Does obesity affect patient-reported outcomes following total knee arthroplasty?

[Influence of obesity on midterm outcome after primary hip and knee arthroplasty in Germany : Analysis from the EPRD]

OBJECTIVES

To determine the influence of obesity on revision rates and mortality after primary elective hip and knee arthroplasty in Germany.

MATERIALS AND METHODS

In the German Arthroplasty Registry (EPRD) there were 403,073 elective total hip arthroplasties (THA), 320,913 bicondylar total knee arthroplasties (TKA) and 48,480 unicondylar knee arthroplasties (UKA) with valid BMI available for analysis. Cumulative revision rates and 1‑year mortality was calculated for BMI groups.

RESULTS

There were increased revision rates with increasing BMI, most distinctive for septic revisions in THA during the first year after surgery (non-obese 0.7%, obesity grade 1 1.3%, grade 2 2.1%, grade 3 4.2%). In TKA and UKA this increase was generally less pronounced. Age- and gender-standardized mortality was lower than expected in most groups, but also increasing with increasing BMI.

CONCLUSION

The risk for revisions in obese patients is more distinctive in hip arthroplasty than in knee arthroplasty and is especially high in morbidly obese patients (BMI ≥ 40 kg/m2). Nonetheless, this risk may be acceptable for affected patients. Therefore, the possible benefits and risks of an arthroplasty should be weighed against each other and individually discussed with the patient.

Factors determinant of quality of life after total knee arthroplasty in knee osteoarthritis: A systematic review

OBJECTIVE

To systematically review, summarize and appraise evidence on the factors determining quality of life (QoL) after total knee arthroplasty (TKA) in individuals with knee osteoarthritis.

METHODS

We searched six databases (PubMed, Scopus, Web of Science, CINAHL, EMBASE, and ProQuest) using appropriate search terms to identify the relevant literature published on the factors determining QoL following TKA. Two reviewers independently performed the study screening and study selection. A third reviewer was consulted in case of any disagreement. The methodological quality of the included studies was assessed using the Modified Downs and Black Index checklist. This review was registered in PROSPERO (CRD42022352887) and reported according to the PRISMA checklist.

RESULTS

We identified a total of 8517 studies, 29 of which were included. Advanced age; female sex; increased body mass index (BMI); the presence of comorbidities such as diabetes; contralateral knee pain; poor preoperative status; psychological and pain-related factors such as the presence of pain catastrophizing; central sensitization; kinesiophobia; anxiety; depression; chronic pain; psychological distress; low level of optimism; and reduced patient satisfaction were used to determine post-TKA QoL scores. High BMI and depression were the most common factors evaluated in these studies. Overall, the methodological quality of the included studies varied from high to low.

CONCLUSION

After TKA, the overall QoL score improved. However, there are a few physical, behavioral, and psychological factors that influence QoL. Identifying these factors could aid clinicians and health professionals in treating and rehabilitating patients by helping them improve patient prognosis after TKA.

Medial opening wedge high tibial osteotomy performs similarly irrespective of body mass index

PURPOSE

This study investigates the effect of the body mass index (BMI) on the early (2 years) to midterm (5 years) results of medial opening wedge high tibial osteotomy (MOWHTO).

METHODS

A prospectively maintained single-centre database of 1138 knee osteotomies, between 2002 and 2022, was retrospectively reviewed. Adult patients who underwent MOWHTO for symptomatic unicompartmental medial knee osteoarthritis (OA), with varus knee malalignment, having failed conservative management, were included. Patients were categorized into three groups according to their BMI as per the classification from the National Institute for Health and Care Excellence (NICE): the healthy weight (HW) group (BMI of 18.5-24.9 kg/m2), the overweight (OW) (BMI of 25-29.9 kg/m2), and the obesity (OB) group (BMI ≥ 30 kg/m2). Multiple patient-reported outcome measures (n = 6) were recorded preoperatively and at 2 and 5 years postoperatively. Deformity analysis was undertaken preoperatively and postoperatively. The relative risk (RR) of the complications between the HW, OW and OB groups was calculated. The rate of conversion to arthroplasty, and 5 and 10 years survivorship were recorded, as well as the hazard ratio (HR) of BMI on survivorship.

