A Systematic Review of Measurement Properties of Patient-Reported Outcome Measures Used in Patients Undergoing Total Knee Arthroplasty

Predictive Validity of the Work, Osteoarthritis, or Joint Replacement Questionnaire for Return to Work After Total Knee Arthroplasty: A 12-Month Multicenter Prospective Cohort Study

BACKGROUND

After total knee arthroplasty (TKA), a minority of working patients are dissatisfied and experience a late or no return to work (RTW). This study aimed to identify whether a predefined grouping based on self-reported ability to perform work-related activities at three months post-TKA was associated with the ability to perform work-related activities at six and 12 months and RTW at three, six, and 12 months post-TKA.

METHODS

A 12-month multicenter prospective cohort study was performed among working TKA patients intending to RTW. The Work, Osteoarthritis, or Joint Replacement questionnaire score (range, 0 to 100) was used to assess patients' ability to perform work-related activities. Patients were grouped into early-, intermediate-, and late-recovery groups at three months post-TKA. The median age of the cohort (n = 182) was 59 years [interquartile range, 55 to 62], and 52% were women. Analyses included Spearman's correlation tests, and Kaplan-Meier survival analyses.

RESULTS

The early- (n = 54) and intermediate-recovery groups (n = 68) clinically improved their ability to perform work-related activities at three and 12 months, respectively, while the late-recovery group (n = 60) did not do so until 12 months (rs = 0.6, 0.27, and 0.25, respectively). The early-recovery group returned to work earlier (median 62 [interquartile range 41 to 90] days) compared to the intermediate- (75 [46 to 115] days) and late-recovery groups (84 [58 to 116] days) and resumed 100 percent of their working hours at six months versus 12 months in the intermediate- and late-recovery groups (rs = 0.37, 0.33, 0.1 at 3, 6, and 12 months, respectively).

CONCLUSIONS

At three months post-TKA, the work, osteoarthritis, or joint replacement questionnaire can be used to distinguish early-, intermediate-, and late-recovery groups, which are associated with the ability to perform work-related activities at six and 12 months post-TKA and RTW at three and six months.

The influence of the number of postoperative radiological outliers on the survival and clinical outcome of total knee arthroplasty

Introduction

After total knee arthroplasty (TKA), dissatisfaction rates are described up to 30 %. Optimal alignment of the prosthesis in TKA is believed to improve clinical outcome and survival rates. Radiological outliers after TKA are used to define this alignment. Limited evidence is available on the cumulative effect of these outliers on survival or clinical outcome. The purpose of this study is to assess whether the amount of postoperative femoral and/or tibial radiological outliers, measured in different planes, influences the survival and clinical outcome after TKA.

Methods

Prospective data were used from a previously published randomized trial, with a mean follow-up of 5-years after surgery. Data of 168 patients who received TKA were assessed. Patients were divided into four groups: 0, 1, 2 or ≥3 postoperative radiological outliers of the femoral and/or tibial component in different planes (e.g. frontal, sagittal). Revision rates were analysed and clinical outcome was assessed using PROMs. The study used a general linear model for repeated measures to compare the difference of each questionnaire over time between the groups.

Results

No statistically significant differences were found between patients with 0, 1, 2 or ≥3 outliers regarding improvement of postoperative PROMs. Data was underpowered to detect a possible relationship between the number of outliers and the survival of the prosthesis.

Conclusion

The number of postoperative radiological outliers did not influence clinical outcome after TKA. High-powered studies are needed to examine the influence of these outliers on survival rates.

Efficacy of a computer vision-based system for exercise management in patients with knee osteoarthritis: a study protocol for a randomised controlled pilot trial

INTRODUCTION

This study aims to evaluate the efficacy of a computer vision system in guiding exercise management for patients with knee osteoarthritis (OA) by comparing functional improvement between a tele-rehabilitation versus an outpatient intervention program.

METHODS AND ANALYSIS

This is a prospective, single-blind, randomised controlled trial of 60 patients with knee OA who will be randomly assigned to exercise therapy (n=30) or control (n=30) . Both groups will receive treatment two times per week for 12 weeks. The primary outcome of the study will be assessed using the University of Western Ontario and McMaster University Osteoarthritis Index (WOMAC). The Knee Injury and Osteoarthritis Outcome Score will be assessed, as well as the visual analogue scale, quality of life score and physical fitness score. All observations will be collected at baseline and at weeks 4, 8 and 12 during the intervention period, as well as at weeks 4, 8, 12 and 24 during the follow-up visits after the end of the intervention.

ETHICS AND DISSEMINATION

This evaluator-blinded, prospective, randomised controlled study was approved by the Biomedical Ethics Review Committee of West China Hospital of Sichuan University.

TRIAL REGISTRATION NUMBER

ChiCTR2300070319.

Systematic reviews and quality assessment of patient-reported outcome measures for physical function in comparative effectiveness studies regarding acute postoperative pain after total knee arthroplasty-Do we need to start all over again?

BACKGROUND AND OBJECTIVE

Recently, a consensus process specified a core outcome set (COS) of domains to be assessed in each comparative effectiveness research and clinical practice related to acute postoperative pain. Physical function (PF) was one of these domains. The aim of this review was to investigate which patient-reported outcome measures (PROMs) are used to assess PF after total knee arthroplasty (TKA) in clinical trials and if they fulfil basic requirements for a COS of PROMs based on their psychometric properties.

METHODS

A systematic review of randomized controlled trials and observational studies based on a search in MEDLINE, EMBASE and CENTRAL was undertaken. PROMs and performance measures were extracted and investigated, including evaluation of psychometric properties of PROMs based on COSMIN recommendations.

RESULTS

From initially 2896 identified records, 479 studies were included in the qualitative synthesis. Only 87 of these trials (18%) assessed PF using PROMs, whereas especially performance outcome measures were used in 470 studies (98%). Application of the 'COSMIN Risk-of-Bias-Box 1' to 13 of the 14 identified PROMs resulted in insufficient content validity of the included PROMs regarding the target population based on the inauguration or development articles.

CONCLUSION

Our data indicate that a patient-centred postoperative assessment of PF in pain-related clinical trials early after TKA is not common, even though patient-reported assessment is widely recommended. In addition, none of the applied PROMs shows content validity based on their inauguration or development articles for the assessment of postoperative pain-related PF after TKA.

SIGNIFICANCE

A systematic search for patient-reported outcome measures assessing postoperative, pain-related physical function after total knee arthroplasty in clinical trials and assessment of their content validity revealed none that fulfilled requirements based on COSMIN recommendations.

Strategies to Manage Poorer Outcomes After Hip or Knee Arthroplasty: A Narrative Review of Current Understanding, Unanswered Questions, and Future Directions

PURPOSE

Although hip or knee arthroplasty is generally a successful intervention, it is documented that 15%-30% of patients undergoing arthroplasty report suboptimal outcomes. This narrative review aims to provide an overview of the key findings concerning the management of poorer outcomes after hip or knee arthroplasty.

METHOD

A comprehensive search of articles was conducted up to November 2023 across three electronic databases. Only studies written in English were included, with no limitations applied regarding study design and time.

RESULT

Efficiently addressing poorer outcomes after arthroplasty necessitates a thorough exploration of appropriate methods for assessing recovery following hip or knee arthroplasty, ensuring accurate identification of patients at risk or experiencing poorer recovery. When selecting appropriate outcome measure tools, various factors should be taken into consideration, including understanding patients' priorities throughout the recovery process, assessing psychometric properties of outcome measure tools at different time points after arthroplasty, understanding how to combine/reconcile provider-assessed and patient-reported outcome measures, and determining the appropriate methods to interpret outcome measure scores. However, further research in these areas is warranted. In addition, the identification of key modifiable factors affecting outcomes and the development of interventions to manage these factors are needed.

CONCLUSION

There is growing attention paid to delivering interventions for patients at risk or not optimally recovering following hip or knee arthroplasty. To achieve this, it is essential to identify the most appropriate outcome measure tools, factors associated with poorer recovery and management of these factors.

Inferior patellar mobility before and after knee arthroplasty: A comparison with healthy knees

PURPOSE

The aim of this study was to evaluate patellar mobility in patients before and after knee arthroplasty (KA) and compare it with that of healthy subjects. It was hypothesised that patellar mobility is diminished in patients with osteoarthritis (OA) and remains unchanged after KA.

METHODS

A total of 101 patients (59 females and 42 males) with a mean age of 70.9 ± 9.9 years underwent KA and were compared with 25 healthy individuals (seven females and 18 males) with a mean age of 32.3 ± 9.3 years. Mediolateral patellar displacement was measured by applying a force of 10 N, and the medial and lateral patellar shifts were recorded separately using a validated novel patellostabilometer. Patients were examined preoperatively and at 3 months postoperatively, assessing the range of knee motion and the clinical and functional status based on the Oxford Knee Score (OKS), Kujala Score, subjective Knee Society Score (sKSS), Forgotten Joint Score (FJS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC).

RESULTS

Total patellar displacement was 42.1 ± 6 mm for healthy subjects, 31 ± 6 mm before surgery and 32.8 ± 7.8 mm after surgery in osteoarthritic patients (p < 0.01). The mean lateral patellar shift differed significantly between healthy individuals (17.9 ± 4 mm) and osteoarthritic patients (15.1 ± 6 mm) (p < 0.01). The mean medial patellar mobility of healthy individuals (24.2 ± 7 mm) was significantly greater than that of osteoarthritic patients (15.8 ± 4.8 mm) (p < 0.01). All scores improved significantly postoperatively. No correlation was found between patellar mobility and OKS, Kujala Score, sKSS, FJS and WOMAC (r = -0.11). Improvement in patellar mobility also showed no correlation with clinical outcomes according to OKS, Kujala Score, sKSS, FJS and WOMAC (r = 0.08).

