Detroit Interventional Pain Assessment Scale: A Pain Score and Method for Measuring and Evaluating Post-Operative Pain Management-A Prospective Study.

Background and Objectives: Orthopedic surgeons commonly prescribe opioids, surpassing all medical specialties. Our objective was to develop a pain management scale that captures medication use, patient-reported pain scores, and helps orthopedic surgeons evaluate their post-operative prescribing practice. Materials and Methods: An IRB-approved prospective study followed 502 post-operative orthopedic surgery patients over a six-month period. All patients were surveyed in an orthopedic clinic at a Level 1 US Trauma Center, during a routine follow-up. Patient pain satisfaction was assessed using the validated Interventional Pain Assessment (IPA) scale, which uses three categories: 0 (no pain), 1 (tolerable pain), and 2 (intolerable pain). Daily narcotic use was translated to morphine milligram equivalents (MMEs) using the Michigan Automated Prescription System (MAPS) narcotics registry. When patient pain satisfaction and narcotic usage were combined, this scale was called the Detroit Interventional Pain Assessment (DIPA) scale. Results: The five classes based on common prescription and usage of narcotics in this cohort include the following: A (no pain medication), B (over-the-counter medication), C (occasional use of short-acting narcotics 1-30 MMEs), D (consistent/regular use of short-acting narcotics 31-79 MMEs), and E (long-duration or stronger short-acting narcotics 80+ MMEs). Patients were most satisfied with their pain management at six weeks (80.5%) and three months (75.65%), and least satisfied at two weeks (62.5%) and six months (60.9%). Additional information displayed on the DIPA graph revealed there was a significant decrease in the percentage of patients on narcotics at two weeks (65.2%) to six months (32.6%) at p < 0.001. Conclusions: The DIPA pain scale shows the relationship between patient pain perception and opioid prescription/usage, while also tracking prescriber tendencies. Providers were able to visualize their post-operative pain management progression at each designated clinic visit with corresponding alphabetical daily MME categories. In this study, results suggest that surgeons were not effective at managing the pain of patients at two weeks post-operative, which is attributed to an inadequate number of pain pills prescribed upon discharge. Overall, the DIPA graph signaled that better pain management interventions are necessitated in periods with lower efficiency scores.

Transparency films: intraoperative templating to prevent limb deformity.

Operative management of fractures and malunions can be challenging when restoring native anatomy is not straightforward. Comminuted fractures and managing deformity correction in the setting of osteolysis, callus, and even complete fracture healing must include careful planning. Preoperative planning has been popularized and taught as an integral part of a surgeon's skill set, with critical evaluation and assessment of the implemented plan being the final step in the process. We present a robust, reproducible, and cost-effective technique for intraoperative fracture fixation assessment with case examples, used routinely at our institution.

Systematic Review of Combined Pelvic Ring and Acetabular Injuries: What Do We Know From the Literature?

The purpose of this review is to examine the literature on combined pelvic ring and acetabular fractures. We hope to further define the classifications, severities (ISS & Mortality), healing, radiographic parameters, and functional outcomes of such injuries to report all potential recommendations based on findings. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and a systematic search on PubMed and Google Scholar was performed. Articles included were in the English Language or through English translation, between the years 1996 and 2022. Articles that had met the inclusion criteria were systematically assessed for the relevance of their content. Eleven articles were identified with a total of 985 patients. All eleven were retrospective case series and the presence of both an injury within the pelvic ring and another injury within the acetabulum, either ipsilateral or contralateral, was the indication of a combination injury. The overall mortality rate averaged over all studies was 7.9% and the Injury Severity Score (ISS) of 22.98. When considering the higher mortality rate seen in pelvic ring injuries compared to the isolated acetabulum, there appears to be survivability beyond reductive means as a reason for reducing and fixing the pelvic ring first. However, accurate reduction of the acetabulum has a greater weight in overall patient recovery compared to the reduction of the pelvic ring and thus surgical emphasis on the anatomic reduction of the acetabulum may be paramount. Despite this good to excellent outcomes can be achieved with careful preoperative planning and surgical execution in patients with fractures of the pelvic ring and acetabulum. Further research as well as uniform radiographic scoring system and outcomes scores should be required to better evaluate and treat these injuries.

Antibiotic Cement-Coated Interlocked Intramedullary Nails for the Treatment of Infected Nonunion After Intramedullary Nailing.

