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Sutton KF, Cabell GH, Ashley LW, Lentz TA, Lewis BD, Olson SA, Mather RC. Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study. BMC Musculoskelet Disord 2024; 25:304. [PMID: 38643071 PMCID: PMC11031887 DOI: 10.1186/s12891-024-07418-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 04/05/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear. METHODS Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool. RESULTS Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME. CONCLUSIONS Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.
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Affiliation(s)
- Kent F Sutton
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Grant H Cabell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Lucas W Ashley
- Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Trevor A Lentz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian D Lewis
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Steven A Olson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Young PF, Roberts C, Shi GG, Heckman MG, White L, Clendenen S, Wilke B. Total Knee Arthroplasty With and Without Schedule II Opioids: A Randomized, Double-Blinded, Placebo-Controlled Trial. Cureus 2024; 16:e56150. [PMID: 38618342 PMCID: PMC11015880 DOI: 10.7759/cureus.56150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION Orthopedic surgeons are the third highest prescribers of narcotics. Previous work demonstrated that surgeons prescribe three times the narcotics required, and most patients do not properly dispose of leftover medication following surgery. This has prompted the creation of multimodal pain regimens to reduce reliance on narcotics. It is unknown if these pathways can effectively eliminate opioids following total knee arthroplasty (TKA). Our purpose was to evaluate a multimodal regimen without schedule II narcotics following TKA, in a randomized, blinded fashion. We hypothesized that there would be no difference in pain scores between groups. METHODS A total of 43 narcotic-naïve patients participated in a randomized, double-blinded, placebo-controlled trial. Postoperative protocols were identical between cohorts, except for the study medication. The narcotic group received an encapsulated 5 mg oxycodone, whereas the control group received an encapsulated placebo. Perioperative outcomes were compared with routine statistical analysis. RESULTS Four patients withdrew early secondary to pain: three in the placebo group and one in the narcotic group (p=1.00). We found no difference in hospital length of stay (p=0.09) or pain scores at all time points between cohorts (all p>0.05). There was a higher proportion of patients using a narcotic in the opioid treatment arm at day 30 (40% vs. 21.4%, p=0.29) and day 60 (20% vs. 7.1%, p=0.32), although this was not statistically significant. CONCLUSION A multimodal regimen without schedule II narcotics demonstrates equivalent pain scores and may reduce the risk of long-term opioid dependence following TKA.
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Affiliation(s)
- Porter F Young
- Orthopedic Surgery, University of Florida, Jacksonville, USA
| | | | | | | | | | - Steven Clendenen
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, USA
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Ilyas AM, Sundaram P, Plusch K, Kasper A, Jones CM. Multimodal Pain Management After Outpatient Orthopedic Hand Surgery: A Prospective Randomized Trial. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:16-20. [PMID: 38313605 PMCID: PMC10837162 DOI: 10.1016/j.jhsg.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 07/29/2023] [Indexed: 02/06/2024] Open
Abstract
Purpose Opioid stewardship ensures effective pain management while avoiding overprescribing of opioids after surgery. This prospective randomized study investigates the efficacy of a multimodal postoperative pain regimen compared to a traditional opioid-only pain regimen following elective outpatient orthopedic hand surgery. We hypothesized that patients receiving multimodal pain management would consume fewer opioids and report greater satisfaction than patients receiving only opioids. Methods Consecutive patients undergoing outpatient hand and upper extremity surgery performed by two board-certified fellowship-trained orthopedic hand surgeons at one institution were recruited and randomized into either a study or control group. The study group received a standing multimodal postoperative regimen consisting of scheduled oral acetaminophen and naproxen as well as oxycodone to be taken as needed. The control group received only oxycodone to be taken as needed. Postoperatively, daily pain levels, medication usage, refills, satisfaction, and adverse events were recorded. Descriptive statistics were performed. Results Of the 112 patients enrolled, 54 were randomized to the control group, and 58 were randomized to the study group. Study and control group patients did not differ significantly based on daily average pain scores or daily worst pain scores. However, study group patients reported fewer average daily oxycodone intake and total oxycodone pill count (7.0 vs 2.4 total pills, P <.005). In addition, the study group patients were more likely to report satisfaction with their postoperative pain control than control regimen patient's and were more likely to use the same pain regimen again if required. Conclusion A multimodal postoperative pain regimen reduces opioid usage and has higher patient satisfaction rates in comparison to traditional opioid-only regimens. Use of multimodal pain regimens that use nonopioids, such as acetaminophen and naproxen, over an opioid should be considered for postoperative pain after orthopedic hand surgery. Level of Evidence Therapeutic II.
