Implementation of Multimodal Pain Protocol Associated With Opioid Use Reduction in Trauma Patients.

INTRODUCTION: Many trauma centers have adopted multimodal pain protocols (MMPPs) to provide safe and effective pain control. The objective was to evaluate the association of a protocol on opioid use in trauma patients and patient-reported pain scores. METHODS: This was a retrospective review of adult trauma patients admitted from 7/1-9/30/2018 to 7/1-9/30/2019 at an urban academic level 1 trauma center. The MMPP consisted of scheduled nonopioid medications implemented on July 1, 2019. Patients were stratified by level of care upon admission, intensive care unit (ICU) or floor, and by injury severity score (ISS) (ISS < 16 or ISS ≥ 16). Pain scores, opioid, and nonopioid analgesic medication use were compared for the hospital stay or first 30 d. RESULTS: Seven hundred ninety eight patients were included with a mean age of 54 ± 22 y and 511 (64.0%) were men. Demographic and clinical characteristics between those in the pre-MMP (n = 404) and post-MMPP (n = 394) groups were not different. The average pain scores were not different between the two groups (3.7 versus 3.8, P = 0.44), but patients in the post-MMPP group received 36% less morphine milliequivalents (109.6 versus 70; P < 0.0001). The MMPP had the largest effect on patients admitted to the ICU regardless of injury severity. ICU patients with ISS ≥ 16 had the greatest reduction in morphine milliequivalents (174.6 versus 84.4; P < 0.0001). The use of nonopioid analgesics was significantly increased in all groups. CONCLUSIONS: A MMPP is associated with a reduction of opioids and increase in nonopioid analgesics with no difference in patient-reported pain scores.

Promoting harm reduction in rural South Dakota using an interdisciplinary consortium.

BACKGROUND: Deaths from drug-related overdoses are increasing. Rural areas continue to have fewer accessible resources than urban areas. The START-SD (Stigma, Treatment, Avoidance, and Recover in Time - South Dakota) project is funded by the Health Resources and Services Administration and aims to address needs surrounding substance use disorder (SUD) in South Dakota. Pharmacists can play a key role in these efforts. OBJECTIVE: Describe harm reduction and prevention activities implemented through START-SD to reduce the impact of SUD in South Dakota. PRACTICE DESCRIPTION: The interdisciplinary team at South Dakota State University, including pharmacists and student pharmacist researchers, partnered with collaborating organizations to provide improved access to prevention, treatment, and recovery services for those impacted by SUD. PRACTICE INNOVATION: Given the rural and conservative nature of the state, the START-SD team used an innovative framework to implement harm reduction and prevention programs that other states could adopt. EVALUATION METHODS: Because the START-SD project uses evidence-based programs, evaluation focuses on the number of programs implemented and the number of people subsequently served. Data are collected and reported biannually by the team. RESULTS: The core team established and expanded an interdisciplinary consortium and advisory board. A variety of harm reduction and prevention strategies were implemented: establishing and developing partnerships with key organizations, working to increase access to harm reduction programs, facilitating educational activities and trainings, and working to reduce stigma related to SUD and harm reduction. DISCUSSION: Reducing the impact of SUD requires a broad, multifaceted approach, as well as overcoming many environmental barriers. Pharmacists and pharmacy staff are uniquely positioned to positively affect harm reduction for patients. CONCLUSION: More work to decrease the impact of SUD is needed, particularly in rural areas. Pharmacists can play a key role in projects to increase the reach and impact of prevention, treatment, and recovery efforts.

Impact of a Public Health Awareness Campaign on Patients' Perceptions of Expanded Pharmacy Services in South Dakota Using the Theory of Planned Behavior.

Background: Pharmacists can offer medication expertise to help better control diabetes and cardiovascular disease (CVD) and improve patient outcomes, particularly in rural communities. This project evaluated the impact of an awareness campaign on perceptions of expanded pharmacy services. Methods: The "Your Pharmacists Knows" campaign included a 30-s commercial, print material, and media announcements. A non-randomized pre-post study was completed using a modified theory of planned behavior (mTPB) to assess knowledge, attitude, perceived benefits and norms, and perceived control. A 73-item survey was administered to a convenience sample (n = 172) across South Dakota. Regression models to assess intent and utilization were conducted using age, gender, race, education, population, and insurance status as predictors for mTPB constructs. Results: Most common predictors were female gender and higher education level (p < 0.001). All mTPB constructs were significant predictors of intent to use services (p < 0.001). Knowledge and perceived control had the largest influence on intent. Additionally, there was significant improvement in post-campaign service utilization (p < 0.001). Conclusions: This campaign positively influenced intent to seek and utilize services in rural communities where pharmacies may be the only healthcare option for miles. Through targeted campaigns, patients with diabetes or CVD may find access to services to better manage their conditions.

