Suspected gluteal compartment syndrome: Etiology predicts clinical course, outcomes and resource utilization.

Background: Gluteal Compartment Syndrome (GCS) is a rare subtype of acute compartment syndrome (ACS), complex to diagnose and potentially fatal if left untreated. The incidence of ACS is estimated to be 7.3 per 100,000 in males and 0.7 per 100,000 in females [1-3]. Given its rare occurrence, the incidence of GCS is not well reported. In the case of GCS, the most common etiologies are surgical positioning, prolonged immobilization secondary to substance use or loss of consciousness, and traumatic injury. Clinical findings are pulselessness, pallor, parasthesia, paralysis, and most notably pain out of proportion. Swift diagnosis and treatment are imperative to reduce morbidity and mortality, however the ideal management of GCS is difficult to ascertain given the rare occurrence and variable presentation. Methods: Orthopaedic trauma database at a level 1 trauma center was reviewed to identify patients for whom the orthopaedic service was consulted due to suspicion of gluteal compartment syndrome. This yielded 11 patients between 2011 and 2019. Patients with a measured ΔP greater than 30 upon initial consultation and with a concerning exam requiring monitoring were included. Patient demographics, comorbidities, GCS etiology, laboratory values, physical exam findings, pain scores (0-10) and patient outcomes were collected via chart review. Patient demographic and injury characteristics were summarized using descriptive statistics. Results: Prolonged immobilization patients had worse outcomes including longer hospital stays (40.5 days) compared to trauma patients (4.5 days). All adverse medical outcomes recorded including acute renal failure, prolonged neuropathic pain, cardiopulmonary dysfunction were exclusively experienced by prolonged immobilization patients. Conclusions: Our descriptive study demonstrates the bimodal distribution of GCS patients based on etiology. Prolonged immobilization patients have a longer hospital course and more complications. Our study confirms prior reports and provides information that can be used to counsel patients and families appropriately about treatment and recovery following GCS. Level of evidence: IV. Study type: Epidemiological.

Opioid Prescribing Rate for Nonoperative Distal Radius Fractures and Clinician Response to a Clinical Decision Support Alert.

BACKGROUND: Opioids are commonly prescribed for the management of acute orthopedic trauma pain, including nonoperative distal radius fractures. OBJECTIVES: This prospective study aimed to determine if a clinical decision support intervention influenced prescribing decisions for patients with known risk factors. We sought to quantify frequency of opioid prescriptions for acute nonoperative distal radius fractures treated. METHODS: We performed a prospective study at one large health care system. Utilizing umbrella code S52.5, we identified all distal radius fractures treated nonoperatively, and the encounters were merged with the Prescription Reporting with Immediate Medication Mapping (PRIMUM) database to identify encounters with opioid prescriptions and patients with risk factors for opioid use disorder. We used multivariable logistic regression to determine patient characteristics associated with the prescription of an opioid. Among encounters that triggered the PRIMUM alert, we calculated the percentage of encounters where the PRIMUM alert influenced the prescribing decision. RESULTS: Of 2984 encounters, 1244 (41.7%) included an opioid prescription. Age increment is a significant factor to more likely receive opioid prescriptions (p < 0.0001) after adjusting for other factors. Among encounters where the physician received an alert, those that triggered the alert for early refill were more likely to influence physicians' opioid prescribing when compared with other risk factors (p = 0.0088). CONCLUSION: Over 90% of patients (106/118) continued to receive an opioid medication despite having a known risk factor for abuse. Additionally, we found older patients were more likely to be prescribed opioids for nonoperatively managed distal radius fractures.

Opioid Prescribing for Chronic Musculoskeletal Conditions: Trends over Time and Implementation of Safe Opioid-Prescribing Practices.

