Management of Lunate Facet Escape after Distal Radius Fracture Volar Plating: Surgical Technique.

Fractures involving the lunate facet of the distal radius (commonly called the volar ulnar corner or "critical corner") are often difficult to recognize radiographically. "Lunate facet escape" refers to the displacement of this fragment after attempted distal radius fracture closed or open reduction methods. Lunate facet escape can have severe consequences including carpal collapse with pain, instability, and arthritis. Challenges to lunate facet fixation include irregular cortical contour that makes plate fixation difficult, as well as deforming forces by inserting structures. The goal of the management of a distal radius fracture with lunate facet involvement is first identification, then adequate stabilization until osseous healing occurs. However, subsequent lunate facet escape can pose a challenging clinical and surgical dilemma. Here we discuss our preferred approach to treat lunate facet escape after distal radius fracture volar locking plating failure.

Extensor tendon transfer for fracture-related extensor pollicis longus rupture: Long-term outcome case series.

BACKGROUND: Spontaneous rupture of the extensor pollicis longus (EPL) tendon following both nonoperative and operative treatment of distal radius fractures has been well described. PURPOSE: The purpose of this study was to assess long-term outcomes of extensor indicis proprius to EPL tendon transfers for patients following distal radius fracture and EPL tendon repair. STUDY DESIGN: Retrospective case series focusing on long-term clinical outcomes. METHODS: A retrospective review was conducted for patients who sustained a distal radius fracture and subsequently underwent extensor tendon transfer from 2005-2015 at a private practice center. Outcome measures including index finger (IF) metacarpophalangeal (MCP) and thumb interphalangeal (IP) active range of motion (ROM), digital extension against resistance, subjective complaints, and QuickDASH scores were recorded at final follow-up. RESULTS: Seven patients were included in the study. There were six females and one male subject, mean age of 54 ± 13 years at injury of EPL, and 5/7 involved the left upper extremity. For isolated function, 7/7 (100%) patients had isolated, active IF MCP extension, 6/7 (86%) could extend IF MCP and thumb IP against resistance. Mean IF MCP extension was 1° ± 2°, mean IF MCP flexion was 89° ± 2°, mean thumb IP extension was -5° ± 4°, and mean thumb IP flexion was 67° ± 15°. Mean QuickDASH score was 16 ± 14. CONCLUSIONS: This series shows good long-term functional and patient reported outcomes in patients following extensor indicis proprius to EPL tendon transfers at a single center.

Pulmonary Complications and Mortality in Patients with SARS-CoV-2 Undergoing Elective and Emergent Hand Surgery.

Background Patients acutely infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may have increased risk for postsurgical pulmonary complications and mortality, particularly with general anesthesia. Surgery is often delayed to mitigate risk; however, excessive delays may result in morbidity. Optimal criteria for delaying surgery in patients with or without symptoms are unknown. This study aimed to evaluate any complications following hand surgery in patients testing positive for SARS-CoV-2. Methods We retrospectively reviewed patients with a positive polymerase chain reaction test within 60 days before or after hand surgery between March 31, 2020 and March 31, 2021. Patients were telephoned also to supplement records. Type of surgery, type of anesthesia, comorbidities, timing of surgery, onset of symptoms, and complications were recorded. Results We identified 21 patients undergoing 26 procedures, of which 21 (81%) were emergency procedures and 5 (19%) were elective. Mean age was 37 years (range: 17-71). General anesthesia was used in 88% of cases, with mean duration of 110 minutes. SARS-CoV-2 was diagnosed on average 6 days preoperatively (range: 39 days preop-14 days postop). Positive tests were usually identified preoperatively (50%), versus day-of-surgery (25%) or postoperatively (25%). Patients were symptomatic in only 27% of cases, and completely asymptomatic in 73%. No asymptomatic patients developed complications. One patient suffered a fracture malunion after delayed surgery. Pulmonary complications were noted in 3 patients; all had prior pulmonary disease and underwent emergency surgeries under general anesthesia. Overall mortality rate was 0%. Conclusion Pulmonary complications and mortality are low following hand surgery in asymptomatic patients with a positive SARS-CoV-2 test.

Analyses of Orthopaedic Surgery Residency Interviews.

