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Background Traditional measures of evaluating scholarly output do not capture the impact social media can provide in disseminating and promoting research. We sought to better understand the level of online attention that high-quality hand research received. Methods Scientific manuscripts published from 2017 in Journal of Hand Surgery (American Volume) ( JHS-A), Journal of Hand Surgery ( European Volume) ( JHS-E), and HAND were recorded. Manuscript characteristics were determined, including the number of citations. Altmetric Attention Score (AAS), a measure of a manuscript’s online attention and impact, was determined, as well as Twitter mentions, Facebook mentions, and news outlet mentions. Spearman rho (ρ) correlation coefficient was used to evaluate the relationship between the number of citations and AAS. Multivariable linear regression analysis was performed to determine which manuscript factors were associated with AAS. Results A total of 323 manuscripts were identified. There was a weak positive correlation between the number of citations and AAS; however, this relationship did not exist for each individual journal. Publication in HAND and JHS-E were associated with lower average manuscript AAS when using JHS-A as the reference group. Two additional factors were also associated with increased manuscript AAS: (1) being a clinical study focused on a specific upper extremity anatomical location; and (2) increasing number of institutions on a study. Conclusions Publication in HAND and JHS-E were associated with lower manuscript AAS when using JHS-A as the reference group, suggesting that HAND and JHS-E have room for improvement in using social media to share their high-quality hand surgery scientific articles.

Background: There is a paucity of research examining the impact of social deprivation on the level of symptom severity at presentation, including in common hand conditions like carpal tunnel syndrome. We aimed to determine whether patient deprivation is associated with worse Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression scores. Methods: Patients presenting to an academic hand clinic from December 2016 to December 2018 for a new patient visit for carpal tunnel syndrome completed PROMIS UE, PF, PI, and Depression Computer Adaptive Tests. Bivariate analyses were done to compare patient variables between the least and most deprived thirds, as measured by Area Deprivation Index (ADI), at the state (New York) and national levels. Multivariable linear regression was used to determine whether there was an association between social deprivation and PROMIS UE, PF, PI, and Depression scores. Results: All PROMIS domain scores were significantly worse in the most deprived cohort at the national level ( P < .05) but not at the state level ( P > .05). In multivariable regression at the national level, ADI values were associated with PROMIS UE (β = −0.06, P < .01) and PROMIS PI (β = .05, P < .01) but not PROMIS PF or PROMIS Depression. In multivariable regression at the state level, ADI values were associated with PROMIS UE (β = −0.79, P = .03) and PROMIS PI (β = 0.58, P < .05) but not PROMIS PF or PROMIS Depression. Conclusions: Higher levels of social deprivation are associated with worse PROMIS UE and PROMIS PI scores on both the state and national levels when initially seeking care for carpal tunnel syndrome.

BACKGROUND: The goal of bundled payments-lump monetary sums designed to cover the full set of services needed to provide care for a condition or medical event-is to provide a reimbursement structure that incentivizes improved value for patients. There is concern that such a payment mechanism may lead to patient screening and denying or providing orthopaedic care to patients based on the number and severity of comorbid conditions present associated with complications after surgery. Currently, however, there is no clear consensus about whether such an association exists. QUESTIONS/PURPOSES: In this systematic review, we asked: (1) Is the implementation of a bundled payment model associated with a change in the sociodemographic characteristics of patients undergoing an orthopaedic procedure? (2) Is the implementation of a bundled payment model associated with a change in the comorbidities and/or case-complexity characteristics of patients undergoing an orthopaedic procedure? (3) Is the implementation of a bundled payment model associated with a change in the recent use of healthcare resources characteristics of patients undergoing an orthopaedic procedure? METHODS: This systematic review was registered in PROSPERO before data collection (CRD42020189416). Our systematic review included scientific manuscripts published in MEDLINE, Embase, Web of Science, Econlit, Policyfile, and Google Scholar through March 2020. Of the 30 studies undergoing full-text review, 20 were excluded because they did not evaluate the outcome of interest (patient selection) (n = 8); were editorial, commentary, or review articles (n = 5); did not evaluate the appropriate intervention (introduction of a bundled payment program) (n = 4); or assessed the wrong patient population (not orthopaedic surgery patients) (n = 3). This led to 10 studies included in this systematic review. For each study, patient factors analyzed in the included studies were grouped into the following three categories: sociodemographics, comorbidities and/or case complexity, or recent use of healthcare resources characteristics. Next, each patient factor falling into one of these three categories was examined to evaluate for changes from before to after implementation of a bundled payment initiative. In most cases, studies utilized a difference-in-difference (DID) statistical technique to assess for changes. Determination of whether the bundled payment initiative required mandatory participation or not was also noted. Scientific quality using the Adapted Newcastle-Ottawa Scale had a median (range) score of 8 (7 to 8; highest possible score: 9), and the quality of the total body of evidence for each patient characteristic group was found to be low using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. We could not assess the likelihood of publication using funnel plots because of the variation of patient factors analyzed in each study and the heterogeneity of data precluded a meta-analysis. RESULTS: Of the nine included studies that reported on the sociodemographic characteristics of patients selected for care, seven showed no change with the implementation of bundled payments, and two demonstrated a difference. Most notably, the studies identified a decrease in the percentage of patients undergoing an orthopaedic operative intervention who were dual-eligible (range DID estimate -0.4% [95% CI -0.75% to -0.1%]; p < 0.05 to DID estimate -1.0% [95% CI -1.7% to -0.2%]; p = 0.01), which means they qualified for both Medicare and Medicaid insurance coverage. Of the 10 included studies that reported on comorbidities and case-complexity characteristics, six reported no change in such characteristics with the implementation of bundled payments, and four studies noted differences. Most notably, one study showed a decrease in the number of treated patients with disabilities (DID estimate -0.6% [95% CI -0.97% to -0.18%]; p < 0.05) compared with before bundled payment implementation, while another demonstrated a lower number of Elixhauser comorbidities for those treated as part of a bundled payment program (before: score of 0-1 in 63.6%, 2-3 in 27.9%, > 3 in 8.5% versus after: score of 0-1 in 50.1%, 2-3 in 38.7%, > 3 in 11.2%; p = 0.033). Of the three included studies that reported on the recent use of healthcare resources of patients, one study found no difference in the use of healthcare resources with the implementation of bundled payments, and two studies did find differences. Both studies found a decrease in patients undergoing operative management who recently received care at a skilled nursing facility (range DID estimate -0.50% [95% CI -1.0% to 0.0%]; p = 0.04 to DID estimate: -0.53% [95% CI -0.96% to -0.10%]; p = 0.01), while one of the studies also found a decrease in patients undergoing operative management who recently received care at an acute care hospital (DID estimate -0.8% [95% CI -1.6% to -0.1%]; p = 0.03) or as part of home healthcare (DID estimate -1.3% [95% CI -2.0% to -0.6%]; p < 0.001). CONCLUSION: In six of 10 studies in which differences in patient characteristics were detected among those undergoing operative orthopaedic intervention once a bundled payment program was initiated, the effect was found to be minimal (approximately 1% or less). However, our findings still suggest some level of adverse patient selection, potentially worsening health inequities when considered on a large scale. It is also possible that our findings reflect better care, whereby the financial incentives lead to fewer patients with a high risk of complications undergoing surgical intervention and vice versa for patients with a low risk of complications postoperatively. However, this is a fine line, and it may also be that patients with a high risk of complications postoperatively are not being offered surgery enough, while patients at low risk of complications postoperatively are being offered surgery too frequently. Evaluation of the longer-term effect of these preliminary bundled payment programs on patient selection is warranted to determine whether adverse patient selection changes over time as health systems and orthopaedic surgeons become accustomed to such reimbursement models.

The purpose of the current study was to (1) determine the percentage of new orthopedic patients reporting their symptoms to be acceptable at presentation, as measured by the Patient Acceptable Symptom State (PASS) question, and (2) evaluate whether patient-reported outcome measures (PROMs), including Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) or Upper Extremity, Pain Interference (PI), and Depression (D), or sociodemographic factors are associated with acceptable symptoms at presentation.Between February 7, 2020, and March 16, 2020, new orthopedic patients who completed PROMs were identified. Patient records were reviewed for those who also completed the PASS question, a yes/no question about whether a patient's current symptom state is satisfactory. Bivariate analysis was conducted to compare patient characteristics, such as area deprivation index (ADI), between those reporting acceptable symptoms and those who did not. Multivariable logistic regression models were used to determine factors associated with acceptable symptoms at presentation.A total of 570 patients were included, with one-fourth (n = 143 [25%]) reporting acceptable symptoms at presentation. In multivariable regression analysis, only pain, as measured by the PROMIS PI, was associated with acceptable symptoms at presentation (non-upper extremity patient regression: PROMIS PI: odds ratio [OR], 0.84; 95% confidence interval [CI], 0.79-0.90, P.01; upper extremity patient regression: PROMIS PI: OR, 0.91; 95% CI, 0.85-0.98, P.01). In both multivariable regression analyses, insurance type (private, Medicare, Medicaid, other), visit subspecialty (sports, hand, joints, foot and ankle, spine, other), PROMIS PF, PROMIS D, and national ADI were not associated with acceptable symptoms at presentation (all P.05).One-fourth of new orthopedic patients reported their symptoms to be acceptable at presentation. Of those who considered their symptom state unsatisfactory, pain-not functional status, mental health, or sociodemographic factors-was the primary determinant.Level III, diagnostic.

