Establishing minimum clinically important difference values for the Patient-Reported Outcomes Measurement Information System Physical Function, hip disability and osteoarthritis outcome score for joint reconstruction, and knee injury and osteoarthritis outcome score for joint reconstruction in orthopaedics

The Impact of Travel Distance on Patient-Reported Outcomes Following Primary Total Hip Arthroplasty

BACKGROUND

Total hip arthroplasties (THAs) are increasingly being performed at high-volume centers, causing some patients to travel further distances to receive care. Concerns remain that increased travel distance limits follow-up, which may impact outcomes and early return to the hospital. The purpose of this study is to evaluate the impact of travel distance on 90-day patient-reported outcomes (PROs) and 90-day complication rates.

METHODS

Patients undergoing inpatient primary THA at a single center by one of three surgeons between 2017 and 2021 were retrospectively reviewed. Patients whose local and distant medical records were available were included. Patients who lived ≥ 40 miles from the location or follow-up were labeled as "travelers," and those < 40 miles were "locals." Primary outcomes included PROs as measured by Veterans Rand 12 Item Health Survey, Harris Hip Score, and Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement. Secondary outcomes included rates of 90-day medical complications, emergency department visits, unplanned readmissions, and reoperations.

RESULTS

A total of 413 patients were analyzed at a mean of 897.1 days (range, 92 to 2,196) including 96 travelers. Travelers averaged 96.1 miles for follow-up (range, 40.1 to 678 miles), and locals averaged 14.1 miles for follow-up (range, 0.3 to 39.8 miles). There were no differences in the percentage of patients achieving minimal clinically important difference in PROs. There was no difference in the rate of 90-day medical complications, 90-day readmissions, and reoperations. Local patients were significantly more likely to have unplanned postoperative emergency department visits (travelers = 0%, locals = 7.4%, P = 0.003).

CONCLUSIONS

Travelers did not demonstrate any significant differences with respect to rates of achieving minimal clinically important difference in PROs or 90-day complication rates. These data suggest that increased travel distance to treatment centers does not impact outcomes following primary THA.

How Should We Define Meaningful Improvement? A Commentary on Minimal Clinically Important Difference Assessment for Hip Disability and Osteoarthritis Outcome Score for Joint Replacement and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement in Total Joint Arthroplasty

Minimal clinically important difference (MCID) thresholds guide clinicians and researchers in determining whether changes in patient-reported outcome measures are truly meaningful from the patient's perspective. This article focuses on MCID calculation methods for the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, two widely used patient-reported outcome measures in total hip and total knee arthroplasty. While distribution-based methods (e.g., the half-standard deviation threshold) are common for their simplicity and lack of extra data requirements, they are limited by reliance on statistical properties rather than patient perception. In contrast, anchor-based methods, endorsed by the Consensus-based Standards for the Selection of Health Measurement Instruments, use external "anchors" such as satisfaction or quality-of-life measures to capture the patient's view of improvement. Predictive modeling, a sophisticated anchor-based technique, is particularly robust, producing smaller confidence intervals and adjusting for various patient characteristics. However, all anchor-based approaches depend heavily on the choice and quality of the anchor, highlighting a need for standardization and validation of these external measures. Moreover, MCID thresholds are population-specific and can vary according to baseline function, comorbidities, demographics, and surgical context. Ceiling effects in both Hip Disability and Osteoarthritis Outcome Score for Joint Replacement and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement further complicate MCID assessment. To address these challenges, the article recommends prioritizing anchor-based methods, standardizing anchors, and interpreting MCID values within each study's clinical context. Comprehensive reporting of baseline characteristics and instrument sensitivity (including ceiling effects) is also essential for reliable comparisons and evidence-based practice.

Preoperative Resilience as a Predictor of Postoperative Regret and Patient-Reported Outcomes in Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a well-established treatment option for advanced knee osteoarthritis, yet some patients remain unsatisfied after surgery. Evaluation of various psychosocial parameters may improve patient optimization and outcomes. The primary aim was to assess whether preoperative resilience remained stable and influenced decision regret postoperatively while the secondary aim was to evaluate its correlation with joint-specific and global health patient-reported outcome measures.

METHODS

A total of 1,269 patients undergoing elective unilateral TKA were included. Patients completed the Brief Resilience Scale preoperatively and postoperatively and were stratified into low, normal, and high resilience cohorts. Decision regret scale scores were obtained postoperatively, and patients were stratified into no regret, mild regret, and moderate/severe regret cohorts. Patients' knee pain and function were assessed using the Knee Osteoarthritis Outcome Score Joint Replacement survey. Physical and mental quality of life was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS-10).

RESULTS

Preoperatively, 8% of patients were categorized as having low resilience, 67% had normal resilience, and 25% had high resilience. Resilience among each cohort remained relatively static. A statistically significant negative correlation between Brief Resilience Scale and decision regret scale scores was observed at 12-month follow-up (P < 0.001). The high resilience cohort demonstrated the lowest decision regret scale scores at all time points. The low resilience cohort reported higher decision regret scale scores at all time points but had the most improvement over the 12-month follow-up (P < 0.001). Knee Osteoarthritis Outcome Score Joint Replacement scores had a weak-to-low positive correlation with preoperative resilience (r = 0.29, P = 0.05). Preoperative resilience had a low positive correlation with PROMIS-10 Physical scores (r = 0.36, P < 0.05), but a moderately strong positive correlation with PROMIS-10 Mental scores (r = 0.47, P < 0.05).

CONCLUSION

Preoperative resilience can markedly influence decision regret after TKA. These findings are valuable because they can help surgeons appropriately counsel patients, leading to improved satisfaction after surgery.

Increasing Body Mass Index Not Associated With Worse Patient-Reported Outcomes After Primary THA or TKA

INTRODUCTION

As the US obesity epidemic continues to grow, so too does comorbid hip and knee arthritis. Strict body mass index (BMI) cutoffs for total hip and knee arthroplasty (THA and TKA) in the morbidly obese have been proposed and remain controversial, although current American Academy of Orthopaedic Surgeons guidelines recommend a BMI of less than 40 m/kg 2 before surgery. This study sought to compare patient-reported outcomes and 30-day complication, readmission, and revision surgery rates after THA or TKA between morbidly obese patients and nonmorbidly obese control subjects.

METHODS

All patients undergoing primary THA and TKA at our institution from May 2020 to July 2022 were identified. Patient demographics, surgical time, length of stay and 30-day readmission, revision surgery, and complication rates were prospectively collected. Preoperative and postoperative Hip and Knee Society (Hip Osteoarthritis Outcome Score [HOOS] and Knee Osteoarthritis Outcome Score [KOOS]) were collected. Patients were stratified by BMI as ideal weight (20 to 24.9), overweight (25 to 29.9), class I obese (30 to 34.9), class II obese (35 to 39.9), and morbidly obese (>40 m/kg 2 ).

RESULTS

A total of 1,423 patients were included for final analysis. No difference was observed in 30-day unplanned return to emergency department, readmission, or revision surgery in the morbidly obese cohort. Morbidly obese patients undergoing THA had lower preoperative HOOS (49.5 versus 54.5, P = 0.004); however, there was no difference in postoperative HOOS or KOOS at 12 months across all cohorts.

DISCUSSION

No difference was observed in 30-day return to emergency department, readmission, or revision surgery in the morbidly obese cohort. Despite a lower preoperative HOOS, there was no difference in 12-month HOOS or KOOS when stratified by BMI. These findings suggest that such patients may achieve similar benefit from arthroplasty as their ideal weight counterparts.

Variation in Demographics, Hospital, and Patient-Reported Outcomes Following Total Hip Arthroplasty According to Biological Sex

BACKGROUND

The effect of biological sex on the outcomes of total hip arthroplasty (THA) remains unclear. Accounting for biological sex in research is crucial for reproducibility and accuracy. Average combined data may mask sex-related variation and obscure clinically relevant differences in outcomes. The aim of this study is to investigate hospital and patient-reported outcome measures (PROMs) after THA by biological sex to elucidate differences and ultimately provide more equitable care.

METHODS

We performed a retrospective review of patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographics, operative variables, hospital outcomes, and PROMs were compared between men and women patients. The PROMs included preoperative, 6-weeks, 6-months, and 1-year Single Assessment Numeric Evaluation, Visual Analog Scale, Hip Disability and Osteoarthritis Outcome Score Joint Replacement, University of California, Los Angeles, and Patient-Reported Outcomes Measurement Information System mental and physical scores, as well as satisfaction scores.

RESULTS

A total of 6,418 patients were included (55% women). Women were older (P < .001), had a lower body mass index (P < .001), and were more likely to have public insurance (P < .001). Fewer women were discharged to home or self-care (P < .001). Women had higher rates of cementation (P < .001) and fracture within 90 days (P < .001), and these associations remained significant with adjusted multivariable analyses. Women had significantly higher pain and lower functional scores preoperatively; postoperatively, most PROMs were equivalent.

CONCLUSIONS

Important differences were observed in several areas. Demographic parameters differed, and a variable effect of biological sex was observed on surgical and hospital outcomes. Women had an increased incidence of cemented femoral components (indicated for osteoporotic bone) and postoperative fractures. Women's PROMs demonstrated globally lower functional scores and higher pain preoperatively. Differences attributed to sex should continue to be investigated and accounted for in risk-stratification models. Future studies are needed to elucidate the underlying causes of observed biological sex differences and are essential for equitable arthroplasty care.

Evaluating the impact of robotic-assisted total knee arthroplasty on quality of care through patient-reported outcome measures in a third-level hospital in Italy: A prospective cohort study

BACKGROUND

With the shift towards personalized medicine, understanding the impact of robotic-assisted total knee arthroplasty (TKA) on patient-reported outcome measures (PROMs) is essential for evaluating its effectiveness and patient satisfaction. The QUAROB (Quality-assessment-of-ROBotic-orthopedic-surgery) study aims at assessing the impact of robotic surgery on quality of care and joint functionality at 6 months post-surgery among patients undergoing robotic-assisted TKA.

METHODS

This observational, prospective cohort study included patients from Ravenna Hospital, Italy, who underwent elective robotic TKA (2022-2023), and a historical cohort who underwent traditional TKA (2019). PROMs questionnaires (EuropeanQualityofLife-Visual AnalogScale, EQ-VAS, EuropeanQualityofLife-5Dimensions-3Likert, EQ-5D-3L, and KneeinjuryOsteoarthritisOutcomeScore-PatientSatisfaction, KOOS-PS) were administered within 30 days before surgery and 6 months post-surgery. Statistical analysis involved comparing baseline and follow-up PROMs, focusing on patients achieving at least a 10% improvement (Minimal Clinically Important Difference, MCID).

RESULTS

The study enrolled 214 robotic surgery patients, with 208 completing baseline and 103 completing 6-month follow-up questionnaires. Patients undergoing robotic-assisted TKA demonstrated significant improvements in EQ-VAS, EQ-5D-3L, and KOOS-PS scores at 6 months. A significant proportion of patients achieved improvements exceeding the MCID threshold (68.9% for EQ-VAS, 58.3% for EQ-5D-3L, and 68.9% for KOOS-PS). Robotic TKA patients experienced shorter hospital stays (7 vs. 9 days, p < 0.001) and higher engagement in rehabilitation compared to traditional TKA patients.

CONCLUSIONS

The QUAROB study provides evidence of the impact and benefits of robotic-assisted TKA, highlighting significant enhancements in PROMs, reduced hospital stays, and increased rehabilitation engagement. These outcomes reinforce the role of robotic technology in improving surgical precision and patient satisfaction in orthopedic surgery.

Evaluating the effectiveness of interlaminar epidural steroid injections for cervical radiculopathy using PROMIS as an outcome measure

Background

Cervical interlaminar epidural steroid injections (CIESI) are frequently used to treat cervical radiculopathy due to cervical nerve root impingement.

Objective

The purpose of this study was to evaluate the therapeutic effect of CIESI for patients with cervical radiculopathy.

