Minimal clinically important improvement (MCII) and patient-acceptable symptom state (PASS) in total hip arthroplasty (THA) patients 1 year postoperatively

Minimal important change in the Hip Disability and Osteoarthritis Outcome Score and the European Quality of Life 5 Dimensions in adults with hip osteoarthritis after 12 weeks of exercise

BACKGROUND

Minimal important change (MIC) is the smallest change that can be considered important. In hip osteoarthritis (OA) several measurement instruments are recommended but lack MIC estimates.

OBJECTIVES

The objective was to estimate the MIC after supervised group-based exercise for the following measurement instruments; Hip Disability and Osteoarthritis Outcome Score (HOOS), European Quality of Life 5 Dimensions (EQ-5D-5L), 30-s Chair Stand Test, 40-m Fast-paced Walk Test, 9-step Stair Climb Test, Nottingham Leg Extension Power Rig, and unilateral One-Repetition-Maximum Leg Press.

DESIGN

Secondary analysis from a randomized trial of 160 participants with hip OA randomized to two different exercise interventions.

METHODS

Participants were assessed using the instruments at baseline and after 12 weeks of exercise. At follow-up the participants also rated their perceived change using a Global Rating of Change Score (GRCS). A correlation of >0.3 between the measurement instruments and the GRCS was a prerequisite for estimating the MIC using the predictive modeling approach.

RESULTS

Only two measurement instruments had acceptable correlations and were included in the MIC analysis. The MIC for the five HOOS subscales ranged from 6 to 10 points (scale range: 0-100). The MIC for the EQ-5D-5L index (scale range: -0.757 to 1) and EQ-VAS (scale range: 0-100) were 0.054 (0.03; 0.08) and 4.83 (1.37; 8.48), respectively.

CONCLUSIONS

The reported MIC values indicate the minimal improvement that the average patient with hip OA would consider important after 12 weeks of exercise and will help clinicians and researchers interpret the clinical importance of the results of exercise interventions.

Establishing the Patient Acceptable Symptoms State for the Boston Carpal Tunnel Questionnaire in a Postoperative Carpal Tunnel Surgery Population

PURPOSE

Threshold scores for patient acceptable symptom state (PASS) represent the score beyond which a patient considers themselves "well." We aimed to determine PASS thresholds for the symptom severity scale (SSS) and functional status scale (FSS) of the Boston Carpal Tunnel Questionnaire in a sample of patients 1 year following carpal tunnel release.

METHODS

Adults (≥ 18 years) from a single, tertiary-care academic institution were contacted 12 ± 1 months after carpal tunnel release. The Boston Carpal Tunnel Questionnaire and two PASS anchor questions were administered via REDCap-one queried acceptability of their current symptoms, and the other queried function. Participants were classified as being in an acceptable symptom state ("PASS(+)") if they answered "very satisfied" or "somewhat satisfied," whereas those responding "neither satisfied nor dissatisfied," "somewhat dissatisfied," or "very dissatisfied" were classified as "PASS(-)." Threshold values were calculated using three methods: (1) the mean score for PASS(+) participants, (2) the 75th percentile score for PASS(+) patients, and (3) the Youden Index determined using receiver operating curve (ROC) analysis to maximize sensitivity and specificity.

RESULTS

The 153 patients included in the study had a mean age of 60 ± 15 years and 60% (94/153) were women. At a mean follow-up of 1.0 ± 0.1 years, SSS and FSS scores were significantly lower (better) for PASS(+) than PASS(-) patients for both anchor questions. PASS estimates ranged from <1.4 to <1.8 for the SSS and from <1.3 to <1.5 for the FSS. All ROC curves produced excellent discrimination (area under the curve > 0.8).

CONCLUSIONS

We propose PASS thresholds of 1.8 for the SSS and 1.5 for the FSS, derived by the Youden or ROC method, which showed excellent discrimination between PASS(+) and PASS(-) patients.

CLINICAL RELEVANCE

These threshold values can be used to assess whether patient populations have achieved an adequate symptom and functional state.

Clinical cut-offs for hip- and knee arthroplasty outcome - minimal clinically important improvement (MCII) and patient acceptable symptom state (PASS) of patient-reported outcome measures (PROM)

PURPOSE

Clinical cut-offs like minimum clinically important improvement (MCII) and patient acceptable symptom state (PASS) increase the interpretability of patient reported outcome measures (PROMs), but cut-off estimates vary considerably, clouding a clear definition of a successful surgical outcome. We report estimates of MCII and PASS following hip- and knee arthroplasty using multiple methods and compare the different estimation methods.

METHODS

Elective hip or knee arthroplasty patients who underwent the regular pre- and postoperative assessments 2014-2018 were included. The generic EQ-5D-5L and either the Hip or Knee disability/injury and Osteoarthritis Outcome Score (HOOS/KOOS) were used. MCII and PASS were estimated based on multiple estimation techniques.

RESULTS

Distributions were skewed, with up to 95% being acceptable according to anchor questions. MCII estimates for HOOS/KOOS Pain ranged 21-60/10-47, with fewest in-sample misclassifications for the lowest cut-offs, provided by the 75th percentile approach. PASS estimates for HOOS/KOOS Pain ranged 84-93/78-91, for EQ-5D Index/EQ-VAS 0.87-0.92/66-79 (for hip), and 0.79-0.88/66-76 (for knee), with fewest misclassifications for the 75th percentile approach (hip) and Pythagoras approach (knee). The 75th percentile approach was the approach most often giving MCII estimates below the minimal detectable change (MDC).

CONCLUSIONS

We report new one-year estimates of MCII and PASS of HOOS, KOOS and EQ-5D subscales following hip- and knee arthroplasty. Estimates varied considerably when using different anchors and estimation techniques. Overall, the 75th percentile approach had fewest misclassifications, and had the lowest thresholds for the MCII estimations, but which were often below the MDC.

Mobile-based in-home telerehabilitation compared with in-hospital face-to-face rehabilitation for elderly patients after total hip arthroplasty in China's level 1 trauma center: a noninferiority randomized controlled trial

Background

Telerehabilitation is gaining popularity in European and American countries, but whether it can be successfully implemented in China still lacks support from clinical studies.

Objective

This trial aimed to determine if a home-based telerehabilitation method is clinically noninferior to standard in-hospital face-to-face rehabilitation for elderly patients with total hip arthroplasty (THA) in China.

Methods

This multicenter randomized controlled trial was conducted from January 2021 to June 2022 at The First Rehabilitation Hospital in Shanghai, Shanghai Jiao Tong University affiliated Sixth People's Hospital and Shanghai Tongji University affiliated Tenth People's Hospital. Sixty-four patients were recruited for this two-arm, single-assessor blinded, randomized controlled trial. The participants were randomly assigned to the in-home telerehabilitation group (TELE group) and the in-hospital physical therapist in-person group (PT group). The intervention consisted of a 12-week home-based rehabilitation program with video instructions and remote coaching on a mobile APP (TELE group). The PT group received a standard in-hospital rehabilitation intervention assisted by a physical therapist for one month and outpatient clinic for the next two months. Patients were evaluated at baseline, 4 weeks, and 12 weeks postoperatively employing functional tests (Timed Up & Go test and Berg balance test) and self-reported questionnaires (Hip disability and Osteoarthritis Outcome Score (HOOS) and Short Form 12 (SF-12)).

Results

There was no significant difference between the two groups for the demographic and clinical characteristics. 61 participants were analyzed (PT group: n = 31, women: 48.4% of participants; TELE group: n = 30, 33.3% of participants) whose median age was 70 and 69 years, in PT group (IQR: 63-73) and TELE group (IQR: 66-72) respectively. At 12 weeks follow-up evaluation, the main differences between the two groups regarding the HOOS gains, adjusted for baseline values, were close to zero (P > 0.05). There was no significant difference in primary and secondary outcome measures between the two groups.

Conclusion

Our results showed the noninferiority of in-home telerehabilitation and advocated its application as a reliable alternative to in-hospital face-to-face rehabilitation for patients who underwent THA.

Clinical Trial Registration

https://www.chictr.org.cn/, Chinese Clinical Trial Registry (Number: ChiCTR1900025825).

Outcomes of Direct Anterior Total Hip Arthroplasty in Patients Who Have Preoperative Gluteal Tendinopathy and Muscle Tears: A Propensity-Matched Analysis

BACKGROUND

The gluteus medius and minimus muscles play a critical role in hip biomechanics; however, there is a paucity of literature examining the impact of preoperative gluteal pathology on outcomes following total hip arthroplasty (THA). This study compared pain, satisfaction, and functional outcomes among patients who had and did not have preoperative gluteal pathology after direct anterior (DA) THA.

METHODS

Using an institutional total joint registry, patients undergoing DA THA for osteoarthritis between 2010 and 2022 were retrospectively reviewed. Those who had magnetic resonance imaging evidence of gluteal muscle tear or tendinopathy within one year before surgery were propensity-matched on a 1:4 basis by age, sex, body mass index, laterality, year of surgery, and surgeon to patients who had no clinical evidence of abductor pathology. There were 22 patients who had gluteal tears (eight of 22 men, age 63 ± 8.1 years) and 29 who had gluteal tendinopathy (nine of 29 men, age 60 ± 10.4 years) who were respectively matched to 88 and 116 controls and followed for 4.0 ± 2.3 (range, 1.1 to 12.7) years following DA THA. Postoperative outcomes were assessed using a visual analog scale (VAS) at rest, VAS with use, Hip Disability and Osteoarthritis Outcome Score pain, Forgotten Joint Score-12, and modified Harris Hip Score (mHHS). Subsequent injections and reoperations were recorded.

RESULTS

While all achieved excellent outcomes, patients who had gluteal muscle tears experienced less improvement in pain and function compared to controls, trending toward a lower final mHHS score (P = 0.052). Patients who had gluteal tendinopathy reported worse pain, satisfaction, and function than controls according to measures of VAS at rest (P = 0.014), VAS with use (P = 0.003), Hip Disability and Osteoarthritis Outcome Score pain (P = 0.005), Hip Disability and Osteoarthritis Outcome Score (P = 0.003), and mHHS (P = 0.007). Postoperative injections and subsequent hip surgeries were infrequent despite no intraoperative tendon treatment. Key limitations included limited sample size and lack of intraoperative data.

CONCLUSIONS

Patients who had gluteal pathology do well following DA THA; however, gluteal muscle tears and tendinopathies are associated with greater pain, decreased satisfaction, and inferior functional outcomes.

Establishment of Minimum Clinically Important Difference and Patient Acceptable Symptom State Thresholds for Foot and Ankle Ability Measure and Visual Analog Scale Scores After Hallux Valgus Surgery

BACKGROUND

Although clinically relevant thresholds such as minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) have been widely described across orthopaedics, their application in hallux valgus surgery remains scarce. The purpose of this study was to determine the MCID and PASS thresholds for the visual analog scale (VAS) and Foot and Ankle Ability Measure (FAAM) scores after hallux valgus surgery.

METHODS

A retrospective review was performed in patients undergoing hallux valgus surgery at a single institution from January 2021 through December 2022. Patient-reported outcome measures (PROMs) were collected preoperatively and 1 year postoperatively. The specific PROMs used were the FAAM-activities of daily living (FAAM-ADL), Single Assessment Numeric Evaluation (SANE), and VAS scale. Two methods were used to calculate MCID and PASS thresholds: a distribution-based approach for MCID and an anchor-based approach using responses to a 1-year postoperative satisfaction question for PASS. The analysis identified optimal cutoff points that maximized sensitivity and specificity based on the Youden index. Overall, 86% (136/158) completed baseline PROMs, and 73% (99/136) completed 1-year PROMs.

RESULTS

The distribution-based MCID for FAAM-ADL, SANE, and VAS were calculated to be 10.8, 14.1, and 1.2, respectively. The percentage of patients who achieved MCID thresholds was 54% for FAAM-ADL, 42% for SANE, and 96% for VAS. The PASS threshold for FAAM-ADL, SANE, and VAS were ≥78.5, ≥85, and ≤ 2, respectively. The percentage of patients who achieved PASS thresholds was 78% for FAAM-ADL, 72% for SANE, and 69% for VAS.

CONCLUSION

This study identified useful values for the MCID and PASS thresholds of FAAM-ADL, SANE, and VAS scores at 1-year follow-up for patients undergoing hallux valgus surgery. Overall, despite not meeting the MCID thresholds, patients undergoing hallux valgus surgery were still likely to be satisfied with their surgery.

Establishing the Patient-Acceptable Symptom State for the Numeric Rating Scale-Pain Score in a Postoperative Non-Shoulder Hand and Upper-Extremity Population

PURPOSE

The patient-acceptable symptom state (PASS) is a threshold score on a patient-reported outcome measurement beyond which patients consider themselves "well." Our purpose was to establish the PASS for the numeric rating scale (NRS) for pain in a 1-year postoperative hand surgery population.