RESULTS

A total of 574 cases were included in the study: the HW group (n = 96), the OW group (n = 233) and the OB group (n = 245), with a mean BMI of 23 ± 1.5 kg/m2, 27.4 ± 1.4 kg/m2 and 34.4 ± 3.8 kg/m2, respectively. The mean follow-up was 13.3 years (4.8-20.3). The mean mechanical tibiofemoral angle corrections were in the HW group: 7.1 ± 3°, OW group: 6.6 ± 3.5° and OB group: 7.1 ± 3.8°, with no intergroup significant difference (p = n.s.). Clinically, despite lower preoperative scores in the OW and OB groups, no difference was observed postoperatively amongst the three groups. The overall complication rate was 12.5% in the HW group, 6.8% in the OW group, and 9.8% in the OB group. There was no significant difference in the RR of complications between the HW and OW groups (RR = 0.6, 95% confidence interval [CI] = 0.3-1.3) (p = 0.2), and the HW and OB groups (RR = 0.8; 95% CI = 0.3-2.2) (p = 0.7). There was no overall significant difference in survival outcomes based on the BMI between the three groups (p = 0.4). The HR of conversion to arthroplasty between the HW and OW groups was 1.4 [95% CI = 0.6-3.5](p = 0.5) and between the HW and OB groups was 1.8 [95% CI = 0.8-4.4] (p = 0.2).

CONCLUSION

BMI has no significant effect on either the radiological corrections, clinical outcomes, complications or survivorship of MOWHTO at short- to medium-term follow-up. No specific cutoff point for BMI can be recommended as a contraindication to MOWHTO.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

The role of obesity and adipose tissue dysfunction in osteoarthritis pain

Obesity has a pivotal and multifaceted role in pain associated with osteoarthritis (OA), extending beyond the mechanistic influence of BMI. It exerts its effects both directly and indirectly through various modifiable risk factors associated with OA-related pain. Adipose tissue dysfunction is highly involved in OA-related pain through local and systemic inflammation, immune dysfunction, and the production of pro-inflammatory cytokines and adipokines. Adipose tissue dysfunction is intricately connected with metabolic syndrome, which independently exerts specific effects on OA-related pain, distinct from its association with BMI. The interplay among obesity, adipose tissue dysfunction and metabolic syndrome influences OA-related pain through diverse pain mechanisms, including nociceptive pain, peripheral sensitization and central sensitization. These complex interactions contribute to the heightened pain experience observed in individuals with OA and obesity. In addition, pain management strategies are less efficient in individuals with obesity. Importantly, therapeutic interventions targeting obesity and metabolic syndrome hold promise in managing OA-related pain. A deeper understanding of the intricate relationship between obesity, metabolic syndrome and OA-related pain is crucial and could have important implications for improving pain management and developing innovative therapeutic options in OA.

Total knee arthroplasty using a cemented single-radius, condylar-stabilized design performed without posterior cruciate ligament sacrifice

Aims

Total knee arthroplasty (TKA) with a highly congruent condylar-stabilized (CS) articulation may be advantageous due to increased stability versus cruciate-retaining (CR) designs, while mitigating the limitations of a posterior-stabilized construct. The aim was to assess ten-year implant survival and functional outcomes of a cemented single-radius TKA with a CS insert, performed without posterior cruciate ligament sacrifice.

Methods

This retrospective cohort study included consecutive patients undergoing TKA at a specialist centre in the UK between November 2010 and December 2012. Data were collected using a bespoke electronic database and cross-referenced with national arthroplasty audit data, with variables including: preoperative characteristics, intraoperative factors, complications, and mortality status. Patient-reported outcome measures (PROMs) were collected by a specialist research team at ten years post-surgery. There were 536 TKAs, of which 308/536 (57.5%) were in female patients. The mean age was 69.0 years (95% CI 45.0 to 88.0), the mean BMI was 32.2 kg/m2 (95% CI 18.9 to 50.2), and 387/536 (72.2%) survived to ten years. There were four revisions (0.7%): two deep infections (requiring debridement and implant retention), one aseptic loosening, and one haemosiderosis.

Results

Kaplan-Meier analysis demonstrated no difference in implant survival according to sex, age, or obesity status. Ten-year PROMs were available for 196/387 (50.6%) surviving patients and were excellent: mean Oxford Knee Score 34.4 (95% CI 32.7 to 36.1); mean Forgotten Joint Score (FJS) 51.2 (95% CI 16.1 to 86.3); mean EuroQol five-dimension five-level questionnaire score 69.9 (95% CI 46.8 to 93.0); 141/196 (71.9%) achieved the 22-point FJS patient-acceptable symptom state (PASS); and 156/196 (79.6%) were "very satisfied or satisfied".

