A prospective population-based study of the predictors of undergoing total joint arthroplasty

Work-restricting musculoskeletal pain after bariatric surgery or usual obesity care in the Swedish Obese Subjects study

OBJECTIVE

The objective of this study was to study the recovery from, and incidence of, work-restricting musculoskeletal pain after bariatric surgery compared with usual obesity care.

METHODS

Pain in different body regions was monitored using questionnaires in the nonrandomized, prospective, controlled Swedish Obese Subjects (SOS) study, which included 2007 participants treated with bariatric surgery and a matched control group of 2040 participants receiving usual obesity care at primary health care centers. Self-reported pain in the neck and shoulders, back, hips, knees, and ankles was captured from questionnaires administered at baseline and after 1, 2, 3, 4, 6, 8, 10, 15, and 20 years.

RESULTS

Compared with matched controls, bariatric surgery was associated with better recovery from baseline work-restricting knee and ankle pain in both the short (1-4 years) and long term (up to 20 years), as well as from back and hip pain in the short term. In participants without pain at baseline, bariatric surgery was associated with a lower incidence of developing new pain in the knee and ankle in the short and long term.

CONCLUSIONS

Bariatric surgery was associated with better recovery from pain, primarily in weight-bearing joints, as well as with prevention of pain development in the knee and ankle compared with matched controls receiving usual obesity care.

Are Outcomes From an Exercise Therapy and Patient Education Program for Osteoarthritis Associated With Hip and Knee Replacement Within Two Years? A Register-Based Study of 9,339 Patients With Osteoarthritis

OBJECTIVE

The objective of this study was to determine whether short-term outcomes from exercise therapy and patient education for osteoarthritis (OA) are associated with hip or knee replacement within two years.

METHODS

Individual-level data from the Good Life with osteoArthritis in Denmark (GLA:D) Registry were linked to the Danish National Patient Registry and other national registries. Cox proportional hazards models were used to investigate associations between program outcomes (baseline to three-month changes) and time to primary hip or knee replacement. Patients who did not receive joint replacement were censored at two years, time of death, or emigration.

RESULTS

A total of 2,304 and 7,035 patients with clinically diagnosed hip and knee OA, respectively, were included. Of these, 30% with hip OA and 10% with knee OA had joint replacement within two years. Postprogram improvements in hip-related quality of life and arthritis self-efficacy (pain subscale) were associated with a reduced hazard of hip replacement (adjusted hazard ratios [HRs] for a 10-unit improvement: 0.74 [95% confidence interval (CI) 0.69-0.80] and 0.90 [95% CI 0.85-0.96], respectively). Improvements in knee pain, knee-related quality of life, and arthritis self-efficacy (pain subscale) were associated with a lower hazard of knee replacement (adjusted HRs for 10-unit improvement: 0.81 [95% CI 0.76-0.86] to 0.90 [95% CI 0.86-0.95], 0.70 [95% CI 0.63-0.78] to 0.79 [95% CI 0.72-0.86], and 0.89 [95% CI 0.83-0.94], respectively).

CONCLUSION

The magnitude of improvement in key measures after exercise therapy and education was significantly associated with the likelihood of surgery. Progression to hip replacement was three times higher than progression to knee replacement. This information can guide patient-clinician conversations around anticipated program outcomes.

Total Hip Arthroplasty in Chile Is Characterized By Low Utilization Rates and Disparity in Access

Background: Disparity in access to total hip arthroplasty (THA) is an internationally recognized phenomenon influenced by social and geographical factors. The Organisation for Economic Co-operation and Development (OECD) employs the utilization rates of THA to evaluate and compare healthcare utilization by its 37 country members, including Chile. Purpose: We sought to describe THA utilization rates in the elderly Chilean population and to compare it with data from other OECD countries. In addition, we sought to identify whether sociodemographic variables influence access to THA in Chile. Methods: We conducted a retrospective review of THA cases performed in Chile between 2016 and 2018 in patients aged 65 years and older in a large database regulated by the Ministry of Health; 8970 patients were included. Mean utilization rates (MURs) of THA within Chile's 346 administrative-territorial divisions (called communes) were calculated. We analyzed associations between the communal MUR and poverty, rurality, insurance type, and geographical health administration dependency. Results: The national MUR of THA in the elderly population in Chile was 144/100,000 for the period studied. The median communal MUR was 107 (interquartile range [IQR]: 66-153). A lower MUR of THA was observed in communes with higher poverty levels, higher rurality, and a lower rates of private insurance. After negative binomial regression analysis, only rurality rate and geographical healthcare service dependency were associated with MUR. Conclusions: This retrospective database study suggests that the utilization of THA in Chile is unequal and well below the average of other OECD countries. Higher rates of rurality and administrative healthcare dependence (a geographical/administrative factor) were associated with disparities in access to THA within Chile.

Net cost savings arising from patient completion of an active self-management program

OBJECTIVE

The objective of this study is to investigate changes in willingness for total knee replacement (TKR) surgery following a randomised control trial (RCT) of an osteoarthritis management program, and to extrapolate orthopaedic cost consequences for private health insurers (PHI).

METHODS

Willingness for surgery data from the RCT is analysed using a multinomial logistic regression model. A decision analytic model is used to conduct a break-even cost benefit analysis of the intervention from a PHI payer perspective. The analysis estimates the minimum probability of progression to surgery required for the intervention to be cost-neutral when considering savings limited to reduced orthopaedic costs. Cost data and orthopaedic pathway probabilities are sourced from payer data.

RESULTS

At baseline, 39% of participants in the treatment and control group were willing for surgery. At 12 months, 16% of participants in the treatment group remained willing for surgery, versus 36% in the control group. Participants in the treatment group are 2.96 (95% CI: 1.01-8.66) times more likely than those in the control group to move from initially willing for surgery, to unsure or unwilling at 12 months. The analysis indicates that the intervention is likely to be cost saving when at least 60% of initially willing participants progress to surgery over a 5-year time horizon.

CONCLUSION

Our study estimates that an education, exercise and weight loss intervention can deliver both improved participant outcomes and a return on investment to Australian PHIs through a reduction in TKR surgery incidence.

Second opinion and time to knee arthroplasty: a prospective cohort study of 142 patients

OBJECTIVE

The objective of this study was to determine the impact of obtaining a second opinion consultation on time to knee arthroplasty (KA). We further examined the frequency of KA and the determinants of KA following the second opinion.

DESIGN

Prospective cohort study.

SETTING

The second opinion programme was implemented at the Ludwig Maximilian University Hospital in Munich.

PARTICIPANTS

Participants comprised patients with knee osteoarthritis who were insured with one of the largest statutory health insurance Allgemeine Ortskrankenkasse Bayern (mean age 64.3±9.6 years). Patients participated in a second-opinion programme and completed questionnaires on site before and after personal presentation for the second opinion consultation. Follow-up questionnaires were delivered by post at 3 and 12 months after the second opinion consultation. Of the 142 patients included in the study, 47 (33.1%) underwent KA within 12 months after obtaining the second opinion.

PRIMARY OUTCOME MEASURES

Primary outcome measure was time until patients received KA. Cox proportional hazard modelling was used to calculate the associations between the selected predictors and time that elapsed between receipt of the second opinion to KA.

RESULTS

Mean time until KA was 17 weeks. Kaplan-Meier curves showed significant differences in time to KA according to the recommendation given at second opinion consultation, knee-related quality of life and Kellgren-Lawrence grade. In multivariate Cox proportional hazard modelling, second opinion recommendation (HR 5.33, 95% CI 1.16, 24.41) and knee-related quality of life (HR 1.03, 95% CI 1.01, 1.06) were significant predictors of time from second opinion to KA.

CONCLUSIONS

Obtaining a second opinion had significant impact on time to knee replacement. Those who were recommended immediate surgery also underwent surgery more quickly after the second opinion. The effect of knee-related quality of life supports the importance of patient-reported outcome measures in the decision for or against KA.

Within-person change in patient-reported outcomes and their association with the wish to undergo joint surgery during a digital first-line intervention for osteoarthritis

AIM

To study the association between within-person changes in patient-reported outcomes (PROMs) and wish for joint surgery during participation in a digital first-line intervention comprising exercise and education for knee/hip osteoarthritis (OA).

METHODS

Retrospective observational registry study. Participants enrolled between June 1, 2018 and October 30, 2021, with follow-up data at three months (n = 13,961). We used asymmetric fixed effect (conditional) logistic regressions to study the association between change in wish to undergo surgery at last available time point (3, 6, 9, or 12 months) and improvement or worsening of PROMs pain (0-10), quality of life (QoL) (EQ5D-5L, 0.243-0.976), overall health (0-10), activity impairment (0-10), walking difficulties (yes/no), fear of movement (yes/no), and Knee/Hip injury and Osteoarthritis Outcome Score 12 Items (KOOS-12/HOOS-12, 0-100) function and QoL subscales.

