Differences between men and women in the rate of use of hip and knee arthroplasty

Sex Differences in Complications Following Total Hip Arthroplasty: A Population-Based Study

BACKGROUND

The relationship between sex and outcomes, especially complications, after total hip arthroplasty (THA) has not been well established. This study aimed to identify if patient biological sex significantly impacted complications after THA in Ontario, Canada.

METHODS

A population-based retrospective cohort study of patients undergoing primary THA in Ontario from April 1, 2015, to March 31, 2020 was conducted. The primary outcome was major surgical complications within a year post-surgery (a composite of revision, deep infection requiring surgery, and dislocation). Secondary outcomes included the individual component of the composite primary outcome and major medical complications within 30 days. Proportional hazards regression calculated the adjusted hazards ratio (aHR) for major surgical complications in men relative to women, adjusting for age, co-morbidities, neighborhood income quintile, surgeon and hospital volume, and year of surgery.

RESULTS

A total of 67,077 patients (median age 68 years; 54.1% women) from 61 hospitals were included; women were older with a higher prevalence of frailty. Women had a higher rate of major surgical complications within one year of surgery compared to men (2.9 versus 2.5%, adjusted OR [odds ratio] 1.19, 95%CI [confidence interval] 1.08 to 1.33, P = 0.0009). Conversely, men had a higher risk for medical complications within 30 days (6.3 versus 2.7%, P < 0.001).

CONCLUSION

Observable sex disparities exist in post-THA complications; women face surgical complications predominantly, while medical complications are more prevalent in men. These insights can shape preoperative patient consultations.

Early cartilage lesion and 5-year incident joint surgery in knee osteoarthritis patients: a retrospective cohort study

OBJECTIVE

to investigate the association between cartilage lesion-related features observed in knee osteoarthritis (OA) patients' first MRI examination and incident knee surgery within 5 years. Additionally, to assess the predictive value of these features for the incident knee surgery.

METHODS

We identified patients diagnosed with knee OA and treated at our institution between January 2015 and January 2018, and retrieved their baseline clinical data and first MRI examination films from the information system. Next, we proceeded to determine joint space narrowing grade, cartilage lesion size grade, cartilage full-thickness loss grade and cartilage lesion sum score for the medial and lateral compartments, respectively. Generalized linear regression models examined the association of these features with 5-year incident knee surgery. Positive and negative predictive values (PPVs and NPVs) were determined referring to 5-year incident knee surgery.

RESULTS

Totally, 878 participants (knees) were found eligible to form the study population. Within the 5 years, surgery was performed on 61 knees. None of the cartilage-related features had been found significantly associated with incident surgery. The results were similar for medial and lateral compartments. The PPVs were low for all the features.

CONCLUSIONS

Among symptomatic clinically diagnosed OA knees, cartilage lesions observed in the first MRI examinations were not found to be associated with the occurrence of joint surgery within a 5-year period. All these cartilage-related features appear to have no additional value in predicting 5-year incident joint surgery.

Did the Comprehensive Care for Joint Replacement Bundled Payment Program Impact Sex Disparities in Total Hip and Knee Arthroplasties?

BACKGROUND

Sex disparities have been noted across various aspects of total hip/knee arthroplasty (THA/TKA). Given incentives to standardize care, bundled payment initiatives including the Comprehensive Care for Joint Replacement (CJR) program may reduce disparities. This study aimed to assess the CJR program's impact on sex disparities in THA/TKA care and outcomes.

METHODS

This retrospective cohort study included 259,673 THAs (61.7% women) and 506,311 TKAs (64.0% women) from a large national database (2013 to 2017). Sex disparities were assessed for care and outcomes related to the period (1) before surgery, (2) during hospitalization for THA/TKA, and (3) after discharge. Disparities were reported as women:men ratios. Difference-in-differences analyses estimated the impact of the CJR program on pre-existing sex disparities.

RESULTS

For both THA and TKA, women were less likely than men to present with a Charlson-Deyo comorbidity index >0 (women:men ratio 0.88 to 0.92), but were more likely to require blood transfusions (women:men ratio 1.48 to 1.79) and be discharged to institutional postacute care (women:men ratio 1.50 to 1.66). Difference-in-differences models demonstrated that the CJR bundled payment program reduced sex disparities in institutional postacute care discharges (THA: -2.28%; 95% confidence interval [CI] -4.20 to -0.35%, P = .02; TKA: -2.07%; 95% CI -3.93 to -0.20%; P = .03) and THA 90-day readmissions (-1.00%, 95% CI -1.88 to -0.13%, P = .02), indicating a differential impact of CJR in women versus men for some outcomes.

CONCLUSIONS

While sex disparities in THA/TKA persist, the CJR program demonstrates potential to impact such differences. Future research should focus on how potential mechanisms could be leveraged to reduce disparities.

Disparities Exist in the Experience of Financial Burden Among Orthopedic Trauma Patients: A Systematic Review

PURPOSE OF REVIEW

There are substantial costs associated with orthopedic injury and management. These costs are likely not experienced equally among patients. At the level of the healthcare and hospital systems, disparities in financial burden and patient demographics have already been identified among orthopedic trauma patients. Accordingly, disparities may also arise at the level of the patient and how they experience the cost of their care. We sought to determine (1) how patient demographics are associated with financial burden/toxicity and (2) if patients experience disproportionate financial burden/toxicity and social support secondary to their economic standing.

RECENT FINDINGS

It has been described that there is an inequitable experience in clinical and economic outcomes in certain socioeconomic demographics leading to disparities in financial burden. It has been further reported that orthopedic injury, management, and outcomes are not experienced equitably among all demographic and socioeconomic groups. Ten articles met inclusion criteria, among which financial burden was disproportionately experienced amid orthopedic trauma patients across age, gender, race, education, and marital status. Financial hardship was also unequally distributed among different levels of income, employment, insurance status, and social deprivation. Younger, female, non-White, and unmarried patients experience increased financial burden. Patients with less education, lower income, limited or no insurance, and greater social deprivation disproportionately experienced financial toxicity compared to patients of improved economic standing. Further investigation into policy changes, social support, and barriers to appropriate care should be addressed to prevent unnecessary financial burden and promote greater patient welfare.

Preoperative veterans RAND-12 mental composite score of < 35 is associated with increased length of stay and high rates of discharge to rehab after primary total joint arthroplasty

PURPOSE

The association between preoperative mental health and immediate postoperative ambulation in primary Total Joint Arthroplasty (TJA) has sparsely been studied. Thus, this study's objective was to investigate the association between mental health (measured by the Mental Component Score (MCS) from the Veterans RAND 12 (VR-12)) and peri-operative metrics.

METHODS

We conducted a retrospective study of patients who underwent primary TJA and completed a VR-12 questionnaire between January 2018 and June 2023 at a single academic hospital. Patients were stratified into terciles based on preoperative MCS. Patient demographics, ambulation within 4 h postop, LOS, and discharge location were compared. The effect of MCS on LOS while controlling discharge location was assessed using negative binomial regression.

RESULTS

1120 patients were included in this analysis (432 THA and 688 TKA). After stratification into terciles (Low: 34.7 ± 6.6, Middle: 49.3 ± 3.7, High:62.1 ± 4.4), comparison of demographics revealed significant differences in age (p = 0.005) and sex distribution (p = 0.04) but no difference in surgery type (p = 0.857). There was no significant difference in ambulation rate between MCS groups (p = 0.789) or in distance covered during first ambulation (p = 0.251). Low MCS patients had a longer LOS (p = 0.000, p = 0.002) and a lower rate of discharged home (p = 0.016). After controlling discharge location, no significant association was found between MCS and LOS (p = 0.288).

CONCLUSION

Patient with low MCS tended to be younger, women, and had poorer preoperative HOOS/KOOS scores. Low MCS was associated with longer LOS and lower rates of discharge home. However, MCS was not associated with early ambulation rate and LOS after controlling discharge location.

Gender Differences in Pain, Function, and Quality of Life Five Years Following Primary Total Knee Arthroplasty

BACKGROUND

Multiple authors have sought to determine what patient characteristics influence outcomes after total knee arthroplasty (TKA). The impact of gender on outcomes after TKA remains controversial. Previous studies had less than 5 years of follow-up after TKA. The aim of this evaluation was to determine what differences in pain, function, and quality of life (QoL) exist between female and male patients 5 years after primary TKA.

METHODS

A prospective, multicenter cohort of 11,602 unilateral primary TKA patients (7,284 females and 4,318 males) was prospectively evaluated. All patients were enrolled in the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement. Demographic data, musculoskeletal and medical comorbid conditions, and patient-reported outcome measures, including the Knee Injury and Osteoarthritis Outcome (KOOS) and Short-Form (36-item) Health Survey mental component score (MCS) and physical component score (PCS) were collected preoperatively and at 5 years after TKA. Descriptive statistics were generated, and stratified by gender, and differences in pain, function, and QoL between female and male patients were evaluated. Multivariate regression models with a 95% confidence interval (CI) were used to assess the role of patient gender as a predictive factor for KOOS pain and function in daily living (ADL) scores reported 5 years after primary TKA, while adjusting for other variables.

RESULTS

Prior to surgery, female patients reported worse pain (KOOS pain 46 versus 52), function (KOOS ADL 53 versus 59), and QoL (KOOS QoL 26 versus 29) than male patients. The differences in preoperative scores ranged from 2.70 (KOOS QoL) to 6.12 (KOOS ADL). At 5 years after TKA, female patients reported slightly worse pain (87 versus 89), function (85 versus 87), and QoL (74 versus 75) when compared to male patients. The differences in the mean 5-year postoperative KOOS scores (range, 0.99 to 2.73), although statistically significant (P < .001), were clinically negligible. Female patients achieved greater improvement in pain (41 versus 37), function (32 versus 29), and QoL (48 versus 46) scores in comparison to male patients. Female patients also reported lower preoperative PCS global function (33 versus 35) scores, 5-year postoperative PCS scores (45 versus 46), and MCS global mental function scores (52 versus 54). Similarly, the differences in the 5-year postoperative Short-Form (36-item) Health Survey MCS and PCS scores were clinically negligible. Multivariate regression analysis showed that female gender was not independently predictive for either pain (β = -1.08; 95% CI [-1.25 to 1.03] [P = .85]) or function (β = 0.64; 95% CI [-0.51 to 1.79] [P = .28]) 5 years after surgery.