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Affiliation(s)
- Asif M Ilyas
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA USA
| | - Padmaja Sundaram
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA USA
| | - Kyle Plusch
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA USA
| | - Alexis Kasper
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA USA
| | - Christopher M Jones
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA USA
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Yang A, Townsend CB, Ilyas AM. Medical Cannabis in Hand Surgery: A Review of the Current Evidence. J Hand Surg Am 2023; 48:292-300. [PMID: 36609049 DOI: 10.1016/j.jhsa.2022.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 08/21/2022] [Accepted: 11/09/2022] [Indexed: 01/06/2023]
Abstract
Acute and chronic pain management remains an ongoing challenge for hand surgeons. This has been compounded by the ongoing opioid epidemic in the United States. With the increasing legalization of medical and recreational cannabis throughout the United States and other countries, previous societal stigmas about this substance keep evolving, and recognition of medical cannabis as an opioid-sparing pain management alternative is growing. A review of the current literature demonstrates a strong interest from patients regarding the use of medical cannabis for pain control. Current evidence demonstrates its efficacy and safety for chronic musculoskeletal and neuropathic pain. However, definitive conclusions regarding the efficacy of cannabis for pain control in hand and upper extremity conditions require continued investigation. The purpose of this article is to provide a general review of the mechanism of medical cannabis and a scoping review of the current evidence for its efficacy, safety, and potential applicability in hand and upper extremity conditions.
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Affiliation(s)
- Andrew Yang
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Clay B Townsend
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Asif M Ilyas
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA; Rothman Orthopaedic Institute Foundation for Opioid Research & Education, Philadelphia, PA.
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Evidenced-Based Opioid Prescribing Recommendations Following Hand and Upper-Extremity Surgery. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:276-282. [PMID: 36157302 PMCID: PMC9492791 DOI: 10.1016/j.jhsg.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/28/2022] [Indexed: 12/03/2022] Open
Abstract
The United States’ opioid epidemic has taken an immense toll over the past 2 decades when assessed by morbidities, mortalities, and economic costs. Prescription opioids are a substantial contribution to this public health emergency, and it is critical for health care providers to practice good analgesic stewardship. Interventions have effectively curtailed opioid overuse, including prescription drug monitoring programs, educational initiatives, and multimodal analgesia strategies. Surgeons, particularly hand surgeons or those who perform musculoskeletal procedures, have been implicated as high-volume opioid prescribers. Guidelines for appropriate opioid dosing and analgesic management strategies after common hand and upper-extremity surgeries are sparse and offer an area for meaningful improvement. We sought to generate comprehensive, evidence-based recommendations for postoperative analgesia regimens for common hand and upper-extremity procedures.
