Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study.

BACKGROUND: Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear. METHODS: Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool. RESULTS: Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME. CONCLUSIONS: Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.

Critical Risk Factors for Opioid Demand after Pelvic and Acetabular Fracture Surgery.

The characteristics that contribute to opioid demand in pelvic and acetabular fracture surgery are not well understood. We hypothesize that fracture pattern and psychiatric comorbidities will be associated with increased opioid demand. This study evaluated perioperative opioid prescription filling in 743 patients undergoing operative fixation of pelvic and acetabular injuries. Multivariable linear and logistic regression models were used to evaluate associations between baseline factors and opioid outcomes. Patients filled prescriptions for 111.2, 89.3, and 200.3 oxycodone 5-mg pills at the 1-month preop to 90-days postop, 3-months postop to 1-year postop, and 1-month preop to 1-year postop timeframes. Operatively treated wall, transverse and two-column acetabular fractures were associated with the highest opioid demand. Drug abuse and pre-injury opioid use were the primary non-surgical drivers of opioid demand. Acetabular fractures, pre-injury opioid filling, and drug abuse were the main risk factors for increased perioperative opioid prescription filling. Level of Evidence: Level III, retrospective, prognostic cohort study. (Journal of Surgical Orthopaedic Advances 32(1):041-046, 2023).

New Developments in Hip Fracture Treatment to Reduce Morbidity and Mortality.

There have been major changes in the treatment of various hip fracture patterns in the proximal femur. The orthopaedic surgeon should be up to date on device management, current guidelines, and techniques in the care of hip fracture patterns.

Evaluation of the safety and efficacy of a new hemostatic powder using a quantitative surface bleeding severity scale.

AIMS OF THE STUDY: The safety and efficacy of a hemostatic powder (HP) versus a control agent, absorbable gelatin sponge and thrombin (G + T), were assessed, using a validated, quantitative bleeding severity scale. METHODS: Subjects were randomized to receive HP (256 subjects) or G + T (132 subjects) for treatment of minimal, mild, or moderate bleeding at 20 investigational sites. The primary efficacy endpoint was non-inferiority of HP relative to G + T for success at achieving hemostasis within 6 minutes. Secondary endpoints in rank order included: superiority of HP relative to G + T in mean preparation time; non-inferiority of HP relative to G + T for achieving hemostasis within 3 min; superiority of HP relative to G + T for achieving hemostasis within 6 min; and superiority of HP relative to G + T for success for achieving hemostasis within 3 min. RESULTS: A total of 388 subjects were included in the primary efficacy analysis. At 6 min, hemostasis was achieved in 93.0% (238/256) of the HP group compared to 77.3% (102/132) of the G + T group (non-inferiority P < 0.0001, superiority P < 0.0001). All secondary endpoints were met. Complications were comparable between treatment groups. CONCLUSIONS: HP had superior rates of hemostasis, shorter preparation time, and a similar safety profile compared to G + T in this prospective, randomized trial using quantitative bleeding severity criteria.

Avoiding and Managing Complications After Hip Fracture Fixation.

There is an enormous burden of disease associated with the management of a failed hip fracture fixation. The goal of surgical management is to facilitate an early return to mobilization with the retention of as much independence as possible. Despite numerous studies that are focused on the care of patients with proximal femur fractures, complication rates remain high. Surgeons should review current strategies to avoid and manage complications after hip fracture fixation. This will have important implications given the detrimental consequences of failed management of hip fractures, including permanent disability, life-threatening medical complications, and an increased risk of death.

Genetic and cellular evidence of decreased inflammation associated with reduced incidence of posttraumatic arthritis in MRL/MpJ mice.

OBJECTIVE: To examine the relationship between inflammation and posttraumatic arthritis (PTA) in a murine intraarticular fracture model. METHODS: Male C57BL/6 and MRL/MpJ "superhealer" mice received tibial plateau fractures using a previously established method. Mice were killed on day 0 (within 4 hours of fracture) and days 1, 3, 5, 7, 28, and 56 after fracture. Synovial tissue samples, obtained prior to fracture and on days 0, 1, 3, 5, and 7 after fracture, were examined by reverse transcription-polymerase chain reaction for gene expression of proinflammatory cytokines and chemokines. Synovial fluid and serum samples were collected to measure cytokine concentrations, using enzyme-linked immunosorbent assay. Whole joints were examined histologically for the extent of synovitis and cartilage degradation, and joint tissue samples from all time points were analyzed immunohistochemically to evaluate the distribution of interleukin-1 (IL-1). RESULTS: Compared to C57BL/6 mice, MRL/MpJ mice had less severe intraarticular and systemic inflammation following joint injury, as evidenced by lower gene expression of tumor necrosis factor α and IL-1ß in the synovial tissue and lower protein levels of IL-1α and IL-1ß in the synovial fluid, serum, and joint tissues. Furthermore, after joint injury, MRL/MpJ mice had lower gene expression of macrophage inflammatory proteins and macrophage-derived chemokine (CCL22) in the synovial tissue, and also had reduced acute and late-stage infiltration of synovial macrophages. CONCLUSION: C57BL/6 mice exhibited higher levels of inflammation than MRL/MpJ mice, indicating that MRL/MpJ mice are protected from PTA in this model. These data thus suggest an association between joint tissue inflammation and the development and progression of PTA in mice.