RESULTS

The proportion of participants wishing to undergo surgery declined by 2% (95% CI: 1.9, 3.0), from 15.7% at the baseline to 13.3% at 3 months. Generally, improvements in PROMs were associated with reduced likelihood of wishing for surgery, while worsening was associated with increased likelihood. For pain, activity impairment EQ-5D and KOOS/HOOS QoL, a worsening led to a change in the probability of wish for surgery of larger absolute magnitude than an improvement in the same PROM.

CONCLUSIONS

Within-person improvements in PROMs are associated with reduced wish for surgery while worsenings with an increased wish for surgery. Larger improvements in PROMs may be needed to match the magnitude of the change in wish for surgery associated with a worsening in the same PROM.

Use of non-surgical treatments on the journey to knee replacement in patients with knee osteoarthritis: a 10-year population-based case-control study

AIM

To investigate temporal trends in primary care visits, physiotherapy visits, dispensed non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in knee osteoarthritis (OA) patients who have and have not undergone knee replacement.

METHODS

We analysed 5665 OA patients from the Skåne Healthcare Register, Sweden, who underwent knee replacement between 2015 and 2019. Controls were OA patients without knee replacement, matched 1:1 by sex, age, time and healthcare level of initial OA diagnosis, and assigned a pseudo-index date corresponding to their case's knee replacement date. Annual prevalence and prevalence ratio of primary care and physiotherapy visits, dispensed NSAIDs and opioids (all for any cause) in the 10 years before knee replacement were estimated using Poisson regression.

RESULTS

The annual prevalence of all-cause primary care visits, physiotherapy visits and opioid use was similar between cases and controls until 3 years before the index date when it started to increase among the cases. The year before the index date, the prevalence ratio (cases vs controls) for physiotherapy use was 1.8 (95% CI 1.7, 1.8), while for opioid use 1.6 (1.5, 1.7). NSAID use was consistently higher among cases, even 10 years before the index date when the prevalence ratio versus controls was 1.3 (1.2, 1.3), increasing to 1.8 (1.7, 1.9) in the year preceding the index date.

CONCLUSIONS

Management of OA patients who have and have not undergone knee replacement appears largely similar except for higher use of NSAIDs in knee replacement cases. Symptomatic treatments start to increase a few years before the surgery in knee replacement cases.

Development of a machine learning algorithm to identify surgical candidates for hip and knee arthroplasty without in-person evaluation

INTRODUCTION

Arthroplasty care delivery is facing a growing supply-demand mismatch. To meet future demand for joint arthroplasty, systems will need to identify potential surgical candidates prior to evaluation by orthopaedic surgeons.

MATERIALS AND METHODS

Retrospective review was conducted at two academic medical centers and three community hospitals from March 1 to July 31, 2020 to identify new patient telemedicine encounters (without prior in-person evaluation) for consideration of hip or knee arthroplasty. The primary outcome was surgical indication for joint replacement. Five machine learning algorithms were developed to predict likelihood of surgical indication and assessed by discrimination, calibration, overall performance, and decision curve analysis.

RESULTS

Overall, 158 patients underwent new patient telemedicine evaluation for consideration of THA, TKA, or UKA and 65.2% (n = 103) were indicated for operative intervention prior to in-person evaluation. The median age was 65 (interquartile range 59-70) and 60.8% were women. Variables found to be associated with operative intervention were radiographic degree of arthritis, prior trial of intra-articular injection, trial of physical therapy, opioid use, and tobacco use. In the independent testing set (n = 46) not used for algorithm development, the stochastic gradient boosting algorithm achieved the best performance with AUC 0.83, calibration intercept 0.13, calibration slope 1.03, Brier score 0.15 relative to a null model Brier score of 0.23, and higher net benefit than the default alternatives on decision curve analysis.

CONCLUSION

We developed a machine learning algorithm to identify potential surgical candidates for joint arthroplasty in the setting of osteoarthritis without an in-person evaluation or physical examination. If externally validated, this algorithm could be deployed by various stakeholders, including patients, providers, and health systems, to direct appropriate next steps in patients with osteoarthritis and improve efficiency in identifying surgical candidates.

LEVEL OF EVIDENCE

III.

An Analysis of the Preoperative Factors, Spinopelvic Mobility and Sagittal Spinal Alignment in Pre-THA Patients

Hip arthroplasty is a very effective medical procedure. The optimal positioning of the components and the functioning of the endoprosthesis are influenced, among other things, by the mobility and balance of the spine. The aim of the study was to analyze the factors influencing the mobility of the lumbar-pelvic-iliac complex (spinopelvic mobility) together with the assessment of sagittal spinal alignment in patients prior to THA (total hip arthroplasty). Patients who underwent hip replacement surgery due to advanced osteoarthritis of the hip were enrolled in the study (n = 103). The sociodemographic characteristics, BMI, radiological advancement of the degenerative disease, quality of life, and range of joint mobility were completed using a proprietary questionnaire, the EQ-5D-5L questionnaire, and a clinical examination. X-ray images were analyzed: AP of the pelvis standing up, lateral of the spine standing and sitting. Key parameters were measured as ∆SS-change in sacrum angle value when changing from standing to sitting position and pelvic incidence (PI)-lumbar lordosis (LL) mismatch-sagittal lumbar pelvic balance measured in standing position. The patients were assigned to the appropriate groups according to the Hip-Spine Classification: normal group: 1A (n = 65; 63.1%), abnormal groups: 1B (n = 17; 16.5%), 2A (n = 16; 15.5%), 2B (n = 5; 4.9%). A correlation was shown between the abnormal groups and the individual components of PROMs in the scope of the self-service and normal activities categories (EQ-5D and EQ-VAS). However, the strength of the relationship turned out to be moderate, and the remaining components of the survey were statistically insignificant. The remaining factors analyzed, i.e., age, BMI, the range of hip motion, the presence of contracture in the joint in a clinical examination, and the radiological advancement of osteoarthritis on the Tonnis scale, do not predict abnormal relationships between the spine and the pelvis in our patients waiting for THA. Therefore, further investigations are needed to evaluate the correlation between preoperative factors and the lumbar-pelvic-iliac complex in patients prior to planned hip arthroplasty.

Sex-Based Differences in the Utilization of Shoulder, Hip, and Knee Arthroplasty

INTRODUCTION

Studies show that females have a higher prevalence of osteoarthritis, worse symptoms, but lower rates of joint replacement surgery (JRS). The reason for this remains unknown.

METHODS

A database of JRS candidates was created for patients seen in 2019 at an academic center. Demographics, Kellgren-Lawrence grades, symptom duration, visual analogue pain score, Charlson Comorbidity Index, and nonsurgical treatments were collected. Patients who were offered but declined surgery were invited to focus groups. Two independent sample t-tests, Mann-Whitney U tests, and chi-square tests were used for continuous, scored, and categorical variables, respectively, with two-tailed significance <0.05. Qualitative, code-based analysis was performed for the focus groups.

RESULTS

The cohort included 321 patients (81 shoulder, 59 hip, and 181 knee) including 199 females (62.0%). There were no differences in proportions of females versus males who underwent JRS or in nonsurgical treatments. Female shoulder arthritis patients were older, had a higher visual analogue pain score, and had a higher Charlson Comorbidity Index. In focus groups, males prioritized waiting for technology advancements to return to an active lifestyle, whereas females experienced negative provider interactions, self-advocated for treatment, concerned about pain, and believed that their sex affected their treatment.

DISCUSSION

We found equal utilization of JRS at our institution. However, female patients experienced unique barriers to surgery.

Randomized-controlled trial assessing a digital care program versus conventional physiotherapy for chronic low back pain

Low back pain (LBP) is the world's leading cause of years lived with disability. Digital exercise-based interventions have shown great potential in the management of musculoskeletal conditions, promoting access and easing the economic burden. However, evidence of their effectiveness for chronic LBP (CLBP) management compared to in-person physiotherapy has yet to be unequivocally established. This randomized controlled trial (RCT) aims to compare the clinical outcomes of patients with CLBP following a digital intervention versus evidence-based in-person physiotherapy. Our results demonstrate that patient satisfaction and adherence were high and similar between groups, although a significantly lower dropout rate is observed in the digital group (11/70, 15.7% versus 24/70, 34.3% in the conventional group; P = 0.019). Both groups experience significant improvements in disability (primary outcome), with no differences between groups in change from baseline (median difference: -0.55, 95% CI: -2.42 to 5.81, P = 0.412) or program-end scores (-1.05, 95% CI: -4.14 to 6.37; P = 0.671). Likewise, no significant differences between groups are found for secondary outcomes (namely pain, anxiety, depression, and overall productivity impairment). This RCT demonstrates that a remote digital intervention for CLBP can promote the same levels of recovery as evidence-based in-person physiotherapy, being a potential avenue to ease the burden of CLBP.

Patient appropriateness for total knee arthroplasty and predicted probability of a good outcome

OBJECTIVES

One-fifth of total knee arthroplasty (TKA) recipients experience a suboptimal outcome. Incorporation of patients' preferences in TKA assessment may improve outcomes. We determined the discriminant ability of preoperative measures of TKA need, readiness/willingness and expectations for a good TKA outcome.