CONCLUSION

This study has demonstrated reduced patellar mobility in patients with OA. While patellar mobility significantly improved after KA, it may not hold clinical significance (p = 0.04). No impact on clinical outcome can be expected when the presurgical patella mobility is preserved in KA.

LEVEL OF EVIDENCE

Level IV.

Patient reported outcome measures (PROMs) as primary and secondary outcomes in total hip and knee arthroplasty randomized controlled trials: a systematic review

BACKGROUND

Significant heterogeneity exists regarding patient reported outcome measures (PROMs) used in total hip (THA) and knee (TKA) arthroplasty randomized controlled trials (RCTs). This study investigates the PROMs used as primary and secondary outcomes in contemporary arthroplasty RCTs.

METHODS

A literature search identified THA and TKA RCTs that were published in top ten impact factor orthopaedic journals from 2017 to 2021. Screening identified 241 trials: 76 THA, 157 TKA, and eight combined. Data were extracted to identify PROMs utilized as either primary or secondary outcomes and the time period of measurement.

RESULTS

Visual Analog Scale (VAS) Pain was the most reported primary PROM in THA (9.2%) and TKA (22.9%) trials. This was followed by Numeric Rating Scale (NRS) Pain (7.9%) and the Harris Hip score (6.6%) in THA trials and NRS Pain (4.5%) and the Knee Society score (4.5%) in TKA trials. Many THA (37.0%) and TKA (52.1%) trials did not clearly specify primary outcome time points. Only pain scales were reported at time points less than one week, while various joint-specific functional outcomes were reported at later time points. As secondary outcomes, the Harris Hip score (28.9%) was most common in THA trials and the Knee Society score (26.1%) was most common in TKA trials. Indeterminate primary or secondary outcomes were reported in 18.2% of studies.

CONCLUSIONS

Contemporary THA and TKA trials exhibit heterogeneity of PROMs as study outcomes after the first postoperative week. Our findings highlight the need for consensus in PROM reporting and better methodological reporting to improve the interpretability of RCT outcomes.

PROSPERO REGISTRATION NUMBER

CRD42022337255.

Effects of amino acid supplementation on muscle mass, muscle performance and functional capacity in subjects undergoing total knee arthroplasty: a systematic review of randomized clinical trials

The aim of the present study was to summarize the effectiveness of amino acid supplementation on muscle strength, muscle volume, and functional capacity in patients undergoing total knee arthroplasty. For this, in November 2022, a search was carried out in the PubMed, Cochrane Library, and EMBASE databases, identifying a total of 2182 documents, of which only 4 were included in the present review. The included studies had 148 participants (47 men and 101 women), with a minimum age of 53 and a maximum of 92 years, and supplementation times of 13 to 30 days (1 to 3 times a day). For the results, in relation to muscle performance, when comparing the control and experimental groups, greater muscle atrophy was observed in the pre- and post-moments of the control group, in relation to the experimental group. In addition, studies suggest a good tendency for muscle mass gain, and improvement in the functional capacities of patients who used supplementation. Therefore, the use of amino acids after TKA surgery reduces muscle atrophy, which preserves muscle mass and leads to better performance in tests of strength and functional capacity, when compared to the use of a placebo.

Establishing the Minimally Important Difference for the KOOS-Joint Replacement and PROMIS Global-10 in Patients After Total Knee Arthroplasty

Background

Despite the overall prevalence and success of total knee arthroplasty (TKA), a significant portion of patients are dissatisfied with their outcomes.

Purpose

To assess the responsiveness and determine the minimally important difference (MID) of 2 patient-reported outcome measures (PROMs)-the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR) and the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS 10)-in patients after TKA.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

Included were patients who underwent TKA from August 2015 through August 2019 and completed baseline and postoperative KOOS-JR and PROMIS 10 surveys. The PROMIS 10 consists of 2 domains: physical health and mental health. Estimates for the reliable change index (RCI) and MID, using anchor-based and distribution-based methods, were calculated for each PROM. Regression modeling was used to determine whether patient and clinical factors predicted MID thresholds or MID achievement.

Results

A total of 1315 patients were included. Distribution-based MIDs, calculated using various methods from baseline scores, ranged from 19.3 to 31 for the KOOS-JR, and the RCI was 4.38. Of these patients, 293 (22.3%) demonstrated small or moderate improvement, and this cohort was included in the calculation of anchor-based MIDs. The anchor-based MIDs were 16.9 and 24.3 at 3-month and 1-year follow-up, respectively, and 66% of patients achieved the MID at 12 months. Higher preoperative PROM score, male sex, non-White race, and current smoker status were predictive of failing to achieve the anchor-based MID for KOOS-JR at 1 year postoperatively (P < .05). Higher preoperative PROM score and any 90-day adverse event predicted lower thresholds of important change in anchor-based MIDs. Higher baseline PROM scores, younger age, male sex, non-White ethnicity, higher American Society of Anesthesiologists classification, preoperative narcotics use, not smoking, and longer hospital stay were all associated with lower odds of achieving the MID on the KOOS-JR or either of the PROMIS 10 subscales.

Conclusion

The study results demonstrated relevant values for interpretation of the KOOS-JR and PROMIS 10. While patient demographics did not accurately predict which patients would achieve the MID, some potential factors predicting successful patient-reported outcomes after TKA were identified.

Only Low Patients' Expectations Are Prognostic for Dissatisfaction With Performing Work-Related Knee-Straining Activities After Total Knee Arthroplasty: A Prospective Multicenter Cohort Study

OBJECTIVE

To investigate whether preoperative expectations regarding performing work-related knee-straining activities were associated with being dissatisfied 6 months after total knee arthroplasty (TKA) among working patients, and, to identify prognostic factors for being dissatisfied with performing these work-related knee-straining activities.

DESIGN

Multicenter prospective cohort study.

SETTING

Orthopedic surgery departments of 7 hospitals in the Netherlands.

PARTICIPANTS

A consecutive sample of 175 working patients who were on the waiting list for TKA (median age 59 years, 53% women) and intended to return to work (N=175).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Dissatisfaction with performing work-related knee-straining activities 6 months postoperative was measured using the Work Osteoarthritis or joint-Replacement Questionnaire (score range 0-100). The clinically relevant cut-off points for being satisfied and dissatisfied were ≥71 and ≤50, respectively.

RESULTS

Thirty-three patients (19%) were dissatisfied with performing work-related knee-straining activities 6 months after TKA. Patients who expected to be dissatisfied preoperative had a 5.1 times higher odds (95% CI 1.7-15.5) of being dissatisfied 6 months postoperatively compared with patients who expected to be satisfied preoperative. Regression analyses revealed that only patients' expectations were prognostic for being dissatisfied 6 months postoperatively rather than age, pain level, or having a knee-straining job.

CONCLUSIONS

Two in 10 working patients are dissatisfied with performing work-related knee-straining activities 6 months after TKA. Only preoperative patients' expectations appeared prognostic. Therefore, we should better prepare working patients with low expectations by managing their preoperative expectations and improving their performance of work-related knee-straining activities in rehabilitation.

High variation among clinical studies in the assessment of physical function after knee replacement: a systematic review

PURPOSE

The purpose of this study was to summarise the current use of outcome measures for the assessment of physical function after knee joint replacement.

METHODS

A systematic approach following the PRISMA guidelines was used. Literature search was performed on MEDLINE database via PubMed and on Epistemonikos. Clinical trials (level of evidence I-II) on knee joint replacement reporting data on the 'physical function' domain published between January 2017 and June 2022 were included. Descriptive statistics were used to summarise the evidence.

RESULTS

In the 181 articles that met the inclusion criteria, 49 different outcome measurements were used to evaluate clinical outcomes after knee joint replacement. The most frequently adopted patient-reported outcome measures (PROMs) were the Knee Society Score (KSS) (78 studies; 43.1%), the Western Ontario and McMaster Universities (WOMAC) Arthritis Index (62 studies; 34.3%), the Oxford Knee Score (OKS) (51 studies; 28.2%) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) (36 studies; 20%). The most frequently used performance-based outcome measures (PBOMs) were the Timed-Up-and-Go (TUG) test (30 studies; 16.6%) and the 6-min-walk test (6MWT) (21 studies; 11.6%). Among impairment-based outcome measures (IBOMs), range of motion (ROM) was the most used (74 studies; 40.9%).

CONCLUSION

There is considerable variation among clinical studies regarding the assessment of the physical function of patients after knee joint replacement. PROMs were found to be the most commonly adopted outcome measures; however, no single PROM was used in more than half of the papers analysed.

LEVEL OF EVIDENCE

Level II, systematic review of level I-II studies.

Patient preferences as human factors for health data recommender systems and shared decision making in orthopaedic practice

Background

A core set of requirements for designing AI-based Health Recommender Systems (HRS) is a thorough understanding of human factors in a decision-making process. Patient preferences regarding treatment outcomes can be one important human factor. For orthopaedic medicine, limited communication may occur between a patient and a provider during the short duration of a clinical visit, limiting the opportunity for the patient to express treatment outcome preferences (TOP). This may occur despite patient preferences having a significant impact on achieving patient satisfaction, shared decision making and treatment success. Inclusion of patient preferences during patient intake and/or during the early phases of patient contact and information gathering can lead to better treatment recommendations.

Aim

We aim to explore patient treatment outcome preferences as significant human factors in treatment decision making in orthopedics. The goal of this research is to design, build, and test an app that collects baseline TOPs across orthopaedic outcomes and reports this information to providers during a clinical visit. This data may also be used to inform the design of HRSs for orthopaedic treatment decision making.

