Opioid Usage After Hallux Valgus Correction Surgery.

BACKGROUND: Given the lack of objective data on opioid use and the difficulty of addressing a patient's postoperative pain, we sought to quantify patient's narcotic use after hallux valgus surgery. The purpose of our study was to determine the average quantity and type of postoperative opioids consumed after hallux valgus surgery and to assess potential predictive factors for increased opioid consumption. METHODS: At the preoperative visit, patients were consented and completed a demographical questionnaire. Data were collected from the operative record, 2, 6, and 12-week postoperative visits. Type and number of pills prescribed were recorded as well as number of pills consumed at each postoperative visit. A logistic regression was performed to determine the average quantity consumed postoperatively and any statistically significant correlations. RESULTS: The average number of opioid pills collectively consumed at the 2-week and 12-week postoperative visit was 20 and 23, respectively. At the 2-week postoperative visit, only patient body mass index (BMI) showed a correlation with increased opioid use. CONCLUSION: Patients consumed an average of 23 of 40 (57.5%) narcotic pain pills prescribed after hallux valgus reconstruction surgery through the 12-week postoperative period. Owing to the opioid epidemic and potential for narcotic diversion, surgeons should counsel their patients on proper nonopioid postoperative pain management. LEVEL OF EVIDENCE: II Therapeutic.

Lateral Lumbar Interbody Fusion at the L5-S1 Vertebral Level: A Unique Anatomical Case Report.

A 57-year-old female presented with L4-L5 and L5-S1 mobile spondylolisthesis and associated stenosis with radiculopathy who failed conservative treatment. This patient underwent lateral lumbar interbody fusion (LLIF) of L4-L5 and L5-S1, and posterior spinal fusion (PSF) with instrumentation. LLIF is a minimally invasive procedure to treat degenerative diseases of the lumbar spine. LLIF at the L5-S1 vertebral level is a relative contraindication secondary to increased risk of injury to the lumbar plexus and access issues at this level during the approach. With the help of imaging, careful preoperative planning can make this a feasible procedure in select patients.

Epidemiology of Lower Leg Soft Tissue Injuries in High School Athletes.

BACKGROUND: Annually there are an estimated 4.5 million sports- and recreation-related injuries among children and young adults in the United States. The most common sports-related injuries are to the lower extremities, with two-thirds occurring among children and young adults (age range 5-24 years). The objective is to describe the epidemiology of lower leg injuries across 27 high school (HS) sports over a 3-year period. METHODS: The Datalys Center for Sports Injury Research and Prevention provided lower leg injury data for 27 sports in 147 high schools for 2011-2012 through 2013-2014 academic years from National Athletic Treatment, Injury and Outcomes Network (NATION) HS Surveillance Program. RESULTS: The overall rate of lower leg injuries over this 3-year period was 1.70 per 10 000 acute events (AEs) (95% CI, 1.59-1.82). In men, the highest number of lower leg injuries was in football (n=181), but indoor track had the highest rate of injury at 2.80 per 10 000 AEs (95% CI, 2.14-3.58). In women, the highest number of lower leg injuries and the highest rate of injury were in cross-country (n=76) at 3.85 per 10 000 AEs (95% CI, 3.03-4.81). The practice injury rate was 0.91 times the competition injury rate (95% CI, 0.78-1.07). CONCLUSION: An improved understanding of the most common sports in which lower leg injuries are seen may help direct appropriate resource utilization. Our data would suggest efforts toward prevention of these overuse injuries, especially in football, track, and cross-country may have the greatest impact on the health of student athletes. LEVEL OF EVIDENCE: Level IV, case series.

Progression of Intracranial Hemorrhage After Chemical Prophylaxis Using Low-Molecular-Weight Heparin in Patients With Traumatic Brain Injury.

