Variation in Postoperative Opioid Prescribing Among Upper-Extremity Surgery Providers.

Purpose: To identify targets for corrective interventions and guide improved opioid stewardship, we studied opioid prescribing patterns of attending surgeons compared with surgical trainees for 2 upper-extremity surgeries: open reduction internal fixation (ORIF) of distal radius fractures (DRF), and carpal tunnel release (CTR). Methods: We retrospectively reviewed records for all patients who underwent CTR or DRF ORIF at 6 hospitals across a large health system from 2016 to 2018. We collected prescriber training level (attending vs trainee), analgesic prescribed, and amount initially prescribed after surgery converted to oral morphine equivalents (OMEs). Regression models evaluated OMEs by prescriber and surgery type. Our final models included an interaction term between prescriber training level and year of surgery to assess group changes over time. No prescription guidelines or formal training was provided during the study period. Results: We included 707 CTR and 383 DRF ORIF patients. Opioids prescribed by trainees ranged from 90 to 300 OMEs (median, 180 OMEs). Opioids prescribed by attendings ranged from 100 to 225 OMEs (median, 150 OMEs). Early in the analyses, trainees prescribed significantly more than attendings (320 versus 180). Over time, trainees reduced overprescribing significantly more, by an additional 40 OME/y. By the end of the analysis period, trainees were prescribing less OME than were attendings (112.5 vs 150). Both groups continued to prescribe more than recently suggested amounts for both procedures. Conclusions: Our study found that both attendings and trainees overprescribed opioids after surgery. Trainees prescribed more than attendings over the study period; however, when analyzing for improvement over time and with no formal intervention or training, trainees showed greater improvement, eventually dropping to levels at or below that of attendings. Considering that most change was seen at the trainee level, education for established providers may be an area in which more improvement can be made. Clinical relevance: Understanding which providers are more likely to overprescribe opioids can help guide interventions that improve opioid stewardship.

Acetabular Component Position and the Risk of Dislocation Following Primary and Revision Total Hip Arthroplasty: A Matched Cohort Analysis.

BACKGROUND: Recently, the importance of acetabular component positioning in the Lewinnek "safe zone" in preventing prosthetic dislocation following total hip arthroplasty (THA) has been questioned. The purpose of this study was to determine the proportion of acetabular components within the Lewinnek safe zone between primary and revision THAs that have sustained a dislocation vs matched controls without a dislocation event. METHODS: This was a retrospective, institutional review board-approved investigation of THAs performed at our institution or referred to our institution between 1997 and 2013. Ninety-six primary THAs and 60 revision THAs that sustained a dislocation were included and matched 1:1 based on age, gender, and body mass index with nondislocated controls. Acetabular component inclination and anteversion were performed using Martell Hip Analysis Suite and compared between the 2 cohorts for both primary and revision THAs. RESULTS: The proportion of acetabular components within the safe zone for both inclination and anteversion was 23 of 96 (24%) in primary THA dislocators vs 48 of 96 (50%, P < .001) in controls. The proportion of acetabular components within the safe zone for both inclination and anteversion was 28 of 60 (47%) in revision THA dislocators vs 40 of 60 (66%, P = .03) in controls. CONCLUSION: Patients sustaining a dislocation following a primary or revision THA had acetabular components less frequently positioned within the safe zone compared to control patients. This study suggests acetabular component positioning remains an important variable in decreasing the risk of dislocation following primary and revision THA.

Revision Ligament Reconstruction Tendon Interposition for Trapeziometacarpal Arthritis: A Case-Control Investigation.