Methods

We created a mobile app to collect TOPs using a direct weighting (DW) technique. We used a mixed methods approach to pilot test the app with 23 first-time orthopaedic visit patients presenting with joint pain and/or function deficiency by presenting the app for utilization and conducting qualitative interviews and quantitative surveys post utilization.

Results

The study validated five core TOP domains, with most users dividing their 100-point DW allocation across 1-3 domains. The tool received moderate to high usability scores. Thematic analysis of patient interviews provides insights into TOPs that are important to patients, how they can be communicated effectively, and incorporated into a clinical visit with meaningful patient-provider communication that leads to shared decision making.

Conclusion

Patient TOPs may be important human factors to consider in determining treatment options that may be helpful for automating patient treatment recommendations. We conclude that inclusion of patient TOPs to inform the design of HRSs results in creating more robust patient treatment profiles in the EHR thus enhancing opportunities for treatment recommendations and future AI applications.

Use of Patient-Reported Outcome Measures in Lower Extremity Research

Background

A large number of patient reported outcome measures (PROMs) have been developed for specific lower extremity orthopaedic pathologies. However, a consensus as to which PROMs are recommended for use in evaluating treatment outcomes for patients with hip, knee, ankle and/or foot pathology based on the strength of their psychometric properties is lacking.

Objective

To identify PROMs that are recommended in systematic reviews (SRs) for those with orthopaedic hip, knee, foot, and ankle pathologies or surgeries and identify if these PROMs are used in the literature.

Study design

Umbrella Review.

Methods

PubMed, Embase, Medline, Cochrane, CINAHL, SPORTDisucs and Scopus were searched for SRs through May 2022. A second search was done to count the use of PROMs in seven representative journals from January 2011 through May 2022.SRs that recommended the use of PROMs based on their psychometric properties were included in the first search. SRs or PROMs not available in the English were excluded. The second search included clinical research articles that utilized a PROM. Case reports, reviews, and basic science articles were excluded.

Results

Nineteen SRs recommended 20 PROMs for 15 lower extremity orthopaedic pathologies or surgeries. These results identified consistency between recommended PROMs and utilization in clinical research for only two of the 15 lower extremity pathologies or surgeries. This included the use of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Copenhagen Hip and Groin Outcome Score to assess outcomes (HAGOS) for those with knee osteoarthritis and groin pain, respectively.

Conclusion

A discrepancy was found between the PROMs that were recommended by SRs and those used to assess clinical outcomes in published research. The results of this study will help to produce more uniformity with the use of PROMs that have the most appropriate psychometric properties when the reporting treatment outcomes for those with extremity pathologies.

Level of evidence

3a.

Reevaluating isolated polyethylene revision for instability after total knee arthroplasty

BACKGROUND

Instability is a common mode of failure after primary total knee arthroplasty (TKA). Surgical management includes total revision and isolated polyethylene exchange. This study aimed to evaluate outcomes after isolated polyethylene exchange for instability in one of the largest cohorts reported to date.

METHODS

This is a retrospective study of 87 patients and 93 cases of isolated polyethylene exchange after TKA for instability at a tertiary academic center. Preoperative and postoperative Knee Society Scores were compared using paired T-testing with a significance level set at p = .05. Secondary outcomes included satisfaction, complications, rates of additional surgery, and recurrent instability.

RESULTS

Of the 87 patients, 61 patients had both pre and post-operative KSS-Knee scores and 60 with matched KSS-Functional scores. KSS-Knee scores significantly increased from 63.78 to 83.13 (p < .05), and KSS-Functional scores increased from 63.80 to 84.00 (p < .05). Seven of 93 cases (7.78%) cases required additional surgery at an average of 3.8 years, including two for recurrent instability. Nine (10%) cases were initially satisfied but developed recurrent instability at an average of 27.6 months.

CONCLUSION

Isolated polyethylene exchange after TKA for instability resulted in significantly increased reported clinical outcome scores. Isolated polyethylene exchange after TKA for recurrent instability may be a viable option but surgeons should consider the rate of complications requiring surgery as well as high rate of recurrent instability. More studies with longer-term follow-up are required to further identify which patients may benefit the most from isolated polyethylene exchange after TKA for recurrent instability.

Establishing minimal detectable change thresholds for the international knee documentation committee and Kujala scores at one and two years after patellofemoral joint arthroplasty

PURPOSE

To define the minimal detectable change (MDC) for the international knee documentation committee (IKDC) and Kujala scores one and two years after patellofemoral joint arthroplasty (PFA).

METHODS

A distribution-based method (one-half the standard deviation of the mean difference between postoperative and preoperative outcome scores) was applied to establish MDC thresholds among 225 patients undergoing primary PFA at a single high-volume musculoskeletal-care center. Stability of change in MDC achievement was explored by quantifying the proportion of achievement at one- and two-year postoperative timepoints. Multivariable logistic regression analysis was performed to explore the association between sociodemographic and operative features on MDC achievement.

RESULTS

MDC thresholds for the Kujala score were 10.3 (71.1% achievement) and 10.6 (70.4% achievement) at one- and two years, respectively. The MDC thresholds for the IKDC score were 11.2 (78.1% achievement) and 12.3 (69.0% achievement) at one- and two years, respectively. Predictors of achieving the MDC for the Kujala and IKDC scores at both time points were lower preoperative Kujala and IKDC scores, respectively. Preoperative thresholds of ≤ 24.1 and 7.6 for the Kujala and IKDC scores, respectively, were associated with a 90% MDC achievement probability. When preoperative thresholds approached 64.3 and 48.3 for the Kujala and IKDC, respectively, MDC achievement probability reduced to 50%.

CONCLUSION

The MDC thresholds for the Kujala and IKDC scores two years after PFA were 10.6 and 12.3, respectively. Clinically significant health status changes were maintained overall, with a slight decrease in achievement rates between one and two years. MDC achievement was associated with disability at presentation, and several probability-based preoperative thresholds were defined. These findings may assist knee surgeons with patient selection and the decision to proceed with PFA by better understanding the patient-specific propensity for MDC achievement.

LEVEL OF EVIDENCE

IV, retrospective case series.

MCID and PASS in Knee Surgeries. Theoretical Aspects and Clinical Relevance References

The application and interpretation of patient-reported outcome measures (PROM), following knee injuries, pathologies, and interventions, can be challenging. In recent years, the literature has been enriched with metrics to facilitate our understanding and interpretation of these outcome measures. Two commonly utilized tools include the minimal clinically important difference (MCID) and the patient acceptable symptoms state (PASS). These measures have demonstrated clinical value, however, they have often been under- or mis-reported. It is paramount to use them to understand the clinical significance of any statistically significant results. Still, it remains important to know their caveats and limitations. In this focused report on MCID and PASS, their definitions, methods of calculations, clinical relevance, interpretations, and limitations are reviewed and presented in a simple approach.

Are modern knee outcomes scores appropriate for evaluating anterior knee pain and symptoms after total knee arthroplasty?

BACKGROUND

Up to 45% of patients who undergo primary total knee arthroplasty (TKA) with contemporary implants have residual anterior knee pain. While a specific evaluation of anterior knee symptoms is mandatory, little is known about the capability of patellofemoral scores to be used individually. This study aimed to assess the distribution of patellofemoral scores after TKA from a uniform cohort and to investigate their external validity and ability to detect anterior knee symptoms using floor and ceiling effects.

HYPOTHESIS

Patellofemoral scores have high construct validity and fewer floor/ceiling effects than general knee scores.

METHODS

We prospectively included 113 consecutive patients who underwent primary TKA for primary osteoarthritis at a single University Hospital. Clinical outcomes included patellofemoral scores (HSS Patella, Kujala and Lille scores) and general knee scores (KOOS and new KSS) at 1-year follow-up. The floor and ceiling effects were considered as significant when greater than 15%. These were determined for each score individually and for composite scores (combination of patellofemoral scores and new KSS). The construct validity of each score and their ability to detect anterior knee pain was evaluated.

RESULTS

Patellofemoral scores showed no floor effect but a significant ceiling effect (from 25% to 65%). This ceiling effect decreased when composite scores were used. The convergent validity test showed strong correlation between patellofemoral scores (from 0.741 to 0.819, p<0.00001) and a better ability to discriminate anterior knee pain than the general knee scores.

CONCLUSIONS

Patellofemoral scores showed no floor effect and a very good construct validity for anterior knee pain after TKA. However, studies aiming to monitor anterior knee symptoms after TKA should combine scoring systems to included patellofemoral-related items rather than use patellofemoral scores alone due their ceiling effects.

LEVEL OF EVIDENCE

III; prospective study.

No consistent association between patient-reported outcome measures and coronal alignment following total knee arthroplasty: a narrative review

BACKGROUND

Total knee arthroplasty is a common procedure for treating knee conditions; however, significant proportions of patients report dissatisfaction post-operatively. Recent data suggests accurate coronal alignment may not be essential for optimizing prosthesis functionality and survivorship. This narrative review utilized a systematic approach to analyse the literature comparing post-operative coronal alignment and PROMs following knee replacement.

METHODS

A systematic search of MEDLINE was utilized to identify publications that directly compare the relationship between coronal alignment and PROMs.

RESULTS

Thirty-one eligible publications were identified. Variability in both study design and findings were observed, with no studies being without risk of bias.

CONCLUSION

Given this variability and lack of consensus among the reported publications, current literature is ill-equipped to describe the exact nature of the relationship between coronal alignment and PROMs following TKA. Further research would ideally utilize both validated generic, and knee-specific PROMs, make use of pre-operative outcome data, and standardized follow-up to develop reliable assessments of coronal alignment and its impact upon both functionality and quality of life.