The role of cytokines in posttraumatic arthritis.

The development of arthritis after joint injury is commonly known as posttraumatic arthritis (PTA). The inciting traumatic event may range from cartilage contusion and bone bruise combined with meniscus or ligament tear, to intra-articular fracture. End-stage PTA is often indistinguishable from primary osteoarthritis. However, knowing the time of the inciting traumatic event in a patient with PTA provides an opportunity to understand the events following joint injury that lead to the progression of arthritis. Joint injury often leads to mechanical alterations in loading of the injured joint, and restoration of joint mechanics through surgical repair remains an important aspect of treatment. However, the accuracy of joint reduction by itself does not account for the variability in outcome following joint injury, as evidenced by the fact that PTA remains a significant clinical problem. Emerging research in animal models and human subjects indicates that several inflammatory cytokines and related inflammatory mediators are elevated following joint injury. Data from animal studies and early clinical trials suggest that early inhibition of the intra-articular inflammatory response may improve clinical outcomes.

Diet-induced obesity significantly increases the severity of posttraumatic arthritis in mice.

OBJECTIVE: Obesity and joint injury are primary risk factors for osteoarthritis (OA) that involve potential alterations in the biomechanical and inflammatory environments of the joint. Posttraumatic arthritis is a frequent long-term complication of intraarticular fractures. Obesity has been linked to primary OA and may potentially contribute to the development of posttraumatic arthritis by a variety of mechanisms. The objectives of this study were to determine whether diet-induced obesity influences the severity of posttraumatic arthritis in mice and to examine the interrelationships between joint degeneration and serum levels of the inflammatory cytokines and adipokines that are involved in this response. METHODS: C57BL/6 mice were fed either normal chow (13% fat) or a high-fat diet (60% fat) starting at 4 weeks of age. At 16 weeks of age, half of the mice in each group were subjected to a closed intraarticular fracture of the left knee. At 8 weeks postfracture, knee OA was assessed by cartilage and synovium histology in addition to bone morphology. Serum cytokine concentrations were determined with multiplex assays. RESULTS: Fractured knee joints of mice receiving a high-fat diet showed significantly increased OA degeneration compared with nonfractured contralateral control knees, while fractured knee joints of mice receiving a low-fat diet did not demonstrate significant differences from nonfractured contralateral control knees. A high-fat diet increased serum concentrations of interleukin-12p70 (IL-12p70), IL-6, and keratinocyte-derived chemokine while decreasing adiponectin concentrations. Joint injury also increased IL-12p70 concentrations in mice receiving a high-fat diet. Systemic levels of adiponectin were inversely correlated with synovial inflammation in control limbs. CONCLUSION: Diet-induced obesity significantly increased the severity of OA following intraarticular fracture. Obesity and joint injury together can alter systemic levels of inflammatory cytokines such as IL-12p70.

Understanding how orthopaedic surgery practices generate value for healthcare systems.

