Patient-Reported Outcome Measures: How to Maximize Their Utility and Mitigate Health Care Disparities

Patient-reported outcome measures (PROMs) provide a standardized assessment from the patient about their own health status. Although originally developed as research tools, PROMs can be used in clinical orthopaedic care to complement objective functional measures (eg, range of motion). When PROMs are used during clinical care, they can improve patient outcomes, engagement, well-being, and patient-physician communication. Therefore, PROMs are increasingly integrated into shared decision-making approaches to guide treatment decisions, enhance treatment plans, and predict outcomes. They are also being used in quality measurement and value-based health care arrangements. However, methods to communicate PROMs with patients have not been fully developed, and there continue to be barriers to implementing their collection and communication at scale. In addition, measuring care quality and communicating PROMs with patients may have unintended consequences, such as when used in measurement without accounting for confounding factors (eg, psychological and social health), or in perpetuating health care disparities when used imprecisely (eg, lack of linguistic or cultural validation). It is important to describe the current state of PROM use in orthopaedic surgery, highlight opportunities and challenges of PROM use in clinical care, and provide a roadmap for how to incorporate PROMs to equitably improve patient health and build orthopaedic surgery practices.

Evaluating medical students' knowledge of patient-reported outcomes and the impact of curriculum intervention in consecutive cohorts

BACKGROUND

Patient-reported outcomes (PROs) collection and utilization improves patient-provider communication, symptom reporting, and patient satisfaction. Despite their significance, the science and utility of PROs are not part of required curriculum in medical education. The authors describe the results of a survey distributed to medical students evaluating their experience, knowledge, and perceptions of PROs, report on outcomes of the impact of formal PRO education on medical student knowledge, and describe strategies to foster the spread of PRO education into other programs.

METHODS

The authors developed and distributed a 20-question web-based survey distributed to medical students at two U.S. medical schools to evaluate students' experience, knowledge, and perceptions of PROs. To compare medical students' knowledge in their pre-clinical years (M1-M2) to those in their clinical years (M3-M4), the authors calculated odds ratios and determined significance determined using chi-squared tests. To determine the utility of formal education on medical students' knowledge of PROs, the authors invited 4th year medical students at a single institution to participate in a survey before and two weeks after receiving formal PRO education as part of the medical school curriculum, spanning three years.

RESULTS

137 (15%) medical students responded to the initial survey. Respondents' knowledge of PROs was low and did not differ when comparing pre-clinical to clinical years in school. Less than 10% had received education on PROs and only 16% felt prepared to use PROs in patient care. Respondents demonstrated positive attitudes towards PROs, with 84% expressing interest in learning about PROs. In the second phase education cohort of 231 (77% response rate) 4th -year medical students over three years, formal education improved correct response rates to PRO questions. After education, 90% (121/134) agreed PROs are an important component of high-quality care.

CONCLUSIONS

This study identifies a gap in knowledge about PROs among medical students irrespective of year in training. It also shows that structured education may help fill the PRO knowledge gap, potentially providing future clinicians with the skills to implement PROs into clinical practice, aligning with the broader shift towards patient-centric evidence-based healthcare practices.

Operationalizing PROMs at the Musculoskeletal Practice and Policy Levels

There continues to be growing interest in patient-reported outcome measures (PROMs), especially as value-based healthcare initiatives gain more traction. Although it is well-established that PROMs can be useful in clinical research, how to operationalize PROMs in clinical care and policy initiatives remains a "work in progress." Following the design of a comprehensive PROM administration and routine collection system, orthopaedic surgeons and their patients can reap the benefits of PROMs in practice through improved shared clinical decision-making discussions at the individual patient level and closer symptom monitoring on a large scale, with improved resource allocation at the population health level. Although certain government and payer incentives exist to collect PROMs at present, it is reasonable to assume that future policy initiatives will begin to use the actual PROM scores to assess clinical outcomes. Orthopaedic surgeons with interest in this area should prioritize their involvement in policy discussion to ensure PROMs are being used appropriately in novel payment models and policy endeavors so that they are both evaluated and compensated fairly. Specifically, orthopaedic surgeons can help ensure appropriate risk adjustment of patients when this is being done. Undoubtedly, PROMs will only become a larger part of musculoskeletal care moving forward.

Impact of Sports Participation on Achievement of Clinically Relevant Outcomes 2 Years After ACL Reconstruction

Background

Clinically relevant threshold values associated with patient-reported outcome measures after orthopaedic procedures such as anterior cruciate ligament reconstruction (ACLR) are important for relating these scores to meaningful postoperative improvement.

Purpose/Hypothesis

The purpose of this study was to determine the Patient Acceptable Symptom State (PASS) for the Patient-Reported Outcomes Measurement Information System Computer Adaptive Test (PROMIS-CAT) after ACLR. It was hypothesized that preoperative sport participation would have an impact on PASS achievement.

Study Design

Case series; Level of evidence, 4.

Methods

Included were consecutive patients who underwent primary assisted ACLR between January 4 and August 1, 2016. Patients were administered the PROMIS-CAT Physical Function (PF) and Pain Interference domains preoperatively and at a minimum 2 years postoperatively, with external anchor questions used to determine the PASS. Receiver operating characteristic (ROC) curves were constructed for the entire study population as well as separately for athletes and nonathletes to determine PROMIS PASS thresholds for each population. A previously published PROMIS-PF minimal clinically important difference was used to evaluate postoperative improvement. A post hoc multivariate nominal logistic multivariate analysis was constructed to assess the effects of preoperative patient characteristics on the likelihood of attaining both the minimal clinically important difference and PASS.

Results

In total, 112 patients were included in the study, with 79 (71%) having recreational or higher levels of athletic participation. The PASS for the study population was 56.0 (area under the ROC curve, 0.86) and was unaffected by baseline PROMIS-PF scores but was affected by preoperative athletic participation (56.0 for athletes, 49.0 for nonathletes). A post hoc analysis found 57 patients (51%) achieved the PASS for the PROMIS-PF (cutoff, 56.0), but when the athlete and nonathlete thresholds were applied to their respective patient groups, 66% of athletes and 64% of nonathletes achieved the PASS postoperatively. The multivariate analysis found that sport participation (odds ratio, 6.2; P = .001) but not age, sex, body mass index, or preoperative PROMIS affected the likelihood of achieving the PASS on the PROMIS-PF.

Conclusion

Preoperative athletic participation significantly affected the ability to achieve PASS.

Republication of "Current Concepts Review: Hallux Rigidus"

Arthritis of the first metatarsophalangeal (MTP) joint, hallux rigid, is a common and disabling source of foot pain in the adult population. Hallux rigidus is characterized by diseased cartilage and large, periarticular osteophytes that result in a stiff, painful joint. Activity modification, sensible shoes, orthotics, anti-inflammatory medications and occasional intra-articular steroid injections can be attempted to alleviate the discomfort associated with hallux rigidus. A number of surgical options exist for the treatment of recalcitrant hallux rigidus. Cheilectomy is a useful treatment for dorsal impingement pain seen in mild hallux rigidus. A new polyvinyl alcohol hemi-arthroplasty implant has shown promising early and midterm results in the treatment of advanced hallux rigidus; however, arthrodesis of the first MTP joint remains the gold standard treatment for advanced hallux rigidus because of unpredictable outcomes after early-generation joint replacement implants.

Does Patient-Reported Outcome Measures Use at New Foot and Ankle Patient Clinic Visits Improve Patient Activation, Experience, and Satisfaction?

BACKGROUND

Patient-reported outcome measures (PROMs) can help predict clinical outcomes and improve shared clinical decision-making discussions. There remains a paucity of research assessing how the use of PROMs may drive improved patient experience and patient activation.

METHODS

New foot and ankle patients completed PROMIS physical function (PF), pain interference (PI), and depression assessments. Patients were then randomized to viewing and discussing their PROMIS scores with their surgeon or not. Following the clinic visit, patients completed a series of Clinician & Group Survey-Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) questions and the Patient Activation Measure (PAM). Responses to the CG-CAHPS questions and PAM were compared between the 2 groups and after clustering on surgeon. Potential interaction effects by social deprivation were also explored.

