Republication of "Postoperative Narcotic Prescription Practice in Orthopedic Foot and Ankle Surgery".

Background: The misuse and abuse of opioid pain medications have become a public health crisis. Because orthopedic surgeons are the third highest prescribers of opioids, understanding their postoperative pain medication prescribing practices is key to solving the opioid crisis. To this end, we conducted a study of the variability in orthopedic foot and ankle surgery postoperative opioid prescribing practice patterns. Methods: Three hundred fifty orthopedic foot and ankle surgeons were contacted; respondents completed a survey with 4 common patient scenarios and surgical procedures followed by questions regarding typical postoperative pain medication prescriptions. The scenarios ranged from minimally painful procedures to those that would be expected to be significantly more painful. Summaries were calculated as percentages and chi-square or Fisher exact tests were used to compare survey responses between groups stratified by years in practice and type of practice. Results: Sixty-four surgeons responded to the survey (92.8% male), 31% were in practice less than 5 years, 34% 6 to 15 years and 34% more than 15 years. For each scenario, there was variation in the type of pain medication prescribed (scenario 1: 17% 5 mg hydrocodone, 22% 10 mg hydrocodone, 52% oxycodone, and 3% oxycodone sustained release [SR]; scenario 2: 15% 5 mg hydrocodone, 13% 10 mg hydrocodone, 58% oxycodone, and 9% oxycodone SR; scenario 3: 11% 5 mg hydrocodone, 13% 10 mg hydrocodone, 56% oxycodone, and 14.1% oxycodone SR; scenario 4: 3% 5 mg hydrocodone, 5% 10 mg hydrocodone, 44% oxycodone, and 45% oxycodone SR) and the number of pills dispensed. Use of multimodal pain management was variable but most physicians use regional nerve blocks for each scenario (76%, 87%, 69%, 94%). Less experienced surgeons (less than 5 years in practice) supplement with tramadol more for scenario 1 (P = .034) as well as use regional nerve blocks for scenario 2 (P = .039) more than experienced surgeons (more than 15 years in practice). Conclusion: It is evident that variation exists in narcotic prescription practices for postoperative pain management by orthopedic foot and ankle surgeons. With new AAOS guidelines, it is important to try to create some standardization in opioid prescription protocols.

Radionuclide imaging in the diagnosis and management of orthopaedic disease.

Nuclear medicine imaging is often used in the diagnosis and management of several orthopaedic conditions. Bone scintigraphy measures gamma ray emission to detect the distribution of an injected radiolabeled tracer on multiple image projections. In general, this imaging modality has relatively high sensitivity but low specificity in the diagnosis of occult fractures, bone tumors, metabolic bone disease, and infection. Positron emission tomography measures tissue metabolism and perfusion by detecting short half-life positron ray emission of an injected radiopharmaceutical tracer. Historically, positron emission tomography has been used only to monitor bone metastasis and aid in the diagnosis of osteomyelitis; however, this technology has recently been applied to other orthopaedic conditions for which current imaging modalities are insufficient.

Percutaneous Fixation of a Fifth Metatarsal Base Fracture.

SUMMARY: Owing to a vascular watershed, zone II and III fifth metatarsal base fractures commonly progress to nonunion without operative intervention. This article and the accompanying video demonstrate the use of intramedullary screw fixation for a fifth metatarsal base fracture and review treatment decisions involved with management of these injuries.

Complications After Popliteal Block for Foot and Ankle Surgery.

BACKGROUND: A popliteal nerve block is a common analgesic procedure for patients undergoing surgery on their knee, foot, or ankle. This procedure carries less risk in a surgical setting compared with other forms of anesthesia such as a spinal block. Previous reports demonstrated few to no complications with the use of this nerve block, but it is unclear whether these data are consistent with the recent increase in use of this analgesic procedure for lower extremity surgery. METHODS: Retrospectively, a busy orthopedic foot and ankle practice performed a chart review examining for postoperative neuropathic complications possibly related to the popliteal nerve block. The 1014 patients who had undergone a popliteal block for foot and/or ankle orthopedic surgery were analyzed for short and long-term neuropathic complications. The collected data consisted of tourniquet time, pressure, and location as well as the method of finding the fossa nerve, adjuncts used, and patient medical history. Data were analyzed using chi-square, Fisher's exact, and t tests for analysis with a significance value of P < .05. RESULT: Of these 1014 patients, 52 patients (5%) developed deleterious symptoms likely resulting from their popliteal block, and 7 (0.7%) of these were unresolved after their last follow-up. No immediately apparent underlying causes were determined for these complications. CONCLUSION: The frequency of a neuropathic complication following a popliteal nerve block was notably higher in the early postoperative period than indicated in the past. The proportion of patients with unresolved neuropathic symptoms at last follow-up is comparable to that previously reported in the literature. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Continuous scale physical functional performance test: appropriateness for middle-aged adults with and without Parkinson's disease.

PURPOSE: Functional measures are needed that are applicable to middle-aged adults with neurological disorders who are on the threshold of disability. One potential measure is the Continuous Scale Physical Functional Performance Test (CS-PFP), which has been normalized and validated to older adults but performance is unknown for adults younger than the age of 65 years with and without neurological disorders. The purposes of this investigation were (1) to compare scores on the CS-PFP of nondisabled adults in three age groups from 35 to 64 years with two groups of individuals older than the age of 65; (2) to determine whether there is a ceiling effect for nondisabled middle-aged adults; and (3) to determine whether performance of individuals in early stages of Parkinson's disease (PD) age 45 to 64 years differ significantly from performance of similarly aged nondisabled adults. METHODS: Data were obtained from three samples: (1) 37 adults with PD (45-54 and 55-64 years; 57% female), (2) 70 nondisabled adults (35-44, 45-54, and 55-64 years; 69% female); (3) 72 nondisabled older adults (65-74 and 75-85 years; 79% female). The CS-PFP was administered in a single test session for each subject. Analysis of variance was performed for group differences with adjustment of sex as a covariate followed by a Student-Newman-Keuls post hoc analysis. RESULTS: For nondisabled individuals, the CS-PFP total and domain scores were significantly lower in the oldest group (75-85 years) compared to all other age groups and significantly higher in the younger two groups (35-44 and 45-54 years) compared to the older groups. There was no ceiling effect for any domain score or total score for the adults younger than 65 years. For individuals with PD, both age groups had significantly lower scores on the CS-PFP than did the nondisabled counterparts. CONCLUSIONS: Results from the nondisabled middle-aged individuals provide comparison data to be used clinically or in investigations of middle-aged adults with neurological dysfunction. Comparison of middle-aged individuals with PD to middle-aged nondisabled adults illustrates the true extent of functional difficulty experienced by individuals with PD and demonstrates the importance of using age appropriate comparison data. The CS-PFP is particularly applicable to middle-aged adults with compromised functional performance for their age but is too high to be effectively quantified with other assessment measures.