Patient Satisfaction After Total Hip Arthroplasty Is Not Influenced by Reductions in Opioid Prescribing.

BACKGROUND: Opioids have played an important part in post-operative analgesia, but concerns with associated morbidity and the fate of leftover pills have prompted the creation of opioid-sparing protocols. The purpose of this study is to investigate the impact of the implementation of an opioid-sparing protocol on survey-based patient satisfaction scores following total hip arthroplasty (THA). METHODS: This study is a retrospective review of prospectively collected data on patients who underwent primary THA between November 2014 and July 2019. Inclusion criteria consisted of primary elective THA with complete Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey information. Cohorts were separated based on their date of surgery relative to the start of an institutional opioid-sparing-protocol in October 2018. Discharge prescriptions and refills were recorded on chart review and converted to milligram morphine equivalents (MME) for comparison between different opioids. HCAHPS results were analyzed for percentage of "top box" ratings for comparison between the 2 groups. RESULTS: In total, 1003 patients met inclusion criteria: 804 pre-protocol and 199 post-protocol. Mean length of stay decreased from 1.74 ± 1.03 to 1.50 ± 1.11 days (P < .001). Pre-operative Visual Analog Scale pain decreased from 7.00 ± 2.30 to 6.41 ± 2.66 (P = .011) as did the rate of opioid refills (15.6%-9.1%; P = .019). Quantity of opioid medication prescribed upon discharge also decreased from 432 ± 298 to 114 ± 156 MME (P < .001). There was no change in "top box percentages" for satisfaction with pain control (79.7% pre-protocol, 82.1% post-protocol; P = .767). There was a significant increase in proportion of patients reporting top box satisfaction with their overall surgical experience after protocol implementation (88.2%-94.0%; P = .018). CONCLUSION: A reduction in opioids prescribed after THA is not associated with a decrease in patient satisfaction with regard to pain control, as measured by the HCAHPS survey, nor is it associated with an increase in post-operative opioid refills. LOE: III. CLINICAL RELEVANCE: This study suggests that HCAHP scores are not negatively impacted by a reduction in post-operative opioid analgesics.

The History of Tourniquet Usage and Modern Utilization in Total Knee Arthroplasty.

The usage of tourniquets in orthopedic surgery is commonplace. This review will describe the history of tourniquet usage throughout medicine and trace this device's evolution to the modern device used today. Several basic principles of tourniquet usage will also be explored, debunking common myths regarding upper time-limits of tourniquet inflation, the ideal pressure of inflation, and tourniquet usage in patients with pre-existing vascular diseases. Additionally, special attention is paid to the utility of lower extremity tourniquets in total knee arthroplasty with regards to cementation, blood loss, pain control, and functional outcomes. Finally, the future of tourniquet usage is discussed.

How Do Sports Medicine and Foot and Ankle Specialists Treat Acute Achilles Tendon Ruptures?

Background. The purpose of this study is to evaluate the treatment considerations and surgical techniques utilized by fellowship-trained orthopaedic sports medicine and foot and ankle specialists in the management of Achilles tendon ruptures. Methods. A blinded electronic survey was distributed to 2062 fellowship-trained sports medicine and 1319 fellowship-trained foot and ankle orthopaedic surgeons. The total number of acute Achilles tendon ruptures managed per year, patient-specific factors associated with surgical decision making and surgical techniques were evaluated. Results. Of the 3381 surveys distributed, 524 responses were included for analysis. Only 9% of respondents manage more than 20 acute Achilles tendon ruptures per year with the majority (75%) managing less than 10 per year. Operative management is the treatment of choice for 76% of total respondents with only 8% managing acute ruptures nonoperatively. Activity level and patient age were the single most important factors for 60.8% and 29.3% of surgeons, respectively, with regard to operative versus nonoperative decision making. Socioeconomic status and workers compensation were the least important patient factors. Conclusion. Surgical repair in the young and active patient is the preferred treatment for the majority of fellowship-trained subspecialists who most commonly encounter this pathology.Levels of Evidence: Therapeutic, Level V: Consensus of Expert Analysis.

Variability of patient and surgical risk factors for infection in a single, urban, academic total joint replacement center.

BACKGROUND: We describe surgeon-specific patient and procedure variability in a single center to determine how much variability exists between surgeons. METHODS: Data was analyzed from 2009 to 2013 at a single center. The total number of primary and revision hip and knee arthroplasty surgeries were quantified for each surgeon. RESULTS: Surgeon caseload varied significantly, with the largest differences observed in primary TKA caseload. The largest patient differences were in regards to percentage of patients with diabetes mellitus amongst primary TKA patients. CONCLUSION: Significant differences in patient characteristics that could significantly impact outcomes after total joint arthroplasty were found amongst surgeons.