BACKGROUND: Orthopaedic surgery practices can provide substantial value to healthcare systems. Increasingly, healthcare administrators are speaking of the need for alignment between physicians and healthcare systems. However, physicians often do not understand what healthcare administrators value and therefore have difficulty articulating the value they create in discussions with their hospital or healthcare organization. Many health systems and hospitals use service lines as an organizational structure to track the relevant data and manage the resources associated with a particular type of care, such as musculoskeletal care. Understanding service lines and their management can be useful for orthopaedic surgeons interested in interacting with their hospital systems. QUESTIONS/PURPOSES: We provide an overview of two basic types of value orthopaedic surgeons create for healthcare systems: financial or volume-driven benefits and nonfinancial quality or value-driven patient care benefits. METHODS: We performed a search of PubMed from 1965 to 2012 using the term "service line." Of the 351 citations identified, 18 citations specifically involved the use of service lines to improve patient care in both nursing and medical journals. RESULTS: A service line is a structure used in healthcare organizations to enable management of a subset of activities or resources in a focused area of patient care delivery. There is not a consistent definition of what resources are managed within a service line from hospital to hospital. Physicians can positively impact patient care through engaging in service line management. CONCLUSIONS: There is increasing pressure for healthcare systems and hospitals to partner with orthopaedic surgeons. The peer-reviewed literature demonstrates there are limited resources for physicians to understand the value they create when attempting to negotiate with their hospital or healthcare organization. To effectively negotiate for resources to provide the best care for patients, orthopaedic surgeons need to claim and demonstrate the value they create in healthcare organizations.

Healthcare technology: physician collaboration in reducing the surgical cost.

BACKGROUND: The increasing cost of providing health care is a national concern. Healthcare spending related to providing hospital care is one of the primary drivers of healthcare spending in the United States. Adoption of advanced medical technologies accounts for the largest percentage of growth in healthcare spending in the United States when compared with other developed countries. Within the specialty of orthopaedic surgery, a variety of implants can result in similar outcomes for patients in several areas of clinical care. However, surgeons often do not know the cost of implants used in a specific procedure or how the use of an implant or technology affects the overall cost of the episode of care. QUESTIONS/PURPOSES: The purposes of this study were (1) to describe physician-led processes for introduction of new surgical products and technologies; and (2) to inform physicians of potential cost savings of physician-led product contract negotiations and approval of new technology. METHODS: We performed a detailed review of the steps taken by two centers that have implemented surgeon-led programs to demonstrate responsibility in technology acquisition and product procurement decision-making. RESULTS: Each program has developed a physician peer review process in technology and new product acquisition that has resulted in a substantial reduction in spending for the respective hospitals in regard to surgical implants. Implant costs have decreased between 3% and 38% using different negotiating strategies. At the same time, new product requests by physicians have been approved in greater than 90% of instances. CONCLUSIONS: Hospitals need physicians to be engaged and informed in discussions concerning current and new technology and products. Surgeons can provide leadership for these efforts to reduce the cost of high-quality care.

Computer-assisted reduction method for periprosthetic distal femur fracture.

The purpose of this case report is to describe a novel use of computer assistance in identifying and restoring the mechanical axis in the treatment of a periprosthetic distal femur fracture in a 76-year-old female patient with a total knee arthroplasty.

Combination of Lidocaine and IL-1Ra Is Effective at Reducing Degradation of Porcine Cartilage Explants.

BACKGROUND: Posttraumatic inflammation after joint injury, ranging from sprains to articular fracture, contributes to the development of arthritis, and the administration of interleukin 1 (IL-1) receptor antagonist (IL-1Ra) is a potential intervention to mitigate this response. Although IL-1Ra mitigates cartilage degenerative changes induced by IL-1, lidocaine is used for local pain management in acute joint injury. Intra-articular delivery of both drugs in combination would be a novel and possibly disease-modifying treatment. However, it is not known whether the interaction with lidocaine at clinical concentrations (1%) would alter the efficacy of IL-1Ra to protect cartilage from the catabolic effects of IL-1. HYPOTHESIS: Treatment of articular cartilage with IL-1Ra in combination with a clinically relevant concentration of lidocaine (1%) will inhibit the catabolic effects of IL-1α in a manner similar to treatment with IL-1Ra alone. STUDY DESIGN: Controlled laboratory study. METHODS: Fresh porcine cartilage explants were harvested, challenged with IL-1α, and incubated for 72 hours with IL-1Ra or a combination of IL-1Ra and lidocaine. The primary outcome was total sulfated glycosaminoglycan (sGAG) release. Additional experiments assessed the effect of storage temperature and premixing of IL-1Ra and lidocaine on sGAG release. All explants were histologically assessed for cartilage degradation using a modified Mankin grading scale. RESULTS: The combination of IL-1Ra and lidocaine, premixed at various time points and stored at room temperature or 4°C, was as effective as IL-1Ra alone at inhibiting IL-1α-mediated sGAG release. Mankin histopathology scores supported these findings. CONCLUSION: Our hypothesis was supported, and results indicated that the combination of IL-1Ra and lidocaine was as efficacious as IL-1Ra treatment alone in acutely mitigating biological cartilage injury due to IL-1α in an explant model. CLINICAL SIGNIFICANCE: The combination of IL-1Ra and lidocaine is stable when reagents are stored in advance of administration at varying temperatures, providing clinically relevant information about storage of medications. The ability to premix and store this drug combination for intra-articular delivery may provide a novel treatment after joint injury to provide pain relief and block inflammation-induced catabolism of joint tissues.

