Change in pain and function while waiting for major joint arthroplasty

Postponement of total knee arthroplasties due to pandemic causes significant deterioration on patients' preoperative knee and quality of life scores

Introduction

Elective surgeries were postponed during the COVID-19 pandemic to alleviate healthcare strains, affecting majority of elective orthopaedic surgeries such as total knee arthroplasties (TKAs). The aim of this study is to evaluate the impact on knee function and quality of life of patients who had their planned TKA postponed due to the pandemic.

Methods

This is a retrospective analysis of data collected in a tertiary hospital. Patients included were diagnosed with primary knee osteoarthritis and they were initially scheduled for primary TKA between January to April 2020 but surgery was postponed by at least 6 months from the initial operative date. 160 patients were included in this study (53 males and 107 females, mean age 68.0 ± 8.1). Patients were assessed prior to initial surgery date and assessed again, prior to the postponed surgery date. Clinical scores included Knee Society Function Score (KSFS), Knee Society Knee Score (KSKS), Oxford Knee scores (OKS) and Short-Form 36 Physical and Mental Component Scores. (SF36 PCS and MCS). Paired T-test was performed for parametric data whereas Wilcoxon signed-rank analysis was performed for non-parametric data.

Results

Comparing initial preoperative versus postponement preoperative scores, the cohort had significantly poorer KSKS (38.4 ± 15.4 and 36.5 ± 15.4, p = 0.034), SF36 PCS (34.3 ± 9.2 and 32.7 ± 8.6, p = 0.02) and OKS (34.9 ± 0.77 and 35.8 ± 8.6, p = 0.02) scores respectively.

Conclusion

The postponement of elective TKAs has resulted in a significant deterioration of knee scores and physical quality of live scores of patients in a short span of 6 months. Further studies can evaluate if there are repercussions on long term TKAs outcomes.

Level of evidence

Retrospective study, Level III.

The functional and psychological impact of delayed hip and knee arthroplasty: a systematic review and meta-analysis of 89,996 patients

This systematic review and meta-analysis aimed to determine the impact of presurgical waiting times on pre-/post-operative joint specific pain and function, health-related quality of life (HRQOL) and perspectives of patients awaiting primary elective total hip (THR) and knee (TKR) replacements. MEDLINE, EMBASE, PUBMED, and CENTRAL databases were searched from inception until 30th January 2023 (CRD42022288128). Secondary literature and unpublished datasets containing paediatric, non-elective, partial, or revision replacement populations were excluded. PRISMA 2020 reporting and GRADE certainty of evidence guidelines were followed. Residual maximum likelihood meta-analysis and linear meta-regression was performed to elucidate the influence of presurgical waiting time. Twenty-six studies were eligible for systematic review and sixteen for meta-analysis, capturing 89,996 patients (60.6% female, mean age 67.4 years) between 2001 and 2022. A significant deterioration in joint function (mean difference (MD):0.0575%; 95% CI 0.0064, 0.1086; p = 0.028(4d.p.); I2 = 73.1%) and HRQOL (MD: 0.05%; 95% CI - 0.0001.0009; p = 0.011(4 d.p.); I2 = 80.6%) was identified per additional day of waiting. Despite qualitative evidence, meta-analysis could not observe a relationship with postoperative outcome data. Patient responses to delayed THR and TKR surgery were unanimously negative. Immediate action should seek to reduce the increased patient anxiety and significant reductions in pre-operative joint functionality and HRQOL associated with prolonged pre-surgical waiting time, whilst mitigating any potential deleterious post-operative effects.

Quantifying Patient-Reported Disability and Health While Waiting for Bunion Surgery

BACKGROUND

Many patients with hallux valgus progress to experiencing pain and loss of function that requires corrective surgery when nonoperative treatments fail. The primary goal of this study was to measure changes in participants' health while patients waited for their operative correction.

METHODS

Patients were prospectively recruited to complete a number of patient-reported outcome measures preoperatively. Baseline data collection was initiated in October 2014, and participants' second surveys were returned by August 2017. The setting of the study was Vancouver, Canada. There were 80 participants in the study. The participation rate among eligible patients was 52.7%.

RESULTS

The average wait time for surgery exceeded 8 months, with a mean wait of 35.7 weeks. Baseline pain among participants was high. Only in the domain of foot- and ankle-related quality of life was the duration of wait time associated with participants' change in health. The other 4 domains of foot function remained stable over the preoperative period.

CONCLUSION

Preoperative health in this study was consistent with other research showing high pain and compromised foot function among patients failing nonoperative therapies for treatment of hallux valgus. This study found high pain and compromised foot function among patients waiting for hallux valgus surgery but only minor relationships between participants' duration of wait time for operative correction of the first metatarsophalangeal joint and changes in patient-reported outcome scores.

LEVEL OF EVIDENCE

Level III, comparative study.

What is the current evidence of the impact on quality of life whilst waiting for management/treatment of orthopaedic/musculoskeletal complaints? A systematic scoping review

PURPOSE

To describe quality of life (QoL) outcome measures that are reported in the literature in patients waiting for outpatient orthopaedic/musculoskeletal specialist care and how waiting impacts on QoL in these terms.

METHODS

A subset of studies reporting on QoL outcome measures were extracted from literature identified in a recent scoping search of Medline, Embase, Pubmed, NHS Economic Evaluation Database (Prospero registration CRD42016047332). The systematic scoping search examined impacts on patients waiting for orthopaedic specialist care. Two independent reviewers ranked study design using the National Health and Medical Research Council aetiology evidence hierarchy, and appraised study quality using Critical Appraisal Skills Programme tools. QoL measures were mapped against waiting period timepoints.

RESULTS

The scoping search yielded 142 articles, of which 18 reported on impact on QoL. These studies reported only on patients waiting for hip and/or knee replacement surgery. The most recent study reported on data collected in 2006/7. The Western Ontario and McMaster Universities Arthritis Index and the SF-36 were the most commonly reported QoL measures. QoL was measured at variable timepoints in the waiting period (from a few weeks to greater than 12 months). The impact of waiting on QoL was inconsistent.

CONCLUSION

The evidence base was over 10 years old, reported only on patients with hip and knee problems, and on limited QoL outcome measures, and with inconsistent findings. A better understanding of the impact on QoL for patients waiting for specialist care could be gained by using standard timepoints in the waiting period, patients with other orthopaedic conditions, comprehensive QoL measures, as well as expectations, choices and perspectives of patients waiting for specialist care.

COST-UTILITY ANALYSIS OF PRIVATE CONTRACTING TO REDUCE PUBLIC WAITING TIMES FOR JOINT REPLACEMENT SURGERY

OBJECTIVES

Earlier treatment of publicly funded patients may achieve health gains that justify the additional costs of reducing waiting times. This study reports on the cost-effectiveness of implementing a private contracting model to meet alternative maximum waiting time targets for publicly funded patients undergoing total knee replacement surgery in Australia.

METHODS

A linked decision tree and cohort Markov model was developed and populated and validated using secondary data sources to represent the pathways, costs, and quality adjusted life-years (QALYs) gained of non-urgent patients with alternative waiting times for total knee replacement surgery to a maximum age of 100 years.

RESULTS

Assuming public waiting times are reduced through the purchase of private services, additional QALYs are gained at an incremental cost of less than $40,000. Value could be increased if lower private prices could be negotiated. Results are also sensitive to the rate of deterioration in function while waiting for surgery and the impact of functional status at the time of surgery on postsurgery outcomes.

CONCLUSIONS

More evidence on the value of expanded capacity or new models of care may inform new funding models to support such investments and reduced prices for new technologies, leading to more efficient and sustainable publicly funded healthcare systems.

Determinants of pain, disability, health-related quality of life and physical performance in patients with knee osteoarthritis awaiting total joint arthroplasty

PURPOSE

In patients suffering from knee osteoarthritis awaiting knee arthroplasty, to measure associations between several selected determinants and pain, disability, health-related quality of life and physical performance.

