The Effect of Total Knee Arthroplasty on Physical Activity and Body Mass Index: An Analysis of the Osteoarthritis Initiative Cohort

Outcomes Vary by Pre-Operative Physical Activity Levels in Total Knee Arthroplasty Patients

Physical activity (PA) is suggested to reduce osteoarthritis pain; however, it may be avoided by patients requiring arthroplasty. Our goal was to investigate objective and patient-reported outcomes as a function of pre-operative PA levels in patients undergoing total knee arthroplasty (TKA). A total of 1941 patients enrolled in a multicenter prospective cohort study investigating a smartphone-based care management platform for self-directed rehabilitation underwent TKA and were included in the analysis. Activity was categorized based on the cohort's step count quartiles into low, moderate, and high pre-operative PA. Pre-operative and post-operative pain, EQ5D5L, KOOS JR, and step counts were compared by ANOVA according to activity group. Pre-operative pain scores increased with the decreasing activity level (all, p < 0.05) and were most improved post-operatively in the low PA group. High PA patients demonstrated the smallest improvements in EQ-5D-5L and KOOS JR. Low and moderate PA patients increased physical activity by three months, reaching 176% and 104% of pre-operative steps; high PA patients did not return to full step counts by one year post-operatively. Patients undergoing TKA who present with higher levels of physical activity report lower levels of pain and higher function pre-operatively but appreciate less improvement up to one year post-operatively. These results may be helpful in appropriate counseling of patient expectations before TKA.

Medication use and comorbidities in an increasingly younger osteoarthritis population: an 18-year retrospective open-cohort study

OBJECTIVES

As understanding of the pathogenesis and treatment strategies for osteoarthritis (OA) evolves, it is important to understand how patient factors are also changing. Our goal was to examine demographics and known risk factors of patients with OA over time.

DESIGN

Open-cohort retrospective study using electronic health records.

SETTING

Large US integrated health system with 7 hospitals, 2.6 million outpatient clinic visits and 97 300 hospital admissions annually in a mostly rural geographic region.

PARTICIPANTS

Adult patients with at least two encounters and a diagnosis of OA or OA-relevant surgery between 2001 and 2018. Because of geographic region, over 96% of participants were white/Caucasian.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

Descriptive statistics were used to examine age, sex, body mass index (BMI), Charlson Comorbidity Index, major comorbidities and OA-relevant prescribing over time.

RESULTS

We identified 290 897 patients with OA. Prevalence of OA increased significantly from 6.7% to 33.5% and incidence increased 37% (from 3772 to 5142 new cases per 100 000 patients per year) (p<0.0001). Percentage of females declined from 65.3% to 60.8%, and percentage of patients with OA in the youngest age bracket (18-45 years) increased significantly (6.2% to 22.7%, p<0.0001). The percentage of patients with OA with BMI ≥30 remained above 50% over the time period. Patients had low comorbidity overall, but anxiety, depression and gastro-oesophageal reflux disease showed the largest increases in prevalence. Opioid use (tramadol and non-tramadol) showed peaks followed by declines, while most other medications increased slightly in use or remained steady.

CONCLUSIONS

We observe increasing OA prevalence and a greater proportion of younger patients over time. With better understanding of how characteristics of patients with OA are changing over time, we can develop better approaches for managing disease burden in the future.

Objectively Measured Physical Activity, Sedentary Behavior and Functional Performance before and after Lower Limb Joint Arthroplasty: A Systematic Review with Meta-Analysis

Patients after joint arthroplasty tend to be less physically active; however, studies measuring objective physical activity (PA) and sedentary behavior (SB) in these patients provide conflicting results. The aim of this meta-analysis was to assess objectively measured PA, SB and performance at periods up to and greater than 12 months after lower limb arthroplasty. Two electronic databases (PubMed and Medline) were searched to identify prospective and cross-sectional studies from 1 January 2000 to 31 December 2020. Studies including objectively measured SB, PA or specific performance tests in patients with knee or hip arthroplasty, were included in the analyses both pre- and post-operatively. The risk of bias was assessed using the Scottish Intercollegiate Guidelines Network (SIGN). After identification and exclusion, 35 studies were included. The data were analyzed using the inverse variance method with the random effects model and expressed as standardized mean difference and corresponding 95% confidence intervals. In total, we assessed 1943 subjects with a mean age of 64.9 (±5.85). Less than 3 months post-operative, studies showed no differences in PA, SB and performance. At 3 months post-operation, there was a significant increase in the 6 min walk test (6MWT) (SMD 0.65; CI: 0.48, 0.82). After 6 months, changes in moderate to vigorous physical activity (MVPA) (SMD 0.33; CI: 0.20, 0.46) and the number of steps (SMD 0.45; CI: 0.34, 0.54) with a large decrease in the timed-up-and-go test (SMD −0.61; CI: −0.94, −0.28) and increase in the 6MWT (SMD 0.62; CI: 0.26–0.98) were observed. Finally, a large increase in MVPA (SMD 0.70; CI: 0.53–0.87) and a moderate increase in step count (SMD 0.52; CI: 0.36, 0.69) were observed after 12 months. The comparison between patients and healthy individuals pre-operatively showed a very large difference in the number of steps (SMD −1.02; CI: −1.42, −0.62), but not at 12 months (SMD −0.75; −1.89, 0.38). Three to six months after knee or hip arthroplasty, functional performance already exceeded pre-operative levels, yet PA levels from this time period remained the same. Although PA and functional performance seemed to fully restore and exceed the pre-operation levels at six to nine months, SB did not. Moreover, PA remained lower compared to healthy individuals even longer than twelve months post-operation. Novel rehabilitation protocols and studies should focus on the effects of long-term behavioral changes (increasing PA and reducing SB) as soon as functional performance is restored.

