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.

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.

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.

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.

Comparison of Outcomes 1 Year After Rotator Cuff Repair With and Without Concomitant Biceps Surgery.

PURPOSE: To compare the outcomes of patients who undergo a long head of the biceps (LHB) procedure (tenotomy or tenodesis) concomitant with rotator cuff repair (RCR) to those of patients who undergo isolated RCR. METHODS: Prospectively collected data were retrospectively reviewed on 80 patients, >18 years old, who underwent repair of a full-thickness rotator cuff tear and with 1-year patient-reported outcome scores collected June 2012 to March 2015. The exclusion criteria were concomitant procedures other than LHB tenotomy, tenodesis, or subacromial decompression; prior shoulder surgery; or other shoulder pathology. The 3 patient groups are as follows: RCR + tenotomy, RCR + tenodesis, and isolated RCR. The primary outcome measures were American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Rotator Cuff (WORC) index, and visual analog scale (VAS) for pain. A t-test measured the mean improvement in LHB patients compared with isolated RCR patients and compared the LHB tenotomy and tenodesis groups. Stepwise linear progression used LHB tenotomy or tenodesis as the primary predictor. RESULTS: The biceps procedure group had more female patients (22 vs 7, P = .01); otherwise there were no significant baseline differences. The LHB procedure group had significantly worse baseline ASES scores (mean, 48.9 vs 58.7; P = .032). All RCR patients showed significant improvement in all 3 outcome measures. Patients who had either LHB tenotomy or tenodesis (n = 45) demonstrated significantly greater mean improvement in ASES (mean, 42.7 vs 23.8; P = .002), VAS (mean, 49.2 vs 35.7; P = .020), and WORC scores (mean, 928 vs 743; P = .029) at 1-year follow-up compared with patients who had isolated RCR. ASES scores at 1 year were significantly better in the biceps group (91.6 vs 82.5; P = .023). Linear regression found a biceps procedure to be predictive of a significantly greater improvement in ASES score (P = .01). Analysis of variance revealed that both the LHB tenotomy (P = .04) and tenodesis (P = .01) groups demonstrated more favorable improvement in ASES when compared with RCR alone. CONCLUSIONS: Patients who underwent a concomitant biceps procedure when indicated at the time of RCR demonstrated inferior baseline patient-reported outcome measures and greater improvement after 1 year, as well as more favorable ASES scores at 1 year compared with isolated RCR patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Restricted Hip Rotation Is Correlated With an Increased Risk for Anterior Cruciate Ligament Injury.

PURPOSE: The primary purpose was to compare ipsilateral hip internal rotation (IR) in male and female athletes with or without an anterior cruciate ligament (ACL) tear. A secondary purpose was to compare radiographic markers of femoroacetabular impingement (FAI) in patients with or without an ACL tear. METHODS: In this prospective case-control study, based on a power analysis, a convenience sample of 25 ACL-injured and 25 control patients matched by age and gender were examined over 14 months. The ACL injury group included preoperative patients 12-40 years old with an ACL rupture within the previous 3 months with no prior lower extremity injuries, ligamentous laxity, or arthralgias. Controls included patients presenting with an upper extremity complaint with no history of knee injury. In the outpatient clinic, hip axial rotation range of motion was measured with a goniometer on physical examination and hip radiographs were evaluated for morphologic variations consistent with FAI. Univariate analysis of variance was used to examine differences between groups. RESULTS: Each group had 13 males and 12 females, average ages of 22.8 ± 7.2 years (ACL group) versus 24.5 ± 7.9 years (controls; P = .439). The average sum of hip rotation (internal plus external) in patients with an ACL tear was 60.3 ± 12.4° compared with 72.6 ± 17.2° in controls (P = .006). ACL-injured patients had decreased hip IR compared with controls, with respective mean measurements of 23.4 ± 7.6° versus 30.4 ± 10.4° (P = .009). For every 10° increase in hip IR, the odds of having an ACL tear decreased by a factor of 0.419 (P = .015). CONCLUSIONS: Risk of ACL injury is associated with restricted hip IR, and as hip IR increases, the odds of having an ACL tear decreases. In addition, ACL injury is associated with FAI in a generalized population of male and female athletes, although causality cannot be determined and most ACL-injured patients do not exhibit hip complaints. LEVEL OF EVIDENCE: Level II, prognostic, prospective cohort study.

Acetabular and Femoral Anteversions in Standing Position are Outside the Proposed Safe Zone After Total Hip Arthroplasty.

