Brenda Chang

What Change in American Shoulder and Elbow Surgeons Score Represents a Clinically Important Change After Shoulder Arthroplasty

BackgroundThe American Shoulder and Elbow Surgeons (ASES) questionnaire was developed to provide a standardized method for evaluating shoulder function. Previous studies have determined the clinical responsiveness of this outcome measure for heterogenous populations or patients with nonoperatively treated rotator cuff disease. Currently, to our knowledge, no studies exist that establish the clinically relevant change in the ASES score after shoulder arthroplasty.Questions/purposesWe asked: (1) What are the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the ASES score after primary and reverse shoulder arthroplasties? (2) Are the MCID and SCB for the ASES score different between primary and reverse shoulder arthroplasties? (3) What patient-related factors are associated with achieving the MCID and SCB after total shoulder arthroplasty and reverse shoulder arthroplasty?MethodsA longitudinally maintained institutional shoulder arthroplasty registry was retrospectively queried for patients who underwent primary shoulder arthroplasty, including anatomic or reverse total shoulder arthroplasty from 2007 to 2013, with a minimum 2-year followup. Seven hundred ninety-four patients were identified and eligible; 304 of these patients did not have 2 years of followup or complete datasets, resulting in a study cohort of 490 patients (62% of the 794 potentially eligible). The MCID and SCB of the ASES score for these patients was calculated using an anchor-based method, using four different anchors measuring satisfaction with work, activities, overall, and activity from the SF-36. The MCID (anchored to somewhat satisfied) and SCB (very satisfied) of the ASES score were calculated for the entire cohort and stratified by arthroplasty type. Multivariate logistic regression of patient-related factors that influence the MCID and SCB achievement was performed.ResultsThe MCID for all patients combined ranged from 6.3 to 13.5; for the overall satisfaction anchor, the MCID was 13.5 ± 4.5 (95% CI, 4.8–22.3). The SCB for the overall cohort ranged from 12.0 to 36.6; for the overall satisfaction anchor, the SCB was 36.6 ± 3.8 (95% CI, 29.1–44.1). There were no differences in the MCID of the ASES score between anatomic and reverse shoulder arthroplasty for any of the anchors (p = 0.159–0.992) or the SCB for any of the anchors (p = 0.467–0.977). Combining anatomic and reverse shoulder arthroplasty in one group, higher preoperative ASES score (odds ratio [OR], 0.96; 95% CI, 0.94–0.98; p < 0.001), having a reverse shoulder arthroplasty (OR, 0.36; 95% CI, 0.16–0.85; p = 0.016), and having rheumatoid arthritis were independent predictors of not achieving an MCID for the ASES 2 years after surgery. Higher preoperative ASES score (OR, 0.91; 95% CI, 0.89–0.92; p < 0.001), a diagnosis of rotator cuff tear arthropathy (OR, 0.14; 95% CI, 0.07–0.30; p < 0.001), a diagnosis of back pain (OR, 0.42; 95% CI, 0.24–0.71); p = 0.002), and living alone (OR, 0.36; 95% CI, 0.19–0.69; p = 0.002) were all independent predictors of not achieving SCB after shoulder arthroplasty.ConclusionsPatients with glenohumeral arthritis or rotator cuff tear arthropathy who undergo primary conventional total or reverse shoulder arthroplasty and have at least a nine-point improvement in their ASES score experience a clinically important change, whereas those who have at least a 23-point improvement in their ASES score experience a substantial clinical benefit. High preoperative function was associated with a decreased likelihood of achieving clinically important change after total shoulder arthroplasty.Level of EvidenceLevel III, therapeutic study.

