Patient-Reported Outcome Measurement Information System Depression and Anxiety in Elective Knee Surgery Patients.

Mental health has been shown to play an important role in patient-reported outcomes (PRO); however, there is a general lack of literature describing patient-reported outcome measurement information system (PROMIS) depression and anxiety computer adaptive tests in elective knee surgery patients. The purpose of our study was to assess the prevalence of depression and anxiety symptoms before and after elective knee surgery and to determine whether these symptoms influence postoperative functional outcomes. An institutional review board-approved prospective orthopaedic registry was retrospectively queried for patients undergoing elective knee surgery from June 2015 to November 2018. Electronic surveys collecting patient demographic information and PROs were administered pre- and postoperatively. Of the 663 patients that completed baseline questionnaires, 466 completed 2-year follow-up (70.3%). PROs included PROMIS depression, PROMIS anxiety, International Knee Documentation Committee Subjective Knee Form (IKDC), and PROMIS physical function (PF). Wilcoxon rank sum and Spearman's rank order correlation were utilized to determine associations between variables. Multivariable analysis was used to control for confounding variables. Average PROMIS depression and anxiety scores significantly improved 2 years after surgery. PROMIS depression and anxiety scores significantly correlated with each other. PROMIS depression and anxiety scores significantly correlated with PROMIS PF and IKDC scores. After controlling for confounders on multivariable analysis, worse 2-year PROMIS anxiety was predictive of less functional improvement and worse 2-year PF and IKDC, while worse 2-year PROMIS depression was predictive of less improvement in IKDC. This study confirms the important relationship between mental health and functional outcomes. Given that psychiatric comorbidities are potentially modifiable with treatment, proper recognition could potentially lead to better orthopaedic outcomes. In addition, the prevalence of depression and anxiety symptoms postoperatively, as documented by PROMIS computer adaptive tests, may act as a barrier to achieving optimal functional outcomes after elective knee surgery. LEVEL OF EVIDENCE: Level III.

Preoperative Factors Associated With Worse PROMIS Pain Interference 2 Years After Hand and Wrist Surgery.

BACKGROUND: The purpose of this study was to identify preoperative factors associated with worse postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores 2 years after hand and wrist surgery. We hypothesized that older age, more comorbidities, increased substance use, and lower socioeconomic status would correlate with worse 2-year PROMIS PI scores. METHODS: This study was a retrospective review of prospectively acquired data on 253 patients. Surveys were administered within 1 week of surgery and 2 years postoperatively. Bivariate and multivariable analyses were conducted to identify significant predictors of worse 2-year PROMIS PI scores and change in PROMIS PI scores. RESULTS: Older age, higher body mass index, more comorbidities, lower preoperative expectations, more prior surgeries, unemployment, smoking, higher American Society of Anesthesiologists (ASA) score, and multiple other socio-demographic factors were correlated with worse 2-year PROMIS PI scores (P ≤ .018). Similar factors were also correlated with less improvement in 2-year PROMIS PI scores (P ≤ .048). Worse scores on all preoperative patient-reported outcome measures correlated with worse 2-year PROMIS PI scores (P ≤ .007). Multivariable analysis identified smoking history, less frequent alcohol consumption, worse preoperative PROMIS social satisfaction and Numeric Pain Scale whole body scores, and higher ASA scores as independent predictors of worse 2-year PROMIS PI. The same factors in addition to better baseline PROMIS PI were predictive of less improvement in 2-year PROMIS PI. CONCLUSION: Numerous preoperative factors were predictive of worse postoperative 2-year PROMIS PI and less improvement in 2-year PROMIS PI for patients undergoing hand and wrist surgery.

Higher preoperative expectations predict better outcomes in shoulder surgery patients.