Conclusion

This is the only large study reporting ten-year implant survival and functional outcomes of TKA using a cemented single-radius design and with a CS tibial bearing construct. The findings of excellent implant survival, safety, and functional outcomes indicate that this combination is a safe and effective option in routine TKA. Further investigation of this single-radius design TKA with CS tibial bearings with well-matched patient study groups will allow further insight into the performance of these implants.

Despite Greater Improvement in Pain and Function Among Obese Patients Shortly After Total Knee Arthroplasty, There is No Difference in Patient-Reported Outcomes and Satisfaction Between Body Mass Index Classes at 1 Year Postoperatively

BACKGROUND

Although obesity may be associated with an increased risk of perioperative and postoperative complications after total knee arthroplasty (TKA), body mass index (BMI) cutoffs for TKA patient selection remain a controversial topic. This study aimed to investigate patient-reported outcomes, satisfaction, and pain among BMI classes at 3 months and 1 year following TKA.

METHODS

A total of 2,365 patients were categorized into Centers for Disease Control BMI classes according to preoperative values. The BMI distribution over the cohort demonstrated 7 underweight, 340 healthy weight, 731 overweight, 666 Class I, 391 Class II, and 230 Class III obesity. Preoperative and postoperative Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), satisfaction, and pain scores were compared by BMI class by Analysis of Variance with pairwise comparisons.

RESULTS

Preoperative KOOS JR scores and satisfaction scores were both significantly greater for healthy weight patients compared to Class III patients (P < .0001). However, KOOS JR, satisfaction, and pain did not vary by BMI class postoperatively. Changes in scores from baseline suggest larger improvements with increasing BMI class, where Class III patients reported the greatest improvements in KOOS JR (23.24 ± 15.67, P < .0001) and pain scores (-3.56 ± 2.65, P < .0001) at 90 days. Significantly greater improvement with increasing BMI was also present at 1-year postoperatively for KOOS JR scores. A total of 85.8% of Class III patients reached the Minimal Clinically Important Difference for KOOS JR at 90 days compared to 76.8% of the healthy weight group (P = .03). Differences between BMI groups in the proportion reaching Minimal Clinically Important Difference at 1 year were not significant.

CONCLUSIONS

Patients of higher BMI reported greater and earlier improvements in satisfaction, knee function, and pain following TKA. Shared decision-making remains paramount to preoperative surgical evaluation. However, rationing of this surgical intervention based on BMI alone may not be warranted.

Preoperative and Postoperative Weight Change has Minimal Influence on Health Care Utilization and Patient-Reported Outcomes Following Total Knee Arthroplasty

As obesity becomes more prevalent, more patients are at risk of lower extremity osteoarthritis and subsequent total knee arthroplasty (TKA). This study aimed to test (1) the association of preoperative weight change with health care utilization and (2) the association of pre- and postoperative weight changes with failure to achieve satisfaction and minimal clinically important difference (MCID) in Knee injury and Osteoarthritis Outcome Score for pain (KOOS-Pain) and function (KOOS-PS) 1 year after TKA. Prospectively collected monocentric data on patients who underwent primary TKA were retrospectively reviewed. Multivariable logistic regression assessed the influence of BMI and weight change on outcomes while controlling for confounding variables. Outcomes included prolonged length of stay (LOS >3 days), nonhome discharge, 90-day readmission rate, satisfaction, and achievement of MCID for KOOS-Pain and KOOS-PS. Preoperative weight change had no impact on prolonged LOS (gain, p = 0.173; loss, p = 0.599). Preoperative weight loss was associated with increased risk of nonhome discharge (odds ratio [OR]: 1.47, p = 0.003). There was also increased risk of 90-day readmission with preoperative weight gain (OR: 1.27, p = 0.047) and decreased risk with weight loss (OR: 0.73, p = 0.033). There was increased risk of nonhome discharge with obesity class II (OR: 1.6, p = 0.016) and III (OR: 2.21, p < 0.001). Weight change was not associated with failure to achieve satisfaction, MCID in KOOS-Pain, or MCID in KOOS-PS. Obesity class III patients had decreased risk of failure to reach MCID in KOOS-Pain (OR: 0.43, p = 0.005) and KOOS-PS (OR: 0.7, p = 0.007). Overall, pre- and postoperative weight change has little impact on the achievement of satisfaction and clinically relevant differences in pain and function at 1 year. However, preoperative weight gain was associated with a higher risk of 90-day readmissions after TKA. Furthermore, patients categorized in Class III obesity were at increased risk of nonhome discharge but experienced a greater likelihood of achieving MCID in KOOS-Pain and KOOS-PS. Our results raise awareness of the dangers of using weight changes and BMI alone as a measure of TKA eligibility.

