The effects of age on patient-reported outcome measures in total knee replacements

Can individual functional improvements be predicted in osteoarthritic patients after total knee arthroplasty?

PURPOSE

Total knee arthroplasty (TKA) is an effective treatment for advanced osteoarthritis, and achieving optimal outcomes can be challenging due to various influencing factors. Previous research has focused on identifying factors that affect postoperative functional outcomes. However, there is a paucity of studies predicting individual postoperative improvement following TKA. Therefore, a quantitative prediction model for individual patient outcomes is necessary.

MATERIALS AND METHODS

Demographic data, radiologic variables, intraoperative variables, and physical examination findings were collected from 976 patients undergoing TKA. Preoperative and 1-year postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were assessed, and multivariate regression analysis was conducted to identify significant factors influencing one-year WOMAC scores and changes in WOMAC scores. A predictive model was developed on the basis of the findings.

RESULTS

The predictive accuracy of the model for 1-year WOMAC scores was poor (all adjusted R2 < 0.08), whereas the model for changes in WOMAC scores demonstrated strong predictability (all adjusted R2 > 0.75). Preoperative WOMAC scores, sex, and postoperative knee range of motion significantly affected all pain, stiffness, and physical function aspects of the WOMAC scores (all P < 0.05). Age, cerebrovascular disease, and patellar resurfacing were associated with changes in physical function (all P < 0.05).

CONCLUSIONS

The developed quantitative model demonstrated high accuracy in predicting changes in WOMAC scores after TKA. The identified factors influencing postoperative improvement in WOMAC scores can assist in optimizing patient outcomes after TKA.

Medial-pivot total knee arthroplasty enhances tibiofemoral axial rotation stability in weight-bearing mid-range flexion compared to posterior-stabilised system

PURPOSE

Total knee arthroplasty (TKA) stands as a primary intervention for severe knee ailments, yet concerns remain regarding postoperative patient satisfaction and flexion instability. This study aims to evaluate the in-vivo kinematics of medial-pivot (MP) and posterior-stabilised (PS) designs during step-up activity, in comparison to the kinematics of the nonoperated contralateral knee.

METHODS

Sixteen patients with PS-TKA and 14 with MP-TKA were retrospectively examined. Clinical outcomes were assessed using patient-completed questionnaires. Motion during step-up was captured using a dual fluoroscopic system. Statistical analysis was applied to evaluate the in-vivo tibiofemoral six-degree-of-freedom kinematics and articular contact positions between the two groups.

RESULTS

Despite being older, patients in the MP group reported higher postoperative subjective scores for weight-bearing functional activities. The axial rotation centres of MP-TKA located on the medial tibial plateau exhibited less variance compared to PS-TKA and contralateral knees. Compared to the contralateral knee (contralateral to medial-pivot [C-MP] or contralateral to posterior-stabilised [C-PS]), the MP group exhibited limited range of motion in terms of anteroposterior translation (MP: 3.6 ± 1.3 mm vs. C-MP: 7.4 ± 2.5 mm, p < 0.01) and axial rotation (MP: 6.6 ± 1.9° vs. C-MP: 10.3 ± 4.9°, p = 0.02), as well as in the PS group for anteroposterior translation (PS: 3.9 ± 1.7 mm vs. C-PS: 7.2 ± 3.7 mm, p < 0.01).

CONCLUSION

The MP group with better postoperative ratings demonstrated a more stable MP axial rotation pattern during step-up activity compared to the PS group, underscoring the pivotal role of prosthetic design in optimising postoperative rehabilitation and functional recovery.

LEVEL OF EVIDENCE

Level III.

Meniscal Transplant surgery or Optimised Rehabilitation full randomised trial (MeTeOR2): a study protocol

INTRODUCTION

Pain and disability after meniscectomy can be a substantial lifelong problem. There are few treatment options, especially for young people. Non-surgical management (rehabilitation) is an option but increasingly surgeons are performing meniscal allograft transplants (MATs) for these individuals. However, this is still an uncommon procedure, and availability and usage of MAT vary widely both in the UK and internationally. It is not known which treatment option is the most effective and cost-effective.

METHODS AND ANALYSIS

The Meniscal Transplant surgery or Optimised Rehabilitation trial is an international, multicentre, randomised controlled trial. The aim is to compare the clinical and cost effectiveness of MAT versus an optimised package of individualised, progressive, rehabilitation that we have called personalised knee therapy (PKT).Participants will be recruited from sites across the UK, Australia, Canada and Belgium. The planned 144 participants provide at least 90% power to detect a 10-point difference in the Knee injury and Osteoarthritis Outcome Score (KOOS4) at 24-months post randomisation (primary outcome). A prospectively planned economic evaluation will be conducted from a healthcare system and personal social services perspective. Secondary outcome data including health utility, occupational status, sports participation, mental well-being, further treatment, and adverse events will be collected at 3, 6, 12, 18, and 24 months. Analysis will be on an intention-to-treat basis and reported in-line with the Consolidated Standards of Reporting Trials statement.

ETHICS AND DISSEMINATION

The trial was approved by the London-Bloomsbury Research Ethics Committee on 19 August 2022 (22/LO/0327) and Northern Sydney Local Health District Human Research Ethics Committee, NSW, Australia on the 13 March 2023 (2022/ETH01890).Trial results will be disseminated via peer-reviewed publications, presentations at international conferences, in lay summaries and using social media as appropriate.This protocol adheres to the recommended Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist.

TRIAL REGISTRATION NUMBER

ISRCTN87336549.

Neuroimaging markers of patient-reported outcome measures in acute ischemic stroke

Objectives

To determine the relationship between patient-reported outcome measures (PROMs) and volumetric imaging markers in acute ischemic stroke (AIS).

Patients and Methods

Patients presenting at Massachusetts General Hospital between February 14, 2017 and February 5, 2020 with a confirmed AIS by MRI were eligible and underwent a telephone interview including PROM-10 questionnaires 3-15 months after stroke. White matter hyperintensity (VWMH) and brain volumes (VBrain) were automatically determined using admission clinical MRI. Stroke lesions were manually segmented and volumes calculated (VLesion). Multivariable and ordinal regression analyses were performed to identify associations between global and PROM-10 subscores with brain volumetrics and clinical variables.

Results

Utilizing data from 167 patients (mean age: 64.7; 41.9% female), higher VWMH was associated with worse global physical (β=-0.6), global mental (β=-0.65), physical health (OR=0.68), social satisfaction (OR=0.66), fatigue (OR=0.69) and social activities (OR=0.59) scores. Higher VLesion was associated with poorer global mental (β=-0.79), mental health (OR=0.68), physical (OR=0.66) and social activities (OR=0.55), and emotional distress (OR=0.68) scores. Higher VBrain was linked to better global mental (β=0.93), global physical (β=0.79), mental health (OR=1.54) and physical activities (OR=1.72) scores.

Conclusions

Neuroimaging biomarkers were significantly associated with PROMs, where higher VWMH and VLesion led to worse outcome, while higher VBrain was protective. The inclusion of neuroimaging analyses and PROMs in routine assessment provides enhanced understanding of post-stroke outcomes.

Age-Related Differences in Pain, Function, and Quality of Life Following Primary Total Knee Arthroplasty: Results from a FORCE-TJR Cohort

INTRODUCTION

The impact of age on patient outcomes after total knee arthroplasty (TKA) remains controversial. Age has shown no effect on outcome in some studies, while others have reported better or worse outcome in younger patients. The aims of this study were to determine the differences in pain, function, and quality of life reported one-year after TKA across different age groups.

METHODS

A prospective, multi-center cohort of 11,602 unilateral primary TKA patients was evaluated. Demographic data, comorbid conditions, and patient-reported outcome measures (PROMs) including the knee injury and osteoarthritis outcome score (KOOS), KOOS-12, KOOS JR, and Short-Form health survey (12-item) were collected pre- and at one-year postoperatively. Descriptive statistics were generated, stratified by age [< 55 years (younger adult), 55 to 64 years (older adult), 65 to 74 years (early elder), and ≥ 75 years (late elder)], and differences in pain, function, and quality of life among the four age groups were evaluated using Chi-square and Kruskal-Wallis tests. Multivariate regression models with 95% confidence interval (CI) were performed to determine if age was predictive for KOOS pain and function scores.

RESULTS

Prior to surgery, younger patients (< 55 years) reported worse KOOS pain (39), function (50), and quality of life (18) scores with poor mental health score (47) than other older patient groups. The mean pre-op score differences across the age groups in the KOOS total score (9.37), KOOS pain (11.61), KOOS-12 pain (10.14), and KOOS/KOOS-12 QoL (12.60) reached the calculated minimal clinically important difference (MCID). At one-year after TKA, younger patients (< 55 years) reported lower KOOS pain, function, and quality of life scores when compared to older patients (≥ 75 years). The differences in one-year postop scores among the 4 age groups (ranging from 4.0 to 12.2) reached the MCID for pain (10.4) and quality of life (12.2). Younger patients (< 55 years) achieved higher baseline to one-year pain (36.8 points), function (30.3 points), and quality of life (40.7 points) score changes when compared to older patients ≥ 75 years. Although statistically significant, the differences in score changes among the age groups were clinically irrelevant. The multivariate regression analyses showed that age was a significant predictor for pain, but not for function at one year where KOOS pain score was predicted to be higher (less pain) (β =6.17; 95% CI (4.12- 8.22) (P<0.001) in older patients (≥ 75 years) when compared to younger patients (< 55 years).

CONCLUSION

A TKA provides a dramatic improvement in pain, function, and quality of life in all age groups. However, there are age-related clinically significant differences in pre-operative pain, quality of life, and mental health and in final post-operative pain and quality of life scores with younger patients (< 55 years) reporting more pain, less quality of life, and worse pre-operative mental health. The PROM data presented here can be used clinically to improve shared decision making and patient expectations prior to TKA.

Quality of Life and Satisfaction in Patients Above and Under 65 Years Old Submitted to Total Knee Arthroplasty

Objective  To compare the level of quality of life and satisfaction after two years of total knee arthroplasties between individuals above and below 65 years of age and to identify predictor factors of poor clinical outcome and low level of satisfaction in patients undergoing arthroplasty.