Purpose We sought to determine whether subjective clinical improvement immediately after carpal tunnel release (CTR) was captured by Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression. Methods Between September 2018 and January 2020, patients presenting to a single academic medical center hand clinic were asked to complete PROMIS UE, PF, PI, and Depression computer adaptive tests. In addition, patients who had CTR were asked to answer the following at their first postoperative clinic visit: “Since my last clinic visit, my condition is: (1) much better; (2) mildly better; (3) no change; (4) mildly worse; (5) much worse.” For each patient, the last clinic visit was the final preoperative visit. The PROMIS domain scores were compared before and after surgery using paired t tests. The percentage of patients subjectively reporting better symptoms was calculated. Results A total of 156 patients fit our inclusion criteria. The average number of days between the final preoperative visit and CTR was 7 (range, 0–30), and the average number of days between CTR and the first postoperative visit was 9 (range, 3–21). A total of 116 patients (74%) reported their carpal tunnel syndrome was better at their first postoperative visit. However, PROMIS UE, PF, and PI scores were significantly worse at the first postoperative visit, although not at clinically appreciable levels. There was no statistical or clinical difference in PROMIS Depression scores from pre- to postoperative time points. Conclusions Nearly 75% of patients subjectively report their carpal tunnel syndrome is better at their first follow-up visit within 3 weeks of CTR; however, PROMIS does not capture this improvement. Clinical relevance Hand surgeons evaluating patients shortly following CTR should be aware of the potential limitation of PROMIS to accurately capture immediate postoperative clinical outcomes. Disease-specific Patient-Reported Outcome Measures, such as the Boston Carpal Tunnel Questionnaire , may be preferred during this immediate postoperative timeframe.

Context In response to growing concerns over rising costs and major variation in quality, improving value for patients has been proposed as a fundamentally new strategy for how healthcare should be delivered, measured, and remunerated. Objective To systematically review the literature regarding the implementation and impact of value-based healthcare in urology. Evidence acquisition A systematic review was performed to identify studies that described the implementation of one or more elements of value-based healthcare in urologic settings and in which the associated change in healthcare value had been measured. Twenty-two publications were selected for inclusion. Evidence synthesis Reorganization of urologic care around medical conditions was associated with increased use of guidelines-compliant care for men with prostate cancer, and improved outcomes for patients with lower urinary tract symptoms. Measuring outcomes for every patient was associated with improved prostate cancer outcomes, while the measurement of costs using time-driven activity-based costing was associated with reduced resource utilization in a pediatric multidisciplinary clinic. Centralization of urologic cancer care in the UK, Denmark, and Canada was associated with overall improved outcomes, although systems integration in the USA yielded mixed results among urologic cancer patients. No studies have yet examined bundled payments for episodes of care, expanding the geographic reach for centers of excellence, or building enabling information technology platforms. Conclusions Few studies have critically assessed the actual or simulated implementation of value-based healthcare in urology, but the available literature suggests promising early results. In order to effectively redesign care, there is a need for further research to both evaluate the potential results of proposed value-based healthcare interventions and measure their effects where already implemented. Patient summary While few studies have evaluated the implementation of value-based healthcare in urology, the available literature suggests promising early results.

Impact factor, citation rate, and other traditional measures of scholarly impact do not account for the role that social media has in the dissemination of research. The Altmetric Attention Score (AAS) quantifies the active online presence of individual articles on various platforms (eg, Twitter, Facebook).We sought to better understand the factors associated with greater online attention and AAS in seven spine journals.Cross-sectional study.No patients were included in this study. We analyzed 380 articles in seven major spine journals.Extracted manuscript characteristics included AAS; number of Twitter, Facebook, and news outlet mentions; number of citations, references, academic institutions, and authors; and sample size, geographic region, subject of study, and level of evidence.All original scientific manuscripts published in the official January, February, and March 2017 issues of Spine, The Spine Journal, Spine Deformity, Journal of Neurosurgery-Spine, Clinical Spine Surgery, Global Spine Journal, and European Spine Journal were identified. The correlation of AAS and number of citations was determined by Spearman's Rho (ρ) correlation coefficient. Manuscript factors associated with AAS were determined by a multivariable linear regression analysis.A total of 380 manuscripts were included in the analysis. The average AAS across all seven journals was 4.9 (SD: 19.4; Range: 0-356), with the highest average AAS reported for The Spine Journal at 8.0 (SD: 13; Range: 0-60). There was a weak, positive correlation between AAS and number of citations (ρ = .32; p.05); this relationship was individually present for four out of the seven included journals. In addition, number of references was associated with higher average manuscript AAS (β: 0.16 [95% CI: 0.002-0.32]; p.05). No manuscript characteristics were associated with lower AAS.Our analysis of seven spine journals revealed a weak, positive correlation between AAS and number of citations. Number of references was associated with higher AAS. We believe these findings may be useful to authors seeking ways to maximize the impact of their research.

Background There is a paucity of literature describing the recovery trajectory after surgery for upper extremity ischemia. Using Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Upper Extremity (UE), Pain Interference (PI), and Depression domains, we aimed to describe the postoperative recovery of such patients. Methods We queried our PROMIS database for patients undergoing surgery for vasospastic or occlusive disease over a 4.5-year period. Inclusion criteria were preoperative, early (average 3 weeks) and late (average 6 months) postoperative PROMIS PF and/or UE, PI, and Depression scores. The change in PROMIS scores was calculated for each time point. Changes in PROMIS scores were compared with minimal clinically important difference estimates. Results We identified 13 patients undergoing 13 surgical interventions that met inclusion criteria. More than one-half of our patients were men (n = 7 [54%]), and more than one-half of the surgeries (n = 7 [54%]) were for isolated occlusive diagnoses, with the remainder for vasospastic disease. At short-term postoperative follow-up, the change in PROMIS PF, UE, PI, and Depression scores was −6.34 (SD: 9.13), −6.81 (SD: 9.61), 3.16 (SD: 5.78), and −3.05 (SD: 8.37), respectively. At mid-term postoperative follow-up, the change in PROMIS PF, UE, PI, and Depression scores was 4.45 (SD: 10.33), 8.04 (SD: 13.84), −7.03 (SD: 7.06), and −12.27 (SD: 10.85), respectively. Conclusions Our findings suggest patients undergoing surgical treatment for upper extremity ischemia experience a worsening of functional symptoms initially, as expected, followed by notable improvement.

Background The early recovery trajectory of patients undergoing ulnar shortening for ulnar impaction syndrome using the Patient-Reported Outcomes Measurement Information System (PROMIS) is unknown. Questions/Purposes Using PROMIS Upper Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression, we asked (1) do patients undergoing operative management for ulnar impaction syndrome present at their preoperative visit with notable impairment?; (2) At immediate follow-up, do patients present with a clinically appreciable change in symptom severity?; and (3) At short-term follow-up, do patients present with a clinically appreciable change in symptom severity? Materials and Methods We identified patients from 01/2017 to 12/2019 at our institution undergoing ulnar shortening for ulnar impaction syndrome who completed all PROMIS domains at a preoperative visit and at least one postoperative time point (i.e., less than 4 weeks and/or greater than 12 weeks). Distribution- and anchor-based minimal clinically important difference estimates were used to evaluate clinically appreciable changes in symptoms over time. Results A total of 38 patients met our inclusion criteria. The average change in PROMIS UE, PF, PI, and Depression scores from preoperative to immediate postoperative follow-up were –3.8, –4.3, 3.2, and 0.5, respectively. However, by short-term follow-up, the average change in PROMIS UE, PF, PI, and Depression scores were 3.7, 3.2, –4.7, and –3.9, respectively. Conclusions Patients have worsening function at the immediate postoperative follow-up. By short-term postoperative follow-up, functional status and PI levels improve. Our findings can help hand surgeons provide evidence-based guidance on expected initial recovery following operative management for ulnar impaction syndrome. Level of Evidence This is a level II, prognostic study.

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.

Introduction The numeric score for the United States Medical Licensing Examination Step 1 is one of the only universal, objective, scaled criteria for comparing the many students who apply to orthopaedic surgery residency. However, on February 12, 2020, it was announced that Step 1 would be transitioning to pass/fail scoring. The purpose of this study was to (1) determine the most important factors used for interview and resident selection after this change and (2) to assess how these factors have changed compared with a previous report on resident selection. Methods A survey was distributed to the program directors (PDs) of all 179 orthopaedic surgery programs accredited by the Accreditation Council for Graduate Medical Education. Questions focused on current resident selection practices and the impact of the Step 1 score transition on expected future practices. Results A total of 78 PDs (44%) responded to the survey. Over half of PDs (59%) responded that United States Medical Licensing Examination Step 2 clinical knowledge (CK) score is the factor that will increase most in importance after Step 1 transitions to pass/fail, and 90% will encourage applicants to include their Step 2 CK score on their applications. The factors rated most important in resident selection from zero to 10 were subinternship performance (9.05), various aspects of interview performance (7.49 to 9.01), rank in medical school (7.95), letters of recommendation (7.90), and Step 2 CK score (7.27). Compared with a 2002 report, performance on manual skills testing, subinternship performance, published research, letters of recommendations, and telephone call on applicants' behalf showed notable increases in importance. Discussion As Step 2 CK is expected to become more important in the residency application process, current applicant stress on Step 1 scores may simply move to Step 2 CK scores. Performance on subinternships will remain a critical aspect of residency application, as it was viewed as the most important resident selection factor and has grown in importance compared with a previous report.

