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.

The impact of external beam radiation therapy on shoulder surgical outcomes: a case series study.

HYPOTHESIS: External beam radiation therapy (XRT) is a commonly used treatment adjunct in patients with breast cancer and is known to cause soft tissue dysfunction. However, data on XRT as a preoperative risk factor for shoulder surgery is limited. The purpose of this study was to assess whether prior history of breast cancer treated with XRT has an impact on surgical complications or outcomes. We hypothesize that patients treated with XRT will have a higher rate of surgical complications and lower outcomes. METHODS: A 20-year retrospective chart review across a large, academic health care system was performed. Inclusion criterion comprised any patient with history of breast cancer of the upper-outer or axillary region treated with XRT. Patients also must have undergone a surgical procedure to the ipsilateral shoulder with at least 1-year postoperative follow-up. Patients were stratified by demographics, hand dominance, and surgery type. Postoperative outcomes including range of motion (ROM) and visual analog scale (VAS) scores for pain were also collected. RESULTS: Eighteen patients were identified (100% female) with an average age of 66.3 years (standard deviation 10.5 years). Ten shoulders underwent rotator cuff repair (RCR), 4 total shoulder arthroplasty (TSA), 3 reverse shoulder arthroplasty (RSA), and 1 arthroscopic superior labrum anterior to posterior (SLAP) repair. Four patients treated with RCR (40%) experienced postoperative complications related to their procedure. These included scapular winging, adhesive capsulitis, stiffness, and one retear. Two patients treated with shoulder arthroplasty (28.6%) experienced postoperative complications that included lymphedema and periprosthetic fracture following a mechanical fall in one RSA patient and periprosthetic infection in a TSA patient. ROM across all groups improved, most significantly in forward flexion and internal rotation among RCR patients (P < .001). Furthermore, a statistically significant improvement in VAS scores was achieved in each group (6.2 ± 2.14 preoperation, 1.06 ± 1.75 postoperation; P < .001). CONCLUSION: When compared to national averages, complication rates in our cohort were higher (40% vs. 10%-17% in RCR patients and 28.6% vs. 4%-14% in arthroplasty patients). On further scrutiny, many of these complications were independent of a history of XRT and many resolved with appropriate therapy. Most importantly, functional outcomes as measured by ROM and pain scores showed appropriate improvement consistent with normal populations without history of XRT. Thus, our results suggest that performing shoulder surgery after ipsilateral XRT for breast cancer is likely safe and may offer improved pain and ROM compared to forgoing surgery without necessarily increasing the risk for postoperative complication.

Multimodal Nonopioid Pain Protocol Provides Equivalent Pain Versus Opioid Control Following Meniscus Surgery: A Prospective Randomized Controlled Trial.

PURPOSE: To assess the effectiveness of a nonopioid pain regimen in controlling postoperative pain as compared with a traditional opioid pain control following primary meniscectomy or meniscal repair. METHODS: Ninety-nine patients undergoing primary meniscectomy or meniscal repair were assessed for participation. A prospective randomized control trial was performed in accordance with the Consolidated Standards of Reporting Trials 2010 statement. The 2 arms of the study included a multimodal nonopioid analgesic protocol and a standard opioid regimen with a primary outcome of postoperative pain level (visual analog scale) for the first 10 days postoperatively. Secondary outcomes included patient-reported outcomes, complications, and patient satisfaction. Randomization was achieved using a random-number generator. Patients were not blinded. Data collection was done by a blinded observer. RESULTS: Eleven patients did not meet the inclusion criteria, and 27 declined participation. A total of 61 patients were analyzed with 30 randomized to the opioid regimen and 31 randomized to the nonopioid regimen. Patients receiving the nonopioid regimen demonstrated noninferior visual analog scale scores compared with patients who received opioid pain medication (P > .05). No significant differences were found in preoperative (opioid: 58.9 ± 7.0; nonopioid: 58.2 ± 5.5, P = .724) or postoperative (opioid: 59.8 ± 6.5; nonopioid: 54.9 ± 7.1, P = .064) Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form scores. No difference was found in recorded side effects between both groups at any given time point: constipation, nausea, diarrhea, upset stomach, and drowsiness (P > .05). CONCLUSIONS: This study found that a multimodal nonopioid pain protocol provided equivalent pain control and patient outcomes following primary meniscus surgery while having an equivalent side effect profile. All patients reported satisfaction with their pain management without requiring emergency opioid analgesia. LEVEL OF EVIDENCE: Level I, prospective randomized controlled trial.

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.

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.

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.

Clinical characteristics and long-term outcomes of septic arthritis of the native hip joint: a 20-year retrospective review.

