Republication of "Postoperative Narcotic Prescription Practice in Orthopedic Foot and Ankle Surgery".

Background: The misuse and abuse of opioid pain medications have become a public health crisis. Because orthopedic surgeons are the third highest prescribers of opioids, understanding their postoperative pain medication prescribing practices is key to solving the opioid crisis. To this end, we conducted a study of the variability in orthopedic foot and ankle surgery postoperative opioid prescribing practice patterns. Methods: Three hundred fifty orthopedic foot and ankle surgeons were contacted; respondents completed a survey with 4 common patient scenarios and surgical procedures followed by questions regarding typical postoperative pain medication prescriptions. The scenarios ranged from minimally painful procedures to those that would be expected to be significantly more painful. Summaries were calculated as percentages and chi-square or Fisher exact tests were used to compare survey responses between groups stratified by years in practice and type of practice. Results: Sixty-four surgeons responded to the survey (92.8% male), 31% were in practice less than 5 years, 34% 6 to 15 years and 34% more than 15 years. For each scenario, there was variation in the type of pain medication prescribed (scenario 1: 17% 5 mg hydrocodone, 22% 10 mg hydrocodone, 52% oxycodone, and 3% oxycodone sustained release [SR]; scenario 2: 15% 5 mg hydrocodone, 13% 10 mg hydrocodone, 58% oxycodone, and 9% oxycodone SR; scenario 3: 11% 5 mg hydrocodone, 13% 10 mg hydrocodone, 56% oxycodone, and 14.1% oxycodone SR; scenario 4: 3% 5 mg hydrocodone, 5% 10 mg hydrocodone, 44% oxycodone, and 45% oxycodone SR) and the number of pills dispensed. Use of multimodal pain management was variable but most physicians use regional nerve blocks for each scenario (76%, 87%, 69%, 94%). Less experienced surgeons (less than 5 years in practice) supplement with tramadol more for scenario 1 (P = .034) as well as use regional nerve blocks for scenario 2 (P = .039) more than experienced surgeons (more than 15 years in practice). Conclusion: It is evident that variation exists in narcotic prescription practices for postoperative pain management by orthopedic foot and ankle surgeons. With new AAOS guidelines, it is important to try to create some standardization in opioid prescription protocols.

Percutaneous Fixation of a Fifth Metatarsal Base Fracture.

SUMMARY: Owing to a vascular watershed, zone II and III fifth metatarsal base fractures commonly progress to nonunion without operative intervention. This article and the accompanying video demonstrate the use of intramedullary screw fixation for a fifth metatarsal base fracture and review treatment decisions involved with management of these injuries.

Estimating and Removing the Sampling Biases of the AIRS Obs4MIPs V2 Data.

The Atmospheric Infrared Sounder (AIRS) Observations for Model Intercomparison Projects (Obs4MIPs) Version 2.0 (V2.0) monthly mean tropospheric air temperature, specific humidity, and relative humidity profile data were designed for climate model evaluation in the context of the Coupled Model Intercomparison Project (CMIP). Due to the limitations of the Aqua satellite orbit and the AIRS retrieval algorithm, the sampling biases of the AIRS Obs4MIPs V2.0 data can be large for certain cases and must be considered when the AIRS Obs4MIPs V2.0 data are used for climate model evaluation. In this study, we estimate the sampling biases of the AIRS Obs4MIPs V2.0 data based on the fifth generation of the European Centre for Medium-Range Weather Forecasts (ECMWF) (ERA5) reanalysis and cross-check them using the Modern-Era Retrospective Analysis for Research and Application, Version 2 (MERRA-2) reanalysis. We then remove the estimated sampling biases from the AIRS Obs4MIPs V2.0 data and produce the sampling-bias-corrected AIRS Obs4MIPs V2.1 data that have been published at the Earth System Grid Federation (ESGF) data centers and should be used in the future for climate model evaluation.

Intercomparison of Surface Temperatures from AIRS, MERRA, and MERRA-2, with NOAA and GC-Net Weather Stations at Summit, Greenland.