Methods

We conducted a retrospective review of consecutive adult patients with cervical radicular pain and corroborative cervical spondylotic foraminal stenosis on MRI that failed at least 6 weeks of conservative management consisting of medication and physical rehabilitation seen at a multidisciplinary, tertiary academic spine center. Patient Reported Outcome Measurement Information System (PROMIS) domains of Physical Function (PF) v1.2/v2.0 and Pain Interference (PI) v1.1 were collected at all patient visits. Scores were recorded at baseline, 3-months, 6-months and 12-months post-procedure. Statistical analysis comparing baseline scores with follow-up postprocedural PROMIS scores was performed. The percentage of patients reporting improvement greater than the minimal clinically important difference (MCID) was calculated for responders and for the worst case scenario.

Results

179 patients met inclusion criteria. PROMIS PI at 3-, 6-, and 12-month follow-up statistically improved by 1.5 (95 % confidence interval [CI] 1.4-1.6; p = 0.02), 1.5 (95 % CI 1.4-1.6; p = 0.03) and 1.7 (95 % CI 1.6-1.8; p = 0.4), respectively. Follow-up PROMIS PF at 3-month follow-up improved by 1.6 (95 % CI 1.5-1.7; p = 0.04) but did not significantly differ at 6- or 12-month follow-up. The percentage of patients that exceeded MCID thresholds of clinical significance was 44 % (95 % CI 36%-53 %) at 3-months, 49 % (95 % CI 39%-59 %) at 6-months, and 54 % (95 % CI 41%-66 %) at 12-months. Worst case scenario analysis demonstrated that 32 % (95 % CI 36%-53 %) of patients exceeded the MCID thresholds at 3-months, 31 % (95 % CI 24%-37 %) at 6-months, and 21 % (95 % CI 15%-27 %) at 12-months.

Discussion/conclusions

Our study demonstrated that CIESI leads to an improvement in function and pain for patients with cervical radiculopathy. This study was limited by retrospective design, loss to follow-up, and variation in steroids used.

Current Use of Patient-Reported Outcome Measures Ignores Functional Demand

INTRODUCTION

Patient-reported outcome measures (PROMs) are used in orthopaedic surgery to measure aspects of musculoskeletal function that are important to patients, such as disability and pain. However, current assessments of function using PROMs do not necessarily consider a patient's functional demands in detail. A patient's functional demands could serve as a confounder to their perception of their functional ability. Hence, functional demands may need to be adjusted for when PROMs are used to measure musculoskeletal function.

METHODS

We conducted a cross-sectional study in which new orthopaedic patients completed a questionnaire regarding demographics, function [Patient-Reported Outcomes Measurement Information System], functional demand (Tegner Activity Level Scale), pain self-efficacy, and symptoms of depression. 169 eligible patients with diverse orthopaedic conditions were enrolled in the study from an orthopaedic clinic, and 19 were excluded for incomplete questionnaires.

RESULTS

The mean Patient-Reported Outcomes Measurement Information System score was 36.5 ± 9.1, and the mean Tegner score was 2.6 ± 2.0. In the multivariable regression model, patient-reported function was significantly associated with functional demand (β = 0.17, P < 0.001). Significant associations were observed for pain self-efficacy (β = 0.15, P < 0.001), acuity (β = -0.10, P = 0.004), and age 80 years or older (β = -0.16, P = 0.004). No notable association was observed with depression or age 65 to 79 years.

DISCUSSION

Higher patient-reported physical function is associated with higher levels of functional demand when controlling for psychosocial factors, acuity, and age. Because of its confounding effect on measuring physical function, functional demand should be assessed and included in models using PROMs before and after surgery. For example, payment models using improvements in PROMs, such as the short form of the Hip dysfunction and Osteoarthritis Outcome Score and the Knee injury and Osteoarthritis Outcome Score after joint arthroplasty, should include functional demand in the model when assessing quality of care.

LEVEL OF EVIDENCE

Level II.

Evaluating Patient-Reported Outcome Measure Collection and Attainment of Substantial Clinical Benefit in Total Joint Arthroplasty Patients

BACKGROUND

Patient-reported outcome measures (PROMs) are important markers of postsurgical outcomes following total joint arthroplasty (TJA). Recent policies by the Centers for Medicare & Medicaid Services will require hospitals to achieve at least 50% postoperative PROM collection rates in order to qualify for their full annual payment in fiscal year 2028. This study aimed to: (1) quantify provider PROMs collection rates for TJA patients; (2) compare mean improvements in postoperative PROMs in TJA patients; (3) identify the proportion of TJA patients achieving substantial clinical benefit (SCB); and (4) identify factors associated with TJA patient completion of matched PROMs and achievement of SCB at one year.

METHODS

This retrospective cohort study included 1,493 primary total hip arthroplasty (THA) and 2,959 primary total knee arthroplasty (TKA) patients who underwent surgery at a single institution from May 2019 to December 2023. The primary outcomes were 1-year paired hip or knee PROM collection, measured by the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and Hip Disability and Osteoarthritis Outcome Score for Joint Replacement surveys, and SCB achievement rates (22 for Hip Disability and Osteoarthritis Outcome Score for Joint Replacement and 20 for Knee Injury and Osteoarthritis Outcome Score for Joint Replacement). Secondary outcomes involved identifying factors associated with PROM completion and SCB achievement. Statistical analyses included descriptive statistics, t-tests, and logistic regression analysis.

RESULTS

There were 61.2% of THA patients and 61.1% of TKA patients who completed 1-year paired PROMs, with 72.8% of THA and 53.3% of TKA patients achieving SCB. Factors associated with higher PROMs completion included technology use (PROMs application, text reminders). For TJA patients, a lower preoperative PROM was associated with achievement of SCB at one year. For THA patients, lower body mass index was associated with SCB attainment. For TKA patients, men were significantly associated with SCB attainment.

CONCLUSIONS

The study indicates compliance with the 50% PROM collection requirement, but this required significant allocation of resources, including the use of a digital care platform. Substantial clinical benefit was achieved in 72.8% of THA patients but only 53.3% of TKA patients at one year, and this was associated with certain patient demographic factors. Achieving compliance with the Centers for Medicare & Medicaid Services requirement may be difficult for many providers and institutions.

Patient-reported outcomes in total hip arthroplasty for patients with anatomically contoured femoral heads

INTRODUCTION

Iliopsoas tendinitis after total hip arthroplasty (THA) has become more prevalent with the increased use of large-diameter femoral heads impinging on native surrounding tissues. Anatomically contoured heads (ACH) are soft-tissue-friendly femoral heads created to minimise this issue. This retrospective study assesses iliopsoas tendinitis prevalence and re-operations in primary THAs with ACH, while determining the minimal clinically important difference (MCID) achievement and improvement with 5 patient-reported outcome measures (PROMs).

METHODS

We conducted a retrospective analysis of 53 ACHs from January 2020 to July 2023. Patients who completed Hip Injury and Osteoarthritis Outcome Score-Physical Function Short Form (HOOS-PS), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF SF-10a), PROMIS Global Health (GH)-Mental, or PROMIS GH-Physical, and pain score questionnaires were identified. PROM scores were collected preoperatively and at 3-month and 1-year postoperative intervals. Comparisons using chi-square and ANOVA tests were applied.

RESULTS

The rates of achieving MCID and improvement within the first year were (69.2 vs. 76.9%) for PROMIS GH-Physical, (38.5 vs. 46.2%) for PROMIS GH-Mental, (71.4 vs. 92.9%) for HOOS-PS, (80.0 vs. 80.0%) for PROMIS PF SF-10a, and (74.0 vs. 91.7%) for pain scores. PROM scores at 3 months and 1 year significantly varied across all categories, except for PROMIS GH-Mental. No patients had iliopsoas tendinitis, dislocations, or re-operations.

DISCUSSION

ACH implants may alleviate anterior hip pain, while maintaining comparable strength and bio-compatibility to conventional femoral heads. This study underscores the early safety and potential of ACH implants in reducing iliopsoas tendinitis and impingement.

Clinical relevance of patient-reported outcome measures in patients who have undergone total hip arthroplasty: a systematic review

INTRODUCTION

In orthopaedic research, it is crucial to determine changes that are statistically significant and clinically meaningful. One approach to accomplish this is by calculating the Minimal Clinically Important Difference (MCID), the Clinically Important Differences (CID), the Minimum Detectable Change (MDC), the Minimal Important Change (MIC), and the Patient Acceptable Symptom State (PASS) values. These tools assist medical professionals in comprehending the patient's viewpoint, enabling them to establish treatment objectives that align with patients' desires and expectations. The present systematic review investigated the MCID, MIC, CID, MDC, and PASS of the most used PROMs to assess patients who have undergone THA.

METHODS

This systematic review followed the 2020 PRISMA guidelines. Web of Science, Embase, and PubMed were accessed in March 2024 without time constraints or additional filters. All the clinical investigations which evaluated data tools (MCID, MIC, CID, MDC, and PASS) to assess the clinical relevance of PROMs in THA were accessed. Articles in Spanish, Italian, German, and English were eligible. Studies with levels of evidence I to III were eligible.

RESULTS

Data from 100,824 patients were collected. All relevant demographic data were analysed and summarised. In addition, the MCID, MIC, CID, MDC and PASS of the COMI, HOOS, SF-36, OHS, Oxford-12, PROMIS-PF, SF-12, and WOMAC scores for THA were determined.

CONCLUSION

Current evidence recommends to collect MCIDs based on anchors routinely. These values should be used as complementary tools to determine the clinical effectiveness of a treatment instead of solely relying on statistically significant improvements.

LEVEL OF EVIDENCE

Level IV, systematic review and meta-analysis.

Effect of Race and Socioeconomic Status on the Attainment of Substantial Clinical Benefit on Patient-Reported Outcome Measures Following Total Joint Arthroplasty

BACKGROUND

Utilization of and access to total joint arthroplasty (TJA) are disproportionately skewed in patients who have low socioeconomic status (SES) and in minority populations. Patient-reported outcome measures (PROMs) are critical markers of post-surgical outcomes following TJA. This study aimed to: 1) evaluate differences in race, SES, and demographic factors between TJA patients who achieved substantial clinical benefit (SCB) and those who did not; 2) assess differences between preoperative PROMs in these patients; and 3) identify whether race and SES are associated with SCB achievement at 1-year post-TJA.

METHODS

This retrospective cohort study included 1,154 total hip arthroplasty (THA) and 1,879 total knee arthroplasty (TKA) patients who underwent surgery at a single academic medical center from May 2019 to February 2023. Preoperative and postoperative PROMs were collected using the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and Hip Disability and Osteoarthritis Outcome Score for Joint Replacement surveys. Demographic and comorbidity data were collected from charts. Multivariable logistic regression analyzed the association between predictive variables and SCB achievement.

RESULTS

No differences in race were found between patients who achieved SCB and those who did not for both TKA and THA (P > 0.05). However, preoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores were lower in Black (P = 0.004) and Hispanic (P < 0.001) patients and preoperative Hip Disability and Osteoarthritis Outcome Score for Joint Replacement scores were lower in Black patients (P < 0.001) than White patients. A higher proportion of patients in the lowest income category achieved SCB for both THA and TKA than those in other income categories (P = 0.04, P = 0.03, respectively). However, race was not associated with SCB likelihood at one year. For TKA patients, men were negative, and bilateral simultaneous TKA was positively associated with SCB achievement when controlling for race, income, and body mass index (P < 0.001, P = 0.01, respectively).

CONCLUSIONS

Race and income category were not significantly associated with achieving SCB at one year among TJA patients. However, non-White patients had a similar likelihood of achieving SCB as White patients, even with lower preoperative PROMs, indicating that these patients may benefit greatly from TJA despite delays in care. Men were negatively associated with TKA SCB achievement, while bilateral simultaneous TKA was positively associated with SCB.

MCID achievement in staged bilateral total knee arthroplasty: Are both joints created equal?

