Can patients help with long-term total knee arthroplasty surveillance? Comparison of the American Knee Society Score self-report and surgeon assessment

Correlation Between Patient-Reported and Clinician-Measured Shoulder Range of Motion in Patients Undergoing Shoulder Surgery

INTRODUCTION

There has been increasing interest in remote measures of patients' health, both in the clinical and research settings. This study sought to evaluate correlations between patient-reported and clinician-measured (CM) shoulder range of motion (ROM).

METHODS

ROM measures including elevation, abduction, and internal rotation were recorded by a patient-reported picture-based survey and clinician measurement during each patient visit. A total of 13,842 visits over a 16-year period met inclusion criteria. Spearman correlation was performed to determine the correlation between patient-reported and CM elevation, abduction, and internal rotation. A subgroup analysis was conducted to evaluate motion in patients who underwent arthroplasty and arthroscopy.

RESULTS

Patients were 52.4% male with a median age of 67 years (range, 18 to 96). PR and CM shoulder ROM were gathered at 13,842 patient visits. Strong correlations between PR and CM elevation (r = 0.70) and internal rotation (r = 0.66) were found, as well as a moderate correlation between PR and CM abduction (r = 0.59). Strong correlations were found between all three PR and CM measures of motion in the arthroplasty subgroup (elevation r = 0.74, abduction r = 0.63, and internal rotation r = 0.64).

CONCLUSIONS

There is a strong correlation between patient-reported and CM shoulder elevation and internal rotation, as well as a moderate correlation between PR and CM abduction. This allows for a method of assessing patient motion without requiring an in-person visit.

LEVEL OF EVIDENCE

Level III Retrospective Cohort Study.

Patients can accurately self-report their elbow range of motion following surgery for trauma

INTRODUCTION

There is an increased demand of telemedicine in the recent century, especially with the outbreak of Covid-19. The aim of this study was to investigate patients' reliability in self-assessing own elbow range of motion following surgery for trauma.

METHODS

All patients of age ≥16 years who underwent surgery for elbow trauma at the local trauma unit between March 2015 to Aug 2018 were reviewed retrospectively. Identified cohort was invited to self-assess their elbow range of motion (ROM) using questionnaire with image instruction. They were then followed up with a clinical review for objective measurements by the lead clinician. Independent T-test was used to compare the measurements between patients and clinician. The power of the study was calculated using G∗Power software.

RESULTS

Thirty-five patients were enrolled in the study with mean age of 41 years. 11 of 35 patients had an associated elbow fracture dislocation associated. Mean patient reported total ROM was 105.7° ± 32.8°, with mean extension of 24.6° ± 18.9° to mean flexion of 130.3° ± 18.2°. Mean objective ROM measured by lead clinician was 112.6° ± 18.3°, with mean extension 22.4° ± 10.9° to mean flexion 135.0° ± 10.8°. No statistical significance was found between self-reported and clinician-based extension (p = 0.36), flexion (p = 0.076), and overall range of motion (p = 0.12).

CONCLUSION

Patients can self-assess their elbow range of motion following surgery for trauma accurately. In the midst of increasing demands for telemedicine, we suggest the application of patients' self-reporting outcome in clinical settings.

The Relationship on Exercise Anticipation, Function and Self-efficacy in Patients After Knee Surgeries Over Six Months: An Observational Study

AIM

To explore the association between the exercise anticipation, function and self-efficacy in patients after knee surgeries over six months and to identify the predictors for rehabilitation.

METHODS

This observational study used the cross-sectional survey method and was divided into two stages: (1) designing the experimental video materials and answer cards about exercise anticipation, and (2) analyzing the correlation of the level of exercise anticipation, knee function, modified gait efficacy scale (mGES), self-efficacy for rehabilitation outcome scale (SER), self-efficacy for exercise scale (SEE), time up and go task (TUG) and knee joint angle in walking. We used IBM SPSS modeler 18.0 software for establishing the Bayesian network data mining model, which can identify strong positive and negative associations.

RESULTS

A total of 110 patients were included in this study. Our research confirmed that the exercise anticipation score exhibited the significant correlation with SER (r=0.552, P<0.01), SEE (r=0.457, P<0.01), TUG (r=-0.419, P<0.01) and knee joint angle in walking (r=-0.342, P<0.01). There is only one parent node of exercise expectation, that is, rehabilitation self-efficacy, which shows that the rehabilitation self-efficacy of patients after knee surgery is directly related to their ability to judge exercise expectation. Meanwhile this study verified the model results, and the area under the ROC curve (AUC) is 0.572 (755/1320), indicating that the prediction performance is acceptable.

