Patient reported outcomes in orthopaedics

Relationships Between PROMIS and Legacy Patient-Reported Outcome Measure (PROM) Scores in the MARS Cohort at 10-Year Follow-up

BACKGROUND

Patient-reported outcome measures (PROMs) are used to evaluate the impact of musculoskeletal conditions and their treatment on patients' quality of life, but they have limitations, such as high responder burden and floor and ceiling effects. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to address these issues but needs to be further evaluated in comparison with legacy PROMs. The goals of this study were to evaluate the floor and ceiling effects of, the correlations between, and the predictive ability of PROMIS scores compared with traditional legacy measures at 10-year follow-up in a cohort who underwent revision anterior cruciate ligament (ACL) reconstruction.

METHODS

A total of 203 patients (88.7% White; 51.7% female) who underwent revision ACL reconstruction completed the PROMIS via computer adaptive tests as well as legacy PROMs at the cross-sectional, 10-year follow-up of the longitudinal MARS cohort study (MARS cohort n = 1,234). Floor and ceiling effects and Spearman rho correlations between PROMIS and legacy measures are reported. Linear regression with quadratic terms were used to develop and evaluate conversion equations to predict legacy scores from the PROMIS.

RESULTS

No floor or ceiling effects were reported for the PROMIS Physical Function (PF) domain, whereas a floor effect was found for 37.9% of the participants for the PROMIS Pain Interference (PI) domain, and a ceiling effect was found for 34.0% of the participants for the PROMIS Physical Mobility (PM) domain. PROMIS domains correlated moderately with the International Knee Documentation Committee total subjective score (absolute value of rho [|ρ|] = 0.68 to 0.74), fairly to moderately with the Knee injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index scores (|ρ| = 0.52 to 0.67), and fairly with the Marx Activity Rating Scale (|ρ| = 0.35 to 0.44). None of the legacy-measure scores were accurately predicted by the PROMIS scores.

CONCLUSIONS

The PROMIS PF domain has value in assessing patients 10 years after revision ACL reconstruction. Because of floor and ceiling effects, using the PI and PM domains may not allow for precision when measuring long-term changes in pain and mobility. Although the PROMIS measures correlated with the legacy measures, with effect sizes ranging from fair to moderate, the legacy scores were not accurately predicted by the PROMIS. The results suggest that knee-specific legacy measures should not be eliminated from long-term follow-up when the goal is to capture the specific knee-related information that they provide.

LEVEL OF EVIDENCE

Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Using artificial intelligence to develop a measure of orthopaedic treatment success from clinical notes

Introduction

A readily available outcome measure that reflects the success of a patient's treatment is needed to demonstrate the value of orthopaedic interventions. Patient-reported outcome measures (PROMs) are survey-based instruments that collect joint-specific and general health perceptions on symptoms, functioning, and health-related quality of life. PROMs are considered the gold standard outcome measure in orthopaedic medicine, but their use is limited in real-world practice due to challenges with technology integration, the pace of clinic workflows, and patient compliance. Clinical notes generated during each encounter patients have with their physician contain rich information on current disease symptoms, rehabilitation progress, and unexpected complications. Artificial intelligence (AI) methods can be used to identify phrases of treatment success or failure captured in clinical notes and discern an indicator of treatment success for orthopaedic patients.

Methods

This was a cross-sectional analysis of clinical notes from a sample of patients with an acute shoulder injury. The study included adult patients presenting to a Level-1 Trauma Center and regional health system for an acute Proximal Humerus Fracture (PHF) between January 1, 2019 and December 31, 2021. We used the progress note from the office visit for PHF-related care (ICD10: S42.2XXX) or shoulder pain (ICD10: M45.2XXX) closest to 1-year after the injury date. Clinical notes were reviewed by an orthopaedic resident and labeled as treatment success or failure. A structured comparative analysis of classifiers including both machine and deep learning algorithms was performed.

Results

The final sample included 868 clinical notes from patients treated by 123 physicians across 35 departments within one regional health system. The study sample was stratified into 465 notes labeled as treatment success and 403 labeled as treatment failure. The Bio-ClinicalBERT model had the highest performance of 87% accuracy (AUC = 0.87 ± 0.04) in correctly distinguishing between treatment success and failure notes.

Discussion

Our results suggest that text classifiers applied to clinical notes are capable of differentiating patients with successful treatment outcomes with high levels of accuracy. This finding is encouraging, signaling that routinely collected clinical note content may serve as a data source to develop an outcome measure for orthopaedic patients.

Why I Want Bunion Surgery-the Patient's Preoperative and Postoperative Perspective

BACKGROUND

Hallux valgus is the most common pathology afflicting the hallux. Surgery is generally offered to symptomatic patients who fail conservative treatment. The aim of this study is to evaluate patient-reported reasons for undergoing hallux valgus corrective surgery in a preoperative and postoperative cohort.

METHODS

We performed a prospective and retrospective cross-sectional study. Our study included all patients aged >18 years who were planning to or have had hallux valgus surgery during the study period. An information sheet including 14 possible reasons for having hallux valgus surgery and a questionnaire to rank each reason (1-10) was sent to all patients. Patients were divided into a preoperative group and a postoperative group to eliminate bias. In our study we had 101 patients, 5 males and 96 females, at an average age of 50.6 years.

RESULTS

The preoperative cohort included 51 patients and the postoperative cohort 50 patients. The 3 most important reasons for having surgery, in both cohorts, were the ability to move pain free, eliminate pain over bunion, and to be able to walk long distance and over uneven terrain without pain. The 3 least important factors were to reduce the need for an orthotic, narrower foot, and to wear high heels. Indications were divided into one of 4 categories. Pain was the highest-rated category in both pre and postoperative groups, followed by function. In the preoperative group, appearance was the next most important group and shoe wear the least. In comparison, in the postoperative group, shoe wear was more important than appearance.

CONCLUSION

Pain and function are the most important reasons patients have for surgery in both the preoperative and postoperative patient cohorts. Patients were more likely to list cosmesis as a reason to undergo surgery in the preoperative than the postoperative group.

Does Discussing Patient-reported Outcome Measures Increase Pain Self-efficacy at an Orthopaedic Visit? A Prospective, Sequential, Comparative Series

BACKGROUND

Pain self-efficacy, or the ability to carry out desired activities in the presence of pain, can affect a patient's ability to function before and after orthopaedic surgery. Previous studies suggest that shared decision-making practices such as discussing patient-reported outcome measures (PROMs) can activate patients and improve their pain self-efficacy. However, the ability of PROMs to influence pain self-efficacy in patients who have undergone orthopaedic surgery has yet to be investigated.

QUESTIONS/PURPOSES

(1) Is immediately discussing the results of a PROM associated with an increase pain self-efficacy in new patients presenting to the orthopaedic surgery clinic? (2) Is there a correlation between patient resilience or patient involvement in decision-making in changes in pain self-efficacy?

METHODS

This was a prospective, sequential, comparative series completed between February to October 2023 at a single large tertiary referral center at a multispecialty orthopaedic clinic. Orthopaedic subspecialties included total joint arthroplasty, spine, hand, sports, and trauma. The first 64 patients underwent standard care, and the following 64 had a conversation with their orthopaedic surgeon about their PROMs during the initial intake visit. We collected scores from the Pain Self-Efficacy Questionnaire (PSEQ), Brief Resilience Scale (BRS), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function form (PF-SF10a) and data on demographic characteristics before the visit. The PSEQ is a validated PROM used to measure pain self-efficacy, while the BRS measures the ability of patients to recover from stress, and the PROMIS PF-SF10a is used to assess overall physical function. PROMs have been utilized frequently for their ability to report the real-time physical and psychological well-being of patients. In the standard care group, the PROMIS PF-SF10a score was not discussed with the patient. In the PROMs group, the physician discussed the PROMIS PF-SF10a score using a script that gave context to the patient's score. Additional conversation about the patient's score was permitted but not required for all patients. Scores from the Observing Patient Involvement in Decision Making (OPTION-5) instrument were recorded during the visit as a measure of patient involvement in clinical decision-making. After the visit, both groups completed the PSEQ. The primary outcome was change in the PSEQ. Change in pain self-efficacy was recorded as greater or less than the minimum clinically important difference, previously defined at 8.5 points for the PSEQ [ 10 ]. The secondary outcomes were correlation between PSEQ change and the BRS or OPTION-5.

RESULTS

Between the PROMs and standard care groups, there was no difference in the change in PSEQ scores from before the visit to after (mean ± SD change in control 4 ± 10 versus change in PROMs group 3 ± 7, mean difference 1 [95% confidence interval (CI) -2.0 to 4.0]; p = 0.29). Fifty-six percent (36 of 64) of patients in the standard care group demonstrated an increase in pain self-efficacy (of whom 22% [14 of 64] had clinically important improvements), and 59% (38 of 64) of patients in the PROMs group demonstrated an increase in pain self-efficacy (of whom 19% [12 of 64] had clinically important improvements). In the control group, there was no correlation between the change in PSEQ score and resiliency (BRS score r = -0.13 [95% CI -0.36 to 0.12]; p = 0.30) or patient involvement in decision-making (OPTION-5 r = 0.003 [95% CI -0.24 to 0.25]; p = 0.98). Similarly, in the PROMs group, there was no correlation between the change in PSEQ score and resiliency (BRS score r = -0.10 [95% CI -0.33 to 0.16]; p = 0.45) or patient involvement in decision-making (OPTION-5 r = -0.02 [95% CI -0.26 to 0.23]; p = 0.88).

CONCLUSION

Discussing PROMs results (PROMIS PF-SF10a) at the point of care did not increase pain self-efficacy during one visit. Therefore, surgeons do not need to discuss pain self-efficacy PROM scores in order to influence patient pain self-efficacy. While PROMs remain valuable tools for assessing patient outcomes, further work may assess whether the collection of PROMs itself may increase pain self-efficacy or whether longitudinal discussion of PROMs with patients changes pain self-efficacy.

LEVEL OF EVIDENCE

Level II, therapeutic study.

A high proportion of patients demonstrate recall bias in the retrospective collection of patient-reported outcomes following hip arthroscopy

PURPOSE

The aim of this study is to assess agreement between retrospectively and prospectively collected patient-reported outcome measures (PROMs) following hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Patients undergoing hip arthroscopy from 2021 to 2023 for FAIS completed preoperative PROMs, including the modified Harris Hip Score (mHHS) and the Non-Arthritic Hip Score (NAHS). Post-operatively, patients were surveyed and asked to recall their preoperative hip function. Paired two-sample t tests were used to compare baseline and recalled baseline PROMs and the difference between scores was compared to previously published minimally clinically important difference (MCID) values. Intraclass correlation coefficients (ICCs) were calculated to test the reliability between scores based on a single-rater, two-way mixed-effects model. Multivariable regression, accounting for age, sex and preoperative baseline scores, was used to evaluate the relationship of time elapsed since surgery with recall accuracy.

RESULTS

A total of 116 patients (age: 37.6 ± 11.8 years; 61.2% female) were included. The mean time elapsed for recalled data was 13.1 months (range: 1-27 months). Overall, patients' recalled scores were significantly lower than those prospectively collected (mHHS: 52.9 ± 20.1 vs. 61.5 ± 18.5, p < 0.0001; NAHS: 54.7 ± 20.0 vs. 58.8 ± 19.1, p < 0.0001). Frequency distribution found 68.1% of recalled mHHS and 61.2% of NAHS scores to have a greater difference (between baseline and recalled scores) than the MCID. The ICC was moderate for both mHHS (ICC = 0.559, 95% confidence interval [CI] = [0.420-0.672], p < 0.001) and NAHS (ICC = 0.612, 95% CI = [0.484-0.714], p < 0.001). Multivariate regression analysis did not find time elapsed since surgery to be associated with the difference between baseline and recalled mHHS (n.s.) or NAHS (n.s.).