Chinese cross-culturally adapted patient-reported outcome measures (PROMs) for knee disorders: a systematic review and assessment using the Evaluating the Measurement of Patient-Reported Outcomes (EMPRO) instrument

BACKGROUND

Knee patient-reported outcome measures (PROMs) are widely used in research in China, but there is limited evidence on the quality of cross-culturally adapted and original Chinese PROMs. We investigated Chinese language knee PROMs to provide evidence for clinicians on their quality and to guide PROM choices.

METHOD

A systematic literature search of databases: PUBMED, CINAHL, EMBASE, and CNKI, using adequate search strings and a three-step screen process identified relevant studies. An independent standardized assessment of the selected studies based on the Evaluating the Measurement of Patient-Reported Outcomes (EMPRO) tool was performed. Inter-rater reliability was assessed using intraclass coefficients (ICC).

RESULTS

Thirty-three articles corresponding to 23 knee PROMs were evaluated with EMPRO global scores (100) ranging from 11.11 to 55.42. The attributes 'reliability,' 'validity,' and 'cultural and language adaptation' were significantly better evaluated compared to the attributes 'responsiveness,' 'interpretability,' and 'burden' (for all comparisons p < 0.0001). Moderate-to-excellent inter-rater agreement was observed with ICC values ranging from 0.538 to 0.934.

CONCLUSION

We identified six PROMs with a minimum acceptable threshold (> 50/100). The osteoarthritis of knee and hip quality of life, the lower extremity function scale, and the Western Ontario Meniscal Evaluation tool ranked highest. Nevertheless, no single PROM had evidence encompassing all EMPRO attributes, necessitating further studies, especially on responsiveness, interpretability, and burden. We identified duplication of effort as shown by repeated translations of the same PROM; this inefficiency could be ameliorated by rapid approval of Chinese language PROMs documented on original PROM developers' platforms.

Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study

BACKGROUND

Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery.

METHODS

This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs.

RESULTS

The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = - 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = - 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = - 0.02 SE = 0.008, p = 0.011) and 365-days (β = - 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = - 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = - 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = - 0.06, SE = 0.41, p = 0.880 EQ-5D: β = - 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect.

CONCLUSIONS

Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.

Clinical Outcomes of Revision Total Knee Arthroplasty among Different Etiologies and Treated with a Condylar Constrained Knee Implant Supported with Cones

The first objective of this paper is to report the clinical and functional results of a cohort of patients who underwent total knee arthroplasty revision at mid–long-term follow-up. The second objective is to investigate possible differences in postoperative functional and clinical outcomes between preoperative-cause-of-revision groups. Methods: we collected data from 105 surgeries performed between January 2008 and December 2014. Eighty-five of these patients were divided into subpopulations according to the causes of revision in order to study differences regarding their outcome. All the patients underwent a standard follow-up protocol with clinical and radiological exams at 1, 3, 6, 12, 24, and 36 months and at last follow-up. During the last follow-up, patient-reported outcome measures (PROMs) were used. We implemented the functional outcomes obtained with clinical data determined by the Oxford knee score (OKS), EQ-VAS, EQ-5D-5L, Knee Society Score (KKS), and range of motion (ROM). Statistically significant differences among the medians of the groups of OKS, EQ-VAS, EQ-5D-5L, KKS, and ROM (p < 0.05) were noticed. The Dunn’s test was used to perform post hoc comparisons, and it determined where the differences lie. Results: the median follow-up was 99 months (interquartile range (IQR) 80–115). The median age was 71.5 IQR 65.1–74.8)) with no relevant differences between the groups. More patients presented a preoperative diagnosis of aseptic loosening (29%), malpositioning (28%), and infection (24%), while a preoperative diagnosis of instability (11%) and periprosthetic fracture was observed in fewer cases. For OKS, the highest median value was in the periprosthetic fracture group (43.25, IQR 32.7–45.3) and the lowest median value was in the infection group (24.8, IQR 17.4–34.8). For EQ-VAS, the highest median value was in the periprosthetic fracture group (73.0, IQR 67.0–78.0) and the lowest median value was in the instability group (39.0, IQR 36.0–48.0). For EQ-5D-5L, the highest median value was in the aseptic loosening group (0.81, IQR 0.74-0.85) and the lowest median value was in the infection group (0.44, IQR 0.32–0.60). For KKS, the highest median value was in the aseptic loosening group (84.0, IQR 81.0–88.0) and the lowest median value was in the malpositioning group (56.5, IQR 49.4–66.0). For ROM, the highest median value was in the periprosthetic fracture group (105.0°, IQR 96.0–111.0°) and the lowest median value was in the infection group (88.5°, IQR 77.5–98.0°). Conclusion: Constrained condylar knee (CCK) prostheses can also be considered a good option to manage difficult cases of total knee arthroplasty revision, with satisfactory results being maintained over time; a preoperative diagnosis of infection is associated with a worse clinical and functional outcome.

No correlation between symmetry-based performance measures and patient-related outcome prior to and after total knee arthroplasty

PURPOSE

Standardized outcome measures are crucial for the evaluation of different treatment and rehabilitation regimes in patients after total knee arthroplasty (TKA). Performance-based measures are necessary to capture different aspects of physical function. High reliability and agreement of five performance-based measures were hypothesized to differentiate between measurement error and change in test performance. Secondary outcomes are the correlation of performance-based measurements to KSS and WOMAC prior to surgery (baseline) and 10 weeks thereafter (t3).

METHODS

The test-retest reliabilities and agreements of the 1-m walk test, the stair-climbing test, the timed-up-and-go test, the weight-balanced-chair-rising test and the isometric maximum knee extension force in patients undergoing total knee replacements were studied. The intraclass correlation coefficient was calculated and a Bland-Altman analysis performed.

RESULTS

The weight-balanced-chair-rising test showed a symmetry at baseline = 0.77, 5 ± 1 days after surgery (t1) = 0.50, 9 ± 1 days (t2) = 0.59 and (t3) = 0.80. All performance tests showed high intraclass correlation coefficients (ICC = 0.81-0.99). The 10-m walk test, stair climbing test, and the timed-up-and-go test showed high agreement in the Bland-Altman analysis. The Bland-Altman analysis for the weight-balanced-chair-rising test and isometric knee extension force indicated high agreement at 5 and 9 days postoperatively, but the relative measurement error increased pre- and 10 weeks postoperatively.

CONCLUSION

In conclusion, symmetry, as an important outcome after TKA, is a reliable and rather unique item that should unquestionably be added to established measurements like walking tests or survey-based function assessment. The implementation of standardized performance-based measures to assess physical function in rehabilitation procedures will help to improve the more objectively based assessment of different rehabilitation protocols.

LEVEL OF EVIDENCE

II.

A Systematic Review of Psychometric Properties of Knee-Related Outcome Measures Translated, Cross-Culturally Adapted, and Validated in Arabic Language

During the previous two decades, patient-reported outcome measures (PROMs) have been well tested, and the tools were validated in different languages across the globe. This systematic review aimed to identify the knee disease-specific outcome tools in Arabic and evaluate their methodological quality of psychometric properties of the most promising tools based on the COSMIN checklist and PRISMA guidelines. Articles published in English, from the inception of databases until the date of search (10 August 2022), were included. Articles without at least one psychometric property (reliability, validity, and responsiveness) evaluation, and articles other than in the English language, were excluded from the study. The key terms [“Arabic” AND “Knee” AND (“Questionnaire” OR “Scale”)] were used in three databases, i.e., PubMed, Scopus, and Web of Science (WoS) in the advanced search strategy. Key terms were either in the title or abstract for PubMed. Key words were in the topic (TS) for WoS. COSMIN (COnsensus-based Standards for the selection of health Measurement Instruments) risk of bias checklist was used to evaluate the methodological quality of psychometric properties of the Arabic knee-related outcome measures. A total of 99 articles were identified in PubMed, SCOPUS, and WoS. After passing inclusion and exclusion criteria, 20 articles describing 22 scales from five countries were included in this review. The instruments validated in the Arabic language are Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), knee injury and osteoarthritis outcome score (KOOS), knee outcome survey- activities of daily living scale (KOS-ADLS), Oxford knee score (OKS), anterior knee pain scale, osteoarthritis of knee and hip health-related quality of life (OAKHQoL) scale, Lysholm knee score (LKS), international documentation committee subjective knee form (IKDC), intermittent and constant osteoarthritis pain (ICOAP) questionnaire, Kujala patellofemoral pain scoring system (PFPSS), anterior knee pain scale (AKPS) and osteoarthritis quality of life questionnaire (OAQoL),. All were found to have good test-retest reliability (Intra Correlation Coefficient), internal consistency (Cronbach’s alpha), and construct validity (Visual Analog Scale, Short Form-12, RAND-36, etc.). Of 20 instruments available to assess self-reported knee symptoms and function, 12 were validated in the Saudi Arabian population. Among them, KOS-ADLS is the best PROM to be used in various knee conditions, followed by KOOS and WOMAC. The assessed methodological quality of evidence says that the knee Arabic PROMs are reliable instruments to evaluate knee symptoms/function.

How Do People With Knee Osteoarthritis Conceptualize Knee Confidence? A Qualitative Study

OBJECTIVE

Reduced knee confidence is common in people with knee osteoarthritis (OA) and is likely to influence how people with knee OA engage with movement and activities. However, there is conflicting evidence surrounding the association between confidence and function. This may be because knee confidence has been assessed via a single questionnaire item that was not developed for people with knee OA and thus may not provide an accurate or comprehensive assessment of confidence in this population. A better understanding of knee confidence could inform a more thorough assessment of the construct both in clinical and research contexts. Therefore, the aim of this study was to explore the meaning of knee confidence from the perspective of people with knee OA.

