Deprivation influences the functional outcome from total hip arthroplasty

Socioeconomic inequalities in patient-reported outcome measures of Dutch primary hip and knee arthroplasty patients for osteoarthritis

OBJECTIVE

To study socio-economic inequalities in patient-reported outcomes in primary hip and knee arthroplasty (THA/TKA) patients for osteoarthritis, using two analytical techniques.

METHODS

We obtained data from 44,732 THA and 30,756 TKA patients with preoperative and 12-month follow-up PROMs between 2014 and 2020 from the Dutch Arthroplasty Registry. A deprivation indicator based on neighborhood income, unemployment rate, and education level was linked and categorized into quintiles. The primary outcome measures were the EQ-5D-3L index and Oxford Hip/Knee Score (OHS/OKS) preoperative, at 12-month follow-up, and the calculated change score between these measurements. We contrasted the most and least deprived quintiles using multivariable linear regression, adjusting for patient characteristics. Concurrently, we calculated concentration indices as a non-arbitrary tool to quantify inequalities.

RESULTS

Compared to the least deprived, the most deprived THA patients had poorer preoperative (EQ-5D -0.03 (95%CI -0.02, -0.04), OHS -1.26 (-0.99, -1.52)) and 12-month follow-up health (EQ-5D -0.02 (-0.01, -0.02), OHS -0.42 (-0.19, -0.65)), yet higher mean change (EQ-5D 0.02 (0.01, 0.03), OHS 0.84 (0.52, 1.16)). The most deprived TKA patients had similar results. The higher mean change among the deprived resulted from lower preoperative health in this group (confounding). After accounting for this, the most deprived patients had a lower mean change. The concentration indices showed similar inequality effects and provided information on the magnitude of inequalities over the entire socio-economic range.

CONCLUSION

The most deprived THA and TKA patients have worse preoperative health, which persisted after surgery. The concentration indices allow comparison of inequalities across different outcomes (e.g., revision risk).

Marginalization Influences Access, Outcomes, and Discharge Destination Following Total Joint Arthroplasty in Canada's Universal Healthcare System

BACKGROUND

The influence of socioeconomic status on outcomes following total joint arthroplasty (TJA) in the Canadian single-payer healthcare system is yet to be elucidated. The objective of the present study was to evaluate the impact of socioeconomic status on TJA outcomes.

METHODS

This was a retrospective review of 7,304 consecutive TJA (4,456 knees and 2,848 hips) performed between January 1, 2001 and December 31, 2019. The primary independent variable was the average census marginalization index. The primary dependent variable was functional outcome scores.

RESULTS

The most marginalized patients in both the hip and knee cohorts had significantly worse preoperative and postoperative functional scores. Patients in the most marginalized quintile (V) showed a decreased odds of achieving a minimal important difference in functional scores at 1-year follow-up (odds ratio [OR] 0.44; 95% confidence interval [CI] [0.20, 0.97], P = .043). Patients in the knee cohort in the most marginalized quintiles (IV and V) had increased odds of being discharged to an inpatient facility with an OR of 2.07 (95% CI [1.06, 4.04], P = .033) and OR of 2.57 (95% CI [1.26, 5.22], P = .009), respectively. Patients in the hip cohort in V quintile (most marginalized) had increased odds of being discharged to an inpatient facility with an OR of 2.24 (95% CI [1.02, 4.96], P = .046).

CONCLUSION

Despite being a part of the Canadian universal single-payer healthcare system, the most marginalized patients had worse preoperative and postoperative function, and had increased odds of being discharged to another inpatient facility.

LEVEL OF EVIDENCE

IV.

Examining Physical and Cognitive Function in Chronic Low Back Pain Through the Use of a Multisystem Resilience Framework

OBJECTIVES

Chronic pain results in significant impairment in older adults, yet some individuals maintain adaptive functioning. Limited research has considered the role of positive resources in promoting resilience among older adults. Likewise, these factors have largely been examined independently. We aimed to identify resilience domains based on biopsychosocial factors and explore whether resilience phenotypes vary across sleep disturbance, fatigue, and cognitive function.

METHODS

Sixty adults (ages ≥60 years) with chronic low back pain completed measures of psychological, health, and social functioning. On the basis of previously published analyses, principal-components analysis was conducted to create composite domains for these measures, followed by cluster analysis to identify phenotypes.

RESULTS

Four profiles emerged: Cluster 1, with high levels of psychosocial and health-related functioning; Cluster 2, with high health-related functioning and low psychosocial functioning; Cluster 3, with high psychosocial functioning and poorer health; and Cluster 4, with low levels of functioning across all domains. Significant differences across cluster membership emerged for sleep disturbance (ηp2 = 0.29), fatigue (ηp2 = 0.29), and cognitive abilities (ηp2 = 0.47). Individuals with the highest levels of resilience demonstrated more optimal outcomes in sleep and fatigue (P values ≤0.001) than did individuals with a less resilient phenotype. Furthermore, the High-Resilience group (Cluster 1) and the High Psychosocial / Low Health group (Cluster 3) had lower cognitive impairment than did the High Health / Low Psychosocial group (Cluster 2) and the Low-Resilience group (Cluster 4) (P values ≤0.009).

CONCLUSIONS

A higher array of protective resources could buffer against the negative sequelae associated with chronic low back pain. These exploratory findings support the multidimensional nature of resilience and suggest that targeting resilience from a multisystem perspective might help to optimize interventions for older adults with chronic pain.

