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

Physical functioning in patients with end-stage knee osteoarthritis: A cross-sectional study in Jordan using self-reported questionnaire and performance-based tests

BACKGROUND

Knee osteoarthritis (OA) is a debilitating condition that leads to functional limitations. Self-reported questionnaires and performance-based tests are tools commonly used for measuring physical function.

OBJECTIVES

(1) To evaluate the impact of end-stage knee OA on functional outcomes and examine the association between self-reported and performance-based measures of function in patients with end-stage knee osteoarthritis awaiting total knee arthroplasty (2) To explore the interrelationships among pain, strength, and overall physical function in this patient population.

METHODS

In this cross-sectional analysis, 33 patients with end-stage knee OA were recruited and completed the knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS) and executed performance-based tests including the Timed Up and Go, the 30-second chair stand test, and the Stair Climbing Test. Knee pain, and isometric hip and knee strength were evaluated.

RESULTS

Patients perceived deficits in their physical functionwith a score of 35/100 on the KOS-ADLS and demonstrated functional limitations in all performed tasks. KOS-ADLs was weakly associated with TUG and 30s-CST (r=-0.301, p= 0.047, and r= 0.39, p= 0.014. respectively). Knee pain was linked with the KOS-ADL score and GRS score (r=-0.406, p= 0.010; r=-0.343, p= 0.027; respectively), while the strength of the affected side was correlated with the performed (p=< 0.001) and reported function outcomes (p= 0.007).

CONCLUSION

Participants exhibit declines in both perceived and executed functional abilities. Self-reported and performance-based functional measures are weakly correlated within our study group, highlighting the importance of incorporating both measures in clinical practice for a comprehensive evaluation of physical function. Pain was linked to subjective aspect of physical function, while strength was connected to perceived and performed functional capacity. Implementing a tailored rehabilitation program targeting muscle weakness and pain holds the potential to mitigate functional decline in individuals awaiting total knee arthroplasty (TKA).

Impact of end-stage knee osteoarthritis on perceived physical function and quality of life: A descriptive study from Jordan

OBJECTIVE

Of the present study was to evaluate the impact of end-stage knee OA on patient's perception of their functional abilities and quality of life (QoL) using the self-reported questionnaire; the Knee Injury and Osteoarthritis Outcome Score (KOOS), and to determine the contribution of knee pain on patient's perceived outcomes.

METHODS

Patients with end-stage knee OA who are on the waiting list for total knee arthroplasty were recruited in this cross-sectional study. Patients were asked to fill out the KOOS questionnaire. Knee pain for both sides was quantified on a continuous scale from 0-10. Age, and anthropometric data were recorded. Descriptive statistics were calculated for patients' characteristics, and for the scores of each KOOS subscale. Hierarchical linear regression models were created to determine the contributions of knee pain on two KOOS subscales; the function in daily living (KOOS-ADL), and the knee-related quality of life (KOOS-QoL).

RESULTS

Patients in this study scored low across KOOS subscales (27.7% - 54.2%) with the QoL subscale being the lowest. After accounting for age and BMI, hierarchical linear regressions revealed that knee pain in both sides were determinants of self-perceived KOOS-ADLs, while only knee pain in the most-affected side significantly contributed to lower KOOS-QOL scores.

CONCLUSION

End-stage knee OA negatively impact the patients' perceived function and quality of life. Patients' KOOS scores were similar to those reported in other countries, with QoL being the domain most affected. Our findings demonstrate that the level of knee pain has a determinant effect on our patients' perceptions of functional abilities and QoL. As waiting-list patients, addressing knee pain with a targeted regimen prior to TKA, as well as increasing patient's awareness about knee pain management, may improve/ or minimize deterioration in perceived functional ability and QoL while awaiting TKA.