INTRODUCTION: Chemical prophylaxis using low-molecular-weight heparin (LMWH) is considered a standard of care for venous thromboembolism in trauma patients. Our center performs a head computed tomography (CT) scan 24 hours after initiation with prophylactic LMWH in the setting of a known traumatic brain injury (TBI). The purpose was to determine the overall incidence of ICH progression after chemoprophylaxis in patients with a TBI. METHODS: This retrospective study was performed at a Level I trauma center, from 1/1/2014 to 12/31/2017. Study patients were drawn from the institution's trauma registry based on Abbreviated Injury Score codes. RESULTS: 778 patients met all inclusion criteria after initial chart review. The proportion of patients with an observed radiographic progression of intracranial hemorrhage after LMWH was 5.8%. 3.1% of patients had a change in clinical management. Observed radiographic progression after LMWH prophylaxis and the presence of SDH on initial CT, the bilateral absence of pupillary response in the emergency department, and a diagnosis of dementia were found to have statistically significant correlation with bleed progression after LMWH was initiated. CONCLUSION: Over a 4-year period, the use of CT to evaluate for radiographic progression of traumatic intracranial hemorrhage 24 hours after receiving LMWH resulted in a change in clinical management for 3.1% of patients. The odds of intracranial hemorrhage progression were approximately 6.5× greater in patients with subdural hemorrhage on initial CT, 3.1× greater in patients with lack of bilateral pupillary response in ED, and 4.2× greater in patients who had been diagnosed with dementia.

Hallux Valgus Deformities: Preferred Surgical Repair Techniques and All-Cause Revision Rates.

INTRODUCTION: Hallux valgus is a commonly treated condition by foot and ankle surgeons with more than 200 different described correction techniques. Recurrence rates range from 5% to 50%, with increasing support of the theory that arthrodesis procedures may have a lower recurrence rate than osteotomies. Arthrodesis procedures to the first metatarsophalangeal (MTP) joint or tarsometatarsal (TMT) joint for correction of hallux valgus deformity are becoming more commonly utilized. The purpose of this study is to investigate the surgical incidence and revision rates of hallux valgus deformities corrected by arthrodesis compared to osteotomy in the state of South Carolina. METHODS: The South Carolina Revenue and Fiscal Affairs Office was queried from 2000 to 2017 to identify all surgically treated hallux valgus deformities. Data extraction included patient demographics, ICD-9 diagnoses, CPT procedure codes, and dates of surgery. A logistic regression model was used for statistical inference. RESULTS: A total of 22 199 feet had surgical treatment for hallux valgus during this time period, with 20 422 (92.0%), 592 (2.7%), and 1185(5.3%) receiving an osteotomy, arthrodesis, or other procedure at initial treatment, respectively. There was an all-cause revision rate of 5.6% in the osteotomy group and 6.4% in the arthrodesis group. Demographic factors such as female sex, white race, and surgery pre-2010 were associated with higher revision rates. Multiple comorbidities were correlated with higher revision rates such as tobacco use, hypothyroidism, osteoarthritis, recurrent dislocations, hallux rigidus, lesser toe deformities, metatarsus varus, and talipes cavus. CONCLUSION: Despite the recent increase in arthrodesis procedures for the treatment of hallux valgus deformity, our results suggest that osteotomy procedures are more commonly performed and there is no difference in all-cause revision surgery. However, there are multiple patient demographics and comorbidities that are associated with higher rates of revision surgery and should be considered and discussed during the preoperative planning period. LEVEL OF EVIDENCE: Level IV.

Correlation of the Single-Assessment Numeric Evaluation (SANE) Score With Hip-Specific Patient-Reported Outcome Measures.

