To examine reported minimal clinically important difference (MCID) and patient-acceptable satisfactory state (PASS) values for patient-reported outcome measures (PROMs) after shoulder instability surgery and assess variability in published values depending on the surgery performed. Our secondary aims were to describe the methods used to derive MCID and PASS values in the published literature, including anchor-based, distribution-based, or other approaches, and to assess the frequency of MCID and PASS use in studies on shoulder instability surgery.

A systematic review of MCID and PASS values after Bankart, Latarjet, and Remplissage procedures was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The Embase, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were queried from 1985 to 2023. Inclusion criteria included studies written in English and studies reporting use of MCID or PASS for patient-reported outcome measures (PROMS) after Latarjet, Bankart, and Remplissage approaches for shoulder instability surgery. Extracted data included study population characteristics, intervention characteristics, and outcomes of interest. Continuous data were described using medians and ranges. Categorical variables, including PROMs and MCID/PASS methods, were described using percentages. Because MCID is a patient-level rather than a group-level metric, the authors confirmed that all included studies reported proportions (%) of subjects who met or exceeded the MCID.

A total of 174 records were screened, and 8 studies were included in this review. MCID was the most widely used outcome threshold and was reported in all 8 studies, with only 2 studies reporting both the MCID and the PASS. The most widely studied PROMs were the American Shoulder and Elbow Surgeons (range 5.65-9.6 for distribution MCID, 8.5 anchor MCID, 86 anchor PASS); Single Assessment Numeric Evaluation (range 11.4-12.4 distribution MCID, 82.5-87.5 anchor PASS); visual analog scale (VAS) (range 1.1-1.7 distribution MCID, 1.5-2.5 PASS); Western Ontario Shoulder Instability Index (range 60.7-254.9 distribution MCID, 126.43 anchor MCID, 571-619.5 anchor PASS); and Rowe scores (range 5.6-8.4 distribution MCID, 9.7 anchor MCID). Notably, no studies reported on substantial clinical benefit or maximal outcome improvement.

Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. Although MCID has been the most frequently reported metric, there is considerable interstudy variability observed in their values.

Knowing the outcome thresholds such as MCID and PASS of the PROMs frequently used to evaluate the results of glenohumeral stabilization surgery is fundamental because they allow us to know what is a clinically significant improvement for the patient.

The delta difference between baseline patient-reported outcome measure scores and postoperative scores is used to measure success following primary total hip arthroplasty (THA). However, statistical improvement is not necessarily equal to clinical benefit. The percentage of the maximal outcome improvement (MOI) is a psychometric tool to determine clinical improvement. This study aimed to determine thresholds of the MOI for the Forgotten Joint Score (FJS), the Harris Hip Score (HHS), and the Visual Analog Scale (VAS) for pain following THA for osteoarthritis.

Data were retrospectively reviewed for all patients who underwent primary THA for hip osteoarthritis between October 2014 and July 2020. Patients who answered an anchor question for satisfaction and had baseline and minimum 2-year follow-up scores were included. Receiver operating characteristic curve analyses were performed to determine the MOI thresholds with the area under the curve. In total, 584 patients were included, 53.1% women and 46.9% men, who had a mean age of 57 years (± 10.4).

Improvement was reported for all patient-reported outcome measure scores (P < 0.0001). The area under the curve values of MOI for the FJS, HHS, and VAS for pain were 0.788, 0.839, and 0.805, respectively. The MOI for the FJS, HHS, and VAS for pain was 54.2, 65, and 67.1%, respectively.

Following primary THA for hip osteoarthritis, percentage thresholds for achieving the MOI for the FJS, HHS, and VAS for pain were 54.2, 65, and 67.1%, respectively. No preoperative predictors of achieving the MOI were identified.

Tranexamic acid (TXA) has emerged as a promising adjunct in arthroscopic shoulder surgery owing to its ability to reduce bleeding and improve visualization, but its overall clinical impact appears modest. TXA likely results in a slight improvement in visual clarity, with little to no effect on postoperative pain, operative time, or blood loss. Although these findings raise questions about the role of TXA in routine shoulder arthroscopy, it may still offer benefit in specific scenarios, such as procedures with high bleeding risk or when intraoperative visualization is particularly challenging. Additionally, TXA's favorable safety profile and low cost make even small benefits worth consideration. The potential to reduce postoperative hemarthrosis or shorten operating room time in select patients could prove meaningful in terms of reducing complications and overall costs. Further investigation is warranted to determine which patient populations may benefit most.

The clinical interpretation of patient-reported outcome measures (PROMs) after anterior cruciate ligament (ACL) reconstruction (ACLR) can be challenging. This study aimed to establish the clinical relevance of PROMs by determining maximal outcome improvement (MOI) thresholds at mid-term follow-up after primary ACLR.

