The use of patient-reported outcomes after routine arthroplasty: beyond the whys and ifs

No differences in mid-term survival and clinical outcome between CT- and MRI-based patient-specific instrumentation for total knee arthroplasty, a randomized controlled trial

PURPOSE

The purpose of this prospective randomized controlled trial was to compare the clinical outcome and the survival rate of total knee arthroplasty between CT- and MRI-based patient-specific instrumentation 5 years after initial surgery.

METHODS

At a mean follow-up of 5.8 years (SD 0.3), 98 patients (64% women, loss to follow-up 28%) were included in this analysis. To assess the differences in clinical outcome, patients fulfilled PROMs preoperatively and at each follow-up moment. At final follow-up, the Forgotten Joint Score was adjusted.

RESULTS

At final follow-up, no new patients underwent revision surgery in both groups. Regarding the clinical outcome, no statistically significant difference between the groups was found. The Forgotten Joint Score was only performed at final follow-up and showed no significant difference between both groups.

CONCLUSION

At mid-term follow-up, survival rates between CT- and MRI-based patient-specific instrumentation did not show a significant difference. Regarding clinical outcome, only the EQ-5D-VAS (p < 0.040) showed a statistically significant difference over time, in favor of the MRI-group.

LEVEL OF EVIDENCE

Level I.

Reliability and validity of commonly used patient-reported outcome measures (PROMs) after medial unicompartmental knee arthroplasty

INTRODUCTION

Many patient-reported outcome measures (PROMs) have been utilized to assess outcomes after unicompartmental knee arthroplasty (UKA). However, most are not specifically designed for UKA and the measurement properties of these PROMs have never been elucidated in the setting of UKA. This study aimed to evaluate the reliability and validity of commonly used PROMs after UKA, which includes the Oxford knee score (OKS), Knee Society Score (KSS)-function score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee Injury and Osteoarthritis Outcome Score (KOOS).

HYPOTHESIS

The four commonly used PROMs after UKA are of good reliability and validity, but with different floor/ceiling effect.

MATERIAL AND METHODS

Prospectively collected postoperative follow-up PROMs scores of patients after medial UKA cases for osteoarthritis between May 2015 and June 2018 were retrospectively analyzed. All of the PROMs were finished on the same electronic questionnaires. Reliability (internal consistency, test-retest reliability, measurement error), construct validity and floor/ceiling effects were assessed.

RESULTS

The whole cohort was composed of 207 cases, with a median age of 62.0 years and a male ratio of 59/207 (28.50%). Internal consistency was high in the OKS, weak in the KSS-function score and with redundancy in the WOMAC and KOOS scores (Cronbach alpha=0.915, 0.610, 0.953, 0.961, respectively). Each of the four PROMs had a high test-retest reliability (all intraclass correlation coefficient (ICC) >0.97). Convergent validity of the four PROMs with the physical component score of the 12-Item Short Form Health Survey (SF-12 PCS) were proven (all r>0.5; p<0.001). While no ceiling effect occurred in the OKS, one was detected in the KSS-function score with 19.81% of patients achieving the best possible score, as well as in the WOMAC sub-score for pain (54.11%) and stiffness (50.72%), in addition to the KOOS sub-score for symptoms (27.54%) and pain (38.16%).

DISCUSSION

The four commonly used PROMs after UKA showed good test-retest reliability and construct validity. The OKS is more recommended for its better performance in internal consistency and ceiling effect than the KSS-function score, the WOMAC and KOOS scores.

LEVEL OF EVIDENCE

III; Diagnostic study.

Improving multimorbidity measurement using individualized disease-specific quality of life impact assessments: predictive validity of a new comorbidity index

BACKGROUND

Interpretation of health-related quality of life (QOL) outcomes requires improved methods to control for the effects of multiple chronic conditions (MCC). This study systematically compared legacy and improved method effects of aggregating MCC on the accuracy of predictions of QOL outcomes.

METHODS

Online surveys administered generic physical (PCS) and mental (MCS) QOL outcome measures, the Charlson Comorbidity Index (CCI), an expanded chronic condition checklist (CCC), and individualized QOL Disease-specific Impact Scale (QDIS) ratings in a developmental sample (N = 5490) of US adults. Controlling for sociodemographic variables, regression models compared 12- and 35-condition checklists, mortality vs. population QOL-weighting, and population vs. individualized QOL weighting methods. Analyses were cross-validated in an independent sample (N = 1220) representing the adult general population. Models compared estimates of variance explained (adjusted R2) and model fit (AIC) for generic PCS and MCS across aggregation methods at baseline and nine-month follow-up.

RESULTS

In comparison with sociodemographic-only regression models (MCS R2 = 0.08, PCS = 0.09) and Charlson CCI models (MCS R2 = 0.12, PCS = 0.16), increased variance was accounted for using the 35-item CCC (MCS R2 = 0.22, PCS = 0.31), population MCS/PCS QOL weighting (R2 = 0.31-0.38, respectively) and individualized QDIS weighting (R2 = 0.33 & 0.42). Model R2 and fit were replicated upon cross-validation.

CONCLUSIONS

Physical and mental outcomes were more accurately predicted using an expanded MCC checklist, population QOL rather than mortality CCI weighting, and individualized rather than population QOL weighting for each reported condition. The 3-min combination of CCC and QDIS ratings (QDIS-MCC) warrant further testing for purposes of predicting and interpreting QOL outcomes affected by MCC.

