Preoperative Patient-reported Outcomes Research Articles

Baseline Neck Disability Index and Patient-Reported Outcomes Measurement Information System Physical Function Predict Postoperative Return to Normal in Cervical Spine Surgery.

Recent studies assessing the importance of various preoperative factors on postoperative outcomes following spine surgery have uncovered several important variables that influence subjective and objective outcomes following cervical spine surgery, but it is still unclear which patients are most likely to benefit from operative management. The objective of this study was to assess whether preoperative patient-reported outcome measures (PROMs) can be used to predict which patients achieve "normal" levels of pain and function after surgery. This was a prospective cohort study. This study included all adult patients undergoing cervical spine surgery by 1 of 7 senior spine surgeons at our institution between 2016 and 2018. Of the 164 patients who were eligible for 6-month follow-up at the time that study data were collected, 139 had available follow-up data and were included in our analysis. Patients completed the Neck Disability Index (NDI) as well as the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference computer adaptive tests preoperatively and at 6 months postoperatively. Patients who achieved postoperative patient-acceptable symptom state (PASS) for NDI (≤17) and the normative mean (50) for PROMIS were identified. The relationship between preoperative PROMs and the probability of achieving PASS and the normative mean was assessed. One hundred thirty-nine patients met inclusion criteria with diagnoses of myelopathy (n = 36), radiculopathy (n = 48), and myeloradiculopathy (n = 49). For NDI, a 1-point worsening in the preoperative score resulted in an OR of achieving PASS of 0.96 (P < 0.001) in the overall population. This association held true for patients with radiculopathy (OR 0.96; P = 0.022) but not myelopathy (OR 0.98; P = 0.35). For PROMIS PF, a 1-point improvement in the preoperative score resulted in an OR of achieving the normative mean of 1.10 (P < 0.001). This association held true for patients with radiculopathy (OR 1.14; P = 0.033) but did not reach statistical significance for patients with myelopathy (OR 1.03; P = 0.515). Preoperative PROMs can predict postoperative benefit for patients undergoing cervical spine surgery, with worse baseline function associated with a lower likelihood of attaining PASS for NDI and the normative mean for PROMIS PF, especially for patients with radiculopathy. Baseline symptoms and function, including myelopathy or radiculopathy-dominant symptoms and preoperative PROMs, may predict postoperative outcomes.

Preoperative patient-reported outcome measures predict minimal clinically important difference and patient-acceptable symptomatic state following arthroscopic Bankart repair.

The aims of this study were to validate the minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) thresholds for Western Ontario Shoulder Instability Index (WOSI), Rowe score, American Shoulder and Elbow Surgeons (ASES), and visual analogue scale (VAS) scores following arthroscopic Bankart repair, and to identify preoperative threshold values of these scores that could predict the achievement of MCID and PASS. A retrospective review was conducted on 131 consecutive patients with anterior shoulder instability who underwent arthroscopic Bankart repair between January 2020 and January 2023. Inclusion criteria required at least one episode of shoulder instability and a minimum follow-up period of 12 months. Preoperative and one-year postoperative scores were assessed. MCID and PASS were estimated using distribution-based and anchor-based methods, respectively. Receiver operating characteristic curve analysis determined preoperative patient-reported outcome measure thresholds predictive of achieving MCID and PASS. MCID thresholds were determined as 169.6, 6.8, 7.2, and 1.1 for WOSI, Rowe, ASES, and VAS, respectively. PASS thresholds were calculated as ≤ 480, ≥ 80, ≥ 87, and ≤ 1 for WOSI, Rowe, ASES, and VAS, respectively. Preoperative thresholds of ≥ 760 (WOSI) and ≤ 50 (Rowe) predicted achieving MCID for WOSI score (p < 0.001). Preoperative thresholds of ≤ 60 (ASES) and ≥ 2 (VAS) predicted achieving MCID for VAS score (p < 0.001). A preoperative threshold of ≥ 40 (Rowe) predicted achieving PASS for Rowe score (p = 0.005). Preoperative thresholds of ≥ 50 (ASES; p = 0.002) and ≤ 2 (VAS; p < 0.001) predicted achieving PASS for the ASES score. Preoperative thresholds of ≥ 43 (ASES; p = 0.046) and ≤ 4 (VAS; p = 0.024) predicted achieving PASS for the VAS. This study defined MCID and PASS values for WOSI, Rowe, ASES, and VAS scores in patients undergoing arthroscopic Bankart repair. Higher preoperative functional scores may reduce the likelihood of achieving MCID but increase the likelihood of achieving the PASS. These findings provide valuable guidance for surgeons to counsel patients realistically regarding their expectations.

Utility of the Patient-Reported Outcomes Measurement Information System Global Mental Health T-Score to Identify Patients at Risk for Poor Postsurgical Outcomes Following Total Hip Arthroplasty

BackgroundMental illness is a known risk factor for poor postoperative outcomes following total hip arthroplasty (THA); however, the relationship between a patients overall mental health and recovery from THA is not as well established. Using the preoperative Patient-Reported Outcomes Measurement Information System (PROMIS-10) Mental Health Subdomain T-Score (MHT), the purpose of this study was to understand the association between mental health and postoperative outcomes up to one year following THA. MethodsThis was a retrospective chart review of patients undergoing elective primary THA. Patients who did not have a formal diagnosis of a mental illness condition were divided based on their MHT (above average [AA] > 50, average 40 to 50, below average [BA] < 40). Postsurgical parameters included inpatient opioid consumption and patient satisfaction, and 1-year postsurgery self-reported pain and patient-reported outcomes scores. A total of 972 patients were included in this study (AA 61.2%, average 33.1%, BA 5.7%). ResultsAfter controlling for confounders, multivariate models demonstrated that the MHT was an independent predictor of pain, opioid consumption, patient-reported outcomes, and satisfaction. Patients in the AA group overall demonstrated better outcomes and required fewer opioids than those in the BA group. ConclusionsThe MHT can be used as a preoperative screening tool that can identify an at-risk group that has not been previously described. An MHT < 40 was associated with poor postoperative outcomes, increased pain and opioid consumption, and lower overall satisfaction scores.

