Association between timing of kyphoplasty and opioid prescribing risk after vertebral fracture.

OBJECTIVE: Approximately 550,000 Americans experience vertebral fracture annually, and most receive opioids to treat the resulting pain. Kyphoplasty of the fractured vertebra is a procedural alternative that may mitigate risks of even short-term opioid use. While reports of kyphoplasty's impact on pain scores are mixed, no large-scale data exist regarding opioid prescribing before and after the procedure. This study was conducted to determine whether timing of kyphoplasty following vertebral fracture is associated with duration or intensity of opioid prescribing. METHODS: This retrospective cohort study used 2001-2014 insurance claims data from a single, large private insurer in the US across multiple care settings. Patients were adults with vertebral fractures who were prescribed opioids and underwent balloon-assisted kyphoplasty within 4 months of fracture. Opioid overdose risk was stratified by prescribed average daily morphine milligram equivalents using CDC guidelines. Filled prescriptions and risk categories were evaluated at baseline and 90 days following kyphoplasty. RESULTS: Inclusion criteria were met by 7119 patients (median age 77 years, 71.7% female). Among included patients, 3505 (49.2%) were opioid naïve before fracture. Of these patients, 31.1% had new persistent opioid prescribing beyond 90 days after kyphoplasty, and multivariable logistic regression identified kyphoplasty after 8 weeks as a predictor (OR 1.34, 95% CI 1.02-1.76). For patients previously receiving opioids, kyphoplasty > 4 weeks after fracture was associated with persistently elevated prescribing risk (OR 1.84, 95% CI 1.23-2.74). CONCLUSIONS: New persistent opioid prescribing occurred in nearly one-third of patients undergoing kyphoplasty after vertebral fracture, although early treatment was associated with a reduction in this risk. For patients not naïve to opioids before fracture diagnosis, early kyphoplasty was associated with less persistent elevation of opioid overdose risk. Subsequent trials must compare opioid use by vertebral fracture patients treated via operative (kyphoplasty) and nonoperative (ongoing opioid) strategies before concluding that kyphoplasty lacks value, and early referral for kyphoplasty may be appropriate to avoid missing a window of efficacy.

Long-term results of cholecystectomy for biliary dyskinesia: outcomes and resource utilization.

BACKGROUND: The purpose of this study is to describe a cohort of pediatric patients undergoing cholecystectomy for biliary dyskinesia (BD) and characterize postoperative resource utilization. METHODS: Single-institution, retrospective chart review of pediatric patients after cholecystectomy for BD was done. Patient demographics and clinical characteristics as well as operative details and postoperative interventions were abstracted. Telephone follow-up was performed to identify persistent symptoms, characterize the patient experience, and quantify postoperative resource utilization. RESULTS: Forty-nine patients were included. Twenty-two patients (45%) were seen postoperatively by a gastroenterologist, of which, only 32% were known to the gastroenterologist before surgery. Postoperative studies included 13 abdominal ultrasounds for persistent pain, 13 esophagogastroduodenoscopies, five endoscopic retrograde cholangiopancreatographies (ERCPs), one endoscopic ultrasound, one magnetic resonance cholangiopancreaticogram, and five colonoscopies. Of the patients with additional diagnostic testing postoperatively, one had mild esophagitis, three had sphincter of Oddi dysfunction, and one was suspected to have inflammatory bowel disease. Telephone survey response rate was 47%. Among respondents, 65.2% reported ongoing abdominal pain, nausea, or vomiting at an average of 26 mo after operation. Of note, all patients who underwent postoperative ERCP with sphincterotomy reported symptom relief following this procedure. CONCLUSIONS: Relief of symptoms postoperatively in pediatric patients with BD is inconsistent. Postoperative studies, though numerous, are of low diagnostic yield and generate high costs. These findings suggest that the initial diagnostic criteria and treatment algorithm may require revision to better predict symptom improvement after surgery. Improvement seen after ERCP/sphincterotomy is anecdotal but appears to merit further investigation.

Does a fixed offset hemiarthroplasty implant have any effect on pain and function in patients with a femoral neck fracture?

INTRODUCTION: Hip hemiarthroplasty is the commonest operation performed for a displaced intracapsular hip fracture in the UK. A variety of implants including fixed offset prostheses are utilised. There has been no study investigating the relationship between restoration of femoral offset and long term pain and function. This study aims to evaluate long-term pain and functional outcomes of a fixed offset hemiarthroplasty implant (the Exeter trauma system). PATIENTS AND METHODS: All patients were retrospectively reviewed from a prospectively collected database. In all, 338 patients met the criteria for evaluation. Patients native offset were calculated from the contralateral hip. Pain and functional outcomes were assessed using validated outcome measures. RESULTS: There were no differences found across a range of natural offsets for long-term pain and functional recovery. CONCLUSION: Our experience with the Exeter trauma system suggests that a 40 mm offset implant is a good standard offset to use.

