Hospital transfer and delayed reduction of traumatic hip dislocations.

INTRODUCTION: Native hip dislocations are high energy injuries that cause substantial patient morbidity. Expedient reduction has been demonstrated to improve patient outcomes. The objective of our study was to compare complication rates in patients with native hip dislocations who presented directly to a level-one trauma center with those transferred from an outside hospital (OSH). Our hypothesis was that those transferred from an OSH would experience a delay in reduction and subsequently would experience higher rates of avascular necrosis (AVN), post-traumatic arthritis (PTA), and need for secondary surgery. MATERIAL AND METHODS: We conducted a retrospective chart review of all native hip dislocations from our level-one trauma center between January 2007 and December 2020. The initial query resulted 628 patients which was refined to 90 patients after excluding patients for incorrect diagnosis code or less than 6 months of follow-up. Our primary outcome was the development of AVN, PTA, and need for secondary surgery. Time from injury to reduction was recorded for all patients included. RESULTS: For every one hour of delay in time to reduction, there was a 3.4% increase in the risk of developing AVN (p = 0.004) and a 4.3% increase in risk for developing PTA (p = 0.01). The risk of requiring a secondary surgery increased 4.6% for each hour of delay in reduction (p = 0.03). The average time to reduction of transferred patients was higher compared to those who presented directly to our center (13.8 h vs 5.7 h); however, transfer status was not found to be an independent risk factor for the measured outcomes. CONCLUSIONS: Transfer status is not an independent risk factor for the development of AVN, PTA, or the need for a secondary surgery. However, transferred patients did experience an average delay of 8 h in time to reduction compared to those who presented directly to a trauma center. Of the 27 patients with a reduction delay greater than 12 h, 26 (96%) were transferred.

Fatigue Increases Dynamic Knee Valgus in Youth Athletes: Results From a Field-Based Drop-Jump Test.

PURPOSE: To determine whether fatigue increases dynamic knee valgus in adolescent athletes, as measured after a standardized exercise protocol and video-based drop-jump test. A secondary aim was to determine whether individual risk factors place certain athletes at increased risk for dynamic knee valgus. METHODS: Athletes aged 14 to 18 years were recruited for this video analysis study. Athletes were recorded performing a standard drop-jump to assess dynamic valgus. Participants then completed a standardized exercise protocol. Fatigue was quantified using a maximum vertical jump, which was compared with pre-exercise values. The drop-jump was repeated postexercise. All drop-jump recordings were randomized and scored for dynamic valgus by 11 blinded reviewers. Univariate analysis was performed to identify characteristics that predisposed athletes to increased dynamic valgus. RESULTS: Eighty-five (47 female, 38 male) athletes with an average age of 15.4 years were included in this study. Forty-nine percent of athletes demonstrated an increase in dynamic valgus determined by drop-jump assessment after exercise. A significantly greater percentage of athletes were graded "medium or high risk" in jumps recorded after the exercise protocol (68%) as compared with before the exercise protocol (44%; P < .01). Female athletes (P < .01) and those older than 15 years of age (P < .01) were the most affected by fatigue. CONCLUSIONS: In conclusion, our study found that exercise increases dynamic knee valgus in youth athletes. Female athletes and those older than 15 years of age were most significantly affected by exercise. Greater fatigue levels were found to correlate with an increase in dynamic knee valgus, which may place athletes at greater anterior cruciate ligament injury risk. The field-based exercise drop-jump test is a low-cost and reproducible screening tool to identify at-risk athletes who could possibly benefit from anterior cruciate ligament injury-prevention strategies. LEVEL OF EVIDENCE: III, Comparative trial.

Cost analysis of Tommy John surgery for Major League Baseball teams.