MATERIAL AND METHODS

Validated self-reported measures were collected: (1) Western Ontario and McMaster Universities Osteoarthritis Index, (2) Lower Extremity Functional Scale (LEFS) and (3) Short-Form 36 (SF-36). Physical performance was also assessed with four validated performance tests. Demographic, socioeconomic, psychosocial and clinical characteristics of the participants were also measured. Multivariate regression analyses were used to evaluate potential associations.

RESULTS

Higher fear-avoidance beliefs, greater comorbidities, psychological distress and use of a walking aid were significantly associated with worse pain, function or HRQOL (p < 0.05) and explained 12%-35% of the variances of the self-reported measure scores. Pretest pain and change in pain during posttest, greater comorbidities, psychological distress and use of a walking aid were significantly associated with worse performance on the physical tests (p < 0.05) and explained 41%-59% of the variances of the different physical tests results.

CONCLUSIONS

Several determinants were significantly associated with worse pain, disability, health-related quality of life or physical performance. Several of these associations may be considered clinically important, including psychosocial determinants in relation to self-reported measures, but to physical performance as well. Implications for rehabilitation Knee osteoarthritis is a highly prevalent and disabling condition incurring important socioeconomic costs. Several modifiable determinants have been shown to contribute to pain and disability in individuals suffering from knee OA awaiting TKA. Recent studies demonstrated the efficacy of education and rehabilitation (prehabilitation) in individuals awaiting TKA.

The Impact of Waiting Time on Health Gains from Surgery: Evidence from a National Patient-reported Outcome Dataset

Reducing waiting times has been a major focus of the English National Health Service for many years, but little is known about the impact on health outcomes. The collection of data on patient-reported outcome measures for all patients undergoing four large-volume procedures facilitates analysis of the impact of waiting times on patient outcomes. The availability of patient-reported outcome measures before and after surgery allows us to estimate the impact of waiting times on the effectiveness of treatment, controlling for pre-surgery health and the endogeneity of waiting times caused by prioritisation with respect to pre-intervention health. We find that waiting time has a negative and statistically significant impact on the health gain from hip and knee replacement surgery and no impact on the effectiveness of varicose vein and hernia surgery. The magnitude of this effect at patient level is small, 0.1% of the outcome measure range for each additional week of waiting. However, the value of this effect is substantially larger than existing estimates of the disutility experienced during the waiting period. The health losses associated with an additional week of waiting for annual populations of hip and knee replacement patients are worth £11.1m and £11.5m, respectively. Copyright © 2015 John Wiley & Sons, Ltd.

Functional Impairment Is a Risk Factor for Knee Replacement in the Multicenter Osteoarthritis Study

BACKGROUND

Debilitating pain associated with knee osteoarthritis (OA) often leads patients to seek and complete total knee arthroplasty (TKA). To date, few studies have evaluated the relation of functional impairment to the risk of TKA, despite the fact that OA is associated with functional impairment.

QUESTIONS/PURPOSES

The purpose of our study was to (1) evaluate whether function as measured by WOMAC physical function subscale was associated with undergoing TKA; and (2) whether any such association varied by sex.

METHODS

The National Institutes of Health-funded Multicenter Osteoarthritis Study (MOST) is an observational cohort study of persons aged 50 to 79 years with or at high risk of symptomatic knee OA who were recruited from the community. All eligible subjects with complete data were included in this analysis. Our study population sample consisted of 2946 patients with 5796 knees; 1776 (60%) of patients were women. We performed a repeated-measures analysis using baseline WOMAC physical function score to predict the risk of TKA from baseline to 30 months and WOMAC score at 30 months to predict risk of incident TKA from 30 months to 60 months. We used generalized estimating equations to account for the correlation between two knees within an individual and across the two periods. We calculated relative risk (RR) of TKA over 30 months by WOMAC function using a score of 0 to 5 as the referent in multiple binomial regressions with log link.

RESULTS

Those with the greatest functional impairment (WOMAC scores 40-68; 62 TKAs in 462 knee periods) had 15.5 times (95% confidence interval [CI], 7.6-31.8; p<0.001) the risk of undergoing TKA over 30 months compared with the referent group (12 TKAs in 3604 knee periods), adjusting for basic covariates, and 5.9 times (95% CI, 2.8-12.5; p<0.001) the risk after further adjusting for knee pain severity. At every level of functional limitation, the RR for TKA for women was higher than for men, but interaction with sex did not reach significance after adjustment for covariates including ipsilateral pain (p=0.138).

CONCLUSIONS

Baseline physical function appears to be an important element in patients considering TKA. Future studies should examine whether interventions to improve function can reduce the need for TKA.

LEVEL OF EVIDENCE

Level III, observational cohort study.

Determinants of pain, functional limitations and health-related quality of life six months after total knee arthroplasty: results from a prospective cohort study

Background

Total knee arthroplasty (TKA) is an effective procedure. However, for some patients, the outcomes are not satisfactory. Identification of TKA determinants could help manage these patients more efficiently. The purpose of this study was to identify pre- and perioperative determinants of pain, functional limitations and health-related quality of life (HRQoL) 6 months after TKA.

Methods

138 participants were recruited from 3 hospitals in Quebec City, Canada and followed up until 6 months after surgery. Data were collected through review of the subjects’ medical files and structured telephone interviews before and 6 months after TKA. Pain and functional limitations were measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and HRQoL was measured with the SF-36 Health Survey. Independent variables included demographic, socioeconomic, psychosocial, clinical and surgical characteristics of participants as well as data on health services utilization. Stepwise multiple regression analysis was used to assess the strength of the associations between the independent variables and the WOMAC and SF-36 scores.

Results

Higher preoperative pain, cruciate retaining implants and the number of complications were significantly associated with worse pain 6 months after TKA (p < 0.05) and explained 11% of the variance of the WOMAC pain score. Higher preoperative functional limitations, being single, separated, divorced or widowed, being unemployed or retired and the number of complications were significantly associated (p < 0.05) with worse functional limitations 6 months after TKA and explained 16% of the variance of the WOMAC function score. Lower preoperative HRQoL, contralateral knee pain, higher psychological distress and comorbidities were significantly associated (p < 0.05) with worse HRQoL 6 months after TKA and explained 23% of the variance of the SF-36 physical functioning score.

Conclusions

Several variables were found to be significantly associated with worse outcomes 6 months after TKA and may help identify patients at risk of poorer outcome. The identification of these determinants could help manage patients more efficiently and may help target patients who may benefit from extensive rehabilitation.

Electronic medical records for appropriate timing of arthroplasty

OBJECTIVE

The objective of this study was to analyse whether electronic medical records (EMRs) of total hip and knee arthroplasty can be used to manage the optimal time of surgery.

DESIGN

Retrospective registry study.

SETTING

Data on waiting time for operation, age, gender, body mass index (BMI), operable condition pre-operatively and the functional scores at 3 and 12 months after arthroplasty were obtained from EMRs and from an electronic implant database.

PARTICIPANTS

The participants of the study were 162 arthroplasty patients.

RESULTS

An increase in waiting time of hip patients decreased significantly the change in functional scores at 3 months (P = 0.006, n = 56). The score reductions of older patients were more marked than of younger patients and of patients of normal weight compared with overweight patients. In patients undergoing knee arthroplasty, the association between a longer waiting time and profound change in functional score was statistically significant after 1 year (P = 0.03, n = 75). After adjustment of the results for pre-operative scores, age group, BMI class, American Society of Anesthesiologists class and gender, the waiting time turned out to affect only the scores of patients undergoing hip arthroplasty at 3 months post-operatively.

CONCLUSIONS

Data from electronic patient entries complemented with data of the operable condition can be used for defining the optimal operation time with regard to the pre-operative condition of the patients. The implication of prolonged waiting times was not very profound, but elderly patients benefit from a short waiting time.

Evaluation of health-related quality of life in patients candidate for spine and other musculoskeletal surgery

INTRODUCTION

Despite the high prevalence of musculoskeletal diseases, in Spain there are few data about how these conditions affect the quality of life of individuals. The objective of this study was to assess the quality of life (QOL) of patients candidate for orthopedic surgical treatment using an age-gender adjusted method of QOL scores.

