Neurostimulation as an Efficacious Nonpharmacologic Analgesic following Arthroscopic Rotator Cuff Repair.

This case highlights the importance of pursuing nonpharmacologic analgesic modalities in orthopedic surgery to combat the current opioid epidemic. Presented is a patient who underwent an arthroscopic rotator cuff repair and biceps tenodesis operation and through the use of neurostimulation (in the form of auricular electrostimulation), fully recovered from surgery without the usage of any opioid or nonsteroidal anti-inflammatory medications. The patient was fitted with a novel auricular electrostimulation device (DyAnsys Primary Relief) in the immediate postoperative period that provided constant neurostimulation for 10 days, this neurostimulator was the only analgesic modality used in this case, and the patient reported minimal postoperative pain. The utility of this case centers around the lack of postoperative opioid use, presenting the idea that postsurgical orthopedic pain can be managed in a nonpharmacologic capacity, combatting the fields' ongoing opioid epidemic.

Reduction in opioid use with perioperative non-pharmacologic analgesia in total knee arthroplasty and ACL reconstruction: a systematic review.

INTRODUCTION: The world's opioid epidemic has gotten increasingly severe over the last several decades and projects to continue worsening. Orthopedic surgery is the largest contributor to this epidemic, accounting for 8.8% of postoperative opioid dependence cases. Total knee arthroplasty (TKA) and anterior cruciate ligament (ACL) reconstruction are commonly performed orthopedic operations heavily reliant on opioids as the primary analgesic in the peri- and immediate postoperative period. These downfalls highlight the pressing need for an alternate, non-pharmacologic analgesic to reduce postoperative opioid use in orthopedic patients. The presented systematic review aimed to analyze and compare the most promising non-pharmacologic analgesic interventions in the available literature to guide future research in such a novel field. METHODS: A systematic search of PubMed, MEDLINE, Embase, Cochrane, and Web of Science was performed for studies published before July 2020 based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, and the obtained manuscripts were evaluated for inclusion or exclusion against strict, pre-determined criteria. Risk-of-bias and GRADE (grades of recommendation, assessment, development, and evaluation) assessments were then performed on all included studies. RESULTS: Six studies were deemed fit for inclusion, investigating three non-pharmacologic analgesics: percutaneous peripheral nerve stimulation, cryoneurolysis, and auricular acupressure. All three successfully reduced postoperative opioid use while simultaneously maintaining the safety and efficacy of the procedure. DISCUSSION: The results indicate that all three presented non-pharmacologic analgesic interventions are viable and warrant future research. That said, because of its slight advantages in postoperative pain control and operational outcomes, cryoneurolysis seems to be the most promising. Further research and eventual clinical implementation of these analgesics is not only warranted but should be a priority because of their vast potential to reduce orthopedics surgeries' contribution to the opioid epidemic.

Fracture healing physiology and the quest for therapies for delayed healing and nonunion.

Delayed healing and nonunion of fractures represent enormous burdens to patients and healthcare systems. There are currently no approved pharmacological agents for the treatment of established nonunions, or for the acceleration of fracture healing, and no pharmacological agents are approved for promoting the healing of closed fractures. Yet several pharmacologic agents have the potential to enhance some aspects of fracture healing. In preclinical studies, various agents working across a broad spectrum of molecular pathways can produce larger, denser and stronger fracture calluses. However, untreated control animals in most of these studies also demonstrate robust structural and biomechanical healing, leaving unclear how these interventions might alter the healing of recalcitrant fractures in humans. This review describes the physiology of fracture healing, with a focus on aspects of natural repair that may be pharmacologically augmented to prevent or treat delayed or nonunion fractures (collectively referred to as DNFs). The agents covered in this review include recombinant BMPs, PTH/PTHrP receptor agonists, activators of Wnt/ß-catenin signaling, and recombinant FGF-2. Agents from these therapeutic classes have undergone extensive preclinical testing and progressed to clinical fracture healing trials. Each can promote bone formation, which is important for the stability of bridged calluses, and some but not all can also promote cartilage formation, which may be critical for the initial bridging and subsequent stabilization of fractures. Appropriately timed stimulation of chondrogenesis and osteogenesis in the fracture callus may be a more effective approach for preventing or treating DNFs compared with stimulation of osteogenesis alone. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:213-223, 2017.

Persistance and Compliance with Osteroporosis Therapies Among Women in a Commercially Insured Population in the United States.

