Background The Covid-19 pandemic threatens to overwhelm scarce clinical resources. Risk factors for severe illness must be identified to make efficient resource allocations.

Background: Postoperative flexion contracture (FC) after total knee arthroplasty (TKA) affects gait and causes pain and fatigue, which can result in poor patient outcomes and decreased satisfaction. This study evaluates a dynamic extension brace that may help improve extension and decrease the rate of postoperative FC. Methods: This study was a prospective randomized controlled trial of 101 patients with a FC of ≥10 degrees scheduled to undergo TKA. Primary outcome was change in maximal active extension during the perioperative period; secondary outcomes were patient-reported outcomes. Data were collected at enrollment, preoperative appointments, and 2-week postoperative appointments. Chi-squared, t tests and repeated measures analysis of variance (ANOVA) were used to evaluate the results between and within groups. Results: Fifty-five patients were in the control group and 46 in the experimental group. The mean FC in the experimental group was significantly worse at enrollment (14.22 degrees vs. 15.76 degrees, P=0.049), but improved by the preoperative appointment (15.76 degrees to 12.52 degrees, P<0.001), while the control group FC remained stable. The experimental group experienced a greater improvement in Knee Society Knee Scores and a smaller decline in Knee Society Function Scores compared with the control group. The experimental group experienced a significant improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) score through all time points (29.47 degrees to 35.84 degrees to 51.33 degrees, P<0.001), while the control group only had significant improvement from enrollment to postoperative appointment (35.06 degrees to 49.15 degrees, P<0.001). Conclusions: Patients with FC that used a dynamic knee extension brace preoperatively had improved extension before surgery and more rapid improvement in outcome measures when compared to patients treated with a standard program alone. Level of Evidence: Level I.

Background: Across upper extremity procedures, patients are being prescribed approximately three times the opioid medication needed. The aim of this study was to evaluate opioid prescribing and consumption trends for patients undergoing various upper extremity surgeries at a regional medical center to further refine prescribing guidelines. Methods: A retrospective review of 152 patients undergoing shoulder, wrist, and forearm or hand surgery who completed a patient-reported opioid consumption tracking form between June 2017 and May 2018 was conducted. Opioid prescription and consumption data were converted into morphine milligram equivalents (MMEs). Results: Average total MME prescribed for the population was 147.5±130.1 MME and was significantly different across procedures (P<0.001). Average MME taken across the cohort was 55.5±61.5 with significant differences across procedure types (P<0.001). Controlling for gender and patient age, when compared with shoulder patients, patients undergoing wrist and forearm or hand procedures were significantly less likely to be overprescribed (OR=0.309, P=0.014; OR=0.225, P=0.001) and were overprescribed less MME on average (wrist and forearm β=−120.1, P<0.001; hand β=−144.4, P<0.001). There was no significant difference in the percentage of patients requiring second opioid fills, with an average refill rate of 14.5% across the cohort (P=0.116). Conclusions: Significant differences in the need for opioid analgesia exist across upper extremity procedures, with shoulder surgery patients being overprescribed most frequently and by the highest MMEs. Due to the variability in narcotic utilization, patient-specific factors must be considered by providers when determining optimal opioid prescribing levels. Level of Evidence: Level IV.

Background The purpose of this study is to evaluate the impact of intravenous tranexamic acid on clinical and hematologic outcomes after total shoulder arthroplasty. Methods Retrospective review was conducted for 282 consecutive patients undergoing either anatomic shoulder arthroplasty or reverse total shoulder arthroplasty. Univariate analysis and multivariate linear regression were used to compare outcomes for patients receiving intravenous tranexamic acid with those who did not. Results Of the 282 patients included in this study, 78 patients received intravenous tranexamic acid and 204 did not. Patients who received intravenous tranexamic acid had significantly lower pre- to postoperative change in hemoglobin and hematocrit, and decreased postoperative drain output. In addition, patients receiving intravenous tranexamic acid were significantly less likely to have a postoperative hematocrit <30. There were no significant differences in length of stay, rate of 30 day hematoma, surgical site infection, deep vein thrombosis, or readmission between groups. Conclusion Intravenous tranexamic acid is associated with a significant reduction in change in hematocrit and hemoglobin and postoperative drain output after both anatomic and reverse total shoulder arthroplasty. Despite improving hematologic outcomes for these patients, tranexamic acid appears to have little impact on clinical outcomes such as length of stay and 30-day complication rates.