Physical activity, pain interference and comorbidities relate to PROMIS physical function in younger adults following total knee arthroplasty

Outcomes following open acetabular labrum reconstruction: Comparing fresh-frozen tendon with fresh meniscus allograft transplantation

Background

Symptomatic acetabular labral insufficiency in young, active patients is often treated with labral repair or reconstruction using fresh-frozen allografts. However, fresh-frozen tendon allografts do not have tissue or material properties that closely mimic acetabular labral fibrocartilage. Recent studies suggest meniscal allografts may be a better biomechanical, geometric, and material alternative for acetabular labrum reconstruction (ALR).

Hypothesis

Patients undergoing open ALR using fresh meniscus allograft transplants (MAT) will have better outcomes than those using fresh-frozen tendon allografts transplants (TAT) when comparing initial treatment success, diagnostic imaging assessments, and patient-reported pain and function scores.

Study design

Cohort Study.

Methods

With IRB approval, patients undergoing ALR with either TAT or MAT were included when initial (>1-year) outcomes data related to treatment success, pain, and function were available. In addition, a subcohort of patients underwent magnetic resonance imaging at least 6-months after surgery to evaluate allograft healing.

Results

Initial success rate, defined as no need for ALR revision or conversion to total hip arthroplasty (THA), was 88.9% for the entire group (n = 27, TAT = 5, MAT = 22) with 1 (20%) patient in the TAT cohort and 2 patients (9.9%) in the MAT cohort undergoing THA. In the MAT cohort, significant improvements were documented for physical function and pain scores at 1 year and final follow-up (FFU)(mean 26.8 months). Improvements in pain and function were noted at 1-year, but not at FFU (mean 59.6 months) in the TAT group. MRIs completed at least 6 months after labrum reconstruction showed improved allograft integrity and integration in the MAT cohort over the TAT cohort.

Conclusion

For acetabular labrum reconstructions, MAT was associated with a higher initial success rate, superior patient reported outcomes, and subjectively better MRI findings when compared to TAT.

Comparison of Outcomes After Primary Versus Salvage Osteochondral Allograft Transplantation for Femoral Condyle Osteochondritis Dissecans Lesions

Background

Osteochondral allograft transplantation (OCAT) allows the restoration of femoral condyle osteochondritis dissecans (OCD) lesions using an osteochondral unit. When OCD lesions are irreparable, or treatments have failed, OCAT is an appropriate approach for revision or salvage surgery. Based on its relative availability, cost-effectiveness, lack of donor site morbidity, and advances in preservation methods, OCAT is also an attractive option for primary surgical treatment for femoral condyle OCD.

Hypothesis

OCAT for large femoral condyle OCD lesions would be highly successful (>90%) based on significant improvements in knee pain and function, with no significant differences between primary and salvage procedure outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients were enrolled into a registry for assessing outcomes after OCAT. Those patients who underwent OCAT for femoral condyle OCD and had a minimum of 2-year follow-up were included. Reoperations, treatment failures, and patient-reported outcomes were compared between primary and salvage OCAT cohorts.

Results

A total of 22 consecutive patients were included for analysis, with none lost to the 2-year follow-up (mean, 40.3 months; range, 24-82 months). OCD lesions of the medial femoral condyle (n = 17), lateral femoral condyle (n = 4), or both condyles (n = 1) were analyzed. The mean patient age was 25.3 years (range, 12-50 years), and the mean body mass index was 25.2 kg/m2 (range, 17-42 kg/m2). No statistically significant differences were observed between the primary (n = 11) and salvage (n = 11) OCAT cohorts in patient and surgical characteristics. Also, 91% of patients had successful outcomes at a mean of >3 years after OCAT with 1 revision in the primary OCAT cohort and 1 conversion to total knee arthroplasty in the salvage OCAT cohort. For both primary and salvage OCATs, patient-reported measures of pain and function significantly improved at the 1-year and final follow-up, and >90% of patients reported that they were satisfied and would choose OCAT again for treatment.

Conclusion

Based on the low treatment failure rates in conjunction with statistically significant and clinically meaningful improvements in patient-reported outcomes, OCAT can be considered an appropriate option for both primary and salvage surgical treatment in patients with irreparable OCD lesions of the femoral condyles.

