Early weight bearing is frequently allowed and encouraged following fixation of hip and femoral and tibial shaft fractures, while pelvis, acetabulum, and lower extremity periarticular fractures are often prescribed 6–12 weeks of restricted weight bearing. Our objective was to perform a feasibility randomized trial of immediate versus delayed weight bearing as tolerated (WBAT) for fractures of the pelvis, acetabulum, distal femur, and proximal and distal tibia. A parallel two-arm pilot feasibility trial was performed at one academic level I trauma center in the United States. Patients with a fracture of the pelvis, acetabulum, distal femur, proximal tibia, or distal tibia were eligible. Patients were randomized to either immediate WBAT or delayed (≥ 6 weeks) weight bearing after surgery. Our feasibility criteria included the following: (1) 25

OBJECTIVES:In far-distal extra-articular tibia fracture "extreme" nailing, debate surrounds the relative biomechanical performance of plating the fibula compared with extra distal interlocks. This study aimed to evaluate several constructs for extreme nailing including one interlock (one medial-lateral interlock), one interlock + plate (one medial-lateral interlock with lateral fibula compression plating), and two interlocks (one medial-lateral interlock and one anterior-posterior interlock). METHODS:Fifteen pairs of fresh cadaver legs were instrumented with a tibial nail to the physeal scar. A 1 cm segment of bone was resected from the distal tibia 3.5 cm from the joint and an oblique osteotomy was made in the distal fibula. We loaded specimens with three different distal fixation constructs (one interlock, one interlock + plate, and two interlocks) through 10,000 cycles form 100N-700 N of axial loading. Load to failure (Newtons), angulation and displacement were also measured. RESULTS:Mean load to failure was 2092 N (one interlock), 1917 N (one interlock + plate), and 2545 N (two interlocks). Linear mixed effects modeling demonstrated that two interlocks had a load to failure 578 N higher than one interlock alone (95 % CI, 74N-1082 N; P = 0.02), but demonstrated no significant difference between one interlock and one interlock + plate. No statistically significant difference in rates or timing of displacement >2 mm or angulation >10° were demonstrated. CONCLUSIONS:When nailing far-distal extra-articular tibia and fibula fractures, adding a second interlock provides more stability than adding a fibular plate. Distal fibula plating may have minimal biomechanical effect in extreme nailing.

INTRODUCTION Regional anesthesia (RA) is commonly used in ankle and distal tibia fracture surgery. However, the pragmatic effects of this treatment on inpatient and outpatient opioid demand are unclear. The hypothesis was that RA would decrease inpatient opioid consumption and have little effect on outpatient demand in patients undergoing ankle and distal tibia fracture surgery compared with patients not receiving RA. METHODS All patients aged 18 years and older undergoing ankle and distal tibia fracture surgery at a single institution between July 2013 and July 2018 were included in this study (n = 1310). Inpatient opioid consumption (0-72 hours postoperatively) and outpatient opioid prescribing (1 month preoperatively to 90 days postoperatively) were recorded in oxycodone 5-mg equivalents (OEs). Adjusted models were used to evaluate the impact of RA versus no RA on inpatient and outpatient opioid demand. RESULTS Patients without RA had higher rates of high-energy mechanism of injury, additional injuries, open fractures, and additional surgery compared with patients with RA. Adjusted models demonstrated decreased inpatient opioid consumption in patients with RA (12.1 estimated OEs without RA vs 8.8 OEs with RA from 0 to 24 hours postoperatively, P < .001) but no significant difference after that time (9.7 vs 10.4 from 24 to 48 hours postoperatively, and 9.5 vs 8.5 from 48 to 72 hours postoperatively). Estimated cumulative outpatient opioid demand was significantly increased in patients receiving RA at all time points (112.5 OEs without RA vs 137.3 with RA from 1 month preoperatively to 2 weeks, 125.6 vs 155.5 OEs to 6 weeks, and 134.6 vs 163.3 OEs to 90 days, all P values for RA <.001). DISCUSSION In ankle and distal tibia fracture surgery, RA was associated with decreased early inpatient opioid demand but significantly increased outpatient demand after adjusting for baseline patient and treatment characteristics. This study encourages the use of RA to decrease inpatient opioid use, although there was a worrisome increase in outpatient opioid demand. LEVEL OF EVIDENCE Level III: Retrospective, therapeutic cohort study.