BACKGROUND

A notable portion of unilateral total knee arthroplasty (TKA) patients undergo arthroplasty of the contralateral knee. The aims of this study were to describe the Minimal Clinically Important Difference for Improvement (MCID-I) and Worsening (MCID-W) in staged bilateral TKAs (BTKAs) and identify factors associated with these outcomes.

METHODS

Patients with staged BTKA were retrospectively reviewed. Demographics, surgery details, and Patient-Reported Outcome Measurement Information System Physical Function Short Form 10a (PROMIS PF10a) were collected. MCID-I and MCID-W were defined for PROMIS PF10a. Patients were stratified into nine groups based on the MCID achievement of the first and second TKA: (A) MCID-I, MCID- I, (B) MCID-I, Neutral, (C) MCID-I, MCID-W, (D) Neutral, MCID-I, (E) Neutral, Neutral, (F) Neutral, MCID-W, (G) MCID- W, MCID-I, (H) MCID-W, Neutral, (I) MCID-W, MCID-W. Neutral patients did not achieve either MCID-I or MCID-W.

RESULTS

The final cohort consisted of 59 staged BTKA patients. In patients who achieved MCID-I in the first TKA, 39.1% achieved MCID-I again in the second TKA (A), 39.1% were neutral (B), and 21.7% achieved MCID-W (C) in the second TKA. However, 77.8% of those who achieved MCID-W in the first joint (n = 9) went on to achieve MCID-I (G) in the second TKA. Those who achieved MCID-I after both TKAs (A) had a longer staged interval than those who achieved first MCID-I, then MCID-W (C) (15 months vs 8 months, P = 0.0113).

CONCLUSION

In staged BTKA, MCID achievement of the first TKA may not be associated with the outcome of the second TKA.

Functional Outcomes of Robotic-Assisted Total Knee Arthroplasty in Severe Varus Deformities of the Knee in the Indian Population

PURPOSE

Correction of severe coronal plane deformities while performing a total knee arthroplasty (TKA) is challenging. The use of functional alignment (FA) strategy along with image-based robotic technology during TKA makes it possible to restore a patient's constitutional alignment with minimal or no soft tissue release. The present study aims to report the functional outcomes of robotic-assisted TKA in Indian patients with severe varus deformity.

METHODS

This retrospective study included 82 primary TKA performed by a single senior arthroplasty surgeon from January 2022 to December 2022. The Visual Analogue Score for Pain (VAS-P) and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) were used to assess functional outcomes. A comparison between mild and severe varus deformities was done using Student's t-test.

RESULTS

The mean age was 66.35 ± 9.21 years. There were 79 (96.34%) knees with a mean preoperative varus hip-knee-ankle angle (HKA) of 12.85° ± 6.03° (range = 177°-148°). Postoperative limb alignment was achieved in the range of HKA 174° to 180°, with mean HKA being 175.78° ± 1.35°. The VAS-P improved significantly from a mean of 7.87 ± 0.81 preoperatively to 1.96 ± 1.43 at 18 months. KOOS-JR improved from 41.22 ± 7.6 preoperatively to 88.44 ± 8.23 at 18 months. A total of 73 (89.02%) cases achieved the minimal clinically important difference (MCID) for VAS-P and 77 (93.9%) cases achieved the MCID for KOOS-JR in our study. Functional outcomes were comparable among the mild (<10°) and severe (>10°) varus deformity cases at 18 months follow-up (p-value > 0.05). There was a significant difference in bone resection from the medial tibial and medial distal femoral condyle (p-value < 0.05) with less bone resected in the severe varus group. The amount of bone resected from the lateral tibial, distal lateral femoral, and posterior femoral condyles was comparable among the two groups (p-value > 0.05). FA was more bone conserving even in severe varus-deformed knees when compared to mechanical alignment (MA).

CONCLUSION

The use of FA with robotic assistance to correct severe varus deformities in TKA showed a significant reduction in VAS-P scores and an improvement in KOOS-JR scores. The functional outcomes were comparable with TKA in mild varus deformities. FA helps in preserving bone from the lateral tibial condyle and distal femur.

Quantifying Patient Expectations for Total Knee Arthroplasty: Expectations for Improvement Are Greater Than Minimal Clinically Important Difference

BACKGROUND

Achieving a minimal clinically important difference (MCID) in patient-reported outcomes following total knee arthroplasty (TKA) is common, yet up to 20% patient dissatisfaction persists. Unmet expectations may explain post-TKA dissatisfaction. No prior studies have quantified patient expectations using the same patient-reported outcome metric as used for MCID to allow direct comparison.

METHODS

This was a prospective study of patients undergoing TKA with 5 fellowship-trained arthroplasty surgeons at one academic center. Baseline Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) domains were assessed. Expected PROMIS scores were determined by asking patients to indicate the outcomes they were expecting at 12 months postoperatively. Predicted scores were generated from a predictive model validated in the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) dataset. T-tests were used to compare baseline, expected, and predicted PROMIS scores. Expected scores were compared to PROMIS MCID values obtained from the literature. Regression models were used to identify patient characteristics associated with high expectations.

RESULTS

There were 93 patients included. Mean age was 67 years (range, 30 to 85) and 55% were women. Mean baseline PROMIS PF and PI was 34.4 ± 6.7 and 62.2 ± 6.4, respectively. Patients expected significant improvement for PF of 1.9 times the MCID (MCID = 11.3; mean expected improvement = 21.6, 95% confidence interval [CI] 19.6 to 23.5, P < .001) and for PI of 2.3 times the MCID (MCID = 8.9; mean expected improvement = 20.6, 95% CI 19.1-22.2, P < .001). Predicted scores were significantly lower than expected scores (mean difference = 9.5, 95% CI 7.7 to 11.3, P < .001). No unique patient characteristics were associated with high expectations (P > .05).

CONCLUSIONS

To our knowledge, this study is the first to quantify preoperative patient expectations using the same metric as MCID to allow for direct comparison. Patient expectations for improvement following TKA are ∼2× greater than MCID and are significantly greater than predicted outcome scores. This discrepancy challenges currently accepted standards of success after TKA and indicates a need for improved expectation setting prior to surgery.

Utilization of Blood Flow Restriction Therapy with a Former Triathlete After Total Knee Arthroplasty: A Case Report

Introduction and Purpose

Knee osteoarthritis (OA) is a common condition that limits function and reduces quality of life. Total knee arthroplasty (TKA) is a surgical procedure that replaces the joint surfaces to address anatomical changes due to knee OA. While TKA improves symptoms and function, postoperative impairments are common, including reduced quadriceps strength. Blood flow restriction (BFR) may be a viable option for patients following TKA, as it can improve strength with a minimal amount of joint loading compared to traditional strength training. The purpose of this case report is to describe the impact of BFR use in an individual after TKA, employing pain measurements, quantitative sensory testing, patient-reported outcome measures, physical performance tests, and muscle strength and power testing to explore potential treatment effects and identify potential predictors of response for future studies.

Case Description

A 49-year-old former female triathlete with a history of knee injury and arthroscopic surgery underwent a right TKA and sought physical therapy (PT) due to pain, limited range of motion (ROM), and knee instability during weight bearing activity. PT interventions included manual therapy, gait training, and a home program. Despite participating in supervised PT, she had persistent pain, ROM deficits, and muscle weakness 16 weeks following TKA. BFR was incorporated into her home program, 16-weeks postoperatively. The Short Form McGill Pain Questionnaire-2 (SF-MPQ-2) and Numeric Pain Rating Scale (NPRS) were used to measure pain. Quantitative sensory testing included pressure pain threshold (PPT) and two-point discrimination (TPD) to measure change in sensory perception. Patient-reported outcome measures to assess perceived physical function were the Knee injury and Osteoarthritis Outcome Score (KOOS) and the KOOS- Joint Replacement (KOOS-JR). Physical performance was measured through the 30-second fast walk test (30SFW), timed stair climb test (SCT), 30-second chair standing test (CST), and the timed up and go (TUG). Knee ROM was assessed through standard goniometry. Knee extensor and flexor muscle strength and power were measured with an instrumented dynamometer for isokinetic and isometric testing, generating a limb symmetry index (LSI).

Outcomes

Pain and quantitative sensory testing achieved clinically meaningful improvement suggesting reduced sensitivity during and after BFR utilization. Perceived physical function and symptoms significantly improved, particularly in sports and recreation activities, and were best captured in the KOOS, not the KOOS-JR. Physical performance reached clinically meaningful improvement in walking speed, chair stand repetitions, and timed stair climb tests after BFR. Isokinetic and isometric strength and power in knee extensors and flexors increased significantly after BFR compared to the uninvolved leg as determined by LSI.

Discussion

In this case, BFR appeared to be a safe and well-tolerated intervention. The results suggest potential benefits in terms of increased function, strength, power, and reduced pain in this specific person after TKA. Comprehensive pain and sensory assessments alongside clinical measures may help identify suitable patients for BFR after TKA. The KOOS-Sport & Recreation subscale may be more responsive to monitor functional recovery compared to the KOOS-JR, possibly due to the subject's athletic background.

Level of Evidence

4.

High Area Deprivation Index is Associated With Not Achieving the Patient-acceptable Symptom State After TKA

BACKGROUND

The Area Deprivation Index (ADI) approximates a patient's relative socioeconomic deprivation. The ADI has been associated with increased healthcare use after TKA, but it is unknown whether there is an association with patient-reported outcome measures (PROMs). Given that a high proportion of patients are dissatisfied with their results after TKA, and the large number of these procedures performed, knowledge of factors associated with PROMs may indicate opportunities to provide support to patients who might benefit from it.

QUESTIONS/PURPOSES

(1) Is the ADI associated with achieving the minimum clinically important difference (MCID) for the Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain, Joint Replacement (JR), and Physical Function (PS) short forms after TKA? (2) Is the ADI associated with achieving the patient-acceptable symptom state (PASS) thresholds for the KOOS pain, JR, and PS short forms?

METHODS

This was a retrospective study of data drawn from a longitudinally maintained database. Between January 2016 and July 2021, a total of 12,239 patients underwent unilateral TKA at a tertiary healthcare center. Of these, 92% (11,213) had available baseline PROM data and were potentially eligible. An additional 21% (2400) of patients were lost before the minimum study follow-up of 1 year or had incomplete data, leaving 79% (8813) for analysis here. The MCID is the smallest change in an outcome score that a patient is likely to perceive as a clinically important improvement, and the PASS refers to the threshold beyond which patients consider their symptoms acceptable and consistent with adequate functioning and well-being. MCIDs were calculated using a distribution-based method. Multivariable logistic regression models were created to investigate the association of ADI with 1-year PROMs while controlling for patient demographic variables. ADI was stratified into quintiles based on their distribution in our sample. Achievement of MCID and PASS thresholds was determined by the improvement between preoperative and 1-year PROMs.

RESULTS

After controlling for patient demographic factors, ADI was not associated with an inability to achieve the MCID for the KOOS pain, KOOS PS, or KOOS JR. A higher ADI was independently associated with an increased risk of inability to achieve the PASS for KOOS pain (for example, the odds ratio of those in the ADI category of 83 to 100 compared with those in the 1 to 32 category was 1.34 [95% confidence interval 1.13 to 1.58]) and KOOS JR (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.29 [95% CI 1.10 to 1.53]), but not KOOS PS (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.09 [95% CI 0.92 to 1.29]).

CONCLUSION

Our findings suggest that social and economic factors are associated with patients' perceptions of their overall pain and function after TKA, but such factors are not associated with patients' perceptions of their improvement in symptoms. Patients from areas with higher deprivation may be an at-risk population and could benefit from targeted interventions to improve their perception of their healthcare experience, such as through referrals to nonemergent medical transportation and supporting applications to local care coordination services before proceeding with TKA. Future research should investigate the mechanisms underlying why socioeconomic disadvantage is associated with inability to achieve the PASS, but not the MCID, after TKA.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Staged Bilateral Total Knee Arthroplasty: Differing Results Comparing the First and Second Knees

BACKGROUND

Patients often prefer one knee over the other following staged bilateral total knee arthroplasty (BTKA). Our study compared patient-reported outcomes scores of each knee following BTKA and identified factors that may contribute to the identified discrepancies.