Three-Dimensional Computed Tomographic Assessment of Temporomandibular Joint Stability After Orthognathic Surgery.

PURPOSE: Ensuring that the condyle is appropriately positioned and that positional changes are minimal is considered crucial for the temporomandibular joint (TMJ) to function without symptoms after orthognathic surgery. The purposes of this study were to evaluate condylar changes after surgery and to examine the association between these changes and TMJ symptoms. PATIENTS AND METHODS: A retrospective cohort study was conducted in patients with mandibular prognathism who underwent orthognathic surgery. Linear and angular changes in the positioning of the condyle were measured by superimposing 3-dimensional computed tomograms taken before surgery and 3 months after surgery. Clinical symptoms of TMJ pain and sound were recorded at 3, 6, 9, and 12 months after surgery. Possible associations between TMJ symptoms and clinical variables, such as postoperative condylar changes, were investigated using multiple logistic regression analysis. RESULTS: Linear condylar displacement after orthognathic surgery occurred predominantly in the anterior, medial, and inferior directions, with minimal changes (<1 mm) observed. Most angular condylar changes were smaller than 4° and occurred in the inward direction in the axial plane and the posterior direction in the sagittal plane. The best predictor of postoperative TMJ signs and symptoms was the preoperative status of TMJ signs and symptoms. Neither linear nor angular condylar displacement showed a relevant influence on postoperative pain and sound. CONCLUSIONS: Within the ranges of linear (<1 mm) and angular (<4°) condylar displacement noted in this study, displacement was not associated with postoperative TMJ pain and sound.

Are routine postoperative radiographs necessary during the first year after posterior spinal fusion for idiopathic scoliosis? A retrospective cohort analysis of implant failure and surgery revision rates.

BACKGROUND: Radiographs are routinely obtained at postoperative visits during the first year after posterior spinal fusion (PSF) for idiopathic scoliosis (IS). The goal of this study was to determine how often radiographic findings change postoperative care. METHODS: A total of 227 consecutive patients aged 10 to 21 years who underwent surgery for IS at our institution from 2004 to 2010 were identified. Charts were reviewed to determine the frequency of the following clinical symptoms during the first year after surgery: pain greater than expected, implant prominence, and sensory/motor disturbance. Radiographs were reviewed to identify implant failure and curve change. Logistic regression analysis was used to identify clinical symptoms associated with treatment deviation. RESULTS: During the first year after surgery, an average of 6 (range, 2 to 12) radiographs were obtained from patients during an average of 3 (range, 2 to 10) follow-up visits. Pain (14%) was the most common symptom. Neurologic symptoms (13%) and implant prominence (4%) were less common. Implant failure was identified in 4 subjects (2%), of which 3 required revision surgery. The incidence of revision surgery was 2.9/1000 radiographs (95% confidence interval, 0.6-8.3). Curve progression >5 degrees in the uninstrumented curve occurred in 2 patients (0.9%). Curve progression did not result in a change in treatment for any of the patients. Pain was the only clinical symptom associated with implant failure (P=0.0047). 169/227 patients did not have any symptoms and only one of these underwent revision surgery. The sensitivity of a clinical test, which uses the presence of pain to guide the need for radiographic evaluation and rule out implant failure, was 75%, specificity 87%, positive predictive value 10%, and negative predictive value 99.5%. CONCLUSIONS: After obtaining baseline postoperative radiographs, additional radiographs during the first year after surgery for IS may not be required in the absence of clinical symptoms. Reducing the number of radiographs taken during the first year after surgery for IS in patients without symptoms can reduce radiation exposure to patients and health care costs without affecting treatment. LEVEL OF EVIDENCE: Level II, Diagnostic Study.

Assessment of cup orientation in hip resurfacing: a comparison of TraumaCad and computed tomography.

PURPOSE: The orientation of the acetabular component in metal-on-metal hip resurfacing arthroplasty affects wear rate and hence failure. This study aimed to establish if interpretation of pelvic radiographs with TraumaCad software can provide a reliable alternative to CT in measuring the acetabular inclination and version. METHODS: TraumaCad was used to measure the acetabular orientation on AP pelvis radiographs of 14 painful hip resurfacings. Four orthopaedic surgeons performed each measurement twice. These were compared with measurements taken from CT reformats. The correlation between TraumaCad and CT was calculated, as was the intra- and inter-observer reliability of TraumaCad. RESULTS: There is strong correlation between the two techniques for the measurement of inclination and version (p <0.001). Intra- and inter-observer reliability of TraumaCad measurements are good (p <0.001). Mean absolute error for measurement of inclination was 2.1°. TraumaCad underestimated version compared to CT in 93% of cases, by 12.6 degrees on average. CONCLUSIONS: When assessing acetabular orientation in hip resurfacing, the orthopaedic surgeon may use TraumaCad in the knowledge that it correlates well with CT and has good intra- and inter-observer reliability but underestimates version by 12° on average.

