Determining Success or Failure After Foot and Ankle Surgery Using Patient Acceptable Symptom State (PASS) and Patient Reported Outcome Information System (PROMIS)

Background: As the role of generic patient-reported outcomes (PROs) expands, important questions remain about their interpretation. In particular, how the Patient Reported Outcome Measurement Instrumentation System (PROMIS) t score values correlate with the patients’ perception of success or failure (S/F) of their surgery is unknown. The purposes of this study were to characterize the association of PROMIS t scores, the patients’ perception of their symptoms (patient acceptable symptom state [PASS]), and determination of S/F after surgery. Methods: This retrospective cohort study contacted patients after the 4 most common foot and ankle surgeries at a tertiary academic medical center (n = 88). Patient outcome as determined by phone interviews included PASS and patients’ judgment of whether their surgery was a S/F. Assessment also included PROMIS physical function (PF), pain interference (PI), and depression (D) scales. The association between S/F and PASS outcomes was evaluated by chi-square analysis. A 2-way analysis of variance (ANOVA) evaluated the ability of PROMIS to discriminate PASS and/or S/F outcomes. Receiver operator curve (ROC) analysis was used to evaluate the ability of pre- (n = 63) and postoperative (n = 88) PROMIS scores to predict patient outcomes (S/F and PASS). Finally, the proportion of individuals classified by the identified thresholds were evaluated using chi-square analysis. Results: There was a strong association between PASS and S/F after surgery (chi-square \u3c0.01). Two-way ANOVA demonstrated that PROMIS t scores discriminate whether patients experienced positive or negative outcome for PASS (P \u3c .001) and S/F (P \u3c .001). The ROC analysis showed significant accuracy (area under the curve \u3e 0.7) for postoperative but not preoperative PROMIS t scores in determining patient outcome for both PASS and S/F. The proportion of patients classified by applying the ROC analysis thresholds using PROMIS varied from 43.0% to 58.8 % for PASS and S/F. Conclusions: Patients who found their symptoms and activity at a satisfactory level (ie, PASS yes) also considered their surgery a success. However, patients who did not consider their symptoms and activity at a satisfactory level did not consistently consider their surgery a failure. PROMIS t scores for physical function and pain demonstrated the ability to discriminate and accurately predict patient outcome after foot and ankle surgery for 43.0% to 58.8% of participants. These data improve the clinical utility of PROMIS scales by suggesting thresholds for positive and negative patient outcomes independent of other factors. Level of Evidence: II, prospective comparative series

PROMIS Pain Interference Is Superior vs Numeric Pain Rating Scale for Pain Assessment in Foot and Ankle Patients

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, prognosti

Is there a Difference in Outcomes between Patients who Received a Double or Triple Arthrodesis for Hindfoot Arthritis?

Introduction/Purpose: Triple arthrodesis has historically been considered the standard of treatment for arthritis of the hindfoot with or without deformity. The complications of this surgery including non-union, malunion, nerve injury, infection and wound healing problems can occur at any of the three joints. Double arthrodesis is capable of producing a similar reduction in degrees of motion and correction of foot deformity but may also cause less patient morbidity in regard to these complications due to one less joint being incorporated into the fusion procedure. What is unknown is the patient reported outcomes, specifically physical function (PF) and pain interference (PI) between these two procedures. The purpose of this study is to evaluate the clinical outcomes for hindfoot deformity using a triple compared to a double arthrodesis

EFFECTS OF INSULIN ON EARLY OA CHANGES

Objective. Obesity is a state of chronic inflammation that is associated with insulin resistance and type 2 diabetes mellitus (DM), as well as an increased risk of osteoarthritis (OA). This study was undertaken to define the links between obesity-associated inflammation, insulin resistance, and OA, by testing the hypotheses that 1) tumor necrosis factor (TNF) is critical in mediating these pathologic changes in OA, and 2) insulin has direct effects on the synovial joint that are compromised by insulin resistance. Methods. The effects of TNF and insulin on catabolic gene expression were determined in fibroblast-like synoviocytes (FLS) isolated from human OA synovium. Synovial TNF expression and OA progression were examined in 2 mouse models, high-fat (HF) diet–fed obese mice with type 2 DM and TNF-knockout mice. Insulin resistance was investigated in synovium from patients with type 2 DM. Results. Insulin receptors (IRs) were abundant in both mouse and human synovial membranes. Human OA FLS were insulin responsive, as indicated by the dose-dependent phosphorylation of IRs and Akt. In cultures of human OA FLS with exogenous TNF, the expression and release of MMP1, MMP13, and ADAMTS4 by FLS were markedly increased, whereas after treatment with insulin, these effects were selectively inhibited by >50%. The expression of TNF and its abundance in the synovium were elevated in samples from obese mice with type 2 DM. In TNF-knockout mice, increases in osteophyte formation and synovial hyperplasia associated with the HF diet were blunted. The synovium from OA patients with type 2 DM contained markedly more macrophages and showed elevated TNF levels as compared to the synovium from OA patients without diabetes. Moreover, insulin-dependent phosphorylation of IRs and Akt was blunted in cultures of OA FLS from patients with type 2 DM. Conclusion. TNF appears to be involved in mediating the advanced progression of OA seen in type 2 DM. While insulin plays a protective, antiinflammatory role in the synovium, insulin resistance in patients with type 2 DM may impair this protective effect and promote the progression of OA

