Failure of humeral shaft fixation: construct characteristics.

PURPOSE: Fixation failure following open reduction and internal fixation (ORIF) of humeral shaft fractures can be a challenging complication. We aimed to identify the modes of failure and characteristics of failed fixation constructs. METHODS: We queried our institutional database for patients > 18 years old with fixation failure after ORIF with single plate and screw constructs of humeral shaft fractures from 2006 to 2017. Demographics, fracture characteristics, fixation construct design and mode of failure were recorded. RESULTS: Twenty-three failures were identified. Mean age was 55.9 years (SD 19.2 years) with 15 (65%) women. Twelve patients (52%) had midshaft fractures; the remainder had distal-third shaft (8 pts, 35%) or proximal-third shaft (3 pts, 13%) fractures. Midshaft fractures were most commonly fixed through an anterolateral approach with plates and all non-locking screws (83%), while distal-third shaft fractures were fixed with a combination of locking and non-locking screws from a posterior approach. Distal-third shaft fractures failed by plate breakage (63%) or screw pullout (38%) and all midshaft failures occurred by screw pullout proximal (92%) or distal (8%) to the fracture. Resultant varus deformity occurred in 20 (87%) fractures. CONCLUSION: Screw pullout in midshaft fractures suggests that fixation to bone was insufficient or biomechanically disadvantageous. Varus moments contribute significantly to the failure of humeral shaft fracture ORIF. Plate breakage in distal fractures suggests high concentrations of stress over a narrow working length of constructs with inadequate plate strength. Recognizing how these constructs fail can aid proper implant selection and application for humeral shaft fracture. LEVEL OF EVIDENCE: Treatment level IV.

Antegrade Fixation of Distal Metaphyseal Ulnar Shortening Osteotomy.

The ulnar shortening osteotomy (USO) is a common procedure used to treat ulnar impaction syndrome secondary to static or dynamic ulnar-positive variance. There are many described techniques for the USO. The distal metaphyseal ulnar shortening osteotomy (DMUSO) with retrograde cannulated screw fixation was described to reduce complications seen with other techniques. Biomechanical analysis of fixation constructs demonstrates 2-screw constructs are significantly stiffer than 1 screw and antegrade constructs have similar or greater stiffness when compared with retrograde constructs. Here, we describe a technique of antegrade cannulated screw fixation for DMUSO that obviates the need for the disruption of the distal radioulnar joint for intra-articular exposure of the ulnar head. Similar to the traditional retrograde DMUSO technique, this construct may also decrease the risk of delayed union, symptomatic implants associated with diaphyseal osteotomies, and disruption of triangular fibrocartilaginous complex in wafer procedures.

Is Hand Surgery in the Procedure Room Setting Associated With Increased Surgical Site Infection? A Cohort Study of 2,717 Patients in the Veterans Affairs Population.

PURPOSE: Procedure rooms (PRs) are increasingly used for hand surgeries, but few studies have directly compared surgical site infection (SSI) rates between the PR and operating room. We tested the hypothesis that procedure setting is not associated with an increased SSI incidence in the VA population. METHODS: We identified carpal tunnel, trigger finger, and first dorsal compartment releases performed at our VA institution from 1999 to 2021 of which 717 were performed in the main operating room and 2,000 were performed in the PR. The incidence of SSI, defined as signs of wound infection within 60 days of the index procedure, which was treated with oral antibiotics, intravenous antibiotics, and/or operating room irrigation and debridement, was compared. We constructed a multivariable logistic regression analysis to assess the association between procedure setting and SSI incidence, adjusting for age, sex, procedure type, and comorbidities. RESULTS: Surgical site infection incidence was 55/2,000 (2.8%) in the PR cohort and 20/717 (2.8%) in the operating room cohort. In the PR cohort, five (0.3%) cases required hospitalization for intravenous antibiotics of which two (0.1%) cases required operating room irrigation and debridement. In the operating room cohort, two (0.3%) cases required hospitalization for intravenous antibiotics of which one (0.1%) case required operating room irrigation and debridement. All other SSIs were treated with oral antibiotics alone. The procedure setting was not independently associated with SSI (adjusted odds ratio, 0.84 [95% confidence interval, 0.49, 1.48]). The only risk factor for SSI was trigger finger release (odds ratio, 2.13 [95% confidence interval, 1.32, 3.48] compared with carpal tunnel release), which was independent of setting. CONCLUSIONS: Minor hand surgeries can be performed safely in the PR without an increased rate of SSI. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Distal Metaphyseal Ulnar Shortening Osteotomy Fixation: A Biomechanical Analysis.

