How Are We Measuring Patient Satisfaction After Anterior Cruciate Ligament Reconstruction?

Implementing a shared decision-making intervention to support treatment decisions for patients following an anterior cruciate ligament rupture - a protocol for the POP-ACLR feasibility study

BACKGROUND

Treatment for anterior cruciate ligament (ACL) rupture may follow a surgical or nonsurgical pathway. At present, there is uncertainty around treatment choice. Two shared decision-making tools have been codesigned to support patients to make a decision about treatment following an ACL rupture. The shared decision-making tools include a patient information leaflet and an option grid. We report the protocol for a mixed-methods feasibility study, with nested qualitative interviews, to understand feasibility, acceptability, indicators of effectiveness and implementation factors of these shared decision-making tools (combined to form one shared decision-making intervention).

METHODS

A single-centre non-randomised feasibility study will be conducted with 20 patients. Patients diagnosed with an ACL rupture following magnetic resonance imaging will be identified from an orthopaedic clinic. The shared decision-making intervention will be delivered during a clinical consultation with a physiotherapist. The primary feasibility outcomes include the following: recruitment rate, fidelity, acceptability and follow-up questionnaire completion. The secondary outcome is the satisfaction with decision scale. The nested qualitative interview will explore experience of using the shared decision-making intervention to understand acceptability, implementation factors and areas for further refinement.

DISCUSSION

This study will determine the feasibility of using a newly developed shared decision-making intervention designed to support patients to make a decision about treatment of their ACL rupture. The acceptability and indicators of effectiveness will also be explored. In the long term, the shared decision-making intervention may improve service and patient outcomes and ensure cost-effectiveness for the NHS; ensuring those most likely to benefit from surgical treatment proceed along this pathway.

TRIAL REGISTRATION

Pending registration on ISRCTN.

Partial debridement is the most commonly reported treatment option for mucoid degeneration of the anterior cruciate ligament: a systematic review

PURPOSE

To determine clinical outcomes and risks of various management strategies for mucoid degeneration of the anterior cruciate ligament (MD-ACL).

METHODS

Three databases MEDLINE, PubMed and EMBASE were searched from inception to January 29th, 2023 for literature outlining clinical outcomes for various management strategies of MD-ACL. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on satisfaction scores, visual analogue scale (VAS) scores, Lysholm scores, International Knee Documentation Committee (IKDC) scores, Knee Osteoarthritis and Outcome Scores (KOOS), range of motion and Lachman test were recorded.

RESULTS

A total of 14 studies comprising 776 patients (782 knees) were included in this review. Partial debridement was reported in ten (71.4%) studies comprising 446 patients, showing significant improvements in VAS, Lysholm, IKDC scores and range of motion. Complete debridement was reported by two (14.2%) studies comprising 250 patients, and resulted in increases in Lysholm scores, KOOS, and range of motion. Reduction plasty was reported in two (14.2%) studies comprising 26 patients and showed improvements in VAS and Lysholm scores, and range of motion. Other methods of treatment included conservative management and ultrasound decompression. Complete debridement resulted in 10/23 (43%) patients with a positive Lachman test. This was followed by reduction plasty and partial debridement, with 5/26 (19.2%) and 45/340 (13.2%) patients respectively having positive Lachman or elevated knee arthrometer scores. Pivot shifting was only reported in studies on partial debridement and reduction plasty, with 14/93 (15.1%) and 1/21 (4.8%) patients have positive results, respectively.

CONCLUSION

The most commonly reported management strategy for MD-ACL is partial debridement with complete debridement, reduction plasty and conservative management as alternative options. Current operative management strategies place individuals at risk for ACL insufficiency. Information from this review can aid surgeons and clinicians in understanding what treatment options are best for this patient population, by understanding the reported clinical benefits and risks of each strategy.

LEVEL OF EVIDENCE

IV.

Knee lesions with anterior cruciate ligament (ACL) tear in Iraqi adult males: arthroscopic findings

This cross-sectional study aimed at exploring the frequency and extent of knee joint lesions associated with delayed treatment of anterior cruciate ligament (ACL) injury. It enrolled 300 patients from 2020 to 2022 who were subjected to arthroscopy for anterior cruciate ligament reconstruction. The sample was comprised of Iraqi adult male patients from different regions of Iraq, and the surgical procedure was carried out in Al-Diwaniyah Teaching Hospital. The findings were recorded by Karl Storz's camera system. Dissection and arthroscopy were done under general anesthesia using an anterolateral portal technique. The study employed a visualization of the anterior cruciate ligament probing the meniscus and reaching the posteromedial space for the ramp lesion. The mean age of patients was 28.05±6.92 years, ranging from 19 to 35 years and the mean duration from onset of injury to the time of operation was 3.69±1.07 years, ranging from 6 months to 10 years. The arthroscopic examination revealed medial meniscus tear in 80% of the cases, lateral meniscus tear in 40% of the cases, cartilage lesion in 40% of the cases, and meniscus ramp lesions in 10% of the cases. Most cases of ACL tear are associated with a meniscus injury, cartilage defect, and collateral ligament tear. These serious lesions, such as complex meniscus tears or full articular cartilage defects, are a direct consequence of delayed treatment. Consequently, it is crucial to inform the patients about the significant issues that can arise due to treatment delays.

Comparison of ACL and Anterolateral Ligament Reconstruction With Isolated ACL Reconstruction Using Hamstring Autograft: Outcomes in Young Female Patients With High-Grade Pivot Shift

Background

Inferior return to sports (RTS) and functional outcomes have been reported in women after anterior cruciate ligament reconstruction (ACLR).