METHODS

All patients who underwent staged BTKA between July 2014 and August 2022 were identified. The patient-reported outcomes were collected preoperatively and at 2 weeks, 6 weeks, 1 year, and 2 years postoperatively. Each knee's results were compared using paired t-tests and McNemar tests. Preoperative Kellgren-Lawrence Grade (KLG), postoperative range of motion (ROM), reoperation rates, and manipulations under anesthesia (MUAs) were collected. Results were stratified based on time between TKAs (< 3 months, 3 to 12 months, 1 to 2 years, and > 2 years).

RESULTS

There were 911 patients who underwent staged BTKA, with a mean 4.1-year follow-up. The ROM, patient satisfaction, MUAs, and reoperations were not significantly different between knees. Comparing the KLG of the first and second knees, 71% had the same KLG for both knees, 21% had a lower KLG, and 7% of the second knees had a higher KLG. The first knee had greater pain reduction (-10.6 at 2 weeks, -27.4 at 6 weeks) compared to the second (9.3 at 2 weeks, -8.1 at 6 weeks) (P < .0001) and better improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score (8.5 at 2 weeks, 16.9 at 6 weeks) compared to the second (-5.8 at 2 weeks, 5.0 at 6 weeks) (P < .0001). The 1-year outcomes between first and second knees, or recovery curves, were not different when stratifying by time between TKAs.

CONCLUSIONS

The second knee in a staged BTKA has less delta improvement in KOOS JR and pain scores at early follow-up, likely due to higher starting KOOS JR and Patient-Reported Outcomes Measurement Information System scores, despite similar final patient satisfaction and clinical outcome measures. Lower KLG in the second total knee arthroplasty (TKA) may contribute to these findings. An MUA after the first TKA is highly predictive of an MUA after the second TKA.

Outcomes following open acetabular labrum reconstruction: Comparing fresh-frozen tendon with fresh meniscus allograft transplantation

Background

Symptomatic acetabular labral insufficiency in young, active patients is often treated with labral repair or reconstruction using fresh-frozen allografts. However, fresh-frozen tendon allografts do not have tissue or material properties that closely mimic acetabular labral fibrocartilage. Recent studies suggest meniscal allografts may be a better biomechanical, geometric, and material alternative for acetabular labrum reconstruction (ALR).

Hypothesis

Patients undergoing open ALR using fresh meniscus allograft transplants (MAT) will have better outcomes than those using fresh-frozen tendon allografts transplants (TAT) when comparing initial treatment success, diagnostic imaging assessments, and patient-reported pain and function scores.

Study design

Cohort Study.

Methods

With IRB approval, patients undergoing ALR with either TAT or MAT were included when initial (>1-year) outcomes data related to treatment success, pain, and function were available. In addition, a subcohort of patients underwent magnetic resonance imaging at least 6-months after surgery to evaluate allograft healing.

Results

Initial success rate, defined as no need for ALR revision or conversion to total hip arthroplasty (THA), was 88.9% for the entire group (n = 27, TAT = 5, MAT = 22) with 1 (20%) patient in the TAT cohort and 2 patients (9.9%) in the MAT cohort undergoing THA. In the MAT cohort, significant improvements were documented for physical function and pain scores at 1 year and final follow-up (FFU)(mean 26.8 months). Improvements in pain and function were noted at 1-year, but not at FFU (mean 59.6 months) in the TAT group. MRIs completed at least 6 months after labrum reconstruction showed improved allograft integrity and integration in the MAT cohort over the TAT cohort.

Conclusion

For acetabular labrum reconstructions, MAT was associated with a higher initial success rate, superior patient reported outcomes, and subjectively better MRI findings when compared to TAT.

Gluteal Tendinopathy Is Associated With Lower Patient-Reported Outcome Measures in Total Hip Arthroplasty With a Posterior Approach: A Prospective Cohort Study of 1,538 Patients

BACKGROUND

Gluteal tendinopathy (GT) is found in 20 to 25% of patients undergoing total hip arthroplasty (THA). Despite this, there is a scarcity of literature assessing the association between GT and THA outcomes. The aim of this study was to evaluate whether intraoperative diagnosis of GT negatively affected postoperative outcomes.

METHODS

Consecutive patients undergoing primary THA for osteoarthritis via a posterior approach over 5 years were recruited in a prospective study. Gluteal tendinopathy was assessed and graded at the time of surgery, but not repaired. A total of 1,538 (93%) completed the patient-reported outcome measures (PROMs) at 1 year after surgery and were included in the analysis. The PROMs included the Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR), and EuroQol 5-Dimension, and were collected preoperatively and one year after THA.

RESULTS

The gluteal tendons were graded as 4 distinct grades: normal (n = 1,023, 66%), tendinopathy but no tear (n = 337, 22%), partial thickness tear (n = 131, 9%), and full thickness tear (n = 47, 3%). The occurrence of GT was associated with age, body mass index, and sex. There was no significant difference in baseline OHS or HOOS JR scores according to GT grade. As GT grade increased, lower median 1-year OHS (P = .001) and HOOS JR (P = .016) were observed. This association was confirmed by linear regression analysis with 1-year OHS (B = 0.5, 95% CI = -0.9 to -0.1, P = .011) when controlled for age and sex.

CONCLUSIONS

Gluteal tendinopathy was commonly observed and was associated with inferior 1-year PROMs in patients undergoing THA via posterior approach. Increasing degree of tendinopathy was a negative prognostic factor for outcomes and patient satisfaction.

LEVEL OF EVIDENCE

Level 2 (High quality prospective cohort study).

Functional Articulating Antibiotic Spacers for Chronic Native Septic Knee Arthritis

Background

Semipermanent functional spacers are now utilized for prosthetic joint infection in an attempt to avoid another surgery with 2-stage treatment. This study evaluates the results of metal-on-polyethylene articulating spacers for the treatment of chronic native septic knee arthritis.

Methods

This is a retrospective review of 18 patients treated with metal-on-polyethylene articulating antibiotic spacers constructed with all-polyethylene tibial components or with polyethylene inserts (PIs) with Steinmann pins or screws for chronic native knee infection. Demographic information, spacer construct type, prior knee surgery, complications, infecting organisms, infection eradication, and functional results were analyzed.

Results

Of 18, 8 (44%) spacers were all-polyethylene tibial components and 10 (56%) were PI. Of 18 patients, 5 (28%) experienced spacer complications. Of 18 patients, 12 (67%) underwent a second reimplantation surgery (mean 106 days), while 6 (33%) retained their spacer (average duration 425 days). The PI group performed better in Knee Injury and Osteoarthritis Outcome score for Joint Replacement according to minimum clinically important difference and patient acceptable symptom state (PASS) criteria. The overall reimplantation group achieved Knee Injury and Osteoarthritis Outcome score for Joint Replacement PASS criteria and minimum clinically important difference criteria, while the maintained articulating spacer group did not achieve PASS criteria; however, they did reach minimum clinically important difference.

Conclusions

Functional articulating spacers are a viable treatment for chronic, native knee septic arthritis. The PI patient group had a greater improvement in Knee Injury and Osteoarthritis Outcome score for Joint Replacement scores and had no significant difference in reimplantation rate as the all-polyethylene tibial components patient group. Both planned 2-stage reimplantation and longer-term spacer retention show promising results for this difficult clinical problem.

Predicting Recovery Following Total Hip and Knee Arthroplasty Using a Clustering Algorithm

Background

Recovery following total joint arthroplasty is patient-specific, yet groups of patients tend to fall into certain similar patterns of recovery. The purpose of this study was to identify and characterize recovery patterns following total hip arthroplasty (THA) and total knee arthroplasty (TKA) using patient-reported outcomes that represent distinct health domains. We hypothesized that recovery patterns could be defined and predicted using preoperative data.

Methods

Adult patients were recruited from a large, urban academic center. To model postoperative responses to THA and TKA across domains such as physical health, mental health, and joint-specific measures, we employed a longitudinal clustering algorithm that incorporates each of these health domains. The clustering algorithm from multiple health domains allows the ability to define distinct recovery trajectories, which could then be predicted from preoperative and perioperative factors using a multinomial regression.

Results

Four hundred forty-one of 1134 patients undergoing THA and 346 of 921 undergoing TKA met eligibility criteria and were used to define distinct patterns of recovery. The clustering algorithm was optimized for 3 distinct patterns of recovery that were observed in THA and TKA patients. Patients recovering from THA were divided into 3 groups: standard responders (50.8%), late mental responders (13.2%), and substandard responders (36.1%). Multivariable, multinomial regression suggested that these 3 groups had defined characteristics. Late mental responders tended to be obese (P = .05) and use more opioids (P = .01). Substandard responders had a larger number of comorbidities (P = .02) and used more opioids (P = .001). Patients recovering from TKA were divided among standard responders (55.8%), poor mental responders (24%), and poor physical responders (20.2%). Poor mental responders were more likely to be female (P = .04) and American Society of Anesthesiologists class III/IV (P = .004). Poor physical responders were more likely to be female (P = .03), younger (P = .04), American Society of Anesthesiologists III/IV (P = .04), use more opioids (P = .02), and be discharged to a nursing facility (P = .001). The THA and TKA models demonstrated areas under the curve of 0.67 and 0.72.

Conclusions

This multidomain, longitudinal clustering analysis defines 3 distinct patterns in the recovery of THA and TKA patients, with most patients in both cohorts experiencing robust improvement, while others had equally well defined yet less optimal recovery trajectories that were either delayed in recovery or failed to achieve a desired outcome. Patients in the delayed recovery and poor outcome groups were slightly different between THA and TKA. These groups of patients with similar recovery patterns were defined by patient characteristics that include potentially modifiable comorbid factors. This research suggests that there are multiple defined recovery trajectories after THA and TKA, which provides a new perspective on THA and TKA recovery.

Level of Evidence

III.

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.

The influence of body mass index on patient-reported outcome measures following total hip arthroplasty: a retrospective study of 3,903 Cases

BACKGROUND

The influence of obesity on patient-reported outcome measures (PROMs) following total hip arthroplasty (THA) is currently controversial. This study aimed to compare PROM scores for pain, functional status, and global physical/mental health based on body mass index (BMI) classification.

METHODS

Primary, elective THA procedures at a single institution between 2018 and 2021 were retrospectively reviewed, and patients were stratified into four groups based on BMI: normal weight (18.5-24.99 kg/m2), overweight (25-29.99 kg/m2), obese (30-39.99 kg/m2), and morbidly obese (> 40 kg/m2). Patient-Reported Outcome Measurement Information System (PROMIS) and Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) scores were collected. Preoperative, postoperative, and pre/post- changes (pre/post-Δ) in scores were compared between groups. Multiple linear regression was used to assess for confounders.

RESULTS

We analyzed 3,404 patients undergoing 3,903 THAs, including 919 (23.5%) normal weight, 1,374 (35.2%) overweight, 1,356 (35.2%) obese, and 254 (6.5%) morbidly obese cases. HOOS, JR scores were worse preoperatively and postoperatively for higher BMI classes, however HOOS, JR pre/post-Δ was comparable between groups. All PROMIS measures were worse preoperatively and postoperatively in higher BMI classes, though pre/post-Δ were comparable for all groups. Clinically significant improvements for all BMI classes were observed in all PROM metrics except PROMIS mental health. Regression analysis demonstrated that obesity, but not morbid obesity, was independently associated with greater improvement in HOOS, JR.

CONCLUSIONS

Obese patients undergoing THA achieve lower absolute scores for pain, function, and self-perceived health, despite achieving comparable relative improvements in pain and function with surgery. Denying THA based on BMI restricts patients from clinically beneficial improvements comparable to those of non-obese patients, though morbidly obese patients may benefit from additional weight loss to achieve maximal functional improvement.

Translation, cross-cultural adaptation, reliability, and convergent and known-group validity of the Turkish full version of the Hip Disability and Osteoarthritis Outcome Score in patients with hip osteoarthritis

Objectives

The study aimed to culturally adapt the full version of the Hip Disability and Osteoarthritis Outcome Score (HOOS) into Turkish and evaluate its reliability and validity.