Postoperative Pancreatic Fistula Following Traumatic Splenectomy: A Morbid and Costly Complication.

INTRODUCTION: Development of clinically relevant postoperative pancreatic fistula (CR-POPF) in adult splenectomies following trauma occur in 1%-3% of cases. We hypothesized that the use of sutures in splenic hilum ligation compared to staples was associated with a reduced rate of CR-POPF incidence. METHODS: Adult trauma patients (age ≥17 y) that underwent nonelective splenectomy from 2010 to 2020 were retrospectively evaluated from the trauma registries of all three adult level 1 trauma centers in Indiana. Patients were excluded if they were pregnant, currently incarcerated, expired within 72 h of admission, or had a pancreatic injury diagnosed preoperatively or intraoperatively. A Firth logistic regression using a penalized-maximum likelihood estimate for rare events was used for univariate predictive modeling (SPSS 28.0) of surgical technique on CR-POPF development. RESULTS: Four hundred nineteen adult splenectomies following trauma were conducted; 278 were included. CR-POPF developed in 14 cases (5.0%). Sutures alone were used in 200 cases: seven developed CR-POPF (3.5%). Staples alone or in combination with sutures were used in 74 cases: seven developed CR-POPF (9.5%). There was no statistically significant difference between the use of sutures alone compared to the use of staples alone (P = 0.123) or in combination (P = 0.100) in CR-POPF incidence. CONCLUSIONS: Our 10-y retrospective review of CR-POPF finds the complication to be rare but morbid. This study was underpowered to show any difference in surgical technique. However, we do propose a new institutional norm that CR-POPF develop in 5% of splenectomies after trauma and conclude that further study of optimal technique for emergent splenectomy is warranted.

Gabapentin and intrathecal morphine combination therapy results in decreased oral narcotic use and more consistent pain scores after posterior spinal fusion for adolescent idiopathic scoliosis.

BACKGROUND: Gabapentin and intravenous patient-controlled analgesia (PCA) can reduce postoperative pain scores, postoperative opioid use, and time to completing physical therapy compared to PCA alone after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Gabapentin combined with intrathecal morphine has not been studied. The primary purpose of this retrospective study was to evaluate whether perioperative gabapentin and intrathecal morphine provide more effective pain control than intrathecal morphine alone after PSF for AIS. METHODS: Patients aged 11 to 18 years who underwent PSF for AIS were identified. Patients who received intrathecal morphine only (ITM group) were matched by age and sex to patients who received intrathecal morphine and perioperative gabapentin (ITM+GABA group). The ITM+GABA group received gabapentin preoperatively and for up to 2 days postoperatively. Both groups received oxycodone and the same non-narcotic adjuvant medications. RESULTS: Our final study group consisted of 50 patients (25 ITM, 25 ITM+GABA). The ITM+GABA group had significantly lower mean total oxycodone consumption during the hospitalization (0.798 vs 1.036 mg/kg, P<0.015). While the ITM group had a lower mean pain score between midnight and 8 am on POD 1 (2.4 vs 3.7, P=0.026), pain scores were significantly more consistent throughout the postoperative period in ITM+GABA group. The ITM+GABA group experienced less nausea/vomiting (52% vs 84%, P=0.032) and pruritus (44% vs 72%, P=0.045). Time to physical therapy discharge and length of hospital stay were similar. CONCLUSION: Addition of gabapentin resulted in reduced oral opioid consumption and more consistent postoperative pain scores after PSF for AIS. The patients who received intrathecal morphine and gabapentin also experienced a lower rate of nausea/vomiting and pruritus. TRIAL REGISTRATION: All data was collected retrospectively from chart review, with institutional IRB approval. Trial registration is not applicable.

A 5-Year Follow-up of Patients Treated for Full-Thickness Rotator Cuff Tears: A Prospective Cohort Study.