METHODS

This retrospective study included adult patients undergoing non-shoulder upper-extremity surgery at a single, tertiary medical center identified over a 9-month period. At 1 year after surgery, NRS pain and responses to a pain-specific anchor question were collected. Patients were dichotomized based on achieving "PASS(+)" or failing to achieve "PASS(-)" an acceptable symptom state based upon their response to a pain-specific anchor question. Threshold values of a PASS(+) state were calculated for the NRS pain score using the following three methods: (1) mean score of PASS(+) patients, (2) Tubach method (75th percentile threshold for PASS(+) patients), and (3) the Youden index (receiver operating curve analysis to maximize sensitivity and specificity).

RESULTS

Of 233 included patients, mean age was 54 years (±17), and 58% (n = 136) were women. Mean NRS pain scores differed between PASS(+) and PASS(-) patients (0.7 ± 1.2 vs 3.8 ± 2.7, respectively). PASS(-) patients were more likely to be non-White and have a diagnosed psychiatric comorbidity. Patient-acceptable symptom state estimates ranged from 0.73 to 2.1 for NRS pain, depending on the calculation method (0.73 for the mean score method, 1.0 for the Tubach method, and 2.1 for the Youden index). The area under the curve for the Youden index method was 0.86 consistent with excellent discrimination.

CONCLUSIONS

We propose the value of 2.1 to represent the PASS threshold for the NRS pain score in this population.

CLINICAL RELEVANCE

This PASS value should be used when interpreting NRS pain score outcomes at a population level. This threshold is expected to yield excellent discrimination for patient satisfaction when applied to a postoperative hand surgery population.

Early Patient-Reported Outcome Measures Following Computer Navigated Total Hip Arthroplasty: A Study From the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Total hip arthroplasty (THA) is a well-established treatment for symptomatic hip osteoarthritis (OA). The use of computer navigation in THA aims to achieve the reconstruction of the joint more consistently and precisely. The aim of this study was to contrast patient-reported outcome measures (PROMs) for THA procedures with and without commercially available navigation technologies.

METHODS

Postoperative PROMs for primary THA procedures performed for OA between August 2018 and December 2022 and recorded in the Australian Orthopaedic Association National Joint Replacement Registry were analyzed. Procedures using computer navigation were compared to those using conventional instrumentation. Baseline patient characteristics and surgeon volume were subanalyzed. Multivariable regressions were used to compare postoperative PROMs.

RESULTS

There were 13,400 THA procedures for OA with PROMs recorded and 749 with navigation. The mean (SD) EuroQol-visual analog scales (EQ-VASs) scores for navigated cases were 67.3 (19.3) preoperatively and 81.7 (15.0) postoperatively, compared with 66.0 (20.3) and 80.5 (15.8) for the non-navigated group. Oxford Hip scores and patient-reported change were similar between groups. The change from preoperative to postoperative EQ-VAS and Oxford Hip score did not significantly differ between computer-navigated and non-navigated cases. After adjusting for patient and procedure factors, the use of computer navigation was associated with a higher rate of procedure satisfaction (rate ratio 1.03, 95% confidence interval 1.01 to 1.06, P = 0.02).

CONCLUSIONS

While procedural satisfaction was marginally higher following navigated THA (P = 0.02), there were no statistically significant differences in the change in EQ-VAS or when comparing navigated with "non-navigated" approaches for primary THAs. Based on the reviewed national registry data for PROMS, we were unable to demonstrate clinically relevant evidence to support claims of superiority of non-navigated or navigated primary THAs. Further work, including similar comparisons with long-term follow-up, will be of value in elucidating if a true clinically relevant difference exists.

Preoperative Osteoporosis Is Associated With Increased Health Care Utilization and Compromised Pain and Function Improvement After Primary Total Hip Arthroplasty: A Prospective Cohort Analysis

BACKGROUND

Osteoporosis (OP) has been linked to complications after total hip arthroplasty (THA), but its impact on health care utilization and patient-reported outcomes remains unclear. This study aimed to evaluate the association between: 1) pre-THA OP and health care utilization as well as patient-reported pain and function outcome measures; and 2) dual energy X-ray absorptiometry (DEXA) scan-based T-scores and the aforementioned outcomes.

METHODS

A retrospective analysis of prospectively collected data of primary THA (2015 to 2018) was performed (n = 5,321) from a validated academic institutional database of a large North American tertiary health care system; of which 4,074 (76.6%) completed 1-year follow-up. Outcomes included prolonged length of stay [LOS] > three days, discharge disposition, 90-day readmission, and 1-year reoperation, as well as Hip Disability and Osteoarthritis Outcome Score (HOOS]) Pain, HOOS-function (PS), and minimal clinically important difference thresholds (MCID), and satisfaction.

RESULTS

The prevalence of OP pre-THA was 56.9%, of which 39.8% were not prescribed OP medications and 15.3% had a DEXA scan. Compared to those who did not have OP, those who had OP were independently associated with higher odds of prolonged LOS, nonhome discharge, 90-day readmission, and 1-year reoperation (P < 0.005). Furthermore, they had significantly higher odds of failing to achieve MCID (odds ratio: 1.41 (95% confidence interval: 1.06 to 1.89)) for HOOS-PS and satisfaction (odds ratio: 1.5 (95% confidence interval: 1.16 to 1.93)) at one year. Higher T-scores were associated with lower odds of prolonged LOS, nonhome discharge, failure to achieve MCID in HOOS-Pain, and HOOS-PS.

CONCLUSIONS

Over half of patients had OP; however, only 15.3% of patients had a DEXA scan before THA. Patients who had OP were at higher risk of prolonged LOS, nonhome discharge, 90-day readmission, and 1-year reoperation in addition to poor pain/function improvement and dissatisfaction one year after THA.

Changes in health-related quality of life in young-old and old-old patients undergoing elective orthopedic surgery: A systematic review

BACKGROUND

There is a significant gap in research exploring changes in postoperative health-related quality of life (HRQoL) among patients aged 65 years and older undergoing hip or knee arthroplasty.

OBJECTIVES

To investigate the variations in HRQoL improvement, as evaluated by patient-reported outcome measures following total hip arthroplasty, total knee arthroplasty, and partial knee arthroplasty between the young-old and old-old adults.

METHODS/DESIGN

We searched six online databases (including MEDLINE, Embase) from their inception dates to May 15, 2023. We included studies using a validated HRQoL assessment tool to evaluate changes in HRQoL in patients aged ≥65 years undergoing hip or knee arthroplasty. These include the EuroQol five-dimension (EQ-5D), Short Form 36 (SF-36) and Short Form 12 (SF-12). The primary outcomes were postoperative HRQoL changes between young-old (65-74 years) and old-old groups (≥75 years). The secondary outcomes included complications, length of stay, and mortality.

RESULTS

The search yielded 12,229 articles; twelve studies (n = 103,613) were included. Studies using EQ-5D found no significant differences between young-old and old-old patients after hip and knee arthroplasty. Analyses of SF-36 and SF-12 scales showed no significant age-related differences in postoperative improvements in physical and mental health. Our review of four studies that included multivariable analyses revealed inconsistent associations between age and EQ-5D. Comparisons between the young-old and old-old age groups in postoperative complications, hospital length of stay, and mortality revealed no associated age-related changes in HRQoL.

CONCLUSIONS

The young-old and old-old patients exhibited comparable improvement in HRQoL following hip or knee arthroplasty. The older patients did not have higher postoperative complications rates, longer hospital length of stay, and increased mortality. While chronological age should be considered when planning hip and knee arthroplasty, greater emphasis should be placed on assessing the comorbidities and functional status of patients.

Systematic review reveals that EQ-5D minimally important differences vary with treatment type and may decrease with increasing baseline score

OBJECTIVES

To provide an updated summary of published anchor-based Minimally Important Difference (MID) estimates for the EQ-5D index and EQ visual analog scale (EQ VAS) scores and identify factors influencing those estimates.

STUDY DESIGN AND SETTING

We systematically searched eight electronic databases from January 1990 to March 2023. We examined the association of baseline score, type of score change (improvement/worsening), data source, value set, disease/condition, treatment type (surgical/non-surgical), and type of anchor (clinical vs. self-rated) with MID estimates for the EQ-5D-3L and EQ-5D-5L indices, and EQ VAS. Significant variables were used to develop prediction formulas for MID by testing both linear and nonlinear regression models.

RESULTS

Of 6786 records reviewed, 47 articles were included for analysis. MID ranges for improved scores were -0.13 to 0.68 (EQ-5D-3L), 0.01-0.41 (EQ-5D-5L), and 0.42-23.0 (EQ VAS). Surgical intervention and lower baseline scores were associated with higher MIDs for both the EQ indices but not for EQ VAS. The nonlinear polynomial model outperformed the linear model in predicting the MIDs. MIDs based on deteriorated scores were insufficient for quantitative synthesis (mean: -0.02 for EQ-5D-3L; -0.04 for EQ-5D-5L; and -6.5 for EQ VAS).

CONCLUSION

This review revealed that the MID of EQ-5D index scores varies with baseline score and treatment type, indicating that use of a uniform MID may not be appropriate. We recommend using baseline score-adjusted and treatment type-specific EQ-5D MIDs, and call for more MID research, particularly in the context of assessing deterioration in health using this widely used generic health-status instrument.

Metabolic syndrome and patient-reported outcome two years after hip and knee arthroplasty

Aims

The influence of metabolic syndrome (MetS) on the outcome after hip and knee arthroplasty is debated. We aimed to investigate the change in patient-reported outcome measure (PROM) scores after hip and knee arthroplasty, comparing patients with and without MetS.

Methods

From 1 May 2017 to 30 November 2019, a prospective cohort of 2,586 patients undergoing elective unilateral hip and knee arthroplasty was established in Denmark. Data from national registries and a local database were used to determine the presence of MetS. Patients' scores on Oxford Hip Score (OHS) or Oxford Knee Score (OKS), EuroQol five-dimension five-level questionnaire (EQ-5D-5L), University of California, Los Angeles (UCLA) Activity Scale, and Forgotten Joint Score (FJS) at baseline, three, 12, and 24 months after surgery were collected. Primary outcome was the difference between groups from baseline to 12 months in OHS and OKS. Secondary outcomes were scores of OHS and OKS at three and 24 months and EQ-5D-5L, UCLA Activity Scale, and FJS at three, 12, and 24 months after surgery. Generalized linear mixed model was applied, adjusting for age, sex, Charlson Comorbidity Index, and smoking to present marginal mean and associated 95% CIs.

Results

A total of 62.3% (1,611/2,586) of the cohort met the criteria for MetS. Both groups showed similar increase in mean OHS (MetS group 22.5 (95% CI 21.8 to 23.1), non-MetS group 22.1 (21.3 to 22.8); p = 0.477) and mean OKS (MetS group 18.0 (17.4 to 18.6), non-MetS group 17.8 (17.0 to 18.7); p = 0.722) at 12 months' follow-up. Between groups, similar improvements were seen for OHS and OKS at three and 24 months postoperatively and for the mean EQ-5D-5L, EuroQol-visual analogue scale (EQ-VAS), UCLA Activity Scale, and FJS at every timepoint.

Conclusion

Patients meeting the criteria for MetS obtain the same improvement in PROM scores as individuals without MetS up to 24 months after hip and knee arthroplasty. This is important for the clinician to take into account when assessing and advising patients with MetS.

Polyurethane: An Old Material for a New Generation of Antibiotic Spacer Implants

Background

Polyurethane tibial and acetabular inserts that release high concentrations of antibiotics were used with debridement and implant retention to treat prosthetic joint infections. The hypothesis was that a low-friction, antibiotic-releasing bearing could provide a simpler, safer, and more patient-accepted treatment for infection using antibiotic cement and intravenous antibiotics.

Methods

Patients (n = 106) with culture-positive infections received antibiotic inserts. Vancomycin and tobramycin were mixed into the polyurethane polymer at 7% by weight. Contraindications to debridement antibiotics and implant retention were a sinus tract, loose prostheses, and/or the wound could not be closed. Measurable outcomes were success in controlling infection, complications, patient acceptable symptomatic state, and need for revision surgery. Antibiotic levels were measured in joint fluid and blood; laboratory mechanical wear tests were performed; and results were compared to bone cement and polyethylene containing antibiotics.

Results

Antibiotic-infused spacers sustained joint fluid antibiotic levels 8-12 times the therapeutic level and produced low serum levels with no toxicities. Mechanical testing showed low wear and retained mechanical integrity. All patients achieved complication-free remission of infection at a follow-up of 5-26 years. All patients had Harris hip and Knee Society scores above 85, and 68% achieved patient acceptable symptomatic state.

Conclusions

All patients achieved remission of infection, fewer complications compared to revision using antibiotic bone cement, no antibiotic toxicity or adverse drug reactions, and 68% achieved patient acceptance. The antibiotic polyurethane inserts provided antibacterial efficacy comparable with currently used bone cement spacers, and their wear rate was approximately 20 times lower than bone cement as an articulation.

High Variability in Standardized Outcome Thresholds of Clinically Important Changes in Shoulder Instability Surgery: A Systematic Review

PURPOSE

To examine reported minimal clinically important difference (MCID) and patient-acceptable satisfactory state (PASS) values for patient-reported outcome measures (PROMs) after shoulder instability surgery and assess variability in published values depending on the surgery performed. Our secondary aims were to describe the methods used to derive MCID and PASS values in the published literature, including anchor-based, distribution-based, or other approaches, and to assess the frequency of MCID and PASS use in studies on shoulder instability surgery.