MATERIALS AND METHODS

The SF-36 Health Survey was administered to 538 patients candidate for surgery between surgical treatment was classified in four groups (lumbar disease, cervical disease, knee arthroplasty, and hip arthroplasty). Associated morbidities were collected retrospectively for all cases using the Charlson co-morbidity index. Univariate, bivariate, and multivariate statistical analyses were done to compare the four groups to each other, to the general population mean, and to the age and gender-adjusted population mean.

RESULTS

234 men and 304 women whose mean age was 58.78 years (19-89) were assessed. Patients candidate for some kind or lumbar surgery had the worst scores in all physical and mental scales as compared to the other disease groups. Patients candidate for knee arthroplasty, had the best quality of life scores in all scales, compared to the other disease groups. Medical conditions had no influence over the summary measures.

CONCLUSION

Presenting the results of SF-36 in standard deviations from the age- and gender-adjusted population mean (T values) leads to a better appreciation of the differences between the various diseases. Patients candidate for surgery of the lumbar spine had a worse QOL, while the QOL in patients candidate for knee arthroplasty was the least affected.

ANALYSIS ON QUALITY OF LIFE OF PATIENTS WITH OSTEOARTHROSIS UNDERGOING TOTAL HIP ARTHROPLASTY

OBJECTIVE

The aim of the study was to evaluate the health-related quality of life among patients affected by hip osteoarthrosis who were treated by means of total hip arthroplasty.

METHODS

A cohort of 38 patients operated by a single surgeon in a regional referential teaching hospital during the year 2010 was prospectively studied and followed up for at least six months until they had achieved satisfactory rehabilitation. Each patient gave responses to the SF-36 form immediately before the operation and six months later and the Harris Hip Score was obtained at the same time. The pre and postoperative results were analyzed and compared with the literature.

RESULTS

The pre and postoperative SF-36 results were as follows: physical function: 13.4-53.7; role physical: 9.21-48.0; body pain: 23.1-62.6; general health: 54.2-71.3; vitality: 40.3-69.9; social function: 40.8-74.3; role emotional: 23.7-64.9; and mental health: 52.6-80.4. The Harris Hip Score went from 36.1 to 92.1, on average. All the results were statistically significant (p < 0.001).

CONCLUSIONS

The combination of two scales was shown to be valuable in identifying bias and gave greater reliability for understanding the different variables. The study showed that there was a significant improvement in health-related quality of life among patients affected by osteoarthrosis of different etiologies who underwent total hip arthroplasty. Health-related quality of life evaluations cannot replace clinical evaluations provided by specific instruments and physicians' experience but can add important data through giving value to patients' sets of expectations regarding medical treatment. Moreover, such evaluations can be considered to be an efficient tool for analyzing the outcomes from total hip arthroplasty.

The effect of waiting times from general practitioner referral to MRI or orthopaedic consultation for the knee on patient-based outcomes

OBJECTIVES

The purpose of this study was to test for the effect of waiting time from general practitioner (GP) referral to MRI or to orthopaedic consultation on outcomes of patients with knee problems, and to test whether any characteristics of trial participants predicted waiting time to MRI or orthopaedics.

METHODS

We undertook secondary analyses of data on 553 participants from a randomised trial who were recruited from 163 general practices during November 2002 to October 2004.

RESULTS

Of the patients allocated to MRI, 263 (94%) had an MRI, and of those referred to orthopaedics, 236 (86%) had an orthopaedic consultation. The median (interquartile range) waiting time in days from randomisation to MRI was 41.0 (21.0-71.0) and to orthopaedic appointment was 78.5 (54.5-167.5). Waiting time was found to have no significant effect on patient outcome for both the Short Form 36-item (SF-36) physical functioning score (p=0.570) and the Knee Quality of Life 26-item (KQoL-26) physical functioning score (p=0.268). There was weak evidence that males waited less time for their MRI (p=0.049) and older patients waited longer for their orthopaedic referral (p=0.049). For patients who resided in the catchment areas of some centres there were significantly longer waiting times for both MRI and orthopaedic appointment.

CONCLUSION

Where patients reside is a strong predictor of waiting time for access to services such as MRI or orthopaedics. There is no evidence to suggest, however, that this has a significant effect on physical well-being in the short term for patients with knee problems.

The impacts of pre-surgery wait for total knee replacement on pain, function and health-related quality of life six months after surgery

OBJECTIVE

The purpose of the current study was to assess, in patients scheduled for primary total knee replacement (TKR), the effects of pre-surgery waiting time on pain and functional limitations related to the knee joint undergoing surgery, on health-related quality of life (HRQoL) and on contralateral knee pain 6 months after surgery.

METHOD

A total of 141 patients scheduled for TKR were recruited from three hospitals in Quebec City, Canada, and followed up until 6 months after surgery. Pre-surgery wait, defined as the time between enrolment on the pre-surgery waiting list and surgery, was considered in four categories (≤3, >3-6, >6-9, >9 months). Pain and functional limitations were measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC). HRQoL was measured with the SF-36.

RESULTS

Mean pre-surgery waiting time was 184 (SD: 120.8) days. Six months after TKR, a significant difference was seen between the four groups of pre-surgery wait in terms of HRQoL SF-36 role physical [F(3, 136) = 2.74, P = 0.046] and contralateral knee WOMAC pain [F(3, 136) = 5.78, P = 0.0009] scores. Participants with the longest pre-surgery wait (>9 months) showed the worst scores 6 months after TKR.

CONCLUSIONS

Longer pre-surgery waiting time had a negative clinically important impact on HRQoL and contralateral knee pain 6 months after surgery.

Decline in Health-Related Quality of Life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study

Background

In many healthcare systems, people with severe joint disease wait months to years for joint replacement surgery. There are little empirical data on the health consequences of this delay and it is unclear whether people with substantial morbidity at entry to the waiting list continue to deteriorate further while awaiting surgery. This study investigated changes in Health-Related Quality of Life (HRQoL), health status and psychological distress among people waiting for total hip (THR) and knee replacement (TKR) surgery at a major metropolitan Australian public hospital.

Methods

134 patients completed questionnaires including the Assessment of Quality of Life (AQoL) instrument, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Kessler Psychological Distress Scale after entering an orthopaedic waiting list (baseline) and before surgery (preadmission). To quantify potential decline in wellbeing, we calculated the proportion of people experiencing clinically important deterioration using published guidelines and compared HRQoL and psychological distress outcomes with population norms.

Results

Most participants (69%) waited ≥6 months for surgery (median 286 days, IQR 169-375 days). Despite poor physical and psychological wellbeing at baseline, there was an overall deterioration in HRQoL during the waiting period (mean AQoL change -0.04, 95%CI -0.08 to -0.01), with 53% of participants experiencing decline in HRQoL (≥0.04 AQoL units). HRQoL prior to surgery remained substantially lower than Australian population norms (mean sample AQoL 0.37, 95%CI 0.33 to 0.42 vs mean population AQoL 0.83, 95%CI 0.82 to 0.84). Twenty-five per cent of participants showed decline in health status (≥9.6 WOMAC units) over the waiting period and prevalence of high psychological distress remained high at preadmission (RR 3.5, 95%CI 2.8 to 4.5). Most participants considered their pain (84%), fatigue (76%), quality of life (73%) and confidence in managing their health (55%) had worsened while waiting for surgery.

Conclusions

Despite substantial initial morbidity, over half of the participants awaiting joint replacement experienced deterioration in HRQoL during the waiting period. These data provide much-needed evidence to guide health professionals and policymakers in the design of care pathways and resource allocation for people who require joint replacement surgery.

Psychometric properties of the Brief Pain Inventory among patients with osteoarthritis undergoing total hip replacement surgery

Background

Pain is a cardinal symptom of osteoarthritis (OA) of the hip and important for deciding when to operate. This study assessed the internal consistency reliability, validity and responsiveness of the Brief Pain Inventory (BPI) among patients with OA undergoing total hip replacement (THR).

Methods

We prospectively included 250 of 356 patients who were accepted to the waiting list for primary THR surgery. All participants responded to the BPI, WOMAC and SF-36 at baseline and 1 year after surgery.

