Surgically-Relevant Quality of Life Thresholds for the Short Inflammatory Bowel Disease Questionnaire in Crohn's disease.

BACKGROUND OR PURPOSE: Despite interest in patient-reported outcome measures to track progression in Crohn's disease, frameworks to apply these questionnaires in the preoperative setting are lacking. Using the short inflammatory bowel disease questionnaire (sIBDQ), this study aimed to describe interpretable quality of life thresholds and examine potential associations with future bowel resection in Crohn's disease. METHODS: Adult Crohn's disease patients completing an sIBDQ at a clinic visit between 2020-2022 were eligible. A stoplight framework was adopted for sIBDQ scores, including a 'Resection Red zone' suggesting poor quality of life that may benefit from discussions about surgery as well as a 'Nonoperative Green' zone. Thresholds were identified with both anchor- and distribution-based methods using receiver operating characteristic curve analysis and subgroup percentile scores, respectively. To quantify associations between sIBDQ scores and subsequent bowel resection, multivariable logistic regression models were fit with covariates of age, sex, body mass index, medications, disease pattern and location, resection history, and the Harvey Bradshaw Index. Incremental discriminatory value of the sIBDQ beyond clinical factors was assessed through area under the receiver operating characteristics curve (AUC) with an internal validation through bootstrap resampling. RESULTS: Of 2003 included patients, 102 underwent Crohn's-related bowel resection. The sIBDQ Nonoperative Green zone threshold ranged from 61 to 64 and the Resection Red zone from 36 to 38. When adjusting for clinical covariates, a worse sIBDQ score was associated with greater odds of subsequent 90-day bowel resection when considered as a one-point (OR [95% CI], 1.05 [1.03-1.07]) or five-point change (OR [95% CI], 1.25 [1.13-1.40]). Inclusion of the sIBDQ modestly improved discriminative performance (AUC [95% CI] 0.85 [0.85 - 0.86]) relative to models that included only demographics (0.57 [0.57 - 0.58]) or demographics with clinical covariates (0.83 [0.83 - 0.84]). DISCUSSION OR CONCLUSION: In the decision-making process for bowel resection, disease-specific patient-reported outcome measures may be useful to identify Crohn's disease patients with poor quality of life and promote shared understanding of personalized burden.

Shared Decision-Making in General Surgery: Prospective Comparison of Telemedicine vs In-Person Visits.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has accelerated a shift toward virtual telemedicine appointments with surgeons. While this form of healthcare delivery has potential benefits for both patients and surgeons, the quality of these interactions remains largely unstudied. We hypothesize that telemedicine visits are associated with lower quality of shared decision-making. STUDY DESIGN: We performed a mixed-methods, prospective, observational cohort trial. All patients presenting for a first-time visit at general surgery clinics between May 2021 and June 2022 were included. Patients were categorized by type of visit: in-person vs telemedicine. The primary outcome was the level of shared decision-making as captured by top box scores of the CollaboRATE measure. Secondary outcomes included quality of shared decision-making as captured by the 9-item Shared Decision-Making Questionnaire and satisfaction with consultation survey. An adjusted analysis was performed accounting for potential confounders. A qualitative analysis of open-ended questions for both patients and practitioners was performed. RESULTS: During a 13-month study period, 387 patients were enrolled, of which 301 (77.8%) underwent in-person visits and 86 (22.2%) underwent telemedicine visits. The groups were similar in age, sex, employment, education, and generic quality-of-life scores. In an adjusted analysis, a visit type of telemedicine was not associated with either the CollaboRATE top box score (odds ratio 1.27; 95% CI 0.74 to 2.20) or 9-item Shared Decision-Making Questionnaire (ß -0.60; p = 0.76). Similarly, there was no difference in other outcomes. Themes from qualitative patient and surgeon responses included physical presence, time investment, appropriateness for visit purpose, technical difficulties, and communication quality. CONCLUSIONS: In this large, prospective study, there does not appear to be a difference in quality of shared decision making in patients undergoing in-person vs telemedicine appointments.

Acetabular Cartilage Lesions Predict Inferior Mid-Term Outcomes for Arthroscopic Labral Repair and Treatment of Femoroacetabular Impingement Syndrome.