RESULTS

After enrolling patients but removing those lost to follow-up or with missing data, 97 and 116 patients remained in the intervention control cohorts, respectively. No difference was found in CG-CAHPS responses nor PAM scores between the 2 groups (P > .05). All surgeons were highly rated by all patients. When clustered by surgeon, intervention subjects were less likely to indicate "top box" scores for the understanding domain of the CG-CAHPS question (OR 0.51, P < .001) and had decreased odds of high patient activation compared to control subjects (OR 0.67; P = .005). Among the most socially disadvantaged patients, there was no difference in control and intervention subjects in their likelihood of having high patient activation (P = .09).

CONCLUSION

Highly rated foot and ankle surgeons who show and discuss PROM results may not improve patient experience or activation and may, in fact, decrease understanding or patient activation in select populations. Future work is needed to determine when PROM discussions are most beneficial and how best to present PROMs data, as we suspect that how the information was presented-and not the use of PROMs-resulted in our findings. Health literacy tools and/or communication training may better engage different patient groups regarding PROMs.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

AOA Critical Issues: Patient-Reported Outcome Measures: Why Every Orthopaedic Practice Should Be Collecting Them

ABSTRACT

Patient-centered care is essential to providing high-quality value-based care. Patient-reported outcome measures (PROMs) are arguably the best tools available to orthopaedic providers for providing patient-centered care. Many clinical opportunities exist for the implementation of PROMs into routine practice, such as shared decision-making, mental health screening, and prediction of postoperative disposition. Routine use of PROMs is also an adjunct to the streamlining of documentation, patient intake, and telemedicine visits, and hospitals can aggregate PROMs for the purpose of risk stratification. Physicians can harness the power of PROMs for quality improvement initiatives and improvement of the patient experience. Despite these numerous applications, PROMs are frequently underutilized tools. Understanding the many benefits of PROMs may allow orthopaedic practices to justify investing in these valuable tools.

Clinical Improvement Following Operative Management of Ankle Fractures Among Patients With and Without Moderate to High Depressive Symptoms: An Analysis Using PROMIS

Background

Understanding the recovery trajectory following operative management of ankle fractures can help surgeons guide patient expectations. Further, it is beneficial to consider the impact of mental health on the recovery trajectory. Our study aimed to address the paucity of literature focused on understanding the recovery trajectory following surgery for ankle fractures, including in patients with depressive symptoms.

Methods

From February 2015 to March 2020, patients with isolated ankle fractures were asked to complete Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), and Depression questionnaires as part of routine care at presentation and follow-up time points. Linear mixed effects regression models were used to evaluate the patient recovery pattern, comparing the preoperative time point to <3 months, 3-6 months, and >6 months across all patients. Additional models that included the presence of depression symptoms as a covariate were then used.

Results

A total of 153 patients met inclusion criteria. By 3-6 months, PROMIS PF (β: 9.95, 95% CI: 7.97-11.94, P < .001), PI (β: -10.30, 95% CI: -11.87 to -8.72, P < .001), and Depression (β: -5.60, 95% CI: -7.01 to -4.20, P < .001) improved relative to the preoperative time point. This level of recovery was sustained thereafter. When incorporating depressive symptoms into our model as a covariate, the moderate to high depressive symptoms were associated with significantly and clinically important worse PROMIS PF (β: -4.00, 95% CI: -7.00 to -1.00, P = .01) and PI (β: 3.16, 95% CI: -0.55 to 5.76, P = .02) scores.

Conclusion

Following ankle fracture surgery, all patients tend to clinically improve by 3-6 months postoperatively and then continue to appreciate this clinical improvement. Although patients with moderate to high depressive symptoms also clinically improve following the same trajectory, they tend to do so to a lesser level than those who have low depressive symptoms.

Level of Evidence

Level III, case-control study.

Can Patient Reported Outcomes be Used to Eliminate Unnecessary Follow Up Clinic Visits after Surgery?

Category:

Other; Ankle; Hindfoot; Midfoot/Forefoot

Introduction/Purpose:

Patient reported outcomes (PROs) have been a powerful tool to inform clinicians on the success or failure of various treatments including surgery. Patient-Reported Outcome Measurement Information System (PROMIS) is a suite of validated symptom-based questions designed to be asked and answered directly by the patient to track treatment progress quickly and accurately. This study uses PROMIS to determine the duration between foot and ankle surgery and assessment of a successful outcome. Additionally, we retrospectively calculate the savings that would be realized by eliminating unnecessary office visits if this model was implemented in clinical practice.

Methods:

Retrospective PROMIS Pain Interference (PI) data were obtained for common elective foot (n=832) and ankle (n=851) surgical procedures. Patients were categorized into quartiles of their pre-operative PI score - quartile 1 (Q1) being 25% of patients with the lowest PI scores. Minimal clinically important difference (MCID) was defined by the ½ standard-deviation of the pre- operative pain interference t-scores. A patient was considered recovered after observing two consecutive MCID decreases in post-operative pain interference t-scores. A cox proportional hazards model stratified by preoperative PI score quartile was used to predict probability patient recovery after adjusting for age, race, ethnicity, gender, and primary payor. The average and total potential savings for the cohort was derived using the number of patient-visits post-recovery.

Results:

Two consecutive decreases in MCID measured by PI PROMIS t-scores were achieved 90 days post-operatively by 16%, 16%, 17%, and 23% of post-operative ankle patients in quartiles 1-4 respectively; post-operative foot patients achieved 18%, 11%, 20%, and 26% in quartiles 1-4 respectively (see Figure 1). Days 30-60 recorded the greatest rate of improvement across quartiles with Q4 showing the greatest improvement. The least improvement occurred between days 90-120 across all quartiles. Patients were seen by the orthopedics departments on average 2.84 times after achieving two consecutive MCID improvements, totaling to $243.63 in expenses to institutional payers per patient. Avoiding these excess visits even after MCID achievement could result in savings ranging from $38,593 to $122,002.

Conclusion:

PI PROMIS t-scores can be used to assess the need for ongoing follow up for surgical patients. If there is evidence that the patient has improved a clinically meaningful amount on two successive visits additionally follow-up may not be needed. Using PROs in clinical decision-making pathways as suggested in this research will eliminate unnecessary visits and save healthcare dollars and valuable resources

Can We Utilize PROMIS Neuropathic Pain Quality for Assessment of Neuropathic Heel Pain?

Category:

Hindfoot; Other

Introduction/Purpose:

Heel pain is one of the most common presentations encountered by foot and ankle specialists. While most etiologies of heel pain such as plantar fasciitis are mechanical stress driven nociceptive pain, a combined neuropathic mechanism may contribute to worse outcomes and challenges in pain management for a subset of these patients. Diagnosis and management of neuropathic pain in foot and ankle patients remain challenging. Since neuropathic pain may play an important part in indicating surgery or counseling heel pain patients, we investigated the plausibility of utilizing the Patient-Reported Outcomes Measurement Information System (PROMIS) Neuropathic Pain Quality (PQN) as an initial screening tool to diagnose and monitor the clinical effects of treatment. Secondary outcomes were prevalence of neuropathic pain and associated risk factors.

Methods:

New patients presenting to a tertiary care academic institution with heel pain were prospectively recruited. PROMIS PQN t-scores were obtained from all patients to detect and determine the severity of NP. Patients were grouped into no neuropathic pain (NP), mild neuropathic pain (NP), and severe NP based on the initial PROMIS PQN t-scores. Pain Interference (PI), Physical Function (PF), and Self-Efficacy (SE) scores were assessed at baseline, 30, and 90-day follow-up timepoints. Other factors such as age, smoking, body mass index (BMI), low back/neck pain, anxiety, depression, and medications were analyzed for association with outcomes. Linear mixed modeling was utilized to assess the main effects of time and NP on PROMIS t-scores, and meaningful clinically important difference (MCID) was compared.

