Comparison of the responsiveness of the SF-36, the Oxford Knee Score, and the Knee Society Clinical Rating System in patients undergoing total knee replacement

Faster improvement in outcome scores in posterior stabilised total knee arthroplasty compared to medial congruent system with posterior cruciate ligament retained

Most studies comparing medial pivot to the posterior stabilised (PS) systems sacrifice the PCL. It is unknown whether retaining the PCL in the Medial Congruent (MC) system may provide further benefit compared to the more commonly used PS system. A retrospective review of a single-surgeon's registry data comparing 44 PS and 26 MC with PCL retained (MC-PCLR) TKAs was performed. Both groups had similar baseline demographics. The PS and MC-PCLR groups had similar pre-operative range of motion (ROM) (PS:104º ± 20º vs. MC-PCLR: 101º ± 19º, p = 0.70), Oxford Knee Score (OKS) (PS: 27 ± 6 vs. MC-PCLR: 26 ± 7, p = 0.62), and Knee Society Scoring System (KS) Function Score (KS-FS) (PS: 52 ± 24 vs. MC-PCLR: 56 ± 23, p = 0.49). The pre-operative KS Knee Score (KS-KS) was significantly lower in the PS group (PS: 44 ± 14 vs. MC-PLR: 53 ± 18, p < 0.05). At 12-months post-operation, there was significant improvement in all parameters (p < 0.01). Both groups had similar ROM (PS: 115º ± 13º vs. MC-PCLR: 114º ± 10º, p = 0.98), OKS (PS: 41 ± 5 vs. MC-PCLR: 40 ± 4, p = 0.50), KS-FS (PS: 74 ± 22 vs. MC-PCLR: 77 ± 16, p = 0.78), and KS-KS (PS: 89 ± 10 vs. MC-PCLR: 89 ± 10, p = 0.89). The PS group had significant improvement in all parameters from preoperation to 3-month postoperation (p < 0.05), but not from 3-month to 1-year postoperation (p ≥ 0.05). The MC-PCLR group continued to have significant improvement from 3-month to 1-year postoperation (p < 0.05). Preserving the PCL when using MC may paradoxically cause an undesired additional restrain that slows the recovery process of the patients after TKA. Compared to MC-PCLR, a PS TKA may expect significantly faster improvement at 3 months post operation, although they will achieve similar outcomes at 1-year post operation.

Robotic-Assisted Knee Arthroplasty: Insights and Implications From Current Literature

Robotic-assisted knee arthroplasty has emerged as a promising development, aiming to enhance surgical precision and patient outcomes. This literature review examines the clinical efficacy, cost implications, environmental impact, and potential of telesurgery in robotic-assisted total knee arthroplasty (RATKA) and robotic-assisted unicompartmental knee arthroplasty (RAUKA) relative to conventional techniques. A thorough literature search was conducted across medical databases. Clinical and radiological outcomes of RATKA and RAUKA were extracted and analyzed. Direct costs, operating time, surgeon learning curve, environmental implications, and the futuristic concept of telesurgery were also considered. Subjective patient assessments such as WOMAC, Oxford Knee Score, and SF-36, alongside objective measures like HSS score and KSS, were commonly used. Radiological parameters like hip-knee-ankle (HKA) and femorotibial angle provided insights into post-operative alignment. Evidence indicated sporadic high-level design studies, often with limited samples. Cost remains a major constraint with robotic systems, though high-volume cases might offset expenses. Environmental assessments revealed robotic surgeries generate a higher carbon footprint. Telesurgery, an evolving field, could transcend geographical boundaries but is not without challenges, including high costs, latency issues, and cyber threats. While robotic-assisted surgeries may hold promise in the future, substantial barriers, including acquisition costs, potential surgeon deskilling, and environmental concerns, need addressing. Greater robot utilization may drive costs down with more competitors entering the market. Continued research, especially multi-center RCTs, is pivotal to solidifying the role of robotic systems in knee arthroplasty.

Patellar resurfacing versus retention in cruciate-retaining and posterior-stabilized total knee arthroplasty

Aims

This systematic review and meta-analysis aimed to compare the influence of patellar resurfacing following cruciate-retaining (CR) and posterior-stabilized (PS) total knee arthroplasty (TKA) on the incidence of anterior knee pain, knee-specific patient-reported outcome measures, complication rates, and reoperation rates.

Methods

A systematic review of MEDLINE, PubMed, and Google Scholar was performed to identify randomized controlled trials (RCTs) according to search criteria. Search terms used included: arthroplasty, replacement, knee (Mesh), TKA, prosthesis, patella, patellar resurfacing, and patellar retaining. RCTs that compared patellar resurfacing versus unresurfaced in primary TKA were included for further analysis. Studies were evaluated using the Scottish Intercollegiate Guidelines Network assessment tool for quality and minimization of bias. Data were synthesized and meta-analysis performed.

