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.
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.
Hypothesis Adhesive capsulitis is a condition that results in restricted glenohumeral motion. Fibroblasts have been implicated in the disease process; however, their role as a contractile element in ...the development of fibrosis and capsular contracture is not well understood. We hypothesized (1) that myofibroblast prevalence in capsular biopsy specimens from patients with adhesive capsulitis would be increased compared with controls and (2) that patients treated with an intra-articular injection of corticosteroid would have fewer myofibroblasts. Methods The study prospectively enrolled 20 consecutive patients with adhesive capsulitis scheduled for capsular release and matched controls. Tissue samples were collected from the posterior and anterior capsule for histomorphologic and immunohistologic analyses. Identical sectioning and preparation was performed in 14 additional adhesive capsulitis specimens from patients who had not received corticosteroid injections. Results Patients with adhesive capsulitis not treated with preoperative corticosteroid demonstrated more histologic evidence of fibromatosis, synovial hyperplasia, and an increase in positive staining for α-smooth muscle actin than patients who had received intra-articular injections of steroid. No specimens obtained from control patients demonstrated positive staining for α-smooth muscle actin. Discussion There was a higher prevalence of myofibroblast staining in patients with adhesive capsulitis, implicating activation of the myofibroblast in the pathophysiology of capsular contracture. Intra-articular steroid injection decreases the presence and amount of fibromatosis, vascular hyperplasia, fibrosis, and the presence of fibroblasts staining for α-smooth muscle actin. This supports the use of steroid injections to alter the disease process by decreasing the pathologic changes found in the capsular tissue.
Background:
Surgeons and health care systems have received a call to action in an effort to curtail the current opioid epidemic.
Purpose:
To (1) define the natural history of opioid demand after ...anterior cruciate ligament reconstruction (ACLR), (2) consider how filling preoperative opioid prescriptions affects opioid demand after ACLR, and (3) evaluate the effect of additional procedures during ACLR and patient age on postoperative opioid demand.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
ACLRs performed in the Humana database between 2007 and 2014 were identified using Current Procedural Terminology code 29888. Patients were considered preoperative opioid users if they had filled an opioid prescription in the 3 months preceding surgery. Patients were defined as “chronic” opioid users if they had filled a prescription preoperatively at 1 to 3 months from surgery. Further categorization was performed by identifying patients who only underwent ACLR with no other procedures, those who underwent ACLR with meniscus repair, those who underwent ACLR with meniscectomy, and those who underwent ACLR with microfracture. Categorization by age was also performed. The relative risk (RR) of postoperative opioid use was calculated, and 95% CIs were determined.
Results:
Over the course of the study period, 4946 ACLRs were performed. At 3 months after their procedure, 7.24% of patients were still filling opioid prescriptions. At 9 and 12 months postoperatively, 4.97% and 4.71% of patients, respectively, were still filling opioid prescriptions. Nearly 35% of patients (1716/4946) were filling opioid pain prescriptions in the 3 months before ACLR. Those filling preoperative opioid prescriptions were 5.35 (95% CI, 4.15-6.90) times more likely to be filling opioid prescriptions at 3 months after ACLR than nonusers (15.38% vs 2.88%, respectively). Those filling opioid prescriptions chronically before surgery were at a 10.50 (95% CI, 7.53-14.64) times increased risk of filling postoperative opioid prescriptions at 5 months. At 5 months postoperatively, patients undergoing ACLR with microfracture had a 1.96 (95% CI, 1.34-2.87) increased risk of filling opioid prescriptions compared with ACLR alone, 2.38 (95% CI, 1.48-3.82) increased risk compared with ACLR with meniscus repair, and 1.51 (95% CI, 1.04-2.19) increased risk compared with ACLR with meniscectomy. Patients younger than 25 years of age had an increased risk of filling opioid prescriptions after ACLR at all time points of the study.
Conclusion:
Opioid demand after ACLR dropped significantly in the vast majority of patients by the third postoperative month. Surprisingly, 35% of patients undergoing ACLR were observed to be using opioid medication preoperatively, and this study found preoperative opioid use to be a strong predictor of postoperative opioid demand with a 5- to 7-fold increased risk in this patient population. Patients who were filling opioid prescriptions 1 to 3 months from their surgical date were at the highest risk for postoperative opioid utilization. Patients undergoing ACLR with microfracture were at an increased risk of filling opioid prescriptions. Patients less than 25 years of age were at an elevated risk of filling opioid prescriptions at all time points postoperatively.
BACKGROUND:Improving outcomes after surgical procedures and determining the value of health care can be facilitated by a scientifically valid, cost-effective, and scalable data outcome collection ...system. We hypothesized that such a system could be constructed in orthopaedic surgery to (1) capture >95% of baseline validated patient-reported outcome measures (PROMs) for patients undergoing elective surgery, (2) capture >95% of surgeon-entered data on disease severity and treatment, and (3) be implemented as standard clinical care in daily practice.
