The Natural Course of Recovery After Hip Arthroscopy for Femoroacetabular Impingement According to the International Hip Outcome Tool–12 and Hip Outcome Score Sports Subscale

Background: A paucity of literature exists regarding trajectories of functional and sports-specific recovery after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Purpose: To determine if subgroups of patients exist based on the recovery trajectory of patient-reported outcomes (PROs) after hip arthroscopy for FAIS in the short-term period and to determine clinical predictors for these subgroups of patients. Study Design: Case-control study; Level of evidence, 3. Methods: A prospectively maintained repository was queried for patients who had undergone primary hip arthroscopy for the treatment of FAIS between January 2012 and May 2018. Patients who completed the preoperative, 1-year, and 2-year International Hip Outcome Tool–12 (iHOT-12) or the Hip Outcome Score Sports Subscale (HOS-SS) were included. The latent class growth analysis (LCGA) and growth mixture models (GMMs) were used to identify subgroups of patients based on trajectories of recovery for the iHOT-12 and the HOS-SS utilizing preoperative, 1-year, and 2-year follow-ups. LCGA and GMM models using 1 to 6 classes for each PRO were performed, and the best-fit model for each PRO was selected. After final model selection, a multivariable multinomial logistic regression was performed, with the largest class being the reference group to determine clinical predictors of subgroup membership. Results: A total of 443 and 556 patients were included in the iHOT-12 and HOS-SS analyses, respectively. For the iHOT-12, we identified the following 3 subgroups: early progressors (70%), late regressors (22.3%), and late progressors (7.7%). Predictors of late regression were workers’ compensation status, psychiatric history, preoperative chronic pain, and lower preoperative iHOT-12 scores; and late progressors were less likely to participate in sports. For the HOS-SS, we identified the following 4 subgroups: early progressors (47.7%), late regressors (17.4%), late progressors (6.8%), and steady progressors (28.1%). Predictors of less favorable recovery trajectories (late regressors and late progessors) were older age, male sex, back pain, psychiatric history, preoperative chronic pain, greater alpha angle, and lower preoperative HOS-SS scores. Conclusion: Using the growth mixture modeling, 3 natural courses of health-related quality of life (early progression, late regression, and late progression) and 4 natural courses of recovery of athletic function (steady progression, late regression, late progression, and early progression) were identified. Preoperative psychiatric conditions, chronic pain, workers’ compensation status, and lower iHOT-12 scores were predictive of less than favorable trajectories of recovery according to the iHOT-12, and male sex, older age, back pain, preoperative narcotic use, and lower preoperative HOS-SS were predictors of less favorable recovery trajectories according to the HOS-SS.

Time to Achieving Clinically Significant Outcomes after Meniscal Allograft Transplantation

Objectives: Meniscal allograft transplantation (MAT) is a surgical treatment option for patients with meniscus deficiencies. Prior studies have defined clinically significant outcomes such as minimal clinical important difference (MCID) and patient acceptable symptomatic state (PASS) for commonly administered patient reported outcome measures (PROMs) after MAT. The purpose of this study was to determine the time to achieving MCID and PASS and to identify any risk factors affecting achievement in patients undergoing MAT. Methods: A prospectively maintained MAT registry was retrospectively reviewed from April 2014-May 2020. Patients who underwent revision MAT or did not complete preoperative PROMs were excluded. International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were administered preoperatively and at 6-months, 1-year, and 2-years postoperatively. Previously defined MCID and PASS thresholds were utilized and Kaplan-Meier survival curve analysis with interval censoring was used to calculate the cumulative percentages of MCID, and PASS achievement at each follow-up time interval (5-7, 11-13, and 23-25 months). Results: Eighty-four patients (mean age: 28.2±9.7) were included. Time to MCID and PASS is presented in Table 1. Previously reported PASS values for KOOS Pain, Symptoms, and Sport did not reach an AUC>0.70 and thus were not included in analysis. Worker’s compensation status was found to delay time to achieving MCID for all PROs (HR=0.238-0.305, P=0.008-0.020) and PASS for KOOS Symptoms (HR=0.171, P = 0.026) and IKDC (HR=1.88, P<0.001) (Table 2 and 3). Higher preoperative PRO score was associated with mildly delaying the time to achieving MCID for all PROs (HR=0.947-0.970, P<0.001), while higher preoperative PRO scores were associated with shorter time to achieving PASS on KOOS Symptoms and KOOS QOL (HR=1.030-1.043, P=0.001). Greater BMI (HR=0.946, P=0.020) and the number of focal chondral defects (HR=0.083-0.255, P=0.007-0.029) was associated with delayed MCID for KOOS ADL and QOL, respectively, while concomitant realignment surgery decreased time to MCID on KOOS Sports (HR=2.542, P=0.008). Conclusions: This study defined the time to achieving MCID and PASS on IKDC and KOOS subscores for patients undergoing MAT. Worker’s compensation status, BMI, and the presence of focal chondral defects may prolong time to achievement of MCID and PASS after MAT. [Table: see text][Table: see text][Table: see text]