Results

There were 4,135 TKAs (2,068 resurfaced and 2,027 unresurfaced) identified in 35 separate cohorts from 33 peer-reviewed studies. Anterior knee pain rates were significantly higher in unresurfaced knees overall (odds ratio (OR) 1.84; 95% confidence interval (CI) 1.20 to 2.83; p = 0.006) but more specifically associated with CR implants (OR 1.95; 95% CI 1.0 to 3.52; p = 0.030). There was a significantly better Knee Society function score (mean difference (MD) -1.98; 95% CI -1.1 to -2.84; p < 0.001) and Oxford Knee Score (MD -2.24; 95% CI -0.07 to -4.41; p = 0.040) for PS implants when patellar resurfacing was performed, but these differences did not exceed the minimal clinically important difference for these scores. There were no significant differences in complication rates or infection rates according to implant design. There was an overall significantly higher reoperation rate for unresurfaced TKA (OR 1.46 (95% CI 1.04 to 2.06); p = 0.030) but there was no difference between PS or CR TKA.

Conclusion

Patellar resurfacing, when performed with CR implants, resulted in lower rates of anterior knee pain and, when used with a PS implant, yielded better knee-specific functional outcomes. Patellar resurfacing was associated with a lower risk of reoperation overall, but implant type did not influence this.

Use of computerised adaptive testing to reduce the number of items in patient-reported hip and knee outcome scores: an analysis of the NHS England National Patient-Reported Outcome Measures programme

OBJECTIVE

Over 160 000 participants per year complete the 12-item Oxford Hip and Knee Scores (OHS/OKS) as part of the NHS England Patient-Reported Outcome Measures (PROMs) programme. We used a modern computational approach, known as computerised adaptive testing (CAT), to simulate individually tailored OHS and OKS assessment, with the goal of reducing the number of questions a patient must complete without compromising measurement accuracy.

METHODS

We fit the 2018/2019 PROMs data to an item response theory (IRT) model. We assessed IRT model assumptions alongside reliability. We used parameters from the IRT model with data from 2017/2018 to simulate CAT assessments. Two simulations were run until a prespecified SE of measurement was met (SE=0.32 and SE=0.45). We compared the number of questions required to meet each cut-off and assessed the correlation between the full-length and CAT administration.

RESULTS

We conducted IRT analysis using 40 432 OHS and 44 714 OKS observations. The OHS and OKS were both unidimensional (root mean square error of approximation 0.08 and 0.07, respectively) and marginal reliability 0.91 and 0.90. The CAT, with a precision limit of SE=0.32 and SE=0.45, required a median of four items (IQR 1) and two items (IQR 1), respectively, for the OHS, and median of four items (IQR 2) and two items (IQR 0) for the OKS. This represents a potential 82% reduction in PROM length. In the context of 160 000 yearly assessments, these methodologies could result in the omission of some 1 280 000 redundant questions per year, which equates to 40 000 hours of patient time.

CONCLUSION

The application of IRT to the OHS and OKS produces an efficient and substantially reduced CAT. We have demonstrated a path to reduce the burden and potentially increase the compliance for these ubiquitous outcome measures without compromising measurement accuracy.

Medial pivot versus (cam post) posterior stabilised total knee arthroplasty, systematic review and meta-analysis of 3837 knees

In the current literature, there is no consensus as to whether the medial pivot (MP) or posterior-stabilised (PS) knee provides the best result for the patient in the context of post-operative range of motion (ROM) and patient reported outcome measures (PROMs). The aim of this systematic review is to provide this equipoise with some clarity. We conducted this study following both the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA) and the Cochrane Handbook for systematic reviews and meta-analysis. Studies comparing the MP and PS knees from all regions and written in any language were included. Twenty- one studies were included in this meta-analysis. They were prepared and analysed using Review Manager V5.0 [Computer Program] (RevMan5). We calculated the risk ratio to measure the treatment effect, taking the heterogeneity of the studies into consideration. Random-effect models were also utilised. MP knees were found to have a significant advantage over PS knees in terms of WOMAC score at the midterm follow up, and insignificant advantages over PS knees in terms of ROM and FJS at one and two years follow- up. Additionally, the PS knees demonstrated an in significantly higher Knee Society Score (KSS) at short and midterm follow up. In terms of ROM, KSS, OKS and FJS this meta-analysis suggests a non-significant advantages for the MP knee compared with the PS prothesis in the short term. The MP implant also showed a significantly superior WOMAC score at short-term follow-up. An extended follow-up period is required to evaluate whether the MP knee is superior than the PS in the long-term.

Improvements in functional outcome and quality of life are not sustainable for patients ≥ 68 years old 10 years after total knee arthroplasty

PURPOSE

The aims of this study are to evaluate whether improvements in functional outcome and quality of life are sustainable 10 years after total knee arthroplasty (TKA), and the age cut-off for clinical deterioration in outcomes METHODS: Prospectively collected registry data of 120 consecutive patients who underwent TKA at a tertiary hospital in 2006 was analysed. All patients were assessed at 6 months, 2 years and 10 years using the Knee Society Function Score, Knee Society Knee Score, Oxford Knee Score, Short-Form 36 Physical/Mental Component Scores and postoperative satisfaction. One-way ANOVA was used to compare continuous variables, while Chi-squared test to compare categorical variables. Multivariate logistic regression and receiver operating curve analysis was performed to evaluate the predictive factors associated with deterioration of scores postoperatively.