Patients and methods

Patients with hip osteoarthritis were included in the methodological crosscultural adaptation study between May 2022 and December 2022. We translated and adapted the HOOS into a Turkish version and validated it in a cohort of native Turkish-speaking patients with hip osteoarthritis. The HOOS includes five subscales named symptoms, pain, activities of daily living (ADL), sport and recreation (Sport/Rec), and quality of life (QoL). The psychometric properties of the Turkish HOOS were assessed. The reliability was investigated using test-retest reliability (intraclass correlation coefficient; ICC) and internal consistency methods (Cronbach's alpha). The convergent validity of the Turkish HOOS was evaluated by testing the predefined hypotheses using the correlations with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the European Quality of Life Scale (EQ-5D-3L), a generic QoL scale.

Results

A total of 202 patients (131 females, 71 males; mean age: 55.2±9.7 years; range, 50 to 70 years) were recruited for the study. Cronbach's alpha values for each subscale of the HOOS were as follows: symptoms=0.76, pain=0.94, ADL=0.96, Sport/Rec=0.87, QoL=0.78, and total score=0.98, indicating it has high internal consistency. For all subscales and total score of the HOOS, the ICC values were between 0.77 and 0.86, indicating good to excellent test-retest reliability. All correlations between each subscale and total score of the Turkish HOOS, WOMAC, and EQ-5D-3L were moderate to strong. Therefore, 23 predefined hypotheses out of 24 were confirmed with a confirmation rate of 96%, indicating the Turkish version of the HOOS had adequate convergent validity.

Conclusion

This study shows that the Turkish version of the HOOS has a convergent and knowngroup validity, internal consistency, and test-retest reliability. It can be used to assess the patient's perception of their hip and associated difficulties, as well as their symptoms and functional limitations.

Robot-Assisted Total Hip Arthroplasty Demonstrates Improved 90-Day Clinical and Patient-Reported Outcomes

Background

The utilization of technology, including robotics and computer navigation, in total hip arthroplasty (THA) has been steadily increasing; however, conflicting data exists regarding its effect on short-term clinical and patient-reported outcomes. Therefore, this study sought to explore the association between different surgical technologies and postoperative outcomes following THA.

Methods

We retrospectively reviewed 9892 primary THA cases performed by 62 surgeons from a single institution from September 2017 to November 2022. Three cohorts were created based on the utilization of technology: conventional (no technology), navigation, or robotics. Patient demographics, clinical outcomes, and patient-reported outcome measures were collected over the first 90 days following surgery. This data was compared using analysis of variance and multivariate logistic regressions. In total, 4275 conventional, 4510 navigation, and 1107 robotic cases were included in our analyses.

Results

The robotic cohort achieved a perfect Activity Measure for Post-Acute Care (AM-PAC) score earliest (0.1 days, P < .001). After adjusting for potential confounding variables, use of robotic assistance was associated with greater odds of achieving a perfect AM-PAC score on postoperative day 0 (odds ratio 1.6, P < .001) and greater odds of having length of stay shorter than 24 hours (odds ratio 2.3, P < .001) compared to no technology use in THA. Hip dysfunction and Osteoarthritis Outcome Score, Joint Replacement and Patient-Reported Outcomes Measurement Information System Pain Interference scores showed the greatest improvement in the robotic cohort at both 6 weeks and 3 months following surgery.

Conclusions

The present study demonstrates favorable clinical and patient-reported outcomes in the first 90 days following surgery for patients undergoing robot-assisted THA compared to conventional and navigation-assisted THA.

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.

Early Recovery Outcomes in Patients Undergoing Contemporary Posterior Approach Total Hip Arthroplasty: Each Week Shows Progress

Background: Little is known about patients' postoperative week-by-week progress after undergoing posterior approach total hip arthroplasty (THA) with regard to pain, function, return to work, and driving. Purpose: We sought to evaluate a large cohort of patients undergoing posterior approach THA with modified posterior hip precautions to better understand the trajectory of recovery. Methods: Patients at a single institution undergoing primary posterior approach THA by fellowship-trained arthroplasty surgeons were prospectively enrolled. Patient functional status and early rehabilitation recovery milestones were evaluated preoperatively and each week postoperatively for 6 weeks. Results: Of 312 patients who responded to weekly questionnaires, there were varying response rates per question. At 1 week after surgery, 15% (39/256) of respondents had returned to work, increasing to 57% (129/225) at week 6. At 6 weeks, 77% of patients (174/225) had returned to driving; 25% (56/225) were taking pain medication (including prescription opioids or nonsteroidal anti-inflammatory drugs); and 15% (34/225) were using assistive devices (down from 91%, 78%, 56%, 35%, and 27% at weeks 1, 2, 3, 4, and 5, respectively). Average postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Lower Extremity Functional Scale scores were significantly higher than preoperative scores. Respondents reported significantly less pain at each week postoperatively than the previous week. Conclusion: These findings suggest that there may be an expected pathway for recovery after posterior THA using perioperative pain protocols, modified postoperative precautions, and physical therapy protocols to improve patient outcomes after THA, with most patients returning to normal at 4 weeks. Defining the expected recovery timeline may help surgeons in counseling patients preoperatively and guiding their recovery.

The Impact of Preoperative Medical Evaluation in an Orthopaedic Perioperative Medical Clinic on Total Joint Arthroplasty Outcomes: An Observational Study

BACKGROUND

A preoperative medical evaluation (PME) in total joint arthroplasty (TJA) is routine despite considerable variation and uncertainty regarding its benefits. The orthopaedic department in our academic health system established a perioperative medical clinic (PMC) to standardize perioperative management and to study the effect of this intervention on total hip arthroplasty (THA) and total knee arthroplasty (TKA) outcomes. This observational study compared the impact of a PME within 30 days prior to surgery at the PMC (Periop30) versus elsewhere ("Usual Care") on postoperative length of stay (LOS), extended LOS (i.e., a stay of >3 days), and Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10) Global Physical Health (GPH) score improvement in TJA.

METHODS

We stratified adult patients (≥18 years of age) who underwent primary TJA between January 2015 and December 2020 into Periop30 or Usual Care. We utilized univariate tests (a chi-square test for categorical variables and a t test for continuous variables) to assess for differences in patient characteristics. For both TKA and THA, LOS was assessed with use of multivariable negative binomial regression models; extended LOS, with use of binary logistic regression; and PROMIS-10 GPH score, with use of mixed-effects models with random intercept and slope. Interaction terms between the focal predictor (Periop30, yes or no) and year of surgery were included in all models.

RESULTS

Periop30 comprised 82.3% of TKAs (1,911 of 2,322 ) and 73.8% of THAs (1,876 of 2,541). For THA, the Periop30 group tended to be male (p = 0.005) and had a higher body mass index (p = 0.001) than the Usual Care group. The Periop30 group had a higher rate of staged bilateral THA (10.6% versus 7.5%; p = 0.028) and a lower rate of simultaneous bilateral TKA (5.1% versus 12.2%; p < 0.001) than the Usual Care group. Periop30 was associated with a lower mean LOS for both TKA (43.46 versus 54.15 hours; p < 0.001) and THA (41.07 versus 57.94 hours; p < 0.001). The rate of extended LOS was lower in the Periop30 group than in the Usual Care group for both TKA (15% versus 26.5%; p < 0.001) and THA (13.3% versus 27.4%; p < 0.001). There was no significant difference in GPH score improvement between Periop30 and Usual Care for either TKA or THA.

CONCLUSIONS

Periop30 decreased mean LOS and the rate of extended LOS for TJA without an adverse effect on PROMIS-10 GPH scores.

LEVEL OF EVIDENCE

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

Diagnosis-Specific Thresholds of the Minimal Clinically Important Difference and Patient Acceptable Symptom State for KOOS After Total Knee Arthroplasty

UPDATE

This article was updated on May 1, 2024 because of a previous error, which was discovered after the preliminary version of the article was posted online. The byline that had read "Ahmed K. Emara, MD 1 *, Ignacio Pasqualini, MD 1 *, Alison K. Klika, MS 1 , Melissa N. Orr, BS 1 , Pedro J. Rullán, MD 1 , Nicolas S. Piuzzi, MD 1 , and the Cleveland Clinic Arthroplasty Group†" now reads "Ahmed K. Emara, MD 1 *, Ignacio Pasqualini, MD 1 *, Yuxuan Jin, MS 1 , Alison K. Klika, MS 1 , Melissa N. Orr, BS 1 , Pedro J. Rullán, MD 1 , Nicolas S. Piuzzi, MD 1 , and the Cleveland Clinic Arthroplasty Group†".

BACKGROUND

Literature-reported minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds for patient-reported outcome measures demonstrate marked variability. The purpose of this study was to determine the minimal detectable change (MDC), MCID, and PASS thresholds for the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subdomain, Physical Function Short Form (PS), and Joint Replacement (JR) among patients with osteoarthritis (OA) who underwent primary total knee arthroplasty (TKA).

METHODS

A prospective cohort of 6,778 patients who underwent primary TKA was analyzed. Overall, 1-year follow-up was completed by 5,316 patients for the KOOS Pain, 5,018 patients for the KOOS PS, and 4,033 patients for the KOOS JR. A total of 5,186 patients had an OA diagnosis; this group had an average age of 67.0 years and was 59.9% female and 80.4% White. Diagnosis-specific MDCs and MCIDs were estimated with use of a distribution-based approach. PASS values were estimated with use of an anchor-based approach, which corresponded to a response to a satisfaction question at 1 year postoperatively.

RESULTS

The MCID thresholds for the OA group were 7.9 for the KOOS Pain, 8.0 for the KOOS PS, and 6.7 for the KOOS JR. A high percentage of patients achieved the MCID threshold for each outcome measure (KOOS Pain, 95%; KOOS PS, 88%; and KOOS JR, 94%). The MDC 80% to 95% confidence intervals ranged from 9.1 to 14.0 for the KOOS Pain, 9.2 to 14.1 for the KOOS PS, and 7.7 to 11.8 for the KOOS JR. The PASS thresholds for the OA group were 77.7 for the KOOS Pain (achieved by 73% of patients), 70.3 for the KOOS PS (achieved by 68% of patients), and 70.7 for the KOOS JR (achieved by 70% of patients).

CONCLUSIONS

The present study provided useful MCID, MDC, and PASS thresholds for the KOOS Pain, PS, and JR for patients with OA. The diagnosis-specific metrics established herein can serve as benchmarks for clinically meaningful postoperative improvement. Future research and quality assessments should utilize these OA-specific thresholds when evaluating outcomes following TKA. Doing so will enable more accurate determinations of operative success and improvements in patient-centered care.

LEVEL OF EVIDENCE

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

Defining Patient-relevant Thresholds and Change Scores for the HOOS JR and KOOS JR Anchored on the Patient-acceptable Symptom State Question

BACKGROUND

When evaluating the results of clinical research studies, readers need to know that patients perceive effect sizes, not p values. Knowing the minimum clinically important difference (MCID) and the patient-acceptable symptom state (PASS) threshold for patient-reported outcome measures helps us to ascertain whether our interventions result in improvements that are large enough for patients to care about, and whether our treatments alleviate patient symptoms sufficiently. Prior studies have developed the MCID and PASS threshold for the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) anchored on satisfaction with surgery, but to our knowledge, neither the MCID nor the PASS thresholds for these instruments anchored on a single-item PASS question have been described.

QUESTIONS/PURPOSES

(1) What are the MCID (defined here as the HOOS/KOOS JR change score associated with achieving PASS) and PASS threshold for the HOOS JR and KOOS JR anchored on patient responses to the single-item PASS instrument? (2) How do patient demographic factors such as age, gender, and BMI correlate with MCID and PASS thresholds using the single-item PASS instrument?

