Are Social Deprivation and Low Traditional Health Literacy Associated With Higher PROMIS CAT Completion in Orthopaedic Surgery?

BACKGROUND: The Patient-Reported Outcomes Measurement Information System® (PROMIS®) may be used to assess an individual patient's perspective of their physical, mental, and social health through either standard or computer adaptive testing (CAT) patient questionnaires. These questionnaires are used across disciplines; however, they have seen considerable application in orthopaedic surgery. Patient characteristics associated with PROMIS CAT completion have not been examined within the context of social determinants of health, such as social deprivation or health literacy, nor has patient understanding of the content of PROMIS CAT been assessed. QUESTIONS/PURPOSES: (1) What patient demographics, including social deprivation, are associated with completion of PROMIS CAT questionnaires? (2) Is health literacy level associated with completion of PROMIS CAT questionnaires? (3) Do patients with lower health literacy have a higher odds of completing PROMIS CAT without fully understanding the content? METHODS: Between June 2022 and August 2022, a cross-sectional study was performed via a paper survey administered to patients at a single, urban, quaternary academic medical center in orthopaedic subspecialty clinics of foot and ankle, trauma, and hand/upper extremity surgeons. We considered all English-speaking patients aged 18 or older, including those with limited reading and/or writing abilities, as eligible provided they received an iPad in clinic to complete the PROMIS CAT questionnaire as part of their routine standard clinical care or they completed the questionnaire via a patient portal before the visit. In all, 946 patients were considered eligible during the study period and a convenience sample of 36% (339 of 946) of patients was approached for inclusion due to clinic time constraints. Fifteen percent (52 of 339) declined to participate, leaving 85% (287 of 339) of patients for analysis here. Median (range) age of study participants was 49 years (35 to 64). Fifty-eight percent (167 of 287) of study participants self-identified as non-Hispanic Black or African American and 26% (75 of 287) as non-Hispanic White. Even proportions were observed across education levels (high school graduate or less, 29% [82 of 287]; some college, 25% [73 of 287]; college graduate, 25% [71 of 287]; advanced degree, 20% [58 of 287]). Eighteen percent (52 of 287) of patients reported an annual income bracket of USD 0 to 13,000, and 17% (48 of 287) reported more than USD 120,000. Forty-six percent (132 of 287) of patients worked full-time, 21% (59 of 287) were retired, and 23% (66 of 287) were unemployed or on disability. The primary outcome of interest was self-reported PROMIS CAT questionnaire completion grouped as: fully completed, partially completed, or no part completed. Overall, self-reported PROMIS CAT questionnaire completion proportions were: 80% (229 of 287) full completion, 13% (37 of 287) partial completion, and 7% (21 of 287) no part completed. We collected the National Area Deprivation Index (ADI) score and the Brief Health Literacy Screening Tool (BRIEF) as part of the study survey to associate with level of completion. Additionally, patient understanding of PROMIS CAT was assessed through Likert-scaled responses to a study survey question that directly asked whether the patient understood all of the questions on the PROMIS CAT questionnaire. Responses to this question may have been limited by social desirability bias, and hence may overestimate how many individuals genuinely understood the questionnaire content. However, the benefit of this approach was it efficiently allowed us to estimate the ceiling effect of patient comprehension of PROMIS CAT and likely had a high degree of specificity for detecting lack of comprehension. RESULTS: ADI score adjusted for age was not associated with PROMIS CAT completion (partial completion OR 1.00 [95% CI 0.98 to 1.01]; p = 0.72, no part completed OR 1.01 [95% CI 0.99 to 1.03]; p = 0.45). Patients with lower health literacy scores, however, were more likely to not complete any part of their assigned questionnaires than patients with higher scores (no part completed OR 0.85 [95% CI 0.75 to 0.97]; p = 0.02). Additionally, 74% (26 of 35) of patients who did not fully understand all of the PROMIS CAT questionnaire questions still fully completed them-hence, 11% (26 of 229) of all patients who fully completed PROMIS CAT did not fully understand the content. Among patients self-reporting full completion of PROMIS CAT with health literacy data (99% [227 of 229]), patients with inadequate/marginal health literacy were more likely than patients with adequate health literacy to not fully understand all of the questions (21% [14 of 67] versus 8% [12 of 160], OR 3.26 [95% CI 1.42 to 7.49]; p = 0.005). CONCLUSION: Within an urban, socioeconomically diverse, orthopaedic patient population, health literacy was associated with PROMIS CAT questionnaire completion. Lower health literacy levels increased the likelihood of not completing any part of the assigned PROMIS CAT questionnaires. Additionally, patients completed PROMIS CAT without fully understanding the questions. This indicates that patient completion does not guarantee comprehension of the questions nor validity of their scores, even more so among patients with low health literacy. This is a substantive concern for fidelity of data gathered from PROMIS CAT. CLINICAL RELEVANCE: Clinical implementation of the PROMIS CAT in orthopaedic populations will benefit from further research into health literacy to increase questionnaire completion and to ensure that patients understand the content of the questions they are answering, which will increase the internal validity of the outcome measure.