Methods  This is a retrospective cohort with data from patients diagnosed with knee osteoarthritis submitted to primary total knee arthroplasty from 2014 to 2018 ( n  = 190). Clinical outcomes were assessed using the following scores: visual analog scale (VAS) of pain, EQ-5D-3L and EUROQOL-VAS (quality of life scales), patient satisfaction level, and functional scale of the Knee Injury and Osteoarthritis Outcome Score (KOOS), collected through a questionnaire applied preoperatively, as well as 1, 3, 12 and 24 months after surgery.

Results  Patients < 65 years old presented significantly lower values (clinical worsening) in KOOS-pain and KOOS-symptoms. There are no differences in the principal clinical scores that assess pain, function, and quality of life after the procedure, as well as in the rate of satisfaction with the procedure, among patients < 65 years old when compared with patients ≥ 65 years old. It was also observed that patients who were not satisfied with the procedure in the 24-month evaluation presented clinical results in some analyzed scores (KOOS-pain and EQ-VAS) similar to patients who declared themselves satisfied.

Conclusion  Scores that assess pain, function, quality of life, as well as satisfaction rate are similar between patients < 65 years old and those ≥ 65 years old.

Aseptic revision total knee arthroplasty outcomes were equivalent to patients' own pre-failure state but inferior to patients without revision

PURPOSE

The purpose of this study was to (1) longitudinally compare the patient-reported outcome measures (PROMs) of the same patients who underwent primary TKA and revision TKA, and (2) compared the results of these revision TKA with a matched cohort of well-functioning primary TKA. The hypothesis was revision TKA could result in equivalent outcomes to patients' own primary TKA or the primary TKA of patients who did not require revision.

METHODS

Prospectively collected data of 123 patients who underwent primary TKA and subsequently aseptic revision TKA ("revised group"), were matched using nearest-neighbor method to 123 well-functioning primary TKA that did not require revision ("control group"). Preoperative (prior to primary TKA), at time of failure (prior to revision TKA), postoperative 6-month and 2-year PROMs included Knee Society scores (KSS), Oxford Knee Score (OKS) and Short Form-36 (SF-36). Minimal clinically important difference (MCID) attainment was analyzed. Wilcoxon and McNemar's tests were used to compare outcomes within the revised group (primary vs revision), Mann-Whitney U test and Chi-Square test for the revised and control groups.

RESULTS

The revised group had poorer KSS objective (p = 0.045), KSS functional (p < 0.001), OKS (p = 0.011) and SF-36 PCS (p < 0.001) at time of failure (prior to revision TKA), compared to their preoperative PROMs (prior to primary TKA). Revision TKA resulted in restoration of KSS objective, OKS and SF-36 PCS (NS) that were equivalent to their primary TKA, but poorer KSS functional (p < 0.050). Patients in the revised group had a lower proportion of MCID attainment in KSS objective (p = 0.014) and OKS (p < 0.001) at 2-year after primary TKA when compared to the control group. Revision TKA also led to poorer KSS objective, KSS functional and SF-36 PCS (p < 0.050) when compared to primary TKA of the control group.

CONCLUSION

Outcomes following aseptic revision were equivalent to patients' own pre-failure state but inferior to patients with non-revised implants. An individualized approach toward goal setting and assessing adequacy of aseptic revision TKA can be adopted based on patients' pre-failure outcomes.

LEVEL OF EVIDENCE

III.

Patient-Reported Outcomes following Total Knee Replacement in Patients Aged 65 Years and Over-A Systematic Review

A previous systematic review showed positive patient-reported outcomes following total knee replacement (TKR) in patients aged < 65 years. However, the question remains as to whether these results are replicated for older individuals. This systematic review evaluated the patient-reported outcomes following TKR in individuals aged ≥ 65 years. A systematic search of Ovid MEDLINE, EMBASE, and Cochrane library were performed to identify studies examining disease-specific or health-related quality of life outcomes following TKR. Qualitative evidence synthesis was performed. Eighteen studies with low (n = 1), moderate (n = 6), or serious (n = 11) overall risk of bias were included, with evidence syntheses derived from 20,826 patients. Four studies reported on pain scales, showing improvement of pain from 6 months to 10 years postoperatively. Nine studies examined functional outcomes, showing significant improvements from 6 months to 10 years after TKR. Improvement in health-related quality of life was evident in six studies over 6 months to 2 years. All four studies examining satisfaction reported overall satisfaction with TKR results. TKR results in reduced pain, improved function, and increased quality of life for individuals aged ≥ 65 years. The improvement in patient-reported outcomes needs to be utilised in conjunction with physician expertise to determine what would comprise clinically significant differences.

Ten-year follow-up of a total knee prosthesis combining multi-radius, ultra-congruency, posterior-stabilization and mobile-bearing insert shows long-lasting clinically relevant improvements in pain, stiffness, function and stability

PURPOSE

There is a paucity of data available on total knee prostheses combining dual-radius, ultra-congruency, posterior-stabilization and mobile-bearing insert. This prospective cohort study aimed to assess the clinical evolution of the FIRST^® prosthesis (Symbios Orthopédie, Yverdon, CH), the earliest prosthesis with this particular design. It was hypothesized that the primary outcomes, evaluating pain, stiffness, function and stability, would improve following arthroplasty and remain improved during the follow-up period of 10 years.

METHODS

All patients programmed for a total knee arthroplasty using a FIRST^® prosthesis at our university hospital between 2006 and 2008 were invited to participate. Study knees were evaluated pre-operatively as well as one, five and ten years post-operatively. Patients filled out questionnaires at each evaluation point and had a radiographic assessment at the five-year and ten-year follow-ups. Primary outcomes were the total, pain, stiffness and function measures of the Western Ontario and McMaster Universities Osteoarthritis questionnaire (WOMAC) and the knee and function measures of the Knee Society Score (KSS). Friedman and Wilcoxon's rank-sum tests were used to compare measures across time points.

RESULTS

Hundred and twenty four prostheses were included (baseline demographics: 69.9 ± 8.3 years old, 28.1 ± 4.3 kg/m², 54% male) and 68 could be followed during ten years. Five prostheses underwent a revision. All other prostheses lost at follow-up were lost for reasons unrelated to the prosthesis. All primary measures reported statistically and clinically significant improvements between baseline and the three follow-up evaluations. Statistically significant improvements at the three follow-up evaluations were also observed for most secondary measures. There was no implant loosening. At ten-year follow-up, radiolucent lines were observed in 2.9% femoral implants and 1.5% tibial implants.

CONCLUSION

The positive results observed in all domains of assessment and the small revision rate demonstrated an effective functioning of the FIRST^® prosthesis during the ten-year follow-up period. The results, globally similar to those previously published for other prosthesis designs, encourage the development of assistive methods to select the most appropriate designs on an individual basis.

LEVEL OF EVIDENCE

IV, prospective cohort study.

Similar survival rate but lower functional outcomes following TKA in the elderly people compared to younger patients: analysis of a posterior stabilised implant with minimum 5-year follow-up

BACKGROUND

Literature regarding outcomes in patients over 80 years old after total knee arthroplasty (TKA) is inconsistent. We aimed to compare implant survivorship and functional outcomes between elderly patients (≥ 80 years) and younger patients (< 80 years) following TKA, using a single modern posterior-stabilized (PS) prosthetic design.

METHODS

This is a retrospective cohort study of 80 patients over 80 years old who underwent TKA between January 2015 and December 2016, who were compared with younger patients (60-75 years old) operated during the same period. Patients were matched with a ratio of 1:3 based on logistic regression analysis of gender and body mass index. All patients received the same cemented PS prosthesis with a fixed bearing polyethylene insert, with or without patellar resurfacing. Implant survival and patient-reported outcome measurements were compared between the two groups. At last follow-up, data were available for 41 knees in the elderly group (including 17 patients who died before 5-year follow-up) and 123 knees in the younger group.

RESULTS

Functional results were better at final follow-up in the group < 80 years with a significantly higher Knee Society Function Subscore (88.6 ± 16.9 vs 79.4 ± 22.1, p < 0.01), but no significant differences in Knee Subscore and global Knee Society Score (p > 0.05), nor regarding maximum flexion (121° ± 12 and 117° ± 13, p = 0.08). The implant survivorship was 100.0% after a mean 64.4-month follow-up (range 60-78), without revision requiring removal of the implant in any group. The survival rate without any reoperation was 97.6% (95% CI 93.0-100.0) in the elderly group and 95.9% (95% CI 92.5-99.5) in the younger group (p = 0.64).

CONCLUSION

At a minimum of 5-year follow-up, there was no revision surgery and a very low rate of complications requiring reoperations both in the group over 80 years of age and in the younger population, with the use of a PS prosthesis. The functional results were slightly lower for elderly patients and correlate with the lower functional demands of this population. The indication for TKA, especially with a PS implant, may be encouraged in appropriately selected elderly patients.

LEVEL OF EVIDENCE

III (retrospective cohort study).

Meaningful values of the EQ-5D-3L in patients undergoing primary knee arthroplasty

AIMS

The aim of this study was to report the meaningful values of the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) and EuroQol visual analogue scale (EQ-VAS) in patients undergoing primary knee arthroplasty (KA).

METHODS

This is a retrospective study of patients undergoing primary KA for osteoarthritis in a university teaching hospital (Royal Infirmary of Edinburgh) (1 January 2013 to 31 December 2019). Pre- and postoperative (one-year) data were prospectively collected for 3,181 patients (median age 69.9 years (interquartile range (IQR) 64.2 to 76.1); females, n = 1,745 (54.9%); median BMI 30.1 kg/m² (IQR 26.6 to 34.2)). The reliability of the EQ-5D-3L was measured using Cronbach's alpha. Responsiveness was determined by calculating the anchor-based minimal clinically important difference (MCID), the minimal important change (MIC) (cohort and individual), the patient-acceptable symptom state (PASS) predictive of satisfaction, and the minimal detectable change at 90% confidence intervals (MDC-90).

