Resilience in the Orthopaedic Patient

The Effect of Patient Resilience on Postoperative Scores After One- and Two-Level Anterior Cervical Discectomy and Fusion

OBJECTIVE

To investigate the association between resilience and outcomes of pain and neck-related disability after single- and double-level anterior cervical discectomy and fusion (ACDF).

METHODS

Patients who underwent single- or double-level ACDF were sent a survey between 6 months and 2 years after surgery. The survey included the Brief Resilience Scale (BRS), visual analogue scale (VAS) for pain, Neck Disability Index (NDI), and Pain Self-Efficacy Questionnaire (PSEQ-2). Patients completed the VAS and NDI twice, once describing preoperative pain and disability and once describing current pain and disability. Respondents were classified as high resilience (HR), medium resilience (MR), or low resilience (LR). Demographics, PSEQ-2 scores, pre- and postoperative VAS and NDI scores, and change in VAS (ΔVAS) and NDI (ΔNDI) scores were compared between groups.

RESULTS

Thirty-three patients comprised the HR group, 273 patients comprised the MR group, and 47 patients comprised the LR group. All groups demonstrated postoperative improvement in VAS and NDI scores that exceeded previously established MCID values. The HR group demonstrated greater improvement in pain compared with the LR group (ΔVAS: -5.8 for HR vs. -4.4 for LR, P = 0.05). Compared with the MR group, the LR group demonstrated greater postoperative pain (VAS: 3.2 for LR vs. 2.5 for MR, P = 0.02) and disability (NDI: 11.9 for LR vs. 8.6 for MR, P = 0.02).

CONCLUSIONS

Patients demonstrated improvement in pain and neck-related disability after single- and double-level ACDF, regardless of resilience score. Patients with greater resilience may be expected to demonstrate more improvement in pain after ACDF.

Association Between Preoperative Patient Resilience and Patient-Reported Outcomes After Rotator Cuff Repair

Background

Mental and emotional health can affect outcomes after orthopaedic surgery, and patient resilience has been found to be significantly related to postoperative functional outcomes.

Purpose

To evaluate the relationship between preoperative patient resilience and 2-year postoperative patient-reported outcomes after rotator cuff repair (RCR). It was hypothesized that patients with low preoperative resilience will have worse patient-reported outcomes at 2 years after RCR versus those with high resilience.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent primary arthroscopic RCR in 2020 at a single institution and completed the Brief Resilience Scale (BRS) preoperatively were identified. Other inclusion criteria were American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores at the 2-year follow-up. Outcomes were compared in patients as divided into low resilience (BRS score >1 SD below the mean), normal resilience (BRS score ≤1 SD of the mean), and high resilience (BRS score >1 SD above the mean) groups.

Results

Overall, 100 patients (52 male, 48 female; mean age, 60 ± 9 years) were included in this study. Mean BRS scores did not change significantly from preoperative to 2-year follow-up (3.8 ± 0.7 vs 3.9 ± 0.8, P = .404). All patients had preoperative ASES scores. Low-resilience patients (n = 17) had significantly lower preoperative ASES scores compared with normal (n = 64) and high resilience (n = 19) patients (35 vs 42 vs 54, respectively; P = .022). There were no significant group differences in postoperative outcomes (revision rate, ASES score, ASES score improvement from preoperative to 2-year follow-up, or SANE score). Multivariate analysis indicated that preoperative resilience was not significantly associated with ASES score improvement (β estimate = -5.64, P = .150), while resilience at 2-year follow-up was significantly related to ASES score improvement (β estimate = 6.41, P = .031).

Conclusion

Patient-reported outcomes at 2-year follow-up did not differ based on preoperative patient resilience for arthroscopic RCR patients. Multivariate analysis also showed that preoperative resilience was not associated with improvement in ASES scores; however, resilience at 2-year follow-up was associated with ASES score improvement.

Anatomic shoulder arthroplasty: the correlation between patient resilience, mental health, and outcome

BACKGROUND

Recovery from anatomic shoulder arthroplasty may be enhanced in patients with good mental health and the resilience to participate in the prescribed postoperative rehabilitation program. To test this concept, we utilized validated and reliable scales in determining whether resilience and mental health are associated with the outcome of anatomic arthroplasty.

METHODS

Three hundred ninety-nine patients (195 ream and run [RnR] and 204 anatomic total shoulder arthroplasty [aTSA]) were surveyed at a mean follow-up of 6.3 ± 3.3 years. Preoperative variables included age, sex, body mass index, history of prior shoulder surgery, diabetes, visual analog scale for pain, Simple Shoulder Test (SST) scores, and Veteran's RAND 12 Mental Component Score (VR-12 MCS). Outcomes collected included the SST, American Shoulder and Elbow Surgeons (ASES) score, revision rate, and patient satisfaction. Resilience was documented using the Connor-Davidson Resilience Scale 10 (CD-RISC 10) at latest follow-up. Univariable and multivariable regression analyses were used to identify factors significantly associated with follow-up postoperative SST, ASES, and satisfaction.