Results

Internal consistency reliability (Cronbach's α) was >0.80 for the BPI, the WOMAC and five of the eight SF-36 scales The pattern of associations of the two BPI scales with corresponding and non-corresponding scales of the WOMAC and SF-36 largely supported the construct validity of the BPI. The responsiveness indices for change from baseline to 1 year after THR ranged from 1.52 to 2.05 for the BPI scales, from 1.69 to 2.84 for the WOMAC scales, and from 0.25 (general health) to 2.77 (bodily pain) for the SF-36 scales.

Conclusions

The BPI showed acceptable reliability, construct validity and responsiveness in patients with OA undergoing THR. BPI is short and therefore is easy to use and score, though the instrument offers few advantages over and duplicates scales of more comprehensive instruments, such as the WOMAC and SF-36.

Is longer waiting time for total knee replacement associated with health outcomes and medication costs? Randomized clinical trial

BACKGROUND

The aim of this prospective randomized study was to evaluate the effect of waiting time (WT) on health-related quality of life (HRQoL), knee pain and physical function, and the use and costs of medication of patients awaiting total knee replacement.

METHODS

When placed on the waiting list, 438 patients were randomized into a short waiting time (SWT ≤ 3 months) or a nonfixed waiting time (NFWT > 3 months) group. HRQoL was measured by the 15D, and pain and physical function by modified Knee Society Clinical Rating System at baseline, admission, and 3 and 12 months postoperatively. The costs of medication due to osteoarthritis were calculated at the same measurement points. All analyses were performed using the intention-to-treat principle.

RESULTS

The mean WT was 94 and 239 days in the SWT and NFWT groups, respectively. Apart from higher weekly cost of medication in the SWT group at admission and better HRQoL in the NFWT group 1 year postoperatively, there were no statistically significant differences between the groups in other outcomes during the follow-up.

CONCLUSION

Those in the SWT group had higher weekly costs of medication at admission, and reached better HRQoL 3 months earlier than those in the NFWT group, but the latter had better HRQoL after operation. Otherwise, the length of WT was not associated with different health and HRQoL outcomes in the groups.

Osteoarthritis in Women: Effects of Estrogen, Obesity and Physical Activity

Arthritis is the leading cause of physical disability in the USA and osteoarthritis (OA), the most common form, affects nearly 27 million people. Women have a higher prevalence of OA than men, but the underlying causes for the increased susceptibility of women to OA are not fully understood. This review discusses the associations of sex hormones, obesity and physical activity with the incidence and progression of OA in women. Although many studies have explored the relationships of estrogen and reproductive history with the risk of OA or joint replacement, there is no consensus on the role of these factors. Obesity clearly increases risk for OA, but whether obesity affects women and men differently is uncertain. Moderate levels of physical activity do not appear to increase the incidence or progression of OA and may even have a weak protective effect. Future investigations should focus on sex-specific mechanisms for the development of OA and determine whether there are modifiable factors (e.g., estrogen, obesity, physical activity) that can be targeted through prevention and treatment strategies to mitigate the increased incidence and prevalence of OA in women.

The impact of waiting for total joint replacement on pain and functional status: a systematic review

OBJECTIVE

To systematically describe changes in pain and functioning in patients with osteoarthritis (OA) awaiting total joint replacement (TJR), and to assess determinants of this change.

METHODS

MEDLINE, EMBASE, CINAHL and Cochrane Database were searched through June 2008. The reference lists of eligible publications were reviewed. Studies that monitored pain and functioning in patients with hip or knee OA during the waiting list for TJR were analyzed. Data were collected with a pre-specified collection tool. Methodological quality was assessed and a best-evidence analysis was performed to summarize results.

RESULTS

Fifteen studies, of which two were of high quality, were included and involved 788 hip and 858 knee patients (mean age 59-72 and main wait 42-399 days). There was strong evidence that pain (in hip and knee OA) and self-reported functioning (in hip OA) do not deteriorate during a <180 days wait. Conflicting evidence was established for the change on self-reported functioning in patients with knee OA waiting <180 days. Moreover, strong evidence was found for an association between the female gender and intensified pain.

CONCLUSION

Patients with OA do not experience deterioration in pain or self-reported functional status whilst waiting <180 days for TJR. Changes over a longer waiting period are unclear. To strengthen and complement the present evidence, further high-quality studies are needed, in which preferably also performance-based measures are used.

Predictors of health-related quality-of-life change after total hip arthroplasty

Various parameters have been considered as possible predictors of health-related quality-of-life outcomes after THA in patients with hip osteoarthritis. We hypothesized the preintervention health status is the main and more homogeneous predictor of changes of the different aspects of health-related quality-of-life outcomes, mental health status has an important influence on results, whereas other sociodemographic or clinical factors had only a punctual influence. All patients who fulfilled the selection criteria completed the Medical Outcomes Study SF-36 and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before and 6 months after the intervention. Seven hundred eighty-eight patients completed the questionnaire before the intervention and 590 completed it (74.9%) at 6 months. The preintervention score in each SF-36 and WOMAC domain and the SF-36 mental health domain predicted changes after the intervention. Female gender, having comorbidities, contralateral hip osteoarthritis, or back pain predicted less improvement on some SF-36 domains. Older age, the presence of contralateral hip osteoarthritis, or back pain predicted less improvement on some of the WOMAC domains. Preintervention health status, measured by the WOMAC or SF-36, and mental health status uniformly predicted health-related quality-of-life changes, whereas some clinical parameters predicted some domains. SF-36 and WOMAC seem to be appropriate tools for predicting THA outcomes.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

The effect of waiting time on health and quality of life outcomes and costs of medication in hip replacement patients: a randomized clinical trial

OBJECTIVE

To evaluate the effect of waiting time on health and quality of life outcomes and costs of medication in total hip replacement (THR) patients in a randomized clinical trial.

METHODS

395 THR patients were recruited into the study. When placed on the waiting list, patients were randomized into a short (< or =3 months) or a non-fixed waiting time (NFWT) (>3 months) group. In the final analyses 309 patients (179 women) with a mean age of 65 years were included. Health-related quality of life (HRQoL) (generic 15D), and pain and function (modified Harris Hip Score (HHS)) were calculated when placed on the waiting list, at hospital admission, and at 3 and 12 months postoperatively. The costs of disease-specific medication were calculated at the same measurement points. All analyses were performed using the intention-to-treat (ITT) principal.

RESULTS

Of the recruited patients, 309 (78%) completed the follow-up (short group 140 and non-fixed group 169 patients). The mean waiting time was 74 days in the short and 194 days in the NFWT groups. In the ITT analyses there were no statistically significant differences between the groups in the weekly use and costs of medication, HRQoL or HHS at baseline, at admission, or 3 or 12 months after surgery. The only difference was in total medication costs during the waiting time period, at EUR 83 and 171, respectively.

CONCLUSIONS

The length of the waiting time did not generate different effects on the studied health and quality of life outcomes of the randomized groups. However, those in short waiting time group reached earlier better HRQoL.

The effect of waiting time on health-related quality of life, pain, and physical function in patients awaiting primary total hip replacement: a randomized controlled trial

OBJECTIVE

This prospective randomized study assessed the effect of waiting time (WT) on health outcomes in Finnish patients admitted to hospital for primary total hip replacement (THR).

METHODS

A total of 395 consecutive patients with a need for a primary THR because of osteoarthritis and who were placed on the waiting list between August 2002 and November 2003. After placement on the waiting list, the patients were randomly assigned to a short WT (<or=3 months) group (n = 174) or a nonfixed WT group (n = 221). The patients completed self-administered questionnaires at the time of placing on the waiting list and at hospital admission. Health-related quality of life was measured by the generic 15D instrument. Hip pain and function were measured by the patient self-report Harris hip score (HHS).