Impact of enhanced recovery pathways on safety and efficacy of hip and knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Over the past decades, clinical pathways (CPs) for hip and knee arthroplasty have been strongly and continuously evolved based on scientific evidence and innovation.

AIM

The present systematic review, including meta-analysis, aimed to compare the safety and efficacy of enhanced recovery pathways (ERP) with regular pathways for patients with hip and/or knee arthroplasty.

METHODS

A literature search in healthcare databases (Embase, PubMed, Cochrane Library, CINAHL, and Web of Science) was conducted from inception up to June 2018. Relevant randomized controlled trials as well as observational studies comparing ERP, based on novel evidence, with regular or standard pathways, prescribing care as usual for hip and/or knee arthroplasty, were included. The effect of both CPs was assessed for (serious) adverse events [(S)AEs], readmission rate, length of hospital stay (LoS), clinician-derived clinical outcomes, patient reported outcome measures (PROMs), and financial benefits. If possible, a meta-analysis was performed. In case of considerable heterogeneity among studies, a qualitative analysis was performed.

RESULTS

Forty studies were eligible for data extraction, 34 in meta-analysis and 40 in qualitative analysis. The total sample size consisted of more than 2 million patients undergoing hip or knee arthroplasty, with a mean age of 66 years and with 60% of females. The methodological quality of the included studies ranged from average to good. The ERP had lower (S)AEs [relative risk (RR): 0.9, 95% confidence interval (CI): 0.8-1] and readmission rates (RR: 0.8, 95%CI: 0.7-1), and reduced LoS [median days 6.5 (0.3-9.5)], and showed similar or improved outcomes for functional recovery and PROMs compared to regular pathways. The analyses for readmission presented a statistically significant difference in the enhanced recovery pathway in favor of knee arthroplasties (P = 0.01). ERP were reported to be cost effective, and the cost reduction varied largely between studies (€109 and $20573). The overall outcomes of all studies reported using Grading of Recommendation, Assessment, Development and Evaluation, presented moderate or high quality of evidence.

CONCLUSION

This study showed that implementation of ERP resulted in improved clinical and patient related outcomes compared to regular pathways in hip and knee arthroplasty, with a potential reduction of costs.

Only limited correlations between patient-reported outcomes and objectively monitored physical activity 10-years after THA

In orthopaedics, patient reported outcomes (PROMs) are designed to quantify changes in pain and to assess physical function, most often after joint arthroplasty. However, PROMs have some disadvantages, most important is their subjective nature. The aim was to investigate how patient-self-reported-outcomes of general health, disease-specific outcome and physical function, joint-awareness and self-perceived activity- levels are correlated with objectively-measured physical-activity (PA) parameters derived from wearable activity-monitors (AM) in subjects with a hip-arthroplasty. A prospective cohort study was conducted in a group of 32 patients, with a mean follow-up of 10 years after total hip arthroplasty. To assess different domains, the SF-36 (general health), HOOS-PS (pain/functional outcome), FJS-12 (joint awareness) and SQUASH (physical activity) were chosen. Activity-monitoring was performed using a 3-axis accelerometer, gyroscope and magnetometer. No significant correlations between PA-parameters and the FJS-12 and SQUASH were found. The HOOS- PS was significant correlated with BMI, the daily time walking and total-time active and the amount of daily steps. The physical functioning-subscale of the SF-36 was significant negative correlated with BMI and time sitting, but significant positive correlated with time walking, total-time active and the amount of daily steps. Considering the value of PA for maintaining general health, the value of using sensor-based AMs to assess efficacy of treatments in this health related dimension or use it as a tool for patient education, awareness and communication, seems very high.

The Hidden Pandemic: the Cost of Postoperative Complications

Purpose of Review

Population-based increases in ageing and medical co-morbidities are expected to substantially increase the incidence of expensive postoperative complications. This threatens the sustainability of essential surgical care, with negative impacts on patients' health and wellbeing.

Recent Findings

Identification of key high-risk areas, and implementation of proven cost-effective strategies to manage both outcome and cost across the end-to-end journey of the surgical episode of care, is clearly feasible. However, good programme design and formal cost-effectiveness analysis is critical to identify, and implement, true high value change.

Summary

Both outcome and cost need to be a high priority for both fundholders and clinicians in perioperative care, with the focus for both groups on delivering high-quality care, which in itself, is the key to good cost management.

Comparison of patient reported outcome measures after single versus two-stage revision for chronic infection of total hip arthroplasty: a retrospective propensity score matched cohort study

INTRODUCTION

Two-stage revision is the current gold standard treatment for infected total hip arthroplasties (THA) with good clinical outcomes. Single-stage revision THA offers the advantage of only a single surgical intervention, potentially leading to improved functional outcomes. This study aimed to compare the differences in patient-reported outcome measures (PROMs) and complications between single and two-stage revision THA for chronic periprosthetic joint infection (PJI).

METHODS

A total of 159 consecutive revision THA patients for chronic PJI with complete pre-and post-operative patient-reported outcome measures (PROM) was investigated. A total of 46 patients with single-stage revision THA was matched to 92 patients following two-stage revision THA using propensity score matching, yielding a total of 136 propensity score-matched patients for analysis.