METHODS

In patients with knee osteoarthritis (OA) undergoing primary TKA, we preoperatively assessed TKA need (Western Ontario-McMaster Universities OA Index (WOMAC) Pain Score and Knee injury and Osteoarthritis Outcome Score (KOOS) function, arthritis coping), health status, readiness (Patient Acceptable Symptom State, depressive symptoms), willingness (definitely yes-yes/no) and expectations (outcomes deemed 'very important'). A good outcome was defined as symptom improvement (met Outcome Measures in Rheumatology and Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria) and satisfaction with results 1 year post TKA. Using logistic regression, we assessed independent outcome predictors, model discrimination (area under the receiver operating characteristic curve, AUC) and the predicted probability of a good outcome for different need, readiness/willingness and expectations scenarios.

RESULTS

Of 1,053 TKA recipients (mean age 66.9 years (SD 8.8); 58.6% women), 78.1% achieved a good outcome. With TKA need alone (WOMAC pain subscale, KOOS physical function short-form), model discrimination was good (AUC 0.67, 95% CI 0.63 to 0.71). Inclusion of readiness/willingness, depressive symptoms and expectations regarding kneeling, stair climbing, well-being and performing recreational activities improved discrimination (p=0.01; optimism corrected AUC 0.70, 0.66-0.74). The predicted probability of a good outcome ranged from 44.4% (33.9-55.5) to 92.4% (88.4-95.1) depending on level of TKA need, readiness/willingness, depressive symptoms and surgical expectations.

CONCLUSIONS

Although external validation is required, our findings suggest that incorporation of patients' TKA readiness, willingness and expectations in TKA decision-making may improve the proportion of recipients that experience a good outcome.

FUNCTIONAL OUTCOME OF PREOPERATIVE EXERCISES ON RANGE OF MOVEMENTS FOLLOWING TKA: A PROSPECTIVE COMPARITIVE STUDY

AIM Range of motion prior to TKRis a key determinant of the post-operative range of motion.The likelihood that the accompanying stiffness of the extensor mechanism will result in limited flexion following surgery increases with the preoperative range of motion.It would make sense to enhance knee ROM before surgery in order to optimize flexion following TKA.Comparisons were made between the patient groups who had knee surgery with preoperative exercises and those who had surgery without them. METHODS 156 patients with knee arthritis were collected over a period of 1.5years. They were divided into two groups. Pre-operative knee exercise was given to 78 patients for aone month. Prior to and following the test group's workouts, all patients were observed.All 156 underwent TKR, and their post-operative range of motion was evaluated at four weeks, three months, six months, and a year. We timed how long it took to fully extend and flex to 90 degrees. RESULTS Thisstudy suggested that the knee workouts were unquestionably helpful in achieving early knee flexion up to 90 in comparison to that of the control group. When the test group was compared to the control group, knee flexion to about 90 and more was attained in about 4 weeks; this difference was statistically significant (p 0.01).But after six months and a year of long-term follow-up, there were no discernible changes in the knee's range of motion. CONCLUSION Prehabilitation significantly improves the Knee Score for the intervention group both before surgery and three months after surgery. Exercises done before to surgery help patients recover more quickly from TKA and may speed up the process of achieving a good flexion and extension range of motion. However there is no significant difference in functional outcome after one year post surgery in both groups.

Predicting total knee replacement at 2 and 5 years in osteoarthritis patients using machine learning

Objectives

Knee osteoarthritis is a major cause of physical disability and reduced quality of life, with end-stage disease often treated by total knee replacement (TKR). We set out to develop and externally validate a machine learning model capable of predicting the need for a TKR in 2 and 5 years time using routinely collected health data.

Design

A prospective study using datasets Osteoarthritis Initiative (OAI) and the Multicentre Osteoarthritis Study (MOST). OAI data were used to train the models while MOST data formed the external test set. The data were preprocessed using feature selection to curate 45 candidate features including demographics, medical history, imaging assessments, history of intervention and outcome.

Setting

The study was conducted using two multicentre USA-based datasets of participants with or at high risk of knee OA.

Participants

The study excluded participants with at least one existing TKR. OAI dataset included participants aged 45-79 years of which 3234 were used for training and 809 for internal testing, while MOST involved participants aged 50-79 and 2248 were used for external testing.

Main outcome measures

The primary outcome of this study was prediction of TKR onset at 2 and 5 years. Performance was evaluated using area under the curve (AUC) and F1-score and key predictors identified.

Results

For the best performing model (gradient boosting machine), the AUC at 2 years was 0.913 (95% CI 0.876 to 0.951), and at 5 years 0.873 (95% CI 0.839 to 0.907). Radiographic-derived features, questionnaire-based assessments alongside the patient's educational attainment were key predictors for these models.

Conclusions

Our approach suggests that routinely collected patient data are sufficient to drive a predictive model with a clinically acceptable level of accuracy (AUC>0.7) and is the first such tool to be externally validated. This level of accuracy is higher than previously published models utilising MRI data, which is not routinely collected.

Disease burden of and expectations from surgery in patients prior to total knee arthroplasty: Results of the prospective FInGK study

BACKGROUND

Disease burden in patients prior to total knee arthroplasty (TKA) varies widely between studies and countries. We aimed to characterize individuals undergoing TKA and examine their expectations from the surgery, focusing on variations in disease burden.

METHODS

Consecutive patients undergoing primary TKA in a German university hospital were recruited. A questionnaire including information on disease burden, preoperative expectations from surgery, health care utilization, demography, and socioeconomics was collected one day prior to surgery and linked to data from medical records. Patients were categorized into disease burden quartiles using the Western Ontario and McMaster Universities Osteoarthritis Index' (WOMAC) total score. Subsequently, study population's characteristics and expectations from surgery were analyzed stratified by disease burden.

RESULTS

A total of 196 patients were included (41 % male; mean age: 68.2 years). The median WOMAC was 52.0 (IQR: 41.0-58.0). Patients in Q1 were more often males (Q1: 63 % vs Q4: 29 %) and had a shorter duration of complaints with the impaired knee. They were also less restricted in social participation, reported less often signs of depression, and were less often treated with physiotherapy (Q1: 27 % vs Q4: 54 %). Furthermore, expectations from surgery were highest in patients with a low disease burden.

CONCLUSION

We found large variations in disease burden with a considerable number of patients undergoing TKA whose functional capacity is still maintained and for which guideline-recommended conservative treatment options are not fully exhausted. Further research on this subgroup as well as establishing an international consensus on specific thresholds for TKA indication are needed.

Genicular artery embolization for treatment of knee osteoarthritis pain: Systematic review and meta-analysis

Objective

Genicular artery embolization (GAE) is a novel, minimally invasive procedure for treatment of knee osteoarthritis (OA). This meta-analysis investigated the safety and effectiveness of this procedure.

Design

Outcomes of this systematic review with meta-analysis were technical success, knee pain visual analog scale (VAS; 0-100 scale), WOMAC Total Score (0-100 scale), retreatment rate, and adverse events. Continuous outcomes were calculated as the weighted mean difference (WMD) versus baseline. Minimal clinically important difference (MCID) and substantial clinical benefit (SCB) rates were estimated in Monte Carlo simulations. Rates of total knee replacement and repeat GAE were calculated using life-table methods.

Results

In 10 groups (9 studies; 270 patients; 339 knees), GAE technical success was 99.7%. Over 12 months, the WMD ranged from -34 to -39 at each follow-up for VAS score and -28 to -34 for WOMAC Total score (all p ​< ​0.001). At 12 months, 78% met the MCID for VAS score; 92% met the MCID for WOMAC Total score, and 78% met the SCB for WOMAC Total score. Higher baseline knee pain severity was associated with greater improvements in knee pain. Over 2 years, 5.2% of patients underwent total knee replacement and 8.3% received repeat GAE. Adverse events were minor, with transient skin discoloration as the most common (11.6%).

Conclusions

Limited evidence suggests that GAE is a safe procedure that confers improvement in knee OA symptoms at established MCID thresholds. Patients with greater knee pain severity may be more responsive to GAE.

Adjunctive platelet-rich plasma and hyaluronic acid injection after arthroscopic debridement in Kellgren-Lawrence grade 3 and 4 knee osteoarthritis

BACKGROUND

Osteoarthritis (OA) is the most common cause of pain and disability, predominantly affecting the knee. The current management of knee OA falls short of completely stopping disease progression, particularly in Kellgren-Lawrence (KL) grade 3 and 4 knee OA. As such, joint replacement is often recommended, although only 15%-33% of candidates accept it. Alternative therapeutic options are still needed to prevent the progression of joint damage and delay the need for knee arthroplasty.

AIM

To investigate the effect of adjunctive platelet rich plasma (PRP) and hyaluronic acid (HA) after arthroscopic debridement in KL grade 3 and 4 knee OA.