Is Social Deprivation Associated With Usage, Adverse Events, and Patient-reported Outcome Measures in Total Joint Arthroplasty? A Systematic Review

BACKGROUND

To capture various social determinants of health, recent analyses have used comprehensive measures of socioeconomic disadvantage such as deprivation and vulnerability indices. Given that studies evaluating the effects of social deprivation on total joint arthroplasty (TJA) have yielded mixed results, a systematic review of this relationship might help answer questions about usage, complications, and results after surgery among patients in different socioeconomic groups and help guide targeted approaches to ensure health equity.

QUESTIONS/PURPOSES

We asked: How is social deprivation associated with TJA (1) usage, (2) adverse events including discharge deposition and length of stay, and (3) patient-reported outcome measures (PROMs)?

METHODS

A comprehensive review of the PubMed, EBSCO host, Medline, and Google Scholar electronic databases was conducted to identify all studies that evaluated social deprivation and TJA between January 1, 2000, and March 1, 2022. Studies were included if they evaluated comprehensive measures of socioeconomic deprivation rather than individual social determinants of health. Nineteen articles were included in our final analysis with a total of 757,522 patients. In addition to characteristics of included studies (such as patient population, procedure evaluated, and utilized social deprivation metric), we recorded TJA usage, adverse events, and PROM values as reported by each article. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean ± SD MINORS score was 13 ± 1 of 16, with higher scores representing better study quality. All the articles included are noncomparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed and results were instead presented descriptively.

RESULTS

Although there were inconsistencies among the included articles, higher levels of social deprivation were associated with lower TJA usage even after controlling for various confounding variables. Similarly, there was agreement among studies regarding higher proportion of nonhome discharge for patients with more social deprivation. Although there was limited agreement across studies regarding whether patients with more social deprivation had differences in their baseline and postoperative PROMs scores, patients with more social deprivation had lower improvements from baseline for most of the included articles.

CONCLUSION

These findings encourage continued efforts focusing on appropriate patient education regarding expectations related to functional improvement and the postoperative recovery process, as well as resources available for further information and social support. We suggest linking patient data to deprivation measures such as the Area Deprivation Index to help encourage shared decision-making strategies that focus on health literacy and common barriers related to access. Given the potential influence social deprivation may have on the outcome and utilization of TJA, hospitals should identify methods to determine patients who are more socially deprived and provide targeted interventions to help patients overcome any social deprivation they are facing. We encourage physicians to maintain close communication with patients whose circumstances include more severe levels of social deprivation to ensure they have access to the appropriate resources. Additionally, as multiple social deprivation metrics are being used in research, future studies should identify a consistent metric to ensure all patients that are socially deprived are reliably identified to receive appropriate treatment.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Social and environmental determinants of health among children with long-term movement impairment

The healthcare research community increasingly recognizes the need to address social (SDOH) and environmental determinants of health (EDOH) to optimize health and healthcare. This is particularly relevant to disability and functioning and to those with child onset conditions that impair mobility and impact functioning and participation. Using the World Health Organization (WHO)'s International Classification of Functioning, Disability, and Health (ICF) as a comprehensive framework, this paper aims to discuss our understanding of the relationships between social and EDOH and outcomes among people with impaired mobility that impacts functioning. This paper offers suggestions for future developments and guidance to use SDOH and EDOH in research and clinical practice.

Do changes in outcomes following primary and revision hip replacement differ and relate to markers of socioeconomic status? A 1-year population-based cohort study

BACKGROUND AND PURPOSE

There is little evidence on improvement after revision total hip replacement (THR). Moreover, improvements may be associated with socioeconomic status (SES). We investigated whether changes in Harris Hip Score (HHS) differ among patients undergoing primary and revision THR, and their association with markers of SES.

PATIENTS AND METHODS

We conducted a populationbased cohort study on 16,932 patients undergoing primary and/or revision THR from 1995 to 2018 due to hip osteoarthritis. The patients were identified in the Danish Hip Arthroplasty Registry. Outcome was defined as mean change in HHS (0-100) from baseline to 1-year follow-up, and its association with SES markers (education, cohabiting, and wealth) was analyzed using multiple linear regression adjusting for sex, age, comorbidities, and baseline HHS.

RESULTS

At 1-year follow-up, HHS improved clinically relevant for patients undergoing both primary THR: mean 43 (95% CI 43-43) and revision THR: mean 31 (CI 29-33); however, the increase was 12 points (CI 10-14) higher for primary THR. For primary THR, improvements were 0.9 points (CI 0.4-1.5) higher for patients with high educational level compared with low educational level, 0.4 points (CI 0.0-0.8) higher for patients cohabiting compared with living alone, and 2.6 points higher (CI 2.1-3.0) for patients with high wealth compared with low wealth.

INTERPRETATION

Patients undergoing primary THR achieve higher improvements on HHS than patients undergoing revision THR, and the improvements are negatively related to markers of low SES. Health professionals should be aware of these characteristics and be able to identify patients who may benefit from extra rehabilitation to improve outcomes after THR to ensure equality in health.

Assessing demographic access to hip replacement surgery in the United Kingdom: a systematic review

Persisting evidence suggests significant socioeconomic and sociodemographic inequalities in access to medical treatment in the UK. Consequently, a systematic review was undertaken to examine these access inequalities in relation to hip replacement surgery. Database searches were performed using MEDLINE, PubMed and Web of Science. Studies with a focus on surgical need, access, provision and outcome were of interest. Inequalities were explored in the context of sociodemographic characteristics, socioeconomic status (SES), geographical location and hospital-related variables. Only studies in the context of the UK were included. Screening of search and extraction of data were performed and 482 articles were identified in the database search, of which 16 were eligible. Eligible studies consisted of eight cross-sectional studies, seven ecological studies and one longitudinal study. Although socioeconomic inequality has somewhat decreased, lower SES patients and ethnic minority patients demonstrate increased surgical needs, reduced access and poor outcomes. Lower SES and Black minority patients were younger and had more comorbidities. Surgical need increased with age. Women had greater surgical need and provision than men. Geographical inequality had reduced in Scotland, but a north-south divide persists in England. Rural areas received greater provision relative to need, despite increased travel for care. In all, access inequalities remain widespread and policy change driven by research is needed.

