Category: Other Introduction/Purpose: The patient acceptable symptom state (PASS) is a validated question establishing if patients activity and symptoms are at a satisfactory low level for pain and function. Surprisingly, ~20% of foot and ankle patients at their initial visit present for care with an acceptable symptom state (i.e. PASS yes). These patients are important to identify to prevent over treatment and avoid excessive cost. It is also unclear what health domains (Pain Interference (PI), Physical Function (PF), or Depression (Dep)) influence a patients judgement of their PASS state (i.e. why they are seeking treatment). The purpose of this analysis is to document the prevalance of PASS state and determine the health domains that discriminate PASS patients and predict PASS state at the initiation of rehabilitation. Methods: Patient reported outcomes measurement information system (PROMIS) computer adaptive test (CAT) scales PF, pain PIand Dep and PASS ratings starting in summer 2017 were routinely collected for patient care. Of 746 unique patients in this data set, 114 patients had ICD-10 codes that were specific to the foot and ankle. Average age was 51years (±18) and 54.4% were female. Patients were seen an average of 19.8(±15.9) days from their referral and were billed as low (51.7%), moderate (44.7%) and high complexity (2.7%) evaluations per current procedural code (CPT) visits. ANOVA models were used to evaluate differences in PROMIS scales by PASS state (Yes/No). The area under receiver operator curve (AUC) was used to determine the predictive ability of each PROMIS scale to determine a PASS state. Thresholds for near 95% specificity were also calculated for a PASS Yes state for each PROMIS scale. Results: The prevalance of PASS Yes patients was 13.2% (15/114). Pass Yes patients were significantly better by an average of 7.2 to 8.0 points across all PROMIS health domains compared to PASS No patients (Table 1). ROC analysis suggested that Dep (AUC=0.73(0.07) p=0.005) was the highest predictor of PASS status followed by PI (AUC=0.70(0.08) p=0.012) and PF (AUC=0.69(0.07) p=0.18). The threshold PROMIS t-score values for determining PASS Yes with nearest 95% specificity were PF = 51.9, PI = 50.6, and Dep = 34. Conclusion: Surprising, yet consistent with previous data, 13.2% of patients at their initial physical therapy consultation rated themselves at an acceptable level of activity and symptoms. Health domains of physical function, pain interference, and depression were better in these patients and showed moderate ability (AUC~0.7) to identify these patients. The PROMIS thresholds suggest patients are identified by pain and physical function equal to the average of the US population (PROMIS T-Score ~50) and extremely low depression scores (34). Clinically it is important to recognize these patients and purposefully provide treatments that reinforce their self efficacy and prevent unnecessary costly treatments.
Category: Diabetes Introduction/Purpose: Diabetic foot ulcers (DFU) is a prevalent problem that can lead to devastating results such as limb loss if left untreated. Nevertheless, the prolonged treatment course can limit the patient’s overall function and quality of life. Utilization of Patient-Reported Outcomes Measurement Information System (PROMIS) in Orthopaedic practice has previously shown that preoperative PROMIS scores can predict postoperative outcomes in foot and ankle surgeries. However, PROMIS assessment has not been used to determine the impact of surgical treatment for DFU on patients’ physical function. We sought to investigate the impact of preoperative PROMIS scores (Physical Function (PF), Pain Interference (PI), Depression (D)), demographic and laboratory values on postoperative PF in this unique patient population. Methods: From an academic orthopaedic surgeon’s practice, we identified infected DFU patients who underwent surgical interventions between February 2015 and November 2018 using ICD-10 code E11.621 (n=240). Patients with at least 3 consecutive visits, 3 month minimum post-surgical follow up and completed PROMIS Computer Adaptive Testing (CAT) assessments for each visit were included (n=92). Demographic data, BMI, medical comorbidities, Hemoglobin A1C, procedure performed, and wound healing status were collected. Amputation level was categorized as the following: 0 = irrigation & debridement (I&D) (n=39), 1 = forefoot amputations (n=46), 2 = mid/hindfoot amputations (n=14), 3 = Syme or above amputations (n=12). Uni- and multivariate analysis were performed to identify factors affecting the post-operative PF within the cohort. Spearman’s rank correlation coefficient, Chi-Squared tests and multidimensional modelling were applied to all variables’ pre-operative and post-operative time points. Based on the results, we formulated a numeric equation to predict post-surgical PROMIS PF. Results: The mean age was 60.5 (33-96) and 4.7 (3-12) months follow up. Mean preoperative PF, PI, and D changed from 34.4, 58.7, 51.4 to postoperative 36.1, 58.8, 51.1, respectively (ΔPF = 1.7, ΔPI=0.1, ΔD = -0.3). Preoperative PF (p < 0.01), PI (p < 0.01), depression (p < 0.01), chronic renal failure (p < 0.02) and amputation level (p < 0.04) showed significant univariate correlation with post-operative PF. Multivariate model (r = 0.6) revealed postoperative PF is predicted by initial PF (p = 0.094), depression (p= 0.008), amputation level (p = 0.002), and wound healing status (p = 0.001). The model had greater prediction power than the best univariate association (Δr = +0.17). Follow up length was not significant (p = 0.08). Conclusion: This study demonstrates that preoperative PROMIS scores combined with clinical factors can predict postoperative PF in DFU patients. Postoperative PF is predicted by: PFlongest_FU = 45.4 +0.20 PFinitial -0.21 Dinitial -6.1 (Heal =1) -2.9 (Amputation Category, 1-3). Additional diseased states not captured in this study and psychosocial variables may improve prediction power of the multivariate model. 70% of the patients’ initial PF were 1 to 2 standard deviations below the US population (n = 49; 28). Therefore, the reported model may serve as a valuable tool for patient education, setting expectations and post-surgical PF prediction in infected DFU patients.
