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Background: Most individuals undergoing elective surgery expect to discontinue opioid use after surgery, but many do not. Modifiable risk factors including psychosocial factors are associated with poor postsurgical outcomes. We wanted to know whether pain catastrophizing is specifically associated with postsurgical opioid and health-care use.Methods: This was a longitudinal cohort study of trial participants undergoing elective spine (lumbar or cervical) or lower-extremity (hip or knee osteoarthritis) surgery between 2015 and 2018. Primary and secondary outcomes were 12-month postsurgical days' supply of opioids and surgery-related health-care utilization, respectively. Self-reported and medical record data included presurgical Pain Catastrophizing Scale (PCS) scores, surgical success expectations, opioid use, and pain interference duration.Results: Complete outcomes were analyzed for 240 participants with a median age of 42 years (34% were female, and 56% were active-duty military service members). In the multivariable generalized additive model, greater presurgical days' supply of opioids (F = 17.23, p < 0.001), higher pain catastrophizing (F = 1.89, p = 0.004), spine versus lower-extremity surgery (coefficient estimate = 1.66 [95% confidence interval (CI), 0.50 to 2.82]; p = 0.005), and female relative to male sex (coefficient estimate = -1.25 [95% CI, -2.38 to -0.12]; p = 0.03) were associated with greater 12-month postsurgical days' supply of opioids. Presurgical opioid days' supply (chi-square = 111.95; p < 0.001), pain catastrophizing (chi-square = 96.06; p < 0.001), and lower extremity surgery (coefficient estimate = -0.17 [95% CI, -0.24 to -0.11]; p < 0.001), in addition to age (chi-square = 344.60; p < 0.001), expected recovery after surgery (chi-square = 54.44; p < 0.001), active-duty status (coefficient estimate = 0.58 [95% CI, 0.49 to 0.67]; p < 0.001), and pain interference duration (chi-square = 43.47; p < 0.001) were associated with greater health-care utilization.Conclusions: Greater presurgical days' supply of opioids and pain catastrophizing accounted for greater postsurgical days' supply of opioids and health-care utilization. Consideration of several modifiable factors provides an opportunity to improve postsurgical outcomes.Level Of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The SOMOS membership includes surgeons from all subspecialties, and both the annual meeting and the research pursued by SOMOS members reflects the breadth of orthopaedic surgery interests. The Society of Military Orthopaedic Surgeons, founded in 1958 on Governor's Island, NY, USA, has long focused on the musculoskeletal care of the combat-wounded warrior [[11]]. The negative effects of the opioid epidemic on a military population were also on display at this year's SOMOS meeting, and SOMOS members continue to look for novel strategies for effective and opioid-sparing perioperative analgesia. [Extracted from the article]

The opioid epidemic continues to be a problem in the United States and prescription opioid overdose fatalities continue to rise. Chronic opioid use threatens military readiness and puts service members at risk for medical separation from military service. Orthopedic surgeons commonly prescribe opioid medications for postsurgical patients. Long-term opioid use can be the result of acute, postoperative opioid intake. Overprescribing may increase the risk of long-term opioid use, medication diversion and adverse outcomes. Preoperative administration of opioids dramatically increases the risk of continued use up to 1 year after surgery. Strategies to minimize opioid use include opioid-specific preoperative counseling, multimodal analgesia with opioid-sparing oral and intravenous medications, regional anesthesia, minimizing tourniquet use, and preoperative behavioral health evaluation. [ABSTRACT FROM AUTHOR]

Background: High-energy extremity trauma is common in combat. Orthotic options for patients whose lower extremities have been salvaged are limited. A custom energy-storing ankle-foot orthosis, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), was created and used with high-intensity rehabilitation as part of the Return to Run clinical pathway. We hy-pothesized that the IDEO would improve functional performance compared with a non-custom carbon fiber orthosis (BlueRocker), a posterior leaf spring orthosis, and no brace. Methods: Eighteen subjects with unilateral dorsiflexion and/or plantar flexion weakness were evaluated with six functional tests while they were wearing the IDEO, BlueRocker, posterior leaf spring, or no brace. The brace order was randomized, and five trials were completed for each of the functional measures, which included a four-square step test, a sit-to-stand five times test, tests of self-selected walking velocity over level and rocky terrain, and a timed stair ascent. They also completed one trial of a forty-yard (37-m) dash, filled out a satisfaction questionnaire, and indicated whether they had ever considered an amputation and, if so, whether they still intended to proceed with it. Results: Performance was significantly better with the IDEO with respect to all functional measures compared with all other bracing conditions (p < 0.004), with the exception of the sit-to-stand five times test, in which there was a significant improvement only as compared with the BlueRocker (p = 0.014). The forty-yard dash improved by approximately 35% over the values for the posterior leaf spring and no-brace conditions, and by 28% over the BlueRocker. The BlueRocker demonstrated a significant improvement in the forty-yard dash compared with no brace (p = 0.033), and a significant improvement in self-selected walking velocity on level terrain compared with no brace and the posterior leaf spring orthosis (p < 0.028). However, no significant difference was found among the posterior leaf spring, BlueRocker, and no-brace conditions with respect to any other functional measure. Thirteen patients initially considered amputation, but after completion of the clinical pathway, eight desired limb salvage, two were undecided, and three still desired amputation. Conclusions: Use of the IDEO significantly improves performance on validated tests of agility, power, and speed. The majority of subjects initially considering amputation favored limb salvage after this noninvasive intervention. [ABSTRACT FROM AUTHOR]