PURPOSE: Ulnar shortening osteotomy can be used to treat ulnar impaction syndrome and other causes of ulnar wrist pain. Distal metaphyseal ulnar shortening osteotomy (DMUSO) is one technique that has been proposed to reduce the complications seen with a diaphyseal USO or a wafer resection. However, to our knowledge, the optimal fixation construct for DMUSO has not been studied. We sought to characterize the biomechanical stiffness and rotational stability of different DMUSO constructs. METHODS: A DMUSO was performed on 40 human cadaveric ulnas using 4 different fixation constructs (10 specimens per group): one 3.0 mm antegrade screw; two 2.2 mm antegrade screws; one 3.0 mm retrograde screw; and two 2.2 mm retrograde screws. Biaxial testing using axial load and cyclical axial torque was performed until failure, defined as 10° of rotation or 2 mm displacement. Specimens were assessed for stiffness at failure. Bone density was assessed using the second metacarpal cortical percentage. RESULTS: Bone density was similar between all 4 testing groups. Of the 4 groups, the 2 antegrade screw group exhibited the highest rotational stiffness of 232 ± 102 Nm/deg. In paired analysis, this was significantly greater than 1 retrograde screw constructs. In multivariable analysis, 2-screw constructs were significantly stiffer than 1 screw and antegrade constructs were significantly stiffer than retrograde. Maximum failure torque did not differ with orientation, but 2 screws failed at significantly higher torques. CONCLUSION: Using 2 screws for DMUSO fixation constructs may provide higher stiffness and maximum failure torque, and antegrade screw constructs may provide more stiffness than retrograde constructs. CLINICAL RELEVANCE: Antegrade screw fixation using 2 screws may provide the strongest construct for DMUSO. Antegrade fixation may be preferred because it avoids violating the distal radioulnar joint capsule and articular surface of the ulna.

Radiocarpal Fusion: Indications, Technique, and Modifications.

Degenerative disorders of the wrist may affect isolated joints and inhibit normal functions of the wrist secondary to pain and stiffness. These processes that affect only the radiocarpal joint may be secondary to posttraumatic osteoarthritis, primary osteoarthritis, or rheumatoid arthritis. Radiocarpal wrist arthrodesis may help preserve some of the native wrist kinematics while alleviating pain and improving the range of motion. However, the surgeon must ensure that the patient's pathologic process primarily affects the radiocarpal articulations while relatively sparing the midcarpal articulations. Depending on the location of the pathology, isolated radiolunate or radioscapholunate arthrodesis have been described to preserve some motion in the midcarpal joint. To maximize motion in the midcarpal joint after radiocarpal arthrodesis, techniques for distal scaphoid and triquetrum excision have been described. We report patient outcomes for various techniques and describe our preferred technique for radioscapholunate arthrodesis using distal scaphoid excision.

Is Opioid-Limiting Legislation Effective for Hand Surgery Patients?

BACKGROUND: The Rhode Island State Legislature passed the Uniform Controlled Substances Act in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use. METHODS: A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as "major surgery" and carpal tunnel and trigger finger release as "minor surgery." Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods. RESULTS: A total of 1380 patients met our inclusion criteria, with 644 prelaw and 736 postlaw patients. Patients undergoing "major surgery" saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing "major surgery" in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use. CONCLUSIONS: In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after "major hand surgery." Additional research is needed to explore the association between legislation and clinical outcomes.

Total Wrist Arthroplasty Alignment and Its Potential Association with Clinical Outcomes.

Purpose There is a lack of quantitative research that describes the alignment and, more importantly, the effects of malalignment on total wrist arthroplasty (TWA). The main goal of this pilot study was to assess the alignment of TWA components in radiographic images and compare them with measures computed by three-dimensional analysis. Using these measures, we then determined if malalignment is associated with range of motion (ROM) or clinical outcomes (PRWHE, PROMIS, QuickDash, and grip strength). Methods Six osteoarthritic patients with a single type of TWA were recruited. Radiographic images, computed tomography images, and clinical outcomes of the wrists were recorded. Using posteroanterior and lateral radiographs, alignment measurements were defined for the radial and carpal components. Radiographic measurements were validated with models reconstructed from computed tomography images using Bland-Altman analysis. Biplanar videoradiography (<1mm and <1 degree accuracy) was used to capture and compute ROM of the TWA components. Linear regression assessed the associations between alignment and outcomes. Results Radiographic measures had a 95% limit-of-agreement (mean difference ± 1.96 × SD) of 3 degrees and 3mm with three-dimensional values, except for the measures of the carpal component in the lateral view. In our small cohort, wrist flexion-extension and radial-ulnar deviation were correlated with volar-dorsal tilt and volar-dorsal offset of the radial component and demonstrated a ROM increase of 3.7 and 1.6 degrees per degree increase in volar tilt, and 10.8 and 4.2 degrees per every millimeter increase in volar offset. The carpal component's higher volar tilt was also associated with improvements in patient-reported pain. Conclusions We determined metrics describing the alignment of TWA, and found the volar tilt and volar offset of the radial component could potentially influence the replaced wrist's ROM. Clinical Relevance TWA component alignment can be measured reliably in radiographs, and may be associated with clinical outcomes. Future studies must evaluate its role in a larger cohort.