Prognostic Factors Affecting Long-Term Outcomes After Elbow Dislocation: A Longitudinal Cohort Study

Purpose

To describe patient-reported outcomes following simple elbow dislocation and to identify the baseline factors that predict outcomes.

Methods

Adult patients treated with a closed reduction for a simple elbow dislocation with or without minor fracture (coronoid avulsion, radial head fracture, or epicondyle avulsion) from 2000 to 2018 completed outcome instruments including Disabilities of the Arm, Shoulder and Hand (QuickDASH) via Research Electronic Data Capture. Descriptive statistics were calculated. Univariate followed by multivariate Tobit regression models were used to determine factors associated with clinical outcomes on QuickDASH. Social deprivation was measured using the Area Deprivation Index. Patients with additional upper-extremity injuries or associated major fractures (Monteggia or terrible triad injuries, distal humerus fractures, etc) were excluded.

Results

At a mean follow-up of 67.5 months, 95% (38/40) of patients reported satisfaction with treatment, and clinical outcomes were good (QuickDASH 9.0 ± 14.8). Univariate analysis showed that higher Area Deprivation Index, older age, female sex, high-energy mechanism of injury, and worker’s compensation (WC) or Medicare insurance status (vs commercial) was associated with significantly worse QuickDASH scores at follow-up. Early therapy, dominant elbow involvement, presence of minor fractures (minimally displaced radial head, coronoid tip, or epicondylar avulsion fractures), race, and treating service did not influence outcomes in univariate analyses. Multivariate analysis demonstrated a significant association between increased social deprivation, WC insurance, and Medicare insurance and worse QuickDASH scores while controlling for new upper-extremity injury, age, sex, and mechanism of injury.

Conclusions

Outcomes and treatment satisfaction following simple elbow dislocation are generally good but are significantly worse for the patients with greater levels of social deprivation and WC or Medicare insurance. Although surgeons should be aware of the possibility that specific subsets of patients may benefit from early therapy, this factor did not appear to influence long-term outcomes in this small cohort.

Type of study/level of evidence

Prognostic III.

Impact of socioeconomic status on the 90- and 365-day rate of revision and mortality after primary total hip arthroplasty: a cohort study based on 103,901 patients with osteoarthritis from national databases in Denmark

Background and purpose - Socioeconomic inequality in health is recognized as an important public health issue. We examined whether socioeconomic status (SES) is associated with revision and mortality rates after total hip arthroplasty (THA) within 90 and 365 days.Patients and methods - We obtained SES markers (cohabitation, education, income, and liquid assets) on 103,901 THA patients from Danish health registers (year 1995-2017). The outcomes were any revision (all revisions), specified revision (due to infection, fracture, or dislocation), and mortality. We used Cox regression analysis to estimate adjusted hazard ratio (aHR) of each outcome with 95% confidence interval (CI) for each SES marker.Results - Within 90 days, the aHR for any revision was 1.3 (95% CI 1.1-1.4) for patients living alone vs. cohabiting. The aHR was 2.0 (CI 1.4-2.6) for low-income vs. high-income among patients < 65 years. The aHR was 1.2 (CI 0.9-1.7) for low liquid assets among patients > 65 years. Results were consistent for any revision within 365 days as well as for revisions due to infection, fracture, and dislocation. The aHR for mortality was 1.4 (CI 1.2-1.6) within 90 days and 1.3 (CI 1.2-1.5) within 365 days for patients living alone vs. cohabiting. Low education, low income, and low liquid assets were associated with increased mortality rate within both 90 and 365 days.Interpretation - Our results suggest that living alone, low income, and low liquid assets were associated with increased revision and mortality up to 365 days after THA surgery. Optimizing medical conditions prior to surgery and implementing different post-THA support strategies with a focus on vulnerable patients may reduce complications associated with inequality.

The Impact of Social Deprivation on Orthopaedic Outpatient Satisfaction Using the Press Ganey Outpatient Medical Practice Survey

INTRODUCTION

In orthopaedics, multiple factors (patient age, wait time, and depression) have been associated with lower Press Ganey Outpatient Medical Practice Survey (PGOMPS) patient satisfaction scores. We hypothesized that increased social deprivation is an independent predictor of lower patient satisfaction, as measured by the PGOMPS.

METHODS

We retrospectively reviewed unique new outpatient orthopaedic surgery visits between January 1, 2014, and December 31, 2016, at a single tertiary academic institution. Given the high ceiling effects, satisfaction was defined a priori as achieving a score above the 33rd percentile. Social deprivation was determined using the 2015 Area Deprivation Index (ADI). Univariate and multivariable binary logistic regressions were used to detect factors associated with patient satisfaction for both the PGOMPS Total Score and Provider Sub-Score.

RESULTS

Of the 4,881 included patients, the mean age was 53.3 ± 15.9 years, 59.3% were women, and mean ADI was 30.1 ± 19.2. Univariate analysis revealed a significantly decreased odds of achieving satisfaction on the Total Score for each decile increase in ADI (odds ratio [OR] 0.94; P < 0.001). Compared with the least deprived quartile, patients of the most deprived quartile were significantly less likely to report satisfaction for both the Total Score (OR 0.56; P = 0.001) and Provider Sub-Score (OR 0.63; P = 0.011). Multivariable analysis revealed that the odds of achieving satisfaction for each decile increase in ADI were 0.96 for the Total Score (P = 0.014) and 0.95 for the Provider Sub-Score (P = 0.004), independent of age, wait time, race, subspecialty, provider type, and the clinic setting.