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Li NY, Kuczmarski AS, Hresko AM, Goodman AD, Gil JA, Daniels AH. Four-Corner Arthrodesis versus Proximal Row Carpectomy: Risk Factors and Complications Associated with Prolonged Postoperative Opioid Use. J Hand Microsurg 2022; 14:163-169. [PMID: 35983285 PMCID: PMC9381174 DOI: 10.1055/s-0040-1715426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Introduction This article compares opioid use patterns following four-corner arthrodesis (FCA) and proximal row carpectomy (PRC) and identifies risk factors and complications associated with prolonged opioid consumption. Materials and Methods The PearlDiver Research Program was used to identify patients undergoing primary FCA (Current Procedural Terminology [CPT] codes 25820, 25825) or PRC (CPT 25215) from 2007 to 2017. Patient demographics, comorbidities, perioperative opioid use, and postoperative complications were assessed. Opioids were identified through generic drug codes while complications were defined by International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification codes. Multivariable logistic regressions were performed with p < 0.05 considered statistically significant. Results A total of 888 patients underwent FCA and 835 underwent PRC. Three months postoperatively, more FCA patients (18.0%) continued to use opioids than PRC patients (14.7%) ( p = 0.033). Preoperative opioid use was the strongest risk factor for prolonged opioid use for both FCA (odds ratio [OR]: 4.91; p < 0.001) and PRC (OR: 6.33; p < 0.001). Prolonged opioid use was associated with an increased risk of implant complications (OR: 4.96; p < 0.001) and conversion to total wrist arthrodesis (OR: 3.55; p < 0.001) following FCA. Conclusion Prolonged postoperative opioid use is more frequent in patients undergoing FCA than PRC. Understanding the prevalence, risk factors, and complications associated with prolonged postoperative opioid use after these procedures may help physicians counsel patients and implement opioid minimization strategies preoperatively.
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Affiliation(s)
- Neill Y. Li
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Alexander S. Kuczmarski
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Andrew M. Hresko
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Avi D. Goodman
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Joseph A. Gil
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
| | - Alan H. Daniels
- Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, United States
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Defining the Opioid Requirement in Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202201000-00011. [PMID: 35025832 PMCID: PMC8759619 DOI: 10.5435/jaaosglobal-d-21-00298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022]
Abstract
Introduction: The amount and duration of opioids necessary after anterior cruciate ligament reconstruction (ACLR) are inadequately defined. This study sought to prospectively (1) define the amount and duration of opioid consumption, (2) investigate the relationship between preoperative pain expectation and postoperative satisfaction with pain management, and (3) identify risk factors for increased opioid use after ACLR. Methods: One hundred eight patients undergoing primary ACLR with hamstring graft were prospectively analyzed for preoperative pain expectation, using visual analog scale (VAS) rating, and postoperative satisfaction with pain management. Univariate and multivariate analyses were done to identify patient characteristics associated with satisfaction and/or amount and duration of opioid use. Results: Mean duration and cumulative intake of opioid consumption after ACLR were 5.3 days and 15.3 tablets, respectively. Patients expected moderate postoperative pain: mean preoperative VAS = 68.9. The preoperative VAS rating was associated with a significantly greater amount (P = 0.0265) and longer duration (P = 0.0212) of opioid consumption. Baseline opioid users took opioids for twice as long postoperatively (10.0 versus 5.0 days; P = 0.0149) and consumed twice as many tablets (29.3 versus 14.8 tablets; P = 0.0280) compared with opioid-naive patients. Discussion: This study demonstrated on average 15.3 opioid tablets over 5.3 days provided satisfactory pain management after ACLR. Risk factors for increased opioid consumption included preoperative opioid use.
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Hozack BA, Rivlin M, Lutsky KF, Beredjiklian PK. Overall Opioid Consumption Is Not Associated With the Amount of Opioids Administered and Prescribed on the Day of Upper Extremity Surgery. Hand (N Y) 2021; 16:781-784. [PMID: 31965858 PMCID: PMC8647310 DOI: 10.1177/1558944719897419] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Orthopedic surgeons need to better understand the effect their opioid-prescribing habits have on patients. The purpose of our study was to evaluate whether the type of procedure or initial amount of opioids prescribed postoperatively leads to increased consumption of opioids. Methods: Consecutive patients undergoing upper extremity surgery were enrolled. The medical record and Pennsylvania Prescription Drug Monitoring Program Web site were used to record all prescriptions of controlled substances consumed intraoperatively, in the recovery room, and in prescriptions filled 6 months postoperatively. Morphine equivalent units (MEUs) were used to quantify the amount of opioids. Results: Two hundred ninety patients were included in the study. The mean MEU administered intraoperatively was 25.1 (0-50). The MEU provided in the recovery room was 2.9 (0-60). The MEU prescribed on the day of surgery was 155.6 (137-178). We used the Pearson correlation coefficient of r = 0, meaning no/weak correlation, and r = 1, meaning a strong correlation. Neither MEUs provided intraoperatively or in recovery, nor MEUs prescribed postoperatively correlated with prescriptions filled (r = 0.13, 0.02, 0.09, respectively). Although patients undergoing bony procedures were prescribed more opioids (P < .001), opioid consumption intraoperatively, in recovery, and in prescriptions filled was not significantly different. Conclusions: The MEUs administered and prescribed on the day of surgery did not affect the amount of prescriptions filled postoperatively. Finally, patients undergoing bony procedures were prescribed more opioids than those undergoing soft tissue procedures, but they did not consume or fill more opioids postoperatively.