BACKGROUND: The evidence in support of operative versus nonoperative management of rotator cuff tears (RCTs) is limited, based primarily on observational studies of lower scientific merit. PURPOSE: To (1) compare the efficacy of operative versus nonoperative management of full-thickness RCTs across time and (2) detect variables that predict success within each group. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: We included patients with symptomatic full-thickness RCTs who were enrolled in an institutional shoulder registry. Patient enrollment began in 2009 and continued until early 2018. The following outcome measures were collected at baseline, then 6 months, 1 year, and annually up to 5 years postoperatively: Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score, Veterans RAND 12-Item Health Survey (VR-12) mental and physical component subscales (MCS and PCS, respectively), 100-point Single Assessment Numeric Evaluation (SANE) rating, and 100-point visual analog scale (VAS) for pain and for patient satisfaction. We performed regression models for all outcome variables across all 5 years of follow-up and included the following predictor variables: treatment type (operative vs nonoperative), sex, age, symptom duration, smoking status, diabetes status, injury side, and obesity status. RESULTS: A total of 595 patients were included. Longitudinal mixed-effects regression revealed that patients who received operative treatment did better across time on all outcomes. Women (n = 242; 40.7%) did not fare as well as did men on the ASES, WORC, or VR-12 PCS. Older patients tended to improve less on the VR-12 PCS and more on the VR12-MCS. Patients with longer symptom duration at baseline had better scores across time on the ASES, WORC, VAS for pain, and SANE. Current or recent smokers and patients with diabetes tended to have lower scores on all measures across time. For changes in scores from baseline, patients in the operative group improved to a larger degree out to 3 years compared with those in the nonoperative group. CONCLUSION: Patients with RCTs tended to improve regardless of whether they received operative or nonoperative treatment, but patients who underwent operative treatment improved faster. There appear to be several predictors of improved and worsened outcomes for patients with RCTs undergoing operative or nonoperative treatment.

Wound Healing Complications in Diabetic Patients Undergoing Carpal Tunnel and Trigger Finger Releases: A Retrospective Cohort Study.

PURPOSE: To evaluate the association of diabetes and perioperative hemoglobin A1C (HgA1C) value with postoperative wound healing complications following carpal tunnel release (CTR) and trigger finger release (TFR). METHODS: A retrospective review of diabetic patients who underwent CTR and/or TFR between 2014 and 2018 was performed. Hemoglobin A1C value within 90 days of surgery was recorded for all diabetic patients. A nondiabetic comparison group was selected from within the same study period in an approximately 1:1 procedural ratio, although direct matching was not performed. A chart review was used to examine postoperative wound healing complications, such as wound infection, wound dehiscence, or delayed wound healing. RESULTS: Two hundred sixty-two diabetic patients and 259 nondiabetic patients underwent 335 and 337 CTR and/or TFR procedures, respectively. There were 36 wound complications in the diabetic group and 9 complications in the nondiabetic group. Logistic regression analysis demonstrated an increased association of wound healing complications with diabetic patients compared to nondiabetic patients. Additionally, an increased association was demonstrated among diabetic patients with an HgA1C value above 6.5% compared with those with an HgA1C value below 6.5%. CONCLUSIONS: Compared with nondiabetic controls, diabetic patients have increased associated risk of postoperative wound healing complications following CTR and/or TFR. This increased association was further demonstrated among diabetic patients with elevated perioperative HgA1C values. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Long-term Follow-up of Lisfranc Injuries Treated With Open Reduction Internal Fixation Patient-Reported Outcomes.

BACKGROUND: There remains a paucity of data regarding long-term patient-reported outcomes following Lisfranc injuries. We sought to collect long-term clinical outcome data following Lisfranc injuries using PROMIS Physical Function (PROMIS-PF) and visual analog scale-foot and ankle (VAS-FA). METHODS: A chart review was performed to identify all patients who had surgical treatment of an acute Lisfranc injury at our institution from 2005 to 2014. Of the 45 patients identified, we were able to recruit 19 for a follow-up clinic visit consisting of physical examination, administration of questionnaires addressing pain and medication usage, radiographs, and completion of outcome surveys including PROMIS-Physical Function and visual analog scale-foot and ankle. RESULTS: There were 14 female and 5 male patients enrolled in the study with a mean time of 6.25 years from the time of injury. Within this cohort, the mean PROMIS-PF score was 52.4±8.2 and the mean VAS-foot and ankle score was 76.6±22.3. CONCLUSION: We report satisfactory long-term patient-reported outcomes using PROMIS-PF and VAS-FA. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Elevated Serum Titanium Levels in Children With Early Onset Scoliosis Treated With Growth-friendly Instrumentation.