Intra-Articular Synovial Fluid With Hematoma After Ankle Fracture Promotes Cartilage Damage In Vitro Partially Attenuated by Anti-Inflammatory Agents.

BACKGROUND: Intra-articular ankle fracture (IAF) causes posttraumatic osteoarthritis (PTOA), but the exact mechanism is unknown. Proinflammatory mediators have been shown to be present in the synovial fluid fracture hematoma (SFFH) but have not been linked to cartilage damage. The purpose of this study was to determine if the SFFH causes cartilage damage and whether this damage can be attenuated by commercially available therapeutic agents. METHODS: Synovial fluid was obtained from 54 IAFs and cultured with cartilage discs from the dome of fresh allograft human tali and randomly assigned to one of the following groups: (A) control-media only, (B) SFFH from days 0 to 2 after fracture, (C) SFFH from days 3 to 9, (D) SFFH from days 10 to 14, (E) group B + interleukin 1 receptor antagonist (IL-1Ra), and (F) group B + doxycycline. The cartilage discs underwent histological evaluation for cell survival and cartilage matrix components. The spent media were analyzed for inflammatory mediators. RESULTS: Cartilage discs cultured with SFFH in groups B, C, and D demonstrated significantly increased production of cytokines, metalloproteinases (MMPs), and extracellular matrix breakdown products. Safranin O staining was significantly decreased in group B. The negative effects on cartilage were partially attenuated with the addition of either IL-1RA or doxycycline. There was no difference in chondrocyte survival among the groups. CONCLUSION: Exposure of uninjured cartilage to IAF SFFH caused activation of cartilage damage pathways evident through cartilage disc secretion of inflammatory cytokines, MMPs, and cartilage matrix fragments. The addition of IL-1Ra or doxycycline to SFFH culture partially attenuated this response. CLINICAL RELEVANCE: IAFs create an adverse intra-articular environment consisting of significantly increased levels of inflammatory cytokines and MMPs able to damage cartilage throughout the joint. These data suggest that the acute addition of specific inflammatory inhibitors may decrease the levels of these proinflammatory mediators.

Development of a collaborative program to provide extracorporeal membrane oxygenation for adults with refractory hypoxemia within the framework of a pandemic.

OBJECTIVE: We report the process used to rapidly develop a collaborative adult respiratory extracorporeal membrane oxygenation program as a response to caring for young adult patients with refractory hypoxemia in the setting of the pH1N1 pandemic. DESIGN: Interdisciplinary response of a complex medical system to a public health crisis. PATIENTS, INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS: After the successful use of extracorporeal membrane oxygenation in young adults with pH1N1-induced acute respiratory distress syndrome refractory to conventional therapies, an adult venovenous extracorporeal membrane oxygenation program was implemented over an 8-wk period. Implementation of this program involved a number of key steps that were crucial in the development process, including administrative and institutional support, multidisciplinary leadership and collaboration, extensive interdisciplinary educational initiatives, and substantial technical modifications. CONCLUSIONS: In the setting of the pH1N1 influenza pandemic, an adult respiratory extracorporeal membrane oxygenation program was successfully developed to complement an established neonatal-pediatric program. This program expansion integrated all of the necessary components involved in the development process from start to finish and confirms that a healthcare system can respond very quickly and successfully to an urgent healthcare need.

Applied biomechanics in articular injuries: perspectives in the basic investigation of articular injuries and clinical application.

Joint injury is an important cause of arthritis. Although the treatment of injury, in general, has been widely studied, the contribution of injury to the development of posttraumatic arthritis is still a relatively understudied area. One of the most perplexing aspects of investigating articular injuries is the complex nature of the injury itself and the multiple facets of the injury mechanism that can potentially lead to the development of arthritis. A symposium by the Orthopaedic Research Society and the American Academy of Orthopaedic Surgeons was designed to examine the spectrum of basic science to clinical investigation in the role of biomechanics in the study of joint injury and subsequent posttraumatic arthritis. Four perspectives in the clinical aspects of managing articular injuries were investigated, including the clinical applications of basic science findings, the challenges and advancements in measuring and modeling articular fractures, the relationship of articular cartilage mechanical injuries and osteoarthritis, and the controlled creation of an intra-articular fracture to permit observations of the natural history of posttraumatic arthritis.

