Preoperative Patient-reported Outcomes Research Articles

The Association of Preoperative Duration of Symptoms With Clinical Outcomes and Minimal Clinically Important Difference Following Anterior Cervical Discectomy and Fusion

This was a retrospective cohort study. The purpose of this study is to examine whether the time duration from symptom onset to operative treatment is associated with postoperative clinical improvement after anterior cervical discectomy and fusion (ACDF). There is a paucity of literature regarding the influence of preoperative symptom duration on patient-reported outcomes (PROs) following ACDF. Patients who underwent primary, single-level ACDF were retrospectively reviewed and stratified according to preoperative symptom duration (<12 and ≥12 mo). Demographic and perioperative characteristics were compared using χ analysis and linear regression. Subgroup mean scores were compared and achievement of minimal clinically important difference (MCID) was assessed for the Neck Disability Index (NDI), Visual Analogue Scale (VAS) neck pain, VAS arm pain, and 12-Item Short-Form Physical Component Score. A total of 109 patients underwent primary, single-level ACDF: 68 had duration of symptoms (DOS) <12 months and 41 had a DOS ≥12 months. When comparing DOS subgroup preoperative PROs, there was no preoperative difference in NDI, VAS arm or neck pain, and 12-Item Short-Form Physical Component Score. In the postoperative period, there were no significant differences in the improvement of PROs throughout the 12-month timepoint. A significantly larger proportion of the <12 months DOS cohort achieved NDI MCID at the 3-month (66.1% vs. 43.8%, P=0.039) and 6-month (76.8% vs. 53.6%, P=0.030) postoperative period. Among the patient subgroups with <12 and ≥12 months DOS, there were no statistically significant differences observed in any of the measured PRO means at any timepoint. When assessing MCID, however, patients with shorter DOS (<12 mo) were observed to attain NDI MCID at the 3- and 6-month timepoints more often than patients with DOS ≥12 months. Our findings suggest that delayed surgical intervention may impair functional recovery to MCID in patients with degenerative cervical disease.

The Effect of Body Mass Index on Long-Term Patient-Reported Outcome Scores after Anterior Cervical Discectomy and Fusion in an Asian Population: A 2-Year Study

Study DesignRetrospective cohort study.PurposeThis study aims to analyze the relationship between body mass index (BMI) subjective patient-reported outcomes (PRO) after 1- and 2-level anterior cervical discectomy and fusion (ACDF).Overview of LiteratureThe prevalence of cervical spondylosis and ACDF in expected to continue rising among the aging population of Asia. Moreover, the prevalence of obesity is also increasing. However, limited information is available about the mechanism by which BMI affects PRO after ACDF.MethodsTotal 878 patients underwent ACDF between 2000 and 2015. After excluding patients with previous cervical instrumentation, >2 levels fused, missing BMI measurement, or neoplastic/trauma indication for surgery, 535 patients were included. The PRO measures of the Neck Disability Index, Numerical Pain Rating Scale (NPRS) for Neck Pain, NPRS for Limb Pain, American Academy of Orthopaedic Surgeons–Neurogenic Symptom Score, and Japanese Orthopaedic Association myelopathy score were used. Patients were grouped based on their preoperative BMI, as per the World Health Organization guidelines for Asian populations. PRO scores were collected preoperatively, at 6 months postoperatively, and 2 years postoperatively. A generalized linear model was used to analyze the relationship of BMI category with the individual score, accounting for several factors that are likely to affect the outcomes.ResultsTotal 19 (3.4%) were underweight, 155 (28.0%) were normal weight, 112 (20.3%) were overweight, and 267 (48.3%) were obese. Patients across all BMI categories experienced significant and similar improvements in their postoperative PRO scores. There were no significant differences in the preoperative, 6-month postoperative, and 2-year postoperative PRO scores of the groups. Rate of reoperation was highest in patients with grade II obesity at 8.07%; however, the difference was not statistically significant.Conclusions Irrespective of the BMI, all patients exhibited similar satisfactory outcomes following ACDF. The results support surgery in all subgroups of patients with symptomatic nerve compression in the cervical spine.

Responsiveness of patient-reported outcomes in shoulder arthroplasty: what are we actually measuring?

The purpose of this study was to determine the prevalence and responsiveness of common patient-reported outcome (PRO) tools in patients undergoing primary total shoulder arthroplasty (TSA) for glenohumeral arthritis. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of anatomic and reverse TSA studies from PubMed, SportDiscus, Cochrane, and CINAHL was performed. Studies on primary TSA for glenohumeral arthritis that reported at least 1 PRO tool were included in the final analysis. A subgroup analysis of studies that reported preoperative and postoperative PRO scores with at least 2-year follow-up data was evaluated to compare the responsiveness between the different PRO instruments. After full-text review of 490 articles, 74 articles metall inclusion criteria and were included in the final analysis. Anatomic TSA was evaluated in 35 studies, reverse TSA in 32 studies, and both anatomic and reverse in 7 studies. There were a total of 7624 patients, and 25 different PRO tools were used. The most commonly reported PRO tools were the American Shoulder and Elbow Surgeons (44 studies), Constant (42 studies), the visual analog scale for pain (23 studies), and the Simple Shoulder Test (17 studies). A median of 3.0 PRO instruments were used in each study. All instruments had large effect sizes. The University of California at Los Angeles (UCLA) score was found to be the most responsive instrument, and the Single Assessment Numeric Evaluationscore was least responsive. The American Shoulder and Elbow Surgeons score was the most responsive instrument that required only patient-reported data. Overall, the UCLA score was found to be the most responsive followed by the Adjusted Constant. However, both the UCLA and Adjusted Constant scores require strength and range of motion assessment that may limit their widespread clinical use. The increased responsiveness of these measures, which include objective clinical testing, speaks to the predicted increases in strength and range of motion after shoulder arthroplasty. Of the measures that can be administered without in-person clinical evaluation, the American Shoulder and Elbow Surgeons score and Western Ontario Osteoarthritis of the Shoulder index were the most responsive.