BACKGROUND: A previous study showed significantly higher serum titanium levels in patients with early-onset scoliosis (EOS) treated with traditional growing rods (TGR) and magnetically controlled growing rods (MCGR) compared with controls. Children with vertical expandable prosthetic titanium rib (VEPTR) were not assessed. The purpose of this study was to compare serum titanium levels in EOS patients treated with TGR, MCGR, and VEPTR. We hypothesized that EOS patients treated with all forms of growth-friendly instrumentation (GFI) have elevated serum titanium levels. METHODS: This was a prospective cross-sectional case series. Serum titanium levels were collected from patients with GFI who were enrolled in an EOS database. Blood samples were collected at a clinic visit or lengthening/exchange procedure between April and December 2018. The normal range for serum titanium is 0 to 1 ng/mL. Analyses were conducted using analysis of variance and Bonferroni post hoc test. RESULTS: A total of 23 patients (2 TGR, 8 MCGR, 13 VEPTR) were analyzed. There was a significant difference in age at the time of blood sample collection (12.5 vs. 9.8 vs. 7.5 y, P=0.015) and serum titanium level (1.5 vs. 4.5 vs. 7.6 ng/mL, P=0.021) between TGR, MCGR, and VEPTR, respectively. All of the MCGR and VEPTR patients had a serum titanium level ≥2 ng/mL. Binary comparisons showed that VEPTR had a significantly higher serum titanium level than TGR (P=0.046). There was no difference in serum titanium level when MCGR was compared with TGR and VEPTR. Time from implant insertion to blood sample collection, number of rods currently implanted, total number of rods implanted throughout treatment, and number of lengthenings per patient was similar between the groups. CONCLUSIONS: Elevated serum titanium levels may be present in EOS patients treated with all forms of GFI. Although our TGR patients had indwelling implants for the longest period of time, they had the lowest serum titanium level. Repetitive chest wall motion during respiration may lead to continued wear and metal ion release with VEPTR. LEVEL OF EVIDENCE: Level II-therapeutic.

A xenograft model to evaluate the bone forming effects of sclerostin antibody in human bone derived from pediatric osteogenesis imperfecta patients.

Osteogenesis imperfecta (OI) is a rare and severe skeletal dysplasia marked by low bone mass and poor bone quality which is especially burdensome during childhood. Since clinical trials for pediatric OI are difficult, there is a widespread reliance on genetically modified murine models to understand the skeletal effects of emerging therapeutics. However a common model does not yet exist to understand how patient-specific genotype may influence treatment efficacy. Recently, sclerostin antibody (SclAb) has been introduced as a novel putative anabolic therapy for diseases of low bone mass, but effects in pediatric patients remain unexplored. In this study, we aim to establish a direct xenograft approach using OI patient-derived bone isolates which retain patient-specific genetic defects and cells residing in their intrinsic extracellular environment to evaluate the bone-forming effects of SclAb as a bridge to clinical trials. OI and age matched non-OI patient bone typically discarded as surgical waste during corrective orthopaedic procedures were collected, trimmed and implanted subcutaneously (s.c.) on the dorsal surface of 4-6-week athymic mice. A subset of implanted mice were evaluated at short (1 week), intermediate (4 week), and long-term (12 week) durations to assess bone cell survival and presence of donor bone cells in order to determine an appropriate treatment duration. Remaining implanted mice were randomly assigned to a two or four-week SclAb-treated (25mg/kg s.c. 2QW) or untreated control group. Immunohistochemistry determined osteocyte and osteoblast donor/host relationship, TRAP staining quantified osteoclast activity, and TUNEL assay was used to understand rates of bone cell apoptosis at each implantation timepoint. Longitudinal changes of in vivo µCT outcomes and dynamic histomorphometry were used to assess treatment response and ex vivo µCT and dynamic histomorphometry of host femora served as a positive internal control to confirm a bone forming response to SclAb. Human-derived osteocytes and lining cells were present up to 12 weeks post-implantation with nominal cell apoptosis in the implant. Sclerostin expression remained donor-derived throughout the study. Osterix expression was primarily donor-derived in treated implants and shifted in favor of the host when implants remained untreated. µCT measures of BMD, TMD, BV/TV and BV increased with treatment but response was variable and impacted by bone implant morphology (trabecular, cortical) which was corroborated by histomorphometry. There was no statistical difference between treated and untreated osteoclast number in the implants. Host femora confirmed a systemic bone forming effect of SclAb. Findings support use of the xenograft model using solid bone isolates to explore the effects of novel bone-targeted therapies. These findings will impact our understanding of SclAb therapy in pediatric OI tissue through establishing the efficacy of this treatment in human cells prior to extension to the clinic.

Level of Experience Does Not Influence the Accuracy of Radiographic and Ultrasound Measurements of Magnetically Controlled Growing Rod Distractions.