OBJECTIVES: This study aimed (1) to determine the impact of a clinical decision support (CDS) tool on rate of opioid prescribing and opioid dose for patients with chronic musculoskeletal conditions and (2) to identify prescriber and facility characteristics associated with adherence to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain in this population.We conducted an interrupted time series analysis to assess trends in percentage of patients from 2016 to 2020, receiving an opioid and the average opioid dose, as well as the change associated with implementation of the CDS toolkit. We conducted a retrospective cohort study to assess the association between prescriber and facility characteristics and safe opioid-prescribing practices. METHODS: We assessed the impact of the CDS intervention on percent of patients receiving an opioid and average opioid dose (morphine milligram equivalents). We operationalized safe opioid prescribing as a composite score of several behaviors (i.e., prescribing naloxone, initiating a pain agreement, prescribing <90 MME, avoiding extended-release prescriptions for opioid-naïve patients, and avoiding coprescribing opioids and benzodiazepines) and used a hierarchical linear regression model to assess associations between prescriber and facility characteristics and safe opioid prescribing. RESULTS: This CDS intervention had a modest but statistically significant 1.6% reduction on the percent of patients (n = 1,290,746) receiving an opioid (mean: 15% preintervention; 10% postintervention). The average dose of opioid prescriptions did not significantly change. Advanced practice providers and prescribers with higher percentages of patients aged 18 to 64 exhibited safer opioid prescribing, while prescribers with higher percentages of white patients and larger numbers of patients on opioids exhibited less safe opioid prescribing. CONCLUSION: A CDS intervention was associated with a small improvement in percent of patients receiving an opioid, but not on average dose. Clinicians are not prescribing opioids for chronic musculoskeletal conditions frequently, when they do, they are generally adhering to guidelines.

Impact of clinical decision support on controlled substance prescribing.

BACKGROUND: Prescription drug overdose and misuse has reached alarming numbers. A persistent problem in clinical care is lack of easy, immediate access to all relevant information at the actionable time. Prescribers must digest an overwhelming amount of information from each patient's record as well as remain up-to-date with current evidence to provide optimal care. This study aimed to describe prescriber response to a prospective clinical decision support intervention designed to identify patients at risk of adverse events associated with misuse of prescription opioids/benzodiazepines and promote adherence to clinical practice guidelines. METHODS: This study was conducted at a large multi-center healthcare system, using data from the electronic health record. A prospective observational study was performed as clinical decision support (CDS) interventions were sequentially launched (January 2016-July 2019). All data were captured from the medical record prospectively via the CDS tools implemented. A consecutive series of all patient encounters including an opioid/benzodiazepine prescription were included in this study (n = 61,124,172 encounters; n = 674,785 patients). Physician response to the CDS interventions was the primary outcome, and it was assessed over time using control charts. RESULTS: An alert was triggered in 23.5% of encounters with a prescription (n = 555,626). The prescriber decision was influenced in 18.1% of these encounters (n = 100,301). As the number of risk factors increased, the rate of decision being influenced also increased (p = 0.0001). The effect of the alert differed by drug, risk factor, specialty, and facility. CONCLUSION: The delivery of evidence-based, patient-specific information had an influence on the final prescription in nearly 1 in 5 encounters. Our intervention was sustained with minimal prescriber fatigue over many years in a large and diverse health system.

Adherence to legislation limiting opioid prescription duration following musculoskeletal injury.