PURPOSE: To analyze the effect of acetabular chondrosis at a minimum of 2 years following hip arthroscopy in patients undergoing labral repair and treatment of femoroacetabular impingement. METHODS: From 2014 to 2017, patients undergoing arthroscopic labral repair were prospectively enrolled in a multicenter hip arthroscopy registry. The registry was retrospectively queried for primary labral repair patients with complete 2-year outcomes and a Tonnis grade of less than 2. Patients were grouped according to severity of articular cartilage damage noted intraoperatively using the Beck classification system: none, low-grade (Grade 1 or 2), or high-grade (Grade 3 or 4) damage. A Kruskal-Wallis test and post hoc Dunn's test with Holm correction compared 2-year postoperative outcome scores of the iHOT-12 scale between groups. The proportion of patients in each cohort who achieved the clinically significant thresholds of the minimum clinically important difference (MCID), patient-acceptable symptom scale, and substantial clinical benefit (SCB) were analyzed. Multivariate logistic regression models identified predictors of achieving clinical thresholds while controlling for demographic variation. RESULTS: 422 patients met inclusion criteria, from which 347 completed 2-year outcomes. All groups experienced improvement in iHOT-12 scores from baseline to follow-up (P < .001). iHOT-12 scores at follow-up were inferior for Low-Grade Damage and High-Grade Damage Groups relative to the No Damage Group (P = .04; P = .03). When accounting for age, body mass index, gender, and preoperative iHOT-12 scores in logistic regression models, the presence of high-grade lesions was a negative predictor for achieving SCB (OR [95% CI], 0.54 [0.29-0.96]) and low-grade lesions a negative predictor for achieving MCID (0.50 [0.27-0.92]. Among patients with high-grade lesions, there was no significant difference in 2-year iHOT-12 scores between those undergoing chondroplasty (n = 50) and those undergoing microfracture (n = 14) (P = .14). CONCLUSIONS: Acetabular cartilage damage portends inferior patient-reported outcomes 2 years after primary labral repair and treatment of femoroacetabular impingement. The presence of cartilage lesions was a negative predictor of individual achievement of several clinical thresholds. LEVEL OF EVIDENCE: III, Retrospective comparative cohort.

Cannabinoids in the Orthopedic Setting: A Literature Review.

Public interest in the analgesic potential of cannabinoids has grown, but there is no consensus regarding orthopedic applications. Available evidence was identified for cannabinoid use in arthritis, neuropathic pain, fibromyalgia, multiple sclerosis, and postoperative pain. Extracted information included the risks of preoperative use, associations with opioid dependence, and surgical complications. There is limited evidence for therapeutic benefit of cannabinoids in rheumatoid arthritis and fibromyalgia. Cannabinoids are not indicated for postoperative pain. Preoperative unregulated use has been linked with postoperative opioid dependence. Cannabinoids may be considered a second- or third-line treatment for analgesia for some orthopedic pathologies. [Orthopedics. 2022;45(4):e183-e189.].

Patient-Reported Outcome Measures and Clinically Important Outcome Values in Hip Arthroscopy: A Systematic Review.