RESULTS

In the univariable analysis, CD-RISC 10 was positively correlated with postoperative SST, ASES, and satisfaction after both RnR and aTSA. The mean CD-RISC 10 scores were higher in the RnR cohort (34.3 ± 4.8 vs. 32.5 ± 6.2 for aTSA, P < .001). Male sex and lower preoperative visual analog scale for pain were correlated with higher ASES after RnR; VR-12 MCS was positively correlated with all outcomes except SST after RnR. In the multivariable linear regression analysis, CD-RISC 10 was independently associated with postoperative SST, ASES and satisfaction scores in aTSA patients. In the RnR cohort, CD-RISC 10 was only correlated with satisfaction. VR-12 MCS was correlated with ASES and satisfaction after RnR.

DISCUSSION

In this study of anatomic arthroplasties, increased resilience and better mental health were correlated with better outcomes. RnR patients had higher resilience than aTSA patients. Greater resilience was associated with better outcomes after aTSA. Better mental health was associated with superior outcomes after the ream and run procedure.

Preoperative Resilience and Improvement in Patient-Reported Outcomes After Lumbar Spinal Fusion

BACKGROUND

It is incompletely understood how preoperative resilience affects 1-year postoperative outcomes after lumbar spinal fusion.

METHODS

Patients undergoing open lumbar spinal fusion at a single-center institution were identified between November 2019 and September 2022. Preoperative resilience was assessed using the Brief Resilience Scale. Demographic data at baseline including age, gender, comorbidities, and body mass index (BMI) were extracted. Patient-reported outcome measures including Oswestry Disability Index, PROMIS (Patient-Reported Outcomes Measurement Information System) Global Physical Health, PROMIS Global Mental Health (GMH), and EuroQol5 scores were collected before the surgery and at 3 months and 1 year postoperatively. Bivariate correlation was conducted between Brief Resilience Scale scores and outcome measures at 3 months and 1 year postoperatively.

RESULTS

Ninety-three patients had baseline and 1 year outcome data. Compared with patients with high resilience, patients in the low-resilience group had a higher percentage of females (69.4% vs. 43.9%; P = 0.02), a higher BMI (32.7 vs. 30.1; P = 0.03), and lower preoperative Global Physical Health (35.8 vs. 38.9; P = 0.045), GMH (42.2 vs. 49.2; P < 0.001), and EuroQol scores (0.56 vs. 0.61; P = 0.01). At 3 months postoperatively, resilience was moderately correlated with GMH (r = 0.39) and EuroQol (r = 0.32). Similarly, at 1 year postoperatively, resilience was moderately correlated with GMH (r = 0.33) and EuroQol (r = 0.34). Comparable results were seen in multivariable regression analysis controlling for age, gender, number of levels fused, BMI, Charlson Comorbidity Index, procedure, anxiety/depression, and complications.

CONCLUSIONS

Low preoperative resilience can negatively affect patient-reported outcomes 1 year after lumbar spinal fusion. Resiliency is a potentially modifiable risk factor, and surgeons should consider targeted interventions for at-risk patient groups.

Resilience as a psychiatric factor affecting outcomes after total joint arthroplasty: a systematic review

INTRODUCTION

Mental and psychiatric status continue to be underscreened prior to total joint arthroplasty (TJA). Research on the role of resilience as a psychiatric factor affecting TJA outcomes remains limited. Therefore, our systematic review sought to evaluate the impact of patient resilience in TJA.

METHODS

A systematic review of the literature from the Pubmed, MEDLINE, EBSCOhost, and Google Scholar online databases was performed in abidance with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Studies reporting on outcomes following primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) segregated by patient resilience were included. Case reports, reviews, meta-analyses, and conference abstracts were excluded. Primary outcomes of interest included patient-reported outcomes (PROs), surgical outcomes, and postoperative opioid consumption.

RESULTS

Twelve articles were included reporting on a total of 1,577 TJAs. There was a strong agreement that the Patient Reported Outcomes Measurement Information System (PROMIS)-Physical Health and Mental Health components were strongly predicted by patient resilience. However, there was inconclusive evidence regarding the impact of resilience on UCLA Activity Scales (UCLA) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) outcomes as well as postoperative hip and knee function. Similarly, conflicting evidence was presented regarding the effect of resilience on length of stay (LOS). Greater resilience was associated with reduced opioid usage in the immediate inpatient postoperative period. However, resilience had no significant effect on opioid requirements in the postoperative outpatient follow-up time frame.

CONCLUSION

The present analysis demonstrated mixed, inconclusive evidence regarding the impact of resilience on postoperative outcomes. The paucity of research evaluating this relationship warrants further investigation, examining both short and long-term outcomes. Due to the limited literature evaluating resilience as a predictor of outcomes following TJA, we cannot definitively rule out resilience as a valuable metric and must further examine its utility as a preoperative screening tool.

LEVEL OF EVIDENCE

III.

Patient Resilience Does Not Conclusively Affect Clinical Outcomes Associated With Arthroscopic Surgery but Substantial Limitations of the Literature Exist

Purpose

To determine whether low resilience is predictive of worse patient-reported outcomes (PROs) or diminished improvements in clinical outcomes after joint preserving and arthroscopic surgery.

Methods

A comprehensive search of PubMed, Medline, Embase, and Science Direct was performed on September 28, 2022, for studies investigating the relationship between resilience and PROs after arthroscopic surgery in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines.