Purpose/Hypothesis

The purpose was to evaluate the results of combined ACLR and anterolateral ligament reconstruction (ALLR) in young women with a high-grade pivot shift (grade ≥2). It was hypothesized that combined ACLR and ALLR would result in better RTS and rotational stability than isolated ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

Two groups were retrospectively evaluated and compared. Group I (n = 39; mean age, 31.1 ± 5.7 years) underwent isolated ACLR using hamstring autografts; group C (n = 39; mean age, 30.4 ± 6.1 years) underwent combined ACLR and ALLR. Subjective outcome measures included the International Knee Documentation Committee subjective form, Lysholm, Tegner, and ACL-Return to Sport after Injury (ACL-RSI). Objective tests included a KT-2000 arthrometer stress test, a pivot-shift test, an isokinetic strength test, a Y-balance test, and a single-leg hop test. A postoperative questionnaire was administered to determine the rates and types of RTS, quality of sports performance, and reinjury and satisfaction rates. Subjective scores and clinical tests were performed at 2 years. Magnetic resonance imaging and second-look arthroscopy were conducted during the 1- and 2-year follow-ups, respectively.

Results

The mean follow-up for groups I and C were 30.4 ± 3.9 and 29.3 ± 3.5 months, respectively (P = .194). Patients in group C had better anteroposterior (P = .001) and rotational (P = .005) stability and higher ACL-RSI scores (P = .025) than those in group I. Group C had higher composite and posteromedial reach scores on the Y-balance test than group I (P = .014 and P = .010, respectively). A total of 26 (66.7%) patients in group C and 17 (43.6%) in group I returned to their prior level of sports (P = .040). Rerupture of the ACL graft and contralateral ACL rupture occurred in 2 (5.1%) and 2 (5.1%) patients in group I, respectively, compared with no rerupture or contralateral ACL rupture in group C.

Conclusion

Combined ACLR and ALLR in young women with a high-grade pivot shift was associated with better knee stability parameters, dynamic postural stability, and psychological readiness to RTS than isolated ACLR.

Patient Satisfaction Scores Are a Poor Metric of Orthopedic Care

Patient satisfaction scores are a popular metric used to evaluate orthopedic care. There is little consistency with how satisfaction is described in the orthopedic literature. Online physician reviews are a growing trend that directly and indirectly affect a surgeon's reputation. There is little correlation of higher satisfaction with improved surgical outcomes, so rating surgical care may be misguided and possibly dangerous. Patient satisfaction is an important part of the patient-centered care model, so rating systems should directly reflect quality. More research is needed to determine the relationship between patient satisfaction and the delivery of quality care. [Orthopedics. 2022;45(3):e127-e133.].

Similar outcomes and satisfaction after transtibial versus transportal femoral drilling for anterior cruciate ligament reconstruction in young adult recreational athletes

PURPOSE

Controversy continues regarding whether the transtibial (TT) and transportal (TP) methods for anterior cruciate ligament (ACL) reconstruction provide similar or different outcomes, and the evidence on patient satisfaction is very limited. The objective of this study was to compare functional outcomes and patient satisfaction in young adult recreational athletes who underwent arthroscopic hamstring ACL reconstruction using either the TT or the TP femoral tunnel drilling method.

METHODS

A nonrandomized prospective study was designed to compare the outcomes of arthroscopic hamstring ACL reconstruction using TT or TP method. Functional outcome was assessed with the Lyshom score, and patient satisfaction with a 5-point Likert scale. Knee stability was measured with the KT-1000 arthrometer.

RESULTS

42 patients in the TT group and 41 in TP group, with age ranged 18-40 years, were compared with a mean follow-up of 42 (range 24-60) months. There were no significant differences between groups in the Lysholm score (n.s.), sport return rate (n.s.) or patient satisfaction with the surgery (n.s.). Satisfaction was only significantly associated with the Lysholm score (OR 1.3; IC 95% 1.06-1.6; p = 0.012), but not with the return to sports (n.s.) or knee anterior laxity (n.s.).

CONCLUSION

This study showed no statistical differences between the TT and the TP method in functional outcomes or patient satisfaction in young adult recreational athletes. In those patients, satisfaction with the surgery was not influenced by the return to sport activities. This study can guide surgeons in the decision-making for ACL reconstruction in recreational athletes.

LEVEL OF EVIDENCE

Level II.

Outcomes Following Anterior Cruciate Ligament Reconstruction with Patellar Tendon vs Hamstring Autografts: A Systematic Review of Randomized Controlled Trials with a Mean Follow-up of 15 Years

BACKGROUND

The two most common surgical treatment modalities for anterior cruciate ligament reconstruction (ACL), patellar tendon (PT) and hamstring tendon (HS) autografts, have been shown to have outcomes that are both similar and favorable; however, many of these are short or intermediate-term. The objective of this systematic review is to evaluate randomized controlled trials (RCTs) with a minimum 10-year follow-up data to compare the long-term outcomes of ACL reconstructions performed using PT and HS autografts.

METHODS

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A search of three databases (PubMed, Cochrane and EMBASE) was performed to identify RCTs with a minimum of 10-year follow-up that compared clinical and/or functional outcomes between PT and HS autografts.