BACKGROUND: The primary purpose of this retrospective case series was to describe the prevalence and outcomes of single-stage hip arthroplasty in patients who were previously treated for septic arthritis of the native hip at our institution over a 20-year period. This study also examined rates of persistent or recurrent infection, reoperation, and mortality for septic arthritis of the native hip. METHODS: Adult patients treated for septic arthritis of the native hip at our institution from 1995 to 2015 were retrospectively identified. Exclusion criteria included age <18 years, missing or incomplete medical records, treatment at an outside institution, and prior surgery of the hip. RESULTS: 97 patients were included in this study. 3 patients (3.1%) who were previously treated for septic arthritis of the native hip underwent single-stage hip arthroplasty an average of 40 ± 25 months from the date of infection. 3 of the 18 (16.7%) patients who were treated with resection arthroplasty underwent second-stage joint reconstruction. There were no cases of periprosthetic joint infection (PJI). 1 patient who underwent single-stage arthroplasty experienced implant-induced metallosis, necessitating removal of the implant. There were no other cases of revision arthroplasty. CONCLUSIONS: The prevalence of single-stage hip arthroplasty in patients with a history of septic arthritis of the native hip joint was 3.1%, which is higher than the prevalence of hip arthroplasty in the United States general population, suggesting that a history of septic arthritis may increase the risk of requiring hip arthroplasty. In the small number of patients who went on to receive a hip replacement, there were no reported cases of PJI. This study suggests that hip arthroplasty is a viable option for patients with symptomatic osteoarthritis and a history of septic arthritis of their hip.

Simultaneous, Ipsilateral Distal Biceps and Distal Triceps Rupture in Healthy Weight Lifter: A Case Report.

CASE: A 38-year-old weight lifter presented with a complete distal biceps rupture with retraction and a near complete ipsilateral distal triceps tear sustained during the bench press exercise. The tendons were fixed operatively using a simultaneous posterior and anterolateral approach to the elbow. CONCLUSION: Simultaneous, ipsilateral distal biceps and distal triceps tendon injury is a rare occurrence that leads to significant functional loss. Repair of distal biceps rupture using a single-incision technique with a cortical button and distal triceps using a double-row suture anchor repair was successful in restoring functional anatomy to our patient.

Return to Golf Following Reverse Total Shoulder Arthroplasty.

BACKGROUND: The object of this study was to examine return to golf and changes in golf performance after shoulder arthroplasty. Additionally, we set out to determine if there were differences in return to play and performance between total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). We also examined pain during the golf swing to determine if there is a change in pain level after surgery. METHODS: Patients were identified using a Current Procedural Terminology code 23472 search for TSA. A 19-question online survey was sent out to each patient with questions detailing golfing performance and pain during the swing before and after surgery. Comparisons were made to determine differences in pain, performance and enjoyment between TSA and RTSA groups before and after surgery. RESULTS: A total of 586 patients who underwent shoulder arthroplasty were sent the online survey via email. Of those patients, 33 identified themselves as golfers and who responded to the survey, resulting in an overall response rate of 5.6%. Twenty-three of 31 (74%) patients were able to return to golf following their procedure. Overall, the respondents who reported pain associated with golfing activity had significantly decreased pain after undergoing either TSA or RTSA. The RTSA group had a significant drop in driving distance following the procedure and this was significantly lower than the postoperative driving distance in the TSA group, despite an insignificant preoperative difference. CONCLUSION: Overall, TSA offers a safe and effective means for reducing pain during the golf swing in patients suffering from advanced shoulder osteoarthritis. While there were no significant changes in performance following TSA, individuals undergoing RTSA can be counseled that they are at risk for lower driving distances due to altered mechanics. Overall, patients were satisfied with their procedure and their ability to return to the golf course.

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.

Does the use of periarticular anesthetic cocktail provide adequate pain control following shoulder arthroplasty?

BACKGROUND: Interscalene nerve block and liposomal bupivacaine have been found to provide adequate pain control following shoulder arthroplasty. We hypothesized that local infiltration of a periarticular cocktail would provide equivalent pain control compared to interscalene nerve block and liposomal bupivacaine. METHODS: Eighty-seven patients undergoing primary shoulder arthroplasty were treated with local infiltration of a periarticular cocktail (200 mg of 0.5% ropivacaine, 1 mg epinephrine, and 30 mg ketorolac), local infiltration of liposomal bupivacaine, or preoperative interscalene nerve block. The outcomes of the study were postoperative visual analog scale scores, opioid consumption, length of stay, and complications. RESULTS: A total of 30 patients receiving local infiltration of a periarticular cocktail, 26 receiving liposomal bupivacaine, and 31 receiving interscalene nerve block were included in the study. Patients who received local infiltration of a periarticular cocktail had a significantly lower mean visual analog scale when compared to interscalene nerve block and liposomal bupivacaine on postoperative day 0 (2.5 versus 4.0 versus 4.8, P = 0.001 and P < 0.001). Pain scores between postoperative day 0-3 were lower in patients who received local infiltration of a periarticular cocktail, but not significantly. Patients who received local infiltration of a periarticular cocktail required significantly less opioids than the interscalene nerve block group on postoperative day 0 (P < 0.001). DISCUSSION: A decrease in early postoperative pain and opioid consumption was found with local infiltration of a periarticular cocktail when compared with interscalene nerve block and liposomal bupivacaine after shoulder arthroplasty.Level of evidence: Level II.