METHODS

This retrospective cohort study used the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and WOMAC sub-scores (pain, stiffness, and function) to assess 21 patients, grouped according to medical record data of treatment received: Arthroscopic debridement (n = 7); arthroscopic debridement with PRP (n = 7); or arthroscopic debridement with HA (n = 7). WOMAC scores and sub-scores at baseline and at 3 mo and 5 mo posttreatment were recorded. The three-group data were statistically analyzed using the tests of paired t, one-way analysis of variance, and post hoc least significant difference.

RESULTS

All three treatment groups showed significant improvements in WOMAC score and sub-scores from before treatment to 3 mo and 5 mo after treatment. However, the arthroscopic debridement with PRP treatment group, in particular, showed a significantly lower WOMAC pain score than the group who received arthroscopic debridement alone at 5 mo after the procedure (P = 0.03).

CONCLUSION

Compared to arthroscopic debridement alone, adjunctive PRP after arthroscopic debridement significantly lessened the patients’ pain symptom.

Characteristics associated with caregiver willingness to consider tonsillectomy for a child's obstructive sleep disordered breathing: Findings from a survey of families in an urban primary care network

OBJECTIVE

Tonsillectomy use is lower among Black children than White children in the U.S. despite their higher prevalence of obstructive sleep disordered breathing (oSDB). We aimed to identify factors associated with parents' willingness to consider tonsillectomy for their child's oSDB and to identify whether parents of Black children are less willing than parents of non-Black children to be willing to consider the procedure.

STUDY DESIGN

Prospective cohort study.

SETTING

Primary care network of a tertiary children's hospital.

METHODS

We surveyed parents/guardians of children aged 2-10 years with oSDB, to assess their knowledge about oSDB and tonsillectomy, perceived severity of their child's oSDB, perceived level of their child's sleep disturbance, perceived risks and benefits of tonsillectomy, stress, trust in their child's primary care physician and physicians in general, and health literacy. We also assessed child clinical and sociodemographic characteristics. Associations between these characteristics and parent/guardian willingness to consider tonsillectomy for their child's oSDB were assessed.

RESULTS

Of the 59 parents/guardians included, 90% were mothers and 71% were Black. Only 58% of caregivers of Black children but 85% of caregivers of non-Black children were willing to consider tonsillectomy (p = 0.04). Caregivers with another child who had undergone tonsillectomy and caregivers who perceived their child's sleep to be more disturbed were more often willing to consider tonsillectomy (both p = 0.02).

CONCLUSIONS

Parents of Black children are less willing to consider tonsillectomy for their child's oSDB, but this was not explained by any factors assessed in this study. Future studies should evaluate additional factors that may explain this difference and that might be targeted to ensure appropriate and equitable access to tonsillectomy among children with oSDB.

Digital Rehabilitation for Acute Low Back Pain: A Prospective Longitudinal Cohort Study

Background

Low back pain (LBP) has a lifetime prevalence of 70–80%. Access to timely and personalized, evidence-based care is key to prevent chronic progression. Digital solutions may ease accessibility to treatment while reducing healthcare-related costs.

Purpose

We aim to report the results of a fully remote digital care program (DCP) for acute LBP.

Patients and Methods

This was an interventional, single-arm, cohort study of patients with acute LBP who received a DCP. Primary outcome was the mean change in disability (Oswestry Disability Index – ODI) after 12 weeks. Secondary outcomes included change in pain (NPRS), analgesic consumption, surgery likelihood, depression (PHQ-9), anxiety (GAD-7), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement.

Results

A total of 406 patients were enrolled in the program and of those, 332 (81.8%) completed the intervention. A significant disability reduction of 55.1% (14.93, 95% CI 13.95; 15.91) was observed, corresponding to a 76.1% responder rate (30% cut-off). Disability reduction was accompanied by significant improvements in pain (61.0%), depression (55.4%), anxiety (59.5%), productivity (65.6%), fear-avoidance beliefs (46.3%), intent to pursue surgery (59.1%), and analgesic consumption (from 35.7% at baseline to 10.8% at program end). DCP-related patient satisfaction score was 8.7/10.0 (SD 1.4).

Conclusion

This study demonstrated the utility of a multimodal DCP for patients with acute LBP. Very high adherence rates and patient satisfaction were observed, alongside significant reductions in all assessed outcomes, consistent with the growing body of evidence supporting the management of acute LBP with DCPs.

The Shoulder Function “Tipping-Point” for Elective Rotator Cuff Repair: Demographic and Longitudinal Trends

Background

A patient's decision to undergo an elective orthopedic procedure is largely based on their symptoms and functional limitations. This point where patients choose to undergo surgery is known as the “tipping point.” The primary aim of this study is to determine the relationship between demographic parameters and the tipping point for elective rotator cuff repair. The secondary aim is to investigate if the tipping point is associated with mental health. The tertiary aim is to determine if the tipping point changes over time.

Methods

Retrospective chart review was used to identify all patients who underwent primary arthroscopic rotator cuff repair between January 1, 2015, to January 1, 2020, with 1 of 3 board-certified orthopedic surgeons. Exclusion criteria included age <18 years, revision surgery, or incomplete datasets (American Shoulder and Elbow Surgeons [ASES], 12-item short form, demographic information, and surgical history). Preoperative ASES score was designated as the tipping point for an individual patient, with a lower score representing worse shoulder function and therefore a higher tipping point and vice versa. Demographic parameters (age, sex, body mass index [BMI], race, and insurance), hand dominance, and surgical history extracted from chart review were analyzed to determine associations with tipping point.

Results

A total of 2153 patients were identified from chart review, with 1731 included in the final analysis. The patients had a mean age of 58.6 ± 9.66 years and a mean BMI of 29.2 ± 6.02 kg/m². There was no significant difference in mean preoperative ASES score by year for the duration of this study (2015-2019, P = .27). Worker's compensation patients had a significantly lower mean preoperative ASES score than patients with commercial or government insurance (P < .01). Spearman's rank correlations showed no relationship between ASES score and patient demographics (age, sex, BMI, race, and hand dominance) or between ASES and previous orthopedic surgery. Preoperative ASES showed a weakly positive correlation (ρ = 0.26) with 12-item short form mental component score. Multivariate linear regression showed male sex is predictive of a lower tipping point (P < .01), whereas higher BMI, African American race, and history of arthroplasty are predictive of a higher tipping point (P ≤ .02).

Conclusion

The tipping point was not demonstrated to change over time in our analysis. Male sex is predictive of a lower tipping point for arthroscopic rotator cuff repair, whereas elevated BMI, African American race, worker's compensation insurance, and prior arthroplasty are predictive of a higher tipping point. Also, better mental health function is associated with a lower tipping point.

Can Patient-Reported Outcome Measurement Information System Measures Differentiate Patients Who Will Undergo Hip and Knee Total Joint Arthroplasty: A Retrospective Case-Control Study

BACKGROUND

The Patient-Reported Outcome Measurement Information System (PROMIS) can be used to monitor patients in population-health-based programs. However, it is unknown which measures are most appropriate to differentiate patients who will undergo hip or knee total joint arthroplasty (TJA) in a cohort of patients with osteoarthritis.

METHODS

A retrospective cohort of new patients consulting for treatment from November 17, 2017 to April 20, 2020 (cases: hip: n = 157, knee: n = 112; randomly selected nonsurgical controls: hip: n = 314, knee: n = 224) was extracted from the electronic health record. We recorded demographics, comorbidity, and PROMIS scores for 8 domains (physical function, pain interference, pain intensity, anxiety, depression, sleep disturbance, ability to participate in social roles and activities, and fatigue). We performed descriptive statistics to characterize the cohorts and baseline PROMIS scores and conducted logistic regression models to determine which PROMIS domains differentiated patients undergoing hip and knee TJA.

RESULTS

In univariate comparisons of PROMIS domains, the hip and knee surgical cohorts differed from controls in physical function (P < .01), pain interference (P < .01), and ability to participate in social roles and activities (P < .02). In logistic regression models informed by univariate analyses, PROMIS physical function was the only PROMIS measure to differentiate undergoing surgery in both hip and knee cohorts (P < .01).

CONCLUSION

PROMIS physical function can differentiate TJA cases from nonsurgical controls in both hip and knee patients. These findings have implications for considering which PROMIS measures to administer in patients with hip and knee osteoarthritis.

Willingness to Have Total Knee Arthroplasty in Rural Areas of Northern China

OBJECTIVE

To evaluate willingness and its potential predictors to have total knee arthroplasty (TKA) among residents in rural areas of northern China.

