Can Use of Default Dispensing Quantities in Electronic Medical Record Lower Opioid Prescribing?

OBJECTIVES: Leftover opioids can contribute to misuse and abuse. Recommended dosing quantities in the electronic medical record can guide prescribing patterns. We hypothesized that decreasing the default from 30 doses to 12 doses would decrease the overall number of opioids prescribed without increasing second opioid prescriptions or additional health utilization. METHODS: We performed a single-center retrospective study of children with forearm and elbow fractures who presented to the emergency department for evaluation and subsequent orthopedic follow-up between January 15, and September 19, 2017. The default dispensing quantity was decreased on June 1, 2016 from 30 doses to 12 doses. Patients were categorized to preintervention and postintervention groups. We compared the number of opioids prescribed, second opioid prescriptions, emergency department visits, and pain-related telephone calls and orthopedic visits with χ2 and logistic regression analyses. RESULTS: There were 1107 patients included. Rates of opioid prescribing were similar preintervention and postintervention (61% vs 56%, P = 0.13). After the change to the default quantity, the median number of doses decreased from 18 to 12 doses, with opioid prescriptions of 30 or more doses dropping from 35% to 11%. No significant association was found between preintervention versus postintervention, opioid prescription at discharge, and having 1 or more pain-related or unexpected follow-up visits. CONCLUSIONS: Lowering the default dispensing quantity of opioids in the electronic medical record decreases the number of opioids prescribed without increasing second prescriptions or additional health care utilization. These findings suggest that a further reduction in the number of opioids prescribed for upper-extremity fractures may be possible.

Intraoperative Neurological Monitoring in Lower Limb Surgery for Patients With Mucopolysaccharidoses.

BACKGROUND: There are reports of spinal cord injury (SCI) occurring after lower extremity (LE) surgery in children with mucopolysaccharidoses (MPS). Intraoperative neurological monitoring (IONM) has been adopted in some centers to assess real-time spinal cord function during these procedures. The aim of this investigation was to review 3 specialty centers' experiences with MPS patients undergoing LE surgery. We report how IONM affected care and the details of spinal cord injuries in these patients. METHODS: All pediatric MPS patients who underwent LE surgery between 2001 and 2018 were reviewed at 3 children's orthopaedic specialty centers. Demographic and surgical details were reviewed. Estimated blood loss (EBL), surgical time, positioning, use of IONM, and changes in management as a result of IONM were recorded. Details of any spinal cord injuries were examined in detail. RESULTS: During the study period, 92 patients with MPS underwent 252 LE surgeries. IONM was used in 83 of 252 (32.9%) surgeries, and intraoperative care was altered in 17 of 83 (20.5%) cases, including serial repositioning (n=7), aggressive blood pressure management (n=6), and abortion of procedures (n=8). IONM was utilized in cases with larger EBL (279 vs. 130 mL) and longer operative time (274 vs. 175 min) compared with procedures without IONM. Three patients without IONM sustained complete thoracic SCI postoperatively, all from cord infarction in the upper thoracic region. These 3 cases were characterized by long surgical time (328±41 min) and substantial EBL (533±416 mL or 30.5% of total blood volume; range, 11% to 50%). No LE surgeries accompanied by IONM experienced SCI. CONCLUSIONS: Patients with MPS undergoing LE orthopaedic surgery may be at risk for SCI, particularly if the procedures are long or are expected to have large EBL. One hypothesis for the etiology of SCI in this setting is hypoperfusion of the upper thoracic spinal cord due to prolonged intraoperative or postoperative hypotension. IONM during these procedures may mitigate the risk of SCI by identifying real-time changes in spinal cord function during surgery, inciting a change in the surgical plan. LEVEL OF EVIDENCE: Level III-retrospective comparative series.

Foot and Ankle Musculoskeletal Imaging of Pediatric Patients With Cerebral Palsy.

OBJECTIVE. Any combination of abnormal positioning of the ankle, hindfoot, midfoot, and forefoot is possible in the context of cerebral palsy, but some patterns are more common than others. The purpose of this article is to discuss the radiographic manifestations and surgical management of the following common conditions: equinus, equinoplanovalgus, equinocavovarus, vertical talus, oblique talus, hallux valgus, and ankle valgus. CONCLUSION. CP is defined by abnormalities of the developing fetal or infant brain that result in permanent central motor dysfunction. Foot and ankle deformities are very common in the patients with CP, occurring in up to 93% of such patients as a result of underlying abnormal muscle tone, impaired motor control, and dynamic muscle imbalance. Radiologists must develop knowledge of the most common changes in alignment and basic techniques for correction to better recognize abnormalities and improve communication with orthopedic colleagues.