PURPOSE: The purpose of this study is to determine if preoperative expectations (PE) are an independent predictor of greater 2-year outcomes and greater improvement from baseline in shoulder surgery patients. METHODS: Two-hundred and sixteen patients who underwent shoulder surgery at one institution were studied. Patients completed both preoperative and 2-year follow-up questionnaires including PROMIS (Patient-Reported Outcome Measurement Information System) computer-adaptive testing in six domains, American Shoulder and Elbow Surgeons (ASES) score, shoulder numeric pain scale (NPS), and the Marx Shoulder Activity Rating Scale (MARS). PE were measured using the Musculoskeletal Outcomes and Data Evaluation Management System (MODEMS) expectations domain, and satisfaction was measured via the Surgical Satisfaction Questionnaire (SSQ-8). RESULTS: The mean PE score was 86.2 ± 17.8. Greater PE were associated with significantly better 2-year scores for ASES, NPS, MARS, SSQ8, and PROMIS domains of Physical Function, Fatigue, Pain Interference Fatigue and Social Satisfaction. Multivariable analyses demonstrated that greater PE were an independent predictor of both better 2-year scores and greater improvement for PROMIS SS (p < 0.001), ASES (p = 0.007), and shoulder NPS (p = 0.011). CONCLUSION: Greater PE are positively associated with numerous patient-based outcomes 2 years after surgery. With regards to pain relief, shoulder function, and social satisfaction, higher PE are also predictive of better outcome scores and more improvement. This study suggests that preoperative assessment of shoulder surgery PE is important, and that counseling patients to optimize realistic expectations may lead to superior outcomes. LEVEL OF EVIDENCE: III.

Response Bias for Press Ganey Ambulatory Surgery Surveys after Knee Surgery.

The Press Ganey Ambulatory Surgery (PGAS) survey is an emerging tool used to capture patient satisfaction after elective surgery. Evaluating patient satisfaction is important; however, quality improvement (QI) surveys used to capture the patient experience may be subject to nonresponse bias. An orthopaedic registry was used to retrospectively identify patients who underwent ambulatory knee surgery from June 2015 to December 2019. Multivariable logistic regression was performed to identify independent predictors of PGAS survey nonresponse and response. In the cohort of 1,161 patients, 142 (12.2%) completed the PGAS survey. Multiple logistic regression demonstrated that male sex, Black race, not living with a caretaker, student or unemployment status, and worse preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) fatigue were predictors of nonresponse. The results of this study highlight the presence of nonresponse bias in the PGAS survey after elective knee surgery.

Preoperative Factors Associated with Press Ganey Patient Satisfaction Scores after Anterior Cruciate Ligament Reconstruction.

Patient satisfaction is increasingly used as a metric to evaluate the quality of healthcare services and to determine hospital and physician compensation. The aim of this study was to identify preoperative factors associated with Press Ganey Ambulatory Surgery (PGAS) satisfaction scores, and to evaluate the effect of each PGAS domain score on the total PGAS score variability in patients undergoing anterior cruciate ligament reconstruction (ACLR). A review of a Press Ganey (PG) database at a single center was performed for patients undergoing ACLR between 2015 and 2019. Ninety-nine patients completed the PGAS survey and 54 also completed preoperative demographic and patient-reported outcome measures (PROMs) for an orthopaedic registry. PGAS scores were calculated and bivariate analysis was performed. Multivariable linear regression determined the effect of each of the six PGAS domains on the total PGAS score variability. In the total cohort of 99 patients, no factors were significantly associated with the total PGAS score or any domain scores. For the 54 patients who also participated in the orthopaedic registry, none of the preoperative PROMs were significantly correlated with total PGAS score. However, having a college degree (89 vs. 95 or 97 points; p = 0.02) and continuous femoral nerve catheter (92 vs. 100 points; p = 0.04) was associated with lower personal issue domain scores, while patients with a greater number of prior surgeries had worse registration domain scores (ρ = -0.27; p = 0.049). For the entire cohort, the registration and facility domains contributed the most variability to the total PGAS score, while the physician domain contributed the least. Few preoperative factors are associated with PGAS scores, and total PGAS scores do not significantly correlate with baseline PROMs. Surgeons may have limited ability to improve their PGAS scores given most of the variability in total scores stems from systemic aspects of the patient experience.