BACKGROUND: Although most hip dislocations occur in either standing or sitting position, the safe zone for implant position is defined for the supine position. Our goal was to determine preoperative and postoperative pelvis and hip orientations and whether the safe zone defined in supine position can be used to assess standing radiographs. METHODS: Preoperative and postoperative three-dimensional EOS images were assessed in 66 total hip arthroplasty patients. None of the patients had dislocation within the follow-up period (12-36 months). The acetabular anteversion (both anterior pelvic plane [APP] and patient functional plane) and the femoral anteversion were measured. The sacral slope, pelvic version, pelvic inclination, and pelvic incidence were also measured. RESULTS: Acetabular anteversion increased postoperatively in both APP and patient functional plane (P <.001). Femoral neck anteversion decreased postoperatively (P =.0942). Sacral slope was 42.4° (-25.9° to 24°) preoperatively compared with 40.3° (-4.1° to 64.2°) postoperatively (P =.013). Pelvic version changed from 15.2° (-10.4° to 43.8°) to 17.2° (-6° to 46.7°; P = 0.008). Pelvic inclination was 1.12° (-25.9° to 24°) before total hip arthroplasty and -1.2° (-40.7° to 23.4°) postoperatively (P =.005). CONCLUSION: The acetabular and femoral implant orientations in standing position reside out of the safe zone in most patients. The APP is not vertical in standing position in most patients due to anterior or posterior pelvic tilt. The proposed safe zone in supine position may not be a useful measure in the assessment of standing radiographs of patients with significant anterior or posterior pelvic tilt. LEVEL OF EVIDENCE: Level IV, therapeutic case series study.

Are advanced three-dimensional imaging studies always needed to measure the coronal knee alignment of the lower extremity?

BACKGROUND: Coronal malalignment of the lower extremity is closely related to the onset and progression of osteoarthritis. Restoring satisfactory alignment after tibial osteotomy improves the long-term success of this conservative surgery. The purpose of our study was to determine (1) if there is a difference between two-dimensional (2D) and 3D measurements of the hip-knee-ankle (HKA) angle between the mechanical axes of the femur and the tibia, (2) which parameter most affects 2D-3D HKA measurement, and (3) the percentage of patients who are at risk of error in HKA measurement. METHODS: We reviewed imaging studies of the consecutive patients referred to us for hip or knee pain between June and October 2013. Patients with previous pelvis or lower extremity surgery were excluded. RESULTS: In 51 % (95/186) of lower extremities examined, the 3D method showed more valgus than the 2D method, and in 49 % (91/186), the 3D method showed more varus. In 12 % of extremities (23/186), the knee varus or valgus alignment was completely opposite in 3D images compared to 2D images. Having more than 7° of flexum/recurvatum alignment increased error in 2D HKA measurement by 5.7°. This was calculated to be 0.15° per 1° increase in femoral torsion and 0.05° per 1° increase in tibial torsion. Approximately 20 % of patients might be at risk of error in HKA angle measurement in 2D imaging studies. CONCLUSIONS: Orthopaedic surgeons should assess lower extremity alignment in standing position, with enough exposure of the extremity to find severe alignment or rotational deformities, and consider advanced 3D images of those patients who have them. Otherwise, HKA angle can be measured with good accuracy with 2D techniques. LEVEL OF EVIDENCE: Level-III diagnostic.

Qualitative Assessment and Quantitative Analysis of the Long Head of the Biceps Tendon in Relation to the Pectoralis Major Tendon Humeral Insertion: An Anatomic Study.

PURPOSE: To qualitatively assess and to quantitatively analyze the long head of the biceps tendon (LHBT) in the region of the pectoralis major (PM). METHODS: From 11 fresh cadaveric donors, 20 cadaveric shoulders without operative scars were dissected-mean age, 76.9 years (range, 61 to 93 years); male, 75%; left-sided, 55%; mean height, 67.8 inches (range, 61 to 71 inches); mean weight, 148.1 pounds (range, 106 to 176 pounds). Two specimens with discovered ruptures were excluded. The LHBT circumference was measured at the anterior edge of supraspinatus, suprapectorally, midpectorally, and subpectorally. The muscle was then removed from the LHBT and the circumference was again measured at the supra-, mid-, and subpectoral levels. These data were used to calculate the area of the tendon. All measurements were performed by 2 independent observers. Statistical analysis was performed to assess reliability of data and the difference between serial measurements. RESULTS: The mean calculated percentage tendon decreased from 86.7% at the superior edge of the PM to 49.8% at the midpoint of the PM and to 17.5% at the inferior edge of the PM. CONCLUSIONS: Distal to the PM, the LHBT was composed of a small percentage of tendon to muscle, which may have implications for the mechanical strength of fixation of tenodesis. The anatomic location of the musculotendinous junction of the LHBT began proximal to the superior edge of the PM tendon, which implies that restoration of anatomic tensioning may require a more proximal docking site than previously described. Tenodesis performed between the midpoint of the PM insertion and more distal points involves a significant portion of muscle, which may not be optimal. CLINICAL RELEVANCE: Tenodesis performed between the midpoint of the PM insertion and more distal points involves a significant portion of muscle, which may affect the mechanical strength or optimal choice of fixation location.

