Background: Opioid-prescribing patterns have been implicated as a contributing factor to the opioid epidemic, yet few evidence-based guidelines exist to assist health-care providers in assessing and possibly modifying their prescribing practices. Methods: Five orthopaedic hand surgeons at a level-I trauma center developed a postoperative prescribing guideline for 25 common hand and upper-extremity outpatient procedures, which were delineated into 5 tiers. Postoperative opioid prescriptions in a 3-month period after implementation of the protocol were compared with those from a 3-month period before implementation of the protocol. Results: There were 231 patients in the pre-implementation group and 287 patients in the post-implementation group. Each individual opioid protocol tier showed a significant decrease in the mean morphine milligram equivalents (MME) prescribed, ranging from a minimum decrease of 97.8% to a maximum decrease of 176.0%. After implementation, adherence to protocol was achieved in 55.1% of patients; the MME amounts prescribed were below protocol for 28.6% and above for 16.4%. The number of additional opioid prescriptions in the 1-month postoperative period was significantly less in the post-implementation group than in the pre-implementation group (p < 0.001). The total number of pills prescribed was reduced by a theoretical equivalent of over three thousand 5-mg oxycodone pills for the 287 patients in the 3-month period. Conclusions: By utilizing a simple consensus protocol, we have demonstrated success diminishing the number of opioids prescribed without leading to an increase in the number of secondary prescriptions written by our providers. These findings are encouraging and suggest that fewer opioids were left in the possession of patients, leaving fewer pills vulnerable to misuse, abuse, and diversion.

There is limited literature characterizing intermediate-term surgical and clinical outcomes of basal thumb arthritis after trapeziectomy and modified abductor pollicis longus suspension arthroplasty (APLSA). We hypothesized that patients who underwent APLSA would have favorable intermediate-term outcomes. Methods: Patients were contacted after APLSA at a median follow-up of 4.8 years (interquartile range, 3.0 e6.0 years). Follow-up clinical evaluation included grip, key pinch, and tip pinch strength. We obtained patient-reported outcomes surveys: visual analog pain score and Disabilities of the Arm, Shoulder, and Hand score. Information on demographics, surgical information, and complications was obtained from the electronic medical record and patient interviews. Results: This study evaluated 66 hands in 60 patients (51 women and 9 men, average age 60.4 years at surgery). At the time of index surgery, 8% of hands had prior ipsilateral surgery (not involving the carpometacarpal joint), 56% had concurrent ipsilateral surgery (35% carpal tunnel release, 32% hemitrapezoid resection, 22% other soft tissue procedures (mucous cyst excision, ganglion cyst excision, or trigger finger release), 5% metacarpal capsulodesis, and 5% metacarpal arthrodesis. Median time between operation and most recent evaluation was 4.8 years (interquartile range, 3.0e6.0 years). Operative hand grip (18.7 ± 11.1 kg), key pinch (4.7 ± 2.1 kg), and tip pinch (3.2 ± 1.7 kg) strength was 94%, 84%, and 86%, respectively, of nonsurgical grip, key pinch, and tip pinch strength. Median (interquartile range) outcomes were a visual analog pain score of 0.0 (0.0e2.0) and Disabilities of the Arm, Shoulder, and Hand score of 9.1 (2.3e26.1). Conclusions: Results at 4.8 years for APLSA demonstrated 84% to 94% grip, key pinch, and tip pinch compared with the contralateral side. Patients experienced little to no pain in the operated joint and minimal disability of the upper extremity at intermediate-term follow-up. Abductor pollicis longus suspension arthroplasty is a favorable procedure for achieving pain relief and functional use associated with basal thumb arthritis. Type of study/level of evidence: Prognostic IV.

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Elbow arthrodesis is an uncommon, typically last resort, salvage procedure to improve comfort and stability of the elbow. Case: Two surgeons performed 3 elbow arthrodesis at 90° elbow flexion secured with a plate and screws. All 3 patients experienced fracture at the most distal aspect of the posterior plate, consistent with a stress riser in this location. Conclusion: The risk of fracture is likely related to vulnerability of the arm with no elbow flexion and may not be ameliorated by changes in operative technique or bone quality. Ulna fracture can be anticipated after elbow arthrodesis and might further limit enthusiasm for elbow arthrodesis.