Demographics are no clinically relevant predictors of patient-reported knee osteoarthritis symptoms - Comprehensive multivariate analysis

Aims & objectives

In clinical practice, arthroplasties are predominantly indicated by clinical and radiological assessment of osteoarthritis. Pain and function are individually considered, but a comprehensive analysis of differences in symptom reporting by pre-operative factors is lacking. In the present study, we determined differences in patient reported outcome measures between demographic groups among patients admitted to total knee arthroplasty.

Materials & methods

Between 2010 and 2019, we collected pre-operative Oxford Knee Scores, Western Ontario and McMaster University Osteoarthritis Index, quality of life in 2555 patients undergoing primary, osteoarthritis-indicated total knee arthroplasty at Patients were categorized by sex, age (<70, 70-80, >80 years), body mass index (BMI <25, 25-30, 30-35, >35 kg/m2), American Society of Anesthesiologists -classification (ASA 1, 2, ≥3) and Charnley score (A, B1, B2, C). Symptom scores (median, IQR) were compared using bivariate and multivariate methods.

Results

The cohort was 60% female, 70.0 years old (69.4-70.1), and BMI was 28.9 kg/m2 (29.6-30.0). As compared to bivariate analyses, between-group differences in multivariate analyses were consistently smaller. BMI and sex remain significant predictors after adjustment for age, ASA, and Charnley. Age, ASA, and Charnley were no independent predictors of symptom scores. A group of patients (30%) reported no physical dysfunction, and less symptom severity in pain and stiffness.

Conclusion

This study is the first to show that differences in symptom reporting between demographic groups are partly colinear, and are negligible for prediction of symptoms. Lastly, for a significant proportion of patients, patient-reported outcome measures do not adequately present disease severity.

Identifying and Understanding the Non-Clinical Impacts of Delayed or Cancelled Surgery in Order to Inform Prioritisation Processes: A Scoping Review

The COVID-19 pandemic has resulted in significant delays to non-urgent elective surgery. Decision making regarding prioritisation for surgery is currently informed primarily by clinical urgency. The ways in which decision making should also consider potential social and economic harm arising from surgical delay are currently unclear. This scoping review aimed to identify evidence related to (i) the nature and prevalence of social and economic harm experienced by patients associated with delayed surgery, and (ii) any patient assessment tools that could measure the extent of, or predict, such social and economic harm. A rapid scoping review was undertaken following JBI methodological guidance. The following databases were searched in October 2020: AMED; BNI; CINAHL; EMBASE; EMCARE; HMIC; Medline; PsychINFO, Cochrane, and the JBI. A total of 21 publications were included. The findings were categorised into five themes: (i) employment, (ii) social function and leisure, (iii) finances, (iv) patients’ experiences of waiting, and (v) assessment tools that could inform decision making. The findings suggest that, for some patients, waiting for surgery can include significant social, economic, and emotional hardship. Few validated assessment tools exist. There is an urgent need for more research on patients’ experiences of surgical delay in order to inform a more holistic process of prioritising people on surgical waiting lists in the COVID-19 pandemic recovery stages.

Early Identification of Patient Satisfaction Two Years After Total Knee Arthroplasty

BACKGROUND

There are numerous reports of poor satisfaction after total knee arthroplasty (TKA), yet there is little known about when to use evidence-based models of care to improve patient outcomes.

OBJECTIVE

This study aimed to characterize longitudinal changes in patient-reported satisfaction after TKA and to identify factors for early identification of poor satisfaction.

METHODS

For a cohort of primary TKA surgeries (n = 86), patient-reported outcomes were captured one week before TKA and 6 weeks, 12 weeks, 6 months, and 1 and 2 years after TKA. "Satisfied" versus "not fully satisfied" patients were defined using a binary response (≥90 vs <90) from a 100-point scale. Wilcoxon signed-rank tests identified changes in satisfaction between follow-up times, and longitudinal analyses examined demographic and questionnaire factors associated with satisfaction.