Does Workers’ Compensation Status Affect Outcomes after Lumbar Spine Surgery? A Systematic Review and Meta-Analysis

Low back pain (LBP) is currently the leading cause of disability worldwide and the most common reason for workers’ compensation (WC) claims. Studies have demonstrated that receiving WC is associated with a negative prognosis following treatment for a vast range of health conditions. However, the impact of WC on outcomes after spine surgery is still controversial. The aim of this meta-analysis was to systematically review the literature and analyze the impact of compensation status on outcomes after lumbar spine surgery. A systematic search was performed on Medline, Scopus, CINAHL, EMBASE and CENTRAL databases. The review included studies of patients undergoing lumbar spine surgery in which compensation status was reported. Methodological quality was assessed through ROBINS-I and quality of evidence was estimated using the GRADE rating. A total of 26 studies with a total of 2668 patients were included in the analysis. WC patients had higher post-operative pain and disability, as well as lower satisfaction after surgery when compared to those without WC. Furthermore, WC patients demonstrated to have a delayed return to work. According to our results, compensation status is associated with poor outcomes after lumbar spine surgery. Contextualizing post-operative outcomes in clinical and work-related domains helps understand the multifactorial nature of the phenomenon.

Time Required to Achieve Clinically Significant Outcomes After Arthroscopic Rotator Cuff Repair

