Opioid prescribing patterns for distal radius fractures in the ambulatory setting: A 10-year retrospective study.

OBJECTIVE: Distal radius fractures (DRFs) are one of the most common orthopedic injuries, with most managed in the nonoperative ambulatory setting. The objectives of this study are to examine National Health Center Statistics (NHCS) data for DRF treated in the nonoperative ambulatory setting to identify opioid and nonopioid analgesic prescribing patterns and to determine demographic risk factors for prescription of these medications. Design, setting, patients, and measures: This study is a retrospective analysis of data collected by the NHCS from 2007 to 2016. Utilizing International Classification of Diseases codes, all visits to emergency departments and doctors' offices for DRFs were identified. Variables of interest included demographic data, expected payment source, and prescription of opioid or nonopioid analgesics. RESULTS: During the study timeframe, 15,572,531 total visits for DRFs were recorded. DRF visits requiring opioid and nonopioid analgesic prescriptions increased over time. Patients aged 45-64 years were significantly more likely to receive an opioid prescription than any other age group (p < 0.05). Opioid prescription was positively correlated with the use of workers' compensation and negatively correlated with patients receiving services under charity care (p < 0.05). CONCLUSIONS: Prescriptions of both opioid and nonopioid analgesic medications for DRF have been steadily increasing over time in the nonoperative ambulatory setting, with middle-aged adults most likely to receive an opioid prescription. Opioid prescription rates differ significantly between patients utilizing workers' compensation and patients receiving services under charity care, suggesting that socioeconomic factors play a role in prescribing patterns.

Association of preoperative opioid use and postoperative complications following breast reconstruction.

BACKGROUND: Previous studies in orthopedics and general surgery have linked negative patient outcomes with preoperative opioid use. In this study, we investigated the association of preoperative opioid use on breast reconstruction outcomes and quality of life (QoL). METHODS: We reviewed our prospective registry of patients who underwent breast reconstruction for documented preoperative opioid use. Postoperative complications were recorded at 60 days after the first reconstructive surgery and 60 days after the final staged reconstruction. We used a logistic regression model to assess the association between opioid use and postoperative complications, controlling for smoking, age, laterality, BMI, comorbidities, radiation, and previous breast surgery; linear regression to analyze RAND36 scores to evaluate the impact of preoperative opioid use on postoperative QoL, controlling for the same factors; and Pearson chi-squared test to assess factors that may be associated with opioid use. RESULTS: Of the 354 patients eligible for inclusion, 29 (8.2%) were prescribed preoperative opioids. There were no differences in opioid use by race, BMI, comorbidities, previous breast surgery, or laterality. Preoperative opioids were associated with increased odds of postoperative complications within 60 days after the first reconstructive surgery (OR: 6.28; 95% CI: 1.69-23.4; p = 0.006) and within 60 days after the final staged reconstruction (OR: 8.38; 95% CI: 1.17-59.4; p = 0.03). Among patients using opioids preoperatively, the RAND36 physical and mental scores decreased but were not statistically significant. CONCLUSION: We found that preoperative opioid use is associated with increased odds of postoperative complications among patients who underwent breast reconstruction and may contribute to clinically significant declines in postoperative QoL.

Does Facial Fracture Management Require Opioids? A Pilot Trial of a Narcotic-Minimizing Analgesia Protocol for Operative Facial Trauma.

