Paper 09 Adductor Canal Block versus Femoral Nerve Block for Pain Control After Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Trial Kelechi R. Okoroha, MD1, Jonathan Lynch, MD2, Vincent Lizzio, MD2, Charles Cong Yu3, Toufic Raja Jildeh4, Vasilios Moutzouros, MD5 1Rush University Medical Center Program, Chicago, IL, 2Henry Ford Hospital, Detroit, MI, 3Henry Ford Health System, Detroit, MI, 4Henry Ford Hospital, Detroit, MI, 5Henry Ford Medical Group, Novi, MI Objectives: Regional anesthesia in the form of a femoral nerve block (FNB) is a commonly performed technique that has been proven to provide effective analgesia following anterior cruciate ligament (ACL) reconstruction. The adductor canal nerve block (ANB) employs a similar sensory block around the knee while avoiding motor blockade of the quadriceps. The purpose of our study was to compare the efficacy of FNB versus ANB for pain control following ACL reconstruction. Our hypothesis was that there would be no difference in pain levels or opioid requirements between the two groups. Methods: We performed a prospective, double-blinded, randomized controlled trial. Sixty patients undergoing primary ACL reconstruction using bone-tendon-bone autograft were randomized to receive either an ANB or FNB preoperatively. The primary outcomes assessed were pain levels (visual analog scale) and narcotic requirements for 4 days following surgery. Secondary outcomes included ability to perform a straight leg raise in the recovery room and difference in thigh circumference between the operative and nonoperative leg measured at 7 days postoperatively. Results: Morphine requirements were less in ACB in the first 4 hours postoperatively (p = .02). Aside from this time interval, there were no differences between the 2 groups with regard to opioid requirements and pain scores at any other time. Similarly, no differences were noted in the patient’s ability to perform a straight leg raise in the recovery room (p = .13) or in thigh circumference at the first postoperative visit (p = .09). Conclusion: The results of our study suggest similar efficacy in perioperative pain control with the use of an ANB for ACL reconstruction when compared to FNB. The potential long-term benefit of quadriceps preservation with the ACB is worthy of future study.

Paper 10 Opioid Use is Reduced in Patients Treated with NSAIDS After Arthroscopic Shoulder Instability Repair: A Randomized Study Kamali A. Thompson, BS, MBA, David S. Klein, DO, Guillem Gonzalez-Lomas, MD, Michael Joseph Alaia, MD, Eric Jason Strauss, MD, Laith M. Jazrawi, MD, Kirk A. Campbell, MD NYU Hospital for Joint Diseases, New York, NY Objectives: The current opioid epidemic necessitates physicians to seek ways to decrease patients’ requirements of narcotic medications without sacrificing their postoperative comfort level. This study evaluated patients’ pain following arthroscopic shoulder instability repair and compared the use of narcotic medications between patients prescribed NSAIDs with rescue opioid prescription to those prescribed opioids alone. We hypothesized there would not be a significant difference in postoperative pain and addition of NSAIDs would result in decreased opioid use. Methods: Forty patients scheduled to undergo an arthroscopic shoulder instability repair were randomized to receive Ibuprofen 600mg and a 10-pill rescue prescription of Percocet 5/325mg (n=20) or Percocet 5/325mg (n=20). Primary outcomes were the amount of Percocet tablets used in the first week and VAS on postoperative day (POD) 1, 4, and 7. Statistical analysis was done using independent t-tests and bivariate analysis for correlation. Findings were considered significant at p<0.05. Results: Forty patients with a mean age of 35.08 (± 8.48)were enrolled between December 2017 and May 2018. The total amount of opioid consumption was statistically significantly lower in the multimodal group compared to the opioid group (p <0.04) as well as Percocet consumption between POD 0-4 (p <0.04). There were no significant differences in VAS at any point between the two groups. One patient in the Ibuprofen cohort experienced dizziness on POD 1. Two patients in the Percocet cohort experienced nausea and vomiting on POD 1 and POD 4. Conclusion: Multimodal analgesia using NSAIDs with an opioid rescue prescription has resulted in significant reduction in postoperative narcotic consumption. As both cohorts showed similar pain levels, it is possible to alleviate postoperative pain with lower amounts of opioids than are currently being prescribed. The public health crisis of opioid abuse requires an immediate solution beginning with the reduction of post-operative narcotics distribution.