Preoperative factors associated with patient satisfaction 2 years after elective shoulder surgery.

Background Purpose: Patient satisfaction has become an increasingly important component of quality measures for both hospital reimbursement and quality assessment. Additionally, patient satisfaction influences patient behavior and patient follow-up. The purpose of this study was to identify preoperative factors associated with patient satisfaction 2 years after shoulder surgery. Methods: Electronic surveys were used to collect patient information including demographic, surgical, and social history, as well as outcome data. Satisfaction was measured 2 years after surgery using the Surgical Satisfaction Questionnaire. Results: Multivariable linear regression identified preoperative Patient-Reported Outcomes Measurement Information System Pain Interference, annual income, and American Society of Anesthesiologists score as independent predictors of lower patient satisfaction, while total shoulder arthroplasty was an independent predictor of greater patient satisfaction. The model accounted for 15% of the variance in satisfaction scores (R2 = 0.15). Conclusion: Patient satisfaction 2 years after shoulder surgery is associated with preoperative patient-reported outcome scores. Lower patient satisfaction is independently predicted by greater preoperative PROMIS PI, income less than $70,000, and ASA score >1, while higher patient satisfaction is predicted by total shoulder arthroplasty.

Correlation of Press Ganey Scores With Early Patient Satisfaction After Anterior Cruciate Ligament Reconstruction.

Background: Patient satisfaction metrics are commonly used to assess the quality of health care and affect reimbursement. The Press Ganey Ambulatory Surgery (PGAS) is a satisfaction survey that has emerged as a prominent quality assessment tool; however, no data exist on whether PGAS scores correlate with early postsurgical satisfaction during the PGAS survey administration period in patients who underwent anterior cruciate ligament reconstruction (ACLR). Purpose: To determine if PGAS scores correlate with measures of satisfaction and patient-reported outcomes (PROs) at 2 weeks postoperatively in ACLR patients. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A retrospective review of patients who underwent ACLR at a single institution was performed. Patients who completed the PGAS survey and PROs at 2 weeks postoperatively were included in the study. Surgical satisfaction was measured with the Surgical Satisfaction Questionnaire (SSQ-8), and PROs included 6 Patient-Reported Outcomes Measurement Information System domains. Bivariate analysis between PGAS and PRO scores was conducted using the Spearman rank correlation coefficient (r S). Results: Of the 716 patients who received the PGAS survey after ACLR, 81 patients completed the survey, and 39 patients also completed PROs and were included in the study. Total converted (mean scaled score) and "top box" (percentages of questions with highest rating selected) PGAS scores showed no significant correlations with the SSQ-8 (r S =-0.24; P = .14). There were no significant correlations between SSQ-8 and PGAS domain scores except for a negative correlation with Facility domain top box scores (r S =-0.33; P = .04), meaning that patients with higher surgical satisfaction had lower PGAS Facility scores. Total PGAS (converted and top box scores) and PGAS domain scores showed no significant correlation with any of the other PROs. Conclusion: PGAS scores showed no significant positive correlation with surgical satisfaction, function, pain, mental health, activity, or expectations of surgery in patients 2 weeks after ACLR. This suggests little to no relationship between PGAS score and surgical satisfaction in the early recovery period after ACLR.

Depression and anxiety are associated with worse baseline function in hip arthroscopy patients.