Preoperative Risk Factors for Pain After Reverse Total Shoulder Arthroplasty: A Systematic Review

Despite being a generally successful procedure, pain following reverse total shoulder arthroplasty (rTSA) is a known complication. The aim of this systematic review is to identify preoperative risk factors for pain following rTSA to encourage evidence-based interventions, inform clinicians, and aid in surgical planning. Studies that reported preoperative risk factors and pain after rTSA were included. Studies which reported outcome measures that incorporated pain scores yet did not display them independently, studies which only reported intraoperative risk factors, and studies involving participants under 18 were excluded. The search was conducted on May 31, 2023, across the following databases: PubMed, Web of Science, Embase, Scopus, and Cochrane Central Register of Controlled Trials. Four independent researchers conducted this systematic review, and a descriptive analysis was subsequently performed. Twenty-five studies were included following the evaluation of full-text articles, involving a total of 9,470 shoulders. Preoperative risk factors identified were categorised into the following groups: BMI, smoking, radiographic findings, age and sex, prior surgery, functional ability and pain, and psychosocial. The strongest associations identified were preoperative opioid use and smoking, which were both associated with worse pain outcomes following rTSA; other preoperative risk factors highlighted in this review showed either weak or no correlation. Preoperative opioid use and smoking are likely risk factors for the development of pain after rTSA. Although the studies included varying levels of quality, the identification of modifiable risk factors is useful in optimising management prior to surgery and guiding patient expectations. The lack of evidence regarding associations with non-modifiable risk factors further reinforces the potential benefits of the procedure on diverse population groups and is useful in itself for assessing the candidacy of patients for the procedure, particularly when postoperative pain is a factor being considered.

Comparison of bilateral cementless total knee arthroplasty results between patients in different BMI groups

INTRODUCTION

The aim of this study was to compare the results of cementless bilateral total knee arthroplasty (TKA) between individuals in different obesity groups.

MATERIALS AND METHODS

This was a retrospective cohort study. Patients with a body mass index (BMI) greater than 25 who underwent bilateral TKA for gonarthrosis between 2014 and 2020 and completed a minimum follow-up of 24 months were included. Age, sex, height, weight, BMI, operation time, length of stay, patient satisfaction, knee scores and complications were compared. Patients with missing data, who were followed for less than 24 months or had postoperative fractures around the knee were excluded.

RESULTS

There was a significant difference between the groups in terms of operation time (Class III > overweight > Class II > Class I p < 0.001). There was a significant difference in complications between the groups (Class III > Class I > Class II > overweight p = 0.010). According to our pairwise comparison, complications were more common in the class III group than in the overweight group. Knee score (KS) and function score (FS) increased significantly after surgery in all groups (p < 0.001), with no difference in FS (p = 0.448). Knee score changes were greater in the overweight and class I groups (p < 0.001). There was a significant interaction between both KS and FS and person satisfaction (p < 0.001).

CONCLUSION

Cementless TKA improved KS and FS in all obesity groups, yielded high patient satisfaction. Although the incidence of complications was higher in the morbidly obese patients than in the overweight patients, the difference was not significant. Patients with morbid obesity should be informed about related risks before planning cementless TKA.

Postoperative function of patients with rheumatoid arthritis after total knee arthroplasty in the last decade was comparable in the unadjusted cohort but inferior in the propensity score matched cohort with that of patients with osteoarthritis

BACKGROUND

The perioperative pain and function of total knee arthroplasty (TKA) in patients with rheumatoid arthritis (RA) approach those in patients with osteoarthritis (OA). This study aimed to evaluate whether the clinical outcomes, especially functions, of patients with RA reached those of OA, utilizing a background-matched cohort.

METHODS

Patients who underwent TKA between 2013 and 2021 were enrolled. Preoperative and minimum 2-year postoperative scores, specifically the Original Knee Society Score (OKSS) and New Knee Society Score (2011KSS), between RA and OA were compared. Clinical assessments were performed on unadjusted and propensity-score matched cohorts, ensuring age, sex, body mass index, and valgus deformity rate parity.

