Jason T. Hamamoto

Patient Reported Outcomes Measurement Information System (PROMIS) in the upper extremity: the future of outcomes reporting?

Patient reported outcomes (PROs) serve an integral role in clinical research by helping to determine the impact of clinical care as experienced by the patient. With recent initiatives in health care policy and pay for performance, outcome reporting is now recognized as a policy-driven requirement in addition to a clinical research tool. For outcome measures to satisfy these regulatory requirements and provide value in understanding disease outcomes, they must be responsive and efficient. Recent research has uncovered certain concerns regarding traditional PROs in patients with upper extremity disability and injury. These include lack of consensus regarding selection of PROs for a given diagnoses, inconsistent techniques of administration of the same PROs, and the administrative burden to patients and providers of completing these forms. To address these limitations, emphasis has been placed on streamlining the outcomes reporting process, and, as a result, the National Institutes of Health (NIH) created the Patient Reported Outcomes Measurement Information System (PROMIS). PROMIS forms were created to comprehensively and efficiently measure outcomes across multiple disease states, including orthopedics. These tools exist in computer adaptive testing and short forms with the intention of more efficiently measuring outcomes compared with legacy PROs. The goals of this review are to highlight the main components of PROMIS reporting tools and identify recent use of the scores in the upper extremity literature. The review will also highlight the research and health policy potentials and limitations of implementing PROMIS into everyday orthopedic practice.

Biomechanical Analysis of Latarjet Screw Fixation: Comparison of Screw Types and Fixation Methods

PURPOSE To compare the initial fixation stability, failure strength, and mode of failure of 5 different screw types and fixation methods commonly used for the classic Latarjet procedure. METHODS Thirty-five fresh-frozen cadaveric shoulder specimens were allocated into 5 groups. A 25% anteroinferior glenoid defect was created, and a classic Latarjet coracoid transfer procedure was performed. All grafts were fixed with 2 screws, differing by screw type and/or fixation method. The groups included partially threaded solid 4.0-mm cancellous screws with bicortical fixation, partially threaded solid 4.0-mm cancellous screws with unicortical fixation, fully threaded solid 3.5-mm cortical screws with bicortical fixation, partially threaded cannulated 4.0-mm cancellous screws with bicortical fixation, and partially threaded cannulated 4.0-mm captured screws with bicortical fixation. All screws were stainless steel. Outcomes included cyclic creep and secant stiffness during cyclic loading, as well as load and work to failure during the failure test. Intergroup comparisons were made by a 1-way analysis of variance. RESULTS There were no significant differences among different screw types or fixation methods in cyclic creep or secant stiffness after cyclic loading or in load to failure or work to failure during the failure test. Post-failure radiographs showed evidence of screw bending in only 1 specimen that underwent the Latarjet procedure with partially threaded solid cancellous screws with bicortical fixation. The mode of failure for all specimens analyzed was screw cutout. CONCLUSIONS In this biomechanical study, screw type and fixation method did not significantly influence biomechanical performance in a classic Latarjet procedure. When performing this procedure, surgeons may continue to select the screw type and method of fixation (unicortical or bicortical) based on preference; however, further studies are required to determine the optimal method of treatment. CLINICAL RELEVANCE Surgeons may choose the screw type and fixation method based on preference when performing the Latarjet procedure.

How Comprehensive and Efficient Are Patient-Reported Outcomes for Rotator Cuff Tears?

