Total joint arthroplasties: current concepts of patient outcomes after surgery

The Relationship between Patient-Reported Readiness for Total Knee Arthroplasty and Likelihood of a Good Outcome at One Year

OBJECTIVE

To determine the relationship between patients' pre-operative readiness for total knee arthroplasty (TKA) and surgical outcome at one-year.

METHODS

This prospective cohort study recruited knee osteoarthritis (OA) patients aged 30+ years referred for TKA at two hip/knee surgery centers in Alberta, Canada. Those who received primary, unilateral TKA completed questionnaires pre-TKA to assess WOMAC-pain, KOOS-physical function, Perceived Arthritis Coping Efficacy, General Self-Efficacy, PHQ-8, BMI, comorbidities and TKA readiness (Patient Acceptable Symptom State; willingness to undergo TKA), and one-year post-TKA to assess outcomes. A good TKA outcome was defined as improved knee symptoms (OARSI-OMERACT responder criteria) AND overall satisfaction with results. Poisson regression with robust error estimation was used to estimate relative risk of a good outcome for exposures, before and after controlling for covariates.

RESULTS

Of 1,272 TKA recipients assessed at one year, 1,053 with data for our outcome were included (mean age 66.9 years (SD 8.8); 58.6% female). Most (87.8%) were definitely willing to undergo TKA and had 'unacceptable' knee symptoms (79.7%). 78.1% achieved a good TKA outcome. Controlling for pre-TKA OA-related disability, arthritis coping efficacy, comorbid hip symptoms and depressed mood, definite willingness to undergo TKA and unacceptable knee symptoms were associated with greater likelihood of a good TKA outcome (adjusted RRs 1.18, 95% CI 1.04-1.35, and 1.14, 95% CI 1.02-1.27, respectively).

CONCLUSION

Among TKA recipients for knee OA, patients' psychological readiness and willingness for TKA were associated greater likelihood of a good outcome. Incorporation of these factors in TKA decision-making may enhance patient outcomes and appropriate use of TKA.

Knee Arthroplasty and Gait: Effect on Level Walking-An Overview

BACKGROUND

Knee arthroplasty (KA) aims to restore normal gait, correct joint alignment, improve the quality of life and activities of daily living, and provide pain relief. Hence, the main purpose of this overview was to summarise data from published reviews exploring gait changes during unaided level walking post-KA, thereby providing for recommendations for future practice and research.

METHOD

A systematic review of review (RoR) for articles published in English and since 2010, was conducted online using PubMed and Google Scholar, as per Preferred Reporting Items for Systematic reviews and Metaanalyses guidelines. Predefined eligibility criteria were applied, and the data thus compiled were analysed. Study quality was assessed using AMSTAR-2 checklist.

RESULT

A total of 5 systematic reviews and meta-analysis consisting of 58 primary studies were included in the review. Based on the very limited evidence, it appears that though gait does not normalize post-KA, there seems to be an improvement in spatiotemporal gait parameters over mid to long term with some decline in gains over long term. Further reviews also suggest no benefits with unicompartmental KA in comparison to healthy controls or total KA patients. Further quality of the study was found to be of critically low confidence based on the AMSTAR-2 scale, suggesting that the results should be interpreted with great caution.

CONCLUSION

The overview highlights the knowledge gap and limitations in gait assessment research post-KA with existing heterogeneity in methods and reporting amidst other factors within primary studies, establishing the need for further research.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-020-00342-w.

Protocol for systematic review: patient decision aids for total hip and knee arthroplasty decision-making

BACKGROUND

Total hip and knee arthroplasty are a highly performed surgery; however, patient satisfaction with surgery results and patient involvement in the decision-making process remains low. Patient decision aids (PtDAs) are tools used in clinical practices to facilitate active patient involvement in healthcare decision-making. Nonetheless, PtDA effects have not been systematically evaluated for hip and knee total joint arthroplasty (TJA) decision-making. The aim of this systematic review is to determine the effect of patient decision aids compared to alternative of care on quality and process of decision-making when provided to adults with hip and knee osteoarthritis considering primary elective TJA.

METHODS

This systematic review will follow the Cochrane Handbook for Systematic Reviews. This protocol was reported based on the PRISMA-P checklist guidelines. Studies will be searched in CINAHL, MEDLINE, Embase, PsycINFO, and Web of Science. Eligible studies will be randomized control trial (RCT) evaluating the effect of PtDA on TJA decision-making. Descriptive and meta-analysis of outcomes will include decision quality (knowledge and values-based choice), decisional conflict, patient involvement, decision-making process satisfaction, actual decision made, health outcomes, and harm(s). Risk of bias will be evaluated with Cochrane's risk of bias tool for RCTs. Quality and strength of recommendations will be appraised with Grades of Recommendation, Assessment, Development and Evaluation (GRADE).

DISCUSSION

This review will provide a summary of RCT findings on PtDA effect on decision-making quality and process of adults with knee and hip osteoarthritis considering primary elective TJA. Further, it will provide evidence comparing different types of PtDA used for TJA decision-making. This review is expected to inform further research on joint replacement decision-making quality and processes and on ways PtDAs facilitate shared decision-making for orthopedic surgery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020171334.

Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT

BACKGROUND

Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes.

OBJECTIVES

To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty.

DESIGN

An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study.

SETTING

The trial took place in 14 NHS physiotherapy departments.

PARTICIPANTS

People identified as being at high risk of a poor outcome after knee arthroplasty.

INTERVENTIONS

A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy.

MAIN OUTCOME MEASURES

The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries.

RESULTS

In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold.

LIMITATIONS

The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded.

CONCLUSIONS

This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13517704.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.

Are Oxford Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index Useful Predictors of Clinical Meaningful Improvement and Satisfaction After Total Hip Arthroplasty?

BACKGROUND

Up to 15% of patients express dissatisfaction after total hip arthroplasty (THA). Preoperative patient-report outcome measures (PROMs) scores can potentially mitigate this by predicting postoperative satisfaction, identifying patients that will benefit most from surgery. The aim of this study was to (1) calculate the minimal clinically important difference (MCID) thresholds for Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 (SF-36) mental component summary (MCS) and physical component summary (PCS) scores and (2) identify the threshold values of these PROMs that could be used to predict patient satisfaction and expectation fulfilment.

METHODS

Prospectively collected registry data of 1334 primary THA patients who returned for 2-year follow-up from 1998 to 2016 were reviewed. All patients were assessed preoperatively and postoperatively at 2 years using the OHS, WOMAC, and SF-36 PCS/MCS scores. The MCID for each PROMs was calculated, and the proportion of patients that attained MCID was recorded. The relationship between satisfaction, expectation fulfilment, and MCID attainment was analyzed using Spearman rank correlation. Optimal threshold scores for each PROM that predicted MCID attainment and satisfaction/expectation fulfilment at 2 years were calculated using receiver operating curve analysis.

RESULTS

The calculated MCID for OHS, WOMAC, SF-36 PCS, and SF-36 MCS were 5.2, 10.8, 6.7, and 6.2, respectively. A threshold value of 24.5 for the preoperative OHS was predictive of achieving WOMAC MCID at 2 years after THA (area under the curve 0.80, P < .001). 93.1% of patients were satisfied, and 95.5% had expectations fulfilled at 2 years. None of the PROMs were able to predict satisfaction.

CONCLUSION

OHS and WOMAC scores can be used to determine clinical meaningful improvement but are limited in their ability to predict patient satisfaction after THA.

Forgotten Joint Score in THA: Comparing the Direct Anterior Approach to Posterior Approach

BACKGROUND

The direct anterior approach (DAA) in total hip arthroplasty (THA) has gained popularity because of potential decreased postoperative pain and quicker recovery after surgery in comparison to the posterior approach (PA). With a growing focus on patient-reported outcome (PRO) measurements after surgery, we sought to determine if one approach led to better PRO scores as determined by the Forgotten Joint Score-12 (FJS-12) questionnaire.

METHODS

A retrospective chart review of primary THAs between September 2016 and September 2019 at a single academic hospital was conducted. Demographic and clinical data in addition to FJS-12 scores were collected. Two groups were created based on THA approach. Frequency rates, means, and standard deviations were used to describe baseline patient characteristics. Differences in demographic data were accounted for using linear regression models.