Health Disparities in Hand and Upper Extremity Surgery: A Scoping Review.

PURPOSE: Social determinants of health (SDOH) are linked to poor health care outcomes across the different medical specialties. We conducted a scoping review to understand the existing literature and identify further areas of research to address disparities within hand surgery. METHODS: A systematic search of PubMed, Scopus, and Cochrane was conducted. Inclusion criteria were English studies examining health disparities in hand surgery. The following were assessed: the main SDOH, study design/phase/theme, and main disease/injury/procedure. A previously described health disparities research framework was used to determine study phase: detecting (identifying risk factors), understanding (analyzing risk factors), and reducing (assessing interventions). Studies were categorized according to themes outlined at the National Institute of Health and American College of Surgeons: Summit on Surgical Disparities. RESULTS: The initial search yielded 446 articles, with 49 articles included in final analysis. The majority were detecting-type (31/49, 63%) or understanding-type (12/49, 24%) studies, with few reducing-type studies (6/49, 12%). Patient factors (31/49, 63%) and systemic/access factors (16/49, 33%) were the most frequently studied themes, with few investigating clinical care/quality factors (4/49, 8%), clinician factors (3/49, 6%), and postoperative/rehabilitation factors (1/49, 2%). The most commonly studied SDOH include insurance status (13/49, 27%), health literacy (10/49, 20%), and social deprivation (6/49, 12%). Carpal tunnel syndrome (9/49, 18%), upper extremity trauma (9/49, 18%), and amputations (5/49, 10%) were frequently assessed. Most investigations involved retrospective or database designs (29/49, 59%), while few were prospective, cross-sectional, or mixed-methods. CONCLUSIONS: Despite an encouraging upward trend in health disparities research, existing studies are in the early phases of investigation. CLINICAL RELEVANCE: Most of the literature focuses on patient factors and systemic/access factors in regard to insurance status. Further work with prospective, cross-sectional, and mixed-method studies is needed to better understand health disparities in hand surgery, which will inform future interventions.

Accreditation Council for Graduate Medical Education Hand Surgery Milestones V2.0 Development and Implementation: What Fellowship Directors, Faculty, and Fellows Need to Know.

Milestones have been in effect for Accreditation Council for Graduate Medical Education-accredited hand surgery fellowships since 2015. In 2016, the Accreditation Council for Graduate Medical Education began an improvement process to make the milestones easier to read, understand, and assess. This article looks at the process used for hand surgery, makes comparisons between the two versions, and discusses the resulting changes. A representative group of hand surgery faculty and fellows worked together to review the milestones data and identify necessary changes. Working iteratively in large and small groups, the milestones were edited, and a supplemental guide was developed. The new hand surgery milestones have fewer patient care subcompetencies, yet include the same overarching themes. The medical knowledge subcompetencies have been reduced to four, and they now focus on key dimensions of knowledge development instead of pure anatomical knowledge. Systems-based practice, practice-based learning and improvement, professionalism, and interpersonal and communication skills include subcompetencies harmonized with all other accredited programs. Finally, the supplemental guide was created as an aid to clinical competency committees to provide clear understanding of the intent of the milestones. The guide includes examples for individual milestones, ideas for how to assess each subcompetency, and resources for faculty and fellows alike. The new hand surgery milestones were designed to be clearer and easier for clinical competency committees to evaluate and for faculty and fellows to understand. The accompanying supplemental guide is a new addition that will help individual programs better understand how to implement these changes. The new hand surgery milestones can be found at https://www.acgme.org/globalassets/pdfs/milestones/handsurgerymilestones.pdf.

Incidence of Trigger Finger in Surgically and Nonsurgically Managed Carpal Tunnel Syndrome.