CONCLUSIONS

There are no clinically significant gender differences in pain, function, or QoL 5 years after TKA. Female patients typically have worse symptoms prior to surgery, improve more than male patients, and end up with pain, function, and QoL scores clinically equal to male patients. These data can enhance the shared decision-making process between female patients and surgeons and assist in setting appropriate patient expectations prior to TKA.

Sex-based Differences in Patient Perspectives and Experiences With Shoulder, Hip, and Knee Arthroplasty

INTRODUCTION

Sex disparities in presentation of osteoarthritis and utilization of joint replacement surgery (JRS) have been demonstrated. The role of patients' unique perspectives on JRS on their treatment decisions is poorly understood.

METHODS

JRS candidates who were offered JRS but declined surgical treatment completed this survey. Survey questions included demographic information, patient experiences and current opinions around JRS, patient experiences with providers, goals and concerns, and barriers to JRS.

RESULTS

More women experience barriers to undergoing JRS compared with men (53% versus 16%; P = 0.014). While both men and women indicated pain relief as their primary goal for treatment, women were significantly more likely to prioritize regaining the ability to complete daily tasks and responsibilities when compared with men (P = 0.007). Both men and women indicated that low symptom severity and nonsurgical treatment options were the reasons for not undergoing JRS (P = 0.455). Compared with men, women trended toward feeling that they were not sufficiently educated about JRS (P = 0.051).

CONCLUSION

Women have unique perspectives and goals for JRS that may pose sex-specific barriers to care. A better understanding of how patients' gendered experiences affect their decision making is necessary to improve treatment of osteoarthritis and decrease disparities in care.

Time to Service and Its Relationship with Outcomes in Workers with Compensated Musculoskeletal Conditions: A Scoping Review

PURPOSE

A comprehensive review of the literature on the time between the onset of symptoms and the first episode of care and its effects on important worker outcomes in compensated musculoskeletal conditions is currently lacking. This scoping review aimed to summarize the factors associated with time to service and describe outcomes in workers with workers' compensation accepted claims for musculoskeletal conditions.

METHODS

We used the JBI guidelines for scoping reviews and reported following the PRISMA-ScR protocol. We included peer-reviewed articles published in English that measured the timing of health service initiation. We conducted searches in six databases, including Medline (Ovid), Embase (Ovid), PsycINFO, Cinahl Plus (EBSCOhost), Scopus, and the Web of Science. Peer-reviewed articles published up to November 01, 2022 were included. The evidence was summarized using a narrative synthesis.

RESULTS

Out of the 3502 studies identified, 31 were included. Eight studies reported the factors associated with time to service. Male workers, availability of return to work programmes, physically demanding occupations, and greater injury severity were associated with a shorter time to service, whereas female workers, a high number of employees in the workplace, and having legal representation were associated with a longer time to service. The relationship between time service and worker outcomes was observed in 25 studies, with early access to physical therapy and biopsychosocial interventions indicating favourable outcomes. Conversely, early opioids, and MRI in the absence of severe underlying conditions were associated with a longer duration of disability, higher claim costs, and increased healthcare utilization.

CONCLUSION

Existing evidence suggests that the time to service for individuals with compensated musculoskeletal conditions was found to be associated with several characteristics. The relationship between time to service and worker outcomes was consistently indicated in the majority of the studies. This review highlights the need to consider patient-centred treatments and develop strategies to decrease early services with negative effects and increase access to early services with better outcomes.

Global, regional, and national trends in osteoarthritis disability-adjusted life years (DALYs) from 1990 to 2019: a comprehensive analysis of the global burden of disease study

OBJECTIVES

This study aimed to investigate global, regional, and national trends in osteoarthritis disability-adjusted life years (DALYs) from 1990 to 2019, identify the burden of osteoarthritis in different age groups, and assess age, period, and cohort effects on osteoarthritis DALYs.

STUDY DESIGN

A comprehensive analysis of the Global Burden of Disease Study 2019 data, covering 204 countries and territories.

METHODS

We conducted a comprehensive analysis using data from the Global Burden of Disease Study 2019, encompassing 204 countries and territories. Age-standardized DALY rates were calculated, and the age-period-cohort model was employed to examine the age, period, and cohort effects on osteoarthritis DALYs. The annual percentage change (APC) and average annual percentage change (AAPC) were estimated to evaluate trends in DALYs.

RESULTS

Globally, osteoarthritis DALYs increased by 114.48 % between 1990 and 2019, with an age-standardized DALY rate growth of 3.3 %. The largest relative growth in DALYs occurred in Middle and Low-middle Socio-Demographic Index (SDI) regions. DALYs increased significantly in almost all age-specific groups, particularly among 45-74 years old age groups. Age, period, and cohort effects analysis revealed a general increase in osteoarthritis DALYs risk over time, with some variations by SDI quintiles and sex. The steepest increase in DALYs occurred in the 30-34 years age group, and the trend attenuated with increasing age. Males showed significantly slower DALYs growth than females in age groups with non-overlapping 95 % confidence intervals. Age effects were consistently higher in females, especially in high-SDI countries. Period and cohort effects generally demonstrated a climbing risk of osteoarthritis DALYs across different SDI quintiles, with more pronounced increases in lower-SDI regions.

CONCLUSIONS

Our findings highlight the substantial and increasing burden of osteoarthritis at global, regional, and national levels from 1990 to 2019, with significant variations by age, period, and cohort. These results underscore the importance of developing targeted public health strategies and interventions to address the growing impact of osteoarthritis, particularly in lower-SDI regions and among older populations.

Association Between Patient and Facility Characteristics and Rehabilitation Outcomes After Joint Replacement Surgery in Different Rehabilitation Settings for Older Adults: A Systematic Review

BACKGROUND AND PURPOSE

In the United States, an exponential increase in total hip arthroplasty (THA) and total knee arthroplasty (TKA) demand has occurred over the last 2 decades. Evidence suggesting patients receiving inpatient rehabilitation following a TKA or THA experience similar outcomes as those with rehabilitation in other settings led to dramatic shifts in postsurgical care settings owing to Centers for Medicare & Medicaid Services (CMS) payment reforms. A contemporary synthesis of evidence about the association between patient and facility factors and outcomes from older adults undergoing THA or TKA in the United States is needed.

METHODS

To identify eligible studies, we searched PubMed, Scopus, and CINAHL. We followed PRISMA guidelines to identify articles evaluating either patient or facility factors associated with outcomes after THA or TKA for older adults who may have been cared for in inpatient settings (ie, inpatient rehabilitation or skilled nursing facility [SNF]). Eligible articles were conducted in the United States and were published between January 1, 2000, and December 31, 2021.

RESULTS

We included 8 articles focused on patient factors and 9 focused on facility factors. Most included older adults and the majority were White (in those reporting race/ethnicity). Most studies evaluated outcomes at discharge and showed that patients admitted to inpatient rehabilitation facilities had either similar or better functional outcomes (mobility, self-care, and functional independence measure (FIM) score) and lower length of stay compared with those in SNFs. Few studies focused on home health care.

CONCLUSIONS

The systematic review focused on older adults showed that findings in these patients are consistent with previous research. Older adults undergoing THA/TKA had acceptable outcomes regardless of postsurgical, inpatient setting of care. Research conducted after CMS payment reforms, in home health care settings, and in more diverse samples is needed. Given the known racial/ethnic disparities in THA/TKA and the shifts to postsurgical home health care with little regulatory oversight of care quality, contemporary research on outcomes of postsurgical THA/TKA outcomes is warranted.

Virtual versus in-person physiotherapy following total knee arthroplasty: a comparative analysis

PURPOSE

At our centre, we developed and implemented a video-based post-operative physiotherapy program for patients undergoing total knee arthroplasty (TKA). Our aims were to analyse and compare the outcomes of this program to in-person physiotherapy.

METHODS

We reviewed the outcomes of 112 patients and captured range-of-motion (ROM) measurements and pain scores (P4 questionnaire). We compared the outcomes to a cohort of 175 patients undergoing in-person therapy. Comparative analysis was performed using a two-tailed Student's t-test.

RESULTS

There was no significant difference between the two groups in age, sex, or initial post-operative knee ROM. On discharge from virtual physiotherapy, mean flexion was 122.6° (SD 7.6). There was no significant difference in improvement in knee flexion between the virtual and in-person groups (mean 30.6° vs 34.0°, p = 0.07). There was no significant difference in the proportion of patients achieving ≥ 120° of flexion (85.0% virtual vs 91.3% in-person, p = 0.11) or those achieving an extension deficit of ≤ 5° (96.0% vs 98.3%, p = 0.25). There was no difference in the number of PT visits to discharge (10.5 vs 11.1, p = 0.14) or final pain scores (12.4 vs 11.9, p = 0.61).

CONCLUSION

Improvements in knee ROM measures are comparable between virtual and in-person physiotherapy with both groups achieving a good functional range. These findings have implications for the virtual delivery of healthcare, especially among remote populations and patients with mobility limitations.

Disparity in sex in ankle fracture treatment

BACKGROUND

Literature has shown implicit bias in the treatment between non-operative and surgical treatment in patients with certain types of ankle fractures, which comprise 7.6% of all adult fractures. An understanding of any bias across all ankle fracture management may prove to be critical for the understanding of potential correlations between treatment methods and outcomes of patients with ankle fractures. Therefore, this study aimed to determine whether there is a sex-based bias in the operative and non-operative treatment of all ankle fractures.