115. Preoperative factors associated with outpatient lumbar decompression surgery

115. Preoperative factors associated with outpatient lumbar decompression surgery

P131. The association of comorbidity burden on lumbar decompression postoperative outcomes

BACKGROUND CONTEXT Central stenosis of the spinal canal can be surgically managed through decompression techniques. There is a lack of research on the influence of comorbidity burden on postoperative patient reported outcome (PRO) improvement and on the achievement of minimum clinically important difference (MCID) following lumbar decompression (LD). PURPOSE This study aims to detail the association between comorbidity burden and achievement of MCID following LD. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE A total of 314 patients undergoing primary or revision, 1 or 2 level MIS TLIF procedures. OUTCOME MEASURES VAS back, VAS leg, ODI, SF-12 Physical Composite Score (PCS), and PROMIS PF scores, MCID. METHODS A prospectively maintained surgical registry was retrospectively reviewed for eligible spine surgeries between May 2015 and July 2019. Inclusion criteria were primary, single or multilevel lumbar decompressions. Patients were excluded if they did not complete a preoperative Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) survey. Patients were stratified based on Charlson Comorbidity Index (CCI) score: 0 points (no comorbidities), 1–2 points (low CCI), ≥3 points (high CCI). A chi-squared test analyzed the association of CCI subgroups in the following variables: gender, smoking status, comorbid diagnoses, and body mass index (BMI). A t-test was used to evaluate subgroups for mean differences in continuous variables, such as age, operative time (from skin incision to closure), estimated blood loss, length of stay, and discharge day (Table 2). A chi-squared test evaluated the distribution of decompression levels. Postoperative improvement was assessed using linear regression to detect a difference between CCI groups for VAS back, VAS leg, ODI, SF-12 Physical Composite Score (PCS), and PROMIS PF scores pre- and postoperatively (eg, 6 weeks, 12 weeks, 6 months and 1 year). Achievement rate of MCID was compared between CCI groups using chi-squared analysis (Table 4). MCID values utilized were VAS back = 1.2, VAS leg = 1.6, ODI = 12.8, SF-12 PCS = 4.0, and PROMIS PF = 8.0. RESULTS A total of 314 LD patients were included; 123 patients had no comorbidities, 100 had low CCI, and 91 had high CCI. Patients with a high CCI were older, more likely to be smokers, and to have the following comorbid diseases: myocardial infarction, diabetes, arthritis, hypertension, PVD, neurological disease and cancer (all p CONCLUSIONS Patients with increased comorbidity burdens undergoing LD had significantly longer procedure times and hospital stays, but their postoperative evaluations demonstrated no difference in achieving MCID for pain (VAS back and VAS leg) or disability (ODI) metrics up to 1-year. Patients in the high CCI group did, however, have a lower rate of achieving MCID for their physical function surveys. Our results suggest that comorbidity burden influences improvement in physical function following LD. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Associations of preoperative patient mental health status and sociodemographic and clinical characteristics with baseline pain, function, and satisfaction in patients undergoing primary shoulder arthroplasty

Shoulder pain and dysfunction are common indications for shoulder arthroplasty, yet the factors that are associated with these symptoms are not fully understood. This study aimed to investigate the associations of patient and disease-specific factors with preoperative patient-reported outcome measures (PROMs) in patients undergoing primary shoulder arthroplasty. We hypothesized that worse mental health status assessed by the Veterans RAND 12-Item Health Survey (VR-12) mental component score (MCS), glenoid bone loss, and increasing rotator cuff tear severity would be associated with lower values for the preoperative total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscores. We prospectively identified 12 patient factors and 4 disease-specific factors as possible statistical predictors of preoperative PROMs in patients undergoing primary shoulder arthroplasty at a single institution over a 3-year period. Multivariable statistical modeling and Akaikeinformation criterioncomparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in the preoperative PSS and its subscores. A total of 788 cases performed by 12 surgeons met the inclusion criteria, with a preoperative median total PSS of 31 points (pain, 10 points; function, 18 points; and satisfaction, 1 point). As hypothesized, a lower VR-12 MCS was associated with lower preoperative PSS pain, function, and total scores, but patients with intact status or small to medium rotator cuff tears had modestly lower PSS pain subscores (ie, more pain) than patients with large to massive superior-posterior rotator cuff tears. Glenoid bone loss was not associated with the preoperative PSS. Female sex and fewer years of education (for all 4 outcomes), lower VR-12 MCS and preoperative opioid use (for all outcomes but satisfaction), and rotator cuff tear severity (for pain only) were the factors most prominently associated with preoperative PROMs. In addition to mental health status and rotator cuff tear status, patient sex, years of education, and preoperative opioid use were most prominently associated with preoperative PROMs in patients undergoing shoulder arthroplasty. Further studies are needed to investigate whether these factors will also predict postoperative PROMs.

Preoperative patient-reported outcome score thresholds predict the likelihood of reaching MCID with surgical correction of adult spinal deformity.