METHODS

A systematic review of MCID and PASS values after Bankart, Latarjet, and Remplissage procedures was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The Embase, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were queried from 1985 to 2023. Inclusion criteria included studies written in English and studies reporting use of MCID or PASS for patient-reported outcome measures (PROMS) after Latarjet, Bankart, and Remplissage approaches for shoulder instability surgery. Extracted data included study population characteristics, intervention characteristics, and outcomes of interest. Continuous data were described using medians and ranges. Categorical variables, including PROMs and MCID/PASS methods, were described using percentages. Because MCID is a patient-level rather than a group-level metric, the authors confirmed that all included studies reported proportions (%) of subjects who met or exceeded the MCID.

RESULTS

A total of 174 records were screened, and 8 studies were included in this review. MCID was the most widely used outcome threshold and was reported in all 8 studies, with only 2 studies reporting both the MCID and the PASS. The most widely studied PROMs were the American Shoulder and Elbow Surgeons (range 5.65-9.6 for distribution MCID, 8.5 anchor MCID, 86 anchor PASS); Single Assessment Numeric Evaluation (range 11.4-12.4 distribution MCID, 82.5-87.5 anchor PASS); visual analog scale (VAS) (range 1.1-1.7 distribution MCID, 1.5-2.5 PASS); Western Ontario Shoulder Instability Index (range 60.7-254.9 distribution MCID, 126.43 anchor MCID, 571-619.5 anchor PASS); and Rowe scores (range 5.6-8.4 distribution MCID, 9.7 anchor MCID). Notably, no studies reported on substantial clinical benefit or maximal outcome improvement.

CONCLUSIONS

Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. Although MCID has been the most frequently reported metric, there is considerable interstudy variability observed in their values.

CLINICAL RELEVANCE

Knowing the outcome thresholds such as MCID and PASS of the PROMs frequently used to evaluate the results of glenohumeral stabilization surgery is fundamental because they allow us to know what is a clinically significant improvement for the patient.

Establishing minimal clinically important differences and patient acceptable symptom state thresholds following birmingham hip resurfacing

INTRODUCTION

Birmingham Hip Resurfacing (BHR) has emerged as a compelling and innovative alternative to total hip arthroplasty (THA), especially among young, active patients. However, the Minimal Clinically Important Difference (MCID) and the Patient Acceptable Symptom State (PASS) thresholds have not yet been determined for patients undergoing BHR. Therefore, the current study aimed to (1) determine the MCID and PASS thresholds for both the Hip disability and Osteoarthritis Outcome Score (HOOS)-Pain and HOOS physical function shortform (PS), for patients who underwent BHR; and (2) identify factors influencing the achievement of MCID and PASS for HOOS-Pain and HOOS-PS.

METHODS

Prospectively collected data from patients undergoing BHR was analyzed. Patients with osteoarthritis and completed preoperative and 1-year postoperative PROMs were included. Distribution-based and anchored-based approaches were used to estimate MCID and PASS, respectively. The optimal cut-off point for PASS thresholds was calculated using the Youden index.

RESULTS

MCID for HOOS-Pain and PS were calculated to be 9.2 and 9.3, respectively. The PASS threshold for HOOS-Pain and PS were ≥ 77.7 and ≥ 87.3, respectively. The current study identified several factors affecting postoperative achievement of thresholds. Baseline Mental Component Summary (MCS) scores were a predictor for achieving MCID for postoperative HOOS-Pain, achieving MCID for postoperative HOOS-PS, achieving PASS for postoperative HOOS-Pain, and achieving PASS for postoperative HOOS-PS. Furthermore, baseline HOOS-Pain was a significant predictor for achieving MCID for postoperative HOOS-PS, achieving PASS for postoperative HOOS-Pain, and achieving PASS for postoperative HOOS-PS.

CONCLUSIONS

MCID and PASS thresholds were established for HOOS-Pain and PS domains following BHR with most patients achieving these clinically meaningful benchmarks. Additionally, several factors affecting achievement of MCID and PASS were identified, including modifiable risk factors that may allow clinicians to implement optimization strategies and further improve outcomes.

What Are the Diagnosis-Specific Thresholds of Minimal Clinically Important Difference and Patient Acceptable Symptom State in Hip Disability and Osteoarthritis Outcome Score After Primary Total Hip Arthroplasty?

BACKGROUND

This study aimed to determine the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) thresholds for Hip Disability and Osteoarthritis Outcome Score (HOOS) pain, physical short form (PS), and joint replacement (JR) 1 year after primary total hip arthroplasty stratified by preoperative diagnosis of osteoarthritis (OA) versus non-OA.

METHODS

A prospective institutional cohort of 5,887 patients who underwent primary total hip arthroplasty (January 2016 to December 2018) was included. There were 4,184 patients (77.0%) who completed a one-year follow-up. Demographics, comorbidities, and baseline and one-year HOOS pain, PS, and JR scores were recorded. Patients were stratified by preoperative diagnosis: OA or non-OA. Minimal detectable change (MDC) and MCIDs were estimated using a distribution-based approach. The PASS values were estimated using an anchor-based approach, which corresponded to a response to a satisfaction question at one year post surgery.

RESULTS

The MCID thresholds were slightly higher in the non-OA cohort versus OA patients. (HOOS-Pain: OA: 8.35 versus non-OA: 8.85 points; HOOS-PS: OA: 9.47 versus non-OA: 9.90 points; and HOOS-JR: OA: 7.76 versus non-OA: 8.46 points). Similarly, all MDC thresholds were consistently higher in the non-OA cohort compared to OA patients. The OA cohort exhibited similar or higher PASS thresholds compared to the non-OA cohort for HOOS-Pain (OA: ≥80.6 versus non-OA: ≥77.5 points), HOOS-PS (OA: ≥83.6 versus non-OA: ≥83.6 points), and HOOS-JR (OA: ≥76.8 versus non-OA: ≥73.5 points). A similar percentage of patients achieved MCID and PASS thresholds regardless of preoperative diagnosis.

CONCLUSIONS

While MCID and MDC thresholds for all HOOS subdomains were slightly higher among non-OA than OA patients, PASS thresholds for HOOS pain and JR were slightly higher in the OA group. The absolute magnitude of the difference in these thresholds may not be sufficient to cause major clinical differences. However, these subtle differences may have a significant impact when used as indicators of operative success in a population setting.

Use of a fluoroscopy-based robotic-assisted total hip arthroplasty system resulted in greater improvements in hip-specific outcome measures at one-year compared to a CT-based robotic-assisted system

BACKGROUND

The purpose of this study was to compare one-year patient reported outcome measures between a novel fluoroscopy-based robotic-assisted (FL-RTHA) system and an existing computerised tomography-based robotic assisted (CT-RTHA) system.

METHODS

A review of 85 consecutive FL-RTHA and 125 consecutive CT-RTHA was conducted. Outcomes included one-year post-operative Veterans RAND-12 (VR-12) Physical (PCS)/Mental (MCS), Hip Disability and Osteoarthritis Outcome (HOOS) Pain/Physical Function (PS)/Joint replacement, and University of California Los Angeles (UCLA) Activity scores.

RESULTS

The FL-RTHA cohort had lower pre-operative VR-12 PCS, HOOS Pain, HOOS-PS, HOOS-JR, and UCLA Activity scores compared with patients in the CT-RTHA cohort. The FL-RTHA cohort reported greater improvements in HOOS-PS scores (-41.54 vs. -36.55; p = 0.028) than the CT-RTHA cohort. Both cohorts experienced similar rates of major post-operative complications, and had similar radiographic outcomes.

CONCLUSIONS

Use of the fluoroscopy-based robotic system resulted in greater improvements in HOOS-PS in one-year relative to the CT-based robotic technique.

Preoperative Function Affects Ability to Achieve One-Year Minimum Clinically Important Difference for Patients Undergoing Total Knee Arthroplasty

Background

Minimum clinically important difference (MCID) values are commonly used to measure treatment success for total knee arthroplasty (TKA). MCID values vary according to calculation methodology, and prior studies have shown that patient factors are associated with failure to achieve MCID thresholds. The purpose of this study was to determine if anchor-based 1-year Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS-JR) MCID values varied among patients undergoing TKA based on patient-specific factors.

Methods

This was a retrospective review of patients undergoing TKA from 2017-2018. Patients without baseline or 1-year KOOS-JR or Patient-Reported Outcome Measurement Information System Global Health data or that underwent procedures other than primary TKA were excluded. MCIDs were calculated and compared between patient groups according to preoperative characteristics.

Results

Among the included 976 patients, 1-year KOOS-JR MCIDs were 26.6 for men, 28.2 for women, 30.7 for patients with a diagnosis of anxiety and/or depression, and 26.7 for patients without a diagnosis. One-year MCID values did not differ significantly according to gender (P = .379) or mental health diagnosis (P = .066), nor did they correlate with body mass index (β = -0.034, P = .822). Preoperative KOOS-JR decile demonstrated an inverse relationship with 1-year MCID values and attainment of MCID.

Conclusions

The proportion of patients attaining KOOS-JR MCID values demonstrated an inverse relationship with preoperative baseline function. Future investigation may identify patient factors that allow surgeons to better capture patient satisfaction with their procedure despite failure to attain a 1-year MCID.

Patient acceptable symptom state and treatment failure threshold values for work productivity and activity Impairment and EQ-5D-5L in osteoarthritis

OBJECTIVE

To estimate patient acceptable symptom state (PASS) and treatment failure (TF) threshold values for Work Productivity and Activity Impairment (WPAI) measure and EQ-5D-5L among people with hip or knee osteoarthritis (OA) 3 and 12 months following participation in a digital self-management intervention (Joint Academy®).

METHODS

Among the participants, we computed work and activity impairments scores (both 0-100, with a higher value reflecting higher impairment) and the Swedish hypothetical- (range: - 0.314 to 1) and experience-based (range: 0.243-0.976) EQ-5D-5L index scores (a higher score indicates better health status) at 3- (n = 14,607) and 12-month (n = 2707) follow-ups. Threshold values for PASS and TF were calculated using anchor-based adjusted predictive modeling. We also explored the baseline dependency of threshold values according to pain severity at baseline.

RESULTS

Around 42.0% and 48.3% of the participants rated their current state as acceptable, while 4.2% and 2.8% considered the treatment had failed at 3 and 12 months, respectively. The 3-month PASS/TF thresholds were 16/29 (work impairment), 26/50 (activity impairment), 0.92/0.77 (hypothetical EQ-5D-5L), and 0.87/0.77 (the experience-based EQ-5D-5L). The thresholds at 12 months were generally comparable to those estimated at 3 months. There were baseline dependencies in PASS/TF thresholds with participants with more severe baseline pain considering poorer (more severe) level of WPAI/EQ-5D-5L as satisfactory.

CONCLUSION

PASS and TF threshold values for WPAI and EQ-5D-5L might be useful for meaningful interpretation of these measures among people with OA. The observed baseline dependency of estimated thresholds limits their generalizability and values should be applied with great caution in other settings/populations.

Clinical Significance Thresholds in Primary and Revision Latarjet Procedures With Comparable Outcome Achievements

BACKGROUND

Given the variability across populations and settings, defining the MCID and the PASS for the Rowe and ASOSS scores and patients undergoing primary and revision Latarjet it is essential to have accurate benchmarks relevant to these groups when interpreting clinical results.

PURPOSE

To determine the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) thresholds for the visual analog scale (VAS) for pain during sports, Athletic Shoulder Outcome Scoring System (ASOSS), and Rowe scores after primary and revision Latarjet procedures for treatment of shoulder instability.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Between January 2018 and January 2020, a retrospective review of 149 patients undergoing primary Latarjet (n = 82) and revision Latarjet (n = 67) to treat shoulder instability was performed in a single institution. Patient-reported outcome measures were collected preoperatively and 1 year postoperatively. The delta was defined as the change between the pre- and postoperative scores. Distribution-based and anchored-based approaches were used to estimate the MCID and the PASS, respectively. The optimal cutoff point and the percentage of patients achieving those thresholds were also calculated.

RESULTS

The distribution-based MCIDs after primary Latarjet were 1.1, 7.5, and 9.6 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the MCID thresholds were 93.9%, 98.7%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds after primary Latarjet were ≤1, ≥90, and ≥85 for the VAS, Rowe, and ASOSS scores, respectively. The percentages of patients who achieved PASS thresholds were 82.9%, 89%, and 86.5% for the VAS, Rowe, and ASOSS scores, respectively. The distribution-based MCIDs after revision Latarjet were 0.6, 6.2, and 3.4 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved MCID thresholds were 89.3%, 100%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds were ≤3, ≥87, and ≥86 after revision Latarjet for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the PASS thresholds were 88%, 88%, and 91% for the VAS, Rowe, and ASOSS, respectively.

CONCLUSION

This study identified useful values for the MCID and PASS thresholds in VAS, Rowe, and ASOSS scores after primary and revision Latarjet procedures for treating shoulder instability. Most patients achieved MCID and PASS benchmarks, indicating successful primary and revision Latarjet procedure outcomes. These metrics can serve as valuable parameters when analyzing parameters in future studies and have the potential to enhance patient care by optimizing treatment strategies and surgical decision making.

