Clinical improvement and satisfaction after total joint replacement: a prospective 12-month evaluation on the patients' perspective

Patient acceptable symptom state and treatment failure threshold values for work productivity and activity Impairment and EQ-5D-5L in osteoarthritis

OBJECTIVE

To estimate patient acceptable symptom state (PASS) and treatment failure (TF) threshold values for Work Productivity and Activity Impairment (WPAI) measure and EQ-5D-5L among people with hip or knee osteoarthritis (OA) 3 and 12 months following participation in a digital self-management intervention (Joint Academy®).

METHODS

Among the participants, we computed work and activity impairments scores (both 0-100, with a higher value reflecting higher impairment) and the Swedish hypothetical- (range: - 0.314 to 1) and experience-based (range: 0.243-0.976) EQ-5D-5L index scores (a higher score indicates better health status) at 3- (n = 14,607) and 12-month (n = 2707) follow-ups. Threshold values for PASS and TF were calculated using anchor-based adjusted predictive modeling. We also explored the baseline dependency of threshold values according to pain severity at baseline.

RESULTS

Around 42.0% and 48.3% of the participants rated their current state as acceptable, while 4.2% and 2.8% considered the treatment had failed at 3 and 12 months, respectively. The 3-month PASS/TF thresholds were 16/29 (work impairment), 26/50 (activity impairment), 0.92/0.77 (hypothetical EQ-5D-5L), and 0.87/0.77 (the experience-based EQ-5D-5L). The thresholds at 12 months were generally comparable to those estimated at 3 months. There were baseline dependencies in PASS/TF thresholds with participants with more severe baseline pain considering poorer (more severe) level of WPAI/EQ-5D-5L as satisfactory.

CONCLUSION

PASS and TF threshold values for WPAI and EQ-5D-5L might be useful for meaningful interpretation of these measures among people with OA. The observed baseline dependency of estimated thresholds limits their generalizability and values should be applied with great caution in other settings/populations.

Who Benefits From Hip Arthroplasty or Knee Arthroplasty? Preoperative Patient-reported Outcome Thresholds Predict Meaningful Improvement

BACKGROUND

Hip arthroplasty (HA) and knee arthroplasty (KA) are high-volume procedures. However, there is a debate about the quality of indication; that is, whether surgery is truly indicated in all patients. Patient-reported outcome measures (PROMs) may be used to determine preoperative thresholds to differentiate patients who will likely benefit from surgery from those who will not.

QUESTIONS/PURPOSES

(1) What were the minimum clinically important differences (MCIDs) for three commonly used PROMs in a large population of patients undergoing HA or KA treated in a general orthopaedic practice? (2) Do patients who reach the MCID differ in important ways from those who do not? (3) What preoperative PROM score thresholds best distinguish patients who achieve a meaningful improvement 12 months postsurgery from those who do not? (4) Do patients with preoperative PROM scores below thresholds still experience gains after surgery?

METHODS

Between October 1, 2019, and December 31, 2020, 4182 patients undergoing HA and 3645 patients undergoing KA agreed to be part of the PROMoting Quality study and were hence included by study nurses in one of nine participating German hospitals. From a selected group of 1843 patients with HA and 1546 with KA, we derived MCIDs using the anchor-based change difference method to determine meaningful improvements. Second, we estimated which preoperative PROM score thresholds best distinguish patients who achieve an MCID from those who do not, using the preoperative PROM scores that maximized the Youden index. PROMs were Hip Disability and Osteoarthritis Outcome Score-Physical Function short form (HOOS-PS) (scored 0 to 100 points; lower indicates better health), Knee Injury and Osteoarthritis Outcome Score-Physical Function short form (KOOS-PS) (scored 0 to 100 points; lower indicates better health), EuroQol 5-Dimension 5-level (EQ-5D-5L) (scored -0.661 to 1 points; higher indicates better health), and a 10-point VAS for pain (perceived pain in the joint under consideration for surgery within the past 7 days) (scored 0 to 10 points; lower indicates better health). The performance of derived thresholds is reported using the Youden index, sensitivity, specificity, F1 score, geometric mean as a measure of central tendency, and area under the receiver operating characteristic curve.

RESULTS

MCIDs for the EQ-5D-5L were 0.2 for HA and 0.2 for KA, with a maximum of 1 point, where higher values represented better health-related quality of life. For the pain scale, they were -0.9 for HA and -0.7 for KA, of 10 points (maximum), where lower scores represent lower pain. For the HOOS-PS, the MCID was -10, and for the KOOS-PS it was -5 of 100 points, where lower scores represent better functioning. Patients who reached the MCID differed from patients who did not reach the MCID with respect to baseline PROM scores across the evaluated PROMs and for both HA and KA. Patients who reached an MCID versus those who did not also differed regarding other aspects including education and comorbidities, but this was not consistent across PROMs and arthroplasty type. Preoperative PROM score thresholds for HA were 0.7 for EQ-5D-5L (Youden index: 0.55), 42 for HOOS-PS (Youden index: 0.27), and 3.5 for the pain scale (Youden index: 0.47). For KA, the thresholds were 0.6 for EQ-5D-5L (Youden index: 0.57), 39 for KOOS-PS (Youden index: 0.25), and 6.5 for the pain scale (Youden index: 0.40). A higher Youden index for EQ-5D-5L than for the other PROMs indicates that the thresholds for EQ-5D-5L were better for distinguishing patients who reached a meaningful improvement from those who did not. Patients who did not reach the thresholds could still achieve MCIDs, especially for functionality and the pain scale.

CONCLUSION

We found that patients who experienced meaningful improvements (MCIDs) mainly differed from those who did not regarding their preoperative PROM scores. We further identified that patients undergoing HA or KA with a score above 0.7 or 0.6, respectively, on the EQ-5D-5L, below 42 or 39 on the HOOS-PS or KOOS-PS, or below 3.5 or 6.5 on a 10-point joint-specific pain scale presurgery had no meaningful benefit from surgery. The thresholds can support clinical decision-making. For example, when thresholds indicate that a meaningful improvement is not likely to be achieved after surgery, other treatment options may be prioritized. Although the thresholds can be used as support, patient preferences and medical expertise must supplement the decision. Future studies might evaluate the utility of using these thresholds in practice, examine how different thresholds can be combined as a multidimensional decision tool, and derive presurgery thresholds based on additional PROMs used in practice.

CLINICAL RELEVANCE

Preoperative PROM score thresholds in this study will support clinicians in decision-making through objective measures that can improve the quality of the recommendation for surgery.

The Relationship between Western Ontario and McMaster Universities Osteoarthritis Index Score and Satisfaction after Total Knee Arthroplasty Changes Over Time

This study aimed to determine whether there was a relationship between preoperative patient-reported outcome measures (PROMs) and satisfaction after total knee arthroplasty (TKA), and whether there was a relationship between the amount of improvement in PROM or final PROM and satisfaction and whether that relationship differed 1 and 2 years after TKA. The Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and satisfaction of 267 limbs who underwent TKA were analyzed. Logistic regression analysis was performed to determine whether there was a relationship between preoperative WOMAC or improvement in WOMAC or final WOMAC and satisfaction at 1 and 2 years after TKA. Pearson and Filon's z test was performed to determine whether there was a difference in evaluating satisfaction between the amount of improvement in WOMAC and final WOMAC. There was no significant relationship between preoperative WOMAC and satisfaction. A higher improvement in WOMAC total score and better final WOMAC total scores at 1 and 2 years after TKA were related to greater satisfaction. At 1 year after TKA, there was no significant difference in evaluating satisfaction between the amount of improvement in WOMAC and final WOMAC. However, 2 years after TKA, the final WOMAC function and total score were more related to satisfaction than the amount of improvement in WOMAC function and total score. In the early postoperative period, there was no difference in evaluating satisfaction between the amount of improvement in WOMAC and final WOMAC, whereas over time, the final WOMAC was more related to satisfaction.

Intersurgeon Variability of Minimal Clinically Important Difference for Worsening Achievement Rates After Total Joint Arthroplasty

BACKGROUND

Using the Patient-Reported Outcome Measurement Information System, we sought to evaluate surgeon performance variability via minimal clinically important difference for worsening (MCID-W) achievement rates in primary and revision total knee and hip arthroplasty.

METHODS

This retrospective study analyzed 3,496 primary total hip arthroplasty (THA), 4,622 primary total knee arthroplasty (TKA), 592 revision THA, and 569 revision TKA patients. Patient factors collected included demographics, comorbidities, and Patient-Reported Outcome Measurement Information System physical function short form 10a scores. Surgeon factors collected included caseload, years of experience, and fellowship training. The MCID-W rate was calculated as the percent of patients in each surgeon's cohort who achieved MCID-W. Distribution was presented via a histogram with associated average, standard deviation, range, and interquartile range (IQR). Linear regressions were performed to evaluate the potential correlation between surgeon- and patient-level factors with MCID-W rate.

RESULTS

The average MCID-W rates of the surgeons represented in the primary THA and TKA cohorts were 12.7 ± 9.2% (range, 0 to 35.3%; IQR, 6.7 to 15.5%) and 18.0 ± 8.2% (range, 0 to 36%; IQR, 14.3 to 22.0%). The average MCID-W rates among the revision THA and TKA surgeons were 36.0 ± 22.2% (range, 9.1 to 90%; IQR, 25.0 to 41.4%) and 21.2 ± 7.7% (range, 8.1 to 37.0%; IQR, 16.6 to 25.4%). Strong correlations were not found between patient- or surgeon-level factors and MCID-W rate of the surgeon.

CONCLUSION

We demonstrated variance in MCID-W achievement rates across surgeons in both primary and revision joint arthroplasty, independent of patient- or surgeon-level factors.

Establishing the Minimal Clinically Important Difference and Patient Acceptable Symptomatic State following Patellofemoral Inlay Arthroplasty for Visual Analog Scale Pain, Western Ontario and McMaster Universities Arthritis Index, and Lysholm Scores

BACKGROUND

The purposes of the study were to define the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after patello-femoral inlay arthroplasty (PFA) and to identify factors predictive for the achievement of clinically important outcomes (CIOs).

METHODS

A total of 99 patients who underwent PFA between 2009 and 2019 and had a minimum of 2-year postoperative follow-up were enrolled in this retrospective monocentric study. Included patients had a mean age of 44 years (range, 21 to 79). The MCID and PASS were calculated using an anchor-based approach for the visual analog scale (VAS) pain, Western Ontario and McMaster Universities Arthritis Index (WOMAC), and Lysholm patient-reported outcome measures. Factors associated with CIO achievement were determined using multivariable logistic regression analyses.