RESULTS

The EQ-5D-3L demonstrated good internal consistency with an overall Cronbach alpha of 0.75 (preoperative) and 0.88 (postoperative), respectively. The MCID for the Index score was 0.085 (95% confidence interval (CI) 0.042 to 0.127) and EQ-VAS was 6.41 (95% CI 3.497 to 9.323). The MIC_COHORT was 0.289 for the EQ-5D and 5.27 for the EQ-VAS. However, the MIC_INDIVIDUAL for both the EQ-5D-3L Index (0.105) and EQ-VAS (-1) demonstrated poor-to-acceptable reliability. The MDC-90 was 0.023 for the EQ-5D-3L Index and 1.0 for the EQ-VAS. The PASS for the postoperative EQ-5D-3L Index and EQ-VAS scores predictive of patient satisfaction were 0.708 and 77.0, respectively.

CONCLUSION

The meaningful values of the EQ-5D-3L Index and EQ-VAS scores can be used to measure clinically relevant changes in health-related quality of life in patients undergoing primary KA.Cite this article: Bone Joint Res 2022;11(9):619-628.

Outcomes Vary Significantly Using a Tiered Approach to Define Success After Total Knee Arthroplasty

BACKGROUND

Patient-reported outcome measures (PROM) allow assessment of clinical outcomes following primary total knee arthroplasty (TKA). The purpose of this study is to use progressively more stringent definitions of success to examine clinical outcomes of primary TKA at 1 year postoperatively and to determine which demographic variables were associated with achieving clinical success.

METHODS

The American Joint Replacement Registry was queried from 2012 to 2020 for primary TKA. Patients who completed the following PROMs preoperatively and 1 year postoperatively were included: Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and KOOS for Joint Replacement (KOOS JR). Mean PROM scores were determined for each visit and between-visit changes were evaluated using paired t-tests. Rates of achievement of minimal clinically important difference (MCID) by distribution-based and anchor-based criteria, Patient Acceptable Symptom State, and substantial clinical benefit were calculated. Logistic regression was used to evaluate the association between demographic variables and odds of clinical success.

RESULTS

In total, 12,341 TKAs were included. Mean improvement in PROM scores were as follows: KOOS JR, 29; WOMAC-Pain, 33; and WOMAC-Function, 31 (P < .0001 for all). Rates of achievement of each metric were the following: distribution-based MCID, 84%-87%; anchor-based MCID, 46%-79%; Patient Acceptable Symptom State, 54%-82%; and substantial clinical benefit, 68%-81%. Patient age and gender were the most influential demographic factors on achievement of clinical success.

CONCLUSION

Clinical outcomes at 1 year following TKA vary significantly when using a tiered approach to define success. A tiered approach to interpretation of PROMs should be considered for future research and clinical assessment.

Preoperative Factors Affecting the Patient-Reported Outcome Measures following Total Knee Replacement: Socioeconomic Factors and Preoperative OKS Have a Clinically Meaningful Effect

The Oxford Knee Score (OKS) is a patient-reported outcome questionnaire typically used to assess function and pain in patients undergoing total knee replacement (TKR). However, research is inconclusive as to which preoperative factors are important in explaining variation in outcome following TKR. The operative records of 12,709 patients who underwent primary TKR over a 9-year period were analyzed. The following variables were collected for each patient: age, sex, body mass index (BMI), Index of Multiple Deprivation decile rank, side of operation, diagnosis, the American Society of Anaesthesiologists (ASA) grade, preoperative OKS, EQ-5D index score, EuroQol visual analog scale (EQ-VAS) score, the postoperative OKS at 1 and 2 years. Generalized linear regression models were performed at 1 and 2 years to investigate the effect of the preoperative variables on the postoperative OKS. The effect of age, sex, BMI, Index of Multiple Deprivation decile rank, diagnosis, ASA grade, preoperative OKS, EuroQoL five-dimensional (EQ-5D) index score, and EQ-VAS score were all statistically significant in explaining the variation in OKS at 1 and 2 years postoperatively, with critical level of significance of 0.05 (5%). Being male aged 60 to 69 years of normal BMI, ASA grade I (fit and healthy), living in an affluent area, not reporting preoperative anxiety/depression, were associated with an enhanced mean postoperative OKS at both 1 and 2 years. When adjusted for potential confounding, age of 60-69 years, male sex, normal BMI, lower ASA grade, higher Index of Multiple Deprivation and higher pre-operative EQ-5D, EQ-VAS and OKS were identified as factors that resulted in higher post-operative OKS after primary TKR.

Patient perspectives of pain and function after knee replacement: a systematic review and meta-synthesis of qualitative studies

Introduction

Joint replacement surgery typically results in good clinical outcome, although some people experience suboptimal pain relief and functional improvement. Predicting surgical outcome is difficult.

Objectives

There is merit in better understanding patients' perspectives of pain and function to identify avoidable problems perceived to contribute to their outcome, to inform prognostic expectations, and to identify potential cointerventions to sit alongside surgery that might mitigate pain/functional problems. Here, we aimed to synthesise the available literature exploring perspectives of people with knee osteoarthritis about their pain and function following joint replacement.

Methods

Six electronic databases and 2 websites were searched. Two independent reviewers completed study inclusion, quality assessment, and data extraction. Data were iteratively synthesised using first-, second-, and third-order analyses.

Results

Twenty-eight studies were included. Four themes were identified; perceptions of pain and function were inseparable. Theme 1 addressed experiences of recovery after surgery, which often differed from expectations. Theme 2 described the challenges of the pain experience and its functional impact, including the difficulty navigating medication use in context of personal beliefs and perceived stigma. Theme 3 articulated the toll of ongoing problems spanning pain-function-mood, necessitating the need to "endure." Theme 4 encompassed the importance of clinical/social interactions on mood and pain, with reports of concerns dismissed and practical support missing.

Conclusions

Together, these findings show that numerous individual considerations beyond the technical aspects of surgery influence experiences of pain and function. A tailored approach addressing these considerations from the patient perspective could provide a basis for improved success of knee replacement surgery.

One-Year Clinical Outcomes of Minimal-Invasive Dorsal Percutaneous Fixation of Thoracolumbar Spine Fractures

Introduction: Minimal-invasive instrumentation techniques have become a workhorse in spine surgery and require constant clinical evaluations. We sought to analyze patient-reported outcome measures (PROMs) and clinicopathological characteristics of thoracolumbar fracture stabilizations utilizing a minimal-invasive percutaneous dorsal screw-rod system. Methods: We included all patients with thoracolumbar spine fractures who underwent minimal-invasive percutaneous spine stabilization in our clinics since inception and who have at least 1 year of follow-up data. Clinical characteristics (length of hospital stay (LOS), operation time (OT), and complications), PROMs (preoperative (pre-op), 3-weeks postoperative (post-op), 1-year postoperative: eq5D, COMI, ODI, NRS back pain), and laboratory markers (leucocytes, c-reactive protein (CRP)) were analyzed, finding significant associations between these study variables and PROMs. Results: A total of 68 patients (m: 45.6%; f: 54.4%; mean age: 76.9 ± 13.9) were included. The most common fracture types according to the AO classification were A3 (40.3%) and A4 (40.3%), followed by B2 (7.46%) and B1 (5.97%). The Median American Society of Anesthesiologists (ASA) score was 3 (range: 1−4). Stabilized levels ranged from TH4 to L5 (mean number of targeted levels: 4.25 ± 1.4), with TH10-L2 (12/68) and TH11-L3 (11/68) being the most frequent site of surgery. Mean OT and LOS were 92.2 ± 28.2 min and 14.3 ± 6.9 days, respectively. We observed 9/68 complications (13.2%), mostly involving screw misalignments and loosening. CRP increased from 24.9 ± 33.3 pre-op to 34.8 ± 29.9 post-op (p < 0.001), whereas leucocyte counts remained stable. All PROMs showed a marked significant improvement for both 3-week and 1-year evaluations compared to the preoperative situation. Interestingly, we did not find an impact of OT, LOS, lab markers, complications, and other clinical characteristics on PROMs. Notably, a higher number of stabilized levels did not affect PROMs. Conclusions: Minimal-invasive stabilization of thoracolumbar fractures utilizing a dorsal percutaneous approach resulted in significant PROM outcome improvements, although we observed a complication rate of 13.2% for up to 1 year of follow-up. PROMs were not significantly associated with clinicopathological characteristics, technique-related variables, or the number of targeted levels.

Development of machine learning algorithms to predict achievement of minimal clinically important difference for the KOOS-PS following total knee arthroplasty

As cost-effective measures become increasingly implemented in the US healthcare system, changes in patient-reported outcome measure (PROM) scores can be utilized to indicate patient satisfaction following procedures including total knee arthroplasty (TKA). The primary aim of this study was to develop and evaluate machine learning algorithms to predict achievement of the minimal clinically important difference (MCID) for the Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form (KOOS-PS) at 1-year following TKA. A retrospective review of primary TKA patients between 2016 and 2018 was performed. Variables considered for prediction included demographics and preoperative PROMs. The KOOS-PS MCID was calculated via a distribution-based method. Five machine learning algorithms were developed and tested by discrimination, calibration, Brier score, and decision curve analysis. Among the 744 patients who met the inclusion criteria, 385 (72.8%) patients achieved the MCID. The elastic-net penalized logistic regression model was selected as the best performing model (c-statistic 0.77, calibration intercept -0.02, calibration slope 1.15, and Brier score 0.14). The most important variables for MCID achievement were preoperative KOOS-PS score, preoperative VAS Pain, preoperative opioid use, preoperative PROMIS global mental health score, age, and sex. Algorithms were incorporated into an open-access digital application available at https://sorg-apps.shinyapps.io/tka_koos_mcid/. This study is the first to predict the probability of achieving the KOOS-PS MCID following TKA using a machine learning-based approach. The results were used to develop a clinical decision aid based on commonly collected predictive variables to preoperatively predict an individual patient's likelihood of attaining an acceptable outcome following TKA.

The German version of the High-Activity Arthroplasty Score is valid and reliable for patients after total knee arthroplasty

PURPOSE

The indications for a total knee arthroplasty (TKA) broadened to younger and more active patients. The High-Activity Arthroplasty Score (HAAS) is a self-administered instrument focussing on the wider range of functional abilities of more active patients. The HAAS was developed in English and is not available in German yet. This study aims to translate, cross-cultural adapt and assess the psychometric properties of the German HAAS in patients 12 months after primary TKA.

