High Variability in Outcome Reporting Patterns in High-Impact ACL Literature

Are Patient-Reported Outcome Measures for Anterior Cruciate Ligament Injuries Validated for Spanish Language and Culture?

Background

Patient-reported outcome measures (PROMs) have been adopted as a way to measure patient self-rated physical function and health status for patients with anterior cruciate ligament (ACL) injuries. Although multiple PROMs exist and have been translated into various languages, the cross-cultural adaptation and validity of these PROMs for Spanish-speaking patients is unknown.

Purpose

To evaluate the adaptation quality and psychometric properties of Spanish-language adaptations of PROMs for patients with ACL injuries.

Study Design

Scoping review; Level of evidence, 3.

Methods

Under PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we reviewed published studies related to adaptation quality and psychometric properties of Spanish PROMs in patients with ACL injuries. The methodological quality of the included studies was assessed using the Guidelines for the Process of Cross-Cultural Adaptation of Self-Reported Measures, the Quality Criteria for Psychometric Properties of Health Status Questionnaires, and the Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. The level of evidence for each PROM was determined based on the number of studies, methodological quality, consistency of results, and sample size.

Results

The initial search strategy identified 5687 articles. After removal of duplicates, 1882 titles were screened, and 114 articles were assessed for eligibility. Six articles were selected for final review, comprising 4 PROMs: the Lysholm knee score, the Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI), the Lower Extremity Functional Scale, and the Lower Limb Functional Index. Three studies followed all 6 processes for cross-cultural adaptation. None of the studies demonstrated all 14 domains required for cross-cultural validity (eg, description of translator expertise). The ACL-RSI achieved the highest level of evidence, with 3 of 9 domains demonstrating moderate evidence.

Conclusion

This review identified 4 instruments that have been translated for Spanish-speaking patients with ACL injuries, none of which demonstrated appropriate adaptation or robust psychometric properties. The study highlights the need for improvement in PROMs for Spanish-speaking patients and the potential for mismeasurement and inappropriate application of PROM results in patients with ACL injuries.

The Use of Patient-Reported Outcome Measures in Clinical Practice and Clinical Decision Making

Patient-reported outcome measures (PROMs) are highly effective measures of quality of care and outcomes that matter to patients regarding their physical, mental, and social health. While PROMs have played a notable role in research and registry reporting, they are also useful as clinical tools. Real-time PROM collection can be integrated into routine clinical care with immediate access to scores within the electronic health record. This can be integral when discussing treatment options and using decision aids. PROM scores can also be useful for postoperative monitoring. Various approaches to quantifying clinical efficacy have been developed, including the minimal clinically important difference, the substantial clinical benefit, and the patient acceptable symptom state (PASS). As the patient experience and patient-reported outcome measurement of health-related outcomes become increasingly emphasized in patient-centered, high value care, so too will the importance of methods to gauge clinical benefit using these instruments for improved clinical decision-making.

Impact of Sports Participation on Achievement of Clinically Relevant Outcomes 2 Years After ACL Reconstruction

Background

Clinically relevant threshold values associated with patient-reported outcome measures after orthopaedic procedures such as anterior cruciate ligament reconstruction (ACLR) are important for relating these scores to meaningful postoperative improvement.

Purpose/Hypothesis

The purpose of this study was to determine the Patient Acceptable Symptom State (PASS) for the Patient-Reported Outcomes Measurement Information System Computer Adaptive Test (PROMIS-CAT) after ACLR. It was hypothesized that preoperative sport participation would have an impact on PASS achievement.

Study Design

Case series; Level of evidence, 4.

Methods

Included were consecutive patients who underwent primary assisted ACLR between January 4 and August 1, 2016. Patients were administered the PROMIS-CAT Physical Function (PF) and Pain Interference domains preoperatively and at a minimum 2 years postoperatively, with external anchor questions used to determine the PASS. Receiver operating characteristic (ROC) curves were constructed for the entire study population as well as separately for athletes and nonathletes to determine PROMIS PASS thresholds for each population. A previously published PROMIS-PF minimal clinically important difference was used to evaluate postoperative improvement. A post hoc multivariate nominal logistic multivariate analysis was constructed to assess the effects of preoperative patient characteristics on the likelihood of attaining both the minimal clinically important difference and PASS.

Results

In total, 112 patients were included in the study, with 79 (71%) having recreational or higher levels of athletic participation. The PASS for the study population was 56.0 (area under the ROC curve, 0.86) and was unaffected by baseline PROMIS-PF scores but was affected by preoperative athletic participation (56.0 for athletes, 49.0 for nonathletes). A post hoc analysis found 57 patients (51%) achieved the PASS for the PROMIS-PF (cutoff, 56.0), but when the athlete and nonathlete thresholds were applied to their respective patient groups, 66% of athletes and 64% of nonathletes achieved the PASS postoperatively. The multivariate analysis found that sport participation (odds ratio, 6.2; P = .001) but not age, sex, body mass index, or preoperative PROMIS affected the likelihood of achieving the PASS on the PROMIS-PF.

Conclusion

Preoperative athletic participation significantly affected the ability to achieve PASS.

Use of Patient-Reported Outcome Measures in Lower Extremity Research

Background

A large number of patient reported outcome measures (PROMs) have been developed for specific lower extremity orthopaedic pathologies. However, a consensus as to which PROMs are recommended for use in evaluating treatment outcomes for patients with hip, knee, ankle and/or foot pathology based on the strength of their psychometric properties is lacking.

Objective

To identify PROMs that are recommended in systematic reviews (SRs) for those with orthopaedic hip, knee, foot, and ankle pathologies or surgeries and identify if these PROMs are used in the literature.

Study design

Umbrella Review.

Methods

PubMed, Embase, Medline, Cochrane, CINAHL, SPORTDisucs and Scopus were searched for SRs through May 2022. A second search was done to count the use of PROMs in seven representative journals from January 2011 through May 2022.SRs that recommended the use of PROMs based on their psychometric properties were included in the first search. SRs or PROMs not available in the English were excluded. The second search included clinical research articles that utilized a PROM. Case reports, reviews, and basic science articles were excluded.

Results

Nineteen SRs recommended 20 PROMs for 15 lower extremity orthopaedic pathologies or surgeries. These results identified consistency between recommended PROMs and utilization in clinical research for only two of the 15 lower extremity pathologies or surgeries. This included the use of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Copenhagen Hip and Groin Outcome Score to assess outcomes (HAGOS) for those with knee osteoarthritis and groin pain, respectively.

Conclusion

A discrepancy was found between the PROMs that were recommended by SRs and those used to assess clinical outcomes in published research. The results of this study will help to produce more uniformity with the use of PROMs that have the most appropriate psychometric properties when the reporting treatment outcomes for those with extremity pathologies.

Level of evidence

3a.

Trends in Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review

Background

Despite the prevalence of patient-reported outcomes (PROs) to evaluate results after anterior cruciate ligament (ACL) reconstruction, there exists little standardization in how these metrics are reported, which can make wider comparisons difficult.

Purpose

To systematically review the literature on ACL reconstruction and report on the variability and temporal trends in PRO utilization.

Study Design

Systematic review.

Methods

We queried the PubMed Central and MEDLINE databases from inception through August 2022 to identify clinical studies reporting ≥1 PRO after ACL reconstruction. Only studies with ≥50 patients and a mean 24-month follow-up were considered for inclusion. Year of publication, study design, PROs, and reporting of return to sport (RTS) were documented.

Results

Across 510 studies, 72 unique PROs were identified, the most common of which were the International Knee Documentation Committee score (63.3%), Tegner Activity Scale (52.4%), Lysholm score (51.0%), and Knee injury and Osteoarthritis Outcome Score (35.7%). Of the identified PROs, 89% were utilized in <10% of studies. The most common study designs were retrospective (40.6%), prospective cohort (27.1%), and prospective randomized controlled trials (19.4%). Some consistency in PROs was observed among randomized controlled trials, with the most common PROs being the International Knee Documentation Committee score (71/99, 71.7%), Tegner Activity Scale (60/99, 60.6%), and Lysholm score (54/99, 54.5%). The mean number of PROs reported per study across all years was 2.89 (range, 1-8), with an increase from 2.1 (range, 1-4) in studies published before 2000 to 3.1 (range, 1-8) in those published after 2020. Only 105 studies (20.6%) discretely reported RTS rates, with more studies utilizing this metric after 2020 (55.1%) than before 2000 (15.0%).

Conclusion

There exists marked heterogeneity and inconsistency regarding which validated PROs are used in studies related to ACL reconstruction. Significant variability was observed, with 89% of measures being reported in <10% of studies. RTS was discretely reported in only 20.6% of studies. Greater standardization of outcomes reporting is required to better promote objective comparisons, understand technique-specific outcomes, and facilitate value determination.

Evaluation of hop performance in children with anterior cruciate ligament reconstruction using healthy reference data: A cross-sectional study

BACKGROUND

Hop performance evaluation in children after anterior cruciate ligament (ACL) reconstruction may benefit from comparison to healthy controls. Thus, the purpose was to investigate the hop performance in children one year after ACL reconstruction with a comparison to healthy controls.

METHODS

Hop performance data from children with ACL reconstruction one year post-surgery and healthy children were compared. Four one-legged hop test data were analyzed: 1) single hop (SH), 2) 6 m timed hop (6 m-timed), 3) triple hop (TH), and 4) cross-over hop (COH). Outcomes were the best result (longest/fastest hop) from each leg and limb asymmetry. Differences in hop performance between-limbs (operated versus non-operated) and between-groups were estimated.

RESULTS

98 children with ACL reconstruction and 290 healthy children were included. Few statistically significant group differences were observed. Girls with ACL reconstruction outperformed healthy controls in two tests on the operated leg SH, COH) and in three tests on the non-operated leg (SH, TH, COH). However, the girls performed 4-5% worse on the operated leg when compared to the non-operated leg in all hop tests. No statistically significant between-group differences in the limb asymmetry were found.

CONCLUSION

The hop performance in children with ACL reconstruction one year post-surgery was largely comparable to the level of healthy controls. Despite this, we cannot exclude that neuromuscular deficits exist among the children with ACL reconstruction. The inclusion of a healthy control group for evaluating hop performance evoked complex findings regarding the ACL reconstructed girls. Thus, they may represent a selected group.

Neural Correlates of Self-Reported Knee Function in Individuals After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) rupture is a common knee injury among athletes and physically active adults. Despite surgical reconstruction and extensive rehabilitation, reinjuries are common and disability levels are high, even years after therapy and return to activity. Prolonged knee dysfunction may result in part from unresolved neuromuscular deficits of the surrounding joint musculature in response to injury. Indeed, "upstream" neurological adaptations occurring after injury may explain these persistent functional deficits. Despite evidence for injury consequences extending beyond the joint to the nervous system, the link between neurophysiological impairments and patient-reported measures of knee function remains unclear.

