Background: Hitherto only studies with selected populations have found an increased all-cause mortality of some selected opioids compared to selected non-opioids for chronic non-cancer pain (CNCP). We have examined the allcause mortality for CNCP associated with all established opioids compared to non-opioid analgesic therapy (anticonvulsants, antidepressants, dipyrone, non-steroidal agents). Methods: The study used the InGef (Institute for Applied Health Research Berlin) database which is an anonymized healthcare claims database including 4,711,668 insured persons who were covered by 61 German statutory health insurances between 2013 and 2017.The health insurance companies are the owners of the database. All-cause mortality was determined from death certificates. Adjusted hazard ratios (HRs) including age, gender, comorbidity index, and propensity score as covariates and risk differences (RD) in incidence of death between patients with long-term opioid therapy (LTOT) and control-drug therapy were calculated. Results: The mean age of participants was 66 years; 55% were women. There were 554 deaths during 10,435 person-years for the LTOT patients, whereas there were 340 deaths during 11,342 person-years in the control group. The HR for all-cause mortality was 1.59 (95% CI, 1.38-1.82) with a risk difference of 148 excess deaths (95% CI 99-198) per 10,000 person-years. The elevated risk of death for LTOT was confined to the out-of-hospital deaths: LTOT patients had 288 out-of-hospital deaths during 10,435 person-years (276 per 10,000 person-years) whereas there were 110 deaths during 11,342 person-years (97 per 10,000 person-years) in the control group. HR was 2.29 (95% CI 1.86, 2.83). Although our propensity score matching model indicated a good classification, residual confounding cannot be fully excluded. The opioid group had a higher prevalence of heart failure and a higher use of antithrombotic and antiplatelet agents and of psycholeptics.

Recent evidence-based guidelines for long-term opioid therapy (LTOT) for chronic noncancer pain (CNCP) have defined daily morphine equivalent doses (MEQ/d) that require particular caution. The recommendation for a threshold MEQ/d is based on North American studies that have demonstrated negative health outcomes associated with high-dose LTOT for CNCP. We have conducted a retrospective cross-sectional study using an anonymized German health claims database, including 4,028,618 persons insured by 69 German statutory health insurances, representative of age and sex for the German population in 2014. Those receiving German guideline-recommended opioid treatments (dose <120 mg MEQ/d) for CNCP were compared with those receiving high-dose LTOT (≥120 mg MEQ/d) for selected health outcomes (risky opioid prescribing; hospital admissions due to diagnoses indicative of abuse/addiction of prescribed opioids; and health costs). The prevalence of LTOT for CNCP was 0.8%, with 9.9% receiving high-dose LTOT. Those receiving German guideline-recommended opioid treatments vs those receiving high-dose LTOT differed for the following parameters: risky opioid prescribing (combination with tranquilizers) (11.1% vs 14.3%; P < 0.001), hospital admissions because of mental and behavioral disorders due to alcohol, opioids, tranquilizers, multiple substances and intoxication by narcotic agents (1.6% vs 2.9%; P < 0.001), and total health costs (7259 vs 10,732 Euro; P < 0.001). The difference in annual costs between the 2 groups was largely due to differences in pharmaceutical costs in the outpatient setting (2282 vs 5402 &OV0556;; P < 0.001). These data confirm recommendations for a threshold MEQ/d for CNCP as recommended by recent opioid prescribing guidelines for CNCP.

Background:Symptomatic cartilage defects of the knee are commonly surgically treated by microfracture (MFX) or matrix-associated chondrocyte implantation (M-ACI). Several randomized controlled trials have compared MFX and M-ACI, showing a tendency to lower reoperation rates for M-ACI, but results vary widely between studies.Purpose:To compare reoperation rates after MFX and M-ACI in cartilage defects of the knee outside clinical trials in a representative sample of the population.Study Design:Cohort study; Level of evidence, 3.Methods:This study was based on anonymized, population-representative claims data of 4 million insured persons in Germany. Patients who underwent MFX or M-ACI for cartilage defects of the knee with a follow-up of 2 years were compared. The primary endpoint was the need for a reoperation, defined as a claim for a second surgical procedure from the same patient at the knee joint (27 procedure codes), meniscus and cartilage (35 procedure codes), or patella (102 procedure codes) or the need for knee replacement (11 procedure codes). Group comparisons were performed using log-rank tests, with a 2-sided P value of <.05 to indicate significance. For adjusted analysis, propensity score matching was applied. Age, sex, comedications, and comorbidities were used as matching parameters.Results:A total of 6425 patients fulfilled the inclusion criteria: 6273 treated with MFX and 152 treated with M-ACI (mean age, 53 and 36 years, respectively). In the 2 years after treatment, 1271 patients in the MFX group needed a reoperation compared with 19 in the M-ACI group (20.3% vs 12.5%, respectively; P = .0199). For adjusted analysis after propensity score matching, 127 patients per group were analyzed. Their mean age was 37 years. At the end of the second follow-up year, 28 and 16 patients needed reoperations in the MFX and M-ACI groups, respectively (22.0% vs 12.6%, respectively; P = .0498).Conclusion:This study used a representative sample of the population and a broad definition of a reoperation, thus expanding evidence from clinical trials. We found a significant advantage of M-ACI in reoperation rates 2 years after treatment. After adjusting for age, sex, comedications, and comorbidities, M-ACI still showed significantly lower reoperation rates after 2 years.

Although the clinical picture of an acute rupture of the Achilles tendon is clear, it remains unrecognized or falsely evaluated in up to 10% of all cases. Wrong management without surgical intervention or adequate immobilization frequently leads to unstable scar tissue, requiring completely different therapy and rehabilitation than in the case of an acute injury. Between 6/2000 and 3/2002 11 patients (average age 53 years, M:F=9:2) with a neglected rupture of the Achilles tendon undergoing reconstruction of unstable scar tissue were evaluated in a prospective study. The preoperative cardinal symptoms were loss of strength and stress pain. The length of the unstable scar tissue measured 3.5 cm on average (2.0-6.0 cm). After resection of the scar lesion, a broad central gastrocnemius aponeurotic flap was performed in nine cases,whereas two cases underwent a central tendon shift. As a result of the surgical tendon reconstruction,we noted a 40% mean increase of strength in the final examination. This improvement was associated with less pain and a comparable range of motion. Protracted wound secretion and superficial wound necrosis were recorded on one and two occasions, respectively. Ultrasound and X-ray as preoperative imaging diagnostic tools in addition to the clinical picture appear to be sufficient for proper indication and planning of surgical intervention. The broad central aponeurotic flap has proven to be the most successful method in our patients. In cases of a short distal end, the "grip-box plasty" with a central tendon shift is indicated. Even lesions up to 6 cm can thus be repaired with autologous tissue.

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