BACKGROUND: Depression symptoms are prevalent in the general population, and as many as one in eight patients seeing a hand surgeon may have undiagnosed major depression. It is not clear to what degree lower mood is the consequence or cause of greater symptoms and limitations. If depressive symptoms are a consequence of functional limitations, they might be expected to improve when pathophysiology and impairment are ameliorated. Because surgical treatment is often disease-modifying or salvage, surgery might have a greater impact than nonoperative treatment, which is more often palliative (symptom relieving) than disease-modifying. QUESTIONS/PURPOSES: (1) For which hand or wrist conditions are depression symptoms lower after operative compared with nonoperative treatment? (2) Among the subset of patients with the highest depression scores, are depression symptoms lower after operative treatment compared with nonoperative treatment? (3) Among the subset of patients who had nonoperative treatment, are depression symptoms lower after a corticosteroid injection compared with no specific biomedical intervention? METHODS: At an academic orthopaedic department, 4452 patients had a new office visit for carpal tunnel syndrome, benign neoplasm, primary hand osteoarthritis, de Quervain's tendinopathy, or trigger digit. We analyzed the 1652 patients (37%) who had a return visit at least 3 months later for the same diagnosis. Patients completed the Patient-reported Outcomes Measurement Information System (PROMIS) Depression computerized adaptive test at every office visit (higher scores indicate more depression symptoms) and PROMIS Pain Interference (higher scores indicates greater hindrance in daily life owing to pain). Patients with a return visit were more likely to have surgical treatment and had greater Pain Interference scores at the first visit. Thirteen percent of patients (221 of 1652) had incomplete or missing scores at the initial visit and 33% (550 of 1652) had incomplete or missing scores at the final return visit. We used multiple imputations to account for missing or incomplete data (imputations = 50). In a multivariable linear regression analysis, we compared the mean change in Depression scores between patients treated operatively and those treated nonoperatively, accounting for PROMIS Pain Interference scores at the first visit, age, gender diagnosis, provider, and treatment duration. A post-hoc power analysis demonstrated that the smallest patient cohort (benign lump, n = 176) provided 99% power (α = 0.05) with eight predictor variables to detect a change of 2 points in the PROMIS Depression score (minimally important difference = 3.5). RESULTS: After controlling for potentially confounding variables such as pain interference and age, only carpal tunnel release was associated with a slightly greater decrease in depression symptoms compared with nonoperative treatment (regression coefficient [RC] = -3 [95% confidence interval -6 to -1]; p = 0.006). In patients with the highest PROMIS Depression scores for each diagnosis, operative treatment was not associated with an improvement in depression symptoms (carpal tunnel release: RC = 5 [95% CI -7 to 16]; p = 0.44). Moreover, a corticosteroid injection was not associated with fewer depression symptoms than no biomedical treatment (carpal tunnel release: RC = -3 [95% CI -8 to 3]; p = 0.36). CONCLUSIONS: Given that operative treatment of hand pathology is not generally associated with a decrease in depression symptoms, our results support treating comorbid depression as a separate illness rather than as a secondary effect of pain or physical limitations. LEVEL OF EVIDENCE: Level II, therapeutic study.

BACKGROUND: There is a paucity of literature examining surgical trends and outcomes in both child and adult cerebral palsy (CP) patients. We aimed to evaluate surgical trends, complications, length of stay, and charges for spinal deformity surgery in CP patients. METHODS: Using the Nationwide Inpatient Sample (NIS) from 2001 to 2013, patients with CP scoliosis who underwent spinal fusion surgery were identified. Patient characteristics and comorbidities were recorded. Trends in spinal fusion approaches were grouped as anterior (ASF), posterior (PSF), or combined anterior-posterior (ASF/PSF). Complication rates, length of stay, and charges for each approach were analyzed. Bivariate analyses using adjusted Wald tests and multivariate analyses using linear (logarithmic transformation) and logistic regressions were performed. RESULTS: Of the 5191 adult CP patients who underwent spinal fusion the majority underwent PSF (86.5%), followed by the ASF/PSF approach (9.3%). The rate of PSF for cerebral palsy patients with spinal deformity increased significantly per 1 million people in the US population (0.90 to 1.30; P = .048). Complication rate, hospital length of stay, and charges were higher for patients undergoing ASF/PSF (P

Study design Literature review. Objective To determine characteristics and trends in published spine research over a recent decade in a high impact, general orthopedic surgery journal. Summary of background data Recent trends in published spine research in a high-impact orthopedic surgery journal are unknown. Such knowledge could guide future research in the field. Methods A comprehensive literature review of clinical and basic science spine articles published in The Journal of Bone & Joint Surgery from 2006 to 2015 was conducted. Articles were assessed for: title, year of publication, authorship, academic degrees of the authors, number of citations, institution of origin, and spine topic. Clinical articles were evaluated for: sex and race/ethnicity of the human subjects, level of evidence, and inclusion of patient-reported outcome measures (PROMs). Basic science articles were evaluated for: type of study (animal, cadaver, cell-based), sex of the animals, cadavers or cells studied (male, female, or male and female), and presence of sex-based reporting (defined as reporting of results by sex). Results A total of 203 spine articles were evaluated from the 10-year study period. At least 35 validated or nonvalidated patient-reported outcome measures were utilized in clinical spine research. The most commonly reported PROMs were the Oswestry Disability Index (24.4%), Short Form-36 Health Survey (23.7%), and Visual Analog Scale for Pain (19.3%). The average level of evidence improved from 3.25 in 2006 to 2.60 in 2015. Only 13.2% of clinical spine articles reported the race/ethnicity of the subjects. Conclusion A consensus regarding validated PROMs in spine research would be valuable. From 2006 to 2015, the level of evidence of spine articles in The Journal of Bone & Joint Surgery improved. Accurate and complete reporting of patient demographics is an area for improvement in spine research in light of studies demonstrating sex and race/ethnicity-related differences in clinical outcome after spine surgery. Level of evidence 5.

STUDY DESIGN Correlational study. OBJECTIVE In spine trauma patients, we aimed to assess the correlation of patient-reported outcome measurement information system (PROMIS) physical function (PF), pain interference (PI), and Depression scores with Oswestry Disability Index (ODI) and Neck Disability Index (NDI) ODI/NDI scores. SUMMARY OF BACKGROUND DATA The ODI and NDI were intended as patient-reported outcome measures (PROMs) to evaluate clinical outcomes in patients seeking spine care. To date, the PROMIS has not been studied in the spine trauma population. METHODS Between January 1, 2015 and December 13, 2017, patients presenting to a single, level 1 trauma center spine clinic with known spine trauma were identified. A total of 56 patients (52 operative, 4 nonoperative) representing 181 encounters were identified. PROMIS PF, PI, and Depression, as well as the ODI or NDI, were administered to patients. Spearman rho (ρ) were calculated between PROMs. RESULTS A strong correlation exists between PROMIS PI and the ODI (ρ = 0.79, P

Study design Case control series. Objective The aim of this study was to evaluate and compare the effectiveness of methods to decrease surgical site infections (SSIs) following spine tumor surgery. Summary of background data With the aging population of the United States, the prevalence of cancer and associated metastatic spine disease is increasing. The most common complication of spine tumor surgery is SSI. Methods This a single-institution case-control series of patients undergoing spine tumor surgery from June 2003 to October 2018. Patients were grouped into the following groups: Betadine irrigation and intrawound vancomycin powder (BIVP), intrawound vancomycin powder only (IVP), and patients receiving neither (NONE). The primary outcome was SSIs/wound complications. Results One hundred fifty-one spine tumor patients undergoing 174 procedures meeting our inclusion criteria were identified. The BIVP group had 60 patients (73 procedures); the IVP group had 46 patients (47 procedures); and the NONE group had 45 patients (54 procedures). The overall infection rate was 8.6% of all procedures (15/174) and 9.9% (15/151) of all patients. Bivariate analysis comparing patients with and without infections noted the patients with SSIs had significantly higher rates of preoperative radiation treatment (53.3% in infection group vs. 25.5% in noninfection group), P = 0.02. Patients undergoing procedures in the BIVP group had a significantly lower rate of infections (2.7%) than the patients in the IVP (12.8%) and NONE (13%) groups, P = 0.04. Stepwise regression analysis was used to evaluate further factors associated with SSIs. Elevated BMI was significantly associated with SSIs in the model [P = 0.02, odds ratio (OR) 1.14]. BIVP was also protective against infections as compared to the IVP and NONE groups, P = 0.02, OR 0.02. Conclusion BIVP led to a significant decrease in SSI rates following spine tumor surgery. Administration of BIVP is not time consuming and decreased SSI rates. Level of evidence 3.

Study Design: Retrospective study. Objective: To evaluate outcomes and complications following operative and nonoperative management of hyperostotic spine fractures. Methods: Patients presenting between 2008 and 2017 to a single level 1 trauma center with hyperostotic spine fractures had their information and fracture characteristics reviewed. Bivariate analyses were conducted to compare patients across a number of characteristics and outcomes. Multivariate logistic regression models for complication and mortality were done in a stepwise fashion. Results: Sixty-five ankylosing spondylitis (AS) or diffuse idiopathic skeletal hyperostosis (DISH) patients with a spine fracture met our inclusion criteria. DISH was slightly more prevalent (55% vs 45%). Overall delayed diagnosis, reoperation, mortality (at 1 year), and complication rates were high at 32%, 13%, 23%, and 57%, respectively. In multivariate logistic regression models, patients undergoing operative management had significantly increased odds of having a complication (odds ratio [OR] = 23.03, 95% confidence interval [CI] = 2.24-236.45, P = .008), while increasing age was associated with increased odds of death (OR = 1.18, 95% CI = 1.06-1.31, P = .003). Conclusions: Patients with AS or DISH who fracture their spine are at high risk of complication and death. However, neither operative nor nonoperative treatment increases the odds of mortality. This study helps add to a growing, but still limited, body of literature on the characteristics of patients with spine fractures in the setting of AS or DISH.