METHODS

A retrospective study of 1175 adult patients with ankle fractures was conducted. Data extracted included sex, race, age, type of treatment (non-operative/operative), fracture type (displaced/non-displaced), fracture class, BMI, and length of hospital stay. Odds ratio (OR), Chi-squared, t-test, and Pearson's correlation tests were used with p < 0.05 considered significant.

RESULTS

The study population consisted of 750 females (63.8%) and 425 males (36.2%). The study demonstrated a sex-based disparity in operative and non-operative treatment revealing that women are less likely than men to receive operative treatment for displaced ankle fractures (OR = 0.7, 95% CI: 0.5-0.9, p = 0.01). Of the 750 females, 417 (55.6%) underwent non-operative treatment, while 333 (44.4%) females had an operation. Of the 425 males, 204 (48%) had non-operative treatment, while 221 (52%) underwent operative treatment. The distribution of ankle fracture classes between both sexes was similar, suggesting fracture class did not influence the observed disparity.

CONCLUSION

Our results suggest sex correlates with the treatment type for ankle fractures, with women more likely to receive non-operative treatment for displaced fractures. As post-treatment outcomes often reflect the chosen form of treatment, it is imperative to determine if a disparity in sex explicates differences in clinical outcomes.

What is the association between gender and self-perceived health status when controlling for disease-specific conditions? A retrospective data analysis of pre- and post-operative EQ-5D-5L differences in total hip and knee arthroplasty

BACKGROUND

The self-perceived health status of patients undergoing total hip and knee arthroplasty (THA and TKA) might differ post-operatively due to gender, age, or comorbidities. Patient-reported outcome measures (PROMs) such as the EQ-5D-5L measure the self-perceived health status. This study investigates whether the index score of the EQ-5D-5L is a valid tool for interpreting gender differences in outcomes for patients undergoing THA and TKA.

METHODS

Routine and PROM-data of elective primary THA or TKA patients in two German hospitals between 2016 and 2018 were analyzed. Univariate analysis with Pearson's chi-square was conducted to identify control variables for gender. To quantify the association between gender and the EQ-5D-5L dimensions, a cumulative odds ordinal logistic regression with proportional odds was conducted.

RESULTS

Two thousand three hundred sixty-eight​​ THA patients (m = 978; f = 1390) and 1629 TKA patients (m = 715; f = 914) were considered. The regression analysis of the individual EQ-5D-5L dimensions showed that female gender was significantly associated with better self-care (THA and TKA) and better post-operative mobility (THA). In contrast, male gender was significantly associated with less pain/discomfort (TKA) and less anxiety/depression (THA) pre-surgery and 3-months post-surgery.

CONCLUSION

Our results confirmed that the self-perceived health status improved after surgery. However, due to the different associations of gender to the individual dimensions of the EQ-5D-5L, the weighted index score clouds the comparability between patients with different gender undergoing THA or TKA. Therefore, we argue to use the individual five dimensions for health status analysis, to reveal relevant additional information.

Women Are Underrepresented Among Principal Investigators of Hip and Knee Arthroplasty Clinical Trials in the United States

BACKGROUND

Leadership of clinical trials confers national recognition and promotes academic advancement. We hypothesized that women would be underrepresented among principal investigators (PIs) of hip and knee arthroplasty clinical trials in the United States.

METHODS

A query of hip and knee arthroplasty clinical trials from 2015 to 2021 was performed on ClinicalTrials.gov. Clinical trials were included if they involved a U.S.-based orthopaedic-surgeon PI. We analyzed the sex representation of arthroplasty PIs among junior-level (assistant professor) and senior-level (associate or full professor) faculty. Participation-to-prevalence ratios (PPRs) were calculated by comparing the sex representation among arthroplasty PIs with that among academic arthroplasty faculty at institutions conducting hip and knee arthroplasty clinical trials. A PPR of <0.8 indicated underrepresentation and a PPR of >1.2 indicated overrepresentation.

RESULTS

A total of 157 clinical trials involving 192 arthroplasty PIs were included. Of these PIs, only 2 (1.0%) were women. PIs were mostly funded by academic institutions (66%) and industry (33%). U.S. federal sources funded a minority (1%) of PIs. Of the 243 male arthroplasty faculty who were eligible, 190 men (78.2%) served as PIs. In contrast, of the 17 female arthroplasty faculty who were eligible, only 2 women (11.8%) served as PIs (p < 0.001). Across the entire cohort of arthroplasty PIs, women were underrepresented (PPR = 0.16), whereas men were equitably represented (PPR = 1.06). Women were underrepresented at the assistant professor (PPR = 0.0), associate professor (PPR = 0.52), and full professor (PPR = 0.58) levels.

CONCLUSIONS

Women were underrepresented among PIs of hip and knee arthroplasty clinical trials, which may lead to disparities in academic promotion and advancement. More research is needed to understand the potential barriers to female leadership of clinical trials. Greater awareness and engagement are needed to create sex equity in clinical trial leadership for hip and knee arthroplasty research.

CLINICAL RELEVANCE

The underrepresentation of women among arthroplasty PIs may lead to fewer options in surgical providers for patients and may limit access to musculoskeletal care for certain patient populations. A diverse arthroplasty workforce can promote attention to issues that disproportionately affect historically underrepresented and vulnerable patient populations.

The International Initiative to Measure Perceived Risk in Arthroplasty: The Results From a Multinational Survey

BACKGROUND

There is an inherent moral imperative to avoid complications from arthroplasty. Doing so at ideal cost is also associated with surgeon reputation, and, increasingly in health care delivery systems that measure and competitively score outcomes, reimbursement to the surgeons and their hospitals. As a result, patients who are perceived to be in higher risk comorbidity groups, such as the obese and diabetics, as well as those challenged by socioeconomic factors may face barriers to access elective arthroplasty.

METHODS

In this initiative, surveys were sent to surgeons in 8 different countries, each adapted for their own unique payment, remuneration, and punitive models. The questions in the surveys pertained to surgeons' perception of risk regarding medical and socioeconomic factors in patients indicated for total hip or knee arthroplasty. This paper primarily reports on the results from Canada, Ireland, and the United Kingdom.

RESULTS

The health care systems varied between a universal/state funded health care system (Canada) to those that were almost exclusively private (India). Some health care systems have "bundled" payment with retention of fees for postoperative complications requiring readmission/reoperation and including some with public publication of outcome data (United States and the United Kingdom), whereas others had none (Canada). There were some major discrepancies across different countries regarding the perceived risk of diabetic patients, who have variable Hemoglobin A1c cut-offs, if any used. However, overall the perception of risk for age, body mass index, age, sex, socioeconomic, and social situations remained surprisingly consistent throughout the health care systems. Any limitations set were primarily driven by surgeon decision making and not external demands.

CONCLUSION

Surgeons will understandably try and optimize the health status of patients who have reversible risks as shown by best available evidence. The evidence is of variable quality, and, especially for irreversible social risk factors, limited due to concerns over cost and quality outcomes that can be influenced by experience-driven perceptions of risk. The results show that perceptions of risk do have such influence on access across many health care delivery environments. The authors recommend better risk-adjustment models for medical and socioeconomic risk factors with possible stratification/exclusions regarding reimbursement adjustments and reporting to help reverse disparities of access to arthroplasty.

The Influence of Patient Sex on Outcomes Following One-Stage and Two-Stage Revision for Periprosthetic Joint Infection in Total Joint Arthroplasty

Although females have a higher rate of primary total joint arthroplasty (TJA), males have a higher rate of revision. The literature lacks studies examining the relationship between sex and outcomes following single and two-stage exchange for periprosthetic joint infection (PJI). The purpose of this study was to examine if differences exist in outcomes following revision for chronic PJI between sexes. A retrospective review was performed on all patients with an MSIS confirmed PJI who underwent a single or two-stage exchange at our institution from January 2010 to January 2021. Patient demographics, comorbidity characteristics, and outcomes were collected and compared between males and females. The primary outcome variable was disease-free survival at 1 year following definitive revision. Multivariable logistic regression analysis was performed to determine risk factors for failure. Of the 470 patients meeting final eligibility criteria, 250 were male and 226 were female (2 males and 4 females had a joint infection of either the contralateral side or a different joint and were treated as separate records). Of the patients in the cohort, 80% of the males (200/250) and 80% of the females (181/226) were found to be disease-free at 1-year follow-up (p > 0.99). Multivariable logistic regression analysis showed that nicotine use and diabetes, but not sex, were significant predictors of failure. Our study did not find a relationship between sex and outcome of revision for PJI. Further research is required to determine whether differences exist between males and females in the expression of PJI and outcomes following treatment.

The impact of moderate to severe osteoarthritis on the physical performance and quality of life: a cross-sectional study in Greek patients (PONOS study)

BACKGROUND

Osteoarthritis (OA) represents a leading cause of disability with limited data available for the Greek patients.

OBJECTIVES

To evaluate the impact of moderate to severe symptomatic hip/knee OA under treatment on physical performance and quality of life.

METHODS

A non-interventional, cross-sectional, epidemiological study of patients with moderate/severe OA, recruited in a single visit from 9 expert sites in Athens, Greece. Assessments were based on commonly used outcome scales: the Hip disability and Osteoarthritis Outcome Score (HOOS), the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the EuroQol-5-Dimensions 3-levels questionnaire (EQ-5D-3L).