Evaluation of American Academy of Orthopaedic Surgeons Appropriate Use Criteria for the management of full-thickness rotator cuff tears.

BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) recently released Appropriate Use Criteria (AUC) to aid in determining the appropriateness of treatment options. This study compares AAOS AUC recommendations with a cohort of patients treated for known full-thickness rotator cuff tears (RCTs). METHODS: Prospectively collected demographic information, treatment allocation, and American Shoulder and Elbow Surgeons (ASES) shoulder and Western Ontario Rotator Cuff Index scores of 134 patients were retrospectively reviewed. Other criteria required by the AAOS AUC were collected by retrospective record review. Criteria were entered into the AAOS AUC Web-based application to rate the "appropriateness" of treatment options. Ratings were compared with actual treatments and outcomes at 32- or 48-week follow-up. RESULTS: There was excellent agreement between the AUC recommendations and the actual treatment administered (κ = .945; 95% confidence interval, 0.892-1.000; P <.0001). The administered treatment was "appropriate" for 79% of patients, "may be appropriate" for 19%, and "rarely appropriate" for 2%. Response to previous treatment (P <.0001), American Society of Anesthesiologists Physical Status Classification (P <.0001), and presence of muscle atrophy or fatty infiltration (P = .047) were the only variables that significantly and independently predicted discordance between treatment and the AUC recommendation. In the cases (n = 3) of discordance, the American Shoulder and Elbow Surgeons score improved significantly more (P = .049) than when there was agreement. CONCLUSIONS: Improved clinical outcomes may be achieved for full-thickness RCTs when AAOS AUC recommendations are followed; however, because improved clinical outcomes may also be achieved when the recommendations are not followed, further investigation is needed in a population of patients in whom there is discordance between AAOS AUC recommendations and the treatment administered.

Do Patients' Perceptions of Leg Length Correlate With Standing 2- and 3-Dimensional Radiographic Imaging?

BACKGROUND: This study compared 2- and 3-dimensional (2D and 3D) radiographic measurements of anatomical and functional leg length and knee coronal and sagittal alignments and correlated these measurements with patients' leg-length perceptions. METHODS: Patients without symptomatic spinal pathology, previous surgery of the spine, and lower extremities (140 lower extremities) were evaluated on EOS images obtained in standing position. Numerous measurements of each limb were compared to the contralateral limb. All 2D/3D measures were evaluated and compared for repeatability and reproducibility. RESULTS: Mean 2D functional and anatomical lengths were 78.7 cm (64.7-88.4, confidence interval [CI] 95%: 77.4-80) and 78.3 cm (64.9-87.9, CI 95%: 77-79.6), respectively. Mean 3D functional and anatomical lengths were 78.9 cm (65.1-88.7, CI 95%: 77.6-80.2) and 78.9 cm (65.6-88.3, CI 95%: 77.8-80.5), respectively (P < .001). Mean 2D and 3D knee varus/valgus angles were -1.9° (-26.4 to 9.1, CI 95%: -3.5 to -0.7) and -0.9° (-19.2 to 11.8, CI 95%: -2.4 to 0.2), respectively (P = .004). Multiple regression analysis found that patients with >10° of flexum/recurvatum were 2.1× more likely to perceive unequal length (P < .1). Patients with irreducible varus/valgus knee deformity were 4× more likely to perceive unequal length (P < .04). CONCLUSION: EOS imaging allows more accurate assessment of anatomical and functional lengths. Patients' perceptions of lower extremity length may correlate more closely with coronal and sagittal alignments of the knee than with femoral or tibial length. This study highlights the importance of physical examination of all the joints and 3D measurements in functional standing position.

A review of the long-term health outcomes associated with war-related amputation.