Background Surgical standardization has been shown to decrease costs without impacting quality; however, there is limited literature on this subject regarding ankle fracture fixation. Methods. Between October 5, 2015 and September 27, 2017, a total of 168 patients with isolated ankle fractures who underwent open reduction, internal fixation (ORIF) were analyzed. Financial data were analyzed across ankle fracture classification type, implant characteristics, and surgeons. Bivariate analyses were conducted. One-way analysis of variance was used to compare hardware costs across all 5 surgeons. Linear regression analysis was used to determine if hardware cost differed by surgeon when accounting for fracture type. Results The mean contribution margin was $4853 (SD $6446). There was a significant difference in implant costs by surgeon (range, lowest-cost surgeon: $471 [SD $283] to $1609 [SD $819]; P < .001). There was no difference in the use of a suture button or locking plate by fracture type (P = .13); however, the cost of the implant was significantly higher if a suture button or locking plate was used ($1014 [SD $666] vs $338 [SD $176]; P < .001). There was an association between surgeon 3 (β = 200.32 [95% CI 6.18-394.47]; P = .043) and surgeon 4 (β = 1131.07 [95% CI 906.84-1355.30]; P < .001) and higher hardware costs. Conclusions Even for the same ankle fracture type, a wide variation in implant costs exists. The lack of standardization among surgeons accounted for a nearly 3.5-fold difference, on average, between the lowest- and highest-cost surgeons, negatively affecting contribution margin. Levels of Evidence Level IV

Background Treatment of distal radius fractures (DRFs) in patients aged >65 years is controversial. The purpose of this study was to identify what patient and fracture characteristics may influence the decision to pursue surgical versus nonsurgical treatment in patients aged >65 years sustaining a DRF. Methods We queried our institutional DRF database for patients aged >65 years who presented to a single academic, tertiary center hand clinic over a 5-year period. In all, 164 patients treated operatively were identified, and 162 patients treated nonoperatively during the same time period were selected for comparison (total N = 326). Demographic variables and fracture-specific variables were recorded. Patient and fracture characteristics between the groups were compared to determine which variables were associated with each treatment modality (operative or nonoperative). Results The average age in our cohort was 72 (SD: 11) years, and 274 patients (67%) were women. The average Charlson Comorbidity Index (CCI) was 4.1 (SD: 2.1). The CCI is a validated tool that predicts 1-year mortality based on patient age and a list of 22 weighted comorbidities. Factors associated with operative treatment in our population were largely related to the severity of the injury and included increasing dorsal tilt (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.05-1.12; P < .001) and AO Classification type C fractures (OR, 5.42; 95% CI, 2.35-11.61; P < .001). Increasing CCI was the only factor independently associated with nonoperative management (OR, 0.84; 95% CI, 0.72-0.997; P = .046). Conclusion Fracture severity is a strong driver in the decision to pursue operative management in patients aged >65 years, whereas increasing CCI predicts nonoperative treatment.

STUDY DESIGN Retrospective, observational study. OBJECTIVE To determine the association of patient socioeconomic disadvantage, insurance type, and other characteristics on presenting symptom severity in patients with isolated lumbar disc herniation. SUMMARY OF BACKGROUND DATA Little is known of the impact of socioeconomic disadvantage and other patient characteristics on the level of self-reported symptom severity when patients first seek care for lumbar disc herniation. METHODS Between April 2015 and December 2018, 734 patients newly presenting for isolated lumbar disc herniation who completed the Patient-Reported Outcomes Measurement Information System Physical Function (PF), Pain Interference (PI), and Depression Computer Adaptive Tests (CATs) were identified. Socioeconomic disadvantage was determined using the Area Deprivation Index, a validated measure of socioeconomic disadvantage at the census block group level (0-100, 100 = highest socioeconomic disadvantage). Bivariate analyses were used. Multivariable linear regression was used to determine if there was an association between socioeconomic disadvantage, insurance type, and other patient factors and presenting patient-reported health status. RESULTS Significant differences in age, insurance type, self-reported race, marital status, and county of residence were appreciated when comparing patient characteristics by socioeconomic disadvantage levels (all comparisons, P

BackgroundDepression is common and can decrease the likelihood that a patient undergoing an orthopaedic procedure will improve after that intervention. Research at a single institution using the Patient-reported Outcomes Measurement Information System (PROMIS) showed that the PROMIS Depressi

STUDY DESIGN Cross-sectional cohort analysis. OBJECTIVE (1) To assess the correlation between Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) in patients seeking spine care; (2) to assess the correlation between PROMIS PF and the Likert Pain Scale (LPS) in patients seeking spine care; (3) to determine which pain scale best correlates to physical function overall and by number of clinic visits. SUMMARY OF BACKGROUND DATA An accurate understanding of a patient's pain level is beneficial in setting clinical and pain management expectations. There is limited work analyzing which instrument best captures pain and its impact on function in patients seeking spine care. METHODS Spine center patients from February 2015 to November 2017 were asked to complete PROMIS PF and PI domains, as well as to report their pain level on a 0 (no pain) to 10 (worst pain) LPS at each visit. Pearson correlation coefficients were calculated between PROMIS PF and PROMIS PI; PROMIS PI and LPS; and PROMIS PF and LPS. Fisher r-z transformation method was utilized for confidence intervals (CIs) and to determine significant correlation differences. Analyses were performed for all data, as well as by office visit. Significance was set at P

Background: There is a concern that patients may answer patient-reported outcome (PRO) questionnaires differently depending on the purpose—clinical care or research (eg, “Hawthorne effect”). We sought to determine whether Patient-Reported Outcomes Management Information System (PROMIS) scores differ at the same clinic visit based on whether a patient was completing the PRO tool for study or clinical care purposes. Methods: Patients presenting to one surgeon at an academic medical center hand clinic were asked to complete PROMIS Physical Function (PF) and Pain Interference (PI) questionnaires as part of routine care. Those diagnosed with carpal tunnel syndrome from February 2015 to April 2017 were then asked to participate in a clinical research project, which had them complete PROMIS PF and PROMIS PI again. Data from those who completed both routine and research PROs at each visit were compared. Between the 2 settings, test-retest reliability was determined using Pearson correlation coefficients ( r), and internal consistency was evaluated using Cronbach α. Results: A total of 128 unique office visits representing 67 patients fit our inclusion criteria. There was a strong correlation between PROMIS PF and PI in the research and patient care setting (PF: r = 0.82, P < .01; PI: r = 0.83, P < .01). Both domains had a Cronbach α of 0.90. The PROMIS PF scores were not different between the 2 groups ( P = .19), but the PROMIS PI scores were slightly different ( P < .01). Conclusions: Patients appear to be consistent when completing PROMIS for both clinical care and research, supporting the idea that data obtained in either setting are generalizable and appropriate for research purposes.

Annual scientific meetings serve as a forum for dissemination of new research findings. Presentations should be of high scientific quality as they have the potential to impact future research projects and current clinical practice. The publication rate of podium presentations at an annual meeting can be used to assess the quality of the research presented. The purpose of this study was to determine the publication rate of podium presentations at the Orthopaedic Research Society (ORS) annual meeting. All podium presentations from the 2012 to 2014 annual ORS meetings were identified. Abstracts were categorized into an orthopaedic topic. A PubMed search was performed to determine if an abstract reached publication in a peer-reviewed journal. The publication rate was determined for each year. Of the 1063 podium presentations identified, 640 (60.2%) reached publication in a peer-reviewed journal. No significant differences were observed in the publication rate between the orthopaedic topics (p = 0.3414). The majority (75.9%) of published abstracts reached publication within 2 years of presentation and the average time to publication was 17.0 months. Abstracts were published in 151 different journals with an average impact factor of 4.46. Time to publication varied significantly by journal (p = 0.025). Journal of Orthopaedic Research, Journal of Biomechanics, PLoS ONE, Osteoarthritis and Cartilage, and Bone were the most common publication journals. This study provides insight into the quality of podium presentations at the ORS annual meeting. The ORS annual meeting compares favorably to other orthopaedic surgery meetings. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:288-292, 2019.

OBJECTIVES The Patient-Reported Outcomes Measurement Information System (PROMIS) is growing in popularity as healthcare shifts towards a value-based system. However, it remains unclear if PROMIS use improves the patient experience. The aim of the present study was to determine if PROMIS use as part of routine orthopaedic clinical care is associated with improved patient experience, as measured by the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) survey. METHODS All patient visits to an orthopaedic surgery clinic at a single academic medical centre between February 2015 and September 2016 were reviewed. Accounting for known patient factors that have an impact on clinic visit satisfaction, CGCAHPS scores were compared between patients who had PROMIS used as part of their routine care and those who had not had PROMIS used as part of their routine care. A p-value of

Retrospective cross-sectional cohort analysis.1) To assess the correlation of Patient-Reported Outcomes Management Information System (PROMIS) domains with SRS-22r/SRS-30 domains in all scoliosis patients; 2) to assess the correlation of PROMIS domains with SRS-30 domains in adult scoliosis patients; 3) to assess the correlation of PROMIS domains with SRS-22r/SRS-30 domains in pediatric scoliosis patients; and 4) to assess ceiling and floor effects of PROMIS and SRS-22r/SRS-30 domains.Studies evaluating correlations between PROMIS and a number of legacy PRO tools have been conducted. To our knowledge, no literature exists examining the correlation of PROMIS and SRS questionnaires in adult and pediatric spinal deformity patients.Outpatient visits from July 2015 to December 2017 with concurrent PROMIS and SRS questionnaires were analyzed. Pediatric patients completed the SRS-22r, whereas adults completed the SRS-30. PROMIS measured Physical Function/Mobility, Pain Interference, and Depression domains. Spearman correlation coefficients (ρ) were calculated. Ceiling and floor effects were calculated and compared.227 (164 adult; 64 pediatric) patient visits representing 173 patients were included. Moderate to strong correlation existed between PROMIS Physical Function/Mobility and SRS Function/Activity (F/A) domains (ρ, range 0.59-0.84; p.001). PROMIS Pain Interference and SRS Pain domains showed strong-moderate to strong correlation (ρ, range -0.68 to -0.83; p.001). PROMIS Depression and SRS Mental Health (MH) domains demonstrated strong-moderate to strong correlation (ρ, range -0.67 to -0.80; p.001). Ceiling and floor effects were all less in PROMIS domains (range, 0.44% to 0.88%) compared with SRS domains (range, 0.88% to 17.62%).PROMIS Physical Function/Mobility, Pain Interference, and Depression domains correlate well with SRS F/A, Pain, and MH. SRS SI/A and Satisfaction are not as well captured. PROMIS showed better ceiling and floor effects than SRS.Level III.

