Functional outcomes following knee replacement in community-dwelling older adults

BACKGROUND

Knee replacements are increasingly performed in older adults but uncertainty remains regarding their benefits in the context of age-related decline in physical function and other comorbidities. This study aimed to examine (1) the effect of knee replacement on functional outcomes in the context of age-related decline in physical function and (2) the factors associated with minimal important improvement in physical function after knee replacement in community-dwelling older adults aged ≥ 70 years.

METHODS

This cohort study was performed within the ASPREE trial, with 889 participants undergoing knee replacement during the trial and 858 age- and sex-matched controls without knee or hip replacement identified from 16,703 Australian participants aged ≥ 70 years. Health-related quality of life was assessed annually using the SF-12, including its physical and mental component summary (PCS and MCS). Gait speed was measured biennially. Multiple linear regression and analysis of covariance were used to adjust for potential confounders.

RESULTS

Participants with knee replacement had significantly lower pre- and post-replacement PCS scores and gait speed compared with age- and sex-matched controls. Participants with knee replacement had significant improvement in PCS score following knee replacement (mean change 3.6, 95% CI 2.9-4.3) while PCS score remaining unchanged in age- and sex-matched controls (-0.02, 95% CI -0.6 to 0.6) during follow-up period. The greatest improvements were observed for bodily pain and physical function. Following knee replacement, 53% of participants experienced minimal important improvement in PCS score (increased by ≥ 2.7), while 24% experienced worsened PCS score (reduced by > 2.7). Participants experiencing improved PCS score postoperatively had significantly lower PCS and higher MCS scores pre-surgery.

CONCLUSIONS

Although community-based older adults experienced a significant improvement in PCS scores after knee replacement, their postoperative physical functional status remained significantly lower than age- and sex-matched controls. The degree of preoperative physical function impairment was a strong predictor of functional improvement, suggesting that this could be an important consideration when identifying older people most likely to benefit from knee replacement surgery.

PANLAR Consensus Recommendations for the Management in Osteoarthritis of Hand, Hip, and Knee

OBJECTIVE

The objective of this consensus is to update the recommendations for the treatment of hand, hip, and knee osteoarthritis (OA) by agreeing on key propositions relating to the management of hand, hip, and knee OA, by identifying and critically appraising research evidence for the effectiveness of the treatments and by generating recommendations based on a combination of the available evidence and expert opinion of 18 countries of America.

METHODS

Recommendations were developed by a group of 48 specialists of rheumatologists, members of other medical disciplines (orthopedics and physiatrists), and three patients, one for each location of OA. A systematic review of existing articles, meta-analyses, and guidelines for the management of hand, hip, and knee OA published between 2008 and January 2014 was undertaken. The scores for Level of Evidence and Grade of Recommendation were proposed and fully consented within the committee based on The American Heart Association Evidence-Based Scoring System. The level of agreement was established through a variation of Delphi technique.

RESULTS

Both "strong" and "conditional" recommendations are given for management of hand, hip, and knee OA and nonpharmacological, pharmacological, and surgical modalities of treatment are presented according to the different levels of agreement.

CONCLUSIONS

These recommendations are based on the consensus of clinical experts from a wide range of disciplines taking available evidence into account while balancing the benefits and risks of nonpharmacological, pharmacological, and surgical treatment modalities, and incorporating their preferences and values. Different backgrounds in terms of patient education or drug availability in different countries were not evaluated but will be important.

Knee Disarticulation for a Total Knee Arthroplasty Periprosthetic Fracture

Total knee arthroplasty, although a very successful surgery, can present the patient with several potential complications, including the risk for periprosthetic fractures. Complications involving periprosthetic fractures after total knee arthroplasty can present a complex clinical scenario for orthopedic surgeons. To date, adequate literature exists to guide surgeons in approaching most periprosthetic fractures; however, standard operating procedure can fall short when confronted with more complex clinical scenarios. The authors present an alternative approach, falling outside the traditional paradigm, to addressing a periprosthetic tibial fracture in the setting of a previous total knee arthroplasty. Given both the patient's physiological factors and the inherent factors of the fracture, the authors found that the first-line treatments for periprosthetic fracture, including open reduction and internal fixation and joint revision, were inadequate and posed more potential risks than benefits for the patient. In light of this situation, the authors elected to treat this patient's periprosthetic fracture with a through knee amputation, as this provided the patient with the lowest cost in morbidity while still addressing the fracture. [Orthopedics. 2016; 39(4):e775-e778.].

The effects of total knee arthroplasty on physical functioning and health among the under age 65 population

OBJECTIVES

This study examined the effects of total knee arthroplasty on six measures of physical functioning, self-rated health, pain, earnings, and employment status among US adults aged 51 to 63 years at baseline.

METHODS

Data came from the Health and Retirement Study, a nationally representative longitudinal study conducted biannually. The analysis sample consisted of individuals aged 51 to 63 years at baseline with arthritis who were resurveyed at 2-year intervals from 1996 to 2010. Propensity score matching was used to compare outcomes of persons receiving total knee arthroplasty (TKA) with those of matched controls. Six measures of physical functioning were examined: lower-body mobility problems, instrumental activities of daily living limitations, activities of daily living limitations, and large muscle, fine motor, and gross motor limitations. Self-rated health and pain were also examined. The two employment-related outcomes were earnings and employment status.

RESULTS

Receipt of TKA was associated with better outcomes for several measures of physical functioning, especially mobility limitations, pain, and self-rated health. Receipt of TKA was not associated with increased earnings or employment.

CONCLUSIONS

Receipt of TKA yields important improvements in physical function among persons with an arthritis diagnosis who received the procedure before reaching the age of 65 years. This study contributes to knowledge about the benefits of TKA in a community setting among nonelderly recipients of TKA.