Preoperative Outcome Scores Are Predictive of Achieving the Minimal Clinically Important Difference After Arthroscopic Treatment of Femoroacetabular Impingement

Background: There is increasing interest in defining meaningful improvement in patient-reported outcomes. Knowledge of the thresholds and determinants for successful femoroacetabular impingement (FAI) outcomes is evolving. Purpose: To define preoperative outcome score thresholds and determine clinical/demographic patient factors predictive for achieving the minimal clinically important difference (MCID) after arthroscopic FAI surgery. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A prospective institutional hip preservation registry was reviewed to identify patients undergoing arthroscopic FAI surgery. The modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS), and the international Hip Outcome Tool (iHOT-33) were administered at baseline and 1 year postoperatively. The MCID was calculated using a distribution-based method. Receiver operating characteristic (ROC) analysis was used to calculate cohort-based threshold values predictive of achieving the MCID. The area under the curve (AUC) was used to define predictive ability, with AUC >0.7 considered acceptably predictive. Multivariable analysis identified patient factors associated with achieving the MCID. Sensitivity analysis was performed to derive the MCID by an alternative anchor-based method. Results: There were 364 patients (mean [±SD] age, 32.5 ± 10.3 years), and 57.1% were female. The MCID for the mHHS, HOS–Activities of Daily Living (HOS-ADL), HOS-Sports, and iHOT-33 was 8.2, 8.3, 14.5, and 12.1, respectively. ROC analysis findings (threshold, percentage achieving the MCID, and strength of association) for these tools were as follows: mHHS (60.5, 77.2%, and 0.68, respectively), HOS-ADL (83.3, 68.1%, and 0.85, respectively), HOS-Sports (58.3, 65.9%, and 0.76, respectively), and iHOT-33 (53.9, 81.9%, and 0.65, respectively). The likelihood for achieving the MCID significantly declined above these thresholds. In multivariable analysis, a higher sagittal center-edge angle (CEA) (odds ratio [OR], 1.04; 95% CI, 1.01-1.08) was a positive predictor of achieving the MCID on the iHOT-33, while a higher Outerbridge grade for the acetabulum was a negative predictor (OR, 0.56; 95% CI, 0.32-0.99) on the mHHS. Sensitivity analysis confirmed these variables and identified relative femoral retroversion as another negative predictor (OR, 0.40; 95% CI, 0.17-0.94). Conclusion: The HOS had excellent predictive ability for identifying patient thresholds of achieving the MCID; patients with preoperative scores below identified thresholds were most likely to achieve the MCID. Additionally, anterior acetabular undercoverage, chondral injuries, and relative femoral retroversion were clinically significant negative modifiers of outcomes. These findings have implications for managing preoperative expectations of FAI surgery.

Defining the “Substantial Clinical Benefit” After Arthroscopic Treatment of Femoroacetabular Impingement

Background: The minimal clinically important difference (MCID) has been defined in orthopaedics and is the smallest change that a patient considers meaningful. Less is known about improvements that the patient perceives as clinically considerable, or the substantial clinical benefit (SCB). For the young, highly functioning patient cohort with femoroacetabular impingement (FAI), the SCB is an important measure of clinical success. Purpose: To derive the SCB for FAI treatment and identify outcome score thresholds and patient variables predictive of the SCB. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The modified Harris Hip Score (mHHS), the Hip Outcome Score activities of daily living (HOS-ADL) and sport (HOS-Sport) subscales, and the international Hip Outcome Tool (iHOT-33) were prospectively administered to 364 patients with a minimum 1-year follow-up. At 1 year postoperatively, patients graded their hip function based on several anchor responses such as “no change” and “much improved.” The SCB was defined as the change on each outcome tool that equated to the difference between “no change” and “much improved” on the health transition question. Receiver operating characteristic analysis with area under the curve (AUC) was used to identify optimal values that were most representative of the SCB. Multivariable analysis identified patient variables predictive of the SCB. Results: The net change in outcome scores corresponding to the SCB for the mHHS, HOS-ADL, HOS-Sport, and iHOT-33 was 19.8, 10.0, 29.9, and 24.5, respectively. The following postoperative outcome scores demonstrated excellent distinction (AUC >0.8) between “no change” and “much improved” and thus were considered absolute values for the postoperative SCB: 82.5 (mHHS), 93.3 (HOS-ADL), 84.4 (HOS-Sport), and 63.5 (iHOT-33). Preoperative scores on the HOS-ADL (83.3) and HOS-Sport (50.0) were significant threshold cutoffs, above which attaining the SCB became less likely. Younger age and lower Outerbridge grade were predictive of achieving the SCB. Conclusion: The SCB has not been previously defined in the hip preservation literature and is complementary to the MCID as the upper bound for clinically significant improvement. We identified predictive preoperative and diagnostic postoperative outcome scores for the SCB that can be used to manage patient expectations and grade outcomes. These findings are objective criteria for defining clinical success after arthroscopic FAI treatment.