OBJECTIVE: To evaluate outcomes using an interlocking antibiotic cement-coated nail and culture-specific systematic antibiotics in the treatment of infected nonunion after intramedullary nailing. DESIGN: Retrospective observational cohort study. SETTING: Urban level I trauma center. PATIENTS/PARTICIPANTS: Forty-one nonconsecutive patients who presented to a level I trauma center who underwent interlocked antibiotic nailing for treatment of infected nonunion status after primary intramedullary nailing. OUTCOMES: Eradication of infection, radiographic union by 2-year follow-up. RESULTS: Antibiotic nailing successfully eradicated infection and led to fracture healing in 35 patients (85.4%), while 6 patients (14.6%) had persistent infection and required further surgical treatment. Of the 6 patients who required further treatment, 5 eventually went on to heal with fracture union and eradication of their infection, while 1 required a salvage procedure. Of the 5 patients who eventually went on to heal, 4 of them healed with repeat antibiotic or intramedullary nails, while 1 required segmental resection and bone grafting before healing. CONCLUSIONS: This study suggests that the proposed interlocked antibiotic nailing technique is a viable therapeutic option to eradicate infected nonunion and support fracture healing. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pelvic Malunion: A Systematic Review, Dichotomy of Definitions and Treatment.

Background and Objectives: Pelvic nonunion and malunion have been documented as rare complications in pelvic fractures and literature describing these topics is severely limited. Articles dedicated solely to pelvic malunion are nearly nonexistent. We conducted a literature search with the goal of providing a summary of the definition, causes, treatment strategies, and outcomes of pelvic malunion correction. Materials and Methods: An initial review of the literature was performed using the PubMed, ScienceDirect, and Cochrane Database of Systematic Reviews databases. Search terms used were "malunion" AND "pelvic" OR "pelvis". Duplicate articles, non-English language articles without translations available and non-human subject studies were excluded. Results: Eleven original publications were found describing experiences with pelvic malunion. Seven of the articles were exclusively dedicated to the topic of pelvic fracture malunion, and only two reported on a series of patients treated for malunion with variably staged procedures. Most reports define pelvic pain as the main indication for surgical correction, along with gait disturbance, standing or sitting imbalance, and urinary or sexual dysfunction. Radiographically, vertical displacement of one to two centimeters and rotation of the hemipelvis of fifteen degrees or more have been described in defining malunion. No treatment algorithms exist, and each patient is treated with a unique work-up and operative plan due to the complexity of the problem. Only one series reported a patient satisfaction rate of 75% following malunion treatment. Conclusions: Pelvic malunion is a rare complication of pelvic ring injury and is seldom discussed in the literature. We found two small case series reporting exclusively on malunion treatment and complications. While some of the combination studies made the distinction in the diagnosis of malunion and nonunion, they rarely differentiated the treatment outcomes between the two categories. This paper describes pelvic malunion and highlights the need for more research into surgical outcomes of treatment specifically regarding functionality, patient satisfaction, and recurrence of preoperative symptoms.

The IPA, a Modified Numerical System for Pain Assessment and Intervention.

INTRODUCTION: The objective of this study was to (1) construct a pain scale that improves communication between healthcare providers and patients (Interventional Pain Assessment [IPA] tool) and (2) to validate this new pain scale with the numeric rating scale of 0 to 10 Numerical Rating System (NRS). METHODS: The IPA uses only three categories: 0 = "I have no pain," 1 = "My pain is tolerable (no intervention needed)," and 2 = "my pain is intolerable, (intervention needed)." An Institutional Review Board-approved study was done on 322 consecutive patients who were recovering from fracture treatment. We compared ratings of the IPA with NRS. We also asked patients which scale they preferred. Statistical analysis included Kendall rank correlation (Kendall τ) and Spearman rho to determine correlation with the NRS. RESULTS: The IPA exhibited a statistically significant association with the NRS (τ = 0.58, P < 0.0001). Discordant answers were provided by 23.6% patients; 4.7% regarded their mild-to-moderate pain as intolerable (15/322) while 18.9% reported their severe pain as tolerable (61/322). Eighty-two percent of patients preferred the IPA. CONCLUSION: The IPA is a valid pain scale and has exhibited strong correlation with the NRS 0 to 10, displays simple minimally clinical important difference calculation, and provides meaningful information on the effect of pain control modulation.

The prevalence of posterolateral tibial baseplate overhang: An anatomical CT study.