The rate of war-related amputations in current U.S. military personnel is now twice that experienced by military personnel in previous wars. We reviewed the literature for health outcomes following war-related amputations and 17 studies were retrieved with evidence that (a) amputees are at a significant risk for developing cardiovascular disease; (b) insulin may play an important role in regulating blood pressure in maturity-onset obesity; (c) lower-extremity amputees are at risk for joint pain and osteoarthritis; (d) transfemoral amputees report a higher incidence of low back pain than transtibial amputees; and (e) 50 to 80% report phantom limb pain, with many amputees stating they were either told that their pain was imagined or their mental state was questioned. The consistency of the observations on health outcomes in these studies warrants careful examination for their implication in the contemporary treatment of war-related amputation.

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.

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.

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.

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.

The effect of lipid levels on patient-reported outcomes in patients with rotator cuff tears.

BACKGROUND: Lipid disorders could be associated with the prevalence and outcomes of rotator cuff diseases. This study aimed to learn how levels of various types of lipids influence the patient-reported outcomes of patients with rotator cuff tears (RCTs). METHODS: Data from a cohort study of 135 patients with RCTs were used. The outcome measures included Western Ontario Rotator Cuff (WORC) index, American Shoulder and Elbow Surgeons (ASES) standardized shoulder assessment form, Single Assessment Numeric Evaluation, visual analog scale for pain and satisfaction, and Veterans RAND 12-Item Health Survey (VR-12). Multivariable random-effects models were built to examine how total cholesterol, triglycerides, high-density lipoprotein (HDL), low-density lipoprotein, and ratio of total cholesterol to HDL influence each outcome, controlling for covariates. RESULTS: After adjusting for age, gender, surgery, smoking, and baseline outcome values, patients with triglycerides >150 mg/dL had significantly higher pain visual analog scale (ß = 5.86; P = .017) and lower VR-12 physical component summary (ß = -2.71; P = .002) scores. Patients with low HDL had significantly worse WORC (ß = 132.26; P = .020) and ASES (ß = -7.05; P = .005) scores, more pain (ß = 6.69; P = .024), and less satisfaction (ß = -6.53; P = .008). The ratio of total cholesterol to HDL was associated with worse WORC (ß = 58.46; P = .006) and ASES scores (ß = -2.74; P = .002), more pain (ß = 4.49; P < .001), and worse VR-12 physical component summary score (ß = -1.03; P = .017). CONCLUSIONS: Dyslipidemia may decrease the improvement of patient-reported outcomes in patients undergoing treatment for RCTs; high triglycerides and low HDL may have the most impact.

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.

Is There an Association Between the "Critical Shoulder Angle" and Clinical Outcome After Rotator Cuff Repair?

BACKGROUND: Variations in scapular morphology have been associated with the development of atraumatic rotator cuff tears (RCTs). The critical shoulder angle (CSA) accounts for both glenoid inclination and lateral extension of the acromion. The impact of the CSA on outcomes after rotator cuff repair (RCR) has not been investigated previously. HYPOTHESIS: Our hypothesis was that individuals with smaller CSAs will have better patient-reported outcome scores over time compared with those with larger CSAs. Theoretically, a smaller CSA minimizes the biomechanical forces favoring superior translation of the humeral head, which may be advantageous after RCR. This is the first study to examine the relationship between the CSA and clinical outcomes after RCR. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Fifty-three patients (mean age, 61 years) with atraumatic full-thickness RCTs who underwent arthroscopic RCR were prospectively evaluated. Demographic data as well as the Western Ontario Rotator Cuff Index (WORC) score, American Shoulder and Elbow Surgeons (ASES) score, and a visual analog scale (VAS) for pain were prospectively collected at various time points up to 24 months postoperatively. Statistical analysis included longitudinal multilevel regression modeling to investigate the association between the CSA and the WORC, ASES, and VAS scores. RESULTS: The overall clinical outcome, as measured by the WORC, ASES, and VAS, improved significantly (P < .0001). Controlling for demographic and clinical characteristics, a multilevel regression analysis demonstrated that the CSA was not a significant independent predictor for change in WORC (P = .581), ASES (P = .458), or VAS (P = .859) scores at 24 months after arthroscopic RCR. Interobserver and intraobserver reliability for CSA measurements resulted in interclass correlation coefficients of 0.986 and 0.982, respectively (P < .001), indicating excellent agreement. CONCLUSION: The CSA did not appear to be a significant predictor of patient-reported outcomes after arthroscopic repair of atraumatic full-thickness RCTs.