The surface skin and air temperatures reported by the Atmospheric Infrared Sounder/Advanced Microwave Sounding Unit-A (AIRS/AMSU-A), the Modern-Era Retrospective analysis for Research and Applications (MERRA), and MERRA-2 at Summit, Greenland are compared with near surface air temperatures measured at National Oceanic and Atmospheric Administration (NOAA) and Greenland Climate Network (GC-Net) weather stations. The AIRS/AMSU-A Surface Skin Temperature (TS) is best correlated with the NOAA 2 m air temperature (T2M) but tends to be colder than the station measurements. The difference may be the result of the frequent near surface temperature inversions in the region. The AIRS/AMSU-A Surface Air Temperature (SAT) is also correlated with the NOAA T2M but has a warm bias during the cold season and a larger standard error than the surface temperature. The extrapolation of the temperature profile to calculate the AIRS SAT may not be valid for the strongest inversions. The GC-Net temperature sensors are not held at fixed heights throughout the year; however, they are typically closer to the surface than the NOAA station sensors. Comparing the lapse rates at the 2 stations shows that it is larger closer to the surface. The difference between the AIRS/AMSU-A SAT and TS is sensitive to near surface inversions and tends to measure stronger inversions than both stations. The AIRS/AMSU-A may be sampling a thicker layer than either station. The MERRA-2 surface and near surface temperatures show improvements over MERRA but little sensitivity to near surface temperature inversions.

Complications After Popliteal Block for Foot and Ankle Surgery.

BACKGROUND: A popliteal nerve block is a common analgesic procedure for patients undergoing surgery on their knee, foot, or ankle. This procedure carries less risk in a surgical setting compared with other forms of anesthesia such as a spinal block. Previous reports demonstrated few to no complications with the use of this nerve block, but it is unclear whether these data are consistent with the recent increase in use of this analgesic procedure for lower extremity surgery. METHODS: Retrospectively, a busy orthopedic foot and ankle practice performed a chart review examining for postoperative neuropathic complications possibly related to the popliteal nerve block. The 1014 patients who had undergone a popliteal block for foot and/or ankle orthopedic surgery were analyzed for short and long-term neuropathic complications. The collected data consisted of tourniquet time, pressure, and location as well as the method of finding the fossa nerve, adjuncts used, and patient medical history. Data were analyzed using chi-square, Fisher's exact, and t tests for analysis with a significance value of P < .05. RESULT: Of these 1014 patients, 52 patients (5%) developed deleterious symptoms likely resulting from their popliteal block, and 7 (0.7%) of these were unresolved after their last follow-up. No immediately apparent underlying causes were determined for these complications. CONCLUSION: The frequency of a neuropathic complication following a popliteal nerve block was notably higher in the early postoperative period than indicated in the past. The proportion of patients with unresolved neuropathic symptoms at last follow-up is comparable to that previously reported in the literature. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Orthopaedic resident preparedness for closed reduction and pinning of pediatric supracondylar fractures is improved by e-learning: a multisite randomized controlled study.

BACKGROUND: There is a need to provide more efficient surgical training methods for orthopaedic residents. E-learning could possibly increase resident surgical preparedness, confidence, and comfort for surgery. Using closed reduction and pinning of pediatric supracondylar humeral fractures as the index case, we hypothesized that e-learning could increase resident knowledge acquisition for case preparation in the operating room. METHODS: An e-learning surgical training module was created on the Computer Enhanced Visual Learning platform. The module provides a detailed and focused road map of the procedure utilizing a multimedia format. A multisite prospective randomized controlled study design compared residents who used a textbook for case preparation (control group) with residents who used the same textbook plus completed the e-learning module (test group). All subjects completed a sixty-question test on the theory and methods of the case. After completion of the test, the control group then completed the module as well. All subjects were surveyed on their opinion regarding the effectiveness of the module after performing an actual surgical case. RESULTS: Twenty-eight subjects with no previous experience in this surgery were enrolled at four academic centers. Subjects were randomized into two equal groups. The test group scored significantly better (p < 0.001) and demonstrated competence on the test compared with the control group; the mean correct test score (and standard deviation) was 90.9% ± 6.8% for the test group and 73.5% ± 6.4% for the control group. All residents surveyed (n = 27) agreed that the module is a useful supplement to traditional methods for case preparation and twenty-two of twenty-seven residents agreed that it reduced their anxiety during the case and improved their attention to surgical detail. CONCLUSIONS: E-learning using the Computer Enhanced Visual Learning platform significantly improved preparedness, confidence, and comfort with percutaneous closed reduction and pinning of a pediatric supracondylar humeral fracture. We believe that adapting such methods into residency training programs will improve efficiency in surgical training.