Advances in biologic augmentation for rotator cuff repair.

Rotator cuff tear is a very common shoulder injury that often necessitates surgical intervention for repair. Despite advances in surgical techniques for rotator cuff repair, there is a high incidence of failure after surgery because of poor healing capacity attributed to many factors. The complexity of tendon-to-bone integration inherently presents a challenge for repair because of a large biomechanical mismatch between the tendon and bone and insufficient regeneration of native tissue, leading to the formation of fibrovascular scar tissue. Therefore, various biological augmentation approaches have been investigated to improve rotator cuff repair healing. This review highlights recent advances in three fundamental approaches for biological augmentation for functional and integrative tendon-bone repair. First, the exploration, application, and delivery of growth factors to improve regeneration of native tissue are discussed. Second, applications of stem cell and other cell-based therapies to replenish damaged tissue for better healing are covered. Finally, this review will highlight the development and applications of compatible biomaterials to both better recapitulate the tendon-bone interface and improve delivery of biological factors for enhanced integrative repair.

Arm pain in youth baseball players: a survey of healthy players.

BACKGROUND: Overuse injury in youth baseball players is increasing in prevalence, and these injuries have been correlated to pitching mechanics and pitch counts/types. Prior studies regarding arm pain in these athletes have focused simply on presence or absence of pain during the season rather than on detailed factors related to arm pain with respect to frequency, severity, and associated performance and psychosocial effect. HYPOTHESIS/PURPOSE: The goal of this study was to investigate frequency, quality, and effect of arm pain in healthy youth baseball players. The hypothesis was that arm pain will affect a majority of healthy baseball players and will be associated with adverse psychosocial effects. STUDY DESIGN: Descriptive epidemiological study. METHODS: A novel survey focusing on arm pain in youth baseball players was developed for the purpose of this study. Survey questions were formulated by a consortium of trainers, clinicians, and coaches. Surveys were administered to healthy youth baseball players throughout the states of New Jersey and New York. RESULTS: A total of 203 healthy players completed the survey; 23% of players (n=47) reported a prior overuse injury. Only 26% and 20% of players reported that their arm never hurt when throwing or the day after throwing, respectively; 30% of players reported that arm pain at least sometimes caused them to have less fun playing; and 46% of players reported at least once being encouraged to keep playing despite having arm pain. Pitchers were more likely to report arm pain while throwing and the day after throwing and to indicate that arm pain held them back from being a better player (all P<.05). Those with prior overuse injury were more likely to have arm pain while throwing, to have arm fatigue during a game or practice, and to be encouraged to keep playing despite having pain (all P<.05). CONCLUSION: A majority of healthy (actively competing) youth baseball players report at least some baseline arm pain and fatigue, and many players suffer adverse psychosocial effects from this pain.

Performance, Return to Competition, and Reinjury After Tommy John Surgery in Major League Baseball Pitchers: A Review of 147 Cases.

BACKGROUND: Pitching performance metrics, durability, and reinjury after Tommy John surgery in professional baseball players have not been well described. PURPOSE: The purpose of this study was to determine the likelihood of return to professional competition, reinjury rate, and change in performance after Tommy John surgery in Major League Baseball pitchers. The hypothesis was that performance metrics and durability will decline after surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Publicly available records were accessed to generate a list of all Major League Baseball pitchers from 1999 to 2011 who had undergone ulnar collateral ligament reconstruction at any point in their careers; those with multiple reconstructive procedures were excluded. Return to active (≥1 game) or established (≥10 games) competition and/or placement on the disabled list was documented for each player. Among established players, pitching performance was compared pre- and postoperatively, as well as with age-matched control pitchers. RESULTS: Of 147 pitchers included, 80% returned to pitch in at least 1 Major League Baseball game. Only 67% of established pitchers returned to the same level of competition postoperatively, and 57% of established players returned to the disabled list because of injuries to the throwing arm. Finally, performance declined across several metrics after surgery compared with preinjury levels, such as earned run average, batting average against, walks plus hits per inning pitched, percentage of pitches thrown in the strike zone, innings pitched, percentage fastballs thrown, and average fastball velocity (P < .05 for all). However, these declines were not statistically different from similar declines found in age-matched controls who did not undergo Tommy John surgery. CONCLUSION: Return to the disabled list after Tommy John surgery is common among professional pitchers (>50%), and performance declines across several major metrics after surgery. Patients undergoing Tommy John surgery should be counseled appropriately regarding the likelihood of return to preinjury levels of competition and performance.