Can We Eliminate Opioids After Anterior Cruciate Ligament Reconstruction? A Prospective, Randomized Controlled Trial.

BACKGROUND: Multimodal pain protocols have been effective for postsurgical pain control; however, no published protocol has been effective in eliminating opioid consumption. PURPOSE: To compare a multimodal nonopioid pain protocol versus traditional opioid medication for postoperative pain control in patients undergoing anterior cruciate ligament reconstruction (ACLR). STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 90 patients undergoing primary ACLR were assessed for participation. We performed a prospective, randomized controlled trial in accordance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement. The study arms were a multimodal nonopioid analgesic protocol (acetaminophen, ketorolac, diazepam, gabapentin, and meloxicam) and a standard opioid regimen (hydrocodone-acetaminophen), and the primary outcome was postoperative visual analog scale (VAS) pain scores for 10 days. Secondary outcomes included patient-reported outcomes, complications, and satisfaction. The observers were blinded, and the patients were not blinded to the intervention. RESULTS: A total of 9 patients did not meet inclusion criteria, and 19 patients declined participation. Thus, 62 patients were analyzed, with 28 patients randomized to the opioid group and 34 to the multimodal nonopioid group. Patients receiving the multimodal nonopioid pain regimen demonstrated significantly lower VAS scores compared with patients who received opioid pain medication (P < .05). Patients were administered the Patient-Reported Outcomes Measurement and Information System Pain Interference Short Form, and no significant difference was found in patients' preoperative scores (opioid group, 58.6 ± 7.9; multimodal nonopioid group, 57.5 ± 7.4; P = .385) and 1-week postoperative scores (opioid group, 66.3 ± 8.2; multimodal nonopioid group, 61.4 ± 8.8; P = .147). When we adjusted for possible confounders (age, sex, body mass index, graft type), no significant differences in pain control were found between the 2 groups. The most common adverse effects for both groups were drowsiness and constipation, with no difference between the groups. All patients in the multimodal nonopioid group reported satisfactory pain management. CONCLUSIONS: A multimodal nonopioid pain protocol provided at least equivalent pain control compared with traditional opioid analgesics in patients undergoing ACLR. Minimal side effects, which did not differ between groups, were noted, and all patients reported satisfaction with their pain management.

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.

Open Acromioclavicular Joint Reconstruction With Semitendinosus Allograft Utilizing the Cerclage Technique.

Acromioclavicular (AC) joint injuries most commonly occur in young males after a direct injury at the acromion. General consensus stresses nonoperative treatment for type I and II injuries and surgical treatment for types IV through VI, whereas management of type III injuries is more controversial. If surgery is indicated, there are multiple techniques including hook plate, screw fixation, coracoclavicular fixation, and anatomic and nonanatomic reconstruction. The overall complication rate is high (14%), regardless of technique. In this Technical Note, we outline a technique for open repair of a chronic AC joint separation using a semitendinosus allograft using the cerclage for enhanced fixation.

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.

Using Patient-Reported Outcome Measurement Information System Computer Adaptive Testing Domains to Investigate the Impact of Obesity on Physical Function, Pain Interference, and Mental Health in Sports Medicine Patients.

BACKGROUND: While obesity has become an increasingly prevalent health concern in the United States, little emphasis has been placed on utilizing patient reported outcome measures (PROM) to investigate its impact on life from the patients' perspective. The purpose of the study was to determine the association between patients' body mass index (BMI) and three Patient-Reported Outcome Measurement Information System (PROMIS) computer adaptive test scores: upper extremity physical function (UE) or lower extremity physical function (PF), pain interference (PI), and depression (D). METHODS: Patients were recruited from two sports medicine orthopedic surgery clinics. PROMIS questionnaires were administered to patients arriving for their first visit. Patients were stratified into BMI groupings according to the National Institute of Health standards. Patients' BMI, sex, race, ethnicity, and injury were determined retroactively. Data were analyzed using a Pearson correlation and a least significant difference post hoc test. RESULTS: A total of 833 patients completed the set of PROMIS questionnaires that were retrospectively analyzed. BMI was found to have a correlation with PROMIS-UE (R=-0.111, P<0.05), PROMIS-PF (R=-0.174, P<0.01), PROMIS-PI (R=0.224, P<0.01), and PROMIS-D (R=0.092, P<0.05). Obese patients also portrayed the worst PROMIS-UE, PROMIS-PI, and PROMIS-PF. CONCLUSION: We found BMI to correlate with each PROMIS domain: negatively with PROMIS-UE, PROMIS-PF, PROMIS-D, and positively with PROMIS-PI. Additionally, overweight and obese BMI patients portrayed worse physical function and pain interference scores than their healthy group counterparts.