Background Preoperative optimization of risk factors has been suggested as a strategy to improve the value of total joint arthroplasty (TJA) care. We assessed the implementation of a TJA preoperative optimization protocol and its impact on length of hospital stay, discharge destination, 90-day readmissions, and hospital direct variable costs. Methods This retrospective cohort study included adults undergoing primary elective TJA from 07/2015-09/2016 at an urban tertiary care hospital. Post-implementation patients were preoperatively screened for 19 risk factors; results and recommended interventions were reported to surgeons, who had the option to postpone or continue surgery as scheduled. Metrics from hospital administrative databases were compared between post-implementation (02/2016-09/2016) and pre-implementation cohorts (07/2015-11/2015). Results The 314 post-implementation patients were slightly younger compared to the 351 pre-implementation patients (64.2 years vs 65.8 years, P = .02) and a higher percentage of patients had diabetes (18% vs 5.1%, P 40 kg/m2 or 35-40 kg/m2 with comorbidities) (13%). Forty-six patients (20%) did not follow through with the recommended optimization before undergoing elective surgery. The post-implementation cohort had shorter average length of hospital stay (1.9 days vs 2.2 days, P Conclusion In our experience, the majority of elective TJA patients have modifiable risk factors, indicating opportunity for preoperative intervention. Our evidence-based preoperative optimization program resulted in higher value care, demonstrated by similar outcomes with lower resource utilization.

Analysis of a national database. To analyze trends in spinal fusion surgery for neurofibromatosis type I (NF-1) patients and to compare the surgical approaches. The preferred surgical approach for fusion treatment of spinal deformity in NF is not well established. We identified 548 patients with a diagnosis of NF-1 who had received spinal fusion surgery between 2003 and 2014. We compared posterior spinal fusion (PSF), anterior-posterior spinal fusion (APSF), and anterior spinal fusion with respect to patient demographics, institutional characteristics, in-hospital complications, and hospitalization lengths and costs. Significance was set at a value of p less than .05. The number of spinal fusions for NF-1 significantly increased (p = .02) over the study period. The rate of PSF surgeries increased 2.9-fold, whereas the rate of APSF surgeries decreased 2.2-fold. There was also a significant association between the location of the fusion and surgical approach (p

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

Numerous studies have analyzed the impact of rheumatoid arthritis (RA) on the cervical spine and its related surgical interventions. However, there is a paucity of literature available conducting the same analyses in patients with non-cervical spine involvement.The objective of this study was to compare patient characteristics, comorbidities, and complications in patients with and without RA undergoing primary non-cervical spinal fusions.This is a retrospective national database review.A total of 52,818 patients with adult spinal deformity undergoing non-cervical spinal fusions (1,814 patients with RA and 51,004 patients without RA).The outcome measures in the study include patient characteristics, as well as complication and mortality rates.Using the Nationwide Inpatient Sample from 2003 to 2014, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes were used to identify patients aged ≥18 years old with and without RA undergoing primary non-cervical spinal fusions. Univariate analysis was used to determine patient characteristics, comorbidities, and complication values for each group. Bivariate analysis was used to compare the two groups. Significance was set at p.05.Patients with RA were older (p.001), were more likely to be women (p.001), had increased rates of osteoporosis (p.001), had a greater percentage of their surgeries reimbursed by Medicare (p.001), and more often had weekend admissions (p=.014). There was no difference in all the other characteristics. Patients with RA had higher rates of iron deficiency anemia, congestive heart failure, chronic pulmonary disease, depression, and fluid and electrolyte disorders (all, p.001). Patients without RA had higher rates of alcohol abuse (p=.027). There was no difference in all the other complications. There was no difference in mortality rate (p=.99). Total complications were greater in patients with RA (p.001). Patients with RA had higher rates of infection (p=.032), implant-related complications (p=.010), incidental durotomies (p=.001), and urinary tract infections (p.001). No difference existed among the other complications.Patients with RA have an increased number of comorbidities and complication rates compared with patients without RA. Such knowledge can help surgeons and patients with RA have beneficial preoperative discussions regarding outcomes.

Introduction While telemedicine usage has increased due to the COVID-19 pandemic, there remains little consensus about how spine surgeons perceive virtual care. The purpose of this study was to explore international perspectives of spine providers on the challenges and benefits of telemedicine. Methods Responses from 485 members of AO Spine were analyzed, covering provider perceptions of the challenges and benefits of telemedicine. All questions were optional, and blank responses were excluded from analysis. Results The leading challenges reported by surgeons were decreased ability to perform physical examinations (38.6%), possible increased medicolegal exposure (19.3%), and lack of reimbursement parity compared to traditional visits (15.5%). Fewer than 9.0% of respondents experienced technological issues. On average, respondents agreed that telemedicine increases access to care for rural/long-distance patients, provides societal cost savings, and increases patient convenience. Responses were mixed about whether telemedicine leads to greater patient satisfaction. North Americans experienced the most challenges, but also thought telemedicine carried the most benefits, whereas Africans reported the fewest challenges and benefits. Age did not affect responses. Conclusion Spine surgeons are supportive of the benefits of telemedicine, and only a small minority experienced technical issues. The decreased ability to perform the physical examination was the top challenge and remains a major obstacle to virtual care for spine surgeons around the world, although interestingly, 61.4% of providers did not acknowledge this to be a major challenge. Significant groundwork in optimizing remote physical examination maneuvers and achieving legal and reimbursement clarity is necessary for widespread implementation.

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 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.

Health care systems globally, including in the United States, continue to undergo a much-needed transformation focused on optimizing value-or health outcomes per dollar spent across a full cycle of care-for patients. Given the traditionally high cost and use of orthopaedic surgery services, the field is ripe for in-depth assessment and comparison of interventions to ensure that evidence-based, high-value care is prioritized. Cost-effectiveness analyses (CEAs) provide an important framework from which to begin effective policy discussions, and a recent study suggests that current orthopaedic economic literature is of high quality. However, the same study demonstrated that no authors published CEAs that also provided commentary on how their work can actually guide policy decisions. Furthermore, the ethical implications of their research or insight into the larger consequences of their findings within and outside the health care sector was not discussed. We must be better at "connecting the dots" between CEAs and value-based health care research and practical policy initiatives while also considering how such proposals promote health equity and address systemic injustices currently found in our health care system.

BACKGROUND Few studies have examined whether orthopaedic surgery, including hand surgery, is associated with patients' financial health. We sought to understand the level of financial burden and worry for patients undergoing two common hand procedures-carpal tunnel release and open reduction and internal fixation for a distal radius fracture-as well as to determine factors associated with a higher financial burden and worry. QUESTIONS/PURPOSES In patients undergoing operative treatment for isolated carpal tunnel syndrome with carpal tunnel release or open reduction and internal fixation for a distal radius fracture, we used validated financial burden and worry questionnaires to ask: (1) What percentage of patients report some level of financial burden, and what is the median financial burden composite score? (2) What percentage of patients report some level of financial worry, and what percentage of patients report a high level of financial worry? (3) When accounting for other assessed factors, what patient- and condition-related factors are associated with financial burden? (4) When accounting for other assessed factors, what patient- and condition-related factors are associated with high financial worry? METHODS In this cross-sectional survey study, a hand and upper extremity database at a single tertiary academic medical center was reviewed for patients 18 years or older undergoing operative treatment in our hand and upper extremity division for an isolated distal radius fracture between October 2017 and October 2019. We then selected all patients undergoing carpal tunnel release during the first half of that time period (given the frequency of carpal tunnel syndrome, a 1-year period was sufficient to ensure comparable patient groups). A total of 645 patients were identified (carpal tunnel release: 60% [384 of 645 patients]; open reduction and internal fixation for a distal radius fracture: 40% [261 of 645 patients). Of the patients who underwent carpal tunnel release, 6% (24 of 384) were excluded because of associated injuries. Of the patients undergoing open reduction and internal fixation for a distal radius fracture, 4% (10 of 261) were excluded because of associated injuries. All remaining 611 patients were approached. Thirty-six percent (223 of 611; carpal tunnel release: 36% [128 of 360]; open reduction and internal fixation: 38% [95 of 251]) of patients ultimately completed two validated financial health surveys: the financial burden composite and financial worry questionnaires. Descriptive statistics were calculated to report the percentage of patients who had some level of financial burden and worry. Further, the median financial burden composite score was determined. The percentage of patients who reported a high level of financial worry was calculated. A forward stepwise regression model approach was used; thus, variables with p values < 0.10 in bivariate analysis were included in the final regression analyses to determine which patient- and condition-related factors were associated with financial burden or high financial worry, accounting for all other measured variables. RESULTS The median financial burden composite score was 0 (range 0 [lowest possible financial burden] to 6 [highest possible financial burden]), and 13% of patients (30 of 223) reported a high level of financial worry. After controlling for potentially confounding variables like age, insurance type, and self-reported race, the number of dependents (regression coefficient 0.15 [95% CI 0.008 to 0.29]; p = 0.04) was associated with higher levels of financial burden, while retired employment status (regression coefficient -1.24 [95% CI -1.88 to -0.60]; p < 0.001) was associated with lower levels of financial burden. In addition, the number of dependents (odds ratio 1.77 [95% CI 1.21 to 2.61]; p = 0.004) and unable to work or disabled employment status (OR 3.76 [95% CI 1.25 to 11.28]; p = 0.02) were associated with increased odds of high financial worry. CONCLUSION A notable number of patients undergoing operative hand care for two common conditions reported some degree of financial burden and worry. Patients at higher risk of financial burden and/or worry may benefit from increased resources during their hand care journey, including social work consultation and financial counselors. This is especially true given the association between number of dependents and work status on financial burden and high financial worry. However, future research is needed to determine the return on investment of this resource utilization on patient clinical outcomes, overall quality of life, and well-being. LEVEL OF EVIDENCE Level III, therapeutic study.