RESULTS

Significant improvements were noted in all functional outcome and quality of life scores at 6 months after TKA. Between 6 months and 2 years, the KSFS and OKS continued to improve but the KSKS, PCS and MCS plateaued. Between 2 and 10 years, there was a deterioration in the KSFS and OKS, whilst KSKS, PCS and MCS were maintained. Increasing age was noted to be a significant risk factor for deterioration of KSFS at 10 years with age ≥ 68 as the cut-off value. 91.7% of patients with KSFS Minimally Clinically Important Difference(MCID) (≥ 7 points) continued to be satisfied after 10 years compared to 100.0% who did not experience KSFS MCID deterioration (p = 0.02).

CONCLUSION

Patients ≥ 68 years experience deterioration in functional outcomes and quality of life from 2 to 10 years after TKA.

LEVEL OF EVIDENCE

Retrospective study, Level III.

Insight Into the Effect of Hospital-Based Prehabilitation on Postoperative Outcomes in Patients With Total Knee Arthroplasty: A Retrospective Comparative Study

BACKGROUND

Osteoarthritis (OA) has become one of the most prevalent joint diseases worldwide, leading to a growing burden of pain and disability as populations age. Although there is consistent evidence to support postoperative rehabilitation and high-intensity prehabilitation for total knee arthroplasty (TKA), the clinical outcomes of hospital-based prehabilitation remain unclear. We aimed to evaluate the effect of a hospital-based prehabilitation program on knee score (KS), function score (FS), and length of stay (LOS) among patients with knee OA after TKA.

METHODS

A retrospective comparative study was conducted at Renmin Hospital of Wuhan University among patients with primary knee OA. Seventy-two postopearative patients who did not undergo the prehabilitation program were included as the control group, while 68 postoperative patients who underwent the prehabilitation program were assigned to the intervention group. All patients went through the same care after TKA. The KS, FS, and pain levels were measured 5 days before surgery, immediately preceding surgery, immediately after the surgery, and at 1 week and 1 month postoperatively. LOS for each patient was recorded.

RESULTS

The new prehabilitation training program significantly improved the KS over time in the intervention group. However, no significant between-group difference was identified in the change of FS. The prehabilitation program also provided shorter LOS.

CONCLUSIONS

The hospital-based prehabilitation program leads to improved recovery, as indicated by higher KS postoperatively, which may result in improved clinical outcomes of TKA.

Early Functional Outcomes After Evolutionary Total Knee Arthroplasty: A Randomized Controlled Trial. Is New Always Better?

Total knee replacement (TKR) designs continue to evolve with the aim of improving patient outcomes; however, there remains a significant patient dissatisfaction rate. We report the early functional outcomes of an evolutionary knee design in the context of a single-blinded, noninferiority, randomized controlled trial.

Does bicompartmental knee arthroplasty hold an advantage over total knee arthroplasty? Systematic review and meta-analysis

INTRODUCTION

The role of bicompartmental knee arthroplasty (BKA) in the treatment of medial patellofemoral osteoarthritis (MPFOA) has been debated by orthopaedic surgeons for years. The BKA is a cruciate ligament retaining prosthesis designed to mimic the kinematics of the native knee that requires resurfacing of only two knee compartments. In this study, we aim to assess the patient recorded outcome measures (PROMs), range of motion (ROM), perioperative morbidity, and implant revision rate in patients undergoing BKA and compare them to those undergoing total knee arthroplasty (TKA) for bicompartmental knee osteoarthritis (OA).

PATIENTS AND METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA). Articles from any country and written in any language were considered. We included all randomized control trials and retrospective cohort studies examining BKA versus TKA for bicompartmental knee OA. The primary outcome measure was knee society score (KSS) at one year and the secondary outcome measures were Oxford knee score (OKS) and short-form survey (SF-)12 at six and twelve months.

RESULTS

We included five studies in our meta-analysis. In terms of OKS, KSS, and SF-12, our meta-analysis suggests better short-term results for the TKA compared with the BKA. TKA was also associated with a shorter operative time and a lower revision rate. The BKA implant did however result in marginally less intraoperative blood loss and slightly better post-operative ROM.

CONCLUSIONS

BKA did not prove to be an equivalent alternative to TKA in bicompartmental knee OA. It was associated with inferior KSS, OKS, and SF-12 at short-term follow-up and a higher revision rate.

Responsiveness of the SF-36 general health domain: observations from 14883 spine surgery procedures

PURPOSE

The study evaluated perceptions of general health (GH) after surgical treatment of spinal stenosis and disk herniation. We used a large longitudinally collected data set to explore differences in responsiveness between the SF-36 GH domain, EQ VAS, EQ-5D index, and SF-6D index.

METHODS

Patients, surgically treated for lumbar spinal stenosis or lumbar disk herniation between 2007 and 2017, were recruited from the national Swedish spine register. A total of 14,883 procedures were eligible for analysis. The responsiveness of the SF-36 GH domain to surgical treatment was evaluated with the standardized response mean (SRM) and effect size (ES). The internal consistency of the GH domain was evaluated, ceiling and floor effects were assessed, and the correlation between GH domain and EQ VAS was analyzed.