Can titanium surface technology reduce cost for biologics in anterior lumbar interbody fusion?

Advances in surface architecture and technology have made interbody fusion devices more bioactive, with the hope of facilitating the fusion process more successfully. The advent of these increasingly bioactive implants may reduce reliance on more expensive biologics that have previously been used to achieve high fusion rates. A retrospective review of prospectively collected data (August 2018-December 2019) was conducted of consecutively performed anterior lumbar interbody fusions in which an acid-etched, nanosurface-modulated, titanium interbody device packed only with corticocancellous allograft chips and local blood was used. Minimum follow-up was 1 year, and inclusion required available imaging and outcome metrics preoperatively and at 1 year. Fusion and subsidence were assessed via CT scans and/or dynamic radiographs. Health-related quality-of-life measures (Oswestry Disability Index [ODI], visual analog scale [VAS] back/leg) were collected pre- and postoperatively. In total, 55 patients met inclusion criteria (1 year of follow-up, available imaging, and outcome metrics). A total of 69 lumbar levels were treated in these 55 patients. The mean age was 67 ± 12.1 years, with 47% female patients. Roughly one-third (35%) had previous spine surgery, and approximately one-tenth (9.1%) had prior spinal fusion. A total of 20.6% were treated at multiple levels (mean levels per patient 1.2, minimum 1, maximum 3). The mean preoperative patient-reported outcomes were as follows: ODI 39.71 ± 18.15, VAS back 6.49 ± 2.19, and VAS leg 5.41 ± 2.71. One year after surgery, the mean improvements in patient-reported outcomes (vs preoperative scores) were as follows: ODI -22.9 ± 13.08 (p < 0.001), VAS back -3.75 ± 2.03 (p < 0.001), VAS leg -3.73 ± 2.32 (p < 0.001). All levels achieved fusion at 1 year postoperatively based on CT scans (65/69 levels) or dynamic radiographs (4/69 levels, change in score < 5% on flexion-extension radiographs). Four of the 65 levels were assigned to the grade 3 category according to a CT-based grading system, meaning cranial and caudal endplate bone apposition to the implant on both surfaces with no clear intervertebral bone connection through or around the implant. Sixty-one of 65 were found to have contiguous intervertebral bone bridging and thus were assigned to grade 1 (n = 54) or grade 2 (n = 7). Low-grade graft subsidence (Marchi grade 0 or I) occurred in 9 levels (13.0%) and high-grade subsidence (Marchi grade II or III) in 4 levels (5.8%). No patients required reoperation at the level of anterior lumbar interbody fusion and no radiographic or clinical evidence of pedicle screw loosening or failure was observed. The combination of advances in materials science and surface technology as demonstrated with a nanotechnology titanium cage resulted in the ability to obtain lumbar interbody fusion with allograft chips and local blood alone. Achieving high fusion rates with low-cost biologics/allograft provides for an attractive pathway toward reducing the cost of reconstructive spine care, and a potential incremental benefit for healthcare economics.

The critical importance of recognition, evaluation, and management of mental health on outcomes following hip arthroscopy – A synthetic narrative review: Current concepts

Mental health and wellness influence patients with hip pain and dysfunction secondary to Femoroacetabular Impingement Syndrome, acetabular dysplasia, and labral injury. Disorders of mental wellness may impact hip preservation surgery patients both before and after surgery. Major depression and generalized anxiety are the two most common diagnoses that affect hip preservation surgery patients. There are dozens of unique questionnaires that can subjectively and objectively characterize the mental health of patients with hip pain. Pain threshold and pain tolerance are two issues that must be recognized to optimally predict treatment outcome in an informed consent shared decision-making discussion. Patient expectations may also significantly influence preoperative symptoms and postoperative outcome. Pain threshold, pain tolerance, and patient expectations are entities traditionally viewed as qualitative and unmeasurable. However, many valid and reliable methods exist to quantitatively assess these patient-specific variables. Recent original research and synthetic review publications have consistently concluded similar findings: patients with disorders of mental wellness generally have lower preoperative patient-reported outcome scores, do improve following surgery, albeit to a lesser magnitude than non-mental disorder patients, and ultimately have lower postoperative scores at their final follow. As with most Orthopedic Surgery literature, the investigation of mental health and hip preservation is primarily via retrospective level four evidence with small numbers of patients from a single-center and single-surgeon at short-term follow-up. Although hip preservation surgeons are Orthopedic Surgeons by training and practice, they must be able to recognize mental wellness disorders and either treat or refer when suspected or identified.

Eight of ten patients return to daily activities, work, and sports after total knee arthroplasty.

Besides return to work (RTW) and return to sports (RTS), patients also prefer to return to daily activities (RTA) such as walking, sleeping, grocery shopping, and domestic work following total knee arthroplasty (TKA). However, evidence on the timelines and probability of patients' RTA is sparse. To assess the percentage of patients able to RTA, RTW, and RTS after TKA, as well as the timeframe and influencing factors of this return. A retrospective cohort study with prospectively collected data was conducted at a medium-sized Dutch orthopedic hospital. Assessments of RTA, RTW, and RTS were performed at 3 mo and/or 6 mo following TKA. Investigated factors encompassed patient characteristics, surgical characteristics, and preoperative patient-reported outcomes. TKA patients [n = 2063; 66 years old (interquartile range [IQR]: 7 years); 47% male; 28 kg/m2 (IQR: 4 kg/m2)] showed RTA ranging from 28% for kneeling to 94% for grocery shopping, with 20 d (IQR: 27 d) spent for putting on shoes to 74 d (IQR: 57 d) for kneeling. RTW rates varied from 62% for medium-impact work to 87% for low-impact work, taking 33 d (IQR: 29 d) to 78 d (IQR: 55 d). RTS ranged from 48% for medium-impact sports to 90% for low-impact sports, occurring within 43 d (IQR: 24 d) to 90 d (IQR: 60 d). One or more of the investigated factors influenced the return to each of the 14 activities examined, with R² values ranging from 0.013 to 0.127. Approximately 80% of patients can RTA, RTW, and RTS within 6 mo after TKA. Return is not consistently influenced by predictive factors. Results help set realistic pre- and postoperative expectations.

