Institution Origin and Medical School Rank Impact the Citation Frequency and Publication Rate in Orthopaedic Sports Medicine Journals.

Purpose: To examine the trends between various categories of institutions with their respective published orthopaedic sports medicine content and to determine the publication output and citation rate from the 25 highest-ranked medical schools compared with lower-ranked institutions. Methods: Publications between 2015 and 2019 from the American Journal of Sports Medicine, Journal of Bone and Joint Surgery, Journal of Shoulder and Elbow Surgery, Clinical Orthopaedics and Related Research, and Arthroscopy were categorized into university/university affiliated hospitals, non-university affiliated teaching hospitals, public/semi-government research institutes, nonprofit research institutes, private sector institutions, government institutions, and other institutions. Citation rates were collected from PubMed for the first and corresponding author. Similarly, corresponding authors were stratified by U.S. News and World Report 2021 medical school research rankings. Results: Of the 12,152 publications identified, 5,044 publications met the inclusion criteria. Nonprofit research institutions garnered the greatest number of citations on average (6.44 based on first author, SD 8.83, n = 214; 6.62 based on corresponding author, SD 9.65, n = 208; P < .001), while university/university-affiliated hospitals produced the majority of published articles (77.0% based on first author, 76.8% based on corresponding author), but had lower average citation rates (4.48 based on first author, SD 6.67, n = 3,886; 4.44 based on corresponding author, SD 6.55, n = 3,873; P < .001). Furthermore, of 1953 medical school publications, the top 25 accounted for 53.1% of publications; however, there was no statistical difference between their citation rates and those of lower rankings (P = 0.47). Conclusions: Publications are cited at different rates, depending on their institution of origin. In addition, high-ranking medical schools produce a disproportionately greater output of publications than lower-ranking schools, but there is no statistically significant difference in citation rates on an individual publication basis. Clinical Relevance: Knowing how an institution's ranking influences publication and citation rates can help us understand bias in the scientific literature.

Trends in Patient-Reported Outcomes Measurement Information System Scores Exist Between Day of Surgical Scheduling and Day of Surgery.

PURPOSE: To examine trends in Patient-Reported Outcome Measurement Information System (PROMIS) scores among orthopedic sports medicine patients undergoing surgery who completed PROMIS forms both in the ambulatory (preoperative) setting at the time of surgical scheduling, as well as on the day of surgery (perioperative) prior to their procedure. METHODS: Consecutive patients undergoing various sports medicine-related surgeries were recruited. Patients were included if they were scheduled for surgery and completed preoperative PROMIS on the day of surgical scheduling and on the day of surgery. Patients were excluded if they refused the questionnaire or had been administered perioperative anesthesia, which would interfere with questionnaire completion. Paired samples t-tests were run between preoperative and perioperative PROMIS scores to determine statistical significance. RESULTS: 153 patients were included with an average age of 46.5 years. The average (SD) time between completion of PROMIS questionnaires was 46.5 (44.4) days. The absolute value change in scores between preoperative and perioperative visits was 4.09 for PROMIS UE, 3.59 for PROMIS PF, 3.67 for PROMIS PI, and 4.13 for PROMIS D. The overall net change of scores between preoperative and perioperative visits were -.57 for PROMIS UE CAT, .16 points for PROMIS PF CAT, -.85 points for PROMIS PI CAT, and -2.14 points for PROMIS D CAT. Statistically significant differences in preoperative and perioperative PROMIS PI (P =.042) and PROMIS D (P =.004) scores were found. CONCLUSIONS: Health states-as measured by PROMIS CAT forms completed among patients undergoing orthopedic surgery-can either improve or worsen preoperatively between the time of administration in both the ambulatory and perioperative setting. Despite the existence of these preoperative trends, it is important to consider patient and surgery-specific causes, such as the anatomic region, type of surgical intervention, and timing of preoperative PROMIS administration. LEVEL OF EVIDENCE: III, prognostic.

Patients With Preoperative Clinical Depression Symptomology Experience Significant Improvements in Postoperative Pain, Function, and Depressive Symptoms Following Rotator Cuff Repair.