METHODS

Fifty-one people with a clinical diagnosis of knee OA took part in a one-to-one semistructured interview. Interviews explored how each participant conceptualized knee confidence. Reflexive thematic analysis was selected as a flexible approach for identifying patterns of meaning across cases through a combination of data-driven and theory-informed coding of the transcribed data.

RESULTS

People with knee OA conceptualized confidence with reference to 1 or more of 4 themes: (1) symptoms, (2) functional ability, (3) the internal structure of the knee, and (4) knowledge about knee OA and its management. Each conceptualization of confidence was associated with present and future concerns.

CONCLUSION

Because people with knee OA conceptualize knee confidence in different ways, a single-item measure is unlikely to capture all of the aspects of this construct in this population. This may explain the conflicting evidence around the association between reduced knee confidence and function in people with knee OA.

IMPACT

This study showed that a multi-item measure is needed to measure knee confidence in people with knee OA. Clinicians and researchers need to understand what knee confidence means to people with knee OA, because it is likely to influence how these individuals engage with movement and activities. Understanding this relationship can enable more targeted education and functional rehabilitation for people with knee OA.

Machine learning algorithms do not outperform preoperative thresholds in predicting clinically meaningful improvements after total knee arthroplasty

PURPOSE

Patient-reported outcome measures (PROMs) are important measures of success after total knee arthroplasty (TKA) and being able to predict their improvements could enhance preoperative decision-making. Our study aims to compare the predictive performance of machine learning (ML) algorithms and preoperative PROM thresholds in predicting minimal clinically important difference (MCID) attainment at 2 years after TKA.

METHODS

Prospectively collected data of 2840 primary TKA performed between 2008 and 2018 was extracted from our joint replacement registry and split into a training set (80%) and test set (20%). Using the training set, ML algorithms were developed using patient demographics, comorbidities and preoperative PROMs, whereas the optimal preoperative threshold was determined using ROC analysis. Both methods were used to predict MCID attainment for the SF-36 PCS, MCS and WOMAC at 2 years postoperatively, with predictive performance evaluated on the independent test set.

RESULTS

ML algorithms and preoperative PROM models performed similarly in predicting MCID for the SF-36 PCS (AUC: 0.77 vs 0.74), MCS (AUC: 0.95 vs 0.95) and WOMAC (AUC: 0.89 vs 0.88). For each outcome, the most important predictor of MCID attainment was the patient's preoperative PROM score. ROC analysis also identified optimal preoperative threshold values of 33.6, 54.1 and 72.7 for the SF-36 PCS, MCS and WOMAC, respectively.

CONCLUSION

ML algorithms did not perform significantly better than preoperative PROM thresholds in predicting MCID attainment after TKA. Future research should routinely compare the predictive ability of ML algorithms with existing methods and determine the type of clinical problems which may benefit the most from it.

LEVEL OF EVIDENCE

II.

Use of computerised adaptive testing to reduce the number of items in patient-reported hip and knee outcome scores: an analysis of the NHS England National Patient-Reported Outcome Measures programme

OBJECTIVE

Over 160 000 participants per year complete the 12-item Oxford Hip and Knee Scores (OHS/OKS) as part of the NHS England Patient-Reported Outcome Measures (PROMs) programme. We used a modern computational approach, known as computerised adaptive testing (CAT), to simulate individually tailored OHS and OKS assessment, with the goal of reducing the number of questions a patient must complete without compromising measurement accuracy.

METHODS

We fit the 2018/2019 PROMs data to an item response theory (IRT) model. We assessed IRT model assumptions alongside reliability. We used parameters from the IRT model with data from 2017/2018 to simulate CAT assessments. Two simulations were run until a prespecified SE of measurement was met (SE=0.32 and SE=0.45). We compared the number of questions required to meet each cut-off and assessed the correlation between the full-length and CAT administration.

RESULTS

We conducted IRT analysis using 40 432 OHS and 44 714 OKS observations. The OHS and OKS were both unidimensional (root mean square error of approximation 0.08 and 0.07, respectively) and marginal reliability 0.91 and 0.90. The CAT, with a precision limit of SE=0.32 and SE=0.45, required a median of four items (IQR 1) and two items (IQR 1), respectively, for the OHS, and median of four items (IQR 2) and two items (IQR 0) for the OKS. This represents a potential 82% reduction in PROM length. In the context of 160 000 yearly assessments, these methodologies could result in the omission of some 1 280 000 redundant questions per year, which equates to 40 000 hours of patient time.

CONCLUSION

The application of IRT to the OHS and OKS produces an efficient and substantially reduced CAT. We have demonstrated a path to reduce the burden and potentially increase the compliance for these ubiquitous outcome measures without compromising measurement accuracy.

Analysis of Patient-reported Outcomes Measures Used in Lumbar Fusion Surgery Research for Degenerative Spondylolisthesis

STUDY DESIGN

Meta-analyses.

OBJECTIVE

This study aims to document the most common Patient-reported Outcome Measures (PROMs) used to assess lumbar fusion surgery outcomes and provide an estimate of the average improvement following surgical treatment.

SUMMARY OF BACKGROUND DATA

As health care institutions place more emphasis on quality of care, accurately quantifying patient perceptions has become a valued tool in measuring outcomes. To this end, greater importance has been placed on the use of PROMs. This is a systemic review and meta-analysis of randomly controlled trials published between 2014 and 2019 assessing surgical treatment of degenerative spondylolisthesis.

METHODS

A fixed effect size model was used to calculate mean difference and a 95% confidence interval (95% CI). Linear regression was used to calculate average expected improvement, adjusted for preoperative scores.

RESULTS

A total of 4 articles (7 study groups) were found for a total of 444 patients. The 3 most common PROMs were Oswestry Disability Index (ODI) (n=7, 100%), Short-Form-12 or Short-Form-36 (SF-12/36) (n=4, 57.1%), and visual analog scale-back pain (n=3, 42.8%). Pooled average improvement was 24.12 (95% CI: 22.49-25.76) for ODI, 21.90 (95% CI: 19.71-24.08) for SF-12/36 mental component score, 22.74 (95% CI: 20.77-24.71) for SF-12/36 physical component score, and 30.87 (95% CI: 43.79-47.97) for visual analog scale-back pain. After adjusting for preoperative scores, patients with the mean preoperative ODI (40.47) would be expected to improve by 22.83 points postoperatively.

CONCLUSIONS

This study provides a range of expected improvement for common PROMs used to evaluate degenerative spondylolisthesis with the goal of equipping clinicians with a benchmark value to use when counseling patients regarding surgery. In doing so, it hopes to provide a comparison point by which to judge individual patient improvement.

LEVEL OF EVIDENCE

Level II.

What Do Orthopaedists Believe is Needed for Incorporating Patient-reported Outcome Measures into Clinical Care? A Qualitative Study

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly promoted for use in routine orthopaedic care with the expectation that if they are made available during encounters, they will be incorporated into clinical practice. We investigated an initiative in which PROMs were systematically collected and provided via the electronic health record but were infrequently used.

QUESTIONS/PURPOSES

In a qualitative study, we asked: (1) Why are PROM results not being used in clinical care when they are available to surgeons? (2) What aspects of PROMs are seen as useful for clinical care? (3) How are PROMs generally perceived by surgeons and orthopaedic leaders?

METHODS

A cross-sectional qualitative study was conducted in a single health system in an urban setting using semistructured interviews with a purposive sample of orthopaedic surgeons and leaders who would have substantial knowledge of and experience with the organization's PROM system, which was embedded in the electronic health record and developed for use in clinical care but was not being used. We included surgeons whose practices consisted of at least 90% patients with osteoarthritis, including surgical and nonsurgical management, and thus their patients would be completing PROMs surveys, or surgeons who were leaders in one of the three orthopaedic divisions in the health plan. The senior research manager for orthopaedics identified 14 potential participants meeting these criteria, 11 of whom agreed to study participation. Participants included nine surgeons and two orthopaedic leaders; the majority were men, with a median of 13 years of clinical practice. Study interviews were conducted by an experienced interviewer not known to participants, in private conference rooms in the healthcare setting, and a median (range) of 27 minutes (16 to 40) in length. A content analysis approach was employed for data analysis, with thematic inductive saturation reached in the analysis and attention to trustworthiness and rigor during the analytic process.

RESULTS

Interviewees reported that PROM scores are not being used in patient clinical care because of logistical barriers, such as access and display issues and the time required, and perceptual barriers, such as concerns about patient understanding and the validity and reliability of measures. Surgeons preferred talking with patients about the personal outcomes patients had identified as important; most patients preferred to assess progress toward their own goals than PROMs scores for other people. Surgeons also identified changes that could facilitate PROM use and reduce barriers in clinical care, including pushing PROM scores to physicians' inboxes, developing inserts for physician notes, using easy-to-understand graphical displays, and engaging patients about PROMs earlier in the care process. Participants all agreed that PROMs in aggregate use are valuable for the organization, department, and individual surgeons, but individual patient scores are not.

CONCLUSION

Despite the availability of PROMs, there are important barriers to incorporating and using PROMs in clinical care. Providing access to PROM scores without clearly understanding how and why surgeons may consider using or incorporating them into their clinical practice can result in expensive and underused systems that add little value for the clinician, patient, or organization.

CLINICAL RELEVANCE

Involving front-line orthopaedic surgeons and leaders in shaping the design and structure of PROM systems is important for use in clinical care, but these interviewees seemed to see aggregate data as more valuable than individual patient scores.

The German version of the High-Activity Arthroplasty Score is valid and reliable for patients after total knee arthroplasty

PURPOSE

The indications for a total knee arthroplasty (TKA) broadened to younger and more active patients. The High-Activity Arthroplasty Score (HAAS) is a self-administered instrument focussing on the wider range of functional abilities of more active patients. The HAAS was developed in English and is not available in German yet. This study aims to translate, cross-cultural adapt and assess the psychometric properties of the German HAAS in patients 12 months after primary TKA.