PURPOSE: The purpose of this study was to analyze the correlation between baseline depression and anxiety and preoperative functional status in hip arthroscopy patients. METHODS: A prospective, institutional review board-approved orthopaedic registry was used to retrospectively study 104 patients undergoing hip arthroscopy. Enrolled patients were administered baseline questionnaires for Patient-Reported Outcomes Measurement Information System (PROMIS) domains, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) preoperative expectations, and Numeric Pain Scale (NPS). RESULTS: The average baseline PROMIS Depression and Anxiety scores were 49.9 ± 9.8 and 55.5 ± 9.3, respectively. Bivariate analysis demonstrated that greater baseline PROMIS Anxiety correlated with worse preoperative PROMIS PI (p < 0.001), Fatigue (p < 0.001), Social Satisfaction (p < 0.001), and NPS score (p = 0.013). Bivariate analysis showed that greater PROMIS Depression correlated with worse preoperative PROMIS PF (p = 0.001), PI (p < 0.001), Fatigue (p < 0.001), SS (p < 0.001), and NPS score (p = 0.004). After controlling for confounders, multivariable analysis confirmed increased PROMIS Depression as an independent predictor of worse preoperative PROMIS PF (p = 0.009), MODEMS Expectations (p = 0.025), and NPS score (p = 0.002). Increased PROMIS Anxiety was predictive of worse baseline PROMIS PI (p < 0.001), Fatigue (p < 0.001), and Social Satisfaction (p < 0.001). A previous clinical diagnosis of depression or anxiety was only an independent predictor of worse baseline PROMIS Fatigue (p = 0.002) and was insignificant in all other models. CONCLUSION: Increasing severity of depression and anxiety correlated with and predicted worse functional status at baseline in hip arthroscopy patients. As compared to clinical diagnosis of anxiety and depression, PROMIS metrics have superior utility in recognizing potentially modifiable mental health concerns that predict worse preoperative status. Ultimately, the study identifies an at-risk population undergoing hip arthroscopy that requires particular attention and potential mental health intervention in the preoperative setting. LEVEL OF EVIDENCE: III.

Patient Perception of Being "Completely Better" After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Contextualizing patient-reported outcomes (PROs) by defining clinically relevant differences is important. Considering that anterior cruciate ligament reconstruction (ACLR) ideally results in the restoration of normal knee function, an assessment of patients' perception of being "completely better" (CB) may be of particular value. PURPOSE: The purpose of this study was to assess the prevalence and characteristics of patients who self-report a CB status after ACLR. Additionally, we aimed to determine whether PROs were associated with a CB status after ACLR as well as to determine CB status thresholds for 2-year and change in values. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We retrospectively analyzed data from an orthopaedic registry at a single institution. Patients were administered the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), PROMIS Pain Interference (PI), and International Knee Documentation Committee (IKDC) Subjective Knee Form preoperatively and at 2 years after ACLR. Additionally, patients completed a CB anchor question at 2 years after ACLR. Thresholds for 2-year and change in PRO scores associated with achieving a CB status were identified with 90% specificity. RESULTS: Overall, 95 of the 136 patients (69.9%) considered their condition to be CB at 2 years after surgery. The 2-year and change in PROMIS PF, PROMIS PI, and IKDC scores were significantly better in the CB group than in the non-CB group. Thresholds associated with a CB status for 2-year PROMIS PF, PROMIS PI, and IKDC scores were more reliable than those for changes in scores and were ≥63, ≤44, and ≥80, respectively. Thresholds for the change in PROMIS PF, PROMIS PI, and IKDC scores were ≥19, ≤-16, and ≥44, respectively. CONCLUSION: The majority of patients reported that they were CB at 2 years after ACLR. This study may serve as a reference for orthopaedic surgeons and researchers when considering outcomes after ACLR.

Long-Term Outcomes of Multiligament Knee Injuries.