OBJECTIVES: North Carolina had implemented legislation (Strengthen Opioid Misuse Prevention (STOP) Act) limiting opioid prescriptions to 5 days for acute pain and 7 days for post-operative pain. This study aimed to identify patient, prescriber, and facility characteristics associated with STOP Act adherence for patients with acute or post-surgical musculoskeletal (MSK) conditions. DESIGN: A three-level hierarchical logistic regression model was used to predict odds of adherence with STOP Act duration limits, accounting for fixed and random effects at the patient, prescriber, and facility levels. SETTING: A large healthcare system in North Carolina. PATIENTS AND PARTICIPANTS: Patients (N = 6,849) presenting from 2018 to 2020 with a diagnosis of an acute MSK injury. INTERVENTIONS: The STOP Act limited the duration of opioid prescriptions in North Carolina. MAIN OUTCOME MEASURE: Prescriptions adhering to the STOP Act duration limits of 5 days (nonoperative) or 7 days (operative) were the primary outcome. RESULTS: Opioids were compliant with STOP Act duration limits in 69.3 percent of encounters, with 33 percent of variation accounted for by clinician and 29 percent by facility. Patients prescribed >1 opioid (odds ratio (OR) 0.46, 95 percent confidence interval (CI): 0.36, 0.58) had reduced odds of a compliant prescription; surgical patients had increased odds of a compliant prescription (outpatient surgery: OR 5.89, 95 percent CI: 2.43-14.29; inpatient surgery: OR 7.71, 95 percent CI: 3.04-19.56). Primary care sports medicine clinicians adhered to legislation less frequently than orthopedic surgeons (OR 0.38, 95 percent CI: 0.15, 0.97). CONCLUSIONS: Most prescriptions adhered to STOP Act legislation. Tailored interventions to improve adherence among targeted groups of prescribers, eg, those treating nonoperative injuries and sport medicine clinicians, could be useful.

Impact of Anesthesia selection on Post-Op Pain Management in Operatively treated Hip Fractures.

OBJECTIVES: To determine if the use of Peripheral Nerve Block (PNB) versus Local Infiltration Analgesia (LIA) for hip fracture patients, affected opioid consumption in the early post-operative period. DESIGN: Retrospective cohort study SETTING: Two level 1 trauma centers PATIENTS/INTERVENTION: 588 patients with surgically treated AO/OTA 31A and 31B fractures between February 2016-October 2017 were included. 415 (70.6%) received general anesthesia (GA) alone, 152 received GA plus perioperative PNB (25.9%), and 21 had GA plus LIA intra-operatively (3.6%). Median age was 82 years; predominantly female (67%) and AO/OTA 31A fractures (55.37%). MAIN OUTCOME MEASURES: Morphine Milligram Equivalents (MME) at 24 and 48 hours postoperatively, length of stay (LOS) and the occurrence of any complication after surgery RESULTS: The PNB cohort was less likely to use any opioid than the GA group at 24 and 48 hours postoperatively (OR: 0.36, 95% CI: 0.22-0.61 and OR: 0.56, 95% CI: 0.35-0.89 respectively). LOS ≥ 10 days had 3.24 times the odds of 24- and 48-hour opioid administration compared to LOS ≤ 10 days (OR: 3.24, 95% CI 1.11-9.42; OR: 2.98, 95% CI 1.38-6.41, respectively). The most common complication was post-operative delirium, with PNB more likely to present with any complication compared to GA (OR= 1.88, 95% CI 1.09-3.26). There was no difference when comparing LIA to general anesthesia. CONCLUSIONS: Our findings suggest PNB for hip fracture can help limit the use of post-operative opioids with adequate pain relief. Regional analgesia does not seem to avoid complications such as delirium.

Health Literacy Awareness Among Orthopaedic Surgery Residents: A COERG Survey.

Musculoskeletal health literacy (HL) is an emerging concept in orthopaedic patient care. Estimated rates of low musculoskeletal HL in patients surpass those of general HL. Studies in other specialties suggest that medical trainees are ill equipped to interact with low HL patients, often with detrimental patient outcomes. The purpose of this study was to (1) establish the current state of HL awareness among orthopaedic surgery trainees, (2) characterize the current state of HL training in orthopaedic surgery programs, and (3) evaluate the desire for formalized HL training among orthopaedic surgery trainees. Methods: This study was endorsed by the Collaborative Orthopaedic Education Research Group board. A 17-item questionnaire was administered anonymously to orthopaedic residents through a secure online platform in the 2020 to 2021 academic year. All participation was voluntary. Results: One hundred ninety-two residents (42%) from 19 orthopaedic programs completed the survey. Most residents felt "somewhat comfortable" with issues related to HL. Most residents reported no specific training in HL issues during residency (77.5%). Of the 43 residents (22.3%) who did receive formal training, most of these individuals felt that the training is effective (N = 42, 97.7%). Role playing/standardized patient encounters were reported as the most effective form of HL training. Residents felt it was somewhat important to receive formal HL training in residency (median = 4.0, interquartile range = 3.0-5.0), and there was a modest desire for formalized training (39%). Discussion: This study is the first to characterize orthopaedic resident perceptions of HL issues in practice and training. Residents were somewhat confident in their understanding of HL concepts, and those who received formal training felt it was effective. However, there remains a low rate of formal orthopaedic resident training in HL issues, which may be an area for improvement in orthopaedic training paradigms.