RESULTS

One hundred sixty-four patients were included in the analysis. Most of the patients were females (78.7%), with a mean age of 70.5 ± 10.2 years. Comorbidities were reported by 87.2% of patients with hypertension being the most frequently reported (53.7%), followed by dyslipidemia (31.1%), obesity (24.4%) and diabetes mellitus (23.2%). Paracetamol was the most common treatment (96%), followed by NSAIDs (75%), opioids (50%) and locally applied medications (42.7%). Both hip and knee OA patients showed substantial deterioration in health-related quality of life (QoL) and health status as reflected by the HOOS/KOOS (Function in sport and recreation was the most impaired subscale, followed by Hip- or Knee-related QoL). The mean EQ-5D-3L index score was 0.396 ± 0.319 and the mean EQ-VAS score was 52.1 ± 1.9. When compared indirectly to the local population norms our OA population had worse QoL indices.

CONCLUSION

Our findings suggest the functional disability and impaired QoL of Greek patients with moderate/severe hip/knee OA under treatment emphasizing the need for novel treatments that will reduce the burden of the disease.

Sex-Based Differences in the Utilization of Shoulder, Hip, and Knee Arthroplasty

INTRODUCTION

Studies show that females have a higher prevalence of osteoarthritis, worse symptoms, but lower rates of joint replacement surgery (JRS). The reason for this remains unknown.

METHODS

A database of JRS candidates was created for patients seen in 2019 at an academic center. Demographics, Kellgren-Lawrence grades, symptom duration, visual analogue pain score, Charlson Comorbidity Index, and nonsurgical treatments were collected. Patients who were offered but declined surgery were invited to focus groups. Two independent sample t-tests, Mann-Whitney U tests, and chi-square tests were used for continuous, scored, and categorical variables, respectively, with two-tailed significance <0.05. Qualitative, code-based analysis was performed for the focus groups.

RESULTS

The cohort included 321 patients (81 shoulder, 59 hip, and 181 knee) including 199 females (62.0%). There were no differences in proportions of females versus males who underwent JRS or in nonsurgical treatments. Female shoulder arthritis patients were older, had a higher visual analogue pain score, and had a higher Charlson Comorbidity Index. In focus groups, males prioritized waiting for technology advancements to return to an active lifestyle, whereas females experienced negative provider interactions, self-advocated for treatment, concerned about pain, and believed that their sex affected their treatment.

DISCUSSION

We found equal utilization of JRS at our institution. However, female patients experienced unique barriers to surgery.

Development of a nomogram prediction model for gait speed trajectories in persons with knee osteoarthritis

To examine heterogeneous trajectories of 8-year gait speed among patients with symptomatic knee osteoarthritis (KOA) and to develop a nomogram prediction model. We analyzed data from the Osteoarthritis Initiative (OAI) assessed at baseline and follow-up over 8 years (n = 1289). Gait speed was measured by the 20-m walk test. The gait speed trajectories among patients with KOA were explored by latent class growth analysis. A nomogram prediction model was created based on multivariable logistic regression. Three gait speed trajectories were identified: the fast gait speed group (30.4%), moderate gait speed group (50.5%) and slow gait speed group (19.1%). Age ≥ 60 years, female, non-white, nonmarried, annual income < $50,000, obesity, depressive symptoms, comorbidity and WOMAC pain score ≥ 5 were risk factors for the slow gait trajectory. The area under the ROC curve of the prediction model was 0.775 (95% CI 0.742-0.808). In the external validation cohort, the AUC was 0.773 (95% CI 0.697-0.848). Heterogeneous trajectories existed in the gait speed of patients with KOA and could be predicted by multiple factors. Risk factors should be earlier identified, and targeted intervention should be carried out to improve physical function of KOA patients.

Instruments to assess appropriateness of hip and knee arthroplasty: a systematic review

OBJECTIVE

To assess criteria and psychometric properties of instruments for assessing appropriateness of elective joint arthroplasty (JA) for adults with primary hip and knee osteoarthritis (OA).

METHODS

A systematic review guided by Cochrane methods and PRISMA guidelines. Studies were searched in five databases. Eligible articles include all study designs developing, testing, and/or using an instrument to assess JA appropriateness. Two independent reviewers screened and extracted data. Instruments were compared with Hawker et al. JA consensus criteria. Psychometric properties of instruments were described and appraised guided by Fitzpatrick's and COSMIN approaches.

RESULTS

Of 55 instruments included, none met all Hawker et al. JA consensus criteria. Criteria the most met were pain (n = 50), function (n = 49), quality of life (n = 33), and radiography (n = 24). Criteria the least met were clinical evidence of OA (n = 18), expectations (n = 15), readiness for surgery (n = 11), conservative treatments (n = 8), and patient/surgeon agree benefits outweigh risks (n = 0). Instrument by Arden et al. met the most criteria (6 of 9). The most tested psychometric properties were appropriateness (n = 55), face/content validity (n = 55), predictive validity (n = 29), construct validity and feasibility (n = 24). The least tested psychometric properties were intra-rater reliability (n = 3), internal consistency (n = 5), and inter-rater reliability (n = 13). Instruments by Gutacker et al. and Osborne et al. met the most psychometric properties (4 of 10).

CONCLUSION

Most instruments included traditional criteria for assessing JA appropriateness but did not include a trial of conservative treatments or shared decision-making elements. There was limited evidence on psychometric properties.

Surgical Management of Facial Paralysis: Demographic and Socioeconomic Associations

Objective: To determine demographic and socioeconomic variables associated with whether surgery is performed for patients with facial paralysis (FP). Background: Management of FP may include elective surgery dependent on patient goals of care and physician experience. Methods: The 2016 State Inpatient Database and State Ambulatory Surgery Services Database for six states were queried to identify patients with FP. These patients were then stratified based on receiving surgery for FP. Demographic and socioeconomic information was collected. Multivariable logistic regression modeling was used to identify predictors of undergoing FP surgery, as well as the hospital setting in which surgery was performed. Results: Of 20,218 patients with FP, 515 underwent surgery. Black patients were significantly less likely to undergo surgery (p < 0.001), as were patients with Medicaid or self-pay insurance (p < 0.001). Those living in rural areas were also less likely to receive surgery (p = 0.001). Individuals receiving surgery in the inpatient setting were more likely to have private insurance, whereas those in the ambulatory setting were more likely to have Medicare (p < 0.001). Conclusion: Several variables are correlated with whether FP is managed surgically, including insurance status, race, and type of residential area.

Disease burden of and expectations from surgery in patients prior to total knee arthroplasty: Results of the prospective FInGK study

BACKGROUND

Disease burden in patients prior to total knee arthroplasty (TKA) varies widely between studies and countries. We aimed to characterize individuals undergoing TKA and examine their expectations from the surgery, focusing on variations in disease burden.

METHODS

Consecutive patients undergoing primary TKA in a German university hospital were recruited. A questionnaire including information on disease burden, preoperative expectations from surgery, health care utilization, demography, and socioeconomics was collected one day prior to surgery and linked to data from medical records. Patients were categorized into disease burden quartiles using the Western Ontario and McMaster Universities Osteoarthritis Index' (WOMAC) total score. Subsequently, study population's characteristics and expectations from surgery were analyzed stratified by disease burden.

RESULTS

A total of 196 patients were included (41 % male; mean age: 68.2 years). The median WOMAC was 52.0 (IQR: 41.0-58.0). Patients in Q1 were more often males (Q1: 63 % vs Q4: 29 %) and had a shorter duration of complaints with the impaired knee. They were also less restricted in social participation, reported less often signs of depression, and were less often treated with physiotherapy (Q1: 27 % vs Q4: 54 %). Furthermore, expectations from surgery were highest in patients with a low disease burden.

CONCLUSION

We found large variations in disease burden with a considerable number of patients undergoing TKA whose functional capacity is still maintained and for which guideline-recommended conservative treatment options are not fully exhausted. Further research on this subgroup as well as establishing an international consensus on specific thresholds for TKA indication are needed.

Cost Effectiveness of Allogeneic Umbilical Cord Blood-Derived Mesenchymal Stem Cells in Patients with Knee Osteoarthritis

OBJECTIVES

The aim of this study was to assess the cost effectiveness of allogeneic umbilical cord blood-derived mesenchymal stem cells with sodium hyaluronate (hUCB-MSC) compared with microfracture in patients with knee cartilage defects caused by osteoarthritis (OA) in South Korea.

METHODS

A partitioned survival model approach was taken consisting of five mutually exclusive health states: excellent, good, fair, poor, and death over a 20-year time horizon. Utility values were obtained from a randomized clinical trial. Cost data were extracted from a database provided by the Health Insurance Review & Assessment Service, and the utilization of healthcare services was estimated from an expert panel of orthopedic surgeons using a structured questionnaire. The incremental cost-effectiveness ratio (ICER) in terms of quality-adjusted life-years (QALY) was calculated. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

In the base case, the incremental costs of US$14,410 for hUCB-MSC therapy along with its associated QALY gain of 0.857 resulted in an ICER of US$16,812 (₩18,790,773) per QALY (95% confidence interval [CI] US$13,408-US$20,828) when compared with microfracture treatment from a healthcare payer perspective. From a societal perspective, the ICER was US$268 (₩299,255) per QALY (95% CI -US$2915 to US$3784). When using a willingness-to-pay threshold of US$22,367/QALY, the probability of hUCB being cost effectiveness compared with microfracture was 99% from the healthcare payer perspective and 100% from the societal perspective.

CONCLUSIONS

The study demonstrated that hUCB-MSC therapy was cost effective compared with microfracture when treating patients with knee OA. These findings should inform health policy decision makers about considerations for cost-effective therapy for treating knee OA to ultimately enhance population health.

Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Mental Health Disparities

Mental illness affects 20.6% of American adults. The lifetime prevalence of depression and anxiety is 17% and 29%, respectively. In particular, women suffer more from mental illness than men. Racial and ethnic minorities experience disproportionate discrimination, which has been linked to depression, anxiety, and psychological distress. African Americans are more likely to be chronically depressed, have higher levels of impairment and more severe symptoms, and often have challenges accessing treatment. Poor mental health is associated with low socioeconomic status, prolonged hospital stays, psychosis, postoperative anemia, infection, and pulmonary embolism. For total hip and knee arthroplasty, mental health conditions have been linked to higher hospital charges, higher rates of nonroutine discharges, and an increased Charlson Comorbidity Index. Mechanisms to address mental health are varied and range from psychosocial to pharmacologic modalities. Optimization in these vulnerable patients includes appropriate preoperative screening, assessment of support systems, identifying resources, and providing a safe discharge plan.

Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Malnutrition Disparities

Malnutrition can negatively affect clinical outcomes in total hip and knee arthroplasty. Food security plays an important and complex role in nutritional status, and 10.5% of American households are currently food insecure. Rates of food insecurity are higher for women, Hispanic, and Black Americans, those of lower socioeconomic status, and those in rural areas. Undernutrition disproportionately affects the elderly, a cohort with a high burden of osteoarthritis. Strategies for optimization begin with a holistic assessment of the patient's nutritional status. Patients should have a body mass index >18.5 kg/m 2 , vitamin D level >30 ng/dL, albumin level >3.5 g/dL, transferrin level >200 mg/dL, and total lymphocyte count of >1,500 cells/mm 3 . We recommend that orthopaedic surgeons screen for malnutrition for all elective total hip/knee arthroplasty patients.

Epidemiology of age-, sex-, and race-specific hospitalizations for abdominal aortic aneurysms highlights gaps in current screening recommendations

BACKGROUND

The detection and elective repair of abdominal aortic aneurysms (AAA) guided by known risk-factor specific screening decrease AAA-related mortality. However, minimal epidemiologic data exist for AAA in female persons and racial minority groups. We established the contemporary risk of US AAA hospitalization across age, sex, and race.

METHODS

National Inpatient Sample and US Census (2012-2018) data were used to quantify age-, sex-, and race-specific incidences and adjusted odds ratios (aOR) of AAA hospitalizations (≥18 years), associated risk factors, and in-hospital mortality. Interaction terms evaluated subgroups.

RESULTS

Among 1,728,374,183 US residents during the study period (51.3% female; 78.4% White, 12.7% Black, 5.7% Asian), 211,501,703 were hospitalized (aged 57.56 ± 0.04 years; 58.4% female; 64.9% White, 14.3% Black, 2.5% Asian) of which 291,850 were for AAA (aged 73.17 ± 0.04 years; 22.6% female; 81.8% White, 5.6% Black, 1.6% Asian). An estimated 15.2 (95% CI, 15.1-15.3) and 1.7 (95% CI, 1.7-1.7) hospitalizations per 100,000 residents were for intact AAA (iAAA) and ruptured AAA (rAAA) AAA, respectively. In addition, 16.2% of iAAA (83.8% male; 79.1% White) and 18.4% of rAAA (86.4% male; 75.0% White) hospitalizations occurred in patients less than 65 years of age. For iAAA, female sex (aOR, 0.27; 95% CI, 0.27-0.28) compared with male sex and both Black (0.47; 95% CI, 0.45-0.49) and Asian (0.86; 95% CI, 0.83-0.93) persons compared with White persons had a reduced aOR for hospitalization. For rAAA, the reduced aOR persisted for female sex (0.33; 95% CI, 0.32-0.36) and for Black persons (0.52; 95% CI, 0.46-0.58). Although female sex demonstrated an overall decreased odds of AAA hospitalization, female persons who were older, Black, or had peripheral vascular disease (Pinteractions < .001) had a relative increase in AAA hospitalization aOR. Female sex (aOR, 1.54; 95% CI, 1.38-1.70), but not Black or Asian race, was associated with increased mortality which was more pronounced for iAAA (1.93; 95% CI, 1.66-2.25) than rAAA (1.29; 95% CI, 1.13-1.48]; Pinteraction < .001).

CONCLUSIONS

We confirmed a substantially decreased adjusted risk of AAA hospitalization for females and racial minority groups; however, aging and comorbid peripheral vascular disease decreased these differences. The disparate risk of AAA hospitalization by sex and race highlights the importance of inclusivity in future AAA studies.

Association Between Time to Source Control in Sepsis and 90-Day Mortality

Importance

Rapid source control is recommended to improve patient outcomes in sepsis. Yet there are few data to guide how rapidly source control is required.

Objective

To determine the association between time to source control and patient outcomes in community-acquired sepsis.

Design, Setting, and Particpants

Multihospital integrated health care system cohort study of hospitalized adults (January 1, 2013, to December 31, 2017) with community-acquired sepsis as defined by Sepsis-3 who underwent source control procedures. Follow-up continued through January 1, 2019, and data analyses were completed March 17, 2022.

Exposures

Early (<6 hours) compared with late (6-36 hours) source control as well as each hour of source control delay (1-36 hours) from sepsis onset.

Main Outcomes and Measures

Multivariable models were clustered at the level of hospital with adjustment for patient factors, sepsis severity, resource availability, and the physiologic stress of procedures generating adjusted odds ratios (aOR) and 95% CI.

Results

Of 4962 patients with sepsis (mean [SD] age, 62 [16] years; 52% male; 85% White; mean [SD] Sequential Organ Failure Assessment score, 3.8 [2.5]), source control occurred at a median (IQR) of 15.4 hours (5.5-21.7) after sepsis onset, with 1315 patients (27%) undergoing source control within 6 hours. The crude 90-day mortality was similar for early and late source control (n = 177 [14%] vs n = 529 [15%]; P = .35). In multivariable models, early source control was associated with decreased risk-adjusted odds of 90-day mortality (aOR, 0.71; 95% CI, 0.63-0.80). This association was greater among gastrointestinal and abdominal (aOR, 0.56; 95% CI, 0.43-0.80) and soft tissue interventions (aOR, 0.72; 95% CI, 0.55-0.95) compared with orthopedic and cranial interventions (aOR, 1.33; 95% CI, 0.96-1.83; P < .001 for interaction).

Conclusions and Relevance

Source control within 6 hours of community-acquired sepsis onset was associated with a reduced risk-adjusted odds of 90-day mortality. Prioritizing the rapid identification of septic foci and initiation of source control interventions can reduce the number of avoidable deaths among patients with sepsis.

Factors That Patients Consider in Their Choice of Non-Surgical Management for Hip and Knee Osteoarthritis: Formative Qualitative Research for a Discrete Choice Experiment

BACKGROUND

Approximately half of patients with hip and knee osteoarthritis have tried non-surgical management before surgical consultation. Understanding the many factors affecting the uptake of recommended strategies is important to inform future development of such management strategies.

OBJECTIVES

The aim of this study was to explore and identify factors that patients with osteoarthritis consider when choosing non-surgical management for hip and knee osteoarthritis, as formative research for a study of patient preferences for non-surgical management programs for osteoarthritis.

METHODS

A qualitative research design was used. Participants were recruited using a combination of stratified and convenience sampling. Interviews were conducted, using a semi-structured interview guide, with English-speaking patients who had self-reported hip and/or knee osteoarthritis and at least one joint that had not undergone replacement surgery. Data were thematically analyzed.

RESULTS

Thirteen patients participated in these interviews. Sixteen factors that participants considered when choosing non-surgical osteoarthritis management were identified. Eleven were extrinsic, relating to features of programs and services, and are categorized as types of interventions, general program and service details, and program-specific details. Five were intrinsic to the individual and influenced how decisions for osteoarthritis management were approached and the options available to choose from. Three novel factors included participants' desire for further management, their views about joint replacement surgery, and whether they felt personal choice was available in osteoarthritis management strategies.

CONCLUSION

Key factors were identified that patients considered when making decisions about non-surgical management for their osteoarthritis that will be used to inform a discrete choice experiment (DCE) that aims to measure preferences for these factors.

Imaging of groin pain in athletes: patterns of injury at MRI and gender differences therein

AIM

The purpose of our study was to review a large cohort of athletes of all levels presenting with groin pain who underwent investigation with MRI and to determine what the commonest patterns of injury were. We aimed to explore whether particular findings were commonly found in association and whether measurable gender differences exist in the incidence of specific injuries.

MATERIALS AND METHODS

Imaging records were reviewed to identify MRI studies of the pelvis performed for the investigation of groin pain in patients who were active in sports/athletic pursuits. Findings were classified and recorded as follows: injury to the common rectus abdominis/adductor longus origin, injury to the short adductor muscles, pubic bone oedema, pubic symphysis degenerative changes, hip joint injury and 'other'. The prevalence of specific injuries in female athletes compared to males was analysed using relative risk ratios.

RESULTS

A total of 470 athletes underwent MRI for the investigation of groin pain during the study period. Forty-six were female, and 424 were male. Female athletes were significantly less likely to have rectus abdominis-adductor longus (RR = 0.31, p = .017), short adductor (RR = 0.14, p = .005) or hip (RR = 0.41, p = .003) injuries. Pubic bone degenerative changes were much more common in female athletes (RR = 7.37, p = .002).

CONCLUSION

Significant gender differences exist in the frequency with which specific injuries are observed. Female athletes are also significantly underrepresented; this is likely a multifactorial phenomenon; however, the possibility of unconscious referrer bias must be considered.

Structural features of subchondral bone cysts and adjacent tissues in hip osteoarthritis

OBJECTIVE

Focal lesions within the subchondral bone, termed subchondral bone cysts (SBCs), are clinically accepted radiographic markers of advanced osteoarthritis (OA), but their etiology in the hip is not well understood.

DESIGN

This study used micro-computed tomography (μCT), and histological and immunocytological analysis to examine the prevalence, size, location, and morphological and cellular features of SBCs found within 34 femoral heads (14 male, 20 female; age range = 43-80 years) obtained from total hip arthroplasty procedures.