RESULTS

In an unadjusted cohort involving 98 patients with RA and 560 patients with OA, patients with RA demonstrated inferior preoperative OKSS-Function Score (FS) but similar postoperative functional scores to OA patients. In the matched cohort of 83, patients with RA displayed lower preoperative OKSS- FS (median difference: 20, P < 0.001) and 2011KSS functional activities (difference: 9, P = 0.01) beyond minimum clinically important differences than patients with OA. Patients with RA improved more in OKSS-FS, yielding no postoperative difference compared with patients with OA. However, postoperative 2011KSS functional activities remained lower in patients with RA (difference: 9.5, P = 0.03), especially in advanced functions, than in those with OA.

CONCLUSION

Postoperative function showed no difference between patients with RA and OA in the unadjusted cohort; within the background-matched cohort, postoperative function, especially advanced function, was inferior in patients with RA to those with OA.

Association between Obesity and Short-Term Patient-Reported Outcomes following Total Knee Arthroplasty: A Retrospective Cohort Study in Japan

Background: This study investigated the association between obesity and short-term patient-reported outcomes after total knee arthroplasty (TKA). Methods: The primary outcomes were the Western Ontario and McMaster Universities Osteoarthritis Index's (WOMAC) pain and function scores. Data were collected preoperatively and 2 and 4 weeks after surgery. Patients were stratified into three groups based on body mass index (BMI): normal weight (BMI < 24.99 kg/m2), overweight (25 ≤ BMI < 29.99 kg/m2), and obese (BMI ≥ 30 kg/m2). The associations between BMI and the WOMAC pain and function scores were assessed using generalized linear mixed models. Results: Among the 102 patients (median age: 75.0, women [85.3%]), 29.4%, 48.0%, and 22.5% were normal weight, overweight, and obese, respectively. The mean pain and function scores at baseline were similar across the BMI-stratified groups (p = 0.727 and 0.277, respectively). The pain score significantly improved 2 weeks post-surgery (p = 0.001). The function score improved significantly 4 weeks post-surgery (p < 0.001). The group and group-by-time interaction effects lacked statistical significance. Conclusions: All patients statistically and clinically showed relevant pain reduction and functional improvement shortly after TKA, irrespective of their obesity status. These data may help healthcare professionals discuss the expectations of pain amelioration and functional improvement with TKA candidates.

Trends in unicompartmental knee arthroplasty among 138 international experienced arthroplasty knee surgeons

Purpose

Unicompartmental knee arthroplasty (UKA) is an established option for treating isolated unicompartmental knee osteoarthritis (OA), but controversies still exist about patient selection, indications, perioperative management and alignment goals. This survey was designed to understand the current trends of experienced arthroplasty knee surgeons performing UKA.

Methods

An online questionnaire was created with SurveyMonkey® to assess global tendencies in the utilization of UKA. A link to the survey was shared with all ESSKA (European Society for Sports Traumatology, Knee Surgery and Arthroscopy) members. The questionnaire consisted of free and multiple-choice questions and was divided into four sections: demographic information, the surgical activity of the respondents, indications for surgery and postoperative alignment goals.

Results

A total of 138 ESSKA members from 34 different countries completed the survey. A total of 81 % of the responders performed fewer than 50 UKAs per year; 53 % of UKAs represented less than 20 % of their knee replacements; 71 % used mainly or only fixed-bearing implants; 81 % performed UKA in a shorter time compared to TKA; and 61 % and 72 % were interested in custom-made UKA and robotics, respectively. Thirty-six percent considered a minimum postoperative alignment of 0° for medial UKA, and 32 % considered 10° as the maximum valgus deformity for lateral UKA. Fifty-five percent had no minimum age cut-off, 47 % had no BMI cut-off, and 57 % believed TKA was better than UKA in knees with concomitant high-grade patellofemoral OA. Approximately 50 % of the surgeons desired a coronal alignment that was the same as the predegeneration alignment.

Conclusion

A high level of agreement was reached regarding the following: preference for fixed-bearing UKAs, lower surgical time for UKA compared to TKA, interest in custom-made and robotic UKAs, no age and weight cut-off, TKA preferred in the presence of patellofemoral OA, and a final alignment goal of the predegenerative state both for medial and lateral. There was no agreement regarding length of stay, rehabilitation protocol, preoperative varus and valgus cut-off values, and treatment in cases of absence of anterior cruciate ligament or previous osteotomy.

