How can we define clinically important improvement in pain scores after biceps tenodesis?

Minimal important clinical difference values are not uniformly valid in the active duty military population recovering from shoulder surgery

BACKGROUND

There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population's fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of 2 different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operating characteristic (ROC) curve-based MCIDs and baseline-adjusted ROC curve MCIDs.

METHODS

All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROM battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Patient Reported Outcome Management Information System (PROMIS) physical function (PF), PROMIS pain interference (PI), and the Warfighter Readiness Survey. Standard anchor-based and baseline-adjusted ROC curve MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval [CI] either completely negative or positive).

RESULTS

A total of 117 patients (136 operations) were identified, comprising 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC curve MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC curve MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7.

CONCLUSION

When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC curve analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC curve method was more effective at discerning changes across a battery of PROMs among the same cohort.

Arthroscopic Suprapectoral Biceps Tenodesis for Isolated Biceps Tendinopathy: Results From 23 Patients

INTRODUCTION

Pathology affecting the long head of the biceps tendon (LHB) is a common cause of shoulder pain. When conservative treatment fails to resolve symptoms, surgical treatment is the modality of choice. The literature describes many arthroscopic and open techniques using different implants. However, no consensus exists on which procedure yields the greatest improvement. The purpose of this study was to evaluate the effectiveness and safety of arthroscopic suprapectoral biceps tenodesis for treating isolated LHB pathology.

MATERIALS AND METHODS

We present a case series of 23 patients with isolated LHB pathology who were treated with arthroscopic suprapectoral tenodesis between 2016 and 2022. All surgeries were performed by the same senior surgeon, and patients were assessed preoperatively and one year after the procedure, using the simple shoulder test (SST), Constant score (CS), and visual analog scale (VAS) by the senior surgeon. Statistical analysis was performed using the Wilcoxon Signed Rank test, with significance defined as p < 0.05.

RESULTS

The CS improved from 68.52 (SD = 1.59) to 98 (SD = 7.1; p < 0.001), the SST improved from 8.78 (SD = 0.998) to 11.21 (SD = 0.42; p < 0.001), and the VAS improved from 8.26 (SD = 0.54) to 0 (SD = 0; p < 0.001) at one-year follow-up. No complications were reported postoperatively or during the follow-up period.

CONCLUSIONS

Arthroscopic suprapectoral biceps tenodesis significantly improved outcomes at one-year follow-up and can be considered an effective and safe choice when treating LHB pathology.

Arthroscopic suprapectoral biceps tenodesis provided earlier shoulder function restoration compared with open subpectoral biceps tenodesis during the recovery phase

BACKGROUND

This study compared the clinical outcomes of open subpectoral biceps tenodesis and arthroscopic suprapectoral biceps tenodesis for symptomatic biceps tenosynovitis. Although both techniques have pros and cons, no studies have compared clinical and functional outcomes during the recovery phase. Previous studies show that suprapectoral tenodesis has a higher probability of Popeye deformity and postoperative bicipital pain and stiffness, whereas subpectoral tenodesis has a higher risk of nerve complications and wound infections. This study aimed for clinical comparison between arthroscopic suprapectoral biceps tenodesis and open subpectoral biceps tenodesis.

METHODS

This study is a retrospective review of institutional records of patients with biceps tendinitis who underwent open or arthroscopic biceps tenodesis. Surgical indications included biceps tenosynovitis, biceps partial tear, and biceps pulley lesion. Patients with prior shoulder surgery, preoperative shoulder stiffness, or full-thickness tear of rotator cuff were excluded. Tenodesis was considered when the pain recurs within 3 months despite conservative treatment including at least 2 triamcinolone injections on the biceps tendon sheath. Visual analog scale (VAS) score for pain, presence of the night pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, and range of motion were assessed preoperatively at 3, 6, 12, and 24 months postoperatively and the last follow-up.

RESULTS

A total of 72 patients (33 with arthroscopic suprapectoral biceps tenodeses and 39 with open subpectoral biceps tenodeses) were included in analysis. At postoperative 6 months, lower VAS score (0.4 ± 0.8 vs. 1.7 ± 1.9, P < .001), and the presence of the night pain (2 [6%] vs. 14 [36%], P = .002), ASES score (89.6 ± 9.2 vs. 81.4 ± 14.6, P = .006), and Constant score (89.4 ± 5.6 vs. 82.0 ± 12.5, P = .003) compared with the subpectoral group. The mean number of postoperative steroid injections for pain control in the subpectoral group (0.51 ± 0.80) was significantly higher than that in the suprapectoral group (0.18 ± 0.40) (P = .031). However, postoperative clinical outcomes were restored similar between the 2 groups at 12 months and the last follow-up.