Improvement in functional outcome 1 year after nonsurgical multidisciplinary treatment for chronic pain after total knee arthroplasty: A prospective cohort study

PURPOSE

The purpose of this study was to evaluate a multidisciplinary intervention developed for patients with debilitating chronic pain after total knee arthroplasty (TKA) unresponsive to existing treatment options.

METHODS

A treatment-based prospective cohort study was caried out in 30 TKA patients with debilitating chronic pain at least 1 year after TKA. The treatment was a multidisciplinary intervention. Main inclusion criteria: no indication for surgery. Primary outcome was function measured by KOOS-PS, OKS, OKS-APQ and WORQ. Secondary outcome measures were pain, fear of movement, self-efficacy, quality of life (QoL), health care and pain medication use, work rehabilitation and patient satisfaction. The assessments took place pre- and directly posttreatment, at 1, 3 and 12 months follow-up. The clinical relevance was assessed by predefined minimal important clinical change (MCIC).

RESULTS

At baseline patients were on average 64.7 (±7.9) years old, 67% were female, and they had knee pain for 42 (10-360) months. The results at 12-month follow-up: first, a significant improvement was shown in function, pain, fear of movement, self-efficacy and QoL. Second, in 38.5%-69.2% of patients clinical relevant improvement was shown for functional outcome, 31% for pain, and 50% for self-efficacy. Third, 42% of patients reported 'no healthcare use in the past three months'.

CONCLUSION

One year after a multidisciplinary treatment a clinically relevant improvement was shown in terms of function, pain, self-efficacy and QoL. It seems to be a promising treatment option in this difficult-to-treat patient group with debilitating chronic pain after TKA. Future research should examine the effect of the treatment in a larger study population, considering a control group, and focusing on the working population and evaluating cost-efficacy.

LEVEL OF EVIDENCE

Level II.

Patient-reported outcomes measurement information system instruments in knee arthroplasty patients: a systematic review of the literature

BACKGROUND

The purpose of this study is to provide a systematic review of the literature pertaining to Patient-Reported Outcome Measurement Information System (PROMIS) validation and utilization as an outcomes metric in total knee arthroplasty (TKA) patients. This is the first systematic review on PROMIS use in total knee arthroplasty patients.

METHODS

A systematic search of the Pubmed/MEDLINE and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study characteristics, patient demographics, psychometric properties (Pearson and Spearman correlation) with legacy patient-reported outcome measurement (PROM) instruments, floor and ceiling effects, responsiveness, and minimum clinically important difference (MCID) and PROMIS outcomes were recorded and analyzed.

RESULTS

Fifteen studies investigating PROMIS in 11,140 patients were included. The weighted-average Pearson correlation coefficient comparing PROMIS domains with legacy patient-reported outcome measurements in total knee arthroplasty patients was 0.62 [standard error (SE) = 0.06] and the weighted-average Spearman correlation comparing PROMIS domains with legacy patient-reported outcome measurements in total knee arthroplasty patients was 0.59 (SE = 0.06), demonstrating moderate-to-strong correlation and validity. There were no differences in weighted average floor [0.03% (SE = 3.1) versus 0% (SE = 0.1) versus 0.01% (SE = 1.1); p = 0.25] or ceiling effects [0.01% (SE = 0.7) versus 0.02% (SE = 1.4) versus 0.04% (SE = 3.5); p = 0.36] between PROMIS and legacy instruments. The weighted average for percentage of patients achieving MCID was 59.1% for global physical health (GPH), 26.0% for global mental health (GMH), 52.7% for physical function (PF), 67.2% for pain interference (PI), and 37.2% for depression.

CONCLUSION

Notably, PROMIS global physical health, physical function, and pain interference were found to be significantly responsive, with PROMIS pain interference most effectively capturing clinical improvement as evidenced by the achievement of MCID.

Identification of Metabolic Factors and Inflammatory Markers Predictive of Outcome after Total Knee Arthroplasty in Patients with Knee Osteoarthritis: A Systematic Review

OBJECTIVE

To identify metabolic factors and inflammatory markers that are predictive of postoperative total knee arthroplasty (TKA) outcome.