OBJECTIVE: To characterize long-term outcomes of multiligament knee injuries (MLKIs) using patient-reported outcome measures, physical examination, and knee radiographs. DESIGN: Retrospective clinical follow-up. METHODS: Twenty knees (18 patients) were evaluated at a mean follow-up of 13.1 years (range 11-15 years). The primary outcome measure was the Internal Knee Documentation Committee score. Patients also completed secondary patient-based outcome assessments including Patient-Reported Outcomes Measurement Information System computer adaptive testing, Short Form-36, and Tegner activity score. Sixteen knees (14 patients) also had physical examination and bilateral knee radiographs assessed with the Kellgren-Lawrence score. RESULTS: The mean Internal Knee Documentation Committee score was 56 points, which was significantly lower than the age-matched normative value of 77 ( P = 0.004) and exceeds the minimum clinically important difference of 12 points. Most secondary outcome scores were worse than normative population values. Posttraumatic arthritis was present in 100% of MLKIs that had radiographs. Comparing operative versus nonoperative management, there were no statistical differences in patient demographics, injury characteristics, physical examination, or imaging, but surgical patients had better Short Form-36 Social Functioning (89 vs. 63, P = 0.02) and Tegner scores (4.5 vs. 2.9, P = 0.05). CONCLUSION: The long-term outcomes of MLKIs are generally poor, and posttraumatic radiographic evidence of arthritis seems to be universal . Operative management of these injuries may improve long-term outcomes. Clinicians should be aware of these results when counseling patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bilateral Extensor Mechanism Allograft Reconstruction in Native Knees: A Case Report.

CASE: A 66-year-old man presented with chronic bilateral extensor mechanism dysfunction and profound patella baja after failed revision surgery for bilateral quadriceps tendon ruptures. Staged bilateral reconstruction with complete extensor mechanism allograft resulted in excellent two-year satisfaction and clinical outcomes. CONCLUSION: Complete extensor mechanism reconstruction can be a successful treatment for chronic quadriceps tendon rupture with profound patella baja.

Preoperative characteristics predictive of PROMIS Pain Interference two years after shoulder surgery.

INTRODUCTION: The objective of this study was to identify preoperative characteristics associated with worse Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) two years after shoulder surgery. METHODS: This was a retrospective analysis of prospectively collected data on 293 patients who underwent elective shoulder surgery. Survey questionnaires were collected within one week of surgery and then two years postoperatively. Bivariate analysis was used to identify associations and multivariable analysis was used to control for confounding variables. RESULTS: Worse two-year PROMIS PI was significantly correlated with older age, higher BMI, greater comorbidities, more prior surgeries, and multiple socio-demographic factors. Less improvement in PROMIS PI was significantly correlated with greater comorbidities, more previous surgeries, unemployment, prior orthopaedic surgery on the operative joint, and a higher American Society of Anesthesiologists (ASA) score. Better scores on all preoperative patient-reported outcome measures correlated with better two-year PROMIS PI. Multivariable analysis demonstrated that worse two-year PROMIS PI was independently predicted by the following preoperative factors: Workers' Compensation claim, opioid use, worse whole body Numeric Pain Score, and worse PROMIS PI. Less improvement in two-year PROMIS PI was predicted by the same preoperative factors. CONCLUSION: Worse PROMIS PI after shoulder surgery was associated with older age, greater comorbidities, mental health impairment, and lower socioeconomic status. Preoperative predictors of worse pain interference two years after shoulder surgery included Workers' Compensation, opioid use, worse whole body pain, and worse PROMIS PI. LEVEL OF EVIDENCE: III.

Perioperative opioid use and Press Ganey patient satisfaction scores after anterior cruciate ligament reconstruction.

BACKGROUND: Satisfaction measures such as Press Ganey (PG) scores are increasingly used to determine reimbursement. PURPOSE: To investigate the relationship between PG satisfaction scores and perioperative opioid use in patients undergoing anterior cruciate ligament reconstruction (ACLR). METHODS: Patients undergoing ACLR were retrospectively identified. Perioperative opioid prescription data were collected using the electronic medical record. RESULTS: Positive correlations existed between immediate preoperative total morphine equivalents (TMEs) and PG scores. There was a negative correlation between "Pain Control" and preoperative TMEs. CONCLUSION: PG scores were correlated with preoperative and intraoperative opioid administration but not postoperative opioid administration.

