Study Design: Retrospective review. Objective: Our purpose was to evaluate factors associated with increased risk of prolonged post-operative opioid pain medication usage following spine surgery, as well as identify the risk of various post-operative complications that may be associated with pre-operative opioid usage. Methods: The MarketScan commercial claims and encounters database includes approximately 39 million patients per year. Patients undergoing cervical and lumbar spine surgery between the years 2005-2014 were identified using CPT codes. Pre-operative comorbidities including DSM-V mental health disorders, chronic pain, chronic regional pain syndrome (CRPS), obesity, tobacco use, medications, and diabetes were queried and documented. Patients who utilized opioids from 1-3 months prior to surgery were identified. This timeframe was chosen to exclude patients who had been prescribed pre- and post-operative narcotic medications up to 1 month prior to surgery. We utilized odds ratios (OR), 95% Confidence Intervals (CI), and regression analysis to determine factors that are associated with prolonged post-operative opioid use at 3 time intervals. Results: 553,509 patients who underwent spine surgery during the 10-year period were identified. 34.9% of patients utilized opioids 1-3 months pre-operatively. 25% patients were still utilizing opioids at 6 weeks, 17.3% at 3 months, 12.7% at 6 months, and 9.0% at 1 year after surgery. Pre-operative opioid exposure was associated with increased likelihood of post-operative use at 6-12 weeks (OR 5.45, 95% CI 5.37-5.53), 3-6 months (OR 6.48, 95% CI 6.37-6.59), 6-12 months (OR 6.97, 95% CI 6.84-7.11), and >12 months (OR 7.12, 95% CI 6.96-7.29). Mental health diagnosis, tobacco usage, diagnosis of chronic pain or CRPS, and non-narcotic neuromodulatory medications yielded increased likelihood of prolonged post-op opioid usage. Conclusions: Pre-operative narcotic use and several patient comorbidities diagnoses are associated with prolonged post-operative opioid usage following spine surgery. Chronic opioid use, diagnosis of chronic pain, or use of non-narcotic neuromodulatory medications have the highest risk of prolonged post-operative opioid consumption. Patients using opiates pre-operatively did have an increased 30 and 90-day readmission risk, in addition to a number of serious post-operative complications. This data provides spine surgeons a number of variables to consider when determining post-operative analgesia strategies, and provides health systems, providers, and payers with information on complications associated with pre-operative opioid utilization.

No abstract

Introduction Opioid abuse has become a national crisis. Published data demonstrate that patients undergoing foot and ankle surgery are left with excess narcotic medications postoperatively. The purpose of our study was to evaluate factors associated with prolonged postoperative opioid use following foot and ankle surgery and identify associations between preoperative opioid use and postoperative complications. Methods MarketScan commercial claims and encounters database was searched to identify foot and ankle patients. Preoperative comorbidities were queried and documented. Patients utilizing opioids 1 to 3 months prior to surgery were identified. Adjusted odds ratios and 95% CIs were calculated using multivariable logistic regression to determine associations between opioid use (preoperatively and postoperatively), readmission, and complications. Results A total of 112 893 patients were included in the study. Preoperative use had a statistically significant association with postoperative use out to 1 year. Tobacco use, chronic pain, mental health diagnosis, and nonopioid medications had a statistically significant association with postoperative use. Preoperative opioid use had a statistically significant association with readmission and postoperative complications. Conclusion Our study found a number of factors associated with prolonged postoperative opioid use (preoperative use, tobacco use, chronic pain, mental health disorders, and certain nonopioid medications). We identified an association between preoperative opioid use and postoperative complications and readmission. Levels of Evidence Prognostic Level IV Evidence

The purpose of this study was to report the natural history, demographics, and mechanisms of requirement for additional surgery in patients undergoing flatfoot reconstruction for adult acquired flatfoot. A total of 321 consecutive patients undergoing flatfoot reconstruction over a 14-year period were included (2002-2016). All procedures were performed by a senior orthopaedic foot and ankle surgeon at our institution. Demographic data, operative reports, clinic notes, and radiographs were available for review. Statistical analysis included calculation of relative risk (RR) ratios. The majority of patients were female (83.2%,) and most patients were overweight with a body mass index greater than 25 kg/m2 (56.4%). Patient comorbidities included diabetes (13.7%) and rheumatoid arthritis (3.7%). Additional surgery was required for 54 patients (16.8%). The most common reasons for additional surgery were the following: painful calcaneal hardware (57.4%), conversion to triple arthrodesis (16.7%), and wound healing complications (9.1%). An increased risk of need for additional surgery was associated with female gender (RR = 3.4; P = .0005), smoking status (RR = 1.9; P = .0081), and age (<60 years of age; RR = 1.8; P = .042). Although retrospective, the results provide insight into the natural history of this procedure. Clinicians may use these data to appropriately counsel patients who are at increased risk of requirement for additional surgery, such as smokers, women, and patients <60 years old, regarding treatment options. Levels of Evidence: Level IV

ABSTRACT: INTRODUCTION:         Both benefits and challenges are associated with training medical students in a community-based setting at a Regional Medical Campus (RMC).  At the RMC, close relationships between learner and teaching faculty can truly be fostered. However, those volunteer teaching faculty are frequently conflicted due to time-constraints and practice productivity requirements that may run counter to maximizing learner involvement.  Longitudinal integrated clerkships (LICs) have been studied and promoted as clinical clerkship structures that, through taking full advantage of the on-going relationship between learner, teacher, patients, and practices, optimize the learning environment for medical students on clinical rotations.  In our resource-limited environment, we wished to create longitudinal educational relationships for all UPRC students with preceptors, practices and patients that would achieve the educational benefits of a true LIC yet not overwhelm the limited resources of this small community. METHODS:                  We created an amalgamative LIC clerkship model that provided a year-long Family Medicine experience integrated within OB-GYN, Surgery and Pediatrics ½-year longitudinal clerkships and three 1-week inpatient adult medicine mini-immersions spaced over the course of ½-year.  Neurology, Psychiatry and Underserved/Rural Medicine (4-weeks each) and subspecialty/elective rotations (2-weeks each) remained in traditional self-contained blocks interspersed within longitudinal experiences.   At 6 and 12 months, we administered a 5-point Likert-type survey to both medical students and teaching faculty asking their perceptions of the educational value and resource requirements for our clinical rotation structure.  Descriptive averages of the ordinal values were reported. RESULTS:                     There were 11/12 students (92.7%) and 11/21 faculty (52.4%) who responded to the survey.   Both students and faculty believed that some of the longitudinal benefits of the amalgamative structure were achieved.  The students especially noted that attending feedback was beneficial due to the longer interaction and that they had a greater ability to interact with patients.  All told, the faculty teachers found the Amalgamative LIC to be slightly less satisfying than the students. CONCLUSIONS:                       While logistical limitations necessitated our unique rotation design, some optimization of education was achieved.  Faculty concerns toward adopting this new structure should be considered for other programs structuring LICs in a similar sparsely resourced environment such as a Regional Medical Campus.