Evaluating Postoperative Pain Management using the Detroit Interventional Pain Management tool after fracture surgery: How well are we really doing?

OBJECTIVES: To assess patients' opioid prescription usage and pain management satisfaction after fracture surgery. METHODS: Design: An IRB-approved prospective prognostic cohort study for postoperative fracture patients was conducted. Patients were evaluated by an independent observer at two weeks, six weeks, three months, and six months postoperatively where they were given Detroit Interventional Pain Assessment (DIPA) questionnaires regarding their postoperative pain and opioid usage. Opioid prescriptions were verified by Michigan Automated Prescription System. All patients were divided into major fractures (tibia, femur, acetabulum, pelvis, calcaneus, talus, and polytrauma) and minor fractures (scapula, clavicle, humerus, radius, ulna, scaphoid, carpal/metacarpal, patella, fibula, ankle, and metarsal) and were followed for two years. SETTING: Single-Center Level One Trauma Center. PATIENT SELECTION CRITERIA: Patients presenting to clinic over a six month period were invited to participate in this study. Patients who did not consent were excluded. OUTCOME MEASURES AND COMPARISONS: Outcome measures were the amount of prescribed opioids in daily Milligram Morphine equivalents (MMEs), opioid usage, DIPA pain scores, pain management efficiency (percentage of patients reporting no pain or tolerable pain with their regimen). Prescribed MMEs, pain management efficiency scores, and the percentage of patients using opioids were compared across all postoperative periods. RESULTS: For 201 fracture patients, the average age was 47.8 ± 16.3 SD (18-87 years) and there were 116 males (57.8%) and 85 females (42.2%). The percentage of patients using opioids and their daily prescribed MMEs significantly decreased from two weeks (48.2%, 21.6 MMEs) to six months (10.3%, 8.13 MMEs) (P < 0.001). Fifty-one percent of patients were off opioids at two weeks, 64.5% at six weeks, 84.2% at three months, and 89.7% at six months. All opioid prescriptions at six months and two years were prescribed to polytrauma patients who underwent sequential surgeries and these prescriptions originated from outside prescribers. Pain management efficiency scores were worst at two weeks (67.2%) but improved at three months (82.6%). CONCLUSIONS: As patients transitioned further from their surgical date, there was a decrease in opioid prescriptions and patient reported opioid usage. Despite the opioid tapering practices by surgeons, polytrauma patients still received prescriptions from outside prescribers for orthopaedic aftercare after three months, signaling the necessity for patients to see outside prescribers for their pain management after this time. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Detroit Interventional Pain Assessment Scale: A Pain Score and Method for Measuring and Evaluating Post-Operative Pain Management-A Prospective Study.

Background and Objectives: Orthopedic surgeons commonly prescribe opioids, surpassing all medical specialties. Our objective was to develop a pain management scale that captures medication use, patient-reported pain scores, and helps orthopedic surgeons evaluate their post-operative prescribing practice. Materials and Methods: An IRB-approved prospective study followed 502 post-operative orthopedic surgery patients over a six-month period. All patients were surveyed in an orthopedic clinic at a Level 1 US Trauma Center, during a routine follow-up. Patient pain satisfaction was assessed using the validated Interventional Pain Assessment (IPA) scale, which uses three categories: 0 (no pain), 1 (tolerable pain), and 2 (intolerable pain). Daily narcotic use was translated to morphine milligram equivalents (MMEs) using the Michigan Automated Prescription System (MAPS) narcotics registry. When patient pain satisfaction and narcotic usage were combined, this scale was called the Detroit Interventional Pain Assessment (DIPA) scale. Results: The five classes based on common prescription and usage of narcotics in this cohort include the following: A (no pain medication), B (over-the-counter medication), C (occasional use of short-acting narcotics 1-30 MMEs), D (consistent/regular use of short-acting narcotics 31-79 MMEs), and E (long-duration or stronger short-acting narcotics 80+ MMEs). Patients were most satisfied with their pain management at six weeks (80.5%) and three months (75.65%), and least satisfied at two weeks (62.5%) and six months (60.9%). Additional information displayed on the DIPA graph revealed there was a significant decrease in the percentage of patients on narcotics at two weeks (65.2%) to six months (32.6%) at p < 0.001. Conclusions: The DIPA pain scale shows the relationship between patient pain perception and opioid prescription/usage, while also tracking prescriber tendencies. Providers were able to visualize their post-operative pain management progression at each designated clinic visit with corresponding alphabetical daily MME categories. In this study, results suggest that surgeons were not effective at managing the pain of patients at two weeks post-operative, which is attributed to an inadequate number of pain pills prescribed upon discharge. Overall, the DIPA graph signaled that better pain management interventions are necessitated in periods with lower efficiency scores.