HYPOTHESIS

Patterns of brain activation for knee control are related to measures of patient-reported knee function in individuals after ACL reconstruction (ACL-R).

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

In this multicenter, cross-sectional study, participants with unilateral ACL-R (n = 25; 10 men, 15 women) underwent task-based functional magnetic resonance imaging testing. Participants performed repeated cycles of open-chain knee flexion/extension. Neural activation patterns during the movement task were quantified using blood oxygen level-dependent (BOLD) signals. Regions of interest were generated using the Juelich Histological Brain Atlas. Pearson product-moment correlations were used to determine the relationship between mean BOLD signal within each brain region and self-reported knee function level, as measured by the International Knee Documentation Committee index. Partial correlations were also calculated after controlling for time from surgery and sex.

RESULTS

Patient-reported knee function was positively and moderately correlated with the ipsilateral secondary somatosensory cortex (r = 0.57, P = 0.005) and the ipsilateral supplementary motor area (r = 0.51, P = 0.01).

CONCLUSION

Increased ipsilateral secondary sensorimotor cortical activity is related to higher perceived knee function.

CLINICAL RELEVANCE

Central nervous system mechanisms for knee control are related to subjective levels of knee function after ACL-R. Increased neural activity may reflect central neuroplastic strategies to preserve knee functionality after traumatic injury.

S, J.S. ST, Nair RR. Comparison of Fixed- and Variable-Loop Button Fixation in Arthroscopic Anterior Cruciate Ligament Reconstruction

Introduction

With the advent of fixed- and variable-loop suspensory fixation devices for arthroscopic anterior cruciate ligament (ACL) reconstruction, a maximum number of grafts can be placed within the femoral tunnel. Although several biomechanical studies have been conducted comparing these two devices, only a few comparative clinical studies are available. This study was conducted to compare the functional outcomes of arthroscopic ACL reconstruction using fixed-loop devices with those of variable-loop devices by determining their effect on graft laxity clinical assessment and patient-reported outcome scores.

Methodology

Out of 32 patients (27 males and five females) who underwent primary ACL reconstruction using tripled hamstring autograft, fixed- and variable-loop devices were used for 13 and 19 patients, respectively. Thirteen patients in each group were evaluated over a period of one year using the Lysholm knee score. Six patients in the variable-loop group had only six months of follow-up. Anterior drawer and Lachman tests were performed at six-month and one-year follow-ups, respectively.

Results

The mean ages of patients in the fixed- and variable-loop groups were 34.5\begin{document}\pm\end{document}11 and 34.1\begin{document}\pm\end{document}9.1 years, respectively. The Lysholm knee score at six weeks was fair in 7.7% of the patients in the fixed-loop group when compared to 52.6% of those in the variable-loop group (p<0.05). All the other parameters were comparable between the two groups. One patient in each group had ligament laxity at six-month and one-year follow-up, respectively.

Conclusion

This study showed no statistically significant difference in graft laxity or functional outcomes of arthroscopic ACL reconstruction with fixed- and variable-loop devices, except for a better patient-reported outcome score in the variable-loop group at six weeks of follow-up. Hence, there is a need for more comparative studies in this direction.

High variability and lack of standardization in the evaluation of return to sport after ACL reconstruction: a systematic review

PURPOSE

Return to sport (RTS) after ACL reconstruction (ACLR) has been recognized as an important outcome, which is associated with success of the surgery. This study aimed to assess the methods used to determine return to sport after ACLR in the published literature, report on variability of methods and evaluate their strength in establishing accurate RTS data.

METHODS

Electronic databases (PubMed, Cochrane Library and Embase) were searched via a defined search strategy with no limits, to identify relevant studies from January 2008 to December 2020 for inclusion in the review. Defined eligibility criteria included studies specifically measuring and reporting on return to sport after ACLR with a clear methodology. Each included study was assessed for the definition of successful RTS, successful return to pre-injury level of sport and for methods used to determine RTS.

RESULTS

One hundred and seventy-one studies were included. Of the included studies, six studies (4%) were level of evidence 1 and seventy-two studies (42%) were level of evidence 4. Forty-one studies (24%) reported on return to a specific sport and 130 studies (76%) reported on return to multiple sports or general sport. Sixteen studies (9%) reported on RTS in the pediatric population, 36 (21%) in the adult population and 119 (70%) reported on a mixed-aged population. The most commonly used definition of successful RTS was return to the same sport (44 of 125 studies, 35%). The most common method used to determine RTS was a non-validated study-specific questionnaire (73 studies, 43%), which was administered in various ways to the patients. Time of RTS assessment was variable and ranged between 6 months and 27 years post-surgery.

CONCLUSION

This review demonstrates high variability in defining, evaluating and reporting RTS following ACLR. The findings of this study reveal low reliability and unproven validity of methods used to evaluate RTS and highlight the challenges in interpreting and using RTS data reported in literature.

LEVEL OF EVIDENCE

IV.

Patient-Reported Outcomes Measurement Information System physical function instruments compare favorably to legacy patient-reported outcome measures in spine patients: a systematic review of the literature

BACKGROUND CONTEXT

Preliminary evidence has suggested favorable correlation between National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) assessments and traditional ("legacy") patient reported outcome measures (PROMs) in spine surgery. There has been a significant increase in PROMIS research with regards to spinal conditions.

PURPOSE

The purpose of this systematic review is to provide an assessment of PROMIS Physical Function (PF) measures in this patient population.

STUDY DESIGN/SETTING

Systematic review.

METHODS

A systematic search of the PubMed/MEDLINE and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify published articles that referenced the various PROMIS PF measures. Two authors independently reviewed selected studies. The search returned 1,060 studies, 124 of which were selected for independent review by two authors. Of these, 37 were selected for inclusion. Mixed linear models were performed to assess for differences between legacy PROMs and PROMIS measures.

RESULTS

The combined sample size of all included studies yielded 10,296 total patients. Overall, PROMIS Physical Function (PF) measures demonstrated strong correlations with legacy PROMs when evaluating spine patients (weighted Pearson correlation, 0.589, standard error [SE]=0.023; weighted Spearman correlation, 0.702, SE=0.028). PROMIS questionnaires had significantly fewer questions than did legacy PROMs (4.2±0.30 vs. 9.53±0.82, p=.015). In spine studies, the PROMIS PF forms were completed in significantly less time than legacy PROMs (48.1±2.9 vs. 174.7±12.6 seconds, p<.001). The differences for the reliability measures and the floor and ceiling effects were not significant.

CONCLUSIONS

Patient-Reported Outcomes Measurement Information System PF forms compare favorably with legacy PROMs with regard to correlations, ease of use, and quality criteria in the field of spine surgery. PROMIS PF scores correlate strongly with commonly used legacy PROMs, particularly in spine patients. Patient-Reported Outcomes Measurement Information System PF forms can be administered efficiently and to a broad patient population while remaining highly reliable.

Patient-reported outcome scores following patellar instability surgery-high prevalence does not equal high responsiveness: a systematic review

PURPOSE

The purpose of this study was to determine the utilization and responsiveness of common patient-reported outcomes (PROs) in patients undergoing surgery for patellar instability.

METHODS

Using PRISMA guidelines, a systematic review of studies reporting outcomes following surgical intervention for patellar instability was conducted using Pubmed, Cochrane, OVID Medline, and Google Scholar. Subgroup analysis of articles reporting at least two PROs with baseline and follow-up data were used to evaluate responsiveness of instruments using relative efficiency and effect size.

RESULTS

From the search, 2,848 unique articles were found, of which 178 were included in final analysis (7,122 patients, mean age 22.6, 63.6% female). The most commonly used PRO was the Kujala score (79.2%), followed by the Lysholm (34.8%), and Tegner (30.9%). Seventy-nine articles were eligible for subgroup analysis. The Kujala had a higher relative efficiency than ten of the 14 instruments to which it was compared but had lower relative efficiency compared to the IKDC and Lysholm scores. The Banff Patella Instability Instrument (BPII) and the Norwich score, condition-specific tools, were unable to be fully assessed due to rarity of use and lack of comparisons.

CONCLUSION

The hypothesis that the Kujala score is the most commonly used PRO for patellar instability, although other instruments offer greater efficiency was supported by our results. The IKDC and Lysholm scores had similar effect sizes but higher relative efficiencies than the Kujala, thus suggesting better responsiveness. This analysis adds useful information for surgeons on the effectiveness of the most common PRO's for evaluating patellofemoral instability outcomes.

LEVEL OF EVIDENCE

Level III.

Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Instruments Compare Favorably With Legacy Patient-Reported Outcome Measures in Upper- and Lower-Extremity Orthopaedic Patients: A Systematic Review of the Literature

PURPOSE

To compare Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) with traditional ("legacy") patient-reported outcome measures (PROMs) in regard to correlations, ease of use, and quality criteria for upper (UE) and lower extremity (LE) orthopaedic conditions.

METHODS

A systematic search of the PubMed/MEDLINE database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify published articles that referenced the various PROMIS PF measures. Two authors independently reviewed selected studies. The search returned 857 studies, 85 of which were selected for independent review by 2 authors. Of these, 54 were selected for inclusion. Mixed linear models were performed to assess for differences between legacy PROMs and PROMIS measures.

RESULTS

The combined sample size of all included studies yielded 6,074 UE and 9,366 LE patients. Overall, PROMIS PF measures demonstrated strong correlations with legacy PROMs among UE (weighted Pearson correlation, 0.624, standard error [SE] = 0.042; weighted Spearman correlation, 0.566, SE = 0.042) and LE patients (weighted Pearson correlation, 0.645, SE = 0.062; weighted Spearman correlation, 0.631, SE = 0.041). PROMIS PF questionnaires completed by UE patients had fewer questions than legacy PROMs (5.9 vs 17.7, P = .0093) and were completed in less time (90.5 vs 223.8 seconds, P = .084). PROMIS PF questionnaires completed by LE patients had fewer questions than legacy PROMs (4.81 vs 15.33, P < .001) and were completed in less time (63.6 vs 203.2 seconds, P = .0063). The differences for the reliability measures were not significant.

CONCLUSIONS

PROMIS PF scores correlate strongly with commonly used legacy PROMs in orthopaedics, particularly in UE and LE patients. PROMIS PF forms can be administered efficiently and to a broad patient population while remaining highly reliable. Therefore, they can be justified for standardized use among orthopaedic patients with UE and LE conditions, improving the ability to aggregate and compare outcomes in orthopaedic research.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV evidence.