RESULTS

Four RCTs with a total of 299 patients were included in the study. The mean follow-up ranged from 10.2 to 17 years (mean, 14.79 years). No significant differences in knee laxity or clinical outcome scores were demonstrated in any of the studies. One study found that PT autografts were significantly more likely to have osteoarthritis identified by radiographic findings. Two studies found that patients with PT autografts reported increase kneeling pain, while none of the four studies reported a difference in anterior knee pain. There were no significant differences in graft failure rates.

CONCLUSION

This review demonstrates no long-term difference in clinical or functional outcomes between PT and HS autografts. However, radiographic and subjective outcomes indicate that patients with PT autografts may experience greater kneeling pain and osteoarthritis. Therefore, orthopaedic surgeons should consider patient-centric factors when discussing graft options with patients.

Quantifying graft impingement in anterior cruciate ligament reconstruction

BACKGROUND

Anterior cruciate ligament reconstructions (ACLR) fail at a rate of 10-15%, with graft impingement often a cause. In this study we investigate the prevalence and causes of impingement seen during ACLR surgery.

METHODS

We reviewed consecutive primary ACLR from 2012-2018. Graft impingement was estimated intraoperatively by placing the arthroscope through the tibial tunnel and passively extending the knee, observing how much was obscured by the lateral femoral condyle from an anterior and lateral direction. Preoperative MRI scans were used to measure the intercondylar notch; Notch Width Index (NWI) and Notch Depth Index (NDI). Positioning of the tunnels was determined on postoperative radiographs.

RESULTS

There were 283 ACLRs performed with 33 failures diagnosed on MRI (11.7%). 257 patients had complete imaging and follow up (91%). The mean age was 28 (±9) years and mean follow-up 5.3 (±1.8) years. The mean NWI was 0.26(±0.03), and NDI was 0.49(±0.06). The tibial tunnel aperture was located 42(±6) % of the way from anterior-posterior and 39(±6) % from medial-lateral. Impingement requiring a notchplasty was observed in 80% of cases, with lateral impingement more prominent.

CONCLUSIONS

The amount of impingement did not correlate with tunnel position, which was located within the recommended area. There was a weak negative correlation between NWI and lateral impingement (r_s = -0.16, p = 0.01), and NDI and anterior impingement (r_s = -0.12, p = 0.04), therefore a smaller notch is associated with greater impingement. Despite optimal tunnel positioning, impingement still occurs in a significant number of cases therefore notchplasty should always be considered to keep revision rates low.

Predictors of patient satisfaction after primary hamstring anterior cruciate ligament reconstruction

BACKGROUND

Predictors of patient satisfaction (PS) after anterior cruciate ligament (ACL) reconstruction are not well known. This study investigated predictors of PS and whether PS was associated with pre-injury level of sport participation, patient reported knee function and quality of life after ACL reconstruction.

METHODS

Patients who underwent primary hamstring ACL reconstruction between January 2015 and December 2017 were retrospectively evaluated. An online survey was used to evaluate PS (yes = satisfied, no = unsatisfied), duration of supervised postoperative rehabilitation, timing of return to pre-injury level of sport, pre-injury level of sport participation, patient reported knee function and quality of life. Preoperative, operative and postoperative variables were collected from the medical records.

RESULTS

A total of 183 patients completed the survey at a median of 3.6 (1.5) years after ACL surgery. At final follow-up, 82% of patients were satisfied with the outcome. Preoperative (e.g. age) and operative (e.g. meniscal tear) variables were not predictors of PS (p > 0.05). Duration of supervised postoperative rehabilitation, timing of return to pre-injury level of sport and postoperative ACL injury were predictors of PS (p = 0.018, p = 0.016 and p < 0.001, respectively). Pre-injury level of sport participation was significantly higher in satisfied compared to unsatisfied patients: 44.7% (n = 67) versus 18.2% (n = 6) (p = 0.005). In addition, satisfied patients reported significantly higher patient reported knee function and quality of life compared to unsatisfied patients (p < 0.001).

CONCLUSION

This study provided data on predictors of PS after primary ACL reconstruction. Furthermore, PS was associated with pre-injury level of sport participation, patient reported knee function and quality of life.

Comparison of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction using a Bone-patellar Tendon-bone Autograft and that Using a Double-Bundle Hamstring Tendon Autograft

PURPOSE

 The purpose of this study was to compare clinical outcomes between revision anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BPTB) autograft and that using a double-bundle hamstring tendon (HT) autograft.

METHODS

 Consecutive cases of revision ACLRs were reviewed. The Lysholm knee scale and Knee Osteoarthritis Outcome Score (KOOS) were recorded at the final follow-up. The pivot shift test, Lachman test, and anterior knee laxity measurement using an arthrometer were evaluated before revision ACLR and at final follow-up. Contralateral knee laxity was also evaluated, and side-to-side differences noted. The Lysholm knee scale, KOOS, the pivot shift test, Lachman test, and anterior knee laxity were compared between HT versus BPTB autograft recipient groups using the Mann-Whitney test or the t-test.

RESULTS

 Forty-one patients who underwent revision ACLR and followed up for at least 2 years were included. The graft source was a BPTB autograft in 23 patients (BPTB group) and a double-bundle HT autograft in 18 patients (HT group). The mean postoperative follow-up period was 44 ± 28 months in the BPTB group and 36 ± 18 in the HT group (p = 0.38). The HT group had significantly higher KOOS in the pain subscale (less pain) than the BPTB group at the final follow-up (BPTB group 84.2 vs. HT group 94.4; p = 0.02). The BPTB group showed significantly smaller side-to-side difference in anterior knee laxity (superior stability) than the HT group (0.3 vs. 2.6 mm; p < 0.01). The percentage of patients with residual anterior knee laxity in the BPTB group was significantly lower than that in the HT group (9.5% vs. 46.7%; odds ratio, 8.3; p = 0.02).