Opioid minimization in the acute postoperative phase is timely in the era of the opioid epidemic. The authors hypothesize that patients with facial trauma receiving multimodal, narcotic-minimizing pain management in the perioperative period will consume fewer morphine milligram equivalents (MMEs) while maintaining adequate pain control compared with a traditional analgesia protocol. An IRB-approved pilot study evaluating isolated facial trauma patients compared 10 consecutive prospective patients of a narcotic-minimizing pain protocol beginning in August 2020 with a retrospective, chart-reviewed cohort of 10 consecutive patients before protocol implementation. The protocol was comprised of multimodal nonopioid pharmacotherapy given preoperatively (acetaminophen, celecoxib, and pregabalin). Postoperatively, patients received intravenous (IV) ketorolac, scheduled acetaminophen, ibuprofen, and gabapentin. Oxycodone was reserved for severe uncontrolled pain. The control group had no standardized protocol, though opioids were ad libitum. Consumed MMEs and verbal Numeric Rating Scale (vNRS) pain scores (0-10) were prospectively tracked and compared with retrospective data. Descriptive and inferential statistics were run. At all recorded postoperative intervals, narcotic-minimizing subjects consumed significantly fewer MMEs than controls [0-8 h, 21.5 versus 63.5 ( P = 0.002); 8-16 h, 4.9 versus 20.6 ( P = 0.02); 16-24 h, 3.3 versus 13.9 ( P = 0.03); total 29.5 versus 98.0 ( P = 0.003)]. At all recorded postoperative intervals, narcotic-minimizing subjects reported less pain (vNRS) than controls (0-8 h, 7.7 versus 8.1; 8-16 h, 4.4 versus 8.0; 16-24 h 4.3 versus 6.9); significance was achieved at the 8 to 16-hour time point ( P = 0.006). A multimodal, opioid-sparing analgesia protocol significantly reduces opioid use in perioperative facial trauma management without sacrificing satisfactory pain control for patients.

An age-related algorithm for management of micro-orbitism from anophthalmia: a systematic review with supplemental case reports.

Management of pediatric anophthalmia and resultant micro-orbitism is challenging. The efficacy and safety of treatment methods vary with age as bony changes grow recalcitrant to implants in those at skeletal maturity and osteotomies become technically challenging following frontal sinus pneumatization. This study aims to review methods for managing micro-orbitism and develop an age-based treatment approach. A systematic literature review was conducted. Data were screened and extracted by two investigators and relevant English-language primary-literature was analyzed. Information on sample-size, number of orbits, intervention, age, complications, and prosthetic retention was obtained. Representative case reports are presented, in addition. Nineteen studies met inclusion: 294 orbits in 266 patients were treated. Two studies reported distraction-osteogenesis. Two studies utilized bone grafting. Osteotomies were performed in 41 patients from three studies. Use of solid implants was detailed in two studies. Three studies described osmotic implant. Four studies described inflatable implants. Other techniques were described by three of the included studies, two of which utilized dermis-fat grafting. All but one study were observational case reports or case series. Across all studies regardless of surgical technique, risk of bias and heterogeneity was high due to attrition bias and selective outcomes-reporting. Selection of therapy should be tailored to skeletal-age to optimize outcomes; those 0-4 yrs are managed with dermis-fat grafts, 5-7 yrs managed with implants, and 8+ yrs managed with osteotomies. For those 8+ yrs with aerated frontal sinuses or insufficient bone stock, we propose onlay camouflage prosthetics which improve projection, increase orbital volume, and avoid risk for frontal sinus injury.

Intraoperative Navigation in Plastic Surgery with Augmented Reality: A Preclinical Validation Study.

BACKGROUND: Augmented reality allows users to visualize and interact with digital images including three-dimensional holograms in the real world. This technology may have value intraoperatively by improving surgical decision-making and precision but relies on the ability to accurately align a hologram to a patient. This study aims to quantify the accuracy with which a hologram of soft tissue can be aligned to a patient and used to guide intervention. METHODS: A mannequin's face was marked in a standardized fashion with 14 incision patterns in red and nine reference points in blue. A three-dimensional photograph was then taken, converted into a hologram, and uploaded to HoloLens (Verto Studio LLC, San Diego, Calif.), a wearable augmented reality device. The red markings were then erased, leaving only the blue points. The hologram was then viewed through the HoloLens in augmented reality and aligned onto the mannequin. The user then traced the overlaid red markings present on the hologram. Three-dimensional photographs of the newly marked mannequin were then taken and compared with the baseline three-dimensional photographs of the mannequin for accuracy of the red markings. This process was repeated for 15 trials (n = 15). RESULTS: The accuracy of the augmented reality-guided intervention, when considering all trials, was 1.35 ± 0.24 mm. Markings that were positioned laterally on the face were significantly more difficult to reproduce than those centered around the facial midline. CONCLUSIONS: Holographic markings can be accurately translated onto a mannequin with an average error of less than 1.4 mm. These data support the notion that augmented reality navigation may be practical and reliable for clinical integration in plastic surgery.