Can PROMIS measures be used to create subgroups for patients seeking orthopaedic care?

AIMS: Patient-reported outcome measures have become an important part of routine care. The aim of this study was to determine if Patient-Reported Outcomes Measurement Information System (PROMIS) measures can be used to create patient subgroups for individuals seeking orthopaedic care. METHODS: This was a cross-sectional study of patients from Duke University Department of Orthopaedic Surgery clinics (14 ambulatory and four hospital-based). There were two separate cohorts recruited by convenience sampling (i.e. patients were included in the analysis only if they completed PROMIS measures during a new patient visit). Cohort #1 (n = 12,141; December 2017 to December 2018,) included PROMIS short forms for eight domains (Physical Function, Pain Interference, Pain Intensity, Depression, Anxiety, Sleep Quality, Participation in Social Roles, and Fatigue) and Cohort #2 (n = 4,638; January 2019 to August 2019) included PROMIS Computer Adaptive Testing instruments for four domains (Physical Function, Pain Interference, Depression, and Sleep Quality). Cluster analysis (K-means method) empirically derived subgroups and subgroup differences in clinical and sociodemographic factors were identified with one-way analysis of variance. RESULTS: Cluster analysis yielded four subgroups with similar clinical characteristics in Cohort #1 and #2. The subgroups were: 1) Normal Function: within normal limits in Physical Function, Pain Interference, Depression, and Sleep Quality; 2) Mild Impairment: mild deficits in Physical Function, Pain Interference, and Sleep Quality but with Depression within normal limits; 3) Impaired Function, Not Distressed: moderate deficits in Physical Function and Pain Interference, but within normal limits for Depression and Sleep Quality; and 4) Impaired Function, Distressed: moderate (Physical Function, Pain Interference, and Sleep Quality) and mild (Depression) deficits. CONCLUSION: These findings suggest orthopaedic patient subgroups differing in physical function, pain, and psychosocial distress can be created from as few as four different PROMIS measures. Longitudinal research is necessary to determine whether these subgroups have prognostic validity. Cite this article: Bone Jt Open 2021;2(7):493-502.

Degenerative joint changes following intra-articular fracture are more severe in mice with T cell deficiency.

The inflammatory response to joint injury, specifically intra-articular fracture, has been implicated in posttraumatic arthritis development. However, the role of T cells in regulating the development of posttraumatic arthritis is unclear. We hypothesized that the absence of T cells would lead to less severe posttraumatic arthritis following intra-articular fracture. T cell-deficient, athymic nude, and wild-type C57BL/6NJ mice were assessed at 8 weeks following closed articular fracture. Joints were assessed using histologic scores of arthritis, synovitis, and bone morphology via micro computed tomography. Cells were profiled in whole blood via flow cytometry, and plasma and synovial fluid derived cytokines were quantified by multiplex analysis. Compared to C57BL/6NJ mice, nude mice had significantly greater histologic evidence of arthritis and synovitis. Whole blood immune cell profiling revealed a lower percentage of dendritic cells but increased natural killer (NK) cells in nude mice. Concurrently, nude mice had significantly higher levels of NK cells in synovial tissue. Concentrations of plasma interleukin 1ß (IL-1ß) and tumor necrosis factor α, and synovial fluid IL-12, IL-17, and IL-6 in both knees were greater in nude mice. Outcomes of this study suggest that T cells may play a protective regulatory role against the development of posttraumatic arthritis. Clinical significance: Lack of functional T cells exacerbated the development of posttraumatic arthritis following intra-articular fracture suggesting that critical regulators of the immune responses, contained within the T cell population, are required for protection. Future research identifying the specific T cell subsets responsible for modulating disease immunopathogenesis will lead to new therapeutic targets to mitigate posttraumatic arthritis.

Initial displacement of the intra-articular surface after articular fracture correlates with PTA in C57BL/6 mice but not "superhealer" MRL/MpJ mice.