RESULTS

Single and two-stage revision THA improved PROM scores post-operatively, with significantly higher PROMs for single-stage revision THA (HOOS-PS: 50.7 vs 46.4, p = 0.04; Physical SF 10A: 42.1 vs 36.6, p < 0.001; PROMIS SF Physical: 41.4 vs 37.4, p < 0.001; PROMIS SF Mental: 52.8 vs 47.6, p < 0.001). There was no significant difference between both cohorts for reinfection rates (p = 0.81) and 90-day mortality rates (p = 1.0).

CONCLUSION

This study found a demonstrable functional benefit of single-stage revision compared to two-stage revision for THA with chronic periprosthetic joint infection, suggesting that single-stage revision THA may provide an effective alternative to two-stage revision in selected patients with chronic PJI.

LEVEL OF EVIDENCE

Level III, case-control retrospective analysis.

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.

CR-lipped bearing is an adequate functional solution to patients with perioperative excessive laxity in cruciate retaining total knee arthroplasty

BACKGROUND

The cruciate retaining lipped (CR-lipped) bearing is designed to provide more anterior-posterior (AP) stability and could be employed to resolve excessive intraoperative laxity during the cruciate retaining TKA (CR-TKA). The aim of the study was to determine whether the CR-lipped bearing in CR-TKAs with a perioperative excessive laxity allows equivalent functional results as compared to the standard CR articulation.

METHODS

A cohort of 111 TKAs with CR-lipped bearings was matched to a cohort of conventional CR bearings regarding age and sex. The CR-lipped bearing was used in patients with excessive knee AP laxity and the regular CR bearing was used in patients without excessive AP laxity during TKA. Various PROMs (WOMAC, KSS, SF-36) were assessed preoperatively and at 5-years postoperative in combination with revision rate and Range of Motion (ROM).

RESULTS

PROMs did not differ significantly between both groups 5-years postoperatively. Mean ROM (flexion) 5-years postoperatively was not significantly different. The implant survivorship was 100% for both cohorts with revision for any reason as end point.

CONCLUSION

Based on these results, the CR-lipped bearing is a safe and effective solution for mild interoperatively assessed PCL laxity during CR-TKA without loss of function or decreased survivorship at 5 years. Peroperative conversion to a PS-TKA in order to obtain satisfactory functional scores might therefore not be necessary when mild PCL laxity is observed during surgery. Further research should focus on verifying this approach and longer follow-up is needed to generate data on long term survivorship.

LEVEL OF EVIDENCE

Level IV therapeutic, retrospective, cohort study.

Single-Stage Revision of the Infected Total Knee Arthroplasty Is Associated With Improved Functional Outcomes: A Propensity Score-Matched Cohort Study

BACKGROUND

Single-stage revision is an alternative to the standard 2-stage revision, potentially minimizing morbidities and improving functional outcomes. This study aimed at comparing single-stage and 2-stage revision total knee arthroplasty (TKA) for chronic periprosthetic joint infection (PJI) with regard to patient-reported outcome measures (PROMs) and complication rates.

METHODS

A total of 185 consecutive revision TKA patients for chronic PJI with complete preoperative and postoperative PROMs were investigated. A total of 44 patients with single-stage revision TKA were matched to 88 patients following 2-stage revision TKA using propensity score matching, yielding a total of 132 propensity score-matched patients for analysis. Patient demographics and clinical information including reinfection and readmission rates were evaluated.

RESULTS

There was no significant difference in preoperative PROMs between propensity score-matched single-stage and 2-stage revision TKA cohorts. Postoperatively, significantly higher PROMs for single-stage revision TKA were observed for Knee disability and Osteoarthritis Outcome Score physical function (62.2 vs 51.9, P < .01), physical function short form 10A (42.8 vs 38.1, P < .01), PROMIS SF Physical (44.8 vs 41.0, P = .01), and PROMIS SF Mental (50.5 vs 47.1, P = .02). There was no difference between propensity score-matched single-stage and 2-stage revision TKA cohorts for clinical outcomes including reinfection rates (25.0% vs 27.2%, P = .78) and 90-day readmission rates (22.7% vs 25.0%, P = .77).

CONCLUSION

This study illustrated that single-stage revision TKA for chronic PJI may be associated with superior patient-reported outcomes compared to 2-stage revision for the infected TKA using a variety of PROMs. Improved PROMs were not accompanied by differences in complication rates between both cohorts, suggesting that single-stage revision TKA may provide an effective alternative to 2-stage revision in patients with chronic TKA PJI.

Feasibility of Collecting Multiple Patient-Reported Outcome Measures Alongside the Dutch Arthroplasty Register

Background:

Compliance rates with patient-reported outcome measures (PROMs) collected alongside arthroplasty registries vary in the literature. We described the feasibility of a routinely collected set PROMs alongside the Dutch Arthroplasty Register.

Methods:

The longitudinal Leiden Orthopaedics Outcomes of OsteoArthritis Study is a multicenter (7 hospitals), observational study including patients undergoing total hip or total knee arthroplasty (THA or TKA). A set of PROMs: Short Form-12, EuroQol 5 Dimensions, Hip/Knee injury and Osteoarthritis Outcome Score, Oxford Hip/Knee Score was collected preoperatively and at 6, 12, 24 months, and every 2 years thereafter. Participation rates and response rates were recorded.