RESULTS

The SF-36 GH domain did not respond to surgical treatment of spinal stenosis and disk herniation. In contrast, EQ VAS, EQ-5D index, and SF-6D showed moderate to large responsiveness. There were pronounced ceiling effects in items 11a-c of the SF-36 GH domain. There was a negative effect size of change for item 11c. The internal consistency of the GH domain was satisfactory. There were marked differences in the correlations between EQ VAS and the GH domain preoperatively and postoperatively.

CONCLUSIONS

The SF-36 GH domain should be used with caution when evaluating effects on GH perceptions after spine surgery procedures. The lack of responsiveness is most probably explained by ceiling effects for items 11a-c and a negative effect size of change for item 11c.

Cohort profile: the St Vincent's Melbourne Arthroplasty Outcomes (SMART) Registry, a pragmatic prospective database defining outcomes in total hip and knee replacement patients

PURPOSE

The St Vincent's Melbourne Arthroplasty Outcomes (SMART) Registry is an institutional clinical registry housed at a tertiary referral hospital in Australia. The SMART Registry is a pragmatic prospective database, which was established to capture a broad range of longitudinal clinical and patient-reported outcome data to facilitate collaborative research that will improve policy and practice relevant to arthroplasty surgery for people with advanced arthritis of the hip or knee. The purpose of this cohort profile paper is to describe the rationale for the SMART Registry's creation, its methods, baseline data and future plans for the Registry. A full compilation of the data is provided as a reference point for future collaborators.

PARTICIPANTS

The SMART Registry cohort comprises over 13 000 consecutive arthroplasty procedures in more than 10 000 patients who underwent their procedure at St Vincent's Hospital Melbourne, since January 1998. Participant recruitment, data collection and follow-up is ongoing and currently includes up to 20 years follow-up data.

FINDINGS TO DATE

SMART Registry data are used for clinical audit and feedback, as well as for a broad range of research including epidemiological studies, predictive statistical modelling and health economic evaluations. At the time of writing, there were 46 publications from SMART Registry data, with contributions from more than 67 coauthors.

FUTURE PLANS

With the recent linking of the SMART Registry with Medicare Benefits Schedule and Pharmaceutical Benefits Scheme data through the Australian Institute of Health and Welfare, research into prescribing patterns and health system utilisation is currently underway. The SMART Registry is also being updated with the Clavien-Dindo classification of surgical complications.

A Randomized Controlled Trial Comparing a Medial Stabilized Total Knee Prosthesis to a Cruciate Retaining and Posterior Stabilized Design: A Report of the Clinical and Functional Outcomes Following Total Knee Replacement

BACKGROUND

The purpose of this randomized controlled trial was to compare the performance of 3 total knee joint replacement (TKJR) designs 6 months after the surgery.

METHODS

Patients were recruited between March 2015 and March 2018. Patients with osteoarthritis consented for TKJR were randomly allocated to a medial stabilized (MS), cruciate retaining (CR), or posterior stabilized (PS) design. Primary outcome measures were self-reported improvement in pain and function 6 months after TKJR, using the Oxford Knee Score. Secondary outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index, Veterans RAND 12-item Health Survey, Knee Society Score 2011, Timed Up and Go test, and Six-Minute Walk Test. Twelve-month outcomes were also measured.

RESULTS

Ninety participants enrolled, 83 were randomized: PS (n = 26), CR (n = 28), and MS (n = 29) designs. One case withdrew before surgery: planned use of non-study implant; 7 did not complete all outcome measures. No 6-month between-group difference was observed for the primary outcome. A 6-month difference was observed in Knee Society Score 2011 Satisfaction: MS favored over CR and PS. Clinically meaningful 12-month differences in Western Ontario and McMaster Universities Osteoarthritis Index Pain, Function, and Global Subscales were observed: MS favored over CR. Twelve-month differences occurred in Veterans RAND 12-item Health Survey mental well-being, favoring MS and PS over CR.

CONCLUSION

MS prosthesis can be expected to yield similar clinical and functional outcomes to PS and CR designs 6 months after TKJR, and patients were more satisfied with their outcome. Compared with CR, patients with MS prosthesis also reported superior pain, function, and quality-of-life outcomes at 12 months.

Pre-existing patellofemoral disease does not affect 10-year survivorship in fixed bearing unicompartmental knee arthroplasty

PURPOSE

The purpose of this study was to assess 10-year functional outcome and survivorship analysis of patients with significant radiographic evidence of patellofemoral joint arthritis treated with fixed bearing unicompartmental knee arthroplasty.

METHODS

Two hundred and sixteen patients (263 knees) that underwent UKA from 2003 to 2005 for a mean of 10.5 ± 2.1 years were prospectively followed up. Preoperative radiological assessment of the patellofemoral joint state was assessed according to the Ahlback classification by an independent assessor and radiographically significant patellofemoral disease was defined as grade 2 or more. Patients with significant bone-on-bone contact in the patellofemoral joint were excluded.

RESULTS

Of the 263 knees, 222 (84.4%) had normal patellofemoral joint state and 41 (15.6%) radiologically significant patellofemoral disease. At 10 years' follow-up, the normal and patellofemoral groups had similar OKS (20 ± 7 vs 20 ± 8, n.s.) and KSS scores (79 ± 20 vs 81 ± 20, n.s.), respectively. There were 12 revision surgeries in the normal group and the most common indication for revision was progression of contralateral compartment osteoarthritis (6 of 12 cases). There was only one revision in the patellofemoral group and it was due to progression of contralateral compartment osteoarthritis (n.s.). When all secondary surgeries to the operated knee were considered as failures, the 10-year survival rate was 95.1% (CI 95%: 92.2-97.7%).

