The influence of preoperative opioid use on inpatient opioid requirements and discharge prescriptions after primary shoulder arthroplasty.

BACKGROUND: Active opioid users experience more pain and require more opioids after primary shoulder arthroplasty than non-opioid users. However, it is unknown whether discharge prescription regimens are tailored to these different postoperative opioid requirements. METHODS: We performed a retrospective analysis of a prospectively collected cohort of patients who underwent primary shoulder replacement over a 15-month period. Demographic and operative variables were collected and compared between prior opioid users and non-opioid users. Inpatient opioid requirements, daily discharge prescription regimens, total prescription quantities, and rates of persistent opioid use 6 weeks after surgery were also compared between these cohorts. RESULTS: A total of 119 patients were analyzed (mean age, 68 years; 53% men; 39.5% prior opioid users). Prior opioid users required considerably more opioids on the first (60 oral morphine equivalents [OMEs] vs 45 OMEs, P = .01) and last (42 OMEs vs 15 OMEs, P < .001) hospitalization days but were discharged with similar daily opioid regimens (90 OMEs vs 90 OMEs, P = .3), total opioid quantities (600 OMEs vs 600 OMEs, P = .24), and total pills (80 vs 60, P = .27) compared with non-opioid users. Persistent opioid use 6 weeks after surgery was 7-fold higher for prior opioid users than nonusers (71.0% vs 9.1%, P < .001). CONCLUSIONS: Daily and total opioid regimens prescribed after primary shoulder arthroplasty were similar between prior opioid users and nonusers despite large differences in their inpatient opioid requirements. Tailoring discharge opioid prescription regimens to inpatient use appears feasible and warrants further study.

Variable Reporting by Authors Presenting Arthroplasty Research at Multiple Annual Conferences.

BACKGROUND: Prior studies have demonstrated discrepancies in financial conflict of interest (COI) disclosure among authors presenting research at multiple spine and sports medicine conferences. The purpose of this study was to quantify the variability of self-reported financial disclosures of individual authors presenting at multiple arthroplasty conferences during the same year. METHODS: The author disclosure information published for the 2012 annual meetings of the American Academy of Orthopaedic Surgeons (AAOS), American Association of Hip and Knee Surgeons, the Hip Society, and the Knee Society were compiled. We tabulated the author disclosures, the number of companies/entities represented, and the types of disclosures reported. The disclosures made by authors presenting at more than one meeting were then compared for discrepancies. RESULTS: Of the 209 authors who presented at both the AAOS and American Association of Hip and Knee Surgeons meetings, 79 (37.79%) demonstrated discrepancies in their disclosures with 7 (8.8%) reporting no disclosures to the AAOS. Of the 84 authors who presented at both the AAOS and Hip Society meetings, 1 (1.19%) had discrepancies in their disclosures. Of the 52 authors who presented at both the AAOS and Knee Society meetings, 2 (3.84%) had discrepancies in their disclosures. CONCLUSION: There is variability in reported financial COIs by authors presenting at multiple arthroplasty conferences within the same year. Further work is warranted to improve transparency of COI disclosures among arthroplasty surgeons presenting research at national meetings.

Postoperative complications after repair of tibial plateau fractures.

Tibial plateau fractures are common orthopedic injuries and represent a spectrum of injury severity defined by the fracture morphology and the associated soft tissue injury. The management of tibial plateau fractures is challenging, and patients are at risk for adverse outcomes including infection, malunion, nonunion, and stiffness. Accurate diagnosis and early management can mitigate the impact of these complications. When complications do occur, a principle-based approach outlined in this review can minimize the burden to patients in their return to function.

Effect of femoral head material on head-to-trunnion impaction motion and taper.

