Patient-Reported Mental Health Score Influences Physical Function After Primary Total Knee Arthroplasty

Unicompartmental knee arthroplasty improves mental health in patients with single compartment knee osteoarthritis

PURPOSE

The purpose of this study was to determine if preoperative mental health status improves following unicompartmental knee arthroplasty (UKA) in patients with single compartment knee osteoarthritis (OA).

METHODS

A total of 163 patients underwent UKA [115 (71%) medial, 48 (29%) lateral] (mean age = 65 ± 11) completed preoperative and minimum 2-year postoperative veterans RAND 12 item health survey (VR-12) mental component score (MCS). VR-12 MCS was the primary outcome measure. Secondary measures included VR-12 physical component summary score (PCS), knee osteoarthritis outcome score (KOOS) and KOOS patient acceptable symptom state at the final follow-up.

RESULTS

The median VR-12 MCS improved from 50.5 [interquartile range (IQR): 43.7-56.8] to 55.0 [IQR: 52.3-57.0] (p < 0.001) at a mean follow-up of 9.5 ± 4 years (range 2-19 years) following UKA. Preoperative VR-12 MCS was significantly correlated with patients postoperative VR-12 PCS (ρ = 0.294, p < 0.01), KOOS pain (ρ = 0.201, p = 0.012), KOOS ADL (ρ = 0.243, p = 0.002) and KOOS quality of life (ρ = 0.233, p < 0.01). Sixty-three (39%) patients improved from low VR-12 MCS (<50) to normal VR-12 MCS (≥50). One hundred forty-two (87%) achieved a normal VR-12 MCS score (≥50) postoperatively.

CONCLUSION

At a mean of 10-year follow-up, patients who underwent UKA for single compartment osteoarthritic knee pain demonstrated significant improvement in mental health scores. UKA resulted in normal mental health in a majority of patients (87%). The resultant improved mental health scores were associated with improved patient pain and activities of daily living.

LEVEL OF EVIDENCE

Level III retrospective cohort study.

Mental Robustness May Be Associated With Improved Physical Function in Bilateral Total Knee Arthroplasty Patients

BACKGROUND

In accordance with the high incidence of bilateral knee osteoarthritis, many patients have undergone bilateral total knee arthroplasty (BTKA). Whether patients undergo bilateral procedures in a staged or simultaneous fashion, the physical and mental burden of undergoing 2 major orthopedic procedures is considerable. The aims of this study were to (1) investigate differences between minimal clinically important difference (MCID) achievement between staged versus simultaneous BTKA, and (2) identify the patient variables, specifically mental scores, that were associated with MCID achievement in patients undergoing BTKA.

METHODS

Simultaneous and staged BTKA patients within a single health care network from 2016 to 2021 were retrospectively reviewed. Patient demographics, surgery details, and Patient-Reported Outcome Measurement Information System Physical Function Short Forms 10a (PROMIS PF10a), PROMIS Mental scores, and Knee Disability Osteoarthritis Outcome Scores (KOOS) were reviewed. Preoperative and postoperative patient-reported outcome measures were collected before the first total knee arthroplasty (TKA) and after the second TKA, respectively, in staged BTKA patients. The final cohort consisted of 249 patients, with an average age of 66 years (range, 21 to 87), 63% women, and an average body mass index of 32 (range, 20 to 52), at a mean follow-up of 1.1 years (range, 0.5 to 2.4). Multivariate regressions were performed on MCID PF10a and KOOS achievement, as well as whether the BTKA was performed simultaneously versus staged.

RESULTS

A preoperative PROMIS Mental score in the upper 2 quartiles was associated with MCID PF10a achievement in BTKA. Men and surgeries performed at an Academic Medical Center were negatively associated with the achievement of MCID KOOS. Interestingly, those who underwent simultaneous BTKA were less likely to achieve MCID KOOS than those who underwent a staged BTKA.

CONCLUSIONS

Preoperative mental robustness may be positively associated with improved physical function outcome in BTKA patients.

Mental Health Effects on the Minimal Clinically Important Difference in Total Joint Arthroplasty

INTRODUCTION

The effect of mental health on patient-reported outcome measures is not fully understood in total joint arthroplasty (TJA). Thus, we investigated the relationship between mental health diagnoses (MHDs) and the Minimal Clinically Important Difference for Improvement (MCID-I) and Worsening (MCID-W) in primary TJA and revision TJA (rTJA).