METHODS:A modified Research Electronic Data Capture (REDCap) system was developed and was implemented at the time of surgery in a prospective cohort to collect demographic data, general health PROMs, joint-specific PROMs, and disease severity and treatments from patients and surgeons. All elective knee, hip, and shoulder orthopaedic surgical procedures performed in the Cleveland Clinic system at 7 hospitals were included.
RESULTS:Of 16,021 consecutive eligible patients (February 18, 2015, to July 31, 2017), 2% (320) were excluded because of language or physical barriers, and 0.6% (91) of the remaining 15,701 patients refused to participate. Of the remaining 15,610 patients, 97.4% (15,202) completed PROMs, and surgeons provided details on the disease severity and treatment for 99.9% (15,592) of the 15,610 patients. Overall, 97.3% (15,185) of the 15,610 patients had complete patient-reported and surgeon-reported baseline enrollment. The median completion time was 11.5 minutes for the patients and 1.6 minutes for the surgeons. The overall complete 1-year follow-up rate was 72.5% (9,354 of 12,896).
CONCLUSIONS:A data collection system with validated measures with >97% baseline completion of PROMs and surgeon forms regarding disease severity and treatments, across elective knee, hip, and shoulder orthopaedic surgical procedures, was successfully implemented at 7 hospitals. The system is potentially scalable to the entire orthopaedic community and could serve as a template for all procedural-based specialties during routine patient care.
To evaluate the Patient-Reported Outcomes Measurement Information System upper extremity item bank (PROMIS UE) and physical function computerized adaptive test (PROMIS PF CAT) in patients with ...rotator cuff (RC) pathology at their preoperative clinic visit.
Patient data were collected from January 2015 to September 2015. Patients with a preoperative diagnosis of RC pathology were prospectively enrolled at the time of their surgical indication for RC repair. Each patient was asked to fill out the Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons Shoulder Assessment Form, Marx Shoulder Activity Scale, Short Form 36 Health Survey Physical Function and General Health (SF-36 PF and GH), EuroQol-5 Dimension (EQ-5D), PROMIS PF CAT, and PROMIS UE. Correlation was defined as excellent (>0.7), excellent-good (0.61-0.7), good (0.4-0.6), and poor (0.2-0.3).
Patient data were collected from January 2015 to September 2015. No patients were excluded from participation in the study. In 82 patients with preoperative RC pathology, the PROMIS UE showed excellent correlation with American Shoulder and Elbow Surgeons Shoulder Assessment Form (r = 0.77, P < .01), WORC (r = 0.73, P < .01), and the EQ-5D (r = 0.73, P < .01); there was excellent-good correlation with the SF-36 PF (r = .66, P < .01) and PROMIS PF CAT (r = .70, P < .01). The PROMIS PF CAT showed excellent correlation with the SF-36 PF (r = 0.77, P < .01); there was excellent-good correlation with EQ-5D (r = 0.65, P < .01) and WORC (r = 0.61, P < .01). There were no significant floor or ceiling effects using the PROMIS UE item bank or PROMIS PF CAT.
We report that in a patient population with preoperative RC pathology, the PROMIS UE and PROMIS CAT are valid patient-reported outcome alternatives that have high correlation with traditional shoulder and upper extremity patient-reported outcomes. We find a decreased question burden using the PROMIS PF CAT. We find no significant floor or ceiling effects present in the PROMIS UE or PROMIS PF CAT.
Level II, prospective diagnostic study.
Background Scapular notching in reverse shoulder arthroplasty occurs in up to 97% of patients. Notching is associated with decreased strength and reduced motion and may lead to long-term failure due ...to polyethylene wear. Many implant systems lateralize the glenosphere to address scapular notching, but the mechanical tradeoffs of lateralization have not been rigorously evaluated. We hypothesized that lateralization would decrease bony impingement but also decrease the mechanical advantage of the deltoid. Methods Finite element models were created using the same implants with different amounts of glenoid lateralization: 5 mm of medialization to replicate glenoid erosion, as well as 2.5, 5, 7.5, and 10 mm of lateralization. Tests were performed with static and dynamic scapulae for motion in either the coronal or scapular plane. The angle of impingement between the scapula and the humeral polyethylene was recorded, as was the deltoid force required to elevate the arm. Results Increasing lateralization decreased impingement while increasing the deltoid force required to elevate the arm. Differences were found between the static and dynamic scapulae, with the dynamic scapula model having increased humeral adduction before impinging. The impingement angle was also substantially affected by the bony prominences on the inferior scapula, showing how individual bony anatomy can affect impingement. Conclusion Lateralization is effective in increasing impingement-free range of motion but also increases the deltoid force required to perform identical tasks. In addition, impingement is determined by scapular motion, which should be included in all shoulder models.
Background:
Subsequent surgeries have a profound effect on patient satisfaction and outcome after primary anterior cruciate ligament reconstruction (ACLR). There have been no prospective studies to ...date describing the rate and predictors (surgical and patient variables) of all subsequent knee surgeries at short-term and midterm follow-up along with analyses of surgical and patient variables that are associated with subsequent surgeries.