CONCLUSION

This preliminary study confirmed that improving the exercise anticipation and rehabilitation self-efficacy is an important method of enhancing the knee function in patients after knee surgeries over six months. In the future, the long-term effect of the exercise anticipation and self-efficacy should be researched.

Comparison of functional outcomes between single-radius and multi-radius femoral components in primary total knee arthroplasty: a meta-analysis of randomized controlled trials

PURPOSE

Our purpose in the current meta-analysis was to compare the functional outcomes in patients who have received single-radius (SR) or multi-radius (MR) femoral components in randomized controlled trials (RCTs) for primary total knee arthroplasty (TKA). The hypothesis was that there would be no statistically significant difference between two groups in terms of functional outcomes.

MATERIALS AND METHODS

We searched the international electronic databases PubMed, Embase, and the Cochrane Central Register of Controlled Trials up to February 2020 for RCTs that compared functional outcomes of SR and MR femoral component designs after primary TKA. We performed a meta-analysis of nine RCTs using the Knee Society Score for the knee (KSS-knee), KSS-function, Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), degree of knee flexion, extension, and complications, including postoperative infection and revision surgery.

RESULTS

The meta-analysis revealed no statistically significant differences in all the analyzed variables, including KSS-knee, KSS-function, KOOS, OKS, knee flexion, and knee extension. For postoperative complications, no statistically significant differences were detected for femoral component designs in postoperative infection or incidence of revision surgery between the two groups.

CONCLUSIONS

The current meta-analysis of RCTs did not show any statistically significant differences between SR and MR femoral component designs in terms of postoperative functional outcomes. Evaluated outcomes included functional outcome scores, degree of knee flexion, extension, and complications. However, because of the limited clinical evidence of this study owing to the heterogeneity between the included RCTs, a careful approach should be made in order not to arrive at definite conclusions.

A High Proportion of Patients Have Unfulfilled Sexual Expectations After TKA: A Prospective Study

BACKGROUND

Most patients have high expectations about restoration of the knee function after TKA, expecting a more active life after retirement. However, 20% to 30% of patients report that their expectations are not met postoperatively. Among those unmet expectations may be the anticipation to engage in sexual activity after surgery, but few studies have evaluated sexual activity after arthroplasty.

QUESTIONS/PURPOSES

In this study, our purposes were (1) to evaluate the anticipation and the fulfillment of sexual activity after TKA in men and women, and (2) to identify prognostic factors for the fulfillment of anticipated postoperative sexual activity.

METHODS

This was a prospective, multicenter study of all 1371 patients scheduled for TKA between June 2012 and July 2015. The study was part of the Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study (LOAS). After screening according to LOAS inclusion criteria, 1213 respondents remained. Our primary study endpoint was whether sexual expectations were met 1 year after TKA; we used the sexual-activity-expectation question from the Hospital for Special Surgery (HSS) Knee Replacement Expectations Survey, which allows the patient to score the result on a 5-point scale. To assess postoperative fulfillment of sexual activity 1 year after TKA, we asked the patient to score the current status of sexual activity on the same 5-point scale: 1 (back to normal), 2 (large improvement), 3 (moderate improvement), 4 (slight improvement), and 5 (does not apply). Patients with incomplete data on the preoperative expectation- and postoperative fulfillment-question of sexual activity were excluded, leaving 71% (866 of 1213) patients for analysis. The difference between the pre- and postoperative scores determined whether expectations of sexual activity were unfulfilled (lower than expected) or fulfilled/exceeded (neutral or higher than expected). Pre- and postoperatively, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Short Form-12 Mental and Physical Component Summary scores (SF-12 MCS and SF-12 PCS), the EuroQoL-5 Dimensions (EQ-5D), and the EQ-5D VAS scale were used. Multivariate regression models were used for analysis.

RESULTS

Preoperatively, 54% patients (467 of 866) anticipated postoperative sexual activity after recovery from surgery. Both genders showed that the proportion who anticipated "back to normal" sexual activity decreased with higher age. Likewise, postoperative fulfillment of anticipated sexual activity was found in 58% (111 of 191 for men; 159 of 276 for women). Younger women (younger than 65 years of age) experienced fulfillment more often compared with younger men. A positive postoperative change in functional and health status was associated with fulfilled/exceeded scores of patients anticipating postoperative sexual activity. A better preoperative health status, the EQ-5D VAS score (odds ratio [OR] 1.02 [95% CI 1.01 to 1.03]; p = 0.006), was associated with a higher likelihood of fulfillment of anticipated postoperative sexual activity.