Purpose To analyze the implementation and benefits of time-driven activity-based costing (TDABC) in the field of orthopaedic surgery. Methods We performed a search of PubMed, Google Scholar, and Embase in March 2020, using the following terms: “Time-Driven Activity-Based Costing,” “TDABC,” “Orthopaedic Surgery,” and “Cost.” Then we selected the studies that used the TDABC methodology to generate costs for a particular aspect of orthopaedic surgery. The included studies were divided into the following 5 main categories for ease of analysis: joint arthroplasty, trauma, hand, electronic medical record (EMR) implementation, and pediatric. We analyzed the overall ability of TDABC in the field of orthopaedic surgery, compared to the standard costing methods. Results We included a total of 19 studies that implemented the TDABC methodology to generate a cost, which was compared to traditional accounting methods. The orthopaedic subspecialty with the most amount of TDABC implementation has been the field of joint arthroplasty. In these studies, the authors have noted that TDABC has provided a more granular breakdown of costs and has calculated a lower cost compared with traditional accounting methods. Conclusion TDABC is a powerful cost analysis method that has demonstrated benefit over the activity-based costing (ABC) approach in determining a lower and more accurate cost of orthopaedic procedures. Furthermore, the TDABC method generates an average cost reduction of $10,000 and $12,000 for total hip arthroplasty and total knee arthroplasty, respectively. Clinical Relevance TDABC can allow health care administration to better determine and understand the cost drivers of particular orthopaedic procedures at their institutions. With improved estimates on the true cost of an activity, hospital administrators and department chairs can adjust to ensure cost-effective, patient-centered health care.

Purpose The thumb carpometacarpal (CMC) joint is the second most common site of osteoarthritis in the hand, yet reported symptoms and ultimate treatment decisions are not simply a function of radiographic appearance. This study aimed to determine the patient- and/or disease-related factors associated with patients undergoing surgical treatment of thumb CMC arthritis. Methods This retrospective cohort study analyzed 1,994 patients with thumb CMC arthritis treated at 2 institutions between February 2015 and November 2018. Patient demographic and clinical information was obtained from medical records to characterize treatment modalities before hand surgeon evaluation, mental and physical comorbidities, and Patient-Reported Outcomes Measurement Information System assessments. After bivariate analysis , a multivariable logistic regression model evaluated factors associated with undergoing thumb CMC surgery. Results This cohort was predominately female (70%) and white (91%), mean age at first appointment, 62 ± 10 years. A total of 170 patients underwent surgery for thumb CMC arthritis (9%) at a median of 114 days (interquartile range, 27–328) after the first visit. Patient-Reported Outcomes Measurement Information System Depression scores correlated with Pain Interference and Physical Function scores. A history of diagnosed depression or anxiety was associated with less perceived Physical Function at presentation. However, only prior contralateral thumb CMC surgery, younger patient age, and treating institution were associated with undergoing surgery in regression modeling. Conclusions Pain and functional limitations associated with thumb CMC arthritis are influenced by mental health comorbidities, but these factors do not predict surgical treatment. Instead, patients’ prior surgical experience and surgeon attitudes toward thumb CMC arthritis appear to have a strong influence on the odds of patients undergoing surgery for thumb CMC arthritis. Type of study/level of evidence Prognostic IV.

The global burden of musculoskeletal trauma is high. There is a need to improve access to safe, high-quality surgery in many low- and middle-income countries (LMICs). Numerous initiatives have taken aim at solving this underlying shortage in surgical care, including mission trips, academic programs, and international collaborations. However, much work remains to be done in LMICs compared with high-income countries (HICs). In HICs, the field of hand surgery has grown partially owing to the rigorous application of clinical research to examine outcomes and determine best practices. Patient-reported outcome measures (PROMs) have a key role as a valid patient-centered method of capturing symptoms and well-being. They have substantial promise in LMICs to understand patient symptom severity and quality of life better, monitor treatment success or failure, determine cost-effectiveness of procedures, and guide capacity building. Contextually appropriate PROMs can improve routine follow-up in LMICs and advance the practice and study of hand surgery worldwide.

» Dropped head syndrome is a group of disorders with diverse etiologies involving different anatomical components of the neck, ultimately resulting in a debilitating, flexible, anterior curvature of the cervical spine. » Causes of dropped head syndrome include myasthenia gravis, amyotrophic lateral sclerosis, Parkinson disease, radiation therapy, and cumulative age-related changes. Idiopathic cases have also been reported. » Nonoperative treatment of dropped head syndrome includes orthotic bracing and physical therapy. » Surgical treatment of dropped head syndrome consists of cervical spine fusion to correct the deformity. » The limited data available examining the clinical and radiographic outcomes of surgical intervention indicate a higher rate of complications with the majority having favorable outcomes in the long term.

There is growing interest in value-based health care in the United States. Statistical analysis of large databases can inform us of the factors associated with and the probability of adverse events and unplanned readmissions that diminish quality and add expense. For example, increased operating time and high blood urea nitrogen (BUN) are associated with adverse events, whereas patients on antihypertensive medications were more likely to have an unplanned readmission. Many surgeons rely on their knowledge and intuition when assessing the risk of a procedure. Comparing clinically driven with statistically derived risk models of total shoulder arthroplasty (TSA) offers insight into potential gaps between common practice and evidence-based medicine. (1) Does a statistically driven model better explain the variation in unplanned readmission within 30 days of discharge when compared with an a priori five-variable model selected based on expert orthopaedic surgeon opinion? (2) Does a statistically driven model better explain the variation in adverse events within 30 days of discharge when compared with an a priori five-variable model selected based on expert orthopaedic surgeon opinion? Current Procedural Terminology codes were used to identify 4030 individuals older than 17 years of age who had TSA in which osteoarthritis was the primary etiology. A logistic regression model for adverse event and unplanned readmission within 30 days was constructed using (1) five variables chosen a priori based on clinic expertise (age, American Society of Anesthesiologists classification ≥ 3, body mass index, smoking status, and diabetes mellitus); and (2) by entering all variables with p < 0.10 in bivariate analysis. We then excluded 870 patients (22%) based on preoperative factors felt to make large discretionary surgery unwise to focus our research on appropriate procedures. Infirm patients have more pressing needs than alleviation of shoulder pain and stiffness. Among the remaining 3160 patients, logistic regression models for adverse event and unplanned readmission within 30 days were constructed in a similar manner to the complete models. The five a priori risk factors used in each model based on clinical expertise were selected by consensus of an expert orthopaedic surgeon panel. When patients unfit for discretionary surgery were excluded, the clinically driven model found no risk factors and accounted for 1.4% of the variation in unplanned readmission. In contrast, the statistically driven model explained 4.6% of the variation and found operating time (hours) (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.04–1.53) and hypertension requiring medications (OR, 1.95; 95% CI, 1.01–3.76) were associated with unplanned readmission accounting for all other factors. However, neither the clinically driven model (pseudo R2, 1.4%) nor statistically driven model (pseudo R2, 4.6%) provided much explanatory power. When patients unfit for discretionary surgery were excluded, no factors in the clinically driven model were significant and the model accounted for 0.95% of the variation in adverse events. In the statistically driven model, age (OR, 1.03; 95% CI, 1.01–1.06), men (OR, 1.64; 95% CI, 1.05–2.57), operating time (hours) (OR, 1.27; 95% CI, 1.07–1.52), and high BUN (OR, 3.12; 95% CI, 1.35–7.21) were associated with adverse events when accounting for all other factors, explaining 3.3% of the variation. However, neither the clinically driven model (pseudo R2, 0.95%) nor the statistically driven model (pseudo R2, 3.3%) provided much explanatory power. The observation that a statistically derived risk model performs better than a clinically driven model affirms the value of research based on large databases, although the models derived need to be tested prospectively. Clinicians can utilize our results to understand that clinician intuition may not always offer the best risk adjustment and that factors impacting TSA unplanned readmission and adverse events may be best derived from large data sets. However, because current analyses explain limited variation in outcomes, future studies might look to better define what factors drive the variation in unplanned readmission and adverse events.

There is evidence that surgeons make different recommendations for people seeking their care than they make for themselves. There may also be differences in pain episodes and management strategies between surgeons and people seeking care, knowledge of which might improve care. We aimed to assess whether the prevalence of non-traumatic pains, treatments and other factors differed between patients and surgeons. Two-hundred and twenty surgeons, members of the Science of Variation Group (SOVG), and 248 patients seeking care at the Hand Service at a large academic hospital completed a survey regarding the lifetime incidence of non-traumatic pains lasting > one month using short versions of the Pain Catastrophising Scale (PCS-4); Patient Health Questionnaire (PHQ-2); and Short Health Anxiety Inventory (SHAI-5). Surgeons had a higher prevalence of at least one non-traumatic pain than patients and were more likely to report pain at more than one anatomical site. Patients were more likely to receive any treatment: surgery; injection; non-opioid medication; opioid medication; physical or occupational therapy. Patients missed work more often than surgeons. Age was the only factor independently associated with patient pain. Practicing in the United States was the only factor independently associated with surgeon pain. Non-traumatic pains are extremely common. Surgeons have particularly effective coping strategies, allowing them to maintain their life roles with limited medical care when in pain. Increasing the appeal and availability of methods for optimising coping strategies might help to narrow the gap between surgeon and patient health.