RESULTS

A total of 1469 cases were identified, with 830 using the DAA and 639 the PA. Significant demographic differences were observed between the 2 groups. However, when controlling for this, there were no differences in FJS-12 scores between approaches at 1 and 1.75 years (P = .232 and P = .486, respectively). At 12 weeks, DAA patients had higher satisfaction (59.21 vs 46.8; P = .006). When controlling for surgeon case volume, no differences in FJS-12 were observed at any of the time points (P = .536, P = .452, and P = .967, respectively) CONCLUSION: DAA THA patients trended toward better PRO scores than their PA counterparts. However, when controlling for surgeon case volume, no differences were observed, which suggests that surgeon case volume and experience have an important effect on patient satisfaction and FJS-12 scores.

Do Patients With Psychological Distress Have Poorer Patient-Reported Outcomes After Total Hip Arthroplasty?

BACKGROUND

Patients with psychological distress are likely to have poorer short-term functional outcomes after total knee arthroplasty. However, the influence of psychological distress on the outcomes of total hip arthroplasty (THA) is relatively understudied. Previous studies also had short follow-ups of 1 year or less. We examined the influence of psychological distress on patient-reported outcomes and satisfaction, and analyzed the change in mental health after THA at a minimum of 2 years.

METHODS

Prospectively collected data of 1384 patients undergoing primary THA in 2001-2015 were reviewed. Patients were assessed using the Oxford Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, and 36-item Short-Form health survey Physical Component Summary and Mental Component Score (MCS). Patients were stratified into those with psychological distress (MCS < 50, n = 720) and those without (MCS ≥ 50, n = 664). Multiple regression analysis was used to control for age, gender, body mass index, and baseline scores. The rate of satisfaction and expectation fulfillment was also analyzed.

RESULTS

Distressed patients had a poorer Physical Component Summary at 6 months. However, there was no difference in patient-reported outcomes at 2 years. A higher proportion of distressed patients attained the minimal clinically important difference for Oxford Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index, while 92.2% of distressed patients and 92.9% of nondistressed patients were satisfied at 2 years (P = .724). There was no difference in MCS after 6 months. The percentage of distressed patients also declined from 41.8% to 27.3%.

CONCLUSION

Patients with psychological distress achieved a comparable level of function, quality of life, and satisfaction 2 years after THA. Undergoing THA may also lead to mental health improvement in a subgroup of distressed patients.

Advantages of 16S rRNA PCR for the diagnosis of prosthetic joint infection

16S ribosomal RNA (rRNA) PCR has been reported to be an effective diagnostic means in patients with prosthetic joint infection (PJI). The aim of the present meta-analysis is to establish the overall diagnostic accuracy of the measurement of 16S rRNA PCR for diagnosing PJI. PubMed, Web of Science, Cochrane Library, EMBASE and Wiley Online Library were searched for studies on 16S rRNA PCR in the diagnosis of PJI. The search incorporated all literature published up until December 2018 and the QUADAS-2 checklist were used for quality assessment. The sensitivity, specificity and other measures of accuracy of 16S rRNA PCR in the diagnosis of PJI were pooled. Statistical analysis was performed by employing Meta-Disc 1.4 and Stata 12.0 software. A total of 15 studies met the inclusion criteria. The summary estimates for 16S rRNA PCR in the diagnosis of PJI in these studies were pooled: Sensitivity, 0.70 (95% CI, 0.67-0.73); specificity, 0.93 (95% CI, 0.91-0.94); positive likelihood ratio, 10.93 (95% CI, 5.55-21.51); negative likelihood ratio, 0.33 (95% CI, 0.28-0.40); diagnostic odds ratio, 41.77 (95% CI, 19.90-87.68); and the area under the curve, 0.89. Subgroup analysis showed that the use of sonicate fluid and periprosthetic tissue has higher sensitivity (0.76; 95% CI, 0.69-0.82; and 0.73; 95% CI, 0.68-0.78, respectively), specificity (0.93, 95% CI, 0.90-0.96; and 0.95; 95% CI, 0.90-0.98, respectively) and area under the curve (0.93 and 0.98, respectively). 16S rRNA PCR assay plays an important role in the diagnosis of PJI. The results of 16S rRNA PCR assays should be interpreted in parallel with clinical findings, the results of microbiological, and other laboratory tests.

Primary total knee replacement leads to an increase in physical activity but no changes in overall time of sedentary behaviour: a retrospective cohort study using an accelerometer

INTRODUCTION

There is no consensus between patient-reported subjective scores and objectively measured physical activity (PA) behaviour after total knee arthroplasty (TKA). The aim of this study was to understand the volume and pattern of physical activity and daily energy consumption after total knee arthroplasty for osteoarthritis.

METHOD

Physical activity patterns of 36 patients (31 female, 5 male) with an average age of 67.3 ± 6.7 (50-81) years and end-stage gonarthrosis were investigated using an accelerometer (ActiCal) for seven consecutive days prior to and six months after total knee arthroplasty. Knee Society scores, Oxford knee scores, range of motion, and muscle strength around knee were also recorded.

RESULTS

Sedentary behaviour did not change after total knee arthroplasty (p = 0.975). Increases in light physical activity time (p = 0.005) and moderate-vigorous physical activity time (p = 0.006) were found significant. In the post-operative period, light PA awake time increased 25% and moderate-vigorous PA awake time increased four times compared with the pre-operative value. In addition, a significant increase was observed in the amount of daily energy expenditure after TKA (p = 0.001). The subjective functional scores were increased in the post-operative period compared with baseline values (p < 0.001). While a significant increase in knee flexion angle was found after TKA (p = 0.01), there was no increase in muscle strength around the knee (p = 0.096).

CONCLUSION

Accumulation patterns of activity evaluated by using an accelerometer objectively can give a new insight to realize the behavioral changes after total knee arthroplasty. Daily life style changes can be encouraged by means of objective evaluations.

Does the Impact of Joint Arthroplasty Extend Beyond the Patient? The Effect of Total Joint Arthroplasty on Patient's Significant Others

BACKGROUND

This prospective cohort study evaluates the impact of total hip arthroplasty and total knee arthroplasty on patient's spouses/significant others (SSOs).

METHODS

Patients and SSOs were provided similar outcome metrics (Global Health Patient-Reported Outcomes Measurement Information System, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement) at preoperative and postoperative visits. Pearson correlation was used to evaluate scores.

RESULTS

Our sample included 99 patients (58 total hip arthroplasties and 41 total knee arthroplasties). We found strong correlation between patient and SSO mental status scores. We found moderate correlation for some physical function domains.

CONCLUSION

SSOs closely share total joint arthroplasty patient's mental and even some of the physical burden of disease and recovery.

Improving Patient Outcomes Following Total Knee Arthroplasty: Identifying Rehabilitation Pathways Based on Modifiable Psychological Risk and Resilience Factors

Total knee arthroplasty (TKA) is a commonly implemented elective surgical treatment for end-stage osteoarthritis of the knee, demonstrating high success rates when assessed by objective medical outcomes. However, a considerable proportion of TKA patients report significant dissatisfaction postoperatively, related to enduring pain, functional limitations, and diminished quality of life. In this conceptual analysis, we highlight the importance of assessing patient-centered outcomes routinely in clinical practice, as these measures provide important information regarding whether surgery and postoperative rehabilitation interventions have effectively remediated patients' real-world "quality of life" experiences. We propose a novel precision medicine approach to improving patient-centered TKA outcomes through the development of a multivariate machine-learning model. The primary aim of this model is to predict individual postoperative recovery trajectories. Uniquely, this model will be developed using an interdisciplinary methodology involving non-linear analysis of the unique contributions of a range of preoperative risk and resilience factors to patient-centered TKA outcomes. Of particular importance to the model's predictive power is the inclusion of a comprehensive assessment of modifiable psychological risk and resilience factors that have demonstrated relationships with TKA and other conditions in some studies. Despite the potential for patient psychological factors to limit recovery, they are typically not routinely assessed preoperatively in this patient group, and thus can be overlooked in rehabilitative referral and intervention decision-making. This represents a research-to-practice gap that may contribute to adverse patient-centered outcomes. Incorporating psychological risk and resilience factors into a multivariate prediction model could improve the detection of patients at risk of sub-optimal outcomes following TKA. This could provide surgeons and rehabilitation providers with a simplified tool to inform postoperative referral and intervention decision-making related to a range of interdisciplinary domains outside their usual purview. The proposed approach could facilitate the development and provision of more targeted rehabilitative interventions on the basis of identified individual needs. The roles of several modifiable psychological risk and resilience factors in recovery are summarized, and intervention options are briefly presented. While focusing on rehabilitation following TKA, we advocate for the broader utilization of multivariate prediction models to inform individually tailored interventions targeting a range of health conditions.