METHODS

After forward and backward translation, we examined the final version regarding its psychometric properties in patients 12 months after primary TKA. The HAAS was sent out to 70 patients together with routine questionnaires comprising the Knee injury and Osteoarthritis Outcome Score (KOOS), the Forgotten Joint Score (FJS-12), the EuroQol (EQ-5D-3L) and 2 numerical pain rating scales. Acceptability, reliability, responsiveness, content and construct validity as well as floor and ceiling effects were evaluated.

RESULTS

Fifty-two patients were recruited. The HAAS was well accepted with a mean time to completion of 2.4 min. Cronbach's alpha for internal consistency was 0.749, test-retest reliability was excellent with an Intraclass Correlation Coefficient (ICC) of 0.961. The smallest detectable change was 1.5. Good content validity was confirmed. A strong correlation was found between the HAAS and KOOS sport (r = 0.661) and a medium correlation for all other KOOS subscales (r = 0.324 to 0.453), the FJS-12 (r = 0.425), the EQ-5D-3L (r = 0.427) and pain (r = - 0.439 to - 0.308). The HAAS showed no floor and ceiling effects.

CONCLUSIONS

The German version of the HAAS provides good validity and reliability. It can be easily self-administered and is recommended to capture high-intensity activities in patients after TKA.

LEVEL OF EVIDENCE

Diagnostic study, Level I.

A Comparison of Clinical Outcomes and Implant Preference of Patients with Bilateral TKA: One Knee with a Patient-Specific and One Knee with an Off-the-Shelf Implant

BACKGROUND

The purpose of this retrospective study was to compare clinical outcome results, perceived function, and overall preference among patients who had undergone staged bilateral total knee arthroplasty (TKA) with a cruciate-retaining, customized implant (customized TKA, or C-TKA) in 1 knee and an off-the-shelf (OTS) implant in the contralateral knee.

METHODS

Forty-seven patients (94 knees) from a single study center who underwent C-TKA in 1 knee and had previously undergone TKA with an OTS implant in the contralateral knee were included in this study. As the primary outcome measures, the Knee injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR) and the Forgotten Joint Score (FJS) were self-administered by the study subjects at a single follow-up time point. Additionally, a follow-up questionnaire to compare patients' perceived joint stability, knee mobility, perceived feeling of the replaced joint, pain levels, and overall preference between their knees was administered.

RESULTS

The average follow-up was 2.3 years (range, 0.7 to 3.8 years) for C-TKA and 6.7 years (range, 1.6 to 11.1 years) for the OTS TKA. Significantly higher KOOS, JR (82 versus 77; p = 0.03) and FJS (68 versus 58; p = 0.04) results were found with C-TKA. The evaluation of the follow-up questionnaire showed that more patients reported having "a little" or "a lot" less pain (49% versus 15%), better perceived mobility (45% versus 12%) and stability (36% versus 13%), and a more "normal" feeling of their knee (60% versus 10%) with the C-TKA implant compared with their OTS counterpart. When patients were asked to directly compare their knees, we found that 72.3% of the patients preferred the knee that received C-TKA over the contralateral OTS knee replacement, with 21.3% seeing no difference and 6.4% preferring the OTS knee replacement.

CONCLUSIONS

We believe that this is the first study to examine patient-reported outcomes of customized and OTS TKA implant designs in the same patient. We conclude that patients in this study cohort who underwent staged bilateral TKA with a C-TKA implant in 1 knee and an OTS prosthesis in the other knee reported better for their patient-specific knee replacement, with higher FJS and KOOS, JR values, and overall, preferred the C-TKA knee more often compared with the OTS knee replacement.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preoperative predictors of health-related quality of life changes (EQ-5D and EQ VAS) after total hip and knee replacement: a systematic review

BACKGROUND

Patient-reported outcomes are of ever-increasing importance in medical decision-making. The EQ-5D is one of the generic instruments measuring health-related quality of life (HRQoL) in arthroplasty. This review aimed to identify possible predictors of HRQoL changes for patients undergoing total knee replacements (TKR) or total hip replacements (THR).

METHODS

A systematic literature review according to the PRISMA guidelines was conducted, searching several databases. Preoperative to postoperative HRQoL changes were evaluated in patients undergoing THR or TKR, using the EQ-5D visual analog scale (VAS) or the preference-based EQ-5D Index were evaluated. Articles were considered with prospectively or retrospectively collected data, as well as registry data, each with statistical analyses of patient-related factors.

RESULTS

Eight hundred eighty-two articles were found, of which 21 studies met the inclusion criteria. Predictors were distinguished in alterable and non-alterable ones. The EQ-5D Index indicated a tendency towards beneficial improvements for patients with a high body mass index (BMI) (> 40) and no significant results for the VAS. Additionally, one study found that patient education and preoperative physiotherapy appeared to enhance HRQoL. Some evidence indicated that male gender was negatively associated with changes in the VAS and the EQ-5D Index, but one study reported the opposite. Changes in VAS and EQ-5D Index were lower for older patients, whereas a higher educational level seemed to be advantageous. A high Charnley class led to deteriorating changes in VAS, although a high Kellgren Lawrence classification was positively associated with the EQ-5D Index, in a limited number of studies. For all results, clinical relevance was calculated differently and mainly reported as uncertain or small.

CONCLUSIONS

The literature on this topic was weak and offers only limited guidance. Results for alterable predictors, such as the BMI, indicated valuable improvements for highly obese patients. Further, high-quality research is required to support medical decision-making.

LEVEL OF EVIDENCE

Level IV, according to the OCEBM Levels of Evidence Working Group.

Total Knee Arthroplasty in Patients with Dementia

There are few studies evaluating total knee arthroplasty (TKA) in patients with dementia. The purpose of this study was to evaluate the rate of revision, complication, emergency department (ED) visitation, and discharge disposition in patients with dementia undergoing primary TKA. In this retrospective study, we evaluated patients from 2007 to 2017 using a national database. Ninety-day complications in patients with dementia undergoing TKA were increased risk of ED visitation and skilled nursing facility (SNF) disposition (p  ≤  0.05). Two-year complications in patients with dementia undergoing TKA were increased risk of ED visitation and SNF disposition (p  ≤  0.05). Patients with dementia undergoing TKA are at an increased risk of resource utilization.

Risk factors associated with poor pain outcomes following primary knee replacement surgery: Analysis of data from the clinical practice research datalink, hospital episode statistics and patient reported outcomes as part of the STAR research programme

OBJECTIVE

Identify risk factors for poor pain outcomes six months after primary knee replacement surgery.

METHODS

Observational cohort study on patients receiving primary knee replacement from the UK Clinical Practice Research Datalink, Hospital Episode Statistics and Patient Reported Outcomes. A wide range of variables routinely collected in primary and secondary care were identified as potential predictors of worsening or only minor improvement in pain, based on the Oxford Knee Score pain subscale. Results are presented as relative risk ratios and adjusted risk differences (ARD) by fitting a generalized linear model with a binomial error structure and log link function.

RESULTS

Information was available for 4,750 patients from 2009 to 2016, with a mean age of 69, of whom 56.1% were female. 10.4% of patients had poor pain outcomes. The strongest effects were seen for pre-operative factors: mild knee pain symptoms at the time of surgery (ARD 18.2% (95% Confidence Interval 13.6, 22.8), smoking 12.0% (95% CI:7.3, 16.6), living in the most deprived areas 5.6% (95% CI:2.3, 9.0) and obesity class II 6.3% (95% CI:3.0, 9.7). Important risk factors with more moderate effects included a history of previous knee arthroscopy surgery 4.6% (95% CI:2.5, 6.6), and use of opioids 3.4% (95% CI:1.4, 5.3) within three months after surgery. Those patients with worsening pain state change had more complications by 3 months (11.8% among those in a worse pain state vs. 2.7% with the same pain state).

CONCLUSIONS

We quantified the relative importance of individual risk factors including mild pre-operative pain, smoking, deprivation, obesity and opioid use in terms of the absolute proportions of patients achieving poor pain outcomes. These findings will support development of interventions to reduce the numbers of patients who have poor pain outcomes.

Osteotomies for lateral compartment knee osteoarthritis

Lateral compartment osteoarthritis (LCOA) is often associated with valgus deformity of the knee. The concept of correcting the alignment by performing distal femoral varus osteotomy (DFVO) to unload the lateral compartment is well accepted and it is viewed as the preferred option for young active patients due to dissatisfaction from arthroplasty under 55 years of age or if they wish to remain active. Beyond this there is no consensus on patient selection, preoperative assessment, techniques to achieve correction, end point of correction, return to work or sports post-surgery, and survivorship of osteotomy with conversion to a total knee replacement as the end point due to heterogenous, retrospective studies. Here, we review relevant literature to help patient selection, preoperative work up, techniques, and outcomes.

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

PURPOSE

To determine if preoperative physical and psychological health risk factors are influential on physical function and satisfaction scores in a cohort of relatively younger adults one year post-total knee arthroplasty.

METHODS

Sixty-five patients were recruited pre- and one year post-total knee arthroplasty. Physical (i.e., body mass index, sex, physical activity level, number of comorbidities) and psychological (i.e., depression, expectations, pain inference) health risk factors were obtained pre-total knee arthroplasty and compared to Patient-Reported Outcomes Measurement Information System physical function computerized adaptive testing and satisfaction scores one year post-total knee arthroplasty.

RESULTS

Bootstrap inclusion fraction methods were performed to compare the stability of each predictor variable prior to final regression analyzes. Poorer preoperative physical activity level (standardized regression coefficient = 0.37; p < 0.01), pain interference (standardized regression coefficient = -0.24; p = 0.03) and greater comorbidities (standardized regression coefficient = -0.27; p = 0.01) resulted in worse physical function scores one year post-total knee arthroplasty. Greater preoperative comorbidities (odds ratio = 0.63; p < 0.01) resulted in worse satisfaction scores one year post-total knee arthroplasty. No other predictor variable had any relationship on either clinical outcome (p > 0.05).