Biomechanics of the Distal Radioulnar Joint During In Vivo Forearm Pronosupination.

Background Ulnar variance (UV) and center of rotation (COR) location at the level of the distal radioulnar joint (DRUJ) change with forearm rotation. Nevertheless, these parameters have not been assessed dynamically during active in vivo pronosupination. This assessment could help us to improve our diagnosis and treatment strategies. Questions/purposes We sought to (1) mathematically model the UV change, and (2) determine the dynamic COR's location during active pronosupination. Methods We used biplanar videoradiography to study DRUJ during in vivo pronation and supination in nine healthy subjects. UV was defined as the proximal-distal distance of ulnar fovea with respect to the radial sigmoid notch, and COR was calculated using helical axis of motion parameters. The continuous change of UV was evaluated using a generalized linear regression model. Results A second-degree polynomial with R 2 of 0.85 was able to model the UV changes. Maximum negative UV occurred at 38.0 degrees supination and maximum positive UV occurred at maximum pronation. At maximum pronation, the COR was located 0.5 ± 1.8 mm ulnarly and 0.6 ± 0.8 mm volarly from the center of the ulnar fovea, while at maximum supination, the COR was located 0.2 ± 0.6 mm radially and 2.0 ± 0.5 mm volarly. Conclusion Changes in UV and volar translation of the COR are nonlinear at the DRUJ during pronosupination. Clinical Relevance Understanding the dynamic nature of UV as a function of pronosupination can help guide accurate evaluation and treatment of wrist pathology where the UV is an important consideration. The dynamic behavior of COR might be useful in designing DRUJ replacement implants to match the anatomical motion.

Parenthood Among Orthopedic Surgery Residents: Assessment of Resident and Program Director Perceptions on Training.

Orthopedic residency training overlaps with common childbearing ages. The purpose of this study was to describe factors affecting male and female residents' family-planning decisions and attitudes of program directors (PDs) toward parenthood during residency. In 2018, using an anonymous survey model, residents and PDs in Accreditation Council for Graduate Medical Education-accredited orthopedic surgery programs were asked about their perceptions of parenthood on training, the availability of family-oriented services at their programs, and the effect of residency culture and policies on their decision to have children. This survey occurred in 2018. Three hundred forty-nine (76.2%) of 458 resident respondents were male and 109 (23.8%) were female. Two hundred four (49.9%) of 409 residents were unsure of their program's parental leave policy. Male residents reported taking an average of 0.8 weeks (95% CI, 0.0-4.0 weeks) of parental leave and females an average of 4.6 weeks (95% CI, 2.0-6.5 weeks) (P<.001). Female residents were more likely to report delaying having children during residency (56.73% vs 38.71%, P=.001) and were more likely to cite reputational concerns (57.63% vs 0.76%, P<.001) and effects on career opportunities (42.37% vs 7.57%, P<.001) as reasons for delaying parenthood. The most commonly cited negative effect of parenthood on residency training by PDs was reduction in off-duty educational time (15 of 29, 51.72%). Twenty-four (80%) of 30 PDs believe that training may need to be extended based on amount of maternity/paternity leave time taken off. Although parenthood during orthopedic training is common, both male and female residents reported delaying parenthood because of residency-related factors. Improved clarification of leave policies and establishment of clear guidelines for parenthood in residency may improve resident wellness. [Orthopedics. 2021;44(2):98-104.].

Measurement of the coracohumeral distance on magnetic resonance imaging in a large patient cohort.