Patients With Preoperative Clinical Depression Symptomology Experience Significant Improvements in Postoperative Pain, Function, and Depressive Symptoms Following Rotator Cuff Repair

PURPOSE

To determine the impact of clinical depression on outcomes after rotator cuff repair (RCR), as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Test (CAT) health domains.

METHODS

RCR patients were given PROMIS CAT assessments for physical function (PROMIS UE), pain interference (PROMIS PI), and depression (PROMIS D) during preoperative and postoperative clinic visits. PROMIS D scores ≥55 correlate with mild clinical depression; thus patients with PROMIS D scores ≥ 55 were placed in the clinical depression (CD) group, whereas patients with scores <55 were placed in the "no clinical depression" (NCD) group. Categorical variables were compared at preoperative and postoperative (6 months and ≥1 year) timepoints using χ² tests. Continuous variables were compared using Student's t-tests.

RESULTS

Of the 340 RCR patients included in this study, 65 (19.1%) were found to have mild clinical depression preoperatively, with that number being reduced to 23 (6.8%) at 6 months and 19 (5.6%) at ≥1 year after surgery. Compared with preoperative PROMIS scores, CD patients had significant postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (26.7 vs 35.5 vs 38.9; P < .001) and PROMIS PI (67.6 vs 56.7 vs 56.4; P < .001). NCD patients had similar postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (30.8 vs 38.6 vs 46.9; P < .001) and PROMIS PI (61.7 vs 53.0 vs 47.6; P < .001). The improvement in PROMIS scores was similar for the CD and NCD groups in both PROMIS UE (12.2 vs 16.1, respectively) and PROMIS PI (-11.2 vs -14.1, respectively).

CONCLUSION

Despite starting with worse PROMIS UE and PROMIS PI scores, patients undergoing RCR with symptoms of CD experienced significant improvement in function, pain, and depressive symptoms. Preoperative depression should not be a contraindication to arthroscopic RCR in patients who are otherwise appropriate operative candidates.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

High Rate of Overlapping Question Content Among Commonly Used Patient-Reported Outcome Measurements for Anterior Cruciate Ligament Injury

Purpose

To precisely compare the questions and content between the most commonly cited knee-specific patient-reported outcome measurements (PROs) for anterior cruciate ligament (ACL) injury.

Methods

A literature review through Medline from November 1, 2018, to November 1, 2020, was performed to find the most cited knee-specific PROs for assessment of ACL injuries. Each question was then classified as 1) identical, similar, or unique; 2) pertaining to 1 of 6 domains (pain, symptoms, functional activities, occupational activities, sports/recreation, and quality of life). The PROs were then compared to each other to assess question overlap and domain coverage.

Results

A total of 133 questions were analyzed from the seven most common PROs: International Knee Documentation Committee (IKDC) form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Scoring Scale, Tegner Activity Scale, Marx Scale, Knee Outcome Survey (KOS), and Cincinnati Knee Rating System (CKRS). The total distribution of identical (31.6%), similar (31.6%), and unique (36.8%) questions was found to be relatively even. However, this distribution varied within each PRO. KOS and Lysholm had the highest percentages of identical questions (64% and 62.5%, respectively). KOOS had the highest number of unique questions (26/42, 61.9%), while Tegner held the highest percentage (11/16, 68.8%). Sports/recreation was the only domain assessed by all PROs.

Conclusion

Nearly two-thirds of questions overlap between the commonly used PROs for ACL injury. Although sports/recreation is assessed by all PROs, each has its own pattern of coverage across this and other domains.

Level of Evidence

IV, cross-sectional study.

Patient-Reported Outcomes and Factors Associated with Achieving the Minimal Clinically Important Difference After ACL Reconstruction: Results at a Mean 7.7-Year Follow-up

Background

Analyzing outcomes and the minimal clinically important difference (MCID) after anterior cruciate ligament reconstruction (ACLR) is of increased interest in the orthopaedic literature. The purposes of this study were to report outcomes after ACLR at medium to long-term follow-up, identify the threshold preoperative outcome values that would be predictive of achieving the MCID postoperatively, and analyze outcome maintenance at medium to long-term follow-up after ACLR.

Methods

Active athletes who underwent ACLR were identified in an institutional ACL registry. Patient-reported outcome measures (PROMs) were administered preoperatively and at the 2-year and >5-year postoperative follow-up; measures included the International Knee Documentation Committee (IKDC) form, the 12-item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS), and Lysholm scale. We calculated the MCID from baseline to each of the 2 follow-up periods (2-year and mean 7.7-year). Logistic regression was performed to investigate factors associated with achievement of the MCID.

Results

A total of 142 patients (mean follow-up, 7.7 years [range, 6.6 to 9.1 years]) underwent ACLR. The mean age and body mass index at the time of surgery were 27.2 ± 13.0 years and 23.2 ± 3.0 kg/m2, respectively. Final postoperative outcome scores improved significantly from baseline for the IKDC (50.9 ± 14.7 to 87.9 ± 11.2), SF-12 PCS (41.6 ± 8.9 to 55.6 ± 3.2), and Lysholm scale (62.2 ± 17.6 to 90.5 ± 10.3) (p < 0.0001), while the SF-12 MCS did not improve significantly (54.2 ± 8.0 to 54.4 ± 6.0) (p = 0.763). Between 2- and >5-year follow-up, the SF-12 PCS showed significant improvement (54.6 ± 4.5 to 55.6 ± 3.2; p = 0.036), while no change was noted in the IKDC (87.6 ± 11.1 to 87.9 ± 11.2), SF-12 MCS (55.5 ± 5.3 to 54.4 ± 6.0), and Lysholm scale (89.8 ± 10.6 to 90.5 ± 10.3) (p ≥ 0.09). At the time of final follow-up, the MCID was achieved by 94.7% of patients for the IKDC, 80.8% for the Lysholm, 79.0% for the SF-12 PCS, and 28.2% for the SF-12 MCS. At 2-year follow-up, 95.3% of patients were either "very" or "somewhat" satisfied with their surgery, compared with 88.6% at the time of final follow-up.

Conclusions

We found a high level of maintained function following ACLR. The IKDC, SF-12 PCS, and Lysholm scores improved significantly after ACLR at the time of final follow-up and were not significantly different between follow-up periods. Approximately 95% and 89% of patients reported being satisfied with the outcome of surgery at the 2-year and final follow-up, respectively.

Level of Evidence

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

Patient-Reported Outcome Measurement Information System (PROMIS) in Orthopaedic Trauma Research

This review describes the development, advantages and disadvantages, and applications of the Patient-Reported Outcome Measurement Information System (PROMIS) in orthopaedic trauma. PROMIS is a useful tool for quantifying outcomes in orthopedic trauma. It allows measurement of outcomes across multiple domains while minimizing administration time. PROMIS also reliably identifies clinical, social, and psychological risk factors for poor outcomes across a variety of orthopaedic injuries and disease states. However, PROMIS lacks specificity for certain anatomic regions and validation for mental health outcomes. It also is limited by ceiling effects in certain active patient populations. Orthopaedic traumatologists should be familiar with PROMIS, as its use is increasing and it is a valuable tool that can aid in clinical decision making.

The Patient Acceptable Symptomatic State in Primary Anterior Cruciate Ligament Reconstruction: Predictors of Achievement

PURPOSE

To identify thresholds for patient acceptable symptomatic state (PASS) achievement in a cohort of primary anterior cruciate ligament reconstruction (ACLR) recipients, and to identify factors predictive of PASS achievement.

METHODS

A prospective clinical registry was queried for primary ACLR patients from January 2014 to April 2017 with serial patient-reported outcome measure (PROM) completion at 6, 12, and 24 months. Exclusion criteria included significant concomitant procedures. Knee-based PROMs included the International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores. PASS threshold values were calculated using receiver operating characteristic (ROC) curves with area under the curve (AUC) analysis. A stepwise multivariate regression identified preoperative and operative predictors of PASS achievement.

RESULTS

A total of 144 primary ACLR patients (30.86 ± 12.78 years, body mass index 25.51 ± 4.64, 41.0% male) were included in the analysis. PASS threshold values were established using ROC curve analysis, all of which exceeded 0.7 on AUC analysis (0.742 to 0.911). Factors impacting odds of PASS achievement in the ACLR cohort included preoperative exercises (odds ratio [OR] 2.95 to 4.74, P = .003 to .038), worker's compensation status (OR 0.25 to 0.28, P = .014 to .033), preoperative scores (OR 1.03 to 1.07, P = .005 to <.001), iliotibial band tenodesis (OR 11.08, P = .010), and anteromedial approach (OR 18.03 to 37.05, P < .001).

CONCLUSION

Factors predictive of PASS achievement in recipients of primary ACLR include functional status (e.g., preoperative exercise, preoperative KOOS Sport/Recreation score), worker's compensation status, technique (e.g., anteromedial) and preoperative PROMs. The results of our study are important in better informing shared decision-making models and improving evidence-based guidelines to optimize patient outcomes.

Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review

BACKGROUND

The Patient-Reported Outcomes Measurement Information SystemⓇ (PROMISⓇ) is a dynamic system of psychometrically sound patient-reported outcome (PRO) measures. There has been a recent increase in the use of PROMIS measures, yet little has been written about the reporting of these measures in the field of orthopedics. The purpose of this study was to conduct a systematic review to determine the uptake of PROMIS measures across orthopedics and to identify the type of PROMIS measures and domains that are most commonly used in orthopedic research and practice.

METHODS

We searched PubMed, Embase, and Scopus using keywords and database-specific subject headings to capture orthopedic studies reporting PROMIS measures through November 2018. Our inclusion criteria were use of PROMIS measures as an outcome or used to describe a population of patients in an orthopedic setting in patients ≥ 18 years of age. We excluded non-quantitative studies, reviews, and case reports.

RESULTS

Our final search yielded 88 studies published from 2013 through 2018, with 57% (50 studies) published in 2018 alone. By body region, 28% (25 studies) reported PROMIS measures in the upper extremity (shoulder, elbow, hand), 36% (32 studies) reported PROMIS measures in the lower extremity (hip, knee, ankle, foot), 19% (17 studies) reported PROMIS measures in the spine, 10% (9 studies) reported PROMIS measures in trauma patients, and 6% (5 studies) reported PROMIS measures in general orthopedic patients. The majority of studies reported between one and three PROMIS domains (82%, 73 studies). The PROMIS Computerized Adaptive Test (CAT) approach was most commonly used (81%, 72 studies). The most frequently reported PROMIS domains were physical function (81%, 71 studies) and pain interference (61%, 54 studies).