Background: Femoroacetabular impingement (FAI) is reportedly a prearthritic condition in young adults that can progress to osteoarthritis. However, the prevalence of FAI is unknown in the young, active population presenting with hip complaints. Questions/purposes: We sought to determine (1) the prevalence of radiographic findings of FAI in a young, active patient population with complaints localized to the region of the hip presenting to primary care and orthopaedic clinics; (2) the percentage of films with FAI with an official reading suggesting the diagnosis; and (3) whether the Tönnis grades of osteoarthritis corresponded to the findings of FAI. Methods: We performed a database review of pelvic and hip radiographs obtained from 157 young (mean age 32 years; range, 18–50 years) patients presenting with hip-related complaints to primary care and orthopaedic clinics. Radiographs were analyzed for signs of FAI (herniation pits, pistol grip deformity, center-edge angle, alpha angle, and crossover sign) and Tönnis grade. Radiology reports were reviewed for a diagnosis of FAI. Results: At least one finding of FAI was found in 135 of the 155 patients (87%). Four hundred thirteen of 487 radiographs (85%) had been read as normal and one read as showing FAI. Tönnis grades did not correlate with radiographic signs of FAI. Conclusions: Radiographic evidence of FAI is common in active patients with hip complaints. Increased awareness of FAI in primary care, radiology, and orthopaedic clinics and additional research into the long-term effects of management are warranted. Level of Evidence: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: While combat spinal injuries have been documented since the fourth century BC, a comprehensive anal-ysis of such Injuries has not been performed for any American military conflict. Recent literature has suggested that spinal Injuries account for substantial disability in wounded service members Methods: The Joint Theater Trauma Registry was queried to Identify all American military personnel who sustained injuries to the back, spinal column, and/or spinal cord In Iraq or Afghanistan from October 2001 to December 2009. Spinal injuries were categorized according to anatomic location, neurological involvement, mechanism of Injury, and concomitant wounds Results: Of 10,979 evacuated combat casualties, 598 (5.45%) sustained 2101 spinal injuries. Explosions accounted for 56% of spinal injuries, motor vehicle collisions for 29%, and gunshots for 15%. Ninety-two percent of all injuries were fractures, with transverse process, compression, and burst fractures the most common. Spinal cord Injuries were present in 17% (104) of the 598 patients. Concomitant injuries frequently occurred In the abdomen, chest, head, and face. Conclusions: The incidence of spine trauma sustained by military personnel in Iraq and Afghanistan Is higher than that reported for previous conflicts, and the nature of these Injuries may be slmilarto those in severely Injured civilians. Further research into optimal management and rehabilitation is critical for military service members and severely Injured civilians with spine trauma [ABSTRACT FROM AUTHOR]

Objective: To define the anatomic "safe zone" for placement of external fixator half pins into the anterior and lateral femur., Methods: In 20 fresh-frozen hemipelvis specimens, the femoral nerve and all branches crossing the femur were dissected out to their final muscular locations. The location where the nerves crossed the anterior femur was measured from the anterior superior iliac spine and inferior margin of the lesser trochanter. The knee joint was then opened, and the distance from the superior reflection of the suprapatellar pouch to the last branch of the femoral nerve crossing the anterior femur was measured, defining the safe zone for anterior pin placement., Results: The last branch of the femoral nerve crossed at an average distance from the anterior superior iliac spine of 174 ± 43 mm (range, 95-248 mm) and from the lesser trochanter at a distance of 58 ± 36 mm (range, 0-136 mm). The average distance from the proximal pole of the patella to the superior reflection of the suprapatellar pouch was 46.3 ± 13.1 mm (range, 20-74 mm). Using the linear distance between the last crossing femoral nerve branch and the superior reflection of the pouch, the average safe zone measured 199 ± 39.8 mm (range, 124-268 mm). The safe zone correlated with thigh length (r = 0.48, P = 0.03). All nerve branches terminated at their muscular origins without crossing lateral to a line from the anterior greater trochanter to the anterior aspect of the lateral femoral condyle., Conclusions: The safe zone for anterior external fixator half pin placement into the femur is on average 20 cm in length and can be as narrow as 12 cm. Anterior pins should begin 7.5 cm above the superior pole of the patella to avoid inadvertent knee joint penetration. Because the entire lateral femur is safely available for half pin placement, including distally, we recommend the use of alternative frame constructs with either anterolateral or lateral pins given the limitations and risks of anterior pin placement.