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Affiliation(s)
- Bryan A. Hozack
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA,Bryan A. Hozack, Rothman Institute, Thomas Jefferson University Hospitals, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA.
| | - Michael Rivlin
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kevin F. Lutsky
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Preoperative Opioid Education has No Effect on Opioid Use in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Prospective, Randomized Clinical Trial. J Am Acad Orthop Surg 2021; 29:e961-e968. [PMID: 33306558 DOI: 10.5435/jaaos-d-20-00594] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 10/12/2020] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES The purpose of this study was to determine whether a preoperative video-based opioid education reduced narcotics consumption after arthroscopic rotator cuff repair in opioid-naive patients. METHODS This was a single-center randomized controlled trial. Preoperatively, the control group received our institution's standard of care for pain management education, whereas the experimental group watched an educational video on the use of opioids. Patients were discharged with 30 × 5 mg/325 mg oxycodone-acetaminophen prescribed: 1 to 2 tablets every 4 to 6 hours. They were contacted daily and asked to report opioid use and visual analog scale pain. A chart review at 3 months post-op was used to analyze for opioid refills. RESULTS A total of 130 patients completed the study (65 control and 65 experimental). No statistically significant differences were noted in patient demographics between groups (P > 0.05). Patients in the education group did not use a statistically significant different number of narcotics than the control group throughout the first postoperative week (14.0 pills experimental versus 13.7 pills control, P = 0.60). No statistically significant differences were noted between groups at follow-regarding the rate of prescription refills (P > 0.05). CONCLUSION This study suggests that preoperative video-based opioid education may have no effect on reducing the number of narcotic pills consumed after arthroscopic rotator cuff repair. CLINICAL RELEVANCE Data exist to suggest that preoperative video-based opioid education has an effect on postoperative consumption; however, the effect of this education in the setting of already-limited opioid-prescribing is not known. CLINICALTRIALSGOV IDENTIFIER NCT04018768.
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Capelle JM, Reddy PJ, Nguyen AT, Israel HA, Kim C, Kaar SG. A Prospective Assessment of Opioid Utilization Post-Operatively in Orthopaedic Sports Medicine Surgeries. THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:503-511. [PMID: 34692932 PMCID: PMC8503755 DOI: 10.22038/abjs.2020.49306.2455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 12/19/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND The healthcare system is plagued finding the balance between opioid use and abuse. Orthopaedic surgeons are expected to curtail the number of opioids prescribed in order to lower opioid abuse. We sought to prospectively evaluate opioid consumption following a wide range of sports orthopaedic surgical procedures to determine utilization patterns. METHODS All patients receiving procedures within a one-year period were consented and then called daily for one week followed by weekly for up to two months or until the patients no longer were taking their opioid medication. We studied the number of opioids patient's took postoperatively and also collected information in regards to the patient and the surgical procedure. RESULTS Included were 223 patients with a mean age of 32.9 years (range, 11 to 82). Surgeons prescribed a mean total of 59.5 pills, and patients reported consuming a mean total of 20.9 pills, resulting in a utilization rate of 40%. 94.4% of patients received no education on how to properly dispose of unused opioids. The mean SANE score was 53.9. The mean Pain Catastrophizing Scale score was 15.1. The mean Opioid Risk Tool was 3.3. The procedures were broken down into: 47.5% ligamentous knee repair, 18.4% shoulder arthroscopy/other shoulder, 7.6% meniscus, 7.6% shoulder arthroplasty, 5.4% distal biceps, 4.0% lower leg (ankle/foot/tibia) and 4.0% shoulder ORIF. CONCLUSION Over-prescribing opioids after sports orthopaedic surgeries is widespread. In this study, we found that patients are being prescribed 2.48 times greater opioid medications than needed following sports orthopaedic surgical procedures. We recommend surgeons take care when prescribing postoperative pain control and consider customizing their opioid prescriptions on the basis of prior opioid usage, anatomic location and procedure type. We also recommend educating the patients on proper disposal of excess opioids and consider involving pain management for patients likely to require prolonged opioid usage.