Results:

A total of 48 patients with mean age of 52.4+-12.5 years old were recruited at the initial visit. The cohort consisted of 35 (73%) female patients, 7 (15%) diabetics, 6 (13%) current smokers, 18 (38%) with low back/neck pain, 6 (13%) with anxiety, 15 (31%) with depression, and 9 (19%) had taken neuromodulator, such as gabapentin. When using the PROMIS PQN as the assessment tool, 33 patients (69%) had NP at baseline; 23 (48%) with mild, and 10 (21%) with severe NP. BMI was the only significant independent factor associated with NP (p = 0.011). Higher baseline NP was significantly associated with higher PQN (p<0.001) and PI (p=0.005), and lower SE (p=0.04) across timepoints. Patients who were detected to have NP based on the PQN t-score had lower PF at baseline with significantly less improvement in PF (3 vs 9.9, p=0.035), and did not meet MCID (Figure 1).

Conclusion:

Prevalence of neuropathic pain in patients presenting with heel pain was high. Neuropathic pain at baseline was significantly associated with worse pain and self-efficacy over time, and less clinically meaningful improvements in function. The PROMIS PQN may serve as a valuable tool to identify and guide clinical treatment decision pathways for patients with neuropathic heel pain.

The OFAR Experiment: Barriers, Lessons, and Findings From an Orthopedic Patient Outcomes Database

Category:

Other; Ankle; Hindfoot; Midfoot/Forefoot

Introduction/Purpose:

As digital healthcare systems advance, patient reported outcomes (PRO) platforms offer an effective strategy for clinicians to evaluate patient relevant treatment outcomes. Initiated by AOFAS in 2018, the Orthopaedic Foot and Ankle Outcomes Research (OFAR) Network was a multi-center surgical outcomes registry platform established to collect, aggregate, and report PRO data. OFAR included surgical information, patient demographics, and PRO instruments developed by the National Institutes of Health (NIH) Patient Reported Outcomes Measurement Information System (PROMIS). Due to high costs and competing technologies, OFAR data collection ended in 2020. Although OFAR did not achieve widespread and sustained use, a large number of patients were enrolled over the 2-year period. We hypothesized that each aggregated PRO metric improved at all post-operative time points compared to preoperative values.

Methods:

From 2018-2020, four sites and 10 orthopedic surgeons were approved and able to contribute patient data to the OFAR database. Enrolled patients completed a pre-operative survey and then post-operative surveys at 3-months, 6-months, and 12-months. Five PROMIS metrics were collected at each survey point, including Physical Function CAT (PF), Pain Intensity Short Form (PI), Pain Interference CAT, Global Health Short Form and Depression CAT. Descriptive statistics were used to summarize the demographics and clinical characteristics of all individuals. Linear mixed models were used to test for differences in patient reported outcomes (PROs) across the study visits. The unstructured covariance structure was used to account for the repeated measures. After the OFAR closed to enrollment, all investigators of the OFAR consortium, including those who were not able to participate as a site, were surveyed to investigate the barriers they faced when launching OFAR at their site.

Results:

The final OFAR database includes 1,675 procedures performed at four institutions, with 1,126 having complete data for analysis. Ankle impingement (12%), ankle fracture/syndesmosis (11%), ankle arthritis (10%), and hallux valgus (9%) were the most common conditions among 28 unique conditions. The cumulative incidence of post-operative complications was 6.2% and the re- operation rate was 1.5%. Relative to the pre-operative visit, there was significant improvement in all metrics across post-operative time points (Table 1). The majority of OFAR consortium member sites (15 of 19) were unable to enroll patients in OFAR. The most common barriers noted included resistance from institutional EMR/IT or compliance teams, and institutional requirements to collect PROs through another platform. The majority of OFAR members (55%) indicated they would participate in a future low-cost, low-effort multi-center outcomes database.

Conclusion:

The OFAR database successfully collected patient outcomes data from multiple institutions. The resulting database also provided a comprehensive resource to answer targeted clinical questions about outcome predictors for common interventions. Barriers to participation in a multi-center registry more frequently emanated from the technologic or compliance constraints of hospital systems rather than individual providers. Increasing demand for PROs in practice, combined with the evolving technical landscape of greater automation and EHR interoperability will lead to more sustainable, affordable, and collaborative outcomes platforms. Institutional EMR and compliance barriers remain an important factor in advancing these important initiatives.

Physical Function and Pain Interference Levels of Hallux Rigidus Patients Before and After Synthetic Cartilage Implant vs Arthrodesis Surgery

BACKGROUND

Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient's physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS).

METHODS

PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests.

RESULTS

Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively (P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals (P < .01). PI t scores were similar between the 2 procedures across time points.

CONCLUSION

The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame.

LEVEL OF EVIDENCE

Level IV, case series.

Prediction of post-interventional physical function in diabetic foot ulcer patients using patient reported outcome measurement information system (PROMIS)

BACKGROUND

Infected diabetic foot ulcer (DFU) patients present with an impaired baseline physical function (PF) that can be further compromised by surgical intervention to treat the infection. The impact of surgical interventions on Patient Reported Outcomes Measurement Information System (PROMIS) PF within the DFU population has not been investigated. We hypothesize that preoperative PROMIS scores (PF, Pain Interference (PI), Depression) in combination with relevant clinical factors can be utilized to predict postoperative PF in DFU patients.

METHODS

DFU patients from a single academic physician's practice between February 2015 and November 2018 were identified (n = 240). Ninety-two patients met inclusion criteria with complete follow-up and PROMIS computer adaptive testing records. Demographic and clinical factors, procedure performed, and wound healing status were collected. Spearman's rank correlation coefficient, Chi-Squared tests and multidimensional modelling were applied to all variables' pre- and postoperative values to assess patients' postoperative PF.

RESULTS

The mean age was 60.5 (33-96) years and mean follow-up was 4.7 (3-12) months. Over 70 % of the patients' initial PF were 2-3 standard deviations below the US population (n = 49; 28). Preoperative PF (p <  0.01), PI (p < 0.01), Depression (p <  0.01), CRF (p <  0.02) and amputation level (p <  0.04) showed significant univariate correlation with postoperative PF. Multivariate model (r = 0.55) showed that the initial PF (p =  0.004), amputation level (p =  0.008), and wound healing status (p =  0.001) predicted postoperative PF.

CONCLUSIONS

Majority of DFU patients present with poor baseline PF. Preoperative PROMIS scores (PF, PI, Depression) are predictive of postoperative PROMIS PF in DFU patients. Postoperative patient's physical function can be assessed by PF_{postoperative} = 29.42 + 0.34 (PF_initial) - 5.87 (Not Healed) - 2.63 (Amputation Category). This algorithm can serve as a valuable tool for predicting post-operative physical function and setting expectations.

Improving Interpretation of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Scale for Specific Tasks in Community-Dwelling Older Adults

BACKGROUND AND PURPOSE

New generic patient-reported outcomes like the Patient-Reported Outcomes Measurement Information System (PROMIS) are available to physical therapists to assess physical function. However, the interpretation of the PROMIS Physical Function (PF) T-score is abstract because it references the United States average and not specific tasks. The purposes of this study were to (1) determine convergent validity of the PROMIS PF scale with physical performance tests; (2) compare predicted performance test values to normative data; and (3) identify sets of PROMIS PF items similar to performance tests that also scale in increasing difficulty and align with normative data.

METHODS

Community-dwelling older adults (n = 45; age = 77.1 ± 4.6 years) were recruited for this cross-sectional analysis of PROMIS PF and physical performance tests. The modified Physical Performance Test (mPPT), a multicomponent test of mostly timed items, was completed during the same session as the PROMIS PF scale. Regression analysis examined the relationship of mPPT total and component scores (walking velocity, stair ascent, and 5 times sit to stand) with the PROMIS PF scale T-scores. Normative data were compared with regression-predicted mPPT timed performance across PROMIS PF T-scores. The PROMIS PF items most similar to walking, stair ascent, or sit to stand were identified and then PROMIS PF model parameter-calibrated T-scores for these items were compared alongside normative data.

