A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures.

Purpose: To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns. Methods: We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis. Results: Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness. Conclusions: The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation. Type of study/level of evidence: Economic/decision analysis II.

Patient-Reported Outcomes Measurements Information System (PROMIS) upper extremity and pain interference do not significantly predict rotator cuff tear dimensions.

BACKGROUND: Proper diagnosis of rotator cuff tears is typically established with magnetic resonance imaging (MRI); however, studies show that MRI-derived measurements of tear severity may not align with patient-reported pain and shoulder function. The purpose of this study is to investigate the capacity for the Patient-reported Outcomes Measurements Information System (PROMIS) computer adaptive tests to predict rotator cuff tear severity by correlating preoperative tear morphology observed on MRI with PROMIS upper extremity (UE) and pain interference (PI) scores. This is the first study to investigate the relationship between tear characteristics and preoperative patient-reported symptoms using PROMIS. Considering the essential roles MRI and patient-reported outcomes play in the management of rotator cuff tears, the findings of this study have important implications for both treatment planning and outcome reporting. METHODS: Two PROMIS-computer adaptive test forms (PROMIS-UE and PROMIS-PI) were provided to all patients undergoing rotator cuff repair by one of three fellowship-trained surgeons at a single institution. Demographic information including age, sex, race, employment status, body mass index, smoking status, zip code, and preoperative PROMIS-UE and -PI scores was prospectively recorded. A retrospective chart review of small to large full- or partial-thickness rotator cuff tears between May 1, 2017 and February 27, 2019 was used to collect each patient's MRI-derived tear dimensions and determine tendon involvement. RESULTS: Our cohort consisted of 180 patients (56.7% male, 43.3% female) with an average age of 58.9 years (standard deviation, 9.0). There was no significant difference in PROMIS-UE or -PI scores based on which rotator cuff tendons were involved in the tear (P > .05). Neither PROMIS-UE nor PROMIS-PI significantly correlated with tear length or retraction length of the supraspinatus tendon (P > .05). The sum of tear lengths in the anterior-posterior and medial-lateral directions was weakly correlated with PROMIS-UE (P = .042; r = -0.152, r2 = 0.031) and PROMIS-PI (P = .027; r = 0.165, r2 = 0.012). CONCLUSION: Rotator cuff tear severity does not significantly relate to preoperative PROMIS-UE and -PI scores. This finding underscores the importance of obtaining a balanced preoperative assessment of rotator cuff tears that acknowledges the inconsistent relationship between rotator cuff tear characteristics observed on MRI and patient-reported pain and physical function.

Risk factors for failure to achieve minimal clinically important difference and significant clinical benefit in PROMIS computer adaptive test domains in patients undergoing rotator cuff repair.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) has emerged as a valid and efficient means of collecting outcomes in patients with rotator cuff tears. The purpose of this study was to establish threshold score changes to determine minimal clinically important difference (MCID) and substantial clinical benefit (SCB) in PROMIS computer adaptive test (CAT) scores following rotator cuff repair (RCR). Additionally, we sought to identify potential risk factors for failing to achieve MCID and SCB. METHODS: Patients undergoing arthroscopic RCR were identified over a 24-month period. Only patients who completed both preoperative and postoperative PROMIS CAT assessments were included in this cohort. PROMIS CAT forms for upper extremity physical function (PROMIS-UE), pain interference (PROMIS-PI), and depression (PROMIS-D) were used with a minimum of 1.5-year follow-up. Statistical analysis was performed to determine threshold score changes to determine anchor-based MCID and SCB, as well as risk factors for failure to achieve significant clinical improvement following surgery. RESULTS: Of 198 eligible patients, 168 (84.8%) were included in analysis. ΔPROMIS-UE values of 5.8 and 9.7 (area under the curve [AUC] = 0.906 and 0.949, respectively) and ΔPROMIS-PI values of -11.4 and -12.9 (AUC = 0.875 and 0.938, respectively) were identified as threshold predictors of MCID and SCB achievement. On average, 81%, 65%, and 55% of patients achieved MCID for PROMIS-UE, PROMIS-PI, and PROMIS-D whereas 71%, 61%, and 38% of patients in the cohort, respectively, achieved SCB. MCID achievement in PROMIS-UE significantly differed according to risk factors, including smoking status (likelihood ratio [LR]: 9.8, P = .037), tear size (LR: 10.4, P < .001), distal clavicle excision (LR: 6.1, P = .005), and prior shoulder surgery (LR: 19.2, P < .001). Factors influencing SCB achievement for PROMIS-UE were smoking status (LR: 9.3, P = .022), tear size (LR: 8.0, P = .039), and prior shoulder surgery (11.9, P < .001). Significantly different rates of MCID and SCB achievement in PROMIS-PI for smoking status (LR: 7.0, P = .030, and LR: 5.2, P = .045) and prior shoulder surgery (LR: 9.1, P = .002, and LR: 7.4, P = .006) were also identified. DISCUSSION AND CONCLUSION: The majority of patients showed clinically significant improvements that exceeded the established MCID for PROMIS-UE and PROMIS-PI following RCR. Patients with larger tear sizes, a history of prior shoulder surgery, tobacco users, and those who received concomitant distal clavicle excision were at risk for failing to achieve MCID in PROMIS-UE. Additionally, smokers and patients who underwent prior shoulder surgery demonstrated significantly lower improvements in pain scores following surgery.