Purpose: The purpose of this study was to determine whether extremities undergoing carpal tunnel release (CTR) have an increased rate of trigger finger (TF) compared with conservatively managed carpal tunnel syndrome. Methods: Data were collected from the Humana Insurance Database, and subjects were chosen on the basis of a history of CTR with propensity matching performed to develop a nonsurgical cohort. Following propensity matching, 16,768 patients were identified and equally split between surgical and nonsurgical treatments. Demographic information and medical comorbidities were recorded. Univariate and multivariate analyses were performed to identify risk factors for the development of TF within 6 months of carpal tunnel syndrome diagnosis. Results: Patients in the surgical cohort were more likely to develop TF than those in the nonsurgical cohort whether in the ipsilateral or contralateral extremity. Whether managed surgically or nonsurgically, extremities with carpal tunnel syndrome demonstrated an increased prevalence of TF than their contralateral, unaffected extremity. Conclusions: Surgeons should be aware of the association of TF and CTR both during the presurgical and postsurgical evaluations as they might impact patient management. With knowledge of these data, surgeons may be more attuned to detecting an early TF during the postsurgical period and offer more aggressive treatment of TF pathology during CTR. Type of study/level of evidence: Prognostic III.

Patient Perspectives after Trapeziectomy and Ligament Reconstruction Tendon Interposition: A Qualitative Analysis.

BACKGROUND: The authors aimed to explore patients' perioperative experience after trapeziectomy and ligament reconstruction tendon interposition through semistructured patient interviews to identify deficiencies in preoperative patient counseling. METHODS: The authors conducted semistructured interviews with 14 patients who had undergone ligament reconstruction tendon interposition either 10 to 14 weeks or 9 to 12 months postoperatively at the time of their interview. The semistructured interview guide was developed by a fellowship-trained hand surgeon and a qualitative research specialist to discuss each patient's perioperative experience. Inductive and deductive qualitative coding strategies were used to develop a codebook. All transcripts were then double-coded and discussed to develop recurrent major themes from the patient interviews. RESULTS: The authors' interviews identified three major themes discussed consistently on the patient perioperative experience. First, despite specific counseling about a 3- to 6-month postoperative rehabilitation period, patients were still surprised at the length of the recovery process in regaining function, range of motion, and strength. Second, patients repeatedly outlined that surgery on the dominant hand imparted specific limitations that made the postoperative course difficult. Third, patients discussed the importance of hand therapy both in rehabilitation and in guiding patient postoperative expectations. CONCLUSIONS: Preoperative counseling is of vital importance to set patient expectations in terms of overall expected outcomes, but also regarding early limitations, expectations, and overall recovery length. These themes have influenced how we counsel our patients about recovery after thumb carpometacarpal surgery and may help other surgeons identify areas for improvement in their discussions with patients.

Outcomes of Acute Versus Subacute Scapholunate Ligament Repair.

Purpose: This study investigated the long-term outcomes of direct scapholunate ligament (SLL) repairs with or without dorsal capsulodesis performed within 6 weeks (acute repair) of a SLL tear versus 6 to 12 weeks following injury (subacute repair). Methods: A review of medical records from April 1996 to April 2012 identified 24 patients who underwent SLL repair (12 acute, 12 subacute). Patients returned to the clinic for radiographic examinations of the injured wrist, standardized physical examinations, and validated questionnaires. Results: The mean follow-up times for the acute and subacute groups were 7.2 and 6.2 years, respectively. At the final examination, patients with acute surgery regained more wrist extension (acute = 55°, subacute = 47°). The total wrist flexion-extension arcs, grip strengths, pinch strengths, and patient-rated outcome scores were found to be similar between groups. The final scapholunate gap, scapholunate angle, and the prevalence of arthritis were also found to be similar between the acute and subacute groups. Conclusions: Although SLL repair is more commonly recommended for treatment of acute SLL injuries, there were no significant long-term differences between acute and subacute SLL surgeries (repair ± capsulodesis). Type of study/level of evidence: Prognostic III.

Impact of Patient-Reported Allergies on Early Postoperative Opioid Use and Outcomes Following Ambulatory Hand Surgery.

Background: Patient-reported allergies (PRAs) are associated with suboptimal orthopaedic surgery outcomes and may serve as a proxy for mental health. While mental health disorders are known risk factors for increased opioid use, less is known about how PRAs impact opioid use after orthopedic surgery. The purpose of this study was to investigate the association between PRAs and postoperative opioid use, pain, and satisfaction following hand surgery. Methods: Patients who underwent ambulatory hand surgery at a single institution from May 2017 to March 2019 were retrospectively reviewed. Various scores, including the Mindfulness Attention Awareness Scale (MAAS), were collected preoperatively. Postoperatively, patients completed a 2-week pain diary, satisfaction, and visual analog scale (VAS) pain scores. Opioid consumption was converted to oral morphine equivalents (OMEs) using standard conversions. Results: A total of 137 patients were divided into 2 groups based on presence (≥1) (n = 73) or absence (0) (n = 64) of PRAs. At baseline, the ≥ 1 PRA group had significantly higher female composition (P < .001) and pain (P < .001) and lower PROMIS mental health scores (P = .044). Postoperative OME consumption averaged 42.5 (range 0-416) in the entire cohort, with no differences between groups. Among patients with ≥ 1 PRA, increasing number of allergies significantly correlated with increasing OME consumption across all time points (week 1, P = .016; week 2, P = .001; total, P = .005). Conclusions: The presence of PRAs did not impact postoperative narcotic usage, pain, or satisfaction. Increasing numbers of PRAs did, however, significantly correlate with higher narcotic use. These results may have implications for postoperative pain management in this population.