The purpose of this study was to evaluate the effect of femoral head material on the impaction force, relative motion, and stability of the trunnion. There were three groups with different head materials (n = 5 per group)-CoCr Group: 36 mm CoCr heads, Ceramic Group: 36 mm ceramic heads, Ceramic + Sleeve Group: 36 mm ceramic heads with a titanium sleeve-that were all impacted twice and disengaged onto titanium alloy (Ti6al4V) trunnions in in vitro conditions. A high-speed camera system was utilized to characterize relative displacement behavior of the head-trunnion junction motion. The first impact force of Ceramic + Sleeve Group (14,241 SD, 935) was significantly lower than the first impact force in Ceramic Group (14,961 N, SD = 184). Ceramic + Sleeve Group had a lower magnitude bounce-back displacement following the first impact (17.7 µm, SD = 11), p < 0.05) compared to CoCr Group (298.8 µm, SD = 84) and Group 2 (196.5 µm, SD = 31). Ceramic + Sleeve Group sat further on the trunnion (cumulative final displacement, 366.8 µm, SD = 71, p < 0.001) compared to CoCr Group (142.5 µm, SD = 41.8) and Ceramic Group (183.8 µm, SD = 30). Ceramic + Sleeve Group demonstrated two distinct disengagement patterns-(a) the sleeve disengaged from the trunnion (pull-off force 6810 N), and (b) the femoral head disengaged from the sleeve (pull-off force 18,620 N), with large fluctuations in pull-off force. The presence of a titanium sleeve with a ceramic head resulted in significant differences in impaction force on the trunnion, motion and displacement, and unique mechanisms for disengagement. Further investigation is required to determine potential clinical impact.

Short-term results of triathlon cementless versus cemented primary total knee arthroplasty.

BACKGROUND: Recent studies have demonstrated that aseptic loosening remains a leading cause of failure after total knee arthroplasty (TKA). Cementless fixation is a possible strategy for countering this problem. This study compared short-term survivorship and functional results of patients undergoing primary TKA with cementless versus cemented implants. METHODS: A multi-center database was utilized to identify 3849 patients undergoing primary TKA between 2012 and 2017 with a minimum two-year follow-up. Patients were divided into cementless (699), and cemented TKA (3150). The outcome of TKA including revision for aseptic or septic reasons, and other outcome variables were compared. Six hundred five patients from the cementless group (case) were matched with 605 patients from the cemented group (controls). Both groups were compared for outcomes and related variables. RESULTS: Both matched groups were similar in age, race, gender, height, weight, BMI, laterality, femoral component type, follow-up duration, preoperative and postoperative physical and mental health, and functional activities (all p-values>0.05). Although the cementless TKA group had more components in varus alignment (p = 0.015) and were taller (p < 0.001), the aseptic revision rate and time to failure were similar in both groups (p-values = 0.256 and 0.0890 respectively). The rate of revision for infection was also the same in both groups (p = 0.452). CONCLUSION: Cementless TKA demonstrated an equivalent rate of aseptic and septic failure when compared to cemented TKA in the short-term. Time to aseptic failure was also similar in both groups.

A Review of Inpatient Opioid Consumption and Discharge Prescription Patterns After Orthopaedic Procedures.

INTRODUCTION: Tailoring opioid prescriptions to inpatient use after orthopaedic procedures may effectively control pain while limiting overprescription but may not be common in the current orthopaedic practice. METHODS: A retrospective review identified opioid-naïve patients admitted after any orthopaedic procedure. Daily and total prescription quantities as well as patient-specific factors were collected. The total opioids used the day before discharge was compared with the total opioids prescribed for the day after discharge. Refill rates were then compared between patients whose daily discharge prescription regimen far exceeded or approximated their predischarge opioid consumption. RESULTS: Six hundred thirteen patients were included (ages 18 to 95 years). The total opioids prescribed for the 24 hours after discharge significantly exceeded the opioids consumed the 24 hours before discharge for each orthopaedic subspecialty. The excessive-prescription group (409 patients) received greater daily opioid (120 oral morphine equivalents [OMEs] versus 60 OMEs; P < 0.01) and total opioid (750 OMEs versus 512.5 OMEs; P < 0.01) at discharge but was more likely to refill their opioid prescription within 30 days of discharge (27.6% versus 20.1%; P = 0.043). DISCUSSION: Opioid regimens prescribed after an orthopaedic surgery frequently exceed inpatient opioid use. Opioid regimens that approximate inpatient use may help curb overprescription and are not associated with higher refill rates compared with more excessive prescriptions. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Irrigation and Debridement, Modular Exchange, and Implant Retention for Acute Periprosthetic Infection After Total Knee Arthroplasty.

