The United States is in the midst of an opioid epidemic. Little is known about perioperative opioid use for total knee arthroplasty (TKA). The purpose of this study was to identify rates of ...preoperative opioid use, evaluate postoperative trends and identify risk factors for prolonged use after TKA.
Patients who underwent primary TKA from 2007-2014 were identified within the Humana database. Postoperative opioid use was measured by monthly prescription refill rates. A preoperative opioid user (OU) was defined by history of opioid prescription within 3 months prior to TKA and a non-opioid user (NOU) was defined by no history of prior opioid use. Rates of opioid use were trended monthly for one year postoperatively for all cohorts.
73,959 TKA patients were analyzed and 23,532 patients (31.2%) were OU. OU increased from 30.1% in 2007 to 39.3% in 2014 (P < .001). Preoperative opioid use was the strongest predictor for prolonged opioid use following TKA, with OU filling significantly more opioid prescriptions than NOU at every time point analyzed. Younger age, female sex and other intrinsic factors were found to significantly increase the rate of opioid refilling following TKA throughout the postoperative year.
Approximately one-third of TKA patients use opioids within 3 months prior to surgery and this percentage has increased over 9% during the years included in this study. Preoperative opioid use was most predictive of increased refills of opioids following TKA. However, other intrinsic patient characteristics were also predictive of prolonged opioid use.
BACKGROUND:Supracondylar humeral fractures (SCHF) are the most common elbow fractures in children. The epidemiology of these injuries in the United States is described.
METHODS:The Nationwide ...Emergency Department Sample database was queried for all children (age, below 18 y) with SCHF treated in the emergency department (ED) from 2006 to 2011, and weighted estimates were extracted.
RESULTS:A total of 63,348 ED visits for SCHF were identified. The weighted estimate of ED visits remained stable over the study period, ranging from 60.3 to 71.8 per 100,000 children annually. There was no significant difference in fracture rate (52% male) by sex. The mean age of closed injury was 5.5±3.1 years, with 53.6% of fractures occurring in children 3 to 6 years. Open injuries accounted for 1.0% of fractures. Children with open injuries were significantly older (mean, 9.1±4.4 y; P<0.0001) and more often male (OR, 1.43; P<0.001). Neurovascular injury occurred in significantly older children (mean, 7.6±3.1 y; P<0.0001) and was documented in 11.4% of open fractures and 3.6% of operative fractures. Although the South had the greatest number of total SCHF-related ED visits, children in the West had significantly more SCHF-related ED visits per 100,000 children annually (77.9) than all other regions (P<0.05). Average fracture rates were approximately 60% higher in April to September than October to March (P<0.001). Mean total charges for patients treated and discharged from the ED were $2965, compared with $17,865 in children admitted for surgery (P<0.05). Mean charges were significantly higher in the West compared with all other regions (P<0.0001).
CONCLUSIONS:The incidence of pediatric SCHF-related ED visits remained stable from 2006 to 2011 and occurred most frequently in children aged 3 to 6 years. Open injuries are rare and are more likely to occur in older boys. There are significant differences in the injury rates and charges across geographic regions, identifying opportunities for injury prevention, cost reduction, and value improvement. The indications for operative management should be clearly delineated given the high cost of surgical treatment.
LEVEL OF EVIDENCE:Therapeutic Level IV.
Background:
Shoulder instability is a relatively common condition occurring in 2% of the population. PROMIS (Patient-Reported Outcome Measurement Information System) was developed by the National ...Institutes of Health in an effort to advance patient-reported outcome (PRO) instruments by developing question banks for major health domains.
Purpose:
To compare PROMIS instruments to current PRO instruments in patients who would be undergoing operative intervention for recurrent shoulder instability.
Study Design:
Cohort study (diagnosis); Level of evidence, 2.
Methods:
A total of 74 patients with a primary diagnosis of shoulder instability who would be undergoing surgery were asked to fill out the American Shoulder and Elbow Surgeons shoulder assessment form (ASES), Marx shoulder activity scale (Marx), Short Form–36 Health Survey Physical Function subscale (SF-36 PF), Western Ontario Shoulder Instability Index (WOSI), PROMIS physical function computer adaptive test (PF CAT), and PROMIS upper extremity item bank (UE). Correlation between PRO instruments was defined as excellent (>0.7), excellent-good (0.61-0.7), good (0.4-0.6), and poor (0.2-0.3).