RESULTS

SBCs were common-present in 91% of the femoral heads examined-and frequently commuted with the surface of the femoral head, but otherwise showed no preferred anatomical location. Few associations were found between SBC features and patient characteristics such as BMI, age and sex. SBCs were also heterogenous in composition, ranging from fibrous (most common) to predominantly fatty (least common) and often containing vasculature, nerve fibers, cartilage islands, and bony spicules. Despite this heterogeneity, focal abnormalities in bone density and cartilage thickness were consistently observed. Bone adjacent to SBCs was denser than that in the primary compressive group, and cartilage thickness in regions overlying SBCs was lower than in non-overlying regions. In contrast to these local bony changes, μCT-based finite element analyses indicated that the stiffness of the primary compressive group was only mildly affected by SBCs.

CONCLUSIONS

These findings indicate that SBCs in the femoral head involve extensive perturbations in cellular activity, culminating in myriad skeletal tissue types and spatially heterogenous changes in bone and cartilage morphology that are likely to affect OA progression.

Total Joint Arthroplasty Direct-to-Consumer Advertising by Medical Device Companies Lacks Patient Diversity

Background

Obese and African American populations suffer from higher incidence of hip and knee osteoarthritis, yet African Americans are less likely to undergo total hip and knee arthroplasty (TJA). Patient interest in TJA is a necessary first step for surgery. Medical device company direct-to-consumer advertising for TJA represents 1 potential factor driving disparities in utilization. Here we analyze demographics of models represented in medical device company direct-to-consumer TJA advertisements to understand whether advertisement content correlates with the population in need.

Methods

We analyzed medical device company pamphlets, websites, and banner and video advertisements of the top 4 medical device companies in US arthroplasty sales, collected via ad-specific search engine and direct correspondence. Variables include model race, sex, age, and weight. Pearson likelihood ratio tests were used to compare categorical variables.

Results

Of the 116 advertisements collected, the model featured in the advertisement was white in 69.8%. The proportion of white models differed across medical device companies (company C, 75%) (P < .001) and advertisement type (video, 81.8%) (P < .001). Only 2.6% of advertisements featured obese models. Neither company C nor D, nor pamphlet or website advertisements used obese models.

Conclusions

Direct-to-consumer advertising from the top 4 orthopedic US medical device companies does not represent the population in need: While TJA remains underutilized by African American/Hispanic patients, models were overwhelmingly white. While obese patients are known to need TJA, patients in the advertisements were overwhelmingly not obese. We advocate for medical device companies to refocus their advertising strategies to target diverse patients in need of TJA.

Level of evidence

III (retrospective cohort study).

Characteristics associated with caregiver willingness to consider tonsillectomy for a child's obstructive sleep disordered breathing: Findings from a survey of families in an urban primary care network

OBJECTIVE

Tonsillectomy use is lower among Black children than White children in the U.S. despite their higher prevalence of obstructive sleep disordered breathing (oSDB). We aimed to identify factors associated with parents' willingness to consider tonsillectomy for their child's oSDB and to identify whether parents of Black children are less willing than parents of non-Black children to be willing to consider the procedure.

STUDY DESIGN

Prospective cohort study.

SETTING

Primary care network of a tertiary children's hospital.

METHODS

We surveyed parents/guardians of children aged 2-10 years with oSDB, to assess their knowledge about oSDB and tonsillectomy, perceived severity of their child's oSDB, perceived level of their child's sleep disturbance, perceived risks and benefits of tonsillectomy, stress, trust in their child's primary care physician and physicians in general, and health literacy. We also assessed child clinical and sociodemographic characteristics. Associations between these characteristics and parent/guardian willingness to consider tonsillectomy for their child's oSDB were assessed.

RESULTS

Of the 59 parents/guardians included, 90% were mothers and 71% were Black. Only 58% of caregivers of Black children but 85% of caregivers of non-Black children were willing to consider tonsillectomy (p = 0.04). Caregivers with another child who had undergone tonsillectomy and caregivers who perceived their child's sleep to be more disturbed were more often willing to consider tonsillectomy (both p = 0.02).

CONCLUSIONS

Parents of Black children are less willing to consider tonsillectomy for their child's oSDB, but this was not explained by any factors assessed in this study. Future studies should evaluate additional factors that may explain this difference and that might be targeted to ensure appropriate and equitable access to tonsillectomy among children with oSDB.

The Shoulder Function “Tipping-Point” for Elective Rotator Cuff Repair: Demographic and Longitudinal Trends

Background

A patient's decision to undergo an elective orthopedic procedure is largely based on their symptoms and functional limitations. This point where patients choose to undergo surgery is known as the “tipping point.” The primary aim of this study is to determine the relationship between demographic parameters and the tipping point for elective rotator cuff repair. The secondary aim is to investigate if the tipping point is associated with mental health. The tertiary aim is to determine if the tipping point changes over time.

Methods

Retrospective chart review was used to identify all patients who underwent primary arthroscopic rotator cuff repair between January 1, 2015, to January 1, 2020, with 1 of 3 board-certified orthopedic surgeons. Exclusion criteria included age <18 years, revision surgery, or incomplete datasets (American Shoulder and Elbow Surgeons [ASES], 12-item short form, demographic information, and surgical history). Preoperative ASES score was designated as the tipping point for an individual patient, with a lower score representing worse shoulder function and therefore a higher tipping point and vice versa. Demographic parameters (age, sex, body mass index [BMI], race, and insurance), hand dominance, and surgical history extracted from chart review were analyzed to determine associations with tipping point.

Results

A total of 2153 patients were identified from chart review, with 1731 included in the final analysis. The patients had a mean age of 58.6 ± 9.66 years and a mean BMI of 29.2 ± 6.02 kg/m². There was no significant difference in mean preoperative ASES score by year for the duration of this study (2015-2019, P = .27). Worker's compensation patients had a significantly lower mean preoperative ASES score than patients with commercial or government insurance (P < .01). Spearman's rank correlations showed no relationship between ASES score and patient demographics (age, sex, BMI, race, and hand dominance) or between ASES and previous orthopedic surgery. Preoperative ASES showed a weakly positive correlation (ρ = 0.26) with 12-item short form mental component score. Multivariate linear regression showed male sex is predictive of a lower tipping point (P < .01), whereas higher BMI, African American race, and history of arthroplasty are predictive of a higher tipping point (P ≤ .02).

Conclusion

The tipping point was not demonstrated to change over time in our analysis. Male sex is predictive of a lower tipping point for arthroscopic rotator cuff repair, whereas elevated BMI, African American race, worker's compensation insurance, and prior arthroplasty are predictive of a higher tipping point. Also, better mental health function is associated with a lower tipping point.

Surgical wait times and socioeconomic status in a public healthcare system: a retrospective analysis

Background

One aim of publicly-funded health care systems is to provide equitable access to care irrespective of ability to pay. At the same time, differences in socioeconomic status (SES) are associated with health outcomes and access to care, including waiting times for surgery. In public systems where both high- and low-SES patients use the same resources, low-SES patients may be adversely impacted in surgical waiting times. The purpose of this study was to determine whether a publicly-funded health system can provide equitable access to surgical care across socioeconomic status.

Methods

Patient-level records were obtained from a comprehensive provincially-administered surgical wait time database, encompassing years 2006–2015 and 98% of Ontario hospitals. Patient SES was determined by linking postal code with the Material and Social Deprivation Index. Surgical waiting times (time in days between decision to treat and surgery) accounted for patient-initiated delays in treatment, and regression analysis considered age, SES, rurality, sex, priority level for surgical urgency (assigned by surgeons), surgical subspecialty, number of visits, and procedure year.

Results

For the 4,253,305 surgical episodes, the mean wait time was 62.3 (SD 75.4) days. Repeated measures least squares regression analysis showed the least deprived SES quintile waited 3 days longer than the most deprived quintile. Wait times dropped in the initial study period but then increased. The proportion of procedures exceeding wait time access targets remained low at 11–13%.

Conclusions

The least deprived SES quintile waited the longest, although the absolute difference was small. This study demonstrates that publicly-funded healthcare systems can provide equitable access to surgical care across SES.

Willingness to Have Total Knee Arthroplasty in Rural Areas of Northern China

Objective

To evaluate willingness and its potential predictors to have total knee arthroplasty (TKA) among residents in rural areas of northern China.

Methods

Data were collected from two population‐based studies on osteoarthritis (OA) in northern China. Residents aged ≥ 50 years in randomly selected rural communities were recruited using a cluster survey method. Participants completed a home interview (including social‐demographic characteristics, clinical information, 12‐Item Short Form Health Surveys [SF‐12], and Visual Analog Scale [VAS] of knee pain), a physical examination, and bilateral weight‐bearing posteroanterior semi‐flexed view of radiographs of knees. Willingness to have TKA was queried by asking: “If you need to undergo total knee arthroplasty as judged by orthopaedic surgeons, are you willing to accept this operation?” Two trained investigators read all radiographs independently and reached an acceptable intra‐reader agreement. We fitted univariate and multivariate regressions adjusting for potential confounders to examine predictors of willingness to have TKA stratified by sex.

Results

A total of 2172 participants were included. The overall rate of willingness to have TKA was 33.8%. Men were more likely to be willing to have TKA than women with an odds ratio (OR) of 0.73 (95% confidence interval [CI]: 0.60–0.89, P = 0.002). A higher household income (OR: 2.34 for men and 1.77 for women, both P < 0.001), higher SF‐12 Physical Component Summary (PCS) score (OR: 1.02 for both gender, P = 0.04 for men and P = 0.01 for women), and being aware of TKA (OR: 2.55 for men and 2.65 for women, both P < 0.001) were associated with a higher willingness to have TKA. Other predictors of higher willingness to have TKA were younger age (OR: 0.66 for 60–70 years, P = 0.01; and 0.48 for >70 years, P = 0.003, respectively) and lower level of physical activity (OR: 0.57 for moderate, p = 0.04; and 0.62 for heavy, p = 0.04, respectively) among men and a higher education (OR: 1.45 for Junior school, P = 0.04; and 1.66 for high school and above, P = 0.02, respectively) and being overweight among women (OR: 1.38, P = 0.008), respectively. No significant difference was observed between willingness to have TKA and frequent knee pain, VAS of knee pain and Kellgren and Lawrence grades in both men and women.