Results:

Between June 2012 and December 2014, 1796 THA and 1636 TKA patients were invited, of whom 1043 THA (58%; mean age 68 years [standard deviation, SD: 10]) and 970 TKA patients (59%; mean age 71 years [SD 9.5]) participated in the study. At 6 months, 35 THA/38 TKA patients were lost to follow-up. Response rates were 90% for THA (898/1000) and 89% for TKA (827/932) participants. At 1 and 2 years, 8 and 18 THA and 17 and 11 TKA patients were lost to follow-up, respectively. The response rates among those eligible were 87% (866/992) and 84% (812/972) for THA and 84% (771/917) and 83% (756/906) for TKA patients, respectively. The 2-year questionnaire was completed by 78.5% of the included THA patients and by 77.9% of the included TKA patients.

Conclusions:

About 60% of patients undergoing THA or TKA complete PROMs preoperatively, with more than 80% returning follow-up PROMs. To increase the participation rates, more efforts concerning the initial recruitment of patients are needed.

Comparable level of joint awareness between the bi-cruciate and cruciate retaining total knee arthroplasty with patient-specific instruments: a case-controlled study

PURPOSE

Bi-cruciate-retaining total knee arthroplasty (BCR-TKA) is recognized as an alternative to the cruciate-retaining total knee arthroplasty (CR-TKA) within the pursuit of retrieving the "forgotten artificial knee joint". The aim of this study was to provide a short-term comparison in functional and clinical outcomes between BCR- and CR-TKA.

METHODS

The cohort consisted of 61 BCR-TKA patients, matched with 61 suitable CR-TKA patients, and operated between 2014 and 2016 due to osteoarthritis. Patient-reported outcome measurements were assessed preoperatively and at 3, 12, 24 and 36 months postoperatively. In addition, perioperative conditions were observed and radiological images were analysed pre- and 1 year postoperatively. Effect size for the FJS-12 was calculated at 3-year follow-up to quantify the difference between BCR- and CR-TKA.

RESULTS

Patients reported a significant improved health-related quality of life (p = 0.017) and a non-significant difference in joint awareness at 3-year-follow-up with a moderate effect size (0.4). Operating time in BCR-TKA (1:16, ± 0:16) is significantly longer (p < 0.000) than in CR-TKA (0:50, ± 0:12). Blood loss significantly increased (p = 0.005) in BCR-TKA (246.4 cc, 79.8) compared to CR-TKA (195.5 cc, ± 106.2). Comparable length of hospital stay (n.s.) was observed in BCR-TKA (1.1 days, ± 1.1) and CR-TKA (1.3 days, ± 1.3). Outliers of the hip-knee-ankle axis occurred significantly more frequent (P = 0.015) in the BCR group (37.7%) compared to CR-TKA (18.0%).

CONCLUSION

Joint awareness of the BCR-TKA was not significantly reduced compared to the CR-TKA. However, this study illustrates that bi-cruciate-retaining surgical technique for TKA is a promising step further in the pursuit of reducing joint awareness and retrieving the artificial forgotten total knee. Since a functional ACL increases rotational stability and proprioception, future research should focus on knee kinematics in modern BCR-TKA measured with gait analyses.

LEVEL OF EVIDENCE

IV therapeutic, retrospective, cohort study.

Patient-Specific or Conventional Instrumentations: A Meta-analysis of Randomized Controlled Trials

Objective

To conduct a meta-analysis of randomized controlled trials (RCTs) to compare knee arthroplasty with patient-specific instrumentation (PSI) with the conventional instrumentation (CI).

Methods

RCTs were selected in PubMed and Embase from 2012 to 2018. Key data extracted included malalignment of mechanical axis, blood loss, surgical time, Oxford Knee Score (OKS), Knee Society Score (KSS), length of stay, and complications. Subgroup analysis was also performed regarding different PSI systems and different image processing methods.

Results

29 RCTs with 2487 knees were eligible for the meta-analysis. Results showed that PSI did not improve the alignment of the mechanical axis compared with CI, but MRI-based PSI and Visionaire-specific PSI decrease the risk of malalignment significantly (P = 0.04 and P = 0.04 and P = 0.04 and P = 0.04 and P = 0.04 and

Conclusion

PSI reduced the blood loss and improved KSS. MRI-based PSI reduced operative time and risk of malalignment of mechanical axis compared with CT-based PSI. Moreover, Visionaire-specific PSI achieves better alignment result of the mechanical axis than other systems.

Patient-reported outcome measures in total joint arthroplasty: defining the optimal collection window

Background

The purpose of this study was to determine the optimal window for collection of patient-reported outcome measures (PROMs) after total joint arthroplasty (TJA).

Methods

Our prospectively collected institutional joint registry was queried for patients who underwent primary, unilateral TJAs. The primary outcomes were the net changes in WOMAC, SF-12 MCS, SF-12 PCS, OHS, KSCRS, and UCLA activity rating system at 6, 12, and 24 months postoperatively. Secondary outcomes were data acquisition costs and follow-up attrition rates.

