Jildeh, Toufic R.

Background: Multimodal pain protocols have been effective for postsurgical pain control; however, no published protocol has been effective in eliminating opioid consumption. Purpose: To compare a multimodal nonopioid pain protocol versus traditional opioid medication for postoperative pain control in patients undergoing anterior cruciate ligament reconstruction (ACLR). Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 90 patients undergoing primary ACLR were assessed for participation. We performed a prospective, randomized controlled trial in accordance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement. The study arms were a multimodal nonopioid analgesic protocol (acetaminophen, ketorolac, diazepam, gabapentin, and meloxicam) and a standard opioid regimen (hydrocodone-acetaminophen), and the primary outcome was postoperative visual analog scale (VAS) pain scores for 10 days. Secondary outcomes included patient-reported outcomes, complications, and satisfaction. The observers were blinded, and the patients were not blinded to the intervention. Results: A total of 9 patients did not meet inclusion criteria, and 19 patients declined participation. Thus, 62 patients were analyzed, with 28 patients randomized to the opioid group and 34 to the multimodal nonopioid group. Patients receiving the multimodal nonopioid pain regimen demonstrated significantly lower VAS scores compared with patients who received opioid pain medication ( P < .05). Patients were administered the Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form, and no significant difference was found in patients’ preoperative scores (opioid group, 58.6 ± 7.9; multimodal nonopioid group, 57.5 ± 7.4; P = .385) and 1-week postoperative scores (opioid group, 66.3 ± 8.2; multimodal nonopioid group, 61.4 ± 8.8; P = .147). When we adjusted for possible confounders (age, sex, body mass index, graft type), no significant differences in pain control were found between the 2 groups. The most common adverse effects for both groups were drowsiness and constipation, with no difference between the groups. All patients in the multimodal nonopioid group reported satisfactory pain management. Conclusions: A multimodal nonopioid pain protocol provided at least equivalent pain control compared with traditional opioid analgesics in patients undergoing ACLR. Minimal side effects, which did not differ between groups, were noted, and all patients reported satisfaction with their pain management.

Purpose To determine whether elbow torque was associated with anatomic adaptations of the medial elbow following a season of competitive pitching. Methods Pitchers from 3 collegiate baseball teams were recruited during the preseason for participation. Before the season, pitchers were recorded throwing 5 “game‐speed” fastball pitches from a standard distance off a mound while wearing a wearable sensor baseball compression sleeve that calculates elbow torque, arm speed, arm slot, and arm rotation. Participants subsequently underwent dynamic ultrasound imaging of the medial elbow, including measurements of the ulnar collateral ligament (UCL) and ulnohumeral joint space to assess elbow laxity. Following a full season of competitive pitching, all testing was repeated, and statistical analysis comparing preseason to postseason sonographic findings was performed. Results Twenty‐eight collegiate pitchers underwent preseason sonographic and kinematic testing. Nineteen pitchers were available for postseason testing. The average age (standard deviation) and playing experience was 19.9 (1.2) and 14.7 (1.5) years. Compared with preseason, there were significant increases in postseason UCL thickness (1.92 ± 0.09 vs 1.56 ± 0.09 mm, P < .01) and elbow laxity (1.77 ± 0.23 vs 1.15 ± 0.22 mm, P = .028) after a season of pitching. No significant changes in pitching kinematic measurements were observed between preseason and postseason testing. Preseason pitching kinematic measurements were significantly associated with increased UCL thickness (arm slot: beta estimate –0.03 ± 0.01, P = .011) and reduction in elbow laxity (elbow torque: beta estimate –0.03 ± 0.01, P = .04) after a season of pitching. Pitchers with increased body weight and arm length demonstrated reduced medial elbow torque during pitching ( P < .05). Conclusions After a season of competitive pitching, adaptive changes of the medial elbow were demonstrated on dynamic ultrasound. However, the influence of pitching kinematic measurements on these adaptations are of small magnitude and unknown clinical significance. Although wearable sensor technology may have value in trending individual pitcher kinematics, no discrete threshold appears to predict the development of adaptive changes at the elbow. Level of Evidence Level II, prospective observational study.