METHODS

Retrospective data were collected using relevant Current Procedural Terminology and MHDs International Classification of Diseases, 10th Revision, codes with completed Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form, Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form, Patient-reported Outcomes Measurement Information System (PROMIS)-Physical Function Short Form 10a, PROMIS Global-Mental, or PROMIS Global-Physical questionnaires. Logistic regressions and statistical analyses were used to determine the effect of a MHD on MCID-I/MCID-W rates.

RESULTS

Data included 4,562 patients (4,190 primary TJAs/372 rTJAs). In primary total hip arthroplasty (pTHA), MHD-affected outcomes for Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (MCID-I: 81% versus 86%, P = 0.007; MCID-W: 6.0% versus 3.2%, P = 0.008), Physical Function Short Form 10a (MCID-I: 68% versus 77%, P < 0.001), PROMIS Global-Mental (MCID-I: 38% versus 44%, P = 0.009), and PROMIS Global-Physical (MCID-I: 61% versus 73%, P < 0.001; MCID-W: 14% versus 7.9%, P < 0.001) versus pTHA patients without MHD. A MHD led to lower rates of MCID-I for PROMIS Global-Physical (MCID-I: 56% versus 63%, P = 0.003) in primary total knee arthroplasty patients. No effects from a MHD were observed in rTJA patients.

DISCUSSION

The presence of a MHD had a prominent negative influence on pTHA patients. Patients who underwent rTJA had lower MCID-I rates, higher MCID-W rates, and lower patient-reported outcome measure scores despite less influence from a MHD.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Biopsychosocial complexity in patients scheduled for elective TKA surgery: A feasibility pilot study with the INTERMED self-assessment questionnaire

OBJECTIVE

Primary aim; to determine the feasibility of implementation of the INTERMED Self-Assessment (IM-SA) in adult patients scheduled for total knee arthroplasty (TKA). Secondary aim; to measure biopsychosocial complexity, referral to psychiatry or psychology in cases of complexity and to gain insight into the relation between biopsychosocial complexity and length of stay (LOS), method of discharge (MOD) and polypharmacy.

METHODS

A feasibility study was conducted with 76 participants in a general hospital in the Netherlands. Feasibility was determined by the number of completed questionnaires, time spent completing the questionnaire and the attitude of staff and patients towards the IM-SA. A cut off point ≥19 on the IM-SA was used to determine the prevalence of biopsychosocial complexity. A case file study was performed to check if referral to psychiatry or psychology had taken place. The Spearman's Rank Correlation Coefficient or Phi was used to determine if there was a relation between biopsychosocial complexity and LOS, MOD and polypharmacy.

RESULTS

All participants completed the IM-SA. The average time spent completing the questionnaire was 11.46 min (SD 5.74). The attitude towards the IM-SA was positive. The prevalence of biopsychosocial complexity was 11.84%. Referral to psychiatry or psychology did not take place. There was no relation between complexity and LOS (Spearman's rho (r) = 0.079, p = 0.499, MOD (Phi = 0.169, p = 0.173) and polypharmacy (Phi = 0.007, p = 0.953).

CONCLUSION

Biopsychosocial complexity can be identified in TKA patients during the pre-operative phase by using the IM-SA. Implementation of the IM-SA in a Dutch general hospital is feasible.

Do preoperative PROMIS scores independently predict 90-day readmission following primary total knee arthroplasty?

INTRODUCTION

The rising demand for total knee arthroplasty (TKA) is expected to increase the total number of TKA-related readmissions, presenting significant public health and economic burden. With the increasing use of Patient-Reported Outcomes Measurement Information System (PROMIS) scores to inform clinical decision-making, this study aimed to investigate whether preoperative PROMIS scores are predictive of 90-day readmissions following primary TKA.

MATERIALS AND METHODS

We retrospectively reviewed a consecutive series of 10,196 patients with preoperative PROMIS scores who underwent primary TKA. Two comparison groups, readmissions (n = 79; 3.6%) and non-readmissions (n = 2091; 96.4%) were established. Univariate and multivariate logistic regression analyses were then performed with readmission as the outcome variable to determine whether preoperative PROMIS scores could predict 90-day readmission.

