Introduction. The prescription of opioids has increased in the last two decades. Recently, several states have developed online Prescription Drug Monitoring Programs aimed at preventing overprescribing of controlled substances. Unicompartmental knee arthroplasty (UKA) has been shown to provide improved early functional outcomes, faster recovery, and less postoperative morbidity and pain than total knee arthroplasty (TKA). The aim of this study is to evaluate differences in opioid prescription requirements between patients undergoing TKA and UKA. Methods. We retrospectively reviewed consecutive series of primary TKA from January 2017 to July 2017 and primary UKA from January 2016 to July 2017 using standardized perioperative pain protocols. All patients that underwent any other procedure 6 months prior to and after index surgery were excluded, resulting in 740 TKA and 241 UKA. Demographic and comorbidity information was collected for all patients. Opioid prescriptions, morphine milligram equivalents (MME), sedatives, benzodiazepines, and stimulants were collected from State Controlled Substance Monitoring website 6 months prior and after index procedures. Univariate and multivariate analysis were performed for patients that had a second prescription and continued use (defined as more than 6 months postoperatively). Results. Patients undergoing UKA had a second opioid prescription filled 50.2% of the time compared to 60.5% for TKA (p=0.006). In addition, continued opioid use after 6 months was 8.3% in UKAs compared to 11.8% in TKAs (p=0.149). When controlling for potential confounders, patients undergoing UKA were less likely to require a second prescription than TKA patients (adjusted odds ratio: 0.603 (95% Confidence Interval (CI): 0.425–0.855). In addition, continued use of opioids after 6 months was also reduced compared to patients undergoing TKA (adjusted OR: 0.51, 95% CI: 0.27–0.97) in the multivariate analysis. Other independent predictors of continued opioid use include obesity (OR 1.79, 95% CI 1.07–3.00) and preoperative opioid use (OR 1.66 per script, 95% CI: 1.49–1.86). Our models for second script and continued use reported AUC scores of 0.65 and 0.85, respectively. Conclusion. Patients with UKA are less likely to require a second opioid prescription and have continued opioid use even when controlling for a variety of potential confounders. Given the reduced opioid requirements associated with UKA, this study supports that orthopaedic surgeons should adjust their prescription patterns and educate patients regarding expected analgesic needs. Due to the retrospective nature of this study we were unable to precisely quantify the amount of opioids consumed in these patient groups. An ongoing prospective study will more accurately determine the duration and quantity of opioid use after UKA compared to TKA

Excessive opioid prescriptions after total joint arthroplasty (TJA) increase risks for adverse opioid related events, chronic opioid use, and increase the availability of opioids for unlawful diversion. Thus, decreasing postoperative prescriptions may improve quality after TJA. Concerns exist that a decrease in opioids prescribed may increase complications such as readmissions, emergency department (ED) visits or worsened patient reported outcomes (PROs). The purpose of this quality improvement study was to explore whether a reduction in opioids prescribed after TJA resulted in increased complications. Methods: Data originated from a statewide arthroplasty database (MARCQI). The database collects over 96% of all TJA performed in the state of Michigan, USA. Data was prospectively abstracted and included OMEs prescribed at discharge, readmissions, ED visits within 30 days and PROs. Data was collected one year before and after the creation of an opioid prescribing protocol that had decreased prescriptions by approximately 50% in opioid naive and tolerant patients. Trends were monitored using Shewhart control charts. 84,998 TJA over two-years were included. All groups showed a reduction in opioids prescribed. Importantly, no increased complications occurred concomitant to this reduction. No increases in ED visits or readmissions, and no decreases in KOOSJR/HOOSJR/PROMIS10 scores were noted in any of the groups. Using large data sets and registries can drive performance and improve quality. The MARCQI Postoperative opioid prescription recommendations and performance measures decreased total oral morphine equivalents prescribed over a large and diverse population by approximately 50% without decreasing PROs or increasing ED visits or hospital readmissions. A reduction in opioids prescribed after TJA can be accomplished safely and without an increase in complications across a large population

