Pearls and pitfalls of PROMIS clinically significant outcomes in orthopaedic surgery.

INTRODUCTION: Patient-Reported Outcome Measurement Information System (PROMIS) was developed as a uniform and generalizable PROM system using item response theory and computer adaptive testing. We aimed to assess the utilization of PROMIS for clinically significant outcomes (CSOs) measurements and provide insights into its use in orthopaedic research. MATERIALS AND METHODS: We reviewed PROMIS CSO reports for orthopaedic procedures via PubMed, Cochrane Library, Embase, CINAHL, and Web of Science from inception to 2022, excluding abstracts and missing measurements. Bias was assessed using the Newcastle-Ottawa Scale (NOS) and questionnaire compliance. PROMIS domains, CSO measures, and study populations were described. A meta-analysis compared distribution and anchor-based MCIDs in low-bias (NOS ≥ 7) studies. RESULTS: Overall, 54 publications from 2016 to 2022 were reviewed. PROMIS CSO studies were observational with increasing publication rates. Evidence-level was II in 10/54, bias low in 51/54, and compliance ≥ 86% in 46/54. Most (28/54) analysed lower extremity procedures. PROMIS domains examined Pain Function (PF) in 44/54, Pain Interference (PI) in 36/54, and Depression (D) in 18/54. Minimal clinically important difference (MCID) was reported in 51/54 and calculated based on distribution in 39/51 and anchor in 29/51. Patient acceptable symptom state (PASS), substantial clinical benefit (SCB), and minimal detectable change (MDC) were reported in ≤ 10/54. MCIDs were not significantly greater than MDCs. Anchor-based MCIDs were greater than distribution based MCIDs (standardized mean difference = 0.44, p < 0.001). CONCLUSIONS: PROMIS CSOs are increasingly utilized, especially for lower extremity procedures assessing the PF, PI, and D domains using distribution-based MCID. Using more conservative anchor-based MCIDs and reporting MDCs may strengthen results. Researchers should consider unique pearls and pitfalls when assessing PROMIS CSOs.

The meniscotibial ligament role in meniscal extrusion: a systematic review and meta-analysis.

INTRODUCTION: The meniscotibial ligament (MTL) limits extrusion of the medial meniscus (MM). While meniscal extrusion may be detrimental to knee joint biomechanics, the role of the MTL in meniscal extrusion is debatable. We sought to perform a systematic review and meta-analysis to evaluate the role of the MTL and surgical techniques for MTL repair. MATERIALS AND METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines we searched PubMed, Cochrane Library, and Embase for: (("Meniscotibial") OR ("Coronary") OR ("Ramp")) AND ("Extrusion"). After screening and applying eligibility criteria, data were extracted for MTL pathology types ("traumatic" ruptures or "induced" injuries) and meniscal extrusion. A meta-analysis evaluated the mean difference of extrusion between "intact" MTLs (native or repaired) and "injured" MTLs (induced or traumatic). We further performed a subgroup analysis between traumatic and induced MTL lesions. RESULTS: This systematic review included six studies, which all evaluated MM extrusion. There were 74 knees with induced MTL injuries and 19 knees with traumatic MTL ruptures. Study designs were heterogenic and utilized three types of MTL repair procedures. The meta-analysis included 18 human knees and revealed that sectioning the MTL created a 2.92 mm [- 0.18 to 6.03] MM extrusion, while MTL repair decreased MM extrusion by - 2.11 mm [- 3.03 to - 1.21]. CONCLUSIONS: MTL injury may result in approximately 3 mm of MM extrusion, while repair of the MTL can decrease extrusion by 2 mm. Several novel surgical techniques exist to repair the MTL. However, studies reporting clinical outcomes of these various procedures are scarce.

Disparities in trauma care education: An observational study of the ATLS course within a national trauma system.

BACKGROUND: Disparities in trauma systems, including gaps between trauma center levels, affect patient outcomes. Advanced Trauma Life Support (ATLS) is a standard method of care that improves the performance of lower-level trauma systems. We sought to study potential gaps in ATLS education within a national trauma system. METHODS: This prospective observational study examined the characteristics of 588 surgical board residents and fellows taking the ATLS course. The course is required for board certification in adult trauma specialties (general surgery, emergency medicine, and anesthesiology), pediatric trauma specialties (pediatric emergency medicine and pediatric surgery), and trauma consulting specialties (all other surgical board specialties). We compared the differences in course accessibility and success rates within a national trauma system which includes seven level 1 trauma centers (L1TC) and twenty-three non-level 1 hospitals (NL1H). RESULTS: Resident and fellow students were 53% male, 46% employed in L1TC, and 86% were in the final stages of their specialty program. Only 32% were enrolled in adult trauma specialty programs. Students from L1TC had a 10% higher ATLS course pass rate than NL1H (p = 0.003). Trauma center level was associated with higher odds to pass the ATLS course, even after adjustment to other variables (OR = 1.925 [95% CI = 1.151 to 3.219]). Compared to NL1H, the course was two-three times more accessible to students from L1TC and 9% more accessible to adult trauma specialty programs (p = 0.035). The course was more accessible to students at early levels of training in NL1H (p < 0.001). Female students and trauma consulting specialties enrolled in L1TC programs were more likely to pass the course (OR = 2.557 [95% CI = 1.242 to 5.264] and 2.578 [95% CI = 1.385 to 4.800], respectively). CONCLUSIONS: Passing the ATLS course is affected by trauma center level, independent of other student factors. Educational disparities between L1TC and NL1H include ATLS course access for core trauma residency programs at early training stages. Some gaps are more pronounced among consulting trauma specialties and female surgeons. Educational resources should be planned to favor lower-level trauma centers, specialties dealing in trauma care, and residents early in their postgraduate training.