RESULTS

The established MCID thresholds for clinical improvement were -2.46 for the VAS pain score, -8.5 for the WOMAC score, and + 25.4 for the Lysholm score. Postoperative scores corresponding to the PASS were <2.55 for the VAS pain score, <14.6 for the WOMAC score, and >52.5 points for the Lysholm score. Preoperative patellar instability and concomitant medial patello-femoral ligament reconstruction were independent positive predictors of reaching both MCID and PASS. Additionally, inferior baseline scores and age were predictive of achieving MCID, whereas superior baseline scores and body mass index were predictive of achieving PASS.

CONCLUSION

This study determined the thresholds of MCID and PASS for the VAS pain, WOMAC, and Lysholm scores following PFA implantation at 2-year follow-up. The study demonstrated a predictive role of patient age, body mass index, preoperative patient-reported outcome measure scores, preoperative patellar instability, and concomitant medial patello-femoral ligament reconstruction in the achievement of CIOs.

LEVEL OF EVIDENCE

Prognostic Level IV.

Long-term health-related quality of life of total hip arthroplasty patients and cost-effectiveness analysis in the Japanese universal health insurance system

AIM

Total hip arthroplasty can effectively improve patients' motility with end-stage osteoarthritis. This study aimed to: (1) compare gradual changes in utility values with total hip arthroplasty and estimated values without; (2) evaluate total hip arthroplasty cost-effectiveness; and (3) evaluate cost-effectiveness by age, diagnosis, and comorbidity.

METHODS

Patients who underwent total hip arthroplasty between January 2008 and December 2009 were included. Patients completed the EuroQol preoperatively and at 1, 3, 5 and 7 years postoperatively. To derive the quality-adjusted life years gained, a utility score was obtained from the EuroQol item scores and combined with 7 years, and estimates were obtained by discounting the postoperative 1-year utility value at an annual rate of 2%-4%. Mixed-effects regression models were used to compare the estimated and the measured utility values.

RESULTS

Mean total cost was 1,921,849 yen, and quality-adjusted life years gain score was 1.746 with per cost as 1,100,715 yen. Compared with actual measurements, the estimated values from 1 to 7 years post-surgery differed significantly, and interaction was observed. Regarding age, the older the patient, the higher the cost per quality-adjusted life years. Patients with lower preoperative physical function had higher quality-adjusted life years gains, while the cost per quality-adjusted life years was lower.

CONCLUSIONS

Total hip arthroplasty was cost-effective. Compared with actual measurements, the estimated utility values from 1 to 7 years post-surgery significantly differed. Even among older patients and those with impaired preoperative physical functions, its cost was lower than patients' willingness to pay in Japan.

Electronic Patient-Reported Outcome Monitoring to Improve Quality of Life After Joint Replacement: Secondary Analysis of a Randomized Clinical Trial

Importance

Although remote patient-reported outcome measure (PROM) monitoring has shown promising results in cancer care, there is a lack of research on PROM monitoring in orthopedics.

Objective

To determine whether PROM monitoring can improve health outcomes for patients with joint replacement compared with the standard of care.

Design, Setting, and Participants

A 2-group, patient-level randomized clinical trial (PROMoting Quality) across 9 German hospitals recruited patients aged 18 years or older with primary hip or knee replacement from October 1, 2019, to December 31, 2020, with follow-up until March 31, 2022.

Interventions

Intervention and control groups received the standard of care and PROMs at hospital admission, discharge, and 12 months after surgery. In addition, the intervention group received PROMs at 1, 3, and 6 months after surgery. Based on prespecified PROM score thresholds, at these times, an automated alert signaled critical recovery paths to hospital study nurses. On notification, study nurses contacted patients and referred them to their physicians if necessary.

Main Outcomes and Measures

The prespecified outcomes were the mean change in PROM scores (European Quality of Life 5-Dimension 5-Level version [EQ-5D-5L; range, -0.661 to 1.0, with higher values indicating higher levels of health-related quality of life (HRQOL)], European Quality of Life Visual Analogue Scale [EQ-VAS; range, 0-100, with higher values indicating higher levels of HRQOL], Hip Disability and Osteoarthritis Outcome Score-Physical Function Shortform [HOOS-PS; range, 0-100, with lower values indicating lower physical impairment] or Knee Injury and Osteoarthritis Outcome Score-Physical Function Shortform [KOOS-PS; range, 0-100, with lower values indicating lower physical impairment], Patient-Reported Outcomes Measurement Information System [PROMIS]-fatigue [range, 33.7-75.8, with lower values indicating lower levels of fatigue], and PROMIS-depression [range, 41-79.4, with lower values indicating lower levels of depression]) from baseline to 12 months after surgery. Analysis was on an intention-to-treat basis.

Results

The study included 3697 patients with hip replacement (mean [SD] age, 65.8 [10.6] years; 2065 women [55.9%]) and 3110 patients with knee replacement (mean [SD] age, 66.0 [9.2] years; 1669 women [53.7%]). Exploratory analyses showed significantly better health outcomes in the intervention group on all PROMs except the EQ-5D-5L among patients with hip replacement, with a 2.10-point increase on the EQ-VAS in the intervention group compared with the control group (HOOS-PS, -1.86 points; PROMIS-fatigue, -0.69 points; PROMIS-depression, -0.57 points). Patients in the intervention group with knee replacement had a 1.24-point increase on the EQ-VAS, as well as significantly better scores on the KOOS-PS (-0.99 points) and PROMIS-fatigue (-0.84 points) compared with the control group. Mixed-effect models showed a significant difference in improvement on the EQ-VAS (hip replacement: effect estimate [EE], 1.66 [95% CI, 0.58-2.74]; knee replacement: EE, 1.71 [95% CI, 0.53-2.90]) and PROMIS-fatigue (hip replacement: EE, -0.65 [95% CI, -1.12 to -0.18]; knee replacement: EE, -0.71 [95% CI, -1.23 to -0.20]). The PROMIS-depression score was significantly reduced in the hip replacement group (EE, -0.60 [95% CI, -1.01 to -0.18]).

Conclusions and Relevance

In this randomized clinical trial, the PROM-based monitoring intervention led to a small improvement in HRQOL and fatigue among patients with hip or knee replacement, as well as in depression among patients with hip replacement.

Trial registration

Deutsches Register Klinischer Studien ID: DRKS00019916.

Using Presurgical Biopsychosocial Features to Develop an Advanced Clinical Decision-Making Support Tool for Predicting Recovery Trajectories in Patients Undergoing Total Knee Arthroplasty: Protocol for a Prospective Observational Study

BACKGROUND

Following total knee arthroplasty (TKA), 10% to 20% of patients report dissatisfaction with procedural outcomes. There is growing recognition that postsurgical satisfaction is shaped not only by the quality of surgery but also by psychological and social factors. Surprisingly, information on the psychological and social determinants of surgical outcomes is rarely collected before surgery. A comprehensive collection of biopsychosocial information could assist clinicians in making recommendations in relation to rehabilitation, particularly if there is robust evidence to support the ability of presurgical constructs to predict postsurgical outcomes. Clinical decision support tools can help identify factors influencing patient outcomes and support the provision of interventions or services that can be tailored to meet individuals' needs. However, despite their potential clinical benefit, the application of such tools remains limited.

OBJECTIVE

This study aims to develop a clinical decision tool that will assist with patient stratification and more precisely targeted clinical decision-making regarding prehabilitation and rehabilitation for TKA, based on the identified individual biopsychosocial needs.

METHODS

In this prospective observational study, all participants provided written or electronic consent before study commencement. Patient-completed questionnaires captured information related to a broad range of biopsychosocial parameters during the month preceding TKA. These included demographic factors (sex, age, and rurality), psychological factors (mood status, pain catastrophizing, resilience, and committed action), quality of life, social support, lifestyle factors, and knee symptoms. Physical measures assessing mobility, balance, and functional lower body strength were performed via video calls with patients in their home. Information related to preexisting health issues and concomitant medications was derived from hospital medical records. Patient recovery outcomes were assessed 3 months after the surgical procedure and included quality of life, patient-reported knee symptoms, satisfaction with the surgical procedure, and mood status. Machine learning data analysis techniques will be applied to determine which presurgery parameters have the strongest power for predicting patient recovery following total knee replacement. On the basis of these analyses, a predictive model will be developed. Predictive models will undergo internal validation, and Bayesian analysis will be applied to provide additional metrics regarding prediction accuracy.

RESULTS

Patient recruitment and data collection commenced in November 2019 and was completed in June 2022. A total of 1050 patients who underwent TKA were enrolled in this study.

CONCLUSIONS

Our findings will facilitate the development of the first comprehensive biopsychosocial prediction tool, which has the potential to objectively predict a patient's individual recovery outcomes following TKA once selected by an orthopedic surgeon to undergo TKA. If successful, the tool could also inform the evolution rehabilitation services, such that factors in addition to physical performance can be addressed and have the potential to further enhance patient recovery and satisfaction.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48801.

Non-English Speakers and Socioeconomic Minorities are Significantly Less Likely to Complete Patient-Reported Outcome Measures for Total Hip and Knee Arthroplasty: Analysis of 16,119 Cases

BACKGROUND

The Comprehensive Care for Joint Replacement requires patient-reported outcome measure (PROM) completion for total knee/hip arthroplasty (TKA/THA) patients. A 90% completion rate to avoid penalties was planned for 2023 but has been delayed. Our analysis compares TKA/THA PROM completion and results across demographics. We hypothesized that minority groups would be less likely to complete PROMs.

METHODS

A retrospective review was performed from 2018 to 2021 of 16,119 patients who underwent primary elective TKA or THA at a single institution. Pairwise chi-squared tests, t-tests, analysis of variance, and multiple logistic regression analyses were used to compare PROM completion rates and scores across demographics and surgery type (TKA/THA).

RESULTS

Comparing patients who had (N = 7,664) and did not have (N = 8,455) documented PROMs, completion rates were significantly lower in patients who were women, Black, Hispanic, less educated, used Medicaid insurance, lived in lower income neighborhoods, spoke non-English languages, required an interpreter, and underwent TKA versus THA. After regression analyses, odds ratios for PROM completion remained significantly lower in non-English speakers, Hispanic and Medicaid patients, lower income groups, and patients undergoing TKA. For the 31.8% of patients who completed both preoperative/postoperative PROMs, women, Black, and non-English speaking patients had significantly lower PROM scores for most measures preoperatively and postoperatively despite similar or better improvements after surgery.

CONCLUSION

Patients undergoing TKA and non-English speaking, ethnic, and socioeconomic minorities are less likely to complete PROMs. Strategies to create, validate, and collect PROMs for these populations are needed to avoid exacerbation of healthcare disparities.

