Background: The opioid epidemic in the United States continues to be problematic as morbidity and mortality rates increase yearly. Orthopaedic surgeons are the third highest prescribing group among physicians. Studies show that orthopaedic surgeons tend to overprescribe opioids, but published data on patient opioid utilization, pain management satisfaction, and national clinical practice guidelines on opioid prescribing are scarce or lacking. Furthermore, little information is available on influences on physician prescribing behavior and whether changes in prescribing habits are lasting. Methods: Using recently published opioid utilization and prescribing guidelines for hand surgery, we created an opioid prescribing quality improvement program with the aim of reducing postoperative opioid prescribing without negatively impacting patient pain satisfaction. The main aspect of the program was the implementation and modification of an opioid prescribing order set, but the program also included surgeon education—executed in 2 intervention steps—about how their prescribing behavior compared with that of their peers. Three phases of data representing 3 months each were collected prior to, between, and after the interventions. Results: Two thousand and sixty-seven hand surgery cases were reviewed (629 in Phase 1, 655 in Phase 2, and 783 in Phase 3). The average number of morphine milligram equivalents (MMEs) was reduced from 142.0 in Phase 1 to 69.9 in Phase 2 (51% reduction) to 61.3 in Phase 3 (57% reduction compared with Phase 1). Significant reductions in MMEs occurred across the procedural categories as well as the hand surgeons. Patient pain satisfaction was similar before and after implementation of the first intervention (p = 0.96). Conclusions: Quality improvement methods were effective in altering prescribing behavior by physicians in the long term, and our approach may be effective if applied more widely. Similar studies on quality improvement methods and prescribing behavior, patient opioid utilization, and patient satisfaction with pain management are needed in other orthopaedic subspecialties. Clinical Relevance: Evidence-based guidelines, a quality improvement process, and unblinded information on prescribing behavior compared with that of peers may result in long-lasting reductions in surgeons’ opioid prescribing practices.

Background: No consensus exists about whether a volar approach (VA) or dorsal approach (DA) for proximal interphalangeal (PIP) arthroplasty yields better results. Previously reported range of motion (ROM) and complications vary from study to study. This retrospective review compared the ROM and complication rates of VA and DA approaches to PIP arthroplasty. Methods: The study included 66 adults (88 digits) who underwent PIP arthroplasty from 2000 to 2015, with minimum 30-day follow-up. Demographic data, surgical approach, pre- and post-operative ROM, duration of immobilization, timing and duration of hand therapy (occupational therapy [OT]), and major and minor complications were recorded. We compared mean change in ROM, postoperative ROM, and complication rates, and examined the association of duration of immobilization and time to OT initiation with postoperative ROM. Results: While there was no difference in postoperative ROM between volar and dorsal groups (56° and 54°, respectively, P > .05), there was a greater gain in ROM in the DA group (25° vs 2.7°, P = .017). There was no statistically significant difference in overall incidence of complications (VA: 37.8%, DA: 30.3%; P > .05) or revision surgery (VA: 15.6%, DA: 17.1%; P > .05). There were no differences in duration of immobilization, time to OT initiation, or number of OT sessions between the two groups, and none of these correlated with postoperative ROM. Conclusions: We identified no statistical difference in mean postoperative ROM, incidence of complications or revision surgery between volar and dorsal approaches for PIP arthroplasty.

Background This study compared the incidence of loss of reduction (LOR) between metacarpal fractures fixed with screws alone and those fixed with plates and screws. Secondary aims included identifying patient or fracture characteristics associated with increased risk of LOR. Methods We retrospectively reviewed 138 metacarpal fractures in 106 patients treated with open reduction internal fixation with screws (60 fractures) or plates and screws (78 fractures) with a mean radiographic follow-up of 50 days for evidence of LOR. We compared the incidence of LOR between the screw and plate groups using a χ2 test. We performed logistic regression analysis to determine whether patient age, sex, metacarpal location (index, long, ring, small), the presence of multiple metacarpal fractures, or fracture pattern were associated with increased incidence of LOR. Results Loss of reduction occurred in 19 (13.8%) of 138 fractures, with no statistically significant difference between lag screw (7 of 60, 11.6%) and plate fixation (12 of 78, 15.4%). Neither fracture pattern nor the presence of multiple metacarpal fractures was associated with an increased incidence of LOR, but patients experienced a 7% increase in the risk of LOR for each additional year of age. Loss of reduction occurred most frequently in index metacarpal fractures (4 of 12, 33%), although this did not reach statistical significance. Conclusions We found no difference in LOR incidence between lag screw fixation and plate fixation. The overall incidence of LOR was higher in this study than previously reported and increased with increasing patient age.