Results

Nine articles (level II-IV studies) were included in the final analysis. A total of 887 patients (54% male, average age 45 years) underwent arthroscopic surgery, including general knee (n = 3 studies), ACLR-only knee (n = 1 study), rotator cuff repair (n = 4 studies), and hip (n = 1 study). The Brief Resilience Scale was the most common instrument measuring resilience in 7 of 9 studies (78%). Five of 9 studies (56%) stratified patients based on high, normal, or low resilience cohorts, and these stratification threshold values differed between studies. Only 4 of 9 studies (44%) measured PROs both before and after surgery. Three of 9 studies (33%) reported rates of return to activity, with 2 studies (22%) noting high resilience to be associated with a higher likelihood of return to sport/duty, specifically after knee arthroscopy. However, significant associations between resilience and functional outcomes were not consistently observed, nor was resilience consistently observed to be predictive of subjects' capacity to return to a preinjury level of function.

Conclusions

Patient resilience is inconsistently demonstrated to affect clinical outcomes associated with joint preserving and arthroscopic surgery. However, substantial limitations in the existing literature including underpowered sample sizes, lack of standardization in stratifying patients based on pretreatment resilience, and inconsistent collection of PROs throughout the continuum of care, diminish the strength of most conclusions that have been drawn.

Level of Evidence

Level IV, systematic review of level II-IV studies.

Assessing the properties of patient-specific treatment effect estimates from causal forest algorithms under essential heterogeneity

BACKGROUND

Treatment variation from observational data has been used to estimate patient-specific treatment effects. Causal Forest Algorithms (CFAs) developed for this task have unknown properties when treatment effect heterogeneity from unmeasured patient factors influences treatment choice - essential heterogeneity.

METHODS

We simulated eleven populations with identical treatment effect distributions based on patient factors. The populations varied in the extent that treatment effect heterogeneity influenced treatment choice. We used the generalized random forest application (CFA-GRF) to estimate patient-specific treatment effects for each population. Average differences between true and estimated effects for patient subsets were evaluated.

RESULTS

CFA-GRF performed well across the population when treatment effect heterogeneity did not influence treatment choice. Under essential heterogeneity, however, CFA-GRF yielded treatment effect estimates that reflected true treatment effects only for treated patients and were on average greater than true treatment effects for untreated patients.

CONCLUSIONS

Patient-specific estimates produced by CFAs are sensitive to why patients in real-world practice make different treatment choices. Researchers using CFAs should develop conceptual frameworks of treatment choice prior to estimation to guide estimate interpretation ex post.

Females show worse functional outcome and quality of life compared to males 2 years after meniscus surgery: Data analysis from the German Arthroscopy Registry

PURPOSE

The purpose of this study was to investigate the impact of sex on knee function, activity and quality of life following meniscus surgery using data from the German Arthroscopy Registry.

METHODS

This is a retrospective cohort study with data collected between 2017 and 2022. Patient-reported outcome measures (PROMs), namely Knee Injury and Osteoarthritis Outcome Score (KOOS), EuroQol Visual Analogue Scale (EQ Scale), and Marx Activity Rating Scale (MARS), were collected preoperatively and at 6, 12 and 24 months postoperatively. Data were analysed to examine differences between male and female patients regarding PROMs, pre-existing conditions, meniscus lesion types and surgical treatments.

RESULTS

A total of 1106 female (36.6%) and 1945 male patients (63.7%) were included. Males were significantly younger than females and had a higher body mass index. Overall, there were four times more medial meniscus lesions (MMLs) (77.5%) than lateral meniscus lesions (LMLs) (27.9%). Degenerative LMLs were more frequent in females, while traumatic LMLs were more common in males. Frequencies of traumatic and degenerative MMLs were similar among males and females. Males had higher absolute KOOS irrespective of treatment or meniscus lesion type. Meniscus repair resulted in similar improvements in ΔKOOS for both sexes, while meniscus resection exhibited higher absolute KOOS for males at each time point. Males generally had higher EQ Scale and MARS than females.

CONCLUSION

Greater improvements in knee function, activity and quality of life were observed in males. While MMLs appear to be comparable among sexes, the nature of LML differed significantly. These results may help surgeons to refine patient selection for specific treatments to improve overall clinical outcomes.

LEVEL OF EVIDENCE

Level III.

Analyzing Resilience in the Orthopedic Sports Medicine Patient Population

Little research has been done to compare resilience, as measured by the Brief Resilience Scale (BRS), across common sports medicine patient populations. Our purpose was to investigate resilience levels across sports medicine patient populations. All patients who underwent reconstruction of the anterior cruciate ligament (ACLR), partial meniscectomy (PM), meniscal repair (MR), rotator cuff repair (RCR), or shoulder stabilization (SS) between January 1 and June 30, 2020, were screened for inclusion. At our institution, BRS scores are routinely collected during the preoperative period. Patients with preoperative BRS scores available were included for analysis. Patients who were eligible on the basis of ACLR who underwent concomitant PM or MR were included in the ACL group. A total of 655 patients with a median age of 49 years were included in analysis. The median preoperative resilience score across all patients was 3.83 (interquartile range, 3.50-4.17), and the highest scores were seen in the ACLR group (median, 4.00; interquartile range, 3.67-4.17). On multivariate regression, scores were significantly and independently lower in the PM and RCR groups. Male patients were found to have significantly higher scores than female patients overall (P=.028), but in subgroup analysis by pathology, this effect was only seen in the SS and PM groups. Psychological factors are important to consider when surgically treating patients, and resilience specifically may play a role in predicting treatment success. Patients undergoing PM and RCR tend to report lower resilience scores than patients undergoing ACLR at preoperative baseline. [Orthopedics. 2024;47(2):95-100.].