Who Benefits From Hip Arthroplasty or Knee Arthroplasty? Preoperative Patient-reported Outcome Thresholds Predict Meaningful Improvement

BACKGROUND

Hip arthroplasty (HA) and knee arthroplasty (KA) are high-volume procedures. However, there is a debate about the quality of indication; that is, whether surgery is truly indicated in all patients. Patient-reported outcome measures (PROMs) may be used to determine preoperative thresholds to differentiate patients who will likely benefit from surgery from those who will not.

QUESTIONS/PURPOSES

(1) What were the minimum clinically important differences (MCIDs) for three commonly used PROMs in a large population of patients undergoing HA or KA treated in a general orthopaedic practice? (2) Do patients who reach the MCID differ in important ways from those who do not? (3) What preoperative PROM score thresholds best distinguish patients who achieve a meaningful improvement 12 months postsurgery from those who do not? (4) Do patients with preoperative PROM scores below thresholds still experience gains after surgery?

METHODS

Between October 1, 2019, and December 31, 2020, 4182 patients undergoing HA and 3645 patients undergoing KA agreed to be part of the PROMoting Quality study and were hence included by study nurses in one of nine participating German hospitals. From a selected group of 1843 patients with HA and 1546 with KA, we derived MCIDs using the anchor-based change difference method to determine meaningful improvements. Second, we estimated which preoperative PROM score thresholds best distinguish patients who achieve an MCID from those who do not, using the preoperative PROM scores that maximized the Youden index. PROMs were Hip Disability and Osteoarthritis Outcome Score-Physical Function short form (HOOS-PS) (scored 0 to 100 points; lower indicates better health), Knee Injury and Osteoarthritis Outcome Score-Physical Function short form (KOOS-PS) (scored 0 to 100 points; lower indicates better health), EuroQol 5-Dimension 5-level (EQ-5D-5L) (scored -0.661 to 1 points; higher indicates better health), and a 10-point VAS for pain (perceived pain in the joint under consideration for surgery within the past 7 days) (scored 0 to 10 points; lower indicates better health). The performance of derived thresholds is reported using the Youden index, sensitivity, specificity, F1 score, geometric mean as a measure of central tendency, and area under the receiver operating characteristic curve.

RESULTS

MCIDs for the EQ-5D-5L were 0.2 for HA and 0.2 for KA, with a maximum of 1 point, where higher values represented better health-related quality of life. For the pain scale, they were -0.9 for HA and -0.7 for KA, of 10 points (maximum), where lower scores represent lower pain. For the HOOS-PS, the MCID was -10, and for the KOOS-PS it was -5 of 100 points, where lower scores represent better functioning. Patients who reached the MCID differed from patients who did not reach the MCID with respect to baseline PROM scores across the evaluated PROMs and for both HA and KA. Patients who reached an MCID versus those who did not also differed regarding other aspects including education and comorbidities, but this was not consistent across PROMs and arthroplasty type. Preoperative PROM score thresholds for HA were 0.7 for EQ-5D-5L (Youden index: 0.55), 42 for HOOS-PS (Youden index: 0.27), and 3.5 for the pain scale (Youden index: 0.47). For KA, the thresholds were 0.6 for EQ-5D-5L (Youden index: 0.57), 39 for KOOS-PS (Youden index: 0.25), and 6.5 for the pain scale (Youden index: 0.40). A higher Youden index for EQ-5D-5L than for the other PROMs indicates that the thresholds for EQ-5D-5L were better for distinguishing patients who reached a meaningful improvement from those who did not. Patients who did not reach the thresholds could still achieve MCIDs, especially for functionality and the pain scale.

CONCLUSION

We found that patients who experienced meaningful improvements (MCIDs) mainly differed from those who did not regarding their preoperative PROM scores. We further identified that patients undergoing HA or KA with a score above 0.7 or 0.6, respectively, on the EQ-5D-5L, below 42 or 39 on the HOOS-PS or KOOS-PS, or below 3.5 or 6.5 on a 10-point joint-specific pain scale presurgery had no meaningful benefit from surgery. The thresholds can support clinical decision-making. For example, when thresholds indicate that a meaningful improvement is not likely to be achieved after surgery, other treatment options may be prioritized. Although the thresholds can be used as support, patient preferences and medical expertise must supplement the decision. Future studies might evaluate the utility of using these thresholds in practice, examine how different thresholds can be combined as a multidimensional decision tool, and derive presurgery thresholds based on additional PROMs used in practice.

CLINICAL RELEVANCE

Preoperative PROM score thresholds in this study will support clinicians in decision-making through objective measures that can improve the quality of the recommendation for surgery.

Establishing the Minimal Clinically Important Difference and Patient Acceptable Symptom State Thresholds Following Arthroscopic Capsular Release for the Treatment of Idiopathic Shoulder Adhesive Capsulitis

PURPOSE

To determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) threshold for the visual analog scale (VAS), Constant, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores following arthroscopic capsular release for the treatment of idiopathic shoulder adhesive capsulitis.

METHODS

A retrospective review of prospective collected data was performed in patients undergoing arthroscopic capsular release for the treatment of idiopathic adhesive capsulitis at a single institution from January 2018 through January 2019. Patient-reported outcome measures were collected preoperatively and 6 months' postoperatively. Delta was defined as the change between preoperative and 6 months' postoperative scores. Distribution-based and anchored-based (response to a satisfaction question at 1 year) approaches were used to estimate MCIDs and PASS, respectively. The optimal cut-off point where sensitivity and specificity were maximized (Youden index) and the percentage of patients achieving those thresholds were also calculated.

RESULTS

Overall, a total of 100 patients without diabetes who underwent arthroscopic capsular release and completed baseline and 6-month patient-reported outcome measures were included. The distribution-based MCID for VAS, Constant, SANE, and ASES were calculated to be 1.1, 10.1, 9.3, and 8.2, respectively. The rate of patients who achieved MCID thresholds was 98% for VAS, 96% for Constant, 98% for SANE, and 99% for ASES. The PASS threshold values for VAS, Constant, and ASES were ≤2, ≥70, ≥80, and ≥80, respectively. The rate of patients who achieved PASS thresholds was 84% for VAS, 84% for Constant, 89% for SANE, and 78% for ASES.

CONCLUSIONS

In patients without diabetes and idiopathic adhesive capsulitis, high rates of MCID and PASS thresholds can be achieved with arthroscopic anteroinferior capsular release LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Establishing the Patient Acceptable Symptom State in a Nonshoulder Hand and Upper Extremity Population for the QuickDASH and PROMIS UE Computer Adaptive Tests

PURPOSE

It is unclear what score thresholds on patient-reported outcomes instruments reflect an acceptable level of upper extremity (UE) function from the perspective of patients undergoing hand surgery. The purpose of this study was to calculate the patient acceptable symptom state (PASS) for the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient-Reported Outcomes Measurement Information System (PROMIS) UE Computer Adaptive Test (CAT), version 2.0, in a population who underwent hand surgery.

METHODS

Adult patients who underwent hand surgery between February 2019 and December 2019 at a single academic tertiary institution were identified. QuickDASH and PROMIS UE CAT version 2.0 scores were collected 1 year after surgery, as were separate symptom- and function-specific anchor questions that queried the acceptability of patients' current state. Threshold values predictive of a patient reporting an acceptable symptom state (PASS[+]) were calculated for both instruments using the 75th percentile score for patients in the PASS(+) group and the Youden Index as determined by receiver operating curve (ROC) analysis.

RESULTS

A total of 222 patients were included. QuickDASH and PROMIS UE CAT scores differed significantly between the PASS(+) and PASS(-) groups. The 75th percentile method yielded PASS values of <16 for the QuickDASH and >43 for the PROMIS UE CAT for both anchor questions. The ROC analysis yielded PASS estimates of <15.9 to <20.5 for the QuickDASH and >38.1 to >46.2 for the PROMIS UE CAT, with ranges calculated from differing threshold values for each of the 2 anchor questions. The ROC-based estimates demonstrated high levels of model discrimination (area under the curve ≥ 0.80).

CONCLUSIONS

We propose PASS estimates obtained using the 75th percentile and ROC methods.

CLINICAL RELEVANCE

Specifically, PASS values in the range of 15.9-20.5 for the QuickDASH and 38.1-46.2 for the PROMIS UE CAT version 2.0 should be used when interpreting outcomes at a population level.

Short versus conventional straight stem in uncemented total hip arthroplasty: functional outcomes up to 5 years and survival up to 12 years: secondary results of a randomized controlled trial

BACKGROUND AND PURPOSE

To date, the mid- and long-term outcomes of the Collum Femoris Preserving (CFP) stem compared with conventional straight stems are unknown. We aimed to compare physical function at a 5-year follow-up and implant survival at an average of 10-year follow-up in an randomized controlled trial (RCT).

METHODS

This is a secondary report of a double-blinded RCT in 2 hospitals. Patients aged 18-70 years with hip osteoarthritis undergoing an uncemented primary THA were randomized to a CFP or a Zweymüller stem. Patient-reported outcomes, clinical tests, and radiographs were collected at baseline, 2, 3, 4, and 5 years postoperatively. Primary outcome was the Hip disability and Osteoarthritis Outcome Score (HOOS) function in activities of daily living (ADL) subscale. Secondary outcomes were other patient-reported outcomes, clinical tests, adverse events, and implant survival. Kaplan-Meier and competing risk survival analyses were performed with data from the Dutch Arthroplasty Registry.

RESULTS

We included 150 patients. Mean difference between groups on the HOOS ADL subscale at 5 years was -0.07 (95% confidence interval -5.1 to 4.9). Overall survival was 92% for the CFP and 96% for the Zweymüller stem. No significant difference was found.

CONCLUSION

No significant differences were found in physical function at 5-year and implant survival at 10-year follow-up between the CFP and Zweymüller stems. When taking cup revisions into account, the CFP group showed clinically inferior survival.

Treatment of Severely Shortened or Comminuted Clavicular Fractures in Older Adolescent Athletes

BACKGROUND

Recent evidence suggests that for completely displaced midshaft clavicular fractures, surgery offers no clear benefit over nonoperative treatment in a general adolescent population from 10 to 18 years of age. However, the comparative outcomes of comminuted and/or severely shortened clavicular fractures specifically in older adolescent athletes have not been explored in a focused, methodologically rigorous fashion.

HYPOTHESIS

The study hypothesis was that outcomes would be superior in older adolescent athletes who underwent operative treatment compared with nonoperative treatment for comminuted and/or severely shortened clavicular fractures.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A level 2, multicenter, prospective cohort study investigating the outcomes of midshaft fractures in adolescents between 2013 and 2017 was filtered to analyze the subcohorts of athletes 14 to 18 years of age with either fracture comminution or fracture shortening of ≥25 mm or both. Patient characteristics, injury mechanisms, fracture characteristics, and treatments were compared. Complications, rates, timing of return to sports (RTS), and patient-reported outcomes (PROs) were analyzed.

RESULTS

The 2 treatment groups, which included 136 older adolescent athletes (69 nonoperative, 67 operative), showed similar distributions of primary sport type, competition level, comminution, shortening, and 2-year PRO response rate (n = 99; 73%). The operative group demonstrated 3 mm-greater mean superior displacement, which was therefore statistically controlled for as a confounder in the comparative PRO analysis. No 2-year differences in nonunion, delayed union, symptomatic malunion, refracture, clinically significant complications, or rates of RTS were detected between treatment groups. The difference in timing of RTS (operative, 10.3 weeks; nonoperative, 13.5 weeks) was statistically significant. After controlling for the minor difference in superior displacement, regression analysis and matched comparison cohorts demonstrated no differences between the nonoperative and operative groups in mean or dichotomized PRO scores.

CONCLUSION

In this prospective, multicenter cohort study investigating older adolescent athletes with comminuted and/or severely shortened clavicular fractures, contrary to the study hypothesis, there were no differences in complications, RTS, or PROs between nonoperatively and operatively treated patients at 2 years. Comparably excellent outcomes of severe clavicular fractures in adolescent athletes can be achieved with nonoperative treatment.

Do the Revision Rates of Arthroplasty Surgeons Correlate With Postoperative Patient-reported Outcome Measure Scores? A Study From the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Patient-reported outcome measures (PROMs) are a pragmatic and efficient means to evaluate the functional quality of arthroplasty beyond revision rates, which are used by most joint replacement registries to judge success. The relationship between these two measures of quality-revision rates and PROMs-is unknown, and not every procedure with a poor functional result is revised. It is logical-although still untested-that higher cumulative revision rates correlate inversely with PROMs for individual surgeons; more revisions are associated with lower PROM scores.

QUESTIONS/PURPOSES

We used data from a large national joint replacement registry to ask: (1) Does a surgeon's early THA cumulative percent revision (CPR) rate and (2) early TKA CPR rate correlate with the postoperative PROMs of patients undergoing primary THA and TKA, respectively, who have not undergone revision?

