Development and Operationalization of an Automated Workflow for Correlation of Knee MRI and Arthroscopy Findings.

OBJECTIVE: In this study, we sought to establish and evaluate an automated workflow to prospectively capture and correlate knee MRI findings with surgical findings in a large medical center. METHODS: This retrospective analysis included data from patients who had undergone knee MRI followed by arthroscopic knee surgery within 6 months during a 2-year period (2019-2020). Discrete data were automatically extracted from a structured knee MRI report template implementing pick lists. Operative findings were recorded discretely by surgeons using a custom-built web-based telephone application. MRI findings were classified as true-positive, true-negative, false-positive, or false-negative for medial meniscus (MM), lateral meniscus (LM), and anterior cruciate ligament (ACL) tears, with arthroscopy used as the reference standard. An automated dashboard displaying up-to-date concordance and individual and group accuracy was enabled for each radiologist. Manual correlation between MRI and operative reports was performed on a random sample of 10% of cases for comparison with automatically derived values. RESULTS: Data from 3,187 patients (1,669 male; mean age, 47 years) were analyzed. Automatic correlation was available for 60% of cases, with an overall MRI diagnostic accuracy of 93% (MM, 92%; LM, 89%; ACL, 98%). In cases reviewed manually, the number of cases that could be correlated with surgery was higher (84%). Concordance between automated and manual review was 99% when both were available (MM, 98%; LM, 100%; ACL, 99%). CONCLUSION: This automated system was able to accurately and continuously assess correlation between imaging and operative findings for a large number of MRI examinations.

Similar Healthcare Utilization and 1-Year Patient-Reported Outcomes between Cemented and Cementless Primary Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

Cementless fixation for total knee arthroplasty (TKA) has gained traction with the advent of newer fixation technologies. This study assessed (1) healthcare utilization (length of stay (LOS), nonhome discharge, 90-day readmission, and 1-year reoperation); (2) 1-year mortality; and (3) 1-year joint-specific and global health-related patient-reported outcome measures (PROMs) among patients who received cementless versus cemented TKA. Patients who underwent cementless and cemented TKA at a single institution (July 2015-August 2018) were prospectively enrolled. A total of 424 cementless and 5,274 cemented TKAs were included. The cementless cohort was propensity score-matched to a group cemented TKAs (1:3-cementless: n = 424; cemented: n = 1,272). Within the matched cohorts, 76.9% (n = 326) cementless and 75.9% (n = 966) cementless TKAs completed 1-year PROMs. Healthcare utilization measures, mortality and the median 1-year change in knee injury and osteoarthritis outcome score (KOOS)-pain, KOOS-physical function short form (PS), KOOS-knee related quality of life (KRQOL), Veteran Rand (VR)-12 mental composite (MCS), and physical composite (PCS) scores were compared. The minimal clinically important difference (MCID) for PROMs was calculated. Cementless TKA exhibited similar rates of median LOS (p = 0.109), nonhome discharge disposition (p = 0.056), all-cause 90-day readmission (p = 0.226), 1-year reoperation (p = 0.597), and 1-year mortality (p = 0.861) when compared with cemented TKA. There was no significant difference in the median 1-year improvement in KOOS-pain (p = 0.370), KOOS-PS (p = 0.417), KOOS-KRQOL (p = 0.101), VR-12-PCS (p = 0.269), and VR-12-MCS (p = 0.191) between the cementless and cemented TKA cohorts. Rates of attaining MCID were similar in both cohorts for assessed PROMs (p > 0.05, each) except KOOS-KRQOL (cementless: n = 313 (96.0%) vs. cemented: n = 895 [92.7%]; p = 0.036). Cementless TKA provides similar healthcare-utilization, mortality, and 1-year PROM improvement versus cemented TKA. Cementless fixation in TKA may provide value through higher MCID improvement in quality of life. Future episode-of-care cost-analyses and longer-term survivorship investigations are warranted.

Should an Age Cutoff Be Considered for Elective Total Knee Arthroplasty Patients? An Analysis of Operative Success Based on Patient-Reported Outcomes.