Establishing the Minimum Clinically Significant Difference (MCID) and the Patient Acceptable Symptom Score (PASS) for the Hospital Anxiety and Depression Scale (HADS) in Patients with Rotator Cuff Disease and Shoulder Prosthesis

Insufficiently treated shoulder pain may cause mental disturbances, including depression and anxiety. The Hospital Anxiety and Depression Scale (HADS) is a patient-reported outcome measure (PROM) that aims to identify depression and anxiety in patients in nonpsychiatric wards. The aim of this study was to identify the minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) scores for the HADS in a cohort of individuals with rotator cuff disease. Using the HADS, participants' degrees of anxiety and depression were assessed at inception and at their final assessment 6 months after surgery. To calculate the MCID and the PASS, distribution and anchor approaches were employed. The MCID from inception to final assessment was 5.7 on the HADS, 3.8 on the HADS-A, and 3.3 on the HADS-D. A 5.7 amelioration on the HADS score, 3.8 on the HADS-A, and 3.3 on the HADS-D, from inception to final assessment, meant that patients had reached a clinically meaningful improvement in their symptom state. The PASS was 7 on the HADS, 3.5 on the HADS-A, and 3.5 on the HADS-D; therefore, for the majority of patients, a score of at least 7 on the HADS, 3.5 on the HADS-A, and 3.5 on the HADS-D at final evaluation was considered a satisfactory symptom state.

Status of robot-assisted artificial total joint arthroplasty in China: a cross-sectional survey of joint surgeons

PURPOSE

The purpose of this study is to report on the use of Robotic-assisted total joint arthroplasty (RA-TJA) in China as well as the experience and expectations of Chinese doctors regarding this technology.

METHOD

A self-administered questionnaire was used to assess the current status of RA-TJA in China, the practical experience and suggestions for improvement of the technology by joint surgeons who have performed RA-TJA, and the interest and expectations of orthopaedic surgeons who have not used RA-TJA. The questionnaire was administered to all the physicians of the Chinese Association of Orthopedic Surgeons (CAOS).

RESULT

A total of 372 qualified questionnaires were generated, among which 28% (n = 104) of the respondents had performed RA-TJA, among those who had performed RA-TJA. When asked how helpful the joint replacement robot was actually/expected to be, there was no significant difference between the expected and actual experience of nonusers and users (p ≥ 0.05); the biggest disadvantage of the current development of RA-TJA was perceived as additional charges to the patient by those who had used it, while those who had not used it perceived it as a limitation of their hospital, both of which were significant differences. Most respondents in both groups (used: 94.2%; not used: 91.4%) were confident in the clinical development of the joint replacement robot.

CONCLUSION

This survey provides cross-sectional data on the current status of Chinese joint surgeons using or not using robots in their daily clinical practice. Improving surgical precision was the consensus of most respondents, while high surgical costs and limitations of hospital conditions were barriers to its development in China.

Patient acceptable symptom state (PASS): thresholds for the EQ-5D-5L and Oxford hip and knee scores for patients with total hip and knee replacement

PURPOSE

To define patient acceptable symptom state (PASS) cut-off values for the EQ-5D-5L and Oxford hip (OHS) and knee (OKS) scores 6 and 12 months after total hip (THR) or knee (TKR) replacement. To compare PASS cut-off values for the EQ-5D-5L scored using: (1) the Canadian value set, (2) the crosswalk value set, and (3) the equal weighted Level Sum Score (LSS).

METHODS

We mailed questionnaires to consecutive patients following surgeon referral for primary THR or TKR and at 6 and 12 months post-surgery. Patient reported outcome measures (PROMs) were the EQ-5D-5L, the OHS, and OKS. We assessed PASS cut-off values for PROMs using percentile and ROC methods, with the Youden Index.

RESULTS

Five hundred forty-two surgical patients (mean age, 64 years, 57% female, 49% THR) completed baseline and 12-month questionnaires. 89% of THR and 81% of TKR patients rated PASS as acceptable at 12 months. PASS cut-off values for THR for the EQ-5D-5L (Canadian) were 0.85 (percentile) and 0.84 (Youden) at 12 months. Cut-off values were similar for the LSS (0.85 and 0.85) and lower for the crosswalk value set (0.74 and 0.73), respectively. EQ-5D-5L cut-off values for TKR were Canadian, 0.77 (Percentile) and 0.78 (Youden), LSS, 0.75 and 0.80, and crosswalk, 0.67 and 0.74, respectively. Cut-off values 6 and 12 months post-surgery ranged from 38 to 39 for the OHS, and 28 to 36 for the OKS (range 0 worst to 48 best).

CONCLUSION

PASS cut-off values for the EQ-5D-5L and Oxford scores varied, not only between methods and timing of assessment, but also by different EQ-5D-5L value sets, which vary between countries. Because of this variation, PASS cut-off values are not necessarily generalizable to other populations of TJR patients. We advise caution in interpreting PROMs when using EQ-5D-5L PASS cut-off values developed in different countries. A standardization of methods is needed before published cut-off values can be used with confidence in other populations.

Higher Dissatisfaction Rate Following Revision Compared With Primary Total Knee Arthroplasty: 1-Year Follow-up of 2151 Primary and 235 Aseptic Revision Surgeries

Postoperative patient satisfaction is related to preoperative expectations. Information regarding expected results following surgery is therefore important. This study evaluated patient-reported outcome measures (PROMs) and patient satisfaction up to 1 year after primary and aseptic revision total knee arthroplasty (TKA). The study included 2151 primary and 235 aseptic revision TKA surgeries conducted between 2010 and 2018. Pain, Knee Injury and Osteoarthritis Outcome Score-Physical Function-Short Form and European Quality of Life-5 Dimension surveys were recorded preoperatively and at 8 weeks and 1 year. To determine satisfaction, patients were asked to rate their knee function compared with that before surgery and to answer whether they would undergo the surgery again given their current knowledge. Patients who had primary TKA improved in all PROMs in each follow-up up to 1 year, whereas patients who had revision TKA showed improvement at 8 weeks with no further improvement at 1 year. In terms of patient satisfaction, 88% of patients in the primary TKA group reported better knee function, and 87% were willing to have the surgery again at 1 year; the proportions were lower for patients who underwent revision TKA (66% and 68%, respectively). Aseptic revision TKA demonstrates inferior PROMs compared with those of primary TKA 1 year after surgery, and more than 30% of the patients who underwent revision TKA stated that they would not have their TKA revised or were uncertain, given the outcome of the procedure. Thus, patients who are candidates for revision TKA should be informed to expect less of an improvement following revision surgery than with the primary TKA. Our findings can facilitate the shared decision-making process by surgeons and patients based on realistic expectations of surgical outcomes. [Orthopedics. 2023;46(1):e52-e57.].

Custom total knee arthroplasty combined with personalised alignment grants 94% patient satisfaction at minimum follow-up of 2 years

PURPOSE

The purpose was to report detailed patient-reported outcome measures (PROMs) and satisfaction rates for computed tomography (CT)-based custom TKA at minimum follow-up of 2 years. The hypothesis was that custom TKA combined with 'personalised alignment' would yield equivalent or better PROMs compared to values reported in systematic reviews and meta-analyses on off-the-shelf (OTS) TKA.

METHODS

Of an initial cohort of 150 custom TKAs, four died (unrelated to surgery), one required a revision, and five refused participation, leaving 140 patients for analysis. Patients completed pre- and post-operative PROMs (Oxford Knee Score (OKS), Forgotten Joint Score (FJS), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster osteoarthritis index (WOMAC)) as well as overall level of satisfaction. Proportions that attained a patient acceptable symptom state (PASS) were calculated for OKS and FJS. Clinical findings were compared to the average scores reported for PROMs in recent systematic reviews and/or meta-analyses on OTS TKA. Descriptive statistics were used to summarise the clinical findings as means, standard deviations (SD) and ranges, or numbers and percentages.

RESULTS

At mean follow-up 33.5 ± 4.5 months, 94% (135/143) were either satisfied or very satisfied. Proportions that achieved PASS were 89% for OKS (120/135), and 85% for FJS (118/139). Median OKS, WOMAC and KOOS Symptoms and Pain scores were all within the 4th quartile of medians reported in systematic reviews and/or meta-analyses.

CONCLUSIONS

At a minimum follow-up of two years following custom TKA combined with 'personalised alignment', 94% of patients were either satisfied or very satisfied, and the PASS criteria were achieved in 89% for OKS and 85% for FJS, all of which compare favourably to published outcomes of OTS TKA. Direct comparisons to the literature may not be appropriate, however, considering the heterogeneity of patient demographics and alignment techniques. Randomised controlled trials with sufficient statistical power are needed to corroborate these findings and generalise them to unselected TKA patients.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Harmonising knee pain patient-reported outcomes: a systematic literature review and meta-analysis of Patient Acceptable Symptom State (PASS) and individual participant data (IPD)

OBJECTIVE

In order to facilitate data pooling between studies, we explored harmonisation of patient-reported outcome measures (PROMs) in people with knee pain due to osteoarthritis or knee trauma, using the Patient Acceptable Symptom State scores (PASS) as a criterion.

METHODS

We undertook a systematic literature review (SLR) of PASS scores, and performed individual participant data (IPD) analysis of score distributions from concurrently completed PROM pairs. Numerical rating scales (NRS), visual analogue scales, KOOS and WOMAC pain questionnaires were standardised to 0 to 100 (worst) scales. Meta-regression explored associations of PASS. Bland Altman plots compared PROM scores within individuals using IPD from WebEx, KICK, MenTOR and NEKO studies.

RESULTS

SLR identified 18 studies reporting PASS in people with knee pain. Pooled standardised PASS was 27 (95% CI: 21 to 35; n = 6,339). PASS was statistically similar for each standardised PROM. Lower PASS was associated with lower baseline pain (β = 0.49, P = 0.01) and longer time from treatment initiation (Q = 6.35, P = 0.04). PASS scores were lowest in ligament rupture (12, 95% CI: 11 to 13), but similar between knee osteoarthritis (31, 95% CI: 26 to 36) and meniscal tear (27, 95% CI: 20 to 35). In IPD, standardised PROMs each revealed similar group mean scores, but scores within individuals diverged between PROMs (LoA between -7 to -38 and +25 to 52).

CONCLUSION

Different standardised PROMs give similar PASS thresholds in group data. PASS thresholds may be affected more by patient and treatment characteristics than between PROMs. However, different PROMs give divergent scores within individuals, possibly reflecting different experiences of pain.