Predictors of postoperative pain using PROMIS pain interference two-years following knee surgery.

INTRODUCTION: The purpose of this study was to identify preoperative factors associated with worse PROMIS Pain Interference (PI) two years following knee surgery. METHODS: Participants completed surveys preoperatively and two years postoperatively. Data collected included demographics, medical history, and multiple patient-reported outcomes measures, including PROMIS PI. RESULTS: After controlling for confounders, lower income, smoking, worse PROMIS Anxiety, worse Numeric Pain Score body pain, and worse Marx Activity Rating Scale were independent predictors for worse PROMIS PI two years after surgery. CONCLUSION: Worse PROMIS PI two years after elective knee surgery is associated with multiple socio-demographic patient identifiers.

Factors Influencing Press Ganey Ambulatory Surgery Scores in Patients Undergoing Upper Extremity Procedures.

INTRODUCTION: We sought to determine whether patient and surgical factors are associated with the Press Ganey Ambulatory Surgery Survey (PGAS) satisfaction scores in patients undergoing outpatient upper extremity procedures. METHODS: A retrospective review of a single academic urban hospital's Press Ganey database was performed for patients undergoing upper extremity procedures. PGAS scores above an a priori threshold were considered satisfied. Logistic regression analyses for the PGAS Total and Provider Scores were performed to determine the predictors of patient satisfaction. RESULTS: Of the 198 patients included, the mean age was 49.6 ± 17.1 years and 55% were men. For the Total Score, multivariable analysis showed significantly less satisfaction with continuous catheter peripheral brachial plexus nerve blocks (CC-PNBs) (odds ratio [OR], 0.37; P = 0.008) and internet surveys (OR, 0.39; P = 0.007), but smokers had surprisingly more satisfaction (OR, 4.90; P = 0.016). For the Provider Score, a multivariable analysis showed less satisfaction with CC-PNBs (OR, 0.45; P = 0.035), internet surveys (OR, 0.46; P = 0.026), and geographic location (OR, 0.40; P = 0.005). Preoperative Patient-Reported Outcomes Measurement Information System scores were not associated with the PGAS scores. DISCUSSION: Factors influencing satisfaction in patients undergoing upper extremity procedures may be modifiable (CC-PNBs and survey administration method) or nonmodifiable (geographic location) and may influence future reimbursement.

Impact of pre-operative recreational marijuana use on outcomes two years after orthopaedic surgery.

PURPOSE: The purpose of this study was to investigate the relationship between recreational marijuana use and patient-reported outcomes two years after orthopaedic surgery. We hypothesized that pre-operative recreational marijuana use would be associated with less pain, better function, and better mental health measures two years after orthopaedic surgery. METHODS: Patients were retrospectively analyzed from a prospective orthopaedic registry at a single urban institution. A total of 1710 patients completed the pre-operative assessment and 1103 patients (64.5%) completed the two-year follow-up questionnaires. The cohort was then divided into two groups based on reported preoperative recreational marijuana usage, and statistical analysis was performed to determine if marijuana use was associated with two-year outcomes. Multivariable analysis was used to control for confounding variables. RESULTS: Marijuana use was reported by 47 (4.3%) patients. Significantly worse scores for two-year PROMIS Anxiety (53.2 vs. 49.2, p = 0.005), PROMIS Depression (51.1 vs. 46.5, p = 0.001), Met Expectations (63.1 vs. 74.4, p = 0.024), Surgical Satisfaction Questionnaire-8 (71.7 vs. 80.4, p = 0.005), and Numeric Satisfaction Scale (75.6 vs. 83.1, p = 0.041) were associated with marijuana use. Marijuana users also had less improvement of Numeric Pain Scores at the operative site (- 1.8 vs. - 2.7, p = 0.037) and greater decrease in Marx activity scores for lower extremities (- 12.3 vs. - 3.9, p = 0.024). Marijuana use was not an independent predictor of any outcome measure in the multivariable analysis. CONCLUSION: Marijuana use was associated with worse mental health scores, lower activity level, less pain relief, and worse satisfaction two years after orthopaedic surgery. However, after controlling for confounding variables, marijuana use was not predictive of any two-year outcome measure. STUDY DESIGN: Cross-sectional study.

