scholarly journals Opioid Consumption Following Outpatient Foot and Ankle Surgery: A Prospective Analysis

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0002
Author(s):  
Erick M. Heiman ◽  
Kevin Wu ◽  
Alexander J. Idarraga ◽  
Daniel D. Bohl ◽  
Johnny Lin ◽  
...  
Keyword(s):  
Pain Control ◽  
Smoking Status ◽  
Study Cohort ◽  
Foot And Ankle ◽  
Opioid Use ◽  
Prescription Patterns ◽  
Analgesic Regimen ◽  
Ankle Surgery ◽  
Significant Difference

Category: Prescription Practices Introduction/Purpose: Opioid abuse has recently reached the conscience of the US healthcare system and news cycle. This epidemic is in part propagated by surgeon over-prescription for common procedures. The purpose of this study is to examine postoperative opioid use following outpatient foot and ankle surgery in order to potentially guide prescription patterns of postoperative narcotics. Methods: Patients undergoing outpatient foot or ankle surgery, performed by one of four fellowship-trained orthopedic foot and ankle surgeons from a single institution, were prospectively enrolled from January to November 2018. Subjects were consented to participate in a phone interview within 7 days of their surgery, with subsequent interviews as needed for continued monitoring. Information collected included: age, gender, procedure, smoking status, payor type, analgesic regimen, number of tablets remaining, pain scale, pain control satisfaction, additional analgesic medications taken, reason for stopping opioid medications, and any adverse reactions encountered. Results: A total of 94 subjects were consented to participate. Of these, 11 were lost to follow up and 2 withdrew from the study, leaving 81 (86%) subjects for analysis. The mean (± standard deviation) number of opioid pills prescribed was 52.2 (±16.4; range: 6-80) pills. Subjects were satisfied or somewhat satisfied with their pain control in 91% of cases. On average, 18.4 (±14.9) pills were consumed by subjects, stopping consumption on post-operative day 4.8 (±3.6). There was no statistically significant difference in narcotic medications consumed whether undergoing ankle surgery (16.4, ±13.7) or foot surgery (20.7, ±15.9) (p=0.11). Overall, an average of 34.3 (±19.3) pills remained unconsumed at the completion of narcotic use, equaling a total of 2,706 excessively prescribed pills in the study cohort. Conclusion: There is a substantial excess of opioid pain medication prescribed to patients for outpatient foot and ankle surgeries, with a wide variation in prescription patterns. Based on our institutional data, a prescription of 35 opioid pills should be sufficient for approximately two-thirds of outpatient procedures and 50 pills should be sufficient for approximately 95% of patients regardless of whether the procedure is for the ankle or foot. This quality improvement assessment has influenced physician practice in our group and prospective follow-up analysis after intervention is warranted.

Postoperative Opioid Use in Sinonasal Surgery

2018 ◽  
Vol 160 (3) ◽  
pp. 402-408 ◽  
Author(s):  
Garrett D. Locketz ◽  
Jason D. Brant ◽  
Nithin D. Adappa ◽  
James N. Palmer ◽  
Andrew N. Goldberg ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Pain Control ◽  
Smoking Status ◽  
Opioid Consumption ◽  
Smoking History ◽  
Opioid Use ◽  
Medical Centers ◽  
Academic Medical ◽  
Significant Difference ◽  
Average Pain

Objective To survey patients following sinonasal surgery regarding postoperative pain and opioid use. Study Design Patients were surveyed for 4 days following sinus and/or nasal surgery regarding their pain level and use of prescribed opioids. Setting Four academic medical centers and 1 private practice institution. Subjects Consecutive adult patients undergoing sinonasal surgery. Results A total of 219 subjects met criteria and were included for analysis; 134 patients (61%) took 5 or fewer combination oxycodone (5-mg) and acetaminophen (325-mg) tablets in the first 3 postoperative days, and 196 patients (89.5%) took fewer than 15. Fifty-one patients (23%) consumed no opioid pain medication. Opioid consumption was positively correlated with postoperative pain ( R2 = 0.2, P < .01) but was not correlated with the use of acetaminophen ( R2 = 0.002, P = .48). No significant difference in postoperative pain or opioid consumption was seen with respect to age, sex, specific procedures performed, postoperative steroids, or smoking history. Current smokers reported higher average pain than nonsmokers ( P < .001) and also required more postoperative opioids ( P = .02). Conclusions An evidence-based approach to postoperative pain control following sinonasal surgery that reduces the number of unused and potentially diverted opioids is needed. The current study suggests that 15 combination oxycodone (5-mg) and acetaminophen (325-mg) tablets provide sufficient pain control for 90% of patients in the immediate postoperative period following sinonasal surgery, irrespective of the specific procedures performed, use of acetaminophen, or use of systemic steroids. Smoking status may help surgeons predict which patients will require larger opioid prescriptions.