Male collegiate basketball (BB) players are at risk for musculoskeletal injury. The rate of time-loss injury in men's collegiate BB, for all levels of National Collegiate Athletic Association (NCAA) competition, ranges from 2.8 to 4.3 per 1000 athletic exposures (AE) during practices and 4.56 to 9.9 per 1000 AE during games. The aforementioned injury rates provide valuable information for sports medicine professionals and coaching staffs. However, many of the aforementioned studies do not provide injury rates based on injury mechanism, region of the body, or player demographics.The purpose of this study is two-fold. The first purpose of this study was to report lower quadrant (LQ = lower extremities and low back region) injury rates, per contact and non-contact mechanism of injury, for a cohort of male collegiate basketball (BB) players. The second purpose was to report injury risk based on prior history of injury, player position, and starter status.Prospective, descriptive, observational cohort.A total of 95 male collegiate BB players (mean age 20.02 ± 1.68 years) from 7 teams (NCAA Division II = 14, NCAA Division III = 43, NAIA = 21, community college = 17) from the Portland, Oregon region were recruited during the 2016-2017 season to participate in this study. Each athlete was asked to complete an injury history questionnaire. The primary investigator collected the following information each week from each team's athletic trainer: athletic exposures (AE; 1 AE = game or practice) and injury updates.Thirty-three time-loss LQ injuries occurred during the study period. The overall time-loss injury rate was 3.4 per 1000 AE. Division III BB players had the highest rates of injury. There was no difference in injury rates between those with or without prior injury history. Guards had a significantly greater rate of non-contact time-loss injuries (p = 0.04).Guards experienced a greater rate of LQ injury than their forward/center counterparts. Starters and athletes with a prior history of injury were no more likely to experience a non-contact time-loss injury than nonstarters or those without a prior history of injury. These preliminary results are a novel presentation of injury rates and risk for this population and warrant continued investigation.2.
Category: Sports Introduction/Purpose: Lateral ankle ligament injuries are common conditions accounting for 25% of musculoskeletal injuries. Prior reports have found increased risk of failed lateral ankle reconstruction in those with a subtle cavus deformity, and therefore, correcting the deformity is often advocated. However, other studies have been unable to identify subtle cavus deformity as a clear risk factor for recurrent injury. The purpose of this study was to 1) compare PROMIS physical function (PF), pain interference (PI), and depression scores in patients with subtle cavus deformities to those without deformity who underwent lateral ankle ligament reconstruction, 2) compare PROMIS scores in allograft and modified Brostrom-Gould (BG) reconstructions in those with subtle cavus, and 3) to evaluate for any post-operative complications in those with subtle cavus. Methods: PROMIS CAT scores were prospectively obtained from patients evaluated in a specialty foot and ankle clinic between February 2015 and December 2017. Using CPT codes, 145 patients who underwent lateral ankle ligament reconstruction were identified. Exclusion criteria consisted of less than three-month follow-up, incomplete PROMIS scores, or multiple surgeries unrelated to the reconstruction during the follow-up period. A total of 78 patients were included in the study. Pre- and post-operative PROMIS PF, PI, and depression were collected. Patients were then divided into two groups: subtle cavus foot (n=23) and non-cavus foot (n=55). A foot was considered cavus based on physical exam and previously published radiographic parameters. The cavus group was further subdivided into allograft reconstruction and BG reconstruction. Post-operative complications were also recorded. Student t-tests were used to evaluate for differences in PF, PI, and depression t-scores in cavus vs. non-cavus groups as well as allograft vs. BG. Results: The average follow-up was 28.59+/-13.27 weeks in the cavus and 29.77+/-16.15 weeks in the non-cavus group (p=0.76). There were no differences in pre-operative PF, PI, or depression t-scores between the two groups (p>0.05). The cavus group had significantly better post-operative PF compared to the non-cavus group (49.24+/-8.14 vs. 43.17+/-6.64, p=0.001). PI was also better in the cavus group (51.12+/-8.33) compared to the non-cavus group (55.09+/-9.45), however not statistically significant (p=0.08). There were no differences in post-operative depression (p=0.58). When subdividing the cavus group, allograft reconstruction (49.49+/-7.48) had better post-operative PI t-scores compared to BG (57.17+/-8.16, p=0.04). In the cavus group, there were no instances of recurrent instability; one patient required a repeat ankle arthroscopy for debridement. One patient in the non-cavus group developed recurrent instability. Conclusion: Patients with subtle cavus deformity undergoing lateral ankle ligament reconstruction had significantly higher post-operative PROMIS PF t-scores compared to those without deformity and a trend towards improved pain post-operatively. When subdividing the subtle cavus group, allograft reconstruction demonstrated better PI scores post-operatively, and thus may be a more favorable technique in patients who have a subtle cavus deformity. Though longer follow-up is needed, our study suggests that patients with subtle cavus deformities may not require a more complex reconstruction with osteotomies to correct their deformity in order to achieve clinically meaningful improved outcomes.