RESULTS

The study cohort consisted of 2170 patients overall. Non-white patients (OR = 3.53, 95% CI [1.16, 10.71], p = 0.026) and patients with cardiovascular or cerebrovascular disease (CVD) (OR = 1.66, 95% CI [1.01, 2.71], p = 0.042) were found to have significantly higher odds of 90-day readmission after TKA. Preoperative PROMIS-PF10a (p = 0.25), PROMIS-GPH (p = 0.38), and PROMIS-GMH (p = 0.07) scores were not significantly associated with 90-day readmission.

CONCLUSION

This study demonstrates that preoperative PROMIS scores may not be used to predict 90-day readmission following primary TKA. Non-white patients and patients with CVD are 3.53 and 1.66 times more likely to be readmitted, highlighting existing racial disparities and medical comorbidities contributing to readmission in patients undergoing TKA.

Patients Consistently Report Worse Outcomes Following Revision Total Knee Arthroplasty Compared to Primary Total Knee Arthroplasty

BACKGROUND

Differences in patient-reported outcome measures (PROMs) between primary TKA (pTKA) and revision TKA (rTKA) have not been well-studied. Therefore, we compared pTKA and rTKA patients by the rates of achieving the Minimal Clinically Important Difference for Improvement (MCID-I) and Worsening (MCID-W).

METHODS

A total of 2,448 patients (2,239 pTKAs/209 rTKAs) were retrospectively studied. Patients who completed the Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form (KOOS-PS), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, or PROMIS Global-Physical questionnaires were identified by Current Procedural Terminology (CPT) codes. Patient-reported outcome measures and MCID-I/MCID-W rates were compared. Multivariate logistic regression models measured relationships between surgery type and postoperative outcomes.

RESULTS

Patients who underwent rTKA (all causes) had lower rates of improvement and higher rates of worsening compared to pTKA patients for KOOS-PS (MCID-I: 54 versus 68%, P < .001; MCID-W: 18 versus 8.6%, P < .001), PF10a (MCID-I: 44 versus 65%, P < .001; MCID-W: 22 versus 11%, P < .001), PROMIS Global-Mental (MCID-I: 34 versus 45%, P = .005), and PROMIS Global-Physical (MCID-I: 51 versus 60%, P = .014; MCID-W: 29 versus 14%, P < .001). Undergoing revision was predictive of worsening postoperatively for KOOS-PS, PF10a, and PROMIS Global-Physical compared to pTKA. Postoperative scores were significantly higher for all 4 PROMs following pTKA.

CONCLUSION

Patients reported significantly less improvement and higher rates of worsening following rTKA, particularly for PROMs that assessed physical function. Although pTKA patients did better overall, the improvement rates may be considered relatively low and should prompt discussions on improving outcomes following pTKA and rTKA.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Postoperative Psychological Predictors for Chronic Postsurgical Pain After a Knee Arthroplasty: A Prospective Observational Study

OBJECTIVE

Chronic postsurgical pain (CPSP) is a significant adverse effect shown in around 20% of people who had undergone a knee arthroplasty (KA). Psychological risk factors have emerged as significant and potentially modifiable risk factors for its development. However, there is still little evidence when assessing these factors during the acute postoperative period. This study aimed to assess the predictive value of postoperative pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes in developing CPSP after KA.

METHODS

A 6-month follow-up prospective observational study design was used. The study sample comprised 115 people who underwent a KA due to painful primary osteoarthritis. Measures of pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes were obtained 1 week after surgery. CPSP was set at an intensity of ≥30 using a 100-mm visual analog scale at 3 and 6 months after surgery.

RESULTS

Analysis revealed that baseline pain intensity, pain catastrophizing, pain-related fear of movement, anxiety, depression, and maladaptive pain attitudes were significant predictors of chronic pain at 3 and 6 months after surgery in a univariate analysis. However, at 3 months after surgery, only pain intensity and pain catastrophizing were predictors in the final multivariate model forecasting disturbing pain. Moreover, 6 months after surgery, pain intensity and distrust in medical procedures remained independent predictors. Most of the psychological factors can be grouped into a single dimension defined as pain-related psychological distress.

CONCLUSION

The results suggest that postoperative pain intensity, pain catastrophizing, and pain attitudes are independent predictors for CPSP after KA.

IMPACT

Postoperative cognitive and emotional factors should be considered alongside pain intensity during postoperative rehabilitation after KA because they could influence the development of CPSP.