METHODS

After forward and backward translation, we examined the final version regarding its psychometric properties in patients 12 months after primary TKA. The HAAS was sent out to 70 patients together with routine questionnaires comprising the Knee injury and Osteoarthritis Outcome Score (KOOS), the Forgotten Joint Score (FJS-12), the EuroQol (EQ-5D-3L) and 2 numerical pain rating scales. Acceptability, reliability, responsiveness, content and construct validity as well as floor and ceiling effects were evaluated.

RESULTS

Fifty-two patients were recruited. The HAAS was well accepted with a mean time to completion of 2.4 min. Cronbach's alpha for internal consistency was 0.749, test-retest reliability was excellent with an Intraclass Correlation Coefficient (ICC) of 0.961. The smallest detectable change was 1.5. Good content validity was confirmed. A strong correlation was found between the HAAS and KOOS sport (r = 0.661) and a medium correlation for all other KOOS subscales (r = 0.324 to 0.453), the FJS-12 (r = 0.425), the EQ-5D-3L (r = 0.427) and pain (r = - 0.439 to - 0.308). The HAAS showed no floor and ceiling effects.

CONCLUSIONS

The German version of the HAAS provides good validity and reliability. It can be easily self-administered and is recommended to capture high-intensity activities in patients after TKA.

LEVEL OF EVIDENCE

Diagnostic study, Level I.

Evaluation of Patient-Reported Outcome Measures of Positive Psychosocial Constructs in Children and Adolescent/Young Adults with Cancer: A Systematic Review of Measurement Properties

Introduction: Children, adolescents, and young adults with cancer are a vulnerable population in whom improvements in psycho-oncology care would be valuable. We previously published a scoping review exploring what is known about positive psychological constructs in this population. A key finding was that evidence-based patient-reported outcome measures (PROMs) were needed to standardize psycho-oncology research. Methods: We undertook a systematic review of measurement properties focused on PROMs in the pediatric and adolescent/young adults (AYAs) with cancer populations. We searched for PROMs that measured at least 1 of 15 previously identified, key positive constructs. This systematic review followed COSMIN guidelines, considered the gold standard manual for systematic reviews of measurement properties. Results: We identified 20 (22 if proxy reports are counted separately) unique PROMs that met inclusion criteria. Of those, only five were recommended for use given the current evidence. The remainder may be used if no alternative exists. Only eight PROMs had any evidence of content validity, considered the most important psychometric property by COSMIN. Many studies were at risk of bias owing to incomplete or suboptimal methods. Discussion: Five PROMs are considered reliable for the pediatric and AYA with cancer populations. A number of PROMs require additional research to ensure their items and instructions are comprehensive, relevant, and comprehensible to children and AYAs. Given the overall lack of research, this review may be considered a starting point for the future refinement of a core set of PROMs to measure positive psychological constructs.

Efficacy and safety of radiofrequency treatment for improving knee pain and function in knee osteoarthritis: a meta-analysis of randomized controlled trials

Background

The clinical utility of radiofrequency (RF) in patients with knee osteoarthritis (OA) remains unclear. We conducted a meta-analysis to systematically evaluate the efficacy and safety of RF treatment in patients with knee OA.

Methods

Searches of the PubMed, Web of Science, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data databases were performed through August 30, 2021. The major outcomes from published randomized controlled trials (RCTs) involving patients with knee OA were compared between RF and control groups, including Visual Analogue Scale (VAS) or Numerical Rating Scale (NRS) scores, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), Global Perceived Effect (GPE) scale, and adverse effects at available follow-up times.

Results

Fifteen RCTs involving 1009 patients were included in this meta-analysis, and the results demonstrated that RF treatment correlated with improvements in pain relief (VAS/NRS score, all P < 0.001) and knee function (WOMAC, all P < 0.001) at 1–2, 4, 12, and 24 weeks after treatment as well as patients’ degree of satisfaction with treatment effectiveness (GPE scale, 12 weeks, P < 0.001). OKSs did not differ significantly between the two groups. Moreover, treatment with RF did not significantly increase adverse effects. Subgroup analysis of knee pain indicated that the efficacy of RF treatment targeting the genicular nerve was significantly better than intra-articular RF at 12 weeks after treatment (P = 0.03).

Conclusions

This meta-analysis showed that RF is an efficacious and safe treatment for relieving knee pain and improving knee function in patients with knee OA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02906-4.

Preoperative Patient-Reported Outcomes Measurement Information System Global Health Scores Predict Patients Achieving the Minimal Clinically Important Difference in the Early Postoperative Time Period After Total Knee Arthroplasty

INTRODUCTION

The patient-specific factors influencing postoperative improvement after total knee arthroplasty (TKA) are important considerations for the surgeon and patient. The primary purpose of this study was to determine which patient demographic factors influence the postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health (GH) scores. In addition, we aimed to compare the prognostic utility of preoperative PROMIS-GH scores and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) in predicting postoperative improvement.

METHODS

This retrospective cohort study of a consecutive series of patients who underwent primary, unilateral TKA analyzed prospectively collected KOOS-JR and PROMIS-GH surveys. PROMIS-GH includes physical health (PH) and mental health scores. Patient demographic and presurgical characteristics were evaluated for prognostic capability in predicting postoperative improvement in the PROMIS scores and achievement of the minimal clinically important difference (MCID). Receiver operating characteristic curves were used to understand the prognostic thresholds of the preoperative PROMIS score and KOOS-JR for predicting MCID achievement.

RESULTS

A total of 872 patients were included. Although unadjusted analyses showed associations between patient demographic factors and PROMIS-PH scores, multivariable regression analysis for predictors of MCID achievement demonstrated that PROMIS-PH was the only significant preoperative variable. Receiver operating characteristic analysis revealed that the area under the curve of PROMIS-PH (0.70; 95% CI, 0.67 to 0.74) was less than that of the KOOS-JR (0.77; 95% CI, 0.73 to 0.81; P = 0.032). Sensitivity and specificity for achieving the MCID were maximized for preoperative PROMIS-PH scores of ≤ 38 (59% and 70%) and for preoperative KOOS-JR ≤ 51 (71% and 69%).

CONCLUSIONS

Preoperative KOOS-JR and PROMIS-PH scores predict clinically meaningful improvement after TKA. The KOOS-JR has greater prognostic utility in the early postoperative period.

LEVEL OF EVIDENCE

Level III, Prognostic Study.

Assessing knee functionality: systematic review of validated outcome measures

BACKGROUND

Functional rating scales allow clinicians to document and quantify alterations and progression of recovery processes. There is neither awareness of numerous knee scales nor are they easy to find or compare to select the most suitable.

OBJECTIVES

We aimed to compile validated knee functional rating tools and analyse the methodological quality of their validation studies. Also, we aimed to provide an operational document of the outcome measures addressing descriptions of parameters, implementations, instructions, interpretations and languages, to identify the most appropriate for future interventions.

METHODS

A systematic review involved a search of PubMed, Web of Science, CINAHL, Scopus, and Dialnet databases from inception through September 2020. The main inclusion criteria were available functional rating scales/questionnaires/indexes for knees and validation studies. Methodological quality was analyzed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) and COnsensus-based Standards for the selection of health Measurement Instruments Risk of Bias (COSMIN-RB).

RESULTS

We selected 73 studies. The studies investigated 41 knee rating tools (general, 46%, and specific, 54%) and 71 validations, including 29,742 individuals with knee disorders. QUADAS-2 obtained the best results in patient selection and index test (applicability section). COSMIN-RB showed the highest quality in construct validity (most analyzed metric property). The specific tools were mainly designed for prosthesis and patellofemoral and anterior cruciate ligament injuries. More considered issues were specific function (93%), especially gait, pain/sensitivity (81%), and physical activity/sports (56%).

CONCLUSIONS AND IMPLICATIONS

We conducted a necessary, useful, unlimited-by-time and feasible compilation of validated tools for assessing knee functional recovery. The methodological quality of the validations was limited. The best validations were for the Copenhagen Knee Range of Motion Scale in osteoarthritis and arthroplasties, Knee Outcome Survey Activities of Daily Living and Lysholm Knee Score for general knee disorders and the Tegner Activity Score for anterior cruciate ligament injuries. The operational document for the scales provides necessary data to identify the most appropriate.

Personalized outcomes for hip and knee replacement: the patients point of view

BACKGROUND

Patient reported outcome measures (PROMs) are increasingly being incorporated into clinical and surgical care for assessing outcomes. This study examined outcomes important to patients in their decision to have hip or knee replacement surgery, their perspectives on PROMs and shared decision-making, and factors they considered important for postoperative care.

METHODS

A cross-sectional study employing survey methods with a stratified random sample of adult orthopedic patients who were scheduled for or recently had hip or knee replacement surgery.

RESULTS

In a representative sample of 226 respondents, patients identified personalized outcomes important to them that they wanted from their surgery including the ability to walk without pain/discomfort, pain relief, and returning to an active lifestyle. They preferred a personalized outcome (54%) that they identified, compared to a PROM score, for tracking progress in their care and thought it important that their surgeon know their personal outcomes (63%). Patients also wanted to engage in shared decision-making (79%) about their post-surgical care and identified personal factors important to their aftercare, such as living alone and caring for pets.

CONCLUSIONS

Patients identified unique personalized outcomes they desired from their care and that they wanted their orthopedic surgeons to know about. Asking patients to identify their personalized outcomes could add value for both patients and surgeons in clinical care, facilitating more robust patient involvement in shared decision-making.