Results

Eight hundred sixty-six procedures (450 total hip arthroplasties, 416 TKAs) were analyzed. A consistent plateau in all PROMs was noted by 6 months postoperatively–except for SF-12 MCS which showed no significant changes at any time interval. For TKA, the percentage of overall improvement achieved by 6 months was 88.7%, 84.5%, 100%, and 90.5% for the WOMAC, SF-12 PCS, UCLA, and KSCRS, respectively. For total hip arthroplasty, these values were 92.7%, 83.5%, 88.0%, and 89.8% for WOMAC, SF-12 PCS, UCLA, and OHS, respectively. There were marginal improvements from 6 to 12 months and no improvement from 12 to 24 months. Follow-up rates at 6, 12, and 24 months were 85%, 69%, and 40%, respectively. Our institutional costs for collecting a complete data set per patient were $128, $158, and $272 for 6, 12, and 24 months, respectively.

Conclusions

Most of the improvement in PROMs after primary TJA occurs within the first 6 months. In addition, limiting PROMs collection to 6 months appears to be cost-efficient owing to increased attrition rates beyond this time interval.

Is Parkinson's Disease Associated with Increased Mortality, Poorer Outcomes Scores, and Revision Risk After THA? Findings from the Swedish Hip Arthroplasty Register

BACKGROUND

Neurological conditions such as Parkinson's disease are commonly accepted as a risk factor for an increased likelihood of undergoing revision surgery or death after THA. However, the available evidence for an association between Parkinson's disease and serious complications or poorer patient-reported outcomes after THA is limited and contradictory.

QUESTIONS/PURPOSES

(1) Do patients with a preoperative diagnosis of Parkinson's disease have an increased risk of death after elective THA compared with a matched control group of patients? (2) After matching for patient- and surgery-related factors, do revision rates differ between the patients with Parkinson's disease and the matched control group? (3) Are there any differences in patient-reported outcome measures for patients with Parkinson's disease compared with the matched control group?

METHODS

Data were derived from a merged database with information from the Swedish Hip Arthroplasty Register and administrative health databases. We identified all patients with Parkinson's disease who underwent THA for primary osteoarthritis between January 1, 1999 and December 31, 2012 (n = 490 after exclusion criteria applied). A control group was generated through exact one-to-one matching for age, sex, Charlson comorbidity index, surgical approach, and fixation method. Risk of death and revision were compared between the groups using Kaplan-Meier and log-rank testing. Patient-reported outcome measures (PROMs), routinely recorded as EQ-5D, EQ VAS, and pain VAS, were measured at the preoperative visit and at 1-year postoperatively; mean absolute values for PROM scores and change in scores over time were compared between the two groups.

RESULTS

The risk of death did not differ at 90 days (control group risk = 0.61%; 95% CI = 0.00-1.3; Parkinson's disease group risk = 0.62%; 95% CI = 0.00-1.31; p = 0.998) or 1 year (control group = 2.11%; 95% CI = 0.81-3.39; Parkinson's disease group = 2.56%, 95% CI = 1.12-3.97; p = 0.670). At 9 years, the risk of death was increased for patients with Parkinson's disease (control group = 28.05%; 95% CI = 22.29-33.38; Parkinson's disease group = 54.35%; 95% CI = 46.72-60.88; p < 0.001). The risk of revision did not differ at 90 days (control group = 0.41%; 95% CI = 0.00-0.98; Parkinson's disease group = 1.03%; 95% CI = 0.13-1.92; p = 0.256). At 1 year, the risk of revision was higher for patients with Parkinson's disease (control group = 0.41%; 95% CI = 0.00-0.98; Parkinson's disease group = 2.10%; 95% CIs = 0.80-3.38; p = 0.021). This difference was more pronounced at 9 years (control group = 1.75%; 95% CI = 0.11-3.36; Parkinson's disease group = 5.44%; 95% CI = 2.89-7.91; p = 0.001) when using the Kaplan-Meier method. There was no difference between the control and Parkinson's disease groups for level of pain relief at 1 year postoperatively (mean reduction in pain VAS score for control group = 48.85, SD = 20.46; Parkinson's disease group = 47.18, SD = 23.96; p = 0.510). Mean change in scores for quality of life and overall health from preoperative measures to 1 year postoperatively were smaller for patients in the Parkinson's disease group compared with controls (mean change in EQ-5D scores for control group = 0.42, SD = 0.32; Parkinson's disease group = 0.30, SD = 0.37; p 0.003; mean change in EQ VAS scores for control group = 20.94, SD = 23.63; Parkinson's disease = 15.04, SD = 23.00; p = 0.027).

CONCLUSIONS

Parkinson's disease is associated with an increased revision risk but not with short-term mortality rates relevant to assessing risk versus benefit before undergoing THR. The traditional reluctance to perform THR in patients with Parkinson's disease may be too conservative given that the higher long-term risk of death is more likely due to the progressive neurological disorder and not THR itself, and patients with Parkinson's disease report comparable outcomes to controls. Further research on outcomes in THR for patients with other neurological conditions is needed to better address the broader assumptions underlying this traditional teaching.Level of Evidence Level III, therapeutic study.

No difference in mid-term survival and clinical outcome between patient-specific and conventional instrumented total knee arthroplasty: a randomized controlled trial

PURPOSE

The purpose of this multicentre prospective randomized controlled trial was to compare the survival rate and clinical outcome in total knee arthroplasty (TKA) after MRI-based patient-specific instruments (PSI) and conventional instruments 5 years after initial surgery.