Primary Total Hip Arthroplasty Outcomes for Labral Tears are Comparable to Advanced Osteoarthritis

BackgroundThere is a paucity of evidence on outcomes following total hip arthroplasty (THA) in patients who have symptomatic degenerative labral tears and mild to moderate osteoarthritis (OA). The purpose of this study was to determine if outcomes of primary THA in the setting of painful, symptomatic labral tear and mild to moderate arthritic changes were comparable to outcomes of primary THA performed for severe arthritic changes. Primary outcomes were patient-reported outcome (PRO) scores. Secondary outcomes included length of stay and perioperative complications. MethodsThis was a retrospective investigation of all THAs between January 2018 and July 2022. There were 111 patients who had THA due to failure of nonoperative treatment of a degenerative labral tear without advanced arthritic changes (mild to moderate OA cohort, Kellgren-Lawrence Grades 1 to 3). These patients were matched to 111 patients who underwent THA for advanced OA (AOA cohort, Kellgren-Lawrence Grade 4). PROs included the Western Ontario McMaster Universities Arthritis Index (WOMAC). The average age for the labral tear cohort was 59 years, with 50.6% women, compared to 70 years (P < 0.001), and 49.4% women (P = 0.93) in the AOA cohort. ResultsThere were no differences in preoperative PROs, complications, or length of stay between groups. When looking at postoperative PROs between cohorts, the labral tear cohort had less improvement in WOMAC-Stiffness (24.3 versus 34.0, P = 0.005) and WOMAC-Functional limitation (26.3 versus 36.0, P = 0.005) at 12 months and greater improvement in WOMAC-Pain at 12 months (38.3 versus 34.7, P = 0.04). The Short Form 12–Physical function scores were significantly higher among the labral tear cohort compared to the AOA cohort at 12 months (48.5 versus 47.8, P < 0.001). The Short Form 12–Mental scores were significantly higher in the AOA cohort compared to the labral tear cohort at 3 months (47.1 versus 47.4, P = 0.02) and 12 months (46.7 versus 47.6, P < 0.001). In the multivariate analysis, the change in WOMAC-Pain at 12 months was significantly better for labral tear patients (odds ratio 7.5, P = 0.008, confidence interval 6.85 to 8.14). ConclusionsOur study showed that patients who have symptomatic degenerative labral tears with mild to moderate arthritic changes have comparable outcomes to patients who have AOA following primary THA. Given suboptimal outcomes with hip arthroscopy for labral tear in the setting of early arthritis, primary THA can be a reasonable treatment modality for patients failing nonoperative treatments.

Poster 344: The New "Terrible Triad": Anterior Cruciate Ligament Reconstruction With Concurrent Meniscal Lateral Root and Medial Ramp Repairs

Objectives: The purpose of this paper was to compare patient reported outcomes (PROMs) between isolated anterior cruciate ligament (ACLR) and ACLR with concomitant medial meniscus ramp and lateral meniscus root repairs and compare PROMs between different medial meniscus ramp and lateral meniscus root repair techniques. Methods: All patients with isolated (ISO) ACL reconstruction or ACL reconstruction with concomitant medial meniscus ramp and lateral meniscus root repairs with a minimum 2 years of follow-up were retrospectively evaluated. Institutional review board approval was obtained for this study. A final total of 42 ISO-ACL patients were matched based upon age, sex, and body mass index to 40 in the “terrible triad” (TT) cohorts. Outcome measures were obtained from 32 patients in the ISO cohort, and 38 patients in the TT cohort. The PROMs used for this study include the International Knee Documentation Committee (IKDC) Subjective Knee, Cincinnati, Tegner, Lysholm, Veterans RAND 12-Item Health Survey (VR-12), and Knee Injury and Osteoarthritis Outcomes Score (KOOS) questionnaire forms. T tests and chi-square goodness of fit tests were used to compare the above PROMs both pre- and postoperatively within each cohort, and between cohorts and rates of revision or reoperation. Results: The preoperative and postoperative PROMs between patients in the isolated cohort and the triad cohort demonstrated no significant differences, except for the Physical category of the VR-12, in which the triad cohort had significantly higher results (p = 0.04) (Figure 1). Both the isolated cohort and the triad cohort reported significant differences between pre- and postoperative PROMs within their own cohorts. When comparing methods of surgery, including all-inside vs. inside-out for the medial meniscus repairs and tunnel versus no-tunnel for the lateral meniscus root repairs, no significant differences were found between postoperative PROMs. Additionally, no significant difference was found in revision or reoperative rates between the triad and isolated cohorts (p = 0.374) (Figure 2), the all-inside versus inside-out medial meniscus cohorts (p = 0.267), or the tunnel vs. no-tunnel lateral meniscus cohorts (p = 0.781). Conclusions: There was no significant difference in PROMs between isolated ACLR versus ACLR with concomitant medial meniscus ramp and lateral meniscus root repairs. While the complexity of the TT ACLR patients was more involved, PROMs and healing rates were similar and performing concurrent medial ramp and lateral root repairs at the time of ACLR should be considered.