Results:
Utilization of the PROMIS UE demonstrated excellent correlation with the SF-36 PF (r = 0.78, P < .01) and ASES (r = 0.71, P < .01); there was excellent-good correlation with the EQ-5D (r = 0.66, P < .01), WOSI (r = 0.63, P < .01), and PROMIS PF CAT (r = 0.63, P < .01). Utilization of the PROMIS PF CAT demonstrated excellent correlation with the SF-36 PF (r = 0.72, P < .01); there was excellent-good correlation with the ASES (r = 0.67, P < .01) and PROMIS UE (r = 0.63, P < .01). When utilizing the PROMIS UE, ceiling effects were present in 28.6% of patients aged 18 to 21 years. Patients, on average, answered 4.6 ± 1.8 questions utilizing the PROMIS PF CAT.
Conclusion:
The PROMIS UE and PROMIS PF CAT demonstrated good to excellent correlation with common shoulder and upper extremity PRO instruments as well as the SF-36 PF in patients with shoulder instability. In patients aged ≤21 years, there were significant ceiling effects utilizing the PROMIS UE. While the PROMIS PF CAT appears appropriate for use in adults of any age, our findings demonstrate that the PROMIS UE has significant ceiling effects in patients with shoulder instability who are ≤21 years old, and we do not recommend use of the PROMIS UE in this population.
The purpose of this study is to answer the following questions: (1) What is the prevalence of opioid use prior to primary total hip arthroplasty (THA)? (2) What is the typical trend in opioid use ...following THA over the first post-operative year? (3) What are the risk factors for prolonged opioid use following primary THA?
Primary THA patients were identified in the Humana database from 2007 to 2015. Pre-operative and post-operative opioid use was measured by monthly prescription refill rates. Rates of opioid use were trended monthly for 1 year post-operatively and compared based on pre-operative opioid user (OU) status as well as other patient demographics and co-morbidities.
In total, 37,393 THA patients were analyzed and 14,309 patients (38.2%) were pre-operative opioid users (OUs). Pre-operative opioid use was the strongest predictor for prolonged opioid use following THA, with non-opioid users filling significantly less opioid prescriptions than OUs at every time point analyzed. Younger age, female sex, and all other diagnoses analyzed were found to significantly increase the rate of opioid refilling following THA throughout the entire post-operative year.
Over one-third of THA patients use opioids within 3 months prior to THA and this percentage has increased 6% during the years included in this study. Pre-operative opioid use was most predictive of increased refills of opioids following THA. These data provide an important baseline for opioid use trends following THA that can be used for future comparison while identifying risk factors for prolonged use that will be helpful to prescribers as we all work to decrease opioid use, misuse, and abuse.
Abstract Objective The aim of this study was to determine whether patients treated with platelet-poor plasma (PPP) after an acute thigh muscle injury would have a faster return to activity compared ...to patients treated with platelet-rich plasma (PRP). Design This quasi-experimental study included 100 patients (ages 16-45) with an acute thigh muscle injury diagnosed by sports ultrasound and treated with either PRP or PPP followed by a course of structured rehabilitation. The primary outcome was the number of days until unrestricted participation in sport, while the secondary outcome was the rate of recurrent injury within 12 months. Result The time until full, unrestricted participation in sport was significantly lower in the PPP group compared to the PRP group for all injury grades, with patients in the PPP group on average returning to unrestricted participation in sport 22.89 days more quickly than the PRP group (p < 0.001). Additionally, no significant difference in recurrent injury up to 12 months post-procedure was seen between groups (p = 0.967). Conclusions PPP resulted in faster return to sport than PRP for acute thigh muscle injuries with a non-inferior injury recurrence rate. These findings suggest that future high level studies comparing PPP and PRP for the treatment of thigh muscle injuries should be considered.
The purpose of this study was to perform a systematic review and meta-analysis to quantitatively assess the association between tobacco use and the risk of any wound complication and periprosthetic ...joint infection (PJI) after primary total hip and total knee arthroplasty procedures.
