A Conceptual Model for Spine Surgery Recovery: A Qualitative Study of Patients' Expectations, Experiences, and Satisfaction

STUDY DESIGN

Qualitative interview study.

OBJECTIVE

The aim was to develop a conceptual model for Spine Surgery Recovery in order to better understand why patients undergo lumbar spine surgery and what factors influence patient satisfaction.

SUMMARY OF BACKGROUND DATA

Quantitative studies have assessed patients' expectations for lumbar spine surgery outcomes, with greater expectation fulfillment leading to higher satisfaction. However, there is limited literature using qualitative methods to understand the patient perspective from the decision to undergo lumbar spine surgery through long-term recovery.

MATERIALS AND METHODS

Semistructured phone interviews were conducted with 20 participants (nine females, mean age ±SD=61.2±11.1 yr) and three focus groups with 12 participants (nine females, mean age ±SD=62.0±10.9 yr). Sessions were audio recorded and transcribed. Two independent researchers coded the transcripts using a hierarchical coding system. Major themes were identified and a conceptual model was developed.

RESULTS

A total of 1355 coded quotes were analyzed. The decision to have lumbar spine surgery was influenced by chronic pain impact on daily function, pain coping, and patient expectations. Results demonstrated that fulfilled expectations and setting realistic expectations are key factors for patient satisfaction after surgery, while less known constructs of accepting limitations, adjusting expectations, and optimism were found by many patients to be essential for a successful recovery. Emotional factors of fear, anxiety, and depression were important aspects of presurgical and postsurgical experiences.

CONCLUSION

Our Spine Surgery Recovery conceptual model provides guidance for future research and clinical practice to optimize treatment and improve overall patient satisfaction. Recommendations based on this model include the assessment of patient expectations and mental well-being throughout postoperative recovery as well as preoperatively to help set realistic expectations and improve satisfaction. Educational, acceptance-based or positive psychological interventions may be potentially beneficial for addressing key factors identified in this model.

Patient-Centered Goals After Lumbar Spine Surgery: A Secondary Analysis of Cognitive-Behavioral-Based Physical Therapy Outcomes From a Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to examine the association between goal attainment and patient-reported outcomes in patients who engaged in a 6-session, telephone-based, cognitive-behavioral-based physical therapy (CBPT) intervention after spine surgery.

METHODS

In this secondary analysis of a randomized trial, data from 112 participants (mean age = 63.3 [SD = 11.2] years; 57 [51%] women) who attended at least 2 CBPT sessions (median = 6 [range = 2-6]) were examined. At each session, participants set weekly goals and used goal attainment scaling (GAS) to report goal attainment from the previous session. The number and type of goals and percentage of goals met were tracked. An individual GAS t score was computed across sessions. Participants were categorized based on goals met as expected (GAS t score ≥ 50) or goals not met as expected (GAS t score < 50). Six- and 12-month outcomes included disability (Oswestry Disability Index), physical and mental health (12-Item Short-Form Health Survey), physical function (Patient-Reported Outcomes Measurement Information System), pain interference (Patient-Reported Outcomes Measurement Information System), and back and leg pain intensity (numeric rating scale). Outcome differences over time between groups were examined with mixed-effects regression.

RESULTS

Participants set a median of 3 goals (range = 1-6) at each session. The most common goal categories were recreational/physical activity (36%), adopting a CBPT strategy (28%), exercising (11%), and performing activities of daily living (11%). Forty-eight participants (43%) met their goals as expected. Participants who met their goals as expected had greater physical function improvement at 6 months (estimate = 3.7; 95% CI = 1.0 to 6.5) and 12 months (estimate = 2.8; 95% CI = 0.04 to 5.6). No other outcome differences were noted.

CONCLUSIONS

Goal attainment within a CBPT program was associated with 6- and 12-month improvements in postoperative physical functioning.

IMPACT

This study highlights goal attainment as an important rehabilitation component related to physical function recovery after spine surgery.

Return to Sports After Anterior Cruciate Ligament Reconstruction: Validity and Reliability of the SPORTS Score at 6 and 12 Months

Background:

The Subjective Patient Outcome for Return to Sports (SPORTS) score is a single-item scale that measures athletes' ability to return to their preinjury sport based on effort and performance.