METHODS

Between July 2020 and September 2021, a total of 10,970 patients underwent one primary unilateral THA or TKA and completed at least one of the three surveys (preoperative HOOS or KOOS JR, 1-year postoperative HOOS or KOOS JR, and 1-year postoperative single-item anchor) at one large, academic medical center. Of those, only patients with data for all three surveys were eligible, leaving 13% (1465 total; 783 THAs and 682 TKAs) for analysis. Despite this low percentage, the overall sample size was large, and there was little difference between completers and noncompleters in terms of demographics or baseline patient-reported outcome measure scores. Patients undergoing bilateral total joint arthroplasty or revision total joint arthroplasty and those without all three surveys at 1 year of follow-up were excluded. A receiver operating characteristic curve analysis, leveraging a 1-year, single-item PASS (that is, "Do you consider that your current state is satisfactory?" with possible answers of "yes" or "no") as the anchor was then used to establish the MCID and PASS thresholds among the 783 included patients who underwent primary unilateral THA and 682 patients who underwent primary unilateral TKA. We also explored the associations of age at the time of surgery (younger than 65 years or 65 years and older), gender (men or women), BMI (< 30 or ≥ 30 kg/m 2 ), and baseline Patient-Reported Outcome Measure Information System-10 physical and mental component scores (< 50 or ≥ 50) for each of the MCID and PASS thresholds through stratified analyses.

RESULTS

For the HOOS JR, the MCID associated with the PASS was 23 (95% CI 18 to 31), with an area under the receiver operating characteristic curve of 0.75, and the PASS threshold was 81 (95% CI 77 to 85), with an area under the receiver operating characteristic curve of 0.81. For the KOOS JR, the MCID was 16 (95% CI 14 to 18), with an area under the receiver operating characteristic curve of 0.75, and the PASS threshold was 71 (95% CI 66 to 73) with an area under the receiver operating characteristic curve of 0.84. Stratified analyses indicated higher change scores and PASS threshold for younger men undergoing THA and higher PASS thresholds for older women undergoing TKA.

CONCLUSION

Here, we demonstrated the utility of a single patient-centered anchor question, raising the question as to whether simply collecting a postoperative PASS is an easier way to measure success than collecting preoperative and postoperative patient-reported outcome measures and then calculating MCIDs and the substantial clinical benefit.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Non-White Race and Concomitant Orthopedic Conditions Are Risk Factors for Failure to Achieve Clinically Relevant Improvement After Total Knee Arthroplasty

BACKGROUND

Data from the American Joint Replacement Registry demonstrate that 1-year minimal clinically important difference (MCID) achievement rates after total knee arthroplasty (TKA) are substantially lower when using general patient reported outcome measures, such as Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), than joint specific measures. The purpose of this study was to evaluate patient characteristics and outcomes associated with MCID achievement after TKA using the PROMIS-PF measure.

METHODS

A retrospective review of 263 patients undergoing TKA with preoperative and 1-year postoperative PROMIS-PF scores from March 12, 2020 to February 8, 2022 was performed. Three multivariate models were built to evaluate predictors of MCID achievement. Preoperative predictors evaluated included demographics, comorbidities, history of spine and knee surgery, and baseline PROMIS-PF. Postoperative clinical outcomes evaluated included lengths of stay, discharge statuses, complications, and utilizations of other orthopaedic services.

RESULTS

There were 109 patients (41%) who achieved an MCID at 1-year postoperatively. Non-white patients had 2.17 times lower odds of achieving MCID. No clinical outcomes assessed were independently predictive of MCID achievement. During the 1-year postoperative period, 63% of patients sought care for another orthopaedic condition. Patients requiring postoperative injections on another joint had a 2.27 times lower odds of achieving MCID. Those seen for spine conditions postoperatively had a 2.44 lower odds of achieving MCID.

CONCLUSIONS

Race, postoperative injections, and treatment for spine conditions after TKA were independent predictors of failure to achieve MCID. These results may guide preoperative patient consultation and risk-adjustment in future studies using PROMIS-PF as an endpoint for evaluation of TKA outcomes.

Use of a fluoroscopy-based robotic-assisted total hip arthroplasty system produced greater improvements in patient-reported outcomes at one year compared to manual, fluoroscopic-assisted technique

INTRODUCTION

The adoption of new technology should be supported by improvements in patient-reported outcomes (PROMs). The purpose of this study was to assess the one-year PROMs of patients who underwent total hip arthroplasty (THA) using a novel, fluoroscopy-based, robotic-assisted (RA-THA) system when compared to a manual, fluoroscopic-assisted technique (mTHA).

MATERIALS AND METHODS

A review of 91 consecutive mTHA and 85 consecutive RA-THA via a direct anterior approach was conducted. All cases were performed by the same surgeon at the same institution, for a pre-operative diagnosis of osteoarthritis, avascular necrosis, or rheumatoid arthritis. Outcomes included one-year Veterans RAND-12 (VR-12) Physical/Mental, Hip Disability and Osteoarthritis Outcome (HOOS) Pain/Physical Function/Joint Replacement, and University of California Los Angeles (UCLA) Activity scores, as well as the difference between pre-operative and one-year post-operative PROMs.

RESULTS

Patients in the RA-THA cohort had lower pre-operative HOOS-JR scores compared to patients in the mTHA cohort (37.0 vs. 43.1; p = 0.031). Cohorts experienced similar one-year post-operative VR-12, HOOS, and UCLA Activity scores. Patients in the RA-THA cohort experienced greater improvements across all pre- and post-operative HOOS scores compared to patients in the mTHA cohort: Pain (+ 54.7 vs. +42.1; p = 0.009), Physical Function (-41.6 vs. -28.7; p = 0.007), and Joint Replacement (+ 46.6 vs. +33.0; p = 0.002). These differences exceeded minimum clinically important difference (MCID).

CONCLUSIONS

Both manual and robotic cohorts experienced benefit from THA at one-year post-operative. Importantly, the use of a novel, fluoroscopy-based robotic assistance system for primary THA resulted in greater improvements in PROMs at one-year relative to manual technique.

Total Knee Conversion Rates and Functional Outcome After Calcium Phosphate Injection for Bone Marrow Lesions of the Knee

Untreated osteoarthritis (OA)-related bone marrow lesions (OA-BML) can hasten the progression of knee OA. Previous studies have shown that fluoroscopically guided intraosseous calcium-phosphate (CaP) injections of OA-BML during knee arthroscopy can lead to pain reduction, improved functionality, and prolonged time until conversion to total knee arthroplasty (TKA). The purpose of this retrospective study is to compare the clinical outcomes of patients who underwent knee arthroscopy and CaP injection for OA-BML versus knee arthroscopy for non-OA-BML pathologies. Two-year follow-up data and patient-reported outcomes including knee injury and operative outcome scores, joint replacement scores (KOOS, JR) were available for 53 patients in the CaP group and 30 patients in the knee arthroscopy group. Results indicate that patients in the CaP group had less frequent conversion to TKA compared with patients in the knee arthroscopy group. Statistical analysis demonstrated a statistical difference between preoperative and postoperative KOOS, JR within the CaP group but not for the knee arthroscopy group. Two-year postoperative KOOS, JR for CaP patients was statistically greater than the 2-year postoperative KOOS, JR of knee arthroscopy patients. Results indicate greater improvement in functional outcomes with knee arthroscopy and CaP injection of OA-BML compared with knee arthroscopy alone for non-OA-BML diagnoses. The results of this retrospective study help to distinguish the benefits of knee arthroscopy accompanied by CaP intraosseous injection from that of knee arthroscopy alone.

Comparison of Outcomes After Primary Versus Salvage Osteochondral Allograft Transplantation for Femoral Condyle Osteochondritis Dissecans Lesions

Background

Osteochondral allograft transplantation (OCAT) allows the restoration of femoral condyle osteochondritis dissecans (OCD) lesions using an osteochondral unit. When OCD lesions are irreparable, or treatments have failed, OCAT is an appropriate approach for revision or salvage surgery. Based on its relative availability, cost-effectiveness, lack of donor site morbidity, and advances in preservation methods, OCAT is also an attractive option for primary surgical treatment for femoral condyle OCD.

Hypothesis

OCAT for large femoral condyle OCD lesions would be highly successful (>90%) based on significant improvements in knee pain and function, with no significant differences between primary and salvage procedure outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients were enrolled into a registry for assessing outcomes after OCAT. Those patients who underwent OCAT for femoral condyle OCD and had a minimum of 2-year follow-up were included. Reoperations, treatment failures, and patient-reported outcomes were compared between primary and salvage OCAT cohorts.

Results

A total of 22 consecutive patients were included for analysis, with none lost to the 2-year follow-up (mean, 40.3 months; range, 24-82 months). OCD lesions of the medial femoral condyle (n = 17), lateral femoral condyle (n = 4), or both condyles (n = 1) were analyzed. The mean patient age was 25.3 years (range, 12-50 years), and the mean body mass index was 25.2 kg/m2 (range, 17-42 kg/m2). No statistically significant differences were observed between the primary (n = 11) and salvage (n = 11) OCAT cohorts in patient and surgical characteristics. Also, 91% of patients had successful outcomes at a mean of >3 years after OCAT with 1 revision in the primary OCAT cohort and 1 conversion to total knee arthroplasty in the salvage OCAT cohort. For both primary and salvage OCATs, patient-reported measures of pain and function significantly improved at the 1-year and final follow-up, and >90% of patients reported that they were satisfied and would choose OCAT again for treatment.

Conclusion

Based on the low treatment failure rates in conjunction with statistically significant and clinically meaningful improvements in patient-reported outcomes, OCAT can be considered an appropriate option for both primary and salvage surgical treatment in patients with irreparable OCD lesions of the femoral condyles.

Outcomes after Anatomic Double-Bundle Posterior Cruciate Ligament Reconstructions Using Transtibial and Tibial Inlay Techniques

Surgical reconstruction is recommended for symptomatic posterior cruciate ligament (PCL) deficiency. While anatomic double-bundle PCL reconstruction (PCLR) has been reported to be associated with biomechanical and clinical advantages over other methods, there is still debate regarding the optimal technique for tibial positioning and fixation. Based on reported advantages and disadvantages, we employed two tibial fixation techniques, transtibial (TT) and tibial inlay (TI) for anatomic double-bundle PCLR with technique selection based on body mass index, comorbidities, and primary versus revision surgery. This study aimed to compare clinical outcomes following PCLR utilizing either TT or TI techniques to validate relative advantages, disadvantages, and indications for each based on the review of prospectively collected registry data. For 37 patients meeting inclusion criteria, 26 underwent arthroscopic TT PCLR using all-soft- tissue allograft with suspensory fixation in the tibia and 11 patients underwent open TI PCLR using an allograft with calcaneal bone block and screw fixation in the tibia. There were no significant preoperative differences between cohorts. Success rates were 96% for TT and 91% for TI with all successful cases documented to be associated with good-to-excellent posterior stability and range of motion in the knee at the final follow-up. In addition, patient-reported outcome scores were within clinically meaningful ranges for pain, function, and mental health after PCLR in both cohorts, suggesting similarly favorable functional, social, and psychological outcomes. Patient-reported pain scores at 6 months postoperatively were significantly (p = 0.042) lower in the TT cohort, which was the only statistically significant difference in outcomes noted. The results of this study support the use of TT and TI techniques for double-bundle anatomic PCLR in restoring knee stability and patient function when used for the treatment of isolated and multiligamentous PCL injuries. The choice between tibial fixation methods for PCLR can be appropriately based on patient and injury characteristics that optimize respective advantages for each technique.

Examining the Relationship Between Value and Patient Satisfaction With Treatment in Total Joint Arthroplasty

Background

A shift toward performance, cost, outcomes, and patient satisfaction has occurred with healthcare reform promoting value-based programs. The purpose of this study was to evaluate the relationship between patient satisfaction and value with treatment in a cohort of patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Methods

Value was determined by the relationship of treatment outcome with episodic cost. Measurements included both clinical outcomes and patient-reported outcomes. Participating surgeons took part in the modified Delphi method resulting in an algorithm measuring patient value. Treatment outcome, cost, and resultant value (outcome/cost) of both TKA and THA were evaluated using binomial logistic regression by adjusting for age, gender, body mass index, Charlson comorbidity index, tobacco, education, and income with patient-reported satisfaction as the outcome.