BACKGROUND: The economic loss following ulnar collateral ligament reconstruction (UCLR) in Major League Baseball (MLB) pitchers has not been evaluated. The purpose of this study is to quantify the financial impact of UCLR on MLB teams. We hypothesize that MLB teams incur significant losses annually as a result of salaries paid to injured players following reconstruction. METHODS: Public records were accessed to identify MLB pitchers from January 1, 2004, to December 31, 2014, who had undergone UCLR. Contract terms and time away from competition were used to approximate economic loss. Successful return was considered when a pitcher returned to play in at least 1 Minor League Baseball (MiLB) or MLB game. RESULTS: One hundred ninety-four MLB pitchers underwent UCLR from 2004 to 2014, missing on average 180.2 days of the MLB regular season. Cost of recovery (COR) amounted to $395 million, averaging $1.9 million per player. Starting pitchers accounted for the largest total COR at $239.6 million, whereas closers had the largest economic loss per player ($3.9 million/player). Only 77% of pitchers returned to MLB play. CONCLUSION: UCLR has a substantial economic impact on MLB teams. Starting pitchers represented a majority of team cost, but closers represented higher costs per pitcher.

Predictors of elbow torque among professional baseball pitchers.

BACKGROUND: Overuse injuries of the shoulder and elbow continue to be prevalent in elite baseball pitchers. Pitch velocity has been shown to impact medial elbow torque in adolescent baseball pitchers. However, the determinants of medial elbow torque in professional baseball pitchers are not known. PURPOSE: To determine the influence of pitch type, velocity, and player characteristics on medial elbow torque in professional baseball pitchers. METHODS: Professional baseball pitchers were recruited for participation. Height, weight, body mass index (BMI), and throwing arm measurements were obtained for all study participants. While wearing a gyroscopic sensor equipped with an accelerometer, participants were instructed to throw a standard, randomized sequence of fastballs, changeups, and curveballs. Elbow torque, arm slot, arm speed, shoulder rotation, and ball velocity were recorded for each pitch. A linear mixed model was used to evaluate the association of pitch type with each pitch parameter, adjusting for pitchers' demographics. RESULTS: A total of 12 professional baseball pitchers were included in this study. Among the pitch types, medial elbow torque was significantly higher in fastballs than in curveballs (P = .001). An increased BMI value was independently associated with decreased elbow torque in pitchers (P = .035). CONCLUSION: Fastballs place significantly higher torque on the medial elbow than do curveballs, which is consistent with previous studies done on high school and collegiate populations. Pitchers with a higher BMI experience significantly less torque across the medial elbow.

Mental Health and Tobacco Use Are Correlated With Physical Function Outcomes in Patients With Knee Pain and Injury.

PURPOSE: To examine the relation between the Patient-Reported Outcomes Measurement Information System (PROMIS) domains of Pain Interference (PROMIS-PI), Depression (PROMIS-D), and Physical Function (PROMIS-PF) for nonoperative patients presenting to our ambulatory sports orthopaedic clinic with knee complaints and to determine whether patient demographic characteristics influence PROMIS scores, particularly tobacco use. METHODS: All patients treated nonoperatively for a primary complaint of knee pain were recruited for participation. Patients were included if they completed all 3 PROMIS questionnaires prior to their clinical evaluation. Patients were excluded if their treatment plan determined that surgical intervention was warranted. Survey results were compiled, and statistical correlations were run between PROMIS domains and patient demographic characteristics. RESULTS: A total of 527 PROMIS questionnaire sets were included. PROMIS-PF had a strong negative correlation with PROMIS-PI (R = -0.75, P < .001) and a nearly moderate negative correlation with PROMIS-D (R = -0.47, P < .001). When evaluating patient demographic characteristics, we found a significant decrease in physical function scores and increases in pain and depression scores in both current and former tobacco users compared with nonsmokers. Differences in all PROMIS domains between smokers and nonsmokers exceeded minimal clinically important differences. CONCLUSIONS: Our study showed an inverse correlation between PROMIS-PI and PROMIS-PF, as well as between PROMIS-D and PROMIS-PI, in patients seen in the ambulatory setting for knee complaints treated nonoperatively. A positive correlation was found between PROMIS-PI and PROMIS-D. Tobacco use was a patient demographic factor found to significantly impact PROMIS scores leading to minimal clinically important differences across all 3 PROMIS domains. The findings of this study may be used to identify patients at high risk of poor outcomes. LEVEL OF EVIDENCE: Level III, observational study.