Purpose/Hypothesis:

The purpose of this study was to examine the psychometric properties of the SPORTS score and a modified score within the first year after anterior cruciate ligament reconstruction (ACLR). The modified version replaced “same sport” with “any sport” in the answer choices. It was hypothesized that both versions of the SPORTS score would have acceptable floor and ceiling effects and internal responsiveness, moderate convergent validity, and excellent test-retest reliability.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Patients were recruited preoperatively from 2 academic medical centers. The authors collected responses to the 1-item SPORTS scores at 6 and 12 months after ACLR and the Tegner activity scale, Lysholm knee score, Knee injury and Osteoarthritis Outcome Score (KOOS)–sport/recreation subscale, and Marx activity rating scale preoperatively and 6 and 12 months after ACLR. Ceiling and floor effects and responsiveness were assessed using descriptive statistics and cross-tabulations, respectively, at both follow-up time points. Spearman correlations and intraclass correlation coefficients were used to examine convergent validity and test-retest reliability, respectively.

Results:

Follow-up rates at 6 and 12 months were 100% and 99%, respectively. Test-retest follow-up was 77%. Floor effects for the SPORTS scores were not observed, while ceiling effects at 12 months ranged from 38% to 40%. Cross-tabulation of the SPORTS scores showed that 64% to 66% of patients reported a change in their score from 6 to 12 months, with significant differences noted between the proportions that improved versus worsened for return to any sport. Convergent validity was observed at 6 and 12 months via moderate correlations with the Tegner, Lysholm, KOOS–sport/recreation, and Marx scores (r = 0.31 to 0.47). Fair to good test-retest reliability (intraclass correlation coefficient, 0.58 and 0.60) was found at 12 months after ACLR.

Conclusion:

The SPORTS score appears to be a reliable, responsive, and valid 1-item scale that can be used during the first year after ACLR. No differences in psychometric properties were found between the SPORTS score and the modified version.

Evaluation of a Vitamin D Screening and Treatment Protocol Using a Seasonal Calculator in Athletes

ABSTRACT

Vitamin D is important in musculoskeletal health, and low serum vitamin D concentration is common in athletes. This study implemented a vitamin D screening and supplementation protocol in a cohort of National Collegiate Athletic Association Division I athletes using summer 25-hydroxyvitamin D concentration and a seasonal variation calculator to achieve sufficient vitamin D concentration year-round. After implementation of the Vitamin D Protocol, there was a nonsignificant difference in athletes with sufficient winter vitamin D concentrations (72.6%) compared with summer vitamin D concentrations (66.1%) (P = 0.40). The Seasonal Variation Calculator predicted winter vitamin D concentrations (8 ± 18 ng·mL-1) higher than actual winter vitamin D concentrations (P < 0.01). While most athletes (78%) believed vitamin D was important for athletic performance, athlete compliance to the Vitamin D Protocol was inconsistent. In the future, adjustment of vitamin D screening and supplementation protocols may help athletes achieve sufficient vitamin D status year-round.

Composite psychosocial risk based on the fear avoidance model in patients undergoing anterior cruciate ligament reconstruction: Cluster-based analysis

OBJECTIVES

To examine associations between preoperative fear-avoidance model (FAM) risk subgroup status and patient expectation of surgical success with postoperative outcomes at 6 and 12 months after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cohort study.

SETTING

Academic medical center.

PARTICIPANTS

54 patients (25 females) undergoing unilateral ACLR.

MAIN OUTCOME MEASURES

Cluster analysis distinguished FAM risk subgroups based on preoperative fear of movement/reinjury, self-efficacy, and pain catastrophizing. Preoperative expectation for surgical success was assessed with a numeric rating scale. Six and 12-month outcomes included Subjective Patient Outcomes for Return to Sport, Knee Injury and Osteoarthritis Outcome Score (KOOS) sports/recreation and quality of life, and International Knee Documentation Committee (IKDC) Subjective Knee Form.

RESULTS

Thirteen (24%) patients were "moderate-to-high FAM risk." Moderate-to-high FAM risk patients had lower odds of return to sport at 12 months (OR = 0.3, p = .05) and lower KOOS sports/recreation at 6 months (st. beta = -0.27, p = .05), KOOS quality of life at 12 months (st. beta = -0.42, p = .007), and IKDC at 6 (st. beta = -0.29, p = .04) and 12 months (st. beta = -0.47, p = .001). Higher expectation was associated with lower 6-month IKDC (st. beta = -0.36, p = .008) and 12-month KOOS quality of life (st. beta = -0.29, p = .05).

CONCLUSIONS

Preoperative FAM risk influences patient-reported outcomes and return to sport at 6 and 12 months.

