So the effect of psychosocial problems on volitional instability have largely sort of been ignored, I think, since the ROSE study. A lot of studies subsequent to the ROSE study have even excluded people based on this designation of volitional, and a lot of people may consider them contraindications to surgical stabilization. But just because a patient can demonstrate the instability, does that really mean they'll fail if we operate on them? So the purpose of this was to determine the prevalence of psychosocial, maladaptive, pathological traits and the prevalence of volitional instability in this multicenter cohort study. And we wanted to look at what are the effects of these psychopathological traits and volitional instability on two-year outcomes following surgery. The study design was a multicenter prospective cohort study. At baseline, maladaptive psychological traits were measured using a personality assessment screener or PASS. A cutoff of 19 has been proposed in use by some. Less than 19, meaning the absence of and over 19 or over the presence of maladaptive traits. Two year endpoints were patient-reported outcomes WOSI, SANE, and FAILURE. And FAILURE was defined as either subjective instability, the patient reporting dislocation, or revision surgery for recurrent dislocation. Regression models were fit to determine the effect of the PASS and volitional instability on these outcomes at two years. An interaction term was created to determine the relationship between the PASS and volitional instability. All the models included the covariates on the right side, the Baden score, handedness, bone loss, age, et cetera. The baseline characteristics of the cohort, there was over 85% follow-up. The median age is 21. The prevalence of volitional instability was 30%, and the prevalence of these maladaptive psychological traits defined by a PASS of 19 or more was 20%. We found improvements in all of the collected PROs at two years, and this is those results stratified by the PASS over 19 and under 19. The baseline WOSI compared to two-year, and we saw basically the BOLD as the median score, and we saw improvements in all of these metrics, however, it was less so in the group with a PASS of 19 or more. Then here's some results from our multivariable regression models, and this is showing you the effect of the PASS on this axis and the predicted WOSI score at two years with volitional instability that a NO is the black line, and the presence of volitional instability is the yellow line, and we see at the score of PASS score of a little over 20, this decline in the WOSI score if they could demonstrate their instability. So a higher PASS score was a significant independent predictor of a lower WOSI. Volitional instability was also, and the interaction term was very significant, meaning there's effect modification. The effect of the one depends on the other. This is a different depiction of the same results showing you if it's in blue it means it's significant, in red it's not significant. The point estimate, the predicted WOSI score at two years, the first one is a PASS score of 26 versus a score of 5 with volitional instability. That was statistically significant and the dashed line is the MCID for the WOSI and it also is above that threshold. A PASS score of 26 versus 5 with no volitional instability, it's still a significant decrease in the WOSI but it doesn't go over that threshold of the MCID. Here's the adjusted effects from the model of the PASS score and volitional instability on the SANE at two years. And a little bit of it at a higher score but somewhere after 20 we see a very similar effect of if they can demonstrate their instability to us and they have a high PASS score of 22 or more, their predicted SANE at two years starts to decline with that increasing score in the PAS versus if they can't demonstrate it, this curve, they have a higher predicted SANE score at two years. And again, the SANE results presented in a different way, blue is significant and that's a PASS of 26 versus 5 in the presence of volitional instability. It is a statistically significant decline in the SANE, it doesn't meet the MCID threshold. So a higher PASS is predictive of a lower SANE and the interaction is significant, meaning one depends on the other. And here is the adjusted effects of the model of the PASS and volitional instability on predicting failure at two years. And in the yellow, you can see somewhere, again, around a PASS of somewhere around 20, the predicted risk of failure goes up dramatically in the volitional instability group. Whereas even with increasing PASS scores, if you can't demonstrate your instability, you don't have that higher risk of failure. So conclusions, psychopathological traits and volitional instability do not appear to be in and of themselves contraindications to surgery. Those that had a PASS over 19 had significant improvement in their PROMs, albeit it was less so than those that had a lower PASS score. Volitional instability wasn't an independent predictor of failure itself. It was a significant interaction with the PASS score, however. So the PASS was an independent predictor of these two-year outcomes, WOSI, SANE, and failure. Volitional instability was an independent predictor of WOSI, but not failure. So if you could demonstrate your instability, that in and of itself was not an independent predictor of failure. However, there is effect modification and the effect of one does depend on the other. So basically, could the PASS be used to identify a subset of people that can demonstrate their instability to us that are at a higher risk of failure if we operate on them? Thank you.

psychosocial problems

volitional instability

surgical outcomes

psychopathological traits

two-year outcomes