METHODS

Data were collected from two population-based studies on osteoarthritis (OA) in northern China. Residents aged ≥ 50 years in randomly selected rural communities were recruited using a cluster survey method. Participants completed a home interview (including social-demographic characteristics, clinical information, 12-Item Short Form Health Surveys [SF-12], and Visual Analog Scale [VAS] of knee pain), a physical examination, and bilateral weight-bearing posteroanterior semi-flexed view of radiographs of knees. Willingness to have TKA was queried by asking: "If you need to undergo total knee arthroplasty as judged by orthopaedic surgeons, are you willing to accept this operation?" Two trained investigators read all radiographs independently and reached an acceptable intra-reader agreement. We fitted univariate and multivariate regressions adjusting for potential confounders to examine predictors of willingness to have TKA stratified by sex.

RESULTS

A total of 2172 participants were included. The overall rate of willingness to have TKA was 33.8%. Men were more likely to be willing to have TKA than women with an odds ratio (OR) of 0.73 (95% confidence interval [CI]: 0.60-0.89, P = 0.002). A higher household income (OR: 2.34 for men and 1.77 for women, both P < 0.001), higher SF-12 Physical Component Summary (PCS) score (OR: 1.02 for both gender, P = 0.04 for men and P = 0.01 for women), and being aware of TKA (OR: 2.55 for men and 2.65 for women, both P < 0.001) were associated with a higher willingness to have TKA. Other predictors of higher willingness to have TKA were younger age (OR: 0.66 for 60-70 years, P = 0.01; and 0.48 for >70 years, P = 0.003, respectively) and lower level of physical activity (OR: 0.57 for moderate, p = 0.04; and 0.62 for heavy, p = 0.04, respectively) among men and a higher education (OR: 1.45 for Junior school, P = 0.04; and 1.66 for high school and above, P = 0.02, respectively) and being overweight among women (OR: 1.38, P = 0.008), respectively. No significant difference was observed between willingness to have TKA and frequent knee pain, VAS of knee pain and Kellgren and Lawrence grades in both men and women.

CONCLUSIONS

The willingness to have TKA among rural residents of northern China was relatively low. Younger age, women, educational level, household income, physical function, and awareness of TKA were positively associated with willingness to have TKA.

Socioeconomic Status Impacts Access to Orthopaedic Specialty Care

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Financial, personal, and structural barriers affect access to all aspects of orthopaedic specialty care.

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Disparities in access to care are present across all subspecialties of orthopaedic surgery in the United States.

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Improving timely access to care in orthopaedic surgery is crucial for both health equity and optimizing patient outcomes.

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Options for improving orthopaedic access include increasing Medicaid/Medicare payments to physicians, providing secondary resources to assist patients with limited finances, and reducing language barriers in both clinical care and patient education.

Telerehabilitation of acute musculoskeletal multi-disorders: prospective, single-arm, interventional study

Background

Acute musculoskeletal (MSK) pain is very common and associated with impaired productivity and high economic burden. Access to timely and personalized, evidence-based care is key to improve outcomes while reducing healthcare expenditure. Digital interventions can facilitate access and ensure care scalability.

Objective

Present the feasibility and results of a fully remote digital care program (DCP) for acute MSK conditions affecting several body areas.

Methods

Interventional single-arm study of individuals applying for digital care programs for acute MSK pain. Primary outcome was the mean change between baseline and end-of-program in self-reported Numerical Pain Rating Scale (NPRS) score and secondary outcomes were change in analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI-GH) and engagement.

Results

Three hundred forty-three patients started the program, of which 300 (87.5%) completed the program. Latent growth curve analysis (LGCA) revealed that changes in NPRS between baseline and end-of-program were both statistically (p < 0.001) and clinically significant: 64.3% reduction (mean − 2.9 points). Marked improvements were also noted in all secondary outcomes: 82% reduction in medication intake, 63% reduction in surgery intent, 40% in fear-avoidance beliefs, 54% in anxiety, 58% in depression and 79% recovery in overall productivity. All outcomes had steeper improvements in the first 4 weeks, which paralleled higher engagement in this period (3.6 vs 3.2 overall weekly sessions, p < 0.001). Mean patient satisfaction score was 8.7/10 (SD 1.26).

Strengths and limitations

This is the first longitudinal study demonstrating the feasibility of a DCP for patients with acute MSK conditions involving several body areas. Major strengths of this study are the large sample size, the wide range of MSK conditions studied, the breadth of outcomes measured, and the very high retention rate and adherence level. The major limitation regards to the absence of a control group.

Conclusions

We observed very high completion and engagement rates, as well as clinically relevant changes in all health-related outcomes and productivity recovery. We believe this DCP holds great potential in the delivery of effective and scalable MSK care.

Trial registration

NCT, NCT04092946. Registered 17/09/2019;

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04891-5.

Characteristics associated between the incidence of hip osteoarthritis and early hip complaints (CHECK study) within 10 years

OBJECTIVE

To determine which baseline characteristics, especially clinically variables like pain, stiffness, physical functioning and disease variables, are associated with incident hip OA within 10 years in first presenters with hip complaints. Rheumatology key messages History taking and not physical exam variables are associated with incident hip osteoarthritis. Specific questions about daily life activities are associated with incident hip OA. These questions are about pain while walking/shopping, difficulties putting socks on/off and rising from bed.

METHODS

Data were obtained from the nationwide prospective Cohort Hip and Cohort Knee (CHECK) study (n = 1002). Incident hip OA was defined as fulfilling the clinical ACR criteria for hip OA, a Kellgren and Lawrence score ≥2 with hip pain, or received a hip replacement during follow-up. Baseline measurements were used of participants with hip complaints and without hip OA. Principal component analysis (PCA) was used to reduce the number of correlated variables. Associations between baseline characteristics (including PCA components) and incident hip OA were investigated using logistic regression analysis, adjusted for age, sex and BMI.

RESULTS

In total, 312 participants (85% female and 98% Caucasian) were included, 181 developed hip OA. PCA resulted in four components. Incident hip OA was associated with (i) component 1 (general presence of pain and symptoms) [odds ratio (OR) = 1.46 (95%CI: 1.08, 1.98)], (ii) component 3 (relatively high levels of pain during shopping/walking combined with less difficulty with putting socks on/off and rising from bed) [OR = 1.58 (95%CI: 1.18, 2.12)] and (iii) knee pain [OR = 0.34 (95% CI: 0.17, 0.66)].

CONCLUSION

In first presenters with hip complaints, use of a few history-taking variables might allow better recognition of those at higher odds for incident hip OA within 10 years.

The role of pain and walking difficulties in shaping willingness to undergo joint surgery for osteoarthritis: Data from the Swedish BOA register

Objectives

To investigate whether the association between pain intensity and willingness to undergo surgery is explained by walking difficulties, in patients with knee or hip osteoarthritis (OA).

Methods

This is an observational study using data from the Better management of patients with Osteoarthritis (BOA) register, which collects data from a publicly financed self-management programme for people with OA in Sweden. We included all patients with knee or hip OA who attended the baseline visit between 2008 and 2016. We conducted separate mediation analyses within a counterfactual framework to estimate the mediation effect of walking difficulties (yes/no) on willingness to undergo surgery (yes/no) for each one-point increase in pain (0-10 on a numeric rating scale), adjusted for relevant confounders.

Results

We included 72,131 patients (69% women, mean age 66, mean pain 5.4, 81% had walking difficulties, 27% was willing to undergo surgery). A one-point increase in pain intensity was associated with 1.53 (95% CI: 1.51; 1.55) higher odds of being willing to undergo surgery. Walking difficulties mediated 10%-25% of the effect of one-point increase in pain when pain was <8/10, while at pain ≥8/10 this percentage decreased to 3%.

Conclusions

More than 80% of the BOA patients have mild to moderate pain (<8/10) and walking difficulties can mediate up to a quarter of the total effect of pain on the willingness to undergo surgery in these patients. Trials to evaluate the potential to lower surgery demand by reducing walking difficulties in people with these characteristics are needed.

Willingness to Undergo Joint Surgery Following a First-Line Intervention for Osteoarthritis: Data From the Better Management of People With Osteoarthritis Register

OBJECTIVE

To assess the proportion of participants reconsidering their willingness to undergo surgery after 3 and 12 months. Secondary aims were to analyze and compare the characteristics of individuals willing and unwilling to undergo joint surgery for osteoarthritis (OA) before a first-line intervention, and to study the association between pain intensity, walking difficulties, self-efficacy, and fear of movement with the willingness to undergo surgery.

METHODS

This was an observational study based on Swedish register data. We included 30,578 individuals with knee or hip OA who participated in a first-line intervention including education and exercise.

RESULTS

Individuals willing to undergo surgery at baseline showed a higher proportion of men (40% versus 27%) and more severe symptoms and disability. Respectively, 45% and 30% of the individuals with knee and hip OA who were willing to undergo surgery at baseline became unwilling after the intervention. At the end of the study period (12 months), 35% and 19% of those with knee and hip OA, respectively, who were willing to undergo surgery at baseline became unwilling. High pain intensity, walking difficulties, and fear of movement were associated with higher odds of being willing to undergo surgery at both follow-ups, while increased self-efficacy showed the opposite association.