BACKGROUND: Magnetically controlled growing rods (MCGR) have become a popular surgical option for the treatment of early-onset scoliosis. Both radiographs and ultrasound are currently used to measure the amount of length achieved when MCGRs are distracted. Previous studies have investigated the intraobserver and interobserver reliability of radiographic and ultrasound measurements of MCGR distraction. Some authors have reported that there is a "learning curve" in measuring MCGR lengthening with ultrasound, suggesting that new users require several months of experience before they can accurately perform the measurements. The goal of this study was to determine whether surgical experience of the rater is associated with the accuracy of radiographic and ultrasound measurements of MCGR distraction. METHODS: Six raters evaluated 29 deidentified radiographs and 30 ultrasound images from early-onset scoliosis patients with MCGR. Raters had varying levels of experience, ranging from a senior fellowship-trained pediatric orthopaedic surgeon to a junior orthopaedic surgery resident. Raters measured the amount of rod distraction in 2 sessions spaced 2 weeks apart. All raters were provided with a document demonstrating the radiographic and ultrasound measurement techniques before the first round of measurements. Intraclass correlation coefficients were calculated. RESULTS: Excellent intraobserver and interobserver agreement was achieved for both radiographic and ultrasound measurements of MCGR distraction. Subanalysis based on experience level showed that excellent intraobserver agreement was maintained with no evidence of decreased reliability in raters with less experience. CONCLUSIONS: Excellent intraobserver and interobserver agreement was obtained with radiographic and ultrasound measurements of MCGR distraction, regardless of the experience level of the rater. Posting a document with the radiographic and ultrasound measurement techniques in the orthopaedic surgery clinic, and perhaps also the radiology reading room may help avoid inaccurate measurements of distraction length secondary to a learning curve. LEVEL OF EVIDENCE: Level III-diagnostic.

Obese Children Have Different Forearm Fracture Characteristics Compared With Normal-weight Children.

BACKGROUND: Current estimates suggest that one third of children and adolescents are overweight and 1 in 5 are obese. Obese children are at increased risk of sustaining more complex fractures, failing nonoperative treatment, and experiencing more complications during treatment. The purpose of this study was to compare forearm fracture characteristics, treatment, and complications in grouped overweight and obese [OW+OB; body mass index-for-age percentile (BMI%) ≥85] pediatric patients compared with normal-weight (NW; BMI%≤84) patients. METHODS: This was a retrospective comparative study of patients aged 2 to 17 years old who presented with a forearm fracture resulting from low-energy trauma between January 2010 and September 2017. Patients with incomplete height and weight data; an underlying condition that predisposes to fractures or altered fracture healing; and torus, greenstick, pathologic, and high-energy fractures were excluded. Demographics, fracture characteristics, treatment, and complications were recorded. Descriptive and inferential analyses were conducted. RESULTS: A total of 565 patients (403 NW, 162 OW+OB) met the inclusion criteria. NW children sustained open fractures nearly twice as frequently as the OW+OB children but this was not statistically significant (9.7% vs. 4.9%; P=0.065). Subanalysis showed that NW children were 4.1 times more likely to sustain an open fracture compared with obese (BMI%≥95) children (9.7% vs. 2.4%; P=0.029). A significant relationship was found between BMI% and location of the fracture, the bones involved, and fracture type. The OW+OB children sustained more distal forearm fractures than midshaft and proximal forearm fractures. Isolated radial shaft fractures were more common in the OW+OB group, whereas isolated ulnar shaft fractures were more common in the NW group. There was no difference in associated neurovascular injury, initial nonoperative versus operative management, failure of nonoperative treatment, and treatment complications. CONCLUSIONS: OW+OB children have different forearm fracture characteristics compared with their NW peers. The thick soft tissue envelope in obese children may be protective against an open forearm fracture. In contrast to previous studies, obesity was not associated with failure of nonoperative treatment or a higher rate of complications. LEVEL OF EVIDENCE: Level III-prognostic.

Surgical Versus Nonsurgical Management of Rotator Cuff Tears: A Matched-Pair Analysis.

BACKGROUND: Rotator cuff disease is a major medical and economic burden due to a growing aging population, but management of rotator cuff tears remains controversial. We hypothesized that there is no difference in outcomes between patients who undergo rotator cuff repair and matched patients treated nonoperatively. METHODS: After institutional review board approval, a prospective cohort of patients over 18 years of age who had a full-thickness rotator cuff tear seen on magnetic resonance imaging (MRI) were retrospectively evaluated. After clinical evaluation, each patient elected to undergo either rotator cuff repair or nonsurgical treatment. Demographic information was collected at enrollment, and self-reported outcome measures (the Normalized Western Ontario Rotator Cuff Index [WORCnorm], American Shoulder and Elbow Surgeons score [ASES], Single Assessment Numerical Evaluation [SANE], and pain score on a visual analog scale [VAS]) were collected at baseline and at 6, 12, and >24 months. The Functional Comorbidity Index (FCI) was used to assess health status at enrollment. The size and degree of atrophy of the rotator cuff tear were classified on MRI. Propensity score analysis was used to create rotator cuff repair and nonsurgical groups matched by age, sex, symptom duration, FCI, tear size, injury mechanism, and atrophy. The Student t test, chi-square test, and regression analysis were used to compare the treatment groups. RESULTS: One hundred and seven patients in each group were available for analysis after propensity score matching. There were no differences between the groups with regard to demographics or rotator cuff tear characteristics. For all outcome measures at the time of final follow-up, the rotator cuff repair group had significantly better outcomes than the nonsurgical treatment group (p < 0.001). At the time of final follow-up, the mean outcome scores (and 95% confidence interval) for the surgical repair and nonsurgical treatment groups were, respectively, 81.4 (76.9, 85.9) and 68.8 (63.7, 74.0) for the WORCnorm, 86.1 (82.4, 90.3) and 76.2 (72.4, 80.9) for the ASES, 77.5 (70.6, 82.5) and 66.9 (61.0, 72.2) for the SANE, and 14.4 (10.2, 20.2) and 27.8 (22.5, 33.5) for the pain VAS. In the longitudinal regression analysis, better outcomes were independently associated with younger age, shorter symptom duration, and rotator cuff repair. CONCLUSIONS: Patients with a full-thickness rotator cuff tear reported improvement in pain and functional outcome scores with nonoperative treatment or surgical repair. However, patients who were offered and chose rotator cuff repair reported greater improvement in outcome scores and reduced pain compared with those who chose nonoperative treatment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Muscle Quality on Operative and Nonoperative Treatment of Rotator Cuff Tears.