One-Year Readmissions Following Total Joint Arthroplasty May Be Associated With Failure to Achieve the Minimal Clinically Important Difference of Patient-Reported Outcomes Measurement Information System Physical, Mental, and Physical-Short Form-10a

The primary aims of our study were to determine if hospital readmissions within one year following primary total joint arthroplasty (TJA) and their relative timing influence patients' ability to achieve the two-year Patient-Reported Outcomes Measurement Information System (PROMIS) physical, PROMIS mental, and PROMIS Physical-Function-Short-Form-10a (SF-10a) minimal clinically important difference (MCID). This is a retrospective study conducted using data from a multi-institutional, arthroplasty registry. Only patients with paired patient-reported outcome measure (PROM) assessments (preoperatively and two years postoperatively) were included. Five separate readmission cohorts were formed: (1) any-cause readmission within one year, (2) any-cause readmission within 90 days, (3) non-index-surgery-related readmission within 90 days, (4) index-surgery-related readmission within one year, and (5) index-surgery-related readmission within 90 days. A propensity score match was used to match each of the patients to one of the 972 patients (1:1 basis) in the non-readmission group. The association between failure to achieve each of the three two-year MCIDs and Readmission status was analyzed using logistic regression. We found that all readmissions within one year and index-surgery-related readmissions within one year resulted in an increased risk of failure to achieve the two-year MCID across all three collected PROMs. Index surgery-related readmissions within 90 days (OR 3.24; 95% CI 1.05-11.05; p=0.048) sustained significantly different rates of two-year PROMIS physical MCID achievement compared to matched controls. Postoperative complications requiring readmission, particularly those related to the joint arthroplasty and those within 90 days of index surgery, significantly impact the ability to achieve the two-year MCID of PROMs.

The influence of obesity on functional outcomes and patient satisfaction 8 weeks after total knee arthroplasty: results of the prospective FInGK study

OBJECTIVES

To investigate obese versus non-obese subjects´ knee joint function, stiffness, pain, expectations, and outcome satisfaction before and two months after total knee arthroplasty (TKA).

METHODS

This study is a secondary analysis of data retrieved via a prospective single-centre cohort study investigating knee joint function and health care services utilization in patients undergoing TKA (FInGK Study). For the primary study, elective TKA patients were consecutively recruited between December 2019 and May 2021. Preoperative expectations, Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), surgery outcome satisfaction, and sociodemographic variables were assessed via self-reported questionnaires. In the current study, obese (Body Mass Index (BMI) ≥ 30 kg/m²) versus non-obese (BMI < 30 kg/m²) subjects' data were exploratively compared before and two months after TKA. Multivariable logistic regression assessed factors associated with TKA satisfaction two months postoperatively. Linear regression evaluated factors associated with higher WOMAC change two months postoperatively.

RESULTS

A total of 241 subjects participated (response: 85.2%). Eighty-seven were non-obese (mean age: 70.7 years, 63.2% female) and 154 were obese (mean age: 67.1 years, 57.8% female). Obese subjects reported inferior pre- and postoperative pain and knee joint function compared to non-obese subjects. Yet, WOMAC scores of obese and non-obese subjects significantly improved from preoperative means of 52.6 and 46.8 to 32.3 and 24.4 after surgery, respectively. The only significant TKA satisfaction predictor was subjects' smoking status. Non-obesity and worse preoperative WOMAC scores were predictive of higher WOMAC change scores after two months.

CONCLUSION

Both obese and non-obese subjects reported significant symptom improvements. However, as obese subjects' short-term outcomes were still inferior, more research on TKA rehabilitation measures adapted to the needs of this growing patient group is warranted to maximize their benefits from TKA.

Patient Acceptable Symptom State Versus Latent Class Analysis Outcome Classification: A Comparative Longitudinal Study of Knee Arthroplasty

OBJECTIVE

To determine whether Patient Acceptable Symptom State (PASS), a single-item deterministic binary measure of pain and function outcome satisfaction, leads to better differentiation of outcome classification versus latent class analysis probability-based outcome subgroups 1 year after knee arthroplasty (KA).

METHODS

We used data from Knee Arthroplasty Skills Training for Pain (KASTPain), a 1-year no-effect multicenter randomized clinical trial of participants with KA, along with prior work that developed and externally validated good and poor outcome trajectories. Confirmatory latent class analyses were conducted on 2 exemplar outcome measures (Euroquol visual analog scale single-item self-rated health and 4-item pain ratings) and compared with PASS scores. Separation of trajectories were used to compare good and poor latent class self-rated health/4-item pain trajectories and PASS score trajectories.

RESULTS

Prevalence rates for poor outcomes were 10% for self-rated health and 20% for 4-item pain and PASS. Probabilistic latent class-derived classifications of self-rated health and 4-item pain outcomes outperformed PASS in separating growth trajectories. The effect size point estimates for 12-month 4-item pain scale score separation was approximately 3 times larger for latent class analyses as compared with PASS.

CONCLUSIONS

When used for outcome classification, observed PASS scores consistently underperform relative to probabilistic latent class-derived subgroups of pain and self-rated health outcome. PASS is a weak substitute for probabilistic classification of other patient-reported outcome measures of KA outcome. Clinicians and researchers should rely on latent class analyses over PASS to differentiate between outcome subgroups after KA.

Defining Failure in Primary Total Joint Arthroplasty: The Minimal Clinically Important Difference for Worsening Score

BACKGROUND

We define the value of the Minimal Clinically Important Difference for Worsening (MCID-W) for Patient-Reported Outcomes Measurement Information System Physical Function short form 10-a (PROMIS-PF-10a) score for primary total joint arthroplasty (TJA) of the hip and knee and describe the risk factors for patients scoring worse than the MCID-W.

METHODS

This retrospective study was performed using 3414 primary TJA patients. PROMIS-PF-10a scores were collected at the preoperatively and postoperatively, and patients were classified based on reaching Minimal Clinically Importance Difference for Improvement (MCID-I), MCID-W, or "no significant change" after TJA (scores betweex`n MCID-W and MCID-I). MCID-W and MCID-I values were determined by a distribution method. The association between numerous variables and scoring worse than the MCID-W of PROMIS-PF-10a was then evaluated through multiple logistic regression. A threshold for preoperative PROMIS-PF-10a score predicting decline past MCID-W was determined using the Youden index and receiver operating characteristic curve.

RESULTS

The MCID-W for TJA was -1.89. Notably, increasing length of stay (odds ratio [OR] 1.073, 95% confidence interval [CI] 1.029-1.119, P < .001) and increasing preoperative PROMIS-PF-10a scores (OR 1.117, 95% CI 1.091-1.144, P < .001) were associated with increased likelihood of decline past the MCID-W of the PROMIS-PF-10a for TJA compared with patients who achieved the MCID-I. A community hospital with a dedicated joint replacement center was associated with a decreased risk for decline past the MCID-W (OR 0.601, 95% CI 0.402-0.899; P = .013).

CONCLUSION

We described the MCID-W value (-1.89) for the PROMIS-PF-10a questionnaire for knee and hip TJA and associated patient- and hospital-level risk factors for failure after TJA. Healthcare funding initiatives should be directed toward modifiable factors associated with clinically significant worse outcomes after TJA.

Moderate relationship between function and satisfaction of total hip arthroplasty patients: a cross sectional study

PURPOSE

Patient satisfaction regarding their hip replacement is often assumed to be directly linked to functional outcomes. We led this study to answer 2 questions: (1) what is the level of patient satisfaction, function, and quality of life after primary total hip replacement (THR); and (2) what is the relationship between patient satisfaction and functional and quality of life PROMs after THR?

METHODS

We led a retrospective study using our institutional registry of prospectively and consecutively collected data on patients after primary THR undertaken between 2004 and 2017. We included 6710 patients with a complete 2-year set of follow-up data for Oxford Hip Score (OHS) (for assessing patient's function), EQ-5D (for assessing patient's quality of life) and satisfaction PROM scores.

RESULTS

There was a significant improvement in all OHS and EQ-5D scores from preoperative level, and the mean postoperative satisfaction score was 89/100. We found moderate positive correlations between the patients' outcome satisfaction VAS score and OHS (r = 0.665) and EQ-5D (r = 0.554).

CONCLUSIONS

THR is a successful procedure generating high levels of patient function and satisfaction. Because patients' OHS and EQ-5D scores may be influenced by comorbidities, those scores are of poor predictive value in estimating patient satisfaction, and therefore should not be used as a surrogate to determine the success of the THR procedure.

A Weighted Scoring System Based on Preoperative and Long-Term Patient-Reported Outcome Measures to Guide Timing of Knee Arthroplasty

BACKGROUND

There is currently no existing consensus regarding timing of knee arthroplasty. This study aimed to develop a weighted scoring system from patient-reported outcome measures (PROMs) to guide timing of knee arthroplasty based on preoperative severity and long-term effectiveness.

METHODS

Prospectively collected data of 766 total knee arthroplasties (TKAs) and 382 unicompartmental knee arthroplasties (UKAs) at a single institution were analyzed. PROMs were assessed preoperatively and at 10 years using the Knee Society Score (KSS), Oxford Knee Score (OKS), and Short Form-36 physical component score (SF-36 PCS). Receiver operating characteristic analysis identified thresholds where preoperative PROMs predicted 10-year clinically meaningful improvements (minimal clinically important difference [MCID]). Threshold weights were assigned to PROMs based on their ability to predict MCID in isolation or in combination.

RESULTS

Poorer baseline PROMs predicted 10-year MCID attainments. The threshold of 49.5 points for the KSS, 30.5 points for the OKS, and 40.7 points for the SF-36 PCS and 55.5 points for the KSS, 33.5 points for the OKS, and 40.5 points for the SF-36 PCS was weighted 1 point for predicting MCID in 1 PROM for TKA and UKA, respectively. The threshold of 33.4 and 33.9 points for the SF-36 PCS was weighted 2 points for predicting MCID in 2 PROMs, whereas 29.3 and 31.3 points for the SF-36 PCS were weighted 3 points for predicting MCID in 3 PROMs for TKA and UKA, respectively. The sum of weighted components from 0 (lowest) to 5 (highest) represented likelihood for long-term benefits at 10 years.

CONCLUSION

This scoring system is a useful clinical adjunct for deciding timing of knee arthroplasty and prioritizing patients in institutions with long waitlists.

LEVEL OF EVIDENCE

II.

Clinical Course of Pain and Function Following Total Knee Arthroplasty: A Systematic Review and Meta-Regression

BACKGROUND

Total knee arthroplasty (TKA) is widely considered a successful intervention for osteoarthritis and other degenerative knee diseases. This study addresses the need for a high-quality meta-analysis that outlines the clinical course of pain and function post-TKA.