Independent Suture Tape Internal Brace Reinforcement of Bone-Patellar Tendon-Bone Allografts: Biomechanical Assessment in a Full-ACL Reconstruction Laboratory Model

Internal bracing for anterior cruciate ligament (ACL) surgery is a relatively new concept. The purpose of this study was to evaluate the effects of an "independent" button-fixed internal brace on the biomechanical properties of ACL reconstruction in a full-construct experimental model. Three groups (n = 10 each) were tested in a full-construct porcine-bone model with human bone-patellar tendon-bone allografts using different reconstruction techniques: interference screw fixation on femur and tibia (S-S group), adjustable-loop device (ALD) fixation on the femur with tibial interference screw without suture tape (ALD-S group), and with internal brace (ALD-S-IB group). Measured outcomes included cyclic displacement, stiffness, and ultimate load to failure. The ALD-S-IB group (2.9 ± 0.8 mm) displaced significantly less than the ALD-S (4.2 ± 0.9 mm; p = 0.015) and S-S group (4.3 ± 1.1 mm; p = 0.017). No significant difference was found between the ALD-S and the S-S group. Construct stiffness was significantly higher for the ALD-S-IB group (156 ± 23 N/mm) and the ALD-S group (122 ± 28 N/mm) than for the S-S group (104 ± 40 N/mm; p = 0.003 and p = 0.0042), but there was no significant difference between both ALD groups. Similarly, ultimate loads in the ALD-S-IB (758 ± 128 N) and the ALD-S groups (628 ± 223 N) were significantly greater than in the S-S group (416 ± 167 N; p < 0.001 and p = 0.025), but there was no significant difference between ALD groups. Adding an internal brace reinforcement to an ALD in a full-construct experimental model significantly decreased cyclic displacement by 31% without increasing construct stiffness or ultimate load significantly. These results indicate that suture tape internal bracing of bone-patellar tendon-bone allograft ACL reconstruction decreases cyclic displacement during experimental testing, which has clinical implications regarding initial construct stability.

All-Inside Quadrupled Semitendinosus Autograft Shows Stability Equivalent to Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction: Randomized Controlled Trial in Athletes 24 Years or Younger

PURPOSE

To compare clinical outcomes of knee anterior cruciate ligament (ACL) autograft reconstruction using all-inside quadrupled semitendinosus (AIST) versus bone-patellar tendon-bone (BPTB) in a high-risk athletic population 24 years or younger.

METHODS

Skeletally mature candidates younger than 24 years old with an ACL tear were randomized into either the AIST (n = 32) or BPTB (n = 32) group and were followed for 2 years. Magnetic resonance imaging scans were obtained at 1-year follow-up, and radiographs were obtained at 2-year follow-up. All surgeries were performed by a single surgeon using an anteromedial portal to establish the femoral tunnel. The primary outcome measure was KT-1000 stability testing. Secondary outcome measures included International Knee Documentation Committee (IKDC) Knee Evaluation Form, IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Marx Activity Scale, visual analog pain scale, and SF-12 (Mental and Physical).

RESULTS

At 2-year follow-up, no statistical difference existed with KT-1000-measured side-to-side laxity between AIST (0.3 ± 0.7 mm, 95% confidence interval 0.0-1.0 mm) and BPTB (0.0 ± 0.8 mm, confidence interval CI -0.3 to 1.1 mm) (P = .197). In addition, no statistical differences between the groups were found for IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Marx, SF-12 Mental, SF-12 Physical, or with regards to imaging findings. Patients with BPTB reported significantly greater postoperative pain scores at days 2 (P = .049), 3 (P = .004), and 7 (P = .015) and had significantly greater kneeling pain at 2 years (P < .019). A return to sport questionnaire at 2 years revealed no significant difference between the groups for returning to preoperative level of sport activity (83% AIST, 74% BPTB; P = .415). Two graft retears (7%; P = .222) occurred in the AIST group. Three patients in the BPTB group experienced ACL tears in the contralateral knee (9%; P = .239).

CONCLUSIONS

ACL reconstruction with an all-inside quadrupled semitendinosus autograft construct is equivalent to patellar BPTB autograft based on KT-1000 stability testing in athletes 24 years or younger.

LEVEL OF EVIDENCE

randomized controlled trial with 92% 2-year follow-up, Level I.