PURPOSE: The purpose of this study was to determine if the Single-Assessment Numeric Evaluation (SANE) score correlates with existing validated hip-specific patient-reported outcome measures (PROMs), including the Modified Harris Hip Score (mHHS), the International Hip Outcome Tool (IHOT-33), the Hip Outcome Score, Activities of Daily Living subscale (HOS-ADL), and the Hip Outcome Score, Sport-Specific subscale (HOS-SS), for patients preparing to undergo hip arthroscopy for treatment of femoroacetabular impingement syndrome (FAIS). METHODS: A single surgeon's operative database was retrospectively reviewed to identify patients undergoing primary hip arthroscopy for treatment of FAIS from April 2018 to October 2019. Patient-specific factors including age, sex, body mass index (BMI), and duration of symptoms were collected. Preoperative SANE, mHHS, IHOT-33, HOS-ADL, and HOS-SS scores were analyzed. Statistical analysis using Pearson correlation was performed to identify the relationship between the SANE score and the mHHS, IHOT-33, HOS-ADL, and HOS-SS, preoperatively. RESULTS: 154 patients were included in the study. The mean mHHS was 54.4 ± 11.7; mean IHOT-33 score was 32.7 ± 15.0; mean HOS-SS 42.9 ± 23.7; and mean HOS-ADL was 63.3 ± 1. The mean SANE score was 36.7 ± 19.9. The Simple Hip Score was directly correlated with the mHHS (P < .01), the IHOT-33 (P < .01); the HOS-ADL (P < .01), and the HOS-SS (P < .01). The mean patient age was 35.9 years; 109 (70.8%) were female and 45 (29.2%) were male. Average patient BMI was 26.9. At the time of patient completion of the questionnaire, the majority of patients (65%) had been having symptoms for >1 year. CONCLUSION: The SANE score was strongly correlated with mHHS, IHOT-33, HOS-ADL, and HOS-SS in the preoperative setting for patients undergoing hip arthroscopy for treatment of FAIS. Given its simplicity, SANE may be a valuable tool for rapid assessment of joint function and pain in this patient population. LEVEL OF EVIDENCE: IV, therapeutic case series.

Physeal-Sparing Rigid Intramedullary Nailing in Adolescent Tibial Shaft Fractures: A Pilot Study.

PURPOSE: Elastic stable intramedullary nailing (ESIN) and open reduction internal fixation (ORIF) are literature-supported operative treatments for displaced tibial shaft fractures in skeletally immature patients. Very little is written about rigid intramedullary nails (RIMNs) in adolescents. Our purpose is to describe a physeal-sparing, reamed, locked RIMN technique for adolescent tibial shaft fractures and report its safety. METHODS: Adolescent patients with tibial shaft fractures indicated for operative intervention at one institution were retrospectively identified from 2011-2018. Patients were classified based on method of fracture fixation. Primary outcomes included fracture union, reoperation, and complication rates. RESULTS: Thirteen patients were included in the RIMN arm, with an average age of 13.8 years. Two patients in the observational group underwent ESIN and seven patients underwent ORIF, with an average age of 11.5 years. Significant differences were found between time of immobilization (28 days vs 121 days), time to touch down weight bearing release (1 day vs 34 days), and hardware pain (2/13 vs 7/9). The RIMN group sustained fewer reoperations (2/13 vs 5/9). No differences were found in rates of complications or fixation failure between groups. CONCLUSIONS: Based on our small pilot study, RIMNs in adolescents should be considered as a potential treatment option when a physeal-sparing distal start point is utilized. Additionally, short-term follow-up suggests safety. Patients who underwent the RIMN procedure required fewer reoperations compared with the observational group. Overall, fracture healing was similar across the two groups. The benefits of RIMN include early immobilization and improved weight-bearing profile. LEVEL OF EVIDENCE: IV.

More Than One-third of Orthopaedic Applicants Are in the Top 10%: The Standardized Letter of Recommendation and Evaluation of Orthopaedic Resident Applicants.