CONCLUSION

In both men and women, two of five patients who anticipated postoperative sexual activity indicated that their expectation of sexual activity was not met 1 year after TKA. These patients had worse functional recovery scores compared with patients who achieved the anticipated level of sexual activity. The latter is associated with functional recovery. Surgeons should be aware that many patients anticipate restoration of normal sexual activity, and that this may be the expectation for patients of all ages and for women and men alike. The results underscore the need for more qualitative research to understand this topic in greater depth.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Development and validation of a self-administered neck mobility assessment tool (S-ROM-Neck) in chronic neck pain patients

BACKGROUND

Cervical spine (CS) range of motion (ROM) is commonly used to assess neck pain. However, this measurement is often limited by the clinician's experience and perception. Therefore, the integration of perceptual feedback of the patient can optimize and personalize treatment.

OBJECTIVE

Develop and validate a questionnaire (S-ROM-Neck) to evaluate ROM of the CS from the patient's perspective.

DESIGN

Validation study.

METHODS

The assessment tool was developed and optimized during pretest sessions. Reliability and construct validity of the questionnaire were tested. 50 participants (age >18 years) with neck pain for >90 days, able to fluently speak, read, and write in German were included. Exclusion criteria included any condition that limited manual therapy to the CS. Participants completed S-ROM-Neck twice within seven days, along with the visual analogue scale (VAS) for pain intensity and the German version of the Neck Disability Index (NDI-G). The relative reliability, internal consistency, and absolute reliability were analyzed, and Bland-Altman plots were generated. Construct validity was established by correlating the total score of S-ROM-Neck with VAS and NDI-G based on pre-set hypotheses.

RESULTS

S-ROM-Neck demonstrated moderate reliability with an intraclass correlation coefficient of 0.718 (Cronbach's alpha of 0.83). There was a medium negative correlation between VAS and S-ROM-Neck [Spearman's rank correlation coefficient (r_s) = -0.30, p = 0.031] and the NDI-G and S-ROM-Neck (r_s = -0.40, p = 0.002).

CONCLUSIONS

These results indicate the reliability and internal consistency of S-ROM-Neck. This scale provides patient feedback and perspectives to optimize assessment of neck pain.

Self-reported knee instability associated with pain, activity limitations, and poorer quality of life before and 1 year after total knee arthroplasty in patients with knee osteoarthritis

Information on the association of self-reported knee instability with clinical outcomes after Total Knee Arthroplasty (TKA) and 1 year follow-up is scarce. The aims were to determine (i) the course and prevalence of self-reported knee instability before and 1 year after TKA and (ii) the associations of preoperative, postoperative, and retained self-reported knee instability with pain, activity limitations, and quality of life (QoL) in patients with knee osteoarthritis. Patients undergoing primary TKA, selected from the Longitudinal Leiden Orthopaedics and Outcomes of OsteoArthritis Study, had their knee instability measured using a questionnaire. The Knee injury and Osteoarthritis Outcome Score pain, activity limitations, and QoL subscales were administered before and 1 year after surgery. Multivariable regression analyses were performed to examine associations between knee instability, pain, activity limitations, and QoL, adjusted for covariates (age, gender, comorbidities, and radiographic severity). Of the 908 included patients, 649 (71%) and 187 (21%) reported knee instability before and following TKA, respectively. Of the patients with preoperative knee instability, this perception was retained in 165 (25%) cases. Knee instability was preoperatively associated with pain (B -9.6; 95%CI: -12.4 to -6.7), activity limitations (B -7.5; 95%CI: -10.2 to -4.8), and QoL (B -4.7; 95%CI: -7.0 to -2.4) and postoperatively with pain (B -15.0; 95%CI: -18.5 to -11.6), activity limitations (B -15.1; 95%CI: -18.4 to -11.8), and QoL (B -18.7; 95%CI: -22.3 to -15.3). Retained knee instability was associated with postoperative pain (B -15.1; 95%CI: -18.9 to -11.2), activity limitations (B -14.1; 95%CI: -17.8 to -10.4), and QoL (B -18.0; 95%CI: -21.7 to -14.3). In conclusion, in clinical care, self-reported knee instability is retained postoperatively in 25% of the patients. Retained knee instability is associated with more pain, activity limitations, and poorer QoL postoperatively. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2671-2678, 2018.