RESULTS

Of the 395 patients, 312 (79%) completed the follow-up (140 patients with short and 172 with nonfixed WT). At admission, the mean 15D scores for patients with short and nonfixed WT were 0.784 and 0.783, respectively. In the intention-to-treatment analysis, the difference between the groups (Delta 0.001, 95% confidence interval [CI]: -0.019 to 0.021) was not statistically significant or clinically important. The mean self-report HHS in patients with short WT was 43.5, and among those with nonfixed WT was 41.9. The difference (Delta 1.6, 95% CI: -1.77 to 4.87) was not statistically significant.

CONCLUSIONS

Both generic and disease-specific measures revealed that longer WTs did not result in poorer health status at admission.

Waiting for total knee replacement surgery: factors associated with pain, stiffness, function and quality of life

Background

Recent evidences show that education and rehabilitation while waiting for knee replacement have positive effects on the patients' health status. Identification of factors associated with worse pain, function and health-related quality of life (HRQoL) while waiting for surgery could help develop pre-surgery rehabilitation interventions that target specifically these factors and prioritize patients that may benefit the most from them. The objectives of this study were to measure pain, stiffness, function and HRQoL in patients at enrolment on waiting lists for knee replacement and to identify demographic, clinical, socioeconomic and psychosocial characteristics associated with these outcomes.

Methods

This study is part of a broader study measuring the effects of pre-surgery wait in patients scheduled for knee replacement. From 02/2006 to 09/2007, 197 patients newly scheduled for total knee replacement were recruited from the waiting lists of three university hospitals in Quebec City, Canada. Pain, stiffness and function were measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and HRQoL was measured with the SF-36 Health Survey. Stepwise multiple regression analysis was used to assess the strength of the associations between the independent variables and the WOMAC and SF-36 scores.

Results

The scores of all eight HRQoL physical and mental domains of the SF-36 were significantly lower than aged matched Canadian normative data (p < 0.05). Contralateral knee pain, higher psychological distress, higher body mass index (BMI) and the use of a walking aid were significantly associated with worse function (p < 0.05) and contributed to 22% of the variance of the WOMAC function score (multiple r = 0.47). A higher BMI, the use of a walking aid, contralateral knee pain and advanced age were significantly associated with worse physical function (p < 0.05) and contributed to 17% of the variance of the SF-36 HRQoL physical functioning score (multiple r = 0.41).

Conclusion

Patients waiting for knee replacement have poor function and HRQoL. Characteristics that were found to be associated with these outcomes could help develop pre-surgery rehabilitation program and prioritize patients that may benefit the most from them. Such programs could include interventions to reduce psychological distress, therapeutic exercises targeting both knees and weight loss management.

Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty

OBJECTIVE

To examine the effect of pre-operative physiotherapy before hip arthroplasty in patients with end-stage hip osteoarthritis.

DESIGN

A prospective randomized controlled study.

SETTING

Physical medicine and rehabilitation and orthopaedic departments of Policlinico Gemelli of Rome.

SUBJECTS

Twenty-three patients randomized in study and control groups.

INTERVENTION

The study group took part in an educational and physiotherapy programme one month before surgery. Both groups took part in the same inpatient rehabilitation programme after surgery.

MAIN OUTCOME MEASURES

Both groups were evaluated one month (T0) and the day before arthroplasty (T1), after 15 days (T2), four weeks (T3) and three months (T4) post surgery, using the Barthel Index, the Short Form-36 (SF-36), the Western Ontario and McMaster Osteoarthritis Index (WOMAC), the Hip Harris Score (HHS), visual analogue scale (VAS), the British Medical Research Council (BMRC) measures of hip abductor and quadriceps strength and range of hip abduction and external rotation.

RESULTS

There were no significant differences between groups with regard to the Barthel Index, SF-36, WOMAC and HHS at T4. The study group presented significant improvements of the SF-36 physical composite score at T1. The hip external rotation was significantly higher in the study group at each evaluation and the visual analogue scale values were lower at T1, T3 and T4.

CONCLUSION

Pre-operative physiotherapy in patients undergoing hip arthroplasty does not improve impairment and health-related quality of life after intervention. Physiotherapy and educational therapy may be useful for end-stage osteoarthritis.

The Manitoba arthroplasty waiting list: impact on health-related quality of life and initiatives to remedy the problem

RATIONALE

With the aging population, arthritis of the hip and knee is increasing exponentially. While total joint replacement of the hip and knee have been proven to provide excellent outcomes for this debilitating clinical entity, the demand in Canada has grown to such an extent that there are thousands of people suffering on wait lists across the country. There have been numerous recent studies focusing on the effects that waiting have on patient post-operative subjective and objective clinical outcomes.

AIMS AND OBJECTIVES

This commentary attempts to provide a review of the relevant data on the impact that waiting has on the health related quality of life of these patients. Additionally, the hip and knee arthroplasty wait list in Manitoba is illustrated to provide an example of interventions that have helped to combat a potential crisis situation in the province.

METHODS

The literature on the impact of waiting times on health-related quality of life in hip and knee arthroplasty patients is reviewed. The example of the Manitoba arthroplasty waiting list is then provided to illustrate potential measures that can be implemented to decrease waiting times.

RESULTS

The literature shows that health-related quality of life declines as patients wait for surgery. The interventions that the province of Manitoba has implemented in the last seven years seem to be reducing waiting times and the number of patients on the waiting list.

CONCLUSIONS

The framework used in Manitoba may serve as an example for other provinces and potentially countries that find themselves faced with the same problem. However, more measures are required to build on the positive results encountered with these initial successes.

Quality of life evaluation in patients affected by osteoarthritis secondary to congenital hip dysplasia after total hip replacement

BACKGROUND

The aim of the study was to evaluate the quality of life (QoL) in patients affected by osteoarthritis (OA) secondary to congenital hip dysplasia (CHD) and treated by hip arthroplasty.

METHODS

We prospectively treated 40 patients admitted to our hospital between 2001 and 2006. Each patient was asked to answer to two questionnaires: WOMAC and MOS SF-36. Patients were evaluated four months before surgery and once they had achieved postoperative rehabilitation. Pre- and postoperative results were analyzed and compared with the international literature on patients affected by OA and also with a healthy population.

RESULTS

Pre- and post-operative results: WOMAC: pain 14.06-0.84; stiffness 4.26-0.52; function 42.68-5.39. SF-36: physical function 18.55-84.52; role physical 28.33-87.10; body pain 23.26-83.39; general health 55.19-81.74; vitality 32.74-72.10; social function 43.55-84.66; role emotional 68.82-93.55; mental health 48.77-79.35. All results were statistically significant.

CONCLUSIONS

The study reports an important QoL improvement in patients affected by arthritis secondary to CHD that underwent hip surgery, and underlines differences with respect to primary OA. QoL evaluation cannot replace either clinical and instrumental evaluation or the physician's experience, but it can give weight to the patient's expectations, and may be considered an efficient test for medical and surgical treatments.

Chronic disease management programme in people with severe knee osteoarthritis: efficacy and moderators of response

AIMS

To establish (1) the efficacy of a six-week chronic disease management programme for knee osteoarthritis and (2) whether previous physiotherapy or being wait listed for surgery moderated the outcome of the programme.

DESIGN

A pretest, posttest design with multivariate statistical modelling.

PARTICIPANTS

One hundred and twenty-one people with severe osteoarthritis who were waiting, or being considered, for surgery.

METHODS AND MEASURES

Western Ontario Osteoarthritis Index (WOMAC) scores, arthritis self-efficacy, distress and a patient-rated global indicator of response were collected at baseline, 6 and 12 weeks. History of previous physiotherapy, waiting list status, symptom duration, New Zealand disease severity score, radiographic changes and self-perceived need for surgery were recorded at baseline.

RESULTS

There were moderate improvements in most outcomes; WOMAC function decreased by 0.29, WOMAC pain by 0.27, pain self-efficacy by 4.4, function self-efficacy by 5.6 and visual analogue scale (VAS) distress by 0.2 (effect sizes ranging from 0.3 to 0.5 at 12 weeks). Waiting list status was a significant modifier for function, pain, distress and self-related outcomes. Participants on the waiting list for surgery experienced lesser improvements. Previous physiotherapy was associated with greater improvements in WOMAC scores at six weeks, but not at 12 weeks.