Opioid-limiting legislation has been enacted in response to the opioid epidemic in the United States. However, the impact of this legislation on perioperative opioid prescribing in elective shoulder surgery is not well understood. This is an observational review of 90-day perioperative opioid-prescription filling by patients undergoing shoulder surgery using a national insurance database (n = 231,634 patients) between 2010 and 2019. Statistics evaluated the impact of the year and opioid-limiting legislation on first prescription and cumulative 90-day opioid filling. Initial and cumulative opioid-prescription volume decreased significantly from 2010 to 2019 (49 to 44.4 initial oxycodone 5-mg equivalents, 132.8 to 72.3 cumulative oxycodone 5-mg equivalents; all p < 0.001). States with opioid-limiting legislation had larger reductions in initial and cumulative opioid-prescription filling over similar time frames (p < 0.001). Perioperative opioid prescribing has decreased significantly in shoulder surgery with time and state legislation. Individual prescribers and state and national legislators should continue to seek ways to reduce opioid overprescribing. (Journal of Surgical Orthopaedic Advances 33(3):152-157, 2024).

The characteristics that contribute to opioid demand in pelvic and acetabular fracture surgery are not well understood. We hypothesize that fracture pattern and psychiatric comorbidities will be associated with increased opioid demand. This study evaluated perioperative opioid prescription filling in 743 patients undergoing operative fixation of pelvic and acetabular injuries. Multivariable linear and logistic regression models were used to evaluate associations between baseline factors and opioid outcomes. Patients filled prescriptions for 111.2, 89.3, and 200.3 oxycodone 5-mg pills at the 1-month preop to 90-days postop, 3-months postop to 1-year postop, and 1-month preop to 1-year postop timeframes. Operatively treated wall, transverse and two-column acetabular fractures were associated with the highest opioid demand. Drug abuse and pre-injury opioid use were the primary non-surgical drivers of opioid demand. Acetabular fractures, pre-injury opioid filling, and drug abuse were the main risk factors for increased perioperative opioid prescription filling. Level of Evidence: Level III, retrospective, prognostic cohort study. (Journal of Surgical Orthopaedic Advances 32(1):041-046, 2023).

Patients undergoing operative treatment of tibial shaft fractures have considerable pain largely managed with opioids. Regional anesthesia (RA) has been increasingly used to reduce perioperative opioid use. This was a retrospective study of 426 patients that underwent operative treatment of tibial shaft fractures with and without RA. Inpatient opioid consumption and 90-day outpatient opioid demand were measured. RA significantly decreased inpatient opioid consumption for 48 h post-operatively (p = 0.008). Neither inpatient use after 48 h nor outpatient opioid demand differed in patients with RA (p > 0.05). RA may help with inpatient pain control and reduce opioid use in tibial shaft fracture. Level III, retrospective, therapeutic cohort study.