Go Big or Go Home: Obesity and Total Joint Arthroplasty

Obesity is highly prevalent, and it is expected to grow considerably in the United States. The association between obesity and an increased risk of complications following total joint arthroplasty (TJA) is widely accepted. Many believe that patients with body mass index (BMI) >40 have complications rates that may outweigh the benefits of surgery and should consider delaying it. However, the current literature on obesity and outcomes following TJA is observational, very heterogeneous, and full of confounding variables. BMI in isolation has several flaws and recent literature suggests shifting from an exclusively BMI <40 cutoff to considering 5 to 10% preoperative weight loss. BMI cutoffs to TJA may also restrict access to care to our most vulnerable, marginalized populations. Moreover, only roughly 20% of patients instructed to lose weight for surgery are successful and the practice of demanding mandatory weight loss needs to be reconsidered until convincing evidence exists that supports risk reduction as a result of preoperative weight loss. Obese patients can benefit greatly from this life-changing procedure. When addressing the potential difficulties and by optimizing preoperative assessment and intraoperative management, the surgery can be conducted safely. A multidisciplinary patient-centered approach with patient engagement, shared decision-making, and informed consent is recommended.

The effect of body mass index and preoperative weight loss in people with obesity on postoperative outcomes to 6 months following total hip or knee arthroplasty: a retrospective study

BACKGROUND

Few studies have investigated the association between obesity, preoperative weight loss and postoperative outcomes beyond 30- and 90-days post-arthroplasty. This study investigated whether body mass index (BMI) and preoperative weight loss in people with obesity predict postoperative complications and patient-reported outcomes 6 months following total knee or hip arthroplasty.

METHODS

Two independent, prospectively collected datasets of people undergoing primary total knee or hip arthroplasty for osteoarthritis between January 2013 and June 2018 at two public hospitals were merged. First, the sample was grouped into BMI categories, < 35 kg/m2 and ≥ 35 kg/m2. Subgroup analysis was completed separately for hips and knees. Second, a sample of people with BMI ≥ 30 kg/m2 was stratified into participants who did or did not lose ≥ 5% of their baseline weight preoperatively. The presence of postoperative complications, Oxford Hip Score, Oxford Knee Score, EuroQol Visual Analogue Scale and patient-rated improvement 6 months post-surgery were compared using unadjusted and adjusted techniques.

RESULTS

From 3,552 and 9,562 patients identified from the datasets, 1,337 were included in the analysis after merging. After adjustment for covariates, there was no difference in postoperative complication rate to 6 months post-surgery according to BMI category (OR 1.0, 95%CI 0.8-1.4, P = 0.8) or preoperative weight loss (OR 1.1, 95%CI 0.7-1.8, P = 0.7). There was no between-group difference according to BMI or preoperative weight change for any patient-reported outcomes 6 months post-surgery.

CONCLUSION

Preoperative BMI or a 5% reduction in preoperative BMI in people with obesity was not associated with postoperative outcomes to 6 months following total knee or hip arthroplasty.

Similar Patient Satisfaction and Quality of Life Improvement Achieved with TKA and THA According to the Goodman Scale: A Comparative Study

Background: Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are effective treatments for severe knee and hip osteoarthritis. Historically, TKA has been associated with lower satisfaction than THA, but recent advances in knee surgery have led to lower dissatisfaction rates. This study aimed to compare the satisfaction and self-reported improvement in the quality of life of two cohorts of patients who underwent TKA and THA, respectively. Methods: This observational study compared two previously published cohorts of patients who underwent THA and TKA in a single university center. The Goodman scale was used to assess satisfaction and self-perception of improved quality of life after TKA and THA at a minimum one-year follow-up. Propensity score matching was used to balance age, gender, and follow-up between groups. Significance was set at 0.05. Results: The study included a total of 105 THAs and 131 TKAs. Both groups had high levels of satisfaction with pain relief, ability to do house/yard work, and overall satisfaction, with above 90% satisfaction rates. Regarding improvement in quality of life, both groups had 86% of patients reporting improvement as "much better." After propensity score matching, no significant difference was found between THA and TKA for any of the comparisons made using the Goodman scale. Conclusions: The study showed that both TKA and THA resulted in high levels of satisfaction and improvement in quality of life. There was no significant difference in satisfaction rates between TKA and THA, contrary to the historical trend of lower satisfaction rates for TKA.