scholarly journals Postoperative Oral Antibiotics in Outpatient Foot and Ankle Surgery: Are We Affecting Postoperative Infections or Wound Healing Complications?

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0012
Author(s):  
Jacob R Carl ◽  
Kevin Ngoc Nguyen ◽  
Trevor J. Shelton ◽  
Eric Giza ◽  
Christopher Kreulen
Keyword(s):  
Wound Healing ◽  
Postoperative Infection ◽  
Smoking Status ◽  
Wound Complications ◽  
Foot And Ankle ◽  
Oral Antibiotics ◽  
Postoperative Infections ◽  
Tourniquet Time ◽  
Ankle Surgery ◽  
Significant Difference

Category: Infection Introduction/Purpose: Postoperative infections after foot and ankle surgery can cause devastating outcomes for patients. Studies of postoperative infection rates in outpatient foot and ankle surgery range from 0.5-6.5%, with increasing numbers found in diabetic patient populations. The use of perioperative antibiotics in the prevention of postoperative infection in outpatient surgery is a topic that has often been discussed yet there remains considerable controversy. The authors hypothesize that there is no difference in postoperative infection rate or wound healing complications in patients who received postoperative oral antibiotics versus those that did not. Additionally, the authors sought to identify patient characteristics associated with postoperative infections or wound complications. Methods: Retrospective chart review of 649 elective outpatient foot and/or ankle surgery cases over a 2-year period performed by two fellowship trained foot and ankle surgeons at an academic medical center ambulatory surgical unit. All cases were included with at least one follow-up visit and no evidence of chronic wounds or infection. Those cases that did not have adequate follow up or if postoperative antibiotic treatment could not be determined were subsequently excluded. Analysis evaluated patients that received postoperative oral antibiotics (PAB) and those that did not receive postoperative oral antibiotics (NAB) to identify whether a difference in infection rate or wound healing complication were present. Patient demographics, medical comorbidities, BMI, smoking status, and tourniquet time were analyzed to identify contributing factors or comorbidities that may be more prevalent in those that developed postoperative infections in the PAB and NAB groups. Results: 633 operative cases were included in the study. The average age of patients in the PAB group and NAB group was equal (age 45 ± 17). The number of infections in PAB was 6, while the number of infections in NAB was 10 (3% vs. 2%, p = 0.60). The number of deep versus superficial infections and wound complications between the two groups was not statistically significant. Patients that developed infections versus those that did not were older (average age 55 vs. 45, p = 0.02), demonstrated a higher prevalence of hypertension (44% vs. 17%, p = 0.01), and a history of neoplasm (19% vs. 2%, p < 0.01). No significant difference was found between groups based on BMI, diabetes, tourniquet time, or smoking status. Conclusion: There are limited studies published on the efficacy of routine postoperative antibiotics in outpatient foot and ankle surgery, despite a majority of surgeons (75%) reporting using postoperative antibiotics.2 The present study suggests there is no benefit to prescribing postoperative oral antibiotics in an outpatient surgery setting. Additionally, older patients, patients with hypertension, and patients with a history of neoplasm made up a larger percentage of patients in the postoperative infection group. BMI, diabetes, tourniquet time and smoking status did not have a significant difference in postoperative infections between the PAB group and NAB group.

scholarly journals Postoperative Pain Control Following Cardiac Implantable Electronic Device Implantation