People Prefer to Continue with Painful Activities Even if They Lead to Earlier Surgery

BACKGROUND

The degree to which physical activity results in arthritis progression is unknown, but it probably is less than most people believe. But the belief that painful activity is harmful has notable associations both with greater pain intensity and greater activity intolerance among people seeking care for painful conditions such as osteoarthritis. If there were evidence that people not seeking care would prefer to accommodate a painful cherished activity, even if such accommodation is harmful, this might remind surgeons that many people seeking their care also hold this value. Care strategies could be designed to help people reconnect with this value by guiding them to an appropriate weighting of the potential benefits and the potential harms of painful activity.

QUESTIONS/PURPOSES

(1) What degree of harm (measured as a decrease in the number of years before reconstructive surgery) are people willing to trade to continue a cherished activity? (2) What factors are associated with the chosen number of years? (3) What percentage of patients is willing to trade harm to the joint (presented as surgery 3 years earlier) to continue their cherished activity? (4) What factors are associated with the choice to trade harm for continued activity?

METHODS

We performed an online, survey-based, time trade-off experiment using a crowdsourcing website that allows users to pay volunteers to complete surveys. The survey was closed when the prespecified number of surveys was obtained. The experiment measured personal and psychological factors associated with the willingness to accommodate harmful painful activity to continue cherished activities among people not currently troubled by the condition, an approach favored in trade-off studies. Large crowdsourcing survey studies may not represent the general population, but they have sufficient diversity to determine factors associated with responses. Participants (539 total, 289 men and 250 women with a mean age of 33 ± 11 years) completed validated measures of symptoms of anxiety and depression, activity tolerance, an 11-point ordinal measure of pain intensity, and three validated questionnaires addressing common misconceptions about pain. To answer our first and second questions, we calculated the harm (measured as a decrease in the number of years before reconstructive surgery) that people were willing to trade to continue their cherished activity, and then we used multiple linear regression to identify factors associated with the number of years. To answer the third and fourth questions, we calculated the percentage of patients who would choose to trade harm to the joint (surgery 3 years earlier) to continue their cherished activity and then we used multiple logistic regression to identify factors associated with the choice to trade harm for activity.

RESULTS

Participants were willing to trade harm in the form of more rapid disease progression leading to surgery a mean of 4.5 ± 3.6 years earlier to continue a cherished activity. Controlling for personal and psychological factors, a greater number of years people were willing to trade was associated with slightly greater bodily pain intensity (r = 0.11; p = 0.01). Seventy-six percent (410 of 539) of participants were willing to trade harm in the form of needing surgery 3 years earlier to continue their cherished activity. Controlling for personal and psychological factors, a choice to trade earlier surgery for continued activity was associated with an income greater than USD 50,000 per year (odds ratio 2.07 [95% confidence interval 1.17 to 3.65]; p = 0.01) and greater fear of painful movement (OR 1.07 [95% CI 1.01 to 1.15]; p = 0.04).

CONCLUSION

People are relatively willing to accommodate pain to continue a cherished activity, even if it causes harm.

CLINICAL RELEVANCE

Musculoskeletal specialists can incorporate strategies to help people seeking care to revitalize their inherent level of willingness to accommodate painful activity. One strategy might be to attend to an appropriate weighting of the potential benefits and the potential harms of painful activity.

LEVEL OF EVIDENCE

Level II, prognostic study.

Evaluation of the Clinical Efficacy of Using Thermal Camera for Cryotherapy in Patients with Total Knee Arthroplasty: A Prospective Study

Background and objectives: Cryotherapy is a method of treatment using cold application. This study aimed to evaluate postoperative clinical and hematological parameters and pain associated with total knee arthroplasty in patients and compared cryotherapy to the conventional method of cold ice pack compressions. Materials and Methods: Between January 2015 and January 2016, 90 patients who underwent total knee arthroplasty for grade 4 gonarthrosis were prospectively evaluated. The patients were divided into three groups (n = 30, each): Group 1, cryotherapy was applied in the pre- and postoperative periods; Group 2, cryotherapy was applied only in the postoperative period; and Group 3 (control group), only a cold pack (gel ice) was applied postoperatively. In all groups, pre- and postoperative evaluations at 6, 24, and 48 h, hemorrhage follow-up, knee circumference measurement, visual analog scale pain score, knee circumference, and temperature measured by thermal camera were recorded. Results: Of the 90 patients, 10% were men and 90% were women. The mean age was 64.3 ± 8.1 (range: 46–83) years. The patella upper end diameter values were significantly lower in the postoperative period in Groups 1 and 2 than in Group 3 (p = 0.003). Hemoglobin levels at 24 and 48 h postoperatively were significantly lower in Group 3 than in Group 1 (p < 0.001, each) and Group 2 (p = 0.038, p < 0.001). At 6, 24, and 48 h follow-ups, pain values were significantly lower in Group 2 than in Group 3 (p < 0.001). Preoperative 6, 24, and 48 h temperature values were significantly lower in Group 1 than in Group 3 (p < 0.001 for each). It was found that the difference between preoperative and postoperative knee flexion measurements was significantly different in both groups or the difference between the groups was changed in each period (p < 0.001). Conclusions: Postoperative cryotherapy is a potentially simple, noninvasive option and beneficial for the reduction of reducing pain, bleeding, length of stay, analgesic requirement and swelling after total knee arthroplasty. Moreover, there was no early or late prosthesis infection in cryotherapy groups, which may be considered as an additional measure to prevent prosthesis infection.