Low Preoperative Brief Resilience Scale Scores Are Associated With Inferior Preoperative and Short-Term Postoperative Patient Outcomes Following Primary Autograft Anterior Cruciate Ligament Reconstruction

Purpose

To assess preoperative Brief Resilience Scale (BRS) scores as they relate to postoperative patient outcomes following primary autograft anterior cruciate ligament reconstruction (ACLR).

Methods

All patients who underwent primary autograft ACLR from 2016 to 2021 and had a patient-reported follow-up of 1 year and a clinical follow-up of 6 months were included in final data analysis. Patients completed validated PROMs pre- and postoperatively. All patients were objectively assessed with range of motion (ROM) and KT-1000 arthrometer testing. Return to sport (RTS) data were obtained for all applicable patients. Patients were divided into 3 groups based on ± ½ the standard deviation for the mean preoperative BRS score.

Results

In total, 170 patients who underwent primary autograft ACLR with a mean age of 20.1 years (range, 13-57 years) and a mean final follow-up time of 2.9 years (range, 1.0-5.8 years) were included in the final analysis. The mean preoperative BRS scores for the high-resilience (HR, n = 67), average-resilience (AR, n = 42), and low-resilience (LR, n = 61) groups were 28.1 (95% CI, 27.8-28.9), 24.5 (95% CI, 24.3-24.6), and 21.1 (95% CI, 20.5-21.7), respectively (P < .001). The HR group demonstrated significantly higher preoperative and postoperative patient-reported outcome measures (PROMs) compared to the AR and LR groups, with more differences seen with the LR group. The HR group demonstrated better knee extension in postoperative month 3 compared to the LR group (0.6° [95% CI, -1.2° to 0.1°] vs -2.3° [95% CI, -3.3° to -1.3°], P = .006). The HR group demonstrated a faster RTS time compared to the LR group (6.4 months [95% CI, 6.1-6.7] vs 7.6 months [95% CI, 7.1-8.1], P = .002). No differences were seen in RTS rate, knee flexion, or KT-1000 arthrometer measurements between the 3 groups.

Conclusions

Low preoperative BRS scores were associated with inferior PROMs preoperatively and in the short-term postoperative period compared to those with higher preoperative BRS scores. Additionally, patients with lower preoperative BRS scores demonstrated a higher degree of knee extension loss 3 months postoperatively as well as a slower RTS.

Level of Evidence

Level III, retrospective cohort study.

Patient-Reported Outcomes Following Open Broström-Gould Procedure: Minimum 5-Year Follow-Up

Background

Ankle sprains are a common musculoskeletal injury among the general population and often involve the lateral ligament complex. Although the majority of ankle sprains are treated successfully with nonsurgical conservative measures, an estimated 5% to 20% of ankle injuries ultimately develop chronic lateral ankle instability (CAI). Multiple surgical treatment modalities for the lateral ankle complex exist, such as anatomical and nonanatomical reconstruction. The current gold standard for primary surgical repair is the Broström-Gould procedure. This is the first article to provide PROMIS scores following BG and the largest study with 5-year outcomes for an open BG.

Methods

This was a descriptive study of a retrospective cohort of patients undergoing a BG with a minimum follow-up of 5 years. Patient-reported outcome instruments collected postoperatively were PROMIS Pain, Physical Function, Depression, and FAAM. Further preoperative clinic characteristics were analyzed to correlate with the final outcome. The electronic medical record was queried for Current Procedural Terminology (CPT) code 27698 (Broström-Gould) from January 2010 to June 2017. Surveys were conducted in the clinic and through phone interviews. Patient charts were reviewed to obtain basic patient demographic information including sex, age, race, and body mass index (BMI). The following preoperative variables were recorded: history of prior CAI procedures, history of major trauma, duration of symptoms, number of diagnosed ankle sprains, other collagen pathologies, generalized ligament laxity, participation in sports/activity level, peroneal subluxation, clinically diagnosed peroneus longus or brevis tendinopathy, deltoid ligament injury, anterior ankle impingement, and posterior ankle impingement. The PROMIS and Foot and Ankle Ability Measure (FAAM) scores were obtained with a combination of clinic and phone interviews. Data were aggregated in Microsoft Excel and entered in R (version 4.2.0) for statistical analysis.

Results

Our results show that the minimum 5-year patient-reported PROMIS scores for patients following a Broström-Gould procedure are as follows: PROMIS physical function, 50.5; PROMIS pain interference, 48.2; and PROMIS depression, 38.2. This indicates, at a minimum, that patients 5 years removed from the procedure are within 1 SD of the general population in regard to PROMIS physical function and pain. Our patient-reported FAAM, activities of daily living, and FAAM sports scores were 59.6 and 13.0 respectively. Preoperative magnetic resonance imaging (MRI) findings were recorded. Arthroscopic examination was performed before lateral ligaments reconstruction for patients with intra-articular pathologies confirmed on MRI.