A total of 343 patients who underwent primary single-bundle ACLR using hamstring tendon autograft at our institute were included. Patients were queried with a 2-option anchor question regarding satisfaction with their current knee symptom state. The MOI of a PROM was calculated for each patient as the percentage of improvement normalized by the maximal possible improvement. The MOI threshold for each PROM was determined as the optimal cutoff value for predicting patient satisfaction based on receiver operating characteristic curve analysis. Multivariable logistic regression analyses were performed to identify predictors of achieving these thresholds. Subgroup analyses that stratified the time from injury to surgery within the cohort were performed, and MOI thresholds were recalculated within each of these subgroups. The PROMs evaluated in this study were the modified Lysholm Knee Score and the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC) score.

The calculated MOI threshold was 35.1% for the Lysholm score and 46.7% for the IKDC score. A longer time from injury to surgery reduced the odds of achieving the MOI threshold for the Lysholm score (odds ratio [OR] per time bracket = 0.7114, p < 0.0001) and IKDC score (OR = 0.8038, p = 0.0003). Male sex was associated with higher odds of achieving the MOI threshold for the IKDC score (OR = 1.9645, p = 0.0143). For patients with chronicity of ≤6 months, the MOI threshold was 35.1% for the Lysholm score and 57.9% for the IKDC score, and for patients with chronicity of >6 months, the thresholds were 24.5% and 27.1%, respectively.

The calculated MOI thresholds for the Lysholm and IKDC scores at mid-term follow-up after primary ACLR were 35.1% and 46.7%, respectively. Greater chronicity of the ACL injury was associated with lower odds of achieving the MOI thresholds for the PROMs at mid-term follow-up.

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Clinically important improvement after total shoulder arthroplasty is often assessed with shoulder-specific patient-reported outcome measures (PROMs) quantifying reduction in pain and restoration in function. It is unclear if commonly used thresholds such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), or patient acceptable symptom state (PASS) represent optimal improvement from the patients' perspective. The objectives of this study were to use the Simple Shoulder Test (SST) to (1) compare commonly used thresholds for change in score and final score to thresholds optimized to patient satisfaction using receiver operating characteristic (ROC) curve analysis, and (2) determine the impact of using different thresholds on reporting of independent predictors of successful outcome in terms of patient satisfaction.

This study included 406 anatomic total shoulder arthroplasty (aTSA) patients from a longitudinally maintained database with 2-year follow-up. Surveys included the SST and a satisfaction questionnaire. SST thresholds were calculated by commonly described techniques for MCID, SCB, %MPI (percentage of maximal possible improvement), and PASS. ROC curves were constructed to determine the optimal threshold of SST change in score (Change-ROC), final SST score (Final-ROC), and %MPI (%MPI-ROC) based on patient satisfaction. Youden index (J) was calculated to determine each threshold's performance in maximizing sensitivity and specificity. Multivariable analysis was performed to determine predictors of surpassing selected threshold values.

The thresholds with the highest Youden index correlating best with patient satisfaction were %MPI-ROC (aTSA, 61%, J = 0.49) and Final-ROC (aTSA, 9.5, J = 0.48). Commonly used thresholds including MCID of 2.0 (J = 0.21) and SCB of 2.7 (2.7) had the lowest Youden index of the thresholds studied. Characteristics predictive of success varied substantially according to the selected threshold.

Current thresholds commonly used to gauge success after aTSA have limited ability to predict success based on patient satisfaction using the SST. Given that focus in health care value is shifting toward patient satisfaction, optimal thresholds used to measure success after shoulder arthroplasty may require reconsideration.

Quality of life in patients receiving knee arthroplasty is crucial for rehabilitation. Even if the validity of the 36-Item Short Form (SF-36) was already confirmed, the Substantial Clinical Benefit (SCB) and Patient Acceptable Symptom Score (PASS) values of this score remain unknown for both Total Knee Arthroplasty (TKA) and Unicompartmental Knee Arthroplasty (UKA).

The purpose of this research was to compute the Minimal Clinically Important Difference (MCID) of the SF-36 after UKA, and the SCB and PASS of SF-36 after TKA and UKA, in order to assess post-surgery quality of life in knee osteoarthritis.

Overall, 59 patients (40 women and 19 men, mean age 60.3 ± 13.1 years) completed the questionnaire until six months follow-up. Of these patients, 22 underwent the TKA procedure, while 37 patients underwent the UKA procedure. The anchor question for computing the MCID and SCB thresholds was "How would you describe your health condition in relation to your previous state?". The PASS scores were determined using the ROC curve and the 75th percentile of the cumulative percentage curve of respondents who believe their symptoms are under control.

