Education, Guidelines, Willingness: Keys to Changing Opioid-Prescribing Habits
When planning for any type of surgical procedure, the orthopaedist considers many patient and injury-specific variables. With a distal radius fracture, for example, the main goal of the surgery—anatomic reconstruction of the distal radius—remains constant. However, there are numerous other variables (fracture morphology and patient age, just to name 2) that have to be considered to achieve that goal. Yet, when it comes to postoperative pain control, I imagine that most orthopaedic surgeons prescribe the same amount of opioids to almost every patient undergoing an open reduction/internal fixation of a distal radius fracture, regardless of unique patient characteristics. Our medical mantra that “no two patients are the same” seems to fall by the wayside when it comes to postoperative pain control.
This disconnect is what I thought about while reading the article by Stepan et al. in the January 2, 2019 issue of The Journal. The authors’ institution developed and disseminated to all prescribers a 1-hour opioid education program and consensus-based postoperative opioid prescription guidelines. They then compared the number of opioid pills and total oral morphine equivalents prescribed after 9 ambulatory procedures within 3 subspecialty services (sports medicine, hand, and foot and ankle) prior to and after implementation of the guidelines. Stepan et al. found a significant decrease in the amount of narcotics prescribed after 6 of the 9 surgery types after implementation of the guidelines. Over the course of a year, those decreases would have equaled about 30,000 fewer opioid pills!
Interestingly, there was no significant post-guideline decrease in opioid prescribing after any of the 3 foot-and-ankle procedures. The authors attribute that finding to the slow adoption of the guidelines due to adherence to previously developed pain-management recommendations in this subspecialty.
It has become apparent that we tend to overprescribe opioids postoperatively (see related OrthoBuzz post). This study supports previous data showing that prescription guidelines can be useful in decreasing the amount of postoperative narcotics prescribed to patients, while maintaining adequate pain management and good levels of patient satisfaction. While further work in developing educational tools and procedure-specific “standards” to help surgeons guide their postoperative prescribing practices would be useful, a surgeon’s mindfulness is equally important. We need first to recognize that orthopaedic surgeons tend to overprescribe postoperative opioids—and second, we must be willing to change our habits. Without both awareness and willingness, the best guidelines and recommendations will be ignored, and an opportunity for us to help curb the opioid crisis in our country will be wasted.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
More Evidence: Coordinated Care Reduces Risk of Second Fragility Fracture
Fracture liaison services and similar coordinated, multidisciplinary fragility-fracture reduction programs for patients with osteoporosis work (see related OrthoBuzz posts), but until now, the data corroborating that have come from either academic medical centers or large integrated health care systems. The November 7, 2018 issue of The Journal of Bone and Joint Surgery presents solid evidence from a retrospective cohort study that a private orthopaedic practice-based osteoporosis management service (OP MS) also successfully reduces the risk of subsequent fragility fractures in older patients who have already sustained one.
Sietsema et al. collected fee-for-service Medicare data for Michigan residents who had any fracture from April 1, 2010 to September 30, 2014 (mean age of 75 years). From that data, they compared outcomes for patients who received nurse-practitioner-led OP MS care from a single-specialty private orthopaedic practice within 90 days of the first fracture to outcomes among a propensity-score-matched cohort of similar patients who did not receive OP MS care. There were >1,300 patients in each cohort, and both groups were followed for an average of 2 years. The private practice’s OP MS services incorporated the multidisciplinary protocols promulgated by the American Orthopaedic Association’s “Own the Bone” program.
The cohort exposed to OP MS had a longer median time to subsequent fracture (998 versus 743 days), a lower incidence rate of any subsequent fracture (300 versus 381 fractures per 1,000 person-years), and higher incidence rates of osteoporosis medication prescriptions filled (159 versus 90 per 1,000 person-years). Over the first 12 months of the follow-up period, total medical costs did not differ significantly between the 2 cohorts.
These findings are consistent with those reported from academic or integrated health-system settings. According to the authors, this preponderance of evidence “emphasize[s] the importance of coordinated care in reducing subsequent fractures, lengthening the time to their occurrence, and improving patient outcomes.” Sietsema et al. conclude further that “the U.S. Medicare population would benefit from widespread implementation of such models in collaboration with orthopaedic providers and payers.”
Pre-Visit Pain and Anxiety Influence Patient Satisfaction
Experienced orthopaedic clinicians understand that anxious patients with high levels of pain are some of the most challenging to evaluate and treat. Both anxiety and pain siphon away the patient’s focus and concentration, complicating the surgeon’s job of relaying key diagnostic and treatment information—often leaving patients confused and dissatisfied. Moreover, such patients usually want a quick solution to their physical pain and mental angst, whether that be a prescription for medication or surgery. At the same time, despite controversy, variously defined levels of “patient satisfaction” are being used as a metric to evaluate quality and value throughout the US health-care system. This reinforces the need for orthopaedists to understand the complex interplay between biological and psychological elements of patient encounters.