Preoperative (pre-op) identification of patients likely to achieve a clinically meaningful improvement following surgery for adult spinal deformity (ASD) is critical, especially given the substantial cost and comorbidity associated with surgery. Even though pain is a known indication for surgical ASD correction, we are not aware of established thresholds for baseline pain and function to guide which patients have a higher likelihood of improvement with corrective surgery. We aimed to establish pre-op patient-reported outcome measure (PROM) thresholds to identify patients likely to improve by at least one minimum clinically important difference (MCID) with surgery for ASD. This is a retrospective cohort study using prospectively collected data. We reviewed 172 adult patients' charts who underwent corrective surgery for spinal deformity. Included measures were the Visual Analog Scale for pain (VAS), Oswestry Disability Index (ODI), and Scoliosis Research Society-22 (SRS-22). Our primary outcome of interest was improvement by at least one MCID on the ODI and SRS-22 at 2years after surgery. As part of usual care, the VAS, ODI, and SRS-22 were collected pre-op and re-administered at 1, 2, and 5years after surgery. MCIDs were calculated using a distribution-based method. Determining significant predictors of MCID at two years was accomplished by Firth bias corrected logistic regression models. Significance of predictors was determined by Profile Likelihood Chi-square. We performed a Youden analysis to determine thresholds for the strongest pre-op predictors. At year two, 118 patients (83%) reached MCID for the SRS and 127 (75%) for the ODI. Lower pre-op SRS overall, lower pre-op SRS pain, and higher pre-op SRS function predicted a higher likelihood of reaching MCID on the overall SRS (p < 0.05). Higher pre-op ODI, lower SRS pain and self-image, and higher SRS overall predicted a higher likelihood of reaching MCID on the ODI (p < 0.05). An ODI threshold of 29 predicted reaching MCID with a sensitivity of 0.89 and a specificity of 0.64 (AUC = 0.7813). An SRS threshold of 3.89 predicted reaching MCID with a sensitivity of 0.93 and specificity of 0.68 (AUC = 0.8024). We identified useful thresholds for ODI and SRS-22 with acceptable predictive ability for improvement with surgery for ASD. Pre-op ODI, SRS, and multiple SRS subscores are predictive of meaningful improvement on the ODI and/or SRS at 2years following corrective surgery for spinal deformity. These results highlight the usefulness of PROMs in pre-op shared decision-making.

Risk Factors for Preoperative Opioid Use in Patients Undergoing Primary Anatomic Total Shoulder Arthroplasty.

The effect of preoperative opioid use in orthopedic patients has been highlighted. Numerous studies have identified worse patient outcomes with pre-operative opioid use; however, there is currently no information identifying risk factors for preoperative opioid use in the total shoulder arthroplasty (TSA) population. The purpose of this study was to determine risk factors for preoperative opioid use in patients undergoing primary anatomic TSA for primary osteoarthritis (OA) and to determine baseline preoperative patient-reported outcomes (PROs) in preoperative opioid users compared with nonopioid users. The authors studied 982 TSAs performed for primary glenohumeral joint OA in a prospective TSA registry. Patient demographic and clinical characteristics were prospectively assessed and included age; sex; socioeconomic status (SES); smoking status; body mass index (BMI); and history of chronic back pain, depression, diabetes mellitus, and heart disease. Preoperative PROs, range of motion measurements, and preoperative opioid use for shoulder pain were assessed. Overall, 254 (25.9%) of 982 total patients were taking preoperative opioids for shoulder pain in the setting of primary OA. Female sex (P=.023), younger age (P=.019), obesity (BMI >30 kg/m2) (P=.043), chronic back pain (P<.001), and lower SES (P=.002) were associated with increased preoperative opioid use following multivariate logistic regression. Patients with opioid use had significantly worse preoperative pain scores (P<.001), American Shoulder and Elbow Surgeons scores (P<.001), and total Constant scores (P<.002) compared with the non-opioid group. [Orthopedics. 2020;43(6):356-360.].

Effect of Psychotropic Medications on Hammertoe Reconstruction Outcomes.

Background:Hammertoe deformities can seriously affect activity level and footwear. The use of prescription, mood-altering medications is very common, with some estimates as high as 25% of the population. Mood disorders, especially depression, negatively affect the results of medical and operative treatments. This study assessed the relationship of mood-altering medication use with the outcomes and complications of operative reconstruction of hammertoes.Methods:Data were prospectively collected from 116 patients who underwent hammertoe reconstruction, including demographic information, medical history, the use of mood-altering psychotropic medications (antidepressants, anxiolytics, hypnotics, and mood stabilizers), and postoperative complications. Preoperative patient-reported outcomes were measured using the visual analog scale (VAS) for pain and Short Form Health Survey (SF-36), which were repeated at 1-year follow-up.Results:A total of 36.2% of patients were taking psychotropic medications. Medication and nonmedication groups had similar pain VAS and SF-36 Physical Component Summary (PCS) scores before and after surgery. Compared with nonmedication patients, patients on psychotropic medications had significantly lower SF-36 Mental Component Summary (MCS) scores preoperatively (P = .001) and postoperatively ( P = .006), but no significant difference in the change in MCS (ΔMCS) from preoperative to postoperative. Psychotropic medication use was associated with superficial wound infections (P = .048), but not other complications.Conclusions:Patients taking psychotropic medications were equally likely to benefit from forefoot reconstruction as nonmedication patients. Preoperative and postoperative PCS and VAS were not significantly different between medication and nonmedication groups. Although the medication group had lower absolute MCS, they reported the same magnitude of improvement in MCS (ΔMCS) as the nonmedication group.Level of Evidence:Level II, prospective cohort study.

How should we define clinically significant improvement on Patient-Reported Outcomes Measurement Information System (PROMIS) for patients undergoing Knee Meniscal Surgery?