The Effect of Standardized Perioperative Patient Education on Opioid Use After Minor Soft Tissue Procedures Distal to the Wrist.

PURPOSE: Several studies have explored opioid consumption and opioid prescriber education for upper extremity procedures; however, less literature has focused on patient-centered interventions and their impact on opioid consumption after surgery. The purpose of this study was to create a standardized perioperative patient education program regarding postoperative pain management after hand surgery and to determine if it could reduce opioid use after hand surgery. METHODS: Patients scheduled to undergo elective outpatient hand surgery comprising minor soft tissue procedures at and distal to the wrist were randomized to receive pain management education or standard care. Before the surgery, all patients viewed a webinar with instructions for participation, whereas the education group received an additional 10 minutes of education on postoperative pain management and a pain management reference card for review after the surgery. All patients completed a postoperative daily log documenting the number of opioids consumed, other pain management modalities used, and pain scores. The primary outcome of the number of opioid pills consumed by the patients was compared between the groups. We constructed a linear regression model to determine the risk factors for postoperative opioid use after surgery. RESULTS: One hundred seventy-four patients completed the study (n = 90 education group; n = 84 standard care group). Patients in the education group took significantly fewer opioid pills (median = 0, range 0-13) than those in the standard care group (median = 0.5, range 0-40). A linear regression model showed that average week-1 pain (B = 0.93; 95% confidence interval, 0.56-1.3) and the number of pills prescribed (B = 0.12; 95% confidence interval, 0.017-0.22) were predictive of greater opioid use. CONCLUSIONS: Perioperative patient education significantly reduced postoperative opioid use following a minor soft tissue hand surgery, with greater than 70% of the patients taking no opioids. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Retrospective study of the effect of opioid prescribing guidelines on prescribing practices in pediatric orthopedic sports medicine patients having knee surgery: A single institution's experience.

OBJECTIVE: Guidelines for opioid prescription post-operatively exist; however, the majority of these are for adults. Nevertheless, opioid risks are present for pediatric patients also. This study investigates the effect of a single institution's guidelines on post-operative opioid prescribing for pediatric orthopedic patients undergoing knee surgery. We hypothesized that a standardized set of prescribing guidelines would result in a decrease in opioids prescribed at discharge home after these surgeries. DESIGN: Retrospective observational. SETTING: Urban, tertiary care, academic orthopedic hospital. PATIENTS: Pediatric, sports knee surgery, 23-month period. INTERVENTIONS: Guidelines were implemented institutionally for post-operative opioid prescribing practices. We reviewed all post-operative opioid prescriptions for pediatric patients undergoing sports knee surgery with two pediatric sports surgeons for the 11 months prior to the guidelines and 12 months afterwards, totaling 316 surgeries. MAIN OUTCOME MEASURE: Oral morphine equivalents (OMEs) prescribed on discharge from the hospital before and after implementation of guidelines. RESULTS: There was a significant reduction in OMEs from 229 OMEs to 175 OMEs before and after opioid prescribing guidelines (p < 0.001). This is a decrease in approximately seven 5 mg oxycodone tablets per patient. CONCLUSIONS: This study demonstrates that at our institution, with a pediatric patient population having sports knee surgery, prescribing guidelines reduced the number of opioids prescribed at discharge.

The Epidemiology of Carpal Tunnel Revision Over a 1-Year Follow-Up Period.