Aims. Due to the opioid epidemic in the USA, our service progressively decreased the number of opioid tablets prescribed at discharge after primary hip (THA) and knee (TKA) arthroplasty. The goal of this study was to analyze the effect on total morphine milligram equivalents (MMEs) prescribed and post-discharge opioid repeat prescriptions. Methods. We retrospectively reviewed 19,428 patients undergoing a primary THA or TKA between 1 February 2016 and 31 December 2019. Two reductions in the number of opioid tablets prescribed at discharge were implemented over this time; as such, we analyzed three periods (P1, P2, and P3) with different routine discharge MME (750, 520, and 320 MMEs, respectively). We investigated 90-day refill rates, refill MMEs, and whether discharge MMEs were associated with represcribing in a multivariate model. Results. A discharge prescription of < 400 MMEs was not a risk factor for opioid represcribing in the entire population (p = 0.772) or in opioid-naïve patients alone (p = 0.272). Procedure type was the most significant risk factor for narcotic represcribing, with unilateral TKA (hazard ratio (HR) = 5.62), bilateral TKA (HR = 6.32), and bilateral unicompartmental knee arthroplasty (UKA) (HR = 5.29) (all p < 0.001) being the highest risk for refills. For these three procedures, there was approximately a 5% to 6% increase in refills from P1 to P3 (p < 0.001); however, there was no significant increase in refill rates after any hip arthroplasty procedures. Total MMEs prescribed were significantly reduced from P1 to P3 (p < 0.001), leading to the equivalent of nearly 500,000 fewer oxycodone 5 mg tablets prescribed. Conclusion. Decreasing opioids prescribed at discharge led to a statistically significant reduction in total MMEs prescribed. While the represcribing rate did not increase for any hip arthroplasty procedure, the overall refill rates increased by about 5% for most knee arthroplasty procedures. As such, we are now probably prescribing an appropriate amount of opioids at discharge for knee arthroplasty procedure, but further reductions may be possible for hip arthroplasty procedures. Cite this article: Bone Joint J 2021;103-B(7 Supple B):103–110

Infection of the musculoskeletal (MSK) system is a dreaded complication that seems to be on the rise. Many factors, such as resistant bacteria or poor host factors, may influence such rise. This increase leads to greater resource consumption, especially due to antibiotic (ATB) prescription. Strategies must be created to detect patients at risk and prevent such infections. Hospital administrators should be made aware of the costs and impact of MSK infections in order to understand the need to prevent such complications. Therefore, our goal is to characterize the infected orthopaedic patient and evaluate the cost associated with ATB prescription in such cases. This is a retrospective and descriptive study, based on patient record analysis of all patients treated at our department, from January 2013 to March 2015. We identified 177 patients with a MSK infection and an isolated infectious agent. There was no predominance of either sex. Approximately 50% of patients were aged between 66 and 85 years old. Most frequent agents were MSSA (30,2%) and MRSA (21,8%), followed by Streptococcus species (8,9%) and Pseudomonas aeruginosas (7,1%). Although most patients were infected by a single agent, 18,6% had two or more causative agents isolated in cultures. Of those, 69,7% had either MSSA or MRSA as one of the isolated agents. Most commonly affected area was the hip (39,5%), followed by the knee (23,2%) and ankle (21,5%). Nearly all patients had had prior surgery, with arthroplasty and osteosynthesis as the most common procedures (52,4% and 33,3%, respectively). Infection related admission was responsible for a total of 6.116 hospital bed-days, with the majority of patients staying in hospital for up to 30 days (77,3%). Total cost of hospital ATB administration was 61.365,61€, with approximately 346,7€ spent in each patient. This corresponds to 42,6% of the total cost of medication during hospital stay (144.146,1€ of total cost, with 814,4€ per patient). The typical infected orthopaedic patient is aged 66 to 85 years old, was operated to his hip or knee, and either an arthroplasty or osteosynthesis was performed. Staphylococcus aureus remains the most common agent. MSK infections have significant costs associated with their treatment, and clinical departments should periodically re-evaluate discharged patients in order to understand what groups are at risk of developing such a complication. Only a correct identification of all these factors makes it possible to create a targeted preventive strategy, in order to reduce costs to the institution

The incidence of total shoulder arthroplasty (TSA) in increasing. Evidence in primary hip and knee arthroplasty suggest that preoperative opioid use is a risk factor for postoperative complication. This relationship in TSA is unknown. The purpose of this study was to investigate this relationship. The Truven Marketscan claims database was used to identify patients who underwent a TSA and were enrolled for 1-year pre- and post-operatively. Preoperative opioid use status was used to divide patients into cohorts based on the number of preoperative prescriptions received. An ‘opioid holiday’ group (patients with a preoperative, 6-month opioid naïve period after chronic use) was also included. Patient information and complication data was collected. Univariate and multivariate logistic regression were then performed. Fifty-six percent of identified patients received preoperative opioids. Multivariate analysis demonstrated that patients on continuous preoperative opioids (compared to opioid naïve) had higher odds of: infection (OR 2.34, 95%CI 1.62–3.36, p<0.001), wound complication (OR 1.97, 95%CI 1.18–3.27, p=0.009), any prosthetic complication (OR 2.62, 95%CI 2.2–3.13, p<0.001), and thromboembolic event (OR 1.42, 95%CI 1.11–1.83, p=0.006). The same group had higher healthcare utilization including extended length of stay, non-home discharge, readmission, and emergency department visits (p<0.001). This risk was reduced by a preoperative opioid holiday. Opioid use prior to TSA is common and is associated with increased complications and healthcare utilization. This increased risk is modifiable, as a preoperative opioid holiday significantly reduced postoperative risk. Therefore, preoperative opioid use represents a modifiable risk factor