Total knee arthroplasty (TKA) is increasing in the elderly population; however, some patients, family members, and surgeons raise age-related concerns over expected improvement and risks. This study aimed to (1) evaluate the relationship between age and change in patient-reported outcome measures (PROMs); (2) model how many patients would be denied improvements in PROMs if hypothetical age cutoffs were implemented; and (3) assess length of stay (LOS), readmission, reoperation, and mortality per age group. A prospective cohort of 4,396 primary TKAs (August 2015-August 2018) was analyzed. One-year PROMs were evaluated via Knee injury and Osteoarthritis Outcome Score (KOOS)-pain, -physical function short form (-PS), and -quality of life (-QOL), as well as Veterans Rand-12 (VR-12) physical (-PCS) and mental component (-MCS) scores. Positive predictive values (PPVs) of the number of postoperative "failures" (i.e., unattained minimal clinically important difference in PROMs) relative to number of hypothetically denied "successes" from a theoretical age-group restriction was estimated. KOOS-PS and QOL median score improvements were equivalent among all age groups (p = 0.946 and p = 0.467, respectively). KOOS-pain improvement was equivalent for ≥80 and 60-69-year groups (44.4 [27.8-55.6]). Median VR-12 PCS improvements diminished as age increased (15.9, 14.8, and 13.4 for the 60-69, 70-79, and ≥80 groups, respectively; p = 0.002) while improvement in VR-12 MCS was similar among age groups (p = 0.440). PPV for failure was highest in the ≥80 group, yet remained <34% for all KOOS measures. Overall mortality was highest in the ≥80 group (2.14%, n = 9). LOS >2, non-home discharge, and 90-day readmission were highest in the ≥80 group (8.11% [n = 24], p < 0.001; 33.7% [n = 109], p < 0.001; and 34.4% [n = 111], p = 0.001, respectively). Elderly patients exhibited similar improvement in PROMs to younger counterparts despite higher LOS, non-home discharge, and 90-day readmission. Therefore, special care pathways should be implemented for those age groups.

Do patient-reported outcome measures improve after aseptic revision total hip arthroplasty?

BACKGROUND: The purpose of this study was to determine patient-reported outcome measures (PROMs) changes in: (1) pain, function and global health; and (2) predictors of PROMs in patients undergoing aseptic revision total hip arthroplasty (rTHA) using a multilevel model with patients nested within surgeon. METHODS: A prospective cohort of 216 patients with baseline and 1-year PROMs who underwent aseptic rTHA between January 2016 and December 2017 were analysed. The most common indication for rTHA was aseptic loosening, instability, and implant failure. The PROMs included in this study were HOOS Pain and HOOS Physical Function Short-form (PS), Veterans RAND-12 Physical Component Score (VR-12 PCS), and VR-12 Mental Component Score (MCS). Multivariable linear regression models were constructed for predicting 1-year PROMs. RESULTS: Mean 1-year PROMs improvement for aseptic revisions were 30.4 points for HOOS Pain and 22.1 points for HOOS PS. Predictors of better pain relief were patients with higher baseline pain scores. Predictors of better 1-year function were patients with higher baseline function and patients with a posterolateral hip surgical approach during revision. Although VR-12 PCS scores had an overall improvement, nearly 50% of patients saw no improvement or had worse physical component scores. Only 30.7% of patients reported improvements in VR-12 MCS. CONCLUSIONS: Overall, patients undergoing aseptic rTHA improved in pain and function PROMs at 1 year. Although global health assessment improved overall, nearly half of aseptic rTHA patients reported no change in physical/mental health status. The associations highlighted in this study can help guide the shared decision-making process by setting expectations before aseptic revision THA.

Evaluation of Health Care Disparities in Patients With Anterior Cruciate Ligament Injury: Does Race and Insurance Matter?

Background: It is unknown whether race- or insurance-based disparities in health care exist regarding baseline knee pain, knee function, complete meniscal tear, or articular cartilage damage in patients who undergo anterior cruciate ligament reconstruction (ACLR). Hypothesis: Black patients and patients with Medicaid evaluated for ACLR would have worse baseline knee pain, worse knee function, and greater odds of having a complete meniscal tear. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A cohort of patients (N = 1463; 81% White, 14% Black, 5% Other race; median age, 22 years) who underwent ACLR between February 2015 and December 2018 was selected from an institutional database. Patients who underwent concomitant procedures and patients of undisclosed race or self-pay status were excluded. The associations of race with preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, KOOS Function subscale, and intraoperatively assessed complete meniscal tear (tear that extended through both the superior and the inferior meniscal surfaces) were determined via multivariate modeling with adjustment for age, sex, insurance status, years of education, smoking status, body mass index (BMI), meniscal tear location, and Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS). Results: The 3 factors most strongly associated with worse KOOS Pain and KOOS Function were lower VR-12 MCS score, increased BMI, and increased age. Except for age, the other two factors had an unequal distribution between Black and White patients. Univariate analysis demonstrated equal baseline median KOOS Pain scores (Black, 72.2; White, 72.2) and KOOS Function scores (Black, 68.2; White, 68.2). After adjusting for confounding variables, there was no significant difference between Black and White patients in KOOS Pain, KOOS Function, or complete meniscal tears. Insurance status was not a significant predictor of KOOS Pain, KOOS Function, or complete meniscal tear. Conclusion: There were clinically significant differences between Black and White patients evaluated for ACLR. After accounting for confounding factors, no difference was observed between Black and White patients in knee pain, knee function, or complete meniscal tear. Insurance was not a clinically significant predictor of knee pain, knee function, or complete meniscal tear.

