Quality Improvement Targeting Non-pharmacologic Care and As-needed Morphine Improves Outcomes in Neonatal Abstinence Syndrome.

Despite the rising incidence of neonatal abstinence syndrome (NAS), there remains wide practice variation in its management. Many recent studies have focused on implementing new symptom scoring systems, typically as part of larger improvement interventions. Despite the continued use of the Finnegan Scoring System, we performed a quality improvement project to reduce the day of life at discharge and cumulative opioid exposure for newborns with NAS. Methods: We developed a protocol for NAS treatment emphasizing early transfer to general pediatric units, maximization of non-pharmacologic care, and use of as-needed morphine whenever pharmacologic treatment is required. Outcome metrics were the day of life at discharge and cumulative morphine exposure. As a process measure, we also monitored the day of life at transfer to general pediatric units. In addition, we utilized statistical process control charts to track changes in performance. Results: Twenty-eight patients met the inclusion criteria for analysis over 24 months following project initiation. Day of life at discharge decreased by 61% (20.0 versus 7.89 days, P < 0.001), and cumulative morphine exposure decreased by 81% (13.66 versus 2.57 mg morphine, P ≤ 0.001). Day of life at transfer to general pediatric units decreased by 49% (11.13 versus 5.7 days, P = 0.002). There were no readmissions or other identified adverse events. Conclusions: We achieved significant improvements in NAS outcomes using improved non-pharmacologic care and as-needed morphine. Moreover, the improvement did not require transitioning to a new scoring system. These results support the efficacy and safety of as-needed morphine for NAS management.

Effects of zone-specific superior labral detachment on biceps anchor stability.

PURPOSE: This study aimed to elucidate the degree of biceps anchor displacement that occurs when specific zones of the superior labrum are detached from the glenoid. STUDY DESIGN: Descriptive laboratory study. METHODS: Twelve cadaveric scapulae with intact labrums were prepared by removing the surrounding musculature with the labrum, biceps anchor, and biceps tendon carefully preserved. Pulleys were used to apply traction in 3 different directions- superior, lateral, and combined posterior/superior/lateral, to simulate the "peel-back" mechanism-while a continuous 1.13 kg of traction was applied to the biceps tendon. Labral tears were created by sharp incisions in isolation and in combinations of 3 zones defined relative to the glenoid fossa: anterior, posterior, or superior. The displacement of the biceps anchor (position of the marker after the simulated lesion relative to the marker position with the labrum intact) was measured relative to a rigid reference frame. RESULTS: The greatest degree of displacement occurred with the sectioning of all 3 zones, followed by the sectioning of 2 adjacent zones. Superior traction created the least displacement in all combinations, while lateral traction created maximal displacement, with one exception: in the setting of anterosuperior/superior lesions, maximal displacement was observed using the peel-back mechanism. CONCLUSION: Biceps anchor displacement, particularly the degree and direction of displacement, is affected by the labral detachment pattern. All 3 labral zones assessed in this study have important biomechanical contributions to biceps anchor displacement. CLINICAL SIGNIFICANCE: These findings have important implications relating to the clinician's arthroscopic assessment of superior labrum anterior and posterior (SLAP) tears, as well as the determination of need for stabilization. This information is particularly useful when treating SLAP tears in certain laborers and athletes, whose activities may cause specific biceps anchor displacement patterns.

Effects of hindfoot constraint on syndesmotic displacement.

BACKGROUND: The effects of altered hindfoot kinematics on the syndesmosis have not been previously studied. Our purpose was to test how the magnitude of displacement across the syndesmosis changes under simulated subtalar (ST) and/or talonavicular (TN) fusion and with altered hindfoot position in a cadaveric model. MATERIALS AND METHODS: Six cadaveric specimens (three matched pairs) age 33 to 43 years were disarticulated at the knee and mounted into a custom six-degree-of-freedom testing frame with a simulated ground reaction force of 700 N and a tensile Achilles load of 500 N. Specimens were then tested through four cycles of internal and external rotation under four conditions: simulated combined ST + TN fusion, ST fusion alone, TN fusion alone and no fusion. Each condition was tested in the neutral coronal position and 9 degrees of inversion and eversion. Infrared light emitting diode (irLED) marker arrays were used to track displacement across the anterior tibiofibular ligament (ATiFL) in order to assess displacement across the syndesmosis. RESULTS: Without fusion, displacement across the ATiFL in inversion is greater than that in neutral (p = 0.015). With ST, the measured ATiFL displacement in inversion is greater than that in neutral (p = 0.042). In neutral, the combined ST + TN significantly increased ATiFL displacement when compared to no fusion (p = 0.0043). Increased displacement was seen in inversion compared to eversion in all testing conditions. CONCLUSION: Simulated ST and TN fusion increases displacement across the ATiFL during simulated physiologic loading. Hindfoot inversion also increases displacement of the ATiFL. CLINICAL RELEVANCE: These observations may have clinical implications with respect to syndesmotic injury and total ankle arthroplasty.