Implementation of required sedation assessment in nursing workflow to address naloxone utilization.

OBJECTIVE: Opioid-related adverse drug events continue to occur. This study aimed to characterize the patient population receiving naloxone to inform future intervention efforts. DESIGN: We describe a case series of patients who received naloxone in the hospital during a 16-week time frame in 2016. Data were collected on other administered medications, reason for admission to the hospital, pre-existing diagnoses, comorbidities, and demographics. SETTING: Twelve hospitals within a large healthcare system. PATIENTS: 46,952 patients were admitted during the study period. 31.01 percent (n = 14,558) of patients received opioids, of which 158 received naloxone. INTERVENTION: Administration of naloxone. Main outcome of interest: Sedation assessment via Pasero Opioid-Induced Sedation Scale (POSS), administration of sedating medications. RESULTS: POSS score was documented prior to opioid administration in 93 (58.9 percent) patients. Less than half of patients had a POSS documented prior to naloxone administration with 36.8 percent documented 4 hours prior. 58.2 percent of patients received multimodal pain therapy with other nonopioid medications. Most patients received more than one sedating medication concurrently (n = 142, 89.9 percent). CONCLUSIONS: Our findings highlight areas for intervention to prevent opioid oversedation. Investing in electronic clinical decision support mechanisms, such as sedation assessment, could detect patients at risk for oversedation and ultimately prevent the need for naloxone. Coordinated order sets for pain management can reduce the percentage of patients receiving multiple sedating medications and promote the use of multimodal pain management in efforts to reduce opioid reliance while optimizing pain control.

Changes in opioid prescription duration for musculoskeletal injury associated with the North Carolina Strengthen Opioid Misuse Prevention (STOP) Act.

OBJECTIVES: To assess whether implementation of the Strengthen Opioid Misuse Prevention (STOP) Act was associated with an increase in the percentage of opioid prescriptions written for 7 days or fewer among patients with acute or postsurgical musculoskeletal conditions. DESIGN: An interrupted time-series study was conducted to determine the change in duration of opioid prescriptions associated with the STOP Act. SETTING: Data were extracted from the electronic health record of a large health care system in North Carolina. SUBJECTS: Patients presenting from 2016 to 2020 with an acute musculoskeletal injury and the clinicians treating them were included in an interrupted time-series study (n = 12 839). METHODS: Trends were assessed over time, including the change in trend associated with implementation of the STOP Act, for the percentage of prescriptions written for ≤7 days. RESULTS: Among patients with acute musculoskeletal injury, less than 30% of prescriptions were written for ≤7 days in January of 2016; by December of 2020, almost 90% of prescriptions were written for ≤7 days. Prescriptions written for ≤7 days increased 17.7% after the STOP Act was implemented (P < .001), after adjustment for the existing trend. CONCLUSIONS: These results demonstrate significant potential for legislation to influence opioid prescribing behavior.

Opioid and benzodiazepine use in gynecologic oncology patients.