Impact of ball weight on medial elbow torque in youth baseball pitchers.

HYPOTHESIS: Our hypothesis was that an increase in ball weight would result in an increase in medial elbow torque during the pitching motion. METHODS: Youth pitchers were recruited for this study and instructed to throw 5 maximum-effort fastballs from ground level using baseballs of 4 different weights: 85 g (3 oz), 113 g (4 oz), 142 g (5 oz), and 170 g (6 oz). The validated Motus sensor was used to assess medial elbow torque, arm speed, arm slot, and shoulder rotation for each pitch. Pitch velocity was measured using a radar gun. Relationships between baseball weight and pitching kinetics and/or kinematics were evaluated using linear mixed-effects analysis. An exit survey was conducted detailing the pitcher's evaluation of the ball weights used. RESULTS: A total of 19 youth baseball pitchers (average age, 11.8 ± 1.1 years; age range, 9-14 years) completed the study. For every 1-oz (28-g) increase in ball weight, ball velocity decreased 2.0 ± 0.1 mph (χ2 = 52.68, P < .001), medial elbow torque increased 0.92 ± 0.37 newton meters (χ2 = 5.36, P = .02), and arm speed decreased 8.52 ± 3.68 rpm (χ2 = 5.03, P = .02). Shoulder rotation and arm slot were not significantly impacted by ball weight (P > .05). Survey results indicated that the 85-g (3-oz) baseball was most favored (8 of 19 pitchers) and believed to result in the highest pitch velocity (15 of 19 pitchers). The 170-g (6-oz) baseball was least favored (17 of 19 pitchers) and believed to result in the slowest pitch velocity (18 of 19 pitchers). No adverse outcomes were reported with the use of any ball weight or the mobile sensor. CONCLUSION: Among youth pitchers, an increase in ball weight correlated with greater medial elbow torque, decreased pitch velocity, and decreased arm speed.

Bone cutting efficiency and heat generation using a traditional fluted Burr and a novel fluteless resurfacing tool.

BACKGROUND: Powered instrumentation is often used for bone preparation and/or removal in many orthopaedic procedures but does risk thermogenesis. This study compares biomechanical properties of a fluted burr and a novel fluteless resurfacing tool. METHODS: Twenty cadaveric metatarsals were tested with four predetermined cutting forces to evaluate heat generation and cutting rate for the fluted burr and fluteless resurfacing tool over 40 s or until a depth of 4 mm was reached. Cutting rate was calculated from displacement transducer data. Heat generation was measured by thermocouples placed in the bone adjacent to the burring site. Assuming a body temperature of 37 °C, a 10 °C increase in heat was used as the threshold of inducing osteonecrosis. FINDINGS: At 1.0 N and 1.7 N, the thermal osteonecrosis threshold was reached at comparable times between burrs, while the bone removed by the resurfacing tool was on average five times greater than fluted burr at 1.0 N and over twice as great at 1.7 N. Statistical analysis of these common cutting forces showed the resurfacing tool had significantly higher cutting rates (P < 0.01). As a result, the fluted burr produced higher temperatures for the same amount of bone removal (P < 0.01). INTERPRETATION: In a cadaveric study, the fluteless resurfacing tool demonstrated higher bone cutting rates and lower heat generation for the same amount of bone removed than a traditional fluted burr.

The Long Head of the Biceps Myotendinous Junction Is Located 1.14 Centimeters Distal to the Proximal Border of the Pectoralis Major Tendon: An Anatomic Study.