BACKGROUND: Rotator cuff muscle atrophy and fatty infiltration are predictors of negative outcomes after rotator cuff repair. However, the impact of muscle degeneration on nonsurgical treatment is unknown. HYPOTHESIS: Rotator cuff muscle atrophy and fatty infiltration will reduce the outcomes of operative repair while having a minimal effect on nonsurgical treatment. Additionally, in the setting of atrophy and fatty infiltration, surgical and nonsurgical treatment will produce equivalent outcomes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing operative and nonoperative treatment of full-thickness rotator cuff tears were prospectively enrolled into a nonrandomized cohort study. Muscle quality was assessed on magnetic resonance imaging by use of the supraspinatus tangent sign, Warner atrophy, and Goutallier fatty infiltration classifications. Grading was performed by 2 independent observers who were blinded to patient treatment and outcomes. Normalized Western Ontario Rotator Cuff (WORC) index was the primary patient-reported outcome. Multivariate linear regression analysis was used to determine the impact of muscle quality on treatment outcomes. RESULTS: The cohort consisted of 157 patients, 89 (57%) surgical and 68 (43%) nonsurgical, with a mean follow-up of 2.4 years (range, 1-5 years). Tangent sign had the best inter- and intrarater reliability, with kappa statistics of 0.81 and 0.86, respectively. Reliability for Warner atrophy was 0.69 to 0.76 and for Goutallier classification was 0.54 to 0.64. Overall, improvement in WORC scores was higher in the surgical group than the nonsurgical group (39.3 vs 21.2; P < .001). A positive tangent sign was the only independent predictor (P < .01) of worse outcomes in the surgical group, accounting for an estimated 22-point lower improvement in WORC scores. CONCLUSION: A positive tangent sign was predictive of worse operative outcomes, resulting in equivalent improvements between surgical and nonsurgical treatment. The tangent sign is a reliable, prognostic indicator that clinicians can use when counseling patients on the optimal treatment of rotator cuff tears.

Clinical Outcomes After Anterior Shoulder Stabilization in Overhead Athletes: An Analysis of the MOON Shoulder Instability Consortium.

BACKGROUND: Traumatic anterior shoulder instability is a common condition affecting sports participation among young athletes. Clinical outcomes after surgical management may vary according to patient activity level and sport involvement. Overhead athletes may experience a higher rate of recurrent instability and difficulty returning to sport postoperatively with limited previous literature to guide treatment. PURPOSE: To report the clinical outcomes of patients undergoing primary arthroscopic anterior shoulder stabilization within the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Consortium and to identify prognostic factors associated with successful return to sport at 2 years postoperatively. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Overhead athletes undergoing primary arthroscopic anterior shoulder stabilization as part of the MOON Shoulder Instability Consortium were identified for analysis. Primary outcomes included the rate of recurrent instability, defined as any patient reporting recurrent dislocation or reoperation attributed to persistent instability, and return to sport at 2 years postoperatively. Secondary outcomes included the Western Ontario Shoulder Instability Index and Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow questionnaire score. Univariate regression analysis was performed to identify patient and surgical factors predictive of return to sport at short-term follow-up. RESULTS: A total of 49 athletes were identified for inclusion. At 2-year follow-up, 31 (63%) athletes reported returning to sport. Of those returning to sport, 22 athletes (45% of the study population) were able to return to their previous levels of competition (nonrefereed, refereed, or professional) in at least 1 overhead sport. Two patients (4.1%) underwent revision stabilization, although 14 (28.6%) reported subjective apprehension or looseness. Age ( P = .87), sex ( P = .82), and baseline level of competition ( P = .37) were not predictive of return to sport. No difference in range of motion in all planes ( P > .05) and Western Ontario Shoulder Instability Index scores (78.0 vs 80.1, P = .73) was noted between those who reported returning to sport and those who did not. CONCLUSION: Primary arthroscopic anterior shoulder stabilization in overhead athletes is associated with a low rate of recurrent stabilization surgery. Return to overhead athletics at short-term follow-up is lower than that previously reported for the general athletic population.