Interviews are a critical component of orthopaedic surgery residency selection for both the applicant and the program. Some institutions no longer report Alpha Omega Alpha (AOA) designation or class rank, and US Medical Licensing Examination (USMLE) Step 1 recently switched to pass/fail scoring. During the coronavirus disease 2019 (COVID-19) pandemic, all Accreditation Council for Graduate Medical Education programs conducted virtual interviews and subinternship rotations were restricted. These changes offer significant challenges to the residency match process. The purpose of this study was to examine the residency applicant interview and ranking process at a large urban academic university setting. We hypothesized that large variability exists among evaluations submitted by faculty interviewers and also that applicant academic factors (i.e., USMLE Step 1 score) would show association with final ranking. Methods: We retrospectively reviewed the 2020-2021 and 2021-2022 residency interview cycles, both conducted virtually due to the COVID-19 pandemic. Residency application (i.e., applicant demographic and academic backgrounds) and interview data (i.e., faculty interviewer scores) were recorded. Interobserver reliability among faculty interviewers was calculated. Statistical analysis was performed to determine factors associated with ranking of applicants. Results: There were 195 included applicants from the 2020 and 2021 interview cycles. There was no true agreement of interviewers' scoring of shared applicants (kappa intraclass coefficient range 0-0.2). Applicant factors associated with being ranked include applying to the match for the first time, USMLE Step 1 and 2 scores, educational break (vs. consecutive completion of college and medical school in 4 years each), higher class rank, and greater interviewer scores. Factors associated with better rank included additional degrees (i.e., PhD or MBA), couples match, AOA designation, educational break, underrepresented minority status, and notable attributes (i.e., collegiate athletics or Eagle Scout participation). Factors associated with worse rank included male sex, international medical graduate, prior match history, science major, extended research (i.e., >1 year spent in a research role), and home medical school students. Conclusions: There was significant variability and no reliability at our institution among faculty interviewers' applicant ratings. Being ranked was based more on academic record and interview performance while final rank number seemed based on applicant qualities. The removal of merit-based objective applicant measurements offers challenges to optimal residency applicant and program match. Level of Evidence: III (retrospective cohort study).

The Impact of Preoperative Symptom Duration on Patient Outcomes After Posterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: To determine if decreased preoperative symptom duration is associated with greater clinical improvement in function and myelopathic symptoms after posterior cervical decompression and fusion (PCDF). METHODS: All patients over age 18 who underwent primary PCDF for cervical myelopathy or myeloradiculopathy at a single institution between 2014 and 2020 were retrospectively identified. Patient demographics, surgical characteristics, duration of symptoms, and preoperative and postoperative patient reported outcomes measures (PROMs) including modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), Visual Analogue Scale (VAS) Neck, VAS Arm, and SF-12 were collected. Univariate and multivariate analyses were performed to compare change in PROMs and minimum clinically important difference achievement (%MCID) between symptom duration groups (< 6 months, 6 months-2 years, > 2 years). RESULTS: Preoperative symptom duration groups differed significantly by sex and smoking status. Patients with < 6 months of preoperative symptoms improved significantly in all PROMs. Patients with 6 months-2 years of preoperative symptoms did not improve significantly in mJOA, Physical Component Scores (PCS), or NDI. Patients with > 2 years of symptoms failed to demonstrate significant improvement in mJOA, NDI, or Mental Component Scores (MCS). Univariate analysis demonstrated significantly decreased improvement in mJOA with longer symptom durations. Increased preoperative symptom duration trended toward decreased %MCID for mJOA and MCS. Regression analysis demonstrated that preoperative symptom duration of > 2 years relative to < 6 months predicted decreased improvement in mJOA and NDI and decreased MCID achievement for mJOA and MCS. CONCLUSION: Increased duration of preoperative symptoms (> 2 years) before undergoing PCDF was associated with decreased postoperative improvement in myelopathic symptoms.

Evidenced-Based Opioid Prescribing Recommendations Following Hand and Upper-Extremity Surgery.

The United States' opioid epidemic has taken an immense toll over the past 2 decades when assessed by morbidities, mortalities, and economic costs. Prescription opioids are a substantial contribution to this public health emergency, and it is critical for health care providers to practice good analgesic stewardship. Interventions have effectively curtailed opioid overuse, including prescription drug monitoring programs, educational initiatives, and multimodal analgesia strategies. Surgeons, particularly hand surgeons or those who perform musculoskeletal procedures, have been implicated as high-volume opioid prescribers. Guidelines for appropriate opioid dosing and analgesic management strategies after common hand and upper-extremity surgeries are sparse and offer an area for meaningful improvement. We sought to generate comprehensive, evidence-based recommendations for postoperative analgesia regimens for common hand and upper-extremity procedures.

Reliability of Assessing Distal Radius Fractures on a Smartphone Versus PACS.

