Background: Threshold values for patient-reported outcome measures, such as the minimum clinically important difference (MCID) and patient acceptable symptomatic state (PASS), are important for relating postoperative outcomes to meaningful functional improvement. Purpose: To determine the PASS and MCID after hip arthroscopy for femoroacetabular impingement using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A consecutive series of patients undergoing primary hip arthroscopy for femoroacetabular impingement were administered preoperative and minimum 1-year postoperative PROMIS surveys focusing on physical function (PF) and pain interference (PI). External anchor questions for the MCID and PASS were given with the postoperative PROMIS survey. Receiver operator curves were constructed to determine the threshold values for the MCID and PASS. Curves were generated for the study population as well as separate cohorts segregated by median baseline PF or PI scores and preoperative athletic participation. A multivariate post hoc analysis was then constructed to evaluate factors associated with achieving the PASS or MCID. Results: There were 113 patients (35% male; mean ± SD age, 32.8 ± 12.5 years; body mass index, 25.8 ± 4.8 kg/m2), with 60 (53%) reporting preoperative athletic participation. Survey time averaged 77.5 ± 49.2 seconds. Anchor-based MCID values were 5.1 and 10.9 for the PF and PI domains, respectively. PASS thresholds were 51.8 and 51.9 for the PF and PI, respectively. PASS values were not affected by baseline scores, but athletic patients had a higher PASS threshold than did those not participating in a sport (53.1 vs 44.7). MCID values were affected by preoperative baseline scores but were largely independent of sports participation. A post hoc analysis found that 94 (83%) patients attained the MCID PF while 66 (58%) attained the PASS PF. A multivariate nominal logistic regression found that younger patients ( P = .01) and athletic patients ( P = .003) were more likely to attain the PASS. Conclusion: The PROMIS survey is an efficient metric to evaluate preoperative disability and postoperative function after primary hip arthroscopy for femoroacetabular impingement. The MCID and PASS provide surgeons with threshold values to help determine PROMIS scores that are clinically meaningful to patients, and they can assist with therapeutic decision making as well as expectation setting.

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Objectives: Depression has been shown to have a negative effect on many orthopaedic surgical outcomes. The purpose of this study was to determine whether preoperative clinical diagnosis of depression and/or PROMIS (Patient-Reported Outcomes Measurement Information System) Depression scores predicted worse postoperative therapy compliance, functional outcomes, and return-to-sport after anterior cruciate ligament (ACL) reconstruction. Methods: A multi-surgeon series of consecutive patients who had undergone ACL reconstruction at a single institution between 1/4/16 and 7/19/16 were evaluated for inclusion. Patients who had completed preoperative PROMIS Depression (D), Physical Function (PF), and Pain Interference (PI) questionnaires were prospectively enrolled to complete minimum 2-year follow-up PROMIS and Return-to-Sport (ACL-RSI short-form) questionnaires. Chart review was conducted to determine depression diagnosis status, demographic data, and rehabilitation physical therapy (PT) compliance. PROMIS D score cutoff for mild depression was >52.5, based on previously established correlation to the validated Patient Health Questionnaire-9. Results: Ninety-five of 115 consecutive patients (81%) met inclusion criteria. Average follow-up was 34+/-1.9 months. Fourteen patients (15%) carried a clinical diagnosis of depression. Thirty-two (34%) had a preoperative PROMIS D score above the mild depression threshold; of those, 2 (2%) scored in the moderate depression range, and 3 (3%) scored in the severe depression range. Overall, the cohort (including depressed patients) showed improvement in PROMIS PF and PI scores postoperatively (p<0.001) (Table 1). Diagnosed depressed patients had a higher rate of PT non-compliance (30.8%±17.3% vs. 21.9%±12.6%; p=0.04) and lower postoperative physical function (50.8±7.7vs. 57.5±10.5; p=0.03), but no differences in post-operative PROMIS PI (50.8±6.9vs. 46.7±6.8; p=0.32), compared to patients without depression diagnosis. The percentage of missed therapy appointments showed a correlation with lower postoperative PROMIS PF scores (r=0.33, p=0.008) in our cohort. PROMIS depressed (PROMIS D>52.5) and undiagnosed depression patients (subgroup of preoperative PROMIS depressed without depression diagnosis) showed no difference in PT compliance or postoperative PROMIS PF or PI, compared to non-depressed patients (Table 2). Undiagnosed preoperative depressed patients (n=21/95 (22%)) also showed improvement in their depression scores postoperatively (mean PROMIS D = 57.4±5.0 preop vs. 44.5±6.6 postop; p<0.0001) (Figure 1) and 19/21 (90.5%) patients in this group showed resolution in their personal PROMIS D score to non-depressed range (p=.001). PROMIS depressed patients were less likely to participate in a sport (16/32 (50.0%) vs. 50/63 (79.3%); p=0.003), but PROMIS depressed athletes had no differences in return to sport rates (10/16 (63%) vs. 25/50 (50%); p=0.38) or responses to the ACL-RSI Short Form questionnaire (p>0.05 for all). Conclusion: Clinically diagnosed depression is predictive of worse rehabilitation therapy compliance and worse functional outcomes after ACL reconstruction surgery, but even depressed patients can be expected to show improvement. PROMIS Depression scores, particularly in those without a clinical diagnosis of depression, can be expected to resolve to non-depressed range after ACL reconstruction. Patients with depressed mood preoperatively but no depression diagnosis could be considered to have “situational depression” and can be reassured that depression will likely resolve after ACL reconstruction. Patients with depression diagnosis, however, should be counseled regarding tempered expectations after ACL reconstruction. Resources should be allocated to incorporate behavioral health counseling pre- and post-surgery in an attempt to maximize outcomes.

A 51-year-old woman with newly diagnosed renal cell carcinoma was evaluated for acute onset dyspnea. Computed tomography angiogram was suspicious for pulmonary embolism originating from the right ventricle (RV). Tissue plasminogen activator was given without resolution of the mass on echocardiogram. Cardiac magnetic resonance imaging was performed to differentiate tumor from thrombus. Steady-state free precession imaging demonstrated a large mass originating from the apex of the RV (Panel A), and a long mobile 11 ϫ 1.3-cm mass extending through the RV outflow tract into the left main pulmonary artery (PA) (Panel B). Long inversion time gadolinium-enhanced images showed suppression of the mobile mass components but not the apical mass, suggesting both mobile thrombus and apical tumor (Panel C). Positron emission tomography-computed tomography showed intense hypermetabolic activity of the apical mass, suggestive of metastatic renal cell carcinoma, and low metabolic activity of the pulmonary artery filling defect consistent with thrombus or tumor embolus (Panel D).

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