2021 ◽  
Author(s):  
Peter Magnusson ◽  
Jo Ann LeQuang ◽  
Joseph V. Pergolizzi
Keyword(s):  
Postoperative Pain ◽  
Pain Control ◽  
Electronic Device ◽  
Perioperative Period ◽  
Cardiac Implantable Electronic Device ◽  
Opioid Use ◽  
Acute Postoperative Pain ◽  
Device Implantation ◽  
Analgesic Regimen ◽  
Short Course

Postoperative pain following cardiac implantable electronic device (CIED) surgery may not always be adequately treated. The postoperative pain trajectory occurs over several days following the procedure with tenderness and limited arm range of motion lasting for weeks after surgery. Pain control typically commences in the perioperative period while the patient is in the hospital and may continue after discharge; outpatients may be given a prescription and advice for their analgesic regimen. It is not unusual for CIED patients to be discharged a few hours after implantation. While opioids are known as an effective analgesic to manage acute postoperative pain, growing scrutiny on opioid use as well as their side effects and potential risks have limited their use. Opioids may be considered for appropriate patients for a short course of treatment of acute postoperative pain, but other analgesics may likewise be considered.

No difference in reoperation rates for nonunions (operative nonunions) in posterior cervical fusions stopping at C7 versus T1/2: a cohort of 875 patients

2021 ◽  
pp. 1-7
Keyword(s):  
Proportional Hazards ◽  
Smoking Status ◽  
Incidence Rates ◽  
Cox Proportional Hazards ◽  
Adjacent Segment ◽  
Spine Registry ◽  
Age At Surgery ◽  
Significant Difference ◽  
Reoperation Rates

OBJECTIVE The challenges of posterior cervical fusions (PCFs) at the cervicothoracic junction (CTJ) are widely known, including the development of adjacent-segment disease by stopping fusions at C7. One solution has been to cross the CTJ (T1/T2) rather than stopping at C7. This approach may have undue consequences, including increased reoperations for symptomatic nonunion (operative nonunion). The authors sought to investigate if there is a difference in operative nonunion in PCFs that stop at C7 versus T1/T2. METHODS A retrospective analysis identified patients from the authors’ spine registry (Kaiser Permanente) who underwent PCFs with caudal fusion levels at C7 and T1/T2. Demographics, diagnoses, operative times, lengths of stay, and reoperations were extracted from the registry. Operative nonunion was adjudicated via chart review. Patients were followed until validated operative nonunion, membership termination, death, or end of study (March 31, 2020). Descriptive statistics and 2-year crude incidence rates and 95% confidence intervals for operative nonunion for PCFs stopping at C7 or T1/T2 were reported. Time-dependent crude and adjusted multivariable Cox proportional hazards models were used to evaluate operative nonunion rates. RESULTS The authors identified 875 patients with PCFs (beginning at C3, C4, C5, or C6) stopping at either C7 (n = 470) or T1/T2 (n = 405) with a mean follow-up time of 4.6 ± 3.3 years and a mean time to operative nonunion of 0.9 ± 0.6 years. There were 17 operative nonunions, and, after adjustment for age at surgery and smoking status, the cumulative incidence rates were similar between constructs stopping at C7 and those that extended to T1/T2 (C7: 1.91% [95% CI 0.88%–3.60%]; T1/T2: 1.98% [95% CI 0.86%–3.85%]). In the crude model and model adjusted for age at surgery and smoking status, no difference in risk for constructs extended to T1/T2 compared to those stopping at C7 was found (adjusted HR 1.09 [95% CI 0.42–2.84], p = 0.86). CONCLUSIONS In one of the largest cohort of patients with PCFs stopping at C7 or T1/T2 with an average follow-up of > 4 years, the authors found no statistically significant difference in reoperation rates for symptomatic nonunion (operative nonunion). This finding shows that there is no added risk of operative nonunion by extending PCFs to T1/T2 or stopping at C7.

scholarly journals Postoperative Tourniquet Pain in Patients Undergoing Foot and Ankle Surgery

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0042
Author(s):  
Ashish Shah ◽  
Eva Lehtonen ◽  
Samuel Huntley ◽  
Harshadkumar Patel ◽  
John Johnson ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Postoperative Pain ◽  
Length Of Stay ◽  
Systolic Blood Pressure ◽  
Foot And Ankle ◽  
Opioid Use ◽  
Tourniquet Time ◽  
Pain Scores ◽  
Regional Nerve Block ◽  
Ankle Surgery