Knee Osteoarthritis Patients Can Provide Useful Estimates of Passive Knee Range of Motion: Development and Validation of the Copenhagen Knee ROM Scale

BACKGROUND

Knee arthroplasty does not always require extensive long-term follow-up. If knee range of motion (ROM) could be assessed reliably by patients, some follow-up visits might be replaced by patient-reported outcome measures, and this additional information could be reported directly to registers. We developed and tested the validity and reliability of a simple scale for patients to self-report their passive knee ROM.

METHODS

Through an iterative process, we created a 2-item scale with 11 illustrations of knee motion in 15° increments. The validity and reliability was tested in knee osteoarthritis and arthroplasty patients at different treatment stages, many with poor ROM. Patient estimates were compared to passive goniometer measurements performed blindly by a physiotherapist and a junior orthopedic surgeon.

RESULTS

The mean difference between 100 patients' (70.9 years) estimates and goniometer measurements was -0.7° (standard deviation, 12.3°) for flexion and 1.1° (standard deviation, 11.6°) for extension, both not significant. Correlation was 0.79 and 0.63, and kappa values at retest were 0.84 and 0.66. For flexion < 110°, sensitivity of patient estimates was 88% and specificity was 88%. For a limit of 100°, values were 95% and 81%. For extension deficits >10°, sensitivity was 78% and specificity 70%. Values were 100% and 66% for a 15° limit.

CONCLUSION

The Copenhagen Knee ROM Scale is a patient-friendly and feasible alternative to passive ROM measurement for registers, research, and selected clinical use. This scale appears reliable and valid compared to reports of similar tools, and patient estimates are better correlated to goniometer measurements.

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

BACKGROUND

While clinical research on total knee arthroplasty (TKA) outcomes is prevalent in the literature, studies often have poor methodological and reporting quality. A high-quality patient-reported outcome instrument is reliable, valid, and responsive. Many studies evaluate these properties, but none have done so with a systematic and accepted method. The objectives of this study were to identify patient-reported outcome measures (PROMs) for TKA, and to critically appraise, compare, and summarize their psychometric properties using accepted methods.

METHODS

MEDLINE, EMBASE, SCOPUS, Web of Science, PsycINFO, and SPORTDiscus were systematically searched for articles with the following inclusion criteria: publication before December 2014, English language, non-generic PRO, and evaluation in the TKA population. Methodological quality and evidence of psychometric properties were assessed with the COnsensus-based standards for the selection of health Status Measurement INstruments (COSMIN) checklist and criteria for psychometric evidence proposed by the COSMIN group and Terwee et al.

RESULTS

One-hundred fifteen studies on 32 PROMs were included in this review. Only the Work, Osteoarthritis or joint-Replacement Questionnaire, the Oxford Knee Score, and the Western Ontario and McMaster Universities Arthritis Index had 4 or more properties with positive evidence.

CONCLUSION

Most TKA PROMs have limited evidence for their psychometric properties. Although not all the properties were studied, the Work, Osteoarthritis or joint-Replacement Questionnaire, with the highest overall ratings, could be a useful PROM for evaluating patients undergoing TKA. The methods and reporting of this literature can improve by following accepted guidelines.

Association between activity limitations and pain in patients scheduled for total knee arthroplasty

Background

Historically, persons scheduled for total knee arthroplasty (TKA) have reported severe pain with low demand activities such as walking, but recent data suggests that TKA recipients may have less preoperative pain. Little is known about people who elect TKA with low levels of preoperative pain. To better understand current TKA utilization, we evaluated the association between preoperative pain and difficulty performing high demand activities, such as kneeling and squatting, among TKA recipients.

Methods

We used baseline data from a randomized control trial designed to improve physical activity following TKA. Prior to TKA, participants were categorized according to Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain scores: Low (0–25), Medium (26–40), and High (41–100). Within each group, limitations in both low demand and high demand activities were assessed.