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Affiliation(s)
- John M Capelle
- Department of Orthopaedic Surgery, St. Louis University, St. Louis, MO, USA
| | - P Jahnu Reddy
- Department of Orthopaedic Surgery, St. Louis University, St. Louis, MO, USA
| | - Andy T Nguyen
- Department of Orthopaedic Surgery, St. Louis University, St. Louis, MO, USA
| | - Heidi A Israel
- Department of Orthopaedic Surgery, St. Louis University, St. Louis, MO, USA
| | - Christopher Kim
- Department of Orthopaedic Surgery, St. Louis University, St. Louis, MO, USA
| | - Scott G Kaar
- Department of Orthopaedic Surgery, St. Louis University, St. Louis, MO, USA
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Flanders TM, Ifrach J, Sinha S, Joshi DS, Ozturk AK, Malhotra NR, Pessoa R, Kallan MJ, Fleisher LA, Ashburn MA, Maloney E, Welch WC, Ali ZS. Reduction of Postoperative Opioid Use After Elective Spine and Peripheral Nerve Surgery Using an Enhanced Recovery After Surgery Program. PAIN MEDICINE 2021; 21:3283-3291. [PMID: 32761129 DOI: 10.1093/pm/pnaa233] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Enhanced recovery after surgery (ERAS) pathways have previously been shown to be feasible and safe in elective spinal procedures. As publications on ERAS pathways have recently emerged in elective neurosurgery, long-term outcomes are limited. We report on our 18-month experience with an ERAS pathway in elective spinal surgery. METHODS A historical cohort of 149 consecutive patients was identified as the control group, and 1,141 patients were prospectively enrolled in an ERAS protocol. The primary outcome was the need for opioid use one month postoperation. Secondary outcomes were opioid and nonopioid consumption on postoperative day (POD) 1, opioid use at three and six months postoperation, inpatient pain scores, patient satisfaction scores, postoperative Foley catheter use, mobilization/ambulation on POD0-1, length of stay, complications, and intensive care unit admissions. RESULTS There was significant reduction in use of opioids at one, three, and six months postoperation (38.6% vs 70.5%, P < 0.001, 36.5% vs 70.9%, P < 0.001, and 23.6% vs 51.9%, P = 0.008) respectively. Both groups had similar surgical procedures and demographics. PCA use was nearly eliminated in the ERAS group (1.4% vs 61.6%, P < 0.001). ERAS patients mobilized faster on POD0 compared with control (63.5% vs 20.7%, P < 0.001). Fewer patients in the ERAS group required postoperative catheterization (40.7% vs 32.7%, P < 0.001). The ERAS group also had decreased length of stay (3.4 vs 3.9 days, P = 0.020). CONCLUSIONS ERAS protocols for all elective spine and peripheral nerve procedures are both possible and effective. This standardized approach to patient care decreases opioid usage, eliminates the use of PCAs, mobilizes patients faster, and reduces length of stay.