Patient-reported outcomes measurement information system instruments in knee arthroplasty patients: a systematic review of the literature

BACKGROUND

The purpose of this study is to provide a systematic review of the literature pertaining to Patient-Reported Outcome Measurement Information System (PROMIS) validation and utilization as an outcomes metric in total knee arthroplasty (TKA) patients. This is the first systematic review on PROMIS use in total knee arthroplasty patients.

METHODS

A systematic search of the Pubmed/MEDLINE and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study characteristics, patient demographics, psychometric properties (Pearson and Spearman correlation) with legacy patient-reported outcome measurement (PROM) instruments, floor and ceiling effects, responsiveness, and minimum clinically important difference (MCID) and PROMIS outcomes were recorded and analyzed.

RESULTS

Fifteen studies investigating PROMIS in 11,140 patients were included. The weighted-average Pearson correlation coefficient comparing PROMIS domains with legacy patient-reported outcome measurements in total knee arthroplasty patients was 0.62 [standard error (SE) = 0.06] and the weighted-average Spearman correlation comparing PROMIS domains with legacy patient-reported outcome measurements in total knee arthroplasty patients was 0.59 (SE = 0.06), demonstrating moderate-to-strong correlation and validity. There were no differences in weighted average floor [0.03% (SE = 3.1) versus 0% (SE = 0.1) versus 0.01% (SE = 1.1); p = 0.25] or ceiling effects [0.01% (SE = 0.7) versus 0.02% (SE = 1.4) versus 0.04% (SE = 3.5); p = 0.36] between PROMIS and legacy instruments. The weighted average for percentage of patients achieving MCID was 59.1% for global physical health (GPH), 26.0% for global mental health (GMH), 52.7% for physical function (PF), 67.2% for pain interference (PI), and 37.2% for depression.

CONCLUSION

Notably, PROMIS global physical health, physical function, and pain interference were found to be significantly responsive, with PROMIS pain interference most effectively capturing clinical improvement as evidenced by the achievement of MCID.

Assessing the Mortality Rate After Primary Total Knee Arthroplasty: An Observational Study to Inform Future Economic Analysis

BACKGROUND

Previous research has focused on the perioperative or short-term (<1 year) mortality rate of total knee arthroplasty (TKA), leaving the long-term (>1 year) mortality rate unresolved. In this study, we calculated the mortality rate up to 15 years after primary TKA.

METHODS

Data from the New Zealand Joint Registry from April 1998 to December 2021 were analyzed. Patients aged 45 years or older who underwent TKA for osteoarthritis were included. Mortality data were linked with national records from births, deaths, and marriages. To determine the expected mortality rates in the general population, age-sex-specific life tables from statistics New Zealand were used. Mortality rate was presented as standardized mortality ratios (SMRs) - a comparison of relative mortality rate between the TKA and general populations. In total, 98,156 patients with a median follow-up of 7.25 years (range, 0.00 to 23.74) were included.

RESULTS

Over the entire follow-up period, 22,938 patients (23.4%) had died. The overall SMR for the TKA cohort was 1.08 (95% confidence interval (CI): 1.06 to 1.09), suggesting that TKA patients have an 8% higher mortality rate compared to the general population. However, a reduction in short-term mortality rate was observed for TKA patients up to 5 years post TKA (SMR 5 years post TKA; 0.59 95% CI: 0.57 to 0.60]). On the contrary, a significantly increased long-term mortality rate was observed in TKA patients with greater than 11 years of follow-up, particularly in men over the age of 75 years (SMR 11 to 15 years post TKA for males ≥ 75 years; 3.13 [95% CI: 2.95 to 3.31]).

CONCLUSION

The results suggest a reduction in short-term mortality rate for patients who undergo primary TKA. However, there is an increased long-term mortality rate particularly in men over the age of 75 years. Importantly, the mortality rates observed in this study cannot be causally attributed to TKA alone.

The development of machine learning algorithms that can predict patients satisfaction using baseline characteristics, and preoperative and operative factors of total knee arthroplasty

BACKGROUND

Patient satisfaction following primary total knee arthroplasty (TKA) is a crucial part to evaluate the success of the procedure. The purpose of this study was to develop to predict patient satisfaction following TKA.