Results

The sample consisted of 202 persons with a mean age of 65 (SD 8) years; 21 %, 34 %, and 45 % were categorized in the Low, Medium, and High Pain groups, respectively. Of the Low Pain group, 60 % reported at least one of the following functional limitations: limited flexion, limp, limited walking distance, and limitations in work or housework. While only 12 % of the Low Pain group reported at least moderate pain with walking on a flat surface, nearly all endorsed at least moderate difficulty with squatting and kneeling.

Conclusions

A substantial number of persons scheduled for TKA report Low WOMAC Pain (≤25) prior to surgery. Persons with Low WOMAC Pain scheduled for TKA frequently report substantial difficulty with high demand activities such as kneeling and squatting. Studies of TKA appropriateness and effectiveness for patients with low WOMAC Pain should include measures of these activities.

Trial registration

Identifier NCT01970631; Registered 23 October 2013.

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

Background

Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.

Objective

To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.

Methods

We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.

Results

Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.

Conclusions

The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Study registration

Current Controlled Trials ISRCTN52305381.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

Similar patient-reported outcomes and performance after total knee arthroplasty with or without patellar resurfacing

Background and purpose - Knee pain after total knee arthroplasty (TKA) is not uncommon. Patellar retention in TKA is one cause of postoperative knee pain, and may lead to secondary addition of a patellar component. Patellar resurfacing in TKA is controversial. Its use ranges from 2% to 90% worldwide. In this randomized study, we compared the outcome after patellar resurfacing and after no resurfacing. Patients and methods - We performed a prospective, randomized study of 74 patients with primary osteoarthritis who underwent a Triathlon CR TKA. The patients were randomized to either patellar resurfacing or no resurfacing. They filled out the VAS pain score and KOOS questionnaires preoperatively, and VAS pain, KOOS, and patient satisfaction 3, 12, and 72 months postoperatively. Physical performance tests were performed preoperatively and 3 months postoperatively. Results - We found similar scores for VAS pain, patient satisfaction, and KOOS 5 subscales at 3, 12, and 72 months postoperatively in the 2 groups. Physical performance tests 3 months postoperatively were also similar in the 2 groups. No secondary resurfacing was performed in the group with no resurfacing during the first 72 months Interpretation - Patellar resurfacing in primary Triathlon CR TKA is of no advantage regarding pain, physical performance, KOOS 5 subscales, or patient satisfaction compared to no resurfacing. None of the patients were reoperated with secondary addition of a patellar component within 6 years. According to these results, routine patellar resurfacing in primary Triathlon TKA appears to be unnecessary.

Comparison of self-reported and measured range of motion in total knee arthroplasty patients

Total knee arthroplasty (TKA) is an established method used in the treatment of end-stage knee osteoarthritis. Range of motion (ROM) and relief from pain show success of TKA. One of the most important aims of this treatment is to achieve an adequate ROM. Numerous outcome instruments and patient-reported questionnaires are in use to evaluate of TKA patients. For this purpose, disease-specific questionnaires and self-reported ROM and function evaluation tools are also being developed. The most important criteria in musculoskeletal care is assessing the joint mobility of the patient's. Joint mobility can be measured with visual estimates, universal goniometer, X-ray radiography, digital gravity goniometers and applications found in smart phones. Apart from the reliability and validity of the method, obtaining the same results from different examiners is very important. The clinical follow-up of patients is an important part of postoperative care after TKA. The follow-up interval and duration remain dependent on the physician's anticipation of the clinical progress of the individual patient. Long-term surveillance of joint arthroplasty is necessary, but it has also become increasingly burdensome as greater numbers of TKAs are performed, and in younger populations. Patient self-reported questionnaires and self-goniometric measurement are used by many investigators to decrease this burden on the surgeon or staff, and in combination with telemedicine radiographs might be a reasonable option to routine clinic visits. They could reasonably be expected to lower the burden on both the patient and the clinician without eliminating contact and thus sacrificing quality of care. At the same time, it would reduce the financial burden too. Self-reported measured ROM can use in the routine follow-ups to reduce surgeons, physiotherapist and other staff.

A comparison of patient-reported and measured range of motion in a cohort of total knee arthroplasty patients

Range of motion (ROM) is an important component of the assessment of total knee arthroplasty (TKA) outcome. We compared patient-reported versus clinically observed ROM in a prospective cohort. Clinically observed ROM was measured using a goniometer by a trained research assistant. Self-reported ROM was estimated using a set of lateral knee photographs depicting varying levels of flexion and extension. All measures were taken pre-operatively, three, and six months postoperatively. We found statistically significant associations between self-reported ROM and clinically observed ROM for flexion and extension (all P < 0.001). We dichotomized flexion at 90° and found that self-report had a specificity of 94% and sensitivity of 65%. We conclude that patient-reported ROM may be a useful outcome measure for TKA.