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Affiliation(s)
- Tracy M Flanders
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph Ifrach
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saurabh Sinha
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Disha S Joshi
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel Pessoa
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee A Fleisher
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael A Ashburn
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eileen Maloney
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William C Welch
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zarina S Ali
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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12
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Caldwell GL, Selepec MA. Surgeon-Administered Nerve Block During Rotator Cuff Repair Can Promote Recovery with Little or No Post-operative Opioid Use. HSS J 2020; 16:349-357. [PMID: 33376459 PMCID: PMC7749895 DOI: 10.1007/s11420-019-09745-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The use of opioid analgesia is common in both the acute and extended post-operative periods after rotator cuff repair. The current opioid crisis has prompted surgeons to seek alternatives that minimize or even eliminate the need for oral opioids after surgery. QUESTIONS/PURPOSES We sought to investigate the effects on post-operative opioid use of a surgeon-administered block of the suprascapular and axillary nerves in arthroscopic rotator cuff repair (ARCR), in particular to quantify outpatient opioid consumption and duration. METHODS In this prospective observational study, all patients undergoing primary ARCR performed under general anesthesia by a single surgeon were studied over a 15-month period. Of 91 ARCRs performed, 87 patients were enrolled and followed prospectively. At the conclusion of the procedure, the surgeon performed "local-regional" nerve blockade with injections to the sensory branches of the suprascapular nerve and the axillary nerve, as well as local infiltration about the shoulder. Use of medications in the post-anesthesia care unit was left up to the anesthesiologist. Patients were prescribed oral opioids (hydrocodone/acetaminophen 5/325 mg) for analgesia after discharge. The quantity and duration of opioid use and pain scores were recorded for 4 months. Statistical analysis was performed to evaluate factors that could account for greater opioid use. RESULTS Total opioid consumption ranged from 0 to 30 opioid tablets (average, 4.2 tablets) over the 4-month period. Post-operatively, 91% of patients took between ten or fewer tablets, and 39% took no opioids. The average duration of opioid use was 2.4 days. No patients were taking opioids at the 4- to 6-week or 4-month follow-up visits, none required refills, and none received prescriptions from outside prescribers. No statistically significant differences were seen in opioids taken or duration of use in regard to tear size, sex, body mass index, surgery location, or procedure time. There was a significant inverse correlation between opioid use and age. In addition, the cost of the surgeon-performed procedure was substantially lower than that associated with pre-operative nerve blockade performed by an anesthesiologist. All patients were satisfied with the post-operative pain management protocol. Average reported post-operative pain scores were low and decreased at each visit. CONCLUSION With this local-regional nerve-blocking protocol, opioid use after ARCR was unexpectedly low, and a large proportion of patients recovered without any post-surgical opioids. The correlation seen between opioid use and age may not be clinically significant, given the low use of post-operative opioids overall. These results may be useful in guiding post-operative opioid prescribing after ARCR, as well as in lowering costs associated with ARCR.
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Affiliation(s)
- George L. Caldwell
- Caldwell Sports Medicine, 2307 West Broward Blvd., Suite 200, Fort Lauderdale, FL 33312 USA
| | - Michael A. Selepec
- Caldwell Sports Medicine, 2307 West Broward Blvd., Suite 200, Fort Lauderdale, FL 33312 USA
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Wong KA, Goyal KS. Postoperative Pain Management of Non-"Opioid-Naive" Patients Undergoing Hand and Upper-Extremity Surgery. Hand (N Y) 2020; 15:651-658. [PMID: 30781996 PMCID: PMC7543219 DOI: 10.1177/1558944719828000] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Patients with prior opioid use are often difficult to manage postoperatively. We examined potential strategies for managing these patients: (1) prescribing a different opioid; and (2) encouraging the use of nonopioid analgesics over opioids. Methods: A pain control program was implemented at an outpatient hand and upper-extremity center. Patients were recruited before (n = 305) and after (n = 225) implementation. Seventy of them were taking opioids prior to surgery. Information about pain control satisfaction and opioid use was collected. The Fisher exact test was used to compare categorical variables with small expected frequencies. Wilcoxon rank sum test was used to compare nonnormally distributed continuous variables. Results: Opioid users used 28.8 ± 25.6 opioid pills; nonopioid users used 14.5 ± 21.5 pills. Furthermore, 41.4% of opioid users sought more pills after surgery compared with 14.0% among nonopioid users. The pain control program was more effective in reducing opioid consumption and waste and increasing nonopioid consumption for nonopioid users than for opioid users. Prior opioid users who were prescribed a different opioid after surgery used 24.6 ± 22.0 opioid pills. Patients prescribed the same opioid used 37.9 ± 30.8 pills. Conclusions: Patients taking opioids prior to hand and upper-extremity surgery use more opioid pills, seek more pills after surgery, and are less satisfied with their pain control than their nonopioid user counterparts. Furthermore, the comprehensive pain plan was less effective in this patient population. Prescribing a different opioid reduced medication requirements for these patients, but additional strategies are needed to address postoperative pain management.