CONCLUSION

A first-line intervention for OA is associated with reduced willingness to undergo surgery, with a greater proportion among patients with knee OA than hip OA. Due to its temporal variability, willingness to undergo surgery should be used with care to deem surgery eligibility.

Socioeconomic status and occurrence of chronic pain: a meta-analysis

OBJECTIVE

To examine the association between socioeconomic status (SES) and the occurrence of chronic pain, defined as pain that persists or recurs for >3 months.

METHODS

We performed a structured search in Medline, Embase, WHO Global Index Medicus and Conference Proceedings Citation Index-Science databases to identify cohort and case-control studies on chronic pain and SES and its subgroups (SES combined index, educational level, income and occupational status). We extracted study characteristics, outcome measures and measures of association and their 95% CIs. Literature search, data extraction and risk of bias assessment were conducted by two independent researchers. We performed main and subgroup meta-analyses using random-effects model, and formally assessed heterogeneity and publication bias.

RESULTS

A total of 45 studies, covering a population of ∼175 000 individuals, were meta-analysed, yielding a pooled Odds Ratio (OR) of 1.32 (95% CI: 1.21, 1.44) and 1.16 (95% CI: 1.09, 1.23) for low and medium SES levels, respectively, compared with high level. We obtained similar results in all the subgroup analyses. Heterogeneity was generally moderate to high across strata, and some evidence of publication bias for low socioeconomic status was found.

CONCLUSION

Our results support a moderate increase in the risk of chronic pain for low and medium SES when compared with high SES, a feature that remained constant in all measures of exposure or outcome used. Further prospective research on populations from developing countries are needed to confirm our findings as the studies available for this meta-analysis were carried out exclusively in developed countries.

Is Geographic Socioeconomic Disadvantage Associated with the Rate of THA in Medicare-aged Patients?

BACKGROUND

Disparities in THA use may lead to inequitable care. Prior research has focused on disparities based on individual-level and isolated socioeconomic and demographic variables. To our knowledge, the role of composite, community-level geographic socioeconomic disadvantage has not been studied in the United States. As disparities persist, exploring the potential underlying drivers of these inequities may help in developing more targeted recommendations on how to achieve equitable THA use.

QUESTIONS/PURPOSES

(1) Is geographic socioeconomic disadvantage associated with decreased THA rates in Medicare-aged patients? (2) Do these associations persist after adjusting for differences in gender, race, ethnicity, and proximity to hospitals performing THA?

METHODS

In a study with a cross-sectional design, using population-based data from five-digit ZIP codes in Maryland, USA, from July 1, 2012 to March 31, 2019, we included all inpatient and outpatient primary THAs performed in individuals 65 years of age or older at acute-care hospitals in Maryland, as reported in the Health Services Cost Review Commission database. This database was selected because it provided the five-digit ZIP code data necessary to answer our study question. We excluded THAs performed for nonelective indications. We examined the annual rate of THA in our study population for each Maryland ZIP code, adjusted for differences across areas in distributions of gender, race, ethnicity, and distance to the nearest hospital performing THAs. Four hundred fourteen ZIP codes were included, with an overall mean ± SD THA rate of 371 ± 243 per 100,000 persons 65 years or older, a rate similar to that previously reported in individuals aged 65 to 84 in the United States. Statistical significance was assessed at α = 0.05.

RESULTS

THA rates were higher in more affluent areas, with the following mean rates per 100,000 persons 65 years or older: 422 ± 259 in the least socioeconomically disadvantaged quartile, 339 ± 223 in the second-least disadvantaged, 277 ± 179 in the second-most disadvantaged, and 214 ± 179 in the most-disadvantaged quartile (p < 0.001). After adjustment for distributions in gender, race, ethnicity, and hospital proximity, we found that geographic socioeconomic disadvantage was still associated with THA rate. Compared with the least-disadvantaged quartile, the second-least disadvantaged quartile had 63 fewer THAs per 100,000 people (95% confidence interval 12 to 114), the second-most disadvantaged quartile had 136 fewer THAs (95% CI 62 to 211), and the most-disadvantaged quartile had 183 fewer THAs (95% CI 41 to 325).

CONCLUSION

Geographic socioeconomic disadvantage may be the underlying driver of disparities in THA use. Although our study does not determine the "correct" rate of THA, our findings support increasing access to elective orthopaedic surgery in disadvantaged geographic communities, compared with prior research and efforts that have studied and intervened on the basis of isolated factors such as race and gender. Increasing access to orthopaedic surgeons in disadvantaged neighborhoods, educating physicians about when surgical referral is appropriate, and educating patients from these geographic communities about the risks and benefits of THA may improve equitable orthopaedic care across neighborhoods. Future studies should explore disparities in rates of appropriate THA and the role of density of orthopaedic surgeons in an area.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Total knee replacement after high tibial osteotomy: time-to-event analysis and predictors

BACKGROUND

An important aim of high tibial osteotomy (HTO) is to prevent or delay the need for total knee replacement (TKR). We sought to estimate the frequency and timing of conversion from HTO to TKR and the factors associated with it.

METHODS

We prospectively evaluated patients with osteoarthritis (OA) of the knee who underwent medial opening wedge HTO from 2002 to 2014 and analyzed the cumulative incidence of TKR in July 2019. The presence or absence of TKR on the HTO limb was identified from the orthopedic surgery reports and knee radiographs contained in the electronic medical records for each patient at London Health Sciences Centre. We used cumulative incidence curves to evaluate the primary outcome of time to TKR. We used multivariable Cox proportional hazards analysis to assess potential preoperative predictors including radiographic disease severity, malalignment, correction size, pain, sex, age, body mass index (BMI) and year of surgery.

RESULTS

Among 556 patients who underwent 643 HTO procedures, the cumulative incidence of TKR was 5% (95% confidence interval [CI] 3%-7%) at 5 years and 21% (95% CI 17%-26%) at 10 years. With the Cox proportional hazards multivariable model, the following preoperative factors were significantly associated with an increased rate of conversion: radiographic OA severity (adjusted hazard ratio [HR] 1.96, 95% CI 1.12-3.45), pain (adjusted HR 0.85, 95% CI 0.75-0.96)], female sex (adjusted HR 1.67, 95% CI 1.08-2.58), age (adjusted HR 1.50 per 10 yr, 95% CI 1.17-1.93) and BMI (adjusted HR 1.31 per 5 kng/m2, 95% CI 1.12-1.53).

INTERPRETATION

We found that 79% of knees did not undergo TKR within 10 years after undergoing medial opening wedge HTO. The strongest predictor of conversion to TKR is greater radiographic disease at the time of HTO.

The Relationship between Patient-Reported Readiness for Total Knee Arthroplasty and Likelihood of a Good Outcome at One Year

OBJECTIVE

To determine the relationship between patients' pre-operative readiness for total knee arthroplasty (TKA) and surgical outcome at one-year.

METHODS

This prospective cohort study recruited knee osteoarthritis (OA) patients aged 30+ years referred for TKA at two hip/knee surgery centers in Alberta, Canada. Those who received primary, unilateral TKA completed questionnaires pre-TKA to assess WOMAC-pain, KOOS-physical function, Perceived Arthritis Coping Efficacy, General Self-Efficacy, PHQ-8, BMI, comorbidities and TKA readiness (Patient Acceptable Symptom State; willingness to undergo TKA), and one-year post-TKA to assess outcomes. A good TKA outcome was defined as improved knee symptoms (OARSI-OMERACT responder criteria) AND overall satisfaction with results. Poisson regression with robust error estimation was used to estimate relative risk of a good outcome for exposures, before and after controlling for covariates.

RESULTS

Of 1,272 TKA recipients assessed at one year, 1,053 with data for our outcome were included (mean age 66.9 years (SD 8.8); 58.6% female). Most (87.8%) were definitely willing to undergo TKA and had 'unacceptable' knee symptoms (79.7%). 78.1% achieved a good TKA outcome. Controlling for pre-TKA OA-related disability, arthritis coping efficacy, comorbid hip symptoms and depressed mood, definite willingness to undergo TKA and unacceptable knee symptoms were associated with greater likelihood of a good TKA outcome (adjusted RRs 1.18, 95% CI 1.04-1.35, and 1.14, 95% CI 1.02-1.27, respectively).

CONCLUSION

Among TKA recipients for knee OA, patients' psychological readiness and willingness for TKA were associated greater likelihood of a good outcome. Incorporation of these factors in TKA decision-making may enhance patient outcomes and appropriate use of TKA.

Concept Endpoints Informing Design Considerations for Confirmatory Clinical Trials in Osteoarthritis

OBJECTIVE

There is an unmet need for therapies that target the underlying pathophysiology of osteoarthritis (OA). However, defining appropriate measures for clinical trials of such therapies is challenging. Our objective is to propose concept clinical endpoints that directly capture clinical benefit in this setting and evaluate the feasibility of their use.

