Institutional reductions in opioid prescribing do not change patient satisfaction on Press Ganey surveys after total shoulder arthroplasty.

BACKGROUND: With an ongoing opioid epidemic in the United States, it is important to examine if decreased opioid prescribing can affect patient experience, namely satisfaction with pain control. PURPOSE: The purpose of this study was to investigate what effect, if any, decreased opioid prescribing after total shoulder arthroplasty had on Press Ganey satisfaction surveys. METHODS: A retrospective review was conducted on patients who underwent primary anatomic or reverse total shoulder arthroplasty between October 2014 and October 2019. Patients with complete Press Ganey survey information and no history of trauma, fracture, connective tissue disease, or prior shoulder arthroplasty surgery were included in the analysis. Patients were segregated into 2 groups, pre-protocol and post-protocol, based on the date of surgery relative to implementation of an institutional opioid reduction protocol, which occurred in October 2018. Prescriptions were converted to morphine milligram equivalents (MME) for direct comparison between different opioid medications. RESULTS: A total of 201 patients met inclusion criteria, and there were 110 reverse total shoulder arthroplasties and 91 anatomic total shoulder arthroplasties. Average opioids prescribed on discharge for the pre-protocol group were 426.3 ± 295 MME (equivalent to 56.8 tablets of oxycodone 5 mg), whereas after the initiation of the protocol, they were 193.8 ± 199 MME (equivalent to 25.8 tablets of oxycodone 5 mg); P < .0001. Average satisfaction with pain control did not change significantly between pre-protocol and post-protocol (4.71 ± 0.65 pre-protocol and 4.74 ± 0.44 post-protocol, P = .82). CONCLUSION: A reduction in opioids prescribed after a total shoulder replacement is not associated with any negative effects on patient satisfaction, as measured by the Press Ganey survey.

Superior Pain Reduction with Anteromedialization Tibial Tubercle Osteotomy Versus Non-Operative Management for Patellofemoral Osteoarthritis.

PURPOSE: The purpose of this study was to compare the clinical outcomes of patients with patellofemoral osteoar-thritis (PFOA) treated non-operatively with those treated operatively with an unloading anteromedialization tibial tubercle osteotomy (TTO). METHODS: A retrospective chart review was performed to identify patients with isolated PFOA who were either managed non-operatively or surgically with a TTO and who had a minimum follow-up of 2 years. Patients were surveyed with the visual analog scale (VAS) for pain, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), Anterior Knee Pain scale (Kujala), and Tegner Activity scale. Statistical analysis included two-sample t-testing, one-way ANOVA, and bivariate analysis. RESULTS: The clinical outcomes of 49 non-operatively managed patients (mean age: 52.7 ± 11.3 years; mean follow-up: 1.7 ± 1.0 years) and 35 operatively managed patients (mean age: 31.8 ± 9.4 years; mean follow-up: 3.5 ± 1.7 years) were assessed. The mean VAS improved sig-nificantly in both groups [6.12 to 4.22 (non-operative), p < 0.0001; 6.94 to 2.45 (TTO); p < 0.0001], with operatively treated patients having significantly lower postoperative pain than non-operatively managed patients at the time of final follow-up [2.45 (TTO) vs. 4.22 (non-operative), p < 0.001]. The mean KOOS-JR score was significantly greater in the operative group at time of final follow-up [78.7 ± 11.6 (TTO) vs. 71.7 ± 17.8 (non-operative), p = 0.035]. There was no significant difference in Kujala or Tegner scores between the treatment groups. Additionally, there was no sig-nificant relationship between the number of intra-articular injections, duration of NSAID use, and number of physical therapy sessions on clinical outcomes in the non-operatively treated group (p > 0.05). CONCLUSIONS: An unloading anteromedialization TTO provides significantly better pain relief and restoration of function compared to non-operative management in the treatment of symptomatic PFOA.