Staged Bilateral Total Knee Arthroplasty: Increased Risk of Recurring Complications

BACKGROUND

As the demand for knee arthroplasty increases, risk assessment and counseling are critical for optimal patient outcomes perioperatively. The purpose of this study was to determine if specific complications occurring after unilateral knee replacement predict the risk of recurrence after a staged replacement of the contralateral knee for patients with bilateral symptomatic disease.

METHODS

Linked, nationwide data from the U.S. Hospital Cost and Utilization Project from 2005 to 2014 were used to measure the occurrence of complications after the first and second procedures in staged bilateral total knee arthroplasties (TKAs). Odds ratios (ORs) and conditional probabilities were determined to assess whether having a specific complication after the first TKA increased the chance that the same complication occurred after the second procedure.

RESULTS

A total of 36,278 patients who underwent staged bilateral TKAs were analyzed. All complications occurring after the first arthroplasty were associated with both a significantly increased probability and odds of recurrence following the second arthroplasty. These included myocardial infarction (OR, 56.63 [95% confidence interval (CI), 18.04 to 155.44]; p < 0.001), ischemic stroke (OR, 41.38 [95% CI, 1.98 to 275.82]; p = 0.03), other cardiac complications (OR, 7.73 [95% CI, 4.24 to 14.11]; p < 0.001), respiratory complications (OR, 8.58 [95% CI, 2.85 to 23.17]; p = 0.002), urinary complications (OR, 11.19 [95% CI, 5.44 to 22.25]; p = 0.001), hematoma (OR, 15.05 [95% CI, 7.90 to 27.27]; p < 0.001), deep vein thrombosis (OR, 7.40 [95% CI, 5.37 to 10.08]; p < 0.001), and pulmonary embolism (OR, 11.00 [95% CI, 5.01 to 23.92]; p < 0.001).

CONCLUSIONS

Medical complications that occur postoperatively after TKA are associated with a significantly increased risk of recurrence of these complications after staged replacement of the contralateral knee. Although overall complication rates remain low, patients who develop these medical complications after the first replacement should be counseled on their increased risk profile prior to the contralateral surgical procedure.

LEVEL OF EVIDENCE

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

Perioperative predictors of prolonged length of hospital stay following total knee arthroplasty: a retrospective study from a single center in China

Background

Decreasing the length of hospital stay is an ideal course of action to appropriately allocate medical resources. The aim of this retrospective study was to identify perioperative factors that may decrease the length of hospital stay (LOS).

Methods

In this study, we collected the data on 1112 patients who underwent primary total knee arthroplasty surgery (TKAs) at our institution from Jan 1, 2011 to Nov 31, 2017. Based on the published literature, 16 potential factors (12 preoperative variables, 1 intraoperative variable, and 3 postoperative variables) were investigated. The patients requiring a hospital stay longer than the mean LOS (8 days) were defined as patients with a prolonged LOS. The factors with a P value less than 0.1 in the univariate analysis were further analysed in a multivariate model. An ordinal regression was used to determine independent risk factors for a prolonged LOS.

Results

The mean LOS was 8.3 days (±4.3), with a range of 2 to 30 days. Sixteen variables were analysed by univariate analysis, and 11 of them had p < 0.1 and were included in the multivariable model. Finally, 9 factors were found to be associated with a prolonged LOS. Among the 9 variables, 2 were surgery-related factors (operative time and intraoperative blood loss), and 3 were patient-related factors (age, ASA classification and neurological comorbidities).

Conclusion

In this study, we found that the clinical protocol, complications, the patient’s age, the ASA classification, neurological comorbidities, the operative time, the ward, intraoperative blood loss and the surgeon were all factors contributing to a prolonged LOS. In clinical practice, these factors provide important information for the surgeon and are useful for identifying patients with a high risk of a prolonged LOS.

Early improvement in physical activity and function after total hip arthroplasty: Predictors of outcomes

Objectives

This study aims to assess early changes in physical activity and function after total hip arthroplasty (THA) using both subjective and objective methods, and to identify predictors of outcomes of THA.

Patients and methods

Between October 2014 and October 2015, a total of 50 patients (14 males, 36 females; mean age 57.1±13.0 years; range, 31 to 75 years) with end-stage primary hip osteoarthritis who were scheduled for THA and 50 age- and sex-matched controls (10 males, 40 females; mean age 52.9±9.3 years; range, 36 to 75 years) were included in the study. Pain was evaluated using the Numeric Rating Scale (NRS), physical function using the Lequesne Index, physical capacity using the Six-Minute Walking Test (6MWT), and physical activity using both International Physical Activity Impact Questionnaire Short Form (IPAQ-SF) and step count monitor. Data at baseline and six weeks and six months were recorded.

Results

Pain severity was significantly lower after THA at six weeks and six months (NRS scores: 2.83 and 0.82, respectively; p<0.001), compared to baseline. Physical function, capacity, and activity significantly improved after THA at six weeks and six months with a mean Lequesne Index score of 2.62 and 1.02, respectively. The mean 6MWT distance was 272.62 at six weeks and 326.16 at six months. The mean IPAQ and 6MWT results were similar between the patient and control groups at six weeks and six months. Age, presence of comorbidities, and baseline Lequesne Index score were found to be effective on functional outcomes of THA. Age and baseline 6MWT scores were correlated with physical capacity after THA.

Conclusion

Our study showed a significant early improvement in pain severity and physical activity and function at six weeks and six months after THA, compared to baseline values. Baseline values and age were the positive predictors of improved postoperative function and physical capacity.

A research agenda to improve patients' experience of knee replacement surgery: a patient-oriented modified Delphi study of patients of South Asian origin in British Columbia

BACKGROUND

Up to 1 in 5 patients who undergo total knee arthroplasty (TKA) express dissatisfaction with their surgery. Our goal was to understand the experiences of patients of South Asian origin who undergo TKA and to identify a research agenda for this patient population.

METHODS

We undertook a modified Delphi study in British Columbia to generate and prioritize potential research topics. An initial list of topics was generated using 3 focus groups with patients of South Asian origin who underwent TKA and their caregivers. Focus group sessions were audiotaped and transcribed, and the data were analyzed using thematic analysis. The resulting Delphi question-naire was administered over 2 rounds to patients, caregivers and health professionals. The second-round questionnaire included only topics that were strongly supported in the first round. A patient-oriented approach was adopted, with 3 patient partners as full research team members, who contributed to scoping, design, data collection, analysis and interpretation.

RESULTS

Twenty-one patients who had undergone TKA and 6 caregivers attended the focus groups. Our analyses resulted in 6 broad themes and 25 research topics, all of which were presented in the first round of the Delphi survey. The survey was completed by 27 patients and 5 caregivers (54% combined response rate) and by 25 clinicians (76% response rate). Top priorities both for patients and caregivers and for clinicians were promoting exercise following surgery and self-management after hospital discharge. One of the highest ranked topics for patients and caregivers was improving knee implants; this was supported by only 60% of clinicians.

INTERPRETATION

The patients and caregivers in our study prioritized research on promotion of exercise and self-management following surgery and improvement in knee implants. Future patient-oriented research efforts in Canada should emphasize these topics for this patient population.

Incidence of Metal Hypersensitivity in Orthopedic Surgical Patients Who Self-Report Hypersensitivity History

INTRODUCTION

Metallic implants are integral to the practice of orthopedic surgery. Delayed-onset T-cell-mediated metal hypersensitivity (diagnosed by patch testing) is reported in 10% to 17% of the general population. Inconclusive evidence exists about the role of metal hypersensitivity in persistently painful or aseptic loosening of arthroplasties. Literature suggests that preoperative patch testing may influence surgical practice.

OBJECTIVE

To determine the incidence of metal hypersensitivity in orthopedic surgical patients who self-report hypersensitivity and to characterize which metals are most commonly implicated.

METHODS

A retrospective chart review of patients from a single surgeon's practice was conducted during a 1-year period. All patients were questioned about metal hypersensitivity history; all patients who responded affirmatively were sent for patch testing for specific metals.

RESULTS

Only 41 (4.9%) of 840 patients self-reported any metal hypersensitivity. Of these, 34 (83%) were patch-test positive to 1 or more metals. There were 27 whose test results were positive for nickel, 4 each to cobalt or gold thiosulfate, and 1 each to tin or titanium. Seven patients had positive results to multiple metals, all of whom were also nickel hypersensitive. Six patients had metal orthopedic implants before patch testing, and 4 (67%) tested positively to a metal in their implant.

CONCLUSION

Metal hypersensitivity can be concerning for treating surgeons and patients. Greater awareness of a history to hypersensitivity may prevent patient exposure to implants containing metals that may cause hypersensitivity. Non-metal-containing or nonreactive metal implants are an option for patients in whom metal hypersensitivity is suspected or confirmed.