STUDY DESIGN

 This was a level 3 retrospective study.

CONCLUSION

 Revision ACLR with a BPTB autograft was associated with superior results regarding restoration of knee joint stability as compared with that with a double-bundle HT autograft, whereas double-bundle HT autograft was superior to BPTB autograft in terms of patient-reported outcomes of pain. The rest of the patient-reported outcomes were equal between the two groups.

Satisfaction with playing pre-injury sports 1 year after anterior cruciate ligament reconstruction using a hamstring autograft

BACKGROUND

Few studies have examined patient satisfaction with playing pre-injury sports after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to investigate patient satisfaction with playing pre-injury sport and identify factors associated with satisfaction.

METHODS

A total of 97 patients underwent unilateral ACL reconstruction using a hamstring autograft and returned to pre-injury sports 1 year after surgery. Patient satisfaction with playing pre-injury sport was assessed by a visual analog scale (VAS) and an ordinal four-grade scale. Problems related to the operated knee were also assessed. Knee muscle strength, single leg hop distance, knee laxity, subjective knee pain, and fear of movement/reinjury using Tampa Scale for Kinesiophobia-11 (TSK-11) were measured. Multivariate linear regression analysis was performed to determine the factors associated with patient satisfaction with playing pre-injury sport 1 year after surgery.

RESULTS

The average VAS score for patient satisfaction with playing pre-injury sports 1 year after surgery was 77.8 ± 20.2. Of the 97 patients, 87 patients (89.7%) answered "satisfied" or "mostly satisfied", whereas 51 patients (52.6%) had one or more problems. Multivariate linear regression analysis identified that the TSK-11 score was associated with patient satisfaction with playing a pre-injury sport 1 year after surgery.

CONCLUSION

Most of the patients who returned to pre-injury sports were satisfied with their outcomes. In contrast, approximately half of the patients had one or more problems after returning to play pre-injury sports. In particular, fear of movement/reinjury was significantly associated with patient satisfaction with playing pre-injury sport 1 year after surgery.

Factors Affecting the Satisfaction Levels of Patients who Underwent Orthopedic Knee Surgery in the Early Postoperative Period

The aim of this study was to investigate the effects of biopsychosocial parameters in the early postoperative period on the satisfaction of patients. Seventy-seven patients (female/male: 61/16, age: 40.28 ± 17.67 years) who underwent arthroscopic meniscectomy (n = 43), anterior cruciate ligament reconstruction (n = 25) and total knee arthroplasty (n = 9) were included in this study. The satisfaction levelwas evaluated using the Orthopedics Service Inpatient Satisfaction Survey (OTISS). In addition, the pain intensity, anxiety, depression, and independence level in daily living activities of the patients were evaluated. There was a very weak negative correlation between the anxiety and the satisfaction level with the physiotherapist and secretary (r: -0.274, p: 0.016; r:-0.265, p: 0.020). A very weak negative correlation was found between the pain intensity at activity and satisfaction with the nurse (r: -0.227, p: 0.048). There were very weak correlations between feeding and satisfaction with the physiotherapist (r: 0.292, p: 0.010), secretary (r: 0.285, p: 0.012), doctor (r: -0.269, p: 0.018), nurse (r: 0.300, p: 0.008) general satisfaction (r: 0.251, p: 0.028) and OTISS total score (r: -0.305, p: 0.007). In conclusion, the pain intensity, anxiety, and independence level in the early postoperative period were related to the satisfaction levels of patients who have undergone orthopedic knee surgery.

Patient-Reported Outcomes and Factors Associated with Achieving the Minimal Clinically Important Difference After ACL Reconstruction: Results at a Mean 7.7-Year Follow-up

Background

Analyzing outcomes and the minimal clinically important difference (MCID) after anterior cruciate ligament reconstruction (ACLR) is of increased interest in the orthopaedic literature. The purposes of this study were to report outcomes after ACLR at medium to long-term follow-up, identify the threshold preoperative outcome values that would be predictive of achieving the MCID postoperatively, and analyze outcome maintenance at medium to long-term follow-up after ACLR.

Methods

Active athletes who underwent ACLR were identified in an institutional ACL registry. Patient-reported outcome measures (PROMs) were administered preoperatively and at the 2-year and >5-year postoperative follow-up; measures included the International Knee Documentation Committee (IKDC) form, the 12-item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS), and Lysholm scale. We calculated the MCID from baseline to each of the 2 follow-up periods (2-year and mean 7.7-year). Logistic regression was performed to investigate factors associated with achievement of the MCID.

Results

A total of 142 patients (mean follow-up, 7.7 years [range, 6.6 to 9.1 years]) underwent ACLR. The mean age and body mass index at the time of surgery were 27.2 ± 13.0 years and 23.2 ± 3.0 kg/m2, respectively. Final postoperative outcome scores improved significantly from baseline for the IKDC (50.9 ± 14.7 to 87.9 ± 11.2), SF-12 PCS (41.6 ± 8.9 to 55.6 ± 3.2), and Lysholm scale (62.2 ± 17.6 to 90.5 ± 10.3) (p < 0.0001), while the SF-12 MCS did not improve significantly (54.2 ± 8.0 to 54.4 ± 6.0) (p = 0.763). Between 2- and >5-year follow-up, the SF-12 PCS showed significant improvement (54.6 ± 4.5 to 55.6 ± 3.2; p = 0.036), while no change was noted in the IKDC (87.6 ± 11.1 to 87.9 ± 11.2), SF-12 MCS (55.5 ± 5.3 to 54.4 ± 6.0), and Lysholm scale (89.8 ± 10.6 to 90.5 ± 10.3) (p ≥ 0.09). At the time of final follow-up, the MCID was achieved by 94.7% of patients for the IKDC, 80.8% for the Lysholm, 79.0% for the SF-12 PCS, and 28.2% for the SF-12 MCS. At 2-year follow-up, 95.3% of patients were either "very" or "somewhat" satisfied with their surgery, compared with 88.6% at the time of final follow-up.