Purpose:
To report the rate and predictors of all subsequent surgeries at short-term and midterm follow-up along with associated patient variables.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
A total of 980 patients (540 male) were prospectively enrolled in a Multicenter Orthopaedic Outcomes Network (MOON) cohort from January 2002 to December 2003. The 2- and 6-year follow-up information for subsequent procedures was obtained. Operative reports were obtained, and all procedures were categorized.
Results:
One hundred eighty-five patients underwent a subsequent surgery on the ipsilateral leg (18.9%) and 100 on the contralateral knee (10.2%) at 6-year follow-up. On the ipsilateral knee, there was a 7.7% rate of ACL revisions, a 13.3% rate of cartilage procedures, a 5.4% rate of arthrofibrosis procedures, and a 2.4% rate of procedures related to hardware. For the contralateral knee, there was a 6.4% rate of primary ACL ruptures. Younger age at the index surgery and the use of allografts were predictors (risk factors) for subsequent surgery. Revision ACLR, female sex, body mass index, and surgical exposure were not significant predictors.
Conclusion:
At 6-year follow-up, 18.9% of patients who had undergone ACLR underwent subsequent surgeries on the ipsilateral knee. The rates between an ipsilateral ACLR graft versus a contralateral normal ACL tear were similar (7.7% vs 6.4%, respectively). Younger age and the use of allografts were risk factors for subsequent surgery.
BACKGROUND:The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed as an extensive question bank with multiple health domains that could be utilized for computerized ...adaptive testing (CAT). In the present study, we investigated the use of the PROMIS Physical Function CAT (PROMIS PF CAT) in an otherwise healthy population scheduled to undergo surgery for meniscal injury with the hypotheses that (1) the PROMIS PF CAT would correlate strongly with patient-reported outcome instruments that measure physical function and would not correlate strongly with those that measure other health domains, (2) there would be no ceiling effects, and (3) the test burden would be significantly less than that of the traditional measures.
METHODS:Patients scheduled to undergo meniscal surgery completed the PROMIS PF CAT, Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Knee Activity Rating Scale, Short Form-36 (SF-36), and EuroQol-5 Dimension (EQ-5D) questionnaires. Correlations were defined as high (≥0.7), high-moderate (0.61 to 0.69), moderate (0.4 to 0.6), moderate-weak (0.31 to 0.39), or weak (≤0.3). If ≥15% respondents to a patient-reported outcome measure obtained the highest or lowest possible score, the instrument was determined to have a significant ceiling or floor effect.
RESULTS:A total of 107 participants were analyzed. The PROMIS PF CAT had a high correlation with the SF-36 Physical Functioning (PF) (r = 0.82, p < 0.01) and KOOS Sport (r = 0.76, p < 0.01) scores; a high-moderate correlation with the KOOS Quality-of-Life (QOL) (r = 0.63, p < 0.01) and EQ-5D (r = 0.62, p < 0.01) instruments; and a moderate correlation with the SF-36 Pain (r = 0.60, p < 0.01), KOOS Symptoms (r = 0.57, p < 0.01), KOOS Activities of Daily Living (ADL) (r = 0.60, p < 0.01), and KOOS Pain (r = 0.60, p < 0.01) scores. The majority (89%) of the patients completed the PROMIS PF CAT after answering only 4 items. The PROMIS PF CAT had no floor or ceiling effects, with 0% of the participants achieving the lowest and highest score, respectively.
CONCLUSIONS:The PROMIS PF CAT correlates strongly with currently used patient-reported outcome measures of physical function and demonstrates no ceiling effects for patients with meniscal injury requiring surgery. It may be a reasonable alternative to more burdensome patient-reported outcome measures.
Background Despite advances in intraoperative techniques, rotator cuff repairs frequently do not heal. Recombinant human parathyroid hormone (rhPTH) has been shown to improve healing at the ...tendon-to-bone interface in an established acute rat rotator cuff repair model. We hypothesized that administration of rhPTH beginning on postoperative day 7 would result in improved early load to failure after acute rotator cuff repair in an established rat model. Methods Acute rotator cuff repairs were performed in 108 male Sprague-Dawley rats. Fifty-four rats received daily injections of rhPTH beginning on postoperative day 7 until euthanasia or a maximum of 12 weeks postoperatively. The remaining 54 rats received no injections and served as the control group. Animals were euthanized at 2 and 16 weeks postoperatively and evaluated by gross inspection, biomechanical testing, and histologic analysis. Results At 2 weeks postoperatively, rats treated with rhPTH demonstrated significantly higher load to failure than controls (10.9 vs. 5.2 N; P = .003). No difference in load to failure was found between the 2 groups at 16 weeks postoperatively, although control repairs more frequently failed at the tendon-to-bone interface (45.5% vs. 22.7%; P = .111). Blood vessel density appeared equivalent between the 2 groups at both time points, but increased intracellular and extracellular vascular endothelial growth factor expression was noted in the rhPTH-treated group at 2 weeks. Conclusions Delayed daily administration of rhPTH resulted in increased early load to failure and equivalent blood vessel density in an acute rotator cuff repair model.
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