Background: Our institution developed a 1-hour mandatory narcotics-prescribing education program as well as postoperative opioid-prescribing guidelines in response to the opioid epidemic. The purpose of this study was to evaluate the effect of this hospital-wide opioid education and subsequent institution of postoperative opioid guidelines on opioid-prescribing practices after ambulatory surgery. Methods: This retrospective study was performed at 1 academic orthopaedic hospital. In November 2016, a 1-hour mandatory opioid education program was completed by all hospital prescribers. Postoperative opioid guidelines were then developed and were disseminated in February 2017. All postoperative narcotic prescriptions after ambulatory procedures performed by 3 separate services (hand, sports, and foot and ankle services) were evaluated over 4 months prior to and after the mandatory opioid education and subsequent release of service-specific guidelines. Results: Overall, there was a significant decrease in pills and total oral morphine equivalents prescribed after dissemination of guidelines compared with the pre-intervention cohort procedures (p < 0.001) performed by the sports and hand services. With regard to the sports medicine service, the mean difference in pills prescribed was 6.47 pills (95% confidence interval [CI], 5.4 to 7.5 pills) for knee arthroscopy, 5.6 pills (95% CI, 2.5 to 8.7 pills) for shoulder arthroscopy, and 16.3 pills (95% CI, 13.6 to 19.1 pills) for hip arthroscopy. With regard to the hand service, the mean difference in pills prescribed was 13.0 pills (95% CI, 10.2 to 15.8 pills) for level-1 procedures, 12.4 pills (95% CI, 9.9 to 15.0 pills) for carpal tunnel release, and 21.7 pills (95% CI, 18.0 to 25.3 pills) for distal radial fractures. The decrease in pills prescribed in the post-intervention cohort amounts to almost 30,000 fewer opioid pills prescribed per year after these 6 procedures alone. There was no significant change (p > 0.05) in either the number of pills or the oral morphine equivalents prescribed after any of the 3 procedures performed by the foot and ankle service (ankle arthroscopy, bunion surgery, and Achilles tendon repair). Conclusions: We developed a prescriber education program and followed up with consensus-based guidelines for postoperative opioid prescriptions. These interventions caused a significant decrease in excessive opioid-prescribing practices after ambulatory orthopaedic surgery at our hospital. We urge initiatives by national orthopaedic organizations to develop and promote education programs and procedure and disease-specific opioid-prescribing guidelines.

Background: Current research on opioid use within orthopedic surgery has focused on efforts to identify patients at risk for chronic opioid use. Studies addressing prevention of opioid misuse related to orthopedic care are lacking. Evidence-based interventions to reduce the reliance on opioids for post-operative pain relief will be a key component of any comprehensive institutional opioid policy. Questions/Purposes: The purpose of this systematic review was to evaluate institutional strategies that reduce opioid administration or consumption after orthopedic surgery. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, a search was conducted of the PubMed database for English-language articles that analyzed interventions by physicians, nurses, pharmacists, physical therapists, or other hospital staff to reduce post-operative opioid use or narcotic prescription amounts after surgery. Studies that contained objective outcome measures (i.e., no expert opinion articles) were selected. Investigations on the effect of pharmacologic adjuvants, cryotherapy, or regional nerve blockades on opioid use were excluded. Results: The initial search yielded 6598 titles, of which 13 full-text articles were ultimately selected for inclusion in this systematic review. The review identified two major categories of interventions—patient-focused and provider-focused (e.g., physicians, nurses, physical therapists, pharmacists). Formal patient education programs were most effective in reducing opioid use. On the provider side, prescribing guidelines appear to decrease the overall number of pills prescribed, often without changes in patient satisfaction or requests for refills. Conclusions: Researchers are just beginning to establish the most effective ways for institutions to reduce opioid use and promote responsible post-operative prescribing. Institutional prescribing guidelines, standardized bedside pain-management programs, and formal patient education curriculums are all evidence-based interventions that can achieve these goals. The available research also supports an interprofessional approach in any institutional opioid-reduction strategy.

Study Design: Technical note. Objectives: To provide spine surgeons new to telemedicine with a structured physical examination technique based on manual motor testing principles. Methods: Expert experience describing a series of specific maneuvers for upper and lower extremity strength testing that can be performed using a telemedicine platform. In addition, we offer instruction on “setting up” for these visits and highlight special tests that can be used to diagnose specific cervical and lumbar spine conditions. Results: From our experiences in conducting telemedicine visits, we provide a means of testing and scoring upper and lower extremity strength for interpretation of weakness in the context of traditional manual motor testing. Also, we acknowledge the limitations of a remote examination and discuss maneuvers that cannot be performed remotely. Conclusions: COVID-19 has drastically altered the delivery of care for patients with spine-related complaints. The need for social distancing has led to the widespread adoption of telemedicine. This technical note provides an urgently needed framework for the standardization of the remote physical exam. Validation of the exam as a diagnostic tool will be a crucial next step in studying the impact of telemedicine.

Spinal implant infections are a serious complications of instrumented spinal fusion surgeries, carrying high morbidity and complex management challenges. Early postoperative infections may manifest with wound-healing issues, back pain, and fevers. Magnetic resonance imaging (MRI) is the preferred imaging modality, but can be limited by metal artifacts. For cases with stable implants, surgical debridement with implant retention combined with at least 12 weeks of antibiotics is currently considered appropriate treatment. Staphylococcal infections are ideally treated with biofilm-active antibiotics. Suppressive antibiotic therapy can be considered when surgical debridement has been delayed or is incomplete, and for those who are poor surgical candidates for another surgery. Chronic infections may present insidiously with implant failure or pseudarthrosis; implant removal or revision is generally pursued. As current guidance is heavily based on the periprosthetic joint infection literature and low-level studies on spinal implant infections, further research on optimizing diagnostic and treatment approaches is needed.

Retrospective cohort study. Violation of the posterior soft tissues is believed to contribute to the development of proximal junctional kyphosis (PJK). Biomechanical and clinical studies suggest that augmentation of the posterior ligamentous structures (PLS) may help prevent PJK. The purpose of this study was to evaluate the effect of PLS augmentation on the rate of PJK at 1 year. A retrospective single-surgeon cohort study was performed of 108 adult spinal deformity patients who underwent 5 level fusions to the pelvis. Patients were divided into 2 groups: PLS+ patients had reconstruction of the PLS between upper instrumented vertebrae +1 (UIV+1) and UIV−1 with a surgical nylon tape while PLS− patients did not. Demographics, surgical data, and sagittal alignment parameters were compared between the cohorts. The primary outcome of interest was the development of PJK at final follow-up. A subgroup propensity match and logistic regression model were utilized to control for differences in the cohorts. A total of 108 patients met final criteria, 31 patients (28.7%) were PLS+. There were no differences with regard to preoperative or final sagittal alignment parameters, number of levels fused, rates of 3-column osteotomies, and body mass index (P > .05), though the PLS+ cohort was older and had larger initial sagittal corrections (P < .05). The rates of PJK for PLS+ (27.3%) and PLS− (28.6%) were similar (P = .827). After controlling for sagittal correction via propensity matching, PLS+ had no impact on PJK (29% vs 38.7%, P = .367). In our multivariate analysis, only increased sagittal malalignment and failure to restore sagittal balance were retained as significant predictors of PJK. Even after controlling for extent of correction and preoperative sagittal alignment, PLS reinforcement at UIV+1 using a hand-tensioned nylon tape does not reduce the incidence of PJK at 1 year.