Optimizing Safe Opioid Prescribing: A Paradigm Shift in Buprenorphine Management for Orthopaedic Surgery.

The worsening opioid epidemic in the United States, exacerbated by the COVID-19 pandemic, necessitates innovative approaches to pain management. Buprenorphine, a long-acting opioid, has gained popularity due to its safety profile and accessibility. Orthopaedic surgeons, encountering an increasing number of patients on buprenorphine, face challenges in perioperative management. This article will update orthopaedic surgeons on new developments in the understanding of buprenorphine as a pain reliever and share evidence-based practice guidelines for buprenorphine management. For patients on buprenorphine for opioid use disorder or chronic pain, the updated recommendation is to continue their home dose of buprenorphine through the perioperative period. The patient's buprenorphine prescriber should be contacted and notified of any impending surgery. The continuation of buprenorphine should be accompanied by a multimodal approach to analgesia, including a preoperative discussion about expectations of pain and pain control, regional anesthesia, standing acetaminophen, Nonsteroidal anti-inflammatory drugs when possible, gabapentinoids at night for patients under 65 years, cryotherapy, elevation, and early mobilization. Patients can also be prescribed short-acting, immediate-release opioids for breakthrough pain. Transdermal buprenorphine is emerging as an excellent option for the management of acute perioperative pain in both elective and nonelective orthopaedic patients. A single patch can provide a steady dose of pain medication for up to 1 week during the postoperative period. A patch delivery method can help combat patient nonadherence and ultimately provide better overall pain control. In the future, transdermal buprenorphine patches could be applied in virtually all fracture surgery, spinal surgery, total joint arthroplasty, ligament reconstructions with bony drilling, etc. As the stigma surrounding buprenorphine decreases, further opportunities for perioperative use may develop.

Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction.

¼ The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).¼ The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.¼ QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.¼ The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.¼ There are emerging data that the QT autograft is a viable option in revision ACLR.

Short-term outcomes following open gluteus maximus transfer for the management of hip abductor tears.

Tears of the gluteus medius and minimus are an important cause of recalcitrant greater trochanteric pain syndrome. Although endoscopic and open abductor repairs have demonstrated promising outcomes, the success of these techniques is dependent on the size of the tear and the quality of the tissue. In patients presenting with abductor insufficiency and evidence of previous repair failure, large retracted tears, muscle atrophy and/or fatty infiltration, reconstruction/augmentation techniques should be considered. In the present study, we present a retrospective cohort study assessing patient outcomes following open gluteus maximus transfer for irreparable or severely retracted gluteus medius tears. Patients were included in the present study if they underwent open gluteus maximus transfer to address hip abductor tears that a senior surgeon deemed irreparable or at high risk for failure following isolated repair secondary to the following tear characteristics: large tears with >2 cm of retraction, the presence of extensive fatty infiltration (Goutallier Grade 3 or greater) and/or patients requiring revision abductor repair due to primary repair failure with associated pain and a Trendelenburg gait. Patients undergoing a concomitant, or those with a previous history of hip arthroplasty, were excluded from the study. All participants were prospectively enrolled in the study, and both pre- and post-operative patient-reported outcomes were collected at 6 months and 1 year including the modified Hip Harris Score, Visual Analog Score, Hip Outcomes Score of Activities Daily Living, Hip Outcomes Score for Sports-Related Activities and Overall Satisfaction with Hip. Pre-operative scores were compared with post-operative assessments using Student's t-test with a significance level of P < 0.05. Twenty-one patients and 22 hips were included. The average age was 69 (SD ±9.2) and 17 (81%) were females. The average body mass index was 30.0 (±6.2). The outcome scores at both 6 months and 1 year demonstrated significant improvements compared with pre-operative functional assessment. This article reports the utility of gluteus medius/minimus repair augmentation or reconstruction via gluteus maximus transfer demonstrating improvement in patient-reported outcomes at short-term follow-up.

Male Youth Ice Hockey Concussion Incidence in a USA Hockey Membership-Adjusted Population: A Peak in 2011 and the Impact of Major Rule Changes.