The role of irrigation and debridement, modular exchange, and implant retention for the treatment of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) remains controversial. The proposed benefits of debridement, antibiotics, and implant retention, often referred to as DAIR, include reduced economic cost and morbidity of 2-stage reimplantation1. The primary disadvantage of this approach is a higher rate of failure and infection recurrence2,3. Furthermore, several authors have demonstrated inferior outcomes of 2-stage exchange revision arthroplasty after a failed attempt at limited debridement with implant retention4-6. Because of study heterogeneity, the outcomes of acute PJI treatment with irrigation and debridement and implant retention have been variable in the literature, with reported success rates ranging from 16% to 100%; overall, the success rate is around 50%3,7,8. Recently, studies evaluating outcomes of DAIR have indicated that host factors, organism type, the timing of intervention, and the duration of symptoms can influence the likelihood of success with this approach7,9-12. DAIR may be considered for all patients with early postoperative PJI or an acute hematogenous infection in the context of well-fixed implants and a healthy soft-tissue envelope. Chronic PJI should be considered an absolute contraindication to DAIR13. The patient's health status, comorbidities, and immune status also should be considered. Caution should be exercised when considering DAIR for a patient in whom preoperative cultures demonstrate a drug-resistant or highly virulent organism, because of a higher risk of failure1,9,14,15. With careful patient selection and meticulous surgical technique, it is possible to achieve success with this treatment strategy. The surgical procedure begins with a medial parapatellar approach and arthrotomy. A complete synovectomy is then performed, and remaining synovial tissue is aggressively debrided. Multiple culture samples should be obtained, and aseptic technique should be utilized to decrease contamination. The implant is interrogated to ensure stable fixation. Following adequate debridement, high-volume irrigation is performed; in cases involving irrigation and debridement with implant retention, we recommend incorporation of an antiseptic solution such as povidone-iodine. We recommend switching to a clean setup to facilitate sterile, uncontaminated closure of the wound, which is performed in a standard fashion. Meticulous attention should be paid to layered closure, and, if there is concern about delayed skin-healing, incisional negative-pressure wound therapy may be utilized.

A Goal-directed Quality Improvement Initiative to Reduce Opioid Prescriptions After Orthopaedic Procedures.

Orthopaedic surgeons are increasingly aware of deleterious effects of the opioid epidemic and the association between overprescription and diversion toward nonmedical opioid use or substance abuse. Opiate prescriptions at the time of hospital discharge have been identified as target for intervention. This study describes the successful outcome of a goal-directed intervention aimed at decreasing opioid overprescription by providing routine feedback to providers regarding their prescribing patterns. METHODS: The amount of opioid medications, quantified as oral morphine equivalents (OMEs), provided to opioid-naive adult patients on discharge after orthopaedic surgery was prospectively collected. As part of an institutional quality improvement initiative, medical providers received reports every 2 months detailing median discharge OMEs prescribed, trended over time. After 6 months, a retrospective comparison was done between preintervention and intervention patient cohorts. RESULTS: There were 401 patients in the preintervention cohort and 429 patients in the intervention cohort. Both groups were similar in regard to age, sex, rates of depression, surgical time, length of stay, orthopaedic subspecialty, and inpatient opioid requirement before discharge. Patients in the intervention cohort were prescribed markedly fewer opioid medications by 25%, equivalent to 20 tablets of 5-mg oxycodone IR (450 versus 600 OMEs, P < 0.001). Despite these opioid medications, opioid refill rates during the first 90 days after discharge did not markedly change between groups. DISCUSSION: It is critical to judiciously treat postoperative pain while avoiding opioid overprescription. This study demonstrated the outcome of a goal-directed initiative to decrease overprescription of opioid medications. The initiative reduced discharge opioid prescriptions yet did not increase the risk of requiring a prescription refill in the postoperative period. This indicates that such an approach can result in opioid reduction, while still providing appropriate care and pain control for patients.

Variability in conflict of interest disclosures by physicians presenting trauma research.