Background: Recent literature has focused on correlating statistically significant changes in outcome measures with clinically significant outcomes (CSOs). CSO benchmarks are being established for arthroscopic rotator cuff repair (RCR), but more remains to be defined about them. Purpose: To define the time-dependent nature of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptomatic State (PASS) after RCR and to define what factors affect this time to CSO achievement. Study Design: Case series; Level of evidence, 4. Methods: An institutional registry was queried for patients who underwent arthroscopic RCR between 2014 and 2016 and completed preoperative, 6-month, 1-year, and 2-year patient-reported outcome measures (PROMs). Threshold values for MCID, SCB, and PASS were obtained from previous literature for the American Shoulder and Elbow Surgeons score (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant score. The time in which patients achieved MCID, SCB, and PASS was calculated using Kaplan-Meier analysis. A Cox multivariate regression model was used to identify variables correlated with earlier or later achievement of CSOs. Results: A total of 203 patients with an average age of 56.19 ± 9.96 years and average body mass index was 30.29 ± 6.49 were included. The time of mean achievement of MCID, SCB, and PASS for ASES was 5.77 ± 1.79 months, 6.22 ± 2.85 months, and 7.23 ± 3.81 months, respectively. The time of mean achievement of MCID, SCB, and PASS for SANE was 6.25 ± 2.42 months, 7.05 ± 4.10 months, and 9.26 ± 5.89 months, respectively. The time of mean achievement of MCID, SCB, and PASS for Constant was 6.94 ± 3.85 months, 7.13 ± 4.13 months, and 8.66 ± 5.46 months, respectively. Patients with dominant-sided surgery (hazard ratio [HR], 1.363; 95% CI, 1.065-1.745; P = .014) achieved CSOs earlier on ASES, while patients with workers’ compensation status (HR, 0.752; 95% CI, 0.592-0.955; P = .019), who were current smokers (HR, 0.323; 95% CI, 0.119-0.882; P = .028), and with concomitant biceps tenodesis (HR, 0.763; 95% CI, 0.607-0.959; P = .021) achieved CSOs on ASES at later timepoints. Patients with distal clavicle excision (HR, 1.484; 95% CI, 1.028-2.143; P = .035) achieved CSOs earlier on SANE. Patients with distal clavicle excision (HR, 1.689; 95% CI, 1.183-2.411, P = .004) achieved CSOs earlier on Constant, while patients with workers’ compensation insurance status (HR, 0.671; 95% CI, 0.506-0.891; P = .006) and partial-thickness tears (HR, 0.410; 95% CI, 0.250-0.671; P < .001) achieved CSOs later on Constant. Greater preoperative score was associated with delayed achievement of CSOs for ASES, SANE (HR, 0.993; 95% CI, 0.987-0.999; P = .020), and Constant (HR, 0.941; 95% CI, 0.928-0.962; P < .001). Conclusion: A majority of patients achieved MCID by 6 months after surgery. Dominant-sided surgery and concomitant distal clavicle excision resulted in faster CSO achievement, while workers’ compensation status, concomitant biceps tenodesis, current smoking, partial-thickness rotator cuff tears, and higher preoperative PROMs resulted in delayed CSO achievement.

Trigger Fingers After Open Carpal Tunnel Release

Trigger finger (TF) and carpal tunnel syndrome (CTS) are common conditions often occurring together with an unclear relationship. While some studies conclude that TFs occur as a result of carpal tunnel release (CTR), others have not established a causal relationship. Our purpose was to evaluate the prevalence and timing of TF development in the same hand after open CTR in our population. This was a retrospective review of 497 patients undergoing open CTR by a single surgeon. Two hundred twenty-nine charts were analysed for age, gender, handedness, BMI, workers’ compensation status, and background disease. We analysed the specific digit involved and timing to development of triggering after CTR. Thirty-one patients developed triggering after CTR (13.5%). Mean age was 52.5 (14.0) years. Follow-up ranged from 1 to 53 months with a median follow-up of 6 months (interquartile range = 2-13). The thumb was the most common to trigger (42.22%), followed by the ring 24.44%, middle 22.22%, little 8.89%, and index fingers 2.22%. Trigger thumb occurred at 3.5 months (3.6) post-operatively, while other digits triggered at 7.5 months (4-10.25) after surgery ( P = .022). No risk factors were associated with TF development. Our results suggest that a trigger thumb develops more frequently and earlier than other trigger digits after an open CTR. Further study is needed to clarify the mechanisms involved and may enable specific treatment such as local anti-inflammatory medication following CTR. We suggest educating prospective carpal tunnel surgery patients to high risk of triggering following CTR.

Predictors of patient satisfaction following 1- or 2-level anterior cervical discectomy and fusion: insights from the Quality Outcomes Database