PURPOSE: To test the null hypothesis that there is no difference in patient-reported and objective outcomes of revision ligament reconstruction and tendon interposition (LRTI) compared with primary LRTI. METHODS: This case-control investigation enrolled 10 patients who had undergone revision LRTI at a tertiary care center. All patients had previously undergone primary trapeziectomy with LRTI. Patients with a minimum of 2 years' follow-up were eligible. All patients completed an in-office study evaluation. Controls (treated only with primary LRTI) were matched from our practice to reach a 1:2 case-control ratio. Outcome measures included Michigan Hand Questionnaire (primary outcome), Quick-Disability of the Arm, Hand, and Shoulder (QuickDASH) questionnaire, visual analog scale (VAS) for pain and improvement, and physical examination. Statistical analyses were conducted to compare patient groups. RESULTS: Patients who underwent revision LRTI reported significantly worse outcomes on all measured standardized questionnaires compared with primary patients. The Michigan Hand Questionnaire indicated worse overall outcomes (54 vs 79) as well as worse pain, appearance, and ability to complete activities of daily living. Compared with those who did not undergo revision LRTI, patients who did also reported more impairment (Quick-Disability of the Arm, Hand, and Shoulder, 47 vs 23), greater pain (VAS pain, 6.3 vs 1), and less improvement after surgery (VAS improvement, 2.7 vs 7.9). There was also a significantly higher rate of patient-reported depression in the revision LRTI group (50% vs 10% of patients treated with primary LRTI). We did not find a significant difference in objective outcomes of pinch strength, grip strength, and thumb palmar abduction between the 2 groups. CONCLUSION: After revision LRTI, patient-reported outcomes indicate worse perceived function and greater pain than are expected following primary LRTI despite similar motion and strength. Revision surgery can be offered in the setting of persistent or recurrent symptoms, but patients should be counseled that improvement of symptoms is unpredictable. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

The use of warfarin for DVT prophylaxis following hip and knee arthroplasty: how often are patients within their target INR range?

The purpose of this study was to determine the percentage of time that patients are therapeutic when prescribed warfarin for chemical thromboprophylaxis following a hip or knee arthroplasty procedure. One hundred eighty-four patients receiving warfarin for 4weeks postoperatively, dosed using a Web-application accounting for patient demographics, INR levels, and concomitant medication use, were included. Patients with a target INR range between 1.7 and 2.7 were therapeutic for only 54.4% of the time (32.5% subtherapeutic, 13.0% supratherapeutic) while patients with a target INR range between 2.0 and 3.0 were therapeutic for only 45.9% of the time (39.2% subtherapeutic, 14.8% supratherapeutic). Patients receiving warfarin for chemical thromboprophylaxis are within their targeted INR range for only a limited period of time during their postoperative course.

Risk factors for nonorganic low back pain in patients with worker's compensation.

BACKGROUND CONTEXT: Nonorganic low back pain (NOLBP) is common in the worker's compensation (WC) population. Consults with specialists constitute an unnecessary cost to the system, and a means of screening for these patients is necessary. PURPOSE: To design easily identifiable criteria to help identify which WC patients are likely to have nonorganic pain. STUDY DESIGN: A retrospective chart review of WC patients with low back pain (LBP) seen in consultation by a single spine surgeon over a 2-year period at a university medical center. PATIENT SAMPLE: One hundred twenty-seven WC patients with LBP were seen in consultation by a single spine surgeon over a 2-year period. All were referred for surgical evaluation. Potential risk factors for nonorganic pain were identified, which included alleged injury in multiple bodily areas, presence of concomitant cervical and/or thoracic complaints, initial presentation to chiropractor, mechanism of injury including slip and fall or lifting of a patient, number of previous independent medical examinations performed, presence of psychiatric diagnosis, areas of pain different from first report of injury, greater than 13 months between evaluations, occupation as a health-care employee, presence of legal representation, amount of time off work, present work status (working or disabled), and number of previous WC claims. OUTCOME MEASURES: Outcome measures included the number of Waddell's signs and additional nonorganic/inconsistent pain behaviors noted during the examination by the spine specialist. Nonorganic low back pain was defined as four or more Waddell's signs or three Waddell's signs plus one additional inconsistent behavior. METHODS: A stepwise logistic regression was used to determine which of the risk factors were significantly associated with nonorganic pain, correcting for age and sex. We then used an analysis of deviance to determine which combination of factors could best differentiate patients with nonorganic findings. RESULTS: Factors that were significantly associated with nonorganic pain included mechanism of injury including slip and fall or lifting of a patient (odds ratio [OR]=5.7, p=.03), alleged injury in greater than two bodily areas (OR=4.2, p=.02), presence of concomitant cervical and thoracic complaints (OR=2.9, p=.04), initial presentation to chiropractor (OR=7.7, p=.01), and back pain not listed on first report of injury (OR=3.3, p=.04). Patients with three or more of these findings were found to be at a very high risk of having nonorganic pain (greater than 95%). CONCLUSIONS: We found a significant association between certain easily identifiable criteria and NOLBP in a cohort of WC patients. These criteria included mechanism of injury including slip and fall or lifting of a patient, alleged injury in greater than two bodily areas, presence of concomitant cervical and/or thoracic complaints, initial presentation to chiropractor, and areas of pain different from first report of injury. More than 95% of patients with three or more of the aforementioned criteria were found to have nonorganic pain. This information may help the specialist and the WC provider identify patients at a high risk for nonorganic pain, thereby reducing unnecessary costs.