Characterizing preoperative expectations for patients undergoing reverse total shoulder arthroplasty.

BACKGROUND: There remains a paucity of information analyzing which factors most influence preoperative expectations for patients undergoing reverse total shoulder arthroplasty (RTSA). The purposes of our study were to characterize preoperative patient expectations for those scheduled to undergo RTSA and to determine the impact of demographic factors, shoulder function, and shoulder pain on these preoperative expectations. METHODS: Patients were prospectively recruited into the study if they were scheduled to undergo an elective unilateral primary RTSA for a diagnosis of glenohumeral arthritis. Preoperative patient expectations were evaluated using the Hospital for Special Surgery's Shoulder Surgery Expectation Survey. Patients also completed the American Shoulder and Elbow Surgeons shoulder score, the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function-Upper Extremity computer adaptive test (version 2.0), the PROMIS Pain Interference (PI) computer adaptive test (version 1.1), the PROMIS Depression computer adaptive test (version 1.0), visual analog scores, and an itemized satisfaction questionnaire, which paralleled the Hospital for Special Surgery's Shoulder Surgery Expectation Survey. Demographic data and preoperative shoulder range of motion (ROM) were also recorded. RESULTS: A total of 107 patients scheduled to undergo RTSA were included in the study. Relief of daytime pain (n = 91, 85%), improvement in self-care (n = 86, 80%), and improvement in shoulder ROM (n = 85, 79%) were most commonly cited as "very important" expectations. In the item-specific analysis, lower PROMIS Upper Extremity scores were correlated with greater expectations for the ability to reach sideways (P = .015) and the ability to perform daily activities (P = .018). Patients with lower shoulder ROM had greater expectations for improved shoulder ROM (internal rotation with arm at 90°, P = .004) and an improved ability to perform daily activities (forward elevation, P = .038; abduction, P = .009). In the cumulative analysis, a greater number of very important expectations was associated with African American race (P = .013), higher PROMIS PI score (r = 0.351, P = .004), and lower overall preoperative satisfaction (r = 0.334, P < .001). CONCLUSION: Patients scheduled to undergo RTSA have the greatest expectations for relief of daytime pain, improvement in self-care, and improvement in shoulder ROM. Patients with limited preoperative ROM have greater expectations for improvement in self-care and the ability to perform daily activities in addition to expectations for improvement in shoulder ROM. Greater overall expectations for surgery were not associated with preoperative physical function but were instead associated with lower preoperative satisfaction and higher PROMIS PI scores.

Establishing Age-calibrated Normative PROMIS Scores for Hand and Upper Extremity Clinic.

The purpose of our study is to investigate differences in normative PROMIS upper extremity function (PROMIS-UE), physical function (PROMIS-PF), and pain interference (PROMIS-PI) scores across age cohorts in individuals without upper extremity disability. METHODS: Individuals without upper extremity disability were prospectively enrolled. Subjects were administered PROMIS-UE, PROMIS-PF, and PROMIS-PI forms. Retrospective PROMIS data for eligible subjects were also utilized. The enrolled cohort was divided into age groups: 20-39, 40-59, and 60-79 years old. ANOVA, ceiling and floor effect analysis, and kurtosis and skewness statistics were performed to assess PROMIS scores trends with age. RESULTS: This study included 346 individuals. In the 20-39 age group, mean PROMIS scores were 56.2 ± 6.1, 59.8 ± 6.9, and 43.1 ± 6.7 for PROMIS-UE, PROMIS-PF, and PROMIS-PI, respectively. In the "40-59" age group, mean PROMIS computer adaptive test scores were 53.3 ± 7.5, 55.3 ± 7.6, and 46.6 ± 7.8 for PROMIS-UE, PROMIS-PF, and PROMIS-PI, respectively. In the 60-79 age group, mean PROMIS scores were 48.4 ± 7.6, 48.5 ± 5.6, and 48.7 ± 6.9 for PROMIS-UE, PROMIS-PF, and PROMIS-PI, respectively. Differences in mean PROMIS scores were significant across all PROMIS domains and age cohorts (P < 0.001). CONCLUSION: Younger individuals without hand or upper extremity disability show higher normative PROMIS-UE and PROMIS-PF scores and lower PROMIS-PI scores, indicating greater function and less pain than older counterparts. A universal reference PROMIS score of 50 appears suboptimal for clinical assessment and decision-making in the hand and upper extremity clinic.