PURPOSE: To determine the impact of clinical depression on outcomes after rotator cuff repair (RCR), as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Test (CAT) health domains. METHODS: RCR patients were given PROMIS CAT assessments for physical function (PROMIS UE), pain interference (PROMIS PI), and depression (PROMIS D) during preoperative and postoperative clinic visits. PROMIS D scores ≥55 correlate with mild clinical depression; thus patients with PROMIS D scores ≥ 55 were placed in the clinical depression (CD) group, whereas patients with scores <55 were placed in the "no clinical depression" (NCD) group. Categorical variables were compared at preoperative and postoperative (6 months and ≥1 year) timepoints using χ2 tests. Continuous variables were compared using Student's t-tests. RESULTS: Of the 340 RCR patients included in this study, 65 (19.1%) were found to have mild clinical depression preoperatively, with that number being reduced to 23 (6.8%) at 6 months and 19 (5.6%) at ≥1 year after surgery. Compared with preoperative PROMIS scores, CD patients had significant postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (26.7 vs 35.5 vs 38.9; P < .001) and PROMIS PI (67.6 vs 56.7 vs 56.4; P < .001). NCD patients had similar postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (30.8 vs 38.6 vs 46.9; P < .001) and PROMIS PI (61.7 vs 53.0 vs 47.6; P < .001). The improvement in PROMIS scores was similar for the CD and NCD groups in both PROMIS UE (12.2 vs 16.1, respectively) and PROMIS PI (-11.2 vs -14.1, respectively). CONCLUSION: Despite starting with worse PROMIS UE and PROMIS PI scores, patients undergoing RCR with symptoms of CD experienced significant improvement in function, pain, and depressive symptoms. Preoperative depression should not be a contraindication to arthroscopic RCR in patients who are otherwise appropriate operative candidates. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

The Presence of Preoperative Depression Symptoms Does Not Hinder Recovery After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The current literature suggests a link between psychosocial factors and poor surgical outcomes in patients with musculoskeletal complaints. However, there remains a limited body of literature examining the effect of depression on outcomes after anterior cruciate ligament reconstruction (ACLR). PURPOSE: The primary purpose of this study was to compare postoperative function patient-reported outcome scores between patients with and patients without preoperative depression symptoms undergoing ACLR. Secondary goals included comparing postoperative pain interference and depression scores between the 2 groups. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: In this single-center retrospective cohort study, pediatric and adult patients who underwent ACLR were included. The Physical Function (PF), Pain Interference (PI), and Depression (D) domain scores of the Patient-Reported Outcomes Measurement Information System (PROMIS) were collected preoperatively and at 6 and 12 months postoperatively. Patients were separated into clinical depression (CD) and no clinical depression (NCD) groups based on their preoperative PROMIS-D score. RESULTS: A total of 82 patients undergoing ACLR were included in this study. Of these, 19 (23%) patients met criteria for the CD group. Preoperatively, the CD group reported lower mean PROMIS-PF (33.3 vs 39.7, respectively; P = .001), higher PROMIS-PI (65.7 vs 59.2, respectively; P <.01), and higher PROMIS-D (62.4 vs 45.1, respectively; P < .001) scores than the NCD group. At 12 months postoperatively, the mean PROMIS-PF scores for the CD and NCD groups were 52.1 and 56.7, respectively (P = .12). The mean 12-month postoperative PROMIS-PI scores for the CD and NCD groups were 52.3 and 47.4, respectively (P = .04). At 12 months after ACLR, there was a substantial improvement in PROMIS-PF and PROMIS-PI scores for both the CD (delta = +18.8 and -13.4, respectively) and NCD (delta = +17.0 and -11.8) groups. CONCLUSION: There was a significant improvement, which exceeded currently accepted minimal clinically important difference values, in PROMIS-PF scores at 12 months after ACLR, regardless of the presence of preoperative depression symptoms. These data suggest that having depression symptoms preoperatively does not significantly hinder a patient's recovery after ACLR.

Investigating the PROMIS Physical Function and Pain Interference Domains in Elite Athletes.

BACKGROUND: Multiple studies have demonstrated the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) to be a responsive and efficient measure for patients undergoing orthopaedic surgery. While these studies were rigorous in their protocol and methodology, no efforts in recent literature have been made to identify if these reference scores apply to elite athletes. PURPOSE/HYPOTHESIS: The purpose of this study was to determine whether there is a difference in the baseline scores of elite athletes versus the general population. We hypothesized that athletes' PROMIS upper extremity general function (PROMIS-UE) and general physical function (PROMIS-PF) scores would vary substantially from the mean health state of the general population. We further hypothesized that these scores would be affected by specific sport and level of competition. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Three PROMIS computer adaptive test (CAT) domains were administered to elite athlete (≥18 years) volunteers (either in person or through email). An elite athlete was defined as one participating in sports at the collegiate level or higher. Test domains included PROMIS-PF, PROMIS-UE, and pain interference (PROMIS-PI). PROMIS domain t scores were defined and assessed against NIH reference values to identify significant differences. Distribution analysis was conducted using histograms and normality assessments. Domains were also subject to correlation analysis. Finally, subgroup analysis was conducted for all athlete characteristics to identify any factors associated with variance. RESULTS: In total, 196 elite athletes (mean age, 21.1 years; range, 18.0-36.7 years) completed all 3 PROMIS-CAT forms. Overall, the mean scores were 56.0 ± 6.4, 58.1 ± 7.7, and 47.1 ± 7.3 for PROMIS-UE, PROMIS-PF, and PROMIS-PI, respectively. Distribution analysis showed nonnormal distribution for all 3 PROMIS domains (Kolmogorov-Smirnov test, P < .001). Similarly, in all 3 PROMIS domains the athletes displayed more disparate scores than the NIH-reported reference values (1-way sign test, P < .001). Only the presence of pain and sport played showed association with variance in PROMIS domain scores (P < .001 and P = .003, respectively). CONCLUSION: Elite athletes displayed more disparate reference scores than the NIH-reported average of 50 for PROMIS-UE, PROMIS-PF, and PROMIS-PI. Furthermore, these forms were sensitive to varying levels of sport among collegiate athletes.