Posteromedial Tibial Bone Bruise After Anterior Cruciate Ligament Injury: An MRI Study of Bone Bruise Patterns in 208 Patients.

Background: Bone bruise patterns after anterior cruciate ligament (ACL) rupture may predict the presence of intra-articular pathology and help explain the mechanism of injury. Lateral femoral condyle (LFC) and lateral tibial plateau (LTP) bone bruises are pathognomic to ACL rupture. There is a lack of information regarding medial tibial plateau (MTP) and medial femoral condyle (MFC) bone bruises. Purpose: To summarize the prevalence and location of MTP bone bruises with acute ACL rupture and to determine the predictors of MTP bone bruises. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Inclusion criteria were patients who underwent ACL reconstruction between February 2015 and November 2017, magnetic resonance imaging (MRI) within 90 days of injury, and participation in the database. Exclusion criteria included previous ipsilateral surgery, multiligamentous injuries, and incomplete imaging. Due to the large number of cases remaining (n = 600), 150 patients were selected randomly from each year included in the study, for a total of 300 patients. Two readers independently reviewed injury MRI scans using the Costa-Paz bone bruise grading system. Logistic regression was used to identify factors associated with MTP bone bruises. Results: Included were 208 patients (mean age, 23.8 years; mean body mass index, 25.6). The mechanism of injury was noncontact in 59% of injuries, with over half from soccer, basketball, and football. The median time from injury to MRI scan was 12 days. Of the 208 patients, 98% (203/208) had a bone bruise, 79% (164/208) had an MTP bone bruise, and 83% (172/208) had bruises in both medial and lateral compartments. The most common pattern, representing 46.6% of patients (97/208), was a bruise in all 4 locations (MFC, LFC, MTP, and LTP). Of the 164 MTP bruises, 160 (98%) involved the posterior third of the plateau, and 161 were grade 1. The presence of an MFC bruise was the only independent risk factor for an MTP bruise (odds ratio, 3.71). The resulting nomogram demonstrated MFC bruise, sport, and mechanism of injury were the most important predictors of an MTP bruise. Conclusion: MTP bruise after acute ACL rupture was as prevalent as lateral bruises. The presence of a posterior MTP bruise suggested anterior tibial translation at the time of injury and could portend more medial compartment pathology at the time of injury than previously recognized.

Evaluation of Differences Between Non-Hispanic White and African American Patients With Sports Medicine-Related Hip Disabilities.

BACKGROUND: Racial disparities within the field of orthopaedics are well-documented in the spinal surgery, knee arthroplasty, and hip arthroplasty literature. Not much is known about racial differences in patients with sports medicine-related hip disabilities. PURPOSE: To investigate whether differences exist between African American and non-Hispanic White (White) patients evaluated for hip disabilities. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We performed a multicenter retrospective cohort study of 905 patients who were evaluated over a 1-year period for hip-related orthopaedic concerns. Patient demographic data, disability characteristics, and hip radiographic findings were obtained from electronic medical records. We also obtained data on whether patients were offered physical therapy, magnetic resonance imaging (MRI), and/or surgery. Comparisons by race and insurance status were evaluated using univariate and multivariate analyses. RESULTS: African Americans comprised a significantly lower proportion of the patients evaluated for hip-related disabilities compared with Whites (6.5% vs 93.5%; P < .001). A significantly smaller proportion of African Americans with hip disabilities was recommended for surgery than White patients (35.6% vs 54.6%; P = .007). Cam deformities were more common in White vs African American patients (39.7% vs 23.7%; P = .021), as were labral tears (54.1% vs 35.6%; P = .009). Logistic regression demonstrated that neither race nor insurance status were significant determinants in surgery recommendations. Conversely, race was a determinant of whether an MRI was performed, as White patients were 2.74 times more likely to have this procedure. There were no differences with respect to obtaining an MRI between private and Medicaid insurance. CONCLUSION: Compared with White patients, there were differences in both the proportion of African Americans evaluated for hip-related disabilities and the proportion receiving a surgery recommendation. African Americans with sports medicine-related hip issues were also less likely to obtain an MRI. With regard to observed pathology, African American patients were less likely to have cam deformities and labral tears than White patients.