Purpose To evaluate the social media usage of orthopaedic residency programs, program directors (PDs), and department chairs across Instagram, Facebook, and Twitter and to determine which types of social media posts are indicative of increased user following. Methods A systematic online search strategy was performed in October 2020 to identify all allopathic orthopaedic surgery residency program accounts on Instagram, Facebook, and Twitter. Instagram posts were further analyzed to evaluate the type of post that significantly correlated with increased follower counts. Results Of 158 orthopaedic surgery programs, 69 (43.7%) had Instagram accounts, 52 (32.9%) had Facebook accounts, and 54 (34.2%) had Twitter accounts. Program presence on Instagram and Twitter continued to grow exponentially ( R 2 = 0.99 and R 2 = 0.95, respectively). Regarding program leadership, a total of 151 PDs and 156 chairs were identified. Of these, 21 PDs (14%) and 8 chairs (5.1%) had Instagram accounts. The number of posts and the numbers of educational, social, program information, and operative posts ( P < .01) significantly correlated with increased followers on Instagram. Conclusions Fewer than one‐half of orthopaedic surgery residency programs and fewer than one‐quarter of PDs and department chairs have a social media presence. However, the number of residency programs on social media continues to rise year‐over‐year. The total number of posts; the amount of educational, social, and program information; and the number of operative posts significantly correlated with increased followers on Instagram. Clinical Relevance With the growing prevalence of social media, orthopaedic surgery residency programs have the opportunity to connect with future applicants and disseminate informational content regarding their programs.

Purpose To investigate the demographic factors that influence time to respond (TTR), time to completion (TTC), and response rate when using a text messaging‐based system and to determine the feasibility and applicability of mobile messaging‐based services for collection of patient‐reported outcomes among orthopaedic sports medicine patients. Methods On the day of surgery, patient mobile phone number was collected and the automated mobile messaging service (MOSIO, Seattle, WA) messaged patients for 10 ``days postoperatively. Patient visual analog scale (VAS) scores were collected 3 times daily, side effects were asked each evening, and Patient‐Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) Short Form was collected on postoperative day 3 and 7. Results A total of 177 patients were enrolled in the study. The overall response rate to the survey questions was 75.0%. For all patients, the average TTR of questions was 35.09 ± 12.57 minutes. The TTC was 2.75 ± 3.56 minutes for PROMIS‐PI, 3.51 ± 1.26 minutes for VAS, and 3.80 ± 6.87 for side‐effect questions. When patients were stratified into age groups, the youngest group, 16 to 32 years, had the greatest response rate of 85.2% and patients in the 49 to 59 years group had the lowest response rate of 68.4% and 69.1%, respectively ( P < .001). There was no significant difference in the TTR or TTC for VAS, PROMIS‐PI, or side‐effect questions when patients were stratified by age or sex groups ( P > .05). Conclusions Collectively, all age groups successfully achieved a mean response rate of 75%; however, significantly lower response rates were observed for patients >49 years old. Differences in age and sex did not impact the overall TTR or TTC for VAS, PROMIS‐PI, or side‐effect questions. Mobile‐based applications present as an emerging opportunity to track postoperative outcome scores and reduce clinic survey load. Level of Evidence Case series, level of evidence IV.

» In the United States, orthopaedic surgeons have a legal obligation to obtain informed consent from patients before performing surgery; it is a process that includes a signed written document. » There are specific legal requirements that vary somewhat by state but generally include disclosure and documentation of the diagnosis, an explanation of the recommended procedure, a conversation about the risks and benefits of the procedure, and a discussion about alternative treatments. » Inadequate disclosure of risks and alternatives is associated with increased indemnity risk. » Studies have shown that many consent processes and forms are suboptimal.

Abstract Posterolateral corner (PLC) reconstruction has been shown to be an effective treatment for PLC injuries. Acute anatomical repair of the PLC has the same potential to stabilize the knee; however, outcomes are less defined. Surgical repair minimizes graft harvest morbidity and allows for the maintenance of native tissue proprioception. Furthermore, augmentation with a flat‐braided suture (SutureTape; Arthrex) portends additional repair strength and protection. The purpose of this Technical Note and video is to provide our preferred method of PLC repair in a patient with an acute knee dislocation and injury to the biceps femoris, lateral collateral ligament, iliotibial band, popliteofibular ligament, and the meniscocapsular attachment of the lateral meniscus. Technique Video video See video under supplementary data.