CONCLUSION

The presence of significant preoperative radiological patellofemoral disease does not affect long-term implant survival and patients have excellent functional outcomes 10 years postoperatively. These patients should not be contraindicated from undergoing unicompartmental knee arthroplasty.

LEVEL OF EVIDENCE

III.

Rotating hinge knee versus constrained condylar knee in revision total knee arthroplasty: A meta-analysis

There is debate in the literature whether rotating hinge knee (RHK) or constrained condylar knee (CCK) prostheses lead to better clinical outcomes and survival rates in patients undergoing revision total knee arthroplasty (RTKA). The purpose of this meta-analysis is to compare the survivorship and clinical outcomes of RHK and CCK prostheses. In this meta-analysis, we reviewed studies that evaluated pain and function scores, range of motion (ROM), complications, and survival rates in patients treated with RHK or CCK with short-term (<5 years) or midterm (5-10 years) follow-up. The survivorship was considered as the time to additional surgical intervention such as removal or revision of the components. A total of 12 studies (one randomized study and 11 non-randomized studies) met the inclusion criteria and were analyzed in detail. The proportion of the knees in which short-term (<5 years) survival rates (RHK, 83/95; CCK, 111/148; odds ratio [OR] 0.52; 95% CI, 0.24-1.11; P = 0.09) and midterm (5-10 years) survival rates (RHK, 104/128; CCK, 196/234; OR 1.05; 95% CI, 0.56-1.97; P = 0.88) were evaluated did not differ significantly between RHK and CCK prostheses. In addition, there were no significant differences in ROM (95% CI: -0.40 to 9.93; P = 0.07) and complication rates (95% CI: 0.66 to 2.49; P = 0.46). In contrast, CCK groups reported significantly better pain score (95% CI: 0.50 to 2.73; P = 0.005) and function score (95% CI: 0.01 to 2.00; P = 0.05) than RHK groups. This meta-analysis revealed that 87.4% of RHK and 75.0% of CCK prostheses survive at short-term (<5 years), while 81.3% of RHK and 83.8% of CCK prostheses survive at midterm (5-10 years). The differences in standardized mean pain and function scores we detected were likely to be imperceptible to patients and almost certainly below the minimum clinically important level, despite a significant difference in both groups. Based on the findings of the current meta-analysis, RHK prostheses continue to be an option in complex RTKA with reasonable midterm survivorship.

Cartilage Surgery in Overweight Patients: Clinical and MRI Results after the Autologous Matrix-Induced Chondrogenesis Procedure

Modern orthopaedic surgery provides a variety of techniques for cartilage repair. The Autologous Matrix-Induced Chondrogenesis (AMIC) procedure is a single-step technique with a collagen I/III scaffold for the treatment of full-thickness cartilage lesions. The aim of the study was to analyze the outcome of the AMIC procedure in overweight patients with knee cartilage defects. Overweight patients treated with AMIC surgery were followed up by clinical and MRI examination. 9 patients with a cartilage defect of the knee with a mean lesion size of 2.1 ± 1.2 cm² and an average body mass index (BMI) of 29.3 were available for the follow-up. The Lysholm Score was significantly improved by the AMIC procedure (38 to 67, p ≤ 0.008). The VAS Score was significantly lower after the procedure (9 to 3, p ≤ 0.018). In the postoperative MOCART Scale, the scaffold reached defect covering of 80%. However, 2 patients had to be revised due to persisting knee pain. The AMIC procedure enhances pain reduction and gain of knee function for cartilage defects of overweight patients. However, in cases of an increased BMI, the patient had to be informed that success rate is reduced despite good defect covering.

Comparison of outcome measures from different pathways following total knee arthroplasty

INTRODUCTION

The benefits of extended inpatient rehabilitation following total knee arthroplasty (TKA) in local community hospitals (CHs) are unproven. Our study compared functional outcomes between patients discharged home and to CHs following TKA.

METHODS

A case-control study was conducted of patients undergoing primary unilateral TKA. Consecutive patients (n = 1,065) were retrospectively reviewed using the Knee Society Clinical Rating System (KSCRS), 36-item Short Form Health Survey (SF-36) and Oxford Knee Score (OKS) preoperatively, and at the six-month and two-year follow-ups.

RESULTS

Overall, 967 (90.8%) patients were discharged home and 98 (9.2%) to CHs. CH patients were older (mean age 70.7 vs. 67.2 years; p < 0.0001), female (86.7% vs. 77.5%; p = 0.0388) and less educated (primary education and above: 61.7% vs. 73.8%; p = 0.0081). Median CH length of stay was 23.0 (range 17.0-32.0) days. Significant predictors of discharge destination were older age, female gender, lower education, and poorer ambulatory status and physical health. Preoperatively, CH patients had worse KSCRS Function (49.2 ± 19.5 vs. 54.4 ± 16.8; p = 0.0201), SF-36 Physical Functioning (34.3 ± 22.6 vs. 40.4 ± 22.2; p = 0.0017) and Social Functioning (48.2 ± 35.1 vs. 56.0 ± 35.6; p = 0.0447) scores. CH patients had less improvement for all scores at all follow-ups. Regardless of preoperative confounders, with repeated analysis of variance, discharge destination was significantly associated with KSCRS, SF-36 and OKS scores.