Conclusion

The findings from our study offer evidence supporting the effectiveness of the Broström-Gould procedure to be associated with normal physical function, even 5 years after surgery. Furthermore, our research identified specific factors such as tobacco use, diabetes, and sports participation that independently correlated with reported outcome measures. These insights enable physicians to better manage patient expectations and tailor treatment strategies accordingly. Our study establishes a foundation for future prospective research endeavors that aim to leverage the PROMIS system for comprehensive outcome assessments.

Level of Evidence

Level III, retrospective cohort study.

Resilience of Patients Undergoing Knee and Shoulder Arthroscopy Procedures

INTRODUCTION

Resilience is a person's capacity to overcome adversity. The purpose was to determine what patient factors correlate with resilience using the Brief Resilience Score. We hypothesize that characteristics of female sex, younger age, Workers' Compensation status, and preoperative opioid use are predictors of a lower preoperative resilience score and that patients with positive psychosocial factors would have higher resilience scores.

METHODS

Eight hundred nine patients undergoing knee or shoulder arthroscopy were preoperatively categorized into low, normal, and high-resilience groups. Preoperative patient-reported outcome measures (PROMs) and demographics were assessed. Statistical analyses evaluated differences in demographics and PROMs between resilience groups.

RESULTS

Analysis disclosed notable differences between low, normal, and high-resilience groups regarding demographics and PROMs. High resilience was seen in older patients, male patients, and patients with positive psychosocial factors. Low resilience scores were discovered in Workers' Compensation patients and those with a history of preoperative opioid use. No difference in resilience scores was observed between smokers and nonsmokers.

DISCUSSION

Preoperative resilience score is associated with age, sex, preoperative opioid use, Workers' Compensation status, and smoking status of patients undergoing knee or shoulder arthroscopy.

Resilience in patients with complex regional pain syndrome 1-a cross-sectional analysis of patients participating in a cross-sectional cohort study

OBJECTIVE

To assess the degree of resilience in patients with complex regional pain syndrome (CRPS) 1, to explore the relationship between resilience and patient-related outcome measurements and to describe a pattern of clinical manifestations associated with low resilience.

METHODS

This study presents a cross-sectional analysis of baseline information collected from patients enrolled in a single center study between February 2019 and June 2021. Participants were recruited from the outpatient clinic of the Department of Physical Medicine & Rheumatology of the Balgrist University Hospital, Zurich, Switzerland. We used linear regression analysis to explore association of resilience with patient reported outcomes at baseline. Furthermore, we explored the impact of significant variables on the low degree resilience using logistic regression analysis.

RESULTS

Seventy-one patients (females 90.1%, mean age 51.2 ± 12.9 years) were enrolled. There was no association between CRPS severity and the level of resilience. Quality of Life was positively correlated with resilience, as was pain self-efficacy. Pain catastrophizing was inversely correlated with the level of resilience. We observed a significant inverse association between anxiety, depression and fatigue and the level of resilience. The proportion of patients with a low resilience increased with higher level of anxiety, depression and fatigue on the PROMIS-29, without reaching statistical significance.

CONCLUSION

Resilience seems to be an independent factor in CRPS 1 and is associated with relevant parameters of the condition. Therefore, caretakers may screen the current resilience status of CRPS 1 patients to offer a supplementary treatment approach. Whether specific resilience training modifies CRPS 1 course, requires further investigations.

Predictors of Return to Activity at 2 Years After Anterior Cruciate Ligament Reconstruction Among Patients With High Preinjury Marx Activity Scores: A MOON Prospective Cohort Study

BACKGROUND

Predictors of return to activity after anterior cruciate ligament reconstruction (ACLR) among patients with relatively high preinjury activity levels remain poorly understood.

PURPOSE/HYPOTHESIS

The purpose of this study was to identify predictors of return to preinjury levels of activity after ACLR, defined as achieving a Marx activity score within 2 points of the preinjury value, among patients with Marx activity scores of 12 to 16 who had been prospectively enrolled in the Multicenter Orthopaedic Outcomes Network (MOON) cohort. We hypothesized that age, sex, preinjury activity level, meniscal injuries and/or procedures, and concurrent articular cartilage injuries would predict return to preinjury activity levels at 2 years after ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

All unilateral ACLR procedures from 2002 to 2008 performed in patients enrolled in the MOON, with preinjury Marx activity scores ranging from 12 to 16, were evaluated with a specific focus on return to preinjury activity levels at 2 years postoperatively. Return to activity was defined as a Marx activity score within 2 points of the preinjury value. The proportion of patients able to return to preinjury activity levels was calculated, and multivariable modeling was performed to identify risk factors for patients' inability to return to preinjury activity levels.

RESULTS

A total of 1188 patients were included in the final analysis. The median preinjury Marx activity score was 16 (interquartile range, 12-16). Overall, 466 patients (39.2%) were able to return to preinjury levels of activity, and 722 patients (60.8%) were not able to return to preinjury levels of activity. Female sex, smoking at the time of ACLR, fewer years of education, lower 36-Item Short Form Health Survey Mental Component Summary scores, and higher preinjury Marx activity scores were predictive of patients' inability to return to preinjury activity levels. Graft type, revision ACLR, the presence of medial and/or lateral meniscal injuries, a history of meniscal surgery, the presence of articular cartilage injuries, a history of articular cartilage treatment, and the presence of high-grade knee laxity were not predictive of a patient's ability to return to preinjury activity level.