BACKGROUND: Coracoid impingement syndrome is an increasingly recognized etiology of anterior shoulder pain. Numerus studies have documented the coracohumeral distance (CHD) as a primary or secondary measurement in symptomatic individuals, but there lacks an evaluation of CHD in a large cohort of asymptomatic individuals. The purpose of this study was to quantify a normative distribution of the CHD in a large cohort of healthy, asymptomatic subjects with no history of impingement or shoulder instability. METHODS: Incoming first-year students in the United States Military Academy were offered enrollment in this study as part of a prospective cohort to assess the normal anatomic relationships of the shoulder girdle. Magnetic resonance images were obtained, and a board-certified, fellowship-trained musculoskeletal radiologist performed measurements of the smallest distance from the coracoid to the humeral head on axial images. RESULTS: Magnetic resonance images of 714 subjects were available for analysis, including 630 males and 84 females, with a total of 1120 individual shoulders with images of adequate quality. The mean CHD for all shoulders imaged was 13.7 mm. The mean CHD in male shoulders was 13.8 mm, and in female subjects the average was 12.4 mm. CONCLUSIONS: This study is the largest of its kind to evaluate the CHD in asymptomatic, healthy shoulders to date and demonstrates a mean CHD of 13.7 mm for all subjects. This information can help to standardize "normal" ranges and act as a comparison for future work, when taken in the context of age and imaging in neutral rotation.

Gorham Disease Limited to the Left Upper Extremity Without Hand Involvement.

In this case report, we present a young female patient with a history of Gorham disease, who sustained pathologic fractures of the left radius and ulna after a low-impact fall. Massive osteolysis of the left forearm and wrist was noted on plain radiographs. The patient had had 8 previous left upper-extremity fractures without evidence of disease in any other area of the body.

Larger Initial Opioid Prescriptions Following Total Joint Arthroplasty Are Associated with Greater Risk of Prolonged Use.

BACKGROUND: The ongoing U.S. opioid epidemic threatens quality of life and poses substantial economic and safety burdens to opioid abusers and their communities, physicians, and health-care systems. Public health experts have argued that prescription opioids are implicated in this epidemic; however, opioid dosing following surgical procedures remains controversial. The purpose of this study was to evaluate the relationship between initial opioid prescribing following total hip arthroplasty (THA) and total knee arthroplasty (TKA) and the risk and quantity of long-term opioid use. METHODS: Patients undergoing THA or TKA from January 1, 2016, to June 30, 2016, were identified. Preoperative 30-day opioid and benzodiazepine exposures were evaluated using the Rhode Island Prescription Drug Monitoring Program. Cumulative morphine milligram equivalents (MMEs) in the postoperative inpatient stay, initial outpatient opioid prescription, and prescriptions filled from 31 to 90 days (prolonged use) and 91 to 150 days (chronic use) following the surgical procedure were calculated. Regression analyses evaluated the association between the initial postoperative opioid dosing and prolonged or chronic use, controlling for demographic characteristics, procedure, preoperative opioid and benzodiazepine exposures, anesthesia type, and use of a peripheral nerve block. RESULTS: A total of 507 patients (198 who underwent a THA and 309 who underwent a TKA) were identified. Increased inpatient opioid dosing (odds ratio [OR], 1.49 per 1 standard deviation increase in inpatient opioid MMEs; p = 0.001) and increased dosing in the first outpatient prescription (OR, 1.26 per 1 standard deviation increase in initial outpatient prescription MMEs; p = 0.049) were each independently associated with an increased risk of prolonged opioid use. Additionally, increased inpatient dosing postoperatively was strongly associated with a greater risk of chronic use (OR, 1.77 per 1 standard deviation increase in inpatient MMEs; p < 0.001). Among the 30% (151 of 507) of patients requiring prolonged postoperative opioids, each 1-MME increase in the initial outpatient prescription dose was associated with a 0.997-MME increase in quantity filled during the prolonged period (p < 0.001). Among the 14% (73 of 507) of patients requiring chronic opioids, every 1-MME increase in the initial outpatient dose was associated with a 1.678-MME increase in chronic opioid dosing (p = 0.008). CONCLUSIONS: Increased opioid dosing in the early postoperative period following total joint arthroplasty (TJA) is associated with an increased risk of extended opioid use. A dose-dependent relationship between initial outpatient dosing and greater future quantities consumed by those with prolonged usage and those with chronic usage was noted. This study suggests that providers should attempt to minimize inpatient and early outpatient opioid utilization following TJA. Multimodal pain management strategies may be employed to assist in achieving adequate pain control while minimizing opioid utilization. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic Surgery Faculty: An Evaluation of Gender and Racial Diversity Compared with Other Specialties.