BACKGROUND: Communication between health care providers is becoming more intertwined with technology. During the pandemic, telehealth strategies grew exponentially. Remote viewing of imaging on a smartphone may offer efficient communication; however, the reliability of injury assessment when compared with traditional methods is not known. The purpose of this study was to evaluate intraobserver and interobserver reliability of distal radius fracture radiograph review for smartphone versus traditional Picture Archiving and Communication System (PACS). METHODS: Eight evaluators (3 attending hand surgeons, 3 hand surgery fellows, 2 orthopedic residents) evaluated 26 distal radius fracture radiographs on 2 different viewers: smartphone or PACS. The reviewers were asked to record: (1) operative or nonoperative preference; (2) fracture classification (based on Fernandez and Jupiter); and (3) treatment strategy (volar plate, dorsal plate, pins, cast, bridge plate, or fragment-specific fixation). The percentage of intraobserver agreement was recorded for each observer. Reliability was calculated using Fleiss' kappa coefficient for intraobserver and interobserver agreement and graded by strength of correlation. RESULTS: Intraobserver agreement averaged 97% when deciding between operative and nonoperative treatment, 76% for classification, and 84% for treatment. Kappa scores were graded as "excellent" for operative decision and "substantial" for classification and treatment. Attendings and fellows generally had higher agreement than that of residents. Interobserver agreement was graded as "substantial" for all categories for both PACS and smartphone. CONCLUSIONS: Evaluation of radiographs on a smartphone for the purpose of treating distal radius fractures does not appear to be significantly different from an evaluation on traditional PACS.

Preoperative Opioid Use Results in Greater Postoperative Opioid Consumption After Thumb Basal Joint Arthroplasty.

Purpose: Thumb basal joint arthroplasty surgery is a common hand surgery after which patients often require opioids. To better understand safe opioid consumption patterns, this study sought to identify risk factors for filling a second prescription and/or prolonged opioid use (prescription over 6 months after the surgery). Preoperative opioid use was hypothesized to show an association with greater postoperative opioid use. Methods: A retrospective review of consecutive patients who underwent primary thumb basal joint arthroplasty was conducted, yielding 110 patients for analysis. Demographic and clinical data were collected. Opioid prescription data were extracted from 6 months before the surgery to 9 months after the surgery using a state prescription drug monitoring program. Bivariate and multivariate analyses were performed for filling a second opioid prescription or filling an opioid prescription over 6 months after the surgery. Results: All the patients filled their initial postoperative prescription. Of the 110 patients, 26.4% filled an opioid prescription before the surgery, 42% filled a second postoperative prescription, and 14.5% were still consuming opioids over 6 months after the surgery. Patients using preoperative opioids had 7-fold higher odds of filling a second opioid prescription and 37-fold higher odds of prolonged use. No other demographic or clinical factors, including the type of procedure or number of initial opioids prescribed, were associated with increased use of postoperative opioids. Of all the opioid prescriptions filled after the initial postoperative prescription, only 9.3% were prescribed by a surgeon's office. Conclusions: Patients who undergo thumb basal joint arthroplasty with preoperative opioid use have much greater odds of filling a second opioid prescription and prolonged use after the surgery. Low initial surgeon-provided opioid dosages did not correlate to filling a second prescription, indicating that lower initial doses are feasible. Finally, nearly all opioid-naïve patients who filled a second opioid prescription received them from providers other than a surgeon, indicating the need for greater communication with nonsurgical providers simultaneously caring for patients in the perioperative period. Type of study/level of evidence: Therapeutic III.

Effects of toothbrushing on surface characteristics of microhybrid and nanofilled resin composites following different finishing and polishing procedures.

