A Novel Prescription Method Reduces Postoperative Opioid Distribution and Consumption: A Randomized Clinical Trial.

BACKGROUND: Prescription opioid abuse in the United States has risen substantially over the past 2 decades. Narcotic prescription refill restrictions may paradoxically be contributing to this epidemic. We investigated a novel, refill-based opioid prescription method to determine whether it would alter postoperative narcotic distribution or consumption. METHODS: In this randomized controlled trial, patients undergoing internal fixation of distal radius fractures or thumb carpometacarpal joint arthroplasty received either a single prescription for all postoperative narcotics (control arm) or the same amount of pain medication divided into 3 equal prescriptions to be filled as needed (experimental arm). Outcomes included total narcotics dispensed, measured in morphine milligram equivalents (MME) through a prescription monitoring program, patient-reported opioid consumption versus opioid not consumed, and a satisfaction survey. RESULTS: Forty-eight participants were enrolled; 25 were randomized to the control arm and 23 to the experimental arm. At 8 weeks post-op, fewer opioids had been dispensed to the experimental arm (177 ± 94 vs 287 ± 123 MME, P = .0025). At 6-week follow-up, the experimental arm reported lower narcotic consumption (124 ± 105 vs 214 ± 110 MME, P = .0131). Subanalysis of the independent surgeries yielded similar results. Some patients reported insurance issues when filling subsequent prescriptions. Consequently, although 100% of control arm patients reported good pain control, only 82.6% of experimental arm patients said likewise (P = .0455). CONCLUSIONS: This randomized clinical trial demonstrated that patients obtained and consumed fewer narcotics when postoperative opioids were given in a refill-based prescription method. More research is needed to determine whether this opioid distribution method is reproducible, translatable, and feasible.

Orthopedic Surgery Residency Application Process in 2020 - Has Diversity been Affected?

Background: Orthopedic surgery is currently the least diverse field in medicine. COVID-19 necessitated a virtual rotation and interview process for orthopedic residency applications in 2020. Given the pressing need to address disparities within the field, any change in the application process should be examined with regard to the potential effects it could have on the diversity of trainees in orthopedic surgery. The purpose of this study was to evaluate the effect of virtual rotations and interviews on the demographic distribution of applicants to orthopedic surgery residency. Methods: A retrospective review of orthopedic surgery residency applicants was performed comparing the 2018 and 2020 application cycle. Self-reported ethnicity on Electronic Residency Application Service (ERAS) forms was recorded for all applicants who met prescreening criteria, were invited to interview and who completed interviews. The proportion of underrepresented minority (URM) applicants was compared between these two cohorts. Results: There were no significant differences between the 2018 and 2020 application cohorts in terms of number or proportion of URM applicants that met initial screening criteria (p=0.7598), female applicants that met initial screening criteria (p=0.3106), URM applicants who were invited to interview (p=0.6647), or female applicants who were invited to interview (p=0.63). Overall, applicants in the 2018 cycle were 2.38 times more likely to be invited to interview (OR 2.38, 95% CI 1.6886-3.3623, p<0.0001) and applicants who were invited to interview were 20.96 times more likely to interview in the 2020 cycle than in the 2018 cycle (OR 20.96, 95% CI 4.89-90.09, p<0.0001). Conclusion: The proportion of URMs applying to orthopedic surgery residency was not significantly different after transitioning to a virtual rotation and interview platform at the single institution studied. Applicants were 2.38 times more likely to be invited to interview in 2018 and were 20.96 times more likely to attend the interview in 2020.Level of Evidence: III.

Does Removing the Photograph and Name Change the Reviewer's Perception of Orthopaedic Residency Applicants?

INTRODUCTION: Orthopaedic surgery remains the least diverse field in medicine regarding female and minority representation. Scarce literature exists evaluating the role of implicit bias in the residency application process. We hypothesized that applicants perceived as underrepresented minorities in orthopaedic surgery (URMs) based on their photograph or name would have a decreased likelihood of being invited to interview. METHODS: Data from the 2018 to 2019 orthopaedic residency application cycle were collected from a single institution. Applications were classified URM or non-URM. After the application cycle was completed, the URM applications were propensity matched with non-URM applicants. Photographs and names were removed, and the applications were rereviewed by the Residency Applicant Review committee. Rank-in-group and the likelihood of being invited for an interview were compared. RESULTS: Four hundred eleven applications were included with 27.5% URM and 72.5% non-URM. During the regular application cycle, 34.7% of those invited to interview were URM and 50% of those who were ranked-to-match range were URM. After propensity matching, 90 matched pairs were rereviewed with their photograph and name removed. In the regular application cycle, the URM applicant was 3.8 times more likely to get an interview than the matched non-URM applicant (odds ratio, 3.8, 95% confidence interval, 1.7 to 8.8, P = 0.0014). In the "blinded" condition, the URM candidate was 2.5 times more likely to get an interview than the non-URM candidate (odds ratio, 2.5, 95% confidence interval, 1.1 to 6.2 P = 0.034). In the unblinded condition, the URM candidate had a higher ranking within their group than the corresponding non-URM applicant (P = 0.0005). DISCUSSION: Contrary to our initial hypothesis, URM applicants were invited to interview at a higher rate than non-URM applicants, both in the regular application cycle and in the propensity-matched "blinded" condition. This suggests that implicit bias based on the picture or name is not negatively affecting URM students during the application review process at our institution. LEVEL OF EVIDENCE: 3.