BACKGROUND: The American Academy of Orthopaedic Surgeons has adopted the strategic goal of evolving its culture and governance to become more strategic, innovative, and diverse. Given the charge to increase diversity, a focus on assessing and increasing diversity at the faculty level may help this cause. However, an analysis of gender and racial diversity among orthopaedic faculty has not been performed. The purpose of this study was to evaluate faculty appointments for underrepresented minority (URM) and female orthopaedic surgeons. We also aim to draw comparisons between orthopaedic surgery and other specialties. METHODS: Data on gender, race, and faculty rank (clinical instructor, assistant professor, associate professor, and professor) of academic faculty for 18 specialties from 1997 to 2017 were obtained from the Association of American Medical Colleges (AAMC) Faculty Roster. Assistant professors were designated as junior faculty, whereas associate professor and professor were considered senior faculty. URMs were defined using the AAMC definition-groups having lower representation than in the general population. Regression analysis was used to evaluate and compare the change over time and to compare the change across different specialties. RESULTS: Over the 20-year study period, the number of female faculty increased (8.8% pts) but represents a lower proportion than other specialties (13.9% pts) (p = 0.029). Female orthopaedic senior faculty grew slower (7.3% pts) than other specialties (14.7% pts) (p < 0.001). There was no difference in the growth of URM faculty positions (2.0% pts) compared with all other specialties (2.4% pts) (p = 0.165). The proportion of orthopaedic URM senior faculty increased less (0.5% pts) than other specialties (2.5% pts) (p < 0.001), whereas more orthopaedic URM junior faculty were added than other specialties (2.2% pts) (p = 0.012). CONCLUSIONS: Although orthopaedic surgery has increased the representation of female and URM faculty members, it continues to lag behind other specialties. In addition, fewer female and URM orthopaedic faculty members obtained senior faculty status than other specialties. To address the differences seen in faculty diversity, a concerted effort should be made to recruit and promote more diverse faculty, given similar qualifications and capabilities. LEVEL OF EVIDENCE: Prognostic Level IV.

Has a Prescription-limiting Law in Rhode Island Helped to Reduce Opioid Use After Total Joint Arthroplasty?

BACKGROUND: In the United States, since 2016, at least 28 of 50 state legislatures have passed laws regarding mandatory prescribing limits for opioid medications. One of the earliest state laws (which was passed in Rhode Island in 2016) restricted the maximum morphine milligram equivalents provided in the first postoperative prescription for patients defined as opioid-naïve to 30 morphine milligram equivalents per day, 150 total morphine milligram equivalents, or 20 total doses. While such regulations are increasingly common in the United States, their effects on opioid use after total joint arthroplasty are unclear. QUESTIONS/PURPOSES: (1) Are legislative limitations to opioid prescriptions in Rhode Island associated with decreased opioid use in the immediate (first outpatient prescription postoperatively), 30-day, and 90-day periods after THA and TKA? (2) Is this law associated with similar changes in postoperative opioid use among patients who are opioid-naïve and those who are opioid-tolerant preoperatively? METHODS: Patients undergoing primary THA or TKA between January 1, 2016 and June 28, 2016 (before the law was passed on June 28, 2016) were retrospectively compared with patients undergoing surgery between June 1, 2017 and December 31, 2017 (after the law's implementation on April 17, 2017). The lapse between the pre-law and post-law periods was designed to avoid confounding from potential voluntary practice changes by physicians after the law was passed but before its mandatory implementation. Demographic and surgical details were extracted from a large multi-specialty orthopaedic group's surgical billing database using Current Procedural Terminology codes 27130 and 27447. Any patients undergoing revision procedures, same-day bilateral arthroplasties, or a second primary THA or TKA in the 3-month followup period were excluded. Secondary data were confirmed by reviewing individual electronic medical records in the associated hospital system which included three major hospital sites. We evaluated 1125 patients. In accordance with the state's department of health guidelines, patients were defined as opioid-tolerant if they had filled any prescription for an opioid medication in the 30-day preoperative period. Data on age, gender, and the proportion of patients who were defined as opioid tolerant preoperatively were collected and found to be no different between the pre-law and post-law groups. The state's prescription drug monitoring program database was used to collect data on prescriptions for all controlled substances filled between 30 days preoperatively and 90 days postoperatively. The primary outcomes were the mean morphine milligram equivalents of the initial outpatient postoperative opioid prescription after discharge and the mean cumulative morphine milligram equivalents at the 30- and 90-day postoperative intervals. Secondary analyses included subgroup analyses by procedure and by preoperative opioid tolerance. RESULTS: After the law was implemented, the first opioid prescriptions were smaller for patients who were opioid-naïve (mean 156 ± 106 morphine milligram equivalents after the law's passage versus 451 ± 296 before, mean difference 294 morphine milligram equivalents; p < 0.001) and those who were opioid-tolerant (263 ± 265 morphine milligram equivalents after the law's passage versus 534 ± 427 before, mean difference 271 morphine milligram equivalents; p < 0.001); however, for cumulative prescriptions in the first 30 days postoperatively, this was only true among patients who were previously opioid-naïve (501 ± 416 morphine milligram equivalents after the law's passage versus 796 ± 597 before, mean difference 295 morphine milligram equivalents; p < 0.001). Those who were opioid-tolerant did not have a decrease in the cumulative number of 30-day morphine milligram equivalents (1288 ± 1632 morphine milligram equivalents after the law's passage versus 1398 ± 1274 before, mean difference 110 morphine milligram equivalents; p = 0.066). CONCLUSIONS: The prescription-limiting law was associated with a decline in cumulative opioid prescriptions at 30 days postoperatively filled by patients who were opioid-naïve before total joint arthroplasty. This may substantially impact public health, and these policies should be considered an important tool for healthcare providers, communities, and policymakers who wish to combat the current opioid epidemic. However, given the lack of a discernible effect on cumulative opioids filled from 30 to 90 days postoperatively, further investigations are needed to evaluate more effective policies to prevent prolonged opioid use after total joint arthroplasty, particularly in patients who are opioid-tolerant preoperatively. LEVEL OF EVIDENCE: Level III, therapeutic study.