Rating a Sports Medicine Surgeon’s “Quality” in the Modern Era: an Analysis of Popular Physician Online Rating Websites

BackgroundConsumer-driven healthcare and an increasing emphasis on quality metrics have encouraged patient engagement in the rating of healthcare. As such, online physician rating websites have become mainstream and may play a potential role in future healthcare policy.Questions/PurposesThe purpose of this study was to evaluate online patient ratings for US sports medicine surgeons, determine predictors of positive ratings and analyze for inter-website scoring correlation.MethodsThe American Orthopedic Society for Sports Medicine (AOSSM) member directory was sampled. Surgeon demographic and rating data were searched on three online physicians rating websites: HealthGrades.com (HG), RateMDs.com (RM) and Vitals.com (V). Written rating comments were categorized as relating to the following: surgeon competence, surgeon affability and process of care. Bivariate linear regression, Pearson correlation and multivariable analyses were used to determine factors associated with positive ratings.ResultsTwo hundred seventy-five sports medicine surgeons were included. Two hundred seventy-one (99%) had ratings on at least one of the three websites. Sports surgeons were rated highly across all three websites (mean >4.0/5); however, there was only a low to moderate degree of correlation among websites. On HG, female surgeons and surgeons in academia were more likely to receive higher overall ratings. Across all three websites, increased number of years in practice inversely correlated with ratings; this relationship neared significance for HG and was significant for RM. A surgeon’s online presence or geographic location was not associated with higher ratings. In multivariable regression analysis for ratings on HG, female sex was the only significant predictor of higher ratings. Two thousand three hundred forty-one written comments were analyzed: perceived surgeon competence and communication influenced the direction of ratings for the top and bottom tier surgeons.ConclusionThere was a low degree of correlation among online websites for surgeon ratings. Female surgeons and those with fewer years in practice appear to have higher ratings on these websites; comment content analysis suggests that high and low ratings are influenced by perceived surgeon competence and affability.

Depression and Patient-Reported Outcomes Following Total Shoulder Arthroplasty.

Background: Recent studies have found that depression is associated with increased pain and impairment following lower-extremity arthroplasty; however, this association has not been investigated for total shoulder arthroplasty. The objective of this study was to investigate the association between depression and patient-reported outcomes following total shoulder arthroplasty. Methods: A prospectively collected institutional registry was queried for consecutive patients who underwent total shoulder arthroplasty for osteoarthritis from 2007 to 2013 with baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores. Revision procedures and total shoulder arthroplasty for diagnoses other than osteoarthritis were excluded. Patients with a preoperative diagnosis of depression (n = 88) formed the study cohort; control patients without a diagnosis of depression were matched to the study patients by age and sex in a 2:1 ratio (n = 176). Baseline characteristics and patient-reported outcome measures were compared between groups, as were minimum 2-year patient-reported outcomes and change in patient-reported outcomes. A multivariable regression was performed to investigate the independent effect of depression on improvement in ASES scores. Results: Except for the Short Form-12 Mental Component Summary (SF-12 MCS) scores, there were no significant differences (p > 0.05) in baseline characteristics between study patients and controls. There was a significant improvement in the ASES score for patients with depression (p < 0.0001) and controls (p < 0.0001). Patients with depression had significantly lower final ASES scores (p = 0.001) and less improvement in ASES scores (p = 0.001) and SF-12 Physical Component Summary scores (p = 0.006) as well as lower satisfaction levels at 2 years; however, the latter difference did not reach clinical importance. Depression (p = 0.018) was an independent predictor of less improvement in ASES scores. Conclusions: Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty. A preoperative diagnosis of depression is an independent predictor of significantly less improvement in ASES scores following total shoulder arthroplasty; however, this difference does not reach clinical importance and should not discourage patients with a clinical diagnosis of depression from undergoing total shoulder arthroplasty. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Return to play and patient satisfaction after ACL reconstruction

