The effect of preoperative counseling on duration of postoperative opiate use in orthopaedic trauma surgery: a surgeon-based comparative cohort study.

OBJECTIVE: The prudent use of prescription opiates is a central aspect of current postsurgical pain management, but surgeons have no guidelines on appropriate duration of opiate treatment. Furthermore, there are no established data on the effect of physician counseling on the duration of opiate use postoperatively. DESIGN: Retrospective surgeon-controlled cohort study. SETTING: Level I regional academic trauma center. PATIENTS: All Utah residents admitted to the orthopaedic trauma service with isolated operative musculoskeletal injury. INTERVENTION: One group of patients was instructed at the time of index procedure that they would receive prescription opiates for a maximum of 6 weeks. The remaining patients were not counseled preoperatively on duration of opiate use postoperatively. MAIN OUTCOME MEASURES: The presence and frequency of prescription opiate use before injury, cessation of opiate use by 6 weeks postoperatively, cessation of opiates by 12 weeks postoperatively, and continuation of prescription opiates greater than 12 weeks postoperatively. RESULTS: Six hundred thirteen patients met inclusion criteria. Those counseled preoperatively to cease opiate use by 6 weeks were significantly more likely to do so than those who did not receive counseling (73% and 64%, respectively; P = 0.012). By 12 weeks, this effect was no longer seen, and patients were just as likely to have stopped (80% and 80%, respectively; P = 0.90). CONCLUSIONS: The orthopaedic trauma population is significantly more likely than the general population to be using prescription opiates before injury. Physician discussion of 6-week opiate prescription limitation at the time of injury seems to lead to a lower rate of use at the 6-week postoperative mark but has no effect on rates of longer-term use. Twenty percent of patients in either group will continue to use opiates after 12 weeks, compared with 15% before injury. Given the scope of prescription opiate use in the United States, surgeons may want to consider preoperative discussion of this issue, but it may not have any effect on usage rates at longer intervals. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rates of prescription opiate use before and after injury in patients with orthopaedic trauma and the risk factors for prolonged opiate use.

BACKGROUND: The prudent use of prescription opiate medications is a central aspect of postoperative pain management. The mortality associated with prescription opiate overdose is reaching epidemic proportions nationally, and is the leading cause of accidental death in greater than half the states in the United States. This study sought to determine the rates of preinjury opiate use in patients with orthopaedic trauma and the risk factors for prolonged use postinjury. METHODS: The Utah Controlled Substance Database was queried to determine the use of prescription opiates by all patients admitted to the orthopaedic trauma service for a two-year period with isolated musculoskeletal injuries. Usage three months prior to injury and six months postinjury was examined. RESULTS: Six hundred and thirteen patients met inclusion criteria. Among patients with orthopaedic trauma, 15.5% had filled a prescription for opiates in the three months prior to injury, compared with 9.2% of the general population (p < 0.001). More than one prescription was filled by 12.2% of the patients with trauma preinjury compared with 6.4% of the general population (p < 0.001). Postoperatively, 68.4% of all patients filled opiate prescriptions for less than six weeks, 11.9% filled opiate prescriptions between six and twelve weeks, and 19.7% filled opiate prescriptions past twelve weeks. Patients with preinjury use of more than one opiate prescription in the three months preinjury were six times as likely to continue use past twelve weeks, and 3.5 times as likely to obtain opiates from a provider other than their surgeon (p < 0.001). Opiate use was briefest with upper-extremity injuries, followed by lower-extremity injuries and pelvic or acetabular injuries. Regression models demonstrate that risk factors for prolonged use of opiates include advancing age and extent of preinjury use. CONCLUSIONS: Patients with orthopaedic trauma are significantly more likely than the general population to use prescription opiates prior to injury. Preinjury opiate use is predictive of prolonged use postinjury and predictive of patients who will seek opiates from other providers.

Long-term follow-up of open reduction surgery for developmental dislocation of the hip.

BACKGROUND: We posed 2 questions: what is the long-term result of open reduction surgery in developmental dysplasia of the hip, and is there an age at surgery above which the outcome was too poor to recommend the operation? METHODS: Between 1955 and 1995, 148 patients with 179 dislocated hips had open reduction surgery for developmental dysplasia of the hip (141 anterior and 38 Ludloff medial approaches). We attempted to locate all 148 patients for the follow-up evaluation. RESULTS: Fifty-three patients (36%) with 66 hips (37%) were located and participated in the study. These 66 hips represented 34% of the anterior open reductions and 47% of the Ludloff medial reductions. Twenty-two of the 66 hips had Severin IV or worse outcomes and included 7 with total hip arthroplasties and 2 with hip fusions. Age at surgery was significantly lower for Severin I, II, and III, compared with Severin IV and above (P=0.003, 0.001, 0.003) with outcomes deteriorating substantially after age 3. Approximately half of the hips required further surgery for dysplasia. All hips that sustained osseous necrosis had Severin IV or worse outcomes, and hips that redislocated and required revision surgery only achieved Severin I or II ratings 18% of the time. Nine "normal" hips became dysplastic and 3 had pelvic osteotomies as teenagers. Two other normal hips developed osseous necrosis during treatment of the contralateral hip. CONCLUSIONS: Results deteriorate as the age at surgery increases. Osseous necrosis and redislocation predict a poor functional and radiographic result. The "normal" hip may develop insidious dysplasia and also may be injured during treatment of the involved hip. Above age 3, some patients may not have sufficient acetabular growth to remodel a surgically reduced hip. LEVEL OF EVIDENCE: Level IV--case series.

Pediatric pelvic fractures.

Pediatric pelvic fractures account for only 1% to 2% of fractures seen by orthopaedic surgeons who treat children. They are typically associated with high-energy trauma, requiring a comprehensive workup for concomitant life-threatening injuries. Anteroposterior radiographs and rapid-sequence computed tomography are the standards of diagnostic testing to identify the fracture and recognize associated injuries. Treatment is individualized based on patient age, fracture classification, stability of the pelvic ring, extent of concomitant injuries, and hemodynamic stability of the patient. Most pelvic injuries in children are treated nonsurgically, with protected weight bearing and gradual return to activity. Open reduction and internal fixation is required for acetabular fractures with >2 mm of fracture displacement and for any intra-articular or triradiate cartilage fracture displacement >2 mm. To prevent limb-length discrepancies, external fixation is necessary for pelvic ring displacement >2 cm. Fractures involving immature triradiate cartilage may lead to growth disturbance of the acetabulum, resulting in acetabular dysplasia, hip subluxation, or hip joint incongruity. Osteonecrosis of the femoral head may develop after acetabular fractures associated with hip dislocation. Other complications include myositis ossificans and neurologic deficits secondary to sciatic, femoral, and/or lumbosacral plexus nerve injuries.