Safety and Efficacy of Forearm Tourniquet Compared to Upper Arm Tourniquet for Local Intravenous Regional Anesthesia in Hand Surgery: A Randomized Clinical Trial.

BACKGROUND: Forearm tourniquets may offer decreased doses of anesthetic, shorter procedure times, and less pain compared to upper arm tourniquets. There is limited data comparing the clinical efficacy of forearm Bier blocks to conventional upper arm Bier blocks. The purpose of this study was to assess the effectiveness, complications, duration, cost, and patient satisfaction between forearm and upper arm Bier blocks during surgery. METHODS: Sixty-six carpal tunnel release, ganglion excision, or trigger finger procedures were performed. Patients were randomized to 3 groups: upper arm tourniquet for 25 minutes, forearm tourniquet for 25 minutes, or forearm tourniquet with immediate deflation following the procedure (<25 minutes). The efficacy of surgical anesthesia, tourniquet discomfort, and supplementary local anesthetic administration were recorded. Pain was assessed intraoperatively and postoperatively. Patient satisfaction was assessed on the first postoperative day. RESULTS: No difference was observed between groups with respect to pain, satisfaction, or administration of supplemental medication. The tourniquet time for the group with immediate deflation following procedure was shorter by an average of 9.3 minutes. Total hospital charges were 9.95% cheaper with immediate tourniquet deflation compared to procedures where the tourniquet remained inflated for at least 25 minutes. CONCLUSION: The forearm Bier block is a safe, efficient, cost-effective technique for intravenous regional anesthesia during hand surgery, and tourniquet deflation immediately following the procedure (<25 minutes) does not increase incidence of complications. The forearm tourniquet reduces the dose of local anesthetic and therefore risk for systemic toxicity, with similar effectiveness as compared to the upper arm technique.Level of Evidence: II.

Postoperative care via smartphone following carpal tunnel release.

INTRODUCTION: This study explores a novel smartphone application for postoperative care following carpal tunnel release (CTR). We hypothesized that a software-based 'virtual visit' for CTR could be safe, effective and convenient for the patient. METHODS: Our group developed the software application utilized in this study. Interactive steps with video instructions enabled patients to complete dressing and suture removal, capture a wound photo, answer a question about median nerve symptoms and capture a video of finger range of motion. Adult patients undergoing endoscopic or open CTR were enrolled. Prior to their scheduled postoperative visit, patients received and completed the module using their smartphone. Agreement between findings of the virtual visit and the corresponding in-person clinical visit was assessed using kappa values. RESULTS: Twenty-two patients were contacted regarding study enrolment and 17 patients were enrolled (ages 23-63, mean 48.2, 6M, 11F). Of 16 patients who participated, all completed dressing removal. Ten of 16 patients removed their sutures successfully. Fourteen patients captured a clinically adequate wound photo and 15 patients answered a question about median nerve symptoms. Fourteen patients captured a range of motion video. Software assessments of surgical wounds, nerve symptoms and physical exams agreed strongly with clinical assessments. DISCUSSION: Most patients were able to respond to a question about their symptoms, provide clinical assessment of their wound via a photo and record a video of their range of motion. Suture removal was the most difficult task. More investigation is needed to determine which patients can reliably remove their sutures.

Breaking Barriers: A Brief Overview of Diversity in Orthopedic Surgery.

Diversity within the field of orthopedic surgery has been slow to progress, even well into the 21st century. Despite the barriers broken in 1932 by Ruth Jackson - the first female member of the American Academy of Orthopedic Surgeons (AAOS) - gender, racial and ethnic diversity continues to be lacking. Research has shown there are clear advantages of a diverse physician population, not only in medicine and patient care but in commercial industry as well. Although the representation of females and underrepresented minorities (URM) in orthopedics is increasing, it is doing so at a slower rate as compared to other surgical subspecialties. Targeted efforts have been made to investigate and promote gender and cultural diversity in orthopedic surgery. New programs and initiatives have been developed to promote diversity in orthopedics through mentorship and enhancing visibility of females and URM in the field.