OBJECTIVES: To evaluate the effects of simulated tooth brushing (STB) on the surface roughness of microhybrid and nanofilled resin composites following different finishing and polishing procedures. MATERIALS AND METHODS: Ninety cylindrical-shaped specimens of Filtek Supreme XT (a universal nano resin composite) and Filtek Z250 (a universal microhybrid resin composite) were prepared. The specimens were allocated at random into 9 paired groups each of 10 specimens. The finishing and polishing systems included were Tungsten Carbide bur (TC); Diamond bur (Db); Sof-Lex discs (S); PoGo discs (PG); TC + S; Db + S; TC + PG; Db + PG. Polymerisation against a Mylar strip without finishing and polishing acted as the control. Surface roughness was measured using a 3D non-contact optical profilometer and surface morphology was examined by scanning electron microscopy. Specimens were subjected to the equivalent of four years STB and surface roughness was measured again. RESULTS: Mylar formed surfaces were the smoothest for both composites before and after STB. Finishing with the diamond finishing bur caused significantly greater surface irregularity (p < 0.0001) before and after STB compared to the tungsten carbide bur. The surface treatment with Db + PG resulted in significantly greater surface roughness following STB than all other regimes of finishing and polishing (p < 0.01). CONCLUSION: Where indicated clinically, finishing is better conducted using a tungsten carbide bur rather than a diamond finishing bur. The combination of tungsten carbide bur/Enhance PoGo and tungsten carbide bur/Sof-Lex surface protocols produced a similarly smooth finish for both composites. The composite surfaces in all groups increased in surface irregularity following STB. CLINICAL SIGNIfiCANCE: Whilst finishing using a tungsten carbide finishing bur followed by either the Sof-Lex or PoGo polishing system may be found to result in a smooth surface finish, all the surfaces investigated increased in surface roughness following toothbrushing.

Collection of Common Knee Patient-reported Outcome Instruments by Automated Mobile Phone Text Messaging in Pediatric Sports Medicine.

BACKGROUND: Patient-reported outcome (PRO) instruments measure health status in a variety of domains. With the proliferation of mobile phones, delivering PROs across patient-friendly platforms (eg, apps, text messaging) may increase completion rates, particularly among children. The purpose of this study was to validate the collection of common knee PROs in sports medicine with text messaging by correlating text-messaging responses with paper delivery in adolescents. METHODS: Patients presenting to a hospital-based pediatric orthopaedic sports medicine clinic with a knee injury were enrolled prospectively. Paper versions of the Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form and the Pediatric Functional Activity Brief Scale (Pedi-Fab Scale) were completed during initial clinic visits. Over the next 72 hours, patients completed the text message delivery of the Pedi-IKDC and Pedi-Fab Scale. Correlations between paper and text message delivery of the 2 PROs were assessed. RESULTS: Ninety-one patients (mean age: 16.0±2.0 y; 48% females) enrolled in the text-messaging study, with 55 (60.4%) completing the Pedi-Fab Scale, 48 (52.7%) completing the Pedi-IKDC, and 39 (42.9%) completing both PROs. The intraclass correlation coefficient between the paper and mobile phone delivery of the Pedi-Fab Scale was 0.95 (P<0.001; 95% confidence interval, 0.91-0.97). The intraclass correlation coefficient between the paper and mobile phone delivery of the Pedi-IKDC was 0.96 (P<0.001; 95% confidence interval, 0.93-0.98). Average Pedi-Fab scores on paper (M=12.7) and mobile phone (M=12.3) were not significantly different (P=0.52). Similarly, average Pedi-IKDC scores on paper (M=68.8) and mobile phone (M=67.7) were not significantly different (P=0.41). Average completion time for the text delivered Pedi-Fab and Pedi-IKDC were 102±224 and 159±155 minutes, respectively. High school enrollment (P=0.025), female sex (P=0.036), and race (P=0.002) were significantly associated with text completion of Pedi-IKDC. CONCLUSIONS: Text message delivery using mobile phones permits valid assessment of Pedi-IKDC and Pedi-Fab scores in adolescents. Questionnaire delivery by automated text messaging allows asynchronous response and may increase compliance and reduce the labor cost of collecting PROs. LEVEL OF EVIDENCE: Level III-prospective cohort study.

Physeal fractures of the distal femur: does a lower threshold for surgery lead to better outcomes?

Distal femur physeal fractures are known to have a high incidence of complications. Our previous reported experience (pre-2007) showed a 40% complication risk, which prompted changes in our approach. The purpose of this study was to evaluate and compare the complication rate and outcome after implementation of these changes. This is a retrospective study of children with distal femur physeal fractures treated at a level 1 pediatric trauma center between 2007 and 2016. Patient demographics, fracture patterns, treatment and outcomes including complications and its risk factors were recorded and analyzed. We compared current results with our previously reported multicenter cohort (n = 73). Patients were male in majority (57/70) with a mean age of 13 ± 4 years. Fractures were most commonly Salter-Harris Type 2 (49/70) and displaced (59/70) on presentation, although neither characteristic was associated with complications. Most patients (63/70) were treated surgically, and the overall complication incidence was 36% (25/70), including growth arrest in 20 patients. The pre-2007 cohort was statistically significantly younger (P < 0.001) and was more commonly treated nonoperatively (P < 0.001). However, there was no statistically significant difference in complication incidence between studies (36% versus 40%, respectively, P = 0.751). Despite a lower threshold for surgery for distal femur physeal fractures in the past decade, the complication rate is still high and unchanged at 40%, and presenting patients are older. There were no new prognostic factors that showed statistically significant association with subsequent complications; however, patients with high-energy injury mechanisms and greater fracture displacements did have higher complication rates. These results demonstrate the inherent high complication risk for these injuries. Level of Evidence: III.