The purpose of this study was to evaluate the impact of opioid-limiting legislation on perioperative opioid prescriptions in total knee arthroplasty. The hypothesis was that opioid legislation has reduced opioid prescription filling above levels anticipated by national trends. This study retrospectively evaluated opioid prescription filling for all patients undergoing total knee arthroplasty in a commercially available insurance database between 2010 and 2018 (n=1,068,764). Initial discharge and 90-day cumulative oxycodone 5-mg equivalents filled were tabulated. Opioid prescription filling was evaluated over time and between states with and without opioid-limiting legislation using analysis of variance and multivariable linear and logistic regression. States with and without opioid legislation had significant reductions in initial and cumulative opioid prescription filling volume (all P<.001). However, the magnitude of this reduction was larger in states with opioid legislation. Legislation targeting duration and volume had the largest impact on initial post-act opioid prescription filling volume compared with states without legislation in an estimated "pre-act" time frame. Legislation targeting duration and volume and no specific target had the largest impact on cumulative post-act opioid prescription filling volume. States without legislation still had large, significant reductions in filling volume, but the magnitude was not as great as in states with opioid legislation. States with and without opioid legislation had significant decreases in initial and cumulative opioid prescription filling volume. However, the magnitude of reduction was larger in states that enacted legislation. Younger age, pre-operative opioid use, and higher comorbidity burden were associated with greater opioid use postoperatively. [Orthopedics. 2023;46(3):142-150.].

Purpose Regional anesthesia (RA) is commonly used in distal radius fracture surgery to reduce pain and opioid consumption. The purpose of this study was to evaluate the real-world impact of RA on inpatient and outpatient opioid consumption and demand in patients undergoing distal radius fracture surgery. Methods All patients ages 18 and older undergoing distal radius fracture surgery between 7/2013 and 7/2018 at a single institution (n = 969) were identified. Inpatient opioid consumption and outpatient opioid prescribing in oxycodone 5-mg equivalents (OE's) up to 90-d post-operative were recorded for patients with and without RA. Adjusted models were used to evaluate the impact of RA on opioid outcomes. Results Adjusted models demonstrated decreases in inpatient opioid consumption in patients with RA (10.7 estimated OE's without RA vs. 7.6 OE's with RA from 0 to 24 h post-op, 10.2 vs. 5.3 from 24 to 48 h post-op and 7.5 vs. 5.0 from 48 to 72 h post-op, p<.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA (65.3 OE's without RA vs. 81.0 with RA from 1-month pre-op to 2-week post-discharge, 76.1 vs. 87.7 OE's to 6-weeks, and 80.8 vs. 93.5 OE's to 90-d, all p values for RA <.05) though rates of refill were significantly lower in patients with RA from 2-week to 6-week post-op compared to patients without RA. Conclusions Patients undergoing RA in distal radius fracture surgery had decreased inpatient opioid consumption but increased outpatient demand after adjustment for patient and operative characteristics.

Background Legislation in the United States has been enacted to reduce opioid overuse and abuse in the setting of the opioid epidemic, and a notable target has been opioid overprescription. However, the impact of this legislation on elective foot and ankle surgery is largely unknown. The purpose of this study was to evaluate the impact of opioid-limiting legislation on opioid prescribing in elective foot and ankle surgery. Methods The 90-day perioperative opioid prescription filling in oxycodone 5-mg equivalents was identified in all patients 18 years of age and older undergoing nontrauma, nonarthroplasty foot and ankle surgery from 2010 to 2019 using a commercial database. States with and without legislation were identified, and opioid prescription filling before and after the legislation were tabulated. Unadjusted and adjusted analyses were performed to evaluate the impact of time and state legislation on perioperative opioid prescribing in this patient population. Results Initial and cumulative opioid prescribing decreased significantly from 2010 to 2019 (39 vs 35.7 initial and 98.1 vs 55.7 cumulative). States with legislation had larger and more significant reductions in initial and cumulative opioid prescribing compared with states without legislation over similar time frames (41.6 to 35.1 with legislation vs 40.6 to 39.1 without legislation initial prescription filling volume and 87.7 to 62.8 vs 88.6 to 74.1 cumulative prescription filling volume). Conclusion State legislation and time have been associated with large, clinically relevant reductions in 90-day perioperative cumulative opioid prescription filling, although reductions in initial opioid prescription filing have remained low. These results encourage states without legislation to enact restraints to reduce the opioid epidemic. Levels of Evidence: Level III: Retrospective, prognostic cohort study