Results

This study had a total of 909 patients (TKA n = 438; THA n = 471), with an average age of 67 (TKA) and 65 (THA) years. Patient satisfaction shared a significant positive relationship with treatment outcome for TKA (odds ratio [OR] = 1.53, confidence interval [CI] = 1.35-1.73, P < .001) and THA (OR = 1.93, CI = 1.62-2.29, P < .001). Higher value was associated with a significantly higher odds of patient satisfaction for both TKA (OR = 1.39, CI = 1.25-1.54, P < .001) and THA (OR = 1.70, CI = 1.47-1.97, P < .001).

Conclusions

This study showed a positive relationship between treatment outcome but not cost with subsequent value and patient satisfaction. This method provides a promising approach to comprehensively evaluate outcomes, cost, and value of total joint arthroplasty procedures. This approach can help predict the probability of value-driven patient satisfaction.

Establishing the Minimally Important Difference for the KOOS-Joint Replacement and PROMIS Global-10 in Patients After Total Knee Arthroplasty

Background

Despite the overall prevalence and success of total knee arthroplasty (TKA), a significant portion of patients are dissatisfied with their outcomes.

Purpose

To assess the responsiveness and determine the minimally important difference (MID) of 2 patient-reported outcome measures (PROMs)-the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR) and the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS 10)-in patients after TKA.

Study Design

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

Methods

Included were patients who underwent TKA from August 2015 through August 2019 and completed baseline and postoperative KOOS-JR and PROMIS 10 surveys. The PROMIS 10 consists of 2 domains: physical health and mental health. Estimates for the reliable change index (RCI) and MID, using anchor-based and distribution-based methods, were calculated for each PROM. Regression modeling was used to determine whether patient and clinical factors predicted MID thresholds or MID achievement.

Results

A total of 1315 patients were included. Distribution-based MIDs, calculated using various methods from baseline scores, ranged from 19.3 to 31 for the KOOS-JR, and the RCI was 4.38. Of these patients, 293 (22.3%) demonstrated small or moderate improvement, and this cohort was included in the calculation of anchor-based MIDs. The anchor-based MIDs were 16.9 and 24.3 at 3-month and 1-year follow-up, respectively, and 66% of patients achieved the MID at 12 months. Higher preoperative PROM score, male sex, non-White race, and current smoker status were predictive of failing to achieve the anchor-based MID for KOOS-JR at 1 year postoperatively (P < .05). Higher preoperative PROM score and any 90-day adverse event predicted lower thresholds of important change in anchor-based MIDs. Higher baseline PROM scores, younger age, male sex, non-White ethnicity, higher American Society of Anesthesiologists classification, preoperative narcotics use, not smoking, and longer hospital stay were all associated with lower odds of achieving the MID on the KOOS-JR or either of the PROMIS 10 subscales.

Conclusion

The study results demonstrated relevant values for interpretation of the KOOS-JR and PROMIS 10. While patient demographics did not accurately predict which patients would achieve the MID, some potential factors predicting successful patient-reported outcomes after TKA were identified.

Prevalence of Depressive Symptoms in Aseptic Revision Total Knee Arthroplasty Based on the Mode of Failure

Background

Complications following total knee arthroplasty (TKA) that necessitate revision cause considerable psychological distress and symptoms of depression, which are linked to poorer postoperative outcomes, increased complications, and increased healthcare utilization. We aimed to identify the prevalence of mental health disorders and symptoms preoperatively and postoperatively in patients undergoing aseptic revision TKA and to stratify these patients based on their mechanism of failure.

Methods

All patients undergoing aseptic revision TKA from 2008 to 2019 with a minimum 1-year follow-up were retrospectively reviewed at a single institution. Patients (n = 394) were grouped based on 7 failure modes previously described. Patients were considered to have depressive symptoms if their Veterans RAND-12 mental component score was below 42. Preoperative and postoperative Veterans RAND-12 mental component scores at the latest follow-up were evaluated.

Results

Overall comparative prevalence of preoperative to postoperative depressive symptoms was 23.4%-18.8%. By mode of failure are as follows: arthrofibrosis (25.8%-16.7%), aseptic loosening (25.3%-18.9%), extensor mechanism disruption (25%-50%), failed unicompartmental knee arthroplasty (8.6%-14.3%), instability (25.7%-17.1%), osteolysis or polyethylene wear (23.1%-23.1%), and patellar failure (11.8%-23.5%). There was no difference in depressive symptoms among failure modes preoperatively (P = .376) or at the latest postoperative follow-up (P = .175).

Conclusions

The prevalence of depressive symptoms in revision TKA patients appears to be independent of failure mode. Surgeon awareness and screening for depressive symptoms in this patient population preoperatively with referral for potential treatment may improve early postoperative outcomes.

Establishing patient-centered metrics for the knee injury and osteoarthritis outcome score following medial unicompartmental knee arthropalsty

BACKGROUND

This study aimed to determine the minimal clinically important difference (MCID) and the patient acceptable symptoms state (PASS) threshold for the knee injury and osteoarthritis outcome score (KOOS) pain subscore, KOOS physical short form (PS), and KOOS joint replacement (JR) following medial unicompartmental knee arthroplasty (mUKA).

METHODS

Prospectively collected data from 743 patients undergoing mUKA from a single academic institution from April 2015 through March 2020 were analyzed. Patient-reported outcome measures (PROMs) were collected both pre-operatively and 1-year post-operatively. Distribution-based and anchored-based approaches were used to estimate MCIDs and PASS, respectively. The optimal cut-off point and the percentage of patients who achieved PASS were also calculated.

RESULTS

MCID for KOOS-pain, KOOS-PS, and KOOS-JR following mUKA were calculated to be 7.6, 7.3, and 6.2, respectively. The PASS threshold for KOOS pain, PS, and JR were 77.8, 70.3, and 70.7, with 68%, 66%, and 64% of patients achieving satisfactory outcomes, respectively. Cut-off values for delta KOOS pain, PS, and JR were found to be 25.7, 14.3, and 20.7 with 73%, 69%, and 68% of patients achieving satisfactory outcomes, respectively.

CONCLUSION

The current study identified useful values for the MCID and PASS thresholds at 1 year following medial UKA of KOOS pain, KOOS PS, and KOOS JR scores. These values may be used as targets for surgeons when evaluating PROMS using KOOS to determine whether patients have achieved successful outcomes after their surgical intervention. Potential uses include the integration of these values into predictive models to enhance shared decision-making and guide more informed decisions to optimize patient outcomes.

LEVEL OF EVIDENCE

III.

Do Patients Living in Rural Areas Report Inferior 1-Year Outcomes After Total Knee Arthroplasty? A Matched Cohort Analysis

BACKGROUND

Rural status has been associated with poor outcomes for several health problems, but its relationship and outcomes following total knee arthroplasty (TKA) has not been fully characterized. Patient-reported outcomes (PROs) are key measures of success following TKA. Therefore, this matched cohort study was designed to test the hypothesis that patients who live in rural settings will report significantly worse PRO scores 1 year after TKA when compared to those who live in urban or suburban settings.

METHODS

Patients undergoing TKA at our institution were categorized into urban, suburban, and rural cohorts based on Rural Urban Commuting Area scores using reported living setting zip codes. Cohorts were matched for body mass index classification. Demographic data were extracted from the medical records, and PRO data (Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS JR), Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health and Mental Health, University of California, Los Angeles (UCLA) Activity Score, and Visual Analog Scale Pain were collected preoperatively and 1-year postoperatively. Comparisons across living settings were made using analysis of variance (ANOVA) tests or Chi-square tests. A total of 882 TKA patients (n = 294 per cohort) were analyzed.

RESULTS

Patients living in urban areas had significantly lower preoperative pain scores compared to suburban and rural residents. All measured PROs significantly improved from preoperative levels at 1 year post-TKA with no significant differences among living setting cohorts.

CONCLUSIONS

In cohorts matched for body mass index, living in a rural setting was not associated with inferior PROs 1 year after TKA.

LEVEL OF EVIDENCE

Level 4, retrospective cohort study.

Rasch Analysis of Joint Replacement Version for Hip Disability and Osteoarthritis Outcome in Individuals With Advanced Osteoarthritis of Hip Awaiting Total Hip Arthroplasty Surgery

OBJECTIVE

The objective of this study was to examine measurement properties of the Joint replacement version for Hip Disability and Osteoarthritis Outcome Score (HOOS-JR) using Rasch analysis in patients with osteoarthritis of hip (HOA).

DESIGN

Cross-sectional clinical measurement SETTING: Patient outcomes database at a tertiary care hospital PARTICIPANTS: Convenience sampling of patients with HOA scheduled for total hip arthroplasty (N=327) OUTCOME MEASURES AND ANALYSIS: The data for pre-surgery assessments for patients with HOA were extracted from an existing database. Variables extracted included HOOS-JR scores, demographic information (age, sex), health-related data, and anthropometric variables. The assumptions of Rasch model such as the test of fit, fit residuals, ordering of item thresholds, factor structure, DIF, internal consistency and Pearson separation index were examined for the HOOS-JR scores.

RESULTS

The HOOS-JR showed adequate overall fit to the Rasch model, logically ordered response thresholds, no floor or ceiling effects, and high internal consistency (Cronbach's alpha of 0.91). The HOOS-JR did not satisfy the assumption of unidimensionality, albeit the violation of this assumption was marginal (6.12% over 5%). Person-item threshold distribution (difference between person and item means were equal to 0.92 which was less than 1 logit unit) confirmed that the HOOS-JR scores were well targeted.

CONCLUSIONS

Given that the violation of unidimensionality for HOOS-JR was marginal, we recommend further studies to validate this finding. Results broadly support the use of HOOS-JR for assessing hip health in patients with HOA.

A scoping review of patient self-report measures of flare in knee and hip osteoarthritis (OA): A report from the OMERACT flares in OA working group

PURPOSE

We aimed to analyze the content validity/domain match and feasibility of self-report instruments that could measure flare in osteoarthritis (OA), by extending our 2017 literature review on the definition of flare in knee and hip OA.

METHOD

We searched PubMed (Medline), Web of Science and PsycInfo (Ebsco Host) databases for original articles reporting research about flare (or synonyms) in humans with knee and hip OA, between 2017 and 2023. Four experts worked independently, checking the records, and assessing content validity and feasibility, writing justification for exclusion.

RESULTS

At literature review phase, 575 papers were filtered. After experts' analysis, 59 studies were included, and 44 instruments associated with flare in OA were identified. Most were studies about pain in knee or hip OA (35 %), cultural adaptation of a measure (33 %) or studies investigating psychometric properties of full (16 %) or short form (4 %) instruments. The assessment of domain match and feasibility revealed that 15 instruments were assigned a label of 'yes' or 'uncertain' as to whether or not there was a good match with the domain concept or whether the instrument was considered feasible to use.

DISCUSSION

Most identified instruments considered different aspects of pain and the associated discomfort in performing daily activities but did not include the central aspects of flare in OA, i.e. the change of state, nor the additional Outcome Measures in Rheumatology (OMERACT) endorsed domains for OA flare namely stiffness, swelling, psychological aspects, impact of symptoms including fatigue and sleep disturbance. Although it is possible that the period specified to conduct this literature review may have led to some recognized instruments being excluded, this review demonstrates the need for the research community to reach consensus on the best way to measure self-reported flares in future clinical trials and observational studies.

Pearls and pitfalls of PROMIS clinically significant outcomes in orthopaedic surgery

INTRODUCTION

Patient-Reported Outcome Measurement Information System (PROMIS) was developed as a uniform and generalizable PROM system using item response theory and computer adaptive testing. We aimed to assess the utilization of PROMIS for clinically significant outcomes (CSOs) measurements and provide insights into its use in orthopaedic research.