Time-Driven Activity-based Costing for Anterior Cruciate Ligament Reconstruction: A Comparison to Traditional Accounting Methods.

PURPOSE: The primary purpose of this study was to compare the cost of care of one of the most common sports medicine surgical procedures, anterior cruciate ligament reconstruction (ACLR), using the time-driven activity-based costing (TDABC) method to traditional accounting methods such as activity-based costing (ABC). Our secondary purpose was to identify the main drivers of the cost of ACLR using both of these techniques. METHODS: A process map of ACLR was constructed through direct observation in the clinical setting according to established techniques to identify drivers of fixed, direct variable, and indirect costs. An episode of care consisted of each step in the surgical process from admission to discharge. Personnel costs were combined with the process map to determine the cost drivers and overall cost of the procedure. The cost generated from the TDABC method was compared with the cost from our institution's internal accounting system, which used an ABC method. RESULTS: The total cost of ACLR was $5,242.25 when using TDABC versus $10,318 when using the traditional ABC method. The largest difference between the 2 methods was within the domain of direct variable costs. CONCLUSIONS: When compared with TDABC, the hospital's traditional cost-accounting estimate for ACLR is nearly twice as costly. These findings highlight the variability of cost calculation for the same clinical episode between the 2 accounting methods. For the traditional accounting method, the direct variable cost was the main cost driver, whereas for the TDABC method, the direct fixed cost was the main cost driver. CLINICAL RELEVANCE: This study is important because it elucidates important cost drivers for one of the most common sports medicine orthopaedic surgical procedures and attempts to identify the true overall cost of the procedure.

Establishing and comparing reference preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores in patients undergoing shoulder surgery.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) has become increasingly popular among orthopedic surgeons treating shoulder pathology. Despite this, there have been few studies that have described and compared preoperative reference scores for specific shoulder surgical procedures. The primary purpose of this study was to establish and compare baseline preoperative PROMIS scores for 3 common types of shoulder surgery: rotator cuff repair (RCR), total shoulder arthroplasty (TSA), and labral repair (LR). The secondary goal was to stratify these operative groups by diagnosis and compare preoperative PROMIS scores. METHODS: In this cross-sectional study, adult and pediatric patients who underwent surgery for either RCR, TSA, or LR were included. PROMIS-Upper Extremity (UE), PROMIS-Pain Interference (PI), and PROMIS-Depression (D) scores that were collected at each patient's preoperative visit were reviewed. Continuous and categorical variables were compared between operative groups using analysis of variance and χ2 or Fisher exact tests, respectively. Multivariable general linear models were used to identify significant independent predictors of PROMIS scores when controlling for age, sex, and body mass index. RESULTS: A total of 413 patients were included in the study: 272 in the RCR group, 84 in the TSA group, and 57 in the LR group. The average PROMIS-UE score was 39.8 in the LR group vs. 29.9 in the RCR group (P < .001) and 29.6 in the TSA group (P < .001). There was no difference between the mean RCR and TSA PROMIS-UE scores (P = .93). The average PROMIS-PI score was 56.6 in the LR group vs. 62.8 in the RCR group (P < .001) and 63.9 in the TSA group (P < .001). There was no difference between RCR and TSA PROMIS-PI scores (P = .09). The average PROMIS-D score was 43.5 in the LR group vs. 47.7 in the RCR group (P = .004) and 50.3 in the TSA group (P < .001). The TSA group had a higher mean PROMIS-D score than the RCR group (P = .03). For PROMIS-UE scores, age and body mass index were not found to be significant independent predictors (P = .98 and P = .88, respectively). For PROMIS-PI scores, age, body mass index, and sex were not found to be significant independent predictors (P = .31, P = .81, and P = .48, respectively). CONCLUSION: Patients undergoing shoulder LR had higher preoperative function scores and lower pain interference and depression scores than those undergoing TSA and RCR. These baseline PROMIS scores should be taken into consideration when tracking a patient's outcomes after surgery, as a certain score could mean drastically different functional and pain outcomes depending on the underlying pathology.