Background: Return to play and patient satisfaction after anterior cruciate ligament reconstruction (ACLR) have been inconsistently studied. The purposes of this study were to (1) investigate rates and predictors of return to play after ACLR, (2) evaluate patient satisfaction after ACLR, and (3) analyze the relationship between return to play and satisfaction with the result of ACLR. Methods: Eligible patients were active athletes included in an institutional ACL registry who had undergone ACLR and had been followed for a minimum of 2 years. A questionnaire was administered to elicit information regarding factors associated with return to play, sports performance, reinjury, and overall patient satisfaction. The Wilcoxon-Mann-Whitney U test was used to compare return to play with patient satisfaction. Multivariable logistic regression was used to identify demographic, sports, and clinical factors associated with return to play. Results: Two hundred and thirty-two patients with a mean age of 26.7 years (standard deviation [SD] = 12.5 years) who had been followed for a mean of 3.7 years were enrolled. Of 231 patients who responded to the return-to-play question, 201 (87.0%) had returned to play, at a mean of 10.1 months; of 175 athletes eligible to return to their prior level of competition, 89.1% had done so. Overall satisfaction was high: 85.4% were very satisfied with the outcome and 98.1% stated that they would have surgery again. Patients were more likely to respond “very satisfied” if they had returned to play (p < 0.001). Use of a patellar tendon autograft (odds ratio [OR] = 5.63, 95% confidence interval [CI] = 1.32 to 25.76) increased the chance of returning to play whereas playing soccer (OR = 0.23, 95% CI = 0.08 to 0.66) or lacrosse (OR = 0.24, 95% CI = 0.06 to 0.99) preoperatively decreased the likelihood of returning to play. Conclusions: The rates of return to play and patient satisfaction are high after ACLR in active athletes. The use of patellar tendon autograft increased the likelihood of returning to play whereas preinjury participation in soccer and lacrosse decreased these odds. Additionally, patients who returned to play were more likely to be very satisfied with the result of the ACLR. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Preoperative Short Form Health Survey Score Is Predictive of Return to Play and Minimal Clinically Important Difference at a Minimum 2-Year Follow-up After Anterior Cruciate Ligament Reconstruction:

