Managing Post-Operative Pain in Orthopedic Patients: An International Comparison.

Introduction: Opioids play a crucial role in post-operative pain management in America, but not in some other countries. We sought to determine if a discrepancy in opioid use between the United States (U.S.) and Romania, a country that administers opioids in a conservative fashion, would show in subjective pain control differences. Methods: Between May 23, 2019, and November 23, 2019, 244 Romanian patients and 184 American patients underwent total hip arthroplasty or the surgical treatment of the following fractures: bimalleolar ankle, distal radius, femoral neck, intertrochanteric, and tibial-fibular. Opioid and non-opioid analgesic medication use and subjective pain scores during the first and second 24 hours after surgery were analyzed. Results: Subjective pain scores for the first 24 hours were higher among patients in Romania compared to the U.S. (p < 0.0001), but Romanians reported lower pain scores than U.S. patients in the second 24-hours (p < 0.0001). The quantity of opioids given to U.S. patients did not differ significantly based on sex (p = 0.4258) or age (p = 0.0975). However, females reported higher pain scores than male patients following the studied procedures (p = 0.0181). No sex-based differences in pain scores were noted among Romanian patients. Conclusions: Higher pain scores in American females, despite equivalent amounts of narcotics to their male counterparts, and the absence of a difference in Romanians suggested that the current American post-operative pain regimen may be tailored to the needs of male patients. In addition, it pointed to the impacts of gender, compared to sex, in pain experiences. Future research should look for the safest, most efficacious pain regimen suitable for all patients.

Lower Extremity Girth Does Not Predict Complications in TKA.

BACKGROUND: Obese patients have increased complications after total knee arthroplasty (TKA). A body mass index (BMI) cutoff of 40 is frequently used to determine eligibility for TKA. Patients with a BMI <40 and extremely large legs which may predispose them to complications are approved for surgery because they fall below this cutoff. Alternatively, patients with truncal obesity and a BMI >40 are accepted because they have thin legs. We sought to determine whether BMI or girth should be used to determine eligibility. METHODS: 453 patients who underwent TKA were included. A lower extremity girth (LEG) ratio was calculated dividing the width of the soft tissue envelope by bone width on lateral radiographs. Receiver operator curves were generated to predict 90-day complications. RESULTS: There was no difference in median LEG ratio between patients with or without a complication (P = .08). Receiver operator curves indicated that size of the soft tissue envelope had no utility in predicting complications. There was no correlation between LEG ratio and specific complications such as infection, malalignment, or wound complications. Using a LEG ratio threshold of 4.834, the sensitivity and specificity for predicting complications were 48% and 64%, respectively. The median BMI for patients with no complication was 32.3 and 35 for patients with a complication (P = .07). CONCLUSION: Complications are not necessarily associated with size of the soft tissue envelope in TKA.Decisions concerning TKA should not be made solely on the size of a patient's leg. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

Delay in the Diagnosis of Stable Slipped Capital Femoral Epiphysis.

INTRODUCTION: Delays in the diagnosis of stable slipped capital femoral epiphysis (SCFE) is common due to the vague symptomatology and the lack of awareness of this entity by healthcare providers. Delays in the diagnosis of this condition can lead to poor outcomes for the patients. This study was designed to identify factors that contributed to delays in the diagnosis or the treatment of patients with SCFE seen at our institution. METHODS: A retrospective chart review of patients with the diagnosis of a stable SCFE who had undergone screw stabilization between 1989 and 2010 at our hospital was performed. For each patient, demographic data, the date of initial onset of symptoms, the date of the first visit to the medical provider, the type of provider seen initially (orthopaedic surgeon or not), the date of diagnosis of SCFE, the type of physician who made the diagnosis (orthopaedic surgeon or not), and the date of surgery were recorded. For each patient, the presenting symptom was recorded as hip, thigh, or knee pain. The effect of demographic data, presenting symptoms, and the type of initial provider seen on the delay to diagnosis was studied using 2 Cox models. RESULTS: A total of 149 patients with 196 stable SCFE were included. The average time from the first physician visit to diagnosis was 94 days in the group seen by a nonorthopaedic provider compared with an average of 2.9 days in the group seen by an orthopaedist (P<0.05). Diagnosis was made in 1 week only in 19% of the group seen by a nonorthopaedic provider versus 97% in the group seen by orthopaedic surgeons. It took significantly longer to be diagnosed with SCFE in patients who presented with initial knee pain (P=0.0097) compared with those who presented with hip pain at the initial visit. CONCLUSIONS: This study shows a significant delay in the diagnosis of SCFE in the United States, particularly in patients seen by nonorthopaedic providers initially. LEVEL OF EVIDENCE: Level III-prognostic.

Understanding the burden of osteoporosis and use of the World Health Organization FRAX.

Fracture prevention is a critical component of managing osteoporosis, which is not longer defined by T-score alone. The internationally validated World Health Organization Fracture Risk Assessment Tool (FRAX) provides the clinician a state-of-the-art tool for predicting patients at greatest risk for fracture. The FRAX tool takes into account country, bone mineral density of the hip (when available), age, sex, and 8 clinical risk factors to calculate the 10-year probability of a major osteoporotic fracture and the 10-year probability of a hip fracture. From this tool, an absolute fracture risk is generated, aiding clinicians in determining which patients with low bone mass and osteoporosis to treat.