Conclusions

We found a high level of maintained function following ACLR. The IKDC, SF-12 PCS, and Lysholm scores improved significantly after ACLR at the time of final follow-up and were not significantly different between follow-up periods. Approximately 95% and 89% of patients reported being satisfied with the outcome of surgery at the 2-year and final follow-up, respectively.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Predictors of two-year patient satisfaction following elective knee surgery

BACKGROUND

Patient satisfaction metrics are increasingly being utilized as tools to evaluate the quality of healthcare and affect reimbursements. The objectives of this study were to (1) identify factors associated with two-year patient satisfaction after elective knee surgery, (2) compare the Surgical Satisfaction Questionnaire-8 (SSQ-8) and a numeric satisfaction scale (NSS), and (3) determine if two-year patient satisfaction can be predicted based on preoperative factors.

METHODS

A total of 365 patients undergoing elective knee surgery at a single center were administered questionnaires to assess demographics, medical history, and various patient-reported outcomes preoperatively and at two years postoperatively. Patient satisfaction was measured at two years postoperatively with SSQ-8 and NSS. Bivariate and multivariate statistical analyses were performed to identify significant associations and independent predictors of satisfaction.

RESULTS

SSQ-8 and NSS scores were significantly correlated (r_s = 0.68, P < 0.0001). Lower SSQ-8 and NSS scores were associated with black race, higher BMI, more comorbidities, unemployment, smoking, higher ASA score, and greater Met Expectations (P < 0.05). Better scores on patient-based outcome measures and better improvement from baseline were significantly correlated with higher satisfaction on both SSQ-8 and NSS. Multivariable analysis identified greater Met Expectations and higher two-year Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference scores as independent predictors of greater SSQ-8 scores (adjusted r² = .52). Greater Met Expectations and better two-year PROMIS Social Satisfaction scores were independent predictors of NSS score (adjusted r² = .41). In contrast, when only preoperative variables were considered, the multivariable regression model accounted for only 14% of the variance in SSQ-8 and 6% of the variance in NSS.

CONCLUSION

While there are multiple preoperative factors that are associated with two-year patient satisfaction after knee surgery, those factors contribute relatively little to satisfaction. Meeting expectations and better patient-based outcomes at two years are more important.

Demographic and Perioperative Factors Associated With Patient-reported Outcomes Measurement Information System (PROMIS) Survey Completion

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

To evaluate independent demographic and perioperative factors associated with lower Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF) survey completion rates after spine surgery.

SUMMARY OF BACKGROUND DATA

There has not been a study evaluating factors related to PROMIS PF survey completion following spine surgery.

METHODS

Patients undergoing spine procedures were retrospectively reviewed. The number of PROMIS PF surveys that were completed at each time period and the number of surveys that were completed in succession starting with the first survey were tabulated and reported using descriptive statistics. Independent preoperative and perioperative factors associated with full survey completion up to the 12-month period were identified using χ analysis and Poisson regression with robust error variance. A final multivariate model was created using a backward, stepwise multivariate regression.

RESULTS

A total of 713 patients were included. Variables positively associated with PROMIS survey completion were aged above 60 years and Patient Health Questionnaire (PHQ)-9≥10. African Americans and Hispanics were negatively associated with survey completion. Postoperative day 0 narcotic use ≥50 oral morphine equivalents was positively associated with survey completion, while outpatient surgical setting and high preoperative radicular arm/leg pain were negatively associated with survey completion. In the final multivariate model, depression was the only variable that was positively associated, while both outpatient surgical setting and high preoperative radicular arm/leg pain were negatively associated with survey completion.

CONCLUSION

This study identified demographic and perioperative variables associated with PROMIS survey completion and response rates. Patients who underwent surgery in the outpatient setting and those with high preoperative radicular limb pain were less likely to complete surveys. Interestingly, patients with clinical signs of depression were more likely to fill out surveys. Understanding variables associated with survey completion may provide the clinician with insight into which demographic groups are the most at-risk for not responding to surveys.

Patient Satisfaction After Total Shoulder Arthroplasty

Although patient-reported outcome measures use objective evaluations of impairment to focus on subjective responses, these measures may not necessarily reflect patient satisfaction with the outcome or the care provided. The goal of this study was to systematically review the available literature to assess patient satisfaction after total shoulder arthroplasty. Two investigators systematically reviewed the MEDLINE database for articles on satisfaction after this procedure. This study included 47 articles. The most commonly used method for assessing satisfaction was an ordinal scale (27 studies, 57.4%). Of the studies, 27 (57.5%) differentiated between patient satisfaction with the care provided and with the outcome achieved. Reported satisfaction rates after anatomic total shoulder arthroplasty ranged from 75% to 100%. For the included studies, increasing age, workers' compensation status, depression, opioid use, and visual analog scale pain score were the only preoperative factors that were significantly associated with worse postoperative satisfaction. Postoperative American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, Subjective Shoulder Value score, Short Form-36 mental component score, range of motion, visual analog scale pain score, and ability to perform activities of daily living showed a significant association with postoperative satisfaction. Studies of satisfaction after total shoulder arthroplasty are of low evidence levels. Although overall patient satisfaction is high, there is no standardized method for measuring satisfaction. For the identified studies, the most common assessment method was an ordinal scale that consists of qualitative values representing increasing levels of satisfaction. Orthopedic surgeons are increasingly expected to demonstrate the value of procedures, and a uniform and validated method of assessing patient satisfaction is needed. [Orthopedics. 2020;43(6):e492-e497.].