The MCID values of global SF-36, Physical Component Summary (PCS) and Mental Component Summary (MCS) after UKA were 11.3, 14.5 and 11.4, respectively. The SCB values of global SF-36, PCS and MCS after UKA were 23.5, 23.1 and 15, respectively. The PASS values of global SF-36, PCS and MCS after TKA were 71.2, 75 and 69.3, respectively. The PASS values of global SF-36, PCS and MCS after UKA were 70.4, 72.1 and 67.5, respectively.

The SF-36 score represents a valid score for quality of life in patients with knee osteoarthritis. Taken together, the results showed a statistically significant improvement between inception and latest follow-up after TKA and UKA.

Measures such as the Patient Acceptable Symptom State and minimum clinically important difference have been used to contextualize patient-reported outcomes (PROs). Assessment of patients' perception of being "completely better" (CB) after hip arthroscopy has not been studied.

To (1) determine the prevalence and characteristics of patients who report being CB at 2 years after hip arthroscopy; (2) determine whether PROs measuring function, pain, and mental health are associated with CB status; and (3) determine threshold values for PROs predictive of achieving CB status.

Case-control study; Level of evidence, 3.

Patients undergoing hip arthroscopy at a single institution from October 2015 to January 2020 were administered electronic surveys assessing sociodemographic variables and PROs at baseline and 2 years postoperatively. The CB anchor question was "Is the condition for which you underwent surgery completely better now?" Threshold values for PROs associated with achieving CB status at 2 years postoperatively were identified with 90% specificity. Variables with an area under the curve of >0.80 on a receiver operating characteristic curve were selected for multivariate analysis.

Overall, 29 of 62 patients (47%) achieved CB status. There were no differences in age, sex, body mass index, race, prior hip surgery, preoperative opioid use, smoking status, or preoperative expectations between the CB and no-CB groups. The CB group had better 2-year postoperative and pre- to postoperative change values on all PROs (P < .05 for all) except for the Patient-Reported Outcomes Measurement Information System (PROMIS)-Depression and the Numeric Pain Scale (NPS) for whole-body pain. Two-year postoperative PRO thresholds for achieving CB status were determined as PROMIS-Physical Function (PF) ≥51.3 or increase in PROMIS-PF ≥12 points, PROMIS-Pain Interference ≤46.6 or decrease in PROMIS-Pain Interference ≥12.2 points, NPS for operative hip pain of ≤1.0, Musculoskeletal Outcomes Data Evaluation and Management System-expectations met ≥95.0, and Surgical Satisfaction Questionnaire (SSQ-8) ≥87.5. Multivariate analysis demonstrated that higher SSQ-8 score and greater improvement on the PROMIS-PF were independent predictors of achieving CB status.

Almost half of the study patients perceived being CB at 2 years after hip arthroscopy. Multiple postoperative PROs scores were associated with achieving CB status.

The purpose of this study was to validate the success of revision arthroscopic circumferential allograft labral reconstruction (CLR) in nonarthritic hips, which, in the rare case of failure, had previously undergone labral reconstruction by the same surgeon. Using a minimum of 24-month follow-up, data from 24 hips having undergone revision CLR were analyzed to determine improvements in patient-reported outcomes (PROs). All included cases completed a minimum of 24 months follow-up, with a success rate of 96%. All PROs improved significantly, with exceptionally strong measures of effect. Modified Harris Hip Scores improved by a mean of 26.68 points, with 88% of patients meeting the minimal clinically important difference (MCID) (+6.49, P ≤ .001, d = 1.32). Lower Extremity Functional Scale scores improved by a mean of 21.88 points, with 78% of patients meeting the MCID (+7.79, P ≤ .001, d = 1.32). Pain as rated by the Visual Analog Scale, including at rest, during activities of daily living, and with sports, was significantly improved with strong measures of effect, with >75% of patients having met the MCID. This study validated that a failed labral reconstruction of the hip can be revised safely and effectively to another labral reconstruction of the hip. While labral reconstruction has broadly been shown to result in highly favorable outcomes, this study demonstrated that in the rare case of failure, revision CLR is not only feasible but results in improved pain and functionality.

Given the growing concerns regarding objective measures of clinical outcomes, attention has recently been devoted to the establishment of clinically significant outcome (CSO) thresholds for patient-reported functional scores after rotator cuff surgery.

To retrospectively compare patient-reported outcome (PRO) measures (PROMs) and radiographic data between patients who underwent arthroscopic superior capsular reconstruction (SCR) with and without long head of the biceps tendon (LHBT) augmentation.