The correct prescription of antibiotics for in-patients is paramount to patient safety. Trust policy states that all in-patients on antibiotics must have a start date, duration, and indication for antibiotics documented on the drug-card. On a single day all drug-cards were reviewed assessing whether documentation was in line with policy. In the initial audit, 28 antibiotic courses were prescribed; of these courses only 15 (53.5%) had an indication documented and 15 (53.5%) had a review/stop date documented. A monthly league table, coined ‘The Champions League’, was created. This named individuals who had correctly or incorrectly prescribed antibiotics, following identification in the monthly audit. It was published monthly and displayed in the doctors' office, on wards and circulated to all Consultants. After two published league tables, 19 antibiotic courses were prescribed. Indication was documented in 18 (94.7%) and 16 (84.2%) had the review date documented. This improvement has continued to the present day. Prescribing standards appear to have improved with the use of this novel motivational tool. The competitive nature of surgical trainees has led to the Champions League becoming a talking point. Top placed doctors are rewarded with Premiership rugby tickets and those who consistently underperform are sensitively offered remedial instruction

The United States and Canada are in the midst of an epidemic of the use, misuse and overdose of opioids, and deaths related to overdose. This is the direct result of overstatement of the benefits and understatement of the risks of using opioids by advocates and pharmaceutical companies. Massive amounts of prescription opioids entered the community and were often diverted and misused. Most other parts of the world achieve comparable pain relief using fewer opioids. The misconceptions about opioids that created this epidemic are finding their way around the world. There is particular evidence of the increased prescription of strong opioids in Europe. Opioids are addictive and dangerous. Evidence is mounting that the best pain relief is obtained through resilience. Opioids are often prescribed when treatments to increase resilience would be more effective. Cite this article: Bone Joint J 2017;99-B:856–64

NICE guidelines state that patients undergoing hip or knee arthroplasty should start as an in-patient and then continue pharmacological VTE prophylaxis for 28–35 days. Retrospective review of all elective hip and knee arthroplasties during one calendar month gave a baseline measurement of how many patients had VTE prophylaxis prescribed on their discharge summary. A new, electronically completed, bespoke Trauma and Orthopaedic discharge summary was created with a discreet area clearly marked for VTE prophylaxis, to serve as a reminder to prescribe it. In March 2012, 93 patients underwent hip/knee arthroplasty. 76% (71/93) were prescribed VTE prophylaxis to take home, there was no clinical reason explaining the failure to prescribe prophylaxis in the remaining 24%. In July 2013, after implementation of the change, 117 patients underwent hip/knee arthroplasty. 99% (116/117) were prescribed VTE prophylaxis to take home. Repeat audit in October 2013 showed that 103 patients underwent hip/knee arthroplasty and 100% were prescribed VTE prophylaxis. A simple but clear change to paperwork, brought about a rapid and seemingly lasting change in the prescription of out-patient VTE prophylaxis. The improvement was seen before and after a change of the Junior Doctor workforce suggesting the change in documentation was the main influencing factor