Conclusions

The willingness to have TKA among rural residents of northern China was relatively low. Younger age, women, educational level, household income, physical function, and awareness of TKA were positively associated with willingness to have TKA.

Obesity, Comorbidities, and the Associated Risk among Patients Who Underwent Total Knee Arthroplasty in Alberta

Obesity, a common risk factor for osteoarthritis (OA), accelerates joint deterioration resulting in the need for early total knee arthroplasty (TKA). The role of obesity in the management of OA remains a controversial topic. In this study, we examined whether obesity along with other comorbidities is associated with peri/postoperative complications in patients who underwent primary unilateral TKA in Alberta, Canada. A retrospective secondary analysis was performed on data extracted from data repository of patients (n = 15,151) who underwent TKA between 2012 and 2016. The sample was divided into five groups based on body mass index (BMI) classification developed by the World Health Organization. The associations between dependent variable (presence or absence of a complication or comorbidity) with the independent variables (year of surgery, age, sex, length of surgery, and BMI groups) were examined using binomial logistic regression. Results showed that obese classes I, II, and III, irrespective of other covariates, were more likely to have diabetes and pulmonary embolism (p < 0.001) compared with the normal BMI group. Patients with obese class III compared with the patients in normal BMI group were more likely to have deep wound infection (p = 0.04). Patients with comorbidities were more likely to have a blood transfusion, infection, pulmonary embolism, and readmission. Patients in higher BMI groups or with comorbidities were more likely to experience peri/postoperative complications following TKA, though the level of risk depends on the severity of obesity. These findings may be used by health care providers to educate patients in higher BMI groups about the risks of TKA and optimize comorbidities prior to the surgery.

Sex Differences in End-Stage Ankle Arthritis and Following Total Ankle Replacement or Ankle Arthrodesis

BACKGROUND

We investigated the influence of sex on patient-reported outcomes preoperatively and following total ankle replacement and ankle arthrodesis.

METHODS

Patients who had undergone total ankle replacement or ankle arthrodesis for the treatment of end-stage ankle arthritis and who had ≥2 years of follow-up were identified from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database. Standard surgical techniques and implantation methods were followed, and STAR, Hintegra, Mobility, and Agility prostheses were used. Data were collected on patient demographics, revisions, secondary procedures, complications, Ankle Osteoarthritis Scale (AOS) scores, Short Form-36 (SF-36) scores, and expectations and satisfaction. Statistical analyses included 3-way repeated-measures analysis of variance (ANOVA) and multiple linear regression models controlling for inflammatory arthritis, age, preoperative scores, and surgery type.

RESULTS

The study included 872 patients: 629 who had undergone total ankle replacement (316 men, 313 women) and 243 who had undergone ankle arthrodesis (154 men, 89 women). The mean duration of follow-up (and standard deviation) was 4.9 ± 2.4 and 4.0 ± 1.9 years for the total ankle replacement and ankle arthrodesis groups, respectively. Men were older than women (p ≤ 0.001). In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS pain scores (i.e., more pain) than men preoperatively (p < 0.05). Pain was reduced significantly in both sexes postoperatively (p < 0.05), with no significant difference between sexes. In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS disability scores (i.e., more disability) and lower SF-36 Physical Component Summary (PCS) scores (i.e., worse function) than men both preoperatively and postoperatively (p < 0.001). Postoperatively, AOS disability and SF-36 PCS scores improved significantly from baseline in both sexes (p < 0.001). After controlling for covariates, sex was not a significant predictor of postoperative SF-36 MCS (Mental Component Summary), AOS pain, or AOS disability scores (p > 0.05) but explained 0.5% of variance in SF-36 PCS scores (p = 0.03). Sex did not significantly influence preoperative expectations or postoperative satisfaction. When patients with inflammatory arthritis were excluded, preoperative and postoperative outcome measures, expectations, and satisfaction were similar.

CONCLUSIONS

Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. Small differences in pain and function between men and women undergoing total ankle replacement and ankle arthrodesis mostly disappeared when controlling for potential confounding variables. Both total ankle replacement and ankle arthrodesis remain good options for men and women with end-stage ankle arthritis.

LEVEL OF EVIDENCE

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

Patient Functional Status as an Indication for Primary Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

The number of total hip arthroplasties performed per year is increasing for reasons not fully explained by a growing and aging population. The purpose of this study was to determine the role of patient functional status as an indication for surgery and determine if patients are undergoing surgery at a better functional status than in the past.

METHODS

A systematic review and meta-analysis of the MEDLINE, EMBASE, and Cochrane databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Functional status was assessed using the 36-Item Short-Form Health Survey's Physical Component Summary score. Only primary procedures were included; revisions were excluded. Articles were screened by 2 independent reviewers with conflicts resolved with a third reviewer. Meta-regression analysis was performed to determine the effect of time, patient age, and gender. Subgroup analysis was performed to compare geographic regions.

RESULTS

A total of 1504 articles were identified. Data from 172 groups representing 18,644 patients recruited from 1990 to 2013 and identified from 107 articles were included. The mean preoperative Physical Component Summary score was 31.2 (95% confidence interval 30.5-31.9) with a 95% prediction interval of 22.6-39.8. The variance across studies was statistically significant (P = .000) with 97.25% true variance. Year of enrollment, age, and the percentage of females were not found to have any significant effect. There were no differences between countries.

CONCLUSION

Patients are undergoing total hip arthroplasty at a similar preoperative physical functional status as in the past. Patient age, gender, and location do not influence the functional status at which patients are indicated for surgery.

1-year trajectories of patients undergoing primary total hip arthroplasty: Patient reported outcomes and resource needs according to education level

Background

Objectives were first to evaluate by education level one-year trajectories of pain, function and general health, as well as hospital resource and medication needs in patients undergoing primary total hip arthroplasty (THA); and second, to evaluate whether outcome differences are related to existing baseline differences in health and disease severity.

Methods

We included all primary THAs from a public hospital-based prospective arthroplasty registry, performed in a high-income country 2010 to 2017. Education was classified in three levels: ≤8years of schooling (low), 9-12years (medium), and ≥13years (high). Pain and function prior to and one-year after surgery were assessed with the Western Ontario McMaster Universities score (WOMAC) and general health with the 12-item short-form health survey (SF-12).

Results

Overall 963 patients were included, 340 (35.3%) with low, 306 (31.8%) with medium, and 317 (32.9%) with high education. With increasing educational level preoperative scores for pain, function and SF-12 mental health component increased. One year after surgery improvement was observed in all education categories for WOMAC pain and function, SF-12 mental and physical component. However, absolute postoperative scores remained lower in all four domains for the low education group. After adjustment for baseline characteristics differences were much attenuated and no longer significant. There was also greater resource need in low educated patients.

Conclusions

The inferior absolute results one year after surgery in less educated patients were largely due to older age, worse preoperative health and greater symptom severity calling for greater attention to timely and equal management, for more targeted perioperative care and increased support for the lower education group.

Shared Decision-Making Is Associated with Better Outcomes in Patients with Knee But Not Hip Osteoarthritis: The DECIDE-OA Randomized Study

BACKGROUND

Current guidelines recommend shared surgical decision-making, yet it is unclear whether shared decision-making improves health outcomes in patients who are considering knee and hip replacement. The purpose of the present study was to examine whether patients who made high-quality, informed, patient-centered (IPC) decisions had better health outcomes, higher satisfaction, and less decision regret compared with those who made lower-quality decisions.

METHODS

A multisite, randomized study of 2 decision aids for patients with hip and knee osteoarthritis was utilized to collect data on decision-making and health outcomes at 2 time points: shortly after the initial surgical evaluation and about 6 months after treatment. We calculated the percentage of patients who made an IPC decision and examined the a priori hypotheses that IPC decisions would be associated with better health outcomes, satisfaction, and less regret at 6 months. Linear and logistic regression models were utilized to examine the relationships.

RESULTS

The analytic sample included 854 patients with a mean age of 65 years (standard deviation, 9 years), of whom 58% were female, 93% were White non-Hispanic, 67% had knee (compared with hip) osteoarthritis, and 62% underwent operative treatment within 6 months of the initial evaluation. The majority of patients (68%) made IPC decisions. The IPC group had significantly larger gains in quality of life (mean difference in EuroQol-5 Dimension, 0.04; 95% confidence interval [CI], 0.02 to 0.07; p < 0.001) compared with the non-IPC group. For knee patients, the IPC group also had significantly better Knee injury and Osteoarthritis Outcome Scores (mean difference, 4.9; 95% CI, 1.5 to 8.3; p = 0.004), higher satisfaction (adjusted odds ratio [aOR], 1.7; 95% CI, 1.2 to 2.3; p = 0.003), much better pain relief (aOR, 2.1; 95% CI, 1.3 to 3.5; p = 0.002), and were more likely to have no decision regret (aOR, 2.3; 95% CI, 1.3 to 4.1; p = 0.003). For hip patients, IPC decisions were not associated with better Harris hip scores or satisfaction and were associated with more regret.

CONCLUSIONS

Higher-quality decisions predicted small improvements in health outcomes, as well as greater satisfaction and less regret for patients with knee osteoarthritis, but not for patients with hip osteoarthritis.