Intraobserver and Interobserver Reliability of Radiographic Analysis of Proximal Humerus Fractures in Adolescents.

BACKGROUND: Multiple studies have shown low intrarater and interrater agreement of radiographic classification systems for proximal humerus fractures (PHFs) in adults. There is no standardized method of measuring angulation of pediatric PHFs, nor is there consensus as to the amount of angulation and displacement that require operative fixation of adolescent PHFs. We propose a new standardized method to measure fracture angulation that is similar to the method used to measure the epiphyseal-shaft angle for slipped capital femoral epiphysis. The primary purpose of this study was to evaluate the intraobserver and interobserver reliability of our proposed method compared with a nonstandardized method. The secondary purpose was to evaluate the intrarater and interrater agreement of the Neer and Horowitz (NH), and Salter-Harris (SH) classification systems. METHODS: Seven raters evaluated 26 deidentified anteroposterior shoulder radiographs of patients 10 to 16 years of age with PHFs. Raters classified each fracture using the NH and SH systems, and used their own method to measure fracture angulation. This process was repeated 2 weeks later. During the second round, raters also measured fracture angulation using our proposed standardized method. Two weeks after the second round, raters reevaluated the radiographs using the standardized method. Intraclass correlation coefficients were calculated. RESULTS: Excellent intraobserver and interobserver agreement was achieved for the standardized method of measuring fracture angulation. All of the raters had an intrarater reliability classified as excellent (>0.80) using the standardized method. Good intrarater and excellent interrater agreement was achieved when raters used their own fracture angulation measurement method but wide confidence intervals suggested that the results were less precise. Fair to moderate intrarater and interrater reliability was seen for the NH and SH classifications. CONCLUSIONS: Our standardized method for measuring angulation in adolescent PHFs demonstrated excellent intrarater and interrater reliability. We propose that this technique may be a more precise method of measuring fracture angulation and this method should be used in future studies that evaluate indications for operative management of adolescent PHFs. LEVEL OF EVIDENCE: Level III-diagnostic.

Impact of smoking on patient outcomes after arthroscopic rotator cuff repair.

BACKGROUND: Cigarette smoking may adversely affect rotator cuff tear pathogenesis and healing. However, the impact of cigarette smoking on outcomes after arthroscopic rotator cuff repair is relatively unknown. PATIENTS AND METHODS: A cohort of 126 patients who underwent arthroscopic rotator cuff repair with minimum 2 years follow-up were retrospectively identified from our institutional database. Patient demographics, comorbidities, and cuff tear index were collected at initial presentation. Outcome measures including American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Rotator Cuff (WORC) score and Visual Analogue Scale (VAS) for pain were collected at each clinical follow-up. Mixed model regression analysis was used to determine the impact of smoking on outcomes, while controlling for tear size and demographics. RESULTS: In our cohort, 14% were active or recent smokers. At baseline, smokers presented with higher pain, greater comorbidities and worse ASES scores than non-smokers. Smokers also had a non-significant trend towards presenting for surgical repair at a younger age and with larger tear sizes. Both smokers and non-smokers had statistical improvements in outcomes at 2 years following repair. Regression analysis revealed that smokers had a worse improvement in ASES but not WORC or VAS pain scores after surgery. CONCLUSION: The minimal clinically important difference was achieved for ASES, WORC and VAS pain in both smokers and non-smokers, suggesting both groups substantially benefit from arthroscopic rotator cuff repair. Smokers tend to present with larger tears and worse initial outcome scores, and they have a lower functional improvement in response to surgery.

Does Increased Body Mass Index Influence Outcomes After Rotator Cuff Repair?