No clinically meaningful difference in 1-year patient-reported outcomes among major approaches for primary total hip arthroplasty.

BACKGROUND: Debate continues around the most effective surgical approach for primary total hip arthroplasty (THA). This study's purpose was to compare 1-year patient-reported outcome measures (PROMs) of patients who underwent direct anterior (DA), transgluteal anterolateral (AL)/direct lateral (DL), and posterolateral (PL) approaches. METHODS: A prospective consecutive series of primary THA for osteoarthritis (n = 2390) were performed at 5 sites within a single institution with standardised care pathways (20 surgeons). Patients were categorised by approach: DA (n = 913; 38%), AL/DL (n = 505; 21%), or PL (n = 972; 41%). Primary outcomes were pain, function, and activity assessed by 1-year postoperative PROMs. Multivariable regression modeling was used to control for differences among the groups. Wald tests were performed to test the significance of select patient factors and simultaneous 95% confidence intervals were constructed. RESULTS: At 1-year postoperative, PROMs were successfully collected from 1842 (77.1%) patients. Approach was a statistically significant factor for 1-year HOOS pain (p = 0.002). Approach was not a significant factor for 1-year HOOS-PS (p = 0.16) or 1-year UCLA activity (p = 0.382). Pairwise comparisons showed no significant difference in 1-year HOOS pain scores between DA and PL approach (p > 0.05). AL/DL approach had lower (worse) pain scores than DA or PL approaches with differences in adjusted median score of 3.47 and 2.43, respectively (p < 0.05). CONCLUSIONS: Patients receiving the AL/DL approach had a small statistical difference in pain scores at 1 year, but no clinically meaningful differences in pain, activity, or function exist at 1-year postoperative.

Interrater Agreement of an Arthroscopic Anterior Cruciate Ligament Tear Classification System.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is the most common ligament injury treated surgically by orthopaedic surgeons. The gold standard for the treatment of the majority of primary ACL tears is ACL reconstruction. However, novel methods of repair, such as bridge-enhanced ACL repair (BEAR), are currently being investigated as alternatives to reconstruction. To assess patients for midsubstance repair suitability, clarify the prognostic implications of injury location and damage, and evaluate the results of a repair technique, it is important to have a baseline classification system or grading scale that is reproducible across surgeons, particularly for multicenter collaboration. Currently, no such system or scale exists. PURPOSE: To develop an arthroscopic ACL tear classification system and to evaluate its interobserver reliability. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Eleven fellowship-trained orthopaedic surgeon investigators reviewed 75 video clips containing arthroscopic evaluation of a torn ACL and then completed the 6-question ACL Pathology Evaluation Form. Agreement statistics including exact agreement, Fleiss κ, Gwet agreement coefficient 1 (AC1), and Gwet AC2 were then calculated to assess interobserver reliability. RESULTS: In aggregate, the multiple assessments of observer reproducibility revealed that surgeon participants in this study, when evaluating the same injury, agreed roughly 80% of the time on whether (1) at least 50% of the tibial footprint remained, (2) the remaining tibial stump was ≥10 mm, and (3) the injury was therefore reparable using the BEAR procedure. Participants also agreed roughly 60% of the time on exactly how many suturable bundles were available. These characteristics are believed to be most important, among those studied, in determining whether a torn ACL is amenable to midsubstance repair. CONCLUSION: This study is the first of its kind to demonstrate the interobserver reliability of arthroscopic classification of ACL tears. We have demonstrated that this classification system, though not ideally reproducible, is reliable enough across surgeons at multiple institutions for use in multicenter studies. REGISTRATION: NCT03776162 (ClinicalTrials.gov identifier).

Developing a personalized outcome prediction tool for knee arthroplasty.