Exploring treatment effect heterogeneity of a PROMs alert intervention in knee and hip arthroplasty patients: A causal forest application

Patient reported outcome measures (PROMs) experience an uptake in use for hip (HA) and knee arthroplasty (KA) patients. As they may be used for patient monitoring interventions, it remains unclear whether their use in HA/KA patients is effective, and which patient groups benefit the most. Nonetheless, knowledge about treatment effect heterogeneity is crucial for decision makers to target interventions towards specific subgroups that benefit to a greater extend. Therefore, we evaluate the treatment effect heterogeneity of a remote PROM monitoring intervention that includes ∼8000 HA/KA patients from a randomized controlled trial conducted in nine German hospitals. The study setting gave us the unique opportunity to apply a causal forest, a recently developed machine learning method, to explore treatment effect heterogeneity of the intervention. We found that among both HA and KA patients, the intervention was especially effective for patients that were female, >65 years of age, had a blood pressure disease, were not working, reported no backpain and were adherent. When transferring the study design into standard care, policy makers should make use of the knowledge obtained in this study and allocate the treatment towards subgroups for which the treatment is especially effective.

Increase in Postoperative Body Mass Index in Patients After Total Knee Arthroplasty

Objectives The aim of this is to investigate the changes in body mass index (BMI) following knee arthroplasty and to evaluate their impact on patient-reported outcomes and functional evaluations. Methods This observational study included 90 patients who underwent total knee arthroplasty (TKA) and were followed up for a median period of 2.6 years. BMI measurements were recorded before and after surgery, and patient-reported outcomes and functional evaluations were assessed using standardized scales and tests. Results Following TKA, BMI increased statistically significantly (Wilcoxon signed-rank test, p < 0.000). In addition, half of the patients experienced an increase in BMI, with 32% moving up in their BMI category. However, there were no clinically significant differences in patient-reported outcomes or functional evaluations between the group that gained BMI and the group that maintained or lost BMI. Conclusion This study reveals that patients tend to have increased BMI following TKA. However, these BMI changes do not significantly impact patient-reported outcomes or functional evaluations. It underscores the importance of patient education regarding healthy lifestyle habits, including diet and physical activity, to address postoperative weight gain effectively.

Is There a Difference in PROMs Between Morbidly Obese Patients and Nonobese Patients Following Primary Total Knee Arthroplasty?

Background

Patient satisfaction and patient-reported outcome measures (PROMs) are important for patients, surgeons, and payers in the current healthcare climate. Morbidly obese patients (body mass index [BMI] >40) have demonstrated higher incidence of complications after total knee arthroplasty (TKA) and can have difficulty obtaining access for their surgical care. The purpose of this study was to evaluate PROMs and patient satisfaction in morbidly obese patients undergoing primary TKA.

Methods

A total of 75 patients with BMI >40 kg/m² undergoing robotic-assisted TKA were retrospectively identified and matched 2:1 to a consecutive cohort of patients with BMI <35. The average BMI of the study cohort was 42.4 kg/m² (39.5-51.3) compared to 28.6 kg/m² (18.5-34.9) in the control group. Clinical outcomes, PROMs, and patient satisfaction were evaluated at a minimum 2-year follow-up.

Results

The patients of the BMI >40 cohort were less likely to be discharged home (P = .0076), had less active flexion at 2 years (P = .0046), and had worse knee scores at 2 years (0.0497). Despite this, the percentage of patients who were satisfied or very satisfied after surgery was similar between the groups (87.5% vs 91.2%, P = .1943).

Conclusions

Morbidly obese patients are less likely to be discharged directly to home and may have functional differences after primary TKA. However, morbidly obese patients have similar PROMs and are as satisfied as nonobese patients at 2 years. Morbidly obese patients with end-stage knee osteoarthritis should also be able to enjoy the benefits of primary TKA following medical and surgical optimization.

Osteoarthritis year in review 2022: epidemiology & therapy

This 'Year in Review' provides a synopsis of key research themes and individual studies from the clinical osteoarthritis (OA) field, focused on epidemiology and therapy. The electronic database search for the review was adapted from the 2021 year in review search, to increase search specificity for relevant study designs, and was conducted in Medline, Embase and medRxiv (31^st March 2021 to 4^th March 2022). Following screening for eligibility, studies were grouped according to their key research design, including reviews, cohorts and randomised trials. 11 key themes emerged, including the importance of several comorbidities in predicting OA incidence and prevalence, surgical approaches that can reduce the risk of post-traumatic OA, the heterogenous but nevertheless relatively stable nature of OA subgroup trajectories, the paucity of robust studies particularly of surgery for OA and the very modest benefit of many therapies under evaluation in trials. A particular interest of the authors was to consider whether new studies are helping determine how to better ensure the right patient with OA is matched to the right treatment at the right time. There are several new studies developing improved predictive models through big data analytics and machine learning which show promise, need validation, and may support new approaches to stratified care.