PURPOSE: To establish the incidence of revision carpal tunnel surgery within a 1-year postoperative period using a national administrative database. This information has been unknown until this point because of the absence of laterality-specific coding with the International Classification of Diseases, Ninth Edition and earlier coding systems. METHODS: Data were collected from the Humana insurance database using PearlDiver patient records from 2015 to 2017. Subjects were identified using Current Procedural Terminology and International Classification of Diseases procedure codes related to carpal tunnel diagnosis and release. Codes were used to identify patients who underwent carpal tunnel release (CTR) and had revision CTR within a 1-year follow-up period. Patient demographic characteristics, including age, sex, medical comorbidities, and smoking status, were collected. In addition, multivariable analysis of the risk of a revision procedure within 1 postoperative year was performed to determine independent risk factors, including the surgical approach, associated with revision CTR. RESULTS: Among 4,549 patients who underwent a primary CTR during the study period, 207 patients (4.8%) underwent a revision CTR within 1 year. The average time from the primary CTR to the revision CTR was 135 days (standard deviation, 99.1 days; range, 21-365 days). Primary endoscopic CTR was associated with an increased rate of revision CTR (odds ratio, 1.3; 95% confidence interval, 1.2-1.6). Patient factors associated with a higher likelihood of requiring revision CTR included diabetes mellitus, tobacco use, psychiatric condition, cervical disease, and history of cubital tunnel release. CONCLUSIONS: This study identified a rate of revision CTR of 4.8% within the first postoperative year. Both the surgical technique and patient-specific risk factors influence the likelihood of requiring revision surgery. Notably, an endoscopic approach is associated with a higher risk of revision surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Standardized Perioperative Patient Education Decreases Opioid Use after Hand Surgery: A Randomized Controlled Trial.

BACKGROUND: Despite the growing hand surgery literature on postoperative opioid use, there is little research focused on patient-centered interventions. The purpose of this randomized controlled trial was to create a standardized patient education program regarding postoperative pain management after hand surgery and to determine whether that education program would decrease postoperative opioid use. METHODS: Patients scheduled to undergo ambulatory hand surgery were recruited and randomized to standardized pain management education or standard of care. All patients received a webinar with instructions for study participation, whereas the education group received an additional 10 minutes of education on postoperative pain management. All patients completed a postoperative daily log documenting opioid consumption. The total number of opioid pills consumed was compared between groups. The authors constructed a linear regression model to determine risk factors for postoperative opioid use after surgery. RESULTS: A total of 267 patients were enrolled in the study. One hundred ninety-one patients completed the study (standardized education, n = 93; control group, n = 97). Patients in the standardized education group were more likely to take no opioid medication (42 percent versus 25 percent; p = 0.01) and took significantly fewer opioid pills (median, two) than those in the control group (median, five) (p < 0.001). Standardized education predicted decreased postoperative opioid pill consumption, whereas higher number of pills prescribed and a history of psychiatric illness were risk factors for increasing opioid use. CONCLUSION: Perioperative patient education and limitation of postoperative opioid prescription sizes reduced postoperative opioid use following ambulatory hand surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Prevalence and Treatment Outcomes of Hand and Wrist Injuries in Professional Athletes: A Systematic Review.

BACKGROUND: Injuries to the hand and wrist constitute up to 25% of all athletic injuries, yet not much information is available on the effects of such injuries on the careers of professional athletes. Understanding whether elite athletes can return to sport and at what level has value for athletes, coaches, managers, and others, including athletes at other levels of play. QUESTIONS/PURPOSES: The purpose of this study was to systematically review the literature on injuries of the hand and wrist in professional athletes to determine the prevalence and types of injuries sustained in professional sports, the management and clinical outcomes of such injuries, and the statistics regarding return to play. METHODS: A systematic review was conducted of PubMed/MEDLINE and the Cochrane Central Register of Controlled Trials to identify all studies reporting on hand and wrist injuries in professional athletes that were published between January 1970 and April 2019. Inclusion criteria were injuries of the upper extremity distal to the elbow that occurred in professional athletes during athletic competition, English language, and a study cohort consisting of four or more subjects. Details of injury sustained, sport, treatment, clinical outcome, and return to sport were extracted. RESULTS: We identified 32 nonoverlapping studies involving a total of 4299 hand and wrist injuries. The most common sport studied was baseball (eight studies), followed by football (seven), boxing (six), and basketball (five). Specific injury type was included in 29 of 32 studies and totaled 792 injuries. Metacarpal fractures were the most common injuries (n = 273; 34.5%), followed by thumb collateral ligament injuries (n = 110; 13.9%), phalangeal fractures (n = 87; 11.0%), and scaphoid fractures (n = 56; 7.1%). The overall operative rate was 18.3% (n = 708 of 3867). One-half of the studies reported the return to play (average, 2.8 months; range, 0.5 to 9 months). Seven studies reported sport-specific objective performance measures, with six describing consistent return to preinjury levels of performance among athletes. CONCLUSIONS: Based on the available evidence, a large majority of hand and wrist injuries in professional athletes are treated conservatively. Athletes frequently return to preinjury levels of performance after surgery. Additionally, return to play after a hand injury appears to be faster than that after other bony injuries. Further research is needed into the impact of these injuries on athletic performance, as well as how surgical intervention affects validated patient-reported outcome measures in professional athletes.