METHODS

Satisfaction outcome data after 435 consecutive conventional TKAs performed between August 2020 and December 2021 were retrospectively collected. The total 26 input data were collected. The most favorable algorithm was first found using logistic regression (LR) and machine learning (ML) algorithms. To evaluate the predictive performance of the models, both area under curve (AUC) and F1-score were used as the primary metrics. The shapley additive explanations (SHAP) feature explanation in XGBoost and LR analysis were performed to interpret the model.

RESULTS

The performance of extreme gradient boosting classifier (XGBoost) was only higher than that of conventional LR in AUC (0.782 vs. 0.689). Comparing the F-1 score, only XGBoost showed better performance than LR (0.857 vs. 0.800). The most predictive feature in XGBoost was Short Form-36 physical and mental component summary scores (SF-36 MCS), followed by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, Bone mineral density (BMD). In the LR analysis, lumbar spine disease, WOMAC pain, and BMD were statistically significant.

CONCLUSION

XGboost showed the best performance and was superior to conventional LR in the prediction of patient satisfaction after TKA. The SF-36 MCS was the most important feature in the ML model. WOMAC pain and BMD were meaningful variables and demonstrated a linear relationship with satisfaction in both the LR and ML models.

LEVEL OF EVIDENCE

Retrospective cohort study; Level of evidence 3.

What is the Association Between Clinically Diagnosed Psychiatric Illness and Total Joint Arthroplasty? A Systematic Review Evaluating Outcomes, Healthcare Use, and Patient-reported Outcome Measures

BACKGROUND

Studies evaluating the effects of a psychiatric illness on orthopaedic surgical outcomes have yielded mixed results. Because awareness of patient comorbid mental health disorders has become increasingly important to tailor treatment plans, the aim of our systematic review was to present the findings of all studies reporting on the association between clinically diagnosed psychiatric illnesses and total joint arthroplasty (TJA) outcomes and evaluate the quality of evidence to provide a comprehensive summary.

QUESTION/PURPOSE

Is there a consistently reported association between comorbid psychiatric illness and (1) complication risk, (2) readmission rates, (3) healthcare use and discharge disposition, and (4) patient-reported outcome measures (PROMs) after TJA?

METHODS

The PubMed, EBSCO host, Medline, and Google Scholar electronic databases were searched on April 9, 2022, to identify all studies that evaluated outcomes after TJA in patients with a comorbid clinically diagnosed mental health disorder between January 1, 2000, and April 1, 2022. Studies were included if the full-text article was available in English, reported on primary TJA outcomes in patients with clinically diagnosed mental health disorders, included patients undergoing TJA without a psychiatric illness for comparison, and had a minimum follow-up time of 30 days for evaluating readmission rates, 90 days for other perioperative outcomes such as length of stay and complications, and 1-year minimum follow-up if assessing PROMs. Studies that used a mental health screening examination instead of clinical diagnoses were excluded to isolate for verified psychiatric illnesses. Additionally, systematic reviews, case reports, duplicate studies between the databases, and gray literature were excluded. Twenty-one studies were included in our final analysis comprising 31,023,713 patients with a mean age range of 57 to 69 years. Mental health diagnoses included depression, anxiety, bipolar disorder, schizophrenia, major personality disorder, and psychosis as well as concomitant mental disorders. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean MINORS score was 19.5 ± 0.91 of 24, with higher scores representing better study quality. All the articles included were retrospective, comparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed, and results are instead presented descriptively.

RESULTS

Patients with schizophrenia were consistently reported to have higher odds of medical and surgical complications than patients without psychiatric illness, particularly anemia and respiratory complications. Among studies with the largest sample sizes, patients with depression alone or depression and anxiety had slightly higher odds of complications. Most studies identified higher odds of readmission among patients with depression, schizophrenia, and severe mental illness after TJA. However, for anxiety, there was no difference in readmission rates compared with patients without psychiatric illness. Slightly higher odds of emergency department visits were reported for patients with depression, anxiety, concomitant depression and anxiety, and severe mental illness across studies. When evaluating healthcare use, articles with the largest sample sizes reporting on depression and length of stay or discharge disposition found modestly longer length of stay and greater odds of nonhome discharge among patients with depression. Although several studies reported anxiety was associated with slightly increased total costs of hospitalization, the most robust studies reported no difference or slightly shorter average length of stay. However, the included studies only reported partial economic analyses of cost, leading to relatively superficial evidence. Patients with schizophrenia had a slightly longer length of stay and modestly lower odds of home discharge and cost. Likewise, patients with concomitant depression and anxiety had a slightly longer average length of stay, according to the two articles reporting on more than 1000 patients. Lastly, PROM scores were worse in patients with depression at a minimum follow-up of 1 year after TJA. For anxiety, there was no difference in improvement compared with patients without mental illness.

