therefore, anterior ring stabilization alone has been the standard treatment recommendation. However, treatment failures using this method have caused a reconsideration of this management strategy. Anterior plus posterior fixation is the main alternative. In the absence of any specific new guidelines, the choice of treatment currently relies on the preference of the treating surgeon. The objective of this survey was to determine the relative use of anterior plus posterior fixation, as opposed to the standard anterior fixation alone, for the treatment of open-book pelvic ring injuries. METHODS: An international group of 176 practicing trauma surgeons experienced in pelvic ring fracture fixation participated in an AO Foundation survey asking for their preferred standard surgical fixation (anterior alone or anterior plus posterior combined) for OTA/AO type 61-B1.1 open-book pelvic fractures. RESULTS: Anterior plate fixation alone (group 1) was preferred by 56% of the survey participants, and combined anterior plus posterior fixation (group 2) was preferred by 44%. Statistical analysis revealed that group 1 participants were significantly older than group 2 participants (P = 0.03) and had more years of surgical experience (P = 0.02). CONCLUSIONS: Concern regarding the inadequacy of anterior fixation alone has led many surgeons, especially those more recently in practice, to add posterior fixation, despite limited data to determine its indications. No doubt the OTA/AO type B 1.1 pelvic ring disruption actually represents a wide spectrum of injury. Further study is needed to determine the best fixation method.

Device Sales Representatives in the Operating Room: Do We Really Need or Want Them? A Survey of Orthopaedic Trauma Surgeons.

INTRODUCTION: The purposes of this study were to determine the current attitude of orthopaedic trauma surgeons toward device sales representatives (DSRs), especially regarding their presence in the operating room (OR), and to establish the existence of any surgeon generational differences. METHODS: A survey was created using a 5-point Likert response scale, related to conflict of interest (COI) and attitudes toward DSRs. Participants were solicited from the Orthopaedic Trauma Association database of 384 active members and 127 (33%) completed the survey. Respondents were divided into 2 subcategories (Generation X vs. Baby Boomers). RESULTS: Overall, respondents viewed their DSRs favorably without any perception of COI. However, they perceived their peers as being at risk for COI (P ≤ 0.004). Generation X responders feel that DSRs should be in the OR for all cases, whereas Baby Boomers do not (P < 0.01). CONCLUSIONS: With one striking generational difference, most orthopaedic trauma surgeons feel that they need DSRs in the OR. Similar to other physician groups, they also feel that they are not subject to COI from salesman contact that affects their peers. Reasons for this perceived need and any related COI risk, and the opportunities to address both, require further study.

Is the Marx Activity Scale Reliable in Patients Younger Than 18 Years?

BACKGROUND: There is no baseline activity scale yet validated in pediatric patients. The Marx and Tegner scales have been validated in adult patients only. The Tegner scale involves questions not pertinent to children, such as their work activity. The Marx scale is simple, and all its questions can be related to athletic activities. HYPOTHESIS: The Marx scale is reliable for use in a pediatric population. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 2. METHODS: Patients younger than 18 years were given the Marx activity scale in clinic and again 3 weeks later. The patients were divided into 3 groups, of at least 50 patients each, based on presenting diagnosis: knee injury, lower extremity (non-knee) injury, and upper extremity injury. Test-retest reliability was determined for the overall scores and the individual questions. Differences in scores were also compared based on age (<14 vs ≥14 years). RESULTS: A total of 162 patients (mean age, 14.4 years; range, 8-17 years) were included. The Marx scale had a high intraclass correlation coefficient (ICC) overall as well as for each of its 4 questions. Both older and younger patients had ICCs >0.80, though the older group generally had higher scores. The mean score was 13.55 (out of 16), and 50.6% scored the maximum; only 1.9% scored the minimum. Mean scores for the knee, lower extremity, and upper extremity groups were 13.71 (SD, 3.70), 13.22 (SD, 4.18), and 13.68 (SD, 3.33), respectively (P > 0.05). There also was no difference in total score based on age (P = 0.88). CONCLUSION: The Marx activity scale is reliable in patients younger than 18 years with injuries to the knee and lower extremities, though the scale was less reliable in patients younger than 14 years. There is a significant ceiling effect present, which limits its overall usefulness. CLINICAL RELEVANCE: Although there is no other current substitute, the Marx activity scale is not an ideal measurement of younger patients' baseline activity levels.

Relationship of cortical thickness of the proximal humerus and pullout strength of a locked plate and screw construct.

BACKGROUND: No study to date has evaluated cortical thickness as it relates to locking plate failure or screw pullout in the proximal humerus. The purpose of this study is to determine the relationship between proximal humerus cortical thickness and locked plate hardware failure in a cadaveric proximal humerus fracture model. METHODS: Twelve humerus specimens were placed into two groups based on the proximal humerus cortical thickness on an anteroposterior radiograph: less than 4 mm and greater than 4 mm. The specimens were plated with a six-hole proximal humerus locking plate and a 15-mm resection osteotomy at the surgical neck was performed. The specimens were tested in a materials testing machine at a displacement of 5 mm/min to failure. RESULTS: Load at failure, stiffness, maximum load, failure, and fracture gap closure were all statistically similar (P > 0.05) between the groups. CONCLUSION: Our biomechanical study used modern locked plate-screw construct fixation of a simulated two-part proximal humerus fracture. The mechanical strength was unaffected based on a threshold combined proximal humerus cortical thickness of 4 mm.