CONCLUSION

Our review found an increase in the reporting of PROMIS measures over the recent years. Utilization of PROMIS measures in orthopedic populations is clinically appropriate and can facilitate communication of outcomes across different provider types and with reduced respondent burden.

REGISTRATION

The protocol for this systematic review was designed in accordance with the PRISMA guidelines and is registered with the PROSPERO database (CRD42018088260).

Psychometric properties of visual analog scale assessments for function, pain, and strength compared with disease-specific upper extremity outcome measures in rotator cuff repair

BACKGROUND

Patient-reported outcome measures (PROMs) are being increasingly used in orthopedic surgery; however, there is significant variability and burden associated with their administration. The visual analog scale (VAS) for function, strength, and pain may represent a simple and efficient way to measure outcomes, specifically after rotator cuff repair (RCR) surgery.

PURPOSE

To define the efficiency and longitudinal psychometric properties of VAS instruments assessing function, strength, and pain after RCR.

METHODS

Single-question VAS measures assessing function, strength, and pain as a percentage of normal were administered alongside legacy PROMs in patients undergoing RCR. VAS and PROMs were administered at preoperative, 6- and 12-month time points between June 2017 and April 2018. An electronic registry was used to examine time-to-completion data. PROM performance was assessed using Spearman correlation coefficients. Both absolute and relative floor and ceiling effects were examined. Effect size was measured at 6 and 12 months through the calculation of Cohen's d coefficient. Receiver-operating curves with area under the curve calculations were used to determine the ability of preoperative VAS scores in predicting minimally clinically important difference achievement on American Shoulder and Elbow Surgeons score (ASES).

RESULTS

A total of 190 patients (55.6 ± 10.9 years, 66.9% male) met criteria. The 3 VAS PROMs required less time to complete than ASES (1.36 ± 1.12 vs. 5.17 ± 2.39) and Patient-Reported Outcome Measurement Information System (PROMIS) Upper Extremity v2.0 (UE) Computer Adaptive Test (1.72 ± 1.48). Compared with ASES, VAS function, strength, and pain demonstrated fair correlations preoperatively (r = 0.44-0.46) that improved to good at 6 months (r = 0.61-0.67) and further improved at 1 year (r = 0.62-0.78). The performance of VAS measures with other function PROMs was comparable with performance relative to ASES, with poor to very good correlations preoperatively (r = 0.21-0.62) that improved to good to excellent by 1 year (r = 0.62-0.94). A significant relative ceiling effect was demonstrated by PROMIS UE at 12 months (16.9%). Large effect sizes were demonstrated by the ASES, Single Assessment Numeric Evaluation, Constant, PROMIS UE, and VAS function and strength instruments (Cohen d ≥ 0.8).

CONCLUSION

Single-question VAS assessments for function, strength, and pain are an efficient means for assessing outcome in RCR surgery and may be particularly useful in the postoperative setting. VAS instruments collectively trended toward floor effects preoperatively, suggesting that legacy instruments may more appropriately establish preoperative baselines. However, in the postoperative setting, VAS instruments demonstrate good-to-excellent correlation, minimized time-to-completion, and no appreciable floor or ceiling effects.

Which Metrics Are Being Used to Evaluate Children and Adolescents After ACL Reconstruction? A Systematic Review

PURPOSE

To identify a comprehensive list of outcome measures previously used in the literature to evaluate clinical outcomes after reconstruction of the anterior cruciate ligament (ACL) in patients 18 years of age or younger.

METHODS

A literature search was performed by querying MEDLINE, Embase and Cochrane computerized databases for relevant articles that reported clinical outcomes in pediatric patients undergoing ACL reconstruction. Studies that were nonclinical, that reported on patients older than 19 years, that were not available in English, or that included fewer than 10 patients were excluded. Outcome measures of all eligible studies were recorded.

RESULTS

We identified 77 studies published between 1986 and 2018 in 20 peer-reviewed journals. The mean age of the patients was 13.9 years. The ACL rerupture rate was reported in 60% of studies; 32 studies (42%) reported a rate of return to preinjury activity or sports. The use of adult-validated patient-reported outcome measures were reported in 63 (82%) articles. The Lysholm (64%), International Knee Documentation Committee (IKDC) (56%) and Tegner (37%) scores were the most commonly reported. Two patient-reported outcome measures designed for pediatric patients (the Pedi-IKDC and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS) were employed in 5 (6%) recent studies.

CONCLUSIONS

There is variability across studies in the metrics used to assess clinical outcomes following ACL reconstruction in children and adolescents. Validated pediatric-specific instruments were used infrequently.

CLINICAL RELEVANCE

A large body of existing pediatric ACL-reconstruction literature relies on a variable set of outcome measures that have not been developed or validated for children and adolescents. More recently, contemporary studies have begun to employ pediatric- and adolescent-specific validated measures, yet their use remains uncommon.

Outcome reporting patterns in total knee arthroplasty: A systematic review

BACKGROUND

Total knee arthroplasty (TKA) is one of the most effective ways to treat end-stage painful conditions of the knee. However, non-standardized reporting patterns can make quantitative analysis of patient outcomes difficult.

METHODS

A systematic review of the literature was performed using keywords "total knee arthroplasty" and "total knee replacement." Randomized controlled trials (RCTs) meeting the inclusion criteria were sorted and reviewed. Type of study, outcome measures used to report their results, and the actual results were recorded. Quantitative analysis was performed.

RESULTS

A total of 233 RCTs were included. There was significant variability in the reporting of short term and long term outcomes in total knee arthroplasty. The most common treatment domains in order of decreasing frequency were objective knee function, subjective knee function, perioperative complications, and pain. Range of motion was the most common outcome metric reported in all the RCTs and also was the most common metric used to assess objective knee function. The most common patient reported outcome measure used to assess postoperative function was the Knee Society Score followed by Knee Injury and Osteoarthritis Outcome Score. The Visual Analog Scale was the most common measurement tool used to assess postoperative pain. Most studies assessed patient outcomes in three treatment domains. None reported outcomes in all seven domains.

CONCLUSION

There is significant variability in outcome reporting patterns in TKA literature. Most studies do not track outcomes comprehensively, with a significant minority of the RCTs tracking outcomes in only one treatment domain.

Wide Variability in Patient-Reported Outcomes Measures After Fusion for Lumbar Spinal Stenosis: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The purpose of this study is to review outcomes reporting methodology in studies evaluating fusion for lumbar spinal stenosis.

METHODS

A systematic review of PubMed and Embase databases was conducted from January 2007 to June 2017 for English language studies with minimum of 2 years postoperative follow-up reporting outcomes after fusion for lumbar spinal stenosis. Two reviewers assessed each study; those meeting inclusion criteria were examined for pertinent data. Outcome measures were categorized into relevant domains: pain/symptomatology, function/disability, and surgical satisfaction. Return to work reporting was also recorded.

RESULTS

Of 123 studies meeting inclusion criteria, 76% included posterior-only fusion, 32% included posterior/transforaminal interbody fusion, and 5% included anterior/lateral interbody fusion (non-mutually exclusive). There was significant variation in patient-reported outcomes (PROs) used-studies reported 31 unique PROs assessing at least one domain: 22 evaluating pain, 23 evaluating function, and 3 evaluating surgical satisfaction. Most commonly utilized PROs were the Oswestry Disability Index (73% of studies), Visual Analog Scale (55%), and 36-Item Short Form Survey (32%). The remaining 28 measures were used in 14% of studies or fewer. PROs specific to symptoms of lumbar spinal stenosis, such as the Zurich Claudication Questionnaire, were only used rarely (7/123 studies). Only 14% of studies reported on time to return to work.

CONCLUSIONS

The literature surrounding fusion in the setting of lumbar stenosis is characterized by substantial variability in outcomes reporting. Very few studies utilized measures specific to lumbar spinal stenosis. Efforts to standardize outcomes reporting would facilitate comparisons of surgical interventions.

Modified Iliotibial Band Tenodesis Is Indicated to Correct Intraoperative Residual Pivot Shift After Anterior Cruciate Ligament Reconstruction Using an Autologous Hamstring Tendon Graft: A Prospective Randomized Controlled Trial

BACKGROUND

The indications for the addition of anterolateral soft tissue augmentation to anterior cruciate ligament (ACL) reconstruction and its effectiveness remain uncertain.

PURPOSE

To determine if modified iliotibial band tenodesis (MITBT) can improve clinical outcomes and reduce the recurrence of ACL ruptures when added to ACL reconstruction in patients with a residual pivot shift.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Patients with a primary ACL rupture satisfying the following inclusion criteria were enrolled: first ACL rupture, involved in pivoting sports, skeletally mature, no meniscal repair performed, and residual pivot shift relative to the contralateral uninjured knee immediately after ACL reconstruction. Patients were randomized to group A (no further surgery) or group B (MITBT added) and were followed up for 2 years. The patient-reported outcome (PRO) measures used were the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) subscale of sport/recreation (Sport/Rec), KOOS subscale of quality of life (QoL), Lysholm knee score (LKS), Tegner activity scale (TAS), recurrent ACL ruptures, or need for further surgery in either knee. Analysis of variance was used to compare PROs; the Wilcoxon test was used for the TAS; and the chi-square test was used for recurrence of ACL ruptures, meniscal injuries, and contralateral ACL ruptures (P < .05).

RESULTS

A total of 55 patients were randomized: 27 to group A (female:male ratio = 15:12; mean age, 22.3 ± 3.7 years) and 28 to group B (female:male ratio = 17:11; mean age, 21.8 ± 4.1 years). At 2-year follow-up, group A had a similar IKDC score (90.9 ± 10.7 vs 94.2 ± 11.2; respectively; P = .21), lower KOOS Sport/Rec score (91.5 ± 6.4 vs 95.3 ± 4.4, respectively; P = .02), similar KOOS QoL score (92.0 ± 4.8 vs 95.1 ± 4.3, respectively; P = .14), lower LKS score (92.5 ± 4.8 vs 96.8 ± 8.0, respectively; P = .004), lower TAS score (median, 7 [range, 7-9] vs 8 [range, 8-10], respectively; P = .03), higher rate of recurrence (14.8% vs 0.0%, respectively; P < .001), similar rate of meniscal tears (14.8% vs 3.6%, respectively; P = .14), and similar rate of contralateral ACL ruptures (3.7% vs 3.6%, respectively; P = .99) relative to group B.

CONCLUSION

The augmentation of ACL reconstruction with MITBT reduced the risk of recurrent ACL ruptures in knees with a residual pivot shift after ACL reconstruction and improved KOOS Sport/Rec, LKS, and TAS scores.