Longitudinal Assessment of Clinical Outcomes After Arthroscopic Treatment for Hip Synovial Chondromatosis and the Effect of Residual Loose Bodies: Minimum 4-Year and 8-Year Follow-up

Background: Arthroscopic treatment is recommended for hip synovial chondromatosis. However, evidence regarding long-term clinical outcomes is limited. Purpose: To evaluate long-term patient-reported outcomes (PROs) and survival, and to determine the potential effect of residual loose bodies, as evaluated by immediate postoperative computed tomography (CT), on clinical outcomes. Study Design: Case series; Level of evidence, 4. Methods: A consecutive cohort of patients undergoing arthroscopic treatment and diagnosed with synovial chondromatosis between March 2010 and May 2015 were included in the study. Preoperative radiography, CT, and magnetic resonance imaging were performed. Preoperative, midterm (minimum of 4 years), and long-term (minimum of 8 years) PROs were collected for visual analog scale for pain, modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and 12-item international Hip Outcome Tool (iHOT-12). The percentages achieving minimal clinically important difference (MCID) were calculated. PROs and survival were compared between patients with and without residual loose bodies evident on immediate postoperative CT scan. Results: A total of 28 patients (20% of patients were lost to follow-up) were included in the study with a mean follow-up period of 104.9 months (range, 96-139 months). PROs including visual analog scale for pain (preoperative, 3.8 ± 1.2; midterm, 0.9 ± 1.7; long-term, 0.8 ± 1.4), mHHS (preoperative, 66.4 ± 14.4; midterm, 92.8 ± 12.3; long-term, 93.5 ± 10.5), NAHS (preoperative, 45.2 ± 16.2; midterm, 81.8 ± 15.3; long-term, 83.1 ± 12.9), and iHOT-12 (preoperative, 48.4 ± 15.6; midterm, 69.3 ± 11.7; long-term, 72.7 ± 11.4) were improved at both midterm and long-term follow-up (all with P < .001). In total, 27 (96.4%), 28 (100%), and 26 (92.9%) patients achieved MCID for mHHS, NAHS and iHOT-12, respectively, at the long-term follow-up. No significant difference was found in any of the PROs and the rate of achieving MCID between midterm and long-term follow-up (all with P > .05). One patient (3.6%) underwent revision surgery. Among the 23 patients who had loose bodies on preoperative CT or radiographs, 14 patients (60.9%) with residual loose bodies evident on immediate postoperative CT demonstrated lower NAHS (P = .045) and iHOT-12 (P = .037) scores but a comparable survival (P > .05) at long-term follow-up compared with those who did not have loose bodies. Conclusion: Arthroscopic treatment for hip synovial chondromatosis achieved satisfactory long-term clinical outcomes with strong survival. Most patients maintained or improved their overall functional status between midterm and long-term follow-up. Furthermore, patients with residual loose bodies had less favorable clinical outcomes, although the survival rate was comparable.

Poster 252: Osteochondral Allograft Transplantation After Failed Autologous Chondrocyte Implantation of the Knee: A Matched Cohort Analysis

Objectives: Osteochondral allograft transplantation (OCA) is a well-established procedure for the management of osteochondral lesions of the knee. OCA after failed prior cartilage restoration procedures has demonstrated similar improvements in patient-reported outcomes (PROs). Outcomes following OCA after failed autologous chondrocyte implantation (ACI) have been minimally reported in the current literature. The present study aims to compare the clinical outcomes, reoperation rates, and failure rates of OCA following failed ACI with those of a matched cohort of patients undergoing primary OCA. Methods: A retrospective matched cohort analysis was conducted on 22 patients who underwent OCA following failed ACI between January 2001 and January 2021, with a minimum 2-year clinical follow-up. Patients were included regardless of concomitant procedures. These patients were matched by age, sex, body mass index, defect location, and defect size to a control group of patients who underwent primary OCA without prior ACI with a similar 2-year clinical follow-up. PROs, defect characteristics, reoperations, and failure rates were analyzed individually and compared between the 2 groups. Results: Twenty-two patients (100% follow-up) were included in the study group with an average follow-up of 5.72 ± 4.2 years (range: 2.0-14.5). The average age was 31.2 ± 6.4 years. Sixteen patients were female (73%) and 6 were male (27%). Patients did not differ in the number of previous surgeries, preoperative baseline PROs, or types of concomitant procedures between the study group and the matched cohort. Both cohorts demonstrated statistically significant postoperative improvements for all PROs including Lysholm, International Knee Documentation Committee, and Knee Injury and Osteoarthritis Outcome Score subscales (p &lt; 0.05). There was no statistical difference between both groups when comparing improvements in PROs, number of reoperations, and failure rates (p &gt; 0.05). Ten patients (45%) in the study group required a reoperation. Four patients (18%) failed OCA following an ACI due to significant graft delamination and disease progression at an average 2.4 ± 2.1 years. Two patients required further revision OCA and 2 underwent significant chondral debridement. All 4 patients were clinically asymptomatic at a final follow-up of 5.9 years. Conclusions: OCA is an excellent treatment option for patients after prior failed ACI. OCA following ACI demonstrates favorable clinical outcomes, comparable reoperation rates, and an acceptable failure rate, similar to OCA performed without prior OCA.

Poster 131: Loop 'N' Tack Tenodesis: A Multi-Center Retrospective Case Series of Clinical and Patient Reported Outcomes of a Novel Suture Technique for Proximal Biceps Tenodesis