METHODS

Elective primary THA and TKA procedures in patients with a primary diagnosis of osteoarthritis that were performed between August 2018 and December 2020 and registered in the Australian Orthopaedic Association National Joint Replacement Registry PROMs program were eligible. THAs and TKAs were eligible for inclusion in the primary analysis if 6-month postoperative PROMs were available, the operating surgeon was clearly identified, and the surgeon had performed at least 50 primary THAs or TKAs. Based on the inclusion criteria, 17,668 THAs were performed at eligible sites. We excluded 8878 procedures that were not matched to the PROMs program, leaving 8790 procedures. A further 790 were excluded because they were performed by unknown or ineligible surgeons or were revised, leaving 8000 procedures performed by 235 eligible surgeons, including 4256 (53%; 3744 cases of missing data) patients who had postoperative Oxford Hip Scores and 4242 (53%; 3758 cases of missing data) patients who had a postoperative EQ-VAS score recorded. Complete covariate data were available for 3939 procedures for the Oxford Hip Score and for 3941 procedures for the EQ-VAS. A total of 26,624 TKAs were performed at eligible sites. We excluded 12,685 procedures that were not matched to the PROMs program, leaving 13,939 procedures. A further 920 were excluded because they were performed by unknown or ineligible surgeons, or because they were revisions, leaving 13,019 procedures performed by 276 eligible surgeons, including 6730 (52%; 6289 cases of missing data) patients who had had postoperative Oxford Knee Scores and 6728 (52%; 6291 cases of missing data) patients who had a postoperative EQ-VAS score recorded. Complete covariate data were available for 6228 procedures for the Oxford Knee Score and for 6241 procedures for the EQ-VAS. The Spearman correlation between the operating surgeon's 2-year CPR and 6-month postoperative EQ-VAS Health and Oxford Hip or Oxford Knee Score was evaluated for THA and TKA procedures where a revision had not been performed. Associations between postoperative Oxford and EQ-VAS scores and a surgeon's 2-year CPR were estimated based on multivariate Tobit regressions and a cumulative link model with a probit link, adjusting for patient age, gender, ASA score, BMI category, preoperative PROMs, as well as surgical approach for THA. Missing data were accounted for using multiple imputation, with models assuming they were missing at random and a worst-case scenario.

RESULTS

Of the eligible THA procedures, postoperative Oxford Hip Score and surgeon 2-year CPR were correlated so weakly as to be clinically irrelevant (Spearman correlation ρ = -0.09; p < 0.001), and the correlation with postoperative EQ-VAS was close to zero (ρ = -0.02; p = 0.25). Of the eligible TKA procedures, postoperative Oxford Knee Score and EQ-VAS and surgeon 2-year CPR were correlated so weakly as to be clinically irrelevant (ρ = -0.04; p = 0.004 and ρ = 0.03; p = 0.006, respectively). All models accounting for missing data found the same result.

CONCLUSION

A surgeon's 2-year CPR did not exhibit a clinically relevant correlation with PROMs after THA or TKA, and all surgeons had similar postoperative Oxford scores. PROMs, revision rates, or both may be inaccurate or imperfect indicators of successful arthroplasty. Missing data may limit the findings of this study, although the results were consistent under a variety of different missing data scenarios. Innumerable factors contribute to arthroplasty results, including patient-related variables, differences in implant design, and the technical quality of the procedure. PROMs and revision rates may be analyzing two different facets of function after arthroplasty. Although surgeon variables are associated with revision rates, patient factors may exert a stronger influence on functional outcomes. Future research should identify variables that correlate with functional outcome. Additionally, given the gross level of function that Oxford scores record, outcome measures that can identify clinically meaningful functional differences are required. The use of Oxford scores in national arthroplasty registries may rightfully be questioned.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Effect of Patient Characteristics on the Minimal Clinically Important Difference and Patient Acceptable Symptom State Thresholds After Arthroscopic Bankart Repair

BACKGROUND

There is scarce literature on clinically significant values after arthroscopic Bankart repair (ABR).

PURPOSE

To determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) thresholds at 1 year for the Rowe and Athletic Shoulder Outcome Scoring System (ASOSS) scores after ABR and to determine the effect of patient characteristics on these metrics after ABR.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of patients undergoing ABR from a single institution between January 2017 and January 2020 was performed. Patients with at least 1 episode of instability and a minimum follow-up of 12 months were included. The exclusion criteria were as follows: bony defects of >20% on the anteroinferior portion of the glenoid based on a preoperative computed tomography scan; engaging Hill-Sachs lesions at 90° of abduction and 90° of external rotation based on an arthroscopic examination; previous surgery on the same shoulder; multidirectional instability or concomitant repair of full-thickness rotator cuff tears; superior labral anterior to posterior lesions; posterior labral tears; or humeral avulsion of the glenohumeral ligament lesions. Patient-reported outcome measures were collected both preoperatively and 1-year postoperatively. Delta was defined as the change between preoperative and 1-year postoperative scores. Distribution-based (one-half the standard deviation of the difference between pre- and postoperative outcome scores) and anchored-based approaches (response to a satisfaction question at 1 year) were used to estimate the MCID and the PASS, respectively. The optimal cutoff point, where sensitivity and specificity were maximized, and the percentage of patients achieving those thresholds were also calculated.

RESULTS

Overall, 190 patients were included. The distribution-based MCID for the Rowe and ASOSS scores were calculated to be 8.2 and 8.7, respectively. The rate of patients who achieved MCID thresholds was 96% for the Rowe and 96% for ASOSS scores. The PASS threshold for the Rowe and ASOSS scores were ≥80 and ≥90, respectively. The rate of patients who achieved PASS scores after ABR were 86% and 83%, respectively. The MCID and PASS values showed great variability based on sex (men: 8.5 and ≥85 for Rowe / 8.9 and ≥90 for ASOSS, respectively, vs women: 6.7 and ≥73 for Rowe / 8.1 and ≥75 for ASOSS), age (≥21: 8.4 and ≥80 / 9.2 and ≥90 vs <21: 7.8 and ≥75 / 7.7 and ≥85), sports participation (sports: 8.8 and ≥85 / 9.5 and ≥90 vs no sports: 8.1 and ≥75 / 8.6 and ≥80), and type of athlete (competitive: 8.4 and ≥85 / 8.9 and ≥87 vs recreational: 7.5 and ≥73 / 8.1 and ≥68).

CONCLUSION

This study identified the MCID and PASS thresholds for the Rowe and ASOSS scores at 1 year after ABR. However, these values showed great variability when accounting for different patient characteristics such as sex, age, sports participation, and type of athlete, highlighting the importance of considering individual patient-specific characteristics for optimal treatment decision-making and ensuring treatment success tailored to each patient's unique needs and expectations.

Hip Resurfacing in Teenagers

BACKGROUND

The goals of hip resurfacing are to relieve pain, restore function, and preserve future reconstructive options. Hip resurfacing is an attractive and sometimes the only option when the femoral canal is blocked, making total hip arthroplasty (THA) difficult. Hip resurfacing also can be an attractive option for a teenager on the rare occasion when a hip implant is needed.

METHODS

A cementless ceramic-coated femoral resurfacing implant matched with a highly cross-linked polyethylene acetabular bearing was used in 105 patients (117 hips) aged 12 to 19 years. The mean follow-up was 14 years (range, 5 to 25). No patients were lost to follow-up before 19 years. Osteonecrosis, residuals of trauma, developmental dysplasia, and childhood hip diseases were the common reasons requiring surgery. Patients were evaluated using patient-reported outcomes, patient acceptable symptom states (PASS), and implant survivorships. Radiographs and retrievals were also examined.

RESULTS

There were 2 revisions (polyethylene liner exchange at 12 years and femoral revision for osteonecrosis at 14 years). The mean postoperative Hip Disability Osteoarthritis Outcome Score (HOOS) was 94 points (range, 80 to 100) and the mean Harris Hip Score (HHS) score was 96 points (range, 80 to 100). All patients achieved Minimal Clinically Important Difference improvement in their HHS and HOOS scores. There were 99 (85%) hip resurfacing procedures achieving a satisfactory PASS and 72 (69%) patients were active in sports.

CONCLUSION

Hip resurfacing is a highly technical procedure. Careful implant selection is required. The meticulous preoperative planning, careful extensile surgical exposure, and exacting implant placement in this study likely contributed to the favorable results achieved. Hip resurfacing allows THA as a future option in patients where the lifetime revision rate is a major consideration.

Sensitivity analysis of EQ-5D-3L index scores in terms of discriminative and known-groups validity in SLE: introducing Adequate Health State

OBJECTIVES

To investigate the ability of different EuroQol 5-Dimensions 3-Levels (EQ-5D-3L) index scores to discriminate between verum drug and placebo (discriminant validity) as well as between responders and non-responders (known-groups validity) in the SLE patient population of two phase III clinical trials of belimumab.

METHODS

Data from the BLISS-52 (NCT00424476) and BLISS-76 (NCT00410384) trials (N = 1684), which both showed superiority of belimumab to placebo, were utilized. Responders were defined as SLE Responder Index 4 (SRI-4) achievers at week 52. The Pearson's χ2 and Mann-Whitney U tests were used for comparisons, and logistic regression analysis was used for adjustments for confounders and assessment of independence.

RESULTS

While full health state (FHS; EQ-5D index score 1) showed the best ability to discriminate between belimumab and placebo [adjusted odds ratio (OR) 1.47; 95% CI 1.11, 1.96; P = 0.008] and between SRI-4 responders and non-responders (adjusted OR 3.47; 95% CI 1.29, 10.98; P = 0.020), the discriminative ability of EQ-5D index scores 0.800 or more reached statistical significance for both discriminant validity (adjusted OR 1.29; 95% CI 1.02, 1.63; P = 0.036) and known-groups validity (adjusted OR 3.08; 95% CI 1.16, 9.69; P = 0.034).

CONCLUSION

Overall, higher EQ-5D index scores were associated with increasing ability to discriminate between belimumab and placebo, and between responders and non-responders. EQ-5D index scores less stringent than FHS may be clinically relevant health-related quality of life goals of treatment in patients with SLE, introducing the concept of EQ-5D adequate health state when FHS is not achievable.

National population-based reference data for the Hip Disability and Osteoarthritis Outcome Score (HOOS)

INTRODUCTION

Interpretation of patient-reported outcome scores such as the Hip Disability and Osteoarthritis Outcome Score (HOOS) can be improved with use of reference values. The aim of the study was to establish population-based reference values for the HOOS' five subscales and its short-form HOOS-12.

MATERIALS AND METHODS

A representative sample of 9997 Danish citizens 18 years and older were identified. The population record-based sample was based on seven predefined age groups and an equal sex distribution within each age group. A national secure electronic system was used to send the HOOS questionnaire and one supplementary question regarding previous hip complaints to all participants.

RESULTS

2277 participants completed the HOOS, 947 women (42%) and 1330 men (58%). The mean HOOS subscale scores were: pain 86.9 (95% CI 86.1-87.7), symptoms 83.7 (95% CI 82.9-84.5), ADL 88.2 (95% CI 87.5-89.0), sport and recreation function 83.1 (95% CI 82.0-84.1), QOL 82.7 (95% CI 81.8-83.6). The youngest age group reported better mean scores in four subscales compared to the oldest age group (pain 91.7 vs. 84.5, mean difference 7.2 95% CI 0.4-14.0), (ADL 94.6 points vs. 83.2, mean difference 11.4 95% CI 4.9-17.8), (sport and recreation function 91.5 points vs. 73.8 points, mean difference 17.7 95% CI 9.0-26.4), (QOL 88.9 points vs. 78.8, mean difference 10.1 points 95% CI 2.0-18.2). Participants with a self-reported hip complaint had worse HOOS scores across all subscales (mean difference range 22.1-34.6). Super obese patients (BMI > 40) had > 12.5 points worse scores across the five HOOS subscales. Results were similar for the HOOS-12.

CONCLUSION

This study provides reference values for the HOOS and its short form HOOS-12. Results show that older patients and patients with a BMI over 40 have worse HOOS and HOOS-12 scores that may be of clinical importance in the interpretation of scores both when evaluating potential for improvement and post-treatment results.

No clinically relevant difference in patient-reported outcomes between the direct superior approach and the posterolateral or anterior approach for primary total hip arthroplasty: analysis of 37,976 primary hip arthroplasties in the Dutch Arthroplasty Registry

BACKGROUND AND PURPOSE

The direct superior approach (DSA) is a modification of the posterolateral approach (PLA) for total hip arthroplasty (THA). Patient-reported outcome measures (PROMs) of the DSA have not been investigated previously using nationwide data. Our aim was to assess PROMs after THA using the DSA compared with the PLA and, secondarily, with the anterior approach (DAA).

PATIENTS AND METHODS

In this population-based cohort study we included 37,976 primary THAs performed between 2014 and 2020 (PLA: n = 22,616; DAA: n = 15,017; DSA: n = 343) using Dutch Arthroplasty Registry data. PROMs (NRS pain, EQ-5D, HOOS-PS, and OHS) were measured preoperatively, and at 3 and 12 months postoperatively. Repeated measurements were analyzed using mixed-effects models, adjusted for confounders, to investigate the association between surgical approach and PROMs over time.