The In-Hospital Length of Stay after Hip Fracture in Octogenarians: Do Delirium and Dementia Shape a New Care Process?

BACKGROUND

Hip fracture is a major health problem and a patient's biological age, comorbidity, and cognitive vulnerability have an impact on its related outcomes. Length of stay (LOS) for these highly vulnerable patients is rather long and the possible causes have not been clearly identified yet.

OBJECTIVE

We aimed to assess the main clinical factors associated with protracted LOS, focusing on delirium with or without dementia in older age hip fractured patients.

METHODS

218 subjects (mean age 86.70±6.18 years), admitted to the Orthogeriatric Unit of the Ospedale Policlinico San Martino (Italy), were recruited. All patients received physical and comprehensive geriatric assessment. Days to surgery, days from surgery to rehabilitation, and LOS were recorded. In-hospital and three months' mortality were reported.

RESULTS

Prevalent delirium at hospital admission was of 3.1%. 35% of patients developed incident delirium. 56.4% were affected by dementia of Alzheimer-type. In addition, 52% of patients developed delirium superimposed to dementia. Mean LOS was 13.5±4.99 days. Namely, delirium, time to surgery, and complication rate disproportionally affected LOS. The analysis with 3 months mortality, based on cognitive vulnerability profiles, showed how delirium mainly affect short-term mortality in patients with dementia.

CONCLUSION

Our exploratory study originally pointed out the high incidence of delirium superimposed to dementia in orthogeriatric wards and how delirium turns to be a moderator of LOS. The results meet the need for additional research by virtue of a deeper understanding of the impact of delirium and dementia on orthogeriatric clinical management and outcomes.

Percutaneous Peripheral Nerve Stimulation to Control Postoperative Pain, Decrease Opioid Use, and Accelerate Functional Recovery Following Orthopedic Trauma

Orthopedic trauma is a significant military problem, causing several of the most disabling conditions with high rates of separation from duty and erosion of military readiness. The objective of this report is to summarize the findings of case series of a non-opioid therapy-percutaneous peripheral nerve stimulation (PNS) - and describe its potential for postoperative analgesia, early opioid cessation, and improved function following orthopedic trauma. Percutaneous PNS has been evaluated for the treatment of multiple types of pain, including two case series on postoperative pain following total knee replacement (n = 10 and 8, respectively) and a case series on postamputation pain (n = 9). The orthopedic trauma induced during TKR is highly representative of multiple types of orthopedic trauma sustained by Service members and frequently produces intense, prolonged postoperative pain and extended opioid use following surgery. Collectively, the results of these three clinical studies demonstrated that percutaneous PNS can provide substantial pain relief, reduce opioid use, and improve function. These outcomes suggest that there is substantial potential for the use of percutaneous PNS following orthopedic trauma.

Efficacy of electro-acupuncture and manual acupuncture versus sham acupuncture for knee osteoarthritis: statistical analysis plan for a randomized controlled trial

BACKGROUND

Acupuncture is widely used for knee osteoarthritis (KOA), despite contradictory evidence. This study is designed to determine the efficacy of electro-acupuncture and manual acupuncture versus sham acupuncture for KOA.

METHODS/DESIGN

This is a multi-center three-arm randomized controlled trial. It will enroll 480 participants with KOA in China. Participants will be randomly assigned 1:1:1 to receive 24 sessions of electro-acupuncture, manual acupuncture, or sham acupuncture over 8 weeks. The primary outcome is the response rate, which is the proportion of patients who achieve the minimal clinically important improvement in pain and function at 8 weeks. The primary outcome will be analyzed using the Z-test with the intention-to-treat set. Secondary outcomes include pain, function, global patient assessment, and quality of life. Full details of the statistical analysis plan for the primary and secondary outcomes will be described in this article. The statistical analysis plan was written and submitted without knowledge of the study data.

DISCUSSION

The data will be analyzed according to this pre-specified statistical analysis plan to avoid data-driven analysis and to enhance the transparency of the trial. The aim of the trial is to provide high-quality evidence on the efficacy of acupuncture for KOA.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03366363 . Registered on 20 November 2017.

Step Length Asymmetry and Its Associations With Mechanical Energy Exchange, Function, and Fatigue After Total Hip Replacement

Abnormalities in gait remain after total hip replacement (THR). The purpose of this study was to evaluate step length asymmetry and its links to other aspects of gait and physical function after THR and to investigate links with mechanical energy exchange. The rationale is that step length asymmetry may influence gait efficiency, which could adversely influence fatigue and physical function. We evaluated 18 participants (6 males and 12 females) 1-5 years post-THR. Step length symmetry and mechanical energy exchange were assessed by instrumented gait analysis. Fatigue was assessed using a PROMIS Fatigue Short Form. We assessed physical function using a 6-minute walk test (6MWT). We used a one sample T test to determine whether the symmetry index (SI) was significantly different from 0 and Pearson's correlations to explore associations among the variables. The step length SI was statistically significantly different from zero (p=0.01). A more symmetric step length was associated with better 6MWT (R=-0.57, p=0.03). Higher (better) mechanical energy exchange was associated with more fatigue (R=0.50, p=0.04). Mechanical energy exchange was not associated with step length SI or 6MWT. Better 6MWT was associated with less fatigue (R=-0.61, P=0.01). This suggests that the association between step length symmetry and function is not directly governed by its effect on the energy exchange. Additionally, after a relatively long period of postsurgery, participants may have adapted their gait by increasing mechanical energy exchange to minimize fatigue. Statement of Clinical Significance: A gait retraining intervention targeting step length symmetry could improve function without adversely affecting walking energetics in THR patients. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1563-1570, 2019.

Light intensity physical activity increases and sedentary behavior decreases following total knee arthroplasty in patients with osteoarthritis

PURPOSE

To describe objectively measured changes in the volume and pattern of physical activity and sedentary behavior in patients undergoing total knee arthroplasty for osteoarthritis.

METHODS

Physical activity and sedentary behavior were measured in patients (13 males, 76 females) with a mean age of 64 years (range 55-80) and end-stage osteoarthritis of the knee, using an accelerometer (ActiGraph GT3X+) for seven consecutive days (24 h/day) prior to, 6 weeks and 6 months after total knee arthroplasty. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), University of California Los Angeles (UCLA) Activity index and range of motion (ROM) were also assessed.

RESULTS

Proportion of time spent in sedentary behavior decreased from baseline to 6 months (mean 70.1 vs. 64.0%; p = 0.009) and the interruptions to sedentary behavior improved between baseline and 6 months after total knee arthroplasty (mean 85.0-93.0 breaks/day, p = 0.014). Proportion of time spent in light physical activity increased from baseline to 6 months after total knee arthroplasty (29.0 vs. 34.8%; p = 0.008). There was no change in time spent in moderate to vigorous physical activity after total knee arthroplasty. WOMAC (median 71.0 vs. 4.0, p < 0.001), UCLA (median 2.0 vs. 5.0, p < 0.001) as well as ROM [median (0.0°-90.0°) vs. (0.0°-110°), p < 0.05] scores improved between baseline and 6 months after total knee arthroplasty.

CONCLUSION

Clinically, functional improvements in patients following total knee arthroplasty may be assessed by objectively measuring changes in low intensity activity behaviors. The use of accelerometers in this study gives new insights into activity accumulation patterns in a clinical population and highlights their use in determining a behavioral response to an intervention.

LEVEL OF EVIDENCE

II.

Development of a functional rehabilitation intervention for post knee arthroplasty patients: COmmunity based Rehabilitation post Knee Arthroplasty (CORKA) trial

Knee osteoarthritis is a common cause of disability in older people and knee arthroplasty surgery in the UK is increasing. The CORKA trial is a randomised controlled trial of rehabilitation targeted at patients identified as being at risk of a poor outcome after knee arthroplasty. This paper describes the development and delivery of the CORKA intervention. It was informed by current evidence, relevant guidelines, expert and patient opinion, practical considerations and a pilot study. The intervention is a multicomponent rehabilitation programme with the main component being an exercise programme delivered to participants in their own home. It includes functional task practice, strategies to improve adherence and where appropriate the provision of appropriate aids and equipment.

Availability of specific tools to assess patient reported outcomes in hip arthroplasty in Spain. Identifying the best candidates to incorporate in an arthroplasty register. A systematic review and standardized assessment

PURPOSE

1) To systematically review the available scientific literature regarding specific instruments developed and/or tested in a Spanish population, to assess these PROMs in hip arthroplasty; 2) to carry out a standardized assessment of their measurement properties; and 3) to identify the best tools for use in Spain in an arthroplasty registry context.