Posttraumatic arthritis (PTA) occurs commonly after articular fracture and may arise, in part, from joint surface incongruity after injury. MRL/MpJ (MRL) "super-healer" mice are protected from PTA compared to C57BL/6 (B6) mice following articular fracture. However, the relationship between the initial displacement of the articular surface, biologic response, and susceptibility to PTA after fracture remains unclear. The objective of this study was to assess whether joint incongruity after articular fracture, as measured by in vivo micro-computed tomography (microCT), could predict pathomechanisms of PTA in mice. B6 and MRL mice (n = 12/strain) received a closed articular fracture (fx) of the left tibial plateau. Articular incongruity was quantified as bone surface deviations (BSD) for each in vivo microCT scan obtained from pre-fx to 8 weeks post-fx, followed by histologic assessment of arthritis. Serum concentrations of bone formation (PINP) and bone resorption (CTX-I) biomarkers were quantified longitudinally. Both strains showed increases in surface incongruity over time, as measured by increases in BSD. In B6 mice, acute surface incongruity was significantly correlated to the severity of PTA (R 2 = 0.988; p = .0006), but not in MRL mice (R 2 = 0.224; p = .220). PINP concentrations significantly decreased immediately post-fx in B6 mice (p = .023) but not in MRL mice, indicating higher bone synthesis in MRL mice. MRL/MpJ mice demonstrate a unique biologic response to articular fracture such that the observed articular bone surface displacement does not correlate with the severity of subsequent PTA. Clinical Relevance: Identifying therapies to enhance acute biologic repair following articular fracture may mitigate the risk of articular surface displacement for PTA.

Timing of definitive fixation of severe tibial plateau fractures with compartment syndrome does not have an effect on the rate of infection.

BACKGROUND: Tibial plateau fractures with associated compartment syndrome are severe injuries with elevated infection rates. The objective of this article was to analyze whether there is an association between infection and the timing of definitive fracture fixation in relation to fasciotomy closure or coverage. METHODS: Eighty-one tibial plateau fractures, complicated by compartment syndrome, were treated with four-compartment fasciotomies and definitive fracture fixation before, at, or after fasciotomy closure or coverage. RESULTS: Thirty extremities were treated with definitive fixation before fasciotomy closure. Seven (23%) of these extremities developed an infection. Twenty-six extremities were treated with definitive internal fixation at the time of fasciotomy closure of which three (12%) developed an infection. Twenty-five extremities were treated definitively after fasciotomy closure of which four (16%) developed an infection. There was no significant difference in the rate of infection among the groups (p = 0.5012). CONCLUSIONS: This study demonstrated no statistical difference in the rate of infection when tibial plateau fractures with four-compartment fasciotomies were treated with open reduction and internal fixation before fasciotomy closure, at fasciotomy closure, or after fasciotomy closure. Based on the data presented herein, it seems that definitive fracture treatment can be determined by the condition of patient and by surgeon preference and experience without exposing the patient to the additional risk of infection.

The Association of Prescriber Awareness of Opioid Consumption Trends with Postoperative Opioid Prescription Volume in Hip Arthroscopy: Prescriber Awareness of Opioid Consumption.

PURPOSE: To evaluate the impact of prescriber knowledge of 6-week postoperative opioid usage trends on postoperative opioid prescribing in hip arthroscopy for femoroacetabular impingement syndrome. METHODS: Two groups of patients undergoing hip arthroscopy for femoroacetabular impingement syndrome with the same 2 surgeons were defined. One group preceded study design and implementation and 1 group was after study completion termed the preawareness group (n = 129) and awareness group (n = 130). Baseline clinical and operative characteristics and cumulative 6-week postoperative opioid prescription amount in oral morphine equivalents (OMEs), initial discharge OMEs, and cumulative 6-week postoperative opioid refills were recorded. Multivariable models were constructed to evaluate the impact of provider awareness of opioid usage along with the other baseline characteristics previously mentioned on the outcomes of postoperative opioid prescribing. RESULTS: Preawareness group (365.8 additional OMEs; 95% confidence interval [CI], 132.6-599; P = .002), preoperative opioid usage (506.2 additional OMEs; 95% CI, 268.0-744.3; P < .001), postoperative nonsteroidal anti-inflammatory drugs (-664.6 additional OMEs; -1002.6 to -326.6; P < .001), and Caucasian race (-597.5 additional OMEs; 95% CI, -914.8 to -280.2; P < .001) were significantly associated with 6-week postoperative opioid prescribing. Caucasian race (odds ratio, 0.4; 95% CI, 0.18-0.86; P = .02) was associated with lower odds of additional postoperative opioid prescriptions whereas preoperative opioid usage (odds ratio, 2.47; 95% CI, 1.4-4.36; P = .002) was associated with increased odds of additional postoperative opioid prescriptions. CONCLUSIONS: Patients in the awareness group received significantly lower opioid volume without an increase in overall prescription numbers. LEVEL OF EVIDENCE: III, prognostic, retrospective comparative study.