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Outcomes for type C proximal humerus fractures in the adult population: comparison of nonoperative treatment, locked plate fixation, and reverse shoulder arthroplasty

BackgroundThis study compares patient-reported outcomes and range of motion (ROM) between adults with an AO Foundation/Orthopaedic Trauma Association type C proximal humerus fracture managed nonoperatively, with open reduction and internal fixation (ORIF), and with reverse shoulder arthroplasty (RSA).MethodsThis is a retrospective cohort study of patients >60 years of age treated with nonoperative management, ORIF, or RSA for AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures from 2015 to 2018. Visual analog scale pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, ROM values, and complication and reoperation rates were compared using analysis of variance for continuous variables and chi square analysis for categorical variables.ResultsA total of 88 patients were included: 41 nonoperative, 23 ORIF, and 24 RSA. At the 2-week follow-up, ORIF and RSA had lower visual analog scale scores and lower PROMIS pain interference scores (P < .05) than nonoperative treatment. At the 6-week follow-up, ORIF and RSA had lower visual analog scale, PROMIS pain interference, and PF scores and better ROM (P < .05) than nonoperative treatment. At the 3-month follow-up, ORIF and RSA had better ROM and PROMIS pain interference and PF scores (P < .05) than nonoperative treatment. At the 6-month follow-up, ORIF and RSA had better ROM and PROMIS PF scores (P < .05) than nonoperative treatment. There was a significantly higher complication rate in the ORIF group than in the non-operative and RSA groups (P < .05).ConclusionThe management of AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures in older adults with RSA or ORIF led to early decreased pain and improved physical function and ROM compared to nonoperative management at the expense of a higher complication rate in the ORIF group

Daily oral consumption of hydrolyzed type 1 collagen is chondroprotective and anti-inflammatory in murine posttraumatic osteoarthritis.

Osteoarthritis (OA) is a degenerative joint disease for which there are no disease modifying therapies. Thus, strategies that offer chondroprotective or regenerative capability represent a critical unmet need. Recently, oral consumption of a hydrolyzed type 1 collagen (hCol1) preparation has been reported to reduce pain in human OA and support a positive influence on chondrocyte function. To evaluate the tissue and cellular basis for these effects, we examined the impact of orally administered hCol1 in a model of posttraumatic OA (PTOA). In addition to standard chow, male C57BL/6J mice were provided a daily oral dietary supplement of hCol1 and a meniscal-ligamentous injury was induced on the right knee. At various time points post-injury, hydroxyproline (hProline) assays were performed on blood samples to confirm hCol1 delivery, and joints were harvested for tissue and molecular analyses were performed, including histomorphometry, OARSI and synovial scoring, immunohistochemistry and mRNA expression studies. Confirming ingestion of the supplements, serum hProline levels were elevated in experimental mice administered hCol1. In the hCol1 supplemented mice, chondroprotective effects were observed in injured knee joints, with dose-dependent increases in cartilage area, chondrocyte number and proteoglycan matrix at 3 and 12 weeks post-injury. Preservation of cartilage and increased chondrocyte numbers correlated with reductions in MMP13 protein levels and apoptosis, respectively. Supplemented mice also displayed reduced synovial hyperplasia that paralleled a reduction in Tnf mRNA, suggesting an anti-inflammatory effect. These findings establish that in the context of murine knee PTOA, daily oral consumption of hCol1 is chondroprotective, anti-apoptotic in articular chondrocytes, and anti-inflammatory. While the underlying mechanism driving these effects is yet to be determined, these findings provide the first tissue and cellular level information explaining the already published evidence of symptom relief supported by hCol1 in human knee OA. These results suggest that oral consumption of hCol1 is disease modifying in the context of PTOA

IKKβ-NF-κB signaling in adult chondrocytes promotes the onset of age-related osteoarthritis in mice.

Canonical nuclear factor κB (NF-κB) signaling mediated by homo- and heterodimers of the NF-κB subunits p65 (RELA) and p50 (NFKB1) is associated with age-related pathologies and with disease progression in posttraumatic models of osteoarthritis (OA). Here, we established that NF-κB signaling in articular chondrocytes increased with age, concomitant with the onset of spontaneous OA in wild-type mice. Chondrocyte-specific expression of a constitutively active form of inhibitor of κB kinase β (IKKβ) in young adult mice accelerated the onset of the OA-like phenotype observed in aging wild-type mice, including degenerative changes in the articular cartilage, synovium, and menisci. Both in vitro and in vivo, chondrocytes expressing activated IKKβ had a proinflammatory secretory phenotype characterized by markers typically associated with the senescence-associated secretory phenotype (SASP). Expression of these factors was differentially regulated by p65, which contains a transactivation domain, and p50, which does not. Whereas the loss of p65 blocked the induction of genes encoding SASP factors in chondrogenic cells treated with interleukin-1β (IL-1β) in vitro, the loss of p50 enhanced the IL-1β–induced expression of some SASP factors. The loss of p50 further exacerbated cartilage degeneration in mice with chondrocyte-specific IKKβ activation. Overall, our data reveal that IKKβ-mediated activation of p65 can promote OA onset and that p50 may limit cartilage degeneration in settings of joint inflammation including advanced age