Radionuclide imaging in the diagnosis and management of orthopaedic disease.

Nuclear medicine imaging is often used in the diagnosis and management of several orthopaedic conditions. Bone scintigraphy measures gamma ray emission to detect the distribution of an injected radiolabeled tracer on multiple image projections. In general, this imaging modality has relatively high sensitivity but low specificity in the diagnosis of occult fractures, bone tumors, metabolic bone disease, and infection. Positron emission tomography measures tissue metabolism and perfusion by detecting short half-life positron ray emission of an injected radiopharmaceutical tracer. Historically, positron emission tomography has been used only to monitor bone metastasis and aid in the diagnosis of osteomyelitis; however, this technology has recently been applied to other orthopaedic conditions for which current imaging modalities are insufficient.

Earth as an extrasolar planet: Earth model validation using EPOXI earth observations.

The EPOXI Discovery Mission of Opportunity reused the Deep Impact flyby spacecraft to obtain spatially and temporally resolved visible photometric and moderate resolution near-infrared (NIR) spectroscopic observations of Earth. These remote observations provide a rigorous validation of whole-disk Earth model simulations used to better understand remotely detectable extrasolar planet characteristics. We have used these data to upgrade, correct, and validate the NASA Astrobiology Institute's Virtual Planetary Laboratory three-dimensional line-by-line, multiple-scattering spectral Earth model. This comprehensive model now includes specular reflectance from the ocean and explicitly includes atmospheric effects such as Rayleigh scattering, gas absorption, and temperature structure. We have used this model to generate spatially and temporally resolved synthetic spectra and images of Earth for the dates of EPOXI observation. Model parameters were varied to yield an optimum fit to the data. We found that a minimum spatial resolution of ∼100 pixels on the visible disk, and four categories of water clouds, which were defined by using observed cloud positions and optical thicknesses, were needed to yield acceptable fits. The validated model provides a simultaneous fit to Earth's lightcurve, absolute brightness, and spectral data, with a root-mean-square (RMS) error of typically less than 3% for the multiwavelength lightcurves and residuals of ∼10% for the absolute brightness throughout the visible and NIR spectral range. We have extended our validation into the mid-infrared by comparing the model to high spectral resolution observations of Earth from the Atmospheric Infrared Sounder, obtaining a fit with residuals of ∼7% and brightness temperature errors of less than 1 K in the atmospheric window. For the purpose of understanding the observable characteristics of the distant Earth at arbitrary viewing geometry and observing cadence, our validated forward model can be used to simulate Earth's time-dependent brightness and spectral properties for wavelengths from the far ultraviolet to the far infrared. Key Words: Astrobiology-Extrasolar terrestrial planets-Habitability-Planetary science-Radiative transfer. Astrobiology 11, 393-408.

Standard radiographs and computed tomographic scan underestimating pediatric acetabular fracture after traumatic hip dislocation: report of 2 cases.

Posterior wall acetabular fractures are rare in the pediatric patient but require proper management to prevent significant complications. Plain radiographs and computed tomography scans are standard diagnostic imaging used with clinical examination of hip stability to determine if the injury requires open reduction and internal fixation. Two cases are presented of adolescent traumatic hip dislocations and posterior wall fractures in which radiography underestimated the extent of the posterior wall fracture. In one case, a magnetic resonance imaging study more clearly characterized the injury. Because the ossification of the posterior wall occurs throughout adolescence, magnetic resonance imaging may be a useful tool in characterizing these fractures and assisting with surgical planning.

Functional movement training for recurrent low back pain: lessons from a pilot randomized controlled trial.