Background: Increasing emphasis is placed on patient-reported outcomes (PROs) after common orthopaedic procedures as a measure of quality. When considering PRO utilization in patients with rotator cuff tears, several different PROs exist with varying levels of accuracy and utilization. Hypothesis/Purpose: Understanding which disease-specific PRO may be most efficiently administered in patients after rotator cuff repair may assist in promoting increased patient and physician adoption of these useful scores. Using a novel assessment criterion, this study assessed all commonly used rotator cuff PROs. We hypothesize that surveys with fewer numbers of questions may remain comparable (with regard to comprehensiveness) to longer surveys. Study Design: Systematic review. Methods: Commonly utilized rotator cuff PROs were analyzed with regard to number of survey components, comprehensiveness, and efficiency. Comprehensiveness (maximum score, 11) was scored as the total number of pain (at rest/baseline, night/sleep, activities of daily living [ADLs], sport, and work) and functional (strength, motion/stiffness, and ability to perform ADLs, sport, and work) metrics included, along with inclusion of quality of life/satisfaction metrics. Efficiency was calculated as comprehensiveness divided by the number of survey components. Results: Sixteen different PROs were studied. Number of components ranged from 5 (University of California at Los Angeles score [UCLA]) to 36 (Short Form–36 [SF-36], Japanese Orthopaedic Association score [JOA]). The Quality of Life Outcome Measure for Rotator Cuff Disease (RC-QoL) included all 5 pain components, while 7 PROs contained all 5 functional components. Ten PROs included a quality of life/satisfaction component. The most comprehensive scores were the RC-QoL (score, 11) and Penn (score, 10), and the least comprehensive score was the Marx (score, 3). The most efficient PROs were the UCLA, the Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDASH), and Constant scores. The least efficient scores were the JOA and SF-36 scores. Conclusion: Many commonly utilized PROs for rotator cuff tears are lacking in comprehensiveness and efficiency. Continued critical assessment of PRO quality may help practitioners identify the most comprehensive and efficient PRO to incorporate into daily clinical practice.

ACL Reconstruction Basics: Quadruple (4-Strand) Hamstring Autograft Harvest

Hamstring tendon autograft remains a popular graft choice for anterior cruciate ligament (ACL) reconstruction. Although there are a variety of autograft and allograft options available for ACL reconstruction, advantages of hamstring tendon autografts include decreased postoperative knee pain and an overall easier surgical recovery compared with bone patellar tendon bone autograft. In addition, 4-stranded (quadruple) hamstring grafts are among the strongest grafts biomechanically (at time equals zero). Although the technique of hamstring autograft harvest is relatively straightforward, it is critical to pay attention to several technical steps to avoid iatrogenic neurovascular damage as well as to avoid premature amputation of the graft while using a tendon stripper. In this Technical Note, we describe a technique of hamstring autograft harvest for ACL reconstruction for a quadruple (4-strand) hamstring graft using the gracilis and semitendinosus tendons.

How Comprehensive and Efficient are Patient Reported Outcomes for Femoroacetabular Impingement

Objectives: Increasing emphasis is placed on patient reported outcomes following common orthopedic procedures as a measure of quality and patient satisfaction. When considering patient reported outcome (PRO) utilization in patients with hip pain secondary to femoroacetabular impingement, several different PRO exist with varying levels of utilization and accuracy. Understanding which disease-specific PRO may be most efficiently administered in patients with femoroacetabular impingement, particularly those undergoing arthroscopic hip procedures, may assist in promoting increased patient and physician adoption of these useful scores. Using a novel assessment criterion, this study assessed all commonly used PRO in hip arthroscopy literature. We hypothesize that surveys with fewer numbers of questions may remain comparable (with regards to comprehensiveness) to longer surveys. Methods: Commonly utilized PRO in hip arthroscopy literature were analyzed with regards to number of survey components, comprehensiveness, and efficiency. Comprehensiveness (maximum score 13) was scored as the total number of pain (at rest/baseline, at night, during activities of daily living, during sport, during work, and mechanical symptoms) and functional (range of motion, ability to perform ADL, sport, work, ability to sit, and pre-injury level of function) metrics included, along with inclusion of quality of life/satisfaction metrics. Efficiency was calculated as comprehensiveness divided by number of survey components. Results: Thirteen different PRO were studied. Number of components ranged from 1 (UCLA Activity Score) - 40 (HOOS). Only the iHOT-33 included all six pain components, while only the iHOT-33 and HOS PRO contained all six functional components. Seven PRO included a quality of life/satisfaction component. The most comprehensive scores were the iHOT-33 (score = 13) and HAGOS (score = 10), and the least comprehensive score was the UCLA (score = 2). The most efficient PROs were the UCLA, MHHS, and EQ-5D scores. The least efficient scores were the HOS and SF-36 scores. Conclusion: Many commonly utilized PRO for FAI are lacking in comprehensiveness and efficiency. Continued critical assessment of PRO quality may help practitioners identify the most comprehensive and efficient PRO to incorporate into daily clinical practice. Figure 1: Bar Graph of Comprehensiveness Scores with Overlying Line Graph of Efficiency Scores on Secondary Axis