RESULTS AND DISCUSSION

There were statistically significant correlations (r = 0.32-0.64) between PROMIS PF T-score and mPPT total and component scores. Regression-predicted times for walking, stair ascent, and sit-to-stand tasks (based on T-scores) aligned with published normative values for older adults. Selected PF items for stair ascent and walking scaled well to discriminate increasing difficulty; however, sit-to-stand items discriminated only lower levels of functioning.

CONCLUSIONS

The PROMIS PF T-scores showed convergent validity with physical performance and aligned with published normative data. While the findings are not predictive of individual performance, they improve clinical interpretation by estimating a range of expected performance for walking, stair ascent, and sit to stand. These findings support application of T-scores in physical therapy testing, goal setting, and wellness plans of care for community-dwelling older adults.

URMC Universal Depression Screening Initiative: Patient Reported Outcome Assessments to Promote a Person-Centered Biopsychosocial Population Health Management Strategy

Background: Patient-reported outcomes (PROs) can promote person-centered biopsychosocial health care by measuring outcomes that matter to patients, including functioning and well-being. Data support feasibility and acceptability of PRO administration as part of routine clinical care, but less is known about its effects on population health, including detection of unmet healthcare needs. Our objectives were to examine differences in rates of clinically significant depression across sociodemographic groups and clinical settings from universal depression screens in a large health system, estimate the number of patients with untreated depression detected by screenings, and examine associations between biopsychosocial PROs-physical, psychological, and social health. Methods: We analyzed data from over 200,000 adult patients who completed depression screens-either PROMIS (Patient Reported Outcomes Measurement Information System) or PHQ-2/9-as part of routine outpatient care. Results: Depression screens were positive in 14.2% of the sample, with more positive screens among younger vs. older adults, women vs. men, non-White vs. White, and Hispanics vs. non-Hispanics. These same sociodemographic indicators, as well as completing screening in primary care (vs. specialty care) were also associated with greater likelihood of detected depression in the medical record. Discussion: Universal screening for depression symptoms throughout a large health system appears acceptable and has the potential to detect depression in diverse patient populations outside of behavioral health. Expanded delivery of PROs to include physical and social health as well as depression should be explored to develop a clinically-relevant model for addressing patients' biopsychosocial needs in an integrated fashion across the health system.

The Impact of Patient Age on Foot and Ankle Arthrodesis Supplemented with Autograft or an Autograft Alternative (rhPDGF-BB/β-TCP)

A recent survey of orthopaedic surgeons asking about risk factors for nonunion following foot and ankle arthrodesis revealed that patient age is considered to be a relatively low risk factor, despite the potential for autologous graft quality to deteriorate with increasing age. The purpose of the current study was to evaluate the impact of patient age and graft type on fusion rates following hindfoot and ankle arthrodesis.

Threshold Values for Success After Hip Arthroscopy Using the Patient-Reported Outcomes Measurement Information System Assessment: Determining the Minimum Clinically Important Difference and Patient Acceptable Symptomatic State

BACKGROUND

Threshold values for patient-reported outcome measures, such as the minimum clinically important difference (MCID) and patient acceptable symptomatic state (PASS), are important for relating postoperative outcomes to meaningful functional improvement.

PURPOSE

To determine the PASS and MCID after hip arthroscopy for femoroacetabular impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

A consecutive series of patients undergoing primary hip arthroscopy for femoroacetabular impingement were administered preoperative and minimum 1-year postoperative PROMIS surveys focusing on physical function (PF) and pain interference (PI). External anchor questions for the MCID and PASS were given with the postoperative PROMIS survey. Receiver operator curves were constructed to determine the threshold values for the MCID and PASS. Curves were generated for the study population as well as separate cohorts segregated by median baseline PF or PI scores and preoperative athletic participation. A multivariate post hoc analysis was then constructed to evaluate factors associated with achieving the PASS or MCID.

RESULTS

There were 113 patients (35% male; mean ± SD age, 32.8 ± 12.5 years; body mass index, 25.8 ± 4.8 kg/m²), with 60 (53%) reporting preoperative athletic participation. Survey time averaged 77.5 ± 49.2 seconds. Anchor-based MCID values were 5.1 and 10.9 for the PF and PI domains, respectively. PASS thresholds were 51.8 and 51.9 for the PF and PI, respectively. PASS values were not affected by baseline scores, but athletic patients had a higher PASS threshold than did those not participating in a sport (53.1 vs 44.7). MCID values were affected by preoperative baseline scores but were largely independent of sports participation. A post hoc analysis found that 94 (83%) patients attained the MCID PF while 66 (58%) attained the PASS PF. A multivariate nominal logistic regression found that younger patients (P = .01) and athletic patients (P = .003) were more likely to attain the PASS.

CONCLUSION

The PROMIS survey is an efficient metric to evaluate preoperative disability and postoperative function after primary hip arthroscopy for femoroacetabular impingement. The MCID and PASS provide surgeons with threshold values to help determine PROMIS scores that are clinically meaningful to patients, and they can assist with therapeutic decision making as well as expectation setting.

Chopart Amputation: Questioning the Clinical Efficacy of a Long-standing Surgical Option for Diabetic Foot Infection

BACKGROUND

Diabetic foot ulcers with associated infection and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation based on the patient's baseline physical function, extent of infection, vascular patency, and comorbidities can be challenging. Although Chopart amputation preserves greater limb length than more proximal alternatives such as Syme or below-the-knee amputations (BKA), challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes of Chopart amputation combined with tendon transfers.

METHODS

We identified patients who underwent Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments. Incidence of postoperative complications and change in patient-reported outcomes before and after surgery were recorded.

RESULTS

Eighteen patients with an average age of 60.8 (range, 44 to 79) years were identified. The mean follow-up was 22.8 months (range, 6.7 to 51.0). Seventeen of the 18 total patients developed postoperative wound complications. These lead to revision amputations in 10 Chopart amputees, consisting of two Syme and eight BKAs. Half of the Chopart patients never received a prosthesis because of delayed wound healing and revision amputation. PROMIS physical function (PF) (31.1 pre-op and 28.6 post-op), pain interference (63.1 pre-op and 59.4 post-op), and depression (53.0 pre-op and 54.8 post-op) did not show significant change (P-values = 0.38, 0.29, 0.72, respectively). Pre- and post-op the PROMIS physical function scores were well below the US average.

DISCUSSION

In our patient cohort, 94% of patients developed postoperative wound complication. Only 44% of patients ever successfully ambulated with a prosthesis after Chopart amputation, and the others (56%) required revision amputations such as a BKA. Even after wound healing, Chopart amputees may struggle with obtaining a prosthesis suitable for ambulation. Surgeons should exercise judicious patient selection before performing Chopart amputation.

LEVEL OF EVIDENCE

IV, Case Series.

Long-term Autograft Harvest Site Pain After Ankle and Hindfoot Arthrodesis

BACKGROUND

Pain following autograft harvest has been studied; however, published literature has typically focused on the iliac crest with follow-up limited to only a few years. It remains unknown if pain continues or improves over time. The purpose of this study was to evaluate long-term pain associated with autograft harvest to supplement hindfoot or ankle arthrodesis.

METHODS

Subjects in the control arm of a previously conducted trial comparing autograft with a synthetic bone graft for hindfoot or ankle arthrodesis were invited back for a single visit at a minimum of 5 years following their initial surgery. Harvest site, fusion site, and weight-bearing pain were evaluated using a 100-point visual analog scale (VAS). Of the 130 invited subjects, 60 (46.1%) returned for assessment, 58 of whom completed pain assessments.

RESULTS

At a mean follow-up of 9.0 years (range, 7.8-10.5), more than a third (36.6%) of subjects had some level of harvest site pain. Using VAS greater than 20 mm as a threshold of clinical significance, pain remained clinically significant in 5.2% of subjects. There was a significant correlation between harvest site pain and both weight-bearing and fusion site pain. There was not a significant correlation between harvest site pain and volume of graft harvested.