OBJECTIVEPatient satisfaction with treatment outcome is gaining an increasingly important role in assessing the value of surgical spine care delivery. Nationwide data evaluating the predictors of patient satisfaction in elective cervical spine surgery are lacking. The authors sought to decipher the impacts of the patient, surgical practice, and surgeon on satisfaction with outcome following anterior cervical discectomy and fusion (ACDF).METHODSThe authors queried the Quality Outcomes Database for patients undergoing 1- to 2-level ACDF for degenerative spine disease since 2013. Patient satisfaction with the surgical outcome as measured by the North American Spine Society (NASS) scale comprised the primary outcome. A multivariable proportional odds logistic regression model was constructed with adjustments for baseline patient characteristics and surgical practice and surgeon characteristics as fixed effects.RESULTSA total of 4148 patients (median age 54 years, 48% males) with complete 12-month NASS satisfaction data were analyzed. Sixty-seven percent of patients answered that “surgery met their expectations” (n = 2803), while 20% reported that they “did not improve as much as they had hoped but they would undergo the same operation for the same results” (n = 836). After adjusting for a multitude of patient-specific as well as hospital- and surgeon-related factors, the authors found baseline Neck Disability Index (NDI) score, US geographic region of hospital, patient race, insurance status, symptom duration, and Workers’ compensation status to be the most important predictors of patient satisfaction. The discriminative ability of the model was satisfactory (c-index 0.66, overfitting-corrected estimate 0.64).CONCLUSIONSThe authors’ results found baseline NDI score, patient race, insurance status, symptom duration, and Workers’ compensation status as well as the geographic region of the hospital to be the most important predictors of long-term patient satisfaction after a 1- to 2-level ACDF. The findings of the present analysis further reinforce the role of preoperative discussion with patients on setting treatment goals and realistic expectations.

Peroneal Tendon Sheath Ultrasound Guided Corticosteroid Injection: Clinical Outcomes and Complications

Category: Ankle Introduction/Purpose: Painful peroneal tendon pathologies fall into three primary categories: tendinopathy, tendon subluxation/dislocation, and tendon tears/ruptures. For symptomatic peroneal tendinopathy and tears, treatment traditionally begins with NSAIDs, rest/activity modification, physical therapy, and immobilization and with surgery typically reserved for cases of failed non-operative treatment. Ultrasound-guided peroneal tendon sheath (US PTS) corticosteroid injection is an additional nonoperative modality used by many orthopedists, however limited data has been published on its safety and efficacy. The purpose of this study was to assess clinical outcomes following US PTS corticosteroid injection for chronic tendinopathy or tears. We hypothesized that following injection, patients would have improved pain without increased incidence of spontaneous tendon rupture. Methods: We identified a retrospective cohort of patients who had undergone US PTS corticosteroid injection for pain due to peroneal tendinopathy, tears, or subluxation. Underlying diagnosis was based on clinical exam, MRI results, and/or intraoperative findings, when available. Medical record data was supplemented by email or telephone follow-up. Collected information included patient age, sex, BMI, smoking status, worker’s compensation status, prior surgeries about the foot and ankle, duration of symptoms prior to injection, perceived improvement in pain following injection and its duration, number of injections, progression to surgery, and any perceived adverse outcomes of injection. Results: We identified 96 patients (109 injections). Thirty-seven (38.5%) had previous foot and ankle surgery, with 17 (17.7%) having surgery specifically on the peroneal tendons. 24/96 (25%) progressed to have surgery on their peroneal tendons following injection. Following injection, 38/87 (43.7%) of patients experienced 0 -1 weeks of pain relief, 11/87 (12.6%) 2-6 weeks, 6/87 (6.9%) 7-12 weeks, and 32/87 (36.8%) >12 weeks of pain relief. Pre-injection duration of symptoms correlated positively with post- injection duration of pain relief (p=0.036). There was no significant difference between progression to surgery or duration of pain relief based on peroneal pathology, prior surgery, smoking status, worker’s compensation status, sex, or BMI. There were 2 reported complications (1.8%): one case of self-limited sural nerve irritation and one of peroneus longus tear progression. Conclusion: In this series of 109 US PTS corticosteroid injections, the complication rate was 1.8%. Pre-injection symptom duration correlated positively with post-injection pain relief duration. Our study demonstrates US PTS corticosteroid injection is safe in patients with pain originating from peroneal tendon tears or tendinopathy, including those who have undergone prior surgery, and should be considered in a comprehensive protocol of nonoperative management. Further research is needed to elucidate the effect of multiple injections and of injection timing, as well as whether these injections can decrease the rate of patients progressing to surgery.