Development and Validation of the Hospital for Special Surgery Anterior Cruciate Ligament Postoperative Satisfaction Survey

PURPOSE

To develop and validate a standardized patient satisfaction measurement tool for adult patients undergoing primary anterior cruciate ligament reconstruction (ACLR).

METHODS

A 4-phase iterative process that included item generation and pilot survey development, item reduction, survey readability, and survey validation was used. To develop and validate the Hospital for Special Surgery ACL Satisfaction Survey (HSS ACL-SS), 70 patients were included in the survey development phase and 77 patients were included in the validation phase. The HSS ACL-SS was compared with other currently used ACLR outcome measures including the International Knee Documentation Committee score, Tegner-Lysholm score, Short Form 12 (SF-12) Mental Component Score, and SF-12 Physical Component Score. Test-retest reliability, internal consistency, convergent and discriminant validity, and floor and ceiling effects were assessed.

RESULTS

The HSS ACL-SS consists of 10 items identified by patients as being important for satisfaction after ACLR. In the validation phase, the mean score on the HSS ACL-SS (of 50) among all patients was 37.9 ± 9.9 (range, 10-50). Statistically significant positive correlations were seen between the HSS ACL-SS score and the International Knee Documentation Committee score (r = 0.351, P = .002) and Tegner-Lysholm score (r = 0.333, P = .003). No statistically significant correlation was found between the satisfaction score and the SF-12 Mental or Physical Component Score. The lowest possible score (10 of 50 points) was achieved in 1 patient (1.3%) and the highest possible score (50 of 50 points) was achieved in 7 patients (9.1%), indicating no significant floor or ceiling effects of the instrument. Internal consistency for all 10 items was strong (Cronbach α, 0.995). The mean intraclass correlation coefficient between test and retest responses was 0.701, indicating moderate agreement.

CONCLUSIONS

The HSS ACL-SS is a validated and reliable patient-derived satisfaction measure with excellent psychometric properties for active adults undergoing ACLR. The results of this study show that the HSS ACL-SS may be a useful tool to measure postoperative patient satisfaction.

LEVEL OF EVIDENCE

Level II, development of diagnostic or monitoring criteria in consecutive patients.

Editorial Commentary: The Hospital for Special Surgery Anterior Cruciate Ligament Postoperative Satisfaction Survey-Just Another Scoring System or a Step Forward? "You Can't Always Get What You Want"

An interesting, easy-to-use scoring system to evaluate the results after anterior cruciate ligament reconstruction developed at the Hospital for Special Surgery-the Hospital for Special Surgery Anterior Cruciate Ligament Post-operative Satisfaction Survey (HSS ACL-SS) score-is presented in this issue. The score can be used both for a physical follow-up and for a web-based questionnaire. It appears to have the opportunity to replace older scores that are more complicated to complete.

Wide Variability in Patient-Reported Outcomes Measures After Fusion for Lumbar Spinal Stenosis: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

The purpose of this study is to review outcomes reporting methodology in studies evaluating fusion for lumbar spinal stenosis.

METHODS

A systematic review of PubMed and Embase databases was conducted from January 2007 to June 2017 for English language studies with minimum of 2 years postoperative follow-up reporting outcomes after fusion for lumbar spinal stenosis. Two reviewers assessed each study; those meeting inclusion criteria were examined for pertinent data. Outcome measures were categorized into relevant domains: pain/symptomatology, function/disability, and surgical satisfaction. Return to work reporting was also recorded.

RESULTS

Of 123 studies meeting inclusion criteria, 76% included posterior-only fusion, 32% included posterior/transforaminal interbody fusion, and 5% included anterior/lateral interbody fusion (non-mutually exclusive). There was significant variation in patient-reported outcomes (PROs) used-studies reported 31 unique PROs assessing at least one domain: 22 evaluating pain, 23 evaluating function, and 3 evaluating surgical satisfaction. Most commonly utilized PROs were the Oswestry Disability Index (73% of studies), Visual Analog Scale (55%), and 36-Item Short Form Survey (32%). The remaining 28 measures were used in 14% of studies or fewer. PROs specific to symptoms of lumbar spinal stenosis, such as the Zurich Claudication Questionnaire, were only used rarely (7/123 studies). Only 14% of studies reported on time to return to work.

CONCLUSIONS

The literature surrounding fusion in the setting of lumbar stenosis is characterized by substantial variability in outcomes reporting. Very few studies utilized measures specific to lumbar spinal stenosis. Efforts to standardize outcomes reporting would facilitate comparisons of surgical interventions.

Timeline for Maximal Subjective Outcome Improvement After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) tears are one of the most common traumatic knee injuries experienced by athletes. Return to sport is considered the pinnacle endpoint among patients receiving ACL reconstruction. However, at the time of return to sport, patients may not be participating at their previous levels of function, as defined by clinical metrics.