Synovial Chondromatosis Involving the Long Head of the Biceps

Synovial chondromatosis (SC) of the shoulder is a rare condition that can lead to degenerative arthritis of the glenohumeral joint. The disease affects young adults in the age range of 30–50 years with a male predominance of 2:1 (Ho, Choueka. J Hand Surg Am 38:804–10, 2013). The pathogenesis of SC involves benign metaplastic change of foci of the synovial membrane with associated hyperplasia. These foci eventually form pedunculated masses or nodules that separate, forming loose bodies within the joint space. Over time, these loose bodies are capable of endochondral ossification, forming hardened loose bodies that can lead to erosive damage of the articulating surfaces and predispose to the development of arthritis (Fowble, Levy. Arthroscopy 19:E2, 2003).

Shoulder Arthroscopy in the Lateral Decubitus Position

Arthroscopic shoulder surgery can be performed in both the beach chair and lateral decubitus positions. The lateral decubitus position allows for excellent exposure to all aspects of the glenohumeral joint and is therefore frequently employed in procedures such as stabilization, in which extensive visualization of the inferior and posterior aspects of the joint is required. Improved visualization is imparted due to applied lateral and axial traction on the operative arm, which increases the glenohumeral joint space. To perform arthroscopy surgery in the lateral decubitus position successfully, meticulous care during patient positioning and setup must be taken. In this Technical Note, we describe the steps required to safely, efficiently, and reproducibly perform arthroscopic shoulder surgery in the lateral decubitus position.

Shoulder Arthroscopy in the Beach Chair Position

Arthroscopic shoulder surgery can be performed in both the beach chair and lateral decubitus positions. The beach chair position is a reliable, safe, and effective position to perform nearly all types of shoulder arthroscopic procedures. The advantages of the beach chair position include the ease of setup, limited brachial plexus stress, increased glenohumeral and subacromial visualization, anesthesia flexibility, and the ability to easily convert to an open procedure. This position is most commonly used for rotator cuff repair, subacromial decompression, and superior labrum anterior-to-posterior repair procedures. To perform arthroscopy surgery in the beach chair position successfully, meticulous care during patient positioning and setup must be taken. In this Technical Note, we describe the necessary steps to safely and efficiently prepare patients in the beach chair position for arthroscopic shoulder surgery.

ACL Reconstruction with a Novel Transtibial Guide System Provides the Benefits of the Anteromedial Portal Technique: A Cadaveric Study

Objectives: Transtibial (TT) anterior cruciate ligament reconstruction (ACL-R) has come under increasing scrutiny due concerns over non-anatomic placement of the femoral tunnel. Modifications to the originally described TT ACL-R technique have attempted to obviate the restrictions of dependent drilling of the femoral tunnel; however, despite these modifications the TT technique has increasingly been replaced with independent drilling techniques such as the anteromedial (AM) portal approach. No study has compared the novel hybrid technique guide system (Pathfinder) to the AM technique. The purpose of this study was to compare the femoral tunnel area, length, and percentage of native femoral ACL footprint covered between the Pathfinder technique and the AM technique. Methods: Seven matched pairs of cadaver knees with no prior history of knee surgery were used for this study. Each matched pair had one knee randomly assigned to the Pathfinder technique and the corresponding knee assigned to the AM technique. Each cadaveric knee had the extensor mechanism removed and was loaded into a customdesigned clamp with the cruciates, collaterals, and posterior capsule intact. Each knee was rigidly fixed in the flexion angle used for ACL-R (90° Pathfinder vs.120° AM) and the native ACL was removed. The ACL femoral footprint was digitized and the area calculated with the MicroScribe. Next, 10 mm tibial and femoral tunnels were drilled in accordance with each technique. The femoral tunnel area and length were digitized with the MicroScribe. The center of the native femoral footprint, femoral tunnel center, and percentage overlap of tunnel and footprint were calculated for each specimen using three-dimensional data acquisition software (Rhinoceros v5.0). Results: The average native ACL femoral footprint area was 109.5 ± 11.5 mm2, with no difference in average area between knees assigned to Pathfinder or AM techniques (112.8 ± 11.3 mm2 vs. 106.1 ± 11.6 mm2, p = 0.29). There was no difference in average femoral tunnel area between Pathfinder and AM techniques (98.5 ± 11.8 mm2 vs. 96.5 ± 7.8 mm2, p = 0.72). The Pathfinder technique generated significantly longer femoral tunnels (46.0 ± 2.3 mm vs. 39.9 ± 5.2 mm, p = 0.02). The center of the femoral tunnel was closer to the center of the native ACL footprint for the AM technique as compared to the Pathfinder technique (1.3 ± 0.5 mm vs. 2.23 ± 0.7 mm, p = 0.01); however, the percentage of the native ACL footprint covered by the femoral tunnel was not significantly different between the techniques (Pathfinder 73.4 ± 10.2% vs. AM 81.7 ± 11.5%, p = 0.18). Furthermore, there was no significant difference between the two techniques as far as percentage of femoral tunnel outside native ACL footprint (Pathfinder 15.9 ± 10.8% vs. AM 10.7 ± 9.0%, p = 0.35). There were no back wall breaches with either technique. International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine 11 th Biennial ISAKOS Congress • June 4-8, 2017 • Shanghai, China ISAKOS