CONCLUSION

Older, female and less educated patients with poorer preoperative functional scores were more likely to be discharged to CHs after TKA. At the two-year follow-up, patients in CHs had less improvement in functional outcomes than those discharged home.

Effect of Celecoxib on Surgical Site Inflammation after Total Knee Arthroplasty: A Randomized Controlled Study

OBJECTIVE

To evaluate the anti-inflammatory effectiveness of celecoxib and its effect on the rehabilitation of joint function after total knee arthroplasty.

METHODS

72 patients presented between 2016 and 2017 and were divided into two groups. The experimental group was given 200 mg celecoxib twice daily with tramadol hydrochloride 50 mg twice daily (as required); the control group was given tramadol hydrochloride 50 mg twice daily for 6 weeks from the first day after total knee arthroplasty. Skin temperature around the knee was measured 1 day before surgery, on postoperative days 1 and 3, and at weeks 1, 2, and 6. Inflammatory markers (white blood cell count, C-reactive protein, erythrocyte sedimentation rate, and interleukin-6) were measured preoperatively, on postoperative day 3, and at weeks 1 and 6. Knee Society Score was recorded preoperatively and at postoperative weeks 1, 2, and 6.

RESULTS

Except for preoperative skin temperature, the recorded skin temperatures of the experimental group were significantly different compared to those of the control group (p = 0.001, 0.024, 0.030, 0.041, 0.047, respectively). Levels of C-reactive protein were significantly different at the 1st and the 6th week after surgery, differing by 19.3 ± 4.64 mg/L (p < 0.001) and 2.6 ± 0.92 mg/L (p = 0.006). Levels of interleukin-6 showed a significant difference of 6.61 ± 2.36 pg/mL (p = 0.007) at the 1st week after surgery. Until the 6th week after surgery, the erythrocyte sedimentation rate in the experimental group and the control group differed by 17 ± 4.6 mm/h (p = 0.001).

CONCLUSIONS

Celecoxib has a significant inhibitory effect on postoperative aseptic inflammation.

DEMQOL and DEMQOL-Proxy: a Rasch analysis

Background

DEMQOL and DEMQOL-Proxy are widely used patient reported outcome measures (PROMs) of health related quality of life in people with dementia (PWD). Growing interest in routine use of PROMs in health care calls for more robust instruments that are potentially fit for reliable and valid comparisons at the micro-level (patients) and meso-level (clinics, hospitals, care homes).

Methods

We used modern psychometric methods (based on the Rasch model) to re-evaluate DEMQOL (1428 PWDs) and DEMQOL-Proxy (1022 carers) to ensure they are fit for purpose. We evaluated scale to sample targeting, ordering of item thresholds, item fit to the model, and differential item functioning (sex, age, relationship), local independence, unidimensionality and reliability on the full set of items and a smaller item set.

Results

For both DEMQOL and DEMQOL-Proxy the smaller item set performed better than the original item set. We developed revised scores using the items from the smaller set.

Conclusions

We have improved the scoring of DEMQOL and DEMQOL-Proxy using the Rasch measurement model. Future work should focus on the problems identified with content and response options.

A Systematic Review of Measurement Properties of Patient-Reported Outcome Measures Used in Patients Undergoing Total Knee Arthroplasty

BACKGROUND

While clinical research on total knee arthroplasty (TKA) outcomes is prevalent in the literature, studies often have poor methodological and reporting quality. A high-quality patient-reported outcome instrument is reliable, valid, and responsive. Many studies evaluate these properties, but none have done so with a systematic and accepted method. The objectives of this study were to identify patient-reported outcome measures (PROMs) for TKA, and to critically appraise, compare, and summarize their psychometric properties using accepted methods.

METHODS

MEDLINE, EMBASE, SCOPUS, Web of Science, PsycINFO, and SPORTDiscus were systematically searched for articles with the following inclusion criteria: publication before December 2014, English language, non-generic PRO, and evaluation in the TKA population. Methodological quality and evidence of psychometric properties were assessed with the COnsensus-based standards for the selection of health Status Measurement INstruments (COSMIN) checklist and criteria for psychometric evidence proposed by the COSMIN group and Terwee et al.

RESULTS

One-hundred fifteen studies on 32 PROMs were included in this review. Only the Work, Osteoarthritis or joint-Replacement Questionnaire, the Oxford Knee Score, and the Western Ontario and McMaster Universities Arthritis Index had 4 or more properties with positive evidence.

CONCLUSION

Most TKA PROMs have limited evidence for their psychometric properties. Although not all the properties were studied, the Work, Osteoarthritis or joint-Replacement Questionnaire, with the highest overall ratings, could be a useful PROM for evaluating patients undergoing TKA. The methods and reporting of this literature can improve by following accepted guidelines.