REGISTRATION

ACTRN12618001043224 (Australian New Zealand Clinical Trials Registry).

Outcome Measure Utilization Demonstrates No Relation to Journal Rank or Level of Evidence for Superior Labral Tears of the Shoulder

Introduction Superior labrum anterior to posterior (SLAP) tears are injuries of the shoulder's glenoid labrum involving biceps tendon insertion. We describe the scope of outcome measures used in the SLAP tear literature over the last decade and evaluate whether objective study metrics relate to level of evidence (LOE) and journal rank. Methods A comprehensive review of the literature was performed to identify all articles on the outcomes of the treatment of patients with SLAP tears published over the period of a decade (2007-2016). Studies were reviewed for LOE, SCImago Scientific Journal Ranking (SJR), study characteristics, and patient demographics. The utilization frequencies of outcome measures were recorded. Outcome measures were categorized as clinician-measured outcomes (CMOs), outcome scores/patient-reported outcomes (PROs), or other reported outcomes (OROs). Univariate analyses compared demographics and outcome-measure utilization among studies grouped by LOE (high: I/II vs. low: III/IV) and SJR (high: >2 vs. low: <2). Results The literature review identified 86 studies meeting inclusion criteria from an initial search of 582 articles. The mean study SJR was 2.02 and 0.85 +/- 0.79 CMOs were included. Twenty different outcome scores were utilized in the reviewed literature with a mean of 2.66 +/- 1.61 PROs/study. The most common outcome scores were ASES score, pain Visual Analog Scale (VAS), and constant score. High SJR studies had longer follow-up (p=0.036). High LOE studies utilized more CMOs (p=0.008) and more commonly included physical exam findings (p=0.0015). Revision surgery rate was less commonly reported in high LOE studies (p=0.036). None of the other outcome measures studied were associated with high study LOE or SJR. Conclusions Considerable variability exists in outcome-measure utilization within the recent SLAP tear literature. ASES score, pain VAS, and constant score are the most commonly reported PROs. CMOs and OROs are infrequently reported. There is little objectivity distinguishing higher and lower quality studies based on the proxy metrics used. Future SLAP tear research should focus on improving the consistency of outcome-measure reporting to enable more meaningful cross-study comparisons.

What Are the Floor and Ceiling Effects of Patient-Reported Outcomes Measurement Information System Computer Adaptive Test Domains in Orthopaedic Patients? A Systematic Review

PURPOSE

To perform a systematic review to answer the following: (1) What are the floor and ceiling (F/C) effects of the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test (CAT) domains of physical function (PF), upper extremity physical function (UE), pain interference (PI), and depression (D) in adult orthopaedic patients? (2) Do the PROMIS-PF and PROMIS-PI domains have differing F/C effects depending on use in upper extremity, lower extremity, spine, neck, and back, or trauma patients?.

METHODS

(Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed, the review was registered on PROSPERO, and the methodological index for non-randomized studies was used for this systematic review. Studies reporting the F/C effects of at least 1 of 4 PROMIS CAT domains in orthopaedic patient cohorts accessed through PubMed and Embase on October 30, 2018, were included. F/C effects for each study were reported within forest plots.

RESULTS

Forty-three studies were included. Generally, varying cohorts demonstrated no F/C effects for PROMIS-PF (0%-9.0%), variable ceiling effects for PROMIS-UE (lower in v2.0; 0%-28.2%), variable floor effects for PROMIS-PI (0%-19.0%), and significant floor effects for PROMIS-D (0.4%-23.4%).

CONCLUSIONS

The orthopaedic literature demonstrated generally favorable floor and ceiling effects for PROMIS CAT domains, with the exception of variable ceiling effects for PROMIS-UE (the newer version exhibits only minor effects), variable floor effects for PROMIS-PI, and significant floor effects for PROMIS-D. In addition, the F/C effects of PROMIS-PF did not vary based on patient population. Although the floor effects of PROMIS-PI did vary based on patient population, the variability does not appear to be based solely on anatomic location. The PROMIS-PF and PROMIS-UE v2.0 demonstrate consistently low floor and ceiling effects. However, the PROMIS-PI and PROMIS-D may need modification before widespread adoption for clinical and research purposes.

LEVEL OF EVIDENCE

III; systematic review of Level I-III studies.

Editorial Commentary: Making the Leap to the Patient-Reported Outcomes Measurement Information System: A Paradigm Shift That Will Ultimately Benefit Our Patients

Numerous studies have demonstrated favorable psychometric and administrative characteristics of the National Institutes of Health Patient-Reported Outcomes Measurement Information System Computer Adaptive Test measures in orthopaedic patient populations. These dynamic assessments require significantly fewer questions than do traditional patient-reported outcome measures, thus requiring less time for survey completion. Their domain-specific nature and standardized scoring make them uniquely suitable for population health assessments. Although some challenges exist in improving adoption of Patient-Reported Outcomes Measurement Information System Computer Adaptive Test forms across orthopaedics, there is growing momentum to increase use of these tools across clinical and research orthopaedic applications.

PROMIS Versus Legacy Patient-Reported Outcome Measures in Patients Undergoing Surgical Treatment for Symptomatic Acetabular Dysplasia

BACKGROUND

No previous study has investigated how the Patient-Reported Outcomes Measurement Information System (PROMIS) performs compared with legacy patient-reported outcome measures in patients with symptomatic acetabular dysplasia treated with periacetabular osteotomy (PAO).

PURPOSE

To (1) measure the strength of correlation between the PROMIS and legacy outcome measures and (2) assess floor and ceiling effects of the PROMIS and legacy outcome measures in patients treated with PAO for symptomatic acetabular dysplasia.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

This study included 220 patients who underwent PAO for the treatment of symptomatic acetabular dysplasia. Outcome measures included the Hip disability and Osteoarthritis Outcome Score (HOOS) pain, HOOS activities of daily living (ADL), modified Harris Hip Score (mHHS), PROMIS pain, and PROMIS physical function subsets, with scores collected preoperatively and/or postoperatively at a minimum 12-month follow-up. The change in mean scores from preoperatively to postoperatively was calculated only in a subgroup of 57 patients with scores at both time points. Distributions of the PROMIS and legacy scores were compared to evaluate floor and ceiling effects, and Pearson correlation coefficients were calculated to evaluate agreement.

RESULTS

The mean age at the time of surgery was 27.7 years, and 83.6% were female. The mean follow-up time was 1.5 years. Preoperatively, neither the PROMIS nor the legacy measures showed significant floor or ceiling effects. Postoperatively, all legacy measures showed significant ceiling effects, with 15% of patients with a maximum HOOS pain score of 100, 29% with a HOOS ADL score of 100, and 21% with an mHHS score of 100. The PROMIS and legacy instruments showed good agreement preoperatively and postoperatively. The PROMIS pain had a moderate to strong negative correlation with the HOOS pain (r = -0.66; P < .0001) and mHHS (r = -0.60; P < .0001) preoperatively and the HOOS pain (r = -0.64; P < .0001) and mHHS (r = -0.64; P < .0001) postoperatively. The PROMIS physical function had a moderate positive correlation with the HOOS ADL (r = 0.51; P < .0001) and mHHS (r = 0.49; P < .0001) preoperatively and a stronger correlation postoperatively with the HOOS ADL (r = 0.56; P < .0001) and mHHS (r = 0.56; P < .0001).

CONCLUSION

We found good agreement between PROMIS and legacy scores preoperatively and postoperatively. PROMIS scores were largely normally distributed, demonstrating an expanded ability to capture variability in patients with improved outcomes after treatment.

Relationship of Knee Forces to Subjective Function Pre- and Post-ACL Reconstruction

PURPOSE

Although basic objective measures (e.g., knee laxity, strength, and hop tests) have been related to subjective measures of function, associations between knee-specific objective and subjective measures have yet to be completed. The objective was to determine if knee joint contact and ligament forces differ between pre- and post-anterior cruciate ligament (ACL) reconstructed states and if these forces relate to their patient's respective subjective functional ability scores.

METHODS

Twelve patients performed a hopping task before and after reconstruction. Magnetic resonance images and OpenSim were used to develop patient-specific models in static optimization and joint reaction analyses. Questionnaires concerning each patient's subjective functional ability were also collected and correlated with knee joint contact and ligament forces.

RESULTS

No significant differences were observed between deficient and reconstructed groups with respect to knee joint contact or ligament forces. Nevertheless, there were several significant (P < 0.05) moderate to strong correlations between subjective and objective measures including Tegner activity level to contact force in both states (r = 0.67-0.76) and International Knee Documentation Committee to compressive and anterior shear forces (r = 0.64-0.66).

CONCLUSION

Knee-specific objective measures of a patient's functional capacity can represent their subjective ability, which explains this relationship to a greater extent than past anatomical and gross objective measures of function. This consolidation is imperative for improving the current rehabilitation schema as it allows for external validation of objective and subjective functional measures. With poor validation of subjective function against objective measures of function, the reinjury rate is unlikely to diminish, continuing the heavy financial burden on health care systems.

Floor and Ceiling Effects, Time to Completion, and Question Burden of PROMIS CAT Domains Among Shoulder and Knee Patients Undergoing Nonoperative and Operative Treatment

The Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) have emerged as an efficient technique for measuring patient-reported outcomes among orthopaedic patients. The purpose of this study was to investigate the floor and ceiling (F/C) effects, time to completion (TTC), and question burden of PROMIS CATs administered to patients presenting to a shoulder and sports medicine orthopaedic clinic.

Timeline for Maximal Subjective Outcome Improvement After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) tears are one of the most common traumatic knee injuries experienced by athletes. Return to sport is considered the pinnacle endpoint among patients receiving ACL reconstruction. However, at the time of return to sport, patients may not be participating at their previous levels of function, as defined by clinical metrics.

PURPOSE

To establish when patients perceive maximal subjective medical improvement according to patient-reported outcome measures (PROMs).

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the PubMed database was conducted to identify studies that reported sequential PROMs up to a minimum of 2 years after ACL reconstruction. Pooled analysis was conducted for PROMs at follow-up points of 3 months, 6 months, 1 year, and 2 years. Clinically significant improvement was determined between pairs of intervals with the minimal clinically important difference.

RESULTS

This review contains 30 studies including 2253 patients who underwent ACL reconstruction. Clinically significant improvement in the KOOS (Knee injury and Osteoarthritis Outcome Score) was seen up to 1 year after ACL reconstruction, but no clinical significance was noted from 1 to 2 years. Clinically significant improvement in the IKDC (International Knee Documentation Committee) and Lysholm questionnaires was seen up to 6 months postoperatively, but no clinical significance was noted beyond that.

