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Objectives: Recovery after shoulder arthroscopy can be impaired by sustained postoperative opioid use, yet there are few validated risk calculators for this outcome. The purpose of this study is to develop and validate a machine learning algorithm that can reliably and effectively predict sustained opioid use in patients following elective shoulder arthroscopy. Methods: A retrospective review of an institutional outcomes database was performed at a tertiary academic medical center to identify adult patients who underwent shoulder arthroscopy between January 1, 2014 and October 1, 2019. Extended postoperative opioid consumption was defined as opioid consumption at least 150 days following surgery. Five machine learning algorithms were developed to predict this outcome. Performance of the algorithms were assessed through discrimination, calibration, and decision curve analysis. Results: Overall, of the 1504 patients included, 132 (8.8%) demonstrated sustained postoperative opioid consumption. The factors determined for prediction of prolonged postoperative opioid prescriptions were preoperative opioid use, age, median percentage of population in patient zip code living at the federal poverty line, preoperative pain score, duration of symptoms, BMI. The random forest model achieved the best performance based on discrimination (AUC = 0.78), calibration, and decision curve analysis. This model was integrated into a web-based open-access application able to provide both predictions and explanations. Conclusions: If externally validated in independent populations, the algorithm developed presently could effectively guide preoperative screening in patients at high risk for extended postoperative opioid prescriptions. Early identification and interdisciplinary counseling in high-risk cases can optimize both resource allocation and surgical outcomes.

Study Design: Review and technical report. Objective: Intraoperative ultrasound has been used by spine surgeons since the early 1980s. Since that time, more advanced modes of intraoperative imaging and navigation have become widely available. Although the use of ultrasound during spine surgery has fallen out of favor, it remains the only true real-time imaging modality that allows surgeons to visualize soft tissue anatomy instantly and continuously while operating. It is our objective to demonstrate that for this reason, ultrasound is a useful adjunctive technique for spine surgeons, especially when approaching intradural lesions or when addressing pathology in the ventral spinal canal via a posterior approach. Methods: Using PubMed, the existing literature regarding the use of intraoperative ultrasound during spinal surgery was evaluated. Also, surgical case logs were reviewed to identify spinal operations during which intraoperative ultrasound was used. Illustrative cases were selected and reviewed in detail. Results: This article provides a brief review of the history of intraoperative ultrasound in spine surgery and describes certain surgical scenarios during which this technique might be useful. Several illustrative cases are provided from our own experience. Conclusions: Surgeons should consider the use of intraoperative ultrasound when approaching intradural lesions or when addressing pathology ventral to the thecal sac via a posterior approach.

Background: Poor sleep quality is prevalent among patients with rotator cuff tears (RCTs) and negatively influences the potential for healing and quality of life. However, there is a paucity of literature describing the magnitude and timing of changes in sleep quality after arthroscopic rotator cuff repair (RCR). Purpose: (1) To evaluate the prevalence of poor sleep quality in patients undergoing arthroscopic RCR and (2) to determine the timing and magnitude of changes in sleep quality after RCR. Study Design: Systematic review; Level of evidence, 4. Methods: PubMed, OVID/Medline, and Cochrane databases were queried in January 2020 for literature investigating the prevalence of poor sleep quality in patients with RCTs or changes in sleep quality after arthroscopic RCR. Data pertaining to study characteristics, risk of bias, sleep quality assessments, and clinical outcomes were extracted. A qualitative analysis of the prevalence of poor sleep quality and changes in sleep quality was performed. Results: A total of 8 studies (1034 patients) were included. The mean Pittsburgh Sleep Quality Index (PSQI) ranged from 5.2 to 15.0 preoperatively among all studies, while the frequency of patients experiencing poor sleep quality ranged from 40.8% to 89.0% in 4 studies. Four studies reported the mean PSQI at a minimum of 6 months postoperatively, which ranged from 4.2 to 7.1. Four studies did not report the PSQI score or the proportion of patients who experienced poor postoperative sleep quality. One study evaluated the PSQI at 12 months postoperatively, which decreased to 4.2 from 5.8 at 6 months. One study evaluated the PSQI at 24 months postoperatively, which decreased to 5.5 from 6.2 at 6 months. Conclusion: Patients with RCTs have a high prevalence of poor sleep quality. Consistent improvements in sleep quality are observed in the 6 months after arthroscopic RCR, but there is limited evidence based on the available data to characterize changes in sleep quality beyond this time. More evidence is needed to characterize changes in sleep quality beyond 6 months and how these changes are perceived by this patient population.

Category: Other Introduction/Purpose: Orthopedic surgery lies at the forefront of the initiative to deliver value-based care. As a result, cost utility analyses have gained increased importance in the orthopedic literature. While other authors have previously reviewed the quality of US-based cost-utility analyses in orthopedic trauma, spine, sports, and arthroplasty, a similar analysis specific to foot and ankle surgery has not been performed. As such, the practicing foot and ankle surgeon does not yet have a comprehensive analysis of the available cost-utility analyses or the quality of the available evidence. The purpose of this study was to perform a systematic review of cost-utility analyses in foot and ankle surgery. Methods: A systematic review of foot and ankle studies was conducted to identify cost-utility based analyses published between 2000 and 2017. Of 687 studies screened by abstract, eight cost-utility foot and ankle studies were identified that met inclusion criteria and were scored by the Quality of Health Economic Studies instrument for overall quality. Results: Of the eight studies that met inclusion criteria, four were published in the U.S. Regarding topic, three examined end-stage arthritis, two examined diabetic foot ulcers, two examined ankle fractures and one examined ankle sprains. Cost-effective interventions identified by these studies included total ankle arthroplasty over ankle fusion or nonoperative treatment, adjunctive hyperbaric oxygen therapy for diabetic foot ulcers, suture button fixation over syndesmotic screws for unstable supination-external rotation type IV ankle fractures, and below knee cast and fracture boot immobilization over tubular bandages for acute severe ankle sprains respectively. The mean Quality of Health Economic Studies scores for these studies was 81.9 with interquartile range, 25th percentile score of 74.8 to 75th percentile score of 86. Conclusion: Despite the increasing focus on value-based care delivery, there are few foot and ankle cost-utility analyses in the current literature. Nonetheless, the quality of existing analyses is high as rated by the Quality of Health Economic Studies and certain interventions have been identified as cost-effective as highlighted above. The findings of this review can be used to help design future analyses in order to best demonstrate the cost-effectiveness of foot and ankle interventions.