Introduction. Rehabilitation after shoulder arthroplasty is a fundamental in enabling patients achieve a good functional outcome. Therapists must consider the underlying diagnosis, operative technique employed and rotator cuff integrity, amongst other factors, in order to select the most appropriate exercise regime. There is an absence of comprehensive studies in the literature with regard to shoulder rotational exercises. Therefore, this study aimed to describe the shoulder girdle muscle activation strategies during eight commonly cited rotational shoulder exercises. Method. Thirty healthy subjects with no history of shoulder problems participated in the study. EMG was recorded from 16 shoulder girdle muscles (surface electrodes: anterior, middle and posterior deltoid, upper, middle and lower trapezius, upper and lower latissimus dorsi, upper and lower pectoralis major; fine wire electrodes: supraspinatus, infraspinatus, subscapularis and rhomboid major) using a telemetry based EMG system. Five external and three internal rotation exercises were included (table 1). Signal acquisition and processing were in accordance with standardised guidelines. Amplitude normalisation was to external and internal rotation maximum voluntary contraction as appropriate. Mean EMG amplitudes between exercises were compared using repeated measures ANOVA. Data for muscle groups was calculated by averaging the activation of the component muscles. Results. External Rotation Exercises: significantly higher levels of deltoid activation were seen in external rotation at 90° abduction compared to the other external rotation exercises (73.7% vs 12.4–27.2%; p < 0.001). Peri-scapular muscle activation was highest in external rotation at 90° abduction and prone external rotation (76.7–83.2% vs 28.2–45.5%; p = 0.013 − <0.001). Activation of latissimus dorsi and teres major was significantly higher during prone external rotation (64.1% vs 18.1–48.4%; p < 0.001). Activation of the rotator cuff muscles was similar across all exercises. Internal Rotation Exercises: the highest deltoid activity was seen during internal rotation at 90°abduction, followed by zero-position internal rotation. It was lowest during internal rotation at 0°abduction (261.6% vs 190.1% vs 40.9%; p = 0.003 − <0.001). A similar activation pattern was also seen for peri-scapular muscles. The highest activation of pectoralis major was seen during zero-position internal rotation (25.4% vs 4.9–15.7%; p = 0.002 − <0.001). Significantly higher levels of rotator cuff activation were seen during internal rotation at 90° abduction (325.0% vs 94.0–188.3%; p = 0.005–0.017). Discussion and Conclusion. This study provides a comprehensive description of muscles activation during common rotational shoulder exercises. It enables therapists to target specific muscles for rehabilitation following shoulder surgery, while minimising the activation of others. Understanding the activation profile of the shoulder girdle muscles during individual exercises forms the basis for exercise prescription and the development of tailored and individual physiotherapy protocols

Object: To assess the benefit of prescribed Iron supplementation on the recovery of patient’s Haemoglobin level after elective joint replacement. Design: A Prospective, Randomised Trial was undertaken. All patients undergoing elective arthroplasty (Hip, Knee, and Revision Hip) at our unit were considered. Qualifying parameters included: a normal store of Iron (Fe) prior to surgery (based on the serum Ferrittin level) and normal markers of inflammation (serum C - reactive protein [CRP] and erythrocyte sedimentation rate [ESR]). Elevated CRP and ESR are known to be factors affecting the serum Ferrittin level. Method: 318 patients undergo joint replacement from May 2004 to Oct 2004 were considered for the study. 208 patients were excluded for the following reasons: 52 patients had low serum Ferrittin level or elevated ESR and CRP levels pre-operatively. 156 patients was normal post operative Haemoglobin (> 11 mg %). This left 110 patients with normal pre-operative inflammatory markers and Iron stores. This cohort formed the basis of the study and was randomised to either receiving prescribed Iron Supplementation (Oral Ferrous Sulphate) twice a day for 8 week or no supplementation. Randomisation was performed based on the month of surgery. Even numbered months received the intervention, odd numbered did not. Post-operatively all patients had serum Haemoglobin checked at intervals 2. nd. –7. th. day and 8 weeks. Results: There was no significant different in mean Haemoglobin level between treatment group i.e. 12.72 mg% (10.8–15.4) and controlled group 12.71 mg% (11–15.3) at 8 weeks follow up. Conclusion: The prescription of oral Iron in healthy postoperative joint replacement patients did not hasten the recovery of Haemoglobin level provided adequate tissue Iron stores were present. The use of Fe supplementation provides no benefit in these patients and our study confirms this. Iron supplementation therapy should be reserved for patients identified pre-operatively with either low Iron stores or elevated serum inflammatory markers

Aim: To identify the incidence of regular medication not being prescribed on initial admission of emergency surgical cases

Material and Method: The data for this audit was taken from all surgical admissions over an approximately one month period between December 2004 and January 2005. Prescribed drugs for each patient were checked the morning after admission. If the patient was unable to provide this information, we obtained their regular medication list from the GP.

A total of 71 admissions were studied, 58% were referred from A& E, whereas 34% from the GP or primary care and a small percentage came from referrals from other wards within the hospital.

Results: Out of the 71 admissions, 46 patients were receiving at least one regular medication. Obviously, some patients were on medications for more than one disease and these were looked at individually.

From all 71 admissions, 21% of them had at least one error, i.e. at least one regular medication was not prescribed on admission.

If there was a documented reason for the omission of a particular drug then this was not counted as an error.