Utility of Perioperative Laboratory Tests in Pediatric Patients Undergoing Spinal Fusion for Scoliosis.

STUDY DESIGN: Retrospective comparative study. OBJECTIVES: We aimed to characterize the frequency of perioperative laboratory tests for posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and to assess whether test results affected clinical management. SUMMARY OF BACKGROUND DATA: Perioperative laboratory tests for PSF including complete blood count, coagulation laboratory tests, basic metabolic panels (BMPs), and type and screen, are commonly ordered based on providers' discretion or existing order sets. Studies have shown unnecessary laboratory tests as financially and physically costly in adults; however, no studies have examined the necessity of common perioperative laboratory tests in pediatric spinal deformity surgery. METHODS: Retrospective review of patients aged 10-18 years who underwent PSF for AIS at our center in the past three years. The clinical utility of perioperative laboratory tests was assessed based on detected incidence of anemia, blood transfusions, hematology/endocrinology/nephrology consultations, insulin administration, and postponed/canceled surgeries. RESULTS: A total of 234 patients were included (mean age 14.4 ± 1.8 years, 75% female). Of 105 (44.9%) patients with preoperative coagulation laboratory tests, 21 (20%) had abnormal results; however, none had subsequent hematology consultations or canceled/postponed surgeries. Postoperatively, only 5 (2.1%) patients and 30 (12.8%) patients had hemoglobin values less than 8 g/dL on postoperative day (POD) 1 and 2, respectively. Multivariate analysis identified POD1 hemoglobin ≤9.35 g/dL as the only predictor of hemoglobin <8 g/dL on POD2. Overall, there were 8 (3.4%) indicated blood transfusions postoperatively. Costs of unnecessary laboratory tests averaged $95.27 (range $49.72 to $240.27) per patient. CONCLUSIONS: Many perioperative laboratory orders may be unnecessary in pediatric spinal deformity surgery, subjecting patients to extraneous costs and needlesticks. In particular, preoperative coagulation laboratory tests, perioperative BMPs, and additional postoperative CBCs for those with hemoglobin >9.35 on POD1 may not be warranted. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Pediatric Type II Tibial Spine Fractures: Addressing the Treatment Controversy With a Mixed-Effects Model.

BACKGROUND: Tibial spine fractures, although relatively rare, account for a substantial proportion of pediatric knee injuries with effusions and can have significant complications. Meyers and McKeever type II fractures are displaced anteriorly with an intact posterior hinge. Whether this subtype of pediatric tibial spine fracture should be treated operatively or nonoperatively remains controversial. Surgical delay is associated with an increased risk of arthrofibrosis; thus, prompt treatment decision making is imperative. PURPOSE: To assess for variability among pediatric orthopaedic surgeons when treating pediatric type II tibial spine fractures. STUDY DESIGN: Cross-sectional study. METHODS: A discrete choice experiment was conducted to determine the patient and injury attributes that influence the management choice. A convenience sample of 20 pediatric orthopaedic surgeons reviewed 40 case vignettes, including physis-blinded radiographs displaying displaced fractures and a description of the patient's sex, age, mechanism of injury, and predominant sport. Surgeons were asked whether they would treat the fracture operatively or nonoperatively. A mixed-effects model was then used to determine the patient attributes most likely to influence the surgeon's decision, as well as surgeon training background, years in practice, and risk-taking behavior. RESULTS: The majority of respondents selected operative treatment for 85% of the presented cases. The degree of fracture displacement was the only attribute significantly associated with treatment choice (P < .001). Surgeons were 28% more likely to treat the fracture operatively with each additional millimeter of displacement of fracture fragment. Over 64% of surgeons chose to treat operatively when the fracture fragment was displaced by ≥3.5 mm. Significant variation in surgeon's propensity for operative treatment of this fracture was observed (P = .01). Surgeon training, years in practice, and risk-taking scores were not associated with the respondent's preference for surgical treatment. CONCLUSION: There was substantial variation among pediatric orthopaedic surgeons when treating type II tibial spine fractures. The decision to operate was based on the degree of fracture displacement. Identifying current treatment preferences among surgeons given different patient factors can highlight current variation in practice patterns and direct efforts toward promoting the most optimal treatment strategies for controversial type II tibial spine fractures.