Opioid-Limiting Regulation: Effect on Patients Undergoing Knee and Shoulder Arthroscopy.

PURPOSE: To determine the effect prescription-limiting legislation passed in Rhode Island has had on opioids prescribed following arthroscopic knee and shoulder surgery at various time points, up to 90 days postoperatively. METHODS: All patients undergoing the 3 most common arthroscopic procedures at our institution (anterior cruciate ligament reconstruction, partial meniscectomy, and rotator cuff repair) were included. Patients were selected from 2 6-month study periods (prepassage and postimplementation of the law). The state's Prescription Drug Monitoring Program database was queried for controlled substances filled in the perioperative period (from 30 days preoperatively to 90 days postoperatively). Multiple logistic regressions were used to identify predictors of chronic (>30 days) opioid use. RESULTS: The morphine milligram equivalents (MMEs) prescribed in the initial postoperative script decreased from 319.04 (∼43 5-mg oxycodone tablets) in the prepassage to 152.45 MMEs (∼20 5-mg oxycodone tablets) in the postimplementation group (P < .001). The total MMEs filled in the first 30 days decreased from 520.93 to 299.94 MMEs (∼70 to ∼40 5-mg oxycodone tablets) (P < .001). MMEs filled between 30 and 90 days fell by 22.5% for all patients in this study; however, this change was not statistically significant (P = .263). Preoperative opioid use (odds ratio, 10.85; P < .001) and preoperative benzodiazepine use (odds ratio, 2.13; P = .005) predicted chronic opioid use postoperatively. CONCLUSIONS: State opioid-limiting legislation reduced cumulative MMEs following arthroscopic knee and shoulder surgery in the first 30 days. Further research assessing the impact of this legislation on postoperative pain control, patient satisfaction, and functional outcomes following surgery is warranted. LEVEL OF EVIDENCE: Level III, case-control study.

Opioid-limiting legislation associated with decreased 30-day opioid utilization following anterior cervical decompression and fusion.

BACKGROUND CONTEXT: Since 2016, 35 of 50 US states have passed opioid-limiting laws. The impact on postoperative opioid prescribing and secondary outcomes following anterior cervical discectomy and fusion (ACDF) remains unknown. PURPOSE: To evaluate the effect of opioid-limiting regulations on postoperative opioid prescriptions, emergency department (ED) visits, unplanned readmissions, and reoperations following elective ACDF. STUDY DESIGN/SETTING: Retrospective review of prospectively-collected data. PATIENT SAMPLE: Two hundred and eleven patients (101 pre-law, 110 post-law) undergoing primary elective 1-3 level ACDF during specified pre-law (December 1st, 2015-June 30th, 2016) and post-law (June 1st, 2017-December 31st, 2017) study periods were evaluated. METHODS: Demographic, medical, surgical, clinical, and pharmacological data was collected from all patients. Total morphine milligram equivalents (MMEs) filled was compared at 30-day postoperative intervals, before and after stratification by preoperative opioid-tolerance. Thirty- and 90-day ED visit, readmission, and reoperation rates were calculated. Independent predictors of increased 30-day and chronic (>90 day) opioid utilization were evaluated. RESULTS: Demographic, medical, and surgical factors were similar pre-law versus post-law (all p>.05). Post-law, ACDF patients received fewer opioids in their first postoperative prescription (26.65 vs. 62.08 pills, p<.001; 202.23 vs. 549.18 MMEs, p<.001) and in their first 30 postoperative days (cumulative 30-day MMEs 444.14 vs. 877.87, p<.001). Furthermore, post-law reductions in cumulative 30-day MMEs were seen among both opioid-naïve (363.54 vs. 632.20 MMEs, p<.001) and opioid-tolerant (730.08 vs. 1,122.90 MMEs, p=.022) patient populations. Increased 30-day opioid utilization was associated with surgery in the pre-law period, preoperative opioid exposure, preoperative benzodiazepine exposure, and number of levels fused (all p<.05). Chronic (>90 day) opioid requirements were associated with preoperative opioid exposure (odds ratio 4.42, p<.001) but not with pre/post-law status (p>.05). Pre- and post-law patients were similar in terms of 30- or 90-day ED visits, unplanned readmissions, and reoperations (all p>.05). CONCLUSIONS: Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations for pain.