CONCLUSION

The chronic disease management programme could be considered for people with severe knee osteoarthritis, but should be given prior to referral and placement on the waiting list for surgery. Previous physiotherapy should not preclude people from participating in a chronic disease management programme.

Cutpoints for mild, moderate and severe pain in patients with osteoarthritis of the hip or knee ready for joint replacement surgery

BACKGROUND

Cutpoints (CPs) for mild, moderate and severe pain are established and used primarily in cancer pain. In this study, we wanted to determine the optimal CPs for mild, moderate, and severe pain in joint replacement surgery candidates with osteoarthritis (OA) of the hip or knee, and to validate the different CPs.

METHODS

Patients (n = 353) completed the Brief Pain Inventory (BPI), the WOMAC Arthritis Index, and the SF-36 health status measure. Optimal CPs for categorizing average pain with three severity levels were derived using multivariate analysis of variance, using different CP sets for average pain as the independent variable and seven interference items from the BPI as the dependent variable. To validate the CPs, we assessed if patients in the three pain severity groups differed in pain as assessed with WOMAC and SF-36, and if BPI average pain with the optimal CPs resulted in higher correlation with pain dimensions of the WOMAC and SF-36 than other CPs.

RESULTS

The optimal CPs on the 0-10 point BPI scale were CP (4,6) among hip patients and CP (4,7) among knee patients. The resulting pain severity groups differed in pain, as assessed with other scales than those used to derive the CPs. The optimal CPs had the highest association of average pain with WOMAC pain scores.

CONCLUSION

CPs for pain severity differed somewhat for patients with OA of the hip and knee. The association of BPI average pain scores categorized according to the optimal CPs with WOMAC pain scores supports the validity of the derived optimal CPs.

Pain, physical functioning and quality of life of individuals awaiting total joint replacement: a longitudinal study

OBJECTIVES

To investigate if pain, physical function and the quality of life changed among adults with osteoarthritis while on the waiting list for hip or knee joint replacement.

METHODS

A longitudinal study of patients listed for primary hip or knee joint replacement. Participants were interviewed at baseline (n = 105) and followed up at 3 (n = 84), 6 (n = 47) and 9 months (n = 24), or until their joint replacement. Measurement tools used were a visual analogue scale (VAS), Western Ontario and McMaster's Universities (WOMAC) Osteoarthritis Index and the Medical Outcomes Study Short Form Health Survey (SF-36).

RESULTS

Baseline data indicated high levels of pain as measured by VAS [mean 7.0 (SD 2.2)] and WOMAC pain [mean 11.2 (SD 3.5)]. At baseline, the mean physical function measured by WOMAC was 40.3 (SD 12.1). At the 3-month follow-up, there was significant deterioration in VAS pain scores (0.6; 95% CI mean difference 0.3, 1.0); WOMAC pain scores (1.2; 95% CI mean difference 0.7, 1.8) and WOMAC physical function scores (4.8; 95% CI mean difference 2.8, 6.7) compared with baseline.

CONCLUSION

The often long wait for joint replacement surgery and deterioration in pain and physical function has highlighted the need for active management by health professionals while patients are on the waiting list.

Quality of care for people with osteoarthritis: a qualitative study

AIM

The overall aim of this qualitative study was to explore within primary care the experiences of management and care of individuals with end-stage lower limb osteoarthritis who are on the waiting list for joint replacement.

BACKGROUND

Osteoarthritis, one of the most common chronic diseases, causes loss of physical function and severe pain among sufferers. Improving quality of care and service provision for individuals with chronic diseases is high on the UK's NHS agenda.

METHODS

Data were collected by semi-structured qualitative interviews with 21 individuals with osteoarthritis who were waiting for a hip or knee replacement operation. Interviews were analysed using framework analysis.

RESULTS

Participants had been suffering with osteoarthritis for between seven months and 38 years. The management by health professionals for people on the waiting list for joint replacement was minimal. However, participants spoke of 'hiding' their symptoms from health professionals and were trying to 'self-manage' their symptoms. Families became more involved in helping individuals with osteoarthritis to manage with everyday life.

CONCLUSION

Management of individuals' osteoarthritis while on the waiting list needs to be given consideration by health professionals in primary and secondary care. Health professionals need to be working with each other to provide more comprehensive care across the primary and secondary care interface.

RELEVANCE TO CLINICAL PRACTICE

Case managers or community matrons could be identified as the co-ordinator and assessor of the needs of patients with osteoarthritis so as to try and improve pain management and service provision for these individuals especially while on the waiting list.

Evaluating waiting time effect on health outcomes at admission: a prospective randomized study on patients with osteoarthritis of the knee joint

AIMS

To evaluate the effect of waiting on health-related quality of life (HRQoL), pain and physical function in patients awaiting primary total knee replacement (TKR) due to osteoarthritis.

METHODS

Some 438 patients awaiting TKR were randomized to a short waiting time (WT) group (< or =3 months) or a non-fixed WT group. In the final assessment, 310 patients (213 women) with a mean age of 68 years were included. HRQoL was measured on being placed on the waiting list and again at hospital admission using the generic 15D. Patients' self-report pain and physical function were evaluated using a scale modified from the Knee Society Clinical Rating System.

RESULTS

The median WTs for patients with short and non-fixed WT were 73 days (range 8-600 days) and 266 days (range 28-818 days), respectively. At admission, as assessed by the intention-to-treat analysis, there were no statistically significant differences between the groups in the 15D total score and disease-specific pain and function.

CONCLUSIONS

Our study showed that longer WT did not result in worse pre-operative HRQoL.

Changes in pain, stiffness and physical function in patients with osteoarthritis waiting for hip or knee joint replacement surgery

OBJECTIVE

Little has been reported on changes in health status in patients with osteoarthritis (OA) while waiting for hip or knee replacement surgery. In this study we assessed (1) changes in self-reported pain, stiffness and physical function in patients with OA of the hip or knee, from the decision to undergo surgery to 14 days prior to surgery, and (2) the determinants of these changes.

METHODS

Among 353 baseline respondents, 170 waited >30 days for surgery, completed the Western Ontario and McMaster Universities Arthritis Index (WOMAC) before surgery and were included in the analysis of changes; 120 with OA of the hip and 50 of the knee. We analyzed changes in WOMAC scores using the paired t test and determinants of the changes using multiple linear regression.

RESULTS

Patients with OA of the hip did not change on any WOMAC scale before surgery. Knee patients deteriorated with time on the WOMAC stiffness and total scales, but not on the pain or physical function subscales. In both patient categories, higher baseline WOMAC scores were associated with smaller changes on all subscales and the total score, and female sex was associated with deterioration on the pain subscale.

CONCLUSIONS

Patients with OA of the hip reported no change in pain, stiffness or physical function while waiting for joint replacement surgery, whereas patients with OA of the knee deteriorated on the stiffness and total scales of the WOMAC. This suggests a difference in patient selection, referral pattern or disease development between the patient categories.

The effect of co-morbidities on health-related quality of life in patients placed on the waiting list for total joint replacement

Background

Co-morbidity is a powerful predictor of health care outcomes and costs, as well as an important cofounder in epidemiologic studies. The effect of co-morbidities is generally related to mortality or complications. This study evaluated the association between co-morbidity and health-related quality of life (HRQoL) in patients awaiting total joint replacement.

Methods

A total of 893 patients were recruited to the study between August 2002 and November 2003 in four Finnish hospitals. The effect of co-morbidity on HRQoL was measured by the generic 15D instrument and by a Visual Analog Scale (VAS). Comparative variance analysis of socio-demographic and clinical characteristics was described by using either an independent samples t-test or the Chi-square test. The differences in each of the 15D dimensions and the overall 15D single index score for patients were calculated. Two-sided p-values were calculated with the Levene Test for Equality of Variances.