Tunnel Widening Following All-Inside Anterior Cruciate Ligament Reconstruction Varies Depending on Soft Tissue Graft Type.

PURPOSE: Bone tunnel widening (TW) is a well-described complication after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to evaluate radiographic bone TW and clinical outcomes in patients with ACLR performed with suspensory fixation on both the femoral and tibial tunnels using different soft tissue grafts. METHODS: Patients who underwent primary ACLR with a soft tissue graft (hamstring autograft or allograft or quadriceps autograft) using an all-inside technique were included for analysis. Anterior cruciate ligament tunnel width was measured postoperatively on anteroposterior and lateral plain radiographs at a minimum of 12 months of follow-up. Clinical outcomes were assessed using the International Knee Documentation Committee (IKDC) subjective knee form as well as assessing patient records for complication data. RESULTS: Fifty patients (15 quadriceps autografts, 24 hamstring autografts, 11 hamstring allografts) were included in this study. The quadriceps autograft cohort was the youngest, (16.6 ± 2.8 years), followed by the hamstring autograft cohort (27.7 ± 9.0 years), and the hamstring allograft cohort (48.2 ± 9.4 years; p < 0.001) for all comparisons. Quadriceps autografts experienced less tibial tunnel-widening (0.6 ± 0.6 mm) than hamstring autografts (2.0 ± 1.1 mm; p = 0.011), which, in turn, experienced less widening than hamstring allografts (3.9 ± 2.3 mm; p < 0.001). Quadriceps autografts also experienced less femoral tunnel widening (0.3 ± 0.6 mm) than hamstring autografts (2.1 ± 1.2 mm; p < 0.001) which, in turn, experienced less tunnel-widening than hamstring allografts (4.0 ± 2.1; p < 0.001). At follow-up, mean IKDC for hamstring autografts, quadriceps autografts, and hamstring allografts were 79.9 ± 17.9, 88.5 ± 7.1, and 77.7 ± 20.4, respectively (p = 0.243). There was no statistically significant difference between groups with respect to postoperative complications; p = 0.874. CONCLUSIONS: Anterior cruciate ligament reconstruction with quadriceps autograft resulted in the least tunnel widening compared to hamstring autograft and allograft when using an all-inside suspensory fixation device. Both autograft groups resulted in less widening than the allograft group. Despite the greatest increased radiographic tunnel widening in the allograft group, there was no significant difference in clinical outcomes or knee laxity.

Wound Closure Following Intervention for Closed Orthopedic Trauma.

The method of skin closure and post-operative wound management has always been important in orthopedic surgery and plays an even larger role now that surgical site infection (SSI) is a national healthcare metric for both surgeons and hospitals. Wound related issues remain some of the most feared complications following orthopedic trauma procedures and are associated with significant morbidity. In order to minimize the risk of surgical site complications, surgeons must be familiar with the physiology of wound healing as well as the patient and surgical factors affecting healing potential. The goal of all skin closure techniques is to promote rapid healing with acceptable cosmesis, all while minimizing risk of infection and dehiscence. Knowledge of the types of closure material, techniques of wound closure, surgical dressings, negative pressure wound therapy, and other local modalities is important to optimize wound healing. There is no consensus in the literature as to which closure method is superior but the available data can be used to make informed choices. Although often left to less experienced members of the surgical team, the process of wound closure and dressing the wound should not be an afterthought, and instead must be part of the surgical plan. Wounds that are in direct communication with bony fractures are particularly at risk due to local tissue trauma, resultant swelling, hematoma formation, and injured vasculature.

Glenohumeral Arthritis in the Young Adult Current Concepts in Treatment.