Assessing the Need for Common Perioperative Laboratory Tests in Pediatric Patients With Femoral Shaft Fractures.

BACKGROUND: Femoral shaft fractures are a common cause for hospital admission and surgery in pediatric patients, and laboratory studies are often ordered for historical concerns of excessive bleeding. Recent literature has challenged these assumptions, and unnecessary testing causes undue pain and costs in children. No previous studies have offered evidence-based recommendations for perioperative laboratories in isolated pediatric femoral shaft fractures. METHODS: We retrospectively reviewed all patients presenting with femoral shaft fractures at our pediatric trauma center between 2013 and 2017. Patients with multitrauma injuries, metabolic/neuromuscular diseases, or intensive care unit stays were excluded. Necessity of laboratory tests was determined by rates of anemia, blood transfusions, specialist consultations, and delayed surgeries. Ordering patterns were recorded, with cost estimation based on Healthcare Bluebook. RESULTS: We reviewed 95 patients (mean age, 7.9±4.8 y; 70 males). Treatments included elastic nails (33/95, 34.7%), reamed intramedullary nails (24/95, 25.3%), plates/screws (12/95, 12.6%), and spica casting (26/95, 27.4%). Of 32 patients with preoperative coagulation laboratories, 11 were abnormal; however none resulted in hematology consultations or procedure delays. Seventy-five patients (78.9%) and 15 patients (15.8%) had complete blood counts preoperatively and postoperative day 1, respectively. Four patients (4.2%) had hemoglobin<8 g/dL postoperatively, however, there were no perioperative blood transfusions. Of these 4, 3 underwent either reamed intramedullary nails or open reduction internal fixation with plates/screws. Twenty-six patients (27.4%) had preoperative basic metabolic panels that did not alter medical care. On the basis of our criteria, over 72% of laboratories appeared unnecessary, with a total potential cost of $8567. Over 80% of orders were from the emergency department by residents or attending physicians. CONCLUSIONS: Perioperative laboratory orders may be unnecessary in most isolated pediatric femoral shaft fractures, subjecting patients to extraneous costs, and associated pain. However, laboratories may be justified based on clinical circumstances or for older patients treated with reamed nails or plates/screws. Evidence-based recommendations for perioperative laboratory orders offer the potential to improve quality and value and minimize harm in pediatric orthopaedic trauma. LEVEL OF EVIDENCE: Level III-retrospective comparative study (therapeutic).

Perioperative Ketorolac for Supracondylar Humerus Fracture in Children Decreases Postoperative Pain, Opioid Usage, Hospitalization Cost, and Length-of-Stay.

BACKGROUND: There is a need for improved opioid stewardship in orthopedic surgery through multimodal analgesia strategies. Perioperative administration of ketorolac in children undergoing closed reduction and percutaneous pinning (CRPP) for displaced supracondylar humerus (SCH) fracture may decrease pain, reduce opioid requirements, and decrease hospitalization costs. METHODS: Retrospective case-control investigation of children (aged, 1 to 14) treated with CRPP for closed, modified Gartland type III extension-type SCH fractures at a single children's hospital between 2011 and 2017. Patients that received ketorolac perioperatively (cases) were randomly matched 1:2 by sex and age (±1 y) with patients that did not receive ketorolac (controls). Data abstraction included demographic and perioperative details including inpatient Wong-Baker FACES pain ratings and analgesic requirements. Analysis included 2-tailed Mann-Whitney U and χ tests. RESULTS: In total, 342 patients were studied including 114 cases and 228 controls. Age (mean, 6.2±2.4 y), sex ratio (M:F, 1.28:1), operative time, and number of pins used were equivalent between groups. Mean pain rating at 0 to 29 minutes postoperatively was lower in the ketorolac group (0.7±1.9) than in controls (1.4±2.6, P=0.017), as well as at 30 to 120 minutes postoperatively (1.1±2.3 and 1.7±2.8, respectively, P=0.036), as seen in Figure 1. Patients in the ketorolac group received a lower number of inpatient oxycodone doses (1.0±0.6) than control patients (1.2±0.5, P=0.003). Mean postoperative length-of-stay (LOS) was 50.0% longer for control patients (20.4±11.3 h) than the ketorolac patients (13.6±8.8 h, P<0.001). Ketorolac administration was associated with 40.4% lower inpatient hospitalization cost compared to control patients, providing a 33.8 times return on investment. There was no difference in the 90-day complication rate between patient groups (P=0.905). CONCLUSIONS: The complementary administration of ketorolac reduces postoperative pain and opioid use in children with displaced supracondylar humerus fractures. Perioperative ketorolac is also associated with reduced LOS following CRPP for supracondylar humerus fractures and offers significant cost savings opportunities. LEVEL OF EVIDENCE: Level 3-Therapeutic: Case-Control Study.