Reliability of the "American Knee Society Score" (AKSS)

Objective

To analyze the reproducibility of the "American Knee Society Score" (AKSS) scale, and determine its measurement, in order to make it useful for the evaluation of patients with osteoarthritis or who have undergone total knee arthroplasty.

Methods

In the first interview, the AKSS was applied along with the SF-36 and WOMAC (examiner 1). After thirty minutes the same patients answered only the AKSS. After a two week break, a third additional interview with AKSS was applied (examiner 2).

Results

We selected 58 patients with a mean age of 67.4 years. In the analysis of reproducibility, by ICC, there was strong inter-examiner and intra-examiner correlation for two AKSS components. In the individual items analysis there was good correlation for "Pain", "Range of Motion", "Flexion contracture" and all items of the AKSS Function component. Validation through the Pearson coefficient showed good correlation between AKSS "Pain," WOMAC "pain" and SF-36 "Pain domain", and good correlation between the AKSS and SF-36 "Functional Capacity domain".

Conclusion

The AKSS adapted to Brazilian culture is useful and reliable for the evaluation of individuals with osteoarthritis or those who have undergone TKA.

Assessment of chronic postsurgical pain after knee replacement: a systematic review

OBJECTIVE

Approximately 20% of patients experience chronic pain after total knee replacement (TKR), yet there is no consensus about how best to assess such pain. This systematic review aimed to identify measures used to characterize chronic pain after TKR.Methods. MEDLINE, Embase, PsycINFO, Cochrane Library, and CINAHL databases were searched for research articles published in all languages from January 2002 to November 2011. Articles were eligible for inclusion if they assessed knee pain at a minimum of 3 months after TKR, yielding a total of 1,164 articles. The data extracted included the study design,country, timings of assessments, and outcome measures containing pain items. The outcome measures were compared with domains recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials(IMMPACT) for inclusion in the assessment of chronic pain–related outcomes within clinical trials. Temporal trends were also explored.

RESULTS

The review found use of a wide variety of composite and single-item measures, with the American Knee Society Score the most common. Many measures used in published studies did not capture the multidimensional nature of pain recommended by the IMMPACT; of those commonly used, the Western Ontario and McMaster Universities Osteoarthritis Index and Oxford Knee Score were the most comprehensive. Geographic trends were evident, with nation-specific preferences for particular measures. A recent reduction in the use of some clinically administered tools was accompanied by an increased use of patient-reported outcome measures.

CONCLUSION

There was wide variation in the methods of pain assessment alongside nation-specific preferences and changing temporal trends in pain assessment after TKR. Standardization and improvements in assessment are needed to enhance the quality of research and facilitate the establishment of a core outcome set.

Postoperative alignment and ROM affect patient satisfaction after TKA

BACKGROUND

Patient satisfaction has increasingly been recognized as an important measure after total knee arthroplasty (TKA). However, we do not know yet how and why the patients are satisfied or dissatisfied with TKA.

QUESTIONS/PURPOSES

We asked: (1) After TKA, how satisfied are patients and which activities were they able to do? (2) Are patient-derived scores related to physician-derived scores? (3) Which factors affect patient satisfaction and function?

METHODS

We retrospectively evaluated 375 patients who had undergone 500 TKAs between February 22, 2000 and December 1, 2009. We sent a questionnaire for The 2011 Knee Society Knee Scoring System to the patients. We determined the correlation of patient- and physician-derived scores and factors relating to the five questions relating to satisfaction and the 19 questions relating function. The minimum followup was 2 years (mean, 5 years; range, 2-11 years).

RESULTS

The mean score for symptoms was 19 (74%), 23 (59%) for patient satisfaction, 10 (64%) for patient expectations, and 53 (53%) for functional activities. We found a poor correlation between the patient-derived and the physician-derived scores. Old age and varus postoperative alignment negatively correlated with the satisfaction. Varus alignment and limited range of motion (ROM) negatively correlated with the expectation. Old age, rheumatoid arthritis, and limited ROM negatively correlated with the functional activities.

CONCLUSIONS

Most patients did not report symptoms, but they experienced difficulty with activities of daily living after TKA. Patient satisfaction is difficult to measure, but avoiding varus alignment and achieving better ROM appear to be important for increasing satisfaction and meeting expectations.