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Affiliation(s)
- Kelvin A. Wong
- College of Medicine, The Ohio State University, Columbus, USA
| | - Kanu S. Goyal
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, USA
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Sheth U, Mehta M, Huyke F, Terry MA, Tjong VK. Opioid Use After Common Sports Medicine Procedures: A Systematic Review. Sports Health 2020; 12:225-233. [PMID: 32271136 PMCID: PMC7222661 DOI: 10.1177/1941738120913293] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
CONTEXT The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America. OBJECTIVE To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures. DATA SOURCES A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018. STUDY SELECTION Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies. RESULTS A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill. CONCLUSION Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.
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Affiliation(s)
- Ujash Sheth
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Mitesh Mehta
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Fernando Huyke
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Michael A. Terry
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
| | - Vehniah K. Tjong
- Department of Orthopaedic Surgery,
Northwestern University, Chicago, Illinois
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15
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Variability in opioid prescribing following fracture fixation: A retrospective cohort analysis. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Padilla JA, Gabor JA, Schwarzkopf R, Davidovitch RI. A Novel Opioid-Sparing Pain Management Protocol Following Total Hip Arthroplasty: Effects on Opioid Consumption, Pain Severity, and Patient-Reported Outcomes. J Arthroplasty 2019; 34:2669-2675. [PMID: 31311667 DOI: 10.1016/j.arth.2019.06.038] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 06/04/2019] [Accepted: 06/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Opioid prescriptions and subsequent opioid-related deaths have increased substantially in the past several decades. Orthopedic surgery ranks among the highest of all specialties with respect to the amount of opioids prescribed. We present here the outcomes of our opioid-sparing pain management pilot protocol for total hip arthroplasty (THA). METHODS A retrospective study was conducted to assess outcomes before and after the implementation of an opioid-sparing pain management protocol for THA. Patients were divided into 2 cohorts for comparison: (1) traditional pain management protocol and (2) opioid-sparing pain management protocol. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, pain severity using a Visual Analog Scale, and inpatient morphine milligram equivalents (MMEs) per day were compared between the 2 cohorts. RESULTS No statistically significant difference was observed in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement between the 2 cohorts at any time point (P > .05). Although there was a significant decrease in pain scores over time (P < .01), there was no statistically significant difference in the rates of change between the 2 pain management protocols at any time point (P = .463). Inpatient opioid consumption was significantly lower for the opioid-sparing cohort in comparison to the traditional cohort (14.6 ± 16.7 vs 25.7 ± 18.8 MME/d, P < .001). Similarly, the opioid-sparing cohort received significantly less opioids than the traditional cohort during the post discharge period (13.9 ± 24.2 vs 80.1 ± 55.9 MME, P < .001). CONCLUSION The results of this study suggest that an opioid-sparing protocol reduces opioid consumption and provides equivalent pain management and patient-reported outcomes during the 90-day THA episode of care relative to a traditional opioid-based regimen. These findings may help decrease the risk of adverse events associated with postoperative opioid use and provide a means of decreasing the opioid footprint in clinical practice.