METHOD

A systematic search of the existing literature was performed using the electronic databases PubMed, Web of Science and Embase until the 1^st of August 2022. Studies that evaluated the influence of metabolic or inflammatory markers (I) on postsurgical outcome (O) in end-stage knee osteoarthritis patients awaiting primary TKA (P) were included in this review.

RESULTS

In total, 49 studies were included. Risk of bias of the included studies was low for one study, moderate for 10 studies and high for the remaining 38 studies. Conflicting evidence was found for the influence of body mass index, diabetes, cytokine levels and dyslipidaemia on pain, function, satisfaction and quality of life at more than six months after TKA.

CONCLUSIONS

Several limitations such as not taking into account known confounding factors, the use of many different outcome measures and a widely varying follow-up period made it challenging to draw firm conclusions and clinical implications. Therefore large-scaled longitudinal studies assessing the predictive value of metabolic and inflammatory factors pre-surgery in addition to the already evidenced risk factors with follow-up of one year after TKA are warranted.

Initial Outcomes After Unicompartmental Tibiofemoral Bipolar Osteochondral and Meniscal Allograft Transplantation in the Knee Using MOPS-Preserved Fresh (Viable) Tissues

BACKGROUND

Unicompartmental tibiofemoral bipolar osteochondral allograft transplantation (OCAT) with meniscal allograft transplantation (MAT) has not historically been associated with consistently successful outcomes for treatment of knee articular cartilage defects with meniscal deficiency.

HYPOTHESIS

Primary OCAT and MAT using fresh tissues will be associated with successful short-term outcomes based on statistically significant and clinically meaningful improvements in pain and function in the majority of patients.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients were prospectively enrolled into a registry for outcomes after OCAT and MAT. Patients included those who underwent primary OCAT and MAT using Missouri Osteochondral Preservation System (MOPS)-preserved allografts for treatment of large bipolar tibiofemoral articular cartilage defects with meniscal deficiency and had a minimum of 2-year follow-up data.

RESULTS

A total of 76 patients (n = 52 male; 68%) met inclusion criteria (mean follow-up, 52 months). The mean age was 41.1 years (range, 15-69 years), and the mean body mass index was 28.9 (range, 17-46); 48 patients underwent another OCAT in addition to the unicompartmental bipolar tibiofemoral OCAT and MAT; 23 patients (30.3%) were documented to be nonadherent to the prescribed postoperative restriction and rehabilitation protocol. The initial success rate (>2 years) was 77.6%, with 8 patients (10.5%) undergoing revision and 9 (11.8%) converting to arthroplasty. Variables associated with an increased risk for treatment failure (revision or arthroplasty) included ipsilateral osteotomy (P = .046; odds ratio [OR] = 3.3), ipsilateral concurrent procedure (P = .0057; OR = 5.5), and nonadherence (P = .0009; OR = 7.2). None of the patients undergoing revision surgery required arthroplasty at the time of data analysis such that the overall success rate for primary and revision unicompartmental bipolar OCA plus MAT was 88.2%. There were statistically significant (P < .0001) and clinically important improvements for all patient-reported outcomes at each annual follow-up time point.

CONCLUSION

Unicompartmental tibiofemoral bipolar OCAT and MAT can result in successful short-term outcomes (2-6 years) and satisfaction in the majority of patients (78%). Primary MOPS-preserved OCAT with MAT for treatment of femoral condyle and tibial plateau articular cartilage defects with concurrent meniscal deficiency was associated with statistically significant and clinically meaningful improvements in patient-reported measures of pain and function.