OBJECTIVE: The goals of this study were to describe opioid and benzodiazepine prescribing practices in the gynecologic oncology patient population and determine risks for opioid misuse in these patients. METHODS: Retrospective study of opioid and benzodiazepine prescriptions for patients treated for cervical, ovarian (including fallopian tube/primary peritoneal), and uterine cancers within a single healthcare system from January 2016 to August 2018. RESULTS: A total of 7643 prescriptions for opioids and/or benzodiazepines were dispensed to 3252 patients over 5754 prescribing encounters for cervical (n=2602, 34.1%), ovarian (n=2468, 32.3%), and uterine (n=2572, 33.7%) cancer. Prescriptions were most often written in an outpatient setting (51.0%) compared with inpatient discharge (25.8%). Cervical cancer patients were more likely to have received a prescription in an emergency department or from a pain/palliative care specialist (p=0.0001). Cervical cancer patients were least likely to have prescriptions associated with surgery (6.1%) compared with ovarian cancer (15.1%) or uterine cancer (22.9%) patients. The morphine milligram equivalents prescribed were higher for patients with cervical cancer (62.6) compared with patients with ovarian and uterine cancer (46.0 and 45.7, respectively) (p=0.0001). Risk factors for opioid misuse were present in 25% of patients studied; cervical cancer patients were more likely to have at least one risk factor present during a prescribing encounter (p=0.0001). Cervical cancer was associated with a higher number of risk factors (p<0.001). CONCLUSIONS: Opioid and benzodiazepine prescribing patterns differ for cervical, ovarian, and uterine cancer patients. Gynecologic oncology patients are overall at low risk for opioid misuse; however, patients with cervical cancer are more likely to have risk factors present for opioid misuse.

How Many Patients Do We Need? Predictors of Consent to Participate in Clinical Research Studies in Orthopaedic Trauma.

OBJECTIVES: To characterize the recruitment rates at a Level I trauma center enroling for multiple prospective orthopaedic trauma research studies and identify patient-related and study-related predictors of consent. DESIGN: We conducted a case-control study to identify predictors of study consent. The authors categorized studies based on intensity of the study intervention (low, intermediate, or high). A 2-level generalized linear model with random intercept for study was used to predict study consent. SETTING: This analysis includes data from 10 federally funded studies conducted as part of a large, national consortium that were enroling patients in 2013-2014. PATIENTS/PARTICIPANTS: Three hundred thirty-four patients were approached for at least 1 study and included in the analysis. INTERVENTION: N/A. MAIN OUTCOME MEASURES: Consent to participate in the research study. RESULTS: A total of 315 patients consented to be in a study (71% of approached patients). Consent rate varied by study (45%-95%). No patient characteristics (race, age, or sex) were associated with consent. Patients approached for studies of intermediate intensity were 83% less likely to consent (odds ratio = 0.17; 95% confidence interval: 0.04-0.67), and those approached for studies of high intensity were 91% less likely to consent (odds ratio = 0.09; 95% confidence interval: 0.03-0.32). CONCLUSION: Patient factors were not associated with consent. Study intensity is a major driver of consent rates. Studies of higher intensity will require the study team to approach up to twice as many patients as the target enrolment. This study provides a framework that can be used in study planning and determination of feasibility.

Patients with glenohumeral arthritis are more likely to be prescribed opioids in the emergency department or urgent care setting.

OBJECTIVE: The objective is to quantify the rate of opioid and benzodiazepine prescribing for the diagnosis of shoulder osteoarthritis across a large healthcare system and to describe the impact of a clinical decision support intervention on prescribing patterns. DESIGN: A prospective observational study. SETTING: One large healthcare system. PATIENTS AND PARTICIPANTS: Adult patients presenting with shoulder osteoarthritis. INTERVENTIONS: A clinical decision support intervention that presents an alert to prescribers when patients meet criteria for increased risk of opioid use disorder. MAIN OUTCOME MEASURE: The percentage of patients receiving an opioid or benzodiazepine, the percentage who had at least one risk factor for misuse, and the percent of encounters in which the prescribing decision was influenced by the alert were the main outcome measures. RESULTS: A total of 5,380 outpatient encounters with a diagnosis of shoulder osteoarthritis were included. Twenty-nine percent (n = 1,548) of these encounters resulted in an opioid or benzodiazepine prescription. One-third of those who received a prescription had at least one risk factor for prescription misuse. Patients were more likely to receive opioids from the emergency department or urgent care facilities (40 percent of encounters) compared to outpatient facilities (28 percent) (p < .0001). Forty-four percent of the opioid prescriptions were for "potent opioids" (morphine milliequivalent conversion factor > 1). Of the 612 encounters triggering an alert, the prescribing decision was influenced (modified or not prescribed) in 53 encounters (8.7 percent). All but four (0.65 percent) of these encounters resulted in an opioid prescription. CONCLUSION: Despite evidence against routine opioid use for osteoarthritis, one-third of patients with a primary diagnosis of glenohumeral osteoarthritis received an opioid prescription. Of those who received a prescription, over one-third had a risk factor for opioid misuse. An electronic clinic decision support tool influenced the prescription in less than 10 percent of encounters.