Objectives: Tenodesis and tenotomy of the long head of the biceps are treatment options for a wide range of pathologies without clear superior technique or site of fixation. Tenotomy may result in a cosmetic “Popeye” deformity and fatigue pain. The Loop ‘N’ Tack technique is a quick, simple, and knotless technique for tenodesis of the long head of the biceps that can be completed entirely arthroscopically. The tensionless repair allows the biceps to scar within the biceps groove, thereby reducing subsidence and formation of a “Popeye" deformity and fatigue pain in the biceps seen with tenotomy alone while eliminating the ability to overtension. The primary objective will be to retrospectively report the clinical outcomes and associated complications of patients undergoing biceps tenodesis utilizing the Loop ‘N’ Tack technique at multiple institutions from 1/1/2015 – 7/25/2021. Methods: CPT procedure codes (29827,29823, 29826) were used to identify participants in the EHR (i.e., Epic) who underwent the Loop ‘N’ Tack biceps tenodesis technique by each author at 9 separate institutions. Patient reported outcomes (PRO) including Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), UCLA Shoulder Rating Scale (UCLA), and Simple Shoulder Test (SST) were recorded at multiple time points throughout the patient’s preoperative and postoperative course. Scores were compared to the established minimal clinically important difference (MCID) for each PRO to assess the viability of this tenodesis technique. Additional metrics including bicipital groove pain, Popeye deformity, and need for revision surgery were also recorded. Results: 1,473 patients were initially screened who underwent the Loop ‘N’ Tack biceps tenodesis technique. 82 patients were excluded secondary to limited follow up or lack of PRO data within the EHR. The average patient age was 64.7 years old with average follow up of 8.11 months. Mean preoperative PRO scores were 5.64 (2.13), 43.31 (20.38), 15.14 (3.52), 5.81 (1.92), and 49.24 (15.06) for the VAS, SANE, UCLA, SST, and ASES scores, respectively. Postoperative PRO scores at most recent follow up respectively measured 1.05 (1.66), 89.56 (17.06), 31.50 (4.01), 10.69 (1.92), and 89.48 (13.81). MCID was reached for each PRO at the 1-2 month mark postoperatively. 36 patients (2.6%) underwent revision surgery for biceps related pathology, while 40 patients (2.9%) required revision shoulder surgery for a separate pathology. Postoperative Popeye deformity was noted in 15 patients (1.08%). Conclusions: The Loop ‘N’ Tack technique results in high rates of patient satisfaction with improvement in shoulder related patient reported outcomes, low incidence of postoperative pain, and low rates of Popeye deformity. This case series establishes the Loop ‘N’ Tack technique as a viable tenodesis approach during shoulder arthroscopy for biceps related pathology.

Effect of Preoperative Motor Weakness on Postoperative Clinical Outcomes in Patients Undergoing Cervical Disk Replacement

Study Design: This is a retrospective review Objective: To examine the effect of preoperative motor weakness on clinical outcomes in patients undergoing cervical disk replacement (CDR). Summary of Background Data: Studies examining the effect of preoperative motor weakness on postoperative clinical outcomes in CDR are limited. Methods: Patient cohorts were based on documented upper-extremity motor weakness on physical exam versus no motor weakness. Demographics, perioperative characteristics, and preoperative patient-reported outcome measures (PROMs) were compared using univariate inferential statistics. PROMs consisted of Visual Analog Pain Scale-Neck (VAS-N), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), VAS-Arm (VAS-A), 12-Item Short Form (SF-12) Physical Component Score (PCS), Oswestry Neck Disability Index (NDI), and SF-12 Mental Component Score (MCS). Postoperative PROMs were collected at the 6-week, 12-week, 6-month, and final follow-up up to 1-yeartime points, and intercohort minimum clinically important difference (MCID) achievement was compared through multivariable linear logistic regression adjusting for significant differences in preoperative characteristics. Results: A total of 118 patients formed cohorts based on documented upper-extremity weakness (n=73) versus no weakness (n=45). The average time to postoperative follow-up was 9.7±7.0 mo. The differences in insurance type between the 2 cohorts were significant (P&lt;0.042). Perioperative diagnosis of foraminal stenosis was significantly more common in the motor weakness cohort (P&lt;0.013). There were no differences in reported PROMs between cohorts. Patients with motor weakness reported significant MCID achievement for PROMIS-PF at 6-/12-weeks (P&lt;0.012, P&lt;0.041 respectively), SF-12 PCS at 6-months (P&lt;0.042), VAS-N at final follow-up (P&lt;0.021), and NDI at final follow-up (P&lt;0.013). Conclusions: CDR patients with preoperative muscle weakness achieved MCID across several PROMs compared with patients without muscle weakness. Patients with motor weakness reported greater improvement in mental health, pain, and disability as early as 6 weeks and up to 1 year after CDR. This information serves to inform physicians that motor weakness may not indicate a negative overall outcome.

Same Day Discharge Total Knee Arthroplasty: Hospital Demonstrates Similar Outcomes to Ambulatory Surgery Center in a More Complex Patient Population

BackgroundThe purpose of this study was to compare outcomes between patients undergoing same-day discharge (SDD) total knee arthroplasty (TKA) at an ambulatory surgery center (ASC) versus a tertiary care university hospital setting. MethodsA single tertiary academic center’s institutional database was reviewed for patients who underwent primary TKA and were discharged the same day from August 2021 to January 2024. Patients who did not have at least 1 year of follow-up were excluded. Patient demographics, comorbidities, patient-reported outcome measures, emergency department visits, admissions, reoperations, and revisions were collected. Patients were stratified by the location of their surgery: ASC versus hospital. Specific criteria had to be met prior to surgery at the ASC, and the final decision regarding the location of surgery was made via shared decision-making between the patient and their surgeon. Patients who did not meet ASC criteria underwent TKA at the main hospital. Univariable analyses were used to compare groups, and multivariable logistic regression was used to determine if surgical location was a significant factor. Of the 449 TKAs meeting inclusion criteria, 63.3% (284) were performed at the ASC and 36.7% (165) at the university hospital at a mean follow-up of 1.51 years (range, 1.00 to 2.40). Of those 165 whose surgery was done at the hospital, 93.9% met at least one ASC exclusion criteria. ResultsPatients whose TKA was done at the hospital had significantly higher weight (P = 0.003), body mass index (P < 0.001), Elixhauser comorbidity index (P < 0.001), proportion of patients who had an American Society of Anesthesiologists classification of 3 (P = 0.023), and proportion of patients who required general anesthesia (P < 0.001). Additionally, patients whose TKA was done at the hospital had higher preoperative patient-reported outcome measurement information system (PROMIS) pain interference (PI) (62.0 [59.0, 66.0] versus 63.0 [61.8, 67.0]; P = 0.006), and lower physical function (PF) (39.0 [36.0, 43.0] versus 38.0 [34.0, 41.0]; P = 0.001). At 1 year, however, patients in both groups had similar PROMIS PI (53.0 [49.0, 59.0] versus 54.0 [44.0, 59.0]; P = 0.785) and PROMIS PF (47.0 [42.0, 51.0] versus 47.0 [41.0, 50.0]; P = 0.422) scores as well as similar rates of achieving minimum clinically important difference for PROMIS PI (64.4 versus 71.4%; P = 0.336) and PROMIS PF (60.5 versus 71.4%; P = 0.124). They also had a similar number of emergency department visits and admissions at 30 and 90 days, as well as similar reoperation-free (92.0 versus 93.3%; P = 0.79) and revision-free (95.5 versus 99.4%; P = 0.59) survival at 2 years ConclusionsAlthough ASCs have strict patient criteria for SDD TKA, complex patients at a tertiary university hospital can be sent home the same day with equivalent outcomes. Therefore, unhealthier patients can safely achieve SDD without compromising outcomes if done in the appropriate setting.