Level of Evidence and Publication Rates of Abstracts Presented at the American Society for Surgery of the Hand Annual Meetings: Comparison Over 23 Years.

PURPOSE: The primary aims of this study were to determine how level of evidence and publication rates of American Society for Surgery of the Hand (ASSH) abstracts presented at the national meeting have changed over the past 23 years. METHODS: Abstracts presented at the ASSH annual meeting from 1992 to 2014 were reviewed. Level of evidence (LoE) and publication status for each abstract were recorded. We calculated annual and overall LoE, publication rates, average time to publication, and top journals of publication for abstracts presented from 1992 to 2014. The LoE was categorized into level 1 or 2 studies, levels 3 to 5 studies, or nonclinical study. RESULTS: A total of 1,757 abstracts were presented at ASSH meetings from 1992 to 2014; 942 abstracts were published in peer-reviewed journals for an overall publication rate of 53.6%. There was a significant increase in the proportion of levels 1 to 2 LoE abstracts over time (18% in 2007-2014 vs 11% in 1999-2006 and 2% in 1992-1998). There was also a significantly higher percentage of abstracts published over time (62% in 2007-2014 vs 52% in 1999-2006 and 47% in 1992-1998). Levels 1 to 2 LoE studies were associated with higher publication rates than nonclinical or levels 3 to 5 LoE studies. CONCLUSIONS: This research provides historical trends on the LoE of abstracts presented at the ASSH annual meetings. Our study shows there are increasing numbers of levels 1 to 2 studies as well as higher publication rates of abstracts presented at more recent ASSH annual meetings. Levels 1 to 2 studies are more likely to be published than nonclinical or levels 3 to 5 studies. CLINICAL RELEVANCE: Although not all questions can be feasibly answered with level 1 or level 2 studies, authors should continue to search for ways to strengthen study designs, producing more valid and comparable results with increased likelihood of publication driving forward the quality of hand surgery research. Higher recent publication rates may be partially due to the increased number of available journals for publication.

Opioid Consumption After Arthroscopic Meniscal Procedures and Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Procedure-specific opioid-prescribing guidelines have the potential to decrease the number of unused pills in the home without compromising patient satisfaction. However, there is a paucity of data on the minimum necessary quantity to prescribe for outpatient orthopaedic surgeries. PURPOSE: To prospectively record daily opioid use and pain levels after arthroscopic meniscal procedures and anterior cruciate ligament reconstruction (ACLR) at a single institution. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 95 adult patients who underwent primary arthroscopic knee surgery (meniscectomy, repair, or ACLR) were enrolled. Patients with a history of opioid dependence were ineligible. Daily opioid consumption and Numeric Rating Scale pain scores were collected through an automated text-messaging platform starting on postoperative day 1 (POD1). At 6 weeks or at patient-reported cessation of opioid use, final survey questions were asked. Patients who failed to complete data collection were excluded. Opioid use was converted into "pills" (oxycodone 5-mg equivalents) to facilitate comparisons and clinical applications. Factors associated with high and low opioid use were compared. RESULTS: Of the 95 patients enrolled, 71 (74.7%) were included in the final analysis. Of these, 40 (56.3%) underwent meniscal surgery and 31 (43.7%) underwent ACLR. After outpatient arthroscopic meniscectomy or repair, the total median postdischarge opioid use was 0.3 pills (oxycodone 5-mg equivalents), with 75% of patients consuming 3.3 or fewer pills (range, 0-19 pills). For ACLR, the median postdischarge consumption was 7 pills (75th percentile, 23.3 pills; range, 0-41 pills). Almost one-third of patients (32.3%) took no opioids after surgery (3 ACLR, 20 meniscus). All meniscus patients and 71% of ACLR patients ceased opioid consumption by postoperative day 7. CONCLUSION: Opioids may not be necessary in all patients, particularly after meniscal surgery and in comparison with ACLR. For patients requesting opioids for pain relief, reasonable prescription quantities are 5 oxycodone 5-mg pills after arthroscopic meniscal procedures and 20 5-mg pills after ACLR. Slowing the current opioid epidemic and preventing future crises is dependent on refining prescribing habits. Clinicians should strongly consider patient education regarding expected pain as well as pain management strategies.

Factors Associated with Scaphoid Nonunion following Early Open Reduction and Internal Fixation.