METHODS

The review included prospective cohort studies assessing pain or function of patients undergoing primary TKA at baseline (preoperatively) and at least 2 additional time points including one at least 12 months postoperatively. Two reviewers independently screened references, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. The time course of recovery of pain and function was modeled using fractional polynomial meta-regression.

RESULTS

In total, 191 studies with 59,667 patients were included, most with low risk of bias. The variance-weighted mean pain score (/100, 0 = no pain) was 64.0 (95% confidence interval [CI] 60.2-67.7) preoperatively, 24.1 (95% CI 20.3-27.9) at 3 months, 20.4 (95% CI 16.7-24.0) at 6 months, and 16.9 (95%CI 13.6-20.3) at 12 months, and remained low (10.1; 95% CI 4.8-15.4) at 10 years postoperatively. The variance-weighted mean function score (/100, 0 = worst function) was 47.1 (95% CI 45.7-48.4) preoperatively, 72.8 (95% CI 71.3-74.4) at 3 months, 76.3 (95% CI 74.7-77.8) at 6 months, and 78.1 (95%CI 76.4-79.7) at 12 months. Function scores were good (79.7; 95% CI 77.9-81.5) at 10 years postoperatively.

CONCLUSION

Patients undergoing primary TKA can expect a large and rapid but incomplete recovery of pain and function in the first postoperative year. At 10 years, the gains in pain scores may still remain while there is an improvement in function.

Participation in a Preoperative Patient Education Session Is a Significant Predictor of Better WOMAC Total Index Score and Higher EQ-5D-5L Health Status Index 1 Year After Total Knee and Hip Arthroplasties: A Retrospective Observational Study

OBJECTIVE

The aim of the study was to investigate whether patient-specific factors, preoperative patient-reported outcome measures, and participation in a preoperative patient education session significantly predict 1-yr Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score and EuroQol 5 Dimensions 5 Levels (EQ-5D-5L) health status index of patients who underwent total hip or knee arthroplasties within an enhanced rehabilitation program.

DESIGN

This is a retrospective observational cohort study. The inclusion criteria were met by 676 (373 total hip arthroplasties and 303 total knee arthroplasties) patients. Two multiple regression models were carried out to estimate the contributions of nine potential predictors.

RESULTS

Younger age (P = 0.006), higher preoperative EQ-5D-5L index (P = 0.004), lower patient clinical complexity level (P = 0.001), lower preoperative WOMAC total score (P < 0.001), preoperative patient education session (P = 0.004), and submitting for total hip arthroplasty (P < 0.001) were significant predictors of better 1-yr WOMAC total score. Higher preoperative EQ-5D-5L index (P < 0.001), lower patient clinical complexity level classification (P < 0.001), lower preoperative WOMAC total score (P = 0.009), preoperative patient education session (P = 0.04), and submitting for total hip arthroplasty (P = 0.01) were significant predictors of higher 1-yr EQ-5D-5L health status index.

CONCLUSIONS

Better baseline patient-reported outcome measure scores, less comorbidities, younger age, submitting for total hip arthroplasty, and attending a preoperative patient education session were significant predictors of better WOMAC total scores and higher EQ-5D-5L health status index 1 yr after total hip or total knee arthroplasties.

Collection and Reporting of Patient-reported Outcome Measures in Arthroplasty Registries: Multinational Survey and Recommendations

BACKGROUND

Patient-reported outcome measures (PROMs) are validated questionnaires that are completed by patients. Arthroplasty registries vary in PROM collection and use. Current information about registry collection and use of PROMs is important to help improve methods of PROM data analysis, reporting, comparison, and use toward improving clinical practice.

QUESTIONS/PURPOSES

To characterize PROM collection and use by registries, we asked: (1) What is the current practice of PROM collection by arthroplasty registries that are current or former members of the International Society of Arthroplasty Registries, and are there sufficient similarities in PROM collection between registries to enable useful international comparisons that could inform the improvement of arthroplasty care? (2) How do registries differ in PROM administration and demographic, clinical, and comorbidity index variables collected for case-mix adjustment in data analysis and reporting? (3) What quality assurance methods are used for PROMs, and how are PROM results reported and used by registries? (4) What recommendations to arthroplasty registries may improve PROM reporting and facilitate international comparisons?

METHODS

An electronic survey was developed with questions about registry structure and collection, analysis, reporting, and use of PROM data and distributed to directors or senior administrators of 39 arthroplasty registries that were current or former members of the International Society of Arthroplasty Registries. In all, 64% (25 of 39) of registries responded and completed the survey. Missing responses from incomplete surveys were captured by contacting the registries, and up to three reminder emails were sent to nonresponding registries. Recommendations about PROM collection were drafted, revised, and approved by the International Society of Arthroplasty Registries PROMs Working Group members.

RESULTS

Of the 25 registries that completed the survey, 15 collected generic PROMs, most frequently the EuroQol-5 Dimension survey; 16 collected joint-specific PROMs, most frequently the Knee Injury and Osteoarthritis Outcome Score and Hip Disability and Osteoarthritis Outcome Score; and 11 registries collected a satisfaction item. Most registries administered PROM questionnaires within 3 months before and 1 year after surgery. All 16 registries that collected PROM data collected patient age, sex or gender, BMI, indication for the primary arthroplasty, reason for revision arthroplasty, and a comorbidity index, most often the American Society of Anesthesiologists classification. All 16 registries performed regular auditing and reporting of data quality, and most registries reported PROM results to hospitals and linked PROM data to other data sets such as hospital, medication, billing, and emergency care databases. Recommendations for transparent reporting of PROMs were grouped into four categories: demographic and clinical, survey administration, data analysis, and results.

CONCLUSION

Although registries differed in PROM collection and use, there were sufficient similarities that may enable useful data comparisons. The International Society of Arthroplasty Registries PROMs Working Group recommendations identify issues that may be important to most registries such as the need to make decisions about survey times and collection methods, as well as how to select generic and joint-specific surveys, handle missing data and attrition, report data, and ensure representativeness of the sample.

CLINICAL RELEVANCE

By collecting PROMs, registries can provide patient-centered data to surgeons, hospitals, and national entities to improve arthroplasty care.

Outpatient total hip and knee arthroplasty exhibit similar early complication rates to inpatient procedures

Purpose

The purpose of this study was to compare early post-operative complications and readmissions between total joint arthroplasty (TJA) patients completed as outpatient versus inpatient procedures.

Methods

A review of 2648 primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients between 2015 and 2019 was performed. Patients who underwent same-day discharge were matched to the inpatient cohort using age, gender, body mass index (BMI), and smoking status. American Society of Anesthesiologists (ASA) Scores were calculated for the two cohorts. A total of 234 matched pairs (468 knees) for the TKA cohort and 132 matched pairs (264 hips) for the THA cohort were identified. Data was collected for six months after surgery for 30- and 90-day readmissions, the occurrence of reoperations, revisions, deep vein thrombosis (DVT), pulmonary embolism (PE), falls within 90 days, fractures, infections and dislocations.

Results

The average age for TJA patients was 60 years, with an average BMI of 32, 58% females, and 51.5% who reported never smoking. Post-operative fall risk was higher in the inpatient TKA cohort compared to the same-day cohort (3.0% vs 0.4%, p = 0.032) as was the risk of 90-day readmission (6.0% vs 2.1%, p = 0.034), respectively. These differences were also observed in the combined THA and TKA cohorts.

Conclusions

We report no increase in reoperations, revisions, 30 or 90-day readmissions, deep vein thrombosis (DVT), pulmonary embolism (PE), fractures, infections or dislocations in the outpatient cohort. Early complications and readmissions of patients who underwent TJA as same-day surgeries compared favorably to a matched cohort of inpatients.

Oxford Knee Score and EQ-5d poorly predict patient's satisfaction following mechanically aligned total knee replacement: A cross-sectional study

BACKGROUND

Patient satisfaction is increasingly used to measure the success of arthroplasty. Satisfaction with the outcome of a total knee replacement (TKR) is traditionally thought to be associated with improvements in functional status and quality of life measures. This study aims to answer the following questions: 1. What is the level of patient satisfaction, improvement in knee function and patient quality of life associated with mechanically aligned TKR? 2. What is the relationship between OKS, EQ-5d scores and 'outcome satisfaction'?

HYPOTHESIS

TKR is associated with a significant improvement in function, satisfaction and quality of life and that there is a strong correlation between OKS, EQ-5d and 'outcome satisfaction'.

METHOD

Five thousand eight hundred and ninety six patients underwent primary TKR between January 2010 and December 2017 and had complete preoperative and 2-year follow-up data for OKS, EQ-5d and satisfaction scores. Outcomes data were collected prospectively and recorded on our institutional database. Minimal clinically important difference (MCID) and the Patient acceptable symptomatic state (PASS) were calculated for OKS and EQ-5d, the association between OKS, EQ-5d and 'outcome satisfaction' was measured using regression analysis.

RESULTS

The median 2-year 'outcome satisfaction' score was 90/100 with 79% of patients reporting excellent satisfaction (≥80/100) and 93.4% of patients satisfied (≥50/100). Postoperatively, median scores were 39 for OKS and 0.8 for EQ-5d. The mean increase in scores was 15.85 for OKS and 0.32 for EQ-5d. Satisfaction showed moderate positive correlation with postoperative OKS (r=0.69) and EQ-5D (0.58) scores, but weaker correlation with the change in OKS (r=0.57) and EQ-5d (r=0.32) scores from preoperative levels.

DISCUSSION/CONCLUSION

Mechanically aligned TKR is overall a successful operation responsible of fair rate of patient satisfaction. OKS and EQ-5d are imperfect predictors for satisfaction as they are significantly influenced by patients' comorbidities. This should be taken into account when evaluating the success of an operation.

LEVEL OF EVIDENCE

IIc; observational study (based on prospectively collected data from an institutional registry).

Patient-reported outcome measures used in patients undergoing total knee arthroplasty

Patient-reported outcome measures (PROMs) are being used increasingly in total knee arthroplasty (TKA). We conducted a systematic review aimed at identifying psychometrically sound PROMs by appraising their measurement properties. Studies concerning the development and/or evaluation of the measurement properties of PROMs used in a TKA population were systematically retrieved via PubMed, Web of Science, Embase, and Scopus. Ratings for methodological quality and measurement properties were conducted according to updated COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. Of the 155 articles on 34 instruments included, nine PROMs met the minimum requirements for psychometric validation and can be recommended to use as measures of TKA outcome: Oxford Knee Score (OKS); OKS-Activity and Participation Questionnaire (OKS-APQ); 12-item short form Knee Injury and Osteoarthritis Outcome (KOOS-12); KOOS Physical function Short form (KOOS-PS); Western Ontario and McMaster Universities Arthritis Index-Total Knee Replacement function short form (WOMAC-TKR); Lower Extremity Functional Scale (LEFS); Forgotten Joint Score (FJS); Patient's Knee Implant Performance (PKIP); and University of California Los Angeles (UCLA) activity score. The pain and function subscales in WOMAC, as well as the pain, function, and quality of life subscales in KOOS, were validated psychometrically as standalone subscales instead of as whole instruments. However, none of the included PROMs have been validated for all measurement properties. Thus, further studies are still warranted to evaluate those PROMs. Use of the other 25 scales and subscales should be tempered until further studies validate their measurement properties. Cite this article: Bone Joint Res 2021;10(3):203-217.