Surgeon and Caregiver Agreement on the Goals and Indications for Scoliosis Surgery in Children With Cerebral Palsy.

STUDY DESIGN: Prospective multicenter comparative study. OBJECTIVES: We aimed 1) to survey surgeons and caregivers to rank the surgical indications for spinal fusion of pediatric patients with neuromuscular scoliosis secondary to cerebral palsy in order of importance and 2) to characterize the agreement of surgeons and caregivers on major (top three) indications. SUMMARY OF BACKGROUND DATA: Surgery for spinal deformity in children with cerebral palsy is a multifaceted and individualized decision that may lead to miscommunication during informed consent. Little data exist on communication effectiveness between surgeon and caregiver during preoperative discussion. METHODS: This is a multicenter, prospective survey of Harms Study Group patient caregivers and their surgeons. Participants ranked their most important of 15 indications in descending level of importance, where the top 3 selections were considered major indications for surgery for the particular patient in question. Demographic and other perioperative factors were recorded. Surgeon-caregiver agreement on major indications was determined, taking into account preoperative factors and intersurgeon differences. RESULTS: 126 surgeon-caregiver pairs responded. The greatest percentage agreement that an indication was major was "to improve sitting" (69.0% major, 0.8% nonmajor), followed by "to prevent pulmonary compromise" (33.3% major, 24.6% nonmajor), "to improve pain" (31.7% major, 20.6% nonmajor), and "to improve head control/position" (20.7% major, 69.0% nonmajor). Preoperative pain showed an association with surgeon-caregiver agreement on pain as a major indication (p=.004), and intersurgeon differences in agreement on gastrointestinal and pain considerations existed (p=.002, p=.007, respectively). CONCLUSIONS: Surgeon-caregiver agreement is greater where literature support for a particular surgical indication is strong (ie, spinal fusion's known improvement of sitting posture in children with neuromuscular scoliosis). Stronger literature support may bolster surgeons' confidence in recommending a particular procedure, fostering greater communication, understanding, and agreement on surgical necessity between caregivers and surgeons. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Safe Transportation in-Spica Following Surgical Treatment of Infantile DDH: Solutions and Threats.

BACKGROUND: Government regulations mandate appropriate vehicular restraints for children under 4 years of age. Patients treated for infantile developmental dysplasia of the hip (DDH) with spica casts often require special accommodations. Previous work suggests that car seat loaner programs may help achieve these goals while avoiding the need for costly ambulance transportation. The purpose of this study was to evaluate our center's experience with postdischarge transportation in a large population of DDH infants and identify future threats to our program. METHODS: We performed a retrospective review of patients 4 years or younger of age who underwent closed or open reduction for DDH at our center between 2011 and 2018. Only the initial surgery of staged procedures was included. Patient demographic factors were recorded, as were procedure type, final restraint used for postdischarge transportation, and any potential discharge delays secondary to transportation issues. Costs were compared amongst transportation options. RESULTS: Our cohort consisted of 130 patients (mean age, 1.4±0.9 y; 98 females) treated for DDH. In total 41 children (31.5%) underwent closed reduction procedures, whereas 89 patients (68.5%) underwent open reductions. After reduction, 62 (47.7%) received 2-legged spica casts and 68 (52.3%) received 1.5-legged casts. The most common restraint was a hospital-loaned Hippo car seat (73, 55.8%) followed by family-owned car seats (27, 20.8%). Eight patients (6.2%) experienced delays in discharge while waiting for adequate restraints, 6 patients (4.6%) were transported by ambulance, and 4 patients (3.1%) left against medical advice with inadequate restraints. CONCLUSIONS: Following surgical treatment of DDH, over 50% of patients with a spica cast were discharged using our center's car seat loaner program. However, availability and cost can present barriers for patients, with 4.6% of patients still being transported home by ambulance and 3.1% with inadequate restraints against medical advice. Costs of car seats are significant both for patients' families intending to purchase them, as well as for hospitals maintaining loaner programs and replacing used/lost seats. Moving forward, the recent cessation of production of the most common "spica car seat" threatens the longevity of existing loaner programs and calls renewed attention to the issue of safe transportation in-spica from providers and car-seat manufacturers alike. LEVEL OF EVIDENCE: Level III.