BACKGROUND: Prior research has shown that rates of persistence and compliance with osteoporosis therapies are associated with significantly fewer vertebral, nonvertebral, and hip fractures. A number of studies have examined medication-taking behavior with oral bisphosphonates and teriparatide, and these 1-year persistence rates have ranged from 39.9% to 56.7%. Limited real-world data are available regarding persistence and compliance rates with newer therapies such as denosumab, a RANK ligand inhibitor administered every 6 months as a subcutaneous injection.  OBJECTIVE: To assess persistence and compliance rates over 1 year with newly initiated osteoporosis therapies, including denosumab, alendronate, ibandronate, risedronate, raloxifene, and teriparatide, within a cohort of commercially insured women.  METHODS: Health insurance claims data derived from Truven Health Analytics MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases (2010-2013) were used to conduct this retrospective cohort study. Adult females aged 18 years and older newly initiated on denosumab, raloxifene, teriparatide, or oral bisphosphonates (alendronate, ibandronate, or risedronate) between January 1, 2012, and March 31, 2012, were identified for inclusion. The date of the first qualifying osteoporosis prescription claim was defined as the index date. Patients were required to have at least 24 months of pre-index and at least 12 months of post-index continuous enrollment with medical and pharmacy benefits. Outcomes of patients initiating zoledronic acid (administered intravenously once yearly) were not assessed because a 12-month follow-up period would be insufficient for tracking persistence and compliance for this medication. Patients with Paget's disease of the bone, osteogenesis imperfecta, hypercalcemia, malignant cancer and metastasis, human immunodeficiency virus, and patients receiving preventive treatment for risk of breast cancer or denosumab in the pre-index period were excluded from the study. A subcohort of women aged 50 years and older at high risk for fracture (indicated by 1 or more of the following: aged ≥ 70 years, a pre-index fracture, or pre-index use of osteoporosis therapy that was discontinued at least 3 months prior to index) was analyzed separately. Propensity score weighting was used to adjust for differences in baseline demographic and clinical characteristics. Persistence, indicated by continuous use of the index therapy without a gap of 60 days or more; medication coverage ratio (MCR), the proportion of days covered by the index therapy; and compliance, defined as an MCR ≥ 0.80, were assessed during the 12-month follow-up. Logistic regression was used to estimate the odds of persistence and compliance for the treatment groups of interest. RESULTS: 10,863 female patients newly initiating osteoporosis medications (mean [SD] age: 66.2 [11.5] years) were identified. In the pre-index period, 35.8% of patients had a diagnosis of osteoporosis, while 11.5% had a diagnosis of osteopenia. Pre-index osteoporosis treatment was identified in 29.1% of patients, and 13.6% had an osteoporosis-related fracture in the pre-index period. Propensity score weight-adjusted 12-month persistence with the index medication varied from 28.9% to 35.1% for oral bisphosphonate users, 42.0% for raloxifene users, 59.1% for teriparatide users, and 68.3% for denosumab users (P less than 0.0001). The adjusted mean [SD] MCR was highest among patients treated with denosumab (0.83 [0.21]), followed by teriparatide (0.67 [0.31]), raloxifene, (0.57 [0.34]), ibandronate (0.54 [0.32]), alendronate (0.51 [0.33]), and risedronate (0.46 [0.33]; P less than 0.0001). The odds of being persistent and compliant across treatments favored denosumab (OR = 1.59 to 5.56, P less than 0.05 for persistence; OR = 2.44 to 7.69, P less than 0.0001 for compliance). Results were similar in the subcohort of women aged 50 years and older at high risk for fracture (n = 6,187; mean [SD] age: 71.9 [10.9] years). The odds of being persistent and compliant across treatments also favored denosumab (OR = 1.62 to 5.75, P less than 0.0001 for persistence; OR = 2.36 to 7.25, P less than 0.0001 for compliance). CONCLUSIONS: In a U.S. setting, rates of persistence and compliance over 12 months were higher among women initiating denosumab compared with those initiating other osteoporosis therapies.

A Systematic Review of the Psychometric Properties of Patient-Reported Outcome Instruments for Use in Patients With Rotator Cuff Disease.