External Validation of Achieving the Patient Acceptable Symptom State for the EuroQol-5 Dimension 1 Year After Total Hip Arthroplasty

BACKGROUND

Patient acceptable symptom state (PASS) thresholds for the EuroQol-5 Dimension-3 Level (EQ-5D-3L) questionnaire have been established for patients being evaluated 1 year following total hip arthroplasty (THA) but with varying derivation cohorts and methods. The aim of this study was to (1) generate an EQ-5D PASS threshold 1 year following THA on the basis of an international patient cohort, (2) validate preexisting and newly generated PASS thresholds 1 year following THA using the institutional registry of an academic care center, and (3) assess whether THA PASS thresholds vary by patient age and sex.

METHODS

The derivation cohort for the THA PASS threshold consisted of 774 patients (after exclusions) who were enrolled in an international, multicenter study from 2007 to 2012 and who completed the EQ-5D and a numerical rating scale (NRS) for satisfaction 1 year postoperatively. With the NRS dichotomized at 2.5 as the anchor, a PASS cutoff for the EQ-5D was generated using the 80% specificity method. The Youden method and 75th percentile approach served as sensitivity analyses. The external validation cohort comprised 1,472 patients who had undergone THA. PASS thresholds were used to dichotomize the external validation sample. The ability of the threshold to predict satisfaction was evaluated with receiver operating characteristic (ROC) curve analysis. Patient subcohorts were stratified by age (>65 and ≤65 years) and sex.

RESULTS

Three THA PASS thresholds of 0.77 (our newly defined threshold), 0.82, and 0.92 were validated in this study. The EQ-5D PASS threshold of 0.77 (area under the curve [AUC] = 0.816) best predicted satisfaction 1 year after THA. Subcohort analyses yielded comparable 1-year PASS thresholds for THA between age cohorts and between sex cohorts.

CONCLUSIONS

This study identifies PASS thresholds that best predict patient satisfaction 1 year following THA. Although the varied methodology and patient cohorts used to derive PASS values complicate the comparison of these thresholds, this analysis can help surgeons understand the level of health-related quality of life associated with patient satisfaction following THA.

LEVEL OF EVIDENCE

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

Customised, individually made total knee arthroplasty shows promising 1-year clinical and patient reported outcomes

INTRODUCTION

Customised individually made (CIM) implants for total knee arthroplasty (TKA) were introduced about 10 years ago. These implants aim to reduce the risk of prosthesis-related issues resulting from anthropometric differences between different knees. The purpose of this study was to analyse the short-term clinical outcome and patient reported outcome measures (PROMs) of a specific CIM implant, the ORIGIN^® knee replacement system (Symbios, Yverdon-les-Bains, Switzerland), which was introduced in 2018.

MATERIALS AND METHODS

This is a prospective cohort study of patients undergoing primary posterior-stabilised (PS) CIM TKA using the specific ORIGIN^® knee replacement system, (Symbios, Yverdon-les-Bains, Switzerland). TKAs were performed from February 2019 to October 2020. Data was collected preoperatively and postoperatively at 4 and 12 months. Outcome measures included the objective part of the Knee Society Score (KSS) with the range of motion (ROM) and the following PROMs: the Knee injury and Osteoarthritis Outcome Score (KOOS), the Forgotten Joint Score (FJS-12), the EuroQol, five dimensions, three levels (EQ-5D-3L) with the EuroQol visual analogue scale (EQ-VAS) and patient satisfaction. Differences in pre- to preoperative data were assessed with paired sample t tests. A p value < 0.05 was considered significant.

RESULTS

Twenty-five CIM TKA (20 patients, 8 female) were included. The mean age at surgery was 66 years (SD, 6.9). At 4 and 12 months, significant improvements in the KSS (p < 0.001), the ROM (p < 0.001), all KOOS subscales (p < 0.001), the FJS (p < 0.001) and the EQ-5D-3L (p < 0.026) were found. Satisfaction rate was 91% and 88% at 4 and 12 months, respectively. Intraoperative complications did not occur and no revision surgeries were undertaken.

CONCLUSIONS

The present study demonstrated significant improvements in the KSS and specific PROMs 1 year after CIM TKA. This study suggests that CIM TKA is a safe and suitable option, which can yield good clinical outcome and PROMs at least during short-term follow-up.

"It's not my knee" - understanding ongoing pain and discomfort after total knee replacement through (re)embodiment

Objective

Up to 20% of people who undergo total knee replacement surgery have ongoing pain and discomfort. The aim of this study was to understand what role the concepts of embodiment (of both having a body and experiencing the world through one's body) and incorporation (integrating something into one's body) might have in understanding experiences of pain and discomfort after total knee replacement.

Methods

We conducted semistructured interviews with 34 people who had received total knee replacement at either of 2 National Health Service hospitals in the UK, and who had chronic postsurgical pain (n = 34, ages 55–93 years). Data were audiorecorded, transcribed, and analyzed thematically.

Results

Two main themes were identified: 1) when describing chronic postsurgical pain, some participants also described sensations of discomfort, including heaviness, numbness, pressure, and tightness associated with the prosthesis; 2) participants reported a lack of felt connection with and agency over their replaced knee, often describing it as alien or other, and lacked confidence in the knee.

Conclusion

Participants’ experiences indicate that some people do not achieve full incorporation of the prosthesis. Our study emphasizes the importance of physicians treating patients as whole people and moving beyond clinical and procedural ideas of success. Our findings suggest that to optimize postoperative outcomes, rehabilitation must focus not only on strengthening the joint and promoting full recovery to tasks but on modifying a person's relationship to the new joint and managing sensations of otherness to achieve full incorporation of the joint or re‐embodiment.

[Realistic preclinical finite element simulation in knee and hip replacements]

BACKGROUND

In the process of developing an implant, computer simulation involving finite element (FE) methods allows the early identification of design-related issues, thus reducing the development process to a minimum. In addition, the FE simulation is used for selecting testing combinations in order to provide the relevant authority with proof of a "worst-case" construct scenario for the subsequent experimental fatigue test.

RESULTS

Research studies with FE simulations show that implant positioning may affect mechanical loads under certain circumstances and, therefore, influence the preclinical evaluation of the prostheses.

DISCUSSION

Although the FE simulation currently contributes significantly to preclinical testing, a standardization of the calculation models allowing comparability of results is lacking. Furthermore, the development of new dynamic and realistic models is necessary in order to identify complex damage modes that currently cannot be reproduced experimentally. When considering everyday clinical life in particular, models that can reproduce intraoperative kinematic changes and the resulting incorrect loads of the implant, as well as address these problems by changing the position or design of the prosthesis, are necessary and would help in future.

TKA patients experience less improvement than THA patients at 3 and 12 months after surgery. A retrospective observational cohort study

PURPOSE

To investigate whether WOMAC scores changes after THA or TKA are gender and joint specific.

METHODS

Retrospective cohort study. The data of 855 THA and 684 TKA patients were analyzed.

RESULTS

Follow-up time (p < 0.001), gender (p < 0.001), joint (p < 0.001), and interaction FU by joint (p < 0.001) had significant effects on WOMAC total and sub-scores. Patients after TKA perceived less improvement in all dimensions in comparison to THA patients (p < 0.001).

CONCLUSION

WOMAC score changes after THA or TKA are joint-specific. Patients after TKA perceived less improvement. These results can be used to adjust patients' expectations.

Why don't patients seek help for chronic post-surgical pain after knee replacement? A qualitative investigation

Background

Although many people are satisfied with their outcome after total knee replacement surgery for osteoarthritis, around 20% report chronic post‐surgical pain. People are often disappointed and unsure about whether their pain is normal and what can be done about it. Given the high prevalence of long‐term post‐operative pain after knee replacement, there is potentially a large hidden population with an unaddressed need for care.

Objective

In this study, we focus on understanding why some people choose not to consult health care for chronic post‐surgical pain after knee replacement.

Methods

Semi‐structured interviews were conducted with people who had received total knee replacement, at either of two National Health Service hospitals in the United Kingdom, and who had chronic post‐surgical pain (n = 34, age 55‐93 years). Data were audio‐recorded, transcribed and analysed thematically.

Results

We found an overall sense of futility amongst participants who believed that nothing further could be done for their on‐going pain. People's perception of their pain was often discordant with that of surgeons and physicians. Other factors that contributed to decisions not to seek help included low expectations about effectiveness and the risks involved in further treatment, treatment burden, participants' prioritization of other health conditions and views about candidacy. Many accepted their on‐going pain.

Conclusion

Our study indicates why some people with chronic pain after knee replacement do not seek further health care. Understanding patients' beliefs and expectations about chronic post‐surgical pain can inform approaches that might enable people to seek help in the future.

Hip resurfacing generates a more physiological gait than total hip replacement: A case-control study

BACKGROUND

Restoration of the constitutional joint anatomy after hip replacement favours physiological peri-articular soft-tissue tension and kinematics, and is likely to be functionally beneficial. Hip resurfacing (HR) and conventional total hip replacement (THR) are two different options for replacing degenerated hips, and are likely to result in different anatomical reconstruction. We initiated this study to investigate the differences in gait performance between these two prosthetic options, and aimed to answer the following questions: (1) does HR result in better restoration of the frontal hip anatomical parameters, (2) and generate a more physiological gait compared to THR? (3) Does the quality of the anatomical restoration after THR influence gait performance?

HYPOTHESES

Our hypothesis was that a better anatomical restoration using HR versus THR would produce more physiological (symmetric) gait.

METHODS

We retrospectively reviewed 52 patients who had unilateral primary osteoarthritis successfully treated by replacement (40 THRs and 12 HRs). Hip anatomical parameters were measured on standing pelvic radiographs on both the prosthetic and the contralateral healthy hips. Patients undertook gait assessment under both normal and stress conditions at a mean follow-up of 14 months (7 to 16 months). Gait performances were compared between HR and THR, and the relationship between gait performances and quality of frontal anatomical restoration (estimated on radiograph) were assessed.