In the November 7, 2018 issue of The Journal, Tyser et al. use validated instruments to clarify the relationship between a patient’s pre-existing function, pain, and anxiety and the satisfaction the patient received from a new or returning outpatient visit to a hand/upper extremity clinic. Not surprisingly, the authors found that higher levels of physical function prior to the clinic visit correlated with increased satisfaction after the visit, as measured by the widely used Press Ganey online satisfaction survey. They also noted that higher antecedent levels of anxiety and pain, as determined by two PROMIS instruments, correlated with decreased levels of patient satisfaction with the visit. The authors assessed patient satisfaction only with the clinic visit and the care provider, not with any subsequent treatment.
Most patients are likely to experience some level of pain or anxiety when they meet with an orthopaedic surgeon. To leave patients more content with these visits, we need to set appropriate expectations for the visit in advance of the interaction and develop real-time, in-clinic strategies that help patients cope with anxiety. Such “biopsychosocial” strategies may not by themselves dictate the ultimate treatment, but they may go a long way toward helping patients understand their options and feel satisfied with the care provided. Secondarily, such strategies may help improve the satisfaction scores that administrators, rightly or wrongly, are increasingly using to evaluate musculoskeletal practitioners.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
October 2018 Article Exchange with JOSPT
In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of October 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Validity of Clinical Small-Fiber Sensory Testing to Detect Small–Nerve Fiber Degeneration.”
This prospective, cross-sectional, diagnostic-accuracy study found that pinprick testing, followed by warm and cold tests if pinprick is normal, is a valid and cost-effective method to detect small-fiber degeneration in a carpal tunnel syndrome model of neuropathy.
September 2018 Article Exchange with JOSPT
In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of September 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Hand-Grip Strength: Normative Reference Values and Equations for Individuals 18 to 85 Years of Age Residing in the United States.”
Hand-grip strength is an indicator of overall strength and a predictor of important outcomes. The normative reference values provided in this study may serve as a guide for interpreting grip-strength measurements obtained from tested individuals.
Properly Selected Patients with Cerebral Palsy Benefit from Upper-Extremity Surgery
The orthopaedic community has been abuzz lately with conversations about the value of interdisciplinary teamwork among clinicians and shared decision-making between patients and clinicians. The positive results of both those approaches, implemented with children and adolescents who have cerebral palsy (CP), are revealed in a clinical cohort study by Louwers et al. in the August 15, 2018 JBJS.
The authors engaged 66 patients with CP in a comprehensive, multidisciplinary screening process and shared decision-making to determine each patient’s suitability for upper-extremity surgery. Forty-four patients were deemed eligible for surgery and 39 (mean age of 15 years) underwent surgery. Seven types of surgery were performed, depending on each patient’s predetermined goals, values, and preferences. Seventy-seven percent of patients had surgery that consisted of flexor carpi ulnaris tendon release or transfer and adductor pollicis muscle slide plus extensor pollicis longus rerouting.
The authors itemize the preoperative and postoperative assessment tools used in the study and describe them as “suitable for selecting patients for upper-extremity surgery and for evaluating the effect of that surgery.”
The bottom line: All outcomes improved significantly after patient-specific upper-extremity surgery in those deemed suitable for it and who opted for surgery after the shared decision-making process. Most of the patients experienced clinically relevant improvement in their functional and cosmetic goals and in manual performance 9 months after their operation.
The two patients who chose nonsurgical treatment after going through the assessment and shared decision-making process did so due to a lack of motivation for the intensive postoperative rehabilitation, which began with upper-limb immobilization for 5 to 6 weeks, followed by a program customized for each patient by his or her rehabilitation physician and occupational therapist.
JBJS 100: Bankart Repair, Carpal Tunnel Assessment
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
The Bankart Procedure: A Long-Term End-Result Study
C R Rowe, D Patel, W W Southmayd: JBJS, 1978 January; 60 (1): 1
This was the first large clinical series with long follow-up to report the findings and results of the open Bankart repair. The results were almost uniformly excellent or good, and this study contributed to the demise of nonanatomic shoulder repairs.
A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome
D W Levine, B P Simmons, M J Koris, L H Daltroy, G G Hohl, A H Fossel, J N Katz: JBJS, 1993 January; 75 (11): 1585
Distinguishing interventions that work from those that don’t requires rigorous outcomes research, which, in turn, relies on standardized, patient-centered measures that have proven reliability and validity. Meeting these criteria are the Symptom Severity and Functional Status Scales for carpal tunnel syndrome described in this oft-cited JBJS study from 25 years ago.
The True “Bottom Line” for Advanced Technology: Patient Outcomes
Orthopaedic surgery has been blessed with an explosion of diagnostic and therapeutic technology over the last several decades. Improvements in advanced imaging, minimally invasive surgical techniques, and biomaterials and implant design have resulted in both perceived and objectively measurable patient benefits. In many cases, these benefits have been documented with patient-reported functional outcome data as well as improved clinical outcomes such as range of motion, strength, return to work, and pain relief.