METHODS

A systematic review of PubMed/MEDLINE and EMBASE and CINHAL was done. Furthermore, a standardized assessment of the questionnaires identified using the Evaluating the Measurement of Patient-Reported Outcomes (EMPRO) tool was performed. All developments, validation and studies aiming to assess the measurement properties of PROMs in hip arthroplasty in the Spanish population were included. Data from the questionnaires on metric properties was taken into account to identify the best candidates for inclusion in a register.

RESULTS

A total of 853 documents were found. After screening title and abstract, 13 full text documents were reviewed and 8 questionnaires adapted and validated to assess some of the aspects of hip arthroplasty in the Spanish population were identified. After the EMPRO assessment, 4 questionnaires showed suitable properties (WOMAC, OAKHQOL, mini-OAKHQOL and PFH).

CONCLUSIONS

In Spain, there are a few suitable hip-specific questionnaires currently available to assess PROMs in hip arthroplasty surgery. Some of the more widely used questionnaires, like the OHS and HOOS, have not been validated in the Spanish population until now. Identified tools are suitable for use in a clinical context, however their use in an arthroplasty register is more questionable due to the lack of validation studies of the widely used tools in other registers.

Clinical outcomes and patient satisfaction after total knee arthroplasty: a follow-up of the first 50 cases by a single surgeon

Objective

To examine the association between single-surgeon learning curve and clinical outcomes following total knee arthroplasty (TKA).

Methods

This prospective study included the first consecutive patients undergoing TKA conducted by the same surgeon using the JOURNEY II Bi-Cruciate Stabilized Knee System (Smith & Nephew, Andover, MA, USA). Patients were assessed preoperatively, and at three months and one year postoperatively using Oxford Knee Score (OKS), Knee Society Score (KSS) and Knee Function Score (KFS). Outcomes were statistically analysed using sequential patient cohorts.

Results

Fifty patients were grouped into five sequential cohorts of 10 patients each. All patients showed significant improvement in postoperative knee scores following TKA. There was a trend toward increased improvement in knee scores in the later patient cohorts, at the three-month and 1-year follow-up.

Conclusions

The single-surgeon learning curve for minimally invasive TKA had a small effect on knee satisfaction scores at 3 months and 1 year following surgery in the first 50 consecutive cases, and only minor complications were encountered. A larger trial is necessary to draw generalizable conclusions regarding patient outcomes during surgeon learning.

Evaluation of the effectiveness of hip and knee implant models used in Catalonia: a protocol for a prospective registry-based study

BACKGROUND

Monitoring results regarding the effectiveness of knee and hip arthroplasties may be useful at the clinical, economic and patient level and help reduce the number of prosthesis revisions. In Spain, and specifically in Catalonia, there is currently no systematic monitoring of the different prosthesis models available on the market. Within this context, the aim of the project presented in this protocol is to evaluate the short- and medium-term effectiveness of knee and hip models implanted in Catalonia and to identify where the results could be better or worse than expected.

METHODS

A prospective observational design will be drawn up based on data from a population-based arthroplasty register for hip and knee replacements that includes data from 53 of the 61 public hospitals in Catalonia. The knee and hip prosthesis models used will be identified and classified according to the type of prosthesis, fixation and, in total hip replacements, the bearing surface. For the data analysis, two methodological approaches will be used sequentially: first, an approach based on a survival analysis, followed by an approach based on standardised revision ratios and funnel plots. Following the analyses, a panel of experts will evaluate the results to identify possible sources of bias. Lastly, those models with results better or worse than expected compared to those from the comparison group will be valued, and strengths and difficulties for routine implementation of this methodology within the Catalan Arthroplasty Register will be identified.

DISCUSSION

The study presented in this protocol will allow us to identify the hip and knee prosthesis models whose results might be better or worse than expected. This information could have a potential impact at the patient, orthopaedic surgeon, healthcare manager, decision-making and industry levels, both in the short term and in the medium and long term.

Internal Validation of a Predictive Model for Complications After Total Hip Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is projected to increase in prevalence and associated complications will impose significant cost on the US healthcare system. The purpose of this study is to validate a predictive model for postoperative complications utilizing a novel 11-component hip-specific questionnaire encompassing preoperatively available clinical and radiographic data.

METHODS

Consecutive primary THA patients between January 2014 and January 2016 were included. Exclusion criteria included patients without questionnaire scoring variables and less than 1-year follow-up. Patients were stratified into 4 tiers based on their questionnaire score: low risk (>74), mild risk (57-73), moderate risk (41-56), and high risk (<40). A binary logistic regression was performed to determine if the questionnaire predicted complications. Receiver-operator curves were constructed to determine the threshold score below which there was a high likelihood of experiencing a complication.

RESULTS

Four hundred fifty patients were included in the final analysis with a mean (range) follow-up of 2.1 years (1.0-5.9), age of 63.1 years (25.7-9.17), and body mass index of 31.7 kg/m² (17.8-64.5). The complication rate was 13.6%. A hip questionnaire score of 73.8 conferred a 98.5% sensitivity and 98.5% negative predictive value for complications. The questionnaire score was the strongest predictor of a decreased complication likelihood (odds ratio 0.94, 95% confidence interval 0.90-0.97, P < .001). Risk tier was significantly associated with complications (low risk: 0; mild risk: 12; moderate risk: 25; and high risk: 24; P < .001).

CONCLUSION

This novel hip questionnaire demonstrated a high sensitivity and negative predictive value to identify patients at risk for postoperative complications. Future studies should attempt to prospectively validate the use of this questionnaire.

Revisiting patient satisfaction following total knee arthroplasty: a longitudinal observational study

Background

Total knee arthroplasty (TKA) is the most common joint replacement surgery in Canada. Earlier Canadian work reported 1 in 5 TKA patients expressing dissatisfaction following surgery. A better understanding of satisfaction could guide program improvement. We investigated patient satisfaction post-TKA in British Columbia (BC).

Methods

A cohort of 515 adult TKA patients was recruited from across BC. Survey data were collected preoperatively and at 6 and 12 months, supplemented by administrative health data. The primary outcome measure was patient satisfaction with outcomes. Potential satisfaction drivers included demographics, patient-reported health, quality of life, social support, comorbidities, and insurance status. Multivariable growth modeling was used to predict satisfaction at 6 months and change in satisfaction (6 to 12 months).

Results

We found dissatisfaction rates (“very dissatisfied”, “dissatisfied” or “neutral”) of 15% (6 months) and 16% (12 months). Across all health measures, improvements were seen post-surgery. The multivariable model suggests satisfaction at 6 months is predicted by: pre-operative pain, mental health and physical health (odds ratios (ORs) 2.65, 3.25 and 3.16), and change in pain level, baseline to 6 months (OR 2.31). Also, improvements in pain, mental health and physical health from 6 to 12 months predicted improvements in satisfaction (ORs 1.24, 1.30 and 1.55).

Conclusions

TKA is an effective intervention for many patients and most report high levels of satisfaction. However, if the TKA does not deliver improvements in pain and physical health, we see a less satisfied patient. In addition, dissatisfied TKA patients typically see limited improvements in mental health.

COmmunity-based Rehabilitation after Knee Arthroplasty (CORKA): statistical analysis plan for a randomised controlled trial

Background

About 15% of patients fail to achieve a satisfactory clinical outcome following knee replacement, which may indicate the existing model of rehabilitation after surgery is possibly not the most efficacious. The COmmunity-based Rehabilitation after Knee Arthroplasty (CORKA) trial evaluates the effects of a new multi-component community-based rehabilitation programme following knee replacement compared with usual care.

Methods/design

The CORKA trial is a multi-centre, single-blind, two-arm randomised controlled trial. The primary outcome is the Late Life Function and Disability Instrument (LLFDI) overall function score measured at 12 months post-randomisation which will be analysed using a linear mixed effects model. Secondary outcomes are measured at 6 and 12 months post-randomisation and include the LLFDI frequency and limitation total dimension scores, the Oxford Knee Score, the Knee injury and Osteoarthritis Outcome Score quality of life subscale, the Physical Activity Scale for the Elderly, the EuroQol EQ-5D-5L, and several measurements of physical function. Full details of the planned analysis approaches for the primary and secondary outcomes are described here, as are the descriptive statistics which will be reported. This is an update to the CORKA protocol which has already been published in this journal.

Discussion

This paper provides details of the planned statistical analyses for this trial and will reduce the risks of outcome reporting bias and data-driven results.