A Biomechanical Study of the Role of the Anterolateral Ligament and the Deep Iliotibial Band for Control of a Simulated Pivot Shift With Comparison of Minimally Invasive Extra-articular Anterolateral Tendon Graft Reconstruction Versus Modified Lemaire Reconstruction After Anterior Cruciate Ligament Reconstruction

PURPOSE

To determine whether the deep fibers of the iliotibial band (dITB) or the anterolateral ligament (ALL) provides more control of a simulated pivot shift and whether a minimally invasive anterolateral reconstruction (ALR) designed to functionally restore the ALL and dITB is mechanically equivalent to a modified Lemaire reconstruction (MLR).

METHODS

Six matched pairs of cadaveric knees (N = 12) were subjected to a simulated pivot shift to evaluate anteroposterior translation; internal rotation; and valgus laxity at 0°, 30°, and 90° of flexion. The anterior cruciate ligament (ACL) was sectioned in all specimens, and retesting was performed. Within each pair, sequential sectioning of the ALL and dITB was performed, followed by testing; the contralateral knee was sectioned in reverse order. Knees underwent ACL reconstruction (ACLR) and repeat testing. Then, MLR (n = 6) or ALR (n = 6) was performed on matched pairs for final testing.

RESULTS

Sectioning of the dITB versus ALL (after ACL sectioning) produced significantly more anterior translation at all flexion angles (P = .004, P = .012, and P = .011 for 0°, 30°, and 90°, respectively). The ACL-plus-dITB sectioned state had significantly more internal rotation at 0° versus ACL plus ALL (P = .03). ACLR plus ALR restored native anterior translation at all flexion angles. ACLR plus MLR restored anterior translation to native values only at 0° (P = .34). We found no statistically significant differences between ACLR plus ALR and ACLR plus MLR at any flexion angle for internal rotation or valgus laxity compared with the native state.

CONCLUSIONS

ALR of the knee in conjunction with ACLR can return the knee to its native biomechanical state without causing overconstraint. The dITB plays a more critical role in controlling anterior translation and internal rotation at 0° than the ALL. The minimally invasive ALR was functionally equivalent to MLR for restoration of knee kinematics after ACLR.

CLINICAL RELEVANCE

The dITB is more important than the ALL for control of the pivot shift. A minimally invasive extra-articular tendon allograft reconstruction was biomechanically equivalent to a modified Lemaire procedure for control of a simulated pivot shift.

Anterior Cruciate Ligament Primary Repair With Independent Tensioning of the Anteromedial and Posterolateral Bundles

This procedure represents an update on traditional primary repair methods by taking advantage of technological advancements to optimize soft tissue fixation and allow for an anatomic double-bundle primary repair with independent bundle tensioning and an internal brace construct to restore normal anterior cruciate ligament biomechanics.

Simplified Arthroscopic Lateral Meniscal Root Repair Involving the Use of 2 Cinch-Loop Sutures

The meniscal root attachments are critical for meniscal function by securing the menisci in place and allowing optimal shock absorption in the knee. Successful meniscal root repair has been shown to restore the knee's tibiofemoral contact pressure to the same state as an intact meniscus. Although there have been multiple different repair techniques described, there is no report in the literature regarding the use of 2 simple cinch-loop sutures for a meniscal root repair. This article presents an arthroscopic lateral meniscal root repair technique involving the use of 2 simple cinch-loop configuration sutures and tibial suture anchor fixation.

Knotless Arthroscopic Reduction and Internal Fixation of a Displaced Anterior Cruciate Ligament Tibial Eminence Avulsion Fracture

Generally occurring in the 8- to 14-year-old population, tibial eminence avulsion fractures are a common variant of anterior cruciate ligament ruptures and represent 2% to 5% of all knee injuries in skeletally immature individuals. In this article, we report on a new arthroscopic reduction and internal fixation technique that involves 2 absorbable anchors with adjustable suture-tensioning technology. This technique optimizes reduction and helps surgeons avoid proximal tibial physeal damage, procedure-related morbidity, and additional surgery.

Allograft Anterior Cruciate Ligament Reconstruction Utilizing Internal Brace Augmentation

Anterior cruciate ligament (ACL) tears are among the most common sports-related injuries. Although studies have reported reliable outcomes with allograft tissue, several studies have shown a higher failure rate in younger patients. Although ACL graft augmentation has been met with varying levels of success, internal bracing of an allograft represents a promising area in ACL reconstruction. The purpose of this article is to detail allograft preparation involving a collagen-coated, ultrahigh-molecular-weight polyethylene/polyester suture tape as an internal brace augmentation for ACL reconstruction using the all-inside ACL GraftLink Technique (Arthrex, Naples, FL).