Objectives:The Patient-Reported Outcomes Measurement Information System (PROMIS) attempts to optimize patient reported outcome (PRO) instruments by utilizing item response theory (IRT) and computer adaptive testing (CAT). Relatively little is known about clinically significant outcome (CSO) improvements on the PROMIS Physical Function (PF) CAT. The objective of this study is to define the minimal clinically important difference (MCID), substantial clinical benefit (SCB) and patient-acceptable symptom state (PASS) of the PROMIS PF CAT in arthroscopic meniscal surgery.Methods:The PROMIS PF CAT, Short Form-12 Health Survey (SF-12 physical health [PCS] and mental health [MCS]), Veterans Rand-12 Health Survey (VR-12 physical health [PH] and mental health [MH]), and the Marx Activities Ratings Scale were administered pre- and post- operatively to patients undergoing arthroscopic meniscal surgery. Six months postoperatively, patients graded their knee function based on a domain-specific anchor question. Answers to the anchor questions were dichotomized to indicate achievement of SCB and MCID. A satisfaction anchor question was used to indicate achievement of PASS. Receiver operating characteristic (ROC) analysis determined the relevant psychometric values. Cutoff analysis was performed to find preoperative PRO scores predicting CSO achievement.Results:Sixty patients (N = 27, 45% female) were included, with mean age of 45.0 ± 14.0 years and average follow up of 24.0 + 1.2 weeks. The most common indication for knee arthroscopy was partial meniscectomy (N = 53; 88.3%) followed by meniscal repair (N = 7; 11.7%). MCID on PROMIS PF was calculated to be 2.08 (AUC: 0.75, 95% CI: 0.57 - 0.94). Net score improvement equivalent to achievement of SCB was found to be 7.41 (AUC: 0.77, 95% CI: 0.55 – 0.99). PASS was found to be 45.47 (AUC: 0.89, 95% CI: 0.79-0.99). Preoperative score below 37.6 on the PROMIS PF CAT predicted achievement of MCID (AUC: 0.76, 95% CI: 0.64-0.88), while scores above 41.7 predicted achievement of PASS (AUC: 0.76, 95% CI: 0.63-0.89). Absence of pre-existing arthritis and higher baseline functional status were also found to be statistically significant predictors of achieving CSOs.Conclusion:Our study defined MCID, SCB, and PASS, for the PROMIS PF CAT. We found that a pre-operative score below 37.6 was predictive for achieving a meaningful clinical change with surgery, while a pre-operative score above 41.7 was predictive of achievement of an acceptable post-operative health state.Table 1.Patient Demographic and Perioperative Variables N Percent Total patients60 Age (Mean±SD)45.0±14 Male3355Worker’s Compensation1016.7Right-sided2846.7Diabetes58.3Depression915Hypertension1016.7Alcohol3558.3Smoking Never5388.3Former58.3Current23.3Days of Exercise Per Week (Mean±SD)2.572.05History of Narcotics Use within Three Months of Surgery Date (%)46.7Tear Location Both711.7Medial4371.7Lateral1016.7Tear Type Horizontal Cleavage917.6Oblique23.9Peripheral47.8Degenerative1121.6Flap Tear59.8Radial59.8Complex917.6Root Tear35.9Bucket Handle35.9Chronicity* Traumatic/Acute2440.0Chronic3660.0Pre-Existing Arthritis^3660.0Surgery Type Partial Menisectomy5388.3Meniscal Repair711.7Root Repair23.3Number of Caritlage/Chondral Defects (Mean±SD)1.22±1.17 Location of Cartilage Defect MFC1728.3LFC813.3Trochlea1626.7Patella1830.0MTP23.3LTP46.7*Injuries were determined to be acute if they had occurred within three months of the date of surgery.^Patients were determined to have preexisting arthritis by intraoperative surgeon determination based on the International Cartilage Repairs Society Classification (ICRS), grade II or greater were deemed arthritis.Table 2.Univariate analysis of demographic variables after stratification by achievement of CSOs based on score on the PROMIS PF CAT MCID SCB PASS Not Achieved (28) Achieved (32) P-value Not Achieved (38) Achieved (22) P-value Not Achieved (31) Achieved (29) P-value Age (Mean±SD)44.59±15.5245.42±12.780.8245.11±14.8544.90±12.740.9647.28±14.4242.63±13.370.20Male, %16 (57.1)17 (53.1)0.9619 (50.0)14 (63.6)0.4515 (48.4)18 (62.1)0.42Worker’s Compensation, %3 (10.7)7 (21.9)0.425 (13.2)5 (22.7)0.558 (25.8)2 (6.9)0.11Brief Resilience Scale Score (Mean±SD)3.81±0.583.93±0.760.513.82±0.703.98±0.650.363.87 (0.69)3.89 (0.67)0.93Right-sided %14 (50.0)15 (46.9)117 (44.7)12 (54.5)0.6415 (48.4)14 (48.3)1Diabetes, %1 (3.6)4 (12.5)0.442 (5.3)3 (13.6)0.523 (9.7)2 (6.9)1Depression, %5 (17.9)4 (12.5)0.836 (15.8)3 (13.6)15 (16.1)4 (13.8)1Dyslipidemia, %1 (3.6)1 (3.1)11 (2.6)1 (4.5)12 (6.5)0 (0.0)0.50Hypertension, %7 (20.6)3 (11.5)0.568 (21.1)2 (9.1)0.405 (16.1)5 (17.2)1Alcohol, %17 (60.7)18 (56.2)0.9322 (57.9)13 (59.1)116 (51.6)19 (65.5)0.41Smoking, % 0.38 0.47 0.33Never26 (92.9)27 (84.4) 35 (92.1)18 (81.8) 29 (93.5)24 (82.8) Former2 (7.1)3 (9.4) 2 (5.3)3 (13.6) 1 (3.2)4 (13.8) Current0 (0.0)2 (6.2) 1 (2.6)1 (4.5) 1 (3.2)1 (3.4) Days of Exercise Per Week (Mean±SD)2.25±2.102.84±2.000.272.21±2.163.18±1.740.082.29±2.162.86±1.920.29Narcotics Use, %2 (7.1)2 (6.2)13 (7.9)1 (4.5)13 (9.7)1 (3.4)0.65Table 3.Multivariate results of contributors of postoperative score and achievement of CSOs in the PRMOS PF CAT after meniscal surgery Significant Contributor Odd Ratio Confidence Interval P-Value Postoperative PROMIS PF CATPreoperative Marx Activity Ratings Scale2.071.28-3.36 0.005 PASSPreoperative Marx Activity Ratings Scale1.191.04-1.36 0.014 MCIDPreoperative PROMIS PF CAT0.790.63-0.99 0.039 Preoperative KOOS QoL Subscore1.161.02-1.31 0.021 Preoperative KOOS Symptoms Subscore0.900.81-0.99 0.029 Preoperative arthritis0.00035.33E-07-0.13 0.009 SCBPreoperative PROMIS PF CAT0.820.69-0.96 0.017 Days of Exercise per Week1.871.14-3.06 0.013 Preoperative arthritis0.110.02-0.69 0.019 Figure 1.