Category: Other Introduction/Purpose: The tourniquet is commonly used in orthopedic surgeries on the upper and lower extremities to reduce blood loss, improve visualization, and expedite the surgical procedure. However, tourniquets have been associated with multiple local and systemic complications, including postoperative pain. Guidelines vary regarding ideal tourniquet pressure and duration, while the practice of fixed, high tourniquet pressures remains common. The relationship between tourniquet pressure, duration, and postoperative pain has been studied in various orthopaedic procedures, but these relationships remain unknown in foot and ankle surgery. The purpose of this study was to assess for correlation between excessive tourniquet pressure and duration and the increased incidence of tourniquet pain in foot and ankle surgery patients. Methods: Retrospective chart review was performed for 132 adult patients who underwent foot and ankle surgery with concomitant use of intraoperative tourniquet at a single institution between August and December of 2015. Patients with history of daily opioid use of 30 or more morphine oral equivalents for greater than 30 days, patients who underwent foot and ankle surgery without regional nerve block, patients deemed to have failed regional nerve block, and patients who underwent foot and ankle surgery without tourniquet use were excluded. Patient’s baseline systolic blood pressure, tourniquet pressure and duration, tourniquet deflation time, tourniquet reinflation pressure and duration, intraoperative blood pressure and heart rate changes, intra-operative opioid consumption, PACU pain scores, PACU opioid consumption, and PACU length of stay were collected. Statistical correlation between tourniquet pressure and duration and postoperative pain scores, pain location, narcotic use, and length of stay in PACU was assessed using linear regression in SPSS. Results: Average age of patients was 47.6 years (Range: 16 - 79). Tourniquet pressure was 280 mmHg in 90.6% of patients (Range: 250-300 mmHg). Only 3.8% percent of patients had tourniquet pressures 100-150 mmHg above systolic blood pressure. Mean tourniquet time was 106.2 ± 40.1 min. Tourniquet time showed significant positive correlation with morphine equivalents used in the perioperative period (N = 121; r = 0.406; p < 0.001). Long tourniquet times (= 90 minutes) were associated with greater intraoperative opioid use than short tourniquet times (= 90 minutes) (19 mg ± 22 mg vs. 5 mg ± 11.6 mg; p <0.001). Tourniquet duration and PACU length of stay had a positive association (R2 = 0.4). Conclusion: The majority of cases of foot and ankle surgery at our institution did not adhere to current tourniquet use guidelines, which recommend tourniquet pressure between 100 and 150 mmHg above patient’s systolic blood pressure. Prolonged tourniquet times at high pressures not based on limb occlusion pressure, as observed in our study, lead to increased pain and opioid use and prolonged time in PACU. Basing tourniquet pressures on limb occlusion pressures could likely improve the safety margin of tourniquets, however randomized studies need to be completed to confirm this.

Use of Prophylaxis for Prevention of Venous Thromboembolism in Patients with Isolated Foot or Ankle Surgery: A Systematic Review and Meta-Analysis

2019 ◽  
Vol 119 (10) ◽  
pp. 1686-1694 ◽  
Author(s):  
Bavand Bikdeli ◽  
Renuka Visvanathan ◽  
David Jimenez ◽  
Manuel Monreal ◽  
Samuel Z. Goldhaber ◽  
...  
Keyword(s):  
Systematic Review ◽  
Venous Thromboembolism ◽  
Meta Analysis ◽  
Evidence Base ◽  
Controlled Trials ◽  
Cochrane Central Register ◽  
Foot And Ankle ◽  
Vte Prophylaxis ◽  
Ankle Surgery ◽  
Significant Difference