Glenohumeral osteoarthritis (GHOA) in the young adult remains a challenging clinical problem to treat. These difficulties stem from the high physical demands and expectations of this patient population, limited longevity of existing treatment modalities, and need for a future revision surgery after primary surgical intervention. Given the heterogeneous etiology, clinical presentation, and radiographic findings, a thorough understanding of the pathology, patient expectations, and outcomes of existing treatment options available is necessary to deliver a treatment that is tailored to individual needs of the patient. None of the available treatment options have shown to alter the natural history of GHOA. Nonsurgical modalities continue to be the first line treatment but there is no consensus if one treatment is more effective than the other. Surgical options include shoulder preserving and shoulder replacing procedures and are usually considered after the nonsurgical options become ineffective in controlling a patient's symptoms. Total shoulder arthroplasty provides predictable pain relief and improvement of function but is limited by the longevity of the implant. Despite the growing research, there continues to be search for a long lasting, durable treatment option that would compete with a young adult's lifetime.

Performance and Return to Sport After Hand, Wrist, and Forearm Fractures in the National Hockey League.

PURPOSE: To examine finger, thumb, hand, wrist, and forearm fractures in the National Hockey League (NHL) and determine: (1) basic demographic data, (2) return to sport (RTS) rates, (3) performance after RTS, and (4) the difference in RTS between players treated operatively versus conservatively. METHODS: NHL players with finger, thumb, hand, wrist, and forearm fractures between the 1995-1996 and 2014-2015 seasons were identified through team injury reports and archives on public record. Player demographics, RTS rate, games played per season, and performance score for each player were recorded and compared between the preinjury season and one season following injury. RESULTS: A total of 247 total NHL players with hand, wrist, and forearm fractures were identified, consisting of 30.8% finger, 38.5% hand, 13.8% thumb, 14.6% wrist, and 2.4% forearm fractures. Defenseman comprised the majority of players (40.1%). The overall RTS rate was 98.0%, with no significant difference between players with surgery or between injury location groups. In total, 52 players (21.1%) underwent surgery with no significant correlation of surgery rates based on fracture location. The mean number of missed games was 13.8 ± 9.9, with players sustaining wrist and forearm fractures missing the largest number of games (21.6 ± 17.7and 22.8 ± 7.5 games missed, respectively). There was no significant change in games played or performance scores 1 year after injury for players with any of the fracture types compared with baseline preoperative games played and performance. CONCLUSIONS: NHL players have a high RTS rate following hand, wrist, and forearm fractures. Players were able to return to preinjury performance within 1 year, regardless of treatment or type of fracture. LEVEL OF EVIDENCE: Level IV, case series.

Recall Bias in Retrospective Assessment of Preoperative Patient-Reported American Shoulder and Elbow Surgeons Scores in Arthroscopic Rotator Cuff Repair Surgery.

BACKGROUND: The gold-standard method for collecting patient-reported outcomes (PROs) is the prospective assessment of preoperative to postoperative change. However, this method is not always feasible because of unforeseen cases or emergencies, logistical and infrastructure barriers, and cost issues. In such cases, a retrospective approach serves as a potential alternative, but there are conflicting conclusions regarding the reliability of the recalled preoperative PROs after orthopaedic procedures. PURPOSE: To assess the agreement between prospectively and retrospectively collected PROs for a common, low-risk procedure. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: Patients who underwent arthroscopic rotator cuff repair between May 2012 and September 2017 at the study institution were identified. All of the patients completed the American Shoulder and Elbow Surgeons (ASES) Standard Shoulder Assessment Form preoperatively at their preassessment appointment. Patients were then contacted in the postoperative period and asked to recall their preoperative condition while completing another ASES form. RESULTS: A total of 84 patients completed the telephone survey and were included in this analysis (mean age, 57.40 ± 9.96 years). The mean duration of time from onset of shoulder symptoms to surgery was 9.13 ± 9.08 months. The mean duration of time between surgery and recall ASES administration was 39.12 ± 17.37 months. The mean recall ASES score was significantly lower than the preoperative ASES score (30.69 ± 16.93 vs 51.42 ± 19.14; P < .001). There was poor test-retest reliability between preoperative ASES and recall ASES (intraclass correlation coefficient, 0.292; 95% CI, -0.07, 0.57; P = .068). Greater age at the time of recall, a shorter symptomatic period before surgery, and less severe preoperative shoulder dysfunction were associated with a greater difference between preoperative ASES and recall ASES. CONCLUSION: Retrospectively reported PROs are subject to significant recall bias. Recalled PROs were almost always lower than their prospectively recorded counterparts. Recalled PROs are more likely to be accurate when reported by younger patients, those with a longer duration of symptoms, and those with more severe preoperative conditions.