Predictors of Large Labral Tears: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study

Objectives:Labral tears are often described by either their location (superior, anterior, or posterior) or their size, commonly defined as degrees of labral involvement from 0° to 360°. Large tears are thought to include 270° or more of the labrum, which has been reported to include 3.3% to 6.5% of those undergoing shoulder instability surgery for labral pathology. Demographic or injury characteristics of those with large labral tears (>270°) has not been defined in the literature. The purpose of this study was to identify factors predictive of a large labral tear at the time of shoulder instability surgery.Methods:As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Those with an isolated SLAP (superior labrum anterior to posterior) tear or a concomitant rotator cuff tear requiring repair were excluded. Demographic data, injury history, preoperative patient-reported outcome scores (PROs), imaging and intraoperative findings, and surgical procedures performed were recorded. The treating surgeon reported the size and location of labral pathology visualized at the time of surgery. Patients with greater than a 270° tear were defined as having a large labral tear. For categorical demographic variables, a chi-square test or Fisher’s Exact test was used, as appropriate based on cell counts. For continuous demographic variables, a two-sample t-test was performed. In order to build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm (Lambert et al. 2018) was used to add significant interaction effects iteratively until no more significant two-way interactions could be added to the model.Results:After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort with an average age of 24.7 years old (12 – 66 years old). The incidence of large tears was 4.6% with the average tear size being 141.9°, or 39.4%. Males accounted for significantly more of the large tears seen in the cohort (94.7%, p = 0.01). Racquet sports (p = 0.002), swimming (p = 0.02), softball (p = 0.05), skiing (p = 0.04), and golf (p = 0.04) were all found to be predictive of large labral tears as was a higher Western Ontario Shoulder Instability (WOSI) score (p = 0.01) (Table 1). Patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (p = 0.007). Age, race, history of dislocation, injury during sport, or previous shoulder surgery were not associated with having a larger tear.Conclusion:Patients with large labral tears are a small, but not insignificant, subset of patients undergoing shoulder instability surgery. Multiple factors were identified as being associated with large labral tears at the time of surgery including male sex, pre-operative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. Surgeons treating patients with these risk factors should be prepared to encounter a large labral tear at the time of surgery. Further studies will evaluate the outcomes of this patient population.Table 1.Comparison of patient demographics and sport history between shoulder instability patients with large labral tears (>270°).Small Tears (<270°)Large Tears(>270°)PN1178 (95.4%)57 (4.6%)-Sex (F, M (%F))219,959 (81.4% M)3, 54 (94.7% M)0.01Age24.69.0265.9.70.13Injury During Sport836 (71.0%)42 (73.7%)0.74Racquet Sport46 (3.9%)7 (12.3%)0.002Swimming205 (17.4%)17 (29.8%)0.02Softball114 (9.7%)10 (17.5%)0.05Skiing206 (17.5%)16 (28.1%)0.04Golf225 (19.0%)17 (19.8%)0.04

Pre-operative comparisons for a return to running protocol in recreational athletes following hip arthroscopy.

The purpose of the current study was to present pre-operative comparisons for recreational athletes attempting a return to running following hip arthroscopy, and the return to running progression protocol used to guide them. A prospective, non-randomized cohort study was conducted to evaluate recreational athletes that returned to running following hip arthroscopy. Return to running was the primary outcome measure and defined as the ability to run at least one mile three times weekly while maintaining patient-reported relief of pre-operative symptoms. Patients included were correlated with the following pre-operative patient-reported outcome measures: hip outcome score (HOS), 12-item international outcome tool (iHOT-12), visual analog scale for pain (VAS) and the Short-Form Health Survey (SF-12). Of the 99 included patients, 94 (95%) returned to running successfully with an average return of 4.8 months. There was no statistical difference in pre-operative comparisons between patients that returned to running and did not return to running (P ≥ 0.154). Evaluation of pre-operative clinical outcomes demonstrated no statistical difference between individuals that returned and did not return to running (P ≥ 0.177), but a large difference between the two groups was identified for HOS-ADL (64.8 versus 53.7, returned versus did not return), iHOT-12 (33.8 versus 25.4) and VAS (58.6 versus 69.3). Patients who returned to running demonstrated similar intraoperative procedures as those that did not return to running (P ≥ 0.214). The current study successfully establishes a management plan and progression protocol for patients identifying a return to recreational running following hip arthroscopy. Level of evidence: 3.