BACKGROUND: Defining success in hip arthroscopy through patient-reported outcome measures (PROMs) is complicated by the wide range of available questionnaires and overwhelming amount of information on how to interpret scores. The minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB) are collectively known as clinically important outcome values (CIOVs). These CIOVs provide benchmarks for meaningful improvement. The aims of this review were to update the evidence regarding joint-specific PROMs used for hip arthroscopy and to collate available CIOVs in this population. METHODS: A systematic review of MEDLINE and Embase databases was performed to identify studies reporting measurement properties of PROMs utilized for hip arthroscopy. Metrics of reliability, validity, and responsiveness were extracted and graded according to an international Delphi study. Questionnaire interpretability was evaluated through CIOVs. RESULTS: Twenty-six studies were reviewed. One study validated a novel questionnaire, 3 studies validated existing questionnaires, and 22 studies reported CIOVs. The most evidence supporting interpretability was found for the Hip Outcome Score (HOS, 11 studies), modified Harris hip score (mHHS, 10 studies), and International Hip Outcome Tool-12 (iHOT-12, 9 studies). Scores indicative of the smallest perceptible versus substantial clinically relevant changes were reported for the iHOT-12 (12 to 15 versus 22 to 28), iHOT-33 (10 to 12 versus 25 to 26), HOS-Activities of Daily Living (HOS-ADL, 9 to 10 versus 10 to 16), HOS-Sports (14 to 15 versus 25 to 30), and mHHS (7 to 13 versus 20 to 23). Absolute postoperative scores indicative of an unsatisfactory versus a desirable outcome were reported for the iHOT-12 (below 56 to 63 versus above 86 to 88), iHOT-33 (below 58 versus above 64 to 82), HOS-ADL (below 87 to 92 versus above 94), HOS-Sports (below 72 to 80 versus above 78 to 86), and mHHS (below 74 to 85 versus above 83 to 95). CONCLUSIONS: Six questionnaires had reported clinically important outcome thresholds, with the HOS, mHHS, and iHOT-12 having the most information to support score interpretation. Thresholds for the HOS, mHHS, iHOT-12, and iHOT-33 describe desirable absolute PROM scores and minimum and substantial change scores within 5 years following hip arthroscopy. Despite substantial heterogeneity in calculation methodology, included cohorts, and follow-up time, available interpretability values could be meaningfully summarized. CLINICAL RELEVANCE: In light of increasing use of PROMs in orthopaedics, a summary of the available CIOVs provides guidance for clinicians in mapping numerical scores from PROMs onto clinical benchmarks.

Substantial Loss to Follow-Up and Missing Data in National Arthroscopy Registries: A Systematic Review.

PURPOSE: To report follow-up methodologies, compliance, and existing strategies for handling missing data in national arthroscopy registries collecting patient-reported outcome measures (PROMs). METHODS: Annual reports, EMBASE, and MEDLINE were queried following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to identify national arthroscopy registries reporting follow-up with a validated PROM and sample size greater than 500. Extracted data included weighted compliance in peer-reviewed publications, cumulative compliance throughout the time span of data collection, and missing-data methodologies. RESULTS: Nine national arthroscopy registries currently collect PROMs, with cumulative rates of follow-up ranging from less than 10% to more than 70%. We identified 36 publications from 5 national registries reporting hip and knee arthroscopies. The weighted mean compliance with PROMs in national registry publications was 56% at 0.5 years, 44% to 59% at 1 year, 40% to 61% at 2 years, 35% to 54% at 5 years, and 40% at 10 years. A missing-data analysis was reported or referenced in 58% of publications. CONCLUSIONS: In national arthroscopy registries, compliance with 2-year PROMs does not meet traditional follow-up thresholds of 60% or 80% and reporting of missing-data methodologies is inconsistent. LEVEL OF EVIDENCE: Level IV, systematic review of Level II through IV studies.

Ankle Impingement: A Critical Analysis Review.

Ankle impingement presents with painful and limited range of motion with dorsiflexion or plantar flexion, originating from pathological contact between bone and/or soft-tissue structures. Diagnosis is made primarily through clinical examination with adjunct radiographs and magnetic resonance imaging, with care taken to rule out a plethora of similarly presenting pathologies. Arthroscopic surgical approaches bring satisfactory short, mid, and long-term outcomes, with the current body of evidence dominated by Level-IV studies. Minimally invasive techniques offer improvements in time to return to play and complication rates relative to open approaches. Recent advances in the arthroscopic management of ankle impingement include long-term outcome studies, novel prognostic classification systems, and strategies for concomitant lesion management.

Operative Approaches to Ankle and Hindfoot Arthroscopy.

The role of arthroscopy in the management of ankle and hindfoot pathology management has increased greatly in recent years with the potential for lower complication rates, faster recovery, improved access, and improved outcomes when compared to open techniques. Procedural variations exist as techniques aim to optimize lesion access, decrease operative time, and improve patient safety. Our goal is to summarize the described approaches and patient positionings common in minimally invasive arthroscopic surgery for anterior, lateral, and posterior ankle pathologies. A survey of pathology organized by arthroscopic approach and a review of recent advances in concomitant lesion management may be useful when planning arthroscopic foot and ankle surgery. LEVEL OF EVIDENCE: Level V, expert opinion.