Preoperative Patient-Reported Outcomes Measurement Information System Global Health Scores Predict Patients Achieving the Minimal Clinically Important Difference in the Early Postoperative Time Period After Total Knee Arthroplasty.

INTRODUCTION: The patient-specific factors influencing postoperative improvement after total knee arthroplasty (TKA) are important considerations for the surgeon and patient. The primary purpose of this study was to determine which patient demographic factors influence the postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health (GH) scores. In addition, we aimed to compare the prognostic utility of preoperative PROMIS-GH scores and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) in predicting postoperative improvement. METHODS: This retrospective cohort study of a consecutive series of patients who underwent primary, unilateral TKA analyzed prospectively collected KOOS-JR and PROMIS-GH surveys. PROMIS-GH includes physical health (PH) and mental health scores. Patient demographic and presurgical characteristics were evaluated for prognostic capability in predicting postoperative improvement in the PROMIS scores and achievement of the minimal clinically important difference (MCID). Receiver operating characteristic curves were used to understand the prognostic thresholds of the preoperative PROMIS score and KOOS-JR for predicting MCID achievement. RESULTS: A total of 872 patients were included. Although unadjusted analyses showed associations between patient demographic factors and PROMIS-PH scores, multivariable regression analysis for predictors of MCID achievement demonstrated that PROMIS-PH was the only significant preoperative variable. Receiver operating characteristic analysis revealed that the area under the curve of PROMIS-PH (0.70; 95% CI, 0.67 to 0.74) was less than that of the KOOS-JR (0.77; 95% CI, 0.73 to 0.81; P = 0.032). Sensitivity and specificity for achieving the MCID were maximized for preoperative PROMIS-PH scores of ≤ 38 (59% and 70%) and for preoperative KOOS-JR ≤ 51 (71% and 69%). CONCLUSIONS: Preoperative KOOS-JR and PROMIS-PH scores predict clinically meaningful improvement after TKA. The KOOS-JR has greater prognostic utility in the early postoperative period. LEVEL OF EVIDENCE: Level III, Prognostic Study.

Rockwood Grade-III Acromioclavicular Joint Separation: A Cost-Effectiveness Analysis of Treatment Options.

BACKGROUND: The treatment of Rockwood Grade-III acromioclavicular (AC) joint separation has been widely disputed since the introduction of the classification system. The present literature does not reach consensus on whether operative or nonoperative management is more advantageous, nor does it effectively distinguish between operative measures. We hypothesized that nonoperative treatment of Rockwood Grade-III AC joint separation would be more cost-effective when compared with surgical options. METHODS: We created a decision-tree model outlining the treatment of Rockwood Grade-III separations using nonoperative management or hook-plate, suture-button, or allograft fixation. After nonoperative intervention, the possible outcomes predicted by the model were uneventful healing, delayed operative management, a second round of sling use and physical therapy, or no reduction and no action; and after operative intervention, the possible outcomes were uneventful healing, loss of reduction and revision, and depending on the implant, loss of reduction and no action, or removal of the implant. A systematic review was conducted, and probabilities of each model state were averaged. A cost-effectiveness analysis was conducted both through rollback analysis yielding net monetary benefit and through incremental cost-effectiveness ratios (ICERs). Thresholds of $50,000/quality-adjusted life-year (QALY) and $100,000/QALY were used for ICER analysis. Furthermore, a sensitivity analysis was utilized to determine whether differential probabilities could impact the model. RESULTS: Forty-five papers were selected from a potential 768 papers identified through our literature review. Nonoperative treatment was used as our reference case and showed dominance over all 3 of the operative measures at both the $50,000 and $100,000 ICER thresholds. Nonoperative treatment also showed the greatest net monetary benefit. Nonoperative management yielded the lowest total cost ($6,060) and greatest utility (0.95 QALY). Sensitivity analysis showed that allograft fixation became the favored technique at a willingness-to-pay threshold of $50,000 if the rate of failure of nonoperative treatment rose to 14.6%. Similarly, at the $100,000 threshold, allograft became dominant if the probability of failure of nonoperative treatment rose to 22.8%. CONCLUSIONS: The cost-effectiveness of nonoperative treatment is fueled by its notably lower costs and overall high rates of success in Grade-III separations. It is important to note that, in our analysis, the societal cost (measured in lost productivity) of nonoperative treatment neared that of surgical treatment, but the cost from the health-care system perspective was minimal. Physicians should bear in mind the sensitivity of these conclusions and should consider cost-effectiveness analyses in their decision-making guidelines. LEVEL OF EVIDENCE: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