Intraoperative Point of View Video Capture and Surgical Segmentation in Carpal Tunnel Release: A Feasibility Analysis.

OBJECTIVE: The purpose of this study was to (1) examine the feasibility of intraoperative point of view video while performing open and endoscopic carpal tunnel release (CTR), (2) define surgical segments of CTR, and (3) describe the duration of various surgical steps of open versus endoscopic CTR in a teaching setting. DESIGN: Fellowship trained hand surgeons reached consensus on surgical segments for CTR. Adult patients 18 and older previously indicated for CTR in clinic were eligible. Head-mounted point-of-view cameras were worn during endoscopic and open CTR by resident surgeons. Video was reviewed to determine segment duration. Independent sample t tests were used for comparison of duration by technique with statistical significance set as p < 0.05. SETTING: University of Iowa Hospitals and Clinics; 200 Hawkins Dr, Iowa City, IA 52242; Tertiary Academic Medical Center. PARTICIPANTS: Orthopedic Surgery Residents and Orthopedic Surgery Faculty. RESULTS: Surgical segments were defined as incision, dissection of superficial soft tissue structures, transection of the carpal ligament, and surgical incision closure. Twelve of 14 video capture events yielded data. In the teaching setting, the average duration of endoscopic CTR was 609.5 seconds (±111.07) versus 547.75 seconds (±82.06) for open with p value = 0.406. No surgical segments were significantly different. Transition time from dissection to ligament transection differed significantly (p = 0.004) between endoscopic (46.88 seconds ± 19.19) and open (9.0 seconds ± 7.90) CTR. Transition time between ligament transection and closure was significantly different (p = 0.029) among endoscopic (50.5 seconds ± 15.0) and open (26.25 seconds ± 2.99) CTR. CONCLUSIONS: Point-of-view video capture is feasible for the capture of video during a common hand surgery procedure. A method for managing device battery power is necessary for future applications. CTR can be defined as, and described in, individual procedure segments potentially useful for surgical education as well as efficiency improvements. Identification of surgical segments may aid the development of better objective tools for the assessment of surgeon skill and competency for common orthopedic procedures.

Detection of Retained Foreign Objects in Upper Extremity Surgical Procedures With Incisions of Two Centimeters or Smaller.

BACKGROUND: While the true incidence of retained foreign bodies after surgery is unknown, it has been approximated at 1:5,500 operations overall, with substantially less frequency in hand and upper extremity procedures. Despite the rarity of foreign body retention in hand and upper extremity surgery, universal radiofrequency scanning for electronically-tagged sponges and automatic radiographic evaluation for incorrect sponge counts are employed for all surgical procedures at our institution. We demonstrate the infeasibility of retaining an operative sponge of a standard size in commonly performed hand and upper extremity procedures with incision sizes of two centimeters or less, and establish that visual detection of sponges in these cases is adequate. METHODS: Eighteen trigger finger releases, five carpal tunnel releases, three trigger thumb releases, and three de Quervain's tenosynovitis releases were successfully performed upon five cadaveric specimens by residents under supervision of fellowship-trained hand surgeons for a total of 29 two-centimeter or smaller incisions. Randomized surgical sponge placement was evaluated by a blinded observer at two distances and incision sizes were quantified. Kappa values were calculated to determine the acuity of visual detection versus the actual presence of a sponge. RESULTS: The maximum length of the standard surgical sponge that could be contained within an incision was three centimeters. When compared with the gold standard (whether the sponge had been placed or not by the operating resident), the placement of a standard surgical sponge could be detected correctly in 100% of cases at both "across the room" and "at the table" distances, for kappa values of 1.0 and 1.0 respectively. This did not vary with incision size or surgical procedure. CONCLUSIONS: The added cost and time from radiofrequency detection of retained sponges and radiographic evaluation in the event of incorrect sponge counts can be safely eliminated if sponges can be reliably visually detected. CLINICAL RELEVANCE: This cadaveric study informs patient safety practices by demonstrating that visual detection of surgical sponges is adequate for certain upper extremity procedures.

A Novel Arthroscopic Inside-Out Repair Technique for PASTA Lesions.

There is no current consensus in the literature on the optimal technique for surgical treatment of partial articular-sided supraspinatus tendon avulsion (PASTA) lesions, although most techniques described to date require takedown of the partially torn tendon or passage of an anchor through the already damaged tendon. We describe a novel inside-out repair technique for partial articular surface supraspinatus tears that does not require further disruption of the partially torn tendon by passage of an anchor.