The Relationship Between Preoperative PROMIS Scores With Postoperative Improvements in Physical Function After Anterior Cervical Discectomy and Fusion.

ObjectiveAssess preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) scores and differences between preoperative and postoperative PROMIS-PF scores for patients undergoing anterior cervical discectomy and fusion (ACDF). MethodsAfter Institutional Review Board approval, a prospectively maintained surgical registry was retrospectively reviewed for elective spine surgeries of nontraumatic, degenerative pathology between 2015–2018. Inclusion criteria were primary or revision, single-level ACDF procedures. Multilevel procedures and patients without preoperative surveys were excluded. A preoperative PROMIS score cutoff of 35 divided patients into PROMIS-PF score categories (e.g., ≥ 35.0, < 35.0). Categorical and continuous variables were evaluated with chi-square tests and t-tests. Linear regression analyzed PROMIS-PF score improvement. ResultsEighty-six patients were selected, the high and low PROMIS-PF subgroups only differed in mean age (49.1 vs. 41.3, p = 0.002). Significant differences in PROMIS-PF scores were observed among high and low preoperative PROMIS-PF score subgroups at 6 weeks (p = 0.006), 12 weeks (p = 0.006), and 6 months (p = 0.014). Mean differences between preoperative and postoperative PROMIS-PF scores were significantly different between the high and low PROMIS-PF subgroups at 6 weeks (p = 0.041) and 1 year (p = 0.038). A significant negative association was observed between preoperative PROMIS scores and magnitude of improvement at the 6-week postoperative time point (slope = -0.6291, p < 0.001). ConclusionPatients with low preoperative PROMIS-PF scores demonstrated greater improvements at 6 weeks and 1 year. Clinicians should consider patients with low preoperative PROMIS-PF scores to be in the unique position to potentially experience larger postoperative improvement magnitudes than patients with higher preoperative PROMIS-PF scores.

Association of Preoperative PROMIS Scores With Short-term Postoperative Improvements in Physical Function After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

ObjectiveThis study examines the associations between preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) score, measured by PROMIS-PF and the change between pre- and postoperative PROMIS-PF scores. MethodsA prospectively maintained surgical registry was retrospectively reviewed for spine surgeries between May 2015–June 2019. Inclusion criteria were primary, single-level minimally invasive transforaminal lumbar interbody fusions. Revisions, multilevel procedures, and patients missing preoperative surveys were excluded. Patients were grouped by preoperative PROMIS-PF scores of ≥ 35 and < 35, with higher scores indicating greater PF. A chi-squared and Student t-test were used to analyze categorical and continuous variables respectively. Linear regression evaluated the relationship of PROMIS-PF score improvement. ResultsOf the 180 subjects, 84 were in the PROMIS-PF < 35 group which had more obese patients (p < 0.001) and more males (p = 0.001). Length of stay was greater for the PROMIS-PF < 35 group (36.2 hours vs. 28.7 hours, p = 0.014). PROMIS-PF and Oswestry Disability Index scores were significantly different between subgroups at all timepoints. PROMIS-PF < 35 cohort had larger postoperative PROMIS-PF improvements at 6 weeks (p = 0.008) and 12 weeks (p = 0.003). Linear regression demonstrated a negative association between preoperative PROMIS-PF scores and improvement at 6 weeks, 12 weeks, 6 months, and 2 years (p < 0.001). PROMIS-PF < 35 demonstrated significantly lower rate of achieving minimum clinically important difference at 6 months, otherwise no difference observed throughout the 2-year follow-up. ConclusionUp to 6 months postoperatively, lower preoperative PROMIS-PF scores were associated with larger PROMIS-PF improvements. Understanding the relationship preoperative PROMIS-PF scores have with postoperative improvement may enable better patient counseling.

The effect of patellar facet angle on patellofemoral alignment and arthritis progression in posterior-stabilized total knee arthroplasty without patellar resurfacing

BackgroundThe purpose of this study was to evaluate the effect of patellar facet angle on pre- and postoperative patellofemoral alignment and the progress of arthritis of the patellofemoral joint in posterior-stabilized total knee arthroplasty (PS TKA) without patellar resurfacing.MethodsPatients who had a PS TKA for a varus osteoarthritic knee who were followed up for more than 2 years were included in this study. The radiologic and clinical outcomes were compared between 72 knees (group A) whose patellar facet angle was greater than 126° (> 126°) and 32 knees (group B) whose patellar facet angle was smaller than or equal to 126° (≤ 126°). For the radiologic assessment, the Kellgren-Lawrence grade, mechanical femorotibial angle, Insall-Salvati ratio, patellar tilt angle, patellar displacement and the osteosclerosis of the patellar ridge were evaluated. The range of motion (ROM) and patient-reported outcomes (the Knee Society knee score, the Knee Society function score, the Feller patellar score, and the Kujala patellofemoral score) were used for the clinical assessment.ResultsThe preoperative patellar tilt angle was 9.8° (standard deviation [SD] 5.5) and 14.6° (SD 4.1) in group A and group B, respectively, a significant difference (p < 0.001). Other preoperative radiologic parameters and preoperative patient-reported outcomes and ROM showed no significant difference between the two groups (all parameters (p > 0.05). At the last-follow-up, 22 knees (30.6%) showed progression of osteosclerosis of the patellar ridge in group A and 13 knees (40.6%) showed progression of osteosclerosis in group B (p = 0.371). The postoperative radiologic and clinical outcomes showed no significant difference between the two groups (all parameters, p > 0.05).ConclusionsAlthough a narrow patellar facet angle was related to an increase of lateral tilting of the patella, it showed no impact on the preoperative clinical assessment. The radiologic and clinical outcomes evaluated after the PS TKA showed no statistical difference according to the patellar shape. Although the patellar shape evaluated by the patellar facet angle can partially affect the preoperative patellofemoral alignment, this study result indicated insignificant clinical relevance of the patellar shape in the PS TKA.