AIMS: The purpose of this study was to develop a personalized outcome prediction tool, to be used with knee arthroplasty patients, that predicts outcomes (lengths of stay (LOS), 90 day readmission, and one-year patient-reported outcome measures (PROMs) on an individual basis and allows for dynamic modifiable risk factors. METHODS: Data were prospectively collected on all patients who underwent total or unicompartmental knee arthroplasty at a between July 2015 and June 2018. Cohort 1 (n = 5,958) was utilized to develop models for LOS and 90 day readmission. Cohort 2 (n = 2,391, surgery date 2015 to 2017) was utilized to develop models for one-year improvements in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score, KOOS function score, and KOOS quality of life (QOL) score. Model accuracies within the imputed data set were assessed through cross-validation with root mean square errors (RMSEs) and mean absolute errors (MAEs) for the LOS and PROMs models, and the index of prediction accuracy (IPA), and area under the curve (AUC) for the readmission models. Model accuracies in new patient data sets were assessed with AUC. RESULTS: Within the imputed datasets, the LOS (RMSE 1.161) and PROMs models (RMSE 15.775, 11.056, 21.680 for KOOS pain, function, and QOL, respectively) demonstrated good accuracy. For all models, the accuracy of predicting outcomes in a new set of patients were consistent with the cross-validation accuracy overall. Upon validation with a new patient dataset, the LOS and readmission models demonstrated high accuracy (71.5% and 65.0%, respectively). Similarly, the one-year PROMs improvement models demonstrated high accuracy in predicting ten-point improvements in KOOS pain (72.1%), function (72.9%), and QOL (70.8%) scores. CONCLUSION: The data-driven models developed in this study offer scalable predictive tools that can accurately estimate the likelihood of improved pain, function, and quality of life one year after knee arthroplasty as well as LOS and 90 day readmission. Cite this article: Bone Joint J 2020;102-B(9):1183-1193.

Predicting the need for surgical intervention prior to first encounter for individuals with shoulder complaints: a unique approach.

BACKGROUND: Increasing demand for musculoskeletal care necessitates efficient scheduling and matching of patients with the appropriate provider. However, up to 47% to 60% of orthopedic visits are made without formal triage. The purpose of this study was to develop a method to identify, prior to the initial office visit, the probability that a patient with shoulder symptoms will need surgery so that he or she can be appropriately matched with an operative or nonoperative provider. We hypothesized that patients who had an injury, previously saw an orthopedic provider, or previously underwent magnetic resonance imaging on the affected shoulder would be more likely to undergo surgery. METHODS: Drawing from expert opinion on potential risk factors (which could be identified prior to the initial office visit) for requiring operative intervention for a chief complaint of shoulder symptoms, we developed a branching-logic questionnaire that required a maximum of 7 responses from the patient during the scheduling process. We administered the questionnaire to patients calling with a chief complaint of shoulder symptoms at the time of initial appointment scheduling in a sports health network. A chart review was later completed to determine the ultimate treatment (operative vs. nonoperative) of each patient's complaint. A multivariate predictive model was then developed to determine the characteristics of patients with a higher surgical risk. RESULTS: We successfully developed a model capable of determining surgical risk from 7% to 90% based on patient sex, previous magnetic resonance imaging status, and injury status. CONCLUSIONS: Our predictive model can aid in patient clinical scheduling and ensure optimal matching of a patient with the best provider for the patient's care. Decreased wait times and appropriate matching may lead to increased patient satisfaction, superior outcomes, and more efficient use of health care resources.

Smartphone Data Capture Efficiently Augments Dictation for Knee Arthroscopic Surgery.

INTRODUCTION: The objectives of this study are (1) to develop a provider-friendly, evidence-based data capture system for lower-limb orthopaedic surgeries and (2) to assess the performance of the data capture system on the dimensions of agreement with operative note and implant log, consistency of data, and speed of provider input. METHODS: A multidisciplinary team developed a database and user interfaces for Android and iOS operating systems. Branching logic and discrete fields were created to streamline provider data input. One hundred patients were randomly selected from the first four months of data collection (February to June 2015). Patients were limited to those undergoing anterior cruciate ligament reconstruction, meniscal repair, partial meniscectomy, or a combination of these procedures. Duplicate data on these 100 patients were collected through chart review. These two data sets were compared. Cohen's kappa statistic was used to assess agreement. RESULTS: The database and smartphone data capture tool show almost perfect agreement (kappa > 0.81) for all data tested. In addition, data are more comprehensive with near-perfect provider completion (100% for all data tested). Furthermore, provider data entry is extremely efficient (median 151-second completion time). CONCLUSION: A well-designed database and user-friendly interface have greater potential for research utility, clinical efficiency, and, thus, cost-effectiveness when compared with standard voice-dictated operative notes. Widespread utilization of such tools can accelerate the pace and improve the quality of orthopaedic clinical research. LEVEL OF EVIDENCE: Level IV.

Predicting the Need for Surgical Intervention Prior to First Encounter for Individuals With Knee Complaints: A Novel Approach.