Older, Male Orthopaedic Surgeons From Southern Geographies Prescribe Higher Doses of Post-Operative Narcotics Than do their Counterparts: A Medicare Population Study.

PURPOSE: We wanted to evaluate opioid prescribing patterns among orthopaedic surgeons and to identify demographics that may be associated with more extensive opioid prescribing habits that could be candidates for targeted education policies. METHODS: Medicare Part D prescriber and prescription information for the most recent available year, 2017, was accessed via a publicly available database offered by the Centers for Medicare and Medicaid. Number of total prescriptions, number of opioid prescriptions, and the total days' supply of opioids prescribed were analyzed for each of 19,219 orthopaedic surgeons. Demographics and board certification status were also recorded. RESULTS: Orthopaedic surgeons who wrote the most opioid prescriptions (>400 per year) also wrote the longest prescription durations (14.1 days/prescription, P < .05 for all comparisons). Surgeons with more than 30 years of experience wrote the longest prescriptions (11.8 days/prescription; P < .001). Male surgeons wrote more opioid prescriptions than female surgeons (151 vs 95, respectively; P < .001). However, female surgeons wrote longer prescriptions than male surgeons (7.5 days/prescription vs 6.1 days/prescription, respectively; P = .01). Surgeons from southern states wrote the most opioid prescriptions (1,386,897) and the longest prescriptions, with an average of 13.0 days per prescription, whereas western states wrote the shortest prescriptions at 10.4 days per prescription (P = .004). CONCLUSION: There are demographic correlations between orthopaedic surgeons and opioid prescribing patterns. In particular, male, older southern surgeons prescribe the highest volumes of opioids. This provides an opportunity for targeted education versus overarching, general policies. Potential directions for future investigation can focus on assessing recent trends in opioid prescriptions among orthopaedic providers. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Effect of Workload After ACL Reconstruction on Rerupture Rates in NBA Players.

BACKGROUND: Rupture of the anterior cruciate ligament (ACL) is a common and potentially career-altering injury sustained by players in the National Basketball Association (NBA). Strategies have been employed by the league to prevent reinjury of players after ACL reconstruction (ACLR), including minute restrictions and rest games; however, it remains unknown whether workload metrics after ACLR influence the risk for reinjury and revision surgery. PURPOSE: To evaluate whether workload changes after return to play (RTP) from primary ACLR influences the risk of rerupture in NBA players. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We identified NBA players from 1975 to 2018 who underwent primary ACLR as well as those who required revision ACLR. Primary outcomes included workload measures such as games played, games started, and minutes per game. Secondary outcomes included in-game performance statistics. Statistical analysis was used to compare relative workload and performance 3 years before and 3 years after undergoing primary ACLR. Workload was also compared between the control group of NBA players who underwent primary ACLR and those who required revision ACLR. RESULTS: A total of 68 players who underwent primary ACLR were included, 8 of whom subsequently required revision ACLR. In their first season upon RTP, control players (primary ACLR) demonstrated a significant reduction in all workload metrics relative to the season before injury (P < .001), while the revision group demonstrated an unchanged to increased workload. In a comparison between the primary and revision groups during the first season after RTP, the primary group demonstrated significantly fewer games started (mean ± SD, 22.2 ± 3.0 vs 35.8 ± 8.3; P = .039) and minutes per game (20.5 ± 1.1 vs 27.0 ± 3.1; P = .048) than revision players. The primary ACLR group demonstrated reduced cumulative workload trends for the first 3 years after RTP relative to 3 years before injury, which was not demonstrated in the revision ACLR group, albeit statistically insignificant. CONCLUSION: Our study found that after ACLR, a reduction in workload parameters relative to preinjury baseline was associated with players who did not sustain rerupture. Further study is required to determine if workload measures following RTP from primary ACLR should be individualized relative to preinjury baseline.

Effect of Achilles Tendon Rupture on Player Performance and Longevity in National Basketball Association Players.

