Diagnosis of Posterior and Combined-Type Shoulder Instability: A 10-Year Cross-sectional Study From a Single Military Base.

Background: Large variations exist in the reported frequency and etiology of posterior and combined shoulder instability in the active-duty military population. Purpose: To compare imaging and clinical examination findings as well as reoperation rates between active-duty military patients who underwent surgery for anterior, posterior, and combined-type shoulder instability. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review was conducted on patients treated surgically for shoulder instability from a single military base from January 2010 to December 2019. Each case was characterized as isolated anterior, isolated posterior, or combined, according to arthroscopic findings. Information was collected on patient characteristics, history of trauma, time to surgery, associated pathological findings, and survivorship at a minimum 2-year follow-up. Results: Overall, 416 patients (n = 394 men; n = 22 women), with a mean age of 29.1 years, underwent primary shoulder stabilization surgery during the study period. There were 158 patients (38%) with isolated anterior instability, 139 (33%) with isolated posterior instability, and 119 (29%) with combined instability. A history of trauma was more prevalent with isolated anterior instability (129 [81.7%]) than with either isolated posterior (95 [68.4%]) or combined instability (73 [61.3%]) (P = .047 and P = .001, respectively). Patients with anterior instability were significantly more likely to be diagnosed on the preoperative physical examination when compared with patients with posterior instability (93% vs 79.1%; P < .001) or combined instability (93% vs 75.6%; P < .001) and were also more likely to have a discrete labral tear detected on a preoperative magnetic resonance arthrogram than patients with posterior instability (82.9% vs 63.3%; P < .001). There was no significant difference in the rate of medical discharge or recurrent instability requiring reoperation between groups. Conclusion: The study findings indicated that young, active-duty military patients are at increased risk for isolated posterior and combined-type shoulder instability, with posterior and combined instability collectively accounting for over 60% of instability cases in this cohort. Orthopaedic surgeons should be aware of instability when evaluating and treating young, active-duty military patients with shoulder pain, even in the absence of diagnostic physical examinations or imaging findings.

Opioid Use and Associated Patient Satisfaction With Pain Control After Endoscopic Surgery and Robotic-Assisted Radical Prostatectomy.

OBJECTIVE: To evaluate patient reported measures in patients undergoing endourologic procedures and robotic assisted radical prostatectomy (RARP) to demonstrate the efficacy of non-opioid postoperative pain management strategies. MATERIALS AND METHODS: A prospective cohort study performed at an academic medical center included a patient telephone questionnaire and chart review. Opioid prescriptions, opioid use, and patient reported outcomes were recorded. Bivariate analyses were used to compare patients who did and did not use opioids in the RARP cohort while overall trends were reported for the endourologic procedures. RESULTS: Of the 68 patients undergoing endoscopic intervention, 14 (21%) were prescribed an opioid and 6 (9%) reported any opioid use. 58 (85%) reported their pain was very well or well controlled while 9 reported their pain was poorly controlled. 59 (87%) were satisfied or very satisfied with their pain control. Fifty-three (93%) of the 57 patients undergoing RARP received an opioid prescription and only 23 reported any opioid use. All but 1 patient reported that their pain was well or very well controlled and almost all (54) of the patients were satisfied with their level of pain control. 36 (63%) reported their pain was less than expected while only 7 (12%) reported it was more than expected. CONCLUSION: Most patients undergoing endourologic procedures do not use postoperative opioids and report favorable outcomes regarding their pain control. Similarly, after RARP, most patients do not use opioids even when they are prescribed and are satisfied with their pain control.

Patient Factors Associated with High Opioid Consumption after Common Surgical Procedures Following State-Mandated Opioid Prescription Regulations.

BACKGROUND: State regulations have decreased prescribed opioids with more than 25% of patients abstaining from opioids. Despite this, 2 distinct populations of patients exist who consume "high" or "low" amounts of opioids. The aim of this study was to identify factors associated with postoperative opioid use after common surgical procedures and develop an opioid risk score. STUDY DESIGN: Patients undergoing 35 surgical procedures from 7 surgical specialties were identified at a 620-bed tertiary care academic center and surveyed 1 week after discharge regarding opioid use and adequacy of analgesia. Electronic medical record data were used to characterize postdischarge opioids, complications, demographics, medical history, and social factors. High opioid use was defined as >75th percentile morphine milligram equivalents for each procedure. An opioid risk score was calculated from factors associated with opioid use identified by backward multivariate logistic regression analysis. RESULTS: A total of 1,185 patients were enrolled between September 2017 and February 2019. Bivariate analyses revealed patient factors associated with opioid use including earlier substance use (p < 0.001), depression (p = 0.003), anxiety (p < 0.001), asthma (p = 0.006), obesity (p = 0.03), migraine (p = 0.004), opioid use in the 7 days before surgery (p < 0.001), and 31 Clinical Classifications Software Refined classifications (p < 0.05). Significant multivariates included: insurance (p = 0.005), employment status (p = 0.005), earlier opioid use (odds ratio [OR] 2.38 [95% CI 1.21 to 4.68], p = 0.01), coronary artery disease (OR 0.38 [95% CI 0.16 to 0.86], p = 0.02), acute pulmonary embolism (OR 9.81 [95% CI 3.01 to 32.04], p < 0.001), benign breast conditions (OR 3.42 [95% CI 1.76 to 6.64], p < 0.001), opioid-related disorders (OR 6.67 [95% CI 1.87 to 23.75], p = 0.003), mental and substance use disorders (OR 3.80 [95% CI 1.47 to 9.83], p = 0.006), headache (OR 1.82 [95% CI 1.24 to 2.67], p = 0.002), and previous cesarean section (OR 5.10 [95% CI 1.33 to 19.56], p = 0.02). An opioid risk score base was developed with an area under the curve of 0.696 for the prediction of high opioid use. CONCLUSIONS: Preoperative patient characteristics associated with high opioid use postoperatively were identified and an opioid risk score was derived. Identification of patients with a higher need for opioids presents an opportunity for improved preoperative interventions, the use of nonopioid analgesic therapies, and alternative therapies.

Patients' Experience With Opioid Pain Medication After Discharge From Surgery: A Mixed-Methods Study.

BACKGROUND: Decreasing the number of prescription opioids has been a leading strategy in combating the opioid epidemic. In Vermont, statewide and institutional policies have affected prescribing practices, resulting in a 40% decrease in postoperative opioid prescribing. The optimal approach to postoperative opioid prescribing remains unknown. In this study, we describe patients' experience with pain control 1 wk after discharge from surgery. MATERIALS AND METHODS: We assessed patients' experience using a telephone questionnaire, 1-wk after discharge after undergoing common surgical procedures between 2017 and 2019 at an academic medical center (n = 1027). Scaled responses regarding pain control, opioids prescribed, and opioids used (response rate 96%) were analyzed using a mixed-methods approach; open-ended patient responses to questions regarding whether the number of opioids prescribed was "correct" were analyzed using qualitative content analysis. RESULTS: One week after discharge, 96% of patients reported that their pain was well controlled. When asked whether they received the correct number of opioid pills postoperatively, qualitative analysis of patient responses yielded the following six themes: (1) I had more than I needed, but not more than I wanted; (2) Rationed medication; (3) Medication was not effective; (4) Caution regarding risks of opioids; (5) Awareness of the public health concerns; and (6) Used opioids from a prior prescription. CONCLUSIONS: Patient-reported pain control after common surgical procedures was excellent. However, patients are supportive of receiving more pain medications than they actually use, and they fear that further restrictions may prevent them or others from managing pain adequately. Understanding the patients' perspective is important for surgical education and improving discharge protocols.