Trial registration

ISRCTN registry, 13517704. Registered on 12 February 2015.

Funding/sponsor

The trial is funded by the National Institute for Health Research Health Technology Assessment programme under its commissioned research programme (HTA 12/196/08). The trial sponsor is the University of Oxford.

Current Trends in Patient-Reported Outcome Measures in Total Joint Arthroplasty: A Study of 4 Major Orthopaedic Journals

BACKGROUND

More emphasis is being placed on patient-reported outcome measures (PROMs), but the myriad of PROMs makes standardization and cross-study comparison difficult. As the era of big data and massive total joint registries matures, it will be critical to identify and implement the best PROMs.

METHODS

All abstracts published in the years 2004, 2009, 2014, and 2016 in the Journal of Bone and Joint Surgery-American volume, the Bone and Joint Journal, Clinical Orthopedics and Related Research, and the Journal of Arthroplasty were reviewed. A PubMed search was performed with filters limiting results only to total knee, total hip, and unicompartmental knee arthroplasty articles with available abstracts. Each abstract was reviewed to identify all PROMs. Trends over time were evaluated using the Cochran-Armitage test. In the non-trend analysis, Pearson chi-square tests and one-way analysis of variance were performed.

RESULTS

A total of 42 unique PROMs were used 1073 times across 644 studies. The number of PROMs in these 4 journals increased from 97 in 2004 to 228 in 2016 (P < .0001). The proportion of articles with more than one PROM increased from 20.6% in 2004 to 47.8% in 2016 (P = .0001). The most common PROMs used in total knee, total hip, and unicompartmental knee arthroplasty studies were the Knee Society Score, the Harris Hip Score, and the Oxford Knee Score, respectively.

CONCLUSION

Providers and registries should consider the relative prevalence of published outcome measures when selecting which PROMs to use, to better facilitate future cross-study comparison.

Sedentary Behavior in Patients With Knee Osteoarthritis Before and After Total Knee Arthroplasty: A Systematic Review

Objective:The objective of this systematic review is to integrate the available evidence on changes in sedentary behavior (SB) in patients with knee osteoarthritis after total knee arthroplasty (TKA).Methods:A systematic literature search from January 2002 to October 31, 2017, was performed for studies assessing objectively and/or subjectively measured SB following TKA. The Scottish Intercollegiate Guidelines Network Methodology appraisal tool was used to critically appraise the methodological quality of the included studies.Results:Ten studies reporting on SB with a total of 1,028 participants were included in the review. Three studies reported changes in SB with two showing a reduction in SB and one (with high risk of bias) an increase in SB after TKA. Seven studies showed no change in SB following TKA.Conclusion:Currently, there is insufficient evidence which suggests that SB time improves following TKA. Detailed assessments of SB after TKA are needed.

The effect of intensive exercise program and kinesiotaping following total knee arthroplasty on functional recovery of patients

Background

Total knee arthroplasty (TKA) is a gold standard for terminal term gonarthrosis patients in order to diminish pain, correct deformities, and regain stability. Postoperative functional recovery of patients depends on the current postoperative rehabilitation program to an important extent. The purpose of our study is to compare midterm functional level of gonarthrosis patients who were included in physiotherapy rehabilitation program following TKA with people in similar ages without any surgical indication nor intervention. We have aimed also to compare functionality of people who had additional kinesiotaping (KT) treatment with people who had conservative treatment only after knee arthroplasty.

Methods

Functional level and knee functionality of people in study were evaluated at the end of postoperative first month by 6-min walk test and Lysholm knee score respectively.

Results

There was no statistical difference between groups with and without TKA in terms of height, weight, body mass index, Lysholm score, and 6-min walk test score (p > 0.05). In patient group with TKA, people with postoperative KT treatment had greater 6-min walk test score for postoperative first month (p = 0.005).

Conclusion

TKA is considered a gold standard procedure in order to increase the quality of life and improve functionality of terminal term gonarthrosis patients. It is necessary to immediately control pain and edema of knee and apply intensive rehabilitation program aimed at muscle strengthening around hip and knee in order to increase the success of operation.

Patient education in physiotherapy in total hip arthroplasty (THA) - The perspective of physiotherapists

BACKGROUND AND PURPOSE

There is limited knowledge about patients' and physiotherapists' perceptions of patient education in physiotherapy in hip arthroplasty. The aim of this study was to describe physiotherapists' conceptions of the patient education in physiotherapy needed by patients undergoing total hip arthroplasty.

METHODS

The data for this qualitative study were collected using group and individual semi-structured interviews. Seven physiotherapists were interviewed. The research data were analyzed using a phenomenographic method.

RESULTS

Three categories of patient education in physiotherapy in hip arthroplasty were produced and the categories formed a hierarchy. The narrowest descriptive category was Schematic physiotherapy complying with the protocol. Identifying individual rehabilitation needs was the second category, and the third, widest category was Coaching home rehabilitation. The differences between the categories were described in four themes: 1) Moving; 2) Exercising; 3) Interaction in relation to patient; and 4) Health care system.

CONCLUSION

According to the results, patient education in physiotherapy optimally aims to identify patients' individual rehabilitation needs, advice on coping at home and especially helping patients to be prepared for and capable of long rehabilitation for which they are themselves responsible. These findings resulting from descriptive categories can be utilized in developing education methods and physiotherapists' competence in patient education.

A systematic review and meta-analysis of direct anterior approach versus posterior approach in total hip arthroplasty

BACKGROUND

This meta-analysis aimed to evaluate the postoperative clinical outcomes and safety of the direct anterior approach (DAA) versus posterior approach (PA) in total hip arthroplasty (THA).

METHODS

We searched PubMed, Embase, Web of Science, the Cochrane Library, and Google databases from inception to June 2018 to select studies that compared the DAA and PA for THA. Only randomized controlled trials (RCTs) were included. Outcomes included Harris hip score at 2 weeks, 6 weeks, 12 weeks, and 1 year; VAS at 24 h, 48 h, and 72 h; incision length, operation time, postoperative blood loss, length of hospital stay, and complications (intraoperative fracture, postoperative dislocation, heterotopic ossification (HO), and groin pain).

RESULTS

Nine RCTs totaling 754 THAs (DAA group = 377, PA group = 377) met the criteria to be included in this meta-analysis. The present meta-analysis indicated that, compared with PA group, DAA group was associated with an increase of the Harris hip score at the 2-week and 4-week time points. No significant difference was found between DAA and PA groups of the Harris hip scores at 12 weeks, 1 year length of hospital stay (p > 0.05). DAA group was associated with a reduction of the VAS at 24 h, 48 h, and 72 h with statistical significance (p < 0.05). What is more, DAA was associated with a reduction of the incision length and postoperative blood loss (p < 0.05). There was no significant difference between the operation time and complications (intraoperative fracture, postoperative dislocation, HO, and groin pain).

CONCLUSION

In THA patients, compared with PA, DAA was associated with an early functional recovery and less pain scores. What is more, DAA was associated with shorter incision length and blood loss.

Modifiable Risk Factors in Primary Joint Arthroplasty Increase 90-Day Cost of Care

BACKGROUND

Risk factors in demographics and health status have been identified that increase the risk of complications after joint arthroplasty, necessitating additional care and incurring additional charges. The purpose of this study was to identify the number of patients in a hospital network database who had one or more predefined modifiable risk factors and determine their impact on average length of stay, need for additional care during the 90-day postoperative period, and the 90-day charges for care.

METHODS

An electronic hospital record query of 6968 lower extremity joint arthroplasty procedures under Diagnosis-Related Group 469/470 performed in 2014-2015 was reviewed, and total 90-day charges were calculated. The case mean was compared to charges for patients with modifiable risk factors: anemia (Hgb < 10 g/dL), malnutrition (albumin < 3.4 g/dL), obesity (body mass index > 45 kg/m²), uncontrolled diabetes (random glucose >180 mg/dL or A1C > 8), narcotic use (prescription filled), and tobacco use (documented within 30 days before surgery). Length of stay, emergency room visits, and hospital readmission were compared.

RESULTS

Mean 90-day charges for Diagnosis-Related Group 469/470 were $36,647. Risk factors were associated with a significant increase in 90-day charges: anemia (+$ 15,869/126 patients), malnutrition (+$9270/592), obesity (+$2048/445), diabetes (+$5074/291), narcotic use (+$1801/1943), and tobacco use (+$2034/1882). Intensive care unit admission rate, emergency department visits, and hospital readmission were significantly increased for patients with each risk factor. Length of stay was higher in patients with anemia, malnutrition, diabetes, and tobacco use. When separated by elective vs fracture admission, 90-day charges were significantly higher for each risk factor.