CONCLUSION

There are significant differences between retrospective and prospectively collected PROMs in patients undergoing hip arthroscopy that are not predicted by time to recall. These findings should impact the interpretation of the existing literature, support the routine collection of prospective data and inform patient counsel regarding their perceived post-operative outcomes.

LEVEL OF EVIDENCE

Level IV.

Assessing Physician and Patient Agreement on Whether Patient Outcomes Captured in Clinical Progress Notes Reflect Treatment Success: Cross-Sectional Study

BACKGROUND

It remains unclear if there is agreement between physicians and patients on the definition of treatment success following orthopedic treatment. Clinical progress notes are generated during each health care encounter and include information on current disease symptoms, rehabilitation progress, and treatment outcomes.

OBJECTIVE

This study aims to assess if physicians and patients agree on whether patient outcomes captured in clinical progress notes reflect a successful treatment outcome following orthopedic care.

METHODS

We performed a cross-sectional analysis of a subset of clinical notes for patients presenting to a Level-1 Trauma Center and Regional Health System for follow-up for an acute proximal humerus fracture (PHF). This study was part of a larger study of 1000 patients with PHF receiving initial treatment between 2019 and 2021. From the full dataset of 1000 physician-labeled notes, a stratified random sample of 25 notes from each outcome label group was identified for this study. A group of 2 patients then reviewed the sample of 100 clinical notes and labeled each note as reflecting treatment success or failure. Cohen κ statistics were used to assess the degree of agreement between physicians and patients on clinical note content.

RESULTS

The average age of the patients in the sample was 67 (SD 13) years and 82% of the notes came from female patients. Patients were primarily White (91%) and had Medicare insurance coverage (65%). The note sample came from fracture-related encounters ranging from the second to the tenth encounter after the index PHF visit. There were no significant differences in patient or visit characteristics across concordant and discordant notes labeled by physicians and patients. Among agreement levels ranging from poor to perfect agreement, physician and patient evaluators exhibited only a fair level of agreement in what they deemed as treatment success based on a Cohen κ of 0.32 (95% CI 0.10-0.55; P=.01). Furthermore, interpatient and interphysician agreement also demonstrated relatively low levels of agreement.

CONCLUSIONS

The findings suggest that physicians and patients demonstrated low levels of agreement when assessing whether a patient's clinical note reflected a successful outcome following treatment for a PHF. As low levels of agreement were also observed within physician and patient groups, it is clear the definition of success varied highly across both physicians and patients. Further research is needed to elucidate physician and patient perceptions of treatment success. As outcome measurement and demonstrating the value of orthopedic treatment remain important priorities, it is important to better define and reach a consensus on what treatment success means in orthopedic medicine.

Clinically Relevant Thresholds for Hip Arthroscopy Vary: A Systematic Review

PURPOSE

To identify the patient acceptable symptom state (PASS) and substantial clinical benefit (SCB) thresholds for hip arthroscopy and provide guidance on how to choose among the thresholds.

METHODS

A systematic review of literature was conducted in PubMed and MEDLINE databases in August 2024 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies with Level I to IV evidence that defined SCB or PASS thresholds for patient-reported outcomes for hip arthroscopy in the setting of intra-articular pathology were included. Case reports, review, technique, and non-English articles were excluded. Title, authors, publication date, study design, patient demographics, timepoint of interest, threshold values, anchor information, and calculation method were recorded.

RESULTS

In total, 35 studies met the inclusion criteria, with 102 PASS thresholds and 82 SCB thresholds being defined across 13 patient-reported outcomes. Hip Outcome Score-Sport-Specific Subscale was the most commonly defined PASS threshold with 22 designations at the 12-, 24-, 60-, and 120-month periods ranging from 63.9-75, 64.3-82.3, 75.2-86.8, and 60.2-61.1, respectively. The International Hip Outcome Tool was the most commonly defined threshold for SCB, with 18 thresholds designations at the 12-, 24-, and 60-month periods ranged from 72.6-86.0, 66.7-86.0, and 86.1-87.5.

CONCLUSIONS

Clinically relevant thresholds exhibit significant variability depending on the characteristics of the specific cohort. This study identified several key factors contributing to the heterogeneity in PASS and SCB values, including (1) the anchor questions used, particularly for SCB, (2) the criteria defining responders versus non-responders, (3) the follow-up time at the time point of interest, (4) sample size, and (5) the demographics of the patient population. When determining which threshold to use, surgeons should prioritize those that align closely with the follow-up timepoint of interest for the specific procedure for more accurate comparisons.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Comparison of four patient reported outcome measures in patients with ankle fracture: A study on patient preferences and psychometric properties

BACKGROUND

The aim was to assess psychometric properties of Manchester Oxford Foot Questionnaire (MOXFQ), the Self-reported Foot and Ankle Score (SEFAS), the Olerud Molander Ankle Score (OMAS), and the Forgotten Joint Score (FJS) in adults with ankle fractures.

METHODS

Patients received all four questionnaires 6, 12, 14, 24, 52, and 104 weeks following an ankle fracture. According to COSMIN guidelines, statistical tests were performed to assess floor- and ceiling effects, structural validity, construct validity and reliability. Cognitive interview was performed with 9 patients.

RESULTS

MOXFQ showed best model fit in Confirmatory Factor Analysis. When testing construct validity, all hypotheses were accepted except for OMAS and FJS. All questionnaires had an almost perfect test-retest reliability (Interclass Correlation Coefficient 0.81 to 0.91) and Cronbach's alpha ranged from 0.76 to 0.95. MOXFQ was the best rated questionnaire.

CONCLUSION

All questionnaires performed well and we recommend MOXFQ for future use in ankle fracture studies.

LEVEL OF EVIDENCE

Level IV.

Research as an Early-Career Sports Surgeon: Keys to Success

Research as an early-career surgeon is challenging. The resources that you had as a trainee are not established yet and it can be difficult to balance while learning to be an effective clinician and surgeon. Starting early, however, before clinical and leadership responsibilities build up is a key to developing a successful research program. There are tangible steps that you can take to build the foundation of the program which will be reviewed. Rejections from journals and grant agencies are common and not a sign of your work and effort.

Increased Activity Level Following Total Ankle Replacement Results in Improved Patient Reported Outcomes

While evidence highlights increased activity levels following total ankle replacement (TAR), the correlation between postoperative activity changes and ankle-surgery-specific patient-reported outcomes is unexplored. This retrospective cohort study investigates the effect of activity level changes on patient-reported outcomes, including the Manchester-Oxford Foot Questionnaire (MOXFQ) and patient satisfaction following TAR. Patient records from a single center performing TARs between January 2014 and February 2023 were reviewed alongside patient questionnaires completed preoperatively and at a mean follow-up of 44 ± 31 months postoperatively (range 6-134 months). Activity participation pre and postoperatively was assessed and correlated with MOXFQ scores. Data from 89 patients was available for analysis (mean age 72.3 ± 8.9 years [range, 48-92]). Postoperatively, 31 patients (35%) increased, 42 (47%) maintained, and 16 (18%) decreased their activity levels. The mean time to return to regular activity was 23.4 weeks. Preoperative MOXFQ scores were similar across all groups (increased: 74.03 ± 14.00; maintained: 73.6 ± 13.9; decreased: 77.0 ± 15.5; p = .71). All groups showed significant improvements in MOXFQ scores from preoperative to postoperative assessments (p < .05). Patients with increased activity levels showed greater MOXFQ improvements (-61.6 ± 19.0) compared to those with decreased activity levels (-38.3 ± 26.6) (p < .01). Following TAR, 82% of patients maintained or increased their activity levels. Patients with increased postoperative activity exhibited superior improvements in MOXFQ scores. These findings underscore the importance of promoting physical activity for optimal outcomes following TAR.

Clinical relevance of current patient-reported outcome measures for ankle fracture: surgeons' perspective

Objectives

Determine the relevance of the most frequently used patient-reported outcome measures (PROMs) for monitoring patient recovery after ankle fracture, from the clinical perspective of orthopaedic trauma surgeons, given lack of validated PROMs.

Design

Prospective cohort.

Setting

Orthopaedic Trauma Association committee meetings, electronic correspondence.

Patients/Participants

Orthopaedic trauma surgeons.

Intervention

Delphi method for consensus activities.

Level of Evidence

IV.

Main Outcome Measurements

Most clinically relevant PROMs for ankle fracture recovery.

Results

Several English-language PROMs were identified based on use in literature and relevance to ankle fractures. 7 were selected by expert consensus. These are the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopaedic Surgeons (AAOS), Foot and Ankle Disability Index (FADI) Score, Lower Extremity Functional Scale (LEFS), Olerud-Molander Ankle Score (OMAS), and Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF). The most clinically relevant PROM is the A-FORM, followed by the AAOS, LEFS, PROMIS PF, FADI, and OMAS, and the least clinically relevant overall, the FAAM.

Conclusions

Understanding which PROM best matches physician expectations for tracking recovery is an important step toward a robust, evidence-based approach to patient care. The A-FORM was identified as the most clinically relevant among the most used PROMs. These results will aid surgeons, clinicians, and scientists to identify a uniformly, clinically relevant PROM for the treatment and study of outcomes and recovery after isolated ankle fracture.

Previous Hip or Knee Arthroplasty is Associated With Less Favorable Patient-reported Outcomes of Lumbar Surgery

STUDY DESIGN

Review of cohort studies.

OBJECTIVE

To ascertain if previous hip (THA) or knee (TKA) arthroplasty was associated with patients' outcomes assessments of subsequent lumbar surgery, specifically overall satisfaction, less disability due to pain, and an affective appraisal reflecting emotional assessment of results.

BACKGROUND

Hip, knee, and lumbar symptoms often co-exist and increasingly are managed with surgery. Whether previous total joint arthroplasty (TJA) impacts patients' perspectives of results of subsequent lumbar surgery is not known.

METHODS

Identical and systematically acquired preoperative and postoperative data from 3 studies assessing psychosocial characteristics and outcomes of lumbar surgery were pooled. Data obtained during interviews included preoperative demographic and clinical variables and 2-year postoperative global overall assessment (very satisfied/satisfied, neither, dissatisfied/very dissatisfied) and global affective assessment (delighted/pleased, mostly satisfied/mixed/mostly dissatisfied, unhappy/terrible). Patients completed the ODI and preoperative to postoperative change was analyzed according to an MCID (15 points). At 2 years patients also reported any untoward events since surgery (ie, fracture, infection, or repeat lumbar surgery). Associations with outcomes were assessed with multivariable logistic ordinal regression controlling for untoward events. Type of arthroplasty was evaluated in subanalyses.

RESULTS

Among 1227 patients (mean: 59 y, 50% women), 12% had arthroplasty (+TJA) and 88% did not (-TJA). In multivariable analysis, +TJA was associated with less global satisfaction (OR: 1.9, CI: 1.3-2.7, P=0.0007), worse global affective assessment (OR: 1.6, CI: 1.1-2.2, P=0.009), and not meeting MCID15 (OR: 1.5, CI: 1.0-2.3, P=0.05). Covariables associated with less favorable outcomes were not working, positive depression screen, and prior lumbar surgery. Compared with -TJA, patients with THA had worse affective assessments and patients with TKA had less satisfaction and were less likely to meet MCID15.