Musculoskeletal Pain Management and Patient Mental Health and Well-being.

SUMMARY: Orthopaedic trauma patients have high rates of psychiatric disorders, which put them at risk for worse outcomes after injury and surgery, including worse pain. Mental health conditions, such as depression and anxiety, can affect the perception of pain. Pain can also exacerbate or contribute to the development of mental illness after injury. Interventions to address both mental health and pain among orthopaedic trauma patients are critical. Balancing safety and comfort amid a drug overdose epidemic is challenging, and many clinicians do not feel comfortable addressing mental health or have the resources necessary. We reviewed the literature on the complex relationship between pain and mental health and presented examples of scalable and accessible interventions that can be implemented to promote the health and recovery of our patients. Interventions described include screening for depression in the orthopaedic trauma clinic and the emergency department or inpatient setting during injury and using a comprehensive and evidence-based multimodal pain management regimen that blends pharmacologic alternatives to opioids and physical and cognitive strategies to manage pain.

Depression Screening and Behavioral Health Integration in Musculoskeletal Trauma Care.

OBJECTIVES: To report our experiences in implementing a behavioral health integration pathway, including a validated depression screening and referral to care. DESIGN: Retrospective case series. SETTING: Single surgeon's musculoskeletal trauma outpatient practice during calendar year 2019. PATIENTS: All patients presenting to the practice during 2019 were included (n = 573). INTERVENTION: We piloted the usage of Patient Health Questionnaire (PHQ)-2 and PHQ-9 screening. An evidence-based, real-time treatment protocol embedded in the electronic health record was triggered when a patient screened positive for depression including an automated behavioral health integration pathway. MAIN OUTCOME MEASUREMENTS: The percentage of patients screened, the results of the PHQ screening, and the number of patients referred and enrolled in behavioral health programs were collected. RESULTS: Of the 573 patients, 476 (83%) received the PHQ-2 screening, 80 (14%) had a current screening on file (within 1 year), and 17 (3.0%) were not screened. One hundred seventy-two patients (36%) had a PHQ-2 score of 2 or greater and completed the PHQ-9; of them, 60 (35% of patients screened with full PHQ-9, 13% of patients screened) screened positive for symptoms of moderate depression (PHQ-9 score ≥10), and 19 (4.0%) reported passive suicidal ideation (PHQ-9 item 9). Fifty of these patients were referred to behavioral health through the pathway, and 8 patients enrolled in the program. Ten patients were not referred because of a technical error that was quickly resolved. Patients reporting suicidal ideation were managed with psychiatric crisis resources including immediate virtual consult in the examination room. CONCLUSIONS: This case series demonstrates the feasibility of screening patients for depressive symptoms and making necessary referrals to behavioral health in outpatient musculoskeletal trauma care. We identified 50 patients with depression and appropriately triaged them for further care in our community.

Impact of an opioid prescribing alert system on patients with posttraumatic stress disorder.