Ultrasound in obstetric anaesthesia: a review of current applications.

Ultrasound equipment is increasingly used by non-radiologists to perform interventional techniques and for diagnostic evaluation. Equipment is becoming more portable and durable, with easier user-interface and software enhancement to improve image quality. While obstetric utilisation of ultrasound for fetal assessment has developed over more than 40years, the same technology has not found a widespread role in obstetric anaesthesia. Within the broader specialty of anaesthesia; vascular access, cardiac imaging and regional anaesthesia are the areas in which ultrasound is becoming increasingly established. In addition to ultrasound for neuraxial blocks, these other clinical applications may be of value in obstetric anaesthesia practice.

Utility of pathologic evaluation following removal of explanted orthopaedic internal fixation hardware.

This report questions the cost and effectiveness of routinely sending explanted hardware to pathology for evaluation. Forty-six consecutive patients who had symptomatic hardware removed were enrolled in this study. Pathology reports following hardware removal were obtained, and charts were reviewed for these patients. The pathology department was contacted for related departmental procedure codes, and hospital billing records were obtained regarding the cost of the procedure. In all cases, the pathology reports gave the gross diagnosis of "hardware" and the gross description included the measurements of the internal fixation hardware removed. In no case did the report alter the plan of the attending physician. The healthcare system may benefit by subspecialty review of the current practice of sending internal fixation devices to pathology for evaluation. We recommend a single radiographic view along with proper documentation in the postoperative report to confirm the removal of internal fixation hardware in lieu of pathologic evaluation.

Stapled hemorrhoidectomy--cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months.

PURPOSE: Stapled hemorrhoidectomy is performed without leaving painful perianal wounds. The aim of this study was to assess any benefits, compared with a conventional open diathermy technique. METHODS: A total of 119 consecutive patients with prolapsed irreducible hemorrhoids were randomly assigned (conventional open diathermy technique = 62; stapled hemorrhoidectomy = 57). Preoperative fecal incontinence scoring, anorectal manometry, and endoanal ultrasound were performed. Postoperatively, these were repeated at up to three months with pain scores, analgesic requirements, quality of life assessment, and total related medical costs. RESULTS: Conventional open diathermy technique was quicker to perform (mean, 11.4 (standard error of the mean, 0.9) vs. 17.6 (3.1) minutes). Hospitalization was similar, but conventional open diathermy technique patients felt more pain during defecation (5.1 (0.4) vs. 2.6 (0.4); P < 0.005) at two weeks, and analgesic requirements were more for up to six weeks (P < 0.05). Up to the latter, 85.5 percent conventional open diathermy technique wounds remained unhealed, with more bleeding (33 (53.2 percent) vs. 19 (33.3 percent); P < 0.05) and pruritus (27 (43.5 percent) vs. 9 (15.8 percent); P < 0.05). Total complication rates were similar (conventional open diathermy technique 16 (25.8 percent) vs. stapled hemorrhoidectomy 10 (17.5 percent)), including mild strictures and bleeding in both groups. Minor incontinence occurred postoperatively in two conventional open diathermy technique and two stapled hemorrhoidectomy patients at six weeks. Endoanal ultrasound internal anal sphincter defects were found in the incontinent conventional open diathermy technique patients, but were asymptomatic in another one conventional open diathermy technique and one stapled hemorrhoidectomy. Only one patient (conventional open diathermy technique with internal sphincter defect) remained incontinent at three months. Changes between preoperative and postoperative anorectal manometry were similar in the two groups. Patients' satisfaction scores and quality of life assessments were also similar. Conventional open diathermy technique patients resumed work later (mean 22.9 (1.8) vs. 17.1 (1.9) days; P < 0.05), but the total costs incurred were less ($921.17 (16.85) vs. $1,283.09 (31.59); P < 0.005). CONCLUSIONS: Stapled hemorrhoidectomy is a safe and effective option in treating irreducible prolapsed piles. It is more expensive but less painful, with less time needed off work. Nonetheless, long-term results are still awaited.

Technetium 99Tcm pyrophosphate scanning in the assessment of the painful hip prosthesis.

Technetium 99Tcm pyrophosphate bone scans were done on 35 patients who complained of persistent hip following total hip replacement. The scans of six patients were normal and the symptoms of these patients either resolved (three) or greatly improved (three) without further treatment. Twenty-nine patients had abnormal scans. Seventeen of these were due to infection or loosening of the prosthesis. Paget's disease of bone, protrusion of the prosthesis and heterotopic ossification also caused scan abnormalities. These causes could not be distinguished from one another on the scan. A radiograph of the hip is essential for interpreting the scan correctly. Scanning of the painful hip prosthesis helps to detect patients in whom serious complications are present or are likely to develop.