Purpose: To describe the proportional anatomic relationship of the long head of the biceps tendon (LHBT) myotendinous junction (MTJ) to pectoralis major tendon (PMT) and to provide an up-to-date review of the current literature. Methods: Ten fresh frozen cadaveric specimens were used. A deltopectoral approach was used for exposure and anatomical location of the MTJ as well as the proximal and distal borders of the PMT were identified by 2 fellowship-trained shoulder and elbow surgeons. The longitudinal length of the PMT, the distance from the long head of the biceps (LHB) MTJ to the proximal border of the PMT (pMTJ), and the distance from the LHB MTJ to the distal border of the PMT (dMTJ) were recorded. The relationship between the pMTJ and the PMT length was then reported as a ratio. Results: The PMT was found to have a length of 5.16 ± 0.64 cm (4.1-6.1 cm). The pMTJ was 1.14 ± 0.52 cm (0.5-1.9 cm), and the dMTJ was 4.02 ± 0.91 cm (2.5-5.3 cm). The pMTJ/PMT ratio was 0.23 ± 0.11 (0.10-0.39). Conclusions: We found the average length of the PMT footprint to be 5.16 cm with the LHB MTJ beginning 1.14 cm distal to its proximal border. Clinical Relevance: It is important to understand the LHBT and its relationship to surgically relevant surrounding anatomy to allow for appropriate tensioning and improved patient outcomes in the treatment of LHBT shoulder pathology.

The Remote Completion Rate of Electronic Patient-Reported Outcome Forms Before Scheduled Clinic Visits-A Proof-of-Concept Study Using Patient-Reported Outcome Measurement Information System Computer Adaptive Test Questionnaires.

INTRODUCTION: Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires are amenable to remote administration. This study sought to determine remote completion rates of PROMIS questionnaires before clinic visits. METHODS: Patients were e-mailed a set of PROMIS forms. Completion rates were analyzed by visit type, provider seen, and patient demographics. RESULTS: Seven hundred forty total appointments were included. Sixty-seven percent of encounters had previsit form completion. High completion rates were found for all visit types (74%, 67%, and 64% for new, return, and postoperative visits, respectively). Women had a higher completion rate than men (71% versus 64%; P = 0.031). White patients (72%; P = 0.001) and patients in the third median household income quartile ($53,725 to $83,088; 72%; P = 0.008) had higher completion rates than their respective counterparts. CONCLUSION: Most patients remotely completed PROMIS forms. The efficiency and accessibility of PROMIS forms may help improve ease of collection of patient-reported outcomes.

External Ventricular Drain Placement Accuracy and Safety When Done by Midlevel Practitioners.

BACKGROUND: External ventricular drains (EVDs) measure intracranial pressure, divert cerebrospinal fluid, and allow for orthotropic administration of pharmacologic agents. Currently, neurosurgeons and neurosurgery residents are the primary practitioners placing EVDs. Due to the urgency of neurosurgical pathologies and the lack of qualified residents at most hospitals, midlevel practitioner (MLP) placement of EVDs would be advantageous. OBJECTIVE: To assess the accuracy and complication rates of MLP and neurosurgeon EVD placement. METHODS: This was a retrospective cohort of all patients with an EVD placed between January 2012 and September 2016 at a level 1 trauma center. We compared safety and accuracy of EVD placement between neurosurgeons and MLPs. RESULTS: MLP first attempted EVD placement in 238 patients and senior neurosurgeon first attempted EVD placement in 70 subjects. There was no significant difference between accuracy of placement within the ventricle (87.4% vs 90.0%, P = .5557), hemorrhage rate (5.9% vs 4.3%, P = .77), or infection rate (0.8% vs 1.4%, P = .5399) for placement attempted by an MLP compared with a neurosurgeon, respectively. CONCLUSION: MLPs perform EVD placement safely with no significant difference in accuracy of placement or complication rates compared with placement by senior neurosurgeons. This may allow for earlier management of elevated intracranial pressure and access to care where previously unavailable; leading to improved patient outcomes.

Impact of Patient Demographic Factors on Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, Pain Interference, and Depression Computer Adaptive Testing Scores in Patients Undergoing Shoulder and Elbow Surgery.