Review of the carotid artery loop procedure in sheep

Carotid loop (CL) surgery involves the permanent externalization of a common carotid artery in a skin tube. The CL facilitates repeated access to the systemic arterial system for blood sampling and blood pressure measurement in laboratory sheep. It eliminates the need for arterial cut-downs and chronic indwelling catheters, reduces the risk of sepsis and infection, and adds flexibility to research protocols. The surgical procedure is aseptically performed under general anesthesia and involves isolation of the common carotid artery, creation of a bipedicled skin tube, and permanent envelopment of the artery in the skin tube. The primary complication is ischemic necrosis with sloughing of the middle of the loop and is usually due to failure to adhere to the critical length-to-width ratio (2.5:1). We have performed 150 CL procedures with an overall success rate of 94%. Nine CL ablations were required, due to necrosis with exposure of the artery (7/9) or stricture formation with loss of patency (2/9). Twenty-two CLs developed complications secondary to partial necrosis, but did not require ablation. Results indicate that the CL is a reliable method to ensure repeated access to the systemic arterial system in sheep. A modification of the standard CL procedure in which the artery is surrounded by a skin tunnel rather than enclosed in a skin loop was performed in 10 sheep. Preliminary results indicate significant reduction in the incidence of complications associated with the standard CL.

Different high-frequency ventilator strategies: effect on the propagation of tracheobronchial histopathologic changes

To assess the role of high-frequency ventilator strategy in the propagation of airway injury, we compared the tracheobronchial histologic alterations in 20 newborn piglets ventilated for 8 hours with high-frequency flow interruption (HFFI). Ten animals were assigned to HFFI with a strategy of continuous pulsations at a frequency of 10 Hz and a mean airway pressure of 16 cm H2O. Ten piglets were treated at identical settings except for 10 one-second baseline pauses per minute to a positive end-expiratory pressure of 5 cm H2O. A semiquantitative scoring system was used to grade light microscopic tissue alterations in the trachea, carina, and mainstem bronchi. Ultrastructural changes were evaluated with scanning electron microscopy. The HFFI-continuous-treated piglets had significantly more damage in all areas than the HFFI-baseline pause group (P less than .001). The upper tracheas of animals in both groups were altered to a greater extent than the lower tracheas (P less than .007). In addition, numerous "skip" areas of injury were noted throughout the tracheas. High-frequency ventilator strategy is a determinant of the severity of airway histologic changes. Factors that adversely affect tissue oxygenation or cause direct mechanical trauma may also influence the degree of injury. Optimal operating characteristics and limitations of different high-frequency devices must be assessed before their use in human neonates.

Determinants of tracheobronchial histologic alterations during conventional mechanical ventilation

It was hypothesized that diverse mechanisms may influence upper airway injury during mechanical ventilation. To assess the roles of several factors in the propagation of such injury, the tracheobronchial histologic changes in 53 newborn piglets were compared following conventional positive pressure ventilation. Eight animals were assigned to each of four positive pressure ventilation groups at "low" settings (an FiO2 of 0.25, a frequency of 10 breaths per minute, a peak inspiratory pressure of 20 cm H2O, a positive end-expiratory pressure of 4 cm H2O, a flow rate of 10 L/min, and an inspiratory time to expiratory time ratio of 1:2): (1) positive pressure ventilation with no hypotension or hypoxemia; (2) positive pressure ventilation with hypotension; (3) positive pressure ventilation with hypoxemia; and (4) positive pressure ventilation with both hypotension and hypoxemia. In addition, eight piglets were assigned to each of two positive pressure ventilation groups at "high" settings (greater frequency [40 breaths per minute], higher peak inspiratory pressure [40 cm H2O], and greater flow rate [17 L/min]): (1) positive pressure ventilation with no hypotension or hypoxemia; and (2) positive pressure ventilation with both hypotension and hypoxemia. The changes were mild and similar among the first three positive pressure groups at low settings. However, the injury scores of the combined hypotension and hypoxemia group (group 4) were greater than those of the former three positive pressure ventilation groups (P less than .004). The piglets receiving positive pressure ventilation at high settings with no hypotension or hypoxemia (group 5) had no more injury than those in the first three groups receiving positive pressure ventilation.(ABSTRACT TRUNCATED AT 250 WORDS)