Background Nonunion after open reduction and internal fixation (ORIF) of scaphoid fractures is reported in 5 to 30% of cases; however, predictors of nonunion are not clearly defined. Objective The purpose of this study is to determine fracture characteristics and surgical factors which may influence progression to nonunion after scaphoid fracture ORIF. Patients and Methods We performed a retrospective case-control study of scaphoid fractures treated by early ORIF between 2003 and 2017. Inclusion criteria were surgical fixation within 6 months from date of injury and postoperative CT with minimum clinical follow-up of 6 months to evaluate healing. Forty-eight patients were included in this study. Nonunion cases were matched by age, sex, and fracture location to patients who progressed to fracture union in the 1:2 ratio. Results This series of 48 patients matched 16 nonunion cases with 32 cases that progressed to union. Fracture location was proximal pole in 15% (7/48) and waist in 85% (41/48). Multivariate regression demonstrated that shorter length of time from injury to initial ORIF and smaller percent of proximal fracture fragment volume were significantly associated with scaphoid nonunion after ORIF (63 vs. 27 days and 34 vs. 40%, respectively). Receiver operating curve analysis revealed that fracture volume below 38% and time from injury to surgery greater than 31 days were associated with nonunion. Conclusion Increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury and when fracture volume was less than 38% of the entire scaphoid. Level of Evidence This is a Level III, therapeutic study.

Opioid Consumption Patterns After Lumbar Microdiscectomy or Decompression.

STUDY DESIGN: Prospective observational study OBJECTIVE.: The aim of this study was to record daily opioid use and pain levels after 1-level lumbar decompression or microdiscectomy. SUMMARY OF BACKGROUND DATA: The standardization of opioid-prescribing practices through guidelines can decrease the risk of misuse and lower the number of pills available for diversion in this high-risk patient population. However, there is a paucity of quantitative data on the "minimum necessary amount" of opioid appropriate for post-discharge prescriptions. METHODS: At two institutions between September 2017 and 2018, we prospectively enrolled 85 consecutive adult patients who underwent one-level lumbar decompression or microdiscectomy. Patients with a history of opioid dependence were excluded. Daily opioid consumption and pain scores were collected using an automated text-messaging-based platform for 6 weeks or until consumption ceased. Refills during the study period were monitored. Patients were asked for the number of pills left over and the method of disposal. Opioid use was converted to oral morphine equivalents (OMEs). Results are also reported in terms of "pills" (oxycodone 5 mg equivalents) to facilitate clinical applications. Risk factors were compared between patients in the top and bottom half of opioid consumption. RESULTS: Total opioid consumption ranged from 0 to 118 pills, with a median consumption of 32 pills (236.3 OME). Seventy-five percent of patients consumed ≤57 pills (431.3 OME). Mean Numeric Rating Scale pain scores declined steadily over the first 2 weeks. By postoperative day 7 half of the study population had ceased taking opioids altogether. Only 22.4% of patients finished their initial prescription, and only 9.4% of patients obtained a refill. CONCLUSION: These data may be used to formulate evidence-based opioid prescription guidelines, establish benchmarks, and identify patients at the higher end of the opioid use spectrum. LEVEL OF EVIDENCE: 2.

The Effect of Plate Design on the Flexor Pollicis Longus Tendon After Volar Locked Plating of Distal Radial Fractures.