Decreasing Trend in Complications for Patients With Obesity and Metabolic Syndrome Undergoing Total Knee Arthroplasty From 2006 to 2017

BACKGROUND

To describe longitudinal trends in patients with obesity and Metabolic Syndrome (MetS) undergoing total knee arthroplasty (TKA) and the impact on complications.

METHODS

We identified primary TKA patients between 2006 and 2017 within the National Surgical Quality Improvement Program database. We recorded patient demographics and 30-day complications. We labeled those with an obese Body Mass Index (BMI ≥30), hypertension, and diabetes as having MetS. We used regression to evaluate trends in BMI and complications over time and variables associated with the odds of complication.

RESULTS

We identified 270,846 TKA patients, 63.71% of which were obese (n = 172,333), 15.21% morbidly obese (n = 41,130), and 12.37% met the criteria for MetS (n = 33,470). Mean BMI increased by 0.03 per year (0.02-0.05). Despite this, the odds of adverse events in obese patients decreased: major complications by 0.94 (0.93-0.96) and minor complications by 0.94 (0.93-0.95). The proportion of patients with MetS remained stable; however, we found improvements in major (0.94 [0.91-0.97]) and minor complications (0.97 [0.94-1.00]) over time. MetS components (hypertension, diabetes, and BMI ≥40) were associated with major and minor complications in obese patients, while neuraxial anesthesia lowered the odds of major complications in obese patients (0.87 [0.81-0.92]).

CONCLUSION

Mean BMI in primary TKA patients increased from 2006 to 2017. MetS components diabetes and hypertension elevated the odds of complications in obese patients. Rates of complications in patients with obesity and MetS exhibited a longitudinal decline. These findings may reflect increased awareness and improved management of these patients.

The relationship between body mass index and clinical efficacy of knee arthroplasty in patients with knee osteoarthritis

Background

Increase body mass index (BMI) is often accompanied by metabolic diseases such as diabetes, which will increase the uncertainty of total knee arthroplasty (TKA) efficacy and the risk of postoperative complications. The present study was to study the relationship between increase BMI and clinical efficacy of knee arthroplasty in patients with knee osteoarthritis.

Methods

A total of 97 patients (36 males and 61 females) with knee osteoarthritis (KOA) who underwent TKA surgery were selected. According to the preoperative body mass index (BMI), the patients were divided into a normal group (n=42), overweight group (n=35), and obese group (n=20). All patients received TKA after admission. Seven days after surgery, the American Knee Society (AKS) and the Hospital for Special Surgery (HSS) scales were used to evaluate the recovery of knee function. The recovery was poor if the scores of AKS and HSS were less than 70.

Results

Seven days after TKA, the scores of AKS and HSS in different BMI groups were significantly different, and decreased with the increase of BMI (P<0.05). Age, increased BMI, diabetes, preoperative range of motion (ROM), intraoperative blood loss, postoperative C-reactive protein (CRP), postoperative posterior slope angle (PSA), postoperative infection, and postoperative deep vein thrombosis (DVT) of lower extremities were related to AKS score <70 (P<0.05). Diabetes, preoperative ROM, intraoperative blood loss, postoperative CRP, postoperative PSA, and postoperative infection were related to HSS score <70 (P<0.05). Increased BMI, diabetes, postoperative CRP, postoperative infection, and postoperative DVT were independent risk factors for AKS score <70 (HR =3.458, 1.152, 2.960, 1.023, 3.589, P<0.05). Increased BMI, diabetes, postoperative CRP, and postoperative infection were independent risk factors for HSS score <70 (HR =6.891, 1.263, 1.967, 1.235, P<1.235). The area under the curve (AUC) (95% CI) of BMI in diagnosing AKS <70 was 0.740 (0.641–0.839). The AUC (95% CI) of BMI in diagnosing HSS <70 was 0.809 (0.723–0.894).

Conclusions

The increase of BMI is an independent risk factor for the poor recovery of knee function after TKA in patients with KOA.