CONCLUSIONS

Increased social deprivation was an independent predictor of orthopaedic outpatient dissatisfaction on the PGOMPS. These findings should be considered when interpreting patient satisfaction scores and lend further support in an effort to improve healthcare inequalities.

LEVEL OF EVIDENCE

Level III.

Increased early mortality and morbidity after total hip arthroplasty in patients with socioeconomic disadvantage: a report from the Swedish Hip Arthroplasty Register

Background and purpose - Socioeconomic status is associated with the outcome of major surgery. We investigated the association of socioeconomic status with the risk of early mortality and readmissions after primary total hip arthroplasty (THA). Patients and methods - We obtained information on income, education, immigration, and cohabiting status as well as comorbidities of 166,076 patients who underwent primary THA due to primary osteoarthritis (OA) from the Swedish Hip Arthroplasty Register, the Swedish National Inpatient Register and Statistics Sweden. Multivariable Cox regression models were fitted to estimate the adjusted risk of mortality or readmissions within 90 days after index surgery. Results - Compared with patients on a low income, the adjusted risk of 30-day mortality was considerably lower in patients on a high income (hazard ratio [HR] 0.5, 95% confidence interval [CI] 0.3-0.7) and in those on a medium income (HR 0.7, CI 0.6-0.9). Similar risk reductions were found for the endpoint 90-day mortality. Patients with a high income had a lower adjusted risk of readmission for cardiovascular reasons than those with a low income (HR 0.7, CI 0.6-0.9), as had those with a higher level of education (adjusted HR 0.7, CI 0.6-0.9). Patients with higher socioeconomic status had a lower degree of comorbidities than socioeconomically disadvantaged patients. However, adjusting for socioeconomic confounders in multivariable models only marginally influenced the predictive ability of the models, as expressed by their area under the curve. Interpretation - Income and level of education are strongly associated with early mortality and readmissions after primary THA, and both parameters are closely connected to health status. Since adjustment for socioeconomic confounders only marginally improved the predictive ability of multivariable regression models our findings indicate that comorbidities may under certain circumstances serve as an acceptable proxy measure of socioeconomic background.

Relationship Between the Patient-Reported Outcome Measurement Information System and Traditional Patient-Reported Outcomes for Osteoarthritis

BACKGROUND

Incorporating patient-reported outcomes (PROs) is paramount to the creation of a value-based healthcare system that prioritizes patient-centered care in total joint arthroplasty. The relationship between global assessment PROs such as Patient-Reported Outcome Measurement Information System (PROMIS) and joint-specific PROs for hip and knee, such as short form variations of Knee Injury and Osteoarthritis Outcome Score (KOOS-JR) and Hip Injury and Osteoarthritis Outcome Score (HOOS-JR), has yet to be assessed.

METHODS

A retrospective analysis was conducted to assess PRO measurements for knee-related and hip-related complaints. The KOOS-JR and HOOS-JR were compared to the PROMIS computerized adaptive test (CAT) short forms (physical function, pain interference, and pain intensity) to assess their relationship.

RESULTS

A total of 3644 patients completed 4609 questionnaires. A modest to strong correlation was observed between the KOOS-JR and the PROMIS CAT (ranging from r = 0.56 to -0.71, P < .05). A modest to strong correlation was also found between the HOOS-JR and the PROMIS CAT (r = 0.59 to -0.79, P < .05).

CONCLUSION

PROMIS CATs demonstrated a modest to strong correlation with KOOS-JR or HOOS-JR. Future studies should further investigate the limitations of global assessment health surveys in capturing disease-specific changes following total joint arthroplasty.

The Impact of Social Deprivation on Pediatric PROMIS Health Scores After Upper Extremity Fracture

PURPOSE

Although social deprivation is acknowledged to influence physical and mental health in adults, it is unclear if and how social deprivation influences perceived health in children. This study was conducted to evaluate the impact of social deprivation on Patient-Reported Outcomes Measurement Information System (PROMIS) scores in children presenting for treatment of upper extremity fractures.

METHODS

This cross-sectional evaluation analyzed data from 975 new pediatric patients (8-17 years old) with upper extremity fractures presenting to a tertiary orthopedic center between June 1, 2016, and June 1, 2017. They completed self-administered PROMIS Computer Adaptive Tests (CATs). The Area Deprivation Index was used to quantify social deprivation. Bivariate statistical analysis determined the effect of disparate area deprivation (based on most and least deprived national quartiles) for the entire population.

RESULTS

A total of 327 children (34%) lived in areas categorized as the most socially deprived quartile of the United States, whereas 202 (21%) arrived from homes in the least socially deprived quartile. Children in the most deprived quartile had significantly worse mean PROMIS Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores than those in the least deprived quartile. Significantly more children from the most socially deprived areas were black. Patient age, sex, and fracture type were not significantly different between patients from the least and the most socially deprived quartiles.

CONCLUSIONS

Children living in areas of greatest social deprivation report worse Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores on self-administered PROMIS CATs than children from areas of least social deprivation at presentation for care of upper extremity fractures. The impact of social deprivation on perceived health and function is evident before adulthood and, therefore, interventions to mitigate this effect should be offered to children as well as adults.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Relationship of weight and obesity with the risk of knee and hip arthroplasty for osteoarthritis across different levels of physical performance: a prospective cohort study

OBJECTIVE

To examine the association between obesity and knee and hip arthroplasty for osteoarthritis across a range of physical performance.