CONCLUSION

Autograft harvest can result in chronic, clinically significant pain that can last up to 10 years. In the era of shared decision making, this information will help surgeons and patients quantify the risks of chronic pain after arthrodesis procedures that include a secondary operative incision for graft harvest.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Talar Avascular Necrosis After Calcium Phosphate Injection Treatment of Talar Bone Marrow Lesions: A Report of 2 Cases

CASE

We report on 2 patients who developed avascular necrosis (AVN) of the talus and poor patient outcomes after undergoing calcium phosphate injection into talar dome bone marrow lesions.

CONCLUSION

Subchondroplasty, defined as calcium phosphate injection for the treatment of articular bone marrow edema, is a recently described procedure for use in the ankle joint. In our opinion, the limited available research is of poor quality and describes equivocal improvement in patient symptoms after this procedure. Given the debilitating outcomes and extensive AVN we observed in 2 patients, we strongly advise caution in the use of this procedure in the talus.

Pattern of recovery and outcomes of patient reported physical function and pain interference after ankle fusion: a retrospective cohort study

Background

Research on outcomes after ankle fusion focuses on basic activities of daily living, fusion rates, and gait parameters. Little has been reported on the patient’s perspective after surgery. The purpose of this study was to determine the change in patient reported physical function and pain interference after ankle fusion surgery to guide patient expectations and improve provider communication.

Methods

This was a retrospective review of prospectively collected patient reported outcome measurement information system (PROMIS) data in 88 ankle arthrodesis procedures performed from May 2015 to March 2018. The PROMIS Physical function (PF) and pain interference (PI) measures were collected as routine care. Linear mixed models were used to assess differences at each follow-up point for PF and PI. Preoperative to last follow-up in the 120–365 day interval was assessed using analysis of variance. Outcomes included T-scores, z-scores, and PROMIS-Preference (PROPr) utility scores for PF and PI and the percentage of patients improving by at least 4 T-score points.

Results

The linear mixed model analysis for PF after the 120–149 days, and for PI, after 90–119 days, indicated recovery plateaued at 39–40 for PF and 57–59 for PI T-scores. The change in the PI T-score was the greatest with a mean T-score improvement of − 5.4 (95% CI − 7.7 to − 3.1). The proportion of patients improving more than 4 points was 66.2% for either PF or PI or both. The change in utility T-scores for both PF (0.06, 95% CI 0.02 to 0.11) and PI (0.15, 95% CI 0.09 to 0.20) was significantly improved, however, only PI approached clinical significance.

Conclusion

Average patients undergoing ankle fusion experience clinically meaningful improvement in pain more so than physical function. Average patient recovery showed progressive improvement in pain and function until the four-month postoperative time point. Traditional dogma states that recovery after an ankle fusion maximizes at a year, however based on the findings in this study, 4 months is a more accurate marker of recovery. A decline in function or an increase in pain after 4 months from surgery may help to predict nonunion and other complications after ankle arthrodesis.

Level of evidence

Level II, prospective single cohort study.

Operative Intervention Does Not Change Pain Perception in Patients With Diabetic Foot Ulcers

Researchers investigated pain perception in patients with diabetic foot ulcers (DFUs) by analyzing pre- and postoperative physical function (PF), pain interference (PI), and depression domains of the Patient-Reported Outcome Measurement Information System (PROMIS). They hypothesized that 1) because of painful diabetic peripheral neuropathy (DPN), a majority of patients with DFUs would have high PROMIS PI scores unchanged by operative intervention, and 2) the initially assessed PI, PF, and depression levels would be correlated with final outcomes. Seventy-five percent of patients with DFUs reported pain, most likely because of painful DPN. Those who reported high PI and low PF were likely to report depression. PF, PI, and depression levels were unchanged after operative intervention or healing of DFUs.

Role of Patient-Reported Outcome Measures on Predicting Outcome of Bunion Surgery

BACKGROUND

Prior studies have suggested preoperative patient-reported outcome scores could predict patients who would achieve a clinically meaningful improvement with hallux valgus surgery. Our goal was to determine bunionectomy-specific thresholds using Patient-Reported Outcomes Measurement Information System (PROMIS) values to predict patients who would or would not benefit from bunion surgery.

METHODS

PROMIS physical function (PF), pain interference (PI), and depression assessments were prospectively collected. Forty-two patients were included in the study. Using preoperative and final follow-up visit scores, minimally clinically important differences (MCID), receiver operating characteristic (ROC) curves, and area under the curve (AUC) analyses were performed to determine if preoperative PROMIS scores predicted achieving MCID with 95% specificity or failing to achieve an MCID with 95% sensitivity.

RESULTS

PROMIS PF demonstrated a significant AUC and likelihood ratio. The preoperative threshold score for failing to achieve MCID for PF was 49.6 with 95% sensitivity. The likelihood ratio was 0.14 (confidence interval, 0.02-0.94). The posttest probability of failure to achieve an MCID for PF was 94.1%. PI and depression AUCs were not significant, and thus thresholds were not determined.

CONCLUSION

We identified a PF threshold of 49.6, which was nearly 1 standard deviation higher than previously published. If a patient is hoping to improve PF, a patient with a preoperative t score >49.6 may not benefit from surgery. This study also suggests the need for additional research to delineate procedure-specific thresholds.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

A Comparative Analysis of Clinical Outcomes in Noninsertional Versus Insertional Tendinopathy Using PROMIS

Background. Achilles tendinopathy is a common clinical disorder. Utilizing the Patient-Reported Outcomes Measurement Information System, we aim to determine clinical response to nonoperative achilles tendinopathy rehabilitative care of insertional achilles tendinopathy compared to non-insertional achilles tendinopathy. Methods. Prospective Patient-Reported Outcomes Measurement Information System Physical Function, Pain Interference, and Depression scores were collected for patients with achilles tendinopathy at presentation and following a standard course of nonoperative care. A distribution-based method was used to determine the minimal clinically important difference. Descriptive statistics were reported and bivariate analysis was used to compare insertional achilles tendinopathy and non-insertional achilles tendinopathy. Receiver operating characteristic curve analysis was used to predict clinical improvement. Results. A total of 102 patients with an average follow-up of 68 days were included. For the non-insertional achilles tendinopathy group: Fifteen (46%), 12 (36%) and 9 (27%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. For the insertional achilles tendinopathy group: Seventeen (25%), 20 (29%) and 22 (32%) patients reached clinical improvement for Physical Function, Pain Interference and Depression, respectively. Physical Function scores improved more in non-insertional achilles tendinopathy patients (4.0 vs. -0.046; p = 0.035) and more patients clinically improved (45.5% vs. 24.6%; p = 0.034). Patients with non-insertional and insertional achilles tendinopathy clinically improved functionally when initial Physical Function scores were equal to or lower than 40.25 and 38.08, respectively. Conclusions. Nonoperative care in achilles tendinopathy is often successful. The Patient-Reported Outcomes Measurement Information System can be used to evaluate and help determine clinical success. Levels of Evidence: Level II: Prospective comparative study.

Do Patient Reported Outcome Measurement Information System (PROMIS) Scales Demonstrate Responsiveness as Well as Disease-Specific Scales in Patients Undergoing Knee Arthroscopy?

BACKGROUND

The Patient Reported Outcomes Information System (PROMIS) is an efficient metric able to detect changes in global health.

PURPOSE

To assess the responsiveness, convergent validity, and clinically important difference (CID) of PROMIS compared with disease-specific scales after knee arthroscopy.

STUDY DESIGN

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

METHODS

A prospective institutional review board-approved study collected PROMIS Physical Function (PF), PROMIS Pain Interference (PI), International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) results in patients undergoing knee arthroscopy. The change from preoperative to longest follow-up was used in analyses performed to determine responsiveness, convergent validity, and minimal and moderate CID using the IKDC scale as the anchor.