CONCLUSION

At 2 years after ACLR, most patients with high preinjury Marx activity scores did not return to their preinjury level of activity. The higher the preinjury Marx activity score that a patient reported at the time of enrollment, the less likely he/she was able to return to preinjury activity level. Smoking and lower mental health at the time of ACLR were the only modifiable risk factors in this cohort that predicted an inability to return to preinjury activity levels. Continued effort and investigation are required to maximize functional recovery after ACLR in patients with high preinjury levels of activity.

Resilience in Residency and Beyond

» Distinct from the burnout and wellness continuum, resilience is a developed and refined characteristic that propels an individual toward personal and professional success.» We propose a clinical resilience triangle consisting of 3 components that define resilience: grit, competence, and hope.» Resilience is a dynamic trait that should be built during residency and constantly fortified in independent practice so that orthopaedic surgeons may acquire and hone the skills and mental fortitude required to take on the overwhelming challenges that we all inevitably face.

Patients With Low Resilience Scores Have Significantly Worse Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction Than Patients With Normal or High Resilience Scores

Purpose

To evaluate the relationship between patient resilience and patient-reported outcome measures (PROMS) after primary anterior cruciate ligament (ACL) reconstruction.

Methods

Patients who underwent an ACL reconstruction by a single surgeon between January 2012 and June 2020 were identified by an institutional query using Current Procedural Terminology codes. Patients were included if they (1) underwent a primary ACL reconstruction and (2) had a minimum of 2 years' follow-up. Data were retrospectively collected regarding demographics, surgical details, visual analog scale (VAS) scores, and 12-item short form survey (SF-12) scores. Resilience scores were obtained via the Brief Resilience Scale questionnaire. Stratification into low (LR), normal (NR), and high resilience (HR) was based on standard deviation from mean Brief Resilience Scale score to determine differences in PROMS between groups.

Results

One-hundred eighty-seven patients were identified by the institutional query. Of the 187 patients, 180 met inclusion criteria. Seven patients underwent revision ACL reconstruction and were excluded from the study. One-hundred three patients (57.2%) completed the postoperative questionnaire and were included. Patients in the NR group and HR group had significantly greater postoperative SF-12 scores (P < .001) and lower postoperative VAS pain scores (P < .001) when compared with those of the LR group. This trend was again shown with breakdown of the SF-12 into physical and mental aspects, each of which were significantly greater in either the NR group or HR group when compared with the LR group (P < .001). Overall, 97.9% and 99.0% of patients had changes in their SF-12 total and VAS pain scores respectively that exceeded the minimal clinically important difference for the cohort.

Conclusions

Patients with lower resilience scores have worse PROMs and increased pain than patients with greater resilience at a minimum of 2-year follow-up after ACL reconstruction.

Level of Evidence

Level IV, prognostic case series.

Pain Self-Efficacy (PSEQ) score of <22 is associated with daily opioid use, back pain, disability, and PROMIS scores in patients presenting for spine surgery

BACKGROUND CONTEXT

Pain self-efficacy, or the belief that one can carry out activities despite pain, has been shown to be associated with back and neck pain severity. However, the literature correlating psychosocial factors to opioid use, barriers to proper opioid use, and Patient-Reported Outcome Measurement Information System (PROMIS) scores is sparse.

PURPOSE

The primary aim of this study was to determine whether pain self-efficacy is associated with daily opioid use in patients presenting for spine surgery. The secondary aim was to determine whether there exists a threshold self-efficacy score that is predictive of daily preoperative opioid use and subsequently to correlate this threshold score with opioid beliefs, disability, resilience, patient activation, and PROMIS scores.

PATIENT SAMPLE

Five hundred seventy-eight elective spine surgery patients (286 females; mean age of 55 years) from a single institution were included in this study.

STUDY DESIGN/SETTING

Retrospective review of prospectively collected data.

OUTCOME MEASURES

PROMIS scores, daily opioid use, opioid beliefs, disability, patient activation, resilience.

METHODS

Elective spine surgery patients at a single institution completed questionnaires preoperatively. Pain self-efficacy was measured by the Pain Self-Efficacy Questionnaire (PSEQ). Threshold linear regression with Bayesian information criteria was utilized to identify the optimal threshold associated with daily opioid use. Multivariable analysis controlled for age, sex, education, income, and Oswestry Disability Index (ODI) and PROMIS-29, version 2 scores.

RESULTS

Of 578 patients, 100 (17.3%) reported daily opioid use. Threshold regression identified a PSEQ cutoff score of <22 as predictive of daily opioid use. On multivariable logistic regression, patients with a PSEQ score <22 had two times greater odds of being daily opioid users than those with a score ≥22. Further, PSEQ <22 was associated with lower patient activation; increased leg and back pain; higher ODI; higher PROMIS pain, fatigue, depression, and sleep scores; and lower PROMIS physical function and social satisfaction scores (p<.05 for all).

CONCLUSIONS

In patients presenting for elective spine surgery, a PSEQ score of <22 is associated with twice the odds of reporting daily opioid use. Further, this threshold is associated with greater pain, disability, fatigue, and depression. A PSEQ score <22 can identify patients at high risk for daily opioid use and can guide targeted rehabilitation to optimize postoperative quality of life.

Associating Outcomes After Hip Arthroscopy With Patient Resilience

Background

Higher patient resilience has been shown to be associated with improved patient-reported outcome measures (PROMs) at 6 months after hip arthroscopy.