Introduction: Peripheral nerve blocks (PNB) has been increasingly used in the care of patients with geriatric hip fracture to reduce perioperative opiate use and the need for general anesthesia. However, the associated motor palsy may impair patients' ability to mobilize effectively after surgery and subsequently may increase latency to key mobility milestones postoperatively, as well as increase inpatient length of stay (LOS). The aim of this study was to investigate time-to-mobility milestones and length of hospital stay between peripheral, epidural, and general anesthesia. Methods: A retrospective review identified 1,351 patients aged 65 years or older who underwent surgery for hip fracture between 2012 and 2018 at a single academic health system. Patients were excluded if baseline nonambulatory, restricted weight-bearing postoperatively, or sustained concomitant injuries precluding mobilization, with a final cohort of 1,013 patients. Time-to-event analyses for discharge and mobility milestones were assessed using univariate Kaplan-Meier and multivariate Cox proportional hazard regression analyses. Results: PNB was associated with delayed postoperative time to ambulation (P < 0.001) and time to out-of-bed (P = 0.029), along with increased LOS (P < 0.001). Epidural anesthesia was associated with less delay to first out-of-bed (P = 0.002), less delay to ambulation (P = 0.001), and overall reduced length of stay (P < 0.001). Discussion: PNB was associated with slower mobilization and longer hospitalization while epidural anesthesia was associated with quicker mobilization and shorter hospital stays. Epidural anesthesia may be a preferable anesthesia choice in patients with geriatric hip fracture when possible. Level of Evidence: Level III

Total ankle arthroplasty (TAA) is an increasingly utilized treatment for ankle arthritis, and opioids are commonly used as part of perioperative pain control. However, many states have enacted opioid-limiting legislation to reduce perioperative opioid prescribing. The aim of this study was to evaluate the impact of time and state legislation on perioperative opioid prescribing in TAA. This study is a retrospective, observational review of 90-day perioperative opioid prescribing in 1,829 patients undergoing TAA throughout the United States using a large insurance database. Initial and cumulative volumes and rates of opioid prescription filling were recorded along with baseline patient and operative characteristics. Dates of state legislation enactment were also recorded. Student t-tests, analysis of variance, and multivariable linear and logistic regression were utilized to analyze the impact of time and state legislation on opioid prescription filling. In the 90-day perioperative time period, initial and cumulative opioid prescription filling in oxycodone 5-mg equivalents has decreased significantly from 2010 (63.8 initial and 163.3 cumulative) to 2019 (41.1 initial and 67.2 cumulative). States with opioid-limiting legislation saw larger and more significant reductions in initial and cumulative opioid prescription filling preact to postact (63.3-50.6 with legislation vs 61.4-51.9 without legislation initial and 146.4-93.3 with legislation vs 125.1-108.6 without legislation cumulative). This study demonstrates that foot and ankle surgeons in states with opioid-limiting legislation have responded by significantly reducing 90-day perioperative opioid prescribing in TAA. These results encourage states without legislation to enact opioid-specific laws to reduce opioid prescribing.