RESULTS

Of the 100 patients enrolled, 76 were included. Values of the effect size index (ESI) ranged from near 0 to 1.69 across time points and were comparable across scales. Correlations of the change in KOOS and PROMIS with IKDC ranged from r values of 0.61 to 0.79. The minimal CID for KOOS varied from 12.5 to 17.5. PROMIS PF and PI minimal CID were 3.3 and -3.2. KOOS moderate CID varied from 14.3 to 18.8. PROMIS PF and PI moderate CID were 5.0 and -5.8.

CONCLUSION

The PROMIS PF and PI showed similar responsiveness and CID compared with disease-specific scales in patients after knee arthroscopy. PROMIS PI, PROMIS PF, and KOOS correlations with IKDC demonstrate that these scales are measuring a similar construct. The ESIs of PROMIS PF and PI were similar to those of KOOS and IKDC, suggesting similar responsiveness at 6 months or longer (ESI >1.0). Minimum and moderate CID values calculated for PROMIS PF and PI using IKDC as an anchor were sufficiently low to suggest clinical usefulness.

CLINICAL RELEVANCE

PROMIS PF and PI can be accurately used to determine improvement or lack thereof with clinically important changes after knee arthroscopy.

Midterm Outcomes of a Synthetic Cartilage Implant for the First Metatarsophalangeal Joint in Advanced Hallux Rigidus

BACKGROUND:

A prospective, randomized, noninferiority clinical trial of synthetic cartilage implant hemiarthroplasty for hallux rigidus demonstrated functional outcomes and safety equivalent to first metatarsophalangeal (MTP) joint arthrodesis at 24 months. We prospectively assessed safety and efficacy outcomes for synthetic cartilage implant hemiarthroplasty at a minimum of 5 years.

METHODS:

Of 135 eligible patients from the original trial, 112 (83.0%) were enrolled (mean age, 58.2 ± 8.8 years; 87 females). Pain visual analog scale (VAS), Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL), and FAAM Sports subscales were completed preoperatively and 2 and 5 years postoperatively. Great toe active dorsiflexion, weightbearing radiographs, secondary procedures, and safety parameters were also evaluated.

RESULTS:

At 24 months, 14/152 (9.2%) patients had undergone implant removal and conversion to arthrodesis. In years 2 to 5, 9/119 (7.6%) patients underwent implant removal and conversion to arthrodesis. At mean 5.8 ± 0.7 (range, 4.4-8.0) years' follow-up, pain VAS, FAAM ADL, and FAAM Sports scores improved by 57.9 ± 18.6 points, 33.0 ± 17.6 points, and 47.9 ± 27.1 points, respectively, from baseline. Clinically significant changes in VAS pain, FAAM ADL, and FAAM Sports were reported by 103/106 (97.2%), 95/105 (90.5%), and 97/104 (93.3%) patients, respectively. Patient-reported outcomes at 24 months were maintained at 5.8 years in patients who were not revised. Active MTP joint peak dorsiflexion was maintained. Ninety-nine of 106 (93.4%) patients would have the procedure again.

CONCLUSION:

Clinical and safety outcomes for synthetic cartilage implant hemiarthroplasty observed at 2 years were maintained at 5.8 years. The implant remains a viable treatment option to decrease pain, improve function, and maintain motion for advanced hallux rigidus.

LEVEL OF EVIDENCE:

Level IV, case series.

Patient-reported outcomes use during orthopaedic surgery clinic visits improves the patient experience

OBJECTIVES

The Patient-Reported Outcomes Measurement Information System (PROMIS) is growing in popularity as healthcare shifts towards a value-based system. However, it remains unclear if PROMIS use improves the patient experience. The aim of the present study was to determine if PROMIS use as part of routine orthopaedic clinical care is associated with improved patient experience, as measured by the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) survey.

METHODS

All patient visits to an orthopaedic surgery clinic at a single academic medical centre between February 2015 and September 2016 were reviewed. Accounting for known patient factors that have an impact on clinic visit satisfaction, CGCAHPS scores were compared between patients who had PROMIS used as part of their routine care and those who had not had PROMIS used as part of their routine care. A p-value of <0.05 was considered significant.

RESULTS

A total of 8,607 patient visits fitted our inclusion criteria. Of these, surgeons elected not to use PROMIS in 8,422 patient encounters, leaving 185 patient visits in which PROMIS was actively used. When PROMIS was used, patients were significantly more likely to feel that the provider had spent enough time with them, to recommend this provider office to another patient and to rate the provider significantly higher on a scale from 0 to 10. Although not significant, a trend was found between use of PROMIS and whether a patient felt that a provider explained health information in way that the patient understood.

CONCLUSIONS

PROMIS use in an orthopaedic clinic visit can have a positive impact on the patient experience, which is currently part of a number of alternative payment models.

PROMIS Pain Interference Is Superior vs Numeric Pain Rating Scale for Pain Assessment in Foot and Ankle Patients

BACKGROUND:

The Numeric Pain Rating Scale (NPRS) is a popular method to assess pain. Recently, the Patient-Reported Outcomes Measurement Information System (PROMIS) has been suggested to be more accurate in measuring pain. This study aimed to compare NPRS and PROMIS Pain Interference (PI) scores in a population of foot and ankle patients to determine which method demonstrated a stronger correlation with preoperative and postoperative function, as measured by PROMIS Physical Function (PF).

METHODS:

Prospective PROMIS PF and PI and NPRS data were obtained for 8 common elective foot and ankle surgical procedures. Data were collected preoperatively and postoperatively at a follow-up visit at least 6 months after surgery. Spearman correlation coefficients were calculated to determine the relationship among NPRS (0-10) and PROMIS domains (PI, PF) pre- and postoperatively. A total of 500 patients fit our inclusion criteria.

RESULTS:

PROMIS PF demonstrated a stronger correlation to PROMIS PI in both the pre- and postoperative settings (preoperative: ρ = -0.66; postoperative: ρ = -0.69) compared with the NPRS (preoperative: ρ = -0.32; postoperative:ρ = -0.33). Similar results were found when data were grouped by Current Procedural Terminology (CPT) code.

CONCLUSION:

PROMIS PI was a superior tool to gauge a patient's preoperative level of pain and functional ability. This information may assist surgeons and patients in setting postoperative functional expectations and pain management.

LEVEL OF EVIDENCE:

Level II, prognostic.

Impact of Knee Scooter Flexion Position on Venous Flow Rate

BACKGROUND:

The knee scooter is a commonly used mobility device in the setting of unilateral below-knee immobilization. The bent-knee posture has been shown to decrease venous flow in a seated position, but the knee scooter differs as the patient is weightbearing through the affected extremity. Our goal was to investigate the effects of knee scooter positioning on popliteal venous flow.

METHODS:

Duplex ultrasonography was performed to obtain venous diameter and flow velocity of the popliteal vein on healthy subjects over the age of 18 without immobilization. Measurements were performed on the left knee of each subject while standing and with the same knee flexed on the knee scooter, by 2 physicians trained in ultrasound techniques. Mean velocity, peak velocity, vessel diameter, and volumetric flow rate were calculated and t tests were performed for each variable. A power analysis was performed, determining that 9 subjects would provide 80% power with an alpha of 0.05. A total of 13 subjects participated in the study. Mean age was 33 (range 20-56) years, with 6 females and 7 males.

RESULTS:

Measurements of subjects while standing and on the knee scooter demonstrated a significant decrease in mean velocity (6.5 vs 3.2 cm/s, P < .01) and volumetric flow rate (227.8 vs 106.2 mL/min, P < .01) while subjects were using the scooter. Vessel diameter (0.82 vs 0.78 cm, P = .15) and peak velocities (19.8 vs 14.7 cm/s, P = .19) were not significantly different between standing and kneeling positions.

CONCLUSION:

Our findings demonstrated a statistically significant decrease in volumetric flow rate in subjects using a knee scooter device with a flexed knee. Although venous stasis is a known risk factor for DVT, flow rate thresholds for increased thrombus formation are not well defined. The duration of scooter use, or flexed knee positioning, may have some effect on the degree of stasis. This finding should caution orthopedists to consider the risk attributed to the knee scooter as part of their overall patient assessment.