Opioid-Limiting Legislation Associated With Reduced Postoperative Prescribing After Surgery for Traumatic Orthopaedic Injuries.

OBJECTIVES: To evaluate opioid-prescribing patterns after surgery for orthopaedic trauma before and after implementation of opioid-limiting mandates in one state. DESIGN: Retrospective review. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Seven hundred fifty-three patients (297 pre-law and 456 post-law) undergoing isolated fixation for 6 common fracture patterns during specified pre-law (January 1, 2016-June 28, 2016) and post-law (June 01, 2017-December 31, 2017) study periods. Polytrauma patients were excluded. INTERVENTION: Implementation of statewide legislation establishing strict limits on initial opioid prescriptions [150 total morphine milligram equivalents (MMEs), 30 MMEs per day, or 20 total doses]. MAIN OUTCOME MEASUREMENTS: Initial opioid prescription dose, cumulative MMEs filled by 30 and 90 days postoperatively. RESULTS: Pre-law and post-law patient groups did not differ in terms of age, sex, opioid tolerance, recent benzodiazepine use, or open versus closed fracture pattern (P > 0.05). The post-law cohort received significantly less opioids (363.4 vs. 173.6 MMEs, P < 0.001) in the first postoperative prescription. Furthermore, the post-law group received significantly less cumulative MMEs in the first 30 postoperative days (677.4 vs. 481.7 MMEs, P < 0.001); This included both opioid-naïve (633.7 vs. 478.1 MMEs, P < 0.001) and opioid-tolerant patients (1659.2 vs. 880.0 MMEs, P = 0.048). No significant difference in opioid utilization between pre- and post-law groups was noted after postoperative day 30. Independent risk factors for prolonged (>30 days) postoperative opioid use included male gender (odds ratio 2.0, 95% confidence interval 1.4-2.9, P < 0.001) and preoperative opioid use (odds ratio 5.1, 95% confidence interval 2.4-10.5, P < 0.001). CONCLUSIONS: Opioid-limiting legislation is associated with a statistically and clinically significant reduction in initial and 30-day opioid prescriptions after surgery for orthopaedic trauma. Preoperative opioid use and male gender are independently associated with prolonged postoperative opioid use in this population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mandatory Prescription Limits and Opioid Utilization Following Orthopaedic Surgery.

BACKGROUND: Since 2016, over half of the states in the United States have passed mandatory limits on opioid prescriptions, with limited evidence of effectiveness. In this study, we evaluated postoperative opioid prescriptions following orthopaedic surgery before and after the implementation of one of the earliest such laws. METHODS: Following the implementation of state legislation limiting opioid prescriptions for opioid-naïve patients, 2 patient cohorts (pre-law and post-law) were compared. Both opioid-tolerant and opioid-naïve patients undergoing 6 common orthopaedic procedures (total knee arthroplasty, rotator cuff repair, anterior cruciate ligament reconstruction, open reduction and internal fixation for a distal radial fracture, open reduction and internal fixation for an ankle fracture, and lumbar discectomy) met inclusion criteria. Patients undergoing >1 primary procedure in the same operative session were excluded. All benzodiazepine and opioid prescriptions from 30 days before to 90 days after the surgical procedure were recorded. Logistic regression was performed to determine risk factors for prolonged postoperative opioid use. RESULTS: In this study, 836 pre-law patients were compared with 940 post-law patients. The 2 groups were similar with regard to demographic variables, baseline opioid tolerance, and recent benzodiazepine use (all p > 0.05). Post-law, for all patients, there were decreases in the initial prescription pill quantity (49.65 pills pre-law and 22.08 pills post-law; p < 0.001) and the total morphine milligram equivalents (MMEs) (417.67 MMEs pre-law and 173.86 MMEs post-law; p < 0.001), regardless of patient preoperative opioid exposure (all p < 0.001). Additionally, there were decreases in the mean cumulative 30-day MMEs (790.01 MMEs pre-law and 524.61 MMEs post-law; p < 0.001) and the 30 to 90-day MMEs (243.51 MMEs pre-law and 208.54 MMEs post-law; p = 0.008). Despite being specifically exempted from the legislation, opioid-tolerant patients likewise experienced a significant decrease in cumulative 30-day MMEs (1,304.08 MMEs pre-law and 1,015.19 MMEs post-law; p = 0.0016). Opioid-tolerant patients required more postoperative opioids at all time points and had an increased likelihood of prolonged opioid use compared with those who were opioid-naïve preoperatively (odds ratio, 8.73 [95% confidence interval, 6.21 to 12.29]). CONCLUSIONS: A clinically important and significant reduction in opioid utilization after orthopaedic surgery was observed following the implementation of statewide mandatory opioid prescription limits. CLINICAL RELEVANCE: After implementation of mandatory opioid prescription regulations, a clinically important and significant decline in the volume of opioids dispensed in the short term and intermediate term following orthopaedic surgery was observed. Furthermore, important clinical predictors of prolonged postoperative opioid use, including preoperative opioid use and preoperative benzodiazepine use, were identified. These findings have important implications for public health, as well as the potential to influence policymakers and to change practice among orthopaedic surgeons.