Relevant articles published before January 2018 were identified by systematically searching PubMed, EMBASE, and Cochrane library databases. Pooled odds ratios (OR) and 95% confidence intervals were calculated for end points of any wound complication and PJI. Additional analyses were performed to evaluate risks between current, former, and non–tobacco users.
Fourteen studies were included in the meta-analysis. Tobacco users had a significantly higher risk of wound complications (OR, 1.78 1.32-2.39) and PJI (OR, 2.02 1.47-2.77) compared to non–tobacco users. Compared to non–tobacco users, there was an increased risk of PJI among current (OR, 2.16 1.57-2.97 and former (OR, 1.52 1.16-1.99) tobacco users. Current tobacco users also had a significantly increased risk of PJI compared to former tobacco users (OR, 1.52 1.07-2.14).
Tobacco use before total hip and total knee arthroplasty significantly increases the risk of wound complications and PJI. This increased risk is present for both current and former tobacco users. However, former tobacco users had a significantly lower risk of wound complications and PJI compared to current tobacco users, suggesting that cessation of tobacco use before TJA can help to mitigate these observed risks.
Opioid Consumption After Rotator Cuff Repair Westermann, Robert W., M.D; Anthony, Chris A., M.D; Bedard, Nic, M.D ...
Arthroscopy,
08/2017, Letnik:
33, Številka:
8
Journal Article
Recenzirano
Odprti dostop
Purpose Rising perioperative opioid use in the United States is of increasing concern. The purposes of this study were (1) to define opioid consumption after rotator cuff repair (RCR) in the United ...States and (2) to evaluate patient factors that may be associated with prolonged opioid use after arthroscopic RCR. Methods All arthroscopic RCRs performed between 2007 and 2014 were identified by use of Current Procedural Terminology code (29,827). Patients who filled opioid prescriptions preoperatively were divided into those who filled prescriptions at 1 to 3 months preceding RCR and those who filled opioid prescriptions only in the 1 month preceding RCR. Risk ratios (RRs) were calculated by dividing the cumulative incidence of opioid prescriptions in patients with each patient factor by the cumulative incidence in those without each patient factor. Results During the study period, 35,155 arthroscopic RCRs were performed. Of the patients, approximately 43% had filled an opioid prescription in the 3 months before RCR. At 3 months after RCR, patients who filled opioid prescriptions at 1 to 3 months before RCR were 7.45 (95% confidence interval CI, 6.95-7.98) times more likely to be filling opioid medication prescriptions than those who had not been prescribed opioid medications before surgery; patients who filled opioid prescriptions in the month before RCR were 3.04 (95% CI, 2.8-3.29) times more likely to be filling opioid prescriptions at 3 months after RCR. Patients with psychiatric diagnoses (RR, 1.94; 95% CI, 1.85-2.04), myalgia (RR, 1.67; 95% CI, 1.6-1.75), and low-back pain (RR, 2.09; 95% CI, 2-2.2) were also found to be at risk of filling opioid prescriptions at 3 months postoperatively. Conclusions We found approximately 43% of patients undergoing RCR received opioid medications before RCR. Patients who are prescribed narcotics before RCR are at increased risk of postoperative opioid demand. Patients with psychiatric diagnoses, myalgia, and low-back pain may be at increased risk of prolonged opioid use after surgery. Level of Evidence Level III, retrospective case-control study.
Controversy surrounds debridement, antibiotic and implant retention (DAIR) for treatment of acute periprosthetic joint infection (PJI). Data regarding DAIR's rate of infection resolution is variable ...with little investigation of functional outcomes.
We identified 191 DAIR cases at a single institution from 2008 to 2020. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Patient Reported Outcome Measurement Information System-10 (PROMIS) scores were collected. Patient Reported Outcome Scores were obtained from 60 cases. Median follow-up (IQR) was 4.5 (2.1 to 7.6) versus 3.0 (1.2 to 5.3) years for the control group. Mean scores were compared to a cohort of uncomplicated total knee arthroplasties matched by age, body mass index, and sex using generalized linear models adjusted for follow-up duration. Kaplan-Meier survivorship curves for PJI were constructed.