CONCLUSIONS

Medical strategies to optimize patients before joint arthroplasty are warranted to improve postoperative outcomes.

Metal allergy in total-joint arthroplasty: Case report and literature review

RATIONALE

Due to the low incidence and lack of effective diagnostic measures for the diagnosis of metal allergy in patients undergoing total joint arthroplasty (TJA), diagnosis relies mainly on the exclusion of other causes, in particular infection. It remains a relatively unpredictable and poorly understood cause of implant failure. At present, skin patch testing, leukocyte migration inhibition test (LMIT) and lymphocyte transformation tests (LTT) are being commonly used to assess metal hypersensitivity.This report presents both a case and literature review.

PATIENT CONCERNS

A 61-year-old female patient experienced continuous swelling and pain in the right knee joint for 9 months after a right-side total knee arthroplasty (TKA).

DIAGNOSES

We believe this is the case report of metal allergy in TKA. The following were the reasons for this. First, no definite symptoms of infection during revision arthroplasty were observed, but with obvious hyperplasia of synovium. Furthermore, a frozen biopsy revealed an extremely low neutrophil count, which was considered to be caused by chronic inflammation. Second, the results of repeated post-operation reexaminations indicate a clear increase in the number of eosinophils, while no bacteria were found in the tissue bacterial smear performed during the operation. Third, improvements were clearly observed in the patient following synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment.

INTERVENTIONS

The patient underwent synovectomy, revision of the polyethylene insert and anti-anaphylactic treatment.

OUTCOMES

The patient's right knee remained mildly swollen; however, the pain has been relieved significantly. The range of motion could achieve 0 degrees of extension and 90 degrees of flexion.

LESSONS

No consensus has been reached about the best diagnostic criteria for this disease, and most physicians would consider it to be a possibility when other diseases including periprosthetic joint infection (PJI) have been excluded. Although this case followed the same course, the outcome following synovectomy and anti-anaphylactic treatment further confirmed our hypothesis.

Gaps in appropriate use of treatment strategies in osteoarthritis

Optimal management of osteoarthritis (OA) requires a combination of therapies, with behavioral (e.g., exercise and weight management) and rehabilitative components at the core, accompanied by pharmacological treatments and, in later stages, consideration of joint replacement surgery. Although multiple sets of OA treatment guidelines have been developed, there are gaps in the implementation of these recommendations. Key areas of concern include the underuse of exercise, weight management, and other behavioral and rehabilitation strategies as well as the overuse of opioid analgesics. In this review, we describe the major categories of treatment strategies for OA, including self-management, physical activity, weight management, physical therapy and other rehabilitative therapies, pharmacotherapies, and joint replacement surgery. For each category, we discuss the current evidence base to report on appropriate use, data regarding adherence to treatment recommendations, and potential approaches to optimize use.

Regenerative Medicine Strategies in Biomedical Implants

PURPOSE OF REVIEW

Recently, significant progress has been made in the research related to regenerative medicine. At the same time, biomedical implants in orthopedics and dentistry are facing many challenges and posing clinical concerns. The purpose of this chapter is to provide an overview of the clinical applications of current regenerative strategies to the fields of dentistry and orthopedic surgery. The main research question in this review is: What are the major advancement strategies in regenerative medicine that can be used for implant research?

RECENT FINDINGS

The implant surfaces can be modified through patient-specific stem cells and plasma coatings, which may provide methods to improve osseointegration and sustainability of the implant. Overall understanding from the review suggesting that the outcome from the studies could lead to identify optimum solutions for many concerns in biomedical implants and even in drug developments as a long-term solution to orthopedic and dental patients.

A qualitative study of older adults' and family caregivers' perspectives regarding their preoperative care transitions

AIMS AND OBJECTIVES

To explore how older patients with multiple chronic conditions and their family caregivers perceive their engagement and overall care experience throughout the preoperative phase of elective orthopaedic hip or knee joint replacement.

BACKGROUND

Patient engagement is a critical component of care necessary for improving patient outcomes. Little is known about how older adults with multiple chronic conditions and their family caregivers engage in preoperative care transitions and the subsequent impact of this experience on postoperative health outcomes.

DESIGN

Prospective qualitative descriptive design was used.

METHODS

Semi-structured telephone interviews with a convenience sample of older adults coping with multiple chronic conditions and their family caregivers. Interviews were conducted prior to surgery and, again 21 days postsurgery, were audio-recorded and transcribed for qualitative content analysis. The Quality Health Outcomes Model was used to categorise study findings.

RESULTS

Eleven patients and five family caregivers participated. Guided by the Quality Health Outcomes Model, four major themes were identified. (i) Older adults perceive that joint replacement is about quality of life. (ii) Standardised interventions often fail to address the unique needs of complex older adults. (iii) Family caregivers perceive they are the primary care coordinators. (iv) Postoperative outcomes and resource utilisation vary widely in complex older adults.

CONCLUSION

Findings suggest that current preoperative care interventions are often not designed to effectively engage complex older patients and their family caregivers. Coordinated patient-centred preoperative care that reflects the needs and goals of complex older patients and their family caregivers may positively influence perioperative care transitions and outcomes beyond this episode of care.

RELEVANCE TO CLINICAL PRACTICE

The current research documents the need for more in-depth knowledge about the relationship between older adults' and their family caregivers' engagement preoperatively and postoperative outcomes and resource utilisation.

Changes in total knee arthroplasty design affect in-vivo kinematics in a redesigned total knee system: A fluoroscopy study

BACKGROUND

Journey II Bi-Cruciate-Stabilized knee system was designed to overcome the complications of Journey Bi-Cruciate-Stabilized, including ilio-tibial band inflammation and episodes of dislocation. The purpose of this study was to assess differences in knee kinematics between the first and second-generation design by means of video-fluoroscopy. Re-designed prosthesis in-vivo kinematics was analyzed during activities of daily living and results were eventually compared with those of the previous system, as reported in a previously published study. It was hypothesized that changes in components' design influences replaced knee's kinematic patterns.

METHODS

Sixteen patients (3 males, 13 females) implanted with the redesigned prosthesis were assessed by video-fluoroscopy during stair-climbing, chair-rising and leg-extension at 8 months of follow-up. Patterns of axial rotation and antero-posterior motion of the medial and lateral femoral condyles were obtained. Range of Motion and International Knee Society Score were recorded pre- and post-operatively. Student t-tests were applied to compare the mean of each interesting variables.

FINDINGS

The comparison of the kinematics of the two designs revealed similar patterns of axial rotation, with progressive femoral external rotation in flexion and reduced absolute values of displacement for the new system. Reduced posterior displacements of the medial and lateral condyles were observed in Journey II patients. In terms of absolute location, the lateral condyle in the redesigned prosthesis showed a more anterior position on the tibial-baseplate embedded coordinate system at maximal flexion.

INTERPRETATION

Design changes in the recently-introduced total knee system contributed to modify its in-vivo knee kinematics as demonstrated by video-fluoroscopy.

The Influence of Radiological Severity and Symptom Duration of Osteoarthritis on Postoperative Outcome After Total Hip Arthroplasty: A Prospective Cohort Study

BACKGROUND

We aimed to investigate the influence of preoperative radiological severity and symptom duration of hip osteoarthritis (OA) on the postoperative functional outcome, quality of life, as well as abductor muscle strength after total hip arthroplasty (THA).

METHODS

In this prospective cohort study, we studied 250 patients. Preoperatively, we evaluated the function with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and quality of life with euroqol-5D (EQ-5D). At 1 year after THA, the same scores and also hip abductor muscle strength were measured in 222 patients. We divided the cohort twice, first according to the radiological OA severity [Kellgren-Lawrence classification (KL)] and then according to the OA symptom duration. We investigated whether the preoperative KL class and symptom duration influenced the 1-year WOMAC (primary outcome measure) or EQ-5D and abductor muscle strength (secondary outcome measures).

RESULTS

The crude results showed that KL class and symptom duration had no influence (P = .90 and P = .20, respectively) on the 1-year WOMAC. Younger age, male gender, and lower body mass index were associated with a better function. Regarding 1-year EQ-5D, the crude results showed that body mass index and KL class had no influence (P = .83 and P = .39, respectively). The adjusted results showed that only age and gender influenced the postoperative EQ-5D. No influence of the tested factors was found on the 1-year abductor muscle strength.

CONCLUSION

Preoperative radiological OA severity and symptom duration had no influence on the outcome of THA and should probably not affect the decision about timing the operative intervention.