Analysing each co morbidity individually, 42% of IHD medication were not prescribed despite being taken on a regular basis by the patient, 33% for hypertensive and diabetic medication, 50% for asthmatic and psychiatric medication and 29% for medication for other less serious conditions.

81% of the errors made were on patients referred from A& E, while 15% where from patients received from the GP/primary care. Only 4% of the errors was made on patients referred from other wards. However, A& E referrals were almost double those of GPs. Hence, in a total of 41 A& E referrals 21 errors were made, while in a total of 24 GP referrals only 4 errors were made. Only 1 error was made in the total of 6 ward referrals.

Conclusion and Discussion: The results of this audit are surprising and alarming. 21% of admissions had at least one regular medication not prescribed by the admitting doctors.

Missing out on regular medication can have potentially life-threatening effects on patients as well as severe medico-legal implications.

Most of the mistakes were being made with patients that are referred from the accident and emergency department. These patients are generally more unwell than the ones referred from the GP or primary care, and quite often are elderly patients on a multitude of drugs that are unable to remember some or all of their tablets. Patients admitted out of hours present an added difficulty in that GPs are not available for confirmation of the patient’s regular medication.

So, more care and emphasis need to be given on drug history when admitting a patient.

Aims. The aim of this study was to report health-related quality of life (HRQoL) and joint-specific function in patients waiting for total hip or knee arthroplasty surgery (THA or TKA) in Northern Ireland, compared to published literature and a matched normal population. Secondary aims were to report emergency department (ED) and out-of-hours general practitioner (OOH GP) visits, new prescriptions of strong opioids, and new prescriptions of antidepressants while waiting. Methods. This was a cohort study of 991 patients on the waiting list for arthroplasty in a single Northern Ireland NHS trust: 497 on the waiting list for ≤ three months; and 494 waiting ≥ three years. Postal surveys included the EuroQol five-dimension five-level questionnaire (EQ-5D-5L), visual analogue scores (EQ-VAS), and Oxford Hip and Knee scores to assess HRQoL and joint-specific function. Electronic records determined prescriptions since addition to the waiting list and patient attendances at OOH GP/EDs. Results. Overall, 712/991 (71.8%) responded at ≤ three months for THA (n = 164) and TKA (n = 199), and ≥ three years for THA (n = 88) and TKA (n = 261). The median EQ-5D-5L score in those waiting ≤ three months was 0.155 (interquartile range (IQR) -0.118 to 0.375) and 0.189 (IQR -0.130 to 0.377) for ≥ three years. Matched controls had a median EQ-5D-5L 0.837 (IQR 0.728 to 1.000). Compared to matched controls, EQ-5D-5L scores were significantly lower in both waiting cohorts (p < 0.001) with significant differences found in every domain. Negative scores, indicating a state “worse than death”, were present in 40% at ≤ three months and 38% at ≥ three years. Patients waiting ≥ three years had significantly more opioid (28.4% vs 15.2%; p < 0.001) and antidepressant prescriptions (15.2% vs 9.9%; p = 0.034) and significantly more joint-related attendances at unscheduled care (11.7% vs 0% with ≥ one ED attendance (p < 0.001) and (25.5% vs 2.5% ≥ one OOH GP attendance (p < 0.001)). Conclusion. Patients on waiting lists in Northern Ireland are severely disabled with the worst HRQoL and functional scores studied. The lack of deterioration in EQ-5D-5L and joint-specific scores between patients waiting ≤ three months and ≥ three years likely reflects floor effects of these scores. Prolonged waits were associated with increased dependence on strong opiates, depression, and attendances at unscheduled care. Cite this article: Bone Joint J 2023;105-B(7):783–794

Aims. The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture. Methods. A total of 734 patients recovering from an isolated upper limb fracture were recruited in this study. Opioid prescription was documented retrospectively for the period preceding the injury, and prospectively at the two- to four-week post-injury visit and six- to nine-month post-injury visit. Bivariate and multivariate analysis sought factors associated with opioid prescription from demographics, injury-specific data, Patient Reported Outcome Measurement Instrumentation System (PROMIS), Depression computer adaptive test (CAT), PROMIS Anxiety CAT, PROMIS Instrumental Support CAT, the Pain Catastrophizing Scale (PCS), the Pain Self-efficacy Questionnaire (PSEQ-2), Tampa Scale for Kinesiophobia (TSK-11), and measures that investigate levels of social support. Results. A new prescription of opioids two to four weeks after injury was independently associated with less social support (odds ratio (OR) 0.26, p < 0.001), less instrumental support (OR 0.91, p < 0.001), and greater symptoms of anxiety (OR 1.1, p < 0.001). A new prescription of opioids six to nine months after injury was independently associated with less instrumental support (OR 0.9, p < 0.001) and greater symptoms of anxiety (OR 1.1, p < 0.001). Conclusion. This study demonstrates that potentially modifiable psychosocial factors are associated with increased acute and chronic opioid prescriptions following upper limb fracture. Surgeons prescribing opioids for upper limb fractures should be made aware of the screening and management of emotional and social health. Cite this article: Bone Jt Open 2021;2(2):119–124

