A Goal-directed Quality Improvement Initiative to Reduce Opioid Prescriptions After Orthopaedic Procedures Introduction: Orthopaedic surgeons are increasingly aware of deleterious effects of the opioid epidemic and the association between overprescription and diversion toward nonmedical opioid use or substance abuse. Opiate prescriptions at the time of hospital discharge have been identified as target for intervention. This study describes the successful outcome of a goal-directed intervention aimed at decreasing opioid overprescription by providing routine feedback to providers regarding their prescribing patterns. Methods: The amount of opioid medications, quantified as oral morphine equivalents (OMEs), provided to opioid-naive adult patients on discharge after orthopaedic surgery was prospectively collected. As part of an institutional quality improvement initiative, medical providers received reports every 2 months detailing median discharge OMEs prescribed, trended over time. After 6 months, a retrospective comparison was done between preintervention and intervention patient cohorts. Results: There were 401 patients in the preintervention cohort and 429 patients in the intervention cohort. Both groups were similar in regard to age, sex, rates of depression, surgical time, length of stay, orthopaedic subspecialty, and inpatient opioid requirement before discharge. Patients in the intervention cohort were prescribed markedly fewer opioid medications by 25%, equivalent to 20 tablets of 5-mg oxycodone IR (450 versus 600 OMEs, P < 0.001). Despite these opioid medications, opioid refill rates during the first 90 days after discharge did not markedly change between groups. Discussion: It is critical to judiciously treat postoperative pain while avoiding opioid overprescription. This study demonstrated the outcome of a goal-directed initiative to decrease overprescription of opioid medications. The initiative reduced discharge opioid prescriptions yet did not increase the risk of requiring a prescription refill in the postoperative period. This indicates that such an approach can result in opioid reduction, while still providing appropriate care and pain control for patients.

Successful Implementation of an Accelerated Recovery and Outpatient Total Joint Arthroplasty Program at a County Hospital Introduction: Outpatient and accelerated recovery total joint arthroplasty (TJA) programs have become standard for private and academic practices. County hospitals traditionally serve patients with limited access to TJA and psychosocial factors which create challenges for accelerated recovery. The effectiveness of such programs at a county hospital has not been reported. Methods: In 2017, our county hospital implemented an accelerated recovery protocol for all TJA patients. This protocol consisted of standardized, preoperative medical and psychosocial optimization, perioperative spinal anesthesia, tranexamic acid and local infiltration analgesia use, postoperative emphasis on non-narcotic analgesia, and early mobilization. LOS, complications, disposition, and cost were compared between patients treated before and after protocol implementation. Results: In 15 months, 108 primary TJA patients were treated. Compared with the previous 108 TJA patients, LOS dropped from 3.4 to 1.6 days (P < 0.001), more patients discharged home (92% versus 72%, P < 0.001), average hospitalization and procedure-specific costs decreased 24.7% and 22.1%, respectively, and were significantly fewer complications (7% versus 21%, P = 0.007). Conclusions: Implementation of an accelerated recovery TJA program at a County Hospital is novel. This implementation requires careful patient selection and a coordinated multidisciplinary approach and is a safe and cost-effective method of delivering high-quality care to an underserved cohort.

Looking Through a Different Lens: Patient Satisfaction With Telemedicine in Delivering Pediatric Fracture Care Introduction: Telemedicine may transform health care by overcoming geographical and travel-associated barriers to patient care. This study assesses patient satisfaction with telemedicine for fracture care. Methods: Two groups of patients were compared from suburban/rural Pennsylvania. One group reported to a regional medical center for real-time video consultation with a pediatric orthopaedic surgeon facilitated by a physician's assistant. The other group underwent conventional outpatient clinic visits at a tertiary care hospital. The distance between the tertiary care hospital and the regional medical center was 69 miles. New or follow-up fracture patients not living in the vicinity of either medical center were included. A satisfaction survey and questionnaire were administered to both groups at the end of their visit. Results: One hundred sixty-seven patients returned the questionnaires (66 conventional and 101 telemedicine). Telemedicine visits decreased indirect and direct costs (P = 0.032). Travel costs and travel times were lower (P < 0.001) in the telemedicine group. Patient satisfaction was similar. Only 8 of 101 patients in the telemedicine cohort preferred their next visit to be a conventional follow-up. Discussion: Utilization of video consultation and trained physician assistants to provide pediatric orthopaedic care across suburban/rural areas can increase pediatric orthopaedic surgeon access and decrease travel costs while maintaining patient satisfaction.