CONCLUSIONS

Previous hip or knee arthroplasty was associated with less favorable patient-reported outcomes of lumbar surgery. Surgeons and patients should discuss differences between procedures preoperatively and during shared postoperative outcome assessment.

LEVEL OF EVIDENCE

Level II.

Cross-Cultural Adaptation and Validation of Foot and Ankle Ability Measure (FAAM) for Arabic-Speaking Patients

BACKGROUND

The original English Foot and Ankle Ability Measure (FAAM) is widely adopted to track changes in foot and ankle function. The aim of this study is to translate it to an Arabic version of FAAM (FAAM-A), and then to assess the validity and reliability of the FAAM-A version.

METHODOLOGY

One hundred five consecutive Arabic-speaking participants with different foot and ankle pathologies completed the FAAM-A. Fifty-six males and 49 females with a mean age of 39.8 years; 78.1% respondents have completed high school or higher. Convergent and divergent validities were assessed using correlation coefficients between the FAAM-A subscales and the short form-36 (SF-36), physical function (PF), physical component summary (PCS), mental health (MH), and mental component summary (MCS). Cronbach's alpha was calculated to assess internal consistency. A subgroup of 20 participants filled the FAAM-A twice to test for test-retest reliability, using intraclass correlation coefficients (ICCs) and minimal detectable changes (MDCs).

RESULTS

The average FAAM-A was 55.32 and 43.23 for the activity of daily life (ADL) and Sports subscales, respectively. FAAM-A ADL subscale had a moderate correlation with the PF, 0.565; PCS, 0.546; and MCS, 0.447; and a low correlation with MH, 0.34. The sports subscale had a moderate correlation with the PF (0.529), PCS (0.513), and a low correlation with MCS (0. 395) and MH (0. 297). Cronbach's alpha was 0.97 and 0.95 for ADL and sports subscales, respectively. Intraclass correlation coefficient was 0.99 for both subscales. Minimal detectable change at a 95% confidence level was 6.81 and 8.19 for the ADL and sports subscales, respectively.

CONCLUSION

The FAAM-A is proven to be valid and reliable instrument for assessing foot and ankle disability. It is an effective tool for clinical assessment and research within Arabic-speaking populations.

LEVEL OF EVIDENCE

Level II, Prospective cohort study.

Simple Hip Value: a simple score to evaluate Hip function

BACKGROUND

Several self-administered questionnaires are available for assessing hip function in clinical practice (HOOS-12, Oxford-12). These questionnaires can be used to assess and monitor patients with hip pathology. However, they are sometimes difficult to deploy in clinical practice. Recent studies on the shoulder and knee have shown that a single-question assessment provides a relevant evaluation of joint function, and correlates with more complex scores. However, this has not yet been evaluated for the hip. We set out to develop a single-question test that would enable patients to assess their hip function between 0 and 100. Therefore, we did a prospective study aiming to assess: (1) the relevance of the SHV (Simple Hip Value) test by comparing it with the Oxford-12 and HOOS-12 scores, (2) the discriminatory capacity and reproducibility of this test.

HYPOTHESIS

The hypothesis of this study was that the assessment of hip function by a single-question patient-completed questionnaire (PROM) would be reliable and useful in clinical practice.

PATIENTS AND METHODS

We conducted a prospective study including 74 patients operated on for total hip arthroplasty from February 2020 to April 2021 in a high-volume center and 20 healthy subjects. The SHV questionnaire, as well as HOOS-12 and OXFORD-12 were submitted on average 18 months after surgery, with values scaled to 100 points. A second test containing the 3 questionnaires was resubmitted to 20 patients randomly chosen from hip arthroplasty group to evaluate the reproducibility of the test. To evaluate the discrimination capacity of our test, 20 controls were selected to respond to the three questionnaires.

RESULTS

Test results were median SHV, Oxford-12 and HOOS-12 scores of 90/100 (Interquartile Range [IQR]: 80-95), 88.5 (IQR: 77.1-95.8) and 79.1 (IQR: 65.1-93.2), respectively. The SHV was strongly correlated with the Oxford-12 (Spearman coefficient: 0.63 [IQR: 0.45-0.76]) and the HOOS-12 (Spearman coefficient: 0.66 [IQR: 0.46-0.79]). The SHV differed significantly from the control group (90.0 vs 100.0 in the control group [p < 0.001]) and had excellent reproducibility (Interclass Correlation Coefficient [ICC]: ICC: 0.82 [CI95%, 0.59-0.93]).

DISCUSSION

The SHV test seems to be a reliable, reproducible and discriminating tool for assessing hip function after total hip arthroplasty, thus offering a simplified and practical approach for practitioners. Further testing in different populations would be useful to validate this test.

LEVEL OF EVIDENCE

III; prospective comparative diagnostic study.

Dedicated locking plate reduces non-union risk in open ankle fusion in obese patients

INTRODUCTION

Obesity is a growing public health concern. In ankle osteoarthritis, non-conservative treatment in advanced stages consists in ankle fusion, or else total ankle replacement, for which obesity is a relative contraindication. One of main complications of ankle fusion is non-union. Devascularization, obesity and fixation material are all factors involved in postoperative non-union, and have to be taken into account in surgical strategy for reliable results. The objective of this study was to compare the rate of ankle non-union in obese patients using quadruple screwing or a dedicated locking plate. The hypothesis was that the locking plate limits the risk of non-union in this population.

METHODS

All patients were obese (BMI>30kg/m2) and presented ankle osteoarthritis with>10° intra-articular deformity. The approach and joint preparation were performed via an anteromedial approach. Group S was composed of 32 patients, operated on by quadruple screwing; group P comprised 10 patients operated on using a dedicated locking plate. The main endpoint was a significant difference in the rate of non-union between the 2 groups. The secondary endpoint was improvement in pre- and 6-month postoperative AOFAS score.

RESULTS

Group S presented 31% non-union (10/32) and group P 0% (0/10) (p<0.05). Postoperative AOFAS score was significantly higher in group P: 67.8±10.4 [range, 40-92] vs. 83.1±8.0 [range, 64-92] (p<0.05).

CONCLUSION

The dedicated anterior locking plate is a technique of choice for ankle fusion in obese patients with intra-articular deformity>10°, to limit the risk of non-union.

LEVEL OF EVIDENCE

IV; retrospective study.

Health Numeracy Is Associated With a Patient's Ability to Interpret Patient-Reported Outcome Measures Data

BACKGROUND

Patient-reported outcome measures (PROMs) were originally developed as research tools; however, there is increasing interest in using PROMs to inform clinical care. Prior work has shown the benefits of implementing PROMs at the point of care, but a patient's health numeracy (their ability to understand and work with numbers) may affect their ability to interpret PROM results.

MATERIALS AND METHODS

We recruited patients presenting to an outpatient orthopedic clinic. Forty-nine patients completed a survey that included demographic information, the short-form General Health Numeracy Test, and accuracy questions about four PROM displays (bar graph, table, line graph, pictograph) that indicated the same PROM results.

RESULTS

Patients with higher health numeracy answered all display accuracy questions correctly (P=.016). Patients who preferred using the table were more likely to answer display accuracy questions incorrectly (odds ratio, 0.013, P=.024). The two most frequently preferred PROM formats were bar graphs and tables, and most patients preferred to learn about their PROM function scores via a combination of displays and verbal discussions.

CONCLUSION

Patient health numeracy is associated with the ability to correctly interpret visual displays of PROMs. Implementation of PROMs at point of care currently does not account for health numeracy. Efforts to account for health numeracy when using PROMs at point of care may improve the efficacy of using PROMs to improve outcomes in orthopedic surgery. [Orthopedics. 2024;47(5):e255-e260.].

4 Domain Sports PROM in Spanish: Cross-cultural adaptation in the Chilean population and reliability analysis

BACKGROUND

Patient-Reported Outcome Measures (PROMs) are tools of increasing interest in the sports population. The purpose of this study was to perform the cross-cultural adaptation and reliability analysis of the 4 Domain Sports Patient-Reported Outcome Measure (4DSP) into Spanish.

METHODS

A six-stage cross-cultural adaptation protocol was executed to obtain the Spanish version of the 4DSP (S-4DSP). Subsequently, the questionnaire was administered to a population of 108 postoperative athletes with ACL (Anterior Cruciate Ligament) injuries. The questionnaire was administered again after 30 days. Acceptability, floor and ceiling effects, internal consistency (Cronbach's alpha), and reproducibility (Intraclass Correlation) were evaluated.

RESULTS

The S-4DSP was fully completed by 108 participants (mean age 34±10.75, 26% women), achieving 100% acceptability. No floor effect was detected. The statistical analysis yielded a global Cronbach's alpha for the questionnaire of 0.65, and domain-specific alphas of 0.88, 0.72, 0.27, and 0.68 for the first, second, third, and fourth domains, respectively. The Intraclass Correlation test reached a maximum of 0.94 and a minimum of 0.48 for the first and fifth questions, respectively.

CONCLUSIONS

The S-4DSP is a reliable and useful tool for evaluating Spanish-speaking athletes after ACL reconstruction.

[Translated article] 4 Domain Sports PROM in Spanish: Cross-cultural adaptation in the Chilean population and reliability analysis

BACKGROUND

Patient-Reported Outcome Measures (PROMs) are tools of increasing interest in the sports population. The purpose of this study was to perform the cross-cultural adaptation and reliability analysis of the 4 Domain Sports Patient-Reported Outcome Measure (4 DSP) into Spanish.

METHODS

A six-stage cross-cultural adaptation protocol was executed to obtain the Spanish version of the 4 DSP (S-4DSP). Subsequently, the questionnaire was administered to a population of 108 postoperative athletes with ACL (Anterior Cruciate Ligament) injuries. The questionnaire was administered again after 30 days. Acceptability, floor and ceiling effects, internal consistency (Cronbach's alpha), and reproducibility (Intraclass Correlation) were evaluated.

RESULTS

The S-4DSP was fully completed by 108 participants (mean age 34±10.75, 26% women), achieving 100% acceptability. No floor effect was detected. The statistical analysis yielded a global Cronbach's alpha for the questionnaire of 0.65, and domain-specific alphas of 0.88, 0.72, 0.27, and 0.68 for the first, second, third, and fourth domains, respectively. The Intraclass Correlation test reached a maximum of 0.94 and a minimum of 0.48 for the first and fifth questions, respectively.

CONCLUSIONS

The S-4DSP is a reliable and useful tool for evaluating Spanish-speaking athletes after ACL reconstruction.

Defining the Patient Acceptable Symptom State (PASS) for PROMIS After Total Ankle Replacement

BACKGROUND

Although patient-reported outcomes (PROs), such as the Patient-Reported Outcomes Measurement Information System (PROMIS), are a key element of evaluating success after total ankle replacement (TAR), many do not explicitly state a key factor of postoperative success: is the patient satisfied with their outcome after TAR? The patient acceptable symptom state (PASS) represents the symptom threshold beyond which patients consider themselves well. This study aimed to establish the PROMIS thresholds for the PASS in a primary cohort of TAR patients.