National Trends and Prescription Patterns in Opiate Analgesia for Urolithiasis Presenting to Emergency Departments: Analysis of the National Hospital Ambulatory Medical Care Survey, 2006-2018.

OBJECTIVE: To analyze the National Hospital Ambulatory Medical Care Survey (NHAMCS) database to determine geographic and temporal trends, as well as variables associated with the likelihood of receiving an opioid prescription for urolithiasis in United States (US) emergency departments (EDs). MATERIALS AND METHODS: All ED visits for urolithiasis between 2006 and 2018 in the NHAMCS database were analyzed. Age, race/ethnicity, insurance status, ED provider credentials, geographic region, and urban vs rural hospital status were extracted. Linear regression was used to examine overall/regional trends in opioid prescriptions over time. Logistic regression was used to estimate factors associated with higher odds of receiving opioids. RESULTS: Fourteen million visits were analyzed, of which, 79.1% (11.0 million) received an opioid prescription. From 2014 to 2018 there was a decline of 3.65%/year of the proportion of visits receiving an opioid prescription (R2 = 0.86, P = .008). Non-Hispanic Black race was associated with a lower chance of receiving opioid prescription (OR = 0.57, P = .02) compared to Non-Hispanic Whites (NHW). Midwestern hospitals had higher odds of opioid prescription compared to the Northeast (OR = 2.05, P = .006). Rural hospitals had lower odds of opioid prescription compared to urban hospitals (OR = 0.62, P = .02). CONCLUSION: Opioid prescriptions for patients presenting with urolithiasis to the ED have steadily declined from 2014 to 2018, except in the Midwest. NHW race, Midwest region, and urban EDs increase the likelihood of receiving opioids. Continued efforts encouraging non-opioid alternatives for urolithiasis are essential, specifically in Midwestern EDs, to mitigate the ongoing opioid epidemic in the US.

Trends in opioid prescription for craniomaxillofacial trauma in the United States: An 11-year retrospective study of emergency room and office visits.

BACKGROUND: Facial trauma is associated with significant long-term morbidity and pain. These patients are routinely prescribed opioid medication and are at risk for opioid dependence. Rates and trends in opioid prescription in the ambulatory setting for management of craniofacial trauma are unknown. METHODS: The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data were analyzed from 2006 to 2016. Using International Classification of Diseases codes, 7,997,454 visits for craniomaxillofacial trauma were identified. Trends in opioid and nonopioid prescriptions were studied, with variables of interest including demographics, geographic region, expected source of payment, and injury location. RESULTS: Over the study period, trends in both opioid and nonopioid prescriptions remained stable, with about 13.4% of all visits receiving opioid prescriptions. Patients aged 18 to 44 (P < .001) and lower face trauma (P = .047) were associated with increased rates, while Medicare and charity payers (P < .001) were associated with lower rates of opioid prescriptions. There was no significant difference in prescription rates across geographical regions, by ethnicity, or sex. CONCLUSION: Opioid medication forms the cornerstone for ambulatory management of craniofacial trauma. Despite increased awareness and emphasis on multimodal pain management, opioid prescription trends have remained relatively stable over time.

Orthoptic Vision Therapy: Establishing a Protocol for Management of Diplopia Following Orbital Fracture Repair.