Background: There is increased interest in understanding the preoperative determinants of postoperative outcomes. Return to play (RTP) and the patient-reported minimal clinically important difference (MCID) are useful measures of postoperative outcomes after anterior cruciate ligament reconstruction (ACLR). Purpose: To define the MCID after ACLR and to investigate the role of preoperative outcome scores for predicting the MCID and RTP after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: There were 294 active athletes enrolled as part of an institutional ACL registry with a minimum 2-year follow-up who were eligible for inclusion. A questionnaire was administered to elicit factors associated with RTP. Patient demographic and clinical data as well as patient-reported outcome measures were captured as part of the registry. Outcome measures included the International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm scale, and 12-Item Short Form Health Survey (SF-12) physical component summary (PCS) and mental component summary (MCS). Preoperative outcome score thresholds predictive of RTP were determined using a receiver operating characteristic (ROC) with area under the curve (AUC) analysis. The MCID was calculated using a distribution-based method. Multivariable logistic models were fitted to identify predictors for achieving the MCID and RTP. Results: At a mean (±SD) follow-up of 3.7 ± 0.7 years, 231 patients were included from a total 294 eligible patients. The mean age and body mass index were 26.7 ± 12.5 years and 23.7 ± 3.2 kg/m2, respectively. Of the 231 patients, 201 (87.0%) returned to play at a mean time of 10.1 months. Two-year postoperative scores on all measures were significantly increased from preoperative scores (IKDC: 50.1 ± 15.6 to 87.4 ± 10.7; Lysholm: 61.2 ± 18.1 to 89.5 ± 10.4; SF-12 PCS: 41.5 ± 9.0 to 54.7 ± 4.6; SF-12 MCS: 53.6 ± 8.1 to 55.7 ± 5.7; P < .001 for all). The corresponding MCID values were 9.0 (IKDC), 10.0 (Lysholm), 5.1 (SF-12 PCS), and 4.3 (SF-12 MCS). Preoperative score thresholds predictive of RTP were the following: IKDC, 60.9; Lysholm, 57.0; SF-12 PCS, 42.3; and SF-12 MCS, 48.3. These thresholds were not independently predictive but achieved significance as part of the multivariable analysis. In the multivariable analysis for RTP, preoperative SF-12 PCS scores above 42.3 (odds ratio [OR], 2.73; 95% CI, 1.09-7.62) and SF-12 MCS scores above 48.3 (OR, 4.41; 95% CI, 1.80-10.98) were predictive for achieving RTP; an ACL allograft (OR, 0.26; 95% CI, 0.06-1.00) was negatively predictive of RTP. In the multivariable analysis for the MCID, patients with higher preoperative scores were less likely to achieve the MCID (P < .0001); however, a higher preoperative SF-12 MCS score was predictive of achieving the MCID on the IKDC form (OR, 1.27; 95% CI, 1.11-1.52) and Lysholm scale (OR, 1.08; 95% CI, 1.00-1.16). Medial meniscal injuries, older age, and white race were also associated with a decreased likelihood for achieving the MCID. Conclusion: Preoperative SF-12 MCS and PCS scores were predictive of RTP after ACLR; patients scoring above 42.3 on the SF-12 PCS and 48.3 on the SF-12 MCS were more likely to achieve RTP. Additionally, we defined the MCID after ACLR and found that higher SF-12 MCS scores were predictive of achieving the MCID on knee-specific questionnaires.

Outcomes for Arthroscopic Treatment of Anterior Inferior Iliac Spine (Subspine) Hip Impingement

Background: Femoroacetabular hip impingement (FAI) is now well recognized; however, anterior inferior iliac spine (AIIS; or subspine) impingement is a form of hip impingement that is underrecognized and can be an important source of hip disability and functional limitation. Purpose: To investigate the outcomes after arthroscopic treatment of AIIS/subspine-related hip impingement in the absence of FAI surgery. Study Design: Case series; Level of evidence, 4. Methods: A prospective institutional hip preservation registry was reviewed to identify patients who underwent arthroscopic AIIS decompression without concurrent treatment of FAI. Primary outcome tools captured in the registry included the modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS), and the International Hip Outcome Tool–33 (iHOT-33). Patients with minimum 1-year follow-up were included. Meaningful outcome improvement was determined per minimal clinically important difference (MCID). Statistical analyses were primarily descriptive. Results: Thirty-three patients with a mean follow-up of 19.1 months (range, 12-44 months) were identified. All patients were female, with a mean ± SD age of 26.1 ± 10.3 years. All patients were found to have an associated labral tear, and the mean acetabular version was increased at 2 and 3 o’clock (14.5° and 19.8°, respectively). Mean preoperative outcome scores on the mHHS, HOS ADL (activities of daily living), HOS sport, and iHOT-33 were 57.2 ± 15.3, 66.9 ± 18.8, 43.9 ± 23.6, and 33.5 ± 18.3, respectively. At final available follow-up, mean scores on these outcome measures were 79.5 ± 19.0, 86.8 ± 15.8, 70.4 ± 32.8, and 65.0 ± 31.0, respectively. By the 1-year follow-up, MCID had been achieved in the majority of patients across all 4 tools. Conclusion: There is a paucity of outcomes evidence on AIIS/subspine-related hip impingement. This study demonstrates that isolated subspine impingement can be a cause of hip disability, even in the absence of FAI. Patients with isolated subspine impingement are more likely to be women and to present with low patient-reported outcome scores. However, meaningful outcome improvement can be achieved with arthroscopic AIIS decompression.