METHODS

This single-institution study included 127 primary TAR patients with preoperative and 2-year postoperative PROMIS scores. At 2 years postoperatively, patients answered 2 PASS anchor questions (Satisfaction, Delighted-Terrible scale) with Likert-scale responses. PASS thresholds with 95% confidence intervals (CIs) were calculated from PROMIS scores using an anchor-based method. Using a bootstrapping technique with 1,000 iterations, the Youden index was calculated to determine the best specificity and sensitivity coordinates to maximize their combination. Finally, preoperative variables associated with the likelihood of achieving the PASS were assessed.

RESULTS

There was a strong association between PASS thresholds and PROMIS domains, especially Pain Interference (PASS threshold of <56.0, area under the receiver operating characteristic curve [AUC] = 0.940), Pain Intensity (<48.4, AUC = 0.936), and Physical Function (>44.7, AUC = 0.883). The likelihood of achieving the PASS was not affected by age, race, gender, American Society of Anesthesiologists (ASA) class, body mass index, or severity of ankle deformity. Patients with worse preoperative Physical Function and Global Mental Health scores were less likely to meet the PASS threshold for Physical Function postoperatively (p = 0.028 and 0.041).

CONCLUSIONS

The ability to reach the PASS after TAR was most strongly associated with postoperative PROMIS pain scores. However, PASS thresholds were generally poorer than population means. This demonstrates that patients do not need to reach normal pain or physical function levels to have an acceptable symptom state after TAR.

LEVEL OF EVIDENCE

Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Variability of MCID, SCB, and PASS Thresholds in Studies Assessing Patient-Reported Outcomes After Rotator Cuff Repair: A Systematic Review

BACKGROUND

An increasing reliance on patient-reported outcomes has led to greater emphasis on minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) thresholds in assessing rotator cuff repairs.

PURPOSE

To review the MCID, SCB, and PASS thresholds reported for patient-reported outcome measures (PROMs) after rotator cuff repair.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PubMed, Embase, Ovid, Cochrane, and Google Scholar databases were queried for full-text journal articles in English published between January 1, 2000, and May 31, 2022. Studies with MCID, SCB, and PASS thresholds reported for patients with rotator cuff repair and a minimum of 12 months of follow-up were included. Reported MCID, SCB, and PASS thresholds and associated calculation methods were extracted.

RESULTS

There were 41 unique studies (6331 shoulders) that met the inclusion criteria. Of these, 37 (90%) reported MCID; 16 (39%), PASS; and 11 (27%), SCB values. The most common PROMs were the American Shoulder and Elbow Surgeons score and the Constant-Murley score. In total, 71% (29/41) of these studies referenced values in the literature, usually studies of patients undergoing rotator cuff repair (21/29). Twelve studies calculated MCID, SCB, or PASS thresholds using anchor-based approaches, whereas 6 studies also calculated thresholds using distribution-based methods. The use of MCID, SCB, and PASS in the rotator cuff repair literature is increasing, with half of the included studies published within the final 17 months of the studied period.

CONCLUSION

Significant variability was seen in the reporting of MCID, SCB, and PASS threshold values after rotator cuff repair. Researchers should prioritize studies that report clinical outcome thresholds calculated using anchor-based methods and should critically review both the anchor question and its response choices. Standardization of MCID, SCB, and PASS values and calculation methods will allow for a more reliable assessment of PROMs in rotator cuff repair moving forward.

Patient-Reported and Clinical Outcomes After Tendon Autograft Reconstruction of the Thumb Ulnar Collateral Ligament

PURPOSE

This study aimed to report clinical and patient-reported outcomes collected in a registry after thumb ulnar collateral ligament (UCL) reconstruction with a free tendon autograft. Furthermore, the patient-reported outcomes of patients with persistent instability after reconstruction and patients with concomitant metacarpophalangeal joint arthritis diagnosed during surgery were analyzed.

METHODS

Patients undergoing reconstruction with a tendon autograft between December 2011 and February 2021 were included. Michigan Hand Outcomes Questionnaire (MHQ) scores at baseline were compared with those at 3 and 12 months after surgery. Stability was tested at 3 months after surgery. Tip and key pinch strength and metacarpophalangeal joint range of motion were measured at baseline and 12 months after surgery.

RESULTS

We included 31 patients with thumb UCL insufficiency or failed UCL surgery who underwent reconstruction. The MHQ total score improved significantly from 62 at baseline to 75 at 3 months and continued to increase to 84 at 12 months after surgery. The MHQ function and pain scores improved significantly from intake to 3 and 12 months after surgery. Twenty-six of 31 patients (84%) regained postoperative metacarpophalangeal stability. Key pinch strength improved significantly 12 months after surgery from 5.2 kg at baseline to 6.4 kg at 12 months. The MHQ total, pain, and function scores of patients with persistent instability remained similar from baseline to 12 months after surgery. In four patients with metacarpophalangeal arthritis, the MHQ total and pain score improved significantly from baseline to 3 and 12 months after surgery.

CONCLUSIONS

Patient-reported outcomes, including pain and function, improved after thumb UCL reconstruction with a tendon autograft. Although the sample size of patients with thumb metacarpophalangeal arthritis diagnosed during surgery was small, they reached adequate patient-reported outcomes at 12 months after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Trochleoplasty Provides Good Outcomes for Recurrent Patellofemoral Dislocations with No Clear Superiority across Different Techniques

Background: Literature is sparse on outcome comparisons between different trochleoplasty techniques in the treatment of patella instability. To date, it is unclear whether there is a technique that offers superior outcomes. This systematic review and meta-analysis aims to compare and evaluate the outcomes of trochleoplasty techniques in the treatment of patellofemoral instability in trochlea dysplasia to establish whether there is an ideal choice of trochleoplasty technique for superior outcomes. Methods: 21 studies involving 880 knees were included. The mean age of the patients was 21.7 years (range 8-49 years). Mean follow-up timeframe of 43.5 months (range 8.8-100 months). Clinical outcomes assessed included rates of recurrence of patellofemoral dislocation, patient satisfaction, Kujala score, International Knee Documentation Committee (IKDC) score, Tegner score, and Lysholm score. Egger's test showed no publication bias across all outcomes assessed. Results: Favourable results were seen across all outcomes assessed and patient satisfaction. Improvements were seen with Kujala, IKDC, and Lysholm scores. Tegner scores showed good return to function. Post-operative dislocation and complication rates were low across the different techniques. Meta-regression for Kujala and IKDC scores showed good outcomes regardless of trochleoplasty technique used (Kujala, p = 0.549, relative risk 492.06; IKDC, p = 0.193, RR 0.001). The exact risk that trochleoplasty poses to the cartilage remains uncertain, as no study had a conservatively managed arm for comparison. Conclusions: Trochleoplasty yielded good outcomes irrespective of technique used with no clear superiority demonstrated in any technique in terms of outcome scores, satisfaction, post-operative dislocation rates or complications.

What are the common factors that lead to the failure to achieve minimal clinically important difference after shoulder surgery? A scoping review

INTRODUCTION

The goal of this research is to identify the factors that negatively impact the achievement of the minimum clinically significant change (MCID) for the American Shoulder and Elbow Surgeons (ASES) score within the realm of various orthopedic shoulder procedures.

METHODS

We conducted a comprehensive review of studies published from 2002 to 2023, utilizing OvidMedline and PubMed databases. Our search criteria included terms such as "minimal clinically important difference" or "MCID" along with associated MeSH terms, in addition to "American shoulder and elbow surgeon" or "ASES." We selectively included primary investigations that assessed factors linked to the failure to achieve MCID for the ASES score subsequent to orthopedic shoulder procedures, while excluding papers addressing anatomical, surgical, or injury-related aspects.

RESULTS

Our analysis identified 149 full-text articles, leading to the inclusion of 12 studies for detailed analysis. The selected studies investigated outcomes following various orthopedic shoulder procedures, encompassing biceps tenodesis, total shoulder arthroplasty, and rotator cuff repair. Notably, factors, such as gender, body mass index, diabetes, smoking habits, opioid usage, depression, anxiety, workers' compensation, occupational satisfaction, and the preoperative ASES score, were all associated with the inability to attain MCID.

CONCLUSION

In summary, numerous factors exert a negative influence on the attainment of MCID following shoulder procedures, and these factors appear to be irrespective of the specific surgical technique employed. Patients presenting with these factors may perceive their surgical outcomes as less successful when compared to those without these factors. Identifying these factors can enable healthcare providers to provide more effective counseling to patients regarding their expected outcomes and rehabilitation course. Furthermore, these findings can aid in the development of a screening tool to better identify these risk factors and optimize them before surgery.

Who Benefits From Hip Arthroplasty or Knee Arthroplasty? Preoperative Patient-reported Outcome Thresholds Predict Meaningful Improvement

BACKGROUND

Hip arthroplasty (HA) and knee arthroplasty (KA) are high-volume procedures. However, there is a debate about the quality of indication; that is, whether surgery is truly indicated in all patients. Patient-reported outcome measures (PROMs) may be used to determine preoperative thresholds to differentiate patients who will likely benefit from surgery from those who will not.

QUESTIONS/PURPOSES

(1) What were the minimum clinically important differences (MCIDs) for three commonly used PROMs in a large population of patients undergoing HA or KA treated in a general orthopaedic practice? (2) Do patients who reach the MCID differ in important ways from those who do not? (3) What preoperative PROM score thresholds best distinguish patients who achieve a meaningful improvement 12 months postsurgery from those who do not? (4) Do patients with preoperative PROM scores below thresholds still experience gains after surgery?

METHODS

Between October 1, 2019, and December 31, 2020, 4182 patients undergoing HA and 3645 patients undergoing KA agreed to be part of the PROMoting Quality study and were hence included by study nurses in one of nine participating German hospitals. From a selected group of 1843 patients with HA and 1546 with KA, we derived MCIDs using the anchor-based change difference method to determine meaningful improvements. Second, we estimated which preoperative PROM score thresholds best distinguish patients who achieve an MCID from those who do not, using the preoperative PROM scores that maximized the Youden index. PROMs were Hip Disability and Osteoarthritis Outcome Score-Physical Function short form (HOOS-PS) (scored 0 to 100 points; lower indicates better health), Knee Injury and Osteoarthritis Outcome Score-Physical Function short form (KOOS-PS) (scored 0 to 100 points; lower indicates better health), EuroQol 5-Dimension 5-level (EQ-5D-5L) (scored -0.661 to 1 points; higher indicates better health), and a 10-point VAS for pain (perceived pain in the joint under consideration for surgery within the past 7 days) (scored 0 to 10 points; lower indicates better health). The performance of derived thresholds is reported using the Youden index, sensitivity, specificity, F1 score, geometric mean as a measure of central tendency, and area under the receiver operating characteristic curve.

RESULTS

MCIDs for the EQ-5D-5L were 0.2 for HA and 0.2 for KA, with a maximum of 1 point, where higher values represented better health-related quality of life. For the pain scale, they were -0.9 for HA and -0.7 for KA, of 10 points (maximum), where lower scores represent lower pain. For the HOOS-PS, the MCID was -10, and for the KOOS-PS it was -5 of 100 points, where lower scores represent better functioning. Patients who reached the MCID differed from patients who did not reach the MCID with respect to baseline PROM scores across the evaluated PROMs and for both HA and KA. Patients who reached an MCID versus those who did not also differed regarding other aspects including education and comorbidities, but this was not consistent across PROMs and arthroplasty type. Preoperative PROM score thresholds for HA were 0.7 for EQ-5D-5L (Youden index: 0.55), 42 for HOOS-PS (Youden index: 0.27), and 3.5 for the pain scale (Youden index: 0.47). For KA, the thresholds were 0.6 for EQ-5D-5L (Youden index: 0.57), 39 for KOOS-PS (Youden index: 0.25), and 6.5 for the pain scale (Youden index: 0.40). A higher Youden index for EQ-5D-5L than for the other PROMs indicates that the thresholds for EQ-5D-5L were better for distinguishing patients who reached a meaningful improvement from those who did not. Patients who did not reach the thresholds could still achieve MCIDs, especially for functionality and the pain scale.