» Orthopaedic surgeons are expected to exercise leadership within a variety of departmental and organizational roles, such as in the context of the clinic, the operating room, private or academic practices, and, more broadly, their respective professional organizations. » Effective leadership can improve patient outcomes and satisfaction, as well as increase team efficacy and gratification. » Exercising insight and understanding as to how and when to employ different leadership styles can help orthopaedic surgeons lead effectively. Additionally, open and effective communication and emotional intelligence play an integral role in effective leadership. » This article reviews some of the current understanding regarding effective leadership in orthopaedic surgery, with a focus on highlighting strategies that are aimed at being a more effective leader.

Purpose To investigate the information quality on YouTube regarding rehabilitation and return to sport (RTS) after hip arthroscopy. Methods By use of private browsing and predefined search terms, 217 unique videos regarding RTS and rehabilitation after hip arthroscopy were included and systematically reviewed. A total of 164 videos were included in the final analysis. Videos were scored using 4 scoring systems: (1) Journal of the American Medical Association benchmark criteria, (2) the Global Quality Score, (3) a score for RTS after hip arthroscopy, and (4) a score for rehabilitation after hip arthroscopy. Results A large majority of the included videos provided substandard information quality, dependability, and precision. RTS videos that were uploaded by physicians had a significantly higher Journal of the American Medical Association score, Global Quality Score, and RTS score compared with commercial and personal testimony videos ( P = .0003, P = .0021, and P = .0005, respectively). Physician videos pertaining to RTS were also significantly longer than videos in other categories ( P = .0397). Conclusions The quality and reliability of video content on YouTube pertaining to rehabilitation and RTS after hip arthroscopy are generally poor. The educational content of YouTube videos produced by physicians is of significantly higher quality as compared with non‐physicians, patient testimonials, and commercials. Clinical Relevance The quality of the information patients receive on rehabilitation and RTS after hip arthroscopy is important for successful outcomes.

Purpose To assess the effectiveness of a nonopioid pain regimen in controlling postoperative pain as compared with a traditional opioid pain control following primary meniscectomy or meniscal repair. Methods Ninety‐nine patients undergoing primary meniscectomy or meniscal repair were assessed for participation. A prospective randomized control trial was performed in accordance with the Consolidated Standards of Reporting Trials 2010 statement. The 2 arms of the study included a multimodal nonopioid analgesic protocol and a standard opioid regimen with a primary outcome of postoperative pain level (visual analog scale) for the first 10 days postoperatively. Secondary outcomes included patient‐reported outcomes, complications, and patient satisfaction. Randomization was achieved using a random‐number generator. Patients were not blinded. Data collection was done by a blinded observer. Results Eleven patients did not meet the inclusion criteria, and 27 declined participation. A total of 61 patients were analyzed with 30 randomized to the opioid regimen and 31 randomized to the nonopioid regimen. Patients receiving the nonopioid regimen demonstrated noninferior visual analog scale scores compared with patients who received opioid pain medication ( P > .05). No significant differences were found in preoperative (opioid: 58.9 ± 7.0; nonopioid: 58.2 ± 5.5, P = .724) or postoperative (opioid: 59.8 ± 6.5; nonopioid: 54.9 ± 7.1, P = .064) Patient‐Reported Outcomes Measurement and Information System Pain Interference Short Form scores. No difference was found in recorded side effects between both groups at any given time point: constipation, nausea, diarrhea, upset stomach, and drowsiness ( P > .05). Conclusions This study found that a multimodal nonopioid pain protocol provided equivalent pain control and patient outcomes following primary meniscus surgery while having an equivalent side effect profile. All patients reported satisfaction with their pain management without requiring emergency opioid analgesia. Level of Evidence Level I, prospective randomized controlled trial.