BACKGROUND: There has been a growing emphasis in orthopaedics on providing patient-centered care. The US National Institutes of Health launched the Patient-Reported Outcomes Measurement Information System (PROMIS) initiative that incorporates patient-reported outcome measures across a number of medical domains. The relationship between PROMIS domains and the impact of patient demographic factors in those undergoing upper extremity surgery remains unclear. PURPOSE/HYPOTHESIS: The goal of this study was to investigate the correlation between physical function, pain interference, and depression in patients undergoing shoulder and elbow surgery as measured by PROMIS computer adaptive testing (CAT) forms and to determine the impact of patient demographic factors. We hypothesized that there would be a significant negative correlation between physical function and both pain interference and depression in this patient population. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: All patients who underwent elective shoulder or elbow surgery by 3 shoulder, elbow, and/or sports medicine fellowship-trained orthopaedic surgeons were included in the study. Preoperative PROMIS-Upper Extremity (PROMIS-UE), PROMIS-Pain Interference (PROMIS-PI), and PROMIS-Depression (PROMIS-D) CAT scores were analyzed. Pearson correlations were calculated between PROMIS domains as well as between PROMIS outcomes with patient demographic factors. RESULTS: Preoperative PROMIS CAT scores for all 3 domains were collected and analyzed from 172 unique patients (516 individual CAT forms) with shoulder and elbow injuries. A negative correlation of moderate strength was found between the PROMIS-UE and PROMIS-PI (R = -0.61; P < .001), and a negligible correlation was found between the PROMIS-UE and PROMIS-D (R = -0.28; P < .001). When stratified by patient demographic factors, the correlation between the PROMIS-UE and PROMIS-PI was stronger in female patients compared with male patients (R = -0.77 vs -0.46, respectively; P < .001 for both), stronger in black patients compared with white patients (R = -0.72 vs -0.56, respectively; P < .001 for both), and highest in current tobacco users (R = -0.80; P < .001). CONCLUSION: Before shoulder and elbow surgery, patients demonstrated impairments in physical function and pain interference as measured by CAT forms, with a moderate negative correlation between baseline upper extremity physical function and pain interference scores. In certain subpopulations, such as female patients, black patients, and current tobacco users, the correlations between these tested domains were stronger than in other groups.

Feasibility of PROMIS CAT Administration in the Ambulatory Sports Medicine Clinic With Respect to Cost and Patient Compliance: A Single-Surgeon Experience.

BACKGROUND: Pay-for-performance reimbursement models are becoming increasingly popular, but the implementation of a routine patient-reported outcome (PRO) collection system places additional burden on both the patient and the provider. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed in an effort to make PRO collection more practical and efficient, but providers may be reluctant to embrace a transition to a PROMIS-based clinical outcome registry. HYPOTHESIS: PROMIS can be successfully incorporated into daily clinical practice, with an overall patient compliance rate of 80%. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: As part of routine practice, all patients presenting to a single surgeon's sports medicine clinic for an appointment were asked to complete a series of PROMIS computerized adaptive tests (CATs), including PROMIS Physical Function, Physical Function-Upper Extremity, Pain Interference, and Depression subscales. Overall compliance was calculated by dividing the number of survey sets completed by the number of eligible clinic visits. Compliance rates were further assessed by patient age, type of clinic visit, and location of injury. Costs associated with this system of routine PRO collection were categorized as start-up or maintenance costs. RESULTS: From August 7, 2017, to December 8, 2017, there were 581 patients (1109 clinic encounters) who met inclusion criteria for the study. Of the 1109 clinic encounters, there was an overall compliance rate of 91.3% (1013/1109 visits during which the patient completed the entire PROMIS survey set). Overall, the full survey set consisted of a mean 15.3 questions and took a mean of 2.6 minutes to complete. Patients who were aged ≥62 years had a significantly lower compliance rate (81.8%; P < .0001) than each of the younger patient quartiles. When analyzing patients by the most common locations of injury (elbow, shoulder, hip, knee), the compliance rate for completing PROMIS was significantly higher for the hip than for the shoulder (95.1% vs 88.9%, respectively; P = .02). The cost of establishing a PROMIS-based registry using our project design and workflow was estimated at $2045, whereas the monthly maintenance cost was $1000. CONCLUSION: The routine electronic collection of PROMIS scores in the ambulatory orthopaedic clinic resulted in a compliance rate of over 90%, although older patients were generally less compliant than younger patients. Our system of data collection is practical and efficient in a high-volume orthopaedic clinic and places minimal financial burden on the provider.