BACKGROUND AND OBJECTIVES: Posttraumatic stress disorder (PTSD) is associated with higher rates of chronic pain and increased risk of developing Opioid use disorder. This paper evaluates the impact of PRIMUM, an electronic health record-embedded (EHR) clinical decision support intervention on opioid prescribing patterns for patients with diagnosis of PTSD. METHODS: Inpatient, emergency department (ED), urgent care, and outpatient encounters with ICD-10 codes F43.1 (PTSD), F43.10 (PTSD, unspecified), F43.11 (PTSD, acute), and F43.12 (PTSD, chronic) at Atrium Health between 1/1/2016 and 12/29/2018 were included in the study. RESULTS: A total of 3121 patients with a diagnosis of PTSD were seen in 37,443 encounters during the study period. Ten percent (n = 3761) of the encounters resulted in prescriptions for opioids and PRIMUM alerts were triggered in 1488 of these encounters. These alerts resulted in "decision influenced" for 17% of patients (n = 255) or no prescriptions for opioids or benzodiazepines for 5.8% (n = 86). The majority of the prescriptions were below 50 Morphine milligram equivalents (MME)/day, but there were 570 (15.5%) prescriptions for doses of 50-90 MME and 721 (19.6%) prescriptions for >90 MME/day. DISCUSSION AND CONCLUSION: The PRIMUM alert system helps improve patient safety. PRIMUM affected clinician decisions 17% of the time, and the effect was greater in patients with opioid overdose history and those presenting for early refills. SCIENTIFIC SIGNIFICANCE: The effectiveness of clinical support interventions for opioid prescribing for patients with PTSD has not been documented previously. Our findings provide novel evidence that the EHR can be used to improve patient safety among patients with PTSD in the context of substance use.

Screws-Only Primary Subtalar Arthrodesis for Calcaneus Fractures.

BACKGROUND: The management of displaced intraarticular calcaneus fractures (DIACFs) is a difficult problem with disappointing results from open reduction internal fixation (ORIF). Alternatively, ORIF with primary subtalar arthrodesis (PSTA) has gained increasing popularity. The purpose of this study is to review patient-centered and radiographic outcomes of ORIF plus PSTA using only screws through a sinus tarsi approach. METHODS: A retrospective study of patients who underwent ORIF+PSTA for DIACFs was conducted. The same surgical technique was used in all cases consisting of only screws; no plates were used. Delayed surgeries past 8 weeks were excluded. Demographic and radiographic data were collected including worker's compensation claims. Plain radiographs were used to characterize injuries and review outcomes. RESULTS: Seventy-nine DIACFs underwent PSTA with a median follow-up of 200 days (n = 69 patients). Median time to weightbearing was 57.5 days postoperatively. Ten fractures were documented as Sanders II, 36 as Sanders III, and 32 as Sanders IV. Sixty-eight fractures (86.1%) achieved fusion on radiographs at a median of 126.5 (range, 54-518) days. Thirty-nine fractures (57.3%) demonstrated radiographic fusion in all 3 predefined locations. Nine of the 14 worker's compensation patients returned to work within the period of observation. There were 8 complications: 3 requiring a secondary operation. Eleven of 79 fractures treated did not go on to achieve radiographic union. CONCLUSION: In this retrospective case series, we found that screws-only primary subtalar arthrodesis for the treatment of DIACFs through a sinus tarsi approach was associated with relatively high rates of return to work and radiographic fusion. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Multimodal analgesia reduces opioid requirements in trauma patients with rib fractures.

BACKGROUND: Rib fractures are common in trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is essential to avoid the complications associated with rib fractures. Opioids are frequently used for analgesia in these patients. This study compared the effect of a multimodal pain regimen (MMPR) on inpatient opioid use and outpatient opioid prescribing practices in adult trauma patients with rib fractures. STUDY DESIGN: A pre-post cohort study of adult trauma patients with rib fractures was conducted at a Level I trauma center before (PRE) and after (POST) implementation of an MMPR. Patients on long-acting opioids before admission and those on continuous opioid infusions were excluded. Primary outcomes were oral opioid administration during the first 5 days of hospitalization and opioids prescribed at discharge. Opioid data were converted to morphine milligram equivalents (MMEs). RESULTS: Six hundred fifty-three patients met inclusion criteria (323 PRE, 330 POST). There was a significant reduction in the daily MME during the second through fifth days of hospitalization; and the average inpatient MME over the first five inpatient days (23 MME PRE vs. 17 MME POST, p = 0.0087). There was a significant reduction in the total outpatient MME prescribed upon discharge (322 MME PRE vs. 225 MME POST, p = 0.006). CONCLUSION: The implementation of an MMPR in patients with rib fractures resulted in significant reduction in inpatient opioid consumption and was associated with a reduction in the quantity of opiates prescribed at discharge. LEVEL OF EVIDENCE: Therapeutic/Care Management; level IV.