Purpose

To examine the relationship between patient resilience and PROMs at minimum 2 years after hip arthroscopy.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

Included were 89 patients (mean age, 36.9 years; mean follow-up, 4.6 years). Patient demographics, surgical details, and preoperative International Hip Outcome Tool-12 (iHOT-12) and visual analog scale (VAS) pain scores were collected retrospectively. Postoperative variables were collected via a survey and included the Brief Resilience Scale (BRS), Patient Activation Measure-13 (PAM-13), Pain Self-efficacy Questionnaire-2 (PSEQ-2), VAS satisfaction, and postoperative iHOT-12, and VAS pain scores. Based on the number of standard deviations from the mean BRS score, patients were stratified as having low resilience (LR; n = 18), normal resilience (NR; n = 48), and high resilience (HR; n = 23). Differences in PROMs were compared between the groups, and a multivariate regression analysis was performed to assess the relationship between pre- to postoperative change (Δ) in PROMs and patient resilience.

Results

There were significantly more smokers in the LR group compared with the NR and HR groups (P = .033). Compared with the NR and HR groups, patients in the LR group had significantly more labral repairs (P = .006), significantly worse postoperative iHOT-12, VAS pain, VAS satisfaction, PAM-13, and PSEQ-2 scores (P < .001 for all), and significantly lower ΔVAS pain and ΔiHOT-12 scores (P = .01 and .032, respectively). Regression analysis showed significant associations between ΔVAS pain and NR (β = -22.50 [95% CI, -38.81 to -6.19]; P = .008) as well as HR (β = -28.31 [95% CI, -46.96 to -9.67; P = .004) and between ΔiHOT-12 and NR (β = 18.94 [95% CI, 6.33 to 31.55]; P = .004) as well as HR (β = 20.63 [95% CI, 6.21 to 35.05]; P = .006). Male sex was a significant predictor of ΔiHOT-12 (β = -15.05 [95% CI, -25.42 to -4.69]; P = .006).

Conclusion

The study results indicate that lower postoperative resilience scores were associated with significantly worse PROM scores, including pain and satisfaction, at 2 years after hip arthroscopy.

Mental health status, not resilience, influences functional recovery after arthroscopic rotator cuff repairs

BACKGROUND

Recent literature has shown the importance of patient psychosocial status in overcoming stressful events, such as surgery. Resilience, the ability to "bounce back" from adversity, has been recently correlated to outcomes following arthroscopic rotator cuff repair (RCR). Overall mental well-being has also been shown to be important because patients with clinical depression and anxiety may have worse outcomes. Substantial clinical benefit (SCB) is the threshold of outcome improvement that a patient perceives as considerable. The purpose of this study was to assess the influence of preoperative resilience, mental health status, and rotator cuff tear size on patient outcome recovery measured by the American Shoulder and Elbow Surgeons (ASES) score.

METHODS

Patients undergoing arthroscopic RCR performed from 2016 through 2019 at a single tertiary institution by fellowship-trained sports surgeons with a high-volume shoulder practice were included. The Brief Resilience Scale (BRS) score and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Score (MCS) were collected preoperatively. ASES scores were obtained preoperatively, as well as 6 and 12 months postoperatively. Patients were divided into 2 groups based on the SCB threshold of 87 for the ASES score based on validated, established literature. Rotator cuff tear size was classified as small (≤3 cm) or large (>3 cm). VR-12 MCS, BRS, and ASES scores were compared at baseline, 6 months, and 1 year using separate mixed-model analyses of variance between the tear size and SCB groups. For ASES score comparison, the VR-12 MCS was used as a covariate to account for differences in baseline mental status.

RESULTS

RCR was performed in 119 patients, with an average age of 61 years (standard deviation, 10 years). There were 71 male and 48 female patients. At 6 months, 43% of patients met the SCB threshold. The VR-12 MCS was significantly different between RCR patients who met the SCB threshold for the ASES score and those who did not at 6 and 12 months for large rotator cuff tears (P = .001) but not small tears (P = .07). The BRS score was not different between the tear size and SCB groups at any time point (P = .12).

CONCLUSION

Our results show that patients who met the SCB threshold at 6 months postoperatively after arthroscopic RCR demonstrated higher preoperative VR-12 MCS values; however, higher preoperative BRS scores were not seen in those meeting the SCB threshold. In fact, when baseline VR-12 MCS values were accounted for in patients with large rotator cuff tears, the differences in ASES scores normalized. This finding suggests that baseline mental health status, as measured by the VR-12 MCS, significantly influenced patients' functional recovery following RCR. Future research should focus on preoperative psychosocial well-being to optimize postoperative outcomes.

Preoperative Resilience and Early Postoperative Outcomes following Lumbar Spinal Fusion

BACKGROUND

Previous studies identified a correlation between preoperative resilience scores and patient reported outcome measures in several surgical subspecialities. No previous studies, to our knowledge, have analyzed preoperative resilience and patient reported outcomes in lumbar spinal fusion.

METHODS

Patients undergoing lumbar spinal fusion completed the brief resilience scale preoperatively, in addition to measures of disability (Oswestry Disability index (ODI)), quality of life (PROMIS global physical and mental health scales and EuroQOL5], and leg and back pain (VAS) at pre- and 3-months postoperatively. The 3-month follow-up was selected due to the association with return to work. Multiple linear regression evaluated relationships between resilience and postoperative changes in outcomes measures, controlling for baseline values and body mass index, age, number of levels fused, and severity of comorbidities.