Sciatic Nerve Palsy After Distal Femoral Traction for Vertically Unstable Pelvic Fracture in a Neurologically Intact Patient Vertically unstable fractures of the pelvis require a notable amount of energy to cause disruption of the posterior elements of the pelvic ring. Superior migration of the hemipelvis demonstrates the inherent instability of this fracture pattern. Surgical fixation is required in most cases, but while resuscitation efforts are underway, placing the patient in skeletal traction to reduce the hemipelvis is often recommended. Although skeletal traction has been described in many sources, no consensus exists on the amount of weight that should be used. This has led to anecdotal recommendations that vary between institutions. Without clear guidelines for treatment, a vertically translated hemipelvis was overreduced and subsequently sustained a sciatic nerve palsy in a patient who was neurologically intact on presentation. We aim to describe a rare complication of skeletal traction and propose a treatment algorithm to reduce the incidence of future complications.

Atraumatic Displaced Femoral Neck Fracture Postpartum: A Case Report and Review of the Literature Hip pathology during pregnancy may include transient osteoporosis of the hip or osteonecrosis associated with pregnancy. Rarely, hip pathology during pregnancy may result in a fragility fracture or advanced collapse of the femoral head, necessitating surgical treatment. We present a case of a 32-year-old woman who postpartum was found to have a displaced right femoral neck fracture and an area of focal edema in the left femoral head with mild flattening of the articular surface. She was successfully treated with a total hip arthroplasty on the right, and a follow-up MRI of the left hip showed near-complete resolution of the edema in the femoral head. This case underlines the importance of maintaining a clinical suspicion for pathology of the hip during pregnancy and the subsequent consequences of a missed diagnosis.

Kyphectomy in Myelomeningocele for Severe Early-Onset Kyphosis Using Distal Intravertebral Fixation and Thoracic Growing Rods Background: Most kyphectomy techniques require distal dissection of the bifid posterior spinal elements for implants placement in the thoracolumbar/pelvic regions, traversing the scarred tissue associated with previous MMC closure, thereby theoretically increasing the risk of wound complications. The Halifax kyphectomy technique avoids the MMC scar but does not reliably facilitate thoracic growth for early-onset kyphosis. This study aims to report the technique and outcomes of a combined Halifax kyphectomy (resection of the apical vertebrae with distal anterior multilevel vertebral body fixation) and thoracic growing rod construct used to treat early-onset symptomatic gibbus in a patient with myelomeningocele (MMC). Methods: A 3-year-old girl with a thoracic MMC presented with symptomatic gibbus requiring surgical intervention. Correction by the Halifax kyphectomy technique combined with spine-based growing rods was performed. Results: After the correction, the skin was closed primarily without the need for any flap for coverage. No wound complications or infection occurred post-operatively. The intraoperative blood loss was 200 mL, and the surgical time was 419 minutes. No pulmonary complications occurred postoperatively. At the final follow-up at 3 years 11 months postoperatively, the child had no recurrence of the deformity. Conclusions: The combination of distal anterior multilevel vertebral body fixation with spine-based thoracic growing rods can successfully achieve kyphosis correction in MMC, with the potential to reduce complication rates and facilitate thoracic growth. Further investigation is necessary to prove whether the outcomes and the complication rates are superior to other established techniques.