Cocaine use and surgical outcomes of cervical spondylotic myelopathy: a retrospective study.

The purpose of this study was to determine the average age of individuals diagnosed with cervical spinal myelopathy who are known cocaine users vs nonusers, as well as the postoperative change in neurological condition between cocaine users and nonusers. Medical records of patients diagnosed with cervical spinal myelopathy between January 1990 and May 2006 were reviewed. Ninety-four patients were identified who underwent any surgical intervention with at least 2 years of follow-up. Group 1 comprised patients with cervical spinal myelopathy who had used cocaine, and group 2 comprised patients with cervical spinal myelopathy who had not used cocaine. All patients were clinically evaluated by the Nurick grade preoperatively and at most recent follow-up. Mean follow-up was 25 months. Mean age at presentation was 52 years (range, 44-62 years) in group 1 and 56 years (range, 42-88 years) in group 2. Average duration of symptoms prior to surgical intervention was 18.6 months in group 1 and 10 months in group 2. Average Nurick grade at presentation was 2.7 for group 1 and 2.7 for group 2. Average postoperative Nurick grade was 1.9 for group 1 and 1.33 for group 2. Change in Nurick grade was 0.8 for group 1 and 1.11 for group 2. Linear regression analysis comparing change in Nurick grade (from pre- to postoperative) was conducted, showing a correlation of -0.45 with a P value of .044. To the authors' knowledge, this is the first study demonstrating that cocaine use has an effect on postoperative improvement of neurological function in cervical spondylotic myelopathy.

Parameters for lateral extent of dissection during anterior cervical decompression and fusion.

The purpose of this anatomic study was to determine the extent of lateral dissection that can be performed during anterior cervical decompression and fusion to maximize decompression without compromising the vertebral arteries. Although vertebral artery injury is rare, it is sometimes catastrophic and leads to significant morbidity and mortality. Previous studies have attempted to establish standards for surgical anatomy during anterior cervical decompression and fusion; however, none have accounted for significant degenerative changes that occur with increased age.The uncus-to-uncus distance, representing part of the vertebral endplate, of 500 cervical spine specimens was measured at each vertebral level from C3 to C7. The corresponding femoral head diameter (a correlate of body mass index) was also measured. These values were used to determine whether a specific uncus-to-uncus distance exists per vertebral level regardless of age, and whether the uncus-to-uncus distance becomes more specific when correlated with body mass index. According to the data, uncus-to-uncus distance increases between each vertebral level, and each level has a range of approximately 6 mm. The range does not decrease when compared with femoral head diameter. Although a statistically significant, positive correlation existed between uncus-to-uncus distance and femoral head diameter, the correlation coefficient was not large enough to suggest that uncus-to-uncus distance varies greatly from femoral head diameter. Although anatomical markers such as the distance between the uncinate processes can aid surgeons in safe decompression of the cervical vertebrae, vertebral artery injury is best avoided by thorough pre- and intraoperative radiological and anatomical analysis.

Treatments to restore respiratory function after spinal cord injury and their implications for regeneration, plasticity and adaptation.

Spinal cord injury (SCI) often leads to impaired breathing. In most cases, such severe respiratory complications lead to morbidity and death. However, in the last few years there has been extensive work examining ways to restore this vital function after experimental spinal cord injury. In addition to finding strategies to rescue breathing activity, many of these experiments have also yielded a great deal of information about the innate plasticity and capacity for adaptation in the respiratory system and its associated circuitry in the spinal cord. This review article will highlight experimental SCI resulting in compromised breathing, the various methods of restoring function after such injury, and some recent findings from our own laboratory. Additionally, it will discuss findings about motor and CNS respiratory plasticity and adaptation with potential clinical and translational implications.