BACKGROUND: Many patient-reported outcome instruments (or questionnaires) have been developed for use in patients with rotator cuff disease. Before an instrument is implemented, its psychometric properties should be carefully assessed, and the methodological quality of papers that investigate a psychometric component of an instrument must be carefully evaluated. Together, the psychometric evidence and the methodological quality can then be used to arrive at an estimate of an instrument's quality. PURPOSE: To identify patient-reported outcome instruments used in patients with rotator cuff disease and to critically appraise and summarize their psychometric properties to guide researchers and clinicians in using high-quality patient-reported outcome instruments in this population. STUDY DESIGN: Systematic review. METHODS: Systematic literature searches were performed to find English-language articles concerning the development or evaluation of a psychometric property of a patient-reported outcome instrument for use in patients with rotator cuff disease. Methodological quality and psychometric evidence were critically appraised and summarized through 2 standardized sets of criteria. RESULTS: A total of 1881 articles evaluating 39 instruments were found per the search strategy, of which 73 articles evaluating 16 instruments were included in this study. The Constant-Murley score, the DASH (Disability of the Arm, Shoulder, and Hand), and the Shoulder Pain and Disability Index were the 3 most frequently evaluated instruments. In contrast, the psychometric properties of the Korean Shoulder Scoring System, Shoulder Activity Level, Subjective Shoulder Value, and Western Ontario Osteoarthritis Shoulder index were evaluated by only 1 study each. The Western Ontario Rotator Cuff Index was found to have the best overall quality of psychometric properties per the established criteria, with positive evidence found in internal consistency, reliability, content validity, hypothesis testing, and responsiveness. The DASH, Shoulder Pain and Disability Index, and Simple Shoulder Test had good evidence in support of internal consistency, reliability, structural validity, hypothesis testing, and responsiveness. Inadequate methodological quality was found across many studies, particularly in internal consistency, reliability, measurement error, hypothesis testing, and responsiveness. CONCLUSION: More high-quality methodological studies should be performed to assess the properties in all identified instruments.

Bioabsorbable tricalcium phosphate bone cement strengthens fixation of suture anchors.

BACKGROUND: Failure of suture anchor fixation in rotator cuff repair can occur at different interfaces. Prior studies show fixation at the bone-anchor interface can be augmented using polymethylmethacrylate (PMMA) cement, and screw fixation into bone can be strengthened using bioabsorbable tricalcium phosphate cement. QUESTIONS/PURPOSES: We wished to determine whether augmentation of suture anchor fixation using bioabsorbable tricalcium phosphate cement would increase pullout strength of suture anchors from bone and the number of cycles to failure, to determine the mode of failure after cement augmentation, and to compare strength and mode of failure with those after augmentation with PMMA. METHODS: We used 10 matched pairs of cadaveric proximal humeri and implanted a metal screw-type suture anchor in one side and on the other side injected tricalcium phosphate cement into the anchor holes before anchor placement. We tested all specimens to failure using a ramped cyclic loading protocol. RESULTS: Tricalcium phosphate cement augmentation increased the final load to failure by 29% and the number of cycles to failure by 20%. Visual inspection confirmed that failure occurred at the cement-bone interface. CONCLUSIONS: Tricalcium phosphate cement appears to augment suture anchor fixation into bone, reducing the risk of anchor pullout and failure. CLINICAL RELEVANCE: When relying on suture anchor fixation in bone of questionable quality, we suggest considering augmentation of suture anchor fixation with bioabsorbable cement. This method also provides potential for bioabsorbability and may be more amenable to arthroscopic application.

Bone cement improves suture anchor fixation.

Suture anchor fixation failure can occur if the anchor pulls out of bone. We hypothesized that suture anchor fixation can be augmented with polymethylmethacrylate cement, and that polymethylmethacrylate can be used to improve fixation in a stripped anchor hole. Six matched cadaveric proximal humeri were used. On one side, suture anchors were placed and loaded to failure using a ramped cyclic loading protocol. The stripped anchor holes then were injected with approximately 1 cc polymethylmethacrylate, and anchors were replaced and tested again. In the contralateral humerus, polymethylmethacrylate was injected into anchor holes before anchor placement and testing. In unstripped anchors, polymethylmethacrylate increased the number of cycles to failure by 34% and failure load by 71% compared with anchors not augmented with polymethylmethacrylate. Polymethylmethacrylate haugmentation of stripped anchors increased the cycles to failure by 31% and failure load by 111% compared with unstripped uncemented anchors. No difference was found in cycles to failure or failure load between cemented stripped anchors and cemented unstripped anchors. Polymethylmethacrylate can be used to augment fixation, reducing the risk of anchor pull-out failure, regardless whether the suture anchor hole is stripped or unstripped.