Correlation of PROMIS Physical Function, Pain Interference, and Depression in Pediatric and Adolescent Patients in the Ambulatory Sports Medicine Clinic.

BACKGROUND: Recently, interest has increased in incorporating the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes into clinical and research applications in sports medicine. The PROMIS forms have not been studied in pediatric and adolescent sports medicine patients. PURPOSE/HYPOTHESIS: The goal of this study was to determine the correlation between PROMIS Computer Adaptive Test (CAT) forms measuring physical function, pain interference, and depression in pediatric and adolescent patients seen in the ambulatory sports medicine clinic. We hypothesized that there would be a negative correlation between physical function and pain interference as well as depression, as has been demonstrated in adult patient populations. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: All patients aged 8 to 17 years seen by 3 shoulder and sports medicine providers were included in this study. Patients completed a series of PROMIS CAT forms at clinic visits, including the PROMIS-PF and PROMIS-UE (Physical Function and Upper Extremity; depending on the nature of the complaint), PROMIS-PI (Pain Interference), and PROMIS-Depression subscales. Pearson correlation coefficients were calculated between the PROMIS forms as well as with other patient demographic data. RESULTS: A total of 236 patient visits (152 patients) were included in the study, comprising 712 total PROMIS CAT forms. A negative correlation was found between PROMIS-PF and both PROMIS-Depression (R = -0.34) and PROMIS-PI (R = -0.76). These correlations with PROMIS-Depression and PROMIS-PI were -0.21 and -0.75, respectively, when considering the PROMIS-UE CAT. Patient demographic information had minimal impact on PROMIS scores as well as on correlations between scores. CONCLUSION: Correlations between physical function, pain interference, and depression were found to be similar in pediatric patients as they are in adult patients, as measured by PROMIS CAT forms.

Aspirin: are patients actually taking it?-A quality assessment study.

BACKGROUND: The purpose of the study was to assess patient adherence to an aspirin-based prophylactic deep venous thromboembolism (DVT) care management plan after total lower extremity arthroplasty. METHODS: Using a cross-sectional study design, patients who underwent total hip or knee replacement surgery by a single senior surgeon were surveyed at their routine 6-week follow-up appointment regarding adherence to aspirin DVT prophylaxis. Postoperatively, patients were advised to take 325 mg of aspirin twice daily for 6 weeks to prevent DVT. RESULTS: Of the 101 patients surveyed, 45 underwent total hip arthroplasty while 56 underwent total knee arthroplasty. There were 48 (48%) patients who were still taking aspirin at their routine 6-week postoperative follow-up appointment and 53 (52%) patients who were not taking aspirin (nonadherent group). Of the latter, 3 (6%) never took aspirin postoperatively, 14 (26%) discontinued within 2 weeks postoperatively, and 23 (43%) did not take it any longer for half the time prescribed. In the nonadherent group, 8 patients reported that they felt they did not need the aspirin prophylaxis, 5 experienced side effects, and 10 were unsure of how long they needed to take it. There was 1 patient with a calf DVT and no episodes of pulmonary embolism. CONCLUSIONS: Over half of our study, patients did not finish their aspirin regimen. We suggest a consistent outline of medication duration throughout the pre/postop course and communication regarding aspirin cessation.

Effect of Fatigue on Medial Elbow Torque in Baseball Pitchers: A Simulated Game Analysis.