LEVEL OF EVIDENCE

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

Gender Influences on Shoulder Arthroplasty

PURPOSE OF REVIEW

As the incidence of shoulder arthroplasty continues to increase, there is growing interest in patient-based factors that may predict outcomes. Based on existing literature demonstrating gender-based disparities following total hip and knee arthroplasty, gender may also influence shoulder arthroplasty. The purpose of this review is to discuss the recent literature on the influence of gender on shoulder arthroplasty, focusing on differences in preoperative parameters, perioperative complications, and postoperative outcomes.

RECENT FINDINGS

While both female and male patients generally benefit from shoulder arthroplasty, several differences may exist in preoperative factors, acute perioperative complications, and postoperative outcomes. Preoperatively, female patients undergo shoulder arthroplasty at an older age compared to their male counterparts. They may also have greater levels of preoperative disability and different preoperative expectations. Perioperatively, female patients may be at increased risk of extended length of stay, postoperative thromboembolic events, and blood transfusion. Postoperatively, female patients may achieve lower postoperative functional scores and decreased range of motion compared to male patients. Differences in postoperative functional scores may be influenced by gender-based differences in activities of daily living. Finally, female patients may be at greater risk for periprosthetic fracture and aseptic loosening while male patients appear to be at greater risk for periprosthetic infection and revision surgery. Current literature on the influence of gender on shoulder arthroplasty is limited and conflicting. Further research is necessary to delineate how gender affects patients at the pre- and postoperative levels to better inform decision-making and outcomes.

Evaluation of Appropriateness of the Reimbursement Criteria of Korean Health Insurance Review and Assessment Service for Total Knee Arthroplasty

Background

We evaluated and compared South Korea's total knee arthroplasty (TKA) reimbursement criteria set by Health Insurance Review and Assessment Service (HIRA) with other TKA appropriateness criteria to find additional criterion to improve its appropriateness by reviewing TKA inappropriate cases.

Methods

Two TKA appropriateness criteria and HIRA's reimbursement criteria for TKA were adapted for use on patients undergoing TKA in one institute from December 2017 to April 2020. Preoperative data including 9 validated questionnaires on knee joint-specific parameters, age, and radiography were used. We categorized cases into appropriate, inconclusive, inappropriate groups and analyzed each group.

Results

Data on 448 cases that underwent TKA were examined. According to the HIRA's reimbursement criteria, 434 cases (96.9%) were appropriate and 14 cases (3.1%) were inappropriate; superior to other TKA appropriateness criteria. The inappropriate group had Knee Injury and Osteoarthritis Outcome score (KOOS) pain, KOOS symptoms, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, and Korean Knee score total score with worse symptoms compared to the appropriate group classified by HIRA's reimbursement criteria.

Conclusions

In terms of insurance coverage, HIRA's reimbursement criteria was more effective in providing healthcare access to patients who had the most pressing need for TKA compared to other TKA appropriateness criteria. However, we found the lower age limit and patient-reported outcome measures of other criteria as useful tools in improving appropriateness of the current reimbursement criteria.

Are We Able to Determine Differences in Outcomes Between Male and Female Servicemembers Undergoing Hip Arthroscopy? A Systematic Review

Background:

Female servicemembers sustain higher rates of lower extremity injuries as compared with their male counterparts. This can include intra-articular pathology in the hip. Female patients are considered to have worse outcomes after hip arthroscopy for femoroacetabular impingement and for hip labral repair.

Purpose:

To (1) compare published rates of hip arthroscopy between male and female military servicemembers and (2) determine if there are any sex-based differences in outcomes after hip arthroscopy in the military.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

We reviewed the literature published from January 1, 2000, through December 31, 2020, to identify studies in which hip arthroscopy was performed in military personnel. Clinical trials and cohort studies were included. The proportion of women within each cohort was identified, and results of any between-sex analyses were reported.

Results:

Identified were 11 studies that met established criteria. Studies included 2481 patients, 970 (39.1%) of whom were women. Surgery occurred between January 1998 and March 2018. Despite women accounting for approximately 15% of the active-duty military force, they represented 39.1% (range, 25.7%-57.6%) of patients undergoing hip arthroscopy. In most cases, there were no differences in self-reported outcomes (pain, disability, and physical function), return to duty, or medical disability status based on sex.

Conclusion:

Women account for approximately 15% of the military, but they made up 40% of patients undergoing hip arthroscopy. Outcomes were not different between the sexes; however, definitive conclusions were limited by the heterogeneity of outcomes, missing data, lack of sex-specific subgroup analyses, and zero studies with sex differences as the primary outcome. A proper understanding of sex-specific outcomes after hip arthroscopy will require a paradigm shift in the design and reporting of trials in the military health system.

Incidence Rates of Surgery After Knee MRI: Association According to Referring Physician Type and Patient's Age and Sex

Background

The utility of magnetic resonance imaging (MRI) in the primary care setting is uncertain, with a perception that there is less likelihood for surgery after MRI ordered by general practitioners (GPs) when compared with orthopaedic surgeons and sports medicine physicians. Additionally, the influence of patient age and sex on subsequent surgical intervention is currently unknown.

Purpose/Hypothesis

The purpose of this study was to compare surgical incidence after MRI referrals by orthopaedic surgeons, GPs, and sports medicine physicians, including a subset analysis for GP patients based on type of approval given by the radiologist. The authors also wanted to explore the association of age and sex on subsequent surgical intervention. They hypothesized that surgical incidence after MRI ordered by orthopaedic surgeons and sports medicine physicians would be higher than after MRI ordered by GPs.

Study Design

Cohort study; Level of evidence, 3.

Methods

Knee MRI referrals by the 3 physician cohorts during May to December 2017 were assessed. For GP patients, the types of approval or recommendation from a radiologist were categorized. Subsequent surgical intervention status was then compared among referral groups up to 2 years after MRI. Associations of age and sex with surgical occurrence were also assessed. Chi-square test, analysis of variance, and univariate/multivariable logistic regression were used for statistical analysis.

Results

Overall, 407 referrals were evaluated (GP, n = 173; orthopaedic, n = 176; sports medicine, n = 58). Surgical incidence was not significantly higher for orthopaedic and sports medicine than GP referrals at 3 months (10%, 3%, and 6%, respectively; P = .23), 6 months (20%, 17%, and 15%; P = .49), and 2 years (30%, 35%, and 24%; P = .25). Surgical incidence for GP patients was higher after discussion with a radiologist or when evaluating specific pathology on prior imaging versus less defined reasons (30.4% vs 15.7%, respectively; P = .03). Surgical incidence was lower for older patients (11% vs 31% for >60 years vs all other age groups combined; P = .002), and women were less likely to undergo surgery than men (22% vs 35%, respectively; P = .008).

Conclusion

Surgical incidence after MRI was likely appropriately lower for older patients. Lower incidence for female patients is of uncertain cause and warrants further study.

Prevalence of joint-specific osteoarthritis and joint pain in British Columbia, Canada

The objective is to determine the prevalence of self-reported physician-diagnosed osteoarthritis (OA) and musculoskeletal symptoms (pain, stiffness or discomfort) in specific joints among adults in British Columbia (BC), Canada. We carried out a cross-sectional mixed-mode survey in a random population sample of persons 18 years of age and older. Estimates were weighted to reflect the age and sex distribution of the population of BC. We obtained responses from 2,233 individuals. Overall, 18.4% (95% CI 16.8-20.1) of the adult population reported OA. Of those, more than 40% had OA in multiple sites. Prevalence ranged from 8.8% (95% CI 7.6-10.1) in the knee to 2.7% (2.1-3.5) in the foot. One-year prevalence of symptoms ranged from 49.1% (47.0-51.2) in the lower back to 23.3% (21.5-25.1) in the hip. Females reported more symptoms and OA than males in all joints. The most common site of self-reported physician-diagnosed OA in BC is the knee, but OA in the hands, hips, and feet is also common. Having OA in one joint is a strong predictor of OA in other joints.

Patient gender does not influence referral to an orthopaedic surgeon by advanced practice orthopaedic providers: a prospective observational study in Canada

Background

The role of an advanced practice physiotherapist has been introduced in many countries to improve access to care for patients with hip and knee arthritis. Traditional models of care have shown a gender bias, with women less often referred and recommended for surgery than men. This study sought to understand if patient gender affects access to care in the clinical encounter with the advanced practice provider. Our objectives were: (1) To determine if a gender difference exists in the clinical decision to offer a consultation with a surgeon; (2) To determine if a gender difference exists in patients’ decisions to accept a consultation with a surgeon among those patients to whom it is offered; and, (3) To describe patients’ reasons for not accepting a consultation with a surgeon.

Methods

This was a prospective study of 815 patients presenting to a tertiary care centre for assessment of hip and knee arthritis, with referral onward to an orthopaedic surgeon when indicated. We performed a multiple logistic regression analysis adjusting for severity to address the first objective and a simple logistic regression analysis to answer the second objective. Reasons for not accepting a surgical consultation were obtained by questionnaire.

Results

Eight hundred and fifteen patients (511 women, 304 men) fulfilled study eligibility criteria. There was no difference in the probability of being referred to a surgeon for men and women (difference adjusted for severity = − 0.02, 95% CI: − 0.07, 0.02). Neither was there a difference in the acceptance of a referral for men and women (difference = − 0.05, 95% CI: − 0.09, 0.00). Of the 14 reasons for declining a surgical consultation, 5 showed a difference with more women than men indicating a preference for non-surgical treatment along with fears/concerns about surgery.

Conclusions

There is no strong evidence to suggest there is a difference in proportion of males and females proceeding to surgical consultation in the model of care that utilizes advanced practice orthopaedic providers in triage. This study adds to the evidence that supports the use of suitably trained alternate providers in roles that reduce wait times to care and add value in contexts where health human resources are limited. The care model is a viable strategy to assist in managing the growing backlog in orthopaedic care, recently exacerbated by the COVID-19 pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06965-5.