Patient-reported outcome measures following revision knee replacement: a review of PROM instrument utilisation and measurement properties using the COSMIN checklist

OBJECTIVES

To identify: (1) patient-reported outcome measures (PROMs) used to evaluate symptoms, health status or quality of life following discretionary revision (or re-revision) knee joint replacement, and (2) validated joint-specific PROMs, their measurement properties and quality of evidence.

DESIGN

(1) Scoping review; (2) systematic review following the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist.

DATA SOURCES

MEDLINE, Embase, AMED and PsycINFO were searched from inception to 1 July 2020 using the Oxford PROM filter unlimited by publication date or language.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies reporting on the development, validation or outcome of a joint-specific PROM for revision knee joint replacement were included.

RESULTS

51 studies reported PROM outcomes using eight joint-specific PROMs. 27 out of 51 studies (52.9%) were published within the last 5 years. PROM development was rated 'inadequate' for each of the eight PROMs studied. Validation studies were available for only three joint-specific PROMs: Knee Injury and Osteoarthritis Outcome Score (KOOS), Lower Extremity Activity Scale (LEAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC). 25 out of 27 (92.6%) measurement properties were rated insufficient, indeterminate or not assessed. The quality of supporting evidence was mostly low or very low. Each of the validated PROMs was rated 'B' (potential for recommendation but require further evaluation).

CONCLUSION

Joint-specific PROMs are increasingly used to report outcomes following revision knee joint replacement, but these instruments have insufficient evidence for their validity. Future research should be directed toward understanding the measurement properties of these instruments in order to inform clinical trials and observational studies evaluating the outcomes from joint-specific PROMs.

A Qualitative Study of Patient Themes for the Quality of the Total Joint Arthroplasty Experience

Patients have limited involvement in the development of quality measures that address the experience of undergoing total joint arthroplasty (TJA). Current quality measures may not fully assess the aspects of care that are important to patients. The goal of this study was to understand quality of care in TJA from the patient perspective by exploring patients' knowledge gaps, experiences, and goals. The authors completed a prospective qualitative analysis of patients who had undergone hip or knee TJA. Patients completed an open-ended, structured questionnaire about the surgical and recovery process as it relates to quality of care. The authors used a phenomenologic approach and purposeful sampling to enroll 74 patients 6 to 8 weeks after TJA. Responses underwent thematic analysis. Codes were used to identify themes that were important to patients in quality of care in TJA. The authors identified 3 themes: (1) returning to activity without pain or complication, which included psychological, functional, and complication-related goals; (2) negotiating the physical and psychological challenges of recovery, which encompassed the need for assistance from the caregiver as well as psychological and physical barriers to recovery; and (3) being prepared and informed for the process of surgery, including physical, logistical, and psychological preparation. Both patients and health systems may benefit from efforts to address these patient-centered themes of quality care through quality measures for TJA (eg, improving the psychological challenges of recovery). Future quality measures, such as assessment of patient experience, may be made more patient centered if they measure and improve aspects of care that matter to patients. [Orthopedics. 2021;44(2):117-122.].

Do Patients With Diabetes Have Poorer Improvements in Patient-Reported Outcomes After Total Knee Arthroplasty?

BACKGROUND

Diabetes is one of the most common comorbidities in patients undergoing total knee arthroplasty (TKA) for osteoarthritis. However, the evidence remains unclear on how it affects patient-reported outcome measures after TKA.

METHODS

We reviewed prospectively collected data of 2840 patients who underwent primary unilateral TKA between 2008 and 2018, of which 716 (25.2%) had diabetes. All patients had their HbA1c measured within 1 month before surgery, and only well-controlled diabetics (HbA1c <8.0%) were allowed to proceed with surgery. Patient demographics and comorbidities were recorded, and multiple regression was performed to evaluate the impact of diabetes on improvements in patient-reported outcome measures (Short Form 36 (SF-36), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Knee Society Score (KSS)) and knee range of motion (ROM).

RESULTS

Compared with nondiabetics, patients with diabetes were more likely to possess a higher body mass index (P-value <.001), more comorbidities (P-value <.001), and poorer preoperative SF-36 Physical Component Summary (PCS) (P-value <.001), WOMAC (P-value = .002), KSS-function (P-value <.001), and knee ROM (P-value <.001). Multiple regression showed that diabetic patients experienced marginally poorer improvements in KSS-knee (-1.22 points, P-value = .025) and knee ROM (-1.67°, P-value = .013) than nondiabetics. However, there were no significant differences in improvements for SF-36 PCS (P-value = .163), Mental Component Summary (P-value = .954), WOMAC (P-value = .815), and KSS-function (P-value = .866).

CONCLUSION

Patients with well-controlled diabetes (HbA1c <8.0%) can expect similar improvements in general health and osteoarthritis outcomes (SF-36 PCS and Mental Component Summary, WOMAC, and KSS-function) compared with nondiabetics after TKA. Despite having marginally poorer improvements in knee-specific outcomes (KSS-knee and knee ROM), these differences are unlikely to be clinically significant.

Clinical Trial Registry Use in Orthopaedic Surgery Systematic Reviews

BACKGROUND

Results from systematic reviews and meta-analyses, which have the highest level of evidence (Level I), often drive clinical decision-making and health policy. Often, unpublished trial data are omitted from systematic reviews, raising concerns about the extent of the reliability and validity of results that have been drawn from systematic reviews. We aimed to determine the extent to which systematic review authors include searches of clinical trial registries for unpublished data when conducting systematic reviews in orthopaedic surgery.

METHODS

Systematic reviews and/or meta-analyses were gathered from the top 5 orthopaedic surgery journals based on the h5-index from Google Scholar Metrics. Systematic reviews that had been published in the Cochrane Database of Systematic Reviews, which requires the inclusion of a clinical trial registry search, served as controls. For the primary outcome, each systematic review from the top 5 orthopaedic journals was screened to determine whether the authors of each study searched for unpublished data in clinical trial registries. We then compared the rate of registry searches with those in the control group. For the secondary analysis, a search of ClinicalTrials.gov was performed for unpublished trial data for 100 randomized systematic reviews.

RESULTS

All 38 of the Cochrane systematic reviews (100%) included clinical trial registry searches, while the top 5 orthopaedic journals had only 31 of 480 studies (6.5%) that looked at clinical trial registries. The secondary analysis yielded 59 of 100 systematic review articles (59.0%) that could have included unpublished clinical trial data from ≥1 studies to their sample.

CONCLUSIONS

Systematic reviews that have been published in the top orthopaedic surgery journals seldom included a search for unpublished clinical trial data.

CLINICAL RELEVANCE

The exclusion of clinical trial registry searches potentially contributes to publication bias within the orthopaedic literature. Moving forward, systematic review authors should include clinical trial registry searches for unpublished clinical trial data to provide the most accurate representation of the available evidence for systematic reviews and meta-analyses.

The PROMISⓇ-Plus-Osteoarthritis of the Knee (OAK) profile measure integrates generic and condition-specific content to enhance relevance and efficiency

OBJECTIVE

The Patient-Reported Outcomes Measurement Information System (PROMIS)-Plus-Osteoarthritis of the Knee (OAK) profile integrates universal PROMIS items with knee-specific items across 13 domains. We evaluated the psychometric properties of a subset of six domains associated with quality of life in people with OAK.

STUDY DESIGN AND SETTING

In a cross-sectional study of OAK patients (n=600), we estimated reliability using Pearson and Spearman correlations with Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores and known-groups validity with PROMIS Global Health. Measure responsiveness was tested via paired t-tests in a longitudinal study (n=238), pre/post total knee replacement.

RESULTS

Across the six domains, internal consistency reliability (Cronbach's alpha) was 0.77-0.95 and test-retest reliability (intraclass correlation coefficients) was ≥0.90. Correlations with Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores and PROMIS Global supported convergent and divergent validity. Known-groups validity testing revealed better scores in all domains for high vs. low global status groups, and knee-specific items added value in physical function and pain. All domains reflected (p<0.001) better health status scores at follow up.

CONCLUSION

The six PROMIS-Plus-OAK profile domains demonstrated good psychometric characteristics. The measure integrates universal and knee-specific content to provide enhanced relevance, measurement precision and efficient administration for patient care and clinical research.

Quadriceps muscle group function and after total knee arthroplasty-asystematic narrative update

BACKGROUND

This article systematically summarizes the present evidences, published in the last 20 years, regarding the pre- and post-operative factors, which may influence recovery of the function of the quadriceps muscle group following total knee arthroplasty (TKA). We following the PRISMA methodology, including meta-analyses and high-level evidence studies (prospective trials, and, when unavailable, retrospective studies).

SOURCES OF DATA

Pubmed and Cochrane databases: 582 articles were identified and 54 of them were selected.

AREAS OF AGREEMENT

Tourniquets inflated at high pressure exert a detrimental effect on the quadriceps muscle group. Faster quadriceps recovery takes place using mini-invasive approaches, an eight-week rehabilitation period including balance training and the use of nutraceuticals.

AREAS OF DISAGREEMENT

Pre-habilitation and pre-operative factors, analgesic methods and different TKA implants.

GROWING POINTS AND AREAS TIMELY FOR DEVELOPING RESEARCH

Telerehabilitation seems a cost-effective tool for rehabilitation after TKA. Patients' optimization protocols before TKA should include standardized nutraceuticals intake.

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.