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Affiliation(s)
- Jorge A Padilla
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Jonathan A Gabor
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
| | - Roy I Davidovitch
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY
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Restrictive Opioid Prescribing Protocols Following Total Hip Arthroplasty and Total Knee Arthroplasty Are Safe and Effective. J Arthroplasty 2019; 34:S135-S139. [PMID: 30890390 DOI: 10.1016/j.arth.2019.02.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/04/2019] [Accepted: 02/11/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Orthopedic surgeons may overprescribe opioids postoperatively. Literature examining opioid prescribing guidelines following total joint arthroplasty (TJA) is limited. METHODS Retrospective review was conducted of primary TJAs from June 2017 to February 2018, with 3-month follow-up. Patients were divided into those who underwent surgery before (historical cohort) and after (restrictive cohort) implementation of a strict postoperative opioid prescribing protocol. RESULTS Three hundred ninety-nine total patients were included (282 in historical cohort, 117 in restrictive cohort). There was no significant difference in preoperative, perioperative, and postoperative inpatient opioid use. Historical cohort was given significantly larger initial prescriptions, received significantly more refills, and received significantly greater total quantity of opioids per patient. There were significantly fewer call-ins in the restrictive cohort. Clinical outcomes were not significantly different. CONCLUSION Drastic reductions in opioid prescriptions following TJA are possible without an increase in refills, call-ins, or adverse clinical effects.
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Opioid Prescribing and Consumption Patterns following Outpatient Plastic Surgery Procedures. Plast Reconstr Surg 2019; 143:929-938. [DOI: 10.1097/prs.0000000000005351] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Caldwell GL, Selepec MA. Reduced Opioid Use After Surgeon-Administered Genicular Nerve Block for Anterior Cruciate Ligament Reconstruction in Adults and Adolescents. HSS J 2019; 15:42-50. [PMID: 30863232 PMCID: PMC6384209 DOI: 10.1007/s11420-018-09665-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/17/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pain management after anterior cruciate ligament reconstruction (ACLR) may pose a risk of prolonged opioid use. QUESTIONS/PURPOSES The purposes of this study in ACLR were to investigate the efficacy of a surgeon-administered local-regional block of specific genicular nerves on post-operative analgesia following ACLR and to quantify the outpatient opioid consumption and duration through the complete post-operative course. METHODS Prospectively, all patients undergoing primary ACLR by a single surgeon were studied over a 10-month period. Exclusion criteria consisted of history of pre-operative opioid use, revision surgery, multi-ligament surgery, allergy to oral opioids, and allergy to local anesthetic. ACLR was performed using autograft or allograft patellar tendon bone (PTB) graft under general anesthesia. At the conclusion of the procedure, all patients received a local anesthetic (bupivacaine 0.25%) injection by the surgeon including a unique circumferential genicular nerve and fat pad block performed based on anatomic landmarks without use of image guidance. Post-operatively, the quantity and duration of opioid use (hydrocodone 5 mg) and pain scores were recorded for 4 months prospectively. Statistical analysis was performed to evaluate risk factors for increased opioid use. RESULTS A single surgeon performed 75 ACLRs. After exclusions, a total of 70 patients were enrolled and followed prospectively. None were lost to follow-up. Total opioid consumption ranged from 0 to 30 tablets. The average number of opioid tablets used over the 4-month post-operative course was 5.5 (± 6.7). After surgery, 84% of patients took between 0 and 10 tablets and 21% of patients took no opioids throughout their entire post-operative course. The average duration of consumption was 2.6 days (± 3.1). No patients were taking opioids at the 6-week or 4-month follow-up. There were no refills required. No statistically significant differences were seen in regard to graft choice of autograft PTB (n = 48) vs allograft PTB (n = 22) in total opioid consumption or duration of use. In comparing adolescent (n = 31) versus adult (n = 39), no significant difference was seen in total opioid consumption or duration of use. All patients were satisfied with the post-operative pain management protocol. CONCLUSION Opioid use was unexpectedly low among patients undergoing ACLR after a surgeon-administered circumferential genicular nerve block and fat pad infiltration. With this protocol, the graft choice and patient age did not correlate with increased opioid use. These results could be useful in guiding post-operative opioid prescribing after ACLR.
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Affiliation(s)
- George L. Caldwell
- Florida Institute of Orthopaedic Surgical Specialists, 2307 West Broward Blvd. Suite 200, Fort Lauderdale, FL 33312 USA
| | - Michael A. Selepec
- Florida Institute of Orthopaedic Surgical Specialists, 2307 West Broward Blvd. Suite 200, Fort Lauderdale, FL 33312 USA
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