INTRODUCTION: Persistent diplopia following orbital fracture is a well-recognized problem. While observation is the standard-of-care, symptoms may be protracted. Orthoptic vision therapy is a form of ocular physical therapy that achieves functional rehabilitation through targeted exercises. This study presents a protocol for post-traumatic orthoptics and describes preliminary results. MATERIALS AND METHODS: Protocols for home-therapy/office-assessment were developed using commercial software and exercises targeting motility and fusion. Office-assessment also included validated questionnaire chronicling symptomatology. Healthy-volunteers (n = 10) trailed the protocol three times (n = 30) and normative data was compiled. Comparative measurements were made in chronic (>1year; n = 8) and acute (<2 weeks; n = 4) fracture cohorts. Time-of-therapy was recorded, monetary cost-analysis performed, and side-effects assessed. RESULTS: Severe/moderate motility limitation was found in 3 of 4 acute fracture patients but not in chronic or healthy cohorts. The acute cohort had worse fusion when comparing convergence (mean break/recovery of 8.0/6.5 prism diopters (pd) versus 31.87/21.23pd; P = 0.001/0.015) and divergence (3.00/1.50pd versus 18.37/12.83pd; P = 0.000/0.001) to the healthy cohort. Those with chronic fracture had lower convergence (15.71/5.00pd; P = 0.01/0.001) and divergence (12.29/4.71pd; P = 0.04/0.002) when compared with healthy subjects, but better function than acute patients. Acute fracture patients reported greater symptomatology than chronic (mean score 18.8 versus 4.6; P = 0.003) or healthy (5.0; P = 0.02) groups, but there was no difference between chronic and healthy groups (P = 0.87). Assessment took <10 minutes. Per patient software cost was <$70. Mild eyestrain related to therapy was self-resolving in all cases. CONCLUSIONS: Orthoptic therapy may improve fusion and motility following orbital fracture. This protocol serves as basis for prospective work.

Postoperative Complications of Panniculectomy and Abdominoplasty: A Retrospective Review.

BACKGROUND: Recent studies of panniculectomy outcomes have reported variable complication rates ranging from 8.65% to 56%. Meanwhile, reported abdominoplasty complication rates are considerably lower (~4%). This discrepancy may be attributable to inaccurate inclusion of abdominoplasty patients in panniculectomy cohorts. We performed the current study to better characterize panniculectomy complication rates at a large tertiary care center. METHODS: We performed a retrospective review of patients who underwent abdominoplasty or panniculectomy at the Johns Hopkins Hospitals between 2010 and 2017. Patients were identified by Common Procedural Terminology codes (15847/17999, 15830) confirmed via the operative note. We examined postoperative complication rates including surgical site infection, seroma formation, wound dehiscence, readmission/reoperation, and postoperative length of stay (LOS). We used parametric and nonparametric methods to determine differences between abdominoplasty and panniculectomy outcomes, as well as logistic regression analysis to evaluate factors associated with patient outcomes following panniculectomy. RESULTS: Of the 306 patients included, 103 underwent abdominoplasty while 203 underwent panniculectomy. Initial complication rates following abdominoplasty and panniculectomy were 1.94% and 12.8%, respectively (P = 0.002). Thirty-day complication rates were 9.7% for abdominoplasty and 21.2% for panniculectomy (P = 0.012). The median LOS was 1 day (interquartile range, 0-1 day) for abdominoplasty and 2 days (interquartile range, 1-4 days) for panniculectomy (P = 0.002). No statistically significant differences in complication rates at 6 months and 1 year were observed. CONCLUSIONS: Panniculectomy offers many functional benefits including improved hygiene and enhanced mobility. However, this study demonstrates that panniculectomy patients may have significantly higher complication rates initially and 30 days postoperatively and longer LOS than individuals undergoing abdominoplasty.

Standardized Schematics for Facial Trauma Planning: A Clinical Education Tool.