BACKGROUND: The American Orthopaedic Association (AOA) released the standardized letter of recommendation (SLOR) form to provide standardized information to evaluators of orthopaedic residency applicants. The SLOR associates numerical data to an applicant's letter of recommendation. However, it remains unclear whether the new letter form effectively distinguishes among orthopaedic applicants, for whom letters are perceived to suffer from "grade inflation." In addition, it is unknown whether letters from more experienced faculty members differ in important ways from those written by less experienced faculty. QUESTIONS/PURPOSES: (1) What proportion of SLOR recipients were rated in the top 10th percentile and top one-third of the applicant pool? (2) Did letters from program leaders (program directors and department chairs) demonstrate lower aggregate SLOR scores compared with letters written by other faculty members? (3) Did letters from away rotation program leaders demonstrate lower aggregate SLOR scores compared with letters written by faculty at the applicant's home institution? METHODS: This was a retrospective, single institution study examining 559 applications from the 2018 orthopaedic match. Inclusion criteria were all applications submitted to this residency. Exclusion criteria included all letters without an associated SLOR. In all, 1852 letters were received; of these, 26% (476) were excluded, and 74% (1376) were analyzed for SLOR data. We excluded 12% (169 of 1376) of letters that did not include a final summative score. Program leaders were defined as orthopaedic chairs and program directors. Away rotation letters were defined as letters written by faculty during an applicant's away rotation. Our study questions were answered accounting for each subcategory on the SLOR (scale 1-10) and the final ranking (scale 1-5) to form an aggregated score from the SLOR form for each letter. All SLOR questions were included in the creation of these scores. Correlations between program leaders and other faculty letter writers were assessed using a chi-square test. We considered a 1-point difference on 5-point scales to be a clinically important difference and a 2-point difference on 10-point scales to be clinically important. RESULTS: We found that 36% (437 of 1207) of the letters we reviewed indicated the candidate was in the top 10th percentile of all applicants evaluated, and 51% (619 of 1207) of the letters we reviewed indicated the candidate was in the top one-third of all applicants evaluated. We found no clinically important difference between program leaders and other faculty members in terms of summative scores on the SLOR (1.9 ± 0.7 versus 1.7 ± 0.7, mean difference -0.2 [95% CI -0.3 to 0.1]; p < 0.001). We also found no clinically important difference between home program letter writers and away program letter writers in terms of the mean summative scores (1.9 ± 0.7 versus 1.7 ± 0.7, mean difference 0.2; p < 0.001). CONCLUSION: In light of these discoveries, programs should examine the data obtained from SLOR forms carefully. SLOR scores skew very positively, which may benefit weaker applicants and harm stronger applicants. Program leaders give summative scores that do not differ substantially from junior faculty, suggesting there is no important difference in grade inflation between these faculty types, and as such, there is no strong need to adjust scores by faculty level. Likewise, away rotation letter writers' summative scores were not substantially different from those of home institution letters writers, indicating that there is no need to adjust scores between these groups either. Based on these findings, we should interpret letters with the understanding that overall there is substantial grade inflation. However, while weight used to be given to letters written by senior faculty members and those obtained on away rotations, we should now examine them equally, rather than trying to adjust them for overly high or low scores. LEVEL OF EVIDENCE: Level III, therapeutic study.

Factors associated with high pain catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome.

The purpose of this study was to determine if physical, mental health and patient-specific factors are associated with increased Pain Catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Patients who underwent primary hip arthroscopy for FAIS were retrospectively analyzed. Patients were included if they completed a standard pre-operative questionnaire which included the Pain Catastrophizing Scale (PCS), VAS and 12-Item Short Form Survey (SF-12) Physical and Mental Composite Scores. Patient-specific variables including age, gender, BMI, tobacco use, number of allergies, pre-operative opioid use and diagnosis of depression or anxiety were recorded. Multiple linear regression was performed to assess for a relationship between physical and mental health scores, patient-specific variables, and a 'High Catastrophizing' PCS score. One-hundred and sixty-eight patients were included in this study. Patients with a PCS score of 22 or above were categorized as 'High Catastrophizing'. The variables included in the multiple linear regression model statistically significantly predicted high pain catastrophizing, F(10,149) = 4.75, P < 0.001, R 2 = 0.4. SF-12 Physical and Mental Composite Scores and a mental health illness diagnosis added statistically significantly to the prediction, P < 0.005. Pre-operative hip arthroscopy patients with better general physical and mental health, as measured by the SF-12, and those without mental health illness are less likely to having higher pain catastrophizing scores. Age, gender, BMI, visual analog pain scale (VAS), tobacco use, number of allergies and pre-operative opioid use were not independently associated with elevated pain catastrophizing scores. These findings may be helpful when interpreting PCS scores and counseling patients prior to arthroscopic hip surgery.