The PROMIS CAT Demonstrates Responsiveness in Patients After ACL Reconstruction Across Numerous Health Domains.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) has emerged as a dynamic, efficient, and validated patient-reported outcome measure in the field of orthopaedics. However, the responsiveness, which is defined as the ability to detect changes in scores over time, of PROMIS computer adaptive tests (CATs) after anterior cruciate ligament reconstruction (ACLR) has not been well documented. PURPOSE: To investigate the responsiveness up to 1 year postoperatively of multiple PROMIS CAT domains in patients undergoing ACLR. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: All patients who underwent ACLR by 1 of 2 fellowship-trained sports medicine orthopaedic surgeons, with preoperative and at least 6 months postoperative visits, were included in this study. PROMIS CAT physical function (PF), pain interference (PI), and depression (D) scores from each visit were collected and analyzed. Preoperative patient-centric factors, including demographic factors and meniscal pathology, were analyzed for associations with improvements in PROMIS scores. RESULTS: A total of 100 patients (62 male patients and 38 female patients; mean age, 27.6 ± 11.8 years) with an average follow-up of 338.5 ± 137.5 days were included in this study. Preoperative PF, PI, and D scores improved significantly from 38.5 ± 7.3, 60.3 ± 7.0, and 47.9 ± 9.1, respectively, to 53.6 ± 10.3, 48.1 ± 8.5, and 41.0 ± 9.9, respectively (P < .001 for each domain). Lower preoperative PF scores, PI scores, and a lower body mass index (BMI) were predictive for greater improvements in PF. Higher preoperative PI scores and a lower BMI were predictors for greater improvements in PI. Meniscal pathology was not predictive of improvement in PROMIS scores. CONCLUSION: PROMIS CAT assessments of PF, PI, and D demonstrated responsiveness in patients undergoing ACLR up to 1 year. Worse preoperative PROMIS scores and a lower BMI were predictive of greater improvements in PROMIS scores.

Investigating the PROMIS Physical Function and Pain Interference Domains in Elite Athletes.

BACKGROUND: Multiple studies have demonstrated the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) to be a responsive and efficient measure for patients undergoing orthopaedic surgery. While these studies were rigorous in their protocol and methodology, no efforts in recent literature have been made to identify if these reference scores apply to elite athletes. PURPOSE/HYPOTHESIS: The purpose of this study was to determine whether there is a difference in the baseline scores of elite athletes versus the general population. We hypothesized that athletes' PROMIS upper extremity general function (PROMIS-UE) and general physical function (PROMIS-PF) scores would vary substantially from the mean health state of the general population. We further hypothesized that these scores would be affected by specific sport and level of competition. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Three PROMIS computer adaptive test (CAT) domains were administered to elite athlete (≥18 years) volunteers (either in person or through email). An elite athlete was defined as one participating in sports at the collegiate level or higher. Test domains included PROMIS-PF, PROMIS-UE, and pain interference (PROMIS-PI). PROMIS domain t scores were defined and assessed against NIH reference values to identify significant differences. Distribution analysis was conducted using histograms and normality assessments. Domains were also subject to correlation analysis. Finally, subgroup analysis was conducted for all athlete characteristics to identify any factors associated with variance. RESULTS: In total, 196 elite athletes (mean age, 21.1 years; range, 18.0-36.7 years) completed all 3 PROMIS-CAT forms. Overall, the mean scores were 56.0 ± 6.4, 58.1 ± 7.7, and 47.1 ± 7.3 for PROMIS-UE, PROMIS-PF, and PROMIS-PI, respectively. Distribution analysis showed nonnormal distribution for all 3 PROMIS domains (Kolmogorov-Smirnov test, P < .001). Similarly, in all 3 PROMIS domains the athletes displayed more disparate scores than the NIH-reported reference values (1-way sign test, P < .001). Only the presence of pain and sport played showed association with variance in PROMIS domain scores (P < .001 and P = .003, respectively). CONCLUSION: Elite athletes displayed more disparate reference scores than the NIH-reported average of 50 for PROMIS-UE, PROMIS-PF, and PROMIS-PI. Furthermore, these forms were sensitive to varying levels of sport among collegiate athletes.