METHOD

The body mass index and physical performance (on the 36-item Short Form Health Survey) of 9135 Australian Diabetes, Obesity and Lifestyle Study participants were measured in 1999-2000. The incidence of knee and hip arthroplasty during 2002-2011 was determined by linking the cohort records to the Australian Orthopaedic Association National Joint Replacement Registry.

RESULTS

Over 9.1 ± 2.3 years (mean ± sd)) of follow-up, 317 participants had knee and 202 had hip arthroplasty for osteoarthritis. Using those with neither obesity nor significantly impaired physical performance as the reference group, participants with both obesity and significantly impaired physical performance had a higher knee arthroplasty risk [hazard ratio (HR) = 5.25, 95% confidence interval (CI) 3.85-7.14] than those with obesity alone (HR = 2.49, 95% CI 1.81-3.44) or impaired physical performance alone (HR = 2.19, 95% CI 1.59-3.02). Similar results were observed for hip arthroplasty (obesity and impaired physical performance: HR = 2.67, 95% CI 1.72-4.15; obesity alone: HR = 1.65, 95% CI 1.08-2.51; impaired physical performance alone: HR = 1.83, 95% CI 1.26-2.66). Among overweight/obese patients, 5 kg greater baseline weight increased the knee arthroplasty risk across all levels of physical performance, and hip arthroplasty risk in those with the highest level of physical performance.

CONCLUSION

Although impaired physical performance is an independent risk factor for knee and hip arthroplasty, greater weight increased knee arthroplasty for overweight/obese participants at all levels of physical performance, but hip arthroplasty only in those with good physical performance. Targeting weight loss has the potential to reduce the risk of knee arthroplasty and improve patient outcomes, even in those with poor physical performance.

A systematic review of preoperative determinants of patient-reported pain and physical function up to 2 years following primary unilateral total hip arthroplasty

Although generally considered successful, total hip arthroplasty (THA) can yield suboptimal results in terms of pain and function in up to one forth of patients suffering from hip osteoarthritis (OA). A thorough understanding of the determinants of patient-reported pain and function following THA can help plan interventions directed at improving surgical results. Previously published systematic reviews do not permit to confidently identify the determinants of THA outcomes because of unsatisfactory methodological designs. Therefore, we aimed to answer: (1) which preoperative factors are most consistently associated with postoperative patient-reported pain and function up to 2 years following primary unilateral THA for hip OA. Medline, Pubmed, Embase and CINAHL were screened from their respective inception dates until April 2015 using a combination of keywords and MESH terms. Criteria for inclusion were: (1) participants with primary unilateral THA for hip OA followed for at least 3 months with a maximal follow-up of 2 years; (2) validated disease-specific patient-reported outcome measures assessing pain and/or disability; (3) identification of determinants obtained via multivariate analyses. Methodological quality was assessed using a modified version of the methodology checklist for prognostic studies. Twenty-two manuscripts were included. Mean score of the methodological quality was 81.0±10.3% (66.7% to 100%). Among socioeconomic determinants, a lower educational level was significantly related to worse pain and function (3 out of 3 studies evaluating the relationship). Clinical determinants of poor outcomes included preoperative levels of pain and physical function (9 out of 12 studies), higher body mass index (6 out of 10 studies), presence/greater level of comorbidities (7 out of 8), worse general health (4 out of 4 studies) and lower radiographic OA severity (3 out of 4 studies). Study heterogeneity limited the pooled assessment of the strength of associations between the preoperative variables and THA outcomes. Studies with moderate-to-high methodological quality allowed to identify 6 preoperative variables consistently associated with medium term pain and function following THA. This knowledge may assist the management of patients at risk of poor results. Further research is required to clarify the force of associations between determinants and THA outcomes.

LEVEL OF EVIDENCE

Level II. Systematic review of cohort studies.

The influence of area level social deprivation on preoperative disease severity and postoperative outcomes following unicompartmental knee joint replacement

BACKGROUND

This study investigated the effect of socioeconomic deprivation on preoperative disease and outcome following unicompartmental knee replacement (UKR).

METHODS

307 Oxford UKRs implanted between 2008 and 2013 under the care of one surgeon using the same surgical technique were analysed. Deprivation was quantified using the Northern Ireland Multiple Deprivation Measure. Preoperative disease severity and postoperative outcome were measured using the Oxford Knee Score (OKS).

RESULTS

There was no difference in preoperative OKS between deprivation groups. Preoperative knee range of motion (ROM) was significantly reduced in more deprived patients with 10° less ROM than least deprived patients. Postoperatively there was no difference in OKS improvement between deprivation groups (p=0.46), with improvements of 19.5 and 21.0 units in the most and least deprived groups respectively. There was no significant association between deprivation and OKS improvement on unadjusted or adjusted analysis. Preoperative OKS, Short Form 12 mental component score and length of stay were significant independent predictors of OKS improvement. A significantly lower proportion of the most deprived group (15%) reported being able to walk an unlimited distance compared to the least deprived group (41%) one year postoperatively.

CONCLUSION

More deprived patients can achieve similar improvements in OKS to less deprived patients following UKR.

[Personality and comorbidity: are there "difficult patients" in hip arthroplasty?]

BACKGROUND

Concomitant disorders at the time of surgery in addition to psychological and socioeconomic patient characteristics may influence treatment outcomes in hip arthroplasty.

OBJECTIVES

To describe the impact of these factors on perioperative complications and postoperative results in terms of function, quality of life, and patient satisfaction.