The current utilization of the patient-reported outcome measurement information system (PROMIS) in isolated or combined total knee arthroplasty populations

Patient reported outcome measures (PROMs) are essential for clinical research and patient-centric care because they allow us to capture patient perspectives on their health condition. In knee arthroplasty, PROMs are frequently used to assess the risks and benefits of new interventions, surgical approaches, and other management strategies. A few examples of PROMs used in total knee arthroplasty (TKA) include the Oxford Knee Score (OKS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Forgotten Joint Score (FJS) (collectively referred to as "legacy" PROMs). More recently, attention has been brought to another PROM called the Patient-Reported Outcomes Measurement Information System (PROMIS). PROMIS was developed by the National Institute of Health (NIH) and has over 300 domains assessing various aspects of patient health, including pain, physical function, and mental health. With the use of PROMIS increasing in TKA literature, there is a need to review the advancements being made in understanding and applying PROMIS for this population. Thus, the purpose of this study is to provide insight on the utilization, advantages, and disadvantages of PROMIS within the field of knee arthroplasty and to provide a comparison to legacy PROMs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictors of PROMIS Physical Function at 2 Years following Knee Surgery

The purpose of this study was to evaluate Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) 2 years following knee surgery, and identify preoperative factors associated with postoperative PROMIS PF. Three hundred and sixty-five patients, age 17 years and older, undergoing knee surgery at one institution were studied. Patients completed multiple questionnaires prior to surgery and again 2 years postoperatively including PROMIS PF, International Knee Documentation Committee (IKDC), joint and body numeric pain scales (NPS), Tegner's activity scale (TAS), and Marx's activity rating scale (MARS). Mean PROMIS PF improved from 41.4 to 50.9 at 2 years postoperatively (p < 0.001) and was strongly correlated with 2-year IKDC scores. Older age, female gender, non-Hispanic ethnicity, unemployment, lower income, government insurance, smoking, preoperative opioid use, having a legal claim, comorbidities, previous surgeries, higher body mass index (BMI), and knee arthroplasty were associated with worse 2-year PROMIS PF. Multivariable analysis confirmed that lower BMI, less NPS body pain, and higher MARS were independent predictors of greater 2-year PROMIS PF and better improvement in PROMIS PF. In this large, broad cohort of knee surgery patients, multiple preoperative factors were associated with PROMIS PF 2 years postoperatively. PROMIS PF scores improved significantly, but worse 2 year PROMIS PF scores and less improvement from baseline were independently predicted by higher BMI, greater NPS body pain, and lower MARS activity level. PROMIS PF can be implemented as an efficient means to assess outcomes after knee surgery.

Predictors of poor pre-operative psychological status among patients with cartilage defects

BACKGROUND

We evaluated the risk factors for pain catastrophizing, kinesiophobia, and elevated depressive symptoms among patients undergoing high-grade cartilage defect surgery. We hypothesized that cartilage patients would demonstrate high scores on pain catastrophizing, kinesiophobia, and depression testing prior to surgery.

METHODS

Two hundred and ten patients undergoing surgery for high-grade cartilage defects (56% chondroplasty, 36% microfracture, 22% autologous chondrocyte implantation) completed a preoperative survey before undergoing surgery. Outcome scores assessed were: International Knee Documentation Committee-Symptom (IKDC-S) score, Tegner activity score, Pain catastrophizing scale (PCS), Tampa scale for kinesiophobia (TSK-11), and Patient Health Questionnaire depression scale (PHQ-9). Multivariate logistic regression was used to determine what pre-operative factors predicted pain catastrophizing, kinesiophobia, and elevated depressive symptoms.

RESULTS

The mean pre-operative Tegner score was 5.8 (SD 2.4) and IKDC-S score was 44.7 (SD 11.1). Prior to surgery, 19% had abnormal pain catastrophizing (PCS ≥ 20 points), 14.4% had moderate-severe depression (PHQ ≥ 10), and 49.0% had high kinesiophobia (TSK-11 ≥ 25). Lower pre-operative Tegner scores predicted moderate-severe depressive symptoms (per point decrease, OR 1.36, 95% CI 1.06, 1.76; p = 0.008). Predictors of elevated pain catastrophizing were lower pre-operative IKDC-S scores (per 5-point decrease, OR 1.28, 95% CI 1.08, 1.51; p = 0.002) and symptom duration >6 months (OR 2.20 CI 1.14, 4.32; p = 0.02). A lower pre-operative IKDC-S score (per 5-point decrease, OR 1.17, CI 1.03, 1.33; p = 0.02) predicted elevated kinesiophobia.

CONCLUSION

Low self-reported function, low activity level and symptom duration greater than six months are associated with poor preoperative psychological status.