CONCLUSION

Younger adults with greater comorbidities, lower physical activity level and higher pain interference scores preoperatively reported poorer functional recovery one year post-total knee arthroplasty. Understanding how preoperative status of younger adults undergoing total knee arthroplasty may lead to better improved surgical decision making and health care delivery for this vulnerable and growing patient subgroup.Implications for RehabilitationProjections estimate total knee arthroplasty in relatively younger adults (<65 years) will make up the majority of surgical procedures performed in the United States within the next two decades, however little is known in this patient population.This study provides evidence that relatively younger adults with greater comorbidities, lower physical activity level and higher pain interference scores preoperatively result in poorer functional recovery one year post-total knee arthroplasty.The results also suggest greater comorbidities identified preoperatively have the largest influence on one year satisfaction scores in younger adults post-total knee arthroplasty.Modifiable characteristics such as improving physical activity level, incorporating pain management strategies and reducing comorbidities preoperatively or adopting into postoperative rehabilitative care may influence the postoperative physical function and satisfaction scores in relatively younger adults undergoing total knee arthroplasty.

Octogenarians Undergoing Medial Unicompartmental Knee Arthroplasty Have Similar Patient-Reported Outcomes as Their Younger Counterparts

BACKGROUND

As a procedure with lower surgical morbidity, unicompartmental knee arthroplasty (UKA) may present a practical solution for elderly patients with unicompartmental arthritis. However, few studies have analyzed the results of UKA in the extreme elderly. This study compared the functional and perioperative outcomes between octogenarians and age-appropriate controls undergoing UKA.

METHODS

Prospectively collected data of 44 patients aged ≥80 years who underwent unilateral UKA were analyzed. Each octogenarian was matched 1:3 with 132 patients aged 65-74 years using propensity scores adjusting for gender, body mass index, Charlson comorbidity index, and preoperative scores. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and Short Form-12 were collected preoperatively and 2 years postoperatively. Complications, reoperations, readmissions, and unplanned visits were recorded up to 1 year postoperatively.

RESULTS

The mean age was 70.0 ± 2.7 years in the control group and 83.0 ± 3.0 years in the octogenarian group (P < .001). The percentage of outpatient procedures was comparable (control 50.0%; octogenarian 45.5%; P = .601). With the exception of poorer Short Form-12 physical scores in octogenarians at 2 years (39.4 ± 14.1 vs 44.9 ± 9.2, P = .028), there was no difference in final postoperative scores or improvement in scores between the groups. The rate of complications, reoperations, readmissions, and emergency room visits was also similar. The five-year survivorship was 97% in the control group and 93% in the octogenarian group (P = .148).

CONCLUSION

Octogenarians undergoing UKA can experience clinical outcomes that are similar to those of their younger counterparts. The clinical trajectory outlined may help clinicians provide valuable prognostic information to elderly patients and guide preoperative counseling.

A review of trauma and orthopaedic randomised clinical trials published in high-impact general medical journals

Introduction

The recent past has seen a significant increase in the number of trauma and orthopaedic randomised clinical trials published in “the big five” general medical journals. The quality of this research has, however, not yet been established.

Methods

We therefore set out to critically appraise the quality of available literature over a 10-year period (April 2010–April 2020) through a systematic search of these 5 high-impact general medical journals (JAMA, NEJM, BMJ, Lancet and Annals). A standardised data extraction proforma was utilised to gather information regarding: trial design, sample size calculation, results, study quality and pragmatism. Quality assessment was performed using the Cochrane Risk of Bias 2 tool and the modified Delphi list. Study pragmatism was assessed using the PRECIS-2 tool.

Results

A total of 25 studies were eligible for inclusion. Over half of the included trials did not meet their sample size calculation for the primary outcome, with a similar proportion of these studies at risk of type II error for their non-significant results. There was a high degree of pragmatism according to PRECIS-2. Non-significant studies had greater pragmatism that those with statistically significant results (p < 0.001). Only 56% studies provided adequate justification for the minimum clinically important difference (MCID) in the population assessed. Overall, very few studies were deemed high quality/low risk of bias.

Conclusions

These findings highlight that there are some important methodological concerns present within the current evidence base of RCTs published in high-impact medical journals. Potential strategies that may improve future trial design are highlighted.

Level of evidence

Level 1.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00590-021-03137-3.

The Renaissance of Unicompartmental Knee Arthroplasty appears rational - A radiograph-based comparative Study on adverse Events and patient-reported Outcomes in 353 TKAs and 98 UKAs

PURPOSE

Total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) are both considered suitable for antero-medial osteoarthritis and spontaneous osteonecrosis of the knee. National registry data are consistent in showing higher revision rates for UKA. Adequately adjusted, these findings may be challenged by differences in adverse events and patient-reported outcomes, as both can have serious long-term implications. Based on preoperative radiographs, the aim was to retrospectively compare the two principle surgeries in these respects.

METHODS

All TKA procedures in 2016 in one Swedish county council were, according to certain radiograph-based consensus criteria, visually evaluated for medial UKA suitability. Then, using different regression models, they were compared with the corresponding medial UKAs performed in 2015-2017 regarding complications and patient-reported outcomes one year after surgery.

RESULTS

The UKA group showed an 82% reduced risk (OR 0.2; 95% CI 0.0-0.6) of any complications, whereas the 55% reduced risk of severe complication did not reach statistical significance (OR 0.5; 95% CI 0.1-2.1). These findings corresponded in high-volume surgeries to an absolute complication rate of 0% in the UKA group and 10% in the TKA group (p = 0.005) and to a severe complication rate of 0% and 5% respectively (p = 0.05). Though no differences were seen in any general patient-reported outcomes, the pain and function based OMERACT-OARSI responder criteria indicated in both around a 60% better chance of any response (OR 1.6 CI % 0.6-4.5) and a high response (OR 1.6; 95% CI 0.7-3.4) in the UKA group.

CONCLUSION

No differences were shown in patient-reported outcomes but a clear difference in risk of complications, favoring the UKA procedure.

Reliability and validity of the Hebrew version of the forgotten joint score for assessing the outcomes of total knee arthroplasty

Background

This prospective study aimed to assess the reliability and validity of the Hebrew version of the forgotten joint score-12 in patients undergoing total knee arthroplasty, because it is going to be used in the Hebrew-speaking populations in Israel.

Methods

The English version of forgotten joint score-12 was translated into Hebrew version by using the standard procedures and in collaboration with its authors. The consecutive patients who had undergone total knee arthroplasty in a single hospital were asked to fill out the Hebrew version of forgotten joint score-12, Oxford knee score, Short Form 12, and visual analog scale. A random subgroup of 60 patients were then asked to fill out a second Hebrew version of forgotten joint score-12 at a minimum of 2-week interval. The reliability was assessed in terms of internal consistency, test-retest reliability and split-half reliability. The validity was measured in terms of the outcomes as mentioned above.

Results

A total of 102 patients participated in the study. The Hebrew version of forgotten joint score-12 showed high reliability. The internal consistency was excellent (Cronbachs’ α = 0.943) and test-retest reliability was high (Intraclass correlation = 0.97). The forgotten joint scores were correlated with the Oxford knee score, Short Form 12, and visual analog scale (r = 0.86, r = 0.72, and r=-0.8, respectively), indicating a high validity.

Conclusions

The Hebrew version of forgotten joint score-12 has excellent reliability, excellent test-retest reliability and good validity. It can be safely used for assessing outcomes of TKA.

Is It the Surgeon, the Patient, or the Device? A Comprehensive Clinical and Radiological Evaluation of Factors Influencing Patient Satisfaction in 648 Total Knee Arthroplasties

Total knee arthroplasty (TKA) is a successful and safe surgical procedure for treating osteoarthritic knees, but despite the overall good results, some patients remain dissatisfied. The aim of this study is to evaluate the influence of patient-related and surgery-related variables in a consecutive group of patients that underwent TKA. Individuals (n = 648) who had TKA performed between 01 January 2013 and 31 December 2017 were enrolled in the study. Postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS) and Forgotten Joint score (FJS-12) were collected at a mean follow-up of 4.79 years. Patient satisfaction was assessed with a questionnaire. Determinants of satisfaction (age, sex, smoking, presence of diabetes or cardiovascular disease, pain in other joints, preoperative arthritic stage) and components of satisfaction (slope variation, mechanical axis variation, outlier final alignment, surgeon experience) were examined to identify which variables correlated with positive outcome. Correlations with septic and mechanicals failures were also evaluated. Thirteen percent of patients were unsatisfied, despite good results in KOOS, WOMAC and FJS-12 tests. Female gender, low Kellgren–Lawrence grade and the presence of back pain and pain in other joints were factors associated with poor clinical results. Poorer clinical results were also reported in younger patients. Infection rate was correlated with active smoking and mechanical failure with an outlier final alignment. Comorbidities, smoking habits and high expectations have a big influence on TKA results and on final satisfaction after surgery.

Functional Outcomes and Health-Related Quality of Life Before and After Primary Total Knee Replacement for Patients From Diverse Geographic Regions

BACKGROUND

The purpose of this study was to investigate whether patient-reported knee function and health status before and after primary total knee replacement (TKR) at an academic medical center differs among patients from diverse geographic regions.

METHODS

We assessed patient-reported outcomes (PROs) as measured by the Oxford Knee Score (OKS) and EuroQoL-5D (EQ-5D) in 2855 TKR patients at preprimary and one year postprimary TKR procedure between January 1, 2012 and June 30, 2014. We compared the demographic characteristics, response rates, and changes in OKS, EQ-5D, and EQ visual analog scale among local, regional, and national patient groups. Patient- or hospital-related predictors of the postoperative scores were identified after controlling for preoperative scores on the PRO measures.

RESULTS

Local patients had more comorbid conditions. Groups were similar in clinical outcomes such as length of stay at hospital, complication, and reoperation rates. Local, regional, and national patients had similar response rates and reported a similar level of knee function and health-related quality of life before and after TKR. Eighty nine percent had clinically important improvement on OKS, 69% on EQ-5D index, and 28% EQ visual analog scale, and there were no differences among groups in the proportions of clinically meaningful change. Better postoperative PRO scores were associated with older age, shorter hospital stay, fewer comorbidities, nonsmoking status, fewer complications, and private health insurance.