Dexamethasone decreases postoperative opioid and antiemetic use in shoulder arthroplasty patients: a prospective, randomized controlled trial.

BACKGROUND: Multimodal pain control can be beneficial in relieving postoperative pain and limiting narcotic use following orthopedic procedures. Additionally, with increasing interest in outpatient arthroplasty procedures, providers have interest in adequate early postoperative pain control and complications. The purpose of this study was to investigate the effect of dexamethasone on pain, postoperative nausea and vomiting, and length of stay following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). METHODS: One hundred twelve patients undergoing TSA or RTSA by a single surgeon were assessed for inclusion in this investigation. We performed a prospective randomized controlled trial to investigate the effect of 10 mg of dexamethasone administered within 90 minutes of surgery. Primary outcome assessed was the average morphine equivalent use over the first 24 hours postsurgery. Secondary outcomes included postoperative visual analog scale (VAS) scores, antiemetic use, postoperative nausea and vomiting, and complications. RESULTS: A total of 75 patients were included in the final analysis, with 32 patients (42.7%) randomized to the control group and 43 (57.3%) randomized to the dexamethasone group. Body mass index was significantly greater in the control group (33.8 vs. 30.3, P = .014); otherwise, there were no significant demographic differences between groups. Average ondansetron use was significantly lower in the dexamethasone group compared with controls for the 0- to 4-hour interval (0.1 vs. 0.9 mg, respectively, P = .006) and was lower overall for the first 24 hours (0.3 vs. 1.0 mg, P = .025). Differences in VAS scores were significantly lower in the dexamethasone group at all time points (P < .05 for all). The average VAS score over the 24-hour period for the dexamethasone group was also significantly lower than the controls (3 vs. 6, P < .001). Morphine equivalent use was significantly lower in the dexamethasone group compared with controls at 12-16 hours (1.7 vs. 4.0 mg, respectively, P = .004) and at 16-20 hours (1.7 vs. 3.4 mg, respectively, P = .006). When averaged over the first 24 hours, morphine equivalent was also significantly lower in the dexamethasone group (16.1 vs. 25.4 mg, P = .007). There was no significant difference in glucose control or complications between groups. CONCLUSION: Dexamethasone decreases opioid requirements in the first 24 hours following surgery, provides improved pain control, and decreases antiemetic use following shoulder arthroplasty. Dexamethasone is an important multimodal adjunct for controlling pain and postoperative nausea and vomiting following primary TSA.

Preoperative Patient-Reported Outcomes Measurement Information System Computerized Adaptive Testing (PROMIS CAT) Scores Predict Achievement of Minimum Clinically Important Difference Following Anterior Cruciate Ligament Reconstruction Using an Anchor-Based Methodology.

PURPOSE: To determine the change in Patient-Reported Outcomes Measurement Information System Computerized Adaptive Testing (PROMIS CAT) scores for physical function, pain interference, and depression that constitute minimum clinically important difference (MCID) using an anchor-based technique and to identify pre-operative clinical thresholds in anchor-based MCID that predict likelihood of achieving MCID following anterior cruciate ligament (ACL) reconstruction. METHODS: Adult patients aged 18 years or older undergoing ACL reconstruction that completed both preoperative and postoperative PROMIS CAT assessments and an anchor-based questionnaire were identified over a 23-month period. Anchor-based MCID was determined for PROMIS CAT forms for physical function (PROMIS PF CAT), pain interference (PROMIS PI CAT), and depression (PROMIS D CAT). RESULTS: A total of 137 patients were included for statistical analysis, with pre-operative PROMIS CAT forms completed 27.9 ± 31.2 days before surgery and 492.5 ± 219.9 days postoperatively on average. Statistically significant improvements were observed for all PROMIS CAT domains. PROMIS PF CAT improved from 39.5 ± 8.2 to 55.0 ± 9.7 (P < .0005), PROMIS PI CAT from 59.8 ± 7.2 to 48.2 ± 8.3 (P < .0005), and PROMIS D CAT from 47.9 ± 8.8 to 41.5 ± 8.6 (P < .0005). Anchor-based MCID for each PROMIS CAT form was calculated to be +4.5, -5.4, and -4.1 for PROMIS PF CAT, PROMIS PI CAT, and PROMIS D CAT, respectively. Mean difference between preoperative and postoperative PROMIS CAT scores exceeded MCID for all domains. The percentage of patients achieving MCID for PROMIS PF CAT, PROMIS PI CAT, and PROMIS D CAT was 85%, 72%, and 55%, respectively. After introduction of 95% specificity cutoffs, the percentage of patients achieving MCID for PROMIS PF CAT, PROMIS PI CAT, and PROMIS D CAT increased to 100% (<35.6 cutoff score), 92% (>65.7 cutoff score), and 83% (>57.5 cutoff score), respectively. CONCLUSIONS: According to anchor-based analysis of PROMIS CAT MCID, ACL reconstruction is effective in improving physical function, pain interference, and depression symptoms. In addition, preoperative PROMIS CAT scores can predict the likelihood of achieving MCID postoperatively. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Preoperative Patient-Centric Predictors of Postoperative Outcomes in Patients Undergoing Arthroscopic Meniscectomy.

