Category: Ankle, Trauma Introduction/Purpose: The use of prescription opioids has risen sharply over the last few decades as pain management has become increasingly recognized as an essential aspect of patient care. In August 2017, Ohio implemented a law limiting the quantity of opioid medications a provider could prescribe for the treatment of acute pain. Specifically, a prescriber may not prescribe more than 7 days of opioids in the first prescription for an acute pain episode and the total morphine equivalent dose (MED) cannot exceed an average of 30 MEDs a day. The purpose of this study is to report patterns of opioid prescription for patients treated operatively for ankle fractures after implementation of the 2017 Ohio Opioid Prescriber Law in comparison to the previous year. Methods: A total of 152 patients operatively treated for isolated ankle fractures during two six-month periods, January 2017 to July 2017 (n=73) and January 2018 to July 2018 (n=79), were retrospectively identified using CPT codes. The earlier time period includes patients treated before implementation of the Ohio Opioid Prescriber Law, and the later time period represents patients treated after implementation of the law. Preoperative and postoperative patient narcotic use was reviewed using a legal prescriber database. The prescription search was limited to prescriptions prescribed within one year prior to surgery and 6 months postoperatively. Total number of prescriptions, quantity of pills, and milligrams of morphine per patient prescribed during the 90- day postoperative period were compared between those treated before and those treated after implementation of the law. Average number of pills and average milligrams per morphine per prescription were also compared. Statistical analysis was conducted using t-tests and fisher exact tests. Results: The average number of opioid prescriptions prescribed per patient in the 90-day postoperative period was 2.3 in the pre-law group and 1.95 in the post-law group (p=0.35). The average milligrams of morphine prescribed per patient dropped from 942.41 mg pre-law to 645.25 mg post-law (p=0.18). Differences in the average number of pills per prescription pre- and post-law (49.72 vs. 36.06) and average milligrams of morphine per prescription (383.11 mg vs. 277.56 mg) were statistically significant (p=0.002 and p=0.014, respectively). Differences in age, gender, Charlson Comorbidity Index, BMI, preoperative narcotic use, and postoperative narcotic use exceeding 90 days were not statistically significant between groups (p>0.05). Conclusion: Following the implementation of the 2017 Ohio Opioid Prescriber Law, there was a significant decline in the number of pills per prescription and milligrams of morphine per prescription in patients operatively treated for isolated ankle fractures. The presence of a downward trend in the quantity of opioids prescribed in this patient cohort suggests the effectiveness of the state prescriber law and is promising in the setting of the current opioid epidemic in the United States.

Intra-articular injections are a common practice in conservative management of knee osteoarthritis.1 Septic arthritis following these injections is a rare but potentially devastating complication. 2 The culpable microorganisms in the majority of cases are from the Staphylococcus or Streptococcus sp. 3 Septic arthritis of the nonoperated knee joint caused by Cutibacterium (Propionibacterium) acnes is not often expected or encountered. The more common presentation of this pathogen in orthopaedics is an indolent prosthetic joint or spinal infection. We present a rare case of C. acnes septic arthritis of the nonoperated knee, following multiple intra-articular injections. This case demonstrates the subtle presentation of C. acnes septic arthritis and suggests careful consideration of the implications of intraarticular injections in management of knee osteoarthritis. Case ReportA 56-year-old male patient with a medical history of diabetes (HgA1c, 7.5) and obesity (body mass index [BMI], 39.15) presented to a sports medicine clinic complaining of right knee pain and mechanical symptoms. Radiographic and clinical evaluation was consistent with primary osteoarthritis. His symptoms were treated conservatively with physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), sodium hyaluronate injections, and multiple corticosteroid injections. The patient returned a year later with acute exacerbation of chronic knee pain. An aspiration was performed under sterile technique and the analysis demonstrated 68,000 white blood cells (WBCs), 88% polymorphonuclear (PMN) leukocytes, positive uric acid crystals, and negative cultures. Indomethacin and colchicine were initiated to treat gout with transient symptomatic improvement. At 1-week follow-up, the patient presented with recurrent pain accompanied by erythema and swelling. Due to concern for septic arthritis, the patient was admitted to the hospital. Aspiration was attempted and he was initiated on IV vancomycin for cellulitis. Gout treatment was continued and he was discharged on oral antibiotics following significant symptomatic improvement. Keywords► Propionibacterium acnes ► Cutibacterium acnes ► septic arthritis ► intra-articular injection ► steroid injection ► septic knee ► corticosteroid Abstract Cutibacterium (Propionibacterium) acnes, a gram-positive bacillus with low pathogenicity, is an uncommon but known cause of prosthetic joint infections, particularly related to shoulder surgery. C. acnes, however, is an extremely rare pathogen in the nonoperated knee joint. This report details an uncommon case of C. acnes septic knee arthritis after multiple intra-articular steroid injections in a 56-year-old male patient. After an indolent presentation and late diagnosis, the patient underwent surgical debridement with IV antibiotic management. This case illustrates that intra-articular corticosteroid injections for the management of osteoarthritis are not without risk. Literature supporting their use remains limited and clinicians should use proficient clinical judgm...

Background: The purpose of this study was to report patterns of opioid prescription for patients treated operatively for ankle fractures after implementation of the 2017 Ohio Opioid Prescriber Law in comparison to the previous year. Methods: A total of 144 patients operatively treated for isolated ankle fractures during two 6-month periods, January 2017 to July 2017 (pre-law) and January 2018 to July 2018 (post-law), were retrospectively identified. Preoperative and postoperative patient narcotic use was reviewed using a legal prescriber database. Total number of prescriptions, quantity of pills, and morphine milligram equivalents (MMEs) per patient prescribed during the 90-day postoperative period were compared between those treated before and those treated after implementation of the Ohio prescriber law. Results: The average number of opioid prescriptions prescribed per patient in the 90-day postoperative period was 2.3 in the pre-law group and 2.1 in the post-law group ( P = .625). The average MMEs prescribed per patient dropped from 942.4 MME pre-law to 700.5 MME post-law ( P = .295). Differences in the average number of pills per prescription pre- and post-law (49.7 vs 36.2) and average MME per prescription (382.1 mg vs 275.2 mg) were statistically significant ( P < .001 and P = .016, respectively). Conclusion: Following the implementation of the 2017 Ohio Opioid Prescriber Law, there was a downward trend in the number of pills per prescription and MMEs per prescription in patients operatively treated for isolated ankle fractures. The presence of a downward trend in the quantity of opioids prescribed in this patient cohort suggests the effectiveness of the state law. Level of Evidence: Level III, comparative study.