DISCUSSION

Arthroscopic suprapectoral biceps tenodesis performed statistically better than the subpectoral biceps tenodesis for the VAS, ASES, night pain, and Constant score at postoperative 6 months. However, only night pain and the Constant score showed differences that exceeded minimum clinically important difference during the recovery phase. At postoperative 12 and 24 months, biceps tenodesis provided satisfactory clinical outcomes and pain relief regardless of the fixation technique and suture anchor location.

An Expedited Sling Immobilization Protocol After Isolated Biceps Tenodesis Results in Clinical and Patient-Reported Postoperative Outcomes Equivalent to a Standard Rehabilitation Protocol

Purpose

To characterize clinical and patient-reported outcomes for patients after isolated biceps tenodesis (BT) who underwent either standard or expedited sling immobilization protocols following surgery.

Methods

This retrospective cohort study compared patients who were assigned to use a sling for either 4 to 6 weeks (standard) or 0 to 2 weeks (expedited) following an isolated BT. Primary endpoint included rate of re-rupture, surgical revision, loss of fixation, and Popeye deformity. Secondary endpoints included shoulder range of motion (ROM) as well as pre- and postoperative patient-reported outcomes (PROs) of pain and function. Missing data were managed via multiple imputation with chained equations. Complication prevalence 95% confidence intervals were calculated using the Clopper Pearson method and a series of hierarchical mixed effects linear regressions were performed to assess differences between sling interventions in PROs and ROM.

Results

The average age of the standard cohort (n = 66) was 49 years (±14 years), and the average age of the expedited cohort (n = 69) was 47 years (±14 years). The expedited and standardized cohorts demonstrated 0.4 and 0.3 complications per 10,000 exposure days, respectively, with no significant difference between groups (1.4 [95% confidence interval 0.2-10.0], P = .727). There was no demonstrated difference in forward flexion, abduction, or external ROM. The expedited group had less improvement in visual analog scale for pain scores that was not clinically significant and there were no differences in PROs of function.

Conclusions

No statistically significant difference in the rate of re-rupture, surgical revision, loss of fixation, or Popeye deformity was noted between protocols after isolated BT. Furthermore, there were no clinically significant differences in ROM or PROs identified between protocols after isolated BT. This study suggests that patients who have undergone isolated BT may safely discontinue sling use within 2 weeks after surgery.

Level of Evidence

Level III, retrospective comparative study.

Minimal clinically important difference of the Michigan Hand Outcomes Questionnaire score and the pain visual analogue scale in conservative treatment of trigger finger

We investigated the minimal clinically important difference (MCID) of the Michigan Hand Outcomes Questionnaire (MHQ) and the pain visual analogue scale (VAS-pain) after conservative treatment of trigger finger. This secondary analysis of a randomized controlled trial compared pain reduction, symptoms and functional improvement at 12 weeks. Patients included were at least 18 years old and able to complete MHQ and VAS-pain at enrolment and 12 weeks after treatment. The MCIDs of MHQ and VAS-pain were evaluated using a distribution-based, anchor-based and receiver operating characteristic (ROC) curve-based approach. Of the 117 patients, the MCIDs of MHQ and VAS-pain using a distribution-based approach were 5.3 and 0.6, respectively; applying ROC method were 23.5 and 2.5, respectively; and using anchor questions were 15 and 2, respectively. These MCID values by anchor-based method with a minimal difference of 15 for MHQ and 2 for VAS-pain are recommended as primary evidence to determine clinically significant improvement after conservative treatment of trigger finger.Level of evidence: I.

An artificial intelligence-powered, patient-centric digital tool for self-management of chronic pain: a prospective, multicenter clinical trial

OBJECTIVE

To investigate how a behavioral health, artificial intelligence (AI)-powered, digital self-management tool affects the daily functions in adults with chronic back and neck pain.

DESIGN

Eligible subjects were enrolled in a 12-week prospective, multicenter, single-arm, open-label study and instructed to use the digital coach daily. Primary outcome was a change in Patient-Reported Outcomes Measurement Information Systems (PROMIS) scores for pain interference. Secondary outcomes were changes in PROMIS physical function, anxiety, depression, pain intensity scores and pain catastrophizing scale (PCS) scores.

METHODS

Subjects logged daily activities, using PainDrainerTM, and data analyzed by the AI engine. Questionnaire and web-based data were collected at 6 and 12 weeks and compared to subjects' baseline.