PURPOSE: To determine the minimal clinically important difference (MCID) using Patient-Reported Outcome Measurement Information System (PROMIS) computer-adaptive testing assessments in patients undergoing arthroscopic partial meniscectomy. The secondary purpose was to identify which preoperative patient factors are associated with MCID achievement. METHODS: Three PROMIS computer-adaptive testing assessments (Physical Function [PF], Pain Interference [PI], and Depression [D]) were administered to all patients presenting to 1 of 2 board-certified, sports medicine orthopaedic surgeons. Patients with Current Procedural Terminology codes of 29880 or 29881 were chart reviewed for a host clinical and demographic factors. PROMIS scores were assessed for improvement and patient characteristics were assessed for influence on any improvement. MCID was calculated according to the distribution methodology and receiver operating characteristics were used to assess preoperative scores predictive ability. RESULTS: In total, 166 patients met inclusion criteria (58 exclusions). Postoperative PROMIS-PF (45.6), PROMIS-PI (54.6), and PROMIS-D (44.1) significantly improved at least 3 months after surgery when compared with baseline (P = .002). MCID values for PROMIS-PF, PROMIS-PI, and PROMIS-D were 3.5, 3.3, and 4.4, respectively. Individuals with PROMIS-PF scores below 34.9 yielded an 82% probability of achieving MCID, while PROMIS-PI scores above 67.5 yielded an 86% probability of achieving MCID and a cutoff of 58.9 for PROMIS-D yielded a 60% probability of achieving MCID, with 90% specificity. CONCLUSIONS: PROMIS scores, obtained preoperatively, were shown to be valid predictors of postoperative clinical improvement in patients undergoing meniscectomy. Our findings suggest that patients with physical function scores of 34.9 or less have an increased probability of reaching a minimal clinically important difference. Similarly, patients with pain interference scores of 67.5 and above have increased probability of reaching MCID for pain interference. These cutoffs may be used by physicians to aid in the counseling of patients considering arthroscopic meniscectomy. LEVEL OF EVIDENCE: IV, Case Series.

Effect of Workload After ACL Reconstruction on Rerupture Rates in NBA Players.

BACKGROUND: Rupture of the anterior cruciate ligament (ACL) is a common and potentially career-altering injury sustained by players in the National Basketball Association (NBA). Strategies have been employed by the league to prevent reinjury of players after ACL reconstruction (ACLR), including minute restrictions and rest games; however, it remains unknown whether workload metrics after ACLR influence the risk for reinjury and revision surgery. PURPOSE: To evaluate whether workload changes after return to play (RTP) from primary ACLR influences the risk of rerupture in NBA players. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We identified NBA players from 1975 to 2018 who underwent primary ACLR as well as those who required revision ACLR. Primary outcomes included workload measures such as games played, games started, and minutes per game. Secondary outcomes included in-game performance statistics. Statistical analysis was used to compare relative workload and performance 3 years before and 3 years after undergoing primary ACLR. Workload was also compared between the control group of NBA players who underwent primary ACLR and those who required revision ACLR. RESULTS: A total of 68 players who underwent primary ACLR were included, 8 of whom subsequently required revision ACLR. In their first season upon RTP, control players (primary ACLR) demonstrated a significant reduction in all workload metrics relative to the season before injury (P < .001), while the revision group demonstrated an unchanged to increased workload. In a comparison between the primary and revision groups during the first season after RTP, the primary group demonstrated significantly fewer games started (mean ± SD, 22.2 ± 3.0 vs 35.8 ± 8.3; P = .039) and minutes per game (20.5 ± 1.1 vs 27.0 ± 3.1; P = .048) than revision players. The primary ACLR group demonstrated reduced cumulative workload trends for the first 3 years after RTP relative to 3 years before injury, which was not demonstrated in the revision ACLR group, albeit statistically insignificant. CONCLUSION: Our study found that after ACLR, a reduction in workload parameters relative to preinjury baseline was associated with players who did not sustain rerupture. Further study is required to determine if workload measures following RTP from primary ACLR should be individualized relative to preinjury baseline.