INTRODUCTION: Learning facial fracture management principles can be challenging for surgical trainees. Residents must assimilate nuances of fixation techniques, skeletal biomechanics, and hardware use while managing acute work-flow limitations. This study aims to design a standardized-schematic for teaching facial fracture management and evaluate its performance improving resident operative planning. METHODS: Printable schematics of the facial skeleton with soft-tissue overlay were developed. Instructions on depicting fracture pattern, incisions, plating sequence, loadbearing/sharing plates, locking/nonlocking screws, and mono/bicortical screws were given. Senior residents (n=5) evaluated computed tomography of 3 mandibular fractures and submitted 3 operative plans per case: first without guidance, then with written instruction, and finally using the schematic (n=45). Performance was graded on content and conceptual correctness. Data on time to completion was obtained. Likert-scale surveys assessing understanding, communication, and operative planning were given RESULTS:: Schematic use improved operative plan content and facilitated communication of resident operative schemes. Of 7 content domains spanning approach, plating strategy, and screw selection, a mean of 2.3, 3.7, and 6.5 were included with no guidance, written instruction, and schematic use respectively. Information on approach (P=0.001), plating type (P=0.02), screw location (P<0.000), screw depth (P=0.000), and screw locking status (P=0.000) were improved when comparing pre- and postintervention plans. Mean time to completion was 8 minutes and 54 seconds. All subjects "agreed" (n=2) or "strongly agreed" (n=3) that schematic use aided planning and communication. CONCLUSIONS: Simple, guided interventions can enhance surgical training by identifying knowledge gaps, improving visuospatial conceptualization, and facilitating targeted discussions with attendings.

Unilateral Coronal Craniosynostosis in an Apert-Like Patient.

BACKGROUND AND SIGNIFICANCE: Apert syndrome is a congenital disorder of patients who typically present with bilateral coronal craniosynostosis and varying degrees of complex syndactyly of the hands and feet, among other features. We describe a unique presentation of a rare Apert-like patient with unilateral coronal craniosynostosis and complex syndactyly of the hands and feet. CASE REPORT: A 2-year-old male patient presented to the craniofacial clinic with his mother due to a concerning head shape. The patient also had bilateral syndactyly of the hands and feet and underwent prior surgical release of the third web space. Computerized tomography of the head illustrated a small open anterior fontanelle, a left harlequin orbit, complete left coronal craniosynostosis, and a patent right coronal suture. The patient subsequently underwent fronto-orbital advancement for expansion of the cranial vault and correction of the asymmetric forehead and orbit. The procedure resulted in improvement of his deformity. CONCLUSION: This case illustrates a unique presentation of an acrocephalosyndactyly (ACS) syndrome with asymmetric, unilateral coronal craniosynostosis and complete complex syndactyly of the hands and feet that is most consistent with Apert syndrome. Although the majority of patients with ACS can be categorized into known syndromes, other more unusual presentations must still be considered. Such unique cases are exceedingly rare and only through additional reporting and review of unique phenotypes can new subtypes of common ACS syndromes be classified.

HISTORIQUE ET SIGNIFICATION: Le syndrome d'Apert est un trouble congénital chez les patients qui, entre autres, ont généralement une craniosynostose coronale bilatérale et divers degrés de syndactylie complexe des mains et des pieds. Les auteurs décrivent la présentation unique d'un patient ayant un rare pseudosyndrome d'Apert qui se manifestait par une craniosynostose coronale unilatérale et une syndactylie complexe des mains et des pieds. RAPPORT DE CAS: Un garçon de deux ans a consulté à la clinique craniofaciale en compagnie de sa mère parce que la forme de sa tête était préoccupante. Il présentait également une syndactylie bilatérale des mains et des pieds et avait déjà subi une libération du troisième espace interdigital. La tomodensitométrie de la tête a révélé une petite fontanelle antérieure ouverte, un œil gauche méphistophélique, une craniosynostose coronale gauche complète et une suture coronale droite ouverte. Le patient a ensuite subi un avancement fronto-orbitaire pour élargir la voûte crânienne et corriger le front asymétrique et l'orbite. L'intervention a atténué ses malformations. CONCLUSION: Ce cas démontre une présentation unique de syndrome d'acrocéphalosyndactylie (ACS) avec craniosynostose coronale unilatérale asymétrique et syndactylie complexe complète des mains et des pieds très évocatrices d'un syndrome d'Apert. Même si la majorité des patients ayant une ACS peuvent être classés dans des syndromes connus, il faut tout de même envisager d'autres présentations plus inhabituelles. Ces cas uniques sont d'une extrême rareté, et ce n'est que par de nouveaux signalements et par l'analyse de phénotypes uniques qu'on pourra classer de nouveaux sous-types de syndromes d'ACS courants.