CONCLUSION

Some patient characteristics such as comorbidities were greater in the local patient cohort versus the national cohort. Nevertheless, clinical outcomes and PROs were comparable across all geographic tiers.

Effect of Patient Demographics on Minimally Important Difference of Ankle Osteoarthritis Scale Among End-Stage Ankle Arthritis Patients

BACKGROUND

Ankle replacement and ankle arthrodesis are standard treatments for treating end-stage ankle arthritis when conservative treatment fails. Comparing patient-reported outcome scores to the instrument's minimal important difference (MID) helps physicians and researchers infer whether a meaningful change in health from the patient's perspective has occurred following treatment. The objective of this study was to estimate the MID of the Ankle Osteoarthritis Scale among a cohort of operatively treated end-stage ankle arthritis patients undergoing ankle replacement or arthrodesis.

METHODS

A survey package including the Ankle Osteoarthritis Scale was completed by participants preoperatively and 2 years postoperatively. Distribution and anchor-based approaches to calculating the MID were used to estimate the MID of the Ankle Osteoarthritis Scale and its 2 domains. The distribution-based approaches used were the small and medium effect size methods, while the mean absolute change method and linear regression method were the anchor-based approaches. Bootstrap sampling was used to obtain the variance of MID estimates. The MID was estimated for sex, age, operative, and baseline health subgroups. The cohort comprised 283 participants, totaling 298 ankles.

RESULTS

The MID did not vary with sex or operative procedure. Age-based differences in MID values may exist for the Ankle Osteoarthritis Scale total score, and MID values were generally smallest among the oldest patients. Patients with the best and worst ankle-related health preoperatively had higher MID values than patients reporting mid-range Ankle Osteoarthritis Scale values preoperatively.

CONCLUSION

The best estimate of the MID of the Ankle Osteoarthritis Scale total score is 5.81. Our findings indicate that the MID of the Ankle Osteoarthritis Scale may not vary by sex or operative subgroups but likely varies by age and preoperative Ankle Osteoarthritis Scale score.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Knee replacement outcome predicted by physiotherapists: a prospective cohort study

Background

Knee arthroplasty (KA) is commonly used for osteoarthritis of the knee joint and it is a highly successful procedure. Still, KA leaves 20% of patients dissatisfied with their outcome. The purpose of this study was to determine if a prognosis made by physiotherapists at the orthopaedic wards during the first post-operative days could predict the 6- and 12-months outcome of KA.

Methods

Physiotherapists at two orthopaedic wards in Denmark were asked to predict the 6- and 12-months outcome of the KA patients they have treated post-operatively on a 0–10 scale (10 representing the best prognosis). At 6 and 12 months post-operatively the patients answered the Oxford Knee Score (OKS), EuroQol 5D-3L and Patient Acceptable Symptom State (PASS). Multivariable logistic regression analyses were performed to assess the prediction of PASS and treatment success. We assessed predictive performance by examining measures of calibration and discrimination.

Results

A total of 361 patients were included. The models for PASS and Treatment Success showed poor to acceptable discriminative values (OR between 1.47 and 1.92 and areas under the curves of 0.62–0.73), however the calibration plots indicated significant uncertainties in the prediction.

Conclusion

Physiotherapists prognoses of recovery after KA are associated with 6- and 12-months patient reported outcomes and satisfaction but have weak predictive value. This study suggests that physiotherapists’ prognoses may be useful as an additional source of information when identifying patients in need of additional post-operative care.

Outcomes and Risk Factors Associated With 2-Stage Reimplantation Requiring an Interim Spacer Exchange for Periprosthetic Joint Infection

BACKGROUND

Patients undergoing a 2-stage revision for periprosthetic joint infection (PJI) often require a repeat spacer in the interim due to persistent infection. This study aims to report outcomes for patients with repeat spacer exchange and to identify risk factors associated with interim spacer exchange in 2-stage revision arthroplasty.

METHODS

A total of 256 consecutive 2-stage revisions for chronic infection of total hip arthroplasty and total knee arthroplasty with reimplantation and minimum 2-year follow-up were investigated. An interim spacer exchange was performed in 49 patients (exchange cohort), and these patients were propensity score matched to 196 patients (nonexchange cohort). Multivariate analysis was performed to analyze risk factors for failure of interim spacer exchange.

RESULTS

Patients in the propensity score-matched exchange cohort demonstrated a significantly increased reinfection risk compared to patients without interim spacer exchange (24% vs 15%, P = .03). Patients in the propensity score-matched exchange cohort showed significantly lower postoperative scores for 3 patient-reported outcome measures (PROMs): hip disability and osteoarthritis outcome score physical function (46.0 vs 54.9, P = .01); knee disability and osteoarthritis outcome score physical function (43.1 vs 51.7, P < .01); and patient-reported outcomes measurement information system physical function short form (41.6 vs 47.0, P = .03). Multivariate analysis demonstrated Charles Comorbidity Index (odds ratio, 1.56; P = .01) and the presence of Enterococcus species (odds ratio, 1.43; P = .03) as independent risk factors associated with 2-stage reimplantation requiring an interim spacer exchange for periprosthetic joint infection.

CONCLUSION

This study demonstrates that patients with spacer exchange had a significantly higher risk of reinfection at 2 years of follow-up. Additionally, patients with spacer exchange demonstrated lower postoperative PROM scores and diminished improvement in multiple PROM scores after reimplantation, indicating that an interim spacer exchange in 2-stage revision is associated with worse patient outcomes.

Differences in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Scores for a Single Surgeon Comparing Two Institutions: An Unfair Reimbursement Metric

BACKGROUND

Emphasis on value-based purchasing links physician financial remuneration to patient-derived outcome scores. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys aim to provide a uniform comparison tool. Of the 22 different survey questions, only 3 (13.6%) focus on experience related to doctors. We sought to determine how HCAHPS scores differ for a single surgeon performing more than 500 total joint arthroplasties annually, divided almost equally between two centers.

METHODS

HCAHPS data from 2015 to 2018 for a single, fellowship-trained arthroplasty surgeon were collected from two different hospitals. More than 200 cases were performed at each center with the same staff. One center is a large metropolitan academic-teaching hospital, and the other is a suburban private hospital. The purpose of the study was to determine if differences existed regarding HCHAPS scores between the two institutions.

RESULTS

A significant difference was found between institutions regarding questions pertaining to "hospital environment," "admission process," and "hospital staff concern for pain," with more patients responding favorably in Institution Two than Institution One.

CONCLUSION

Patient perceptions and ratings of overall experience differ significantly between hospitals even when surgery is performed by a single surgeon. These results lend credence to the fact that surgeons should not be unduly penalized for the hospital in which they operate, and financial remuneration involving HCAHPS scores must be approached with caution. This unfair system could potentially drive surgeons to perform the majority of their cases in the hospital system with higher scores in the nonphysician related domains as this would affect overall patient satisfaction, and thus, financial compensation.

Return to Work After Distal Femoral Varus Osteotomy

Background

Distal femoral varus osteotomy (DFVO) is a well-described procedure to address valgus deformity of the knee. There is a paucity of information available regarding patients' ability to return to work (RTW) after DFVO.

Purpose

To report the objective findings for RTW rates and times for patients receiving a DFVO for lateral compartment osteoarthritis secondary to valgus deformity of the knee.

Study Design

Cohort study; Level of evidence, 3.

Methods

This was a retrospective study of patients who received a lateral-wedge opening DFVO. Patients must have worked within 3 years before their operation to be included for analysis. Patients were contacted at a minimum of 2 years postoperatively for interview and questionnaire evaluation, including a subjective work questionnaire, visual analog scale (VAS) for pain, Single Assessment Numerical Evaluation (SANE), and a satisfaction questionnaire.

Results

Overall, 32 patients were contacted at a mean follow-up of 7.1 ± 4.1 years (range, 2.2-13.3 years). The mean ± SD age at the time of surgery was 30.8 ± 8.8 years (range, 17.2-46.5 years), and 65.6% of patients were female. Eleven patients (34.4%) received a concomitant meniscal allograft transplant, and 12 (37.5%) received a cartilage grafting procedure. The average VAS pain score decreased significantly from 6.1 preoperatively to 3.2 postoperatively (P = .03). All patients were able to RTW, at a mean time of 6.0 ± 13.2 months postoperatively (range, 0-72 months). When stratified by work intensity, the average time to return was 13.8, 3.1, 2.7, and 2.9 months for high, moderate, light, and sedentary occupations, respectively. There was no significant difference between these RTW times (P = .16), although this analysis may have been limited by the small sample size. Four patients whose work was classified as heavy work (50%) and 3 whose work was classified as moderate work (18.8%) either switched jobs or kept the same job with lighter physical duties as a result of their procedures.

Conclusion

In a young and active population, DFVO for valgus deformity reliably afforded the ability to RTW within a relatively short time for patients with sedentary, light, and moderate occupational demands. However, patients with moderate- to high-intensity occupational demands may be unable to RTW at their preoperative level.

Is there an optimal age for total knee arthroplasty?: A systematic review

PURPOSE

The purpose of this systematic review was to elucidate the optimal age for patients undergoing total knee arthroplasty (TKA), to optimize the balance between the benefits and risks by analyzing patient-reported outcome measurements (PROM), revision rate, and mortality according to age.

MATERIALS AND METHODS

A rigorous and systematic approach was used and each of the selected studies was evaluated for methodological quality. Data were extracted according to the following: study design, patients enrolled, patient age at the time of surgery, follow-up period, PROM, revision rate, and mortality.

RESULTS

Thirty-nine articles were included in the final analysis. The results were inconsistent in the PROM analysis, but there was consensus that PROM were good in patients in their 70s . In the revision rate analysis, there was consensus that the revision rate tends to increase in TKA in younger patients, but no significant difference was observed in patients > 70 years of age. In the mortality analysis, there was consensus that the mortality was not significantly different in patients < 80 years of age, but tended to increase with age.

CONCLUSION

This systematic review shows that the PROM were good when TKA was performed in patients between 70 and 80 years of age; the best PROM could be achieved around 70 years of age, and no significant difference in the revision or mortality rates was observed between 70 and 80 years of age; however, mortality tended to increase with age. Therefore, the early 70s could be recommended as an optimal age to undergo TKA.