Pediatric PROMIS Computer Adaptive Tests Are Highly Correlated With Adult PROMIS Computer Adaptive Tests in Pediatric Sports Medicine Patients.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) is a powerful set of patient-reported outcome measures (PROMs) that are gaining popularity throughout orthopaedic surgery. The use of both adult and pediatric PROMIS questionnaires in orthopaedic sports medicine limits the value of the PROMIS in routine sports medicine clinical care, research, and quality improvement. Because orthopaedic sports medicine surgeons see patients across a wide age range, simplifying the collection of PROMIS computer adaptive tests (CATs) to a single set of questionnaires, regardless of age, is of notable value. PURPOSE/HYPOTHESIS: The purpose was to determine the strength of the correlation between the pediatric and adult PROMIS questionnaires. We hypothesized that there would be a high correlation between the adult and pediatric versions for each PROMIS domain, thereby justifying the use of only the adult version for most sports medicine providers, regardless of patient age. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHODS: Between December 2018 and December 2019, all pediatric sports medicine patients presenting to a single, academic, orthopaedic sports medicine clinic were asked to participate in the present study with their parents' consent. Patients were asked to complete a set of adult PROMIS domains (Physical Function and/or Upper Extremity, Pain Interference, and Depression) as well as a set of pediatric PROMIS domains (Mobility and/or Upper Extremity, Pain Interference, and Depressive Symptoms). Concurrent validity was assessed using Pearson correlation coefficients (r). Ceiling and floor effects were determined. RESULTS: A total of 188 patients met our inclusion criteria. The correlation between the adult and pediatric PROMIS Upper Extremity, Physical Function and Mobility, Pain Interference, and Depression and Depressive Symptoms forms were high-moderate (r = 0.68; P < .01), high-moderate (r = 0.69; P < .01), high (r = 0.78; P < .01), and high (r = 0.85; P < .01), respectively. Both adult and pediatric depression-related PROMIS domains demonstrated notable floor effects (adult: 38%; pediatric: 24%). The pediatric PROMIS Upper Extremity domain demonstrated a ceiling effect (20%). CONCLUSION: Adult PROMIS CATs may be used in an orthopaedic sports medicine clinic for both adult and pediatric patients. Our findings will help decrease the amount of resources needed for the implementation and use of PROMs for patient care, research, and quality improvement in orthopaedic sports medicine clinics.

Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Short Forms Demonstrate Responsiveness in Patients Undergoing Knee Arthroplasty.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) is an alternative to legacy outcome metrics. We investigated the relationship between Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS-JR) and PROMIS Global Health forms of Physical Health (PH) and Mental Health (MH) in knee arthroplasty patients. METHODS: This is a retrospective cohort study of knee arthroplasty patients from December 2017 through April 2019 who had surveys collected preoperatively and postoperatively. We excluded patients undergoing revision surgery. Outcome scores were analyzed for responsiveness, effect size index (ESI), minimal clinically important difference (MCID), and correlation with each other through 12 months postoperatively. RESULTS: A total of 875 patients were included. Floor and ceiling effects were 0% for PROMIS-PH. Postoperative PROMIS-PH and KOOS-JR scores significantly correlated with one another and increased from baseline at each postoperative time point (P < .001 for all). PROMIS-MH did not change between time points (P > .05). PROMIS-PH showed moderate responsiveness at 1 and 3 months (ESI >0.2) and excellent responsiveness at 6 and 12 months (ESI >0.8), whereas KOOS-JR was responsive at all time points (ESI >0.8). The MCID of PROMIS-PH correlated significantly with KOOS-JR, and a preoperative PROMIS-PH score of less than 32.5 predicted achieving MCID with 97% specificity. CONCLUSION: PROMIS global health forms are a valid metric which capture patient outcomes and correlate with KOOS-JR scores after knee arthroplasty. Although KOOS-JR may be more responsive in the early postoperative time period, both measures show excellent responsiveness at 6 and 12 months after knee arthroplasty.

PROMIS CAT forms demonstrate responsiveness in patients following arthroscopic rotator cuff repair across numerous health domains.