INTRODUCTION: Total Knee Arthroplasty (TKA) is used in patients with osteoarthritis who have failed conservative management to reduce pain, improve functional outcomes and ultimately quality of life. However, less than optimal patient satisfaction has led to continued improvements in design and technology of TKA. One factor that can limit patient satisfaction is postero-lateral overhang of the tibial baseplate. The purpose of our study is to utilize pre-operative CT scans to assess the prevalence of posterolateral tibial overhang with the use of a symmetric tibial baseplate component in a popular knee system with robotic assistance. METHODS: Ninety-eight (98) consecutive patients who underwent robotic-assisted total knee arthroplasty (TKA) were included in this study. Using both the most medial aspect of the tibial tubercle and the medial ⅓ of the tibial tubercle as reference points, we quantified the extent of posterolateral overhang when determining the rotation of the tibial component. RESULTS: Using the most medial aspect of the tibial tubercle as a reference point for rotation of the tibial baseplate, 63% of the instances of reviewed CT scans (369/588) had posterolateral overhang. Furthermore, 81% (406/588) had posterolateral overhang when using the medial ⅓ aspect of the tibial tubercle as the reference for rotation of the tibial baseplate. The average posterolateral tibial baseplate overhang was 1.5 mm (range 0-8 mm) when using the most medial aspect of the tibial tubercle and 2.4 mm (range 0-8 mm) when using the medial ⅓ tibial tubercle as the centering point for the tibial baseplate. DISCUSSION: Tibial baseplate overhang could lead to potential pain from irritation of soft tissues. To our knowledge, this is the first study that was able to valencquantify the amount of tibial baseplate overhang using pre-operative CT scans. Rotational alignment of the tibial baseplate needs to be balanced to ensure minimal lateral overhang while achieving sufficient external rotation of the tibial component. An asymmetric tibial component may provide a compromise in certain situations. LEVEL OF EVIDENCE: Diagnostic level IV case series.

Musculoskeletal Education in Medical Schools: A Survey of Allopathic and Osteopathic Medical Students.

BACKGROUND: Musculoskeletal (MSK) disorders are one of the most common causes of disability and emergency department and physician visits in the United States. However, there is very little consistency in how physicians in training are prepared to treat MSK disorders. On the basis of published reports, medical school graduates have a relative lack of cognitive mastery in MSK medicine, even with the recent increase in instruction. This study sought to compare MSK education at an allopathic medical school with that at an osteopathic medical school. METHODS: An anonymous survey of students in medical school graduate years 2, 3, and 4 at Michigan State University College of Human Medicine (allopathic) and College of Osteopathic Medicine (osteopathic) was conducted. Questions were structured into three main categories: demographic information, content of the current MSK curriculum, and opinions regarding importance, instruction, and assessment of MSK education. RESULTS: As of 2010, 83% of medical schools require MSK courses because of the United States Bone and Joint Initiative to incorporate such coursework into core curriculum. Yet only 54% of surveyed students thought that their MSK education was adequate. A greater portion of osteopathic students (57.1%) compared with allopathic students (26.8%) thought that their MSK curriculum is adequate, and as a consequence, 36.6% of allopathic students thought that they were inadequately prepared for the MSK content of US medical licensing examinations compared with 8.1% of osteopathic students. Further curriculum development and improvement is needed to advance physicians' abilities to address and treat MSK disorders. Medical students surveyed feel that this goal can be accomplished by emphasizing MSK education in third and fourth years of medical school. CONCLUSION: These findings highlight differences in MSK education between an allopathic and osteopathic medical school. Further standardization of the curriculum in medical schools may help improve the quality of teaching student comfort levels of new physicians. LEVEL OF EVIDENCE: Level III.

Effect of lateralized design on muscle and joint reaction forces for reverse shoulder arthroplasty.

BACKGROUND: Manufacturers of reverse shoulder arthroplasty (RSA) implants have recently designed innovative implants to optimize performance in rotator cuff-deficient shoulders. These advancements are not without tradeoffs and can have negative biomechanical effects. The objective of this study was to develop an integrated finite element analysis-kinematic model to compare the muscle forces and joint reaction forces (JRFs) of 3 different RSA designs. METHODS: A kinematic model of a normal shoulder joint was adapted from the Delft model and integrated with the well-validated OpenSim shoulder model. Static optimizations then allowed for calculation of the individual muscle forces, moment arms, and JRFs relative to net joint moments. Three-dimensional computer models of 3 RSA designs-humeral lateralized design (HLD), glenoid lateralized design, and Grammont design-were integrated, and parametric studies were performed. RESULTS: Overall, there were decreases in deltoid and rotator cuff muscle forces for all 3 RSA designs. These decreases were greatest in the middle deltoid of the HLD model for abduction and flexion and in the rotator cuff muscles under both internal rotation and external rotation. The JRFs in abduction and flexion decreased similarly for all RSA designs compared with the normal shoulder model, with the greatest decrease seen in the HLD model. CONCLUSIONS: These findings demonstrate that the design characteristics implicit in these modified RSA prostheses result in mechanical differences most prominently seen in the deltoid muscle and overall JRFs. Further research using this novel integrated model can help guide continued optimization of RSA design and clinical outcomes.