BACKGROUND: The incidence of overuse injury to the elbow among baseball pitchers continues to rise, despite extensive efforts at pitch count regulations and emphasis on proper throwing mechanics. PURPOSE: To determine if the medial elbow experiences increased torque levels as a baseball pitcher fatigues through the course of a simulated game. STUDY DESIGN: Descriptive laboratory study. METHODS: High school and collegiate baseball pitchers were recruited for this simulated game study. Each pitcher completed a simulated game consisting of 6 innings and a standardized pitching scheme of fastballs, curveballs, and changeups. In total, each pitcher threw 90 pitches. Fatigue was reported per inning with a visual analog scale, and pitch velocity was captured per pitch with a radar gun. Outcome measures were assessed with a validated mobile sensor and included medial elbow torque, arm speed, arm rotation, and arm slot. Linear and quadratic regression modeling was used to evaluate the relationship between pitcher fatigue and pitching kinematics. RESULTS: A total of 11 pitchers (mean age, 17.6 years; range, 15-20 years) completed the study. Visual analog scale fatigue scores increased 0.72 points per inning pitched ( P < .01, effect size = 0.64). Medial elbow torque also increased beyond inning 3, with an increase of 0.84 N·m each inning ( P < .01, effect size = 0.08), while pitch velocity decreased (0.28 mph per inning, P < .01, effect size = 0.27). Fastballs generated the greatest amount of medial elbow torque (49.3 ± 1.4 N·m, P < .01, effect size = 0.24). There were no differences in arm rotation ( P = .42) or arm speed ( P = .80) as the game progressed. However, arm slot decreased with each successive inning (0.73° on average per inning, P = .03, effect size = 0.12). No adverse outcomes were noted with use of the mobile sensor. CONCLUSION: In this simulated game analysis, pitchers experienced increased fatigue after each successive inning. While the average pitch velocity declined with each successive inning, the torque on the medial elbow increased after inning 3. These findings signify a possible relationship between fatigue and injury risk.

How Long Does It Take for Patients to Complete PROMIS Scores?: An Assessment of PROMIS CAT Questionnaires Administered at an Ambulatory Sports Medicine Clinic.

BACKGROUND: Challenges exist in routinely collecting patient-reported outcomes (PROs) from patients at a busy ambulatory clinic. A number of validated Patient-Reported Outcomes Measurement Information System (PROMIS) subdomains allow for efficient PRO administration. PURPOSE: To determine the time to completion (TTC) of 3 PROMIS computer adaptive test (CAT) scores. CAT questionnaires were administered at the ambulatory clinic with the following PROMIS subdomains: Pain Interference (PI), Depression, and Physical Function for lower extremity (PF) or for upper extremity (UE). The secondary purpose was to determine the influence of patient demographic factors on TTC. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients were recruited from 3 fellowship-trained upper extremity and sports medicine orthopaedic surgery clinics. PROMIS CAT questionnaires were administered to consecutive patients during the study period (July 2017-September 2017). The start and completion times of each CAT were recorded. The primary outcome of interest was TTC of the questionnaires. Patients were stratified into age quartiles to determine the impact of age on TTC. Patient demographic information, such as sex, race, and ethnicity, was determined retroactively. RESULTS: A total of 1178 questionnaire sets consisting of 3658 individual PROMIS forms were analyzed. The mean TTC was 3.29 minutes for all 4 forms in aggregate, with PROMIS PI, PF, UE, and Depression taking on average 1.05, 0.74, 0.96, and 0.57 minutes to complete, respectively. Patients from the oldest age quartile (mean ± SD, 70.3 ± 7.5 years) had a statistically significant longer TTC as compared with the second quartile (41.2 ± 4.7 years) (3.70 vs 2.87 minutes; P < .05). Asian patients had the longest PROMIS PF TTC, while white patients completed PF with the shortest TTC (1.28 vs 0.68 minutes; P < .05). Patients of unstated ethnicity had a longer TTC for PF as compared with their Hispanic/Latino and non-Hispanic/Latino counterparts (0.91 vs 0.30 and 0.70 minutes; P < .05). CONCLUSION: PROMIS CAT forms are efficient tools for collecting patient-reported outcomes in the ambulatory orthopaedic surgery clinic. Older patients, Asian patients, and patients of unstated ethnicity took longer to complete the forms.