RESULTS

Subjects completed the 6- (n = 41) and 12-week (n = 34) questionnaires. A statistically significant Minimal Important Difference (MID) for pain interference was demonstrated in 57.5% of the subjects. Similarly, MID for physical function was demonstrated in 72.5% of the subjects. A pre- to post-intervention improvement in depression score was also statistically significant, observed in 100% of subjects, as was the improvement in anxiety scores, evident in 81.3% of the subjects. PCS mean scores was also significantly decreased at 12 weeks.

CONCLUSION

Chronic pain self-management, using an AI-powered, digital coach anchored in behavioral health principles significantly improved subjects' pain interference, physical function, depression, anxiety, and pain catastrophizing over the 12-week study period.

Incidence and risk factors for complex regional pain syndrome in radius fractures: meta-analysis

PURPOSE

This meta-analysis aimed to evaluate the incidence and risk factors for complex regional pain syndrome (CRPS) in radius fractures.

METHODS

The meta-analysis was performed using the PubMed, Embase, Scopus, and Cochrane Collaboration Library databases. Studies focusing on patients with conservative or surgically treated radius fractures leading to CRPS were included. A control group consisting of patients with radius fractures and no CRPS (-) was included. The outcome measures were incidence and risk factors. Comparative studies were also included. Data were combined using Review Manager 5.4.

RESULTS

Out of 610 studies, nine studies were included. The incidence of CRPS after radius fractures ranged from 0.19 to 13.63% (95% CI: 11.12-16.15%). Open fractures, high-energy mechanisms in radial head fractures, and associations with ulnar fractures were risk factors for CRPS [(RR: 0.98; 95% CI: 0.97-1.00), (RR: 0.18; 95% CI: 0.07-0.47), and (RR: 1.25; 95% CI: 1.17-1.35), respectively]. Other risk factors were female sex and high body mass index [(RR: 1.20; 95% CI: 1.05-1.37) and (MD: 1.17; 95% CI: 0.45-1.88)]. Psychiatric factors also increased the incidence of CRPS (RR: 2.04; 95% CI: 1.83-2.28). On the other hand, the type of surgery (external fixation or open reduction and internal fixation) and manipulations; associated comorbidities (diabetes and hypertension) together with tobacco and alcohol abuse; marital status, educational level, employment status, and socioeconomic status were not risk factors (p > 0.05).

CONCLUSION

The incidence of CRPS in radius fractures was 13.63%. Fractures with greater complexity or greater associated tissue damage, female sex, high BMI, and psychiatric disorders were risk factors for the development of CRPS.

LEVEL OF EVIDENCE

Meta-analysis of cohort and case series studies; II.

Establishing the Minimal Clinically Important Difference and Substantial Clinical Benefit for the Pain Visual Analog Scale in a Postoperative Hand Surgery Population

PURPOSE

Although the pain visual analog scale (VAS-pain) is a ubiquitous patient-reported outcome instrument, it remains unclear how to interpret changes or differences in scores. Therefore, our purpose was to calculate the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population.

METHODS

Adult postoperative patients treated by 1 of 5 fellowship-trained orthopedic hand surgeons at a single tertiary academic medical center were identified. Inclusion required VAS-pain scores at baseline (up to 3 months before surgery) and follow-up (up to 4 months after surgery), in addition to a response to a pain-specific anchor question at follow-up. The MCID estimates were calculated with (1) the 1/2 standard deviation method; and (2) an anchor-based approach. The SCB estimates were calculated with (1) an anchor-based approach; and (2) a receiver operator curve method that maximized the sensitivity and specificity for detecting a "much improved" pain status.

RESULTS

There were 667 and 148 total patients included in the MCID and SCB analyses, respectively. The 1/2 standard deviation MCID estimate was 1.6, and the anchor-based estimate was 1.9. The anchor-based SCB estimate was 2.2. The receiver operator curve analysis yielded an SCB estimate of 2.6, with an area under the curve of 0.72, consistent with acceptable discrimination.

CONCLUSIONS

We propose MCID values in the range of 1.6 to 1.9 and SCB values in the range of 2.2 to 2.6 for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population.

CLINICAL RELEVANCE

These MCID and SCB estimates may be useful for powering clinical studies and when interpreting VAS-pain score changes or differences reported in the hand surgery literature. These values are to be applied at a population level, and should not be applied to assess the improvement, or lack thereof, for individual patients.

Primary Double-Pulley SLAP Repair in an Active-Duty Military Population With Type II SLAP Lesions Results in Improved Outcomes and Low Failure Rates at Minimum Six Years of Follow-up

Purpose

To report mid-term outcomes of active-duty patients younger than the age of 35 years with shoulder type II SLAP lesions following our technique for double-pulley SLAP repair (DPSR).