RESULTS

From baseline to 3 and 12 months, improvements for NRS pain scores, EQ-5D, and OHS were comparable for the DSA compared with the PLA or DAA. No difference was found in HOOS-PS improvement 3 months postoperatively between DSA and PLA (-0.2, 95% confidence interval [CI] -2.4 to 1.9) and between DSA and DAA (-1.7, CI -3.9 to 0.5). At 12 months postoperatively, patients in the DSA group had improved -2.8 points (CI -4.9 to -0.6) more in HOOS-PS compared with the DAA, but not with the PLA group (-1.0, CI -3.2 to 1.1).

CONCLUSION

Our study showed no clinically meaningful differences between the DSA and either PLA or DAA.

The Minimum Clinically Important Difference for the Patient-Rated Wrist Evaluation in Surgical Fixation of Distal Radius Fractures: Does Hand Dominance Make a Difference?

BACKGROUND

Distal radius fractures (DRFs) are common orthopaedic injuries. They can be treated in many ways, but the volar locking plate (VLP) is more frequent. Currently, there is limited information regarding the minimum clinically important difference (MCID) in surgically treated DRFs. The purpose of this study was to calculate MCID values for the Patient-Reported Wrist Evaluation (PRWE) in the setting of VLP-treated DRFs.

METHODS

A retrospective review was conducted for patients with isolated, surgically-treated DRFs with a VLP. Exclusions included any concomitant procedure other than a carpal tunnel release, skeletal immaturity, polytrauma, open fracture, or missing PRWE data. MCID was calculated using PRWE, an overall health question, and the anchor-based method.

RESULTS

A total of 131 patients were identified. Approximately 54.2% injured their dominant hand. AO/OTA classification 23C was the most common (n=89, 67.9%). Average baseline, 6-week, and 12-week PRWE were 71.8 ± 19.6, 34.3 ± 20.1, and 21.2 ± 18.0 respectively. This corresponds to an average change from baseline PRWE at 6 weeks and 12 weeks of -37.5 ± 23.4 and -50.6 ± 22.3, respectively. Average MCID values for 6 weeks and 12 weeks were 43.1 ± 18 and 56.0 ± 20.0, respectively (p<0.001). Hand dominance did not correlate with MCID value (rs = 0.084 at six weeks, rs = 0.099 at 12 weeks). MCID value additionally did not correlate with sex, AO/OTA classification, smoking status, ASA score, or BMI. Treatment at a level 1 trauma center and diagnosis of anxiety and/or depression correlated with a higher 6-week MCID value (rs = 0.308 and rs = 0.410, respectively). Increasing age weakly correlated with higher 12-week MCID value (rs = 0.352).

CONCLUSIONS

This study demonstrated an MCID calculation using an overall health anchor. MCID value varied with follow-up time and correlated weakly with age, diagnosis of anxiety and/or depression, and treatment facility, but it did not correlate with injury of the dominant hand. Future research should analyze how to apply MCID and identify successful treatment in the setting of DRF care.

Outcome of patients with osteoarthritis aged 90 to 101 years after cemented total hip arthroplasty: 1,385 patients from the Swedish Arthroplasty Register

BACKGROUND AND PURPOSE

Few studies have focused on nonagenarians treated with total hip arthroplasty (THA). We investigated 30- and 90-day postoperative mortality, patient-reported outcome measures (PROMs), reoperation rate, risk factors for reoperation, and relative patient survival in nonagenarians or older.

PATIENTS AND METHODS

167,091 patients with primary cemented THA performed for osteoarthritis between 1992 and 2019 were identified in the Swedish Arthroplasty Register. Patients were divided into age groups based on age at time of surgery: 60-74 (n = 90,285), 75-89 (n = 75,421), and > 90 years (n = 1,385). Mortality rate, PROMs (pain-Likert scale, satisfaction-Likert scale, EQ-VAS, n = 67,553), reoperation rate, risk factors for reoperation, and relative patient survival were studied.

RESULTS

The nonagenarians had the highest postoperative mortality rate, 1.7% and 2.6% at 30 and 90 days, respectively. Nonagenarian females reported significantly lower pre- and postoperative EQ-VAS compared with patients aged 60-89 years but reported least pain and highest patient satisfaction 1 year after surgery. At 2 years the nonagenarians had highest reoperation frequency-2.7%-due to infection (1.5%), dislocation (0.8%), and periprosthetic fracture (0.4%). Increasing age, male sex, and polished stem were associated with higher risk of reoperation within 2 years. 8-year age- and sex-matched relative survival was highest among nonagenarians (study group/matched population: ≥ 90 years 3.4, 95% confidence interval [CI] 3.0-3.8; 75-89 years: 1.4, CI 1.4-1.4, and 60-74 years: 1.1, CI 1.1-1.1).

CONCLUSION

30- and 90-day postoperative mortality and reoperation rates were higher in nonagenarians but PROM data showed least pain and highest patient satisfaction 1 year after surgery with THA among female nonagenarians with primary osteoarthritis.

Incidence of bony Bankart lesions in Sweden: a study of 790 cases from the Swedish fracture register

BACKGROUND

A bony Bankart lesion directly affects the stability of the shoulder by reducing the glenoid joint-contact area. The aim of this study was to report on the epidemiological data relating to bony Bankart lesions in Sweden using the Swedish fracture register. The purpose is to evaluate age and sex distribution in the population with bony Bankart lesions, its impact on treatment strategy and further to analyse patient-reported outcomes.

METHODS

This was an epidemiological descriptive study. The inclusion criteria were all patients with a unilateral bony Bankart lesion registered between April 2012 and April 2019. The patients' specific data (age, sex, type and time of injury, treatment option and patient-reported outcomes) were extracted from the Swedish fracture register database.

RESULTS

A total of 790 unilateral bony Bankart fractures were identified. The majority of the patients were male (58.7%). The median age for all patients at the time of injury was 57 years. Females had a higher median age of 66 years, compared with males, 51 years. Most of the bony Bankart lesions, 662 (91.8%), were registered as a low-energy trauma. More than two-thirds of all treatment registered cases, 509/734 patients (69.3%), were treated non-surgically, 225 (30.7%) were treated surgically, while, in 17 patients (7.5% of all surgically treated patients), the treatment was changed from non-surgical to surgical due to recurrent instability. Surgical treatment was chosen for 149 (35%) of the males and for 76 (25%) of the females. Patient quality of life decreased slightly in both surgically and non-surgically treated groups 1 year after bony Bankart injury.

CONCLUSION

This national register-based study provides detailed information on the epidemiology, choice of treatment and patient-reported outcomes in a large cohort of bony Bankart lesions. Most bony Bankart lesions affected males between 40 and 75 years after low-energy falls and non-surgical treatment dominated.

Predicting whether patients will achieve minimal clinically important differences following hip or knee arthroplasty

Aims

A substantial fraction of patients undergoing knee arthroplasty (KA) or hip arthroplasty (HA) do not achieve an improvement as high as the minimal clinically important difference (MCID), i.e. do not achieve a meaningful improvement. Using three patient-reported outcome measures (PROMs), our aim was: 1) to assess machine learning (ML), the simple pre-surgery PROM score, and logistic-regression (LR)-derived performance in their prediction of whether patients undergoing HA or KA achieve an improvement as high or higher than a calculated MCID; and 2) to test whether ML is able to outperform LR or pre-surgery PROM scores in predictive performance.

Methods

MCIDs were derived using the change difference method in a sample of 1,843 HA and 1,546 KA patients. An artificial neural network, a gradient boosting machine, least absolute shrinkage and selection operator (LASSO) regression, ridge regression, elastic net, random forest, LR, and pre-surgery PROM scores were applied to predict MCID for the following PROMs: EuroQol five-dimension, five-level questionnaire (EQ-5D-5L), EQ visual analogue scale (EQ-VAS), Hip disability and Osteoarthritis Outcome Score-Physical Function Short-form (HOOS-PS), and Knee injury and Osteoarthritis Outcome Score-Physical Function Short-form (KOOS-PS).

Results

Predictive performance of the best models per outcome ranged from 0.71 for HOOS-PS to 0.84 for EQ-VAS (HA sample). ML statistically significantly outperformed LR and pre-surgery PROM scores in two out of six cases.

Conclusion

MCIDs can be predicted with reasonable performance. ML was able to outperform traditional methods, although only in a minority of cases.

Interpretation threshold values for patient-reported outcomes in patients participating in a digitally delivered first-line treatment program for hip or knee osteoarthritis

Objective

Establish proportions of patients reporting important improvement, acceptable symptoms and treatment failure and define interpretation threshold values for pain, patient-reported function and quality-of-life after participating in digital first-line treatment including education and exercise for hip and knee osteoarthritis (OA).

Methods

Observational study. Responses to the pain Numeric Rating Scale (NRS, 0-10 best to worst), Knee injury and Osteoarthritis Outcome Score 12 (KOOS-12) and Hip disability and Osteoarthritis Outcome Score 12 (HOOS-12, both 0-100 worst to best) were obtained for 4383 (2987) and 2041 (1264) participants with knee (hip) OA at 3 and 12 months post intervention. Threshold values for Minimal Important Change (MIC), Patient Acceptable Symptom State (PASS) and Treatment Failure (TF) were estimated using anchor-based predictive modeling.

Results

70-85% reported an important improvement in pain, function and quality of life after 3 and 12 months follow-up. 42% (3 months) and 51% (12 months) considered their current state as satisfactory, whereas 2-4% considered treatment failed. MIC values were -1 (NRS) and 0-4 (KOOS/HOOS-12) across follow-ups and joint affected. PASS threshold value for NRS was 3, and 53-73 for the KOOS/HOOS-12 subscales Corresponding values for TF were 5 (NRS) and 34-55 (KOOS/HOOS-12). Patients with more severe pain at baseline had higher MIC scores and accepted poorer outcomes at follow-ups.

Conclusion

Threshold estimates aid in the interpretation of outcomes after first-line OA interventions assessed with NRS Pain and KOOS/HOOS-12. Baseline pain severity is important to consider when interpreting threshold values after first-line interventions in these patients.

Effectiveness of rehabilitation for working-age patients after a total hip arthroplasty: a comparison of usual care between the Netherlands and Germany

BACKGROUND

Postoperative rehabilitation after primary total hip arthroplasty (p-THA) differs between the Netherlands and Germany. Aim is to compare clinical effectiveness and to get a first impression of cost effectiveness of Dutch versus German usual care after p-THA.

METHODS

A transnational prospective controlled observational trial. Clinical effectiveness was assessed with self-reported questionnaires and functional tests. Measurements were taken preoperatively and 4 weeks, 12 weeks, and 6 months postoperatively. For cost effectiveness, long-term economic aspects were assessed from a societal perspective.

RESULTS

124 working-age patients finished the measurements. German usual care leads to a significantly larger proportion (65.6% versus 47.5%) of satisfied patients 12 weeks postoperatively and significantly better self-reported function and Five Times Sit-to-Stand Test (FTSST) results. German usual care is generally 45% more expensive than Dutch usual care, and 20% more expensive for working-age patients. A scenario analysis assumed that German patients work the same number of hours as the Dutch, and that productivity costs are the same. This analysis revealed German care is still more expensive but the difference decreased to 8%.

CONCLUSIONS

German rehabilitation is clinically advantageous yet more expensive, although comparisons are less straightforward as the socioeconomic context differs between the two countries.

TRIAL REGISTRATION

The study is registered in the German Registry of Clinical Trials (DRKS00011345, 18/11/2016).

Discordance Abounds in Minimum Clinically Important Differences in THA: A Systematic Review

BACKGROUND

The minimum clinically important difference (MCID) is intended to detect a change in a patient-reported outcome measure (PROM) large enough for a patient to appreciate. Their growing use in orthopaedic research stems from the necessity to identify a metric, other than the p value, to better assess the effect size of an outcome. Yet, given that MCIDs are population-specific and that there are multiple calculation methods, there is concern about inconsistencies. Given the increasing use of MCIDs in total hip arthroplasty (THA) research, a systematic review of calculated MCID values and their respective ranges, as well as an assessment of their applications, is important to guide and encourage their use as a critical measure of effect size in THA outcomes research.

QUESTIONS/PURPOSES

We systematically reviewed MCID calculations and reporting in current THA research to answer the following: (1) What are the most-reported PROM MCIDs in THA, and what is their range of values? (2) What proportion of studies report anchor-based versus distribution-based MCID values? (3) What are the most common methods by which anchor-based MCID values are derived? (4) What are the most common derivation methods for distribution-based MCID values? (5) How do the reported medians and corresponding ranges compare between calculation methods for each PROM?