Cohort study; Level of evidence, 3.

A total of 43 patients receiving arthroscopic SCR between 2016 and 2020 were enrolled, including a biceps augmentation group (n = 27) and a nonaugmentation group (n = 16). Patients were asked an anchor question regarding their satisfaction and perception of improvements. PROMs of American Shoulder and Elbow Surgeons (ASES), Constant score, Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) for pain scores and radiographic data including magnetic resonance imaging and plain radiographs were collected and compared between the 2 groups. Anchor questions in CSO analysis for deriving the minimal clinically importance difference (MCID), substantial clinical benefit (SCB), Patient Acceptable Symptom State (PASS), and maximal outcome improvement (MOI) values were applied ≥2 years postoperatively.

Based on satisfaction responses, 17 patients were classified as satisfied, 16 as unsatisfied, and 10 as fair. Additionally, 13 patients felt they were improved, 14 changed, and 16 unchanged. Intergroup comparison based on patients' satisfaction and perception of change or improvement exhibited significant differences in all 4 functional scores in favor of the satisfied and improved patients. However, there was no significant difference in the ΔVAS scores between the groups. CSO analyses showed no significant difference in percentage of patients achieving MCID, SCB, and PASS thresholds for the ΔASES, ΔConstant, and ΔSANE scores between patients undergoing arthroscopic SCR with or without LHBT augmentation. A significant difference was found in the percentage of patients achieving the MOI for ΔASES score with 70.4% in the augmented group and 37.5% in the nonaugmented group, respectively. The mean acromiohumeral distance (AHD) differed significantly between augmentation (8.1 ± 2.2 mm) and nonaugmentation (7 ± 1.9 mm) groups. The graft tear rate did not differ significantly.

There was no significant difference in PROs and percentage of patients achieving MCID, SCB, and PASS between isolated and augmented SCR groups. A higher percentage of patients achieving MOI and slightly greater AHD were found in the augmented group. Further evaluation is required to determine if there is any long-term benefit to LHBT augmentation of SCR.

Reverse total shoulder arthroplasty (RTSA) is a common procedure utilized to address degenerative pathologies of the glenohumeral joint and rotator cuff. Increased reliance on patient-reported outcome measures (PROMs) have placed emphasis on the utilization of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), patient acceptable symptom state (PASS), and maximal outcome improvement (MOI) thresholds to assess the clinical efficacy of RTSA. In this study, we systematically reviewed the MCID, SCB, PASS, and MOI thresholds reported for PROMs following RTSA.

PubMed, Embase, MEDLINE, Cochrane Library, and Google Scholar were queried for articles from January 1, 2000 to August 31, 2023 reporting MCID, SCB, PASS, or MOI values for PROMs following RTSA. Patient demographic data, study characteristics, MCID/SCB/PASS/MOI thresholds, and threshold calculation methods were extracted.

One hundred and forty-one articles were screened with 39 ultimately included, comprising 11,984 total patients that underwent RTSA. 34 (87%) studies reported MCID thresholds, 20 (51%) reported SCB, 5 (13%) reported PASS, and 2 (5%) reported MOI. 25/39 (64%) studies referenced a previous study when reporting MCID, SCB, PASS, or MOI values, 11 (28%) used an anchor-based method to calculate threshold values, 1 (3%) used a distribution-based method, and 2 (5%) used both anchor and distribution methods. There were 19 newly calculated MCID (11), SCB (5), PASS (1), and MOI (2) thresholds. For 5 of the 6 most utilized PROMs (ASES, SST, Constant, UCLA, and SPADI), the range of reported MCID values exceeded 50% of the most common threshold. For 3 of 6, the range of SCB values exceeded 25% of the most common threshold.

There is substantial variability in the MCID and SCB threshold values reported in the RTSA literature. Standardizing the methodologic calculation and utilization of MCID, SCB, PASS, and MOI thresholds for RTSA may allow for improved assessment of PROMs.

The reporting and analysis of patient-reported outcome measures have come a long way. Since the concept of the minimally clinically important difference was first introduced in 1989, threshold scores have grown to include substantial clinical benefit and patient acceptable symptomatic state (PASS). The initial motivation for developing these thresholds was rooted in separating clinical significance from statistical. These thresholds provide insight into the relationship between scores on patient-reported outcome measures (PROM) and patient-reported improvement and satisfaction. It follows that in order to evaluate PROM scores, the best method for deriving the threshold typically uses an anchor-based methodology, i.e., "ask the patient." Specifically, patients are asked how much change they've experienced and whether they consider their current state to be satisfactory. The responses to these questions are compared with the scores on PROMs to find outcome thresholds that best separate patients who reported no improvement from those who reported minimal improvement, substantial improvement, and satisfaction with their current state of health (PASS). The PASS is of particular importance as it speaks to what arguably matters most to patients-a satisfactory state of health. Finally, viewing the PASS from the perspective of variation from study to study rather than as a uniform classifier is needed to make use of the growing number of papers reporting these thresholds. Examining differences in PASS values across papers can provide insight into how well PROM scores reflect patient satisfaction in different settings.