Comparison of patient-reported and clinician-assessed outcomes following total knee arthroplasty

BACKGROUND

Although the necessity of long-term follow-up after total knee arthroplasty is unquestioned, this task may become burdensome as greater numbers of total knee arthroplasties are performed. We sought to use comparisons with clinician-assessed values to determine whether patients could reliably assess their own outcome with use of a combination of American Knee Society Score and Oxford Knee Score questionnaires and self-reported knee motion. We hypothesized that patients would self-report worse pain and function and a similar range of knee motion than clinicians would.

METHODS

One hundred and forty patients (181 knees) scheduled for routine follow-up at two centers after primary total knee arthroplasty were mailed American Knee Society Score and Oxford Knee Score questionnaires, a set of photographs illustrating knee motion in 5° increments for comparison with the patient's range of knee motion, and a goniometer with instructions. The patient's American Knee Society Score, Oxford Knee Score, and knee motion were then independently assessed within two weeks of the self-evaluation by one of three clinicians who had not been involved with the surgery. Patient-reported and clinician-assessed measures were compared with use of a paired-sample t test and the Spearman correlation coefficient.

RESULTS

The mean patient-reported American Knee Society pain subscore was 4 points worse than the clinician-assessed score, and the function subscore was 10 points worse (p < 0.001 for both). The mean Oxford Knee Score did not differ significantly between the patient self-assessment and the clinician assessment (p = 0.05). The mean maximum flexion reported by the patient with use of the photographs differed by <1° from the mean value reported by the patient with use of the goniometer or the mean value measured by the clinician; these differences were not clinically important.

CONCLUSIONS

Patients' self-reported American Knee Society pain and function subscores were worse than the corresponding clinician assessments, but the two Oxford Knee Scores were similar. Range of knee motion may reasonably be self-assessed by comparison with photographs. Long-term follow-up of patients after total knee arthroplasty may be possible with use of patient-reported measures, alleviating the burden of clinic visits yet maintaining contact, but further studies involving other validated instruments is warranted.

Responsiveness differences in outcome instruments after revision hip arthroplasty: what are the implications?

Responsiveness to change is an important psychometric property of an outcome instrument. Assessment of health-related quality of life (HRQoL) is critical to outcome assessment after total joint replacement, a surgery aimed at improving pain, function and HRQoL of the patients undergoing these procedures. In a recent study, Shi et al. examined the responsiveness to change of various subscales of two instruments, physician-administered Harris Hip Score and patient self-administered Short Form-36 (SF-36), 6 months after revision total hip arthroplasty. The responsiveness statistics for both scales were reasonable, higher for Harris Hip Score than SF-36. This is the first study to examine responsiveness of these instruments in revision THA patients in a systematic fashion.

Surgical release of the pediatric trigger thumb

PURPOSE

The spontaneous recovery rate for locked pediatric trigger thumb (PTT) has recently been reported at between 24% and 66%; these studies concluded that a conservative approach for this condition could be adopted. The aims of this study were to review our results of surgical release of the PTT and to survey pediatric hand surgeons regarding their practice patterns for treatment of the PTT.

METHODS

After institutional review board approval, we retrospectively reviewed 173 consecutive patients with 217 thumbs treated surgically at our institution. An e-mail survey of 27 pediatric hand surgeons questioned treatment of a 2-year-old child with a 6-month history of a locked trigger thumb and of an intermittently triggering thumb.

RESULTS

The retrospective review demonstrated that preoperative range of motion averaged 36° loss of extension (range, 0° to 90°; SD, 22°); postoperative range of motion averaged 1° loss of extension (range, 0° to 30°; SD, 7°) at 27-day follow-up. Using a parent questionnaire at an average follow-up of 4.2 years, there were no major complications or recurrences identified. Five thumbs developed minor skin complications that healed with conservative management. There were no secondary surgeries. The practice pattern survey demonstrated that 85% of pediatric hand surgeons would treat a locked PTT in a 2-year-old with surgical release and 52% would treat an intermittently triggering thumb in a 2-year-old with continued observation if the triggering thumb was not painful.

CONCLUSIONS

The surgical results reported in this study, along with the practice pattern survey, confirm that surgical release is a short, safe, and effective procedure when performed by specialty trained hand surgeons, and it is the treatment of choice for a locked PTT.