CONCLUSION

We found that patients who experienced meaningful improvements (MCIDs) mainly differed from those who did not regarding their preoperative PROM scores. We further identified that patients undergoing HA or KA with a score above 0.7 or 0.6, respectively, on the EQ-5D-5L, below 42 or 39 on the HOOS-PS or KOOS-PS, or below 3.5 or 6.5 on a 10-point joint-specific pain scale presurgery had no meaningful benefit from surgery. The thresholds can support clinical decision-making. For example, when thresholds indicate that a meaningful improvement is not likely to be achieved after surgery, other treatment options may be prioritized. Although the thresholds can be used as support, patient preferences and medical expertise must supplement the decision. Future studies might evaluate the utility of using these thresholds in practice, examine how different thresholds can be combined as a multidimensional decision tool, and derive presurgery thresholds based on additional PROMs used in practice.

CLINICAL RELEVANCE

Preoperative PROM score thresholds in this study will support clinicians in decision-making through objective measures that can improve the quality of the recommendation for surgery.

Postoperative Benefits of Soft Tissue Wrist Arthroscopy: Retro- and Prospective Analyses of Outcome Measures

Background: Elective soft-tissue-only wrist arthroscopy is a standard procedure in hand surgery for the diagnosis and treatment of wrist pain. A number of pathologies can be treated arthroscopically, with the aim of pain reduction and improved wrist mobility. A postinterventional evaluation of the treatment using objective and patient-reported outcome measures (PROMs) allows for an evidence-based statement about the benefits of soft-tissue-only wrist arthroscopy. Methods: A dual-center study combining retro- and prospective clinical analyses of patient outcomes after soft-tissue-only wrist arthroscopies was performed. The data were collected at two hospitals with departments specializing in hand surgery. The outcome was measured by assessing the range of motion of the wrist and its manual strength, as well as PROMs, including Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: A total of 154 soft interventions met the study criteria and could be included. Seven months after the elective soft-tissue-only wrist arthroscopies, mobility improved significantly for active extension and flexion, as well as the ulnar and radial abduction of the wrist. The grip strength also improved significantly, by an average of 6 kg, during this period. The DASH score improved significantly, from 35 points to 14 points. Additionally, wrist pain at rest was reduced significantly. Conclusions: After elective soft-tissue-only wrist arthroscopy, patients showed an overall functional improvement in their wrist, with a significant reduction in pain and improvement of mobility and grip strength. This study emphasizes the importance of wrist arthroscopy as a successful treatment option for soft tissue pathologies of the wrist.

Clinically Significant Outcome Scores in Orthopaedic Sports Medicine Shoulder and Knee Surgery Are Increasing in Prevalence but Often Reported Incorrectly

PURPOSE

To study the prevalence and quality of application of minimal clinically important difference (MCID), substantial clinical benefit (SCB), patient-acceptable symptomatic state (PASS), and maximum outcome improvement (MOI), reported in the orthopaedic sports medicine knee and shoulder literature in recent years and to bring awareness of proper use of such metrics.

METHODS

A literature review of all shoulder and knee articles published from the American Journal of Sports Medicine (AJSM), Journal of Shoulder and Elbow Surgery (JSES), and Arthroscopy from 2016 to 2020 was performed, specifically investigating whether MCID, SCB, PASS, or MOI were used or reported. Additionally, the way these metrics were reported and interpreted was recorded.

RESULTS

Out of 5,039 studies, 889 shoulder and knee studies met the inclusion criteria. Overall, 16.7% reported either MCID, PASS, or SCB. MCID was the most reported across all 3 journals. MCID was reported 12.4% of the time throughout the 5 years. PASS was reported 3.2% and SCB 1.1% of the time over the 5 years. MOI was not reported by any of the journals during this period. There was a statistically significant increase in MCID reporting in 2 of the 3 journals over the 5-year course, Arthroscopy (P = .02) and AJSM (P = .05). There was no statistically significant increase in PASS or SCB reporting rates in all 3 journals. Only 39.1% of studies reported MCID correctly (i.e., defined as the number of individual patients meeting MCID/total patients in the study).

CONCLUSIONS

This study shows an increasing trend in the use of clinically significant outcome metrics, such as MCID, for interpretation of patient-reported outcomes; however, these individual metrics are often not being used on the individual level and subsequently not reported accurately. We recommend determining whether the specific metric met the threshold per individual patient and then reporting those as a percentage of the sample population to achieve the full potential of these metrics and translate them accurately across various studies.

CLINICAL RELEVANCE

As the usage of clinically significant outcome metrics rises, so does the need for accurate reporting. These findings will encourage future studies to follow a more standardized format.

Patient-reported outcome measures in hip fracture patients

Aims

The aims of this study were to assess quality of life after hip fractures, to characterize respondents to patient-reported outcome measures (PROMs), and to describe the recovery trajectory of hip fracture patients.

Methods

Data on 35,206 hip fractures (2014 to 2018; 67.2% female) in the Norwegian Hip Fracture Register were linked to data from the Norwegian Patient Registry and Statistics Norway. PROMs data were collected using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) scoring instrument and living patients were invited to respond at four, 12, and 36 months post fracture. Multiple imputation procedures were performed as a model to substitute missing PROM data. Differences in response rates between categories of covariates were analyzed using chi-squared test statistics. The association between patient and socioeconomic characteristics and the reported EQ-5D-3L scores was analyzed using linear regression.

Results

The median age was 83 years (interquartile range 76 to 90), and 3,561 (10%) lived in a healthcare facility. Observed mean pre-fracture EQ-5D-3L index score was 0.81 (95% confidence interval 0.803 to 0.810), which decreased to 0.66 at four months, to 0.70 at 12 months, and to 0.73 at 36 months. In the imputed datasets, the reduction from pre-fracture was similar (0.15 points) but an improvement up to 36 months was modest (0.01 to 0.03 points). Patients with higher age, male sex, severe comorbidity, cognitive impairment, lower income, lower education, and those in residential care facilities had a lower proportion of respondents, and systematically reported a lower health-related quality of life (HRQoL). The response pattern of patients influenced scores significantly, and the highest scores are found in patients reporting scores at all observation times.

Conclusion

Hip fracture leads to a persistent reduction in measured HRQoL, up to 36 months. The patients' health and socioeconomic status were associated with the proportion of patients returning PROM data for analysis, and affected the results reported. Observed EQ-5D-3L scores are affected by attrition and selection bias mechanisms and motivate the use of statistical modelling for adjustment.

Orthopaedic Hand Patient Support Systems Have Valuable Insight to Patient Function and Pain

Patient-reported outcome measures (PROs) are increasingly used in clinical assessment. Research on how patient support systems contribute to physician understanding of patient condition is limited. Thus, insights from significant others may provide value, especially when concerns exist regarding patient response validity. Patients recruited from the pre-operative environment undergoing orthopaedic hand procedures responded to PROMIS-Pain Interference (PI), PROMIS-Upper Extremity (UE), PROMIS-Depression (D), and QuickDASH. They then selected a significant other (SO) to do the same. Patients and SOs were also asked to complete the West Haven-Yale Multidimensional Pain Inventory (WHYMPI) as a measure of support-related responses. Patient and SO responses were compared, and support-related responses were added in subsequent analyses to examine their effect on SO PRO assessment.

Validation of the Parisian Hamstring Avulsion Score (PHAS) in the Evaluation and Follow-up of Patients Operated for Proximal Hamstring Avulsion

BACKGROUND

No validated score is available for the prediction of return to sport (RTS) after proximal hamstring avulsion (PHA) surgery.

PURPOSE

To validate a new assessment tool for patients after PHA surgery: the Parisian Hamstring Avulsion Score (PHAS).

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

All patients at our clinic who had surgery for PHA between January 2015 and March 2018 were included in this study. A suspected clinical diagnosis of PHA was confirmed by magnetic resonance imaging. PHA was repaired by surgical reinsertion with suture anchors. Minimum postoperative follow-up was 2 years, and the PHAS, University of California, Los Angeles (UCLA), score, and Tegner score were used. The PHAS is a patient-reported outcome measure, evaluating the effect of PHA injury with 9 items. It was validated by calculating its psychometric properties, and then correlation analysis was performed to determine the relationship between the PHAS, UCLA score, and Tegner score. Cutoff values for the prediction of RTS were determined.

RESULTS

A prospective case series study was performed. A total of 156 patients were included. Median age (first quartile; third quartile) was 54.2 years (44.7 years; 61.3 years), and the mean ± SD time of the final follow-up was 69 ± 11.6 months. Two years after surgery, 66.7% (n = 104) of patients were able to RTS. A strong correlation was noted between all 3 scores at 1 year postoperatively. Overall internal consistency was high, with a Cronbach alpha coefficient of 0.86. The intraclass correlation coefficient was 0.96, showing excellent reliability. The minimal detectable change was 12.9. No patients reached the maximum score at 2 years. Analysis of the receiver operating characteristic curves of the 3 scores at postoperative 9 months in relation to the RTS at 1 and 2 years showed area under the curve values of >0.7, indicating significant discriminant capacity for the RTS. A PHAS cutoff value of 86 at 9 months for the prediction of RTS at postoperative 1 year had a sensitivity of 65.6% (95% CI, 53.7%-77.5%) and a specificity of 81.4% (95% CI, 69.8%-93%).

CONCLUSION

PHAS is a valid and reliable tool for follow-up after PHA surgery. It also offers a simple way to predict RTS.

No clinically significant differences in patient-reported outcome measures across total hip arthroplasty approaches

INTRODUCTION

As recent studies demonstrate an ongoing debate surrounding outcomes and complications with respect to different total hip arthroplasty (THA) approaches, patient-reported outcome measures (PROMs) may provide valuable information for clinician and patient decision-making. Therefore, our systematic review aimed to assess how surgical approach influences patient-reported outcomes.

METHODS

5 online databases were queried for all studies published between January 1, 1997 and March 4, 2022 that reported on PROMs across various surgical approaches to THA. Studies reporting on PROMs in primary THA patients segregated by surgical approach were included. Articles reporting on revision THA, hip resurfacing, and arthroscopy were excluded. Mantel-Haenszel (M-H) models were utilised to calculate the pooled mean difference (MDs) and 95% confidence interval (CIs).

RESULTS

No differences between the DAA and other approaches were observed when evaluating HOOS (MD -0.28; 95% CI, -1.98-1.41; p = 0.74), HHS (MD 2.38; 95% CI, -0.27-5.03; p = 0.08), OHS (MD 1.35; 95% CI, -2.00-4.71; p = 0.43), FJS-12 (MD 5.88; 95% CI, -0.36-12.12; p = 0.06), VAS-pain (MD -0.32; 95% CI, -0.68-0.04; p = 0.08), and WOMAC-pain (MD -0.73; 95% CI, -3.85-2.39; p = 0.65) scores. WOMAC (MD 2.47; 95% CI, 0.54-4.40; p = 0.01) and EQ-5D Index (MD 0.03; 95% CI, 0.01-0.06; p = 0.002) scores were found to significantly favour the DAA cohort over the other approaches. Only the EQ-5D index score remained significant following sensitivity analysis.