METHODS

The EMBASE, MEDLINE, and PubMed databases were systematically reviewed from inception through March 2022 for THA studies reporting an MCID value for any PROMs. Two independent authors reviewed articles for inclusion. All articles calculating new PROM MCID scores after primary THA were included for data extraction and analysis. MCID values for each PROM, MCID calculation method, number of patients, and study demographics were extracted from each article. In total, 30 articles were included. There were 45 unique PROMs for which 242 MCIDs were reported. These studies had a total of 1,000,874 patients with a median age of 64 years and median BMI of 28.7 kg/m 2 . Women made up 55% of patients in the total study population, and the median follow-up period was 12 months (range 0 to 77 months). The overall risk of bias was assessed as moderate using the modified Methodological Index for Nonrandomized Studies criteria for comparative studies (the mean score for comparative papers in this review was 18 of 24, with higher scores representing better study quality) and noncomparative studies (for these, the mean score was 10 of a possible 16 points, with higher scores representing higher study quality). Calculated values were classified as anchor-based, distribution-based, or not reported. MCID values for each PROM, MCID calculation method, number of patients, and study demographics were extracted from each study. Anchor-based and distribution-based MCIDs were compared for each unique PROM using a Wilcoxon rank sum test, given the non-normal distribution of values.

RESULTS

The Oxford Hip Score (OHS) and the Hip Injury and Osteoarthritis Score (HOOS) Pain and Quality of Life subscore MCIDs were the most frequently reported, comprising 12% (29 of 242), 8% (20 of 242), and 8% (20 of 242), respectively. The EuroQol VAS (EQ-VAS) was the next-most frequently reported (7% [17 of 242]) followed by the EuroQol 5D (EQ-5D) (7% [16 of 242]). The median anchor-based value for the OHS was 9 (IQR 8 to 11), while the median distribution-based value was 6 (IQR 5 to 6). The median anchor-based MCID values for HOOS Pain and Quality of Life were 33 (IQR 28 to 35) and 25 (14 to 27), respectively; the median distribution-based values were 10 (IQR 9 to 10) and 13 (IQR 10 to 14), respectively. Thirty percent (nine of 30) of studies used an anchor-based method to calculate a new MCID, while 40% (12 of 30) used a distribution-based technique. Thirty percent of studies (nine of 30) calculated MCID values using both methods. For studies reporting an anchor-based calculation method, a question assessing pain relief, satisfaction, or quality of life on a five-point Likert scale was the most commonly used anchor (30% [eight of 27]), followed by a receiver operating characteristic curve estimation (22% [six of 27]). For studies using distribution-based calculations, the most common method was one-half the standard deviation of the difference between preoperative and postoperative PROM scores (46% [12 of 26]). Most reported median MCID values (nine of 14) did not differ by calculation method for each unique PROM (p > 0.05). The OHS, HOOS JR, and HOOS Function, Symptoms, and Activities of Daily Living subscores all varied by calculation method, because each anchor-based value was larger than its respective distribution-based value.

CONCLUSION

We found that MCIDs do not vary very much by calculation method across most outcome measurement tools. Additionally, there are consistencies in MCID calculation methods, because most authors used an anchor question with a Likert scale for the anchor-based approach or used one-half the standard deviation of preoperative and postoperative PROM score differences for the distribution-based approach. For some of the most frequently reported MCIDs, however, anchor-based values tend to be larger than distribution-based values for their respective PROMs.

CLINICAL RELEVANCE

We recommend using a 9-point increase as the MCID for the OHS, consistent with the median reported anchor-based value derived from several high-quality studies with large patient groups that used anchor-based approaches for MCID calculations, which we believe are most appropriate for most applications in clinical research. Likewise, we recommend using the anchor-based 33-point and 25-point MCIDs for the HOOS Pain and Quality of Life subscores, respectively. We encourage using anchor-based MCID values of WOMAC Pain, Function, and Stiffness subscores, which were 29, 26, and 30, respectively.

Do patient-reported outcome measures improve after aseptic revision total hip arthroplasty?

BACKGROUND

The purpose of this study was to determine patient-reported outcome measures (PROMs) changes in: (1) pain, function and global health; and (2) predictors of PROMs in patients undergoing aseptic revision total hip arthroplasty (rTHA) using a multilevel model with patients nested within surgeon.

METHODS

A prospective cohort of 216 patients with baseline and 1-year PROMs who underwent aseptic rTHA between January 2016 and December 2017 were analysed. The most common indication for rTHA was aseptic loosening, instability, and implant failure. The PROMs included in this study were HOOS Pain and HOOS Physical Function Short-form (PS), Veterans RAND-12 Physical Component Score (VR-12 PCS), and VR-12 Mental Component Score (MCS). Multivariable linear regression models were constructed for predicting 1-year PROMs.

RESULTS

Mean 1-year PROMs improvement for aseptic revisions were 30.4 points for HOOS Pain and 22.1 points for HOOS PS. Predictors of better pain relief were patients with higher baseline pain scores. Predictors of better 1-year function were patients with higher baseline function and patients with a posterolateral hip surgical approach during revision. Although VR-12 PCS scores had an overall improvement, nearly 50% of patients saw no improvement or had worse physical component scores. Only 30.7% of patients reported improvements in VR-12 MCS.

CONCLUSIONS

Overall, patients undergoing aseptic rTHA improved in pain and function PROMs at 1 year. Although global health assessment improved overall, nearly half of aseptic rTHA patients reported no change in physical/mental health status. The associations highlighted in this study can help guide the shared decision-making process by setting expectations before aseptic revision THA.

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.

Patient acceptable symptom state (PASS): thresholds for the EQ-5D-5L and Oxford hip and knee scores for patients with total hip and knee replacement

PURPOSE

To define patient acceptable symptom state (PASS) cut-off values for the EQ-5D-5L and Oxford hip (OHS) and knee (OKS) scores 6 and 12 months after total hip (THR) or knee (TKR) replacement. To compare PASS cut-off values for the EQ-5D-5L scored using: (1) the Canadian value set, (2) the crosswalk value set, and (3) the equal weighted Level Sum Score (LSS).

METHODS

We mailed questionnaires to consecutive patients following surgeon referral for primary THR or TKR and at 6 and 12 months post-surgery. Patient reported outcome measures (PROMs) were the EQ-5D-5L, the OHS, and OKS. We assessed PASS cut-off values for PROMs using percentile and ROC methods, with the Youden Index.

RESULTS

Five hundred forty-two surgical patients (mean age, 64 years, 57% female, 49% THR) completed baseline and 12-month questionnaires. 89% of THR and 81% of TKR patients rated PASS as acceptable at 12 months. PASS cut-off values for THR for the EQ-5D-5L (Canadian) were 0.85 (percentile) and 0.84 (Youden) at 12 months. Cut-off values were similar for the LSS (0.85 and 0.85) and lower for the crosswalk value set (0.74 and 0.73), respectively. EQ-5D-5L cut-off values for TKR were Canadian, 0.77 (Percentile) and 0.78 (Youden), LSS, 0.75 and 0.80, and crosswalk, 0.67 and 0.74, respectively. Cut-off values 6 and 12 months post-surgery ranged from 38 to 39 for the OHS, and 28 to 36 for the OKS (range 0 worst to 48 best).

CONCLUSION

PASS cut-off values for the EQ-5D-5L and Oxford scores varied, not only between methods and timing of assessment, but also by different EQ-5D-5L value sets, which vary between countries. Because of this variation, PASS cut-off values are not necessarily generalizable to other populations of TJR patients. We advise caution in interpreting PROMs when using EQ-5D-5L PASS cut-off values developed in different countries. A standardization of methods is needed before published cut-off values can be used with confidence in other populations.

Custom-made acetabular revision arthroplasty for pelvic discontinuity: Can we handle the challenge? : a prospective cohort study

AIMS

The aim of this study was to assess the clinical and radiological results of patients who were revised using a custom-made triflange acetabular component (CTAC) for component loosening and pelvic discontinuity (PD) after previous total hip arthroplasty (THA).

METHODS

Data were extracted from a single centre prospective database of patients with PD who were treated with a CTAC. Patients were included if they had a follow-up of two years. The Hip Disability and Osteoarthritis Outcome Score (HOOS), modified Oxford Hip Score (mOHS), EurQol EuroQoL five-dimension three-level (EQ-5D-3L) utility, and Numeric Rating Scale (NRS), including visual analogue score (VAS) for pain, were gathered at baseline, and at one- and two-year follow-up. Reasons for revision, and radiological and clinical complications were registered. Trends over time are described and tested for significance and clinical relevance.

RESULTS

A total of 18 females with 22 CTACs who had a mean age of 73.5 years (SD 7.7) were included. A significant improvement was found in HOOS (p < 0.0001), mOHS (p < 0.0001), EQ-5D-3L utility (p = 0.003), EQ-5D-3L NRS (p = 0.013), VAS pain rest (p = 0.008), and VAS pain activity (p < 0.0001) between baseline and final follow-up. Minimal clinically important improvement in mOHS and the HOOS Physical Function Short Form (HOOS-PS) was observed in 16 patients (73%) and 14 patients (64%), respectively. Definite healing of the PD was observed in 19 hips (86%). Complications included six cases with broken screws (27%), four cases (18%) with bony fractures, and one case (4.5%) with sciatic nerve paresthesia. One patient with concurrent bilateral PD had revision surgery due to recurrent dislocations. No revision surgery was performed for screw failure or implant breakage.

CONCLUSION

CTAC in patients with THA acetabular loosening and PD can result in stable constructs and significant improvement in functioning and health-related quality of life at two years' follow-up. Further follow-up is necessary to determine the mid- to long-term outcome.Cite this article: Bone Jt Open 2023;4(2):53-61.

Client and service factors associated with changes in health-related quality of life following community rehabilitation

PURPOSE

To identify client and service factors associated with changes in health-related quality of life following community rehabilitation.

METHODS

We conducted a retrospective observational cohort study within a community rehabilitation program. Health-related quality of life was measured using the EuroQol five Dimensions, five response level version (EQ-5D-5L). Our primary outcome was the Visual Analogue Scale (VAS) rating of overall health. Analyses were stratified by diagnostic group: traumatic orthopaedic, elective orthopaedic, neurological, medical, and other. The association between client and service factors and discharge VAS scores, adjusted for baseline scores were determined using multivariable regression.

RESULTS

EQ-5D-5L data were available for 981 of 1350 participants. Treatment intensity was associated with a seven-point increase (β = 7.22, 95%CI 2.28-12.2, p = 0.004) in VAS scores for traumatic orthopaedic participants. For neurological participants, there was a positive interaction between comorbidities and intensity of therapy (β = 7.9, 95%CI 2.75-13.1, p = 0.003), indicating that greater therapy intensity in those with higher comorbidity scores was associated with an improvement in VAS scores. Age was negatively associated with VAS scores for traumatic orthopaedic participants and socioeconomic status was positively associated with VAS scores for elective orthopaedic participants.

CONCLUSIONS

Treatment intensity is a modifiable service factor that may positively influence health-related quality of life.Implications for rehabilitationIn addition to providing information on client progress towards attainment of individual treatment goals, routine collection of patient reported outcome measures within a community rehabilitation program can elicit information that can inform rehabilitation service improvement.Clients of a community rehabilitation program with a neurological or medical condition demonstrate the least improvement in overall health profile and may require additional rehabilitation or supports.Across all diagnostic groups, problems with anxiety and depression were least likely to improve following receipt of community rehabilitation. Improving access to psychological services and associated referral pathways in community rehabilitation services could improve these outcomes.Initiatives aimed at increasing intensity of therapy such as targeted triage and resource allocation, may improve health-related quality of life for clients of a community rehabilitation program with traumatic orthopaedic conditions.For clients with a neurological condition, initiatives aimed at increasing intensity of therapy may improve health-related quality of life in more complex patients with comorbid health conditions.

Patient-reported outcome for 17,648 patients in 5 different Swedish orthopaedic quality registers before and 1 year after surgery: an observational study

BACKGROUND AND PURPOSE

The EQ-5D is a patientreported outcome measure (PROM). To make priorities and allocate resources between patients and surgical procedures it is necessary to evaluate outcome differences, which is why comparing PROMs between registers is important. We compared EQ-5D data and the follow-up rate for selected diagnoses reported to Swedish orthopedic registers before and 1 year after surgery.

PATIENTS AND METHODS

Patients from 5 orthopedic registers (Swespine, Swedish Hip Arthroplasty Register, Swedish Knee Arthroplasty Register, Swedankle, and Swefoot) who, in 2014-2018, underwent surgery in southern Sweden were included in the study. Data on the EQ-5D index, individual questions, and the EQ-VAS at baseline and at the 1-year follow-up was compared.

RESULTS

17,648 patients had completed the EQ-5D pre- and 1-year postoperatively. The follow-up rate ranged from 32% to 88%. All registers showed a statistical and clinically relevant improvement in the EQ-5D index (mean improvement 0.29-0.39), where patients who underwent hip arthroplasties experienced the largest improvement. The EQ-5D index improvements in patients with foot and ankle surgeries were larger than for patients with knee arthroplasties and spinal surgeries. The dimensions "self-care" and "usual activities" had the largest change in patients reporting "some problems."

CONCLUSION

All 5 registers showed a clinically relevant improvement 1 year postoperatively regarding the EQ-5D index, supporting continuous resource allocation to these groups of patients and surgical procedures. However, using PROM data to present register differences was challenged by the high number of non-responders.