The Learning Curve in Hip Arthroscopy: Effect on Surgical Times in a Single-Surgeon Cohort.

PURPOSE: To quantify the effect of the learning curve in performing hip arthroscopy for femoroacetabular impingement (FAI) and labral tears on total operating room time, including times for setup, surgery, and wake up, during a single surgeon's initial hip arthroscopy procedures. METHODS: A single surgeon's case list was retrospectively reviewed to identify all primary hip arthroscopy surgeries between November 1, 2018, and February 28, 2018, for the treatment of FAI and labral tears. Surgical times were recorded, including total room time; surgical time; setup time; and wake-up time. Linear regression was used to evaluate the relationship of these times relative to case number in the series. In addition, the series was divided into 3 sequential groups to further compare these times. RESULTS: In total, 225 patients were included in the study. The mean total room time for all cases was 155.4 minutes, 95% confidence interval ([CI] 150.9-160.0); mean surgical time was 115.6 minutes (95% CI 111.5-119.8), and mean setup time was 32.6 minutes (95% CI 31.8-33.4). Decreasing surgical time was associated with advancing number in the case series (P < .001, R2 = 0.36). Decreasing total room time was accordingly associated with advancing number in the case series (P < .001, R2 = 0.34). There were no significant differences in setup time and wake-up time as the case series advanced. When groups of 75 sequential cases were compared, significant decreases in surgical and total room time were noted between the first and second groups (P < .001) but not between the second and third groups (P = .52). Increasing complexity of surgeries was noted as the series advanced, including capsular closure and subspine decompression. CONCLUSIONS: This study supports the existence of a substantial learning curve for hip arthroscopy in the treatment of FAI and labral tears. Our findings suggest decreasing surgical time as the surgeon advances through the learning curve, with the initial 75 procedures requiring longer time to perform than subsequent cases. CLINICAL RELEVANCE: Hip arthroscopy is a technically demanding procedure. Understanding the long duration of the hip arthroscopy learning curve is helpful for surgeons considering the addition of hip arthroscopy to their practice.

Acetabular Subchondral and Cortical Perforation During Labral Repair With Suture Anchors: Influence of Portal Location, Curved Versus Straight Drill Guides, and Drill Starting Point.

PURPOSE: To evaluate the impact of the portal used for drilling, the position of the drill guide on the acetabular rim, and the use of straight versus curved drill guides on drill perforation of the acetabular subchondral bone and the outer cortex of the acetabulum. METHODS: Sixty acetabular models were marked at the 3-, 2-, 1-, 12-, and 11-o'clock positions. Simulated anterior, anterolateral, and distal anterolateral accessory (DALA) portals were created. Twelve groups of 5 acetabula were drilled at each clock-face position using all combinations of variables. RESULTS: A total of 38 of 300 drillings (12.7%) perforated the subchondral bone, and 45 of 300 (15%) breached the outer cortex. Drilling from the anterior, anterolateral, and DALA portals perforated the acetabular subchondral bone on 21 of 100 attempts (21%), 17 of 100 attempts (17%), and 0 of 100 attempts (0%), respectively (P < .001), and perforated the outer acetabular cortex on 36 of 100 attempts (36%), 1 of 100 attempts (1%), and 8 of 100 attempts (8%), respectively (P < .001). The use of a curved or straight drill guide did not make a statistically significant difference. Drilling with a starting point on the acetabular rim perforated the acetabular subchondral bone on 29 of 150 attempts (19.3%) compared with 9 of 150 attempts (6%) when the starting point was 2 mm removed from the acetabular rim (P < .001). CONCLUSIONS: The use of the DALA portal and a drill starting point slightly off the acetabular rim was associated with the lowest rate of acetabular subchondral perforation and is recommended to reduce the risk of iatrogenic chondral injury. CLINICAL RELEVANCE: Iatrogenic chondral injury is a relatively common complication of hip arthroscopy. Increased awareness of factors associated with drill perforation during suture anchor placement can help surgeons mitigate this risk.