CONCLUSION

Our systematic review found that individuals with psychiatric illness had an increased risk of postoperative complications, increased length of stay, higher costs, less frequent home discharge, and worse PROM scores after TJA. These findings encourage inclusion of comorbid psychiatric illness when risk-stratifying patients. Attention should focus on perioperative interventions to minimize the risk of thromboembolic events, anemia, bleeding, and respiratory complications as well as adequate pain management with drugs that do not exacerbate the likelihood of these adverse events to minimize emergency department visits and readmissions. Future studies are needed to compare patients with concomitant psychiatric illnesses such as depression and anxiety with patients with either diagnosis in isolation, instead of only comparing patients with concomitant diagnoses with patients without any psychiatric illnesses. Similarly, the results of targeted interventions such as cognitive behavioral therapy are needed to understand how orthopaedic surgeons might improve the quality of care for patients with a comorbid psychiatric illness.

Patient-Reported Outcomes following Total Knee Replacement in Patients Aged 65 Years and Over-A Systematic Review

A previous systematic review showed positive patient-reported outcomes following total knee replacement (TKR) in patients aged < 65 years. However, the question remains as to whether these results are replicated for older individuals. This systematic review evaluated the patient-reported outcomes following TKR in individuals aged ≥ 65 years. A systematic search of Ovid MEDLINE, EMBASE, and Cochrane library were performed to identify studies examining disease-specific or health-related quality of life outcomes following TKR. Qualitative evidence synthesis was performed. Eighteen studies with low (n = 1), moderate (n = 6), or serious (n = 11) overall risk of bias were included, with evidence syntheses derived from 20,826 patients. Four studies reported on pain scales, showing improvement of pain from 6 months to 10 years postoperatively. Nine studies examined functional outcomes, showing significant improvements from 6 months to 10 years after TKR. Improvement in health-related quality of life was evident in six studies over 6 months to 2 years. All four studies examining satisfaction reported overall satisfaction with TKR results. TKR results in reduced pain, improved function, and increased quality of life for individuals aged ≥ 65 years. The improvement in patient-reported outcomes needs to be utilised in conjunction with physician expertise to determine what would comprise clinically significant differences.

Preoperative mental distress is associated with poorer physical improvements after revision total hip arthroplasty

Aims

Despite the increasing prevalence of mental health disorders in revision arthroplasty patients, the impact of preoperative mental distress on functional outcomes after revision total hip arthroplasty (rTHA) remains unclear. Our study aims to investigate the impact of preoperative mental distress on functional outcomes after rTHA.

Methods

Prospectively collected data of 84 rTHAs was extracted from a single institution's joint replacement registry. Preoperative Short Form-36 (SF-36) mental component summary (MCS) was used to dichotomize patients to those who were distressed (MCS <50) and non-distressed (MCS ≥50). Multivariable analysis was used to analyze the impact of preoperative mental distress on various outcomes such as the SF-36 physical component summary (PCS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Hip Score (OHS), patient satisfaction and expectation fulfilment at 6 months and 2 years postoperatively.

Results

Compared to non-distressed patients, patients with preoperative mental distress had poorer improvements in PCS (+11.4 vs + 16.9, p = 0.007) and lower rates of minimal clinically important difference (MCID) attainment (55.2% vs 73.0%, p = 0.026) at 2 years postoperatively. However, there were no significant differences in improvements for WOMAC and OHS (p > 0.05). Despite experiencing greater absolute improvements in MCS (+12.1 vs -2.1, p < 0.001) and higher MCID attainment rates (65.5% vs 24.3%, p = 0.005) at 2 years, preoperatively distressed patients had lower MCS levels compared to their non-distressed counterparts at all time points (p-value<0.05). There were no significant differences in patient satisfaction (p = 0.509) or expectation fulfilment (p-value = 0.342) at 2 years postoperatively.

Conclusion

Revision THA led to substantial mental health improvements in patients with preoperative mental distress. Despite this, preoperative mental distress was associated with poorer physical improvements after surgery.