One-Year Readmissions Following Total Joint Arthroplasty May Be Associated With Failure to Achieve the Minimal Clinically Important Difference of Patient-Reported Outcomes Measurement Information System Physical, Mental, and Physical-Short Form-10a

The primary aims of our study were to determine if hospital readmissions within one year following primary total joint arthroplasty (TJA) and their relative timing influence patients' ability to achieve the two-year Patient-Reported Outcomes Measurement Information System (PROMIS) physical, PROMIS mental, and PROMIS Physical-Function-Short-Form-10a (SF-10a) minimal clinically important difference (MCID). This is a retrospective study conducted using data from a multi-institutional, arthroplasty registry. Only patients with paired patient-reported outcome measure (PROM) assessments (preoperatively and two years postoperatively) were included. Five separate readmission cohorts were formed: (1) any-cause readmission within one year, (2) any-cause readmission within 90 days, (3) non-index-surgery-related readmission within 90 days, (4) index-surgery-related readmission within one year, and (5) index-surgery-related readmission within 90 days. A propensity score match was used to match each of the patients to one of the 972 patients (1:1 basis) in the non-readmission group. The association between failure to achieve each of the three two-year MCIDs and Readmission status was analyzed using logistic regression. We found that all readmissions within one year and index-surgery-related readmissions within one year resulted in an increased risk of failure to achieve the two-year MCID across all three collected PROMs. Index surgery-related readmissions within 90 days (OR 3.24; 95% CI 1.05-11.05; p=0.048) sustained significantly different rates of two-year PROMIS physical MCID achievement compared to matched controls. Postoperative complications requiring readmission, particularly those related to the joint arthroplasty and those within 90 days of index surgery, significantly impact the ability to achieve the two-year MCID of PROMs.

Preoperative Patient-Reported Outcome Measure Thresholds Should Not be Used for Indicating Total Knee Arthroplasty

BACKGROUND

While Medicare requires patient-reported outcome measures (PROMs) for many quality programs, some commercial insurers are requiring preoperative PROMs when determining eligibility for total knee arthroplasty (TKA). Concerns exist that these data may be used to deny TKA to patients above a specific PROM score, but the optimal threshold is unknown. We aimed to evaluate TKA outcomes based on theoretical PROM thresholds.

METHODS

We retrospectively analyzed 25,246 consecutive primary TKA patients from 2016 to 2019. Hypothesized preoperative knee injury and osteoarthritis outcome score for joint replacement cutoffs of 40, 50, 60, and 70 points were used. Preoperative scores below each threshold were considered "approved" surgery. Preoperative scores above each threshold were considered "denied" surgery. In-hospital complications, 90-day readmissions, and discharge disposition were evaluated. One-year minimum clinically important difference (MCID) achievement was calculated using previously validated anchor-based methods.

RESULTS

For "denied" patients below thresholds 40, 50, 60, and 70 points, 1-year MCID achievement was 88.3%, 85.9%, 79.6%, and 77%, respectively. In-hospital complication rates for approved patients were 2.2%, 2.3%, 2.1%, and 2.1%, while 90-day readmission rates were 4.6%, 4.5%, 4.3%, and 4.3%, respectively. Approved patients had higher MCID achievement rates (P < .001) for all thresholds but higher nonhome discharge rates than denied patients for thresholds 40 (P < .001), 50 (P = .002), and 60 (P = .024). Approved and denied patients had similar in-hospital complication and 90-day readmission rates.

CONCLUSION

Most patients achieved MCID at all theoretical PROMs thresholds with low complication and readmission rates. Setting preoperative PROM thresholds for TKA eligibility can help optimize patient improvement, but such a policy can create access to care barriers for some patients who would otherwise benefit from a TKA.

The Appropriateness of Preoperative Patient Reported Outcome Measures as an Indication for Total Hip Arthroplasty

BACKGROUND

While Medicare requires patient-reported outcome measures (PROMs) for many quality programs, some commercial insurers have begun requiring preoperative PROMs when determining patient eligibility for total hip arthroplasty (THA). Concerns exist these data may be used to deny THA to patients above a specific PROM score, but the optimal threshold is unknown. We aimed to evaluate outcomes following THA based on theoretical PROM thresholds.

METHODS

We retrospectively analyzed 18,006 consecutive primary THA patients from 2016-2019. Hypothesized preoperative Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS-JR) cutoffs of 40, 50, 60, and 70 points were used. Preoperative scores below each threshold were considered "approved" surgery. Preoperative scores above each threshold were considered "denied" surgery. In-hospital complications, 90-day readmissions, and discharge disposition were evaluated. HOOS-JR scores were collected preoperatively and 1-year postoperatively. Minimum clinically important difference (MCID) achievement was calculated using previously validated anchor-based methods.

RESULTS

Using preoperative HOOS-JR thresholds of 40, 50, 60, and 70 points, the percentage of patients who would have been denied surgery was 70.4%, 43.2%, 20.3%, and 8.3%, respectively. For these denied patients, 1-year MCID achievement was 75.9%, 69.0%, 59.1%, and 42.1%, respectively. In-hospital complication rates for approved patients were 3.3%, 3.0%, 2.8%, and 2.7%, while 90-day readmission rates were 5.1%, 4.4%, 4.2%, and 4.1%, respectively. Approved patients had higher MCID achievement (P < .001) but higher nonhome discharge (P = .01) and 90-day readmissions rates (P = .036) than denied patients.

CONCLUSION

Most patients achieved MCID at all theoretical PROM thresholds with low complication and readmission rates. Setting preoperative PROM thresholds for THA eligibility did not guarantee clinically successful outcomes.

Determination of Patient Acceptable Symptom State for the Oswestry Disability Index Score in Patients Who Underwent Minimally Invasive Discectomy for Lumbar Disc Herniation: 2-Year Follow-up Data from a Randomized Controlled Trial

OBJECTIVE

We aim to determinate the patient acceptable symptom state (PASS) for the Oswestry Disability Index (ODI) score in patients undergoing minimally invasive discectomy for the treatment of lumbar disc herniation.

METHODS

A post hoc analysis of prospectively collected, 2-year follow-up data was conducted. The anchor for determination of PASS was the European Quality of Life Visual Analog Scales question, and the Pearson correlation test was performed to evaluate its validity. The receiver operating characteristics (ROC) curve analysis was conducted to determine the PASS thresholds for ODI and its discriminative ability assessment. Sensitivity analyses were also carried out for alternative definition of PASS, different follow-up periods, and different subgroups.

RESULTS

A total of 222 patients (92.1%) completed the 2-year follow-up, 92.8% of whom considered their state to be acceptable. The area under the ROC curve (AUC) were all >0.8, indicating a high discriminative ability. The PASS threshold for the ODI was suggested to be 5 at 6 months (AUC: 0.80; sensitivity: 79.0%, specificity: 73.7%) and 2 years (AUC: 0.98; sensitivity: 90.3%, specificity: 100%) postoperatively. Despite some variations found in different body mass index and baseline ODI subgroups, sensitivity analysis showed that the above-mentioned threshold was robust.

CONCLUSIONS

An ODI of 5 was noted to be the PASS threshold for patients received minimally invasive discectomy for the treatment of LDH. This ODI threshold was robust, and therefore recommended as the ultimate goal of minimally invasive treatment for LDH, which can help to present results of clinical research at an individual level.

Philosophies of Surgical Care Are Embedded in Outcome Studies: An Illustrative Reanalysis of the Cartiva MOTION Trial

BACKGROUND

Subjective assumptions on the definition of surgical success are inherent to the design of clinical trials with a categorial outcome. The current study used reasonable alternative assumptions about surgical care to reassess data for the randomized controlled Cartiva trial (MOTION).

METHODS

Data from the published study were augmented by publicly accessible internal US Food and Drug Administration documents. As in the published report, 1-sided lower bound 95% CIs (LBCI95) for the difference of proportions were calculated for a series of alternative scenarios in which the assumptions underlying what constitutes surgical success were altered.

RESULTS

Using a noninferiority margin of -15%, the MOTION trial reported success based on a 1-sided LBCI95 of -10.9%. Each of the 3 independent alternative scenarios analyzed yielded results that altered the primary outcome of the trial: (1) eliminating failures based solely upon radiographs findings, thereby considering a painless pseudarthrosis as a success (1-sided LBCI95 of -15.9%), (2) considering only major surgical revision as a failure and discounting isolated hardware removal (1-sided LBCI95 of -15.1%), and (3) using a visual analog scale (VAS) pain threshold of &lt;30 as the success criterion rather than a 30% reduction in VAS pain score (1-sided LBCI95 of -15.8%).

CONCLUSION

In this reanalysis, applying any of 3 reasonable alternative assumptions about the definition of surgical success to the data resulted in failure to prove noninferiority of Cartiva over arthrodesis, a reversal of the reported trial result. These results highlight the effect of subjective assumptions in the design of clinical trials with a categorical outcome and illustrate how differing philosophies about what constitutes surgical success can be pivotal in determining the final result.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

How do Patient-reported Outcome Scores in International Hip and Knee Arthroplasty Registries Compare?

BACKGROUND

Patient-reported outcome measures (PROMs) are the only systematic approach through which the patient's perspective can be considered by surgeons (in determining a procedure's efficacy or appropriateness) or healthcare systems (in the context of value-based healthcare). PROMs in registries enable international comparison of patient-centered outcomes after total joint arthroplasty, but the extent to which those scores may vary between different registry populations has not been clearly defined.

QUESTIONS/PURPOSES

(1) To what degree do mean change in general and joint-specific PROM scores vary across arthroplasty registries, and to what degree is the proportion of missing PROM scores in an individual registry associated with differences in the mean reported change scores? (2) Do PROM scores vary with patient BMI across registries? (3) Are comorbidity levels comparable across registries, and are they associated with differences in PROM scores?

METHODS

Thirteen national, regional, or institutional registries from nine countries reported aggregate PROM scores for patients who had completed PROMs preoperatively and 6 and/or 12 months postoperatively. The requested aggregate PROM scores were the EuroQol-5 Dimension Questionnaire (EQ-5D) index values, on which score 1 reflects "full health" and 0 reflects "as bad as death." Joint-specific PROMs were the Oxford Knee Score (OKS) and the Oxford Hip Score (OHS), with total scores ranging from 0 to 48 (worst-best), and the Hip Disability and Osteoarthritis Outcome Score-Physical Function shortform (HOOS-PS) and the Knee Injury and Osteoarthritis Outcome Score-Physical Function shortform (KOOS-PS) values, scored 0 to 100 (worst-best). Eligible patients underwent primary unilateral THA or TKA for osteoarthritis between 2016 and 2019. Registries were asked to exclude patients with subsequent revisions within their PROM collection period. Raw aggregated PROM scores and scores adjusted for age, gender, and baseline values were inspected descriptively. Across all registries and PROMs, the reported percentage of missing PROM data varied from 9% (119 of 1354) to 97% (5305 of 5445). We therefore graphically explored whether PROM scores were associated with the level of data completeness. For each PROM cohort, chi-square tests were performed for BMI distributions across registries and 12 predefined PROM strata (men versus women; age 20 to 64 years, 65 to 74 years, and older than 75 years; and high or low preoperative PROM scores). Comorbidity distributions were evaluated descriptively by comparing proportions with American Society of Anesthesiologists (ASA) physical status classification of 3 or higher across registries for each PROM cohort.

RESULTS

The mean improvement in EQ-5D index values (10 registries) ranged from 0.16 to 0.33 for hip registries and 0.12 to 0.25 for knee registries. The mean improvement in the OHS (seven registries) ranged from 18 to 24, and for the HOOS-PS (three registries) it ranged from 29 to 35. The mean improvement in the OKS (six registries) ranged from 15 to 20, and for the KOOS-PS (four registries) it ranged from 19 to 23. For all PROMs, variation was smaller when adjusting the scores for differences in age, gender, and baseline values. After we compared the registries, there did not seem to be any association between the level of missing PROM data and the mean change in PROM scores. The proportions of patients with BMI 30 kg/m 2 or higher ranged from 16% to 43% (11 hip registries) and from 35% to 62% (10 knee registries). Distributions of patients across six BMI categories differed across hip and knee registries. Further, for all PROMs, distributions also differed across 12 predefined PROM strata. For the EQ-5D, patients in the younger age groups (20 to 64 years and 65 to 74 years) had higher proportions of BMI measurements greater than 30 kg/m 2 than older patients, and patients with the lowest baseline scores had higher proportions of BMI measurements more than 30 kg/m 2 compared with patients with higher baseline scores. These associations were similar for the OHS and OKS cohorts. The proportions of patients with ASA Class at least 3 ranged across registries from 6% to 35% (eight hip registries) and from 9% to 42% (nine knee registries).

CONCLUSION

Improvements in PROM scores varied among international registries, which may be partially explained by differences in age, gender, and preoperative scores. Higher BMI tended to be associated with lower preoperative PROM scores across registries. Large variation in BMI and comorbidity distributions across registries suggest that future international studies should consider the effect of adjusting for these factors. Although we were not able to evaluate its effect specifically, missing PROM data is a recurring challenge for registries. Demonstrating generalizability of results and evaluating the degree of response bias is crucial in using registry-based PROMs data to evaluate differences in outcome. Comparability between registries in terms of specific PROMs collection, postoperative timepoints, and demographic factors to enable confounder adjustment is necessary to use comparison between registries to inform and improve arthroplasty care internationally.

LEVEL OF EVIDENCE

Level III, therapeutic study.