PURPOSE

To establish when patients perceive maximal subjective medical improvement according to patient-reported outcome measures (PROMs).

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the PubMed database was conducted to identify studies that reported sequential PROMs up to a minimum of 2 years after ACL reconstruction. Pooled analysis was conducted for PROMs at follow-up points of 3 months, 6 months, 1 year, and 2 years. Clinically significant improvement was determined between pairs of intervals with the minimal clinically important difference.

RESULTS

This review contains 30 studies including 2253 patients who underwent ACL reconstruction. Clinically significant improvement in the KOOS (Knee injury and Osteoarthritis Outcome Score) was seen up to 1 year after ACL reconstruction, but no clinical significance was noted from 1 to 2 years. Clinically significant improvement in the IKDC (International Knee Documentation Committee) and Lysholm questionnaires was seen up to 6 months postoperatively, but no clinical significance was noted beyond that.

CONCLUSION

After ACL reconstruction, maximal subjective medical improvement is established 1 year postoperatively, with no further perceived clinical improvement beyond this time point according to current PROMs. The KOOS may be a more responsive metric to subjective improvements in this patient cohort than other patient-reported outcomes, such as the IKDC and Lysholm.

CLINICAL RELEVANCE

After ACL reconstruction, patients perceive interval subjective improvements until 1 year postoperatively.

Arthroscopic Labral Treatment in Adolescents: Clinical Outcomes With Minimum 5-Year Follow-up

BACKGROUND

The success of hip arthroscopy has led to increased application in younger populations. However, hip arthroscopy remains a challenging procedure, and its safety and efficacy in the adolescent population have been controversial. Most existing literature on outcomes in such patients contains only short-term follow-up, and a paucity of evidence is available regarding long-term outcomes in adolescents.

PURPOSE

To report on clinical outcomes at a minimum 5-year follow-up in patients younger than 18 years who underwent arthroscopic treatment of labral tears.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients younger than 18 years who underwent hip arthroscopy in a tertiary hip preservation setting at a single institution. Patients were excluded if they had previous ipsilateral hip conditions or surgery. All patients underwent either labral repair or debridement for treatment of a labral tear. Patient-reported outcome measures were recorded at 3 months and at 1, 2, or a minimum of 5 years. These included the modified Harris Hip Score (mHHS), Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale (HOS-SSS), visual analog scale, and patient satisfaction. Additionally, the abbreviated International Hip Outcome Tool and Short Form Health Survey were collected at latest follow-up.

RESULTS

The study included 44 hips in 32 patients that underwent arthroscopic labral repair (86.4%) or labral debridement (13.6%) between April 2008 and April 2011, with latest follow-up at a mean of 69.2 months (range, 60.0-89.9 months) postoperatively. The average age at surgery was 16.3 years (range, 14.2-17.9 years), and 39 hips from female patients. Statistically significant improvements were seen in all patient-reported outcome measures from preoperative to minimum 5-year follow-up. Improvements were noted at 1-year follow-up and maintained at minimum 5-year follow-up. At the latest follow-up, the Patient Acceptable Symptomatic State was achieved in 95.5% of patients for the mHHS and 72.7% for the HOS-SSS. Two patients subsequently underwent secondary arthroscopy on the ipsilateral hip; however, the survivorship of all hips was 100%.

CONCLUSION

Hip arthroscopy for the treatment of labral tears in adolescents remains a technically challenging procedure that should be approached with appropriate caution. The results of the present study on a population treated in a specialized hip preservation center demonstrate that hip arthroscopy is a safe procedure with stable improvement in patient-reported outcome measures at 5 years.

Outcome of isolated posterior cruciate ligament reconstruction at mean 6.3-year follow up: a consecutive case series

OBJECTIVES

There is a paucity of reporting on surgical outcomes of isolated posterior cruciate ligament reconstruction (PCLR). We hypothesize that isolated PCL injuries failing nonoperative treatment achieve good outcomes and are able to return to sport following PCLR.

METHODS

A retrospective analysis was performed to identify patients with isolated PCL injuries that underwent reconstruction between 2001 and 2014. Patients with multi-ligamentous injury or another concomitant knee pathology were excluded. Medical records were reviewed for demographic, clinical and operative data. Patients were contacted for administration of a telephone-based questionnaire which included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form, Lysholm-Tegner scales, Marx activity scale (MAS), return to sport status, and patient satisfaction instruments.

RESULTS

A total of 15 isolated PCL reconstructions in 14 patients with a mean age of 27.5 years (range 17-43) met the study inclusion criteria; mean follow up was 6.3 years (range 1.4-15.2). Pre-operatively, the primary complaint was knee instability in all patients; on physical examination, lack of a firm end point during posterior drawer testing was found in 93% (14/15) of the knees. In total, 12 of 15 knees underwent transtibial, single-bundle PCLR and three of 15 underwent tibial inlay, double bundle PCLR. Graft types included: quadriceps autograft (7/15), Achilles allograft (6/15), and hamstring autograft (2/15). There were no graft failures in our patient cohort. At most recent follow up the mean scores respectively on the IKDC form, Lysholm-Tegner scales and MAS were (standard deviation): 77.3 (16.5), 83.1 (17.9), 6.13 (2.6), and 7.1 (6.0). All fourteen patients were athletes prior to their injury and 79% (11/14) returned to sport and overall patient satisfaction was 9.2/10.

CONCLUSIONS

Isolated PCLR provides good outcomes at mean medium-term follow up with restoration of function, high rate of return to sport and overall patient satisfaction.