BACKGROUND: Recent studies of patients with rotator cuff tears have demonstrated improved efficiency with Patient-Reported Outcomes Measurement Information System (PROMIS) when compared with traditional patient-reported outcome measures (PROM). However, these studies have been cross-sectional in nature and the responsiveness of PROMIS computer adaptive test (CAT) forms has not been evaluated. The purpose of this study was to determine the responsiveness of PROMIS CAT assessments in patients undergoing arthroscopic rotator cuff repair. METHODS: All patients undergoing arthroscopic rotator cuff repair by one of 3 fellowship-trained surgeons were included in the study. PROMIS CAT upper extremity physical function ("PROMIS-UE"), pain interference ("PROMIS-PI"), and depression ("PROMIS-D") scores from preoperative and 6-month postoperative visits were collected and analyzed. Patient-centric demographic factors, tear size, and biceps involvement were also correlated to preoperative and postoperative PROMIS scores. RESULTS: A total of 101 patients were enrolled in the study. The average age was 59.8 ± 8.9 years with 51 males (50.5%). Preoperative PROMIS-UE, PROMIS-PI, and PROMIS-D CAT scores improved significantly from 29.8 ± 6.0, 62.6 ± 5.1, and 48.4 ± 8.7, respectively, to 40.9 ± 9.8, 51.2 ± 9.3, and 42.9 ± 9.0, respectively, at 6-month follow-up (P < .001). Preoperative correlations were found between PROMIS-UE and PROMIS-PI scores (P < .001) and between PROMIS-PI and PROMIS-D scores (P = .001). No significant correlation was found between PROMIS-UE and PROMIS-D scores (P = .08), preoperatively. Preoperative PROMIS-UE, PROMIS-PI, or PROMIS-D scores were not correlated with rotator cuff tear size (P = .4). CONCLUSION: PROMIS CAT forms demonstrate responsiveness in patients undergoing arthroscopic rotator cuff repair across numerous domains.

Using a Web-Based Data Collection Platform to Implement an Effective Electronic Patient-Reported Outcome Registry.

Modern health care places significant emphasis on patient-centered care. As a result, many orthopaedic providers are incorporating routine patient-reported outcome measure (PROM) collection into their practice. However, routine PROM collection often disrupts clinical workflow and can place a burden on both the patient and the provider. Electronic PROM collection systems, if implemented deliberately to maximize convenience and efficiency, have the potential to mitigate these obstacles. This technique guide presents an overview of designing and implementing a PROM-based clinical registry for the ambulatory orthopaedic clinic using Research Electronic Data Capture (REDCap; Vanderbilt University, Nashville, TN). We outline the basic steps of creating a simple but effective patient registry using this accessible data collection platform.

Establishing "Normal" Patient-Reported Outcomes Measurement Information System Physical Function and Pain Interference Scores: A True Reference Score According to Adults Free of Joint Pain and Disability.

Numerous recent studies have demonstrated the validity and efficiency of the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) forms in patients undergoing orthopaedic surgical procedures. It is assumed that a score of 50 in each domain represents the health state of a "reference" population, but this threshold has not been definitively proven. In order to truly assess whether a given orthopaedic intervention is successful, the comparative scores of healthy individuals must be known for any given health domain measured. Therefore, the purpose of this study was to determine baseline scores for the PROMIS general physical function (PROMIS-PF), pain interference (PROMIS-PI), and upper-extremity physical function (PROMIS-UE) domains in physically healthy, asymptomatic adult individuals. We hypothesized that, in individuals <40 years old, the mean PROMIS-PF and PROMIS-UE scores would be >50 and PROMIS-PI scores would be <50. We further hypothesized that these scores would be impacted by participant age. METHODS: Three PROMIS computer adaptive test (CAT) domains were administered (either in person or through email) to healthy adult volunteers. These domains included PROMIS-PF, PROMIS-UE, and PROMIS-PI. Individuals who reported joint pain or dysfunction were excluded. RESULTS: In total, 294 healthy volunteers with a mean age of 33.2 years (range, 18 to 83 years) completed all 3 PROMIS CAT forms. The mean (and standard deviation) PROMIS-UE, PROMIS-PF, and PROMIS-PI scores were 55.9 ± 6.6, 59.7 ± 8.0, and 43.6 ± 7.6, respectively, for individuals <40 years old and 51.2 ± 8.2, 52.9 ± 7.6, and 49.0 ± 8.0, respectively, for individuals ≥40 years old. Age correlated significantly with PROMIS-UE and PROMIS-PF in the older cohort. CONCLUSIONS: For individuals <40 years old, baseline PROMIS-PF scores were significantly higher than 50 and PROMIS-PI scores were significantly lower. This difference was less pronounced in individuals ≥40 years old. When treating young patients, clinicians should be cognizant of these healthy baseline scores. CLINICAL RELEVANCE: In this study, reference range for asymptomatic musculoskeletal volunteers was determined across PROMIS CAT forms. These reference scores are important in treating and counseling patients with musculoskeletal conditions in order to determine relative impairment or functional capabilities.