AbstractAlthough prophylaxis for venous thromboembolism (VTE) is recommended after many surgeries, evidence base for use of VTE prophylaxis after foot or ankle surgery has been elusive, leading into varying guidelines recommendations and notable practice variations. We conducted a systematic review of the literature to determine if use of VTE prophylaxis decreased the frequency of subsequent VTE, including deep vein thrombosis (DVT) or pulmonary embolism (PE), compared with control. We searched PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through May 2018, for randomized controlled trials (RCTs) or prospective controlled observational studies of VTE prophylaxis in patients undergoing foot and ankle surgery. Our search retrieved 263 studies, of which 6 were finally included comprising 1,600 patients. Patients receiving VTE prophylaxis had lower risk for subsequent DVT (risk ratio [RR]: 0.72; 95% confidence interval [CI]: 0.55–0.94) and subsequent VTE (RR: 0.72; 95% CI: 0.55–0.94). There was only one case of nonfatal PE, no cases of fatal PE, and no change in all-cause mortality (RR: 3.51; 95% CI: 0.14–84.84). There was no significant difference in the risk for bleeding (RR: 2.12; 95% CI: 0.53–8.56). Very few RCTs exist regarding the efficacy and safety of VTE prophylaxis in foot and ankle surgery. Prophylaxis appears to reduce the risk of subsequent VTE, but the event rates are low and symptomatic events are rare. Future studies should determine the subgroups of patients undergoing foot or ankle surgery in whom prophylaxis may be most useful.

scholarly journals Long-Term Outcome and Secondary Operations after Proximal Row Carpectomy or Four-Corner Arthrodesis

2017 ◽  
Vol 07 (01) ◽  
pp. 051-056 ◽  
Author(s):  
John Williams ◽  
Hadley Weiner ◽  
Andrew Tyser
Keyword(s):  
Smoking Status ◽  
Proximal Row Carpectomy ◽  
Long Term Outcome ◽  
Wrist Arthrodesis ◽  
Conversion Rates ◽  
Significant Difference ◽  
Patient Reported ◽  
Secondary Operations

Background Proximal row carpectomy (PRC) and four-corner arthrodesis (FCA) are common surgical procedures used to treat degenerative wrist conditions; however, complications and failures can occur. Purpose This study aimed to investigate and compare the long-term rate of secondary surgeries including conversion to total wrist arthrodesis in patients who underwent PRC or FCA. Materials and Methods A retrospective chart review of all patients who underwent PRC or FCA in the past 20 years at a tertiary referral institution and associated Veterans Affairs (VA) hospital was performed. Patient demographics, comorbidities, surgical indications, and associated complications were tabulated. Patients were contacted via phone to obtain additional follow-up information regarding any additional surgeries, 10-point visual analog scale (VAS) for pain, quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) scores, hand dominance, and occupational data. Results A total of 123 wrists made up the final dataset. Sixty-two wrists treated with PRC and 61 wrists treated with FCA were reviewed at a mean follow-up of 8.2 years. We did not find a significant difference in the rate of conversion to total wrist arthrodesis between the PRC (14.5%) and FCA (19.5%, p = 0.51) cohorts. Secondary operations were significantly greater in the FCA group (34.4%) compared with the PRC group (16.1%, p = 0.02). Females were 2.6 times more likely than males to undergo secondary operations when controlling for surgical procedure and smoking status (p = 0.04). We did not detect a significant difference in VAS pain or in quickDASH scores between the two groups (p = 0.35, 0.48, respectively). Conclusion PRC and FCA have comparable patient reported outcomes and wrist arthrodesis conversion rates at a mean follow-up of 8.2 years. In contrast, the FCA patient group had a significantly higher rate of secondary operations, including those for nonunion, symptomatic hardware, and other implant-related issues, when combined with wrist arthrodesis conversion. Level of Evidence Level IV, therapeutic study.

scholarly journals Comparison of Midfoot and Metatarsal Dorsal Wedge Osteotomy to Treat Cavovarus Foot Deformity in Adolescents

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0024
Author(s):  
Jinsong Hong
Keyword(s):  
Retrospective Study ◽  
Analogue Scale ◽  
Early Stage ◽  
Wedge Osteotomy ◽  
Foot And Ankle ◽  
Foot Deformity ◽  
Significant Difference ◽  
Spss Software ◽  
American Orthopaedic