OBJECTIVE: Despite considerable effort to reduce low back pain (LBP), approximately 60% of patients have recurrence after their first episode. The high rate of recurrence suggests that more effective intervention approaches are needed. This randomized, controlled feasibility trial was designed to compare disability, physical functional capacity, and pain outcomes at 2, 6, and 12 months for 2 conventional and 1 novel physical therapy (functional movement training) intervention for recurrent LBP. DESIGN: Randomized, controlled feasibility trial. SETTING: University hospital outpatient physical therapy clinic. PARTICIPANTS: Sixty-one participants (60% female) with recurrent LBP. INTERVENTIONS: Subjects were randomized to 1 of 3 intervention groups: group 1 had a single session consisting of standard back pain education; group 2 had 6 sessions in 8 weeks of conventional physical therapy; and group 3 had 6 sessions in 8 weeks of a novel method of functional movement training. Change from baseline was used to determine within-group changes and between-group differences for participants who finished each time point (2, 6, and 12 months). Changes were evaluated using analysis of variance and Newman-Keuls post hoc analysis. MAIN OUTCOME MEASURES: The primary outcome measure was the novel Continuous Scale Physical Functional Performance test (CS-PFP), a measure of actual physical functional capacity. Secondary measures included the revised Oswestry Disability Index, a measure of pain-related disability, the Roland Morris Disability Questionnaire, and a standard visual analogue pain scale. RESULTS: Of the participants, 67% provided data at 2 months and 44% provided information at 12 months. Raw change scores were evaluated at 2, 6, and 12 months. While no statistical significance was reached with any outcome measure, the trends suggested little change for group 1 (education) and suggested that greatest improvement in function may occur in group 3 (functional movement training). In particular, at 2 months, the CS-PFP change scores revealed a trend (P=.072) toward greater improvement in groups 2 (conventional physical therapy) and 3 (functional movement training) compared with group 1. At 12 months, Oswestry Disability Index and CS-PFP scores also trended toward significance for groups 2 and 3 (P=.7 and .9, respectively). Mean change scores were also calculated and revealed groups 2 and 3 had improved by 2 months and this improvement remained stable at the 1-year mark. Trends in the direction of best improvement occurred for those in the functional movement training group. CONCLUSION: A large-scale randomized, controlled trial is warranted to determine whether an intervention based on functional movement training is superior to conventional, impairment-based intervention for individuals with recurrent LBP.

Continuous scale physical functional performance test: appropriateness for middle-aged adults with and without Parkinson's disease.

PURPOSE: Functional measures are needed that are applicable to middle-aged adults with neurological disorders who are on the threshold of disability. One potential measure is the Continuous Scale Physical Functional Performance Test (CS-PFP), which has been normalized and validated to older adults but performance is unknown for adults younger than the age of 65 years with and without neurological disorders. The purposes of this investigation were (1) to compare scores on the CS-PFP of nondisabled adults in three age groups from 35 to 64 years with two groups of individuals older than the age of 65; (2) to determine whether there is a ceiling effect for nondisabled middle-aged adults; and (3) to determine whether performance of individuals in early stages of Parkinson's disease (PD) age 45 to 64 years differ significantly from performance of similarly aged nondisabled adults. METHODS: Data were obtained from three samples: (1) 37 adults with PD (45-54 and 55-64 years; 57% female), (2) 70 nondisabled adults (35-44, 45-54, and 55-64 years; 69% female); (3) 72 nondisabled older adults (65-74 and 75-85 years; 79% female). The CS-PFP was administered in a single test session for each subject. Analysis of variance was performed for group differences with adjustment of sex as a covariate followed by a Student-Newman-Keuls post hoc analysis. RESULTS: For nondisabled individuals, the CS-PFP total and domain scores were significantly lower in the oldest group (75-85 years) compared to all other age groups and significantly higher in the younger two groups (35-44 and 45-54 years) compared to the older groups. There was no ceiling effect for any domain score or total score for the adults younger than 65 years. For individuals with PD, both age groups had significantly lower scores on the CS-PFP than did the nondisabled counterparts. CONCLUSIONS: Results from the nondisabled middle-aged individuals provide comparison data to be used clinically or in investigations of middle-aged adults with neurological dysfunction. Comparison of middle-aged individuals with PD to middle-aged nondisabled adults illustrates the true extent of functional difficulty experienced by individuals with PD and demonstrates the importance of using age appropriate comparison data. The CS-PFP is particularly applicable to middle-aged adults with compromised functional performance for their age but is too high to be effectively quantified with other assessment measures.