Category: Bunion, Midfoot/Forefoot Introduction/Purpose: Hallux valgus is a common condition of the foot with 4.4 million patients seeking care yearly for this condition. A previous study suggested specific pre-operative cut-off scores based on Patient Reported Outcomes Measurement Information System (PROMIS) physical function (PF), pain interference (PI), and depression (D) values could predict post-operative outcomes in foot and ankle surgery. Though hallux valgus correction, among other procedures, were identified as one of the most common surgeries in the previous study, specific conditions were not considered separately. The purpose of this study was to evaluate the validity of applying a published comprehensive pre-surgical PROMIS profile of PF, PI and D to patients undergoing bunionectomy surgery. Methods: PROMIS scores were prospectively obtained from patients evaluated in a specialty foot and ankle clinic between February 2015 and November 2016. Using ICD-9/10 and CPT codes, a total of 65 patients with hallux valgus who underwent a bunionectomy by a single surgeon were identified. Those with less than two-month follow-up, multiple procedures during the follow-up period, and incomplete PROMIS assessment scores were excluded, resulting in 42 patients. Using pre-operative scores and scores at the last follow-up visit, minimally clinically important differences (MCID), receiver operating characteristic (ROC) curves, and area under the curve (AUC) were obtained to determine if pre-operative PROMIS scores predicted achieving MCID with 95% specificity or failing to achieve a MCID with 95% sensitivity. New cut-off values were then compared to the previous study. Results: The AUC for PF (p=0.01) and Mood (p=0.03) were significant. However, PI AUC was not significant (p=0.14). The PF cut off for 95% specificity of exceeding MCID was 39.6 and 50.2 for 95% sensitivity for failing to achieve MCID. The D cut off for 95% specificity of exceeding MCID was 39.4 and 58.1 for 95% sensitivity for failing to achieve MCID. Patients below the 50.2 threshold (n=27) had significantly greater improvements on PF (2.3 95% CI 0.5 to 4.3) and PI (-3.8 95% CI -6.9 to -0.7) but not D. Patients above the 50.2 cut off (n=15) were significantly worse on PF (-7.3 95% CI -12.0 to -2.7) at this short follow up and were statistically unchanged on PI and D. Conclusion: This data confirms that pre-surgical PROMIS PF and Depression scores are significant post-surgical predictors. However, cut-off scores for 95% sensitivity/specificity were one standard deviation higher for PROMIS PF (>50.2 versus previous study >42) and similar for Depression (<39.4 versus previous study <41.5) as compared to all foot and ankle surgeries. Patients meeting the new cut-off (>50.2) experienced significantly better outcomes on all PROMIS scales and patients not meeting the cut- off (~30%) were significantly worse. Although longer term follow-up is desirable, this short term follow up suggests a significant clinical impact of using PROMIS scores for pre-surgical decisions.
Study Design Controlled laboratory study using a cross-sectional design. Objectives To compare lower extremity force applications during a sit-to-stand (STS) task with and without upper extremity assistance in older individuals post-hip fracture to those of age-matched controls. Background A recent study documented the dependence on upper extremity assistance and the uninvolved lower limb during an STS task in individuals post-hip fracture. This study extends this work by examining the effect of upper extremity assistance on symmetry of lower extremity force applications. Methods Twenty-eight community-dwelling elderly subjects, 14 who had recovered from a hip fracture and 14 controls, participated in the study. All participants were independent ambulators. Four force plates were used to determine lower extremity force applications during an STS task with and without upper extremity assistance. The summed vertical ground reaction forces (vGRFs) of both limbs were used to determine STS phases (preparation/rising). The lower extremity force applications were assessed statistically using analysis of variance models. Results During the preparation phase, side-to-side symmetry of the rate of force development was significantly lower for the hip fracture group for both STS tasks (P<.001). During the rising phase, the vGRF impulse of the involved limb was significantly lower for the hip fracture group for both STS tasks (P = .045). The vGRF impulse for the uninvolved limb was significantly increased when participants with hip fracture did not use upper extremity assistance compared to elderly controls (P = .002). This resulted in a significantly lower vGRF symmetry for the hip fracture group during both STS tasks (P<.001). Conclusion Participants with hip fracture who were discharged from rehabilitative care demonstrated decreased side-to-side symmetry of lower extremity loading during an STS task, irrespective of whether upper extremity assistance was provided. These findings suggest that learned motor control strategies may influence movement patterns post-hip fracture. J Orthop Sports Phys Ther 2012;42(5):474–481. doi:10.2519/jospt.2012.3562