Mean Patient Reported Outcome Scores for the DAIR cohort were 57.2 ± 19.7 for KOOS-JR, 41.6 ± 7.1 for PROMIS physical health (PH), and 46.6 ± 8.7 for PROMIS mental health (MH). Mean control group values were 65.8 ± 21.0 for KOOS-JR, 44.6 ± 8.4 for PROMIS PH, and 49.2 ± 9.2 for PROMIS MH. No difference was observed in KOOS-JR (P = .83) or PROMIS MH (P = .11). PROMIS PH was lower in the DAIR cohort compared to the control group (P = .048). Median follow-up (years) for all 191 cases was 5.9 (range, 0.5 to 13.1). Survivorship (years) without subsequent operation for infection was 84% at 1, 82% at 2, and 79% at 5.
Knee and MH outcomes in successful DAIR procedures were similar to uncomplicated total knee arthroplasty. DAIR's success rate was 79% in treating acute PJI at 5 years.
Level III.
To compare postoperative pain and early recovery after hip arthroscopy with and without a perineal post for joint distraction.
We retrospectively reviewed a consecutive series of patients who ...underwent hip arthroscopy before and after the adoption of a postless technique. Patients who underwent concurrent periacetabular or femoral osteotomy were excluded. Demographic information, procedure variables, and visual analog scale (VAS) pain scores were recorded. Analgesic medications given were converted to morphine milligram equivalents (MME) for comparison. Uni- and multivariate analyses were conducted to compare total MME, postoperative pain, and time to discharge between groups.
One hundred patients were in each group. The overall age (mean ± standard deviation) was 26.5 ± 9.9 years (Post P: 57 females; No Post NP: 68 females). Total operative time (P 100.4 ± 17.9 minutes vs NP 89.1 ± 25.5 minutes, P = .0004), traction time (P 45.8 ± 10.3 minutes vs NP 40.9 ± 11.1 minutes, P = .0017), and operating room time (P 148.8 ± 19.3 minutes vs NP 137.3 ± 25.8 minutes, P = .0005) were found to be shorter in the NP group. Total MME, and final VAS pain scores in the PACU were similar between both groups (MME, P = .1620; VAS, P = .2139). Time to discharge was significantly shorter in the NP group (P 207.2 ± 58.8 vs NP 167.5 ± 47.9, P < .0001). Patient age (≥25 years) (65.2 ± 18.1 vs 59.8 ± 15.7 MME, P = .0269) and elevated body mass index (≥25) (65.1 ± 17.1 vs 59.3 ± 16.4 MME, P = .0164) were factors associated with greater total MME consumption. Female sex was associated with higher postoperative VAS pain scores (FM 4.1 ± 1.6 vs M 3.4 ± 1.8 P = .0027).
Adoption of the postless technique did not result in prolonged operating room or operative time. Overall, both groups had similar postoperative pain, however, the time from surgery to hospital discharge was shorter in the postless group.
III, retrospective comparison study.
Body mass index (BMI) cutoffs are commonly utilized to decide whether to offer obese patients elective total hip arthroplasty (THA). However, weight loss goals may be unachievable for many, and some ...patients are thereby denied complication-free surgery. The purpose of this study was to assess the impact of varying BMI cutoffs on the rates of complication-free surgery after THA.
Patients undergoing THA between 2015 and 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Common Procedural Terminology code 27130. BMI and rates of 30-day complications were collected. BMI cutoffs of 30, 35, 40, 45, and 50 kg/m2 were applied to model the incidence of complications if THA would have been allowed to proceed based on BMI.
A total of 192,394 patients underwent THA, and 13,970 (7%) of them had a BMI ≥40 kg/m2. With a BMI cutoff of 40 kg/m2, 178,424 (92.7%) patients would have proceeded with THA. From this set, 170,296 (95.4%) would experience complication-free surgery, and 11.8% of complications would be prevented. THA would proceed for 191,217 (99.3%) patients at a BMI cutoff of 50 kg/m2, of which 182,123 (95.2%) would not experience a complication, and 1.3% of complications would be prevented. Using 35 kg/m2 as the BMI cutoff would prevent 28.6% of complications and permit 75.9% of complication-free surgeries to proceed.
Lower BMI cutoffs for THA can result in fewer complications although they will consequentially limit access to complication-free THA. Consideration of risks of obesity in THA may be best considered as part of a holistic assessment and shared decision-making when deciding on goals for weight reduction.
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