MATERIALS AND METHODS

Review of relevant clinical studies, meta-analyses, and presentation of our own results.

RESULTS

Comorbidities in general, especially in combination, increase the perioperative risk profile. Socioeconomic factors (education, professional qualifications, social deprivation) in addition to psychological variables (depression, distressed personality) can have a major impact on postoperative functional outcomes and patient satisfaction.

CONCLUSIONS

It is of crucial importance to avoid inequalities in the provision of joint replacement for patients with hip osteoarthritis and co-existing risk factors. Preventive strategies should be implemented to reduce the negative impact of comorbidities on treatment outcome. Personalized communication and education may be helpful in avoiding unrealistic patient expectations before hip replacement.

The influence of education and income on responses to the QuickDASH questionnaire

We studied the influence of levels of income and education on QuickDASH scores. The scores were collected in a random sample of 1376 residents of Norway. The level of income was divided into four bands and level of education into five bands. The mean QuickDASH score for both men and women fell with every increase in education and income level. For women the mean score was 30 for those with the shortest education and 9 for those with the longest (p < 0.001). The corresponding figures for men were 19 and 7 (p < 0.01). The women with the lowest level of income had a mean score of 23, compared with 8 for women with the highest income level (p < 0.001). For men the corresponding mean scores were 20 and 5 (p < 0.001). Analysis of variance showed that age alone accounted for 16% of the variability of the scores among women and 7% among men. When levels of education and income were added to the analysis, these three factors accounted for 21% of the variability among women and 13% among men. We conclude that socioeconomic factors significantly influence QuickDASH scores.

LEVEL OF EVIDENCE

3.

Long-term outcomes of isolated stable radial head fractures

BACKGROUND

There is evidence to support primary nonoperative management of isolated stable fractures of the radial head, although minimal data exist regarding long-term outcomes. The aim of this study was to report subjective long-term outcomes of isolated stable fractures of the radial head and neck following primary nonoperative management.

METHODS

From a prospective database of proximal radial fractures, we identified all skeletally mature patients who sustained an isolated stable Mason type-1 or type-2 fracture of the radial head or neck during an eighteen-month period. Inclusion criteria were a confirmed isolated stable fracture of the proximal aspect of the radius, primarily managed nonoperatively. The primary long-term outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

The study cohort comprised 100 patients with a mean age of forty-six years (range, seventeen to seventy-nine years). A fall from a standing height accounted for 69% of all injuries. Thirty-five percent of the patients had one or more comorbidities. There were fifty-seven Mason type-1 fractures and forty-three Mason type-2 fractures. At a mean of ten years post injury (range, 8.8 to 10.2 years), the mean DASH score was 5.8 (range, 0 to 67.2) and the mean Oxford Elbow Score (OES) was 46 (range, 14 to 48). Fourteen (14%) of the patients reported stiffness and twenty-four (24%) reported some degree of pain. A worse DASH score was associated with older age (p = 0.002), one or more comorbidities (p = 0.008), increasing socioeconomic deprivation by Index of Multiple Deprivation quintile (p = 0.026), increasing amount of fracture displacement (p = 0.041), and involvement in compensation proceedings (p = 0.006).

CONCLUSIONS

Long-term patient-reported outcomes were excellent following the nonoperative management of isolated stable fractures of the radial head or neck. We suggest that routine primary nonoperative management of these fractures provides a satisfactory outcome for the majority of patients, with few patients in our study requiring further intervention for persisting complaints.

LEVEL OF EVIDENCE

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

Outcomes following large joint arthroplasty: does socio-economic status matter?

BACKGROUND

We sought to determine whether socio-economic status (SES) is an independent predictor of outcome following total knee (TKR) and hip (THR) replacement in Australians.

METHODS

In this prospective cohort study, we included patients undergoing TKR and THR in a public hospital in whom baseline and 12-month follow-up data were available. SES was determined using the Australian Bureau of Statistics 'Index of Relative Advantage and Disadvantage'. Other independent variables included patients' demographics, comorbidities and procedure-related variables. Outcome measures were the International Knee Society Score and Harris Hip Score pain and function subscales, and the Short Form Health Survey (SF-12) physical and mental component scores.

RESULTS

Among 1,016 patients undergoing TKR and 835 patients undergoing THR, in multiple regression analysis, SES score was not independently associated with pain and functional outcomes. Female sex, older age, being a non-English speaker, higher body mass index and presence of comorbidities were associated with greater post-operative pain and poorer functional outcomes following arthroplasty. Better baseline function, physical and mental health, and lower baseline level of pain were associated with better outcomes at 12 months. In univariate analysis, for TKR, the improvement in SF-12 mental health score post arthroplasty was greater in patients of lower SES (3.8 ± 12.9 versus 1.5 ± 12.2, p=0.008), with a statistically significant inverse association between SES score and post-operative SF-12 mental health score in linear regression analysis (coefficient-0.28, 95% CI: -0.52 to -0.04, p=0.02).

CONCLUSIONS

When adjustments are made for other covariates, SES is not an independent predictor of pain and functional outcome following large joint arthroplasty in Australian patients. However, relative to baseline, patients in lower socioeconomic groups are likely to have greater mental health benefits with TKR than more privileged patients. Large joint arthroplasty should be made accessible to patients of all SES.

The relationship between social deprivation and the incidence of adult fractures

BACKGROUND

Social deprivation is associated with many diseases. To our knowledge, there has been no previous investigation of its role in the epidemiology and incidence of fractures in adults.

METHODS

We analyzed 6872 consecutive fractures in patients fifteen years of age or older over a one-year period. Social deprivation was analyzed using the Carstairs score, which is derived from patients' postal codes and accurately defines social deprivation in our population.