Clinical outcome assessment in clinical trials of chronic pain treatments

Clinical outcome assessments (COAs) measure outcomes that are meaningful to patients in clinical trials and are critical for determining whether a treatment is effective. The objectives of this study are to (1) describe the different types of COAs and provide an overview of key considerations for evaluating COAs, (2) review COAs and other outcome measures for chronic pain treatments that are recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) or other expert groups, and (3) review advances in understanding pain-related COAs that are relevant to clinical trials. The authors reviewed relevant articles, chapters, and guidance documents from the European Medicines Agency and U.S. Food and Drug Administration. Since the original core set of outcome measures were recommended by IMMPACT 14 years ago, several new advancements and publications relevant to the measurement or interpretation of COAs for chronic pain trials have emerged, presenting new research opportunities. Despite progress in the quality of measurement of several outcome domains for clinical trials of chronic pain, there remain some measurement challenges that require further methodological investigation.

Choosing the most appropriate PROM for clinical studies in sports medicine

Choosing the most appropriate patient-reported outcome measure (PROM) for a clinical study is essential in order to achieve trustworthy results. This choice will depend on (a) the objective of the study and hence the research question; (b) the choice of a theoretical framework, such as the World Health Organization's International Classification of Functioning, Disability, and Health (ICF); (c) whether there currently is a PROM that possesses high content validity and high construct validity for the specific patient group and objective, and if not; (d) the decision on whether to use a suboptimal PROM or develop and validate a new PROM. This paper presents the steps that should be followed in order to assess the relevance of PROMs and suggests ways to enhance the choice depending on the goal of the study.

Systematic review and meta-analysis of measurement properties of the Hip disability and Osteoarthritis Outcome Score - Physical Function Shortform (HOOS-PS) and the Knee Injury and Osteoarthritis Outcome Score - Physical Function Shortform (KOOS-PS)

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate all evidence on measurement properties of the Hip disability and Osteoarthritis Outcome Score - Physical function Shortform (HOOS-PS) and the Knee Injury and Osteoarthritis Outcome Score - Physical function Shortform (KOOS-PS).

DESIGN

This study was conducted according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline for systematic reviews of PROMs. MEDLINE, EMBASE, The Cochrane Library, CINAHL and PsychINFO through February 2019 were searched. Eligible studies evaluated patients with hip or knee complaints and described a measurement property, interpretability, feasibility, or the development of either the HOOS-PS or KOOS-PS.

RESULTS

Twenty-three studies were included. For both questionnaires, the content validity was found inconsistent and the quality evidence was moderate for a sufficient reliability and high for an insufficient construct validity. The HOOS-PS had a high quality evidence of sufficient structural validity and internal consistency (pooled Cronbach's alpha 0.80; n = 3761) and low quality evidence of sufficient measurement error and indeterminate responsiveness. Concerning the KOOS-PS, the quality evidence was high for an insufficient responsiveness, moderate for an inconsistent structural validity and internal consistency and low for an inconsistent measurement error.

CONCLUSIONS

The inconsistent evidence for content validity implies that scores on the HOOS-PS and KOOS-PS may inadequately reflect physical functioning. Furthermore, there is evidence for insufficient construct validity and responsiveness in patients with knee osteoarthritis receiving conservative treatment. Using the HOOS-PS or KOOS-PS as outcome measurement instruments for comparing outcomes, measuring improvements or benchmarking in patients with hip or knee complaints or undergoing arthroplasty should only be done with great caution.

REVIEW REGISTRATION

PROSPERO number CRD42017069539.

Evolving Outcome Measures in Total Knee Arthroplasty: Trends and Utilization Rates Over the Past 15 Years

BACKGROUND

Patient-reported outcome metrics and reporting are important for demonstrating value associated with total knee arthroplasty (TKA). This review studied the patient-reported outcome utilization trends as reported within the TKA literature over a 15-year period.

METHODS

A PubMed search of all manuscripts related to TKA from January 2005 to December 2019 was performed. Descriptive statistics were used for individual outcome metrics as proportions of total article publications focusing on TKA outcomes. Linear regressions analysis was performed to demonstrate significant changes in utilization rates over time.

RESULTS

There was a significant overall increase in studies utilizing outcome metrics between 2005 and 2019 (16.1%-45.0%; P < .001; R² = 98.7%). Within joint-specific metrics (2005-2019), use of Knee Disability and Osteoarthritis Outcome score increased (0%-14.8%; P < .001); while use of Knee Society Knee Scoring System decreased (55.2%-35.4%; P = .007). Of the studies reporting general health, use of the Forgotten Joint Score-12 decreased (100%-66.7% from 2014 to 2019; P = .006), and Patient-Reported Outcome Measurement Information System Global-10 increased (0%-21.4% from 2005 to 2019; P < .001). In the quality of life subcategory (2005-2019), EuroQol 5-Dimension Health Outcome Survey increased in usage (14.3%-28.0%; P < .001), while Short Form-36 use decreased (85.7%-36.6%; P < .001).

CONCLUSION

Although utilization of outcome metrics has significantly increased over the last 15 years in the TKA literature, there still exists considerable heterogeneity of outcome metrics. This lack of consensus may impede comparisons of studies for clinical and research purposes, as well as hinder cross-walk of outcome tools over time. Further study is needed to identify ideal global and joint-specific tools, while balancing issues like ease of use and utility in specific populations such as the young and highly active.

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.

Knee arthroplasty system with medialized keel: Seven-year follow-up of a pioneer cohort

BACKGROUND

In this clinical investigation, a new design with a progressive increased keel medialization according to the size was implanted. The cohort of patients was followed up for seven years.

METHODS

From May 2012 to November 2012, we implanted 70 total knee arthroplasties in 69 patients. The mean age of the patients was 76.2 years. We followed up 56 patients for seven years; we evaluated the patients at six and 60 months after surgery by Patient Reported Outcome Measures score. During the seven-year follow-up, all patients were clinically re-evaluated using the Knee Society Score and the Forgotten Joint Score. All patients underwent a preoperative and postoperative radiographic investigation. At the last follow-up the presence of any radiolucency lines was checked using the Knee Society Total Knee Arthroplasty Radiographic Evaluation and Scoring System.

RESULTS

The patients defined the surgical results as excellent in 66% of the cases, very good in 23%, good in five percent. The analysis of the functional data at seven years, performed by administering the Forgotten Joint Score, showed average values of 70.4. The clinical analysis, performed through the Knee Society Score at the same follow-up, showed average values of 90.4. The seven-year radiological analysis revealed the presence of radiolucency lines in 20 implants. The sum of the line widths never exceeded the critical value of nine millimeters, always remaining below four millimeters. Only one patient was revised.

CONCLUSIONS

The results showed an excellent outcome of this design. The medialization of the tibial keel showed good bone fixation and component alignment at seven-year follow-up.

Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Short Forms Demonstrate Responsiveness in Patients Undergoing Knee Arthroplasty

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) is an alternative to legacy outcome metrics. We investigated the relationship between Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS-JR) and PROMIS Global Health forms of Physical Health (PH) and Mental Health (MH) in knee arthroplasty patients.

METHODS

This is a retrospective cohort study of knee arthroplasty patients from December 2017 through April 2019 who had surveys collected preoperatively and postoperatively. We excluded patients undergoing revision surgery. Outcome scores were analyzed for responsiveness, effect size index (ESI), minimal clinically important difference (MCID), and correlation with each other through 12 months postoperatively.

RESULTS

A total of 875 patients were included. Floor and ceiling effects were 0% for PROMIS-PH. Postoperative PROMIS-PH and KOOS-JR scores significantly correlated with one another and increased from baseline at each postoperative time point (P < .001 for all). PROMIS-MH did not change between time points (P > .05). PROMIS-PH showed moderate responsiveness at 1 and 3 months (ESI >0.2) and excellent responsiveness at 6 and 12 months (ESI >0.8), whereas KOOS-JR was responsive at all time points (ESI >0.8). The MCID of PROMIS-PH correlated significantly with KOOS-JR, and a preoperative PROMIS-PH score of less than 32.5 predicted achieving MCID with 97% specificity.

CONCLUSION

PROMIS global health forms are a valid metric which capture patient outcomes and correlate with KOOS-JR scores after knee arthroplasty. Although KOOS-JR may be more responsive in the early postoperative time period, both measures show excellent responsiveness at 6 and 12 months after knee arthroplasty.

The AAHKS Clinical Research Award: No Evidence for Superior Patient-Reported Outcome Scores After Total Hip Arthroplasty With the Direct Anterior Approach at 1.5 Months Postoperatively, and Through a 5-Year Follow-Up

BACKGROUND

The direct anterior approach to total hip arthroplasty (THA) may result in superior early postoperative patient-reported outcome measures (PROMs). This study compared PROMs between THA patients treated with the direct anterior or posterolateral approach between 1.5 months and 5 years, using literature-derived patient acceptable symptom state (PASS) and minimal clinically important improvement (MCII) thresholds.

METHODS

A propensity score match of 93 direct anterior patients to 93 posterolateral patients from a multicenter US collaboration (6 centers, 398 patients) was performed. The Harris Hip Score (HHS), the Short-Form 36, and a Numerical Rating Scale for Pain were collected preoperatively, postoperatively (mean days: 47), and at 1, 3, and 5 years. The proportion of patients reaching the HHS PASS, Pain MCII, and Function MCII in the direct anterior and posterolateral groups was compared using binary logistic regressions, controlling for age, gender, body mass index, and Charnley score.

RESULTS

Direct anterior patients were less likely to reach the HHS PASS at the postoperative visit (P = .015; odds ratio = 0.454), but not at later visits (P > .082). Direct anterior patients had no difference from posterolateral patients in their tendency to reach the Pain MCII postoperatively or at 1 year (P > .090). The direct anterior patients were less likely to reach the Function MCII at the postoperative visit (P = .011; odds ratio = 0.422), but not at 1 year (P = .958).

CONCLUSION

No evidence was found of superior early postoperative PROM scores in THA patients treated with the direct anterior approach. No PROM differences were found at or beyond 1 year, indicating that patients reach similar final symptom states, regardless of surgical approach.