The 36-Item Short-Form Health Survey questionnaire (SF-36) is a reliable tool to assess the health-related quality of life of patients. If a mean difference between pre-operative evaluation and final follow-up is found to be statistically significant, then the change in score is not random. However, a statistically significant mean change may not correspond to a clinical amelioration for the patient or mean that the patient's state of health is to be considered acceptable. For this reason, interest in the concepts of minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) has grown within recent years. The goal of the present work of research was to determine the MCID and PASS values for the SF-36 in patients who received rotator cuff repair (RCR). Forty-six patients (18 women and 28 men, mean age 58.5 ± 12.9) previously diagnosed with rotator cuff disease were enrolled. All of these patients underwent RCR. They were evaluated pre-operatively and six months after the surgical intervention as a final follow-up. The SF-36 questionnaire was assessed at each evaluation. The MCID cut-offs of the total, physical, and mental dimensions of the SF-36 for patients who underwent RCR were 23.1, 32.5, and 18.1, respectively. A 23.1 improvement in the SF-36 score at six months following RCR can be correlated with patients having reached a clinically significant improvement in health status. If 81.9 or more is attained in the SF-36 score after surgical repair, the symptom state can be judged as satisfactory by the majority of patients.

The Patient Acceptable Symptom State (PASS) after primary hip arthroscopy has been determined; nonetheless, the PASS still needs to be defined for revision hip arthroscopy.

To define minimum 2-year follow-up PASS thresholds for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), visual analog scale (VAS) for pain, and International Hip Outcome Tool-12 (iHOT-12) after revision hip arthroscopy, and to identify predictors of achieving the PASS.

Case-control study; Level of evidence, 3.

Data were prospectively collected and retrospectively reviewed for all patients who underwent revision hip arthroscopy between April 2017 and July 2020. Patients were included if they had baseline and minimum 2-year follow-up scores for the mHHS, NAHS, HOS-SSS, VAS for pain, and iHOT-12. PASS was calculated using the anchor-based method. Receiver operating characteristic curve analysis was used to determine the thresholds for the PASS. A multivariate logistic regression was used to identify predictors for achieving the PASS.

A total of 318 patients who underwent revision hip arthroscopy met the inclusion criteria. Of those patients, 292 (91.8%) had baseline and minimum 2-year follow-up. Of this group, 68 patients (72.1% female and 27.9% male; mean age, 32.9 years) answered the PASS anchor question. Achievement PASS rates were 58.8%, 41.2%, 52.9%, 60.3%, and 52.9% for the mHHS, NAHS, HOS-SSS, VAS, and iHOT-12, respectively. The area under the curve (AUC) values for the PASS for mHHS, NAHS, HOS-SSS, VAS, and iHOT-12 were 0.912, 0.888, 0.857, 0.903, and 0.871, respectively, indicating excellent discrimination. The PASS for the mHHS was 76 (sensitivity, 0.809; specificity, 0.905), for the NAHS was 86.3 (sensitivity, 0.660; specificity, 1), for the HOS-SSS was 64.3 (sensitivity, 0.745; specificity, 0.905), for the VAS was 3 (sensitivity, 0.830; specificity, 0.905), and for the iHOT-12 was 64.3 (sensitivity, 0.745; specificity, 0.905). Body mass index (BMI) was identified as a significant predictor of achieving PASS for the NAHS (OR, 0.967; 95% CI, 0.940-0.996; P = .027), as patients with a BMI ≤25.4 had 1.03 times higher odds ratio of achieving PASS for the NAHS.

After revision hip arthroscopy, the minimum 2-year follow-up PASS thresholds for the mHHS, NAHS, HOS-SSS, VAS for pain, and iHOT-12 were 76, 86.3, 64.3, 3, and 64.3, respectively. The odds ratio of achieving PASS for the NAHS was 1.03 times higher for patients with a BMI ≤25.4.