CONCLUSION

After ACL reconstruction, maximal subjective medical improvement is established 1 year postoperatively, with no further perceived clinical improvement beyond this time point according to current PROMs. The KOOS may be a more responsive metric to subjective improvements in this patient cohort than other patient-reported outcomes, such as the IKDC and Lysholm.

CLINICAL RELEVANCE

After ACL reconstruction, patients perceive interval subjective improvements until 1 year postoperatively.

Outcome Measures After ACL Injury in Pediatric Patients: A Scoping Review

BACKGROUND

The incidence of anterior cruciate ligament (ACL) injuries in children is increasing. However, no standardized core set of outcome measures exists for evaluating pediatric ACL injuries.

PURPOSE

To perform a scoping review of the literature to identify patient-reported outcome measures (PROMs) and objective outcome measures used to evaluate pediatric patients after ACL injury and to classify these in accordance with the International Classification of Functioning, Disability, and Health (ICF) domains.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The literature was systematically searched with the PubMed, EMBASE, CINAHL, and PEDro databases. The inclusion criteria were Danish, Norwegian, Swedish, German, or English language; publication between 2010 and 2018; pediatric ACL injury (patients ≤15 years old); and outcome measures. The selected papers were screened for title, abstract, and full text in accordance with predefined inclusion and exclusion criteria.

RESULTS

A total of 68 papers (4286 patients; mean ± SD age, 12.2 ± 2.3 years) were included. Nineteen PROMs and 11 objective outcome measures were identified. The most frequently reported PROMs were the International Knee Documentation Committee (IKDC) Subjective Knee Form (51% of studies), Lysholm scoring scale (46% of studies) and Tegner activity rating scale (37% of studies). Additionally, return to sport was reported in 41% of studies. The most frequent objective measures were knee laxity (76% of studies), growth disturbances (69% of studies), range of motion (41% of studies), and muscle strength (21% of studies). With respect to the ICF domains, the IKDC covered all 3 ICF health domains, the Lysholm score covered the Body Structure and Function and the Activity Limitation domains, while the Tegner score covered the Participation Restriction domain. Objectively measured knee joint laxity, range of motion, and muscle strength covered 1 domain (Body Structure and Function).

CONCLUSION

Pediatric patients with ACL injury were mainly evaluated subjectively with the IKDC and objectively by knee joint laxity. No consensus exists in the evaluation of children after ACL injury. The majority of applied outcome measures are developed for adults. To cover the ICF health domains, future research needs to consider reliable and valid outcome measures relevant for pediatric patients with ACL injury.

Patterns in Outcomes Reporting of Operatively Managed Pediatric Patellofemoral Instability: A Systematic Review and Meta-analysis

BACKGROUND

Traumatic patellofemoral dislocation is a common injury in pediatric patients, and surgical treatment is often recommended. Increasingly, it has been recognized that clinical studies need to report age-appropriate treatment outcomes. However, the variability and appropriateness of outcomes reporting in the youth patellar instability literature are unknown.

PURPOSE

To analyze the patterns of outcomes reporting in studies published in high-impact orthopaedic journals after operative management of pediatric patellar instability.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Six high-impact orthopaedic journals were searched using PubMed and EMBASE to identify studies reporting outcomes of operative management of pediatric patellar instability. Studies containing adults were excluded. Clinical and radiographic outcomes were recorded from included articles. Descriptive statistics were calculated for overall instability recurrence rates, return-to-activity rates, and changes in Kujala and Tegner scores.

RESULTS

Of 545 identified articles, 8 studies met the inclusion criteria. These studies encompassed 213 patients and 230 knees (mean age, 13.2 years; range, 4.5-18.3 years). Seven of 8 studies reported patients' physeal status, but only 4 studies limited their outcomes reporting to patients with open physes. Two studies reported postoperative radiographic measures, and 5 studies reported preoperative radiographic findings. Six studies reported patient-reported outcome measures (PROMs). Seven unique PROMs were reported. All but one study reported complication rates and types of complications. The mean postoperative change in Tegner scores was -0.07 (range, -0.6 to 1.0). Among studies examining medial patellofemoral ligament reconstruction with adequate data, the mean return-to-activity rate was 86% (range, 81%-92%), the instability recurrence rate was 3% ± 20%, and the mean improvement in Kujala scores postoperatively was 22.1 (range, 19.9-26).

CONCLUSION

There is a need for more pediatric-specific outcomes studies regarding operatively managed traumatic patellofemoral instability. Of the outcomes reported, both radiographic outcomes and PROMs should be standardized. Among radiographic outcomes, there is a need for more studies that report tibial tubercle-trochlear groove distances and use Caton-Deschamps and/or Blackburne-Peel indices to assess patellar height. Among PROMs, there is a need for studies that use PROMs validated in pediatric populations, such as the International Knee Documentation Committee Pediatric Form or the Hospital for Special Surgery Pediatric Functional Activity Brief Scale.

Editorial Commentary: A Primer on the Patient-Reported Outcomes Measurement Information System-Understanding How This Powerful Tool Can Be Used for Clinical and Research Gains

The National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) assessments are gaining traction in orthopaedics as dynamic and efficient methods for measuring patient-reported outcomes. Numerous recent studies have shown favorable psychometric properties of PROMIS forms compared with traditional, "legacy" patient-reported outcome measures. Despite these early findings, however, additional validation research is needed to justify widespread adoption of PROMIS as a clinical and research tool.

The Correlation Between PROMIS Pain Interference and VAS Pain in Ambulatory Orthopedic Patients

The purpose of this study was to investigate the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) score with traditionally collected visual analog scale (VAS) scores and to determine the influence of patient demographics on PROMIS PI and VAS scores. Patient demographics were collected, and PROMIS PI, PROMIS Physical Function (PF), and VAS questionnaires were distributed to 215 patients in orthopedic ambulatory clinics. The primary outcome was correlation between PROMIS PI and VAS questionnaires. The statistical method of seemingly unrelated regressions was used to identify significant predictors and strengths of correlation between PROMIS PI and conventional forms. The PROMIS PI score was highly correlated to conventional pain and functional scores, with each standard deviation increase in PROMIS PI score predicting a 16-point increase for pain-related VAS scores (current pain, pain at rest, pain during activity, pain at night), an 18-point decrease in satisfaction of function score, and a 6-point decrease in general health score. Each standard deviation increase in PROMIS PF score for black patients predicted a reduction of 11 points for current pain, 10 points for pain at rest, 10 points for pain during activity, and 12 points for pain at night scores. The PROMIS PI score consistently predicts changes in VAS pain scores and can be considered a useful, standardized tool for measuring pain for clinical and research purposes. [Orthopedics. 2018; 41(6):e813-e819.].

High Degree of Variability in Reporting of Clinical and Patient-Reported Outcomes After Hip Arthroscopy

BACKGROUND

Hip arthroscopy for the treatment of intra-articular pathology is a rapidly expanding field. Outcome measures should be reported to document the efficacy of arthroscopic procedures; however, the most effective outcome measures are not established.

PURPOSE

To evaluate the variability in outcomes reported after hip arthroscopy and to compare the responsiveness of patient-reported outcome (PRO) instruments.

STUDY DESIGN

Systematic review.

METHODS

We reviewed primary hip arthroscopy literature between January 2011 and September 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Patient and study characteristics were recorded. Pre- and postoperative means and SDs of PROs were recorded from articles that used 2 or more PROs with a 1-year minimum follow-up. From this subset of articles, we compared the responsiveness between PRO instruments using the effect size, standard response mean, and relative efficiency.

RESULTS

We identified 130 studies that met our inclusion/exclusion criteria, which totaled 16,970 patients (17,511 hips, mean age = 37.0 years, mean body mass index = 25.9 kg/m²). Radiographic measures were reported in 100 studies. The alpha angle and center-edge angle were the most common measures. Range of motion was reported in 81 of 130 articles. PROs were reported in 129 of 130 articles, and 21 different PRO instruments were identified. The mean number of PROs per article was 3.2, and 78% used 2 or more PROs. The most commonly used PRO was the modified Harris Hip Score, followed by the Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sport, visual analog scale, and Nonarthritic Hip Score (NAHS). The 2 most responsive PRO tools were the International Hip Outcome Tool (iHOT)-12 and the NAHS.

CONCLUSION

Outcomes reporting is highly variable in the hip arthroscopy literature. More than 20 different PRO instruments have been used, which makes comparison across studies difficult. A uniform set of outcome measures would allow for clearer interpretation of the hip arthroscopy literature and offer potential conclusions from pooled data. On the basis of our comparative responsiveness results and previously reported psychometric properties of the different PRO instruments, we recommend more widespread adoption of the iHOT PROs instruments to assess hip arthroscopy outcomes.

The lack of standardized outcome measures following lower extremity injury in elite soccer: a systematic review

PURPOSE

Sport-specific, performance-based outcomes are increasingly used to improve evaluation of treatment efficacy in elite athletes; however, its usage in elite soccer may be limited. The purpose of this investigation is to (1) assess current outcome reporting in elite soccer; (2) identify any variability in reporting of outcomes; and (3) determine how sport-specific performance-based outcomes are utilized to assess treatment efficacy in elite soccer.

METHODS

A systematic review of the Pubmed, MEDLINE, and Embase, Scopus, SportDiscus, CINAHL and HealthSource: Nursing databases was performed without limitation on publication year. Inclusion criteria were (1) reporting of outcomes after a (2) lower extremity injury in (3) elite soccer players. The study's population, type of injury, return to play, as well as functional, objective, and sport-specific performance-based outcomes were extracted from each article. The methodological index for nonrandomized studies was used for quality assessment.

RESULTS

Twenty-one studies were selected after application of the inclusion and exclusion criteria. Objective outcomes were reported by 6 (29%) studies, and 6 (29%) employed patient-reported outcomes. The visual analog scale, Lysholm, and Tegner scores were the most common patient-reported outcomes (PROs). Return to play was reported by 18 (86%) studies, and only 2 (10%) utilized sport-specific performance-based outcomes. Despite the majority of studies reporting return to play, variation was seen in the definitions, and 15 (71%) studies reported the activity level of the players at final follow-up.

CONCLUSION

Assessment of treatment efficacy is limited in elite athletes, and PROs lack the sensitivity to identify residual performance deficits after an injury. Although performance-based measures are available at the elite level, these outcomes were seldom used for evaluation of treatment efficacy.

CLINICAL RELEVANCE

When treating elite soccer players, patient-reported outcome measures lack the sensitivity to detect changes in patient function, thus performance-based metrics may be more efficacious in assessing return from injury in these patients.

LEVEL OF EVIDENCE

IV.