OBJECTIVE: To investigate the incidence of youth ice hockey-related concussions preceding and following the implementation of new body-checking and head contact rules by USA hockey in 2011. We hypothesized a decrease in concussions after the rule change. DESIGN: Retrospective analysis. SETTING: United States emergency department (ED) data queried in the National Electronic InjurySurveillance System (NEISS). PATIENTS: National Electronic Injury Surveillance System reported male youth (≤18 years) ice hockey concussion cases from January 1, 2002, to December 31, 2016. In total, 848 players were diagnosed with concussion, representing a national estimate of 17 374 cases. INDEPENDENT VARIABLES: Time, specifically years. MAIN OUTCOME MEASURES: Incidences and incidence rates (measured per 10 000 person-years) of male youth ice hockey concussions. Annual trends were analyzed using descriptive and linear or polynomial regression analysis. RESULTS: The national estimate of youth ice hockey-related concussions seen in US emergency departments (EDs) increased significantly from 656 in 2007 to 2042 in 2011 (P < 0.01). During the same period, their respective incidence increased significantly from 21.8 to 66.8 per 10 000, before dropping through 2016 (P < 0.05). After 2011, concussions decreased from 1965 in 2012 to 1292 in 2016 (P = 0.055). The gap in concussion incidence between the 11 to 12 and 13 to 14 divisions widened after 2011 (before 2011: 41 vs 49 per 10 000 person-years [P = 0.80]; after 2011: 45 and 89, respectively [P < 0.01]). CONCLUSIONS: US EDs experienced a significant increase in youth ice hockey concussion visits from 2007 to 2011. After the 2011 rule changes, concussion visits decreased significantly from 2012 to 2016.

Epidemiology of female youth ice hockey injuries presenting to United States emergency departments from 2002 to 2019.

BACKGROUND: This study documented injury types, rates and mechanisms for female youth ice hockey players reporting to US emergency departments to inform safety measures and sideline medical preparedness. METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried for ice hockey injuries (product code 1279) from 1 January 2002 to 31 December 2019. Incidence rate ratios (IRR) were calculated using OpenEpi and compared between age divisions. Spearman's rank correlation was utilized to evaluate the correlation between age and injury incidence. USA Hockey membership statistics were used to establish the population at risk and calculate incidence rates (IR). RESULTS: An estimated 20,384 ice hockey injuries presented to participating United States emergency departments. The number of female youth ice hockey players increased significantly from 36,258 in 2002 to 65,072 in 2019 (p < 0.01). The most commonly injured body parts were the head (n = 5,519, IR = 62.1 [95%CI 54.3-70.0 per 10,000 athletes), trunk (n = 2,364, IR = 26.6 [95%CI 21.2-32.0] per 10,000 athletes), and wrist (n = 1,824, IR = 20.5 [95%CI 15.7-25.4] per 10,000 athletes). The most commonly reported mechanisms of injury were player-to-player collision (n = 4,746, IR = 53.4 [95%CI 46.4-60.5] per 10,000 athletes) and falls (n = 4,585, IR = 51.6 [95%CI 44.1-59.1] per 10,000 athletes). The most common diagnoses were traumatic brain injury (n = 5,333, IR = 60.0 [95%CI 52.3-67.8] per 10,000 athletes), contusion (n = 4,204, IR = 47.3 [95%CI 40.3-54.4] per 10,000 athletes) and strain/sprain (n = 3,601, IR = 40.5 [95%CI 34.1-47.0] per 10,000 athletes). A positive correlation was found between age and injury incidence, as well as increasing age and injuries from player-to-player collision and TBI's. CONCLUSIONS: Though body checking is illegal at all levels of women's ice hockey, player-to-player collision prevailed as the leading mechanism on injury. Hopefully this study informs players, parents, coaches, trainers and clinicians about the impact of player-to-player collisions on overall injury burden in the older age divisions of youth female hockey.

Increases in Firework-Related Upper Extremity Injuries Correspond to Increasing Firework Sales: An Analysis of 41,195 Injuries Across 10 Years.

INTRODUCTION: Between 2008 and 2017, the American Pyrotechnics Association reported a 41% increase in revenue from firework sales, with 2017 showing $885 million US dollars in consumer sales. We sought to evaluate the epidemiology of firework-related upper extremity injuries during this 10-year period, hypothesizing that hand/upper extremity injuries from fireworks were increasing in the United States. METHODS: Observational epidemiologic assessment of a weighted cohort of patients via the National Electronic Injury Surveillance System from 2008 to 2017. The National Electronic Injury Surveillance System provides a nationwide probability sample of injuries related to consumer products based on emergency department visits collected from a cohort of about 100 US hospitals. RESULTS: A total of 1,079 patients representing an estimated 41,195 firework-related upper extremity injuries presented to US emergency departments from 2008 to 2017. The number of injuries increased significantly from 2,576 in 2008 to 5,101 in 2017 (R2 = 0.85, R = 0.92, P < 0.001). A Spearman rank-order correlation determined that there was a strong, positive correlation between the increase in firework sales and the increase in injuries (rs = 0.939, P < 0.01). The overwhelming majority of firework-related injuries were seen in males (77%) aged 11 to 29 years (48%). The hand and fingers accounted for 85.8% of injuries, with the thumb being the most commonly injured body part (51.3%). Burns were the most common injury across all body sites except the wrist, where fractures were most common. CONCLUSION: Ten-year firework-related upper extremity injuries increased, corresponding to increased consumer sales across the same period. This study provides previously absent population-level data to provide a framework for discussion among policy makers and physicians alike in an attempt to mitigate the use of fireworks and their associated upper extremity injuries. LEVEL OF EVIDENCE: Level III.