RESULTS

Compared to the native contralateral side, the HR procedure tended to decrease all independent anatomical radiographic parameters with the exception of the vertical centre of rotation offset, whilst the THR procedure tended to increase them; the difference between HR and THR was only statistically significant for femoral offset and global horizontal offset (increased after THR while reduced after HR). Only 50% of THR and 25% of HR procedures closely anatomically (±15%) recreated both global horizontal offset and global vertical offset. Under normal conditions (normal walking speed and flat ramp), the gait was fairly symmetric for both the HR and the THR patients with a symmetry index of 0.62% and 3.14% respectively. At high walking speed (stress conditions), the symmetry index degraded for both groups, but the gait remained more symmetric in the HR group (2.09%), compared to the THR group (5.74%); nevertheless, the difference remained not statistically significant (p=0.159). We were unable to detect any significant relationship between gait performances and radiographically measured hip frontal anatomical parameters.

DISCUSSION/CONCLUSIONS

HR procedure is more consistent than conventional THR in generating a more physiological gait under stress conditions. Radiographic estimation of the quality of the frontal anatomical hip restoration is of poor value to predict gait performances of THR patients.

LEVEL OF EVIDENCE

III - retrospective case-control study with prospective data collection.

The Patient Acceptable Symptom State for the Harris Hip Score Following Total Hip Arthroplasty: Validated Thresholds at 3-Month, 1-, 3-, 5-, and 7-Year Follow-Up

BACKGROUND

The Patient Acceptable Symptom State (PASS) represents the value on a patient-reported outcome measure scale beyond which patients consider themselves well or in a satisfactory state. The aim of this study is to define and validate the PASS threshold for the HHS at 3 months, 1, 3, 5, and 7 years after THA.

METHODS

A total of 976 patients from 14 centers in 7 countries were enrolled into a prospective study. Patients completed the HHS and a numerical rating scale for satisfaction at each follow-up. PASS thresholds for the HHS were calculated at each follow-up interval using the anchor-based, 80% specificity method. A bootstrapping method was used to internally validate the primary PASS thresholds. A patient sample sourced from an institutional registry was used for external validation.

RESULTS

The HHS was an excellent predictor of satisfaction at each time point (area under the curve > 0.8; P < .001). PASS thresholds for the HHS were 76 points at 3 months, 89 points at 1 year, 93 points at 3 years, 94 points at 5 years, and 93 points at 7 years. When applied to the internal and external validation cohorts, all PASS thresholds showed acceptable or excellent ability to predict satisfaction (area under the curve = 0.73-80; P < .001).

CONCLUSION

The present study is the first to present validated PASS thresholds for the HHS following THA. These findings will serve as a useful reference for future THA outcome studies and as benchmarks for surgeons in their assessment of their patients' clinical success.

Can We Help Patients Forget Their Joint? Determining a Threshold for Successful Outcome for the Forgotten Joint Score

BACKGROUND

Clinically important thresholds improve interpretability of patient-reported outcomes. A threshold for a successful outcome does not exist for the Forgotten Joint Score (FJS). The purpose of this study is to determine a threshold score for the FJS, 1 and 2 years after total hip arthroplasty (THA).

METHODS

A retrospective analysis of 247 primary THA recipients between December 2012 and April 2017 was performed. A binary "successful treatment" was defined as achieving a composite criterion of pain, function, and satisfaction. Receiver operator characteristic analysis determined thresholds for successful outcome at 1 and 2 years postoperatively, subanalyzed by demographics. Results were validated by a 75th centile comparison. The ceiling effect of FJS was also assessed.

RESULTS

The average FJS was 70.06 ± 29.39 and 75.05 ± 28.73 at 1 and 2 years, respectively (P < .001). The proportion of patients meeting the composite criteria for success was 66.8% at 1 year and 76.5% at 2 years (P = .017). The receiver operator characteristic analysis for FJS at 1 and 2 years yielded excellent accuracy as defined by area under the curve (0.91 and 0.92, respectively). The threshold values were 73.96 and 69.79 at the respective time points. A mild ceiling effect was found with 16% and 23% of cases achieving a score of 100 at 1 and 2 years, respectively.

CONCLUSION

The FJS has excellent accuracy in demonstrating successful outcome following THA. The FJS threshold for success at 1 and 2 years postoperatively is 73.96 and 69.79, respectively. The higher rates of success at 2 years, along with a rise in the mean FJS, may indicate continued clinical improvement up to 2 years after THA.

Patient characteristics and valuation changes impact quality of life and satisfaction in total knee arthroplasty - results from a German prospective cohort study

Background

Evaluation of variations in pre- and postoperative patient reported outcomes (PRO) and the association between preoperative patient characteristics and health and satisfaction outcomes after total knee arthroplasty (TKA) may support shared decision-making in Germany. Since previous research on TKA health outcomes indicated valuation differences in longitudinal data, experienced-based population weights were used for the first time as an external valuation system to measure discrepancies between patient and average population valuation of HRQoL.

Methods

Baseline data (n = 203) included sociodemographic and clinical characteristics and PROs, measured by the EQ-5D-3 L and WOMAC. Six-month follow-up data (n = 161) included medical changes since hospital discharge, PROs and satisfaction. A multivariate linear regression analysis was performed to evaluate the relationship between preoperative patient characteristics and PRO scores. Patient acceptable symptom state (PASS) was calculated to provide a satisfaction threshold. Patient-reported health-related quality of life (HRQoL) valuations were compared with average experienced-based population values to detect changes in valuation.

Results

One hundred thirty-seven subjects met inclusion criteria. All PRO measures improved significantly. Preoperative WOMAC and EQ-5D VAS, housing situation, marital status, age and asthma were found to be predictors of postoperative outcomes. 73% of study participants valued their preoperative HRQoL higher than the general population valuation, indicating response shift. Preoperatively, patient-reported EQ-5D VAS was substantially higher than average experienced-based population values. Postoperatively, this difference declined sharply.

Approximately 61% of the patients reported satisfactory postoperative health, being mainly satisfied with results if postoperative WOMAC was ≥82.49 (change ≥20.25) and postoperative EQ-5D VAS was ≥75 (change ≥6).

Conclusion

On average, patients benefited from TKA. Preoperative WOMAC and EQ-5D VAS were predictors of postoperative outcomes after TKA. Particularly patients with high absolute preoperative PRO scores were more likely to remain unsatisfied. Therefore, outcome prediction can contribute to shared-decision making. Using general population valuations as a reference, this study underlined a discrepancy between population and patient valuation of HRQoL before, but not after surgery, thus indicating a potential temporary response shift before surgery.

Patient expectations and satisfaction 6 and 12 months following total hip and knee replacement

PURPOSE

To assess (1) patient expectations before total hip (THR) and knee (TKR) replacement; (2) which expectations are met and unmet 6 and 12 months post-surgery; (3) the role of unmet expectations in satisfaction.

METHODS

Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR. Patients listed their own expectations and also completed the Hospital for Special Surgery (HSS) Expectation Survey. We used content analysis to group expectations into themes. At 6 and 12 months post-surgery, patients were given a copy of their own list of individual expectations and reassessed each one as met or unmet. We also assessed fulfilled HSS expectations and satisfaction with surgery.

RESULTS

The sample of 556 patients (49% THR, 57% female) had a mean age of 64 years (SD10). The five most frequent expectation themes were pain relief, mobility, walking, physical activities, and daily activities. Of these, physical activities had the lowest percentage met 12 months post-surgery. 95% (THR) and 87% (TKR) were satisfied/very satisfied with their surgery 12 months post-surgery. Very satisfied patients had a significantly greater percentage of met expectations (96% THR; 92% TKR) than dissatisfied patients (42% THR; 12% TKR). Although most expectations listed by patients were included in the HSS surveys, some were not, particularly for TKR. From 6 to 12 months, there was a significant increase in patient satisfaction for self-care, daily activities, and met expectations for THR and pain relief, self-care, daily activities, and recreational activities for TKR.

CONCLUSIONS

Expectations should be explicitly addressed before surgery, including a discussion of realistic expectations, particularly for physical activities.

A systematic review of estimates of the minimal clinically important difference and patient acceptable symptom state of the Western Ontario and McMaster Universities Osteoarthritis Index in patients who underwent total hip and total knee replacement

OBJECTIVE

To systematically review the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) estimates in pain and function measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in patients who underwent primary total knee replacement (TKR) and primary total hip replacement (THR).

DESIGN

The study was carried out following PRISMA recommendations. We searched five electronic databases. Two reviewers independently screened titles, abstracts and full-text papers using a priori inclusion/exclusion criteria. Data were extracted by two independent reviewers. Data were synthesized, with WOMAC values converted to 0-100 scores (0 = best, 100 = worst).

RESULTS

Thirteen studies were included. Research methods used to calculate MCIDs and PASS varied across studies (e.g., using anchor-based or distribution methods, wording of anchor questions within anchor-based methods). Baseline WOMAC scores also varied across studies. Across studies and methods, MCIDs for the WOMAC in patients undergoing TKR ranged from 13.3 to 36.0 for pain and 1.8-33.0 for function; values for WOMAC in THR ranged from 8.3 to 41.0 for pain and from 9.7 to 34.0 for function. PASS cut-offs for TKR ranged from 25.0 to 28.6 for pain and 32.3-36.7 for function, and cut-offs for THR from 15.0 to 30.6 for pain and 28.0-42.0 for function.

CONCLUSION

Although the WOMAC is a commonly used measure for a single condition, the variability in methods used to calculate MCID and PASS estimates results in a range of values across studies making it unclear whether values reported in the literature can be applied with confidence. Future research is needed to refine methods used to calculate MCIDs and PASS.

Early Experience and Results Using Patient-Reported Outcomes Measurement Information System Scores in Primary Total Hip and Knee Arthroplasty

BACKGROUND

Our study determined if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores could predict achieving minimum clinically important differences (MCIDs) in postoperative PROMIS scores after primary total hip and knee arthroplasty.

METHODS

Ninety-three patients were administered the PROMIS Depression, Pain Interference, and Physical Function domains at their preoperative appointment and 6-week follow-up visit. MCIDs were drawn from existing literature for the PROMIS domains.

RESULTS

The MCID was achieved in 74% of patients for Pain Interference, 34% for Physical Function, and 24% for Depression. Our model could predict with 90% specificity which patients would meet MCID if their preop PROMIS Pain score was above 38, Physical Function score less than 19, or Depression score above 22.

CONCLUSION

Preoperative PROMIS Pain Interference, Physical Function, and Depression scores can predict achieving MCID in postoperative PROMIS scores.