RESULTS

Social deprivation is associated with an increasing fracture incidence. The effect is not linear, and the most deprived 10% of society are affected. The odds ratios of the most deprived 10% of society having an increased incidence of fractures are 3.7 in males and 3.1 in females.

CONCLUSIONS

Social deprivation is associated with a significant increase in the incidence of fractures in the most deprived 10% of the population. Most fracture types are affected.

Socioeconomic status affects the Oxford knee score and short-form 12 score following total knee replacement

We assessed the effect of social deprivation upon the Oxford knee score (OKS), the Short-Form 12 (SF-12) and patient satisfaction after total knee replacement (TKR). An analysis of 966 patients undergoing primary TKR for symptomatic osteoarthritis (OA) was performed. Social deprivation was assessed using the Scottish Index of Multiple Deprivation. Those patients that were most deprived underwent surgery at an earlier age (p = 0.018), were more likely to be female (p = 0.046), to endure more comorbidities (p = 0.04) and to suffer worse pain and function according to the OKS (p < 0.001). In addition, deprivation was also associated with poor mental health (p = 0.002), which was assessed using the mental component (MCS) of the SF-12 score. Multivariable analysis was used to identify independent predictors of outcome at one year. Pre-operative OKS, SF-12 MCS, back pain, and four or more comorbidities were independent predictors of improvement in the OKS (all p < 0.001). Pre-operative OKS and improvement in the OKS were independent predictors of dissatisfaction (p = 0.003 and p < 0.001, respectively). Although improvement in the OKS and dissatisfaction after TKR were not significantly associated with social deprivation per se, factors more prevalent within the most deprived groups significantly diminished their improvement in OKS and increased their rate of dissatisfaction following TKR.

Income and patient-reported outcomes (PROs) after primary total knee arthroplasty

BACKGROUND

To assess whether income is associated with patient-reported outcomes (PROs) after primary total knee arthroplasty (TKA).

METHODS

We used prospectively collected data from the Mayo Clinic Total Joint Registry to assess the association of income with index knee functional improvement, moderate to severe pain and moderate to severe activity limitation at 2-year and 5-year follow-up after primary TKA using multivariable-adjusted logistic regression analyses.

RESULTS

There were 7, 139 primary TKAs at 2 years and 4, 234 at 5 years. In multivariable-adjusted analyses, at 2-year follow-up, compared to income > US$45, 000, lower incomes of ≤ US$35, 000 and > US$35, 000 to 45, 000 were associated (1) significantly with moderate to severe pain with an odds ratio (OR) 0.61 (95% CI 0.40 to 0.94) (P = 0.02) and 0.68 (95% CI 0.49 to 0.94) (P = 0.02); and (2) trended towards significance for moderate to severe activity limitation with OR 0.78 (95% CI 0.60 to 1.02) (P = 0.07) and no significant association with OR 0.96 (95% CI 0.78 to 1.20) (P = 0.75), respectively. At 5 years, odds were not statistically significantly different by income, although numerically they favored lower income. In multivariable-adjusted analyses, overall improvement in knee function was rated as 'better' slightly more often at 2 years by patients with income in the ≤ US$35, 000 range compared to patients with income > US$45, 000, with an OR 1.9 (95% CI 1.0 to 3.6) (P = 0.06).

CONCLUSIONS

We found that patients with lower income had better pain outcomes compared to patients with higher income. There was more improvement in knee function, and a trend towards less overall activity limitation after primary TKA in lower income patients compared to those with higher incomes. Insights into mediators of these relationships need to be investigated to understand how income influences outcomes after TKA.

Socioeconomic deprivation predicts outcome following radial head and neck fractures

INTRODUCTION

There is increasing evidence demonstrating an association between fracture epidemiology and socioeconomic status. However, the influence of socioeconomic deprivation on fracture outcome has not been documented before. The aim of this study was to determine if socioeconomic deprivation influenced the short-term outcome following a fracture of the radial head or neck.

METHODS

We identified from a prospective database all patients who sustained a radial head or neck fracture over an 18-month period. The primary outcome measure for this study was the patient-reported short musculoskeletal function assessment (SMFA). The Index of Multiple Deprivation (IMD) was used to quantify deprivation, and any correlation with functional outcome was determined. Multivariate regression analysis was used to determine the influence of deprivation on outcome once other significant demographic and fracture characteristics had been accounted for.

RESULTS

There were 200 patients in the study cohort, of which 107 (53.5%) were female and the mean age was 44 years (16-83). At a mean follow-up of 6 months the median SMFA score was 0.54 (0-55.4). The SMFA was found to be influenced by the IMD, with increasing deprivation associated with a poorer outcome (p=0.006). On multivariate analysis, the AO fracture classification, compensation and increasing deprivation were the only independent predictors of outcome (all p<0.05).

CONCLUSIONS

We have a shown a clear correlation between functional outcome and socioeconomic status, with the most deprived patients reporting a poorer outcome. Future work should be aimed at determining which aspects of deprivation influence patient outcome, with modifiable factors targeted in future health-care planning.

Socioeconomic differences in patient-reported outcomes after a hip or knee replacement in the English National Health Service

BACKGROUND

We investigated socioeconomic differences in patient-reported outcomes after a hip or knee replacement and the contribution of health differences beforehand.

METHODS

Our sample included 121 983 patients in England who had an operation in 2009-2011. Socioeconomic status was measured with quintiles of the ranking of areas by the English Index of Multiple Deprivation. Outcomes at 6 months were the Oxford hip or knee score (OHS or OKS) that measure pain and disability on a scale from 0 (worst) to 48 (best), and the percentage reporting no improvement in problems. Adjustment was made for age, sex, ethnicity, comorbidity, general health, revision surgery, primary diagnosis, preoperative OHS or OKS and having longstanding problems.

