Factors Associated With Increased Opioid Prescriptions Following Anterior Cruciate Ligament Reconstruction in Opioid-Naïve Patients

Purpose

To identify the mean morphine milligram equivalent (MME) opioid prescriptions for opioid-naïve patients undergoing isolated anterior cruciate ligament reconstruction (ACLR) between 4 weeks before surgery and the first 90 days after surgery and to describe opioid prescriptions filled per patient and mean MMEs per year within 90 days following ACLR.

Methods

Exclusion criteria were patients having concurrent other cruciate or collateral ligament repair or reconstruction, meniscus procedures (repair and debridement), any cartilage procedure, lower-extremity osteotomy, or knee procedures for fracture, infection, or neoplasms; patients with substance use disorder or chronic pain also were excluded. Opioid use between 4 weeks before surgery and the first 90 days after surgery was recorded. Prescribing physician specialty also was tracked. The correlation of patient factors and prescriber specialty of MME were compared using the Student's t-test. Significance was defined at P < .05.

Results

Opioid-naïve patients undergoing isolated ACLR were included. Isolated arthroscopic ACLRs performed between 2010 and Q3 2020 in opioid-naïve patients were identified within the PearlDiver M91 national database. A total of 37,200 patients were identified. Mean MME per patient was 340.9 ± 198.2, with an average MME per day of 59.9. Factors associated with increased opioid use during the 90 days following ACLR were older age (P < .001) and preoperative diagnosis of depression (P < .001). Orthopaedic surgeons were primarily responsible for the number of opioid prescriptions after ACLR (n = 29,326, 73.0%) but 27% (n = 10,797) of prescriptions came from nonorthopaedic surgeon medical providers who prescribed significantly greater MMEs of opioids than orthopaedic surgeons (456.5 vs 339.2, P < .001) per patient. Lastly, decreasing yearly opioid prescriptions per patient (2.4 to 1.6 prescriptions) and the mean MME per patient (428.4 to 257.1) occurred from 2010 to 2020.

Conclusions

Older age and preoperative diagnosis of depression are associated with greater opioid doses after ACLR. In addition, the vast majority of opioid prescriptions are written by orthopaedic surgeons on the day of ACLR and decreased considerably by four weeks after surgery. Patients receiving opioid prescriptions by nonorthopaedic surgeon medical providers receive significantly greater doses.

Level of Evidence

Level IV, retrospective cohort study.

The Multiligament Knee Injury Classification Stratifies Patients into Risk Categories

Objectives:

Our goal was to characterize the precise ligamentous injury locations and patterns of acute multi-ligament knee injuries (MLKI) and determine associated rates of dislocations, fractures, peroneal nerve palsies, and vascular injuries.

Methods:

All patients at a single level one trauma center who received operative treatment for MLKI between 2001 and 2019 were retrospectively identified. Demographic, injury mechanism, injury patterns, presence of dislocation, and associated injuries including vascular injury, peroneal nerve palsy, and fracture were assessed for each patient. MLKI both with and without a document knee dislocation were classified into five classes based on pattern of ligamentous tear (Figure 1). Class 1 included unicruciate tear with any combination of collateral tear. Class 2 are a bicruciate tear without collateral involvement. Class 3 are bicruciate tears with either a medial or lateral sided tear. Class 4 are bicruciate tears with both medial and lateral sided tears. Class 5 are periarticular fracture with any of the preceding ligamentous injury patterns. Rates of dislocation, vascular injury and peroneal nerve injury were analyzed among each class. Single variable statistics such as t-tests as well as multivariable techniques such as Chi square and multiple regression analysis was performed to identify patterns of injury and to predict risk of associated injuries.

Results:

100 knees were identified as multiligament knee injuries. 34 of the knees (34%) were dislocated at presentation, and the remaining 66 (66%) did not have a documented knee dislocation. Patients with a documented knee dislocation had higher rates of vascular injury (24% vs. 3%, p = 0.0148), but not higher rates of peroneal nerve injury (32% vs. 20%, p = 0.0863). Patients with PLC injuries had statistically higher rates of peroneal nerve injury compared to acute multiligament knee injuries without a lateral sided injury (30% vs. 3%, p = 0.005). Rates of vascular injury between MLK Class are shown in Table 1. MLK Class was found to be predictive of vascular injury, but not of peroneal nerve injury.

Conclusion:

We present a new classification of multiligament knee injuries with the goal of providing a more precise diagnosis to aid in the surgical planning and decision making as well as to enhance clinical outcomes research of these complicated injury patterns. By classifying these injuries into five separate classes and further subclassified based on presence of dislocation and lateral sided injury, we are better able to predict likelihood of neurovascular injury. We hope that understanding the risks associated with each class will allow physicians to better appreciate the likelihood of potential complications of these injuries.