Suture Suspension Arthroplasty for the Treatment of Thumb Carpometacarpal Arthritis.

PURPOSE: Most studies have demonstrated little difference in the outcome of the various techniques proposed for the surgical treatment of thumb carpometacarpal (CMC) arthritis. However, the difficulty and time required to perform each technique vary widely. In addition, the introduction of recent implants has increased the cost of the overall procedure. We hypothesize that using a simple, yet stable, suture suspension technique without tendon interposition or ligament reconstruction yields similar results to conventional approaches with less operative time. METHODS: Three hundred twenty consecutive patients underwent thumb CMC arthroplasty by trapezial excision and metacarpal suspension using #2 high-strength orthopedic suture locked weave alone passed from the distal most abductor pollicis longus and flexor carpi radialis insertions without K-wire fixation or tendon transfer. Average duration of preoperative symptoms was 17.8 months. Patient radiographs were graded for arthritis severity and a visual analog scale (VAS) pain score (scale 0-10) obtained. Postoperative clinical and radiological follow-up averaged 5.4 years (minimum, 24 months). RESULTS: The average age at surgery was 57.3 years and there were 221 women (243 procedures) and 65 men (77 procedures). Average total operative time was 23.4 minutes. The dominant hand was involved in 52% of patients. All had prior treatment including orthoses and nonsteroidal anti-inflammatory drugs with 312 having had at least 1 steroid injection. Five patients had stage 1, 134 had stage 2, 164 had stage 3, and 17 had stage 4 disease on radiographs. Average trapezial space height on final follow-up radiographs was 0.8 cm. Two patients had complete trapezial space collapse and required a revision procedure. The average VAS score was 0.6 with pain eliminated in 269 thumbs, minimal in 49, and unchanged/worse in 2. All patients that were employed at the time of surgery returned to work at an average of 2.3 months (range, 3-16 weeks). CONCLUSIONS: Suture suspension thumb CMC arthroplasty provides comparable clinical results and several advantages over many current techniques that are described in the literature. The advantages include shortened operative time, inherent stability of the thumb metacarpal height, and no necessity for K-wire fixation, tendon transfers, or implants. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Risk Factors for 30-Day Complications After Thumb CMC Joint Arthroplasty: An American College of Surgeons National Surgery Quality Improvement Program Study.

BACKGROUND: The first carpometacarpal (CMC) joint is a common site of osteoarthritis, with arthroplasty being a common procedure to provide pain relief and improve function with low complications. However, little is known about risk factors that may predispose a patient for postoperative complications. METHODS: All CMC joint arthroplasty from 2005 to 2015 in the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database were identified. Bivariate testing and multiple logistic regressions were performed to determine which patient demographics, surgical variables and medical comorbidities were significant predictors for complications. These included wound related, cardiopulmonary, neurological and renal complications, return to the operating room (OR) and readmission. RESULTS: A total of 3344 patients were identified from the database. Of those, 45 patients (1.3%) experienced a complication including wound issues (0.66%), return to the OR (0.15%) and readmission (0.27%) amongst others. When performing bivariate analysis, age over 65, American Society of Anesthesiologists (ASA) Class, diabetes and renal dialysis were significant risk factors. Multiple logistic regression after adjusting for confounding factors demonstrated that insulin-dependent diabetes and ASA Class 4 had a strong trend while renal dialysis was a significant risk factor. CONCLUSIONS: CMC arthroplasty has a very low overall complication rate of 1.3% and wound complication rate of 0.66%. Diabetes requiring insulin and ASA Class 4 trended towards significance while renal dialysis was found to be a significant risk factors in logistic regression. This information may be useful for preoperative counseling and discussion with patients who have these risk factors.