BACKGROUND: Orthopaedic complaints, particularly those relating to the knee, are some of the most common conditions that bring patients to the hospital. Many patients bypass their primary care physician to seek the care of an orthopaedic surgeon without referral, leaving the surgeon to manage an increasingly large number of patients, many of whom will never require surgery. PURPOSE: To develop a brief questionnaire that can be administered via phone/web at the time of appointment request to predict an individual patient's probability of requiring surgical intervention. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: All patients (N = 1307) seeking an appointment for a new knee-related complaint completed a branching-logic questionnaire. A retrospective chart review was conducted following the conclusion of each patient's episode of care to determine whether surgery was recommended. Logistic regression models were used to predict the risk of surgery based on triage question responses, basic demographics (age, sex), and laterality (unilateral vs bilateral). The ability of the models to discriminate between those who did and did not receive a surgical recommendation was measured with a concordance index. RESULTS: The model provided a high level of discrimination between surgical and nonsurgical cases (concordance index, 0.69). Recent injury with inability to walk and no recent injury with no pain were both associated with an increased probability of receiving a recommendation of surgical intervention as compared with patients who reported pain without recent injury (odds ratio [OR]: 3.51 [P < .001] and 2.78 [P = .008], respectively). A unilateral complaint was associated with needing surgical intervention (OR, 4.52 [P < .001]). Age had a significant nonlinear relationship with odds of needing of surgery, with middle-aged patients (range, 20-50 years) having the greatest odds. CONCLUSION: The current model, which utilizes demographic questions and portions of a routine history alone, was able to accurately identify individuals who are most likely (up to 65% probability) and least likely (<5% probability) to need knee surgery. This model can quickly and easily conduct triage at the time of appointment request to ensure that patients with the highest likelihood of receiving a recommendation for surgical intervention are seen by surgical providers, while those who are unlikely to receive such a recommendation can be seen by nonsurgical providers.

A smart decision: smartphone use for operative data collection in arthroscopic shoulder instability surgery.

OBJECTIVE: This study tested validity, accuracy, and efficiency of the Orthopaedic Minimal Data Set Episode of Care (OME) compared with traditional operative report in arthroscopic surgery for shoulder instability. As of November 2017, OME had successfully captured baseline data on 97% of 18 700 eligible cases. MATERIALS AND METHODS: This study analyzes 100 cases entered into OME through smartphones by 12 surgeons at an institution from February to October 2015. A blinded reviewer extracted the same variables from operative report into a separate database. Completion rates and agreement were compared. They were assessed using raw percentages and McNemar's test (with continuity correction). Agreement between nominal variables was assessed by unweighted Cohen's kappa and a concordance correlation coefficient measured agreement between continuous variables. Efficiency was assessed by median time to complete. RESULTS: Of 37 variables, OME demonstrated equal or higher completion rates for all but 1 and had significantly higher capture rates for 49% (n = 18; P < .05). Of 33 nominal variables, raw proportional agreement was ≥0.90 for 76% (n = 25). Raw proportional agreement was perfect for 15% (n = 5); no agreement statistic could be calculated due to a single variable in operative note and OME. Calculated agreement statistic was substantial or better (κ > 0.61) for 51% (n = 17) for the 33 nominal variables. All continuous variables assessed (n = 4) demonstrated poor agreement (concordance correlation coefficient <0.90). Median time for completing OME was 103.5 (interquartile range, 80.5-151) seconds. CONCLUSIONS: The OME smartphone data capture system routinely captured more data than operative report and demonstrated acceptable agreement for nearly all nominal variables, yet took <2 minutes to complete on average.

Validity and efficiency of a smartphone-based electronic data collection tool for operative data in rotator cuff repair.

BACKGROUND: This study tested validity and efficiency of Orthopaedic Minimal Data Set (OrthoMiDaS) Episode of Care (OME). METHODS: We analyzed 100 isolated rotator cuff repair cases in the OME database. Surgeons completed a traditional operative note and OME report. A blinded reviewer extracted data from operative notes and implant logs in electronic medical records by manual chart review. OME and electronic medical record data were compared with data counts and agreement between 40 variables of rotator cuff disease and repair procedures. Data counts were assessed using raw percentages and McNemar test (with continuity correction). Agreement of categorical variables was analyzed using Cohen κ (unweighted) and of numerical variables using the concordance correlation coefficient (CCC). Efficiency was assessed by median time to complete. RESULTS: OME database had significantly higher data counts for 25% (10/40) of variables. A high level of proportional and statistical agreement was demonstrated between the data. Among 35 categorical variables, proportional agreement was perfect for 17%, almost perfect (0.81 ≤ κ ≤ 1.00) for 37%, substantial (0.61 ≤ κ ≤ 0.80) for 20%, moderate (0.41 ≤ κ ≤ 0.60) for 14%, fair (0.21 ≤ κ ≤ 0.40) for 6%, and slight (0.0 ≤ κ ≤ 0.20) for 6%. Of 5 numerical variables, agreement was almost perfect (CCC > 0.99) for 20% and poor (CCC < 0.90) for 80%. Median OME completion time was 161.5 seconds (interquartile range, 116-224.5). CONCLUSION: OME is an efficient, valid tool for collecting comprehensive, standardized data on rotator cuff repair.

