Estimating measurement error of the Oswestry Disability Index with missing data.

BACKGROUND CONTEXT: The Oswestry Disability Index (ODI) is the most commonly used patient-reported outcome measure for low back pain. Incomplete ODI questionnaires may induce measurement error, causing misclassification of disability level. PURPOSE: We determined which scoring method-alternative scoring (AS) or multiple imputation (MI)-produced the best estimate of measurement error with missing items; and assessed the precision of AS and MI when scoring the ODI and classifying disability level with increasing numbers of missing items. STUDY DESIGN/SETTING: Quantitative study PATIENT SAMPLE: We included 995 patients who underwent lumbar spine surgery from 2014 to 2020 and who had complete ODI data. OUTCOME MEASURES: Measurement error. METHODS: We (1) simulated 1000 datasets for each number of ODI items (1-9) for which data could be missing by randomly setting items to missing; (2) calculated simulated scores using AS or MI; (3) calculated absolute percentage error (APE) of simulated vs. true scores; (4) classified disability level using the simulated score; and (5) compared APE between scoring methods to assess precision and misclassification rates. RESULTS: For 1, 5, and 9 missing items using AS, APE was 0.6%, 3.1%, and 12%, respectively, and misclassification rates were 0.6%, 4.6%, and 13%. For 1, 5, and 9 missing items using MI, APE was 1.3%, 7.9%, and 56%, respectively, and misclassification rates were 4.6%, 9.7%, and 58%, respectively. CONCLUSION: With increasing numbers of missing ODI items, MI introduced more measurement error than AS did. Clinicians should consider APE when interpreting ODI scores with missing data and classifying disability level. Inaccurate interpretations could negatively affect assessments and treatment plans. LEVEL OF EVIDENCE: IV.

COVID-19 Significantly Impacted Hospital Length of Stay and Discharge Patterns for Adult Spinal Deformity Patients.

STUDY DESIGN: Retrospective review. OBJECTIVE: The primary aim was to compare length of stay (LOS) and discharge disposition of adult spinal deformity (ASD) patients undergoing surgery before and during the pandemic. Secondary aims were to compare the rates of 30-day complications, reoperations, readmissions, and unplanned emergency department (ED) visits. SUMMARY OF BACKGROUND DATA: ASD patients often require extended LOS and non-routine discharge. Given resource limitations during the Coronavirus Disease 2019 (COVID-19) pandemic and caution regarding hospital stays, surgeons modified standard postoperative protocols to minimize patient exposure. METHODS: We identified all patients who underwent elective thoracolumbar ASD surgery with more than or equal to five levels fusion at a tertiary care center during two distinct time intervals: July to December 2019 (Pre-COVID, N = 60) and July to December 2020 (During-COVID, N = 57). Outcome measures included LOS and discharge disposition (home vs. non-home), as well as 30-day major complications, reoperations, readmissions, and ED visits. Regression analyses controlled for demographic and surgical factors. RESULTS: Patients who underwent ASD surgery during the pandemic were younger (61 vs. 67 yrs) and had longer fusion constructs (nine vs. eight levels) compared with before the pandemic (P < 0.05 for both). On bivariate analysis, patients undergoing surgery during the pandemic had shorter LOS (6 vs. 9 days) and were more likely to be discharged home (70% vs. 28%) (P < 0.05 for both). After controlling for age and levels fused on multivariable regression, patients who had surgery during the pandemic had shorter LOS (IRR = 0.83, P = 0.015) and greater odds of home discharge (odds ratios [OR] = 7.2, P < 0.001). Notably, there were no differences in major complications, reoperations, readmissions, or ED visits between the two groups. CONCLUSION: During the COVID-19 pandemic, LOS for patients undergoing thoracolumbar ASD surgery decreased, and more patients were discharged home without adversely affecting complication or readmission rates. Lessons learned during the pandemic may help improve resource utilization without negatively influencing short-term outcomes.Level of Evidence: 3.

Associations of depression and sociodemographic characteristics with patient activation among those presenting for spine surgery.