Unicompartmental knee arthroplasty versus total knee arthroplasty: Which type of artificial joint do patients forget?

PURPOSE

During recent years, there has been an intensive growth of interest in the patient's perception of functional outcome. The Forgotten Joint Score (FJS) is a recently introduced score that measures joint awareness of patients who have undergone knee arthroplasty and is less limited by ceiling effects. The aim of this study was to compare the FJS between patients who undergo medial unicompartmental knee arthroplasty (UKA) and patients who undergo total knee arthroplasty (TKA) 1 and 2 years post-operatively.

METHODS

This prospective study compares the FJS at a minimum of one (average 1.5 years, range 1.0-1.9) and a minimum of 2 years (average 2.5 years, range 2.0-3.6) post-operatively between patients who underwent medial UKA and TKA.

RESULTS

One-hundred and thirty patients were included. Sixty-five patients underwent medial UKA and 65 patients underwent TKA. At both follow-up points, the FJS was significantly higher in the UKA group (FJS 1 year 73.9 ± 22.8, FJS 2 year 74.3 ± 24.8) in contrast to the TKA group (FJS 1 year 59.3 ± 29.5 (p = 0.002), FJS 2 year 59.8 ± 31.5, (p = 0.004)). No significant improvement in the FJS was observed between 1- and 2-year follow-up of the two cohorts.

CONCLUSION

Patients who undergo UKA are more likely to forget their artificial joint in daily life and consequently may be more satisfied.

LEVEL OF EVIDENCE

II.

Joint awareness in osteoarthritis of the hip and knee evaluated with the 'Forgotten Joint' Score before and after joint replacement

PURPOSE

To utilize the 'Forgotten Joint' Score (FJS), a 12-item questionnaire analysing the ability to forget the joint, for comparing preoperative status in osteoarthritic patients scheduled for total hip arthroplasty (THA) or total knee arthroplasty (TKA). Higher scores represent a better result with a maximum of 100. The hypothesis of this study was that a preoperative difference in favour of hip arthritis could eventually explain why THA is cited more often as a forgotten joint than TKA.

METHODS

A prospective cohort study was conducted in 150 patients with either tricompartmental knee (n = 75) or hip osteoarthritis (n = 75). Patients completed FJS-12 scores preoperatively and 1 year postoperatively.

RESULTS

A similar preoperative FJS-12 was observed for hip (22 (15)) and knee osteoarthritis (24 (17)) (n.s.). The postoperative FJS-12 score was significantly higher for THA (80 (24)) than for TKA (70 (27)) (p < 0.05). High reliability after 6 weeks was observed for the preoperative FJS-12 test-retest reliability (ICC = 0.87) in TKA. A preoperative floor effect of 15 % in THA and 0 % in TKA was found as well as a postoperative ceiling effect of 33 % in THA and 9 % in TKA.

CONCLUSIONS

The clinical relevance of utilizing the FJS-12 as an instrument to evaluate outcome is strongly proposed for knee arthroplasty. In general, one is not aware of a healthy joint during the ADL, and it can therefore be regarded as 'forgotten'. The preoperative FJS-12 Score is a powerful tool to provide patients with clearer insights into their positive evolution after surgery. The use of the FJS-12 in THA is a topic for further research, as this study found that floor and ceiling effects limit its usefulness in studies evaluating clinical outcome in this area.

LEVEL OF EVIDENCE

II.

The Use of Scoring Systems in Knee Arthroplasty: A Systematic Review of the Literature

BACKGROUND

The primary purpose of this systematic review was to clarify and quantify scoring system utilization in knee arthroplasty literature. In addition, the study considered the frequency and relationship of score use in articles published across a range of orthopedic journals, and the influence of study design, level of evidence, primary research topic, and study country of origin on the scoring system used.

METHODS

A systematic search of 8 electronic databases was performed to identify publications of clinical studies involving knee arthroplasty, in which a scoring system was used to assess patient outcomes.

RESULTS

Of the 1994 unique publications identified, 438 met the selection criteria. Identified articles reported a total of 86 scoring systems, 5 of which were reported in greater than 10.0% of included studies. The 1989 Knee Society Score was markedly the most utilized scoring system (58.7%). Use of the Knee Society Score was significantly associated with orthopedic journal impact factor (IF; P = .001), with greater use observed in journals of lower IF. Use of the Western Ontario and McMaster Universities Osteoarthritis Index escalated with increasing IF; however, no statistically significant association was observed. A preference for scoring systems developed in the country of residence of the first author was also identified.

CONCLUSIONS

A large number of scoring systems are used to assess knee arthroplasty patients; however, 5 scores are consistently reported. By identifying and quantifying scoring system use, this review hopes to stimulate regularity in score usage to allow for improvements in comparability of clinician and patient-reported outcome measures in the knee arthroplasty literature.

Inconsistent Patient Responses May Limit the Value of Using Multiple Total Knee Arthroplasty Assessment Tools to Define Implant Performance

Prior studies have suggested that using single validated instruments may not adequately characterize total knee arthroplasty (TKA) performance. However, the consistency of patient responses when answering multiple inventories has not been defined. We retrospectively evaluated 269 patient responses to four postoperative TKA inventories, including 24 parallel questions related to 6 low demand activities. The influence of patient age, sex, and race on response consistency was assessed. Thirty percent of patients gave discordant responses for at least 2 of 11 question categories, unaffected by chronological or categorical age. Discordant answers were more commonly obtained from minority and female patients (P<0.01). Combining multiple instruments to assess TKA outcomes may introduce confounding effects that limit their benefit.