The Impact of Surgeon Variability on Patient-Reported Outcome Measures, Length of Stay, Discharge Disposition, and 90-Day Readmission in TKA

BACKGROUND

Studies involving total knee arthroplasty (TKA) have focused on patient-related factors as drivers of outcomes. Although some studies have investigated surgeon and/or surgery-level factors (i.e., approach, volume), the measure of variance in postoperative outcomes across surgeons following TKA has not been determined. The aim of the current study was to evaluate the relationship between the surgeon and 1-year patient-reported outcome measures, the length of stay, the discharge disposition, and 90-day readmission after TKA, as well as the differences in these variables among surgeons.

METHODS

Data were prospectively collected for 5,429 patients who underwent TKA at a large health-care system with 36 surgeons between 2016 and 2018. Likelihood ratio tests were performed to investigate the relationship between surgeon and the 1-year Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain subscale, KOOS-Physical Function Shortform (KOOS-PS), KOOS for Joint Replacement (KOOS-JR), patient acceptable symptom state (PASS), length of stay, discharge disposition, and 90-day readmission. The minimal clinically important difference (MCID) was used to assess meaningful outcomes. Variable importance was determined by the Akaike information criterion (AIC) increase, using ordinal and binary-response mixed-effect models.

RESULTS

There was a significant association between surgeon and KOOS-Pain (p < 0.001), KOOS-PS (p = 0.001), KOOS-JR (p < 0.001), PASS (p = 0.024), length of stay (p < 0.001), discharge disposition (p < 0.001), and 90-day readmission (p < 0.001). When modeling 1-year KOOS-Pain (AIC increase, 15.6), KOOS-PS (AIC increase, 6.8), KOOS-JR (AIC increase, 13.5), PASS (AIC increase, 1.9), length of stay, and discharge disposition, the surgeon variable contributed more to the 1-year outcome than some patient-level factors (e.g., body mass index, Charlson Comorbidity Index). The difference between the highest and lowest median probabilities of attaining the same value for the KOOS-Pain (11.2%), KOOS-PS (9.4%), KOOS-JR (11.8%), PASS (5.9%), length of stay (46.6%), discharge disposition (22.8%), and readmission (13.1%) indicated surgeon-level variability.

CONCLUSIONS

Surgeon-related factors may be stronger contributors to the 1-year patient-reported outcome measures and length of stay than patient characteristics emphasized in the literature. Current findings have suggested variability in patient-reported outcome measures, length of stay, discharge location, and 90-day readmission among surgeons. Surgeon variability should be considered when model-fitting in the setting of TKA.

LEVEL OF EVIDENCE

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

The Paradox of Patient-Reported Outcome Measures: Should We Prioritize "Feeling Better" or "Feeling Good" After Total Knee Arthroplasty?

BACKGROUND

The use of preoperative patient-reported outcome measure (PROM) thresholds for patient selection in arthroplasty care has been questioned recently. This study aimed to identify factors affecting achievement of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) after total knee arthroplasty (TKA) and determine the overlap between the two outcomes.

METHODS

We identified 1,239 primary, unilateral TKAs performed at a single institution in 2015-2019. PROMs including the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and 12-item Short Form Health Survey (SF-12) were collected preoperatively and 1-year postoperatively. The likelihood of attaining PASS as per attainment of MCID was assessed. A multivariable regression was used to identify predictors of MCID and PASS.

RESULTS

In total, 71.3% achieved MCID and 75.5% achieved PASS for KOOS-JR. Only 7.7% achieved MCID but not PASS, whereas almost twice this number did not achieve MCID but did achieve PASS (11.9%). Poorer preoperative KOOS-JR (OR 0.925), better SF-12 physical (OR 1.025), and mental (OR 1.027) were associated with MCID attainment. In contrast, better preoperative KOOS-JR (OR 1.030) and SF-12 mental (OR 1.025) were associated with PASS attainment. Age, gender, race, ethnicity, body mass index, Charlson index, American Society of Anesthesiologists classification, and smoking status were not significant predictors.

CONCLUSION

Preoperative PROMs were associated with achieving MCID and PASS after TKA, albeit some positively and some negatively. In the era of value-based care, clinicians should not only strive to help patients "feel better" but also ensure that patients "feel good" after surgery. This study does not support the use of PROMs in prioritizing access to care.