However, some of these technological advances serve as expensive substitutes for many of the basic procedures that are universally available at a fraction of the cost, such as taking a thorough history, performing a complete physical examination, and employing basic and time-tested surgical techniques when indicated. While new minimally invasive techniques and computer-assisted preoperative planning are impressive in many respects, it is important to remember the ultimate goal of any orthopaedic operation: improving the patient’s musculoskeletal function.
In the July 18. 2018 issue of The Journal, Buijze et al. examine results from a multicenter randomized trial that compared patient-reported outcomes after using either 2-dimensional (standard radiographs) or 3-dimensional (CT with computer assistance) planning for corrective osteotomy in patients with a distal radial malunion. Although post-hoc analysis revealed that this study was underpowered, the patient-reported outcomes (as measured by DASH and PRWE) were not significantly different between the two preoperative planning groups.
These findings do not mean that advanced technology does not have a place in preoperative planning, but for me the findings emphasize that the most important factors in any orthopaedic surgery are the surgeon’s judgment, skill, and experience. When a surgeon needs assistance maximizing one of those three variables, more advanced technologies may play a role in improving patient outcome. For example, among less experienced surgeons, I suspect that more detailed preoperative planning for a relatively uncommon procedure would improve patient outcome, but it would probably have little impact on the results of procedures performed by more experienced surgeons.
The authors of this study focus on the true bottom line for any surgical intervention: patient outcome. But the other bottom line must also be considered. With the per-procedure incremental cost of 3-D planning and patient-specific surgical guides for upper-extremity deformity corrections estimated to range between $2,000 and $4,000, we must continue to conduct this type of Level I research. For the days of laying one “advance” on top of another with no attention paid to the cost for individual patients and the overall system are long gone.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Immobilization after Fixation of Distal Radial Fractures
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Matthew Herring, MD, in response to a recent study in JBJS.
Postoperative immobilization after internal fixation of fractures is common practice. However, immobilization after locked volar plate fixation of distal radial fractures may actually thwart our patients’ rehabilitation—at least in the short term. So suggest the findings from Watson et al. in the July 5, 2018 issue of JBJS.
The authors randomized 133 patients who underwent locked volar plate fixation of distal radial fractures to 1, 3, or 6 weeks of postoperative immobilization. All patients were placed into volar splints postoperatively. After 1 week, splints were removed entirely or converted to short-arm circumferential casts based on the patient’s allocation. All patients started physical therapy within 3 days of definitive splint or cast removal.
Outcomes were evaluated at 6, 12, and 26 weeks and included patient-reported measures (PRWE, VAS pain scores, and DASH), active wrist range of motion, and postoperative complications. Six weeks following surgery, the results favored 1 or 3 weeks of immobilization over 6 weeks of casting in terms of improved patient-reported outcomes and objective wrist range of motion. However, those between-group differences disappeared at 12 and 26 weeks of follow-up. No significant differences were found in complication rates between the 3 groups.
For me, the primary message of this article is that early mobilization after distal radial fracture fixation offers improved short-term outcomes with little or no risk of adverse effects. For most patients, a major goal of fracture treatment is to restore normal function as quickly as possible. With early mobilization, patients reported less pain and less disability, and they demonstrated greater range of motion at 6 weeks.
However, the quick restoration of function must be done safely and without complications. In this cohort, 6 patients lost fracture reduction—5 in the 1-week immobilization group and 1 in the 6-week group. While that difference was not statistically significant, the study was not sufficiently powered to detect that difference. A quick power analysis, assuming an anticipated 11% loss-of-reduction rate as seen in the 1-week group and a 2% rate as seen in the 6-week group, estimates that 234 patients would be needed to confidently avoid a type II error when analyzing loss of reduction.
Translating findings like these into practice constitutes the art of medicine. It is probably safe, and perhaps even beneficial, to allow early mobilization of distal radial fractures treated with volar locking plates. However, there is probably a subset of patients who are at risk for losing reduction, and therefore it may be prudent to have a low threshold for keeping certain patients casted for a longer duration. The orthopaedist who extends cast immobilization beyond 3 weeks can take comfort in the findings that reported outcomes and range of motion in the 6-week-immobilization group quickly caught up with the results of the early-mobilization cohorts by 12 weeks after surgery.
Matthew Herring, MD is a fellow in orthopaedic trauma at the University of California, San Francisco and a member of the JBJS Social Media Advisory Board.
Percutaneous Needle Fasciotomy Versus Collagenase Treatment for Dupuytren Contracture
Local disruption of the cord that causes contracture of the finger in Dupuytren disease can be achieved either through mechanical division by percutaneous needle fasciotomy (PNF) or through enzymatic digestion by injectable collagenase Clostridium histolyticum (CCH). #JBJS #VisualAbstract
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