The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS): Normative Data

BACKGROUND

Recent data have shown an increase in youth sports participation at younger ages, which may be linked to greater musculoskeletal injury risk. The Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS) is a validated 8-item instrument designed to quantify the activity of children between 10 and 18 years old. Normative data on pediatric and adolescent activity level are unknown.

PURPOSE

To establish normative activity-level data for American youth and to determine if there is a natural decrease in activity level during adolescence.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A cross-sectional investigation was performed among 2002 US children and adolescents equally split by sex and age and representing census-weighted distributions of state of residency, race/ethnicity, and health insurance status. Respondents completed the HSS Pedi-FABS, as well as survey questions on demographics and sports participation. Normative data were reported with descriptive statistics. Linear regression analysis was performed to determine if there was an effect of age on activity level during adolescence.

RESULTS

A total of 2002 respondents completed the survey; the mean age of the respondents at the time of survey completion was 14.0 ± 2.6 years. Mean weekly amount of reported physical activity was 9.3 ± 8.4 hours. HSS Pedi-FABS scores were normally distributed with a mean of 15.4 ± 8.5 points (out of 30 possible points). There was a modest but statistically significant decrease in HSS Pedi-FABS activity scores with increasing age ( r = -0.175, P < .001), corresponding to a linear decrease in activity scores by 27% on average from age 10 to 18 years.

CONCLUSION

The current study provides baseline normative data for activity level in a census-weighted representative population sample of 2002 American youth through the use of a validated activity score (HSS Pedi-FABS). There was a modest but statistically significant decrease in activity scores with increasing age. These results will aid future research by providing normative, representative population-level activity data and will help to quantify the natural rate of decreased activity during adolescence.

Can Biologic Augmentation Improve Clinical Outcomes Following Microfracture for Symptomatic Cartilage Defects of the Knee? A Systematic Review

Objective To perform a systematic review of clinical outcomes following microfracture augmented with biological adjuvants (MFX+) compared with microfracture (MFX) alone. Design The MEDLINE, Scopus, and Cochrane databases were searched for clinical studies on MFX+ for chondral defects of the knee. Study characteristics and clinical outcome score data were collected. Subjective synthesis was performed using data from randomized controlled studies to determine effect size of MFX+ procedures performed with either injectable or scaffold-based augmentation compared with MFX alone. Results A total of 18 articles reporting on 625 patients (491 MFX+, 134 MFX) were identified. Six studies were level II evidence and 1 study was level I evidence. Mean patient age range was 26 to 51 years, and mean follow-up ranged from 2 to 5 years. All studies demonstrated significant improvement in reported clinical outcome scores at follow-up after MFX+ therapy, and 87% of patients reported satisfaction with treatment. The most commonly reported treatment complication was postoperative stiffness (3.9% of patients). Subjective synthesis on randomized controlled trials demonstrated that 2/2 injectable MFX+ interventions had significantly greater improvements in International Knee Documentation Committee Subjective Knee Form (IKDC; P = 0.004) and Knee injury and Osteoarthritis Outcome Score (KOOS; P = 0.012) scores compared with MFX alone, while 2/2 trials on scaffolding MFX+ adjuvants showed comparable postoperative improvements. Conclusions MFX+ biological adjuvants are safe supplements to marrow stimulation for treating cartilage defects in the adult knee. Early literature is heterogenous and extremely limited in quality. Individual trials report both equivalent and superior clinical outcomes compared with MFX alone, making definitive conclusions on the efficacy of MFX+ difficult without higher quality evidence.

Male Sex, Decreased Activity Level, and Higher BMI Associated With Lower Completion of Patient-Reported Outcome Measures Following ACL Reconstruction

Background:

Patient-reported outcome (PRO) surveys have become increasingly important in both improving patient care and assessing outcomes.

Purpose/Hypothesis:

The purpose of this study was to evaluate which variables are associated with compliance with completing PRO surveys in patients who have undergone anterior cruciate ligament reconstruction (ACLR). The authors hypothesized that older patient age and longer time since ACLR would be associated with lower completion rates of PRO surveys preoperatively and at postoperative time points.

Study Design:

Case series; Level of evidence, 4.

Methods:

All patients who underwent ACLR by a sports medicine fellowship–trained orthopaedic surgeon at a single institution and were electronically assigned PRO surveys through a data collection system preoperatively between December 2013 and March 2015 were included. Postoperatively, PRO surveys were sent to patients’ email addresses at 6, 12, and 24 months. Demographics, history, and operative and postoperative information were evaluated for an association with survey completion rates.

Results:

A total of 256 patients met the inclusion criteria. There were 140 (54.7%) male and 116 (45.3%) female patients, with an overall mean age of 28.6 ± 11.9 years. Only 19 (7.4%) patients completed all preoperative and postoperative surveys at all time points. Less than half of the patients (n = 104; 40.6%) completed both the preoperative survey and at least 1 postoperative survey. There was a steady decrease in the completion rate of PRO surveys postoperatively over time (Pearson r = –0.995, P = .005). Male patients had significantly worse compliance with completing PRO surveys preoperatively and at a minimum of 1 time point postoperatively (P = .044). Patients who did not identify as athletes or report frequent exercise (≥3 times/wk) had significantly worse compliance with completing any PRO surveys (P = .046). Lower body mass index was associated with greater odds of compliance with completing the preoperative survey and 24-month postoperative survey (odds ratio, 0.902; P = .029).

Conclusion:

An inverse relationship was found between the surgery-to-survey period and percentage of those completing PRO surveys, with poor overall compliance. Male sex and not self-identifying as an athlete or performing frequent physical exercise were associated with lower completion rates of PRO surveys, while lower body mass index was associated with a greater rate of completion.

Patient-Reported Outcomes Measurement Information System and Legacy Patient-Reported Outcome Measures in the Field of Orthopaedics: A Systematic Review

PURPOSE

To compare Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) with legacy patient-reported outcome measures with regard to correlations, ease of use, and quality criteria for orthopaedic conditions.

METHODS

A systematic search of the PubMed/MEDLINE database was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify published articles that referenced the various PROMIS PF measures. Three authors independently reviewed selected studies. The search returned 130 studies, 44 of which underwent review. Of these, 18 were selected for inclusion. A general linear model and paired t-tests were used to assess for differences between legacy patient-reported outcome measures and PROMIS.

RESULTS

The combined sample size of all articles yielded 3,047 total patients. Overall, PROMIS PF measures and legacy scores showed strong correlations (range: 0.59-0.83) when evaluating upper extremity, lower extremity, and spine patients. PROMIS questionnaires (6.04, standard error [SE] = 0.7) have significantly fewer questions than legacy forms (24.27, SE = 4.36). In lower extremity studies, the PROMIS PF (100.14 seconds, SE = 28.41) forms were completed in significantly less time (P = .03) than legacy forms (243.70 seconds, SE = 45.8). No significant difference was found between the reliabilities of the 2 types of measures.

CONCLUSIONS

PROMIS PF scores correlate strongly, particularly in lower extremity patients, with some of the most commonly used legacy measures in orthopaedics. PROMIS can be administered quicker and applied to a broader patient population while remaining highly reliable.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV evidence.

Patient Compliance With Electronic Patient Reported Outcomes Following Shoulder Arthroscopy

PURPOSE

To determine the patient compliance in completing electronically administered patient-reported outcome (PRO) scores following shoulder arthroscopy, and to determine if dedicated research assistants improve patient compliance.

METHODS

Patients undergoing arthroscopic shoulder surgery from January 1, 2014, to December 31, 2014, were prospectively enrolled into an electronic data collection system with retrospective review of compliance data. A total of 143 patients were included in this study; 406 patients were excluded (for any or all of the following reasons, such as incomplete follow-up, inaccessibility to the order sets, and inability to complete the order sets). All patients were assigned an order set of PROs through an electronic reporting system, with order sets to be completed prior to surgery, as well as 6 and 12 months postoperatively. Compliance rates of form completion were documented. Patients who underwent arthroscopic anterior and/or posterior stabilization were excluded.

RESULTS

The average age of the patients was 53.1 years, ranging from 20 to 83. Compliance of form completion was highest preoperatively (76%), and then dropped subsequently at 6 months postoperatively (57%) and 12 months postoperatively (45%). Use of research assistants improved compliance by approximately 20% at each time point. No differences were found according to patient gender and age group. Of those completing forms, a majority completed forms at home or elsewhere prior to returning to the office for the clinic visit.

CONCLUSIONS

Electronic administration of PRO may decrease the amount of time required in the office setting for PRO completion by patients. This may be mutually beneficial to providers and patients. It is unclear if an electronic system improves patient compliance in voluntary completion PRO. Compliance rates at final follow-up remain a concern if data are to be used for establishing quality or outcome metrics.

LEVEL OF EVIDENCE

Level IV, case series.

Preoperative Short Form Health Survey Score Is Predictive of Return to Play and Minimal Clinically Important Difference at a Minimum 2-Year Follow-up After Anterior Cruciate Ligament Reconstruction

BACKGROUND

There is increased interest in understanding the preoperative determinants of postoperative outcomes. Return to play (RTP) and the patient-reported minimal clinically important difference (MCID) are useful measures of postoperative outcomes after anterior cruciate ligament reconstruction (ACLR).

PURPOSE

To define the MCID after ACLR and to investigate the role of preoperative outcome scores for predicting the MCID and RTP after ACLR.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

There were 294 active athletes enrolled as part of an institutional ACL registry with a minimum 2-year follow-up who were eligible for inclusion. A questionnaire was administered to elicit factors associated with RTP. Patient demographic and clinical data as well as patient-reported outcome measures were captured as part of the registry. Outcome measures included the International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm scale, and 12-Item Short Form Health Survey (SF-12) physical component summary (PCS) and mental component summary (MCS). Preoperative outcome score thresholds predictive of RTP were determined using a receiver operating characteristic (ROC) with area under the curve (AUC) analysis. The MCID was calculated using a distribution-based method. Multivariable logistic models were fitted to identify predictors for achieving the MCID and RTP.