Patient-reported outcome measures (PROMs) are highly effective measures of quality of care and outcomes that matter to patients regarding their physical, mental, and social health. While PROMs have played a notable role in research and registry reporting, they are also useful as clinical tools. Real-time PROM collection can be integrated into routine clinical care with immediate access to scores within the electronic health record. This can be integral when discussing treatment options and using decision aids. PROM scores can also be useful for postoperative monitoring. Various approaches to quantifying clinical efficacy have been developed, including the minimal clinically important difference, the substantial clinical benefit, and the patient acceptable symptom state (PASS). As the patient experience and patient-reported outcome measurement of health-related outcomes become increasingly emphasized in patient-centered, high value care, so too will the importance of methods to gauge clinical benefit using these instruments for improved clinical decision-making.

Platelet-rich plasma (PRP) is an autologous blood product containing a high concentration of platelets, growth factors, and cytokines, which basic science studies have shown may improve tendinopathy. However, there is controversy over its clinical efficacy with randomized controlled trials and subsequent meta-analysis finding mixed results when treating shoulder rotator cuff tendinopathy. The effect of leukocyte concentration on PRP has been shown to be paramount, with different concentrations being favored for different pathologies. In those with tendinopathy, it is unclear whether leukocyte-rich or leukocyte-poor PRP is superior. Recent research shows that PRP injections produced a significant improvement in most patients with rotator cuff tendinopathy. However, improvement in symptoms and functional outcomes is worse in patients who have a partial-thickness rotator cuff tear compared with isolated tendinopathy without a partial tear. PRP may be more advantageous than corticosteroids. Both function as anti-inflammatories, but PRP may be potentially anabolic, whereas as corticosteroids have a catabolic effect on tendons, which may reduce repairability if patients proceed with surgery. Additionally, there are higher infection rates if patients ultimately go on to surgery within 3 months after corticosteroid injections. Ultimately, we must refine the indications for best use for PRP shoulder injections and determine the 5 R's: right patient, right drug, right dose, right route, and right time. Finally, we must remember that patients can first try conservative management, including physical therapy.

Clinically relevant threshold values associated with patient-reported outcome measures after orthopaedic procedures such as anterior cruciate ligament reconstruction (ACLR) are important for relating these scores to meaningful postoperative improvement.

The purpose of this study was to determine the Patient Acceptable Symptom State (PASS) for the Patient-Reported Outcomes Measurement Information System Computer Adaptive Test (PROMIS-CAT) after ACLR. It was hypothesized that preoperative sport participation would have an impact on PASS achievement.

Case series; Level of evidence, 4.

Included were consecutive patients who underwent primary assisted ACLR between January 4 and August 1, 2016. Patients were administered the PROMIS-CAT Physical Function (PF) and Pain Interference domains preoperatively and at a minimum 2 years postoperatively, with external anchor questions used to determine the PASS. Receiver operating characteristic (ROC) curves were constructed for the entire study population as well as separately for athletes and nonathletes to determine PROMIS PASS thresholds for each population. A previously published PROMIS-PF minimal clinically important difference was used to evaluate postoperative improvement. A post hoc multivariate nominal logistic multivariate analysis was constructed to assess the effects of preoperative patient characteristics on the likelihood of attaining both the minimal clinically important difference and PASS.

In total, 112 patients were included in the study, with 79 (71%) having recreational or higher levels of athletic participation. The PASS for the study population was 56.0 (area under the ROC curve, 0.86) and was unaffected by baseline PROMIS-PF scores but was affected by preoperative athletic participation (56.0 for athletes, 49.0 for nonathletes). A post hoc analysis found 57 patients (51%) achieved the PASS for the PROMIS-PF (cutoff, 56.0), but when the athlete and nonathlete thresholds were applied to their respective patient groups, 66% of athletes and 64% of nonathletes achieved the PASS postoperatively. The multivariate analysis found that sport participation (odds ratio, 6.2; P = .001) but not age, sex, body mass index, or preoperative PROMIS affected the likelihood of achieving the PASS on the PROMIS-PF.

Preoperative athletic participation significantly affected the ability to achieve PASS.

The Shoulder Disability Questionnaire (SDQ) is a Patient-Reported Outcome Measure (PROM) applied to evaluate shoulder surgery outcomes. The purpose of this study is to identify the accurate Minimal Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB) and Patient Acceptable Symptom State (PASS) values for the SDQ score. A total of 35 patients (21 women and 16 men, mean age 76.6 ± 3.2 years) were followed up at 6 months postoperatively. To assess the patient's health satisfaction and symptoms, anchor questions were used. The MCID and SCB values of the SDQ score for patients who underwent arthroscopic rotator cuff repair from inception to final follow-up were 40.8 and 55.6, respectively. A change of 40.8 in the SDQ score at 6 months after surgery shows that patients achieved a minimum clinically important improvement in their state of health, and a 55.6 change in the SDQ score reflects a substantial clinically important improvement. The PASS cut-off of the SDQ score at 6 months postoperatively ranged from 22.5 to 25.8. If an SDQ score of 22.5 or more is attained after surgery, the health condition can be recognized as acceptable by the majority of patients. These cut-offs will help with understanding specific patient results and allow clinicians to personally assess patient improvement after rotator cuff repair.