Risk of failure of primary hip arthroscopy—a population-based study

Abstract The aims of this study are (i) to report on the rates of subsequent surgery following hip arthroscopy and (ii) to identify prognostic variables associated with revision surgery, survival rates and complication rates. The Statewide Planning and Research Cooperative System database, a census of hospital admissions and ambulatory surgery in New York State, was used to identify cases of primary hip arthroscopy. Demographic information and rates of subsequent revision hip arthroscopy or arthroplasty were collected. The risks were modeled with use of age, sex, procedure and surgeon volume as risk factors. Survival analyses were also performed, and 30-day complication was recorded. We identified 8267 procedures in 7836 patients from 1998 to 2012. Revision surgery occurred in 1087 cases (13.2%) at a mean of 1.7 ± 1.6 (mean ± SD) years. Revision arthroscopy accounted for 311 cases (3.8%), and arthroplasty for 796 (9.7%) cases. Survival analysis showed a 2-year survival rate of 88.1%, 5-year of 80.7% and 10-year of 74.9%. Regression analysis revealed that age >50 years [hazard ratio (HR) 2.09; confidence interval (CI) 1.82–2.39, P < 0.01] and a diagnosis of osteoarthritis (HR 2.72; CI 2.21–3.34, P < 0.01) were associated with increased risk of re-operation. Labral repair was associated with a lower risk of re-operation (HR 0.71; CI 0.54–0.93, P = 0.01). Finally, higher surgeon volume (>164 cases/year) resulted in a lower risk of re-operation versus lower volume (<102 cases/year) (HR 0.42; CI 0.32–0.54, P < 0.01). The 30-day complication rate was 0.2%. Older age and pre-existing osteoarthritis increased the likelihood of re-operation following hip arthroscopy, whereas performing a labral repair and having the procedure performed by a higher-volume surgeon lowered the risk of re-operation.

Outcomes of Patellofemoral Osteochondral Lesions Treated With Structural Grafts in Patients Older Than 40 Years

Background Chondral lesions in the patellofemoral compartment represent a difficult entity to treat among active patients, with no clear consensus on the optimal treatment strategy. The purpose of this study was to review the functional outcomes of patients >40 years old with primary patellofemoral osteochondral lesions who underwent a cartilage restoration procedure with a structural graft. Methods Following institutional review board approval, 35 patients >40 years treated for patellofemoral chondral or osteochondral injuries were retrospectively identified. Seventeen (47%) had prior surgery (mean 1.4 procedures, range 1-4). Average follow-up was 3.6 ± 1.6 years. Average patient age was 51.5 years (range 40-72 years); 54% were male. Twenty-six (74%) had isolated trochlear lesions, 7 had isolated patellar lesions (20%), while 2 (6%) had bipolar lesions. Twenty patients (57%) were treated with synthetic biphasic scaffold plugs (SS), 9 (26%) with fresh osteochondral allograft (OCA) and 6 (17%) with osteochondral autograft transfer (OAT). Outcomes were measured with validated measures: Activity of Daily Living Score (ADL), International Knee Documentation Committee (IKDC) Subjective Evaluation form, and Marx Activity Scale (MAS). Results The average lesion size for the entire cohort was 3.1 ± 1.7 cm2. Average defect size was 2.6 ± 1.7 cm2 for the SS group, 4.3±1.5 cm2 for the OCA group, and 2.9 ± 0.8 cm2 for the OAT group (P > 0.051). Outcome scores for the entire population demonstrated significant improvement in ADL (P = 0.002) and IKDC scores (P = 0.004) between baseline and final follow-up, while MAS scores were maintained (P = 0.51). Conclusion Structural grafts are a viable treatment option for symptomatic focal osteochondral lesions of the patellofemoral joint in patients 40 years and older, with anticipated improvements in pain and function and maintenance of preoperative activity levels.