Paper 11 Risk Factors for Opioid Use Following Anterior Cruciate Ligament Reconstruction (ACLR) in a Cohort of 21,202 ACLR Anita G. Rao, MD1, Heather A. Prentice, PhD2, Priscilla Hannah Chan, MS2, Liz W. Paxton, MA2, Tadashi Ted Funahashi, MD3, Gregory B. Maletis, MD4 1Kaiser Permanente, Vancouver, WA, 2Kaiser Permanente, San Diego, CA, 3Kaiser Permanente, Irvine, CA, 4Kaiser Permanente Hospital, Baldwin Park, CA Objectives: The misuse of opioid medication has contributed to a significant national crisis affecting public health, as well as patient morbidity and medical costs. We sought to determine baseline opioid utilization in patients undergoing ACLR and examine demographic, patient characteristics, and medical factors associated with postoperative opioid utilization. Methods: Primary elective ACLR were identified using an integrated healthcare system’s ACLR registry (January 2005-January 2015). Patients with cancer or those who had other knee surgery in the preceding year were excluded. We studied the effect of preoperative and intraoperative risks factors on number of dispensed opioid medication prescriptions (Rx) in the early (0-90 days) and late (91-360 days) postoperative periods using logit regression. Risk factors studied included: number of opioid Rx in preceding year, age, gender, race, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), activity at the time of injury, time from injury to ACLR, concomitant procedure or injury, medical comorbidities, and opioid-use comorbidities. Results: Of 21202 ACLR from 20813 patients, 25.5% used at least 1 opioid Rx in the one-year preoperative period. 17.7% and 2.7% used ≥2 opioid Rx in the early and late recovery periods, respectively. The risk factors associated with greater opioid Rx in both the early and late periods included: preoperative opioid use, age >20 years, ASA classification of ≥3, other activity at the time of injury, repaired cartilage injury, chronic pulmonary disease, and substance abuse. Risk factors associated with opioid Rx use during the early period only included: other race, acute ACL injury, repaired meniscal injury, multi-ligament injury, and dementia/psychoses. Risk factors associated with greater opioid Rx during the late period included: female gender, BMI >25 kg/m2, motor vehicle accident as the mechanism of injury, and hypertension. Conclusion: We identified several risk factors for postoperative opioid usage after ACLR. The strongest predictors of postoperative prescription opioid usage after ACLR included preoperative opioid use, increasing age, ASA classification of 3 or more, other activity at the time of injury, repaired meniscal injury, cartilage repair, chronic pulmonary disease, and substance abuse. Awareness of risk factors for postoperative opioid usage may encourage more targeted utilization of opioids in pain management. Surgeons may consider additional support or referral to a pain specialist for patients with these risk factors.

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Paper 12 The Incidence of Chronic Opioid Use Following Arthroscopic Rotator Cuff Repair and Patient Opioid Education. Danielle G. Weekes, MD1, Jenna A. Feldman2, Richard E. Campbell, BS2, Michael DeFrance, DO3, Fotios P. Tjoumakaris, MD4, Luke Austin, MD2 1Rothman Institute, Egg Harbor Township, NJ, 2The Rothman Institute, Philadelphia, PA, 3Rowan University, Stratford, NJ, 4The Rothman Institute, Egg Harbor Township, NJ Objectives: Opioids are commonly prescribed for pain management following Arthroscopic Rotator Cuff Repair (ARCR). While their efficacy outweighs their risks in the short term, chronic opioid use is associated with significant adverse effects, such as dependence, endocrine imbalance or respiratory depression. The rate of chronic opioid use and dependence following ARCR is unknown. The purpose of this study is to determine the rate of chronic opioid use following ARCR and establish the effect of preoperative opioid education on reducing chronic consumption. A secondary aim is to determine if any correlation exists between chronic opioid use and shoulder functionality. Methods: A prospective, randomized study of 140 patients undergoing ARCR was performed with a minimum follow-up of 24 months. Patients were randomized to receive preoperative opioid education (risks of abuse, dependence, etc.) or no education. State registry database opioid prescription data monitoring software were utilized to search for all opioid prescriptions following ARCR in our patient population and this was compared to our electronic medical database for accuracy/discrepancy. The total number of opioid prescriptions and number of tablets was determined as well as time from surgery to most recent prescription. Patients were contacted to determine a shoulder Single Assessment Numeric Evaluation (SANE) score and Visual Analog Scale (VAS) pain score. Categorical data was analyzed via chi-squared tests as appropriate. Numeric data was analyzed using t-tests as appropriate. Results: Forty-five patients (32%) continued to fill opioid prescriptions chronically following ARCR. Seventeen (38%) of these patents received pre-operative opioid educated, whereas twenty-eight (62%) did not (p=0.05). Sixty percent of patients with a history of pre-operative opioid use continued to take opioids, while 23% of opioid naive patients continued (p< 0.01). There was no significant difference in SANE (p= 0.53) or VAS (p= 0.65) scores between the education and control group. Patients taking opioids prior to surgery had worse SANE scores (71.28) than the non-users (86.28), p< 0.01.