Preoperative opioid use correlates with worse patient-reported outcomes two years after elective shoulder surgery.

INTRODUCTION: Prescription opioid consumption in the United States is a well-known public health problem, however, the deleterious effect of opioids may not be fully understood. The purpose of this study was to investigate the relationship between preoperative opioid use and patient-reported outcomes two years after shoulder surgery. We hypothesized preoperative opioid use would be predictive of worse two-year patient reported outcome scores. METHODS: Patients undergoing shoulder surgery at an urban institution from June 2015 to July 2017 were prospectively enrolled into our orthopaedic registry. Preoperative opioid use and its association to patient outcome scores was retrospectively analyzed through bivariate analysis. Multivariate analysis was used to control for confounding variables and to determine independent predictors of two-year outcome scores. RESULTS: Preoperative opioid use was associated with significantly worse scores on all two-year patient reported outcomes, and less improvement in PROMIS Physical Function and Numeric Pain Score (NPS) Body Pain two years postoperatively. Multivariate analysis showed preoperative opioid use to be an independent predictor of worse two-year scores in PROMIS Physical Function, PROMIS Pain Interference, PROMIS Social Satisfaction, American Shoulder and Elbow Surgeons Standardized Shoulder Form and NPS Operative Site. Preoperative opioid use was not an independent predictor of change in any outcome measure. CONCLUSION: Preoperative opioid use was associated with worse scores on all two-year patient reported outcomes, and after controlling for confounders, preoperative opioid use was predictive of worse scores in several two-year outcome measures. To our knowledge, this is one of the few studies investigating the impact of preoperative opioid use on postoperative outcomes after shoulder surgery.

Press Ganey Surveys in Patients Undergoing Upper-Extremity Surgical Procedures: Response Rate and Evidence of Nonresponse Bias.

BACKGROUND: Patient satisfaction surveys are important measures of the patient experience that provide data for quality improvement. The purpose of this study was to establish the response rate and the factors associated with the completion of the Press Ganey (PG) Ambulatory Surgery Survey (PGAS) in patients who underwent ambulatory upper-extremity surgical procedures. METHODS: A prospective orthopaedic registry at a single academic ambulatory surgical center was retrospectively reviewed for patients who underwent an upper-extremity surgical procedure from 2015 to 2019. The institutional PG database was queried to determine the patients who completed the PGAS postoperatively. The response rate was calculated, and baseline characteristics and patient-reported outcome measures were compared between responders and nonresponders. RESULTS: Of the 1,489 patients included, 201 (13.5%) were responders and 1,288 (86.5%) were nonresponders. Differences existed in baseline characteristics between groups, with responders being significantly older (p = 0.004) and having significantly higher proportions of White race (p < 0.001), college education (p = 0.011), employment (p = 0.005), marriage (p = 0.006), and higher income earners (p < 0.001). Responders had significantly better baseline Patient-Reported Outcomes Measurement Information System scores across multiple domains (p < 0.05), but these differences were not clinically meaningful. CONCLUSIONS: PGAS response rates were low (13.5%), and differences between responders and nonresponders may be utilized by hospitals to target feedback from underrepresented patient populations. Surgeons, policymakers, and health-care administrators should use caution with the interpretation of PGAS results because responders may not be representative of all patients.

Estrogen Deficiency Promotes Cerebral Aneurysm Rupture by Upregulation of Th17 Cells and Interleukin-17A Which Downregulates E-Cadherin.