Poster 205: Long-Term Outcomes for Patients Undergoing Revision Hip Arthroscopy

Objectives: Previous studies have reported outcomes after revision hip arthroscopy at mid-term follow-up. These studies demonstrate that patients can expect clinical improvement and low rates of reoperation following their revision surgery. However, in comparison to primary hip arthroscopy patients they experience worse outcomes. The purpose of this study was (1) To evaluate long-term outcomes after revision hip arthroscopy and (2) to identify factors that contribute to poorer outcomes. Methods: Patients who underwent revision hip arthroscopy for FAIS between 1/2012-9/2015 were reviewed. Patients were excluded if they underwent revision hip arthroscopy for a reason other than FAIS, underwent staged or prior PAO, had Tönnis grade &gt; 1, had a history of congenital hip disorder (e.g., slipped capital femoral epiphysis), or were missing 8+ year follow-up. Patient-reported outcome (PRO) measures were collected both pre- and post-operatively including Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports Scale (HOS-SS), modified Harris Hip Score (mHHS), and international Hip Outcome Tool (iHOT-12). Minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds were calculated using the distribution and anchor methods, respectively. Rates of MCID and PASS achievement were then evaluated. Rates of reoperation including repeat revision hip arthroscopy and conversion to total hip arthroplasty (THA) were evaluated. Patients were also divided into clinical successes and failures and compared. A clinical failure was defined as failure to achieve MCID or PASS for any PRO or undergoing a reoperation. Results: A total of 43 patients (72% female; age: 30.1 ± 10.3 years; BMI: 25.8 ± 6.0 kg/m2) met criteria for inclusion. Average follow-up was 9.3 years. At last follow-up there were significant improvements across all PROs (p &lt; 0.001, for all). MCID achievement at final follow-up for each PRO was ≥ 56.5%, with achievement of MCID in any PRO occurring in 73.9% of patients. PASS achievement at final follow-up for each PRO was ≥ 29.6%, with achievement of PASS in any PRO occurring in 63.0% of patients. PASS achievement was 75.7% at two years and 75.8% at five years. Incidence of secondary revision hip arthroscopy was 23.3% and THA was 14.0%, occurring at mean 3.9 ± 2.8 years and 4.2 ± 3.0 years following index revision, respectively. 22 patients were considered clinical successes, and 21 patients were determined to be clinical failures. Both groups demonstrated similar age (28.6 ± 8.5 years vs 31.6 ± 11.9, p = 0.351), sex (77.3% female vs 66.7% female, p = 0.438), and BMI (25.7 ± 7.9 vs 25.9 ± 3.6, p = 0.915). Additionally, clinical successes and failures had similar preoperative PROs (p ≥ 0.133, for all). Presence of preoperative pain for over two years occurred more frequently in clinical failures (45.5% vs 76.2%, p = 0.039). Tönnis grade 1 was also present at a higher rate amongst clinical failures (0% vs 23.8%, p = 0.015). Conclusions: Patients undergoing revision hip arthroscopy can see significant clinical improvement, particularly within the first five years following surgery. However, some patients may see clinical decline beyond eight years post-operatively. Revision hip arthroscopy is associated with relatively high reoperation rate. Those with greater Tönnis grade on preoperative radiographs and increased prevalence of chronic preoperative pain were less likely to achieve a clinical success.

Effect of Spinopelvic Parameters on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Background: Spinopelvic parameters, including pelvic tilt (PT), sacral slope (SS), and pelvic incidence, have been developed to characterize the relationship between lumbar spine and hip motion, but a paucity of literature is available characterizing differences in spinopelvic parameters among patients with femoroacetabular impingement syndrome (FAIS) versus patients without FAIS, as well as the effect of these parameters on outcomes of arthroscopic treatment of FAIS. Purpose: To (1) identify differences in spinopelvic parameters between patients with FAIS versus controls without FAIS; (2) identify associations between spinopelvic parameters and preoperative patient-reported outcomes (PROs); and (3) identify differences in PROs between patients with stiff spines (standing-sitting ΔSS ≤10°) versus those without. Study Design: Cohort study; Level of evidence, 2. Methods: The study enrolled patients ≥18 years of age who underwent primary hip arthroscopy for treatment of FAIS with cam, pincer, or mixed (cam and pincer) morphology. Participants underwent preoperative standing-sitting imaging with a low-dose 3-dimensional radiography system and were matched on age and body mass index (BMI) to controls without FAIS who also underwent EOS imaging. Spinopelvic parameters measured on EOS films were compared between the FAIS and control groups. Patients with FAIS completed the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) before surgery and at 1-year follow-up. Outcome scores were compared between patients with stiff spines versus those without. Associations between spinopelvic parameters and baseline outcome scores were assessed with Pearson correlations. Continuous variables were compared with Student t test and/or Mann-Whitney U test, and categorical variables were compared with Fisher exact test. Results: A total of 50 patients with FAIS (26 men; 24 women; mean age, 36.1 ± 10.7 years; mean BMI, 25.6 ± 4.2) were matched to 30 controls without FAIS (13 men; 17 women; mean age, 36.6 ± 9.5 years; mean BMI, 26.7 ± 3.6). Age, sex, and BMI were not significantly different between the FAIS and control groups (P > .05). Standing PT was not significantly different between stiff and non-stiff cohorts (P = .73), but sitting PT in the FAIS group was more than double that of the control group (36.5° vs 15.0°; P < .001). Incidence of stiff spine was significantly higher in the FAIS group (62.0% vs 3.3%; P < .001). Among FAIS patients, those with stiff spines had a significantly higher prevalence of cam impingement, whereas those with non–stiff spines had a higher prevalence of mixed impingement (P = .04). No significant differences were seen in preoperative mHHS or NAHS scores or pre- to postoperative improvement in scores between FAIS patients with stiff spines versus those without (P > .05), but a greater sitting SS was found to be positively correlated with a higher baseline mHHS (r = 0.36; P = .02). Conclusion: Patients with FAIS were more likely to have a stiff spine (standing-sitting ΔSS ≤10°) compared with control participants without FAIS. FAIS patients with stiff spines were more likely to have isolated cam morphology than patient without stiff spines. Although sitting SS was positively correlated with baseline mHHS, no significant differences were seen in 1-year postoperative outcomes between FAIS patients with versus without stiff spine.