The Cost-Effectiveness of Platelet-Rich Plasma Injections for Knee Osteoarthritis: A Markov Decision Analysis

BACKGROUND

Use of platelet-rich-plasma (PRP) injections for treating knee osteoarthritis has increased over the past decade. We used cost-effectiveness analysis to evaluate the value of PRP in delaying the need for total knee arthroplasty (TKA).

METHODS

We developed a Markov model to analyze the baseline case: a 55-year-old patient with Kellgren-Lawrence grade-II or III knee osteoarthritis undergoing a series of 3 PRP injections with a 1-year delay to TKA versus a TKA from the outset. Both health-care payer and societal perspectives were included. Transition probabilities were derived from systematic review of 72 studies, quality-of-life (QOL) values from the Tufts University Cost-Effectiveness Analysis Registry, and individual costs from Medicare reimbursement schedules. Primary outcome measures were total costs and quality-adjusted life years (QALYs), organized into incremental cost-effectiveness ratios (ICERs) and evaluated against willingness-to-pay thresholds of $50,000 and $100,000. One and 2-way sensitivity analyses were performed as well as a probabilistic analysis varying PRP-injection cost, TKA delay intervals, and TKA outcomes over 10,000 different simulations.

RESULTS

From a health-care payer perspective, PRP resulted in 14.55 QALYs compared with 14.63 for TKA from the outset, with total health-care costs of $26,619 and $26,235, respectively. TKA from the outset produced a higher number of QALYs at a lower cost, so it dominated. From a societal perspective, PRP cost $49,090 versus $49,424 for TKA from the outset. The ICER for TKA from the outset was $4,175 per QALY, below the $50,000 willingness-to-pay threshold. Assuming the $728 published cost of a PRP injection, no delay time that was <10 years produced a cost-effective course. When the QOL value was increased from the published value of 0.788 to >0.89, PRP therapy was cost-effective with even a 1-year delay to TKA.

CONCLUSIONS

When considering direct and unpaid indirect costs, PRP injections are not cost-effective. The primary factor preventing PRP from being cost-effective is not the price per injection but rather a lack of established clinical efficacy in relieving pain and improving function and in delaying TKA. PRP may have value for higher-risk patients with high perioperative complication rates, higher TKA revision rates, or poorer postoperative outcomes.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does Age Influence Patient-Reported Outcomes in Unilateral Primary Total Hip and Knee Arthroplasty?

BACKGROUND

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are used to treat patients with end-stage arthritis. Previous studies have not demonstrated a consistent relationship between age and patient-reported outcomes. The purpose of this study is to assess the impact of age on patient-reported outcomes after unilateral primary THA or TKA.

METHODS

A retrospective review of available data in Alberta Bone and Joint Health Institute (ABJHI) Data Repository was performed. We identified 53,498 unilateral primary THA and TKA between April 2011 and 2017. Patients were divided by age into 3 categories: <55, 55-70, and >70. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and EuroQoL 5-dimension (EQ-5D) Canada scores were obtained at presurgery, 3 and 12 months postoperatively.

RESULTS

For TKA, younger patients had larger improvements in WOMAC scores at 3 and 12 months (P = <.001-.033), and in EQ-5D scores at 3 months (P < .001). When adjusted, patients <55 had lower WOMAC and EQ-5D scores at 3 months postoperatively compared to those 55-70 or >70 (all P < .01). Outcomes at 12 months did not differ between age-groups. For THA, younger patients had larger improvements in WOMAC at 3 months (P = .03). When adjusted, patients <55 had higher WOMAC scores at 12 months postoperatively compared to those 55-70 or >70, and higher EQ-5D scores compared to those 55-70 (all P < .05).

CONCLUSION

While a multitude of factors go in to quantifying successful THA or TKA, this study suggests that patient age should not be a deterrent when considering the impact of age on patient-reported outcomes.

Can Octogenarians Undergoing Total Knee Arthroplasty Experience Similar Functional Outcomes, Quality of Life, and Satisfaction Rates as Their Younger Counterparts? A Propensity Score Matched Analysis of 1188 Patients

BACKGROUND

Current literature lacks consensus regarding the impact of advanced age on the clinical outcomes of total knee arthroplasty (TKA). Moreover, there is paucity of literature on the subjective benefit reported by elderly patients. We compared the functional outcomes, quality of life, and satisfaction rates between octogenarians and age-appropriate controls undergoing primary TKA with a minimum follow-up of 2 years.

METHODS

Prospectively collected registry data of 594 patients aged ≥80 years (n = 594) and a propensity score matched cohort of 594 patients aged 65-74 years who underwent primary TKA at a single institution were reviewed. The range of motion, clinical outcome scores, and satisfaction rates were assessed at 6 months and 2 years. Revision rates were also recorded.

RESULTS

Octogenarians had a significantly lower Knee Society Function Score, Oxford Knee Score, and SF-36 Physical Component Summary at 6 months and 2 years (P < .05 for each). Furthermore, a lower proportion of octogenarians achieved the minimal clinically important difference for each score (P < .05 for each). Although the rates were similar at 6 months (P = .853), octogenarians were less satisfied at 2 years compared to age-appropriate controls (89.3% vs 93.3%, P = .042), and there was a trend toward poorer expectation fulfillment (88.4% vs 92.1%, P = .062).

CONCLUSION

Octogenarians undergoing TKA had a relatively lower rate of satisfaction and clinically meaningful improvement compared to younger controls. Nevertheless, elderly patients still experienced a successful outcome after surgery. The clinical trajectory outlined may help clinicians provide valuable prognostic information to elderly patients and guide preoperative counseling.

How well do elderly patients do after total knee arthroplasty in the era of fast-track surgery?

Introduction

Total knee arthroplasty (TKA) in the elderly population is becoming increasingly prevalent. This study aimed to compare outcomes of patients aged ≥80 years with those aged < 80 years at time of TKA and to assess the effect of fast track peri-operative care on outcomes in the elderly.

Materials and methods

422 TKAs were performed in aged ≥80 at the time of surgery between 2009 and 2018. A control group aged < 80 years (37–79 +/− 7.6) was established. Peri-operative mortality, complications, 30-day re-admission, length of stay (LOS) and rehabilitation parameters were recorded.

Results

Mean age at operation for the ≥80’s group and control group was 82.7 (80–93+/− 2.5) and 69.3 (37–79+/− 7.6) years respectively. Post-operative Knee Society Functional Assessment (KSFA) scores were higher in the control group (49 vs. 57, p = 0.003). Average LOS was longer in the ≥80’s group (17.2 vs. 12.4 days respectively, p < 0.01). Mortality within 3 months of operation was 0.7% in the ≥80 group and 0% in the control group. Incidence of complications was comparable between the two groups at 12.8 and 12.9% for the group ≥80’s and control groups respectively (p = 0.962). Patients ≥80 years, receiving fast track peri-operative care had significantly shorter LOS and higher post-operative KSFA scores at all time points post-operation and shorter LOS (p < 0.01) compared to those who received conventional rehabilitation. LOS was longer in the ≥80’s group, which was likely related to higher levels of comorbidities. Complications were comparable in the two groups but were more severe in the elderly. Mortality rate after TKA was very low even in those over the age of 80. Younger patients benefited more in terms of functional improvement after TKA.

Conclusion

TKA is a safe and efficacious procedure for the elderly. More severe complications, longer length of stay and smaller gains in functional improvement can be expected in the elderly compared to younger patients. Fast track peri-operative care is useful in improving outcomes after TKA for elderly patients.

Reduction in patient outcomes but implant-derived preservation of function following total knee arthroplasty: longitudinal follow-up of a randomized controlled trial

AIMS

There are comparatively few randomized studies evaluating knee arthroplasty prostheses, and fewer still that report longer-term functional outcomes. The aim of this study was to evaluate mid-term outcomes of an existing implant trial cohort to document changing patient function over time following total knee arthroplasty using longitudinal analytical techniques and to determine whether implant design chosen at time of surgery influenced these outcomes.

METHODS

A mid-term follow-up of the remaining 125 patients from a randomized cohort of total knee arthroplasty patients (initially comprising 212 recruited patients), comparing modern (Triathlon) and traditional (Kinemax) prostheses was undertaken. Functional outcomes were assessed with the Oxford Knee Score (OKS), knee range of movement, pain numerical rating scales, lower limb power output, timed functional assessment battery, and satisfaction survey. Data were linked to earlier assessment timepoints, and analyzed by repeated measures analysis of variance (ANOVA) mixed models, incorporating longitudinal change over all assessment timepoints.

RESULTS

The mean follow-up of the 125 patients was 8.12 years (7.3 to 9.4). There was a reduction in all assessment parameters relative to earlier assessments. Longitudinal models highlight changes over time in all parameters and demonstrate large effect sizes. Significant between-group differences were seen in measures of knee flexion (medium-effect size), lower limb power output (large-effect size), and report of worst daily pain experienced (large-effect size) favouring the Triathlon group. No longitudinal between-group differences were observed in mean OKS, average daily pain report, or timed performance test. Satisfaction with outcome in surviving patients at eight years was 90.5% (57/63) in the Triathlon group and 82.8% (48/58) in the Kinemax group, with no statistical difference between groups (p = 0.321).

CONCLUSION

At a mean 8.12 years, this mid-term follow-up of a randomized controlled trial cohort highlights a general reduction in measures of patient function with patient age and follow-up duration, and a comparative preservation of function based on implant received at time of surgery. Cite this article: Bone Joint J 2020;102-B(4):434-441.

Individual Gait Features Are Associated with Clinical Improvement After Total Knee Arthroplasty

BACKGROUND

Over 20% of patients do not report clinically relevant pain relief or functional improvements after total knee arthroplasty (TKA). The aim of this study was to investigate the effect of demographics, pre-TKA knee-joint biomechanics, and postoperative changes in knee biomechanics on meaningful improvements in self-reported pain and function after TKA.