CONCLUSIONS

Superiority of any 1 approach could not be concluded based on the mixed findings of the present analysis. Although our pooled analysis found no significant differences in outcomes except for those measured by the EQ-5D index, a few additional metrics, notably the WOMAC, HHS, FJS-12, and VAS-pain scores, leaned in favour of the DAA.

A comparative analysis of suture-augmented and standard hamstring autograft single-bundle ACL reconstruction outcomes: short-term functional benefits without long-term impact

BACKGROUND

Augmentation of the biologic graft with nonabsorbable suture material during anterior cruciate ligament reconstruction (ACLR) is a relatively new technique to enhance its biomechanical properties and add additional support to the critical process of healing. We aimed to compare the short-term functional patient-reported outcome measures (PROMs) and complication rates of patients treated with either standard single-bundle four-strand hamstring ACLR or added suture augmentation (SA).

METHODS

Patients undergoing arthroscopic ACLR between February 2015-January 2017 and in the standard ACLR group, and between February 2017-September 2019 in the SA-ACLR group operated by adding a no.5 FiberWire® (Arthrex, Naples, FL, USA) braided suture to the hamstring autograft, were retrospectively reviewed and the PROMs were compared. Patients were followed up for a 24-month period and PROMs were assessed by the International Knee Documentation Committee (IKDC) Subjective Knee Form and Tegner-Lysholm knee score. Patients' demographic and clinical characteristics, and postoperative complications including graft retear requiring revision surgery, deep vein thrombois, and surgical site infection were recorded and analyzed.

RESULTS

We included 79 patients with mean age of 31.6 ± 8.3 years in the standard ACLR group, and 90 patients with mean oge of 30.5 ± 7.6 in the SA-ACLR group. There was no statistically significant difference between the two groups in terms of age, sex, body mass index, and medical comorbidities. The values of the IKDC scores increased to 75.8 ± 18.9 in the standard ACLR group, and 85.6 ± 12.6 in the SA-ACLR group, 24 months after the operation (P < 0.05). The 24-month postoperative Tegner-Lysholm scores escalated to 79.3 ± 21.0 in the standard ACLR group and 91.0 ± 13.7 in the SA-ACLR group (P < 0.05). Four (5.1%) patients in the standard ACLR group and 4 (4.4%) in the SA-ACLR group experienced graft retear requiring revision surgery (P > 0.05). Incidence of surgical site infection and deep vein thrombosis showed no significant differences between the two groups, 24 months after ACLR.

CONCLUSION

SA-ACLR is associated with improved short-term functional PROMs compared to the standard hamstring ACLR. Although SA did not reduce the retear rate, and infection and DVT rates did not differ between study groups, superior improvement of PROMs in SA approach, leverages this method for ACLR.

The Significance of Selecting an Appropriate Patient-Reported Outcome Measure (PROM): A Cross-Cultural Adaptation of the Specific Paediatric International Documentation Committee Subjective (Pedi-IKDC) Knee Form

INTRODUCTION

The selection of an appropriate PROM is a crucial aspect in assessing outcomes. Questionnaires that have not been designed or validated for a paediatric population are routinely used. Using a questionnaire requires translation, cultural adaptation, and testing the psychometric properties of the translated questionnaire. There is no applicable questionnaire in our country for children with knee-specific conditions in sports orthopaedics. Therefore, this study aims to translate, culturally adapt, and assess the psychometric properties of the Paediatric IKDC (Pedi-IKDC) questionnaire within the Lithuanian paediatric population.

METHODS

The translation was conducted in accordance with international standards. Patients aged 11-17 years with various knee disorders participated in three surveys and completed the Pedi-IKDC, Lysholm, and PedsQL questionnaires. Interviews with patients following the translation process, in addition to floor and ceiling effects, were used to assess content validity. Cronbach alpha (α) statistics and the intraclass correlation coefficient (ICC) were applied to measure internal consistency and reproducibility, respectively. The standard error of measurement (SEM) and smallest detectable change (SDC) were calculated to assess reliability. Pearson correlations were calculated between Pedi-IKDC and Lysholm PedsQL scores to determine criteria validity. The effect size (ES) and standardised response mean (SRM) were calculated to assess the responsiveness to change.

RESULTS

Cronbach's alpha (α) was 0.91 for the total score, 0.75 for symptoms, and 0.92 for the sport/function component. The ICC for overall scores was 0.98, with each question ranging from 0.87 to 0.98. The SEM was 2.97, and the SDC was 8.23. Lysholm and PedsQL physical functioning domain scores had moderate correlations (0.8 > r > 0.5), and the overall PedsQL score had a weak correlation (0.5 > r > 0.2) to the Pedi-IKDC score. The floor and ceiling effects were 3.3% and 1.6%, respectively. The SRM was 1.72 and the ES was 1.98.

CONCLUSIONS

The Lithuanian Pedi-IKDC version is an appropriate evaluation instrument for assessing outcomes in children with knee disorders. All of the psychometric features produced acceptable results.

Correlation between Harris hip score and gait analysis through artificial intelligence pose estimation in patients after total hip arthroplasty

BACKGROUND

Recently, open pose estimation using artificial intelligence (AI) has enabled the analysis of time series of human movements through digital video inputs. Analyzing a person's actual movement as a digitized image would give objectivity in evaluating a person's physical function. In the present study, we investigated the relationship of AI camera-based open pose estimation with Harris Hip Score (HHS) developed for patient-reported outcome (PRO) of hip joint function.

METHOD

HHS evaluation and pose estimation using AI camera were performed for a total of 56 patients after total hip arthroplasty in Gyeongsang National University Hospital. Joint angles and gait parameters were analyzed by extracting joint points from time-series data of the patient's movements. A total of 65 parameters were from raw data of the lower extremity. Principal component analysis (PCA) was used to find main parameters. K-means cluster, X-squared test, Random forest, and mean decrease Gini (MDG) graph were also applied.

RESULTS

The train model showed 75% prediction accuracy and the test model showed 81.8% reality prediction accuracy in Random forest. "Anklerang_max", "kneeankle_diff", and "anklerang_rl" showed the top 3 Gini importance score in the Mean Decrease Gini (MDG) graph.

CONCLUSION

The present study shows that pose estimation data using AI camera is related to HHS by presenting associated gait parameters. In addition, our results suggest that ankle angle associated parameters could be key factors of gait analysis in patients who undergo total hip arthroplasty.

Development and validation of a French-language cross-cultural adaptation of the Pedi-IKDC Questionnaire

BACKGROUND

The Pedi-IKDC is an English-language, knee-specific, paediatric questionnaire used by orthopaedic surgeons around the world as a valuable patient-reported outcome measure (PROM). The objective of this study was thus to extend the applicability of the Pedi-IKDC to French-speaking Canadian patients, for both clinical practice and research, by developing a French-language cross-cultural adaptation of the original version.

HYPOTHESIS

The French adaptation of the Pedi-IKDC is valid and reliable for evaluating French-speaking children with knee conditions.

PATIENTS AND METHODS

The Pedi-IKDC was translated to French by a panel of orthopaedic surgeons then back-translated by a professional translator. The original English version and the back-translation were compared to assess their similarity and confirm the faithfulness of the French translation. The validity of the French version was then tested at a major paediatric hospital in French-speaking Canada, in 203 children, including 163 with knee pain and 40 without knee symptoms. Internal consistency, construct validity, and discriminant capacity of the French version were assessed.

RESULTS

Internal consistency of the Pedi-IKDC adaptation was excellent (Cronbach's alpha, 0.934 in the knee-pain group). Construct validity was robust, with all nine hypotheses adapted from the original Pedi-IKDC article demonstrating strong (n=7) or moderate (n=2) correlations (p<0.001). The evaluation of discriminant capacity identified no statistically significant score differences according to most of the respondent characteristics (body mass index, age group, type of diagnosis, and type of treatment). However, scores differed significantly between females and males.

DISCUSSION

The French-language cross-cultural adaptation of the Pedi-IKDC obtained using a universally recognized method for translating PROMs demonstrated good performance, with psychometric properties similar to those of the original Pedi-IKDC and of its Danish, Italian, and Russian adaptations.

LEVEL OF EVIDENCE

II.

Young or Old Age and Non-White Race Are Associated With Poor Patient-Reported Outcome Measure Response Compliance After Orthopaedic Surgery

Purpose

To investigate orthopaedic patient compliance with patient-reported outcome measures (PROMs) and identify factors that improve response rates.

Methods

Our search strategy comprised a combination of key words and database-specific subject headings for the concepts of orthopaedic surgical procedures, compliance, and PROMs from several research databases from inception to October 11, 2022. Duplicates were removed. A total of 97 studies were included. A table was created for the remaining articles to be appraised and analyzed. The collected data included study characteristics, follow-up/compliance rate, factors that increase/decrease compliance, and type of PROM. Follow-up/compliance rate was determined to be any reported response rate. The range and average used for analysis was based on the highest or lowest number reported in the specific article.

Results

The range of compliance reported was 11.3% to 100%. The overall response rate was 68.6%. The average baseline (preoperative/previsit) response rate was 76.6%. Most studies (77%) had greater than 50% compliance. Intervention/reminder of any type (most commonly phone call or mail) resulted in improved compliance from 44.6% to 70.6%. Young and elderly non-White male patients had the lowest compliance rate. When directly compared, phone call (71.5%) resulted in a greater compliance rate than electronic-based (53.2%) or paper-based (57.6%) surveys.

Conclusions

The response rates for PROMs vary across the orthopaedic literature. Patient-specific factors, such as age (young or old) and race (non-White), may contribute to poor PROM response rate. Reminders and interventions significantly improve PROM response rates.

Clinical Relevance

PROMs are important tools in many aspects of medicine. The data generated from these tools not only provide information about individual patient outcomes but also make hypothesis-driven comparisons possible. Understanding the factors that affect patient compliance with PROMs is vital to our accurate understanding of patient outcomes and the overall advancement of medical care.

Pearls and pitfalls of PROMIS clinically significant outcomes in orthopaedic surgery

INTRODUCTION

Patient-Reported Outcome Measurement Information System (PROMIS) was developed as a uniform and generalizable PROM system using item response theory and computer adaptive testing. We aimed to assess the utilization of PROMIS for clinically significant outcomes (CSOs) measurements and provide insights into its use in orthopaedic research.

MATERIALS AND METHODS

We reviewed PROMIS CSO reports for orthopaedic procedures via PubMed, Cochrane Library, Embase, CINAHL, and Web of Science from inception to 2022, excluding abstracts and missing measurements. Bias was assessed using the Newcastle-Ottawa Scale (NOS) and questionnaire compliance. PROMIS domains, CSO measures, and study populations were described. A meta-analysis compared distribution and anchor-based MCIDs in low-bias (NOS ≥ 7) studies.

RESULTS

Overall, 54 publications from 2016 to 2022 were reviewed. PROMIS CSO studies were observational with increasing publication rates. Evidence-level was II in 10/54, bias low in 51/54, and compliance ≥ 86% in 46/54. Most (28/54) analysed lower extremity procedures. PROMIS domains examined Pain Function (PF) in 44/54, Pain Interference (PI) in 36/54, and Depression (D) in 18/54. Minimal clinically important difference (MCID) was reported in 51/54 and calculated based on distribution in 39/51 and anchor in 29/51. Patient acceptable symptom state (PASS), substantial clinical benefit (SCB), and minimal detectable change (MDC) were reported in ≤ 10/54. MCIDs were not significantly greater than MDCs. Anchor-based MCIDs were greater than distribution based MCIDs (standardized mean difference = 0.44, p < 0.001).