Category: Ankle; Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is an increasingly-utilized treatment for ankle arthritis, and opioids are commonly used as part of perioperative pain control. However, many states have enacted opioid-limiting legislation to reduce perioperative opioid prescribing. The aim of this study was to evaluate the impact of time and state legislation on perioperative opioid prescribing in TAA. Methods: This study is a retrospective, observational review of 90-day perioperative opioid prescribing in 1,829 patients undergoing TAA throughout the United States using a large insurance database. Initial and cumulative volumes and rates of opioid prescription filling were recorded along with baseline patient and operative characteristics. Dates of state legislation enactment were also recorded. Student t-tests, analysis of variance (ANOVA), and multivariable linear and logistic regression were utilized to analyze the impact of time and state legislation on opioid prescription filling. Results: In the 90-day perioperative time period, initial and cumulative opioid prescription filling in oxycodone 5-mg equivalents has decreased significantly from 2010 (63.8 initial and 163.3 cumulative oxycodone 5-mg equivalents filled) to 2019 (41.1 initial and 67.2 cumulative oxycodone 5-mg equivalents filled). States with opioid-limiting legislation saw larger and more significant reductions in initial and cumulative opioid prescription filling pre-act to post-act (63.3 to 50.6 oxycodone 5-mg equivalents filled with legislation vs 61.4 to 51.9 oxycodone 5-mg equivalents filled without legislation initial and 146.4 to 93.3 oxycodone 5-mg equivalents filled with legislation vs 125.1 to 108.6 oxycodone 5-mg equivalents filled without legislation cumulative). Conclusion: This study demonstrates that orthopaedic surgeons in states with opioid-limiting legislation have responded by significantly reducing 90-day perioperative opioid prescribing in TAA. These results encourage states without legislation to enact opioid-specific laws to reduce opioid prescribing.

Background: Hip fracture surgery is painful, and regional anesthesia (RA) has been used in an attempt to reduce pain and opioid consumption after surgery. Despite potential analgesic benefits, the effect of RA on inpatient and outpatient opioid demand is not well known. We hypothesized that RA would be associated with decreased inpatient opioid demand and has little effect on outpatient opioid demand in hip fracture surgery. Methods: This study retrospectively evaluated all patients of 18 years and older undergoing hip fracture surgery from July 2013 to July 2018 at a single, level I trauma center (n = 1,659). Inpatient opioid consumption in 24-hour increments up to 72-hour postoperative and outpatient opioid prescribing up to 90-day postoperative were recorded in oxycodone 5-mg equivalents (OE's). Adjusted models evaluated the effect of RA on opioid demand after adjusting for other baseline and treatment variables. Results: After adjusting for baseline and treatment variables, there were small increases in inpatient opioid consumption in patients with RA (2.6 estimated OE's without RA versus three OE's with RA from 0 to 24 hours postoperatively, 2.1 versus 2.4 from 24 to 48 hours postoperatively, and 1.6 versus 2.2 from 48 to 72 hours postoperatively, all P values for RA <0.001). However, there were no notable differences in outpatient opioid demand. Discussion: RA did not decrease inpatient or outpatient opioid demand in patients undergoing hip fracture surgery in this pragmatic study. In fact, there were slight increases in inpatient opioid consumption, although these differences are likely clinically insignificant. These results temper enthusiasm for RA in hip fracture surgery. Level of Evidence: Level III, retrospective, therapeutic cohort study.

Introduction Regional anesthesia (RA) is used reduce pain in proximal humerus and humeral shaft fracture surgery. The study hypothesis was that RA would decrease opioid demand in patients undergoing fracture surgery. Materials and methods Opioid demand was recorded in all patients ages 18 and older undergoing proximal humerus or humeral shaft fracture surgery at a single, Level I trauma center from 7/2013 – 7/2018 (n = 380 patients). Inpatient opioid consumption from 0–24, 24–48, and 48–72 h and outpatient opioid demand from 1-month pre-operative to 90-days post-operative were converted to oxycodone 5-mg equivalents (OE's). Unadjusted and adjusted models were constructed to evaluate the impact of RA and other factors on opioid utilization. Results Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (6.8 estimated OE's without RA vs 8.8 estimated OE's with RA from 0–24 h post-op; 10 vs 13.7 from 24–48 h post-op; and 8.7 vs 11.6 from 48–72 h post-op; all p < 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA at all timepoints. Discussion In proximal humerus and humeral shaft fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics.