Aims. Unicompartmental knee arthroplasty (UKA) provides improved early functional outcomes and less postoperative morbidity and pain compared with total knee arthroplasty (TKA). Opioid prescribing has increased in the last two decades, and recently states in the USA have developed online Prescription Drug Monitoring Programs to prevent overprescribing of controlled substances. This study evaluates differences in opioid requirements between patients undergoing TKA and UKA. Patients and Methods. We retrospectively reviewed 676 consecutive TKAs and 241 UKAs. Opioid prescriptions in morphine milligram equivalents (MMEs), sedatives, benzodiazepines, and stimulants were collected from State Controlled Substance Monitoring websites six months before and nine months after the initial procedures. Bivariate and multivariate analysis were performed for patients who had a second prescription and continued use. Results. Patients undergoing UKA had a second opioid prescription filled 50.2% of the time, compared with 60.5% for TKA (p = 0.006). After controlling for potential confounders, patients undergoing UKA were still less likely to require a second prescription than those undergoing TKA (adjusted odds ratio (OR) 0.58, 95% confidence interval (CI) 0.42 to 0.81; p = 0.001). Continued opioid use requiring more than five prescriptions occurred in 13.7% of those undergoing TKA and 5.8% for those undergoing UKA (p = 0.001), and was also reduced in UKA patients compared with TKA patients (adjusted OR 0.33, 95% CI 0.16 to 0.67; p = 0.022) in multivariate analysis. The continued use of opioids after six months was 11.8% in those undergoing TKA and 8.3% in those undergoing UKA (p = 0.149). The multivariate models for second prescriptions, continued use with more than five, and continued use beyond six months yielded concordance scores of 0.70, 0.86, and 0.83, respectively. Conclusion. Compared with TKA, patients undergoing UKA are less likely to require a second opioid prescription and use significantly fewer opioid prescriptions. Thus, orthopaedic surgeons should adjust their patterns of prescription and educate patients about the reduced expected analgesic requirements after UKA compared with TKA. Cite this article: Bone Joint J 2019;101-B(7 Supple C):22–27

Canada is second only to the United States worldwide in the number of opioid prescriptions per capita. Despite this, little is known about prescription patterns for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to detail preoperative opioid use patterns and investigate the effect it has on perioperative quality outcomes in patients undergoing elective total hip and total knee arthroplasty surgery (THA and TKA). The study cohort was constructed from hospital Discharge Abstract Data (DAD) and National Ambulatory Care Reporting System (NACRS) data, using Canadian Classification of Health Intervention codes to select all primary THA and TKA procedures from 2017-2020 in Nova Scotia. Opioid use was defined as any prescription filled at discharge as identified in the Nova Scotia Drug Information System (DIS). Emergency Department (ED) and Family Doctor (FD) visits for pain were ascertained from Physician Claims data. Multivariate logistic regression was used to test for associations controlling for confounders. Chi-squared statistics at 95% confidence level used to test for statistical significance. In total, 14,819 TJA patients were analysed and 4306 patients (29.0%) had at least one opioid prescription in the year prior to surgery. Overall, there was no significant difference noted in preoperative opiate use between patients undergoing TKA vs THA (28.8% vs 29.4%). During the period 2017-2019 we observed a declining year-on-year trend in preoperative opiate use. Interestingly, this trend failed to continue into 2020, where preoperative opiate use was observed to increase by 15% and exceeded 2017 levels. Within the first 90 days of discharge, 22.9% of TKA and 20.9% of THA patients presented to the ED or their FD with pain related issues. Preoperative opiate use was found to be a statistically significant predictor for these presentations (TKA: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.29 to 1.62; THA: OR, 1.46; 95% CI, 1.28 to 1.65). Preoperative opioid consumption in TJA remains high, and is independently associated with a higher risk of 90 day return to the FD or ED. The widespread dissemination of opioid reduction strategies introduced during the middle of the last decade may have reduced preoperative opiate utilisation. Access barriers and practice changes due to the COVID-19 pandemic may now have annulled this effect