METHODS

Forty-six patients underwent 3-dimensional gait analysis and completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire before and 1 year after TKA. Response to treatment in terms of pain relief and functional improvement ("pain and function responders") was defined as improvements in WOMAC scores that met minimal clinically important difference thresholds in the pain and function domains. Differences between responder and non-responder demographics, severity of the osteoarthritis as seen radiographically, and knee kinematics and kinetics before TKA were explored using the t test and Mann-Whitney U test. Correlations and regression models were used to examine demographics, baseline knee kinematics and kinetics, and post-TKA kinematic and kinetic improvements associated with being a pain responder and a function responder separately. Analyses were conducted using a hypothesis-driving approach.

RESULTS

Of the 46 patients, 34 were pain responders and 36 were function responders. Preoperatively, both responder groups had a higher radiographic severity (Kellgren-Lawrence) grade (p = 0.03) and pain responders were more symptomatic according to their WOMAC score (p < 0.04). Less preoperative stance-phase flexion-extension angle range (p ≤ 0.03), lower preoperative stance-phase adduction (varus) angle magnitude (p = 0.01), and less postoperative reduction in the adduction angle magnitude (p ≤ 0.009) were independently associated with more self-reported improvement in pain and function.

CONCLUSIONS

Patients with a higher radiographic severity grade, with specific frontal and sagittal knee kinematic patterns during gait before TKA, and who demonstrated less reduction in frontal plane angles during gait after TKA had greater self-reported pain and function score improvements after standard TKA. Gait analysis may aid preoperative identification of kinematic subgroups associated with self-reported improvements after TKA, and provide evidence that may inform triaging, surgical planning, and expectation management strategies.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Translation, cross-cultural adaptation, and validation of the Italian language Forgotten Joint Score-12 (FJS-12) as an outcome measure for total knee arthroplasty in an Italian population

Background

With ever-increasing numbers of patients undergoing elective total knee arthroplasty (TKA) and as TKA is performed in increasingly younger patients, patient demands and expectations have also increased. With improved patient outcomes, new PROMs with heightened discriminatory power in well-performing patients are needed. The present study aimed to translate and validate the Italian version of the Forgotten Joint Score (FJS-12) as a tool for evaluating pre-operative through longitudinal post-operative outcomes in an Italian population.

Methods

In this prospective study, patients with unilateral osteoarthritis, undergoing TKA surgery between May 2015 and December 2017 were recruited to participate in the study. The FJS-12 and WOMAC were collected pre-operatively and at six and 12 months post-operatively. According to the COSMIN checklist, reliability, internal consistency, validity, responsiveness, effect size, and ceiling effects and floor effects were evaluated.

Results

One hundred twenty patients completed the study, 66 of which participated in the evaluation of test-retest reliability. Good test-retest reliability was found (ICC = 0.90). The FJS-12 also showed excellent internal consistency (Cronbach α = 0.81). Construct validity with the WOMAC, as a measure of the Pearson correlation coefficient, was moderate (r = 0.45 pre-operatively; r = 0.46 at 6 months and r = 0.42 at 12 months post-operatively). From six to 12 months, the change was slightly greater for the WOMAC than for the FJS-12 patients (effect size d = 0.94; d = 0.75, respectively). At 12-months follow-up, the ceiling effects reflecting the maximum score were 12% for the FJS-12 and 6% for the WOMAC; however, scores within 10% of the maximum score were comprised 30% of the FJS-12 scores and 59% for the WOMAC.

Conclusion

The Italian FJS-12 demonstrated strong measurement properties in terms of reliability, internal consistency, and construct validity in TKA patients. Furthermore, a more detailed look at ceiling effects shows a superior discriminatory capacity when compared to the WOMAC at 12-months follow-up, particularly in better-performing patients.

Trial registration

clinicaltrials.gov NCT03805490. Registered 18 January 2019 (retrospectively registered).

Global management of patients with knee osteoarthritis begins with quality of life assessment: a systematic review

Background

Knee osteoarthritis (KOA) is a prevalent form of chronic joint disease associated with functional restrictions and pain. Activity limitations negatively impact social connectedness and psychological well-being, reducing the quality of life (QoL) of patients. The purpose of this review is to summarize the existing information on QoL in KOA patients and share the reported individual factors, which may influence it.

Methods

We conducted a systematic review examining the literature up to JAN/2017 available at MEDLINE, EMBASE, Cochrane, and PsycINFO using KOA and QOL related keywords. Inclusion criteria were QOL compared to at least one demographic factor (e.g., age, gender), lifestyle factor (e.g., functional independence), or comorbidity factor (e.g., diabetes, obesity) and a control group. Analytical methods were not considered as part of the original design.

Results

A total of 610 articles were reviewed, of which 62 met inclusion criteria. Instruments used to measure QoL included: SF-36, EQ-5D, KOOS, WHOQOL, HAS, AIMS, NHP and JKOM. All studies reported worse QoL in KOA patients when compared to a control group. When females were compared to males, females reported worse QOL. Obesity as well as lower level of physical activity were reported with lower QoL scores. Knee self-management programs delivered by healthcare professionals improved QoL in patients with KOA. Educational level and higher total mindfulness were reported to improve QoL whereas poverty, psychological distress, depression and lacking familial relationships reduce it. Surgical KOA interventions resulted in good to excellent outcomes generally; although, results varied by age, weight, and depression.

Conclusion

KOA has a substantial impact on QoL. In KOA patients, QoL is also influenced by specific individual factors including gender, body weight, physical activity, mental health, and education. Importantly, education and management programs designed to support KOA patients report improved QoL. QoL data is a valuable tool providing health care professionals with a better comprehension of KOA disease to aid implementation of the most effective management plan.

Younger age is associated with increased odds of manipulation under anesthesia for joint stiffness after total knee arthroplasty

INTRODUCTION

Limited range of motion (ROM) after total knee replacement (TKR) is associated with low function and might require manipulation under anaesthesia (MUA). In order to identify factors associated with a limited ROM we investigated predictors for MUA. We hypothesized that older age was associated with higher MUA due to limited ROM post TKR.

METHODS

In a case control study we investigated all patients undergoing primary TKR at a University Hospital in Sweden between 2007-2012. We registered background factors and compared those between the group who underwent MUA and those who did not. Odds ratios (OR) were calculated in a univariate analysis and an adjusted regression analysis.

RESULTS

Of the total of 669 TKRs performed, 31 patients who had undergone MUA were identified. The prevalence of MUA was 4.6%. The mean increase in ROM after MUA was 27 degrees at final minimum one-year follow-up. After controlling for confounders, patients with good health and young age had increased OR for MUA. OR decreased 0.93 (CI 0.93-0.97) per increased age year in the multiple regression analysis. Diabetes mellitus, BMI and sex did not have a significant effect on the odds ratio for MUA.

DISCUSSION

Young patients undergoing TKR has earlier been identified as a group with a higher grade of dissatisfaction and complications. We found an association between young age and MUA after TKR indicating an additional, rather unknown complication for this group of patients. The background and reasons for this has to be further investigated.

LEVEL OF EVIDENCE

II, cohort study/case control study (case control is level III).

Despite Improved Survivorship of Uncemented Fixation in Total Knee Arthroplasty for Osteoarthritis, Cemented Fixation Remains the Gold Standard: An Analysis of a National Joint Registry

BACKGROUND

Total knee arthroplasty (TKA) numbers are increasing worldwide. While cement fixation for both femoral and tibial components is commonly used, alternatives include hybrid and uncemented TKAs. This study aimed to evaluate survivorship, revision rates, and patient-reported outcomes for cemented, hybrid, and uncemented TKAs using New Zealand Joint Registry (NZJR) data.

METHODS

NZJR data relating to all TKAs performed during the 19 years up to the end of December 2017 were analyzed. Outcomes were assessed using prosthesis survivorship data (including reasons for revision) and Oxford scores at 6 months, 5 years, and 10 years postoperatively.

RESULTS

A total 96,519 primary TKAs were performed during the period examined. Most (91.5%) were fully cemented with 4.8% hybrid and 3.7% uncemented. Mean Oxford scores at 6 months were highest in cemented and lowest in uncemented TKAs (P < .001). However, this was not clinically significant. There was no difference at 5 or 10 years. Ten-year survival rates were 97%, 94.5%, and 95.8% for cemented, uncemented, and hybrid TKAs, respectively. Revision rates were 0.47, 0.74, and 0.52 per 100 component years for cemented, uncemented, and hybrid prostheses, respectively. The revision rate for uncemented prostheses compared with cemented was higher (P < .001). When stratified by age group, there were differences in survival rates between cemented and uncemented groups (P = .001) and hybrid and uncemented groups (P = .038) in patients aged <55 years; between cemented and uncemented groups in those aged 55-64 years (P = .031); and between cemented and hybrid groups in those aged >75 years (P = .004).

CONCLUSION

Uncemented TKAs had similar patient-reported outcomes but higher revision rates and worse survivorship compared with hybrid or fully cemented TKAs.

Increasing Public Interest in Stem Cell Injections for Osteoarthritis of the Hip and Knee: A Google Trends Analysis

BACKGROUND

Stem cell injections are being offered to patients as a nonoperative treatment for osteoarthritis of the hip and knee. To our knowledge, no peer-reviewed data exist to document the usage frequency of these injections nor to quantify the public interest in these injections. We sought to use Google Trends to provide a quantitative analysis of interest in hip and knee stem cell injections at the population level.

METHODS

Google Trends search parameters were set to obtain query data from January 2010 through December 2017. 'Arthritis,' 'osteoarthritis,' 'stem cell,' 'injection,' 'knee,' and 'hip' were entered in various combinations to obtain the highest yield search volume. Trend analyses were performed.

RESULTS

Six linear models were generated to show trends in the volume of searches for the United States and the World. Model fit was good, and regression analysis showed significant trends over time for all searches. Use of search terms increased significantly over time (all models P < .001). Adjusted R-square values ranged from 54.4% to 78.1%. All trends showed an upward trajectory for the entirety of the study time period.

CONCLUSION

There has been a marked and statistically significant rise in search query volume related to stem cells and osteoarthritis of the hip and knee since 2010. Online interest in stem cell injections may suggest increased utilization of these procedures. Well-designed clinical studies are required to keep pace with the rising popularity and public interest in this intervention for hip and knee arthritis.