PURPOSE: To investigate the associations of sociodemographic characteristics and PROMIS domain scores with patient activation among patients presenting for spine surgery at a university-affiliated spine center. METHODS: Patients completed a survey collecting demographic and social information. Patients also completed the Patient-Reported Outcomes Measurement Information System (PROMIS) and Patient Activation Measure questionnaires. The associations of PROMIS scores and sociodemographic characteristics with patient activation were assessed using linear and ordinal logistic regression (patient activation stage as ordinal). RESULTS: A total of 1018 patients were included. Most respondents were white (84%), married (73%), and female (52%). Patients were distributed among the 4 activation stages as follows: stage I, 7.7%; stage II, 12%; stage III, 26%; and stage IV, 55%. Mean (±standard deviation) patient activation score was 70 ± 17 points. Female sex (adjusted coefficient [AC] = 4.3; 95% confidence interval [CI] 2.1, 6.4) and annual household income >$80,000 (OR = 3.7; 95% CI 0.54, 6.9) were associated with higher patient activation scores. Lower patient activation scores were associated with worse PROMIS Depression (AC = -0.31; 95% CI -0.48, -0.14), Fatigue (OR = -0.19; 95% CI -0.33, -0.05), Pain (OR = 0.22; 95% CI 0.01, 0.43), and Social Satisfaction (OR = 0.33; 95% CI 0.14, 0.51) scores. CONCLUSION: Depression and socioeconomic status, along with PROMIS Pain, Fatigue, and Social Satisfaction domains, were associated with patient activation. Patients with a greater burden of depressive symptoms had lower patient activation; conversely, women and those with higher income had greater patient activation. LEVEL OF EVIDENCE: Level 1.

Appropriate Opioid Use After Spine Surgery: Psychobehavioral Barriers and Patient Knowledge.

OBJECTIVE: To identify spine patients' barriers to appropriate postoperative opioid use, comfort with naloxone, knowledge of safe opioid disposal practices, and associated factors. METHODS: We preoperatively surveyed 174 spine patients about psychobehavioral barriers to appropriate opioid use, comfort with naloxone, and knowledge about opioid disposal. Multivariable logistic regression identified factors associated with barriers and knowledge (α = 0.05). RESULTS: Common barriers were fear of addiction (71%) and concern about disease progression (43%). Most patients (78%) had neutral/low confidence in the ability of nonopioid medications to control pain; most (57%) felt neutral or uncomfortable with using naloxone; and most (86%) were familiar with safe disposal. Anxiety was associated with fear of distracting the physician (adjusted odds ratio [aOR], 3.8; 95% confidence interval [CI], 1.1-14) and with lower odds of knowing safe disposal methods (aOR, 0.18; 95% CI, 0.04-0.72). Opioid use during the preceding month was associated with comfort with naloxone (aOR, 4.9; 95% CI, 2.1-12). Patients with a higher educational level had lower odds of reporting fear of distracting the physician (aOR, 0.30; 95% CI, 0.09-0.97), and those with previous postoperative opioid use had lower odds of concern about disease progression (aOR, 0.25; 95% CI, 0.09-0.63) and with a belief in tolerating pain (aOR, 0.34; 95% CI, 0.12-0.95). CONCLUSIONS: Many spine patients report barriers to appropriate postoperative opioid use and are neutral or uncomfortable with naloxone. Some are unfamiliar with safe disposal. Associated factors include anxiety, lack of recent opioid use, and no previous postoperative use.

Effect of biceps tenodesis on speed of recovery after arthroscopic rotator cuff repair.

BACKGROUND: Concomitant biceps tendon pathology is often present in patients undergoing rotator cuff repair (RCR). Management of biceps pathology has been reported to influence outcomes of RCR; however, the impact on the pace of recovery remains unclear. The purpose of this study was to analyze the effects of simultaneous RCR with biceps tenodesis (RCR-BT) on time to achieve maximum improvement and recovery speed for pain and function. METHODS: A retrospective review of 535 patients who underwent primary RCR for full-thickness tears. Patients treated with simultaneous RCR-BT were compared with RCR-only. Outcome measures and motion were recorded at preoperative routine postoperative intervals. Plateau in maximal improvement and recovery speed were analyzed for both pain and functional recovery. RESULTS: Baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) function was significantly lower for the RCR-BT cohort (20.5) compared with RCR-only (23.9; P = .008). For visual analog scale (VAS) pain and measured motion, the plateau in maximal improvement occurred at 6 months for RCR-BT compared with 12 months for the RCR-only group. The remainder of the patient-reported outcome measures took 12 months to achieve a plateau in maximal improvement. At 3 months, 79% of improvement in pain and 42%-49% of functional improvement was achieved in the RCR-BT cohort. Similarly, at 3 months, the RCR-only cohort achieved 73% of pain improvement and 36%-57% of functional improvement at 3 months. CONCLUSION: Patients requiring RCR with simultaneous biceps tenodesis have lower baseline ASES function and earlier postoperative plateaus in pain relief and motion improvement following surgery. Nonetheless, the speed of recovery was not influenced by the biceps tenodesis.