Aims. Bone health assessment and the prescription of medication for secondary fracture prevention have become an integral part of the acute management of patients with hip fracture. However, there is little evidence regarding compliance with prescription guidelines and subsequent adherence to medication in this patient group. Patients and Methods. The World Hip Trauma Evaluation (WHiTE) is a multicentre, prospective cohort of hip fracture patients in NHS hospitals in England and Wales. Patients aged 60 years and older who received operative treatment for a hip fracture were eligible for inclusion in WHiTE. The prescription of bone protection medications was recorded from participants’ discharge summaries, and participant-reported use of bone protection medications was recorded at 120 days following surgery. Results. Of 5456 recruited patients with baseline data, 2853 patients (52%) were prescribed bone protection medication at discharge, of which oral bisphosphonates were the most common, 4109 patients (75%) were prescribed vitamin D or calcium, and 606 patients (11%) were not prescribed anything. Of those prescribed a bone protection medication, only 932 patients (33%) reported still taking their medication 120 days later. Conclusion. These data provide a reference for current prescription and adherence rates. Adherence with oral medication remains poor in patients with hip fracture. Cite this article: Bone Joint J 2019;101-B:1402–1407

Aim. The primary aim of this quality improvement project was to assess compliance with BOAST 4 guidelines for the delivery of antibiotic prophylaxis in patients presenting to a major trauma centre with open limb fracture and evaluate the impact of implemented changes on attainment of these guidelines. Secondary aims were to assess adherence to local guidelines for the type of antibiotic prescribed. Method. A multi-cycle audit and quality improvement project was carried out for all patients presenting to Brighton and Sussex University Hospitals NHS Trust (BSUH) with open limb fractures from 1st September 2018 to 31st January 2019, and 1. st. November 2019 to 31. st. March 2020. Patients were identified through retrospective screening of electronic operation records (Bluespier) by authors, and paper records were subsequently reviewed for data pertaining to antibiotic prescriptions. Following the initial audit cycle, targeted teaching was carried out for orthopaedic trainees, new posters were placed in key clinical areas to highlight local guidelines, and alterations to the trauma clerking proforma were implemented, to include BOAST 4 guidelines. Results. In cycle 1, a total of 52 patients received surgical treatment for open limb fractures, of which 48 (92.3%) were prescribed antibiotics prior to definitive management, with a mean time to administration of 271 minutes. Of these, 41 (78.8%) received prescriptions according to BSUH guidelines. The use of STAT prescriptions was found to significantly reduce the mean time to administration from 298 minutes to 144 minutes (p = 0.044). In cycle 2, a total of 29 patients received surgical treatment for open limb fractures, of which all 100% were prescribed antibiotics prior to definitive management, with a reduced mean time to administration (233 minutes). Of these, 26 (89.7%) received prescriptions according to BSUH guidelines, and a significantly greater proportion (p = 0.0003) received initial STAT ‘once-only’ prescriptions (51.7% vs. 15.4%). Conclusions. This quality improvement project has demonstrated the successful implementation of targeted changes to improve the attainment of BOAST 4 guidelines. Following a multi-cycle audit, all patients now receive antibiotic prophylaxis, with a higher proportion receiving antibiotics according to local BSUH guidelines. Furthermore, the use of STAT ‘once-only’ prescriptions, which was shown to be beneficial during the first audit cycle, has now significantly increased following intervention

This study aims to 1) determine reported cannabis use among patients waiting for thoracolumbar surgery and to 2) identify demographics and health differences between cannabis-users and non-cannabis users. This observational cohort study is a retrospective national multicenter review data from the Canadian Spine Outcomes and Research Network registry. Patients were dichotomized as cannabis users and non-cannabis users. Variables of interest: age, sex, BMI, smoking status, education, work status, exercise, modified Oswestry Disability Index (mODI), the Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness scale, SF-12 Quality of Life Questionnaire - Mental Health Component (MCS), use of prescription cannabis, recreational cannabis, and narcotic pain medication. Continuous variables were compared using an independent t-test and categorical variables were compared using chi-square analyses. Cannabis-use was reported by 28.4% of pre-operative patients (N=704), 47% of whom used prescription cannabis. Cannabis-use was reported most often by patients in Alberta (43.55%), British Colombia (38.09%) and New Brunswick (33.73%). Patients who reported using cannabis were significantly younger (mean=52.9 versus mean=61.21,). There was a higher percentage of concurrent narcotic-use (51.54 %) and smoking (21.5%) reported in cannabis-users in comparison to non-cannabis users (41.09%,p=0.001; 9.51%, p=0.001, respectively). There were significant differences in cannabis-use based on pathology (p=0.01). Patients who report using cannabis had significantly worse MCS scores (difference=3.93, p=0.001), and PHQ-8 scores (difference=2.51, p=0.001). There was a significant difference in work status (p=0.002) with cannabis-users reporting higher rates (20%) of being employed, but not working compared to non-cannabis users (11.13%). Non-cannabis users were more likely to be retired (45.92%) compared to cannabis-users (31.31%). There were no significant differences based on cannabis use for sex, education, exercise, NRS-back, NRS-Leg, tingling-leg, mODI, or health state. Thoracolumbar spine surgery patients are utilizing cannabis prior to surgery both through recreational use and prescription. Patients who are using cannabis pre-operatively did not differ in regards to reported pain or disability from non-users, though they did in demographic and mental health variables