RESULTS

Comparing the most- with the least-deprived group, the mean OHS was 5.0 points lower and the OKS 5.4 lower. Adjusted differences, reflecting the differences in improvement in the condition, were 2.8 [95% confidence interval (CI): 2.5-3.0] on OHS and 2.4 (95% CI: 2.2-2.7) on OKS. Adjusted odds ratios for reporting no improvement were 1.4 (1.2-1.6) for the hip and 1.4 (1.3-1.5) for the knee.

CONCLUSIONS

On average, patients living in socioeconomically deprived areas had worse outcomes after surgery, partly related to preoperative differences in health and disease severity and partly to less postoperative improvement.

Socioeconomic deprivation and the epidemiology of carpal tunnel syndrome

Deprivation has been recognized as a major determinant of health and is associated with several musculoskeletal conditions. This study examines the effect of deprivation on the incidence of carpal tunnel syndrome using a regional prospective audit database. Over a 6 year period there were 1564 patients diagnosed with CTS with an annual incidence of 72/100,000 population. There was a significant difference in population incidence of CTS from the most deprived (81/100,000) to the least deprived (62/100,000) (p = 0.003). Functional impairment was higher in the most deprived group compared with the least (DASH 56 vs 48, p = 0.001). The most deprived group exhibited the greatest exposure to occupation vibration (42.7%), and had the greatest risk of bilateral disease (OR = 2.33, p < 0.001). We report an association between socioeconomic deprivation and carpal tunnel syndrome, with the disease being more likely to be bilateral and have a poorer DASH score in the most deprived patients.

The epidemiology of radial head and neck fractures

PURPOSE

The aim of this study was to define the epidemiological characteristics of proximal radial fractures.

METHODS

Using a prospective trauma database of 6,872 patients, we identified all patients who sustained a fracture of the radial head or neck over a 1-year period. Age, sex, socioeconomic status, mechanism of injury, fracture classification, and associated injuries were recorded and analyzed.

RESULTS

We identified 285 radial head (n = 199) and neck (n = 86) fractures, with a patient median age of 43 years (range, 13-94 y). The mean age of male patients was younger when compared to female patients for radial head and neck fractures, with no gender predominance seen. Gender did influence the mechanism of injury, with female patients commonly sustaining their fracture following a low-energy fall. Radial head fractures were associated more commonly with complex injuries according to the Mason classification, while associated injuries were related to age, the mechanism of injury, and increasing fracture complexity.

CONCLUSIONS

Radial head and neck fractures have distinct epidemiological characteristics, and consideration for osteoporosis in a subset of patients is recommended.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The relationship of fall-related fractures to social deprivation

The relationship between fall-related fractures and social deprivation was studied in 3,843 patients. The incidence of fractures correlated with deprivation in all age groups although the spectrum of fractures was not affected by deprivation. The average age and the prevalence of hip fractures decreased with increasing deprivation.

INTRODUCTION

This study examines the relationship between social deprivation and fall-related fractures. Social deprivation has been shown to be a predisposing factor in a number of diseases. There is evidence that it is implicated in fractures in children and young adults, but the evidence that it is associated with fragility fractures in older adults is weak. As fragility fractures are becoming progressively more common and increasingly expensive to treat, the association between social deprivation and fractures is important to define.

METHODS

All out-patient and in-patient fractures presenting to the Royal Infirmary of Edinburgh over a 1-year period were prospectively recorded. The fractures caused by falls from a standing height were analysed in all patients of at least 15 years of age. Social deprivation was assessed using the Carstairs score and social deprivation deciles, and the 2001 census was used to calculate fracture incidence. The data were used to analyse the relationship between social deprivation and fall-related fractures in all age groups.

RESULTS

The incidence of fall-related fractures correlated with social deprivation in all age groups including fragility fractures in the elderly. The overall spectrum of fractures was not affected by social deprivation although the prevalence of proximal femoral fractures decreased with increasing deprivation. The average age of patients with fall-related fractures also decreased with increasing social deprivation as did the requirement for in-patient treatment.

CONCLUSIONS

This is the first study to show the relationship between fall-related fractures and social deprivation in older patients. We believe that the decreased incidence of proximal femoral fractures, and the lower average age of patients with fall-related fractures, in the socially deprived relates to the relative life expectancies in the different deprivation deciles.

Socioeconomic status affects the early outcome of total hip replacement

This prospective study assessed the effect of social deprivation on the Oxford hip score at one year after total hip replacement. An analysis of 1312 patients undergoing 1359 primary total hip replacements for symptomatic osteoarthritis was performed over a 35-month period. Social deprivation was assessed using the Carstairs index. Those patients who were most deprived underwent surgery at an earlier age (p = 0.04), had more comorbidities (p = 0.02), increased severity of symptoms at presentation (p = 0.001), and were not as satisfied with their outcome (p = 0.03) compared with more affluent patients. There was a significant improvement in Oxford scores at 12 months relative to pre-operative scores for all socioeconomic categories (p < 0.001). Social deprivation was a significant independent predictor of mean improvement in Oxford scores at 12 months, after adjusting for confounding variables (p = 0.001). Deprivation was also associated with an increased risk of dislocation (odds ratio 5.3, p < 0.001) and mortality at 90 days (odds ratio 3.2, p = 0.02).

Outcome, risk of dislocation and early mortality after a total hip replacement are affected by the socioeconomic status of the patient