Antibiotic Cement-Coated Interlocked Intramedullary Nails for the Treatment of Infected Nonunion After Intramedullary Nailing.

OBJECTIVE: To evaluate outcomes using an interlocking antibiotic cement-coated nail and culture-specific systematic antibiotics in the treatment of infected nonunion after intramedullary nailing. DESIGN: Retrospective observational cohort study. SETTING: Urban level I trauma center. PATIENTS/PARTICIPANTS: Forty-one nonconsecutive patients who presented to a level I trauma center who underwent interlocked antibiotic nailing for treatment of infected nonunion status after primary intramedullary nailing. OUTCOMES: Eradication of infection, radiographic union by 2-year follow-up. RESULTS: Antibiotic nailing successfully eradicated infection and led to fracture healing in 35 patients (85.4%), while 6 patients (14.6%) had persistent infection and required further surgical treatment. Of the 6 patients who required further treatment, 5 eventually went on to heal with fracture union and eradication of their infection, while 1 required a salvage procedure. Of the 5 patients who eventually went on to heal, 4 of them healed with repeat antibiotic or intramedullary nails, while 1 required segmental resection and bone grafting before healing. CONCLUSIONS: This study suggests that the proposed interlocked antibiotic nailing technique is a viable therapeutic option to eradicate infected nonunion and support fracture healing. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The prevalence of posterolateral tibial baseplate overhang: An anatomical CT study.

INTRODUCTION: Total Knee Arthroplasty (TKA) is used in patients with osteoarthritis who have failed conservative management to reduce pain, improve functional outcomes and ultimately quality of life. However, less than optimal patient satisfaction has led to continued improvements in design and technology of TKA. One factor that can limit patient satisfaction is postero-lateral overhang of the tibial baseplate. The purpose of our study is to utilize pre-operative CT scans to assess the prevalence of posterolateral tibial overhang with the use of a symmetric tibial baseplate component in a popular knee system with robotic assistance. METHODS: Ninety-eight (98) consecutive patients who underwent robotic-assisted total knee arthroplasty (TKA) were included in this study. Using both the most medial aspect of the tibial tubercle and the medial ⅓ of the tibial tubercle as reference points, we quantified the extent of posterolateral overhang when determining the rotation of the tibial component. RESULTS: Using the most medial aspect of the tibial tubercle as a reference point for rotation of the tibial baseplate, 63% of the instances of reviewed CT scans (369/588) had posterolateral overhang. Furthermore, 81% (406/588) had posterolateral overhang when using the medial ⅓ aspect of the tibial tubercle as the reference for rotation of the tibial baseplate. The average posterolateral tibial baseplate overhang was 1.5 mm (range 0-8 mm) when using the most medial aspect of the tibial tubercle and 2.4 mm (range 0-8 mm) when using the medial ⅓ tibial tubercle as the centering point for the tibial baseplate. DISCUSSION: Tibial baseplate overhang could lead to potential pain from irritation of soft tissues. To our knowledge, this is the first study that was able to valencquantify the amount of tibial baseplate overhang using pre-operative CT scans. Rotational alignment of the tibial baseplate needs to be balanced to ensure minimal lateral overhang while achieving sufficient external rotation of the tibial component. An asymmetric tibial component may provide a compromise in certain situations. LEVEL OF EVIDENCE: Diagnostic level IV case series.