Expectations and depression in patients who have undergone total hip arthroplasty in Japan: A prospective cohort study

BACKGROUND

Patients with hip osteoarthritis may be severely depressed preoperatively due to pain and limited daily-living activities. Hence, evaluating their expectations preoperatively might underestimate their true hopes regarding the upcoming total hip arthroplasty (THA).

AIM

We aimed to assess changes in patients' level of depression, understand their expectations and fulfillment, and identify factors affecting fulfillment.

METHOD

We performed a longitudinal study of 366 Japanese patients who had undergone THA during 2005-2006. Those with THA of the contralateral hip were excluded. Patients' expectations, fulfillment, depression, and physical function were assessed perperative and at 6 weeks and one year postoperatively using our own questionnaire, the Arthritis Impact Measurement Scale 2, and by the Oxford Hip Score . Logistic regression analysis was applied to identify independent predictors of expectation fulfillment.

RESULTS

At 6 weeks, 78.1% expressed expectation fulfillment and drastic alleviation of depression. Preoperative depression and fulfillment of patient expectations at 6 weeks were significant predictors of expectation fulfillment at 1 year (95% confidence intervals: 1.01-2.48 and 2.30-9.92, respectively.

CONCLUSIONS

It is worthwhile for health providers to investigate patients' expectations early in the postoperative period by considering their preoperative depression to confirm fulfillment of expectations.

Hip Arthroplasty After Hip Arthroscopy: Are Short-term Outcomes Affected? A Systematic Review of the Literature

PURPOSE

To systematically review the published literature regarding intraoperative measures, patient-reported outcomes, and complications of total hip arthroplasty (THA) in patients with or without a history of prior hip arthroscopy.

METHODS

PubMed and Cochrane Library databases were searched for all publications regarding patients who had undergone a THA after a prior ipsilateral hip arthroscopy. Included studies were comparative in nature and included postoperative outcome measures. Excluded studies were opinion articles, review articles, cadaveric studies, case reports, or technique articles. Patient demographics, surgical outcomes, complications, and patient-reported outcome measures (PROMs) were recorded. This study was performed at the American Hip Institute.

RESULTS

Eight studies were included in this systematic review. These included 305 hips with a THA following a prior hip arthroscopy, with 502 matched control hips. Mean time for conversion from prior hip arthroscopy was 23 months and mean follow up was 35.9 versus 36.1, for the prior arthroscopy and control groups respectively. No significant differences were found regarding intraoperative measures and PROMs. There was no difference in rate of revisions at latest follow up. However, there was a trend toward higher rates of dislocations and infections in the prior hip arthroscopy group.

CONCLUSION

The short-term PROMs of those who underwent total hip arthroplasty with a prior history of an ipsilateral hip arthroscopy are comparable to those of patients undergoing primary THA. Although a conclusion could not be made regarding differences in complication rates between patients with a history of prior arthroscopy and patients undergoing primary THA, it is still imperative to consider the possible implications of a prior hip procedure on postoperative stability and infection rates. In summary, hip arthroplasty following a prior hip arthroscopy is a safe procedure with comparable short-term outcomes to primary arthroplasty.

LEVEL OF EVIDENCE

Level III, systematic review.

Relationship Between Magnitude of Limitations and Patient Experience During Recovery from Upper-Extremity Fracture

The relationship between the magnitude of limitations (measured by patient-reported outcome measures, or PROMs) and satisfaction with care providers and hospital services (measured by patient-reported experience measures, or PREMs) over the course of recovery after injury is unclear. The purpose of this study was to assess the relationship between a range of PROMs and 2 PREMs at 3 time points (initial office visit within a week, 2 to 4 weeks, and 6 to 9 months) after shoulder, elbow, and wrist fractures.

Patient Acceptable Symptom State at 1 and 3 Years After Total Knee Arthroplasty: Thresholds for the Knee Injury and Osteoarthritis Outcome Score (KOOS)

BACKGROUND

To facilitate the interpretation of numerical patient-reported outcome measure (PROM) scales, concepts such as the patient acceptable symptom state (PASS) have been introduced. Currently, no PASS thresholds have been established for the Knee injury and Osteoarthritis Outcome Score (KOOS) after total knee arthroplasty. The aims of the current study were to define PASS thresholds for the KOOS subscales and several other generic and knee-specific PROMs at 1 and 3 years after total knee arthroplasty using data from an international, multicenter clinical outcome study of a modern, well-performing implant system.

METHODS

The study cohort consisted of 499 patients undergoing total knee arthroplasty from an international, multicenter study. At 1 and 3 years after a total knee arthroplasty, patients completed the KOOS, EuroQoL 5-dimension 3-level (EQ-5D-3L), EuroQol visual analog scale (EQ-VAS), and numerical rating scales (NRS) for knee-related pain and satisfaction. PASS thresholds were calculated at each follow-up interval using 3 anchor-based approaches, using patient-reported satisfaction as the anchor.

RESULTS

According to our satisfaction anchor, 302 (78.9%) of 383 responding patients were satisfied at 1 year, and 242 (80.4%) of 301 responding patients were satisfied at 3 years. PASS thresholds were 84.5 points at 1 year and 87.5 points at 3 years for KOOS pain, 80.5 points at 1 year and 84.0 points at 3 years for KOOS symptoms, 83.0 points at 1 year and 87.5 points at 3 years for KOOS activities of daily living, 66.0 points at 1 year and 66.0 points at 3 years for KOOS quality of life, 83.0 points at 1 year and 90.5 points at 3 years for EQ-VAS, 0.80 point at 1 year and 0.80 point at 3 years for EQ-5D, and 1.8 points at 1 year and 1.8 points at 3 years for NRS pain.

CONCLUSIONS

The current study is the first, to our knowledge, to propose PASS thresholds for the KOOS subscales at 1 and 3 years after total knee arthroplasty and contributes to PASS literature on other common PROMs. These findings will provide a useful reference for future total knee arthroplasty outcome studies and will help to determine what patients consider to be satisfactory operations.

LEVEL OF EVIDENCE

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

Knee joint function, walking ability and quality of life within 6 weeks after total knee arthroplasty: A prospective cohort study

AIMS AND OBJECTIVES

To track changes in patients' knee function, walking ability and quality of life (QOL) before and after knee arthroplasty surgery and explore factors that influenced these parameters.

BACKGROUND

The number of days as an inpatient for those who undergo joint replacement operations has been greatly reduced in recent years. However, it remains unclear whether shortening the inpatient time has affected patients' recovery or their QOL.

DESIGN

Prospective cohort study.

METHOD

In total, 101 participants who underwent total knee arthroplasty (TKA) were enrolled, with data collected preoperatively and at the 2nd and 6th weeks postoperatively. We followed the STROBE checklist to ensure the rigour of our study.

RESULTS

Forty-nine participants underwent unilateral TKA (UTKA; 48.5%), and 52 underwent simultaneous bilateral TKA (SBTKA; 51.5%). At the 2nd week postoperatively, knee joint function was significantly worse than that preoperatively. However, these patients did not exhibit significant differences in the EQ-5D utility index (EQ-5D UI) compared to their preoperative scores. At the 6th week postoperatively, the knee joint function and EQ-5D UI were significantly better than preoperative values. Participants who underwent UTKA scored higher on the Oxford knee score (OKS) than did SBTKA participants. However, no significant differences were noted between the two groups for the knee flexion angle, the timed up and go (TUG) test, or the EQ-5D UI score.

CONCLUSIONS AND SUGGESTIONS

At the postoperative 6th week, participants exhibited improved knee joint function and QOL, but there was no difference in the walking ability compared to preoperative values. At the 6th week after surgery, patients who underwent SBTKA exhibited poorer joint function than did those who underwent UTKA.

RELEVANCE TO CLINICAL PRACTICE

These results can assist nursing staffs and serve as a reference for providing patient education and nursing intervention to TKA patients.

Patient satisfaction - A comparison between patient-specific implants and conventional total knee arthroplasty

Background

Despite recent innovations in total knee arthroplasty, 20% of the patients are not completely satisfied with the clinical results. Regarding patient-specific implants (PSI), the study aims to compare individual and off-the-shelf implant (OSI) total knee arthroplasty (TKA) concerning the postoperative outcome like function and global patient satisfaction.

Methods

In 2013/14 228 patients received a TKA due to primary osteoarthritis with an indication for a bicondylar, cruciate retaining prosthesis. 125 patients received a PSI and 103 an OSI TKA. The outcome after surgery was evaluated retrospectively by two questionnaires and a clinical follow-up examination. The Knee Society Score (KSS) was used to evaluate function. To compare the satisfaction the Knee Injury and Osteoarthrosis Outcome Score (KOOS) and a modified EuroQol (EQ) including five additional questions were used. Finally, 84 patients with PSI and 57 with OSI completed follow-up.

Results

Concerning demographic data, the PSI group showed a significantly younger age, five years on average. The ROM was comparable in both groups. The KSS and the separate function score achieved significantly better results in the PSI group. For subjects with PSI TKA, the global satisfaction showed significant better values.

Conclusions

The significantly higher values in KSS and its function score lead to a better basic daily function in PSI group. In addition, the PSI TKA achieved a higher global patient satisfaction. Nevertheless, both should mainly be assessed in the context of average younger age and the influence of expectations.

Clinical outcomes and patient satisfaction after total knee arthroplasty: a follow-up of the first 50 cases by a single surgeon

Objective

To examine the association between single-surgeon learning curve and clinical outcomes following total knee arthroplasty (TKA).

Methods

This prospective study included the first consecutive patients undergoing TKA conducted by the same surgeon using the JOURNEY II Bi-Cruciate Stabilized Knee System (Smith & Nephew, Andover, MA, USA). Patients were assessed preoperatively, and at three months and one year postoperatively using Oxford Knee Score (OKS), Knee Society Score (KSS) and Knee Function Score (KFS). Outcomes were statistically analysed using sequential patient cohorts.

Results

Fifty patients were grouped into five sequential cohorts of 10 patients each. All patients showed significant improvement in postoperative knee scores following TKA. There was a trend toward increased improvement in knee scores in the later patient cohorts, at the three-month and 1-year follow-up.

Conclusions

The single-surgeon learning curve for minimally invasive TKA had a small effect on knee satisfaction scores at 3 months and 1 year following surgery in the first 50 consecutive cases, and only minor complications were encountered. A larger trial is necessary to draw generalizable conclusions regarding patient outcomes during surgeon learning.

Bacterial detection and identification from human synovial fluids on an integrated microfluidic system

An integrated microfluidic system was developed for detecting and identifying four bacteria in human joint fluid with the limit of detection as low as 100 colony forming units (CFUs) per milliliter (or 20 CFUs per reaction).