METHODS

At a mean follow-up of 5.1 years (0.4), 163 patients (90.6%) with a mean age of 71.8 years (8.7) were analysed. A survival analysis with revision of the TKA as endpoint was performed. The Knee Society Score (KSS), evaluations on plain radiographs and patient-reported outcome measures (PROMs) were obtained preoperatively and at each FU.

RESULTS

At final follow-up, one TKA in the PSI- (1.2%) and 3 TKAs in the conventional group (3.8%) had undergone revision surgery (n.s.). No radiological abnormalities were noted at any time point. Postoperatively, the KSS and PROMs significantly improved within each group compared with the preoperative values. There were no clinically relevant differences for the KSS [PSI: 77.4, 9.8 (95% CI 75.0-79.7) vs. conventional: 77.3 10.5 (95% CI 74.9-79.8)] and the PROMs between both groups (n.s.) at 5 years follow-up.

CONCLUSION

There is still a lack of reliable data on the survival of TKA and clinical evidence, when using PSI for TKA. Longer follow-up studies are, therefore, needed.

LEVEL OF EVIDENCE

I.

Determination of normal KOOS and WOMAC values in a healthy population

PURPOSE

The KOOS questionnaire is used to assess the symptoms and function of patients with traumatic or degenerative knee pathology. The WOMAC score has been validated mainly in the context of knee osteoarthritis. The distribution of these scores in a non-diseased population is not known. The hypothesis was that KOOS and WOMAC scores were influenced by patients' age, sex, and BMI. The primary objective of this study was to describe, for the first time, the distribution of KOOS and WOMAC scores in a healthy population based on age, sex, and BMI.

METHODS

This was a pilot (innovative), cross-sectional, international, multicenter, descriptive study. Persons accompanying patients to our clinic were invited to participate in this study by filling out the KOOS questionnaire. These data were also used to calculate the WOMAC score. The study was designed according to guidelines on pilot studies and planned to enroll a minimum of 30 subjects in each age, gender, and BMI group. Expected KOOS and WOMAC scores by age, gender, and BMI were determined using a linear regression model.

RESULTS

Seven hundred and fourteen subjects were included: 305 men (42.7%) and 409 women (57.3%). For the KOOS score, as age increases, there was a decrease in the "ADL" (p = 0.0001) and "sport" (p = 0.0001) items and an increase in the "symptoms" (p = 0.0025) and "QOL" items (p = 0.0001). Women had lower scores (p < 0.05) than men on all the KOOS items, except "QOL". For the WOMAC, the "pain", "stiffness", and "function" items varied significantly based on age (p = 0.0203) and sex (p = 0.0121). The "stiffness" item varied significantly based on age (p = 0.0005) and sex (p = 0.0477). The "function" item varied significantly based on age (p = 0.0001) and sex (p = 0.0256). The expected value for the KOOS and WOMAC scores in a healthy population without any knee ailments were determined.

CONCLUSIONS

The KOOS and WOMAC scores vary significantly based on age, sex, and BMI in a healthy population. This study also provides KOOS and WOMAC values in a population without any knee issue. These scores can be used, in a daily practice, as a reference to assess functional outcomes after a surgical procedure.

LEVEL OF EVIDENCE

IV.

Consistency in patient-reported outcome measures after total knee arthroplasty using patient-specific instrumentation: a 5-year follow-up of 200 consecutive cases

PURPOSE

The purpose of this study was to evaluate the 5-year follow-up results of the first 200 total knee arthroplasties (TKA) performed by one high-volume surgeon, using patient-specific information (PSI). To date, there has been no other research into the mid-term follow-up of TKA performed using PSI.

MATERIALS AND METHODS

A total of 184 consecutive patients (200 TKA) were evaluated. Outcome measures included implant survival rate, adverse events, and the following patient-reported outcome measures (PROMs); Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), Pain Visual Analogue Score (VAS) and EuroQol-5D Score (EQ-5D).

RESULTS

Revision surgery was performed for late secondary prosthetic joint infection (n = 1, total revision), aseptic loosening (n = 1, tibial component revision), instability (n = 1, isolated polyethylene insert exchange), and polyethylene insert breakage (n = 1, isolated polyethylene insert exchange). Other adverse events were as follows: debridement, antibiotics and implant retention for early prosthetic joint infection (n = 1), surgical debridement for haemarthrosis (n = 1), superficial wound infection (n = 2), thromboembolic events (n = 2), compartment syndrome (n = 1), and nerve injury (n = 2). All median outcome scores for patient reported outcome measures at 5 years improved significantly compared with the preoperative values (p ≤ 0.05). Median outcome scores were not significantly different between 1- and 5-year moments of follow-up, except for a significant decrease of EQ-VAS (p ≤ 0.05) between these two follow-up moments.

CONCLUSION

PROMs are consistent for 5-year follow-up of TKA using PSI. After 5 years of follow-up, revision surgery for any reason occurred in four patients (2%).

LEVEL OF EVIDENCE

III.