Background: The materials and techniques for both primary and revision total hip arthroplasty (THA) have changed over time. This study evaluated if the indications for revision THA, rates of components utilized (femoral or acetabulum, both, or head/liner exchange), length of stay (LOS), and payments to surgeons and facilities have also changed. Methods: A retrospective study, utilizing the PearlDiver database, of 38,377 revision THA patients from January 2010 through December 2018 was performed. Data included the indication for revision, components revised (femoral or acetabulum, both, or head/liner exchange), LOS, and payments. Indications and components were analyzed by logistic regression (Dunnett's post hoc test). Revision totals were analyzed with a linear regression model. Analysis of variance assessed changes in LOS and payments. Results: Patients' median age was 67 years (Q1-Q3: 59-74), and 58.7% were female. Revisions for dislocation decreased between 2010 and 2018 (odds ratio [OR] 0.82, 95% confidence interval [CI] 0.68-0.98). Revisions for component loosening increased (OR 1.54, 95% CI 1.25-1.91). Dislocation remained the most common indication (19.3%), followed by PJI (17.3%) and loosening (17.1%). Both-component (OR:1.45; 95% CI:1.25-1.67) and femoral component only revisions increased; acetabular component only and head/liner exchanges decreased. Acetabular (OR 0.57, 95% CI 0.47-0.70) and head/liner exchange (OR 0.29, 95% CI 0.20-0.43) revisions decreased, while both component exchange (OR 1.45, 95% CI 1.25-1.67) and femoral revisions (OR 1.17, 95% CI 0.99-1.37) increased. Average LOS (-0.68 days; P<.001) and surgeon payments decreased (-$261.8; P <.001) while facility payments increased ($4,211; P <.001). Conclusion: Indications for revision THA in this database study changed over time, with revision for dislocation decreasing and revision for loosening increasing over time. Both component and femoral revisions increased, and acetabular component and head/liner exchanges decreased. It is possible that these associations could be attributed to a number of details, the method of femoral fixation, surgical approach, and cementing, all of which require additional study. (C) 2022 Elsevier Inc. All rights reserved.

Introduction: The role of deltoid ligament repair is controversial in the treatment of bimalleolar equiv-alent ankle injuries. Our purpose was to compare midterm functional outcomes and reoperation rates of unstable distal fibula fractures treated with open reduction internal fixation (ORIF) of the fibula and either deltoid ligament repair, trans-syndesmotic fixation, or combined fixation. Methods: Skeletally mature subjects were retrospectively identified after fixation of isolated unstable distal fibula fractures treated at a single academic level 1 hospital from January 2005 to May 2019. The AAOS Foot and Ankle Module outcomes questionnaire (AAOS-FAM) was obtained at a mean time from surgery of 4.6 + /-3.1 years. Subjects underwent one of three methods of fixation including distal fibula ORIF and one of the following: trans-syndesmotic fixation ( N = 66), deltoid ligament repair ( N = 16), or combined trans-syndesmotic fixation and deltoid ligament repair ( N = 26). Outcomes scores and Charlson Comorbidity Index scores were compared between groups by Kruskal-Wallis testing for non-normally distributed data. Rates of reoperation were compared by Fisher's exact test. Statistical significance was set to P < 0.05 for all comparisons. Results: There was no significant difference in AAOS-FAM scores between the three groups ( P = 0.18). No subjects in the deltoid ligament repair group underwent reoperation compared to 17 (26%) in the trans-syndesmotic fixation group and six (23%) in the combined fixation group. The most common reason for reoperation was removal of hardware, which was performed in 12 (18%) subjects in the trans-syndesmotic fixation group and three (12%) subjects in the combined fixation group. Conclusions: Direct deltoid ligament repair yields similar functional scores and fewer reoperations com-pared to trans-syndesmotic fixation at midterm follow up. Deltoid ligament repair may be a favorable treatment strategy when considering trans-syndesmotic fixation in the surgical treatment of unstable distal fibula fractures. (C) 2022 Elsevier Ltd. All rights reserved.