RESULTS

At a mean (±SD) follow-up of 3.7 ± 0.7 years, 231 patients were included from a total 294 eligible patients. The mean age and body mass index were 26.7 ± 12.5 years and 23.7 ± 3.2 kg/m², respectively. Of the 231 patients, 201 (87.0%) returned to play at a mean time of 10.1 months. Two-year postoperative scores on all measures were significantly increased from preoperative scores (IKDC: 50.1 ± 15.6 to 87.4 ± 10.7; Lysholm: 61.2 ± 18.1 to 89.5 ± 10.4; SF-12 PCS: 41.5 ± 9.0 to 54.7 ± 4.6; SF-12 MCS: 53.6 ± 8.1 to 55.7 ± 5.7; P < .001 for all). The corresponding MCID values were 9.0 (IKDC), 10.0 (Lysholm), 5.1 (SF-12 PCS), and 4.3 (SF-12 MCS). Preoperative score thresholds predictive of RTP were the following: IKDC, 60.9; Lysholm, 57.0; SF-12 PCS, 42.3; and SF-12 MCS, 48.3. These thresholds were not independently predictive but achieved significance as part of the multivariable analysis. In the multivariable analysis for RTP, preoperative SF-12 PCS scores above 42.3 (odds ratio [OR], 2.73; 95% CI, 1.09-7.62) and SF-12 MCS scores above 48.3 (OR, 4.41; 95% CI, 1.80-10.98) were predictive for achieving RTP; an ACL allograft (OR, 0.26; 95% CI, 0.06-1.00) was negatively predictive of RTP. In the multivariable analysis for the MCID, patients with higher preoperative scores were less likely to achieve the MCID ( P < .0001); however, a higher preoperative SF-12 MCS score was predictive of achieving the MCID on the IKDC form (OR, 1.27; 95% CI, 1.11-1.52) and Lysholm scale (OR, 1.08; 95% CI, 1.00-1.16). Medial meniscal injuries, older age, and white race were also associated with a decreased likelihood for achieving the MCID.

CONCLUSION

Preoperative SF-12 MCS and PCS scores were predictive of RTP after ACLR; patients scoring above 42.3 on the SF-12 PCS and 48.3 on the SF-12 MCS were more likely to achieve RTP. Additionally, we defined the MCID after ACLR and found that higher SF-12 MCS scores were predictive of achieving the MCID on knee-specific questionnaires.

Clinical Outcome Reporting in Youth ACL Literature Is Widely Variable

Background:

Advances in anterior cruciate ligament (ACL) reconstruction procedures in pediatric and adolescent patients have resulted in an increase in recent clinical studies on this topic. However, the consistency with which outcome measures are reported in this demographic is unknown.

Purpose:

To document outcome reporting patterns of youth ACL reconstruction studies in high-impact journals.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

All articles published in 5 high-impact orthopaedic journals from 2010 to 2016 were reviewed to identify those reporting clinical outcomes of young patients who underwent ACL reconstruction. Studies that were nonclinical, reported on patients older than 18 years, or included fewer than 10 patients were excluded. Outcome measures used in all included studies were recorded.

Results:

Seventeen studies encompassing 772 subjects (mean age, 14.3 years; range, 6.3-18.0 years) were analyzed. Eight studies (47%) reported on Tanner stage of subjects, while 1 study reported skeletal age. Ten studies (59%) clearly documented the presence or absence of surgical complications. Range of motion was reported in 65% of studies. Leg-length discrepancy and angular deformity were each reported in 76% of studies, with 12% quantifying results through radiographic measurements. Ligament testing was variably defined by inclusion of instrumented testing (65%), Lachman test (53%), and pivot-shift test (53%). Fourteen studies (82%) explicitly reported on the rate of ACL rerupture, while 71% reported on the rate of revision surgery. Rate of return to preinjury activity was reported in 8 studies (47%), of which 2 defined criteria for return to sport and 3 defined the level of competitive sport. Patient-reported outcome measures (PROMs) were used variably. For the 3 most commonly reported PROMs (Lysholm, International Knee Documentation Committee, and Tegner), 24% of studies reported all 3 PROMs, 35% of studies reported 2 PROMs, and 6% of studies reported 1 PROM in isolation. A pediatric-specific PROM was reported in 1 of the 17 studies.

Conclusion:

Studies on pediatric ACL reconstruction published in high-impact journals unreliably defined subjects’ skeletal maturity, inconsistently reported on objective outcome measures, and used disparate adult-validated PROMs to assess subjective outcomes. These findings highlight the need for standardized, pediatric-specific outcome measures to be applied in future studies evaluating ACL reconstruction in children and adolescents.

Validating the forgotten joint score-12 in patients after ACL reconstruction

BACKGROUND

The forgotten joint score-12 (FJS-12), used to measure postoperative joint awareness, has been extensively validated to assess outcomes after arthroplasty, however the new score has never been validated in evaluating anterior cruciate ligament (ACL) reconstruction. The purpose of our study was to validate the FJS-12 versus the knee injury and osteoarthritis outcome score (KOOS) for patients who have undergone ACL reconstruction.

METHODS

All patients who had undergone ACL reconstruction with the same arthroscopic surgical technique at our institution between 2011 and 2014 (medium-term follow-up group (M-FU)) or between 2000 and 2005 (long-term follow-up group (L-FU)) were considered for inclusion in the study. To analyze unidimensionality of the FJS-12, we calculated Cronbach's alpha, item-total correlations and conducted an exploratory principal component factor analysis. To assess convergent validity, we calculated Spearman correlation coefficients for the FJS-12 and its comparable scales.

RESULTS

We analyzed 58 patients of the M-FU (mean follow-up 31.5 (SD13.4) months, range 12-54), and 58 patients of the L-FU (mean follow-up 139 (SD15.2) months, range 120-179). The FJS-12 showed high internal consistency (Cronbach's alpha=0.95). Ceiling effects were considerably lower for the FJS-12 (M-FU 12.1%, L-FU 15.5%) compared with the KOOS subscales (M-FU 5.2-37.9%; L-FU 13.8-55.2%) and WOMAC subscales (M-FU 37.9-62.1%; L-FU 44.8-60.3%).

CONCLUSIONS

The FJS-12 is a valid measurement tool to evaluate outcomes of ACL reconstruction. This study extends the possibilities of measuring joint awareness as a patient-reported outcome parameter from joint arthroplasty to ACL reconstruction.

Return to Play and Patient Satisfaction After ACL Reconstruction: Study with Minimum 2-Year Follow-up

BACKGROUND

Return to play and patient satisfaction after anterior cruciate ligament reconstruction (ACLR) have been inconsistently studied. The purposes of this study were to (1) investigate rates and predictors of return to play after ACLR, (2) evaluate patient satisfaction after ACLR, and (3) analyze the relationship between return to play and satisfaction with the result of ACLR.

METHODS

Eligible patients were active athletes included in an institutional ACL registry who had undergone ACLR and had been followed for a minimum of 2 years. A questionnaire was administered to elicit information regarding factors associated with return to play, sports performance, reinjury, and overall patient satisfaction. The Wilcoxon-Mann-Whitney U test was used to compare return to play with patient satisfaction. Multivariable logistic regression was used to identify demographic, sports, and clinical factors associated with return to play.

RESULTS

Two hundred and thirty-two patients with a mean age of 26.7 years (standard deviation [SD] = 12.5 years) who had been followed for a mean of 3.7 years were enrolled. Of 231 patients who responded to the return-to-play question, 201 (87.0%) had returned to play, at a mean of 10.1 months; of 175 athletes eligible to return to their prior level of competition, 89.1% had done so. Overall satisfaction was high: 85.4% were very satisfied with the outcome and 98.1% stated that they would have surgery again. Patients were more likely to respond "very satisfied" if they had returned to play (p < 0.001). Use of a patellar tendon autograft (odds ratio [OR] = 5.63, 95% confidence interval [CI] = 1.32 to 25.76) increased the chance of returning to play whereas playing soccer (OR = 0.23, 95% CI = 0.08 to 0.66) or lacrosse (OR = 0.24, 95% CI = 0.06 to 0.99) preoperatively decreased the likelihood of returning to play.

CONCLUSIONS

The rates of return to play and patient satisfaction are high after ACLR in active athletes. The use of patellar tendon autograft increased the likelihood of returning to play whereas preinjury participation in soccer and lacrosse decreased these odds. Additionally, patients who returned to play were more likely to be very satisfied with the result of the ACLR.

LEVEL OF EVIDENCE

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

Joint awareness after ACL reconstruction: patient-reported outcomes measured with the Forgotten Joint Score-12

PURPOSE

To measure joint awareness in patients who have undergone anterior cruciate ligament (ACL) reconstruction and to investigate medium- and long-term results of the procedure.

METHODS

All patients who had undergone ACL reconstruction with the same arthroscopic surgical technique at our institution between 2011 and 2014 (medium-term follow-up group (Group I)) or between 2000 and 2005 (long-term follow-up group (Group II)) were considered for inclusion in the study. A group of healthy controls were recruited to obtain reference values for the FJS-12 (Forgotten Joint Score-12). Propensity score matching was applied to improve comparability of patients and healthy controls in terms of sex and age.

RESULTS

Fifty-eight patients of the Group I (mean follow-up 31.5 (SD13.4) months, range 12-54), 57 patients of the Group II (mean follow-up 139 (SD15.2) months, range 120-179), and the healthy control samples (100 individuals) were analysed. Significantly lower FJS-12 was found in both groups (Group I: 71.6 and Group II: 70.1), compared to the two matched control groups (88.1 and 90.0).

CONCLUSIONS

The concept of joint awareness was successfully applied to evaluate medium- and long-term results of ACL reconstruction. The clinical relevance of this study is that it extends the construct of joint awareness as a patient-reported outcome parameter to ACL reconstruction surgery.

LEVEL OF EVIDENCE

Level III.

Limitations in predicting outcome following primary ACL reconstruction with single-bundle hamstring autograft - A systematic review

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is one of the most well studied and performed procedures in the world. Thus, it would be useful to develop a tool to predict patient outcomes post-operatively to allow clinicians to optimise management.

PURPOSE

To identify and summarise factors predictive of graft failure and patient-reported outcome (PROM) measures at minimum two years after ACLR with single-bundle quadruple hamstring autograft via the anteromedial portal technique.

METHODS

Studies reporting IKDC, KOOS, Lysholm and graft failure in ACLR were systematically reviewed. A methodological score was applied to these studies, with those above the mean analysed further. Only those reporting primary predictors of patient outcomes following ACLR were included.

RESULTS

Twenty-six studies satisfied our inclusion criteria. Fourteen scored above the mean 20 Downs and Black score (18.4) and were considered higher level evidence. The higher quality papers reported that younger age, female sex, higher BMI, smoking history and activity levels predicted poorer outcomes. High-grade tears of the menisci or full-thickness cartilage defects were identified as predictors of poorer PROMs. None of the factors investigated by more than a single paper were unanimously significant in predicting the outcome of ACLR.

CONCLUSIONS

The evidence surrounding predictors of outcome was inconsistent in design, methodology and reporting of results, hindering our ability to draw conclusions regarding the validity of the reported relationships. However, this systematic review identified several patient demographics, concomitant injuries, and surgical factors that could be investigated further in future prospective studies to create a definitive predictive model.