Results

Patients with co-morbidity totaled 649; the incidence of co-morbidity was 73%. The mean number of co-morbidities among the patients was two. At baseline the 15D score in patients with and without co-morbidity was 0.778 vs 0.816, respectively. The difference of the score (0.038) was clinically and statistically significant (P < 0.001). The patients' scores with and without co-morbidity on the different 15D dimensions related to osteoarthritis-moving, sleeping, usual activities, discomfort and symptoms, vitality and sexual activity–were low in both groups. Patients with co-morbidity scored lower on the dimensions of moving, vitality and sexual activity compared to the patients without co-morbidity. Co-morbidity was significantly associated with a reduced HRQoL. Patients without co-morbidity had poorer VAS, arthritis had strong effect to their quality of life compared to the patients with co-morbidity.

Conclusion

Assessing co-morbidity in patients placed on the waiting list for joint replacement may be useful method to prioritization in medical decision-making for healthcare delivery. The assessment of co-morbidities during waiting time is important as well as evaluating how the co-morbidity may affect the final outcomes of the total joint replacement.

Measurement properties of the WOMAC LK 3.1 pain scale

OBJECTIVE

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is applied extensively to patients with osteoarthritis of the hip or knee. Previous work has challenged the validity of its physical function scale however an extensive evaluation of its pain scale has not been reported. Our purpose was to estimate internal consistency, factorial validity, test-retest reliability, and the standard error of measurement (SEM) of the WOMAC LK 3.1 pain scale.

METHOD

Four hundred and seventy-four patients with osteoarthritis of the hip or knee awaiting arthroplasty were administered the WOMAC. Estimates of internal consistency (coefficient alpha), factorial validity (confirmatory factor analysis), and the SEM based on internal consistency (SEM(IC)) were obtained. Test-retest reliability [Type 2,1 intraclass correlation coefficients (ICC)] and a corresponding SEM(TRT) were estimated on a subsample of 36 patients.

RESULTS

Our estimates were: internal consistency alpha=0.84; SEM(IC)=1.48; Type 2,1 ICC=0.77; SEM(TRT)=1.69. Confirmatory factor analysis failed to support a single factor structure of the pain scale with uncorrelated error terms. Two comparable models provided excellent fit: (1) a model with correlated error terms between the walking and stairs items, and between night and sit items (chi2=0.18, P=0.98); (2) a two factor model with walking and stairs items loading on one factor, night and sit items loading on a second factor, and the standing item loading on both factors (chi2=0.18, P=0.98).

CONCLUSION

Our examination of the factorial structure of the WOMAC pain scale failed to support a single factor and internal consistency analysis yielded a coefficient less than optimal for individual patient use. An alternate strategy to summing the five-item responses when considering individual patient application would be to interpret item responses separately or to sum only those items which display homogeneity.

Delays worsen quality of life outcome of primary total hip arthroplasty

Although there are indications of health status deterioration for patients while waiting for elective total hip arthroplasties, controversy exists regarding the effect of waiting on postoperative outcomes. We hypothesized that longer waiting times are detrimental to achieving the full benefit of surgery. We prospectively examined 201 patients with osteoarthritis who were on the waiting list for primary total hip arthroplasties. The Western Ontario and McMaster Universities Osteoarthritis Index questionnaire was used to assess patients at surgical consultation (preoperative) and 1 year postoperative. The study included regression models to determine the expected outcome for an individual's preoperative score. Logistic regression models were used to assess the relationship between waiting time and the probability of a better than expected outcome. We found that the odds of achieving a better than expected postoperative functional outcome decreased by 8% for each month on the waiting list. Expedited access resulted in a larger proportion of patients with better than expected function 12 months after surgery.

Personal meanings in the construction of need for total knee replacement surgery

This study explores patients' personal meanings of knee osteoarthritis (OA) and total knee replacement (TKR). Personal meanings are important because decisions regarding the need for TKR do not seem to be explained by symptoms alone. A total of 18 semi-structured interviews were conducted with a purposive sample of respondents who were listed for TKR at one UK specialist orthopaedic hospital, and who had lower than average disease burden according to standard quantitative criteria. Data were analysed using interpretive phenomenological analysis. Several themes related to need for TKR emerged: adoption of the medical model, a person's social network, pain, functional loss, feelings of vulnerability, dependency, low mood and fatigue, ideas related to disease progression and expectations of TKR. Results suggest that the decision to undergo TKR is not related to symptoms alone, but to personal meanings. Some of these personal meanings may not be useful in accurately assessing the need for TKR, and may result in mis-targeting of treatment. It is important for health professionals to explore and tackle personal meanings when considering treatment. In particular, it may be important to consider gender differences that may influence when men and women are listed for TKR. For example: women may be less likely to discuss treatment options with their doctor; they may be more likely to have heard negative examples of TKR from friends or family; they may be more likely to discuss pain and mobility issues than activities requiring higher function; and they may be more likely to discuss the effect on their mood and the emotional impact of OA.

Health-related quality of life in patients waiting for major joint replacement. A comparison between patients and population controls

Background

Several quality-of-life studies in patients awaiting major joint replacement have focused on the outcomes of surgery. Interest in examining patients on the elective waiting list has increased since the beginning of 2000. We assessed health-related quality of life (HRQoL) in patients waiting for total hip (THR) or knee (TKR) replacement in three Finnish hospitals, and compared patients' HRQoL with that of population controls.

Methods

A total of 133 patients awaiting major joint replacement due to osteoarthritis (OA) of the hip or knee joint were prospectively followed from the time the patient was placed on the waiting list to hospital admission. A sample of controls matched by age, gender, housing and home municipality was drawn from the computerised population register. HRQoL was measured by the generic 15D instrument. Differences between patients and the population controls were tested by the independent samples t-test and between the measurement points by the paired samples t-test. A linear regression model was used to explain the variance in the 15D score at admission.

Results

At baseline, 15D scores were significantly different between patients and the population controls. Compared with the population controls, patients were worse off on the dimensions of moving (P < 0.001), sleeping (P < 0.001), sexual activity (P < 0.001), vitality (P < 0.001), usual activities (P < 0.001) and discomfort and symptoms (P < 0.001). Further, psychological factors – depression (P < 0.001) and distress (P = 0.004) – were worse among patients than population controls. The patients showed statistically significantly improved average scores at admission on the dimensions of moving (P = 0.026), sleeping (P = 0.004) and discomfort and symptoms (P = 0.041), but not in the overall 15D score compared with the baseline. In patients, 15D score at baseline (P < 0.001) and body mass index (BMI) (P = 0.020) had an independent effect on patients' 15D score at hospital admission.

Conclusion

Although patients' HRQoL did not deteriorate while waiting, a consistently worse HRQoL was observed in patients waiting for major joint replacement compared with population controls.

Waiting for surgery; living a life on hold--a continuous struggle against a faceless system

This interpretive-phenomenological study examined the lived experience of being on the waiting list for arthroplastic surgery of the knee or hip. Interviews reveal that respondents experience suffering in different ways: illness-, caring- and life-suffering. Suffering leads to a struggle in order to have their caring needs met and the struggle is often fruitless-against a faceless enemy-"the system". No one is there to answer their plea or the frustration they experience. This in combination with their present life situation may lead to a disrupted self-image. Finding or creating meaning in suffering appears to be a crucial issue in the struggling process. Respondents who are able to preserve or create meaning in life are able to reformulate their life-world and live a full life, in spite of severe pain and disability.

The impact of non-traumatic hip and knee disorders on health-related quality of life as measured with the SF-36 or SF-12. A systematic review

OBJECTIVES

The purpose of this review is to summarize the available evidence on the impact of non-traumatic hip or knee disorders on health-related quality of life (HRQL), as measured with the Short Form 36 Health Survey (SF-36) or Short Form 12 Health Survey (SF-12), by comparing this with data from reference populations.

METHODS

Studies were identified by an electronic search of the MEDLINE, PsychInfo and Cinahl databases. Studies with the following features were included: study population included patients with non-traumatic hip or knee disorders, the SF-36 or SF-12 was used as an outcome measure and mean scores on these HRQL measures were presented. Using mean HRQL scores from the selected studies and scores from reference populations, z-scores were computed. Pooled estimates were computed for subgroups of studies with similar patients in similar settings.