Comparing the Use of Axillary Radiographs and Axial Computed Tomography Scans to Predict Concentric Glenoid Wear.

BACKGROUND: Axillary radiographs traditionally have been considered sufficient to identify concentric glenoid wear in osteoarthritic shoulders; however, with variable glenoid wear patterns, assessment with use of computed tomography (CT) has been recommended. The purpose of the present study was to compare the use of axillary radiographs and mid-glenoid axial CT scans to identify glenoid wear. METHODS: Preoperative axillary radiographs and mid-glenoid axial CT scans for 330 patients who underwent anatomic total shoulder arthroplasty were reviewed. Five independent examiners with differing levels of experience characterized the glenoid morphology as either concentric or eccentric. The morphologies determined with use of axillary radiographs and CT scans were assessed for correlation, and both intraobserver and interobserver consistency were calculated. RESULTS: Concentric wear identified with use of radiographs was confirmed with use of CT scans in an average of 61% of cases (range, 53% to 76%). Intraobserver consistency averaged 75% for radiographs and 73% for CT scans. There was significant interobserver consistency, as higher levels of training corresponded with greater consistency between imaging analyses (p < 0.001). The most senior observer identified the highest proportion of concentric wear on radiographs (p < 0.001), showed the greatest consistency between attempts when using CT (p < 0.001), and had the greatest agreement of radiographs and CT evaluating glenoid morphology (p < 0.001). CONCLUSIONS: For the experienced shoulder surgeon, concentric glenoid wear identified on axillary radiographs will appear concentric on 2-dimensional CT in approximately 75% of cases. Obtaining a CT scan to confirm glenoid wear patterns most greatly benefits less-experienced surgeons. Across all levels of experience, axillary radiographs and single-slice, mid-glenoid CT scans appear insufficient for consistently predicting wear patterns. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Medial calcar bone resorption after anatomic total shoulder arthroplasty: does it affect outcomes?

BACKGROUND: The incidence of medial calcar resorption has been shown to be common after uncemented total shoulder arthroplasty (TSA). With etiologies including stress shielding, debris-induced osteolysis, and infection, the clinical impact of medial calcar resorption has not been specifically examined. The purpose of this study was to determine whether resorption is associated with inferior outcomes or higher rates of radiographic loosening in TSA patients. METHODS: We conducted a retrospective review of TSA patients with minimum 2-year clinical follow-up. Patient-reported and functional outcome measures were recorded preoperatively and postoperatively. Postoperative radiographs were evaluated for glenoid and humeral component loosening. A new calcar resorption grading system was introduced to quantify the degree of resorption and assess the progression. RESULTS: A total of 171 patients met the inclusion criteria, with average clinical and radiographic follow-up periods of 50 and 46 months, respectively. Calcar resorption was identified in 110 patients (64.3%). No significant overall differences were observed between the patients with and without calcar resorption. Subgroup analysis showed that patients with grade 3 resorption had a higher incidence of glenoid radiolucencies (50%, P = .001) and patients with a progression from grade 1 to grade 3 had higher incidences of glenoid (50%, P = .003) and humeral (9%, P = .039) radiolucencies. CONCLUSION: Medial calcar resorption following TSA with a standard-length press-fit humeral component is common. Overall, no differences in patient-reported outcome measures or radiographic loosening were found compared with patients without calcar resorption. However, grade 3 calcar resorption and more dramatic progression of resorption should raise the suspicion of prosthetic loosening.