Control Strategies for Infection Prevention in Total Joint Arthroplasty.

Despite the development of newer preventative measures, the rate of infection continues to be approximately 1% for patients undergoing total joint arthroplasty (TJA). The extent of the infection can range from a mild superficial infection to a more serious periprosthetic joint infection (PJI). PJIs not only play a significant role in the clinical well-being of the TJA patient population, but also have substantial economic implications on the health care system. Several approaches are currently being used to mitigate the risk of PJI after TJA. The variety of prophylactic measures to prevent infection after TJA must be thoroughly discussed and evaluated.

Brachial Plexus Blockade Causes Subclinical Neuropathy: A Prospective Observational Study.

Background: The objective of this study is to determine subclinical changes in hand sensation after brachial plexus blocks used for hand surgery procedures. We used Semmes-Weinstein monofilament testing to detect these changes. We hypothesized that patients undergoing brachial plexus nerve blocks would have postoperative subclinical neuropathy detected by monofilament testing when compared with controls. Methods: In total, 115 hand surgery adult patients were prospectively enrolled in this study. All patients undergoing nerve-related procedures were excluded as well as any patients with preoperative clinically apparent nerve deficits. Eighty-four patients underwent brachial plexus blockade preoperatively, and 31 patients underwent general anesthesia (GA). Semmes-Weinstein monofilament testing of the hand was performed preoperatively on both the operative and nonoperative extremities and postoperatively at a mean of 11 days on both hands. Preoperative and postoperative monofilament testing scores were compared between the block hand and the nonoperated hand of the same patient, as well as between the block hands and the GA-operated hands. Results: There were no recorded clinically relevant neurologic complications in the block group or GA group. A statistically significant decrease in sensation in postoperative testing in the operated block hand compared with the nonoperated hand was noted. When comparing the operated block hand with the operated GA hand, there was a decrease in postoperative sensation in the operated block hand that did not reach statistical significance. Conclusions: Brachial plexus blockade causes subtle subclinical decreases in sensibility at short-term follow-up, without any clinically relevant manifestations.

PHYRN: a robust method for phylogenetic analysis of highly divergent sequences.

Both multiple sequence alignment and phylogenetic analysis are problematic in the "twilight zone" of sequence similarity (≤ 25% amino acid identity). Herein we explore the accuracy of phylogenetic inference at extreme sequence divergence using a variety of simulated data sets. We evaluate four leading multiple sequence alignment (MSA) methods (MAFFT, T-COFFEE, CLUSTAL, and MUSCLE) and six commonly used programs of tree estimation (Distance-based: Neighbor-Joining; Character-based: PhyML, RAxML, GARLI, Maximum Parsimony, and Bayesian) against a novel MSA-independent method (PHYRN) described here. Strikingly, at "midnight zone" genetic distances (~7% pairwise identity and 4.0 gaps per position), PHYRN returns high-resolution phylogenies that outperform traditional approaches. We reason this is due to PHRYN's capability to amplify informative positions, even at the most extreme levels of sequence divergence. We also assess the applicability of the PHYRN algorithm for inferring deep evolutionary relationships in the divergent DANGER protein superfamily, for which PHYRN infers a more robust tree compared to MSA-based approaches. Taken together, these results demonstrate that PHYRN represents a powerful mechanism for mapping uncharted frontiers in highly divergent protein sequence data sets.