BACKGROUND: Estrogen deficiency is associated with the development of cerebral aneurysms; however, the mechanism remains unknown. We explored the pathway of cerebral aneurysm development by investigating the potential link between estrogen deficiency and inflammatory factors. METHODS AND RESULTS: First, we established the role of interleukin-17 (IL-17)A. We performed a cytokine screen demonstrating that IL-17A is significantly expressed in mouse and human aneurysms (P=0.03). Likewise, IL-17A inhibition was shown to prevent aneurysm formation by 42% (P=0.02) and rupture by 34% (P<0.05). Second, we found that estrogen deficiency upregulates T helper 17 cells and IL-17A and promotes aneurysm rupture. Estrogen-deficient mice had more ruptures than control mice (47% versus 7%; P=0.04). Estradiol supplementation or IL-17A inhibition decreased the number of ruptures in estrogen-deficient mice (estradiol 6% versus 37%; P=0.04; IL-17A inhibition 18% versus 47%; P=0.018). Third, we found that IL-17A-blockade protects against aneurysm formation and rupture by increased E-cadherin expression. IL-17-inhibited mice had increased E-cadherin expression (P=0.003). E-cadherin inhibition reversed the protective effect of IL-17A inhibition and increased the rate of aneurysm formation (65% versus 28%; P=0.04) and rupture (12% versus 0%; P=0.22). However, E-cadherin inhibition alone does not significantly increase aneurysm formation in normal mice or in estrogen-deficient mice. In cell migration assays, E-cadherin inhibition promoted macrophage infiltration across endothelial cells (P<0.05), which may be the mechanism for the estrogen deficiency/IL-17/E-cadherin aneurysm pathway. CONCLUSIONS: Our data suggest that estrogen deficiency promotes cerebral aneurysm rupture by upregulating IL-17A, which downregulates E-cadherin, encouraging macrophage infiltration in the aneurysm vessel wall.

Monocyte Chemotactic Protein-1-Interleukin-6-Osteopontin Pathway of Intra-Aneurysmal Tissue Healing.

BACKGROUND AND PURPOSE: We have previously demonstrated that the local delivery of monocyte chemotactic protein-1 (MCP-1) via an MCP-1-releasing poly(lactic-co-glycolic acid)-coated coil promotes intra-aneurysmal tissue healing. In this study, we demonstrate that interleukin-6 (IL-6) and osteopontin are downstream mediators in the MCP-1-mediated aneurysm-healing pathway. METHODS: Murine carotid aneurysms were created in C57BL/6 mice. Drug-releasing coils (MCP-1, IL-6, and osteopontin) and control poly(lactic-co-glycolic acid) coils were created and then implanted into the aneurysms to evaluate their intra-aneurismal-healing capacity. To investigate the downstream mediators for aneurysm healing, blocking antibodies for IL-6 receptor and osteopontin were given to the mice implanted with the MCP-1-releasing coils. A histological analysis of both murine and human aneurysms was utilized to cross-validate the data. RESULTS: We observed increased expression of IL-6 in MCP-1-coil-treated aneurysms and not in control-poly(lactic-co-glycolic acid)-only-treated aneurysms. MCP-1-mediated intra-aneurysmal healing is inhibited in mice given blocking antibody to IL-6 receptor. MCP-1-mediated intra-aneurysmal healing is also inhibited by blocking antibody to osteopontin. The role of IL-6 in intra-aneurysmal healing is in recruiting of endothelial cells and fibroblasts. Local delivery of osteopontin to murine carotid aneurysms via osteopontin-releasing coil significantly promotes intra-aneurysmal healing, but IL-6-releasing coil does not, suggesting that IL-6 cannot promote aneurysm healing independent of MCP-1. In the MCP-1-mediated aneurysm healing, osteopontin expression is dependent on IL-6; inhibition of IL-6 receptor significantly inhibits osteopontin expression in MCP-1-mediated aneurysm healing. CONCLUSIONS: Our findings suggest that IL-6 and osteopontin are key downstream mediators of MCP-1-mediated intra-aneurysmal healing.