CONCLUSIONS

PROMIS CSOs are increasingly utilized, especially for lower extremity procedures assessing the PF, PI, and D domains using distribution-based MCID. Using more conservative anchor-based MCIDs and reporting MDCs may strengthen results. Researchers should consider unique pearls and pitfalls when assessing PROMIS CSOs.

Operationalizing PROMs at the Musculoskeletal Practice and Policy Levels

There continues to be growing interest in patient-reported outcome measures (PROMs), especially as value-based healthcare initiatives gain more traction. Although it is well-established that PROMs can be useful in clinical research, how to operationalize PROMs in clinical care and policy initiatives remains a "work in progress." Following the design of a comprehensive PROM administration and routine collection system, orthopaedic surgeons and their patients can reap the benefits of PROMs in practice through improved shared clinical decision-making discussions at the individual patient level and closer symptom monitoring on a large scale, with improved resource allocation at the population health level. Although certain government and payer incentives exist to collect PROMs at present, it is reasonable to assume that future policy initiatives will begin to use the actual PROM scores to assess clinical outcomes. Orthopaedic surgeons with interest in this area should prioritize their involvement in policy discussion to ensure PROMs are being used appropriately in novel payment models and policy endeavors so that they are both evaluated and compensated fairly. Specifically, orthopaedic surgeons can help ensure appropriate risk adjustment of patients when this is being done. Undoubtedly, PROMs will only become a larger part of musculoskeletal care moving forward.

The Impact of Total Hip Arthroplasty Surgical Approach on Short-Term Postoperative and Patient-Reported Outcomes

Background While multiple studies have compared outcomes between the direct anterior approach (DAA) and posterolateral (PL) total hip arthroplasty (THA), the debate over the optimal approach remains. Proponents of the DAA suggest that its muscle-sparing properties and unrestricted rehabilitation facilitate a more rapid return to function. The majority of studies demonstrate that patient-reported outcomes (PROs) are similar between approaches beyond the one-year timeframe, but results are mixed when evaluating earlier time points. The purpose of this study was to compare clinical outcomes and PROs between DAA and PL THAs at six weeks postoperatively. Methods A retrospective review of 749 primary THAs (151 PL, 598 DAA) from March 2020 to November 2022 was performed. All surgeries were performed by one of the five board-certified and fellowship-trained orthopedic surgeons. All patients completed Patient Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF) questionnaires preoperatively and at six weeks postoperatively. A univariate comparison of clinical outcomes (length of stay (LOS), home discharge rate, 90-day ED returns, and readmissions) and six-week PROMIS-PF scores between approaches was performed. Multivariate analysis was performed to evaluate the effect of the approach on outcomes after adjusting for baseline differences between groups. Results Patients undergoing DAA THA experienced significantly shorter average LOS (0.71 vs. 1.36 days, p<0.001), higher rates of home discharge (99.0 vs. 92.1%, p<0.001), and lower rates of 90-day readmissions (0.7 vs. 6.0%, p<0.001) than those undergoing the PL approach. At six weeks postoperatively, DAA patients achieved higher average PROMIS-PF scores (42.2 vs. 39.9, p=0.001). After adjusting for the Charlson Comorbidity Index and baseline physical function, the DAA was significantly associated with shorter LOS (β=-0.52, p<0.001), increased odds of home discharge (OR=5.70, p=0.001), reduced risk of 90-day readmission (OR=0.14, p=0.001), and higher PROMIS-PF scores at six weeks postoperatively (β=1.37, p=0.045). Conclusion In comparison to patients undergoing PL THA, those treated using the DAA experienced improved clinical and PROs over the six-week postoperative period. While both approaches resulted in satisfactory outcomes, these results support the assertion that DAA THA may result in more rapid recovery and return to function.

Arthroscopic Meniscectomy vs Meniscal Repair: Comparison of Clinical Outcomes

Background Meniscal tears are the most common injury of the knee. Surgical treatment has fallen into contention recently and includes arthroscopic meniscectomy and meniscal repair. The primary aim of this study was to quantitatively evaluate patients with isolated meniscal tears and compare their outcomes with patients who have undergone arthroscopic meniscus surgery. The secondary aim of this study was to compare the clinical outcomes of patients who have undergone arthroscopic meniscectomy with patients who have undergone arthroscopic meniscal repair. Methods This comparative clinical study screened 334 patients to identify subjects who underwent arthroscopic knee surgery for isolated meniscal tears and compare them to patients with symptomatic isolated meniscal tears awaiting surgery using validated patient-reported outcome measures. These included the Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Form, Lysholm score, Tegner score, EuroQol-5 Dimension, and the 12-Item Short Form Health Survey. Results A total of 117 patients (Meniscal Tear group (n=36), Meniscectomy group (n=64), and Meniscal Repair group (n=17)) were included in the final data analysis. Both the Meniscectomy group and the Meniscal Repair group (mean 55-month follow-up) showed significantly better clinical outcomes than patients in the Meniscal Tear group (p<0.05). Overall, the Meniscal Repair group demonstrated superior clinical outcomes when compared to the Meniscectomy group (p<0.05). Conclusion Arthroscopic knee surgery showed significant clinical benefit at medium-term follow-up in treating patients with isolated meniscal tears. When feasible, meniscal repair should be performed preferentially over meniscectomy.

Review of the Most Cited Patient-Reported Outcome Measure (PROM) Studies Published in the Neurospine Surgical Literature

Patient-reported outcome measures (PROMs) are validated tools that are widely utilized in research and patient care. Their diversity, quality, and application remain matters of peak research interest. This article is a review of the PROMs that were utilized in high-impact publications in the neurospine surgical literature. The 50 most cited articles on the subject were selected and analysed. Most (42 articles) were published in spine journals and, in particular, in the journal Spine (Phila Pa 1976) (28 articles). A total of 34 PROMs were utilized, of which 24 were used only once in single studies. The four most common PROMs were Scoliosis Research Society-22 (SRS-22) (15 articles), Short Form-12 and Short Form-36 (SF-12 and SF-36) (11 articles), Ronald-Morris Disability Questionnaire (RMDQ) (nine articles), and Oswestry Disability Index (ODI) (five articles). Nineteen articles focused on validating translated versions of 11 PROMs to other languages. The languages that had the maximal number of tools translated to amongst the highly cited articles were Italian (six tools), Portuguese (four tools), German (three tools), and Japanese (three tools). The most common diagnoses and the PROMs used for them were back pain and cervical spine disorder (SF-12 and SF-36 (nine articles), RMDQ (eight articles), and ODI (five articles)), and idiopathic scoliosis (SRS-22) (14 articles)). The median (range) article citation number was 137 (78-675). The four most cited PROMs were SRS-22 (2,869), SF-12 and SF-36 (2,558), RMDQ (1,456), and ODI (852). Citation numbers were positively impacted by article age and participant number but not by tool type or clinical diagnosis. In conclusion, a wide range of PROMs was utilized in the 50 most cited publications in the neurospine surgical literature. The majority were disease-specific rather than generic and targeted particular spine pathology. Neurosurgical PROMs were under-represented amongst the most cited articles. Awareness of the PROMs used in high-impact studies may be helpful in tool selection in future research. PROMs are valuable in standardizing subjective outcomes. Their use in research and clinical settings in any validated language is highly encouraged.

The Effects of Sociodemographic Factors on Baseline Patient-Reported Outcome Measures in Patients with Foot and Ankle Conditions

BACKGROUND

Racial and ethnic care disparities persist within orthopaedics in the United States. This study aimed to deepen our understanding of which sociodemographic factors most impact patient-reported outcome measure (PROM) score variation and may explain racial and ethnic disparities in PROM scores.

METHODS

We retrospectively reviewed baseline PROMIS (Patient-Reported Outcomes Measurement Information System) Global-Physical (PGP) and PROMIS Global-Mental (PGM) scores of 23,171 foot and ankle patients who completed the instrument from 2016 to 2021. A series of regression models was used to evaluate scores by race and ethnicity after adjusting in a stepwise fashion for household income, education level, primary language, Charlson Comorbidity Index (CCI), sex, and age. Full models were utilized to compare independent effects of predictors.

RESULTS

For the PGP and PGM, adjusting for income, education level, and CCI reduced racial disparity by 61% and 54%, respectively, and adjusting for education level, language, and income reduced ethnic disparity by 67% and 65%, respectively. Full models revealed that an education level of high school or less and a severe CCI had the largest negative effects on scores.

CONCLUSIONS

Education level, primary language, income, and CCI explained the majority (but not all) of the racial and ethnic disparities in our cohort. Among the explored factors, education level and CCI were predominant drivers of PROM score variation.

LEVEL OF EVIDENCE

Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Patient preferences as human factors for health data recommender systems and shared decision making in orthopaedic practice

Background

A core set of requirements for designing AI-based Health Recommender Systems (HRS) is a thorough understanding of human factors in a decision-making process. Patient preferences regarding treatment outcomes can be one important human factor. For orthopaedic medicine, limited communication may occur between a patient and a provider during the short duration of a clinical visit, limiting the opportunity for the patient to express treatment outcome preferences (TOP). This may occur despite patient preferences having a significant impact on achieving patient satisfaction, shared decision making and treatment success. Inclusion of patient preferences during patient intake and/or during the early phases of patient contact and information gathering can lead to better treatment recommendations.

Aim

We aim to explore patient treatment outcome preferences as significant human factors in treatment decision making in orthopedics. The goal of this research is to design, build, and test an app that collects baseline TOPs across orthopaedic outcomes and reports this information to providers during a clinical visit. This data may also be used to inform the design of HRSs for orthopaedic treatment decision making.

Methods

We created a mobile app to collect TOPs using a direct weighting (DW) technique. We used a mixed methods approach to pilot test the app with 23 first-time orthopaedic visit patients presenting with joint pain and/or function deficiency by presenting the app for utilization and conducting qualitative interviews and quantitative surveys post utilization.

Results

The study validated five core TOP domains, with most users dividing their 100-point DW allocation across 1-3 domains. The tool received moderate to high usability scores. Thematic analysis of patient interviews provides insights into TOPs that are important to patients, how they can be communicated effectively, and incorporated into a clinical visit with meaningful patient-provider communication that leads to shared decision making.

Conclusion

Patient TOPs may be important human factors to consider in determining treatment options that may be helpful for automating patient treatment recommendations. We conclude that inclusion of patient TOPs to inform the design of HRSs results in creating more robust patient treatment profiles in the EHR thus enhancing opportunities for treatment recommendations and future AI applications.

Illicit drug and alcohol use and measures of musculoskeletal function and mental health in orthopaedic trauma patients

Objectives

The objective of this study was to describe the relationship between positive toxicology screens and measures of preinjury mental health and physical function in an orthopaedic trauma population.

Design

This was a cross-sectional study.

Setting

Urban Level 1 trauma center.

Patients

A total of 125 trauma patients gave written consent for this study.

Main Outcome Measurements

Questionnaires such as, Patient Health Questionnaire-9, General Anxiety Disorder-7, PCL-5, and Short Musculoskeletal Function Assessment, were used to survey patients after surgical intervention.