Trends in hip replacements between 1999 and 2012 in Sweden

National Registers document changes in the circumstance, practice, and outcome of surgery with the passage of time. In the context of total hip replacement (THR), registers can help elucidate the relevant factors that affect the clinical outcome. We evaluated the evolution of factors related to patient, surgical procedure, socio-economy, and various outcome parameters after merging databases of the Swedish Hip Arthroplasty Register, Statistics Sweden and the National Board of Health and Welfare. Data on 193,253 THRs (164,113 patients) operated between 1999 and 2012 were merged. We studied the evolution of surgical volume, patient demographics, socio-economic factors, surgical factors, length-of-stay, mortality rate, adverse events, re-operation and revision rates, and Patient Reported Outcome Measures (PROMs). Throughout this time period the majority of patients were operated on with a diagnosis of primary osteoarthritis. Comorbidity indices increased each year observed. The share of all-cemented implants has dropped from 92% to 68%. More than 88% of the bearings were metal-on-polyethylene. Length-of-stay decreased by 50%. There was a reduction in 30- and 90-day mortality. Re-operation and revision rates at 2 years are decreasing. The post-operative PROMs improved despite the observation of worse pre-operative pain scores getting over time. The demographics of patients receiving a THR, their comorbidities, and their primary diagnosis are changing. Notwithstanding these changes, outcomes like mortality, re-operations, revisions, and PROMs have improved. The practice of hip arthroplasty has evolved, even in a country such as Sweden that is considered to be conservative with regard taking on new surgical practices. © 2017 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 36:432-442, 2018.

Physical activity after outpatient surgery and enhanced recovery for total knee arthroplasty

PURPOSE AND HYPOTHESIS

The purpose of this study was to 'objectively' measure improvement of physical activity with the use of an activity monitor between patients who followed an enhanced recovery- or outpatient surgery pathway after total knee arthroplasty (TKA). It was hypothesized that both pathways will have comparable physical activity after TKA at 6-week follow-up.

METHODS

This prospective observational comparative case study was designed to investigate activity parameters (e.g. physical activity, number of steps, sit-stand transfers) of two different pathways after 6 weeks with the use of a non-invasive triaxial accelerometer activity monitor. This study included 20 patients with a mean age of 65.5 years (SD 6.1) undergoing TKA who were allocated to follow one of the two pathways: enhanced recovery (n = 10) or outpatient surgery (n = 10). Patients were monitored for 4 days pre-, 4 days during and 4 days after 5 weeks postoperatively. Patient-reported outcome measures (PROMs) and range of knee motion were obtained pre- and 6 weeks postoperatively.

RESULTS

The activity parameters recovered steeply during the first 4 postoperative days and continued to improve within both pathways (n.s.). Preoperative and during the first 4 days and 5 weeks postoperative, activity parameters were comparable (n.s.) between both pathways but did not reach preoperative levels of physical activity and range of motion (n.s.). PROMs improved within each pathway, and no difference between both pathways was observed (n.s.).

CONCLUSIONS

This study demonstrates that the early physical activity parameters of patients after TKA, following the outpatient surgery pathway, were similar to patients who followed the standard enhanced recovery pathway. The activity monitor is an added value for a more detailed and objective analysis of the physical performance in patients after TKA.

LEVEL OF EVIDENCE

III.

Can a Made-for-Consumer Activity Monitor Assess Physical Activity in Adolescents and Young Adults After Lower Extremity Limb Salvage for Osseous Tumors?

BACKGROUND

The purpose of this study was to test the validity of a consumer-oriented activity monitor in adolescents and young adults undergoing limb salvage for primary bone malignancies.

METHODS

A cross-sectional population of participants with an average age of 16 (range 12 to 22) years produced 472 days of activity monitoring during 25 evaluations periods alongside patient-reported outcome measures.

RESULTS

Average daily steps ranged from 557 to 12,756 (mean=4711) and was moderately associated with the short-form (SF) 36 physical component subscale (r=0.46, P=0.04) as well as the SF6D health state utility measure (r=0.48, P=0.04), but not the SF36 mental component subscale (P=0.66) or Toronto extremity salvage score (P=0.07). Time from surgery was strongly correlated with average daily steps (r=0.7, P<0.001).

CONCLUSIONS

A made-for-consumer activity monitor provided real-world data regarding the outcome of adolescent and young adult limb salvage, and evidence of validity in this population. Such lower cost, user-friendly devices may facilitate assessment of free-living activity and allow novel comparisons of treatment strategies.

LEVEL OF EVIDENCE

Level II-diagnostic.

Using Text Messaging in Long-Term Arthroplasty Follow-Up: A Pilot Study

Background

Patient-reported outcome measures (PROMs) and mobile technology have the potential to change the way patients are monitored following joint replacement surgery.

Objective

The aim of this study was to determine the feasibility of text messaging to record PROMs in long-term follow-up of hip and knee arthroplasty. Our participants were 17 patients 2-years-plus post hip or knee arthroplasty attending clinic with a mobile telephone number on record.

Methods

A simple PROM (Oswestry Very Short Form) was texted to the patient. Responses were compared to clinical, radiographic, and existing PROM findings. Patients were interviewed to discover their opinions on this use of texting.

Results

A total of 11 patients engaged with the text messaging. Reasons for not engaging included wrong numbers, physical barriers, and lack of understanding. A total of 8 patients attending clinic allowed comparison of text messaging with clinical findings. The average age was 70 years. A total of 4 patient text messaging responses matched clinical and radiographic findings; 3 also matched PROM scores collected in clinic. The 3 patients with mixed responses had abnormal clinical, radiographic, or PROM findings. One patient’s text responses conflicted with clinical outcome. Analysis of patients’ views showed a generally positive opinion: patients were happy to communicate with surgeons by text. Practical problems, PROM limitations, and trustworthiness of texting were highlighted.