Return to Work After Anterior Cruciate Ligament Reconstruction: A Systematic Review.

The timing of return to work (RTW) after anterior cruciate ligament (ACL) reconstruction (ACLR) is a less studied milestone compared with return to sports. To systematically review the rate and postoperative timing of RTW after ACLR. Systematic review; Level of evidence, 4. This study was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. A literature search was performed in PubMed, Embase, Cochrane, and Ovid databases for clinical studies reporting RTW after ACLR, and 806 studies were identified in August 2022. A quality assessment was performed using the Methodological Index of Nonrandomized Studies (MINORS) grading system. The following data were extracted from studies: study characteristics, cohort demographics, ACLR technique, concomitant meniscal and/or cartilage procedures, preoperative patient-reported outcomes, rates of RTW, and days required for RTW after ACLR. A total of 13 studies met inclusion criteria, totaling 1791 patients (86.4% male). Wide variability was observed in the methodological quality of the assessed studies (MINORS score range, 8-17). Hamstring tendon (HT) autograft was used in 76.8% (n = 1377; mean age, 30.5 years old), allograft in 17.1% (n = 308; mean age, 33.1 years old), the ligament advanced reinforcement system in 2.5% (n = 46; mean age, 33.2 years old), bone-patellar tendon-bone autograft in 2% (n = 36; mean age, 28.5 years old), and quadriceps tendon autograft in 1.3% (n = 24; mean age, 24.1 years old). Among the included patients, 99.1% (n = 1781) reported successful RTW after surgery. The mean time to RTW was 84.2 days (range, 31.4-107.1 days) for HT and 69.5 days (range, 49-56.6 days) for allograft. While data regarding work intensity before and after ACL injury were absent, our study results suggested that patients most often RTW within 90 days of surgery. Patients with allograft ACLR may RTW earlier than patients undergoing ACLR with HT autograft.

Reverse shoulder arthroplasty for patients with cuff tear arthropathy: do clinical outcomes differ by inlay vs. onlay design?

The influence of position of the humeral tray (inlay or onlay) on clinical outcomes in reverse shoulder arthroplasty (RSA) is a topic of debate. The purpose of this study was to compare clinical and radiographic outcomes of patients with cuff tear arthropathy treated with RSA systems with inlay or onlay humeral tray design, similar neck-shaft angles, and lateralized glenospheres. This was a retrospective study of prospectively obtained data from 1 tertiary care center. We identified all patients who underwent primary RSA between 2009 and 2017 (N=511). We included 102 patients with diagnosed cuff tear arthropathy treated with RSA prostheses with a lateralized glenosphere and 135° neck-shaft angle (with either an inlay or onlay humeral tray design) who had a minimum of 2 years of follow-up (mean, 44months; range, 24-125months). Sixty-three patients (62%) had an inlay humeral tray (inlay group) and 39 (38%) had an onlay tray (onlay group). All patients underwent preoperative and postoperative evaluations, including measures of patient-reported outcomes (PROs), shoulder range of motion (ROM) testing, and radiographic imaging. Clinical relevance of changes in PROs and ROM was evaluated using published values for minimal clinically important differences. The 2 groups did not differ by demographic characteristics except for a higher proportion of women in the inlay group (75%) than in the onlay group (56%) (P=.04). Preoperative PROs and ROM were not significantly different between groups. At final follow-up, PROs and ROM were not different between groups in terms of statistical significance or clinical relevance. We found no significant differences in the rate of baseplate loosening (inlay, 3.2% vs. onlay, 5.1%, P=.63), revision surgery (inlay, 0% vs. onlay 5.1%, P=.07), acromial stress fracture (inlay, 3.2% vs. onlay, 5.1%, P=.63), prosthesis dislocation (inlay, 0% vs. onlay, 2.6%, P=.20), or scapular notching (inlay, 21% vs. onlay, 7.7%, P=.08). At 2-year minimum follow-up, the position of the humeral tray in RSA prostheses (either inlay or onlay) for cuff tear arthropathy was not associated with PROs, shoulder ROM, or rates of complications, including baseplate loosening, acromial stress fracture, and scapular notching.

Preoperative opioid use is associated with worse preoperative patient-reported outcomes in hip arthroscopy patients