Hypothesis: Regional anesthesia (RA) can be used to manage perioperative pain in the treatment of periarticular elbow fracture fixation. However, the opioid-sparing benefit is not well-characterized. The hypothesis of this study was that RA had reduced inpatient opioid consumption and outpatient opioid demand in patients who had undergone periarticular elbow fracture surgery. Methods: This study retrospectively reviews inpatient opioid consumption and outpatient opioid demand in all patients aged >18 years at a single Level I trauma center undergoing fixation of periarticular elbow (distal humerus and proximal forearm) fracture surgery (n=418 patients). In addition to RA vs. no RA, additional patient and operative characteristics were recorded. Unadjusted and adjusted models were constructed to evaluate the impact of RA and other factors on inpatient opioid consumption and outpatient opioid demand. Results: Adjusted models demonstrated decreases in inpatient opioid consumption postoperation in patients with RA (13.7 estimated oxycodone 5-mg equivalents or OEs without RA vs. 10.4 OEs with RA from 0 to 24 hours postoperation, P = .003; 12.3 vs. 9.2 OEs from 24 to 48 hours postoperation, P = .045). Estimated cumulative outpatient opioid demand differed significantly in patients with RA (166.1 vs. 132.1 OEs to 6 weeks, P = .002; and 181 vs. 138.6 OEs to 90 days, P < .001). Discussion: In proximal forearm and distal humerus fracture surgery, RA was associated with decreased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results encourage utilization of perioperative RA to reduce opioid use. Level of evidence: Level III; Retrospective Cohort Comparison; Treatment Study (c) 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Category: Ankle; Trauma Introduction/Purpose: The impact of time and state regulation on opioid prescribing in orthopaedic trauma is not well known. The purpose of this study is to evaluate the impact of time and state-level opioid legislation on 90-day perioperative opioid prescribing in ankle fracture surgery from 2010 - 2019. Methods: This is a retrospective, cohort study using a national insurance database including commercial insurance, Medicare, Medicaid, and cash pay patients to evaluate 90-day perioperative opioid prescription filling in 40,286 patients ages 18 and older undergoing Current Procedural Terminology codes 27766, 27769, 27792, 27814, 27822, and/or 27823 between 2010 and 2019 in all 50 United States. The primary study outcome was initial and cumulative 90-day perioperative opioid prescription filling and rates of filling and refills. Results: Mean first prescription volume has not changed dramatically from 2010 (37 oxycodone 5-mg pills) to 2019 (33.3 oxycodone 5-mg pills). However, cumulative prescriptions within the 90-day perioperative timeframe have decreased considerably from 2010 (128.5 oxycodone 5-mg pills) to 2019 (70.4 oxycodone 5-mg pills, p<0.001), and cumulative prescription filling in years 2018 and 2019 was significantly less than in 2010. Legislation targeting duration or duration and volume had the largest impacts on initial and cumulative opioid prescribing (approximately 14-22 fewer oxycodone 5-mg pills filled in states with legislation compared to states without legislation, p<0.001). The figure shows state-level pre-act and post-act cumulative 90-day opioid prescribing in ankle fracture surgery. Conclusion: In ankle fracture surgery, cumulative opioid prescribing has decreased dramatically over time. In addition, states with opioid prescribing legislation had larger reductions in perioperative opioid prescribing compared to states without opioid legislation. Legislation targeting duration or duration and volume had the largest impacts on opioid prescribing.