Methods

All consecutive patients aged 18 to 35 years from January 2014 through December 2015 who underwent primary DPSR by the senior surgeon with complete outcome scores were identified. The clinical significance measures (patient acceptable symptomatic state [PASS], substantial clinical benefit [SCB], minimal clinically important difference [MCID]) have not yet been fully defined for type II SLAP repair procedures, so the values for biceps tenodesis were used as a stand-in. Patients were excluded if they were lost to follow-up of if they underwent a concomitant rotator cuff repair. Outcome measures were completed by patients within 1 week before surgery and at latest follow-up.

Results

Overall, 22 of 41 (53.7%) patients met the inclusion criteria for the study, and all were active-duty military at time of surgery. In total, 21 of 22 (95.5%) patients met the PASS, whereas 20 of 22 (90.9%) achieved SCB and 22 of 22 (100.0%) exceeded the MCID for their operative shoulder as determined by the American Shoulder and Elbow Surgeons score. In total, 19 of 22 (86.4%) patients met the PASS, whereas 22 of 22 (100.0%) achieved SCB and exceeded the MCID for their operative shoulder as determined by the Single Assessment Numeric Evaluation. In addition, 21 of 22 (95.5%) met the PASS, whereas 22 of 22 (100%) achieved SCB and exceeded the MCID for their operative shoulder as determined by the pain visual analog scale. Pre- and postoperative range of motion did not vary significantly. In total, 18 of 22 (81.8%) of patients remained on active duty and were able to return to preinjury work and recreation activity levels. In 2 patients (9.09%), the repair did not heal.

Conclusions

Mid-term outcomes in this population of young, active-duty patients undergoing DPSR for type II SLAP tears demonstrate a statistically and clinically significant improvement in patient-reported outcomes and an overall return to active-duty rate of 81.8%.

Level of Evidence

Level IV, therapeutic case series.

Anchored Minimal Clinically Important Difference Metrics: Considerations for Bias and Regression to the Mean

Minimal clinically important differences (MCIDs) are used to understand clinical relevance. However, repeated observations produce biased analyses unless one accounts for baseline observation, known as regression to the mean (RTM). Using an International Knee Documentation Committee (IKDC) survey dataset, we can demonstrate the effect of RTM on MCID values by (1) MCID-estimate dependence on baseline observation and (2) MCID-estimate bias being higher when the posttest-pretest data correlation is lower. We created 10 IKDC datasets with 5000 patients and a specific correlation under both equal and unequal variances. For each 10-point increase in baseline IKDC, MCID decreased by 3.5, 2.7, 1.9, 1.2, and 0.7 points when posttest-pretest correlations were 0.10, 0.25, 0.50, 0.75, and 0.90, respectively, under equal variances. Not accounting for RTM resulted in a static 20-point MCID. Minimal clinically important difference estimates may be unreliable. Minimal clinically important difference calculations should include the correlation and variances between posttest and pretest data, and researchers should consider using a baseline covariate-adjusted receiver operating characteristic curve analysis to calculate MCID.

Influence of workers' compensation status on postoperative outcomes in patients following biceps tenodesis: a matched-pair cohort analysis

BACKGROUND AND HYPOTHESIS

Although the literature on the association of workers' compensation (WC) status with negative outcomes after orthopedic surgery is extensive, there is a paucity of evidence on outcomes in WC recipients undergoing biceps tenodesis. We hypothesized that WC patients would report significantly worse outcomes postoperatively on patient-reported outcome measures (PROMs).

METHODS

Functional and health-related quality-of-life PROMs and a visual analog scale score for pain were administered preoperatively and at 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018 at our institution. Thirty-eight WC patients were matched 1:2 to non-WC patients by age, body mass index, and operative limb. The minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state were calculated for all patients via anchor- and distribution-based methods. Rates of achievement and the likelihood of achievement were determined.

RESULTS

All patients showed significant improvements in all outcome measures (P < .001). WC patients reported inferior postoperative scores on all PROMs examined. WC status significantly predicted a reduced likelihood of achieving substantial clinical benefit for the American Shoulder and Elbow Surgeons score (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.17-0.81; P = .01) and the patient acceptable symptom state (OR, 0.28; 95% CI, 0.12-0.65; P = .003) for the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (OR, 0.24; 95% CI, 0.10-0.61; P = .003), Constant-Murley Subjective Assessment (OR, 0.25; 95% CI, 0.08-0.77; P = .016), and visual analog scale pain score (OR, 0.27; 95% CI, 0.16-0.47; P < .001).

CONCLUSION

WC patients reported inferior scores on all postoperative PROMs and demonstrated lower odds of achieving substantial benefit and satisfaction regarding improvements in both function and pain compared with non-WC patients.