ObjectivesThe purpose of this study was to define the rate of preoperative opioid use among patients undergoing hip arthroscopy, ascertain which clinical factors are associated with opioid use, and assess the effect of preoperative opioid usage on preoperative patient-reported outcome (PRO) measures. MethodsA single institution orthopedic registry was retrospectively analyzed for patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) syndrome with or without labral tear between 2015 and 2022. Patients completed Patient-Reported Outcomes Measurement Information System (PROMIS) in six domains, Numeric Pain Scores (NPS), and Musculoskeletal Outcomes Data Evaluation and Management System expectations domain preoperatively. Patients’ charts were reviewed to determine demographic factors and identify any active opioid prescription within 6 weeks before surgery. Bivariate analysis was used to determine associations between preoperative opioid use and baseline PROs. Statistically significant bivariate associations were further tested by multivariate analysis to determine independent predictors. ResultsA total of 123 patients were included (age 39.7 ​± ​12.0 years; 87 females; body mass index 27.4 ​± ​5.7 kg/m2). There were 21 patients (17%) using opioids preoperatively. Prior orthopedic or other surgery and lower education level were associated with preoperative opioid use. Patients with preoperative opioid use scored statistically significantly worse compared with those without preoperative opioid use on baseline PROMIS Physical Function (38.6 vs 40.5, p ​= ​0.01), Pain Interference (65.9 vs 60.2, p ​= ​0.001), Fatigue (60.7 vs 51.6, p ​= ​0.005), Social Satisfaction (38.2 vs 43.2, p ​= ​0.007), and Depression (54.2 vs 48.8, p ​= ​0.01). Preoperative opioid use was also associated with statistically significantly worse preoperative NPS for both the operative hip (6.3 vs 4.6, p ​= ​0.003) and whole body (3.0 vs 1.4, p ​= ​0.008). Preoperative opioid use was an independent predictor of worse baseline PROMIS Pain Interference, Fatigue, Social Satisfaction, and NPS for the operative hip. ConclusionPatients using opioids preoperatively had worse baseline PROs for physical function, pain, social satisfaction, and depression than those not using opioids preoperatively. When controlling for confounding variables, preoperative opioid use was independently predictive of worse baseline pain, fatigue, and social satisfaction. Level of EvidenceLevel III, prognostic study.

Novel 3D MRI-based volumetric assessment of rotator cuff musculature demonstrates stronger correlation with preoperative functional status when compared to the Goutallier grading scheme

The Goutallier classification (GC) is used to assess fatty atrophy in rotator cuff (RC) tears, yet limitations exist. A battery of 3-dimensional (3D) magnetic resonance imaging (MRI) volumetric scores (VSs) was developed to provide comprehensive characterization of RC pathology. The purposes of this study were to (1) describe the correlation between GC and VSs for supraspinatus changes in RC tears, (2) characterize the chronicity of RC tears using a battery of 12 VS measurements, and (3) compare GC and VSs to determine which method most closely corresponds with preoperative patient-reported outcome measures (PROMs). Preoperative shoulder MRIs were reviewed after arthroscopic RC repair. Preoperative GC stage and Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores were collected. The battery of VSs included fat infiltration (FIS), muscle size (MSS), and relative volume contribution (RCS) for each RC muscle. Backward linear regression was performed to compare GC stage with preoperative PROMIS PF and PI to determine which VS measurement most closely correlated with preoperative PROMs. Eighty-two patients underwent RC repair (mean age 55±8.2 years, 63% male, 68% GC stage ≤1). In evaluation of the supraspinatus, there was a moderate positive correlation between GC and FIS (r=0.459, P<.001); strong negative correlations were observed between MSS (r=-0.800, P<.001) and RCS (r=-0.745, P<.001) when compared to GC. A negligible linear correlation was observed between GC and preoperative PROMIS PF (r=-0.106, P=.343) and PI (r=-0.071, P=.528). On multivariate analysis, subscapularis MSS (β >0, P=.064) was a positive predictor and subscapularis FIS (β <0, P=.137), teres minor MSS (β <0, P=.141), and FIS (β <0, P=.070) were negative predictors of preoperative PF (r=0.343, P=.044); in contrast, supraspinatus MSS (β >0, P=.009) and FIS (β >0, P=.073), teres minor FIS (β >0, P=.072), and subscapularis FIS (β >0, P=.065) were positive predictors of preoperative PI (r=0.410, P=.006). Although the criterion standard in evaluation of RC pathology, GC demonstrated negligible correlation with preoperative functional disability. Alternatively, a battery of 3D VSs showed strong correlation with GC through a quantitative, comprehensive evaluation of the RC unit including several moderate predictors of preoperative functional disability.

Outcomes of Flexibility Sport Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Analysis at Minimum 2-Year Follow-up

Background: Hip arthroscopy has proved successful in treating femoroacetabular impingement syndrome (FAIS) in patients with and without borderline hip dysplasia (BHD). Despite a high prevalence of BHD in patients who participate in sports with high flexibility requirements, a paucity of literature evaluates the efficacy of hip arthroscopy in treating FAIS in flexibility sport athletes with BHD. Purpose: To compare minimum 2-year patient-reported outcomes (PROs) and achievement of clinically significant outcomes in flexibility sport athletes with BHD undergoing primary hip arthroscopy for FAIS with capsular plication with results in flexibility sport athletes without dysplasia. Study Design: Cohort study; Level of evidence, 3. Methods: Data were prospectively collected for patients undergoing primary hip arthroscopy for FAIS with BHD, defined as a lateral center-edge angle of 18° to 25°, who reported participation in a sport with a high flexibility requirement, including dance, gymnastics, figure skating, yoga, cheerleading, and martial arts, according to previous literature. These patients were matched 1:2 to flexibility sport athletes without dysplasia, controlling for age, sex, and body mass index. Preoperative and minimum 2-year postoperative PROs were collected and compared between groups. Cohort-specific minimal clinically important difference and patient acceptable symptom state achievement was compared between groups. Results: In total, 52 flexibility sport athletes with BHD were matched to 104 flexibility sport athletes without BHD. Both groups showed similar sport participation (P = .874) and a similar level of competition (P = .877). Preoperative lateral center-edge angle (22.2°± 1.6° vs 31.5°± 3.9°; P < .001) and Tönnis angle (10.9°± 3.7° vs 5.8°± 4.4°; P < .001) differed between groups. Capsular plication was performed in all cases. Both groups achieved significant improvement in all PROs (P < .001) with no differences in postoperative PROs between groups (P≥ .147). High minimal clinically important difference (BHD group: 95.7%; control group: 94.8%) and patient acceptable symptom state (BHD group: 71.7%; control group: 72.2%) achievement for any PRO was observed with no differences between groups (P≥ .835). Conclusion: Flexibility sport athletes with BHD achieved similar outcomes as those of flexibility sport athletes without BHD after hip arthroscopy for FAIS with capsular plication.