Conclusion: Almost a third of patients will chronically use opioids following ARCR, including 23% of opioid naive patients. Preoperative opioid use is strongly associated with chronic opioid utilization, as well as decreased shoulder function 2 years after ARCR. Preoperative opioid education significantly decreased the rate of chronic opioid use; however, there is no effect on long-term shoulder function.

Two-year Opioid Use and Shoulder Outcomes following Patient Opioid Education Chronic Opioid Use

Frequency Mean ± SD SANE score

Mean Pain ± SD VAS score

Opioid Education 24.3% 76.51 ± 29.38 1.53 ± 2.34 No Opioid Education 40.0% 80.08 ± 27.65 1.75 ± 2.53

p-value 0.047 0.529 0.653

Paper 13 Prevalence of Clinical Depression among Patients after Shoulder Stabilization Repair: A Prospective Study Danielle G. Weekes, MD1, Richard E. Campbell, BS2, Nicholas J. Giunta1, Matthew D. Pepe, MD2, Bradford S. Tucker, MD3, Michael G. Ciccotti, MD4, Kevin B. Freedman, MD5, William D. Emper, MD4, Fotios P. Tjoumakaris, MD1 1The Rothman Institute, Egg Harbor Township, NJ, 2The Rothman Institute, Philadelphia, PA, 3The Rothman Institute, Egg Harbor Twp, NJ, 4Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, 5Rothman Institute at Thomas Jefferson University Hospital, Bryn Mawr, PA Objectives: Young, athletic patients who sustain a musculoskeletal injury can suffer from major depressive disorder (MDD), either pre-existing the injury, or in response to injury. Depression can have deleterious effects on mental and physical well-being, and can ultimately lead to suicide. In fact, suicide may represent over 7% of deaths in young, high-level athletes. Therefore, it is paramount among surgeons to recognize vulnerable patient populations. The purpose of the present investigation was to determine the prevalence of MDD in patients with shoulder instability and its’ effect on outcomes in patients undergoing primary arthroscopic shoulder stabilization. Methods: Eighty-eight patients undergoing primary arthroscopic shoulder stabilization were prospectively enrolled and queried at 6 weeks, 3 months, 6 months, and 1 year. Depression symptoms were assessed with the Quick Inventory of Depressive Symptomatology (QIDS-SR16). MDD diagnosis was defined as a QIDS-SR16 score ≥6. Shoulder functionality was assessed with the Western Ontario Shoulder Instability Index (WOSI). Patients were grouped based on their MDD symptomatology preoperatively into MDD and Non-MDD groups. T-test analysis was used to compare outcomes between the groups. Results: The average age of patients on the day of surgery was 29.9 years old. Seventy-four (84.1%) participants were male, while 14 (15.9%) were female. Of the 88 patients enrolled, 44 (50%) met MDD criteria. Baseline averaged WOSI scores for the MDD cohort were worse than the non-MDD group (p= 0.016), 64.9% and 55.0%, respectively. Shoulder function, measured via the WOSI score, significantly improved throughout the study except at the 6-week follow-up point; however, the MDD group continued to have worse shoulder function at 6 weeks post-op (p= 0.04) , 6 months post-op (p=0.03) and 1 year post-op (p< 0.01). There was no significant difference in mean WOSI score between the MDD and non-MDD group at 3 months (p= 0.16). WOSI scores at 1-year for the MDD and non-MDD cohort were 21.1% and 8.9%, respectively. MDD diagnosis increased at the 6-week time point (p= 0.023); however, it declined during the rest of the study period (p< 0.01).

Conclusion: A significant proportion of patients with shoulder instability exhibit depression symptoms (50% in this series). Our results suggest that pre-operative depression negatively correlates with shoulder outcome functionality. Interestingly, arthroscopic shoulder stabilization can lead to post-operative depression; however, by 3-months there is a strong reversal of this effect, with significant reduction of depression symptoms in all patients. This effect may be secondary to the significant physical limitations caused by shoulder immobilization protocols for the first 6 weeks. As patients regain shoulder strength, stability and function, they exhibit less depression symptoms, indicating surgical intervention can significantly decrease depression symptoms that are secondary to musculoskeletal injuries.