RESULTS

A total of 40 studies met the inclusion criteria. Patients with non-traumatic hip and knee disorders scored up to 2.5 standard deviations (SDs) below reference population values, especially on the physical aspects of HRQL. Social and mental aspects were up to 1 SD below reference population values, especially in patients in clinical settings.

CONCLUSIONS

The impact of non-traumatic hip or knee disorders on HRQL is substantial, especially on the physical aspects of HRQL.

Association between radiographic joint space narrowing, function, pain and muscle power in severe osteoarthritis of the knee

OBJECTIVE

To examine the association between radiographic classification of severe knee osteoarthritis and measurements of function, pain and power.

DESIGN

Cross-sectional study.

SETTING

Specialist orthopaedic hospital.

SUBJECTS

One hundred and twenty-three patients on the waiting list for elective knee arthroplasty.

OUTCOME MEASURES

Weight-bearing antero-posterior radiographs scored for severity of osteoarthritis using the Kellgren and Lawrence scale. Function measured using the function subscale of the WOMAC (Western Ontario and McMaster Universities) index, timed tests of walking speed and sit-to-stand. Pain measured using the pain subscale of the WOMAC index and a visual analogue scale. Extensor strength of the lower limb measured with the leg extensor power rig.

RESULTS

Within any radiographic grade there was considerable variation in function: WOMAC function for patients with grade 2 mean 64 (47-86), grade 3 mean 47 (12-89) grade 4 mean 45 (2-92). There was poor correlation between radiographic score function, pain or muscle power, with no statistically significant associations. A wide range of scores was also seen within patients with the same radiographic grade.

CONCLUSIONS

Radiographic score was not found to be closely associated with function. Amongst patients with the same radiographic score there was considerable variation in function, pain and power.

Assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty

Background

Physical performance measures play an important role in the measurement of outcome in patients undergoing hip and knee arthroplasty. However, many of the commonly used measures lack information on their psychometric properties in this population. The purposes of this study were to examine the reliability and sensitivity to change of the six minute walk test (6MWT), timed up and go test (TUG), stair measure (ST), and a fast self-paced walk test (SPWT) in patients with hip or knee osteoarthritis (OA) who subsequently underwent total joint arthroplasty.

Methods

A sample of convenience of 150 eligible patients, part of an ongoing, larger observational study, was selected. This included 69 subjects who had a diagnosis of hip OA and 81 diagnosed with knee OA with an overall mean age of 63.7 ± 10.7 years. Test-retest reliability, using Shrout and Fleiss Type 2,1 intraclass correlations (ICCs), was assessed preoperatively in a sub-sample of 21 patients at 3 time points during the waiting period prior to surgery. Error associated with the measures' scores and the minimal detectable change at the 90% confidence level was determined. A construct validation process was applied to evaluate the measures' abilities to detect deterioration and improvement at two different time points post-operatively. The standardized response mean (SRM) was used to quantify change for all measures for the two change intervals. Bootstrapping was used to estimate the 95% confidence intervals (CI) for the SRMs.

Results

The ICCs (95% CI) were as follows: 6MWT 0.94 (0.88,0.98), TUG 0.75 (0.51, 0.89), ST 0.90 (0.79, 0.96), and the SPWT 0.91 (0.81, 0.97). Standardized response means varied from .79 to 1.98, being greatest for the ST and 6MWT over the studied time intervals.

Conclusions

The test-retest estimates of the 6MWT, ST, and the SPWT met the requisite standards for making decisions at the individual patient level. All measures were responsive to detecting deterioration and improvement in the early postoperative period.

Prioritization of patients on waiting lists for hip and knee replacement: validation of a priority criteria tool

OBJECTIVES

This study tested the reliability and validity of the Western Canada Waiting List Project priority criteria score (PCS) for prioritizing patients waiting for hip and knee arthroplasty.

METHODS

Sixteen orthopedic surgeons assessed 233 consecutive patients at consultation for hip or knee arthroplasty. Measures included the PCS, a visual analogue scale of urgency (VAS urgency), and maximum acceptable waiting time (MAWT). Patients completed a VAS urgency, an MAWT, the Western Ontario McMaster Osteoarthritis Index (WOMAC), and the EQ-5D. Using correlational analysis, convergent and discriminant validity was assessed between similar constructs in the priority criteria and WOMAC. Median MAWTs were determined for five levels of urgency based on PCS percentiles. Internal consistency reliability was assessed with Cronbach's alpha.

RESULTS

The sample of 233 patients (62 percent female) ranged in age from 18 to 89 years (mean, 66.3 years). A total of 45 percent were booked for hip and 55 percent for knee arthroplasty. Correlations were strong between the PCS and surgeon VAS urgency (r = .79) and weaker between patient and surgeon measures of VAS urgency (r = .24) and MAWT (r = .44). Correlation coefficients between similar constructs in the priority criteria and WOMAC ranged from 0.24 to 0.32 and were higher than those measuring dissimilar constructs. For decreasing levels of urgency, the median MAWT ranged from 10 to 12 weeks for surgeons and 4 to 12 weeks for patients. Cronbach's alpha was 0.79.

CONCLUSIONS

Results support the validity of the PCS as a measure of surgeon-rated urgency. Patients might be ranked differently with different prioritization measures.

Severely compromised quality of life in women and those of lower socioeconomic status waiting for joint replacement surgery

OBJECTIVE

To determine health-related quality of life (HRQOL), psychological distress, physical function, and self efficacy in persons waiting for lower-limb joint replacement surgery.

METHODS

A total of 214 patients on a waiting list for unilateral primary total knee or hip replacement at a large Australian public teaching hospital completed questionnaires after entry to the list. HRQOL and psychological distress were compared with available population norms.

RESULTS

Average HRQOL was extremely poor (mean +/- SD 0.39 +/- 0.24) and much lower (>2 SD) than the population norm. Near death-equivalent HRQOL or worse than death-equivalent HRQOL were reported by 15% of participants. High or very high psychological distress was up to 5 times more prevalent in the waiting list sample (relative risk 5.4 for participants ages 75 years and older; 95% confidence interval 3.3, 9.0). Women had significantly lower HRQOL, self efficacy, and physical function scores than men. After adjusting for age and sex, significant socioeconomic disparities were also found. Participants who received the lowest income had the poorest HRQOL; those with the least education or the lowest income had the highest psychological distress. Low self efficacy was moderately associated with poor HRQOL (r = 0.49, P < 0.001) and more strongly associated with high psychological distress (r = -0.55, P < 0.001).

CONCLUSION

Patients waiting for joint replacement have very poor HRQOL and high psychological distress, especially women and those from lower socioeconomic backgrounds. Lengthy waiting lists mean patients can experience extended and potentially avoidable morbidity. Interventions to address psychological distress and self efficacy could reduce this burden and should target women and lower socioeconomic groups.

Trends in hip and knee joint replacement: socioeconomic inequalities and projections of need

OBJECTIVES

To examine trends in primary and revision joint (hip and knee) replacement in England between 1991 and 2000.

METHODS

Analysis of hospital episodes statistics between 1 April 1991 and 30 March 2001 for total hip replacement (THR) and total knee replacement (TKR). Descriptive statistics and regression modelling were used to summarise patients' demographic and clinical characteristics and to explore variations in joint surgery rates by age, sex, and deprivation.

RESULTS

Between 1991 and 2000, the incidence of primary THR increased by 18%, while the incidence of revision THR more than doubled. The incidence of primary TKR doubled, with revision TKR increasing by 300%. Over the 10 year period, the proportion of THR episodes that involved revision operations rose from 8% to 20%. Substantial variations in operation rates by socioeconomic status were seen, with the most deprived fifth of the population experiencing significantly lower rates. Projections estimate that primary THR numbers could rise by up to 22% by the year 2010, with primary TKR numbers rising by up to 63%.

CONCLUSIONS

Provision of joint replacement surgery in English NHS hospitals has increased substantially over the past decade. Revision operations in particular have increased markedly. The growth in primary operations has mostly occurred among those aged 60 years and over; rates among young people have changed very little. There is a significant deprivation based gradient in rates. If current trends continue there would be almost 47 000 primary hip and 54 000 primary knee operations annually by 2010.