BACKGROUND: Patient-reported outcome measures such as the Patient-Reported Outcomes Measurement Information System (PROMIS) allow surgeons to evaluate the most important outcomes to patients, including function, pain, and mental well-being. However, PROMIS does not provide surgeons with insight into whether patients are able to successfully cope with their level of physical and/or mental health limitations in day-to-day life; such understanding can be garnered using the Patient-acceptable Symptom State (PASS). It remains unclear whether or not the PASS status for a given patient and his or her health, as evaluated by PROMIS scores, differs based on sociodemographic factors; if it does, that could have important implications regarding interpretation of outcomes and fair delivery of care. QUESTIONS/PURPOSES: In a tertiary-care foot and ankle practice, (1) Is the PASS associated with sociodemographic factors (age, gender, race, ethnicity, and income)? (2) Do PROMIS Physical Function (PF), Pain Interference (PI), and Depression scores differ based on income level? (3) Do PROMIS PF, PI, and Depression thresholds for the PASS differ based on income level? METHODS: In this retrospective analysis of longitudinally obtained data, all patients with foot and ankle conditions who had new-patient visits (n = 2860) between February 2015 and December 2017 at a single tertiary academic medical center were asked to complete the PROMIS PF, PI, and Depression survey and answer the following single, validated, yes/no PASS question: “Taking into account all the activity you have during your daily life, your level of pain, and also your functional impairment, do you consider that the current state of your foot and ankle is satisfactory?” Of the 2860 new foot and ankle patient visits, 21 patient visits (0.4%) were removed initially because all four outcome measures were not completed. An additional 225 patient visits (8%) were removed because the patient chart did not contain enough information to accurately geocode them; 15 patients visits (0.5%) were removed because the census block group median income data were not available. Lastly, two patient visits (0.1%) were removed because they were duplicates. This left a total of 2597 of 2860 possible patients (91%) in our study sample who had completed all three PROMIS domains and answered the PASS question. Patient sociodemographic factors such as age, gender, race, and ethnicity were recorded. Using census block groups as part of a geocoding method, the income bracket for each patient was recorded. A chi-square analysis was used to determine whether sociodemographic factors were associated with different PASS rates, two-way ANOVA analyses with pairwise comparisons were used to determine if PROMIS scores differed by income bracket, and a receiver operating characteristic (ROC) curve analysis was performed to determine PASS thresholds for the PROMIS score by income bracket. The minimum clinically important difference (MCID) for PROMIS PF in the literature in foot and ankle patients ranges from about 7.9 to 13.2 using anchor-based approaches and 4.5 to 4.7 using the ½ SD, distribution-based method. The MCID for PROMIS PI in the literature in foot and ankle patients ranges from about 5.5 to 12.4 using anchor-based approaches and about 4.1 to 4.3 using the ½ SD, distribution-based method. Both were considered when evaluating our findings. Such MCID cutoffs for PROMIS Depression are not as well established in the foot and ankle literature. Significance was set a priori at p < 0.05. RESULTS: The only sociodemographic factor associated with differences in the proportion of patients achieving PASS was age (15% [312 of 2036] of patients aged 18-64 years versus 11% [60 of 561] of patients aged ≥ 65 years; p = 0.006). PROMIS PF (45 ± 10 for the ≥ USD 100,000 bracket versus 40 ± 10 for the ≤ USD 24,999 bracket, mean difference 5 [95% CI 3 to 7]; p < 0.001), PI (57 ± 8 for ≥ USD 100,000 versus 63 ± 7 for ≤ USD 24,999, mean difference -6 [95% CI -7 to -4]; p < 0.001), and Depression (46 ± 8 for the ≥ USD 100,000 bracket versus 51 ± 11 for ≤ USD 24,999, mean difference -5 [95% CI -7 to -3]; p < 0.001) scores were better for patients in the highest income bracket compared with those in the lowest income bracket. For PROMIS PF, the difference falls within the score change range deemed clinically important when using a ½ SD, distribution-based approach but not when using an anchor-based approach; however, the score difference for PROMIS PI falls within the score change range deemed clinically important for both approaches. The PASS threshold of the PROMIS PF for the highest income bracket was near the mean for the US population (49), while the PASS threshold of the PROMIS PF for the lowest income bracket was more than one SD below the US population mean (39). Similarly, the PASS threshold of the PROMIS PI differed by 6 points when the lowest and highest income brackets were compared. PROMIS Depression was unable to discriminate the PASS. CONCLUSIONS: Discussions about functional and pain goals may need to be a greater focus of clinic encounters in the elderly population to ensure that patients understand the risks and benefits of given treatment options at their advanced age. Further, when using PASS in clinical encounters to evaluate patient satisfaction and the ability to cope at different symptom and functionality levels, surgeons should consider income status and its relationship to PASS. This knowledge may help surgeons approach patients with a better idea of patient expectations and which level of symptoms and functionality is satisfactory; this information can assist in ensuring that each patient’s health goal is included in shared decision-making discussions. A better understanding of why patients with different income levels are satisfied and able to cope at different symptom and functionality levels is warranted and may best be accomplished using an epidemiologic survey approach. LEVEL OF EVIDENCE: Level III, diagnostic study.

Study design A retrospective database analysis. Objective The aim of this study was to analyze US trends in surgical approaches for ossification of the posterior longitudinal ligament (OPLL); and to compare US patient and hospital characteristics, length of stay, total charges, and 30-day complications by surgical approach in OPLL management. Summary of background data A robust literature on surgical management of OPLL in East Asian countries, where OPLL has a higher prevalence, exists. However, there is a paucity of literature evaluating the surgical management of OPLL in non-Asian countries. Methods Using the Nationwide Inpatient Sample (NIS), we identified surgically treated OPLL patients from 2003 to 2014. Data on patient characteristics, surgical approaches, complications, hospital characteristics, length of stay, and hospital charges were extracted and analyzed. Analysis of variance (ANOVA) and Chi-squared tests were used to assess variation across categorical variables. Linear regression was used to evaluate the trend of surgical management for OPLL over the study timeframe. Results Five thousand two hundred twelve patients fit our inclusion criteria. The overall complication rate was 21.5%, but the highest complication rate was for patients undergoing a combined anterior-posterior decompression/fusion (44.7%). Patients undergoing a combined anterior-posterior decompression/fusion had a longer length of stay and higher total charges (P Conclusion To our knowledge, this is the largest study examining the surgical treatment of OPLL in a non-Asian country. OPLL surgical cases increased over the study timeframe and the overall surgical complication rate was 21.5%. The percentage of Asians or Pacific Islanders with OPLL undergoing surgical intervention was 10.8%, which is higher than the prevalence in the US population (4.9%). This suggests a potential genetic component to OPLL. Future work is warranted to determine how best to decrease the high complication rate. Level of evidence 4.

BACKGROUND The Patient-reported Outcome Measurement Information System (PROMIS) continues to be an important universal patient-reported outcomes measure (PROM) in orthopaedic surgery. However, there is concern about the performance of the PROMIS as a general health questionnaire in hand surgery compared with the performance of region- and condition-specific PROMs such as the Michigan Hand Questionnaire (MHQ) and the Boston Carpal Tunnel Questionnaire (BCTQ), respectively. To ensure that PROMIS domains capture patient-reported outcomes to the same degree as region- and condition-specific PROMs do, comparing PROM performance is necessary. QUESTIONS/PURPOSES (1) Which PROMs demonstrate high responsiveness among patients undergoing carpal tunnel release (CTR)? (2) Which of the PROMIS domains (Physical Function [PF], Upper Extremity [UE], and Pain Interference [PI]) demonstrate concurrent validity with the HHQ and BCTQ domains? METHODS In this prospective study, between November 2014 and October 2016, patients with carpal tunnel syndrome visiting a single surgeon who elected to undergo CTR completed the BCTQ, MHQ, and PROMIS UE, PF, and PI domains at each visit. A total of 101 patients agreed to participate. Of these, 31 patients (31%) did not return for a followup visit at least 6 weeks after CTR and were excluded, leaving a final sample of 70 patients (69%). We compared the PROMIS against region- and condition-specific PROMs in terms of responsiveness and concurrent validity. Responsiveness was determined using Cohen's d or the effect-size index (ESI). The larger the absolute value of the ESI, the greater the effect size. Using the ESI allows surgeons to better quantify the impact of CTR, with a medium ESI (that is, 0.5) representing a visible clinical change to a careful observer. Concurrent validity was determined using Spearman's correlation coefficient with correlation strengths categorized as excellent (> 0.7), excellent-good (0.61-0.70), good (0.4-0.6), and poor (< 0.4). Significance was set a priori at p < 0.05. RESULTS Among PROMIS domains, the PI demonstrated the best responsiveness (ESI = 0.74; 95% CI, 0.39-1.08), followed by the UE (ESI = -0.66; 95% CI, -1.00 to -0.31). For the MHQ, the Satisfaction domain had the largest effect size (ESI = -1.48; 95% CI, -1.85 to -1.09), while for the BCTQ, the Symptom Severity domain had the best responsiveness (ESI = 1.54; 95% CI, 1.14-1.91). The PROMIS UE and PI domains demonstrated excellent-good to excellent correlations to the total MHQ and BCTQ-Functional Status scores (preoperative UE to MHQ: ρ = 0.68; PI to MHQ: ρ = 0.74; UE to BCTQ-Functional Status: ρ = 0.74; PI to BCTQ-Functional Status: ρ = 0.67; all p < 0.001), while the PROMIS PF demonstrated poor correlations with the same domains (preoperative PF to MHQ; ρ = 0.33; UE to BCTQ-Functional Status: ρ = 0.39; both p < 0.01). CONCLUSIONS The PROMIS UE and PI domains demonstrated slightly worse responsiveness than the MHQ and BCTQ domains that was nonetheless acceptable. The PROMIS PF domain was unresponsive. All three PROMIS domains correlated with the MHQ and BCTQ, but the PROMIS UE and PI domains had notably stronger correlations to the MHQ and BCTQ domains than the PF domain did. We feel that the PROMIS UE and PI can be used to evaluate the clinical outcomes of patients undergoing CTR, while also providing more robust insight into overall health status because they are general PROMs. However, we do not recommend the PROMIS PF for evaluating patients undergoing CTR. LEVEL OF EVIDENCE Level II, diagnostic study.