Cerebral palsy - beyond hip deformities.

Cerebral palsy is a neurologic condition with myriad musculoskeletal and articular manifestations. While every patient is unique with innumerable variations in presentation, symptoms and treatments, there are broad themes and recognizable patterns of development. Many of these findings spill over to other neurodevelopmental disorders, and lessons learned from children with cerebral palsy translate well to multiple neurologic conditions. This review focuses on the more common manifestations involving the spine, knee, foot and ankle, with an emphasis on collecting and describing imaging features, along with clinical and radiologic pearls and pitfalls.

Rectus Femoris Transfer Surgery Worsens Crouch Gait in Children With Cerebral Palsy at GMFCS Levels III and IV.

BACKGROUND: Previous study has shown that children with cerebral palsy (CP) functioning at Gross Motor Function Classification System (GMFCS) levels III and IV do not benefit from distal rectus femoris transfer (DRFT) due to lack of improvement in stance knee extension. The fate of knees in such subjects who do not undergo DRFT is unknown. The purpose of this study was to compare knee kinematic outcomes in patients with CP and stiff knee gait who underwent single-event multilevel surgery with and without DRFT. METHODS: Preoperative and postoperative gait analysis data were retrospectively reviewed for ambulatory (GMFCS levels I to IV) patients with CP with crouch and stiff knee gait whom underwent single-event multilevel surgery, including hamstring lengthening either with DRFT (N=34) or without DRFT (N=40). Statistical analyses included t tests and χ tests, and multiple regression analysis was performed to adjust for covariates. Data were stratified by GMFCS level groups I/II and III/IV. RESULTS: Improved maximum knee extension in stance was seen for both the DRFT (P=0.0002) and no DRFT groups (P≤0.0006) at GMFCS levels I/II, and the no DRFT group at GMFCS levels III/IV (P=0.02). Excessive stance knee flexion persisted for those at GMFCS level III/IV after DRFT. Maximum knee flexion in swing was maintained after DRFT, but significantly decreased in the no DRFT group (P<0.002) for both GMFCS groups. Change in total knee range of motion improved after DRFT only in the GMFCS I/II group subjects with unilateral involvement (P=0.01). Timing of maximum knee flexion in swing improved for all patients regardless of DRFT or GMFCS level group (P<0.0001). CONCLUSIONS: In patients with CP functioning at GMFCS levels III and IV, DRFT results in persistent crouch postoperatively. Given the importance of maintaining upright posture in these patients, we do not recommend DRFT in patients functioning at GMFCS levels III and IV. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Percutaneous Hamstring Lengthening Surgery is as Effective as Open Lengthening in Children With Cerebral Palsy.

BACKGROUND: Surgical lengthening of the hamstrings is often performed to correct crouch gait in children with cerebral palsy (CP). Previous studies have demonstrated the effectiveness of open hamstring lengthening (oHSL) in improving knee extension static and dynamic range of motion; however, literature regarding percutaneous hamstring lengthening (pHSL) is limited. The purpose of this study was to investigate the effect of open versus pHSL for improving crouch gait and knee function in children with CP. METHODS: This retrospective cohort study included 87 ambulatory children with CP who underwent HLS surgery with both preoperative and postoperative gait analysis (mean time, 29.4±19.9 mo after surgery) testing between 1997 and 2015. In total, 65 patients underwent oHLS surgery (mean age, 8.5±2.5 y) and 22 patients underwent pHSL surgery (mean age, 8.3±2.3 y). Lower extremity three-dimensional kinematic data were collected while subjects walked at a self-selected speed. Outcome variables for operative limbs were compared within and between groups using t tests, χ tests, and multiple regression analysis. RESULTS: Significant postoperative decreases in knee flexion at initial contact were seen for both open (Δ12.7±13.4 degrees; P<0.001) and percutaneous (Δ19.1±13.1 degrees; P<0.001) groups. Increased postoperative maximum knee extension in stance was found for both open (Δ8.2±16.8 degrees; P=0.001) and percutaneous (Δ14.4±16.5 degrees; P=0.001) groups. No significant differences between open and percutaneous groups were found when comparing postoperative changes in kinematic variables between groups after adjusting for covariates. Postoperative changes in static range of motion were similar between lengthening groups. CONCLUSIONS: pHSL is as effective as open lengthening in improving stance phase knee kinematics during gait in children with CP. This is the first study to compare the kinematic effects of open versus pHSL in the pediatric population. Percutaneous lengthening is tolerated well by patients, and as it allows for rapid rehabilitation it may be preferable to the open procedure. LEVEL OF EVIDENCE: Level III-retrospective comparative study.