LEVEL OF EVIDENCE:

Level II, therapeutic, comparative study.

Responsiveness of the PROMIS and FAAM Instruments in Foot and Ankle Orthopedic Population

BACKGROUND:

Investigating the responsiveness of an instrument is important in order to provide meaningful interpretation of clinical outcomes. This study examined the responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), the PROMIS Pain Interference (PI), and the Foot and Ankle Ability Measure (FAAM) Sports subscale in an orthopedic sample with foot and ankle ailments.

METHODS:

Patients presenting to an orthopedic foot and ankle clinic during the years 2014-2017 responded to the PROMIS and FAAM instruments prior to their clinical appointments. The responsiveness of the PROMIS PF v1.2, PROMIS PI v1.1, and FAAM Sports were assessed using paired samples t test, effect size (ES), and standardized response mean (SRM) at 4 different follow-up points. A total of 785 patients with an average age of 52 years (SD = 17) were included.

RESULTS:

The PROMIS PF had ESs of 0.95 to 1.22 across the 4 time points (3, >3, 6, and <6 months) and SRMs of 1.04 to 1.43. The PROMIS PI had ESs of 1.04 to 1.63 and SRMs of 1.17 to 1.23. For the FAAM Sports, the ESs were 1.25 to 1.31 and SRMs were 1.07 to 1.20. The ability to detect changes via paired samples t test provided mixed results. But in general, the patients with improvement had statistically significant improved scores, and the worsening patients had statistically significant worse scores.

CONCLUSION:

The PROMIS PF, PROMIS PI, and FAAM Sports were sensitive and responsive to changes in patient-reported health.

LEVEL OF EVIDENCE:

Level II, prospective comparative study.

Patient-Reported Outcome Measures: How and Why They Are Collected

Patient-reported outcomes measures (PROM) have become increasingly emphasized in the transition from volume-based to value-based orthopaedic care. Incorporation of PROM collection into daily clinical practice can be challenging, however, because of financial and logistic constraints. In modern orthopaedics, PROM are important and can be successfully and practically incorporated into clinical practice.

PROMIS and FAAM Minimal Clinically Important Differences in Foot and Ankle Orthopedics

BACKGROUND:

Establishing score points that reflect meaningful change from the patient perspective is important for interpreting patient-reported outcomes. This study estimated the minimum clinically important difference (MCID) values of 2 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the Foot and Ankle Ability Measure (FAAM) Sports subscale within a foot and ankle orthopedic population.

METHODS:

Patients seen for foot and ankle conditions at an orthopedic clinic were administered the PROMIS Physical Function (PF) v1.2, the PROMIS Pain Interference (PI) v1.1, and the FAAM Sports at baseline and all follow-up visits. MCID estimation was conducted using anchor-based and distribution-based methods.

RESULTS:

A total of 3069 patients, mean age of 51 years (range = 18-94), were included. The MCIDs for the PROMIS PF ranged from approximately 3 to 30 points (median = 11.3) depending on the methods being used. The MCIDs ranged from 3 to 25 points (median = 8.9) for the PROMIS PI, and from 9 to 77 points (median = 32.5) for the FAAM Sports.

CONCLUSIONS:

This study established a range of MCIDs in the PROMIS PF, PROMIS PI, and FAAM Sports indicating meaningful change in patient condition. MCID values were consistent across follow-up periods, but were different across methods. Values below the 25th percentile of MCIDs may be useful for low-risk clinical decisions. Midrange values (eg, near the median) should be used for high stakes decisions in clinical practice (ie, surgery referrals). The MCID values within the interquartile range should be utilized for most decision making.

LEVEL OF EVIDENCE:

Level I, diagnostic study, testing of previously developed diagnostic measure on consecutive patients with reference standard applied.

New Technology in the Treatment of Hallux Rigidus with a Synthetic Cartilage Implant Hemiarthroplasty

Synthetic cartilage implant surgery is an excellent option for the patient with great toe arthritis and good alignment of the toe who wishes to retain first metatarsophalangeal motion and obtain 90% improved pain relief and function. Patients with osteoporosis, osteopenia, or bone defects from surgery or disease may not maintain the implant position due to poor bone quality, resulting in less than desired outcomes. Despite this being a straightforward surgery, patients need to be aware that the pain relief may not begin until 3+ months after surgery because this procedure does require bone resection and implant placement.

Treatment of first metatarsophalangeal joint arthritis using hemiarthroplasty with a synthetic cartilage implant or arthrodesis: A comparison of operative and recovery time

BACKGROUND

First metatarsophalangeal joint (MTPJ1) hemiarthroplasty using a novel synthetic cartilage implant was as effective and safe as MTPJ1 arthrodesis in a randomized clinical trial. We retrospectively evaluated operative time and recovery period for implant hemiarthroplasty (n=152) and MTPJ1 arthrodesis (n=50).

METHODS

Perioperative data were assessed for operative and anaesthesia times. Recovery and return to function were prospectively assessed with the Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) subscales and SF-36 Physical Functioning (PF) subscore.

RESULTS

Mean operative time for hemiarthroplasty was 35±12.3min and 58±21.5min for arthrodesis (p<0.001). Anaesthesia duration was 28min shorter with hemiarthroplasty (p<0.001). At weeks 2 and 6 postoperative, hemiarthroplasty patients demonstrated clinically and statistically significantly higher FAAM Sport, FAAM ADL, and SF-36 PF subscores versus arthrodesis patients.

CONCLUSION

MTPJ1 hemiarthroplasty with a synthetic cartilage implant took less operative time and resulted in faster recovery than arthrodesis.

LEVEL OF EVIDENCE

III, Retrospective case control study.

Determining Success or Failure After Foot and Ankle Surgery Using Patient Acceptable Symptom State (PASS) and Patient Reported Outcome Information System (PROMIS)

BACKGROUND

As the role of generic patient-reported outcomes (PROs) expands, important questions remain about their interpretation. In particular, how the Patient Reported Outcome Measurement Instrumentation System (PROMIS) t score values correlate with the patients' perception of success or failure (S/F) of their surgery is unknown. The purposes of this study were to characterize the association of PROMIS t scores, the patients' perception of their symptoms (patient acceptable symptom state [PASS]), and determination of S/F after surgery.

METHODS

This retrospective cohort study contacted patients after the 4 most common foot and ankle surgeries at a tertiary academic medical center (n = 88). Patient outcome as determined by phone interviews included PASS and patients' judgment of whether their surgery was a S/F. Assessment also included PROMIS physical function (PF), pain interference (PI), and depression (D) scales. The association between S/F and PASS outcomes was evaluated by chi-square analysis. A 2-way analysis of variance (ANOVA) evaluated the ability of PROMIS to discriminate PASS and/or S/F outcomes. Receiver operator curve (ROC) analysis was used to evaluate the ability of pre- (n = 63) and postoperative (n = 88) PROMIS scores to predict patient outcomes (S/F and PASS). Finally, the proportion of individuals classified by the identified thresholds were evaluated using chi-square analysis.

RESULTS

There was a strong association between PASS and S/F after surgery (chi-square <0.01). Two-way ANOVA demonstrated that PROMIS t scores discriminate whether patients experienced positive or negative outcome for PASS ( P < .001) and S/F ( P < .001). The ROC analysis showed significant accuracy (area under the curve > 0.7) for postoperative but not preoperative PROMIS t scores in determining patient outcome for both PASS and S/F. The proportion of patients classified by applying the ROC analysis thresholds using PROMIS varied from 43.0% to 58.8 % for PASS and S/F.

CONCLUSIONS

Patients who found their symptoms and activity at a satisfactory level (ie, PASS yes) also considered their surgery a success. However, patients who did not consider their symptoms and activity at a satisfactory level did not consistently consider their surgery a failure. PROMIS t scores for physical function and pain demonstrated the ability to discriminate and accurately predict patient outcome after foot and ankle surgery for 43.0% to 58.8% of participants. These data improve the clinical utility of PROMIS scales by suggesting thresholds for positive and negative patient outcomes independent of other factors.