METHODS

This analysis used the multi-center, longitudinal, observational Osteoarthritis Initiative (OAI) database. OAI participants primarily had knee OA, with follow-up of up to nine years and assessments of joints, surgical interventions, performance outcomes, and patient-reported outcomes (PROs). We examined this dataset to identify existing outcome measures of direct clinical benefit. We evaluated the feasibility of conducting trials using these candidate endpoints by estimating incidence rates and resulting required sample sizes and study durations in time-to-event analyses.

RESULTS

We identified candidate endpoints based on total knee replacement (TKR) and composite endpoints defined by TKR and conservative thresholds of PROs of pain and function. Using time to TKR as an endpoint, a study with an average follow-up time of three years requires approximately 3,000 to 18,000 subjects depending on effect size. Alternatively, a composite endpoint such as 'time to TKR or severe pain or severely impaired functioning', the required sample sizes ranged from approximately 2,000 to 11,000 for a three-year study.

CONCLUSION

The proposed concept endpoints can reliably and feasibly evaluate effectiveness of therapies for this unmet need. In particular, the composite endpoint approach can substantially reduce sample sizes (up to approximately 40%) compared to the use of TKR alone.

A qualitative dominant mixed methods exploration of novel educational material for patients considering total knee arthroplasty

PURPOSE

To optimize non-operative management and decision making surrounding TKR we created educational whiteboard videos for patients with knee OA. The purpose of this study was to pilot our educational videos with end-users (patients) to determine patients' experiences and perspectives regarding the content and clarity of videos and to better understand their potential impact on patient's health behaviour. Materials and methods: This was a mixed methods evaluation, using a qualitative descriptive approach, of patients attending their first consultation with an arthroplasty surgeon for TKR. We conducted in-depth semi-structured interviews with patients. Three members of the research team coded data independently, implementing a thematic analysis. Results: Thirteen participants were included. Participants indicated that the videos enhanced their confidence and clarity surrounding their decision to undergo TKR. The videos also addressed several knowledge gaps in their understanding of OA management. Barriers to uptake of the education were identified including limited access to PTs and the challenge of weight loss. Conclusions: The current educational intervention was valued by patients with knee OA. Implementation of these videos may have important implications for patients, providers, and our health care system.IMPLICATIONS FOR REHABILITATIONPatients with knee OA referred by primary care physicians to arthroplasty surgeons have knowledge gaps that may influence their self-management and decision making surrounding their condition.Educational materials can address these gaps and support patients in their understanding and management of their condition, which may have important downstream implications.Barriers to accessing non-operative care including physiotherapy must be pre-emptively addressed to ensure that enhanced knowledge is met with improved access for patients.

Developing prediction models for total knee replacement surgery in patients with osteoarthritis: Statistical analysis plan

Background

Approximately 12-20% of those with osteoarthritis (OA) in Australia who undergo total knee replacement (TKR) surgery do not report any clinical improvement. There is a need to develop prediction tools for use in general practice that allow early identification of patients likely to undergo TKR and those unlikely to benefit from the surgery. First-line treatment strategies can then be implemented and optimised to delay or prevent the need for TKR. The identification of potential non-responders to TKR may provide the opportunity for new treatment strategies to be developed and help ensure surgery is reserved for those most likely to benefit. This statistical analysis plan (SAP) details the statistical methodology used to develop such prediction tools.

Objective

To describe in detail the statistical methods used to develop and validate prediction models for TKR surgery in Australian patients with OA for use in general practice.

Methods

This SAP contains a brief justification for the need for prediction models for TKR surgery in general practice. A description of the data sources that will be linked and used to develop the models, and estimated sample sizes is provided. The planned methodologies for candidate predictor selection, model development, measuring model performance and internal model validation are described in detail. Intended table layouts for presentation of model results are provided.

Conclusion

Consistent with best practice guidelines, the statistical methodologies outlined in this SAP have been pre-specified prior to data pre-processing and model development.

"I've been to physical therapy before, but not for the knees." A qualitative study exploring barriers and facilitators to physical therapy utilization for knee osteoarthritis

BACKGROUND

Physical therapy (PT) is recommended to reduce pain and improve function. However, only 10%-15% of adults with knee osteoarthritis (OA) use PT in the United States. The purpose of this study was to explore patient-reported barriers and facilitators to PT utilization for knee OA, to understand why PT is underutilized.

METHODS

Qualitative descriptive study using semi-structured interviews was conducted, that is, one-on-one phone interviews with adults from local community centers. Participants were eligible if they were fluent in English and self-reported knee OA (1) over 45 years of age, (2) have activity-related knee pain, and (3) have no morning stiffness or morning stiffness in the knee(s) for ≤30 min. Interviews were audio-recorded and transcribed. To identify barriers and facilitators to PT utilization for knee OA, a coding framework, thematic analysis, and a constant comparative approach were used.

RESULTS

Of 22 participants with health insurance and who participated, 59% were considering PT, 23% refused PT, and 18% used PT for knee OA. Themes identified as either barriers or facilitators for participants were (1) previous experience with PT, (2) physician referral, (3) beliefs about treatment efficacy before and after knee replacement surgery, (4) insurance coverage, and (5) preference to avoid surgery.

CONCLUSION

A previous positive encounter with PT and a physician referral may facilitate PT utilization for adults with knee OA. Knowledge about and access to PT services were not identified as barriers related to PT utilization. Further research is necessary to confirm findings in a broader group of adults with knee OA.

The risk factors for early conversion to total knee arthroplasty after high tibial osteotomy

The primary aim was to identify potential risk factors for early conversion to total knee arthroplasty (TKA) in patients with high tibial osteotomy (HTO) surgery. A retrospective study was conducted and 240 patients received HTO surgery between January 2008 and January 2014 were included in this study. The associations between different clinical factors and HTO survivorship were analyzed. A logistic regression analysis was performed to detect independent risk factors for HTO survivorship. The cut-off value, sensitivity and specificity of these independent factors were calculated by receiver operating characteristic (ROC) curve. In this study, thirty-five (14.6%) patients were early conversion to TKA within a 5-year follow-up. These results indicated that age, body mass index (BMI), preoperative Kellgren-Lawrence (K-L) grade and preoperative visual analogue scale (VAS) score were potential risk factors for HTO survivorship. The cut-off values of those factors were 60 years, 25.35 kg/m2, 2 and 5, respectively. The combination of age, BMI, preoperative K-L grade and preoperative VAS score has the highest predictive value for HTO survivorship (AUC = 0.896, P < 0.001). Based on the present study, the five-year HTO survivorship for the treatment of medial compartment osteoarthritis of the knee was approximately 85.4%. We identified age >60 years, BMI >25.35 kg/m2, preoperative K-L grade >2 and preoperative VAS score >5 as independent risk factors for early conversion to TKA in patients with HTO surgery, and those factors combined had the highest predictive value for predicting early conversion to TKA.

The association between socioeconomic status and joint replacement of the hip and knee: A population-based cohort study of older adults in Tasmania

BACKGROUND

A socioeconomic gradient exists in the utilisation of total hip replacements (THR) and total knee replacements (TKR) for osteoarthritis. However, the relations between socioeconomic status (SES) and time to THR or TKR is unknown.

AIM

To describe the association between SES and time to THR and TKR.

METHODS

1072 older-adults residing in Tasmania, Australia were studied. Incident primary THR and TKR were determined by data linkage to the Australian Orthopaedic Association National Joint Replacement Registry. At baseline, each participant's area-level SES was determined by the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD), from the Australian Bureau of Statistics' 2001 census data. IRSAD was analysed in two ways; 1) categorised into quartiles, whereby quartile 1 represented the most socioeconomically disadvantaged group, 2) the cohort dichotomised at the quartile 1 cut-point.

RESULTS

The mean age was 63.0 (±7.5) years, and 51% were women. Over the median follow-up of 12.9 (Interquartile range: 12.2-13.9) years, 56 (5%) participants had a THR, and 79 (7%) had a TKR. Compared to the most disadvantaged quartile, less disadvantaged participants were less likely to have a THR (i.e. less disadvantaged participants had a longer time to THR) (HR: 0.56, 95% CI 0.32, 1.00) but not TKR (HR: 0.90, 95% CI 0.53, 1.54). However, the former became non-significant after adjustment for pain and radiographic osteoarthritis, suggesting that the associations may be mediated by these factors.

CONCLUSIONS

This study suggests that time to joint replacement was determined according to the symptoms/need of the participants rather than their SES. This article is protected by copyright. All rights reserved.

Regional variation in hip and knee arthroplasty rates in Switzerland: A population-based small area analysis

Background

Compared to other OECD countries, Switzerland has the highest rates of hip (HA) and knee arthroplasty (KA).

Objective

We assessed the regional variation in HA/KA rates and potential determinants of variation in Switzerland.

Methods

We conducted a population-based analysis using discharge data from all Swiss hospitals during 2013–2016. We derived hospital service areas (HSAs) by analyzing patient flows. We calculated age-/sex-standardized procedure rates and measures of variation (the extremal quotient [EQ, highest divided by lowest rate] and the systemic component of variation [SCV]). We estimated the reduction in variance of HA/KA rates across HSAs in multilevel regression models, with incremental adjustment for procedure year, age, sex, language, urbanization, socioeconomic factors, burden of disease, and the number of orthopedic surgeons.