Patient Reported Outcomes for Rotator Cuff Disease - Which PRO Should You Use?

Objectives: Patient reported outcomes (PRO) are important clinical and research tools that are utilized by orthopedic surgeons in order to assess health outcomes following treatment. This is particularly so in the setting of rotator cuff pathology, in which several different validated patient reported outcomes exist. However, multiple recent studies have demonstrated a lack of standardization in the utilization of these scores. Moreover, many of these scores contain numerous components, thereby making them difficult to administer in a busy ambulatory setting. The goal of this study was to quantitatively assess the commonly used PRO for rotator cuff disease in order to identify the most efficient and comprehensive ones available for clinicians. Methods: Fifteen different PROs commonly used for rotator cuff pathology were selected for review. These outcome tools were assessed by the study team and reviewed for comprehensiveness with regards to assessment of pain, strength, activity, motion, and quality of life. The comprehensiveness and efficiency of each tool was evaluated by inclusion of questions addressing each domain. PROs were also evaluated with a focus of pain criteria (night pain, baseline/general pain, pain during activities of daily living, pain during sport, and pain during work). Finally, all PROs were assessed with regards to comprehensiveness in assessing activity scores (motion/stiffness, activities of daily living, sport, and work). Comprehensiveness scores were calculated by dividing the number of domains or subdomains present by the total domains or subdomains possible. Efficiency was calculated by dividing the number of domains present by the number of questions contained in each PRO. Results: The UCLA, Western Ontario Rotator Cuff Index (WORC), Disabilities of the Arm, Shoulder, and Hand (DASH), PENN, Shoulder Rating Questionnaire (SRQ), and Korean Shoulder Score (KSS) had an overall comprehensiveness score of 1.00 indicating all domains were present. The American Shoulder and Elbow Surgeons score (ASES), Constant score, Simple Shoulder Test (SST), 36 item Short Form Health Survey (SF-36), and Shoulder Pain and Disability Index (SPADI) had an overall comprehensiveness score of 0.80. The remaining PROs had a score of 0.60 or less. The highest scoring PROs for efficiency were UCLA, Constant, and Marx with scores of 1.00, 0.50, and 0.43 respectively. The UCLA, DASH, PENN, and SRQ had the highest pain comprehensiveness score of 0.60. The ASES, SST, WORC, DASH, Quick DASH, PENN, and SRQ had the highest activity comprehensiveness score of 1.00. The three highest averages of overall comprehensiveness, overall efficiency, pain comprehensiveness, and activity comprehensiveness were the UCLA, SRQ, and PENN PROs with averages of 0.78, 0.71, and 0.70 respectively. Conclusion: This is the first study to quantitatively assess quality and efficiency of patient reported outcomes for rotator cuff tears. The UCLA shoulder score was determined to be the most comprehensive and efficient when compared to fourteen other shoulder PROs in regards to the domains of pain, strength, activity, motion, and quality of life. Clinicians should consider these metrics when incorporating these tools in everyday clinical practice and research.