Prospective Evaluation of the Patient Acceptable Symptom State to Identify Clinically Successful Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The length of most patient-reported outcome measures creates significant response burden, which hampers follow-up rates. The Patient Acceptable Symptom State (PASS) is a single-item, patient-reported outcome measure that asks patients to consider all aspects of life to determine whether the state of their joint is satisfactory; this measure may be viable for tracking outcomes on a large scale. HYPOTHESIS: The PASS question would identify clinically successful anterior cruciate ligament reconstruction (ACLR) at 1-year follow-up with high sensitivity and moderate specificity. We defined "clinically successful" ACLR as changes in preoperative to postoperative scores on the Knee injury and Osteoarthritis Outcome Score (KOOS) pain subscale and the KOOS knee-related quality of life subscale in excess of minimal clinically important difference or final KOOS pain or knee-related quality of life subscale scores in excess of previously defined PASS thresholds. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Patients enrolled in a prospective longitudinal cohort completed patient-reported outcome measures immediately before primary ACLR. At 1-year follow-up, patients completed the same patient-reported outcome measures and answered the PASS question: "Taking into account all the activity you have during your daily life, your level of pain, and also your activity limitations and participation restrictions, do you consider the current state of your knee satisfactory?" RESULTS: A total of 555 patients enrolled in our cohort; 464 were eligible for this study. Of these, 300 patients (64.7%) completed 1-year follow-up, of whom 83.3% reported satisfaction with their knee after surgery. The PASS question demonstrated high sensitivity to identify clinically successful ACLR (92.6%; 95% CI, 88.4%-95.6%). The specificity of the question was 47.1% (95% CI, 35.1%-59.5%). The overall agreement between the PASS and our KOOS-based criteria for clinically successful intervention was 81.9%, and the kappa value indicated moderate agreement between the two methods (κ = 0.44). CONCLUSION: The PASS question identifies individuals who have experienced clinically successful ACLR with high sensitivity. The limitation of the PASS is its low specificity, which we calculated to be 47.1%. Answering "no" to the PASS question meant that a patient neither improved after surgery nor achieved an acceptable final state of knee health. The brevity, interpretability, and correlation of the PASS question with significant improvements on various KOOS subscales make it a viable option in tracking ACLR outcomes on a national or global scale.

Validation of a Novel Surgical Data Capturing System After Hip Arthroscopy.

INTRODUCTION: The purpose of this study is to compare the utility and validity of the OrthoMiDaS (Orthopaedic Minimal Data Set) Episode of Care (OME) database with the current benchmark for recording procedural details, the operative note (OpNote), with regard to disease severity and risk factors for hip arthroscopy cases. METHODS: A convenience sample of the first 100 hip arthroscopy cases for labral tears done at our institution between February and August 2015 were selected for this study. Surgeons recorded procedural details within OME after each case. An individual blinded to the OME data performed a chart review of the OpNote and/or implant log and recorded the information in a separate REDCap database. RESULTS: OME demonstrated higher completion rates than the OpNote for important procedural details such as previous left and right hip surgery (P < 0.001), anchor type (P = 0.008), and labrum tear clockface variables (P < 0.001 for both). In addition, OME exhibited "near-perfect" agreement with the OpNote for several important procedural details such as surgical limb (Kappa = 1.000), suture configuration (Kappa = 0.982), repair type (Kappa = 0.947), tear clockface: from (Kappa = 0.949), and tear clockface: to (Kappa = 0.885). On average, surgeons took 117 seconds to complete data entry within OME. CONCLUSION: The findings of this study validate the ability of OME to accurately and consistently capture important procedural details pertaining to arthroscopic hip surgery. Through the use of OME, high-quality standardized information can be captured and used to advance the field of hip arthroscopy by determining the clinically useful predictors of patient-reported outcome measures.