To assess 5-year outcomes and survival rate of hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) and to determine achievement rates of clinically significant outcomes.

Three databases were searched around the following terms: hip arthroscopy, FAIS, and 5-year follow-up. Articles available in English, presenting original data, and reporting minimum 5-year follow-up after primary HA using either patient reported outcomes (PROs) or conversion to total hip arthroplasty (THA) and/or revision surgery were included. Quality assessment was completed using MINORS assessment, and relative agreement was calculated using Cohen's kappa.

Fifteen articles were included. MINORS assessment ranged from 11-22, with excellent (k=0.842) inter-rater reliability between reviewers. 2080 patients were included at a follow-up range of 60.0-84 months. Labral repair was the most commonly performed procedure (range: 8.0%-100%). All studies included PROs and all reported statistically significant improvement (p<0.05) at the 5-year timepoint. The most frequent PRO reported was modified Harris Hip Score (mHHS) (n=8). Nine studies reported on clinically significant outcome achievement, with mHHS being the most common (n=8). The rate of achieving minimal clinically important difference (MCID) ranged from 64-100%, patient-acceptable symptomatic state (PASS) ranged from 45-87.4%, and substantial clinical benefit (SCB) ranged from 35.3-66%. Conversion to THA and revision surgery varied across studies, with ranges of 0.0%-17.9% (duration: 28.8-87.1 months) and 1.3%-26.7% (duration: 14.8-83.7 months), respectively. The most common definition of failure was conversion to THA or revision (n=7). Increased age (n=5) and greater joint degeneration (n=4) were the most common predictors of clinical failure.

Patients undergoing primary hip arthroscopy for FAIS demonstrate significant improvement at 5-year follow-up, with maintained rates of achievement of MCID, PASS, and SCB. Survival rate of HA at 5-years is overall high, with ranges of 0.0-17.9% and 1.3-26.7% % conversion to THA or revision surgery, respectively. Across studies, increased age and greater joint degeneration were the most common cited predictors of clinical failure.

The purpose of this study was to perform a systematic review of studies reporting on minimum 5-year outcomes of patients undergoing primary hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) to determine whether capsular management influences patient-reported outcomes (PROs), rates of clinically significant outcome, and rates of revision surgery or conversion to total hip arthroplasty (THA).

PubMed, Scopus, and Google Scholar were searched around the terms hip arthroscopy, FAIS, five-year follow-up, and capsule management. Articles available in English, presenting original data, and reporting minimum 5-year follow-up after HA using either PROs or conversion to THA and/or revision surgery were included. Quality assessment was completed using MINORS assessment. Articles were stratified into unrepaired and repaired capsule cohorts (excluding periportal capsulotomy techniques).

Eight articles were included. MINORS assessment ranged from 11-22, with excellent (k=0.842) inter-rater reliability. Populations without capsular repair were identified in four studies including a total of 387 patients, at an age of 33.1-38.0 years and follow-up range of 60.0-77 months. Populations with capsular repair were identified in five studies including a total of 835 patients, at an age range of 33.6-43.1 years and follow-up range of 60.0-78.0 months. All studies included PROs and all reported significant improvement (p<0.05) at the 5-year timepoint, with modified Harris Hip Score (mHHS) being the most frequent (n=6). No differences were noted between groups regarding any of the measured PROs. Average rates of achieving MCID and PASS for mHHS were similar between patients without capsular repair (MCID 71.1%, PASS 73.7%, n=1) and with capsular repair (MCID 66.0%-90.6%, PASS 55.3%-87.4%, n=4). Conversion to THA occurred in 12.8-18.5% and 0.0-29.0% for patients with an unrepaired and repaired capsule, respectively. Revision HA occurred in 15.4-25.5% and 3.1-15.4% in unrepaired and repaired capsular patients, respectively.

Patients undergoing hip arthroscopy for FAI had significant improvement in PRO scores at minimum 5-year follow-up, and scores did not differ between patients that underwent capsular repair and those that did not. Similar rates of markers of clinical benefit and THA conversion were achieved by both groups; however, lower rates of revision hip arthroscopy were demonstrated in the capsular repair cohort.

Sports levels, baseline patient-reported outcome measures (PROMs), and surgical procedures are correlated with the outcomes of anterior cruciate ligament reconstruction (ACLR). Machine learning may be superior to conventional statistical methods in making repeatable and accurate predictions.