Patient-reported outcome measures after total knee arthroplasty: a systematic review

Objectives

A lack of connection between surgeons and patients in evaluating the outcome of total knee arthroplasty (TKA) has led to the search for the ideal patient-reported outcome measure (PROM) to evaluate these procedures. We hypothesised that the desired psychometric properties of the ideal outcome tool have not been uniformly addressed in studies describing TKA PROMS.

Methods

A systematic review was conducted investigating one or more facets of patient-reported scores for measuring primary TKA outcome. Studies were analysed by study design, subject demographics, surgical technique, and follow-up adequacy, with the ‘gold standard’ of psychometric properties being systematic development, validity, reliability, and responsiveness.

Results

A total of 38 articles reported outcomes from 47 different PROMS to 85 541 subjects at 26.3 months (standard deviation 30.8) post-operatively. Of the 38, eight developed new scores, 20 evaluated existing scores, and ten were cross-cultural adaptation of existing scores. Only six of 38 surveyed studies acknowledged all ‘gold standard’ psychometric properties. The most commonly studied PROMS were the Oxford Knee Score, New Knee Society Score, Osteoarthritis Outcome Score, and Western Ontario and McMaster Universities Osteoarthritis Index.

Conclusions

A single, validated, reliable, and responsive PROM addressing TKA patients’ priorities has not yet been identified. Moreover, a clear definition of a successful procedure remains elusive.

Cite this article: Bone Joint Res 2015;4:120–127

Does intraoperative application of leukocyte-poor platelet-rich plasma during arthroscopy for knee degeneration affect postoperative pain, function and quality of life? A 12-month randomized controlled double-blind trial

INTRODUCTION

We aimed to identify the effects of intraoperative applied leukocyte-poor platelet-rich plasma (LP-PRP) during knee arthroscopy for degenerative lesions involving pain, function and quality of life.

METHODS

We performed a randomized controlled, double-blind trial (RCT) including 58 patients for arthroscopic knee surgery for cartilage or meniscal degeneration with allocation into the LP-PRP (n = 24) or control group (n = 34). During arthroscopy, LP-PRP was injected intra-articular in the intervention group. At baseline, 6 weeks, 6 months and 12 months pain, function, and life quality were assessed.

RESULTS

91 % of enrolled patients were available for 12 months follow-up. Pain was significantly lower in the LP-PRP group (VAS 0.9. vs. 2.3) at 6 (p = 0.008) but not at 12 months (VAS 1.0 vs. 1.6, p = 0.063). LP-PRP application improved the Lysholm Score at 6 (77.5 vs. 65.6, p = 0.033) and 12 months (83.2 vs.70.0, p = 0.007). Assessment of life quality (SF-36) concerning the physical component summary was significantly higher at 6 weeks (33.9 vs. 25.6, p = 0.001) and 6 months (29.9 vs. 27.1, p = 0.027) in the LP-PRP group but equal at 1 year (31.4 vs. 30.1, p = 0.438).

CONCLUSIONS

Intraoperative application of LP-PRP may enhance pain reduction and gain of knee function within 6-12 months compared to arthroscopy alone.

LEVEL OF EVIDENCE

II, randomized controlled clinical trial with reduced power. CLINICALTRIALS.

GOV IDENTIFIER

NCT02189408.

Comparative responsiveness of outcome measures for total knee arthroplasty

OBJECTIVE

The aim of this study was to compare the responsiveness of various patient-reported outcome measures (PROMs) and clinician-reported outcomes following total knee arthroplasty (TKA) over a 2-year period.

METHODS

Data were collected in a prospective cohort study of primary TKA. Patients who had completed Forgotten Joint Score-12 (FJS-12), Western Ontario and McMaster Universities (WOMAC) osteoarthritis (OA) index, EQ-5D, Knee Society Score and range of movement (ROM) assessment were included. Five time points were assessed: pre-operative, 2 months, 6 months, 1 year and 2 years post-operative.

RESULTS

Data from 98 TKAs were available for analysis. Largest effect sizes (ES) for change from pre-operative to 2-month follow-up were observed for the Knee Society Score (KSS) Knee score (1.70) and WOMAC Total (-1.50). For the period from 6 months to 1 year the largest ES for change were shown by the FJS-12 (0.99) and the KSS Function Score (0.88). The EQ-5D showed the strongest ceiling effect at 1-year follow-up with 84.4% of patients scoring the maximum score. ES for the time from 1- to 2-year follow-up were largest for the FJS-12 (0.50). All other outcome measures showed ES equal or below 0.30.

CONCLUSION

Outcome measures differ considerably in responsiveness, especially beyond one year post-operatively. Joint-specific outcome measures are more responsive than clinician-reported or generic health outcome tools. The FJS-12 was the most responsive of the tools assessed; suggesting that joint awareness may be a more discerning measure of patient outcome than traditional PROMs.