Patients With a Hypotrophic Labrum Achieve Similar Outcomes After Primary Labral Repair Compared With Patients With a Normal-Sized Labrum: A Matched Cohort Analysis of 346 Patients With Femoroacetabular Impingement Syndrome

To compare patient functional scores and rates of achieving minimum clinically important differences (MCID) and patient acceptable symptomatic state (PASS) between patients with a hypotrophic labrum with those with a normal labrum width at a minimum 1-year follow-up from arthroscopic treatment of femoroacetabular impingement syndrome. Data from consecutive patients who underwent primary hip arthroscopy between November 2015 and July 2018 for the treatment of femoroacetabular impingement syndrome were analyzed. Baseline demographic data, preoperative patient-reported outcome measures (PROMs), and minimum 1-year PROMs, including Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, modified Harris Hip Score, international Hip Outcome Tool 12 questions, and visual analog scale for pain and satisfaction were recorded. The labrum size was determined using an arthroscopic probe at the 12- to 2-o'clock position with a hypotrophic labrum being defined as <4 mm and normal labrum defined as having a width between 4 and 7 mm on the articular side. Patients with hypotrophic labrum were matched 1:1 by age and body mass index to patients with normal labrum width. A total of 346 patients were included in the study with an average age of 31.4 ± 11.9 and a majority being female (72.0%). There were 173 in each of the normal and hypotrophic groups. There were no significant differences seen in 1-year PROMs between the 2 groups (P > .05 for all). The normal labrum group achieved MCID at a rate of 75% to 84% and PASS at a rate of 51% to 70%. The hypotrophic labrum group achieved MCID at a rate of 70% to 85% and PASS at a rate of 57% to 71%. There were no significant differences in rates between each group (P > .05 for all). Patients with an intraoperative finding of labral hypotrophy achieve 1-year meaningful clinical outcome at the same rate as those with normal labral width following arthroscopic labral repair. III, Case-control study.

Patient-reported outcomes (PROs) in older adults with gastrointestinal (GI) cancer undergoing surgery.

e24032 Background: Older adults with GI cancer often experience poor surgical outcomes, yet little is known about their PROs, such as physical function, quality of life (QOL), and physical and psychological symptom burden. Methods: As part of a randomized trial of perioperative geriatric care, we prospectively enrolled older adults with GI cancer planning to undergo surgical resection. We asked patients preoperatively to self-report their physical function (ability to perform activities of daily living [ADLs] and instrumental ADLs [IADLs], higher scores indicate better functioning), QOL (EORTC QLQ-C30, higher scores indicate better QOL), symptom burden (Edmonton Symptom Assessment System [ESAS], higher scores indicate more severe symptoms, scores &gt; 3 considered moderate/severe [mod/sev]), and depression symptoms (Geriatric Depression Scale [GDS], higher scores indicate more severe symptoms, scores &gt; 4 represent a positive screen for depression). We used regression models to identify patient characteristics associated with these PROs. We also explored relationships among PROs and surgical outcomes (receiving planned surgery, postoperative readmissions, and survival). Results: We enrolled 160 of 221 (72.4%) patients approached. A minority of patients were independent in all ADLs (5.2%) and IADLs (47.7%). Patients reported an average of 2.56 mod/sev ESAS symptoms, and 27.7% screened positive for depression, with 53.1% reporting at least one comorbidity. The number of comorbidities was significantly associated with impaired ADLs (B = -0.63, P &lt; .01) and lower QOL (EORTC: B = -2.74, P = .03). For surgical outcomes, patients with better physical function were more likely to receive their planned surgery (ADLs: OR = 1.21, P = .02; IADLS: OR = 1.30, P = .03). Higher QOL correlated with greater odds of receiving planned surgery (EORTC: OR = 1.03, P = .06), but this did not reach statistical significance. A higher number of mod/sev ESAS symptoms was associated with greater postoperative readmission risk within 90 days of surgery (HR = 1.13, P = .03). Better physical function was associated with better postoperative survival (ADLs: HR = 0.87, P = .02; IADLs: HR = 0.73, P &lt; .01), and higher depression scores correlated with worse survival (GDS: HR = 1.13, P = .02). Conclusions: Older adults with GI cancer often have baseline functional limitations and a high physical and psychological symptom burden, all of which are associated with worse surgical outcomes. Future work should study whether addressing preoperative PROs could improve older patients’ surgical outcomes. Clinical trial information: NCT02810652 .

Recall Bias in Retrospective Assessment of Preoperative Patient-Reported American Shoulder and Elbow Surgeons Scores in Arthroscopic Rotator Cuff Repair Surgery