To identify the best-performing machine learning models for predicting the objective and subjective clinical outcomes of ACLR and to determine the most important predictors.

Case-control study; Level of evidence, 3.

A total of 432 patients who underwent anatomic double-bundle ACLR with hamstring tendon autograft between January 2010 and February 2019 were included in the machine learning analysis. A total of 15 predictive variables and 6 outcome variables were selected to validate the logistic regression, Gaussian naïve Bayes machine, random forest, Extreme Gradient Boosting (XGBoost), isotonically calibrated XGBoost, and sigmoid calibrated XGBoost models. For each clinical outcome, the best-performing model was determined using the area under the receiver operating characteristic curve (AUC), whereas the importance and direction of each predictive variable were demonstrated in a Shapley Additive Explanations summary plot.

The AUC and accuracy of the best-performing model, respectively, were 0.944 (excellent) and 98.6% for graft failure; 0.920 (excellent) and 91.4% for residual laxity; 0.930 (excellent) and 91.0% for failure to achieve the minimal clinically important difference (MCID) of the Lysholm score; 0.942 (excellent) and 95.1% for failure to achieve the MCID of the International Knee Documentation Committee (IKDC) score; 0.773 (fair) and 70.5% for return to preinjury sports; and 0.777 (fair) and 69.2% for return to pivoting sports. Medial meniscal resection, participation in competitive sports, and steep posterior tibial slope were top predictors of graft failure, whereas high-grade preoperative knee laxity, long follow-up period, and participation in competitive sports were top predictors of residual laxity. High preoperative Lysholm and IKDC scores were highly predictive of not achieving the MCIDs of PROMs. Young age, male sex, high preoperative IKDC score, and large graft diameter were important predictors of return to preinjury or pivoting sports.

Machine learning analysis can provide reliable predictions for the objective and subjective clinical outcomes (graft failure, residual laxity, PROMs, and return to sports) of ACLR. Patient-specific evaluation and decision making are recommended before and after surgery.

The identification of factors that specify prognostic models for postoperative results should be based on the best scientific evidence and expert assessment. We aimed to identify, map, and evaluate potential prognostic factors for the improvement of shoulder function in patients undergoing arthroscopic rotator cuff repair.

Longitudinal primary studies of arthroscopic rotator cuff repair reporting any multivariable factor analyses for shoulder function improvement with an endpoint assessment of at least 6 months were included. We systematically searched EMBASE, Medline, and Scopus for articles published between January 2014 and June 2021. The risk of bias of included studies and the quality of evidence were assessed using the Quality in Prognosis Studies tool and an adapted Grading of Recommendations, Assessment, Development, and Evaluations framework.

Overall, 24 studies including 73 outcome analyses were included. We classified younger age and smaller tear size as probably prognostic for a greater improvement in objective outcomes. Shorter symptom duration, absence of a worker compensation claim, low preoperative level of functional status, and high preoperative pain level were classified as probably prognostic for greater improvement in patient-reported outcome measures. The quality of the synthesized evidence was low. Twenty-one studies had an overall high risk of bias.

Six potential prognostic factors for shoulder function after arthroscopic rotator cuff repair were identified. Along with ongoing expert opinion assessments, they will feed into a prognostic model-building process.

Platelet-rich plasma (PRP) is an autologous blood product containing a high concentration of platelets, growth factors, and cytokines, which basic science studies have shown may improve tendon healing by promoting angiogenesis, cellular migration, proliferation, and matrix deposition. However, there is still controversy over its clinical efficacy, with randomized controlled trials and subsequent meta-analyses finding mixed results when PRP is used to augment rotator cuff repair. Meta-analyses have found that leukocyte-poor PRP significantly reduces the rate of incomplete tendon healing and retear, but the evidence does not support the use of leukocyte-rich PRP or platelet-rich fibrin matrix compositions. Optimizing PRP use may be as simple as the right PRP preparation or the right concentration of the important cytokines.

Clinically important outcome assessment has been a point of increasing emphasis in the orthopaedic literature. The minimal clinically important difference, patient acceptable symptom state, and substantial clinical benefit are the most reported in the hip preservation literature. Maximal outcome improvement (MOI) is now also being reported; however, its relation to patients undergoing hip preservation surgery is not well understood. The threshold values that represented satisfaction with surgery were 54.8%, 52.5%, 55.5%, and 55.8% of the MOI for the modified Harris Hip Score, Nonarthritic Hip Score, visual analog scale score for pain, and International Hip Outcome Tool-12 score, respectively. Although the MOI is helpful for characterizing outcome improvement, established measures such as substantial clinical benefit may be better used to grade outcomes in patients with high preoperative function.