BACKGROUND: Injury to and rupture of the flexor pollicis longus (FPL) tendon are known complications after volar locking plate fixation for distal radial fractures. Recent investigations have demonstrated that plate positioning contributes to the risk of tendon rupture; however, the impact of plate design has yet to be established. The purpose of this study was to compare FPL tendon-to-plate distance, FPL tendon-plate contact, and sonographic changes in the FPL tendon for 2 volar locking plate designs (ADAPTIVE compared with FPL) using ultrasound examination. METHODS: We identified patients who underwent distal radial fracture fixation by 2 fellowship-trained hand surgeons with either standard (ADAPTIVE) or FPL plates. Patients were matched by age, sex, and Soong grade. Enrolled patients returned for a research-related office visit for a clinical examination and bilateral wrist ultrasound. We measured plate-tendon distance, plate-tendon contact, sonographic changes in the FPL tendon, and postoperative radiographic parameters in the operatively treated wrist and the uninjured wrist. RESULTS: Forty patients with Soong grade-1 or 2 plate prominence underwent bilateral wrist ultrasound examination; all of the patients had distal radial fracture fixation, 20 with the standard volar locking plate and 20 with the FPL volar locking plate. Similar proportions of patients with the FPL plate (65%) and those with the standard plate (79%) had plate-tendon contact (p = 0.48); however, the FPL volar locking plate group had significantly less of the FPL tendon in contact with the volar plate than the standard volar locking plate group at wrist extension at both 0° (p < 0.001) and 45° (p < 0.001). There was no difference (p = 0.5) in the proportion of patients with sonographic changes in the FPL tendon between the FPL volar locking plate group (25%) and the standard volar locking plate group (21%). The postoperative volar tilt was significantly lower in patients with FPL plate-tendon contact (p = 0.01) and correlated moderately with the percentage of FPL tendon-plate contact at 0° (r = -0.51; p < 0.001) and 45° (r = -0.53; p < 0.001). There were no cases of tendon rupture in the cohort. CONCLUSIONS: We found that the FPL volar locking plate and increased volar tilt significantly reduced the plate-tendon contact area compared with the standard volar locking plate. In our asymptomatic cohort, we were unable to find a difference in sonographic changes in the FPL tendon. Further studies are needed to determine the clinical importance of decreased tendon-plate contact area seen in modified volar locking plate designs. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Subspecialty Rotation Exposure Across Accreditation Council for Graduate Medical Education-Accredited Orthopaedic Surgery Residency Programs.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) mandates certain procedural minimums for graduating residents of orthopaedic surgery programs and provides residency programs with comparative data on surgical case volume. It provides much less guidance and feedback to programs regarding the amount of time residents should spend on different rotations during residency. Comparative data regarding how much time residents are spending on general and subspecialty rotations may be of use to educational leadership as they consider curriculum changes and alternative training structures. The purpose of this study is to summarize the subspecialty rotation exposure across ACGME-accredited orthopaedic residency programs and to correlate the subspecialty rotation exposure with available program-specific factors. METHODS: This study contacted 162 ACGME-accredited orthopaedic residency programs and received rotation schedules from 115 programs (70.1%). Rotation schedules for postgraduate year 2 to 5 residents were categorized into the number of months spent on the following rotations: general orthopaedics, trauma, pediatrics, hand, sport, foot and ankle, arthroplasty, oncology, spine, research, and elective. The percentage of residency spent in each category was then calculated as the number of months divided by 48 months. Differences in the percent of residency spent on subspecialty rotations were compared for the following variables: program size and presence of subspecialty fellowships at the institution. RESULTS: On average, the greatest percentage of residency spent was in the following categories: trauma (16.6%; 8.0 months), general orthopaedics (13.7%; 6.6 months), and pediatrics (12.5%; 6.0 months). Rotations with the highest variation between programs included the following: general orthopaedics (SD 5.8 months; range 0 to 30 months), sport (SD 2.5 months; range 0 to 15 months), and arthroplasty (SD 2.3 months; range 0 to 11.8 months). Sixty-seven programs (63.2%) had dedicated blocks for research, and 25 programs (23.6%) had dedicated blocks for electives. No notable correlations were found between subspecialty exposure and program size or availability of subspecialty fellowship training at the program. CONCLUSION: Variability exists between ACGME-accredited orthopaedic surgery residency programs in subspecialty rotation exposure. Summarizing the subspecialty rotation exposure across accredited orthopaedic residency programs is useful to graduate medical education leadership for comparative purposes because they design and modify resident curricula.

Institutional Guidelines Can Decrease the Amount of Opioids Prescribed After Total Joint Replacement.

BACKGROUND: In the midst of the nationwide opioid epidemic, our institution began an effort to improve the education of opioid prescribers and disseminate procedure-specific guidelines for the number of opioid pills to prescribe post-operatively for total joint arthroplasty. The number of opioid pills suggested for total hip or knee replacement was 70 tablets. QUESTIONS/PURPOSES: We sought to evaluate the impact of the new institutional guideline on opioid prescribing practices, hypothesizing that it would lead to a decrease in the number of pills prescribed but an increase in patient call volume after discharge. METHODS: After the new guidelines were implemented in February 2018, we retrospectively reviewed all opioid prescriptions written for patients on the joint-replacement service from March 2016 to March 2018. In addition, we tabulated post-operative telephone calls made to the nurse practitioner service before and after guideline implementation. The majority of calls to the nurse practitioner service are for opioid renewals. RESULTS: We included 9514 patients in the analysis. Prior to guideline implementation, the mean number of pills prescribed after primary total joint arthroplasty was 91 ± 26.6 pills and after it was 65 ± 16.3 pills. The monthly number of unique patient telephone interactions was statistically significantly lower after the implementation of the new guidelines. CONCLUSION: An institutional guideline for opioid prescribing after total joint arthroplasty significantly reduced the number of pills prescribed to patients without causing a significant increase in the number of phone calls to the service.