Results

Overall, 69,578 HA and 69,899 KA from 55 HSAs were analyzed. The mean age-/sex-standardized HA rate was 265 (range 179–342) and KA rate was 256 (range 186–378) per 100,000 persons and increased over time. The EQ was 1.9 for HA and 2.5 for KA. The SCV was 2.0 for HA and 2.2 for KA, indicating a low variation across HSAs. When adjusted for procedure year and demographic, cultural, and sociodemographic factors, the models explained 75% of the variance in HA and 63% in KA across Swiss HSAs.

Conclusion

Switzerland has high HA/KA rates with a modest regional variation, suggesting that the threshold to perform HA/KA may be uniformly low across regions. One third of the variation remained unexplained and may, at least in part, represent differing physician beliefs and attitudes towards joint arthroplasty.

Which disease-related factors influence patients' and physicians' willingness to consider joint replacement in hip and knee OA? Results of a questionnaire survey linked to claims data

Background

A great heterogeneity in total joint replacement (TJR) rates has been reported for osteoarthritis (OA), most likely arising from a gap between patients’ and physicians’ views on the need for TJR. The purpose of this study therefore was to analyze potential cofactors which might influence the desire of patients to undergo TJR and physicians’ willingness to discuss surgery with their patients.

Methods

A total of 8995 patients in Germany with a claims data diagnosis of hip or knee OA or polyarthrosis were asked to complete a questionnaire for this cross-sectional study of sociodemographic factors, indicators of current joint function (WOMAC score), willingness to undergo TJR and whether they had already discussed TJR with a physician. The overall response rate was 40%. Responders with polyarthrosis and individuals without current or chronic symptoms in the corresponding joints, pain in already replaced joints or simultaneous symptomatic hip and knee OA were excluded. We linked the survey results to claims data. Separate logistic regression models were used to assess which parameters were associated with patients’ willingness to undergo TJR and physicians’ discussion of surgery.

Results

We analyzed 478 hip OA and 932 knee OA patients. Just 17% with hip OA and 14% with knee OA were willing to undergo TJR, although 44 and 45% had already discussed surgery with their physicians.

Patients’ willingness was associated with higher WOMAC scores, a deterioration of symptoms over the last 2 years, and previous TJR for another joint. The discussion with a physician was influenced by the impact on personal life and previous arthroplasty. Older age (odds Ratio (OR) 1.2 per 10 years), male sex (OR 0.69 vs female), longer symptom duration (OR 1.08 per 5 years), deterioration of symptoms (OR 2.0 vs no change/improvement), a higher WOMAC score (OR 1.3 per 10% deterioration) and reduced well-being (OR 1.1 per 10% deterioration) were associated with physician discussion in knee OA patients.

Conclusions

The proportion of patients willing to undergo TJR is lower than the proportion in whom physicians discuss surgery. While previous TJR seems to enhance patients’ and surgeons’ willingness, the influence of other cofactors is heterogeneous.

Predictors of a change in patient willingness to have Total knee arthroplasty: Insights from the osteoarthritis initiative

BACKGROUND

While many factors have been shown to influence patient willingness to have total joint arthroplasty, factors associated with changes in patient willingness to have arthroplasty have not been studied. The objective of this research is to identify predictors of change in patient willingness to have total knee arthroplasty (TKA).

METHODS

Patient willingness to have TKA as well as questionnaire, clinical, and radiographic data, were obtained from the Osteoarthritis Initiative (OAI) for individuals with, or at high risk for developing knee OA. Mixed effects ordinal logistic regressions were employed to assess the relationships between 40 predictors and change in willingness to have surgery. Predictors significant in univariate models were included in a multivariable analysis.

RESULTS

Three thousand three hundred and ninety-four OAI patients were included in our analysis. Between baseline and follow-up, 462 (13.6%) became more willing and 533 (15.7%) became less willing to have TKA. After controlling for demographic factors in multivariable analysis, patients with higher income and expected difficulty with postoperative walking were more likely to increase their willingness to have TKA. General health, race, and knee injections within the past six months approached significance with regard to increasing willingness to have TKA over time.

CONCLUSION

Income and expectations of difficulty walking postoperatively were significantly associated with changes in patient willingness to have TKA independent of age, sex, health coverage, employment, marriage status, and knee pain. Understanding factors influencing patient willingness to have surgery may be instrumental in counseling and addressing the mismatch of OA disease burden to surgical utilization.

Deep Learning Predicts Total Knee Replacement from Magnetic Resonance Images

Knee Osteoarthritis (OA) is a common musculoskeletal disorder in the United States. When diagnosed at early stages, lifestyle interventions such as exercise and weight loss can slow OA progression, but at later stages, only an invasive option is available: total knee replacement (TKR). Though a generally successful procedure, only 2/3 of patients who undergo the procedure report their knees feeling “normal” post-operation, and complications can arise that require revision. This necessitates a model to identify a population at higher risk of TKR, particularly at less advanced stages of OA, such that appropriate treatments can be implemented that slow OA progression and delay TKR. Here, we present a deep learning pipeline that leverages MRI images and clinical and demographic information to predict TKR with AUC 0.834 ± 0.036 (p < 0.05). Most notably, the pipeline predicts TKR with AUC 0.943 ± 0.057 (p < 0.05) for patients without OA. Furthermore, we develop occlusion maps for case-control pairs in test data and compare regions used by the model in both, thereby identifying TKR imaging biomarkers. As such, this work takes strides towards a pipeline with clinical utility, and the biomarkers identified further our understanding of OA progression and eventual TKR onset.

Mapping the Diffusion of Technology in Orthopaedic Surgery: Understanding the Spread of Arthroscopic Rotator Cuff Repair in the United States

BACKGROUND

The mechanism by which surgical innovation is spread in orthopaedic surgery is not well studied. The recent widespread transition from open to arthroscopic rotator cuff repair techniques provides us with the opportunity to study the spread of new technology; doing so would be important because it is unclear how novel orthopaedic techniques disseminate across time and geography, and previous studies of innovation in healthcare may not apply to the orthopaedic community.

QUESTIONS/PURPOSES

(1) How much regional variation was associated with the adoption of arthroscopic rotator cuff repair in the United States Medicare population between 2006 and 2014 and how did this change over time? (2) In which regions of the United States was arthroscopic rotator cuff repair first adopted and how did it spread geographically? (3) Which regional factors were associated with the adoption of this new technology?

METHODS

We divided the United States into 306 hospital referral regions based upon referral patterns observed in the Centers for Medicare & Medicaid Services MedPAR database, which records all Medicare hospital admissions; this has been done in numerous previous studies using methodology introduced by the Dartmouth Atlas. The proportion of arthroscopic rotator cuff repairs versus open rotator cuff repairs in each hospital referral region was calculated using adjusted procedural rates from the Medicare Part B Carrier File from 2006 to 2014, as it provided a nationwide sample of patients, and was used as a measure of adoption. A population-weighted, multivariable linear regression analysis was used to identify regional characteristics independently associated with adoption.

RESULTS

There was substantial regional variation associated with the adoption of arthroscopy for rotator cuff repair as the percentage of rotator cuff repair completed arthroscopically in 2006 ranged widely among hospital referral regions with a high of 85.3% in Provo, UT, USA, and a low of 16.7% in Seattle, WA, USA (OR 30, 95% CI 17.6 to 52.2; p < 0.001). In 2006, regions in the top quartiles for Medicare spending (+9.1%; p = 0.008) independently had higher adoption rates than those in the bottom quartile, as did regions with a greater proportion of college-educated residents (+12.0%; p = 0.009). The Northwest region (-14.4%; p = 0.009) and the presence of an academic medical center (-5.8%; p = 0.026) independently had lower adoption than other regions and those without academic medical centers. In 2014, regions in the top quartiles for Medicare spending (+5.7%; p = 0.033) and regions with a greater proportion of college-educated residents (+9.4%; p = 0.005) independently had higher adoption rates than those in the bottom quartiles, while the Northwest (-9.6%; p = 0.009) and Midwest regions (-5.1%; p = 0.017) independently had lower adoption than other regions.

CONCLUSION

The heterogeneous diffusion of arthroscopic rotator cuff repair across the United States highlights that Medicare beneficiaries across regions did not have equal access to these procedures and that these discrepancies continued to persist over time. A higher level of education and increased healthcare spending were both associated with greater adoption in a region and conversely suggest that regions with lower education and healthcare spending may pursue innovation more slowly. There was evidence that regions with academic medical centers adopted this technology more slowly and may highlight the role that private industry and physicians in nonacademic organizations play in surgical innovation. Future studies are needed to understand if this later adoption leads to inequalities in the quality and value of surgical care delivered to patients in these regions.

LEVEL OF EVIDENCE

Level III, therapeutic study.