Postoperative Pain and Opioid Use in Children with Supracondylar Humeral Fractures: Balancing Analgesia and Opioid Stewardship.

BACKGROUND: Effective postoperative analgesia remains a priority in orthopaedic surgery, but concerns with regard to opioid diversion and misuse have brought overdue attention to improving opioid stewardship. Normative data for postoperative pain and opioid use are needed to guide and balance these dual priorities. We aimed to characterize postoperative pain and opioid use for an archetypal pediatric orthopaedic procedure: closed reduction and percutaneous pinning of a supracondylar humeral fracture. METHODS: Children at a single pediatric trauma center who underwent closed reduction and percutaneous pinning of a supracondylar humeral fracture were enrolled and were prospectively followed. Validated pain scores (Wong-Baker FACES Pain Rating Scale) and opioid utilization data were collected using an automated text message-based protocol on postoperative days 1 to 7, 10, 14, and 21. Data were analyzed with descriptive and univariate statistics. RESULTS: Eighty-one patients with a mean age (and standard deviation) of 6.1 ± 2.1 years (62% of whom were male) were enrolled, including 53.1% who had Type-II fractures and 46.9% who had Type-III fractures. The mean pain ratings were highest on arrival to the emergency department (3.5 ± 3.5 points) and the morning of postoperative day 1 (3.5 ± 2.4 points). By postoperative day 3, the mean pain rating decreased to <2 (1.8 ± 1.8 points) and the mean opioid doses decreased to <1 dose (0.8 ± 1.2 doses). Postoperative opioid use decreased in parallel to reported pain (r = 0.972; p < 0.001). The interquartile range of opioid use was 1 to 7 doses, and patients used only 24.1% of the prescribed opioids (mean, 4.8 ± 5.6 doses used and 19.8 ± 7.1 doses prescribed). There was no significant difference (p > 0.05) in pain ratings or opioid use by fracture classification, age, or sex. CONCLUSIONS: Following closed reduction and percutaneous pinning for supracondylar humeral fracture, pain levels and opioid usage decrease to a clinically unimportant level by postoperative day 3. Patients who report pain scores of ≥6 points following discharge are outliers and should be screened for compartment syndrome or ischemia. Patients used <25% of prescribed opioid medication, suggesting the potential for overprescription and opioid diversion. A prescription for 7 opioid doses after discharge should allow adequate postoperative analgesia in the majority of patients while improving narcotic stewardship. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Self-Reported Postoperative Opioid-Prescribing Practices Following Commonly Performed Orthopaedic Hand and Wrist Surgical Procedures: A Nationwide Survey Comparing Attending Surgeons and Trainees.

BACKGROUND: Although orthopaedic surgeons have been shown to prescribe excessive amounts of opioid analgesics postoperatively, the degree in which surgical trainees contribute to this trend is unknown. The purpose of this study was to compare self-reported opioid-prescribing behavior, factors influencing this behavior, and perceptions of patient opioid utilization and disposal between hand surgeons and trainees. METHODS: Attending hand surgeons and trainees in hand, orthopaedic, and plastic surgery programs were invited to participate in a web-based survey including demographic characteristics; self-reported prescribing behavior specific to 4 procedures: open carpal tunnel release, trigger finger release, thumb carpometacarpal arthroplasty, and distal radial fracture open reduction and internal fixation; and perceptions and influencing factors. Analgesic medications were converted to morphine milligram equivalents and were compared across groups of interest using independent t tests or analysis of variance for each procedure. RESULTS: A total of 1,300 respondents (266 attending surgeons, 98 fellows, 708 orthopaedic residents, and 228 plastic surgery residents) were included. Surgeons reported prescribing fewer total morphine milligram equivalents compared with residents for all 4 procedures. Personal experience was the most influential factor for prescribing behavior by surgeons and fellows. Although residents reported that attending surgeon preference was their greatest influence, most reported no direct opioid-related communication with attending surgeons. CONCLUSIONS: Residents self-report prescribing significantly higher morphine milligram equivalents for postoperative analgesia following commonly performed hand and wrist surgical procedures than attending surgeons. Poor communication between residents and attending surgeons may contribute to this finding. Residents may benefit from education on opioid prescription, and training programs should encourage direct communication between trainees and attending surgeons.