Category: Midfoot/Forefoot Introduction/Purpose: To compare the clinical result of midfoot and metatarsal dorsal wedge osteotomy for the treatment of cavovarus foot deformity in adolescents. Methods: A comparative retrospective study of 24 patients with cavovarus foot deformity in adolescents was conducted between March 2012 and March 2015 in the Guangzhou Orthopaedic Hospital. All patients were flexible deformity. 10 patients were treated with midfoot dorsal wedge osteotomy, while 14 patients received metatarsal dorsal wedge osteotomy. The clinical curative effects, complications and image differences were compared between the two groups. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Visual Analogue Scale (VAS) score were evaluated for each patient during the follow-up. All statistics were analyzed using the SPSS software system. Results: No early stage soft tissue complications occurred in all patients. All the patients obtained an average 21.5 months (ranged,10-30 months) follow-up.X-ray demonstrated that bone healing was obtained, the midfoot dorsal wedge osteotomy group at an average of 11.2 weeks (ranged,10-13 weeks). the metatarsal dorsal wedge osteotomy group at an average of 13.4 weeks (ranged,12-15 weeks). By AOFAS foot score and VAS pain score: There is no significant difference between the two groups (P=0.138). No complications of nonunion, recurrence of de-fortuity or implant failure were seen during follow-up. Conclusion: The midfoot and metatarsal dorsal wedge osteotomy are the effective methods for the treatment of cavovarus foot deformity in adolescents. For severe deformity midfoot metatarsal dorsal wedge osteotomy can provide more powerful correction.

scholarly journals Pain and Complications following Bone Marrow Aspirate Concentrate (BMAC) Harvested from the Iliac Crest in Foot and Ankle Surgery

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0014
Author(s):  
Christy M. Christophersen ◽  
Osama Elattar ◽  
Daniel Farber
Keyword(s):  
Bone Marrow ◽  
Patient Satisfaction ◽  
Bone Graft ◽  
Iliac Crest ◽  
Bone Marrow Aspirate ◽  
Foot And Ankle ◽  
Ankle Surgery ◽  
Harvest Site ◽  
Telephone Questionnaire

Category: bone graft in foot and ankle surgery Introduction/Purpose: Autologous bone is recognized as the gold standard for bone grafting in orthopedics with the iliac crest being the common harvest site. In an attempt to minimize morbidity associated with structural bone graft harvest from the iliac crest and still maintain the proposed benefit of collecting and transplanting live cells and growth factors, Bone Marrow Aspirate Concentrate (BMAC) obtained from the iliac crest has become increasingly popular. However, any harvest procedure can potentially induce pain and introduce complications. The purpose of this study was to evaluate the safety and complications of BMAC from the anterior iliac crest for use in various foot and ankle fusion procedures. Methods: A retrospective chart review was performed on all patients that underwent BMAC harvest from the iliac crest at the time of their foot or ankle surgical procedure by one of four fellowship trained surgeons between 2014 and 2017 with a minimum of six-month follow-up. Patients were evaluated for complications, pain, and functional limitation secondary to the BMAC harvest. The final outcome follow-up for the cohort was conducted using a specifically designed telephone questionnaire to assess patient satisfaction. A total of 55 patients were included, with a median age of 58 years (range 31 to 81 years) and 69% were female. Results: Out of the 55 patients, 52 patients (94.5%) reported reported good to excellent results and were satisfied with the procedure at the time the questionnaire was conducted. Only 3 patients reported persistent complications and some element of dissatisfaction with the procedure after 6 months (the minimum follow up), 1 patient reported persistent numbness at the harvest site, and 2 reported some persistent pain at the harvest site lasting up to 6 months. Some patients reported transient complications that eventually resolved with no implication on their satisfaction of the procedure at the time of the telephone questionnaire. Four patients reported hematoma that was treated conservatively and eventually resolved spontaneously. Four patients reported transient numbness at the harvest site with eventual resolution. Immediately post-operatively, 50% of patients reported some element of post-operative pain. However, at the time of the final follow-up (at least 6 months), only 2 patients reported persistent pain at the harvest site lasting up to 6 months, but it was not considered activity-limiting pain. Conclusion: BMAC harvest is a safe procedure with a high rate of patient satisfaction and minimal morbidity with mostly self- limiting complications. This is the first study to evaluate the safety of BMAC as a part of foot and ankle surgical procedures.

Sign in / Sign up

Export Citation Format

Share Document