MATERIALS AND METHODS

We reviewed PROMIS CSO reports for orthopaedic procedures via PubMed, Cochrane Library, Embase, CINAHL, and Web of Science from inception to 2022, excluding abstracts and missing measurements. Bias was assessed using the Newcastle-Ottawa Scale (NOS) and questionnaire compliance. PROMIS domains, CSO measures, and study populations were described. A meta-analysis compared distribution and anchor-based MCIDs in low-bias (NOS ≥ 7) studies.

RESULTS

Overall, 54 publications from 2016 to 2022 were reviewed. PROMIS CSO studies were observational with increasing publication rates. Evidence-level was II in 10/54, bias low in 51/54, and compliance ≥ 86% in 46/54. Most (28/54) analysed lower extremity procedures. PROMIS domains examined Pain Function (PF) in 44/54, Pain Interference (PI) in 36/54, and Depression (D) in 18/54. Minimal clinically important difference (MCID) was reported in 51/54 and calculated based on distribution in 39/51 and anchor in 29/51. Patient acceptable symptom state (PASS), substantial clinical benefit (SCB), and minimal detectable change (MDC) were reported in ≤ 10/54. MCIDs were not significantly greater than MDCs. Anchor-based MCIDs were greater than distribution based MCIDs (standardized mean difference = 0.44, p < 0.001).

CONCLUSIONS

PROMIS CSOs are increasingly utilized, especially for lower extremity procedures assessing the PF, PI, and D domains using distribution-based MCID. Using more conservative anchor-based MCIDs and reporting MDCs may strengthen results. Researchers should consider unique pearls and pitfalls when assessing PROMIS CSOs.

Robotic-Assisted Total Knee Arthroplasty Can Increase Frequency of Achieving Target Limb Alignment in Primary Total Knee Arthroplasty for Preoperative Valgus Deformity

Background

Robotic-assisted total knee arthroplasty (rTKA) has been shown to reduce the number of alignment outliers and to improve component positioning compared to manual TKA (mTKA). The primary purpose of this investigation was to compare the frequency of achieving target postoperative limb alignment and component positioning for rTKA vs mTKA.

Methods

A retrospective comparative study was performed on 250 patients undergoing primary TKA by 2 fellowship-trained arthroplasty surgeons. Surgeon A performed predominantly rTKA (103 cases) with the ROSA system (Zimmer Biomet, Warsaw, IN) and less frequently mTKA (44 cases) with conventional instrumentation. Surgeon B performed only mTKA (103 cases). Target limb alignment for surgeon A was 0° for all cases and for surgeon B was 2° varus for varus knees and 0° for valgus knees. Radiographic measurements were determined by 2 reviewers. Target zone was set at ± 2 degrees from the predefined target.

Results

When comparing rTKA to mTKA performed by different surgeons, there were no differences in the percentage within the target zone (57.28% vs 53.40%, P = .575), but rTKA did result in a greater percentage for cases with preoperative valgus (71.42% vs 44.12%, P = .031). Patient-reported Outcomes Measurement Information System Global-10 physical scores were statistically higher at both 3 (P = .016) and 6 months (P = .001) postoperatively for rTKA compared to mTKA performed by different surgeons.

Conclusions

Although experienced surgeons can achieve target limb alignment correction with similar frequency when comparing rTKA to mTKA for all cases, rTKA may achieve target limb alignment with more accuracy for preoperative valgus deformity.

Level of Evidence

Retrospective Cohort Study, Level III.

Patients Undergoing Primary, Cementless TKA had Similar Pain, Opioid Utilization, and Functional Outcomes Compared to Matched Patients With Cemented Fixation

BACKGROUND

Despite renewed interest in cementless fixation of total knee implants, many surgeons have anecdotal concerns about slower recovery and higher early pain scores. We sought to analyze 90-day opioid utilizations, inhospital pain scores, and patient-reported outcome measures (PROMs) in patients undergoing primary cemented versus cementless total knee arthroplasty (TKA).

METHODS

We retrospectively identified a cohort of opioid naïve patients undergoing primary TKA for osteoarthritis. There were 186 patients who had cementless TKAs matched 1:6 with 1,116 who received a cemented TKAs based on age (±6 years), body mass index (BMI) (±5), and sex. We compared inhospital pain scores, 90-day opioid utilizations in morphine milligram equivalents (MMEs), and early postoperative PROMs.

RESULTS

The cemented and cementless cohorts had similar lowest (0.09 versus 0.08), highest (7.36 versus 7.34), and average (3.26 versus 3.27) pain scores using numeric rating scale (P > .05). They received similar inhospital (90 versus 102, P = .176), discharge (315 versus 315, P = .483), and total (687 versus 720, P = .547) MMEs. They had similar average inpatient hourly opioid consumption (2.5 versus 2.5 MMEs/hour, P = .965). Average refills 90 days postoperatively were similar in both cohorts (1.5 versus 1.4 refills, P = .893). Also, preoperative, 6-week, 3-month, delta 6-week, and delta 3-month PROMs scores were similar between cemented and cementless cohorts (P > .05) CONCLUSION: This matched study demonstrated similar in-hospital pain scores and opioid utilization, total MMEs prescribed within 90 days, and PROMs at 6 weeks and 3 months postoperatively between cemented and cementless TKAs.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Rural-Urban Differences in Hospital and Patient-Reported Outcomes Following Total Hip Arthroplasty

Background

Rural patients have unique health-care factors influencing outcomes of arthroplasty, hypothetically putting these patients at increased risk for complications following total joint arthroplasty. The aim of this study is to better understand differences in patient outcomes and satisfaction between rural and urban patients receiving care in an urban setting and to provide more equitable care.

Methods

A retrospective chart review was performed on patients undergoing primary total hip arthroplasty at a single large academic center between January 2013 and August 2020. Demographic, operative, and hospital outcomes were obtained from the institutional electronic medical record. Rurality was determined by rural-urban code (RUC) classifications by zip code with RUC codes 1-3 defined as urban and RUC 4-10 defined as rural.

Results

Patients from urban areas were more likely to visit the emergency department within 30 days postoperatively (P = .006) and be readmitted within 90 days (P < .001). However, unplanned (P < .001) admissions were higher in the rural group. There was no statistical difference in postoperative complications (P = .4). At 6 months, rural patients had higher patient-reported outcome measures (PROMs) including Hip Disability and Osteoarthritis Outcome Score total (P = .05), Hip Disability and Osteoarthritis Outcome Score interval (P = .05), self-reported functional improvement (P < .05), improvements in pain (P < .05), and that the surgery met expectations (P < .05). However, these values did not reach minimal clinically important difference.

Conclusions

There may be differences in emergency department visits, readmissions, and PROMs in rural vs urban populations undergoing total hip arthroplasty in an urban setting. Patient access to care and attitudes of rural patients toward health care may underlie these findings. Understanding differences in PROMs, satisfaction, and hospital-based outcomes based on rurality is essential to provide equitable arthroplasty care.

A Matched Comparison of the Rates of Achieving the Minimal Clinically Important Difference Following Conversion and Primary Total Hip Arthroplasty

BACKGROUND

Patient-reported outcome measures (PROMs) are often lower following conversion total hip arthroplasty (cTHA) compared to matched primary total hip arthroplasty (THA) controls. However, the minimal clinically important differences (MCIDs) for any PROMs are yet to be analyzed for cTHA. This study aimed to (1) determine if patients undergoing cTHA achieve primary THA-specific 1-year PROM MCIDs at comparable rates to matched controls undergoing primary THA and (2) establish 1-year MCID values for specific PROMs following cTHA.

METHODS

A retrospective case-control study was conducted using 148 cases of cTHA which were matched 1:2 to 296 primary THA patients. Previously defined anchor values for 2 PROM measures in primary THA were used to compare cTHA to primary THA, while novel cTHA-specific MCID values for 2 PROMs were calculated through a distribution method. Predictors of achieving the MCID of PROMs were analyzed through multivariate logistic regressions.

RESULTS

Conversion THA was associated with decreased odds of achieving the primary THA-specific 1-year Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement PROM (Odds Ratio: 0.319, 95% Confidence Interval: 0.182-0.560, P < .001) and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a PROM (Odds Ratio: 0.531, 95% Confidence Interval: 0.313-0.900, P = .019) MCIDs in reference to matched primary THA patients. Less than 60% of cTHA patients achieved an MCID. The 1-year MCID of the Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a specific to cTHA were +10.71 and +4.68, respectively.

CONCLUSION

While cTHA is within the same diagnosis-related group as primary THA, patients undergoing cTHA have decreased odds of achieving 1-year MCIDs of primary THA-specific PROMs.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

How Much Perioperative Pain and Dysfunction Underlie the HOOS JR and KOOS JR?

BACKGROUND

The Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR) and Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR) scores represent pain and dysfunction as a single number ranging from 0 (extreme pain and dysfunction) to 100 (no pain or functional limitations). However, scores between 0 and 100 lack a simple interpretation because they reflect varying combinations of pain levels and dysfunction. Given that most adverse events and improvement occur within the first 90 days after surgery, a deeper understanding of the level of pain and dysfunction may reveal missed opportunities for patient care.

QUESTIONS/PURPOSES

(1) What does a given preoperative or postoperative HOOS JR and KOOS JR score indicate about pain and ability to perform daily activities? (2) How much of a change in score (that is, delta) is needed to indicate significant improvement in pain control and daily functioning?

METHODS

The Michigan Arthroplasty Registry Collaborative Quality Initiative contains more than 95% of THAs and TKAs performed in Michigan. Between January 2017 and March 2019, 84,175 people in the registry underwent primary THA or TKA and were potentially eligible for this retrospective, comparative study of the first 90 postoperative days. Eighty-four percent (70,608 of 84,175) were excluded because their surgeons did not attain a target survey collection proportion of 70% and another 6% (5042) were missing covariate information or surveys, leaving 10% (8525) for analysis. The mean age and percentage of women were 65 ± 11 years and 55% (2060 of 3716), respectively, for patients undergoing THA and 67 ± 9 years and 61% (2936 of 4809), respectively, for those undergoing TKA. There were no clinically meaningful differences between patients who were analyzed and those who were excluded except for lower representation of non-White patients in the analyzed group. For interpretation, patient responses to Question 7 (pain) and Question 6 (function) from the Patient-Reported Outcomes Measurement Information System global items (PROMIS-10) were dichotomized into "much pain" (rating of pain 4 to 10 of 10) versus "less pain" (rating of ≤ 3) and "good function" (able to perform most activities) versus "poor function" (not able to perform most activities) and combined into four pain-function categories. We examined the mean preoperative and postoperative HOOS JR and KOOS JR scores for each pain-function category, adjusted for patient characteristics. We calculated the size of the delta associated with an increase to a more favorable category postoperatively (versus staying in the same or worse category) via multivariable logistic regression that controlled for patient characteristics.

RESULTS

Patients in the least favorable "much pain, poor function" category preoperatively had adjusted mean scores of 40 (95% confidence interval 39 to 41) for both the HOOS JR and KOOS JR. Those with mixed levels of pain and function had mean scores between 46 and 55. Those in the most favorable "less pain, good function" category had means of 60 (95% CI 58 to 62) and 59 (95% CI 58 to 61) for the HOOS JR and KOOS JR, respectively. The adjusted delta to achieve a pain level of ≤ 3 or the ability to perform most activities was 30 (95% CI 26 to 36) on the HOOS JR and 27 (95% CI 22 to 29) on the KOOS JR scales.

CONCLUSION

These adjusted means of the HOOS JR and KOOS JR provide context for understanding the levels of pain and dysfunction for individuals as well for patients reported in other studies. Potential quality improvement efforts could include tracking the proportion of patients with THA or TKA who achieved a sufficient delta to attain pain levels of ≤ 3 or the ability to perform most activities. Future studies are needed to understand pain and function represented by the HOOS JR and KOOS JR at 1 to 2 years, how these may differ by patient subgroups, and whether scores can be improved through quality improvement efforts.

LEVEL OF EVIDENCE

Level III, therapeutic study.