Mid-Term Results and Predictors of Patient-Reported Outcomes of Birmingham Hip Resurfacing.

BACKGROUND: Birmingham hip resurfacing (BHR) is the only Food and Drug Administration approved resurfacing option currently available in the United States. While adequate BHR outcomes are established, there is a paucity of US-based literature demonstrating factors critical to improve patient reported outcomes (PROs). This study answers: (1) What is the implant survivorship in a large US cohort? (2) Which preoperative factors result in higher PRO scores over 5 years postoperatively? METHODS: A retrospective 541 hip single-surgeon cohort with mean of 6.2 years follow-up (range 5-8.1) was collected. Preoperative patient/implant variables, including postoperative radiographic acetabular inclination and femoral component position, clinical outcomes, and follow-up PRO questionnaire information were collected. Validated PROs included the Hip Disability and Osteoarthritis Outcome Score (HOOS), Veterans Rand-12, and University of California Los Angeles (UCLA) activity. PROs were modeled with ordinary least squares then used to create nomograms. RESULTS: Average patient age was 53 years with 391 (72%) males. Seven hips were revised, resulting in an overall survival of 98.8% at 5 years. Predictive modeling identified preoperative variables (sex, body mass index, smoking, and comorbidity) that had statistically significant associations with HOOS pain (P = .049), HOOS activities of daily living (P = .017), UCLA activity (P < .001), and Veterans Rand-12 physical (P < .001) PROs at latest follow-up. Nomograms predicted follow-up PROs using preoperative patient-specific variables. CONCLUSION: This study documents excellent survival of the largest reported single-center cohort of BHRs in the United States with a mean 6.2 years follow-up. Multivariate modeling shows male nonsmokers with low body mass index, and no comorbidities will have less hip pain, better function in daily life, higher activity, and better general physical health after BHR arthroplasty.

Responsiveness Comparison of the EQ-5D, PROMIS Global Health, and VR-12 Questionnaires in Knee Arthroscopy.

BACKGROUND: The EuroQol 5 dimensions questionnaire (EQ-5D), Patient-Reported Outcomes Measurement Information System (PROMIS) 10 Global Health, and Veterans RAND 12-Item Health Survey (VR-12) are generic patient-reported outcome (PRO) questionnaires that assess a patient's general health. In choosing a PRO to track general health status, it is necessary to consider which measure will be the most responsive to change after treatment. To date, no studies exist comparing responsiveness among the EQ-5D, PROMIS 10 Global Health, and the Veterans Rand 12-Item Health Survey (VR-12). PURPOSE: To determine which of the generic PROs are most responsive internally and externally in the setting of knee arthroscopy. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Fifty patients who underwent knee arthroscopy were surveyed preoperatively and a mean 3.6 months postoperatively, with 90% follow-up. PROs included the EQ-5D, EQ-5D visual analog scale, PROMIS 10 Global Health (PROMIS 10) physical and mental components, VR-12 physical and mental components, and the Knee injury and Osteoarthritis Outcome Score (KOOS)-pain subscale. Internal responsiveness was evaluated by performing paired t tests on the changes in measures and calculating 2 measures of effect size: Cohen d and standardized response mean (SRM). External responsiveness was evaluated by comparing Pearson correlation measures between the disease-specific reference KOOS-pain and generic PROs. RESULTS: For internal responsiveness, 3 PROs showed a statistically significant improvement in score after treatment (EQ-5D: +0.10 [95% CI, 0.06-0.15], VR-12 physical: +7.2 [95% CI, 4.0-10.4]), and PROMIS 10 physical: +4.4 [95% CI, 2.6-6.3]) and effect size statistics with moderate change (Cohen d and SRM, 0.5-0.8). Assessing external responsiveness, a high correlation with the disease-specific reference (KOOS-pain score) was found for EQ-5D (0.65), VR-12 physical (0.57), and PROMIS 10 physical (0.77). For both internal and external responsiveness, the EQ-5D, VR-12 physical, and PROMIS 10 physical showed significantly greater responsiveness compared with the other general PRO measures but no statistical differences among themselves. CONCLUSION: There is no statistical difference in internal or external responsiveness to change among the EQ-5D, VR-12 physical, and PROMIS 10 physical instruments. In tracking longitudinal patient health, researchers and administrators have the flexibility to choose any of the general PROs among the EQ-5D, VR-12 physical, and PROMIS 10 physical. We recommend that any study tracking PROs in knee arthroscopy include 1 of these generic instruments.