Comparison of direct anterior, lateral, posterior and posterior-2 approaches in total hip arthroplasty: network meta-analysis

Total hip arthroplasty (THA) is generally considered to be one of the most successful orthopedic surgical procedures. THA patients continue to experience symptoms, most commonly pain, which prevent their return to full function and activity. Possible causes include failure of fixation, instability and damage to soft tissues, associated with the trauma of the surgical procedure. Choosing the optimal surgical approach can minimize these risks and therefore improve the outcome of THA. Surgical approaches in THA include anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson-Jones)], posterior (posterolateral and posterior) and posterior-2 techniques. However, there is no current consensus regarding which approach is the most suitable. Therefore, we conducted a systematic review and network meta-analysis to compare the postoperative outcomes and complications among THA approach and identify which approach is the best for THA. We searched all RCT studies that compared intra-operative and postoperative outcomes of anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson-Jones)], posterior (posterolateral and posterior) and posterior-2 approaches for THA from the PubMed and Scopus databases up to February 1, 2017. Data were independently extracted by two reviewers. A network meta-analysis was applied to assess treatment outcomes. Probability of being the best treatment was estimated using surface under the cumulative ranking curves (SUCRA). Fourteen RCTs (N = 1017 patients) met inclusion criteria. Interventions were anterior (N = 233 patients), lateral (N = 334 patients), posterior (N = 405 patients) and posterior-2 (N = 45 patients) approaches. A network meta-analysis showed that effects of anterior approach were higher to lateral, posterior and posterior-2 approaches with the pooled mean postoperative within 1 month and last follow-up of HHS of 2.56 (95% CI - 0.79, 5.91), 4.80 (95% CI 1.33, 8.26), 10.80 (95% CI 2.10, 19.49) and 6.40 (95% CI 0.72, 12.09), 2.22 (95% CI - 3.21, 7.66), 4.22 (95% CI - 6.81, 15.25), respectively. For VAS, lateral approach was lower to anterior, posterior and posterior-2 approaches. In terms of complication, posterior approach was the lowest risk with RR of 0.39 (95% CI 0.19, 0.81), 0.57 (95% CI 0.21, 1.57) and 1.74 (95% CI 0.36, 8.33) when compared to anterior, followed by lateral and posterior-2 approaches. Results of SUCRA indicated anterior and lateral approaches were the first and second ranks for postoperative HHS and VAS score, while posterior and lateral approaches were the first and second ranks for postoperative complications. We recommended using lateral approach that has an acceptable postoperative pain, function and complications (second rank for all outcomes) as a surgical technique for THA.

ACL status in arthroplasty patients, why not to preserve?

Introduction: Only 70–85% of patients that had total knee arthroplasty (TKA) are satisfied with their knees. The need for a near to normal knee kinematics is crucial and maybe the solution to their needs. Addressing the cruciate ligaments during surgery along with the extent of arthrosis may give a solution to this problem.

Material and methods: One hundred consecutive patients in whom a total knee arthroplasty was indicated and performed were prospectively documented. During the knee replacement surgery, the condition of the anterior and posterior cruciate ligaments and the degree of osteoarthritis (OA) in the medial and lateral compartments as well as in the patello-femoral joint were documented using the Outerbridge classification. The patients’ average age was 72.3 years, with the majority being female. In all patients, a total bi-compartmental knee replacement was indicated.

Results: Our results showed that in 78% of all patients the anterior, and in 98% the posterior cruciate ligament was still intact. Seventy-one percent of cases suffered from grade 4 medial osteoarthritis, 19% from grade 3 and 10% from grade 2. Thirty-six of patients suffered from grade 4 lateral osteoarthritis, 36% from grade 3, 24% from grade 2 and 4% from grade 1. Grade 4 patello-femoral osteoarthritis was present in 32% of all patients, grade 3 in 60% and grade 2 in 8% of all patients.

Discussion: The goal of arthroplasty is to approximate the function of a normal knee. The retention of the anterior cruciate ligament (ACL) allows for better knee, kinematics, improved proprioception, increased flexion and an overall improvement in knee function. The decreased constraint that is possible with retention of both cruciates may decrease implant stresses and improve the implant survivorship. The distribution of OA shows that the medial and patello-femoral compartments of the joint are primarily affected. This could also allow for a more conservative and patient-tailored prosthetic design.

Metal hypersensitivity in total hip and knee arthroplasty: Current concepts

Metal hypersensitivity (MHS) is a rare complication of total joint arthroplasty that has been linked to prosthetic device failure when other potential causes have been ruled out. The purpose of this review was to conduct an analysis of existing literature in order to get a better understanding of the pathophysiology, presentation, diagnosis, and management of MHS. It has been described as a type IV hypersensitivity reaction to the metals comprising prosthetic implants, often nickel and cobalt-chromium. Patients suffering from this condition have reported periprosthetic joint pain and swelling as well as cutaneous, eczematous dermatitis. There is no standard for diagnosis MHS, but tests such as patch testing and lymphocyte transformation testing have demonstrated utility, among others. Treatment options that have demonstrated success include administration of steroids and revision surgery, in which the existing metal implant is replaced with one of less allergenic materials. Moreover, the definitive resolution of symptoms has most commonly required revision surgery with the use of different implants. However, more studies are needed in order to understand the complexity of this subject.

Effect of Obesity on Pain and Functional Recovery Following Total Knee Arthroplasty

BACKGROUND

While obesity may be a risk factor for complications following total knee arthroplasty, data remain sparse on the impact of the degree of obesity on patient-reported outcomes following this procedure. Our objective was to determine the extent to which obesity level affects the trajectory of recovery as well as patient-reported pain, function, and satisfaction with surgery following total knee arthroplasty.

METHODS

We followed a cohort of patients who underwent total knee arthroplasty at 1 of 4 medical centers. Patients were ≥40 years of age with a primary diagnosis of osteoarthritis. We stratified patients into 5 groups according to the World Health Organization classification of body mass index (BMI). We assessed the association between BMI group and pain and function over the time intervals of 0 to 3, 3 to 6, and 6 to 24 months using a piecewise linear model. We also assessed the association between BMI group and patient-reported outcomes at 24 months. Multivariable models adjusted for age, sex, race, diabetes, musculoskeletal functional limitations index, pain medication use, and study site.

RESULTS

Of the 633 participants included in our analysis, 19% were normal weight (BMI of <25 kg/m), 32% were overweight (BMI of 25 to 29.9 kg/m), 27% were class-I obese (BMI of 30 to 34.9 kg/m), 12% were class-II obese (BMI of 35 to 39.9 kg/m), and 9% were class-III obese (BMI of ≥40 kg/m). Study participants with a higher BMI had worse preoperative WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain and function scores and had greater improvement from baseline to 3 months. The mean change in pain and function from 3 to 6 and from 6 to 24 months was similar across all BMI groups. At 24 months, participants in all BMI groups had similar levels of pain, function, and satisfaction.

CONCLUSIONS

Because of the differential trajectory of recovery in the first 3 months following total knee arthroplasty, the participants in the higher BMI groups were able to attain absolute pain and function scores similar to those in the nonobese and class-I obese groups. These data can help surgeons discuss expectations of pain relief and functional improvement with total knee arthroplasty candidates with higher BMI.

LEVEL OF EVIDENCE

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

Advantages and limitations of national arthroplasty registries. The need for multicenter registries: the Rempro-SBQ

While the value of national arthroplasty registries (NAR) for quality improvement in total hip arthroplasty (THA) has already been widely reported, some methodological limitations associated with observational epidemiological studies that may interfere with the assessment of safety and efficacy of prosthetic implants have recently been described in the literature.

Among the main limitations of NAR, the need for at least 80% compliance of all health institutions covered by the registry is emphasized; completeness equal or greater than 90% of all THA performed; restricted data collection; use of revision surgery as the sole criterion for outcome; and the inability of establishing a definite causal link with prosthetic dysfunction.

The present article evaluates the advantages and limitations of NAR, in the light of current knowledge, which point to the need for a broader data collection and the use of more structured criteria for defining outcomes.

In this scenario, the authors describe of idealization, conceptual and operational structure, and the project of implantation and implementation of a multicenter registry model, called Rempro-SBQ, which includes healthcare institutions already linked to the Brazilian Hip Society (Sociedade Brasileira de Quadril [SBQ]). This partnership enables the collection of more reliable and comprehensive data at a higher hierarchical level, with a significant reduction in maintenance and financing costs. The quality improvement actions supported by SBQ may enhance its effectiveness and stimulate greater adherence for collecting, storing, interpreting, and disseminating information (feedback).