Analysis of a national database.To analyze trends in fusion surgery for spinal deformity in Marfan syndrome (MFS) patients, compare patients with and without Marfan, and evaluate differences in surgical approaches.National trends of fusion surgery for spinal deformities in MFS patients are not known. Given the rarity of MFS and the nuanced differences in the spinal deformity it causes, it is important to explore differences in fusion surgery between spinal deformity patients with and without MFS.We identified 314 patients (1,410 weighted) with a diagnosis of MFS and spinal deformity who underwent spinal fusion between the years 2003 and 2014. Our primary outcome was national trends in the use of posterior (PSF), anterior-posterior (APSF), and anterior (ASF) spinal fusions. We also compared perioperative complications, mortality rate, length of stay, and hospital charges in a propensity score matched sample of spinal fusion patients with and without a diagnosis of MFS.The proportion of PSF surgeries increased significantly (p.01) from 66.7% in 2003 to 92.0% in 2014. MFS patients were more likely to have higher neurologic (2.4% vs. 0.79%, p=.01) complications. There was a significant association between age and approach (p.01). PSF had a mean age of 20.2, whereas APSF and ASF had mean ages of 27.1 and 35.2, respectively. Approximately 62% of cervical fusions used ASF.Our study provides findings from the largest sample analyzed to date and is the only thus far that investigates national trends. Our results are largely consistent with those of other works in that MFS patients undergoing spinal fusion surgery have higher neurologic complications. We also report that surgical treatment has shifted toward a posterior approach. Our findings can give surgeons a better understanding of the postoperative complications and changing national trends in spinal fusion surgery for patients with MFS.

BACKGROUND: Overuse of healthcare resources is burdensome on society. Prior research has demonstrated that many patients with traumatic musculoskeletal injuries continue to seek care long after appropriate healing is well established, suggesting an overuse of services. However, few studies have examined the factors—including patient-reported outcomes—associated with an increased number of clinic visits for traumatic hand and wrist conditions. QUESTIONS/PURPOSES: (1) After accounting for surgical treatment, surgeon, and demographic factors, is a patient’s PROMIS Pain Interference score associated with the total number of office visits? (2) Is PROMIS Depression, combination of PROMIS Depression and Pain Interference, or Physical Function scores associated with the number of office visits? METHODS: Between June 2015 and May 2018, 1098 patients presenting for a new patient visit at a single, urban academic medical center for distal radius fracture, wrist or hand sprain, tendon rupture, traumatic finger amputation, or scaphoid fracture were identified. Of those, 823 (75%) patients completed all PROMIS domains and presented before the trailing period and thus were included in this retrospective study. We recorded a number of variables including: Total number of office visits, age, sex, race, marital status, diagnosis, provider, and operative or nonoperative treatment. Multivariable Poisson regression analysis was conducted to determine whether Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI), Physical Function (PROMIS PF), and Depression scores measured at the first visit were associated with the total number of office visits, after accounting for the other factors we measured. RESULTS: Higher PROMIS PI scores were associated with greater number of clinic visits (0.0077; 95% CI, 0.0018–0.014; p = 0.010). Although PROMIS Depression scores were not associated with the number of office visits (0.0042; 95% CI, -0.0099 to 0.0094; p = 0.112), higher PROMIS PF scores were associated with fewer office visits when accounting for confounding variables (-0.0077; 95% CI, -0.0012 to -0.0029; p = 0.001). Additionally, across all individual PROMIS models, there was an association between the variables “operative treatment” (PI: 0.85; 95% CI, 0.72–0.98; p < 0.001; Depression: 0.87; 95% CI, 0.74–1.0; p < 0.001; PF: 0.85; 95% CI, 0.72–0.99; p < 0.001) and “traumatic finger amputation” (PI: 0.22; 95% CI, 0.016–0.42; p = 0.034; Depression: 0.2; 95% CI, 0.086–0.47; p = 0.005; PF: 0.21; 95% CI, 0.014–0.41; p = 0.036) with an increased total number of office visits. Provider team 5 (PI: -0.62; 95% CI, -0.98 to -0.27; p = 0.001; Depression: -0.61; 95% CI, -0.96 to -0.26; p = 0.001; PF: -0.60; 95% CI, -0.96 to -0.25; p = 0.001) was associated with fewer office visits. In both the PROMIS Depression and PROMIS PF regression models, increasing age (Depression: -0.0048; 95% CI, -0.0088 to -0.00081; p = 0.018; PF: -0.0045; 95% CI, -0.0085 to -0.0006; p = 0.024) was also associated with fewer total number of office visits. CONCLUSIONS: This study helps surgeons understand that patients who present at their initial office visit for traumatic hand and wrist conditions displaying worse pain coping strategies and decreased physical function will have more office visits. We recommend that surgeons engage in a comprehensive care approach that is empathetic, fosters effective pain coping strategies (and so might decrease PROMIS PI scores), and educates patients about expectations by providing educational materials and/or including other health professionals (such as, social work, physical therapy, mental health professional) as needed. This may decrease healthcare use in patients with traumatic hand and wrist conditions. LEVEL OF EVIDENCE: Level IV, prognostic study.

Ankylosing spondylitis (AS) is a rheumatologic condition that affects the axial skeleton. Structural changes render the spine susceptible to fractures, which can be treated operatively or non-operatively. The preferred surgical approach is not well established. The objective of this study is to evaluate trends in the surgical treatment of AS patients with cervical and thoracolumbar spine fractures.Using the nationwide inpatient sample (NIS) database, we identified 961 (4,683 weighted) AS patients from 2003 to 2014 who had fusion surgery for vertebral fractures. Our primary outcome was the national trend in use of posterior (PSF), anterior posterior (APSF), and anterior fusion (ASF) surgeries. In addition, we examined patient demographics, complications, institutional characteristics, and hospitalization lengths and costs.The number of fusions performed in AS patients with fractures increased significantly (P0.01). The proportion of cervical fractures receiving fusions stayed consistent, whereas that of thoracolumbar fractures increased significantly (P0.01). Patients undergoing APSF had higher hospitalization lengths in cervical and thoracolumbar fractures (P0.01). There was significant association between pulmonary complications and cervical fusions (P0.01).Surgical treatment has been growing in popularity for thoracolumbar fractures but staying consistent for cervical fractures in AS patients. Surgical approach has shifted for cervical fractures with APSF transitioning from most to least popular approach from 2003 to 2014. For thoracolumbar fractures, PSF has remained the preferred approach. APSF had significantly higher pulmonary complication rates with cervical fractures. This finding can help surgeons in treating fractures in AS patients with underlying pulmonary disease.

Background: The Numeric Pain Rating Scale (NPRS) is a popular method to assess pain. Recently, the Patient-Reported Outcomes Measurement Information System (PROMIS) has been suggested to be more accurate in measuring pain. This study aimed to compare NPRS and PROMIS Pain Interference (PI) scores in a population of foot and ankle patients to determine which method demonstrated a stronger correlation with preoperative and postoperative function, as measured by PROMIS Physical Function (PF). Methods: Prospective PROMIS PF and PI and NPRS data were obtained for 8 common elective foot and ankle surgical procedures. Data were collected preoperatively and postoperatively at a follow-up visit at least 6 months after surgery. Spearman correlation coefficients were calculated to determine the relationship among NPRS (0-10) and PROMIS domains (PI, PF) pre- and postoperatively. A total of 500 patients fit our inclusion criteria. Results: PROMIS PF demonstrated a stronger correlation to PROMIS PI in both the pre- and postoperative settings (preoperative: ρ = −0.66; postoperative: ρ = −0.69) compared with the NPRS (preoperative: ρ = −0.32; postoperative:ρ = −0.33). Similar results were found when data were grouped by Current Procedural Terminology (CPT) code. Conclusion: PROMIS PI was a superior tool to gauge a patient’s preoperative level of pain and functional ability. This information may assist surgeons and patients in setting postoperative functional expectations and pain management. Level of Evidence: Level II, prognostic.

As consumerism in health care increases, physician-review websites (PRWs) are becoming a common online resource for patients to seek out information. The vast majority of ratings and comments are positive across all orthopaedic subspecialties. Surgeon-related factors that tend to be associated with higher ratings are younger age, having an active presence on social media, demonstrating trustworthiness, spending time with patients, and answering questions. Non-surgeon-related factors that tend to impact ratings include staff courtesy and ease of scheduling.

Purpose Because psychological and social factors increase symptoms and limitations, it is possible that they are also related to higher use of care. Methods We used a database of an academic outpatient orthopedic department in which patient-reported outcome measures were routinely collected and identified 3,620 patients with de Quervain tendinopathy, ganglion, trapeziometacarpal arthritis, trigger digit, or carpal tunnel syndrome who remained in care at least 3 months. At every office visit, patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Test (CAT), PROMIS Pain Interference CAT, and PROMIS Depression CAT. We conducted multivariable Poisson regression analysis of factors associated with the total number of office visits, accounting for PROMIS scores at the first office visit, age, surgical treatment, sex, diagnosis, and clinician team. Results Operative treatment had the greatest influence on the number of office visits. Other variables associated with the number of visits were female sex, younger age, higher PROMIS Depression scores, and higher Pain Interference scores. Conclusions Treatment choice had the greatest influence on the number of subsequent visits for atraumatic conditions. The fact that the total number of office visits is associated with greater symptoms of depression and greater pain interference, independent of treatment choice, suggests a relation between mental health and resource use. Clinical relevance Quality improvement efforts and future research might address whether adding strategies to decrease symptoms of depression and optimize coping strategies (to reduce pain interference) might improve upper-extremity health more efficiently than standard treatment alone.