AIM: To quantify the variability of financial disclosures by authors presenting orthopaedic trauma research. METHODS: Self-reported authorship disclosure information published for the 2012 American Academy of Orthopaedic Surgeons (AAOS) and Orthopaedic Trauma Association (OTA) meetings was compiled from meeting programs. Both the AAOS and OTA required global disclosures for participants. Data collected included: (1) total number of presenters; (2) number of presenters with financial disclosures; (3) number of disclosures per author; (4) total number of companies supporting each author; and (5) specific type of disclosure. Disclosures made by authors presenting at more than one meeting were then compared for discrepancies. RESULTS: Of the 5002 and 1168 authors presenting at the AAOS and OTA annual meetings, respectively, 1649 (33%) and 246 (21.9%) reported a financial disclosure (P < 0.0001). At the AAOS conference, the mean number of disclosures among presenters with disclosures was 4.01 with a range from 1 to 44. The majority of authors with disclosures reported three or more disclosures (n = 876, 53.1%). The most common cited disclosure was as a paid consultant (51.5%) followed by research support (43.0%) and paid speaker (34.8%). Among the 256 physicians with financial disclosures presenting at the OTA conference, the mean number of disclosures was 4.03 with a range from 1 to 22. Similar to the AAOS conference, the majority of authors with any disclosures at the OTA conference reported three or more disclosures (n = 140, 54.7%). Most authors with a disclosure had three or more disclosures and the most common type of disclosure was paid consulting. At the OTA conference, the most commonly cited form of disclosure was paid consultant (54.3%) followed by research support (46.1%) and paid speaker (42.6%). Of the 346 researchers who presented at both meetings, 112 (32.4%) authors were found to have at least one disclosure discrepancy. Among authors with a discrepancy, 36 (32.1%) had three or more discrepancies. CONCLUSION: There were variability and inconsistencies in financial disclosures by researchers presenting orthopaedic trauma research. Improved transparency of conflict of interest disclosures is warranted among trauma researchers presenting at national meetings.

Del1 Knockout Mice Developed More Severe Osteoarthritis Associated with Increased Susceptibility of Chondrocytes to Apoptosis.

OBJECTIVE: We identified significant expression of the matricellular protein, DEL1, in hypertrophic and mature cartilage during development. We hypothesized that this tissue-specific expression indicated a biological role for DEL1 in cartilage biology. METHODS: Del1 KO and WT mice had cartilage thickness evaluated by histomorphometry. Additional mice underwent medial meniscectomy to induce osteoarthritis, and were assayed at 1 week for apoptosis by TUNEL staining and at 8 weeks for histology and OA scoring. In vitro proliferation and apoptosis assays were performed on primary chondrocytes. RESULTS: Deletion of the Del1 gene led to decreased amounts of cartilage in the ears and knee joints in mice with otherwise normal skeletal morphology. Destabilization of the knee led to more severe OA compared to controls. In vitro, DEL1 blocked apoptosis in chondrocytes. CONCLUSION: Osteoarthritis is among the most prevalent diseases worldwide and increasing in incidence as our population ages. Initiation begins with an injury resulting in the release of inflammatory mediators. Excessive production of inflammatory mediators results in apoptosis of chondrocytes. Because of the limited ability of chondrocytes to regenerate, articular cartilage deteriorates leading to the clinical symptoms including severe pain and decreased mobility. No treatments effectively block the progression of OA. We propose that direct modulation of chondrocyte apoptosis is a key variable in the etiology of OA, and therapies aimed at preventing this important step represent a new class of regenerative medicine targets.

How do supervising physicians decide to entrust residents with unsupervised tasks? A qualitative analysis.

BACKGROUND: Medical supervisors struggle to find meaningful ways to evaluate the preparedness of trainees to independently perform patient care tasks. The aim of this study was to describe the factors that influence how attending and resident physician perceptions of trust impact decision making. METHODS: Internal medicine residents and attending physicians at a tertiary academic medical center were interviewed during a single academic year. Participants were asked to describe, using the critical incident technique, entrustment decisions made during their clinical rotations. A deductive qualitative analysis using the entrustable professional activities framework was used. The inter-rater reliability was calculated using a generalized kappa statistic. RESULTS: Eighty-four percent (46/50) of residents and 88% (44/50) of attending physicians participated. The analysis yielded 535 discrete mentions of entrusting factors that were mapped to the following domains deductively, with inductively derived subthemes: trainee factors (eg, confidence, specialty plans), supervisor factors (eg, approachability), task factors (eg, situational characteristics) and systems factors (eg, workload). The inter-rater kappa between the 2 raters was 0.84. CONCLUSIONS: Factors influencing trust in a trainee are related to the supervisor, trainee, their relationship, task, and the environment. Attending physicians note early interactions and language cues as markers of trustworthiness. Attending physicians reported using perceived confidence as a gauge of the trainee's true ability and comfort. Attendings noted trainee absences, even those that comply with regulation, negatively affected willingness to entrust. Future studies are needed to develop better assessment instruments to understand how entrustment decisions for independent practice are made.