Preoperative Strength Training for Clinical Outcomes Before and After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Background

There is an increasing interest in preoperative strength training for promoting post-operative rehabilitation, but the effectiveness of preoperative strength training for clinical outcomes after total knee arthroplasty (TKA) remains controversial.

Objective

This study aims to systematically evaluate the effect of preoperative strength training on clinical outcomes before and after TKA.

Methods

We systematically searched PubMed, Cochrane Library, Web of Science, and EMBASE databases from the inception to November 17, 2021. The meta-analysis was performed to evaluate the effects of preoperative strength training on clinical outcomes before and after TKA.

Results

Seven randomized controlled trials (RCTs) were included (n = 306). Immediately before TKA, the pooled results showed significant improvements in pain, knee function, functional ability, stiffness, and physical function in the strength training group compared with the control group, but not in strength (quadriceps), ROM, and WOMAC (total). Compared with the control group, the results indicated strength training had a statistically significant improvement in post-operative knee function, ROM, and functional ability at less than 1 month and 3 months, and had a statistically significant improvement in post-operative strength (quadriceps), stiffness, and WOMAC (total) at 3 months, and had a statistically significant improvement in post-operative pain at 6 months. However, the results indicated strength training had no statistically significant improvement in post-operative strength (quadriceps) at less than 1 month, 6, and 12 months, had no statistically significant improvement in post-operative pain at less than 1 month, 3, and 12 months, had no statistically significant improvement in post-operative knee function at 6 and 12 months, and had no statistically significant improvement in post-operative physical function at 3 months.

Conclusions

Preoperative strength training may be beneficial to early rehabilitation after TKA, but the long-term efficacy needs to be further determined. At the same time, more caution should be exercised when interpreting the clinical efficacy of preoperative strength training for TKA.

Short-term functional outcome after fast-track primary total knee arthroplasty: analysis of 623 patients

Background and purpose - Early functional outcome after total knee arthroplasty (TKA) has been described before, but without focus on the presence of certain functional recovery patterns. We investigated patterns of functional recovery during the first 3 months after TKA and determined characteristics for non-responders in functional outcome.Patients and methods - All primary TKA in a fast-track setting with complete patient-reported outcome measures (PROMs) preoperatively, at 6 weeks, and 3 months postoperatively were included. Included PROMs were Oxford Knee Score (OKS), Knee disability and Osteoarthritis Outcome Score Physical Function Short-Form (KOOS-PS), and EuroQol 5 dimensions (EQ-5D) including the self-rated health Visual Analogue Scale (VAS). Patients with improvement on OKS less than the minimal clinically important difference (MCID) were determined as non-responders at that time point. Characteristics between groups of responders and non-responders in functional recovery were tested for differences: we defined 4 groups a priori, based on the responder status at each time point.Results - 623 patients were included. At 6 weeks OKS, KOOS-PS, and EQ-5D self-rated health VAS were statistically significant improved compared with preoperative scores. The mean improvement was clinically relevant at 6 weeks for KOOS-PS and at 3 months for OKS. Patient characteristics in non-responders were higher BMI and worse scores on EQ-5D items: mobility, self-care, usual activities, and anxiety/depression.Interpretation - Both statistically significant and clinically relevant functional improvement were found in most patients during the first 3 months after primary TKA. Presumed modifiable patient characteristics in non-responders on early functional outcome were BMI and anxiety/depression.

Digital Disparities: Lessons learned from a Patient Reported Outcomes Program During the COVID-19 Pandemic

The collection of patient reported outcomes (PROs) allows us to incorporate the patient's voice within their care in a quantifiable, validated manner. Large scale collection of PROs is facilitated by the electronic health record (EHR) and its portal, though historically patients have eschewed the portal and completed patient reported outcome measures (PROMS) in clinic via tablet. Furthermore, access to and use of the portal is associated with known racial inequities. Our institution oversees the largest clinical PRO program in the world, and has a long history of racially equitable PRO completion rates via tablet. However, when the COVID-19 pandemic forced us to remove tablets from clinics and rely exclusively on portal use for PRO completion, profound racial disparities resulted immediately. Our experience quantifiably demonstrates the magnitude of inequity that the portal, in its current configuration, generates and serves as a cautionary tale to other health care systems and EHRs.