This study aims to 1) determine reported cannabis use among patients waiting for thoracolumbar surgery and to 2) identify demographics and health differences between cannabis-users and non-cannabis users. This observational cohort study is a retrospective national multicenter review data from the Canadian Spine Outcomes and Research Network registry. Patients were dichotomized as cannabis users and non-cannabis users. Variables of interest: age, sex, BMI, smoking status, education, work status, exercise, modified Oswestry Disability Index (mODI), the Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness scale, SF-12 Quality of Life Questionnaire - Mental Health Component (MCS), use of prescription cannabis, recreational cannabis, and narcotic pain medication. Continuous variables were compared using an independent t-test and categorical variables were compared using chi-square analyses. Cannabis-use was reported by 28.4% of pre-operative patients (N=704), 47% of whom used prescription cannabis. Cannabis-use was reported most often by patients in Alberta (43.55%), British Colombia (38.09%) and New Brunswick (33.73%). Patients who reported using cannabis were significantly younger (mean=52.9 versus mean=61.21,). There was a higher percentage of concurrent narcotic-use (51.54 %) and smoking (21.5%) reported in cannabis-users in comparison to non-cannabis users (41.09%,p=0.001; 9.51%, p=0.001, respectively). There were significant differences in cannabis-use based on pathology (p=0.01). Patients who report using cannabis had significantly worse MCS scores (difference=3.93, p=0.001), and PHQ-8 scores (difference=2.51, p=0.001). There was a significant difference in work status (p=0.002) with cannabis-users reporting higher rates (20%) of being employed, but not working compared to non-cannabis users (11.13%). Non-cannabis users were more likely to be retired (45.92%) compared to cannabis-users (31.31%). There were no significant differences based on cannabis use for sex, education, exercise, NRS-back, NRS-Leg, tingling-leg, mODI, or health state. Thoracolumbar spine surgery patients are utilizing cannabis prior to surgery both through recreational use and prescription. Patients who are using cannabis pre-operatively did not differ in regards to reported pain or disability from non-users, though they did in demographic and mental health variables

Aims. This study was designed to develop a model for predicting bone mineral density (BMD) loss of the femur after total hip arthroplasty (THA) using artificial intelligence (AI), and to identify factors that influence the prediction. Additionally, we virtually examined the efficacy of administration of bisphosphonate for cases with severe BMD loss based on the predictive model. Methods. The study included 538 joints that underwent primary THA. The patients were divided into groups using unsupervised time series clustering for five-year BMD loss of Gruen zone 7 postoperatively, and a machine-learning model to predict the BMD loss was developed. Additionally, the predictor for BMD loss was extracted using SHapley Additive exPlanations (SHAP). The patient-specific efficacy of bisphosphonate, which is the most important categorical predictor for BMD loss, was examined by calculating the change in predictive probability when hypothetically switching between the inclusion and exclusion of bisphosphonate. Results. Time series clustering allowed us to divide the patients into two groups, and the predictive factors were identified including patient- and operation-related factors. The area under the receiver operating characteristic (ROC) curve (AUC) for the BMD loss prediction averaged 0.734. Virtual administration of bisphosphonate showed on average 14% efficacy in preventing BMD loss of zone 7. Additionally, stem types and preoperative triglyceride (TG), creatinine (Cr), estimated glomerular filtration rate (eGFR), and creatine kinase (CK) showed significant association with the estimated patient-specific efficacy of bisphosphonate. Conclusion. Periprosthetic BMD loss after THA is predictable based on patient- and operation-related factors, and optimal prescription of bisphosphonate based on the prediction may prevent BMD loss. Cite this article: Bone Joint Res 2024;13(4):184–192