What effect does anterior cruciate ligament tibial guide orientation have on tibial tunnel length?

PURPOSE: To evaluate the effects of alteration in tibial guide pin insertion angle and external starting point on tibial tunnel length for anterior cruciate ligament (ACL) reconstruction. METHODS: Ten cadaveric tibial specimens were used. One pin was placed at each of variable insertion angles (55°, 50°, and 45°) of the tibial targeting device aimed at the center of the tibial ACL footprint. These 3 pins started externally along the anterior border of the superficial medial collateral ligament. A fourth pin at 50° was placed at a different external tibial starting point 1.5 cm anterior to the anterior border of the superficial medial collateral ligament. The intraosseous length of each pin was measured. Statistic analyses were performed with the Kruskal-Wallis test, with significance set at P < .05. RESULTS: The mean length for the 55° tibial tunnel was 50.3 mm (range, 42 to 56 mm); for the 50° tunnel, it was 48.9 mm (range, 44 to 55 mm); for the 50° anterior tunnel, it was 47.6 mm (range, 39 to 55 mm); and for the 45° tunnel, it was 47.3 mm (range, 41 to 52 mm). Changing the angle of the tibial guide did not significantly affect the length of the tibial tunnel (P = .18). Changing the external tibial starting point did not affect the length of the tibial tunnel (P = .39). CONCLUSIONS: Changing the tibial guide angle between 45°, 50°, and 55° does not appreciably change tibial tunnel length. Moving the starting point anterior 1.5 cm toward the tibial tubercle also has no effect on the tibial tunnel length. The lack of significant changes in tunnel length with these interventions may reflect the associated changes that occur in proximal tibial morphometry with change in external tibial starting position. CLINICAL RELEVANCE: Changing tibial tunnel length in ACL reconstruction likely requires more distalization of the external tibial starting point than is achieved simply by altering the tibial aiming guide angle by 10° or less.

Inter- and intraobserver reliability of the clock face representation as used to describe the femoral intercondylar notch.

PURPOSE: To validate the use of the clock face reference as a reliable means of communicating femoral intercondylar notch position. METHODS: A single red mark was made on ten identical left Sawbones femurs in the intercondylar notch at variable locations. Ten surgeons, who routinely perform ACL reconstructions, were presented the femurs in random order and asked to state the position of the mark to the nearest 30-min interval. Responses were recorded and then repeated 3 weeks later. The same 10 surgeons were presented with 30 actual arthroscopic photographs of the intercondylar notch, performed at 90° of knee flexion, with a probe pointing at various locations (10 knees; 3 photographs/knee) along the lateral aspect of the notch. The results were then analyzed with an ICC, Cronbach's alpha test, and descriptive statistics. RESULTS: For the Sawbones, the ICC was 0.996 while individual physician's Cronbach's alpha test ranged from 0.954 to 0.999, indicating a very high interobserver and intraobserver reliability. The mean range of responses among the 10 surgeons was 1.6 h, SD 0.6. For the photographs, the ICC was also high at 0.997. There was a mean range of 1.1 h, SD 0.4, among surgeons. CONCLUSIONS: The clock face method is commonly utilized for both placement of the femoral tunnel during ACL reconstruction as well as describing the location of the ACL femoral tunnel between communicating surgeons. Despite a high statistical interobserver correlation, there is significant range among different surgeons' responses. The present study questions the reliability of the clock face method for use between surgeons as a stand alone tool. Other methods also utilizing anatomic landmarks may be more accurate for describing intercondylar notch anatomy. LEVEL OF EVIDENCE: III.

Community opinions in the management of corneal ulcers and ophthalmic antibiotics: a survey of 4 states.

OBJECTIVE: To evaluate the ophthalmic community's current opinions of the management of bacterial keratitis and usage of the currently available ophthalmic antibiotics. METHODS: An anonymous questionnaire was mailed to ophthalmologists in California, Florida, Illinois, and Missouri. The results were tabulated and analyzed statistically. RESULTS: Six hundred twenty-nine usable questionnaires (10.3%) were returned. In the management of corneal ulcers, 42.2% of comprehensive ophthalmologists and 75.3% of cornea specialists perform Gram stains some of the time. A total of 73.3% of comprehensive ophthalmologists and 93.7% of cornea specialists perform corneal cultures some of the time. A total of 88.8% of comprehensive ophthalmologists and 76% of cornea specialists initiate treatment with the newer fluoroquinolone antibiotics. A total of 12.1% of comprehensive ophthalmologists and 41% of cornea specialists would select fortified antibiotics for the treatment of corneal ulcers. The percentage of those who feel that fortified antibiotics are superior ranges from 17.7% for comprehensive ophthalmologists to 33.3% for cornea specialists. A total of 65.7% of comprehensive ophthalmologists indicate that the newer fluoroquinolones have impacted their practices, and 58.3% indicate that they represent an improvement over older fluoroquinolones. CONCLUSIONS: Most responding ophthalmologists initiate empiric therapy with the newer fluoroquinolone antibiotics for corneal ulcers, forgoing Gram staining and culturing. However, respondents are not universally sanguine about the newer fluoroquinolones. The practice patterns and opinions on antibiotics differ almost universally between comprehensive ophthalmologists and cornea specialists. Larger, more detailed surveys and more specific analyses would help to further establish the factors that lead to differing management choices and opinions.