Patient Satisfaction After Total Knee Replacement: A Systematic Review

BACKGROUND

The quality and state of satisfaction reporting after total knee replacement (TKR) is variable.

QUESTIONS/PURPOSES

The purposes of this systematic review were (1) to examine the available literature on patient satisfaction after TKR, (2) to evaluate the quality of available evidence, and (3) to identify predictors of patient satisfaction after TKR.

METHODS

A systematic review of the MEDLINE database was performed. The initial search yielded 1219 studies. The inclusion criteria were English language, clinical outcome study with primary outcome related to TKR for osteoarthritis, and patient-reported satisfaction included as an outcome measure. Studies were assessed for demographics, methodology for reporting satisfaction, and factors influencing satisfaction.

RESULTS

Two hundred eight studies, including 95,560 patients who had undergone TKR, met all inclusion and exclusion criteria; 112 (53.8%) of these studies were published in the past 3 years. Satisfaction was most commonly measured using an ordinal scale. Twenty-seven studies (13%) used a validated satisfaction survey. Eighty-three percent of studies reported more than 80% satisfaction. The most commonly reported predictor of satisfaction was post-operative patient-reported functional outcome. Pre-operative anxiety/depression was the most common pre-operative predictor of dissatisfaction.

CONCLUSION

There are numerous studies reporting patient satisfaction after TKR, and publication on the topic has been increasing over the past decade. However, the majority of studies represent lower levels of evidence and use heterogeneous methods for measuring satisfaction, and few studies use validated satisfaction instruments. In general, the majority of studies report satisfaction rates ranging from 80 to 100%, with post-operative functional outcome and relief of pain being paramount determinants for achieving satisfaction.

Clinical Outcomes, Return to Sports, and Patient Satisfaction After Anterior Cruciate Ligament Reconstruction in Young and Middle-Aged Patients in an Asian Population-A 2-Year Follow-up Study

PURPOSE

To compare the clinical outcomes of arthroscopic anterior cruciate ligament (ACL) reconstruction in young and middle-aged Asians.

METHODS

A retrospective study was performed using prospectively collected data from a tertiary institution ACL registry. All Asian patients with ACL tears who underwent primary arthroscopic ACL reconstruction by a single surgeon between 2008 and 2014, with minimum 2-year follow-up, were included. Patients with previous knee surgery or multiligamentous knee injuries were excluded. Two groups were formed: young patients (YP) (age <30) and middle-aged patients (MP) (age >40). They were compared preoperatively and 6 months, 1 year, and 2 years postoperatively for demographics, knee range of motion, anterior laxity, Tegner level, Lysholm and International Knee Documentation Committee grade, ability to return to preinjury level of activity, and patient satisfaction.

RESULTS

YP (n = 84) and MP (n = 22) had differences in mean age (YP = 23.1 years, range 18-29 years; MP = 46.4 years, range 41-59 years, P < .001), preinjury Tegner level (YP = 7.4, MP = 6.4, P = .005), and preoperative Lysholm scores (YP = 65.3, MP = 53.0, P = .034). The incidence of meniscal and chondral injuries was similar. Two years postoperatively, both groups had comparable knee range of motion and anterior laxity. The Tegner score was different (YP = 6.3, MP = 5.2, P = .028), but the proportion of patients returning to preinjury Tegner level (YP = 45.2%, MP = 46.9%, P = .812), Lysholm scores (YP = 92.5, MP = 93.8, P = .794), proportion of patients with knees rated International Knee Documentation Committee A/B (YP = 77.4%, MP = 81.8%, P = .777), and satisfaction levels (YP = 98.5%, MP = 94.1%, P = .370) were similar. There were no graft ruptures or reoperations.

CONCLUSIONS

In an Asian, predominantly male population, the clinical outcomes of arthroscopic ACL reconstruction in YP and MP are equally good at 2-year follow-up. MP can benefit as much as younger patients from ACL reconstruction in terms of restoration of knee function and return to preinjury activity level, are equally satisfied with outcomes, and should not be excluded from surgery on the basis of age alone.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The role of ultrasonography in the diagnosis of anterior cruciate ligament injury: A systematic review and meta-analysis

To evaluate the value of ultrasonography in the diagnosis of anterior cruciate ligament injury (ACL injury) by conducting a systematic review and meta-analysis. A literature search was carried out in the Cochrane Library, Embase, Pubmed databases and included studies prior to April 2017. Based on inclusion and exclusion criteria, studies evaluating ultrasound to diagnose ACL injury were selected. MRI, arthroscopy and clinical-follow were considered the reference standards. The diagnostic accuracy of ultrasound was assessed using a combination of sensitivity, specificity, likelihood ratio (LR), post-test probability, diagnostic odds ratio (DOR) and by summarizing the area under the receiver operating characteristic (SROC) curve. A total of 4 studies involving 246 patients were eventually included in the analysis. In these four studies, the combined sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, post-test probability and DOR were 90.0% (95% CI: 77-96), 97% (95% CI: 90-99), 31.08 (95% CI: 8.75-110.41), 0.11 (95% CI: 0.05-0.24), 89% (3%) and 288.81 (95% CI: 78.51-1062.48), respectively. The area under the SROC curve was 0.98 (95% CI: 0.97-0.99). Our meta-analysis showed that ultrasound can play an important role in the diagnosis of ACL injury. Because of its high sensitivity, high specificity and high diagnostic ability, ultrasound should be a part of the standard diagnostic work-up of an ACL injury.