Results

Patient Health Questionnaire-9 (P = 0.05) and PCL-5 (P = 0.04) were not found to have significant differences between positive and negative toxicology screens. Both General Anxiety Disorder-7 (P = 0.004) and Short Musculoskeletal Function Assessment function (P = 0.006) were significantly higher in patients with positive toxicology screens.

Conclusions

Positive toxicology seems to be associated with preinjury anxiety. Patient reported preinjury function was not adversely affected by the presence of illicit substances or alcohol, nor were levels of post-traumatic stress disorder and depression found to be higher in patients with positive toxicology screens.

Level of Evidence

Level IV Cross-Sectional Study.

The Oxford Elbow Score demonstrated good measurement properties when used with a shortened 7-day recall period

Background

The Oxford Elbow Score (OES) is a well-validated, elbow-specific, patient-reported outcome measure (PROM), originally assigned a 4-week recall period. For PROMs, short recall periods could have some advantages, such as optimizing validity by minimizing the negative effects of inaccurate recollection and temporal trends (increase or decrease) in symptoms over the course of the recall period. Temporal trends in elbow function can, for example, be expected to occur over 4 weeks in patients recovering from an injury or surgery. The purpose of this study was to evaluate the measurement properties of the OES using a shortened, 7-day, recall period (OES-7d).

Methods

The inclusion criteria were fracture, tendon rupture or dislocation affecting the elbow, and age ≥18 years. Patients with Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores of ≥10 points preinjury (pre-existing upper extremity condition) or concurrent upper extremity injuries were excluded. Patients completed the OES-7d, QuickDASH, and Single Assessment Numeric Evaluation-Function for the last 7 days preinjury (T1), the first 7 days postinjury (T2) and a 7-day period 3-5 months postinjury (T3). Correlations were assessed with Spearman's rho. Analyses of construct validity (correlation between scores) and internal consistency (Cronbach's alpha) were based on T3 data. Responsiveness was assessed by correlating changes in scores (change scores) between time points. Intra-rater reliability was assessed by calculating intraclass correlation coefficients based on 2 administrations (1- to 3-week interval) of PROMs in a separate group of patients who had sustained an elbow injury 1-2 years previously.

Results

Seventy-five patients (45 women) were included between May 2020 and July 2021. Their mean age was 51.7 years. At T3, Spearman's rho was -0.91 for the correlation between OES total and QuickDASH scores and 0.76 for the correlation between OES total scores and Single Assessment Numeric Evaluation-Function values (construct validity). Spearman's rho for correlation between OES total and QuickDASH change scores from T2 to T3 (T3 minus T2) was -0.85 (responsiveness for improvement) and -0.88 for change scores from T1 to T2 (T2 minus T1, responsiveness for deterioration). For the OES domains, Cronbach's alpha was 0.83 for elbow function, 0.91 for pain and 0.90 for social-psychological domains. The intraclass correlation coefficient for the OES total score was 0.96.

Conclusion

The OES demonstrated good measurement properties when used with a 7-day recall period (OES-7d). These results further establish the OES as a well-validated, elbow-specific PROM and support using a 7-day recall period.

Anxiety and Depressive Symptoms Correlated to Patient-Reported Outcome Measures after Rotator Cuff Repair: A Prospective Study in the Perioperative Period

Anxiety and depressive symptoms adversely affect surgical outcomes in patients with rotator cuff tear (RCT) undergoing surgical repair. Patients without a diagnosis of mood disorders, such as anxiety and depression, before rotator cuff repair (RCR) can be considered an optimal candidate for surgery. The objective of this prospective observational study was to evaluate the relationship between anxiety and depressive symptoms, using the Hospital Anxiety and Depression Scale (HADS) as an assessment tool, and patient-reported outcome measures in RCT after repair surgery. This study included patients with RCT undergoing arthroscopic rotator cuff repair (RCR). Forty-three patients were included who had completed the HADS, Constant Murley Score (CMS), and Short Form Health Survey 36 (SF-36) questionnaires before surgery and in the postoperative follow-up, at 1 month, 3 months, and 6 months. The Friedman test showed that there were statistically significant changes in the different times point for HADS (p < 0.001), anxiety subscale of HADS, i.e., HADS-A (p < 0.001), depression subscale of HADS, i.e., HADS-D (p < 0.001), CMS (p < 0.001), and SF-36 (p < 0.001). The average scores of HADS, HADS-A, and HADS-D improved at each follow-up, showing improvement in discomfort. From the third month after surgery, there was an improvement in anxiety and depression disorders related to improved quality of life, functionality, and pain perception. The trend remained stable until the sixth month of follow up. This study shows that anxiety and depressive symptoms in RCT patients are significantly reduced after RCR with subsequent important improvements in terms of functionality, ability to carry out activities of daily living, perceived pain, and quality of life.

Do we still need to screen our patients?-Orthopaedic scoring based on motion tracking

PURPOSE

Orthopaedic scores are essential for the clinical assessment of movement disorders but require an experienced clinician for the manual scoring. Wearable systems are taking root in the medical field and offer a possibility for the convenient collection of motion tracking data. The purpose of this work is to demonstrate the feasibility of automated orthopaedic scorings based on motion tracking data using the Harris Hip Score and the Knee Society Score as examples.

METHODS

Seventy-eight patients received a clinical examination and an instrumental gait analysis after hip or knee arthroplasty. Seven hundred forty-four gait features were extracted from each patient's representative gait cycle. For each score, a hierarchical multiple regression analysis was conducted with a subsequent tenfold cross-validation. A data split of 70%/30% was applied for training/testing.

RESULTS

Both scores can be reproduced with excellent coefficients of determination R2 for training, testing and cross-validation by applying regression models based on four to six features from instrumental gait analysis as well as the patient-reported parameter 'pain' as an offset factor.

CONCLUSION

Computing established orthopaedic scores based on motion tracking data yields an automated evaluation of a joint function at the hip and knee which is suitable for direct clinical interpretation. In combination with novel technologies for wearable data collection, these computations can support healthcare staff with objective and telemedical applicable scorings for a large number of patients without the need for trained clinicians.

Do web-based follow-up surveys have a better response rate than traditional paper-based questionnaires following outpatient arthroscopic rotator cuff repair? A randomized controlled trial

INTRODUCTION

Considering the extensive use of smartphones in current societies, web-based applications could be considered as a new option for patient follow-up in surgery. By means of such tool, automated and periodic questionnaires could improve the rigor, accuracy and the comprehensiveness of postoperative monitoring, as well as early detection of complications, especially in the current context of evolving ambulatory surgery.

HYPOTHESIS

The web-based surveys would improve the quality of immediate postoperative monitoring.

MATERIAL AND METHODS

For 7 months, we included all patients who underwent outpatient arthroscopic rotator cuff repair. After preoperative randomization, each patient was asked postoperatively to complete either paper-based forms or digital questionnaires via a website (Orthense.com®, Digikare Inc. Blagnac, France). Both media (i.e. paper and digital) followed the same postoperative agenda (i.e., D+3, D+14, D+28, D+45, D+90) and had the same content, including pain and discomfort assessments, functional scores (i.e. Shoulder subjective value, simple shoulder test and auto-constant scores). The main objective was to investigate the quality of postoperative follow-up after outpatient arthroscopic rotator cuff surgery, using either printed questionnaires or web-based surveys. The hypothesis was that using a web-based survey would result in greater response rates and increased patient satisfaction regarding follow-up. Primary outcomes were questionnaire response rates at D+45 and D+90, while secondary outcomes were overall response rates, patient recommendation for the monitoring medium and overall patient satisfaction regarding their follow-up using the net promoter score (NPS).

RESULTS

Among the 59 consecutive patients who were included, there were 27 females and 26 males with a mean age of 57±10.2 years; 27 patients completed the web-based survey (Group A) and 26 patients answered paper-based questionnaires (Group B). Regarding the D+45 questionnaire, response rates were 85.2% (n=23) in group A and 42.3% (n=11) in group B (p=.005); a similar significant difference was observed regarding the D+90 questionnaire, with response rates of 70.4% and 34.6%, respectively (p=.027). The mean NPS for the survey was 10 in Group A and 8.29 in Group B (p=.016). Overall, satisfaction regarding postoperative care did not differ between the two groups.

DISCUSSION

Compared to traditional paper-based forms, web-based surveys appear to increase patient adherence to short-term postoperative monitoring. If these findings were to be confirmed in long-term follow-up, such straightforward and cost-effective tool could be of great use in clinical care and research.

LEVEL OF EVIDENCE

I; Randomized controlled clinical trial.

Do Patients Accurately Recall Their Preoperative Symptoms After Elective Orthopedic Procedures?

Patient-reported outcome measures are a frequent tool used to assess orthopedic surgical outcomes. However, recall bias is a potential limitation of these tools when used retrospectively, as they rely on patients to accurately recall their preoperative symptoms. A database search of Cochrane Library, PubMed, Medline Ovid, and Scopus until May 2021 was completed in duplicate by two reviewers. Studies considered eligible for inclusion were those which reported on patient recall bias associated with orthopedic surgery. The primary outcome of interest investigated was the accuracy of patient recollection of preoperative health status. Any factors that were identified as affecting patient recall were secondary outcomes of interest. Of the 4,065 studies initially screened, 20 studies with 3,454 patients were included in the final analysis. Overall, there were 2,371 (69%) knee and hip patients, 422 (12%) shoulder patients, 370 (11%) spine patients, 208 (6%) other upper extremity patients, and 83 (2%) foot and ankle patients. Out of the eight studies that evaluated patient recall within three months postoperatively, seven studies concluded that patient recall is accurate. Out of the 13 studies that evaluated patient recall beyond three months postoperatively, nine studies concluded that patient recall is inaccurate. The accuracy of patient recall of preoperative symptoms after elective orthopedic procedures is not reliable beyond three months postoperatively.

An Exploratory Factor Analysis of the National Institutes of Health Patient-Reported Outcomes Measurement Information System and the Single Assessment Numeric Evaluation in Knee Surgery Patients

INTRODUCTION

Patient-Reported Outcomes (PROs) have been suggested for use in measuring treatment effectiveness. To minimize patient burden, two approaches have been proposed: An orthopedic-specific Single Assessment Numeric Evaluation (SANE) or computer adaptive testing methods such as the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS). The goal of this work was to examine the constructs measured by the SANE and PROMIS system in a military orthopedic population undergoing knee surgery.

MATERIALS AND METHODS

In 732 patients and 2,166 complete observations, the SANE-Knee PRO and PROMIS surveys for Depression, Anxiety, Pain Interference, Sleep Disturbance, and Physical Function were obtained. A correlation matrix between the PROs was calculated, the number of latent factors to extract was determined via parallel plot, and the final principal axis exploratory factor analysis was performed.

RESULTS

The parallel plot analysis indicated that two latent factors existed. One latent factor corresponded to measures of psychological distress (PROMIS Sleep Disturbance, Depression, and Anxiety) and the second latent factor corresponded to physical capability (SANE, PROMIS Physical Function, Pain Interference, and Sleep Disturbance). Both PROMIS Physical Function (0.83) and Pain Interference (-0.80) more strongly weigh on the physical capability latent factor than SANE (0.69).

CONCLUSIONS

In a knee surgical population, the SANE, PROMIS Physical Function, and PROMIS Pain Interference measure the same human dimension of physical capability; however, PROMIS Physical Function and Pain Interference may measure this construct more effectively in isolation. The SANE may be a more viable option to gauge physical capability when computer adaptive testing is not possible.