RESULTS

Ninety-five participants (mean age = 58 years, 56% male) completed the BRS preoperatively and outcome measures before and 3-months after lumbar fusion. On average, participants reported significant postoperative improvements on all outcome measures (p<.001). Higher preoperative resilience scores related to greater postoperative improvements in back and leg pain, global mental and physical health and EuroQol scores (p<0.05), after controlling for baseline values and other covariates. Resilience scores did not significantly correlate with postoperative changes in ODI (p>0.05).

CONCLUSIONS

Preoperative resilience is associated with improvement in pain, physical and mental health quality of life during the early postoperative period following lumbar spinal fusion. Additional research is needed to determine if improvements are maintained beyond this interval and whether resilience can be modified to optimize outcomes.

Do Unhelpful Thoughts or Confidence in Problem Solving Have Stronger Associations with Musculoskeletal Illness?

BACKGROUND

Measures of unhelpful thoughts and distress correlate with the intensity of pain and the magnitude of incapability among people seeking musculoskeletal specialty care. In this evolving knowledge area, we want to be sure we have not neglected other important mental health factors. This study addressed how measures of confidence in problem solving as well as past and current ability to achieve goals account for variation in symptoms and capability independent of unhelpful thoughts and distress.

QUESTIONS/PURPOSES

(1) Are measures of confidence in problem solving ability and past and current ability to achieve goals regarding future outcomes associated with variation in capability, independent of measures of symptoms of depression and anxiety (distress) and measures of unhelpful thoughts (worst-case thinking, negative pain thoughts)? (2) Are these measures independently associated with variation in pain intensity? (3) Are these measures associated with measures of symptoms of depression, symptoms of anxiety, and unhelpful thoughts?

METHODS

Over a 7-month period during the pandemic, we enrolled sporadically from the offices of four surgeons treating patients who sought care for various upper and lower extremity conditions. We invited approximately 200 adult new and returning patients to participate (the number of invitations was not formally tracked) and 187 accepted. Thirty-one were excluded due to markedly incomplete entries (related to a problematic attempt to use the patient's cell phone to complete questionnaires as a pandemic work around), leaving 156 for analysis. Patients completed an 11-point ordinal rating of pain intensity, two measures of unhelpful thoughts (the Pain Catastrophizing Scale and the Negative Pain Thoughts Questionnaire), the Adult Hope Scale to measure past and current ability to achieve goals, the Personal Optimism and Self-Efficacy Optimism Scale to measure confidence in problem solving ability, the Patient-reported Outcomes Measurement Information System (PROMIS) computer adaptive test to measure symptoms of anxiety, the PROMIS computer adaptive test to measure symptoms of depression, and the PROMIS physical function computer adaptive test to assess the magnitude of capability. All questionnaires were validated in previous studies. We used bivariate analyses to identify factors associated with magnitude of capability, pain intensity, confidence in problem solving ability, and past and current ability to achieve goals. All factors with a p value of less than 0.1 were included in multivariable analyses to seek associations between these measures accounting for confounders. We reported partial η2 as a measure of effect size for all multivariable regression models. The following rules of thumb are used to interpret values for partial η2: a value of 0.01 = small, 0.06 = medium, and values of 0.14 and higher show large effect size.

RESULTS

Greater capability was modestly associated with fewer negative pain thoughts (β = -0.63 [95% CI -1.0 to -0.22]; standard error = 0.20; partial η2 = 0.06; p = 0.003) and no self-reported comorbidities (β = 2.6 [95% CI 0.02 to 5.3]; standard error = 1.3; partial η2 = 0.03; p = 0.048) after controlling for education, symptoms of depression and anxiety, worst-case thinking, as well as past and current ability to achieve goals. In a similar multivariable model, greater pain intensity was modestly associated with greater worst-case thinking (β = 0.33 [95% CI 0.20 to 0.45]; standard error = 0.06; partial η2 = 0.16; p < 0.001) and established patients (β = -1.1 [95% CI -1.8 to -0.31]; standard error = 0.38; partial η2 = 0.05; p = 0.006). In another similar multivariable model, having more confidence in problem solving ability had a limited association with higher ratings of past and current ability to achieve goals (β = 0.15 [95% CI 0.09 to 0.21]; standard error = 0.03; partial η2 = 0.13; p < 0.001). In a final multivariable model, lower past and current ability to achieve goals was independently associated with having greater symptoms of depression (β = -0.45 [95% CI -0.67 to -0.23]; standard error = 0.11; partial η2 = 0.1; p < 0.001) and more negative pain thoughts (β = -0.49 [95% CI -0.89 to -0.09]; standard error = 0.20; partial η2 = 0.04; p = 0.02).

CONCLUSION

The observation that unhelpful thoughts about symptoms are more strongly associated with symptom intensity than past and current ability to achieve goals and confidence in problem solving ability add to the evidence that attentiveness to unhelpful thinking is an important aspect of musculoskeletal health. Musculoskeletal specialists can prioritize communication strategies such as relationship building and motivational interviewing that develop trust and facilitate reorientation of common unhelpful thoughts.

LEVEL OF EVIDENCE

Level II, prognostic study.