BACKGROUND: National Basketball Association (NBA) players who return to sport (RTS) after Achilles tendon rupture have been reported to have poor outcomes. PURPOSE: To evaluate the effect of Achilles tendon ruptures on player performance and career longevity in NBA athletes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: NBA players who sustained Achilles tendon ruptures between 1970 and 2019 were identified using publicly available resources and were matched 1:1 to a healthy control group by age, position, height, and body mass index. Demographic characteristics, player utilization (games and minutes), and performance efficiency rating (PER) were documented for all athletes. The season of Achilles tendon rupture was set as the index year, and statistical analysis compared postindex versus preindex data both acutely and in the long term. Percentages relative to preoperative values were calculated to compare the injured and control groups in a standardized fashion. RESULTS: Of 47 players, 34 (72.3%) with Achilles tendon ruptures returned to play at the NBA level after surgical intervention. A total of 7 players were excluded from the study. No differences were found in demographic characteristics or PER (2 years before injury) between the remaining 27 players and matched controls. The injured players had significantly shorter careers compared with control players (3.1 ± 2.3 vs 5.8 ± 3.5 seasons, respectively; P < .05). Injured players demonstrated significant declines in games per season (GPS), minutes per game (MPG), and PER at 1 year and 3 years after RTS compared with preindex baseline (P < .05). Injured players, compared with control players, had reduced relative percentages of games started (GS) (50% vs 125%, respectively), MPG (83% vs 103%), and PER (80% vs 96%) at 1 year after return (P < .05), but reductions at extended 3-year follow-up were seen only in GPS (71% vs 91%) and GS (39% vs 99%) (P < .05). CONCLUSION: Our study found that 72.3% of NBA players returned to play after Achilles tendon repair, but they had shorter careers compared with uninjured controls. Players returning from Achilles tendon repairs had decreased game utilization and performance at all time points relative to their individual preindex baseline. However, for the injured players when compared with controls, game utilization but not performance was found to be decreased at 3-year follow-up.

Mini-Open Distal Biceps Tendon Repair Using All-Suture Anchors.

Distal biceps tendon ruptures are uncommon injuries that can cause impairment in range of motion and function. While distal bicep tendon repair to the radial tuberosity has been demonstrated to restore function and strength, there is a lack of consensus on the optimal technique. The purpose of this Technical Note and video is to provide our preferred method of repair using an open, onlay-tissue fixation with all-suture anchors (FiberTak; Arthrex) and anatomic positioning of the biceps tendon on the radial tuberosity.

Pediatric PROMIS Computer Adaptive Tests Are Highly Correlated With Adult PROMIS Computer Adaptive Tests in Pediatric Sports Medicine Patients.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) is a powerful set of patient-reported outcome measures (PROMs) that are gaining popularity throughout orthopaedic surgery. The use of both adult and pediatric PROMIS questionnaires in orthopaedic sports medicine limits the value of the PROMIS in routine sports medicine clinical care, research, and quality improvement. Because orthopaedic sports medicine surgeons see patients across a wide age range, simplifying the collection of PROMIS computer adaptive tests (CATs) to a single set of questionnaires, regardless of age, is of notable value. PURPOSE/HYPOTHESIS: The purpose was to determine the strength of the correlation between the pediatric and adult PROMIS questionnaires. We hypothesized that there would be a high correlation between the adult and pediatric versions for each PROMIS domain, thereby justifying the use of only the adult version for most sports medicine providers, regardless of patient age. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 2. METHODS: Between December 2018 and December 2019, all pediatric sports medicine patients presenting to a single, academic, orthopaedic sports medicine clinic were asked to participate in the present study with their parents' consent. Patients were asked to complete a set of adult PROMIS domains (Physical Function and/or Upper Extremity, Pain Interference, and Depression) as well as a set of pediatric PROMIS domains (Mobility and/or Upper Extremity, Pain Interference, and Depressive Symptoms). Concurrent validity was assessed using Pearson correlation coefficients (r). Ceiling and floor effects were determined. RESULTS: A total of 188 patients met our inclusion criteria. The correlation between the adult and pediatric PROMIS Upper Extremity, Physical Function and Mobility, Pain Interference, and Depression and Depressive Symptoms forms were high-moderate (r = 0.68; P < .01), high-moderate (r = 0.69; P < .01), high (r = 0.78; P < .01), and high (r = 0.85; P < .01), respectively. Both adult and pediatric depression-related PROMIS domains demonstrated notable floor effects (adult: 38%; pediatric: 24%). The pediatric PROMIS Upper Extremity domain demonstrated a ceiling effect (20%). CONCLUSION: Adult PROMIS CATs may be used in an orthopaedic sports medicine clinic for both adult and pediatric patients. Our findings will help decrease the amount of resources needed for the implementation and use of PROMs for patient care, research, and quality improvement in orthopaedic sports medicine clinics.