Epidemiology and trends of adult ice hockey injuries presenting to United States emergency departments: A ten-year analysis from 2007-2016.

PURPOSE: The adult population is under-represented in existing ice hockey injury studies, despite the number of United States (US) adult ice hockey players increasing from 103,533 in 2007 to 180,400 in 2016 (74%). This study establishes trends in demographics, injury location, and injury type for adult ice hockey players (≥19 years old) in the United States. METHODS: The National Electronic Injury Surveillance System (NEISS) was queried for all ice hockey injuries from January 1, 2007 to December 31, 2016. Cases under age 19 were excluded. Each injury's narrative text field was reviewed to determine mechanism of injury. RESULTS: A total of 1,653 patients, representing an estimated 68,786 ice-hockey related injuries, presented to NEISS-participating US EDs. The most commonly injured body parts were the face (n = 12,432, 18.1%), head (n = 10,201, 14.8%), shoulder (n = 9,654, 14.0%) and ankle (n = 5,389, 7.8%). The most common diagnoses made were laceration (n = 18,153, 26.4%), strain/sprain (n = 12,202, 17.7%), fracture (n = 10,079, 14.7%), contusion (n = 9,283, 13.5%) and concussion (n = 4,794, 7.0%). The most common mechanisms of injury were falling (n = 11,786, 18.7%), puck contact (n = 10,544, 15.3%) and player contact (n = 9,449, 13.7%). Concussions increased from 46 in 2007 to 928 in 2016 (R2 = 0.8, ß = 0.9, p < 0.001). Females (n = 1,852, 32%) had a higher proportion of head injuries than males (n = 8,349, 13.3%) (IPR = 2.4, p < 0.0001). The 50+ year old cohort showed a significant increase in injuries during the study period (n = 146 vs. 982, R2 = 0.75, ß = 0.87, p = 0.001). CONCLUSIONS: Despite changing trends in age and sex-related demographics, the majority of injuries in this population may be preventable with adequate enforcement of protective gear use. Increased education amongst players, coaches, trainers, orthopaedic surgeons and primary care physicians should be encouraged to minimize injuries.

Resolution of Preoperative Peroneal Nerve Palsy After Total Knee Arthroplasty: A Case Report.

CASE: We present the case of a 71-year-old man with right knee osteoarthritis (OA) and a varus deformity who developed a progressive common peroneal nerve palsy that resolved after total knee arthroplasty (TKA). After decades of knee pain, the patient gradually developed a foot drop as well as numbness and paresthesias over the foot dorsum during the course of 1 month. The patient underwent TKA and within 6 weeks postoperatively had complete resolution of the peroneal nerve symptoms. CONCLUSION: A progressive common peroneal palsy in advanced varus knee OA may resolve after a properly aligned TKA without nerve decompression.

A novel method of standardized myocardial infarction in aged rabbits.

The incidence of both myocardial infarction (MI) and sudden cardiac death increases with age. Here, we describe the development of a minimally invasive large animal model of MI that can be applied to young or aged animals. We demonstrate that rabbit coronary anatomy is highly variable, more so than described in previous literature. In this work, we categorize the coronary pattern of 37 young rabbits and 64 aged rabbits. Aged rabbits had a higher degree of branching from the left main coronary artery. Standardizing the model across age cohorts required a new approach, targeting an area of myocardium rather than a specific vessel. Here, we present a method for achieving a reproducible infarct size, one that yielded a consistent scar encompassing ~30% of the apical left ventricular free wall. The model's consistency allowed for more valid comparisons of MI sequelae between age cohorts.NEW & NOTEWORTHY This study describes the coronary angiographic imaging of young and aged rabbits. We developed and improved a novel minimally invasive approach for coil embolization that targets a specific area of myocardium and yielded a consistent scar encompassing ~30% of the left ventricular free wall of young and aged rabbit hearts.