Objectives: To evaluate the prevalence of post-traumatic stress disorder (PTSD) symptoms in individuals who are further removed from injury (up to 3 years) and to identify injury-specific characteristics that are associated with an increased risk for persistent PTSD symptoms. Design: Cross-sectional, retrospective cohort. Setting: Level I trauma center. Patients/Participants: Two hundred forty-three patients operatively treated for orthopaedic trauma between March 2017 through June 2018. Intervention: Orthopaedic trauma requiring operative intervention. Main Outcome Measurements: The primary outcome was score on the PTSD Checklist for the DSM-5 (PCL-5) survey. A score of 31 or higher was considered concerning for PTSD. Results: Forty-nine of 239 respondents (20.5%) scored positive for PTSD. Multivariate analysis demonstrated an increased risk of PTSD for patients with a history of smoking and those who required delayed reoperation (greater than 90 days postoperative). White race and low-energy mechanisms of injury were associated with decreased risk of PTSD. Fracture locations were not associated with a higher likelihood of PTSD. Conclusions: The prevalence of PTSD symptoms in patients up to 3 years after surgery remains higher than the estimated prevalence of PTSD in the general US population. It is similar to previously documented rates of PTSD for patients less than 1 year after injury. Long-term complication requiring reoperation was associated with an increased risk of persistent PTSD symptoms. Orthopaedic providers should be mindful of PTSD symptoms not only in the immediate postoperative period but throughout the treatment course particularly for those with identified PTSD risk factors. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Shoulder arthroplasty is increasingly performed for patients with symptoms of glenohumeral arthritis. Advanced imaging may be used to assess the integrity of the rotator cuff preoperatively because a deficient rotator cuff may be an indication for reverse shoulder arthroplasty (RSA) rather than anatomic total shoulder arthroplasty (TSA). However, the cost-effectiveness of advanced imaging in this setting has not been analyzed.QUESTIONS/PURPOSES:In this cost-effectiveness modeling study of TSA, all patients underwent history and physical examination, radiography, and CT, and we compared (1) no further advanced imaging, (2) selective MRI, (3) MRI for all, (4) selective ultrasound, and (5) ultrasound for all.METHODS:A simple chain decision model was constructed with a base-case 65-year-old patient with a 7% probability of a large-to-massive rotator cuff tear and a follow-up of 5 years. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with a willingness to pay of both USD 50,000 and 100,000 per quality-adjusted life year (QALY) used, in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. Diagnostic test sensitivity and specificity were extracted from published systematic reviews and meta-analyses, and patient utilities were obtained using the Cost-Effectiveness Analysis Registry from the Center for the Evaluation of Value and Risk in Health. Final patient states were categorized as either inappropriate or appropriate based on the actual rotator cuff integrity and type of arthroplasty performed. Additionally, to evaluate the real-world impact of intraoperative determination of rotator cuff status, a secondary analysis was performed where all patients indicated for TSA underwent intraoperative rotator cuff examination to determine appropriate implant selection.RESULTS:Selective MRI (ICER of USD 40,964) and MRI for all (ICER of USD 79,182/QALY) were the most cost-effective advanced imaging strategies at a willingness to pay (WTP) of USD 50,000/QALY gained and 100,000/QALY gained, respectively. Overall, quality-adjusted life years gained by advanced soft tissue imaging were minimal: 0.04 quality-adjusted life years gained for MRI for all. Secondary analysis accounting for the ability of the surgeon to alter the treatment plan based on intraoperative rotator cuff evaluation resulted in the no further advanced imaging strategy as the dominant strategy as it was the least costly (USD 23,038 ± 2259) and achieved the greatest health utility (0.99 ± 0.05). The sensitivity analysis found the original model was the most sensitive to the probability of a rotator cuff tear in the population, with the value of advanced imaging increasing as the prevalence increased (rotator cuff tear prevalence greater than 12% makes MRI for all cost-effective at a WTP of USD 50,000/QALY).CONCLUSION:In the case of diagnostic ambiguity based on physical exam, radiographs, and CT alone, having both TSA and RSA available in the operating room appears more cost-effective than obtaining advanced soft tissue imaging preoperatively. However, performing selective MRI to assess rotator cuff integrity to indicate RSA or TSA is cost-effective if surgical preparedness, patient expectations, and implant availability preclude the ability to switch implants intraoperatively.LEVEL OF EVIDENCE:Level III, economic and decision analysis.