Conclusions

Engaging with changing technology creates challenges for patients and health care professionals. Despite this, our results suggest text messaging is a promising way to communicate with arthroplasty patients. Earlier integration of text communication in the patient pathway may be important and needs further research.

Using Patient-Reported Outcomes for Economic Evaluation: Getting the Timing Right

BACKGROUND

Patient-reported outcome measures (PROMs) are becoming increasingly popular in orthopedic surgery. Preoperative and postoperative follow-up often elicit PROMs in the form of generic quality-of-life instruments (e.g., Short Form health survey SF-12 [SF-12]) that can be used in economic evaluation to estimate quality-adjusted life-years (QALYs). However, the timing of postoperative measurement is still under debate.

OBJECTIVES

To explore the timing of postoperative PROMs collection and the implications for bias in QALY estimation for economic evaluation.

METHODS

We compared the accuracy of QALY estimation on the basis of utilities derived from the SF-12 at one of 6 weeks, 3 months, 6 months, and 12 months after total knee arthroplasty, under different methods of interpolation between points. Five years of follow-up data were extracted from the St. Vincent's Melbourne Arthroplasty Outcomes (SMART) registry (n = 484). The SMART registry collects follow-up PROMs annually and obtained more frequent outcomes on subset of patients (n = 133).

RESULTS

Postoperative PROM collection at 6 weeks, 6 months, or 12 months biased the estimation of QALY gain from total knee arthroplasty by -41% (95% confidence interval [CI] -59% to -22%), 18% (95% CI 4%-32%), and -8% (95% CI -18% to -2%), respectively. This bias was minimized by collecting PROMs at 3 months postoperatively (6% error; 95% CI -9% to 21%).

CONCLUSIONS

The timing of PROM collection and the interpolation assumptions between measurements can bias economic evaluation. In the case of total knee arthroplasty, we recommend a postoperative measurement at 3 months with linear interpolation between preoperative and postoperative measures. The design of economic evaluations should consider timing and interpolation issues.

Psychiatric disease as a risk factor in fast-track hip and knee replacement

Recent studies suggest that patients with psychiatric disorders tend to do worse than patients without a psychiatric diagnosis when undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Whether this is due to their psychiatric condition, pharmacological treatment, a combination of the two, or something else has not been thoroughly analyzed-and there are no internationally accepted guidelines for perioperative management of psychiatric patients. This overview summarizes our current knowledge on perioperative risks in patients with preoperative psychiatric disorders and the possible role of psychotropic drugs in the perioperative course. This will be useful when planning future strategies for improvement of surgical outcome following hip and knee arthroplasty.

No difference in clinical outcome between patient-matched positioning guides and conventional instrumented total knee arthroplasty two years post-operatively

Aims

We wished to compare the clinical outcome, as assessed by questionnaires and the rate of complications, in total knee arthroplasty (TKA) undertaken with patient-matched positioning guides (PMPGs) or conventional instruments.

Patients and Methods

A total of 180 patients (74 men, 106 women; mean age 67 years) were included in a multicentre, adequately powered, double-blind, randomised controlled trial. The mean follow-up was 44 months (24 to 57).

Results

There were no significant or clinically relevant differences between the two groups for all outcome measures (Knee Society Score, p = 0.807; Oxford Knee Score, p = 0.304; Western Ontario and McMaster osteoarthritis index, p = 0.753; visual analogue scale for pain, p = 0.227; EuroQol-5D-3L index score, p = 0.610; EuroQol-5D-3L VAS health, p = 0.968.) There was no difference in the rate of complications (p = 0.291).

Conclusion

PMPGs are already in relatively common use and their short-term clinical results are equal to conventional instrumented TKA. Cite this article: Bone Joint J 2016;98-B:939–44.

Translation and Validation of the Finnish Version of the Patient-Rated Wrist Evaluation Questionnaire (PRWE) in Patients with Acute Distal Radius Fracture

BACKGROUND AND AIMS

Patient-rated outcome measures have become increasingly important in clinical research. They provide research and clinical tools which can be utilized in the assessment of patient recovery and treatment efficacy. The purpose of our study was to translate and validate the original version of the PRWE form into Finnish.

MATERIAL AND METHODS

We conducted the translation of the PRWE questionnaire according to standardized guidelines. Patients (N = 119) with an acute distal radius fracture were recruited, and they completed the PRWE and QuickDASH questionnaires at 2 months and 4 months after the wrist injury.

RESULTS

The mean answering times were 52 days (standard deviation [SD] 9.8 days) and 116 days (standard deviation [SD] 14.8 days), respectively. Both the internal consistency (Cronbach's alpha) of 0.976 and the intraclass correlation coefficient (ICC) of 0.992 (95% CI 0.966-0.998) showed excellent reliability for the total PRWE score. The correlation coefficients between the total score, the subscales, and for improvement over time for PRWE and QuickDASH were excellent. The responsiveness was good with an effect size of 0.83 and a standard response mean of 1.22.

CONCLUSION

Our study shows that the Finnish version of the PRWE is reliable, valid, and responsive for the evaluation of pain and disability after distal radius fracture.