Exploring the characteristics of successful prehospital trauma care teams: Insights from military trauma care simulations.

BACKGROUND: Trauma care teams play a crucial role in determining the outcomes of trauma victims. The composition and training of these teams can vary. Our study seeks to examine the characteristics of successful military Advanced Life Support (ALS) teams and the factors that affect them. METHODS: A retrospective study was conducted at the Israel Defense Force (IDF) Military Medical Academy throughout 2021, where prehospital medical teams were observed in trauma care simulations. Teams were led by ALS providers (military physicians or paramedics) trained in IDF Military Trauma Life Support. Demographic and training data were collected. Teams were categorized into high or subpar performance groups based on simulation scores. Specific skills were assessed by trauma instructors using a points system. Scores were compared between the groups and analyzed for correlations with demographic and training data. RESULTS: Overall, 63 team simulations were analyzed, with teams led by a military paramedic in 78% of simulations. The mean overall simulation performance was 81% ±6.2, and there were no differences in scores of single or multicasualty simulations. A total 3% of the teams achieved successful results and were more likely to have a paramedic as the ALS provider ( p = 0.028). A sensitivity analysis excluding physicians was conducted and showed that high-performance teams had significantly higher skill assessments for primary survey ( p = 0.004), injury recognition ( p = 0.002), exposure ( p = 0.006), adherence to clinical practice guidelines ( p = 0.032), and medical device use ( p = 0.002). CONCLUSION: Our study found that ALS provider is associated with overall simulation performance in prehospital ALS teams, with military paramedics more likely to be successful. These findings have implications for the training and staffing of prehospital ALS teams, suggesting that teams should be composed accordingly and that training should focus on skills affected by the ALS provider type. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Succeeding in Continuing Trauma Education During a Pandemic.

BACKGROUND: Corona virus disease 2019 (Covid-19) impacted continuing medical education programs such as the Advanced Trauma Life Support (ATLS) course. Modifications made to medical training like teleconferencing could affect students' learning success. We sought to evaluate the effects of the American College of Surgeons modifications on success rates in passing the ATLS course. METHODS: This study evaluated 28 ATLS 10th edition courses educating 898 students at our region before and after Covid-19 modifications. Traditional two-day courses were performed in-person while modified courses were conducted with a one-day teleconference followed by a second in-person practical day. We compared the characteristics and course pass rates between the traditional and modified ATLS courses. RESULTS: Modified ATLS courses had significantly lower pass rates (81.0%; 95% confidence interval = [74.8-87.3]) compared to traditional ATLS courses (94.3%; [92.2-96.3]). CONCLUSIONS: Modifications to the ATLS course are associated with lower student pass. This is possibly due to ineffective knowledge consolidation. Better modifications to the course are required such as use of electronic learning tools with modification to course schedule or returning to the traditional course but with the use of Covid-19 vaccines and other protective measures. These suggestions should be considered and evaluated further by ATLS program leaders.

The impact of body mass index on the accuracy of the physical examination of the knee.

PURPOSE: Obesity is a worldwide pandemic; however, no adaptations were made to the physical examination of obese patient's knees. The accuracy of the physical examination is critical for correct assessment and selection of treatment. We aimed to assess whether body mass index (BMI) affects the sensitivity and specificity of common provocative knee tests. METHODS: We studied 210 patients who underwent knee arthroscopy to treat anterior cruciate ligament (ACL) and meniscal pathologies. BMI and the knee's physical examination were documented pre-operatively. Sensitivity, specificity, and accuracy of ACL and meniscal provocative tests in relation to BMI were evaluated using arthroscopy as a gold standard. RESULTS: The Anterior Drawer, Lachman, and Pivot-Shift tests for ACL tears were significantly less accurate and sensitive, yet more specific, in obese patients when compared to normal and overweight patients. The McMurray, Apley Grind, and Thessaly tests for medial meniscus tears showed greater sensitivity, but lower specificity, in patients with increased BMI. Above normal BMIs, independently of age and gender, were significantly associated with higher odds for positive ACL tests. CONCLUSION: Tests for ACL tears are less sensitive in obese patients and alternatives to the classic tests should be considered. Medial meniscus tests tend to be more sensitive and less specific in patients with greater BMIs. Their results should be carefully interpreted due to possible false positives. The physician should take into consideration the impact of patient BMI on the accuracy of their physical examination of the knee to optimize treatment decision-making.