PURPOSE: To investigate the influence of pre-existing obesity (body mass index [BMI] ≥ 30) on outcomes after rotator cuff repair surgery. METHODS: We collected data on adult patients who underwent surgical repair for symptomatic full-thickness rotator cuff tears confirmed by imaging between 2012 and 2015. The required follow-up was 3 years. At baseline and 6, 12, 24, and 36 months, the American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff index, and visual analog scale pain scores were collected. Complications were assessed by a chart review. Obesity was defined as BMI ≥ 30. Chi-square analysis and Student's t-test examined differences between categorical and continuous variables at baseline. Generalized estimating equations examined the effects of fixed factors on outcome variables longitudinally from baseline to 36 months. RESULTS: Thirty-nine percent of 213 subjects were obese (mean BMI = 29.2; range, 16-48; standard deviation, 5.8). There were no statistically significant differences between obese and nonobese subjects in other baseline characteristics. When controlling for covariates, obese subjects reported no differences in Western Ontario Rotator Cuff, American Shoulder and Elbow Surgeons, or visual analog scale pain scores when compared with nonobese subjects at baseline and over 3 years from surgery. Although obese patients were more likely to have inpatient surgery, there was no difference in the incidence of postoperative complications. CONCLUSIONS: Contrary to our hypothesis, obese participants who underwent rotator cuff repair reported no difference in functional outcome or pain scores compared with nonobese participants over 3 years. In addition, obesity was not associated with postoperative complications in this study. However, as we hypothesized, obese participants were more likely than nonobese participants to have repair in the inpatient setting. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Intrathecal Morphine and Oral Analgesics Provide Safe and Effective Pain Control After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: The aim of this study was to demonstrate that intrathecal morphine (ITM) and oral analgesics provide effective pain control after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), and this protocol has a low complication rate so patients can be admitted to a general care floor. SUMMARY OF BACKGROUND DATA: Previous studies have shown that ITM combined with intravenous patient-controlled analgesia or epidural infusion (EPI) provides effective pain control after PSF for AIS. Owing to concerns for respiratory depression, ITM patients were routinely admitted to the intensive care unit (ICU) postoperatively. There are little data on ITM combined with oral analgesics. METHODS: We identified AIS patients aged 10 to 17 years who had undergone PSF. Twenty-eight patients who received ITM were matched to 28 patients who received a hydromorphone EPI. The ITM group received oral oxycodone starting at 16 hours postinjection. The EPI group received oxycodone after the epidural catheter was removed on postoperative day 2. Pain scores, adverse events, and length of stay were recorded. RESULTS: A higher number of EPI patients received fentanyl (11 vs. 3, P = 0.014) in the post-anesthesia care unit (PACU). The ITM group had lower pain scores between PACU discharge and midnight (mean 2.9 vs. 4.2, P = 0.034). Pain scores were similar during the remaining postoperative periods. All ITM patients transitioned to oxycodone without intravenous opioids. Time to ambulation (19.9 vs. 26.5 hours, P = 0.010) and Foley catheter removal (21.3 vs. 41.9 hours, P < 0.001) were earlier in the ITM patients. Length of hospital stay was shorter in the ITM group (3.1 vs. 3.5 days, P = 0.043). Adverse events occurred at similar rates in both groups. CONCLUSION: ITM and oral analgesics provide safe and effective pain control after PSF for AIS. Routine postoperative admission to the ICU is not necessary. LEVEL OF EVIDENCE: 3.

Do Medical Comorbidities Affect Outcomes in Patients With Rotator Cuff Tears?

BACKGROUND: The effects of medical comorbidities on clinical outcomes in patients with rotator cuff tears (RCTs) have not been fully elucidated. This study investigates the association between medical comorbidities, as measured by the Functional Comorbidity Index (FCI), and clinical outcomes in patients treated surgically or nonsurgically for symptomatic, full-thickness RCTs. HYPOTHESIS: Patients with RCTs who have more comorbidities will have worse outcome scores. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We collected the following outcome measures at baseline and at regular intervals up to 64 weeks in all patients: FCI, the Western Ontario Rotator Cuff Index (WORC), and the American Shoulder and Elbow Surgeons (ASES) score. Changes in outcomes were compared separately for surgical and nonsurgical patients using paired t tests. The relationship of the FCI and all outcomes of interest at baseline, at 64-week follow-up, and for changes from baseline was explored using linear regression modeling. RESULTS: Of the 222 study patients (133 males; mean age, 60.0 ± 9.6 years), 140 completed the 64-week WORC and 120 completed the 64-week ASES. Overall, 128 patients underwent RCT repair, and 94 patients were treated nonsurgically. Both treatment groups improved compared with baseline at 64 weeks on the ASES score and WORC. At 64 weeks, patients with higher baseline FCI scores had worse WORC score (by 74.5 points; P = .025) and ASES score (by 3.8 points; P < .01). A higher FCI score showed a trend toward predicting changes in the WORC and ASES scores at 64 weeks compared with baseline, but this did not reach statistical significance (WORC change, P = .15; ASES change, P = .07). CONCLUSION: Patients with higher FCI scores at baseline reported worse baseline functional scores and demonstrated less improvement with time. The magnitude of this change may not be clinically significant for single comorbidities.