The Influence of Medical Insurance on Patient Access to Orthopaedic Surgery Sports Medicine Appointments Under the Affordable Care Act

Background:

The goal of the Patient Protection and Affordable Care Act (PPACA) was to expand patient access to health care. Since the rollout of the PPACA, Medicaid patients have demonstrated difficulty obtaining appointments in some specialty care settings.

Purpose:

To assess the effect of insurance type (Medicaid and private) on patient access to orthopaedic surgery sports medicine specialists for a semiurgent evaluation of a likely operative bucket-handle meniscus tear. The study was designed to determine whether disparities in access exist since the PPACA rollout.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

The design was to call 180 orthopaedic surgery sports medicine specialists in 6 representative states (California, Ohio, New York, Florida, Texas, and North Carolina) between June 2015 and December 2015. An appointment was requested for the caller’s fictitious 25-year-old-brother who had suffered a bucket-handle meniscus tear. Each office was called twice to assess the ease of obtaining an appointment: once for patients with Medicaid and once for patients with private insurance. For each call, data pertaining to whether an appointment was given, wait times, and barriers to receiving an appointment were recorded.

Results:

A total of 177 surgeons were called within the study period. Overall, 27.1% of offices scheduled an appointment for a patient with Medicaid, compared with 91.2% (P < .0001) for a patient with private insurance. Medicaid patients were significantly more likely to be denied an appointment due to lack of referral compared with private patients (40.2% vs 3.7%, P < .0001), and Medicaid patients were more likely to experience longer wait times for an appointment (15 vs 12 days, P < .029). No significant differences were found in patients’ access to orthopaedic surgery sports medicine specialists between Medicaid-expanded and -nonexpanded states. Medicaid reimbursement for knee arthroscopy with meniscus repair was not significantly correlated with appointment success rate or patient waiting periods.

Conclusion:

Despite the passage of the PPACA, patients with Medicaid have reduced access to care. In addition, patients with Medicaid confront more barriers to receiving appointments than patients with private insurance and wait longer for an appointment.

Symptomatic hip plica: MR arthrographic and arthroscopic correlation

Two cases of unilateral hip pain are reported in which MR arthrography demonstrated a prominent band medial to the ligamentum teres, running in the AP direction, consistent with a hip plica. Both patients underwent hip arthroscopy with resection of the band. No labral tear or additional intra-articular pathological features was identified in either case. Both patients became asymptomatic following surgery and have remained such. The pathology report demonstrated the specimens to be a synovial band with fibroconnective tissue. This is the first MR arthrographic report of the identification and resection of a symptomatic hip plica. The symptomatic plica may represent an alternative diagnosis for mechanical hip pain.

Hip arthroscopy without a perineal post: a safer technique for hip distraction

Pudendal nerve palsy is a reported complication of hip arthroscopy. We report a technique using a deflated taped beanbag rather than a perineal post. The patient is placed in the supine or lateral position on a fracture table. The beanbag is contoured around the patient's flank and thorax. The distal aspect of the beanbag is placed no further than the iliac crest, and care is taken to avoid compression of the posterior aspect of the axillary region or the posterior humerus. The molded beanbag is deflated, a blanket is positioned over the abdomen and lower thorax, and with the use of 3-in-wide cloth tape, the patient and beanbag are secured to the operative table circumferentially. The superior margin of the deflated beanbag remains firm, preventing compression of the thorax and avoiding compromised ventilation. The arm on the operative side is placed across the chest and secured to avoid obstruction of the operative field. This patient positioning provides sufficient stability for adequate traction and good visualization while minimizing the risk of a pudendal nerve palsy.

Partial-thickness rotator cuff tears

Partial-thickness rotator cuff tears are not a single entity; rather, they represent a spectrum of disease states. Although often asymptomatic, they can be significantly disabling. Overhead throwing athletes with partial-thickness rotator cuff tears differ with respect to etiology, goals, and treatment from older, nonathlete patients with degenerative tears. Pathogenesis of degenerative partial-thickness tears is multifactorial, with evidence of intrinsic and extrinsic factors playing key roles. Diagnosis of partial-thickness rotator cuff tears should be based on the patient's symptoms together with magnetic resonance imaging studies. Conservative treatment is successful in most patients. Surgery generally is considered for patients with symptoms of sufficient duration and intensity. The role of acromioplasty has not been clearly delineated, but it should be considered when there is evidence of extrinsic causation for the partial-thickness rotator cuff tear.