Opioid Prescribing Risk Factors in Nonoperative Ankle Fractures: The Impact of a Prospective Clinical Decision Support Intervention.

Opioids are frequently used for acute pain management of musculoskeletal injuries, which can lead to misuse and abuse. This study aimed to identify the opioid prescribing rate for ankle fractures treated nonoperatively in the ambulatory and emergency department setting across a single healthcare system and to identify patients considered at high risk for abuse, misuse, or diversion of prescription opioids that received an opioid. A retrospective cohort study was performed at a large healthcare system. The case list included nonoperatively treated emergency department, urgent care and outpatient clinic visits for ankle fracture and was merged with the Prescription Reporting With Immediate Medication Mapping (PRIMUM) database to identify encounters with prescription for opioids. Descriptive statistics characterize patient demographics, treatment location and prescriber type. Rates of prescribing among subgroups were calculated. There were 1,324 patient encounters identified, of which, 630 (47.6%) received a prescription opioid. The majority of patients were 18-64 years old (60.3%). Patients within this age range were more likely to receive an opioid prescription compared to other age groups (p < .0001). Patients treated in the emergency department were significantly more likely to receive an opioid medication (68.3%) compared to patients treated at urgent care (33.7%) or in the ambulatory setting (16.4%) (p < .0001). Utilizing the PRIMUM tool, 14.2% of prescriptions were provided to patients with at least one risk factor. Despite the recent emphasis on opioid stewardship, 14.2% of patients with risk factors for misuse, abuse, or diversion received opioid analgesics in this study, identifying an area of improvement for prescribers.

Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center.

OBJECTIVES: Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic. DESIGN: Retrospective chart review. SETTING: Outpatient visits (in-person, telephone, virtual-Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic. INTERVENTION: Virtual visits utilizing the Doxy.me platform. MAIN OUTCOME MEASURES: Accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). METHODS: All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). RESULTS: Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028). CONCLUSION: A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.

Traumatic Arthrotomies: Do They All Need the Operating Room?

OBJECTIVES: To compare complications and cost of care in patients with traumatic arthrotomies (TAs) treated with surgical debridement, irrigation, and closure to those treated with nonoperative treatment and local wound care. DESIGN: This is a prospective observational multicenter study. SETTING: This study was conducted at multiple Level I trauma centers. PATIENTS: Patients with TAs. INTERVENTION: Patients were treated with operative versus nonoperative management decided by the attending surgeon. Nonoperative treatment of TAs included bedside irrigation, primary closure, antibiotics, and discharge from the emergency department with close follow-up unless admission was otherwise indicated. MAIN OUTCOME MEASUREMENTS: Primary outcomes included adverse outcomes and cost. VR-12 was captured at the time of injury and 3 months postinjury. RESULTS: Of 189 major joint TAs, 64 arthrotomies were treated nonoperatively and 125 operatively. Seventy percent of the arthrotomies in the nonoperative group were small (less than 50 mm in size) and 95% had minimal/no gross contamination, whereas the operative group (OG) had significantly more arthrotomies greater than 50 mm in size and with moderate/severe gross contamination. There was one septic joint in the nonoperative group (1.5%) and 7 in the OG (5.6%). Nonoperative treatment was associated with significantly lower total charges when compared with the OG. CONCLUSIONS: Although further study may still be needed, this study suggests that small, minimally contaminated TAs with no associated fracture have a low risk of adverse complications, can safely be treated nonoperatively, and are associated with a significantly decreased cost of care. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.