LEVEL OF EVIDENCE

II, prospective comparative series.

Validation and Generalizability of Preoperative PROMIS Scores to Predict Postoperative Success in Foot and Ankle Patients

BACKGROUND

A recent publication reported preoperative Patient-Reported Outcomes Measurement Instrumentation System (PROMIS) scores to be highly predictive in identifying patients who would and would not benefit from foot and ankle surgery. Their applicability to other patient populations is unknown. The aim of this study was to assess the validation and generalizability of previously published preoperative PROMIS physical function (PF) and pain interference (PI) threshold t scores as predictors of postoperative clinically meaningful improvement in foot and ankle patients from a geographically unique patient population.

METHODS

Prospective PROMIS PF and PI scores of consecutive patient visits to a tertiary foot and ankle clinic were obtained between January 2014 and November 2016. Patients undergoing elective foot and ankle surgery were identified and PROMIS values obtained at initial and follow-up visits (average, 7.9 months). Analysis of variance was used to assess differences in PROMIS scores before and after surgery. The distributive method was used to estimate a minimal clinically important difference (MCID). Receiver operating characteristic curve analysis was used to determine thresholds for achieving and failing to achieve MCID. To assess the validity and generalizability of these threshold values, they were compared with previously published threshold values for accuracy using likelihood ratios and pre- and posttest probabilities, and the percentages of patients identified as achieving and failing to achieve MCID were evaluated using χ² analysis.

RESULTS

There were significant improvements in PF ( P < .001) and PI ( P < .001) after surgery. The area under the curve for PF (0.77) was significant ( P < .01), and the thresholds for achieving MCID and not achieving MCID were similar to those in the prior study. A significant proportion of patients (88.9%) identified as not likely to achieve MCID failed to achieve MCID ( P = .03). A significant proportion of patients (84.2%) identified as likely to achieve MCID did achieve MCID ( P < .01). The area under the curve for PROMIS PI was not significant.

CONCLUSIONS

PROMIS PF threshold scores from published data were successful in classifying patients from a different patient and geographic population who would improve with surgery. If functional improvement is the goal, these thresholds could be used to help identify patients who will benefit from surgery and, most important, those who will not, adding value to foot and ankle health care.

LEVEL OF EVIDENCE

Level II, Prospective Comparative Study.

Five-year Outcomes of a Synthetic Cartilage Implant for the First Metatarsophalangeal Joint in Advanced Hallux Rigidus

Category:

Midfoot/Forefoot

Introduction/Purpose:

Hallux rigidus is the most common arthritic condition of the foot. A prospective, randomized, non-inferiority clinical trial of first metatarsophalangeal joint (MTPJ) hemiarthroplasty with a synthetic polyvinyl alcohol hydrogel implant, for moderate to severe hallux rigidus, demonstrated maintenance of MTPJ active dorsiflexion motion and excellent pain relief; additionally, the trial showed functional outcomes and safety equivalent to first MTPJ arthrodesis at 24 months (Baumhauer et al. 2016; FAI:37(5):457-469). Recognizing that many hemiarthroplasty and total toe implants have initially good results that deteriorate over time, the purpose of this study was to prospectively assess the safety and efficacy outcomes for the synthetic cartilage implant population and to determine if the excellent outcomes were maintained at >5 years.

Methods:

One hundred and fifty-two patients underwent implant hemiarthroplasty in the original trial; 14 underwent implant removal and conversion to fusion and 3 were lost to follow-up during the first 24 months, leaving 135 eligible for this study. One hundred patients were evaluated at 5+ years; 5 could not be reached for follow-up. Thirty are pending consent, follow-up, and/or data entry; their status will be available for inclusion at the conference presentation. Patients completed a pain visual analogue scale (VAS) and Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) scores, preoperatively and at 2, 6, 12, 26, 52, 104 and 260 weeks postoperatively. Minimal clinically important differences are: =30% difference for pain VAS, 9 points for FAAM Sports, and 8 points for FAAM ADL. Great toe active dorsiflexion, weight-bearing radiographs, secondary procedures, and safety parameters were evaluated.

Results:

Of 100 synthetic cartilage implant hemiarthroplasty patients available at mean 5.8 years follow-up (SD ±0.7; range: 4.4- 7.4), 5 underwent implant removal and conversion to fusion in years 2-5 (Figure 1), and 2 underwent subsequent surgical interventions during the pivotal trial and were censored, leaving 93 patients for evaluation. Pain and function outcomes observed at 5.8 years were similar to those at 2 years (Figure 1). VAS Pain and FAAM Sports Scores were maintained or improved at 5.8 years follow-up, but these differences were not clinically significant. Joint motion was maintained at 5.8 years. No evidence of avascular necrosis, device migration or fragmentation was observed upon independent radiographic review. Eighty-six percent of patients agreed their overall well-being had improved, and 92% would have the procedure again.

Conclusion:

Clinical and safety outcomes of patients having undergone synthetic cartilage implant hemiarthroplasty for the surgical treatment of hallux rigidus were previously demonstrated to be non-inferior to the gold standard treatment, MTPJ fusion, at 2 years. Prospectively determined outcomes for 100/135 of these implant hemiarthroplasty patients at 5.8 years are similar to those reported at 2 years. Longer-term results demonstrate that clinical and safety outcomes for synthetic cartilage implant hemiarthroplasty are durable, and that the implant remains a viable treatment option to decrease pain, improve function and maintain motion for advanced hallux rigidus.

Current Concepts Review

Arthritis of the first metatarsophalangeal (MTP) joint, hallux rigid, is a common and disabling source of foot pain in the adult population. Hallux rigidus is characterized by diseased cartilage and large, periarticular osteophytes that result in a stiff, painful joint. Activity modification, sensible shoes, orthotics, anti-inflammatory medications and occasional intra-articular steroid injections can be attempted to alleviate the discomfort associated with hallux rigidus. A number of surgical options exist for the treatment of recalcitrant hallux rigidus. Cheilectomy is a useful treatment for dorsal impingement pain seen in mild hallux rigidus. A new polyvinyl alcohol hemi-arthroplasty implant has shown promising early and midterm results in the treatment of advanced hallux rigidus; however, arthrodesis of the first MTP joint remains the gold standard treatment for advanced hallux rigidus because of unpredictable outcomes after early-generation joint replacement implants.

Correlation of Hallux Rigidus Grade With Motion, VAS Pain, Intraoperative Cartilage Loss, and Treatment Success for First MTP Joint Arthrodesis and Synthetic Cartilage Implant

BACKGROUND

Grading systems are used to assess severity of any condition and as an aid in guiding treatment. This study examined the relationship of baseline motion, pain, and observed intraoperative cartilage loss with hallux rigidus grade.

METHODS

A prospective, randomized study examining outcomes of arthrodesis compared to synthetic cartilage implant was performed. Patients underwent preoperative clinical examination, radiographic assessment, hallux rigidus grade assignment, and intraoperative assessment of cartilage loss. Visual analog scale (VAS) score for pain was obtained preoperatively and at 24 months. Correlation was made between active peak dorsiflexion, VAS pain, cartilage loss, and hallux rigidus grade. Fisher's exact test was used to assess grade impact on clinical success ( P < .05).

RESULTS

In 202 patients, 59 (29%), 110 (55%), and 33 (16%) were classified as Coughlin grades 2, 3, and 4, respectively. There was no correlation between grade and active peak dorsiflexion (-0.069, P = .327) or VAS pain (-0.078, P = .271). Rank correlations between grade and cartilage loss were significant, but correlations were small. When stratified by grade, composite success rates between the 2 treatments were nearly identical.

CONCLUSIONS

Irrespective of the grade, positive outcomes were demonstrated for both fusion and synthetic cartilage implant. Clinical symptoms and signs should be used to guide treatment, rather than a grade consisting of radiographic, symptoms, and range of motion factors.

LEVEL OF EVIDENCE

Level II, randomized clinical trial.