Background: The gold-standard method for collecting patient-reported outcomes (PROs) is the prospective assessment of preoperative to postoperative change. However, this method is not always feasible because of unforeseen cases or emergencies, logistical and infrastructure barriers, and cost issues. In such cases, a retrospective approach serves as a potential alternative, but there are conflicting conclusions regarding the reliability of the recalled preoperative PROs after orthopaedic procedures. Purpose: To assess the agreement between prospectively and retrospectively collected PROs for a common, low-risk procedure. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: Patients who underwent arthroscopic rotator cuff repair between May 2012 and September 2017 at the study institution were identified. All of the patients completed the American Shoulder and Elbow Surgeons (ASES) Standard Shoulder Assessment Form preoperatively at their preassessment appointment. Patients were then contacted in the postoperative period and asked to recall their preoperative condition while completing another ASES form. Results: A total of 84 patients completed the telephone survey and were included in this analysis (mean age, 57.40 ± 9.96 years). The mean duration of time from onset of shoulder symptoms to surgery was 9.13 ± 9.08 months. The mean duration of time between surgery and recall ASES administration was 39.12 ± 17.37 months. The mean recall ASES score was significantly lower than the preoperative ASES score (30.69 ± 16.93 vs 51.42 ± 19.14; P < .001). There was poor test-retest reliability between preoperative ASES and recall ASES (intraclass correlation coefficient, 0.292; 95% CI, –0.07, 0.57; P = .068). Greater age at the time of recall, a shorter symptomatic period before surgery, and less severe preoperative shoulder dysfunction were associated with a greater difference between preoperative ASES and recall ASES. Conclusion: Retrospectively reported PROs are subject to significant recall bias. Recalled PROs were almost always lower than their prospectively recorded counterparts. Recalled PROs are more likely to be accurate when reported by younger patients, those with a longer duration of symptoms, and those with more severe preoperative conditions.

Five-Year Outcomes After Arthroscopic Surgery for Femoroacetabular Impingement Syndrome in Elite Athletes

Background: Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain and disability in athletes. Arthroscopic treatment for FAIS is well-established; however, the long-term results in elite athletes are limited. Purpose: To evaluate outcomes 5 years after arthroscopic treatment for FAIS in elite athletes. Study Design: Case series; Level of evidence, 4. Methods: Elite athletes undergoing arthroscopic treatment for FAIS with a minimum 5-year follow-up were included. They were prospectively followed up with patient-reported outcome measures. An elite athlete was defined as having a Hip Sports Activity Scale (HSAS) level of 7 or 8 before the onset of symptoms. Preoperatively and 5 years after surgery, all athletes completed a web-based questionnaire, including the Copenhagen Hip and Groin Outcome Score (comprising 6 subscales), the EQ-5D and EQ-VAS (European Quality of Life–5 Dimensions Questionnaire and European Quality of Life–Visual Analog Scale), iHOT-12 (International Hip Outcome Tool), a visual analog scale for hip function, and the HSAS. Moreover, patients reported their overall satisfaction with their hip function. Preoperative measurements were compared with the 5-year follow-up. Results: A total of 64 elite athletes (52 men, 12 women) with a mean ± SD age of 24 ± 6 years were included. On average, patients reported a statistically significant and clinically relevant improvement from preoperative patient-reported outcome measures to the 5-year follow-up (P < .0003), Copenhagen Hip and Groin Outcome Score subscales (symptoms, 51.7 vs 71.9; pain, 61.0 vs 81.1; function of daily living, 67.1 vs 83.6; function in sports and recreation, 40.0 vs 71.5; participation in physical activity, 25.0 vs 67.4; hip and groin–related quality of life, 34.4 vs 68.0), EQ-5D (0.60 vs 0.83), EQ-VAS (66.1 vs 76.7), and iHOT-12 (40.0 vs 68.8). At the 5-year follow-up, 90.5% reported satisfaction with their overall hip function. In total, 54% still participated in competitive sports (HSAS, 5-8) at follow-up, while 77% had decreased their level. Older patients and patients with longer duration of symptoms reported a significantly lower level of sports activity (HSAS, 0-4; P < .009). Conclusion: Arthroscopic treatment for FAIS in elite athletes results in a statistically significant and clinically relevant improvement regarding symptoms, hip function, quality of life, and pain 5 years after surgery. Approximately half of the cohort was still in competitive sports at follow-up, yet 77% had decreased their level of sports. Nine of 10 patients were satisfied with their surgery.

Postoperative Pain, Narcotics Consumption, and Patient-Reported Outcomes Based on PROMIS Physical Function Following a Single-Level Anterior Cervical Discectomy and Fusion.

Retrospective. To determine the association between preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) scores with postoperative pain, narcotics use, and patient-reported outcomes (PRO) following a single-level anterior cervical discectomy and fusion (ACDF) procedure. There is a scarcity of prior literature on the ability of baseline PROMIS scores to predict clinical outcomes for patients undergoing ACDF procedures. Patients who underwent a primary ACDF were retrospectively reviewed and stratified into low and high disability cohorts. Preoperative PROMIS PF cohorts were tested for association with demographic and perioperative characteristics using chi-square analysis and one-way analysis of variance. Cohorts were tested for association with inpatient pain scores and narcotics consumption, as well as postoperative improvements in PROMIS PF, neck disability index (NDI), and visual analog scale (VAS) neck and arm pain using linear regression. Ninety one patients were included: 39 low disability and 52 high disability. Inpatient postoperative VAS pain scores and narcotic consumption are also compared between cohorts. Patients with greater disability reported higher VAS pain scores (P = 0.003). However, patients in both cohorts consumed comparable amounts of narcotics (P = 0.926). Patients with greater preoperative disability demonstrated lower PROMIS PF scores, greater NDI scores, and greater VAS Neck scores at the preoperative baseline. However, patients demonstrated similar improvement of VAS neck and arm pain, as well as NDI at all postoperative timepoints. Patients with low disability reported worsened physical function at the 6 weeks timepoint. Patients with worse preoperative disability as measured by PROMIS PF reported increased pain but comparable narcotics consumption in the immediate postoperative period following a single-level ACDF procedure. Furthermore, patients experienced similar long-term postoperative improvement of PROs regardless of preoperative physical function. PROMIS PF can efficiently quantify physical function before and after the ACDF procedure as self-evaluated by patients. 3.