RESULTS

Improvements in satisfaction occurred within the first 6 months after TKA (P ≤ 0.01). Preoperative patient-reported outcome measures alone were not predictive of satisfaction. Key factors that improved longitudinal satisfaction included higher Oxford Knee Scores (odds ratio (OR) = 2.1, P < .001), general health (EQ-VAS, OR = 1.3, P = .03), and less visual analog scale pain (VAS; OR = 1.7, P < .001). Differences in these factors between satisfied and not fully satisfied patients were identified as early as 6 weeks after surgery.

CONCLUSION

Visibly different satisfaction profiles were captured among satisfied and not fully satisfied patient responses, with differences in patient-perceived joint function, general health, and pain severity occurring as early as 6 weeks after surgery. This study provides metrics to support early identification of patients at risk of poor TKA satisfaction, enabling clinicians to apply timely targeted treatment and support interventions, with the aim of improving patient outcomes.

Canceled Total Joint Arthroplasty: Who, What, When, and Why?

BACKGROUND

Unexpected cancelation of scheduled total joint arthroplasty (TJA) procedures creates patient distress and disruption for the clinical team. The purpose of this study is to identify the etiology and fate of cancelations for scheduled TJAs.

METHODS

A consecutive series of 11,670 patients at a single institution from 2013 to 2017 was reviewed in March 2020. All patients who were scheduled for a primary total hip arthroplasty or total knee arthroplasty and subsequently canceled were identified. The etiology of cancelation and time to rescheduling were recorded.

RESULTS

Of the 505 (4.3%) canceled patients, 209 (42%) were due to medical reasons. Three hundred ninety-one patients (77%) eventually underwent their procedure at a mean delay of 165 days (19-1908). Only 53 (25%) patients canceled for a medical reason underwent further diagnostic or therapeutic intervention for their medical condition. When compared to patient-driven cancelations, those canceled for medical reasons had a higher mean Charlson Comorbidity Index (0.82 vs 0.39, P < .001), were canceled closer to the scheduled surgery date (8.55 vs 18.1 days, P < .001), and were more likely to eventually undergo surgery (86% vs 73%, P = .004).

CONCLUSION

Canceled elective TJA surgeries are most often due to a medical concern, however only a minority of these patients undergo intervention for that medical condition. To minimize the risk of cancelation, healthcare providers may consider early referral of medically complex patients to the patient's primary care physician. After cancelation, patients should have a clearly defined path to return to the operative schedule to prevent further delays.

COVID-19-related cancellation of elective orthopaedic surgery caused increased pain and psychosocial distress levels

PURPOSE

Health care systems in most European countries were temporarily restructured to provide as much capacity as possible for the treatment of coronavirus disease 2019 (COVID-19) patients. Subsequently, all elective surgeries had to be cancelled and postponed for months. The aim of the present study was to assess the pretreatment health status before and after COVID-19-related cancellation and the psychosocial distress caused by the cancellation.

METHODS

For this study, a questionnaire was developed collecting sociodemographic data and information on health status before and after the cancellation. To assess psychosocial distress, the validated depression module of the Patient Health Questionnaire (PHQ-9), was implemented. PHQ-9-Scores of 10 and above were considered to indicate moderate or severe depressive symptoms. In total, 119 patients whose elective orthopaedic surgery was postponed due to the COVID-19 pandemic were surveyed once at least 8 weeks after the cancellation.

RESULTS

Seventy-seven patients (65%; 34 female, 43 male) completed the questionnaire and were included. The predominant procedures were total knee arthroplasty (TKA), hip arthroscopy and foot and ankle surgery. The mean pain level significantly increased from 5.5 ± 2.2 at the time of the initially scheduled surgery to 6.2 ± 2.5 at the time of the survey (p < 0.0001). The pain level before cancellation of the surgery was significantly higher in female patients (p = 0.029). An increased analgetic consumption was identified in 46% of all patients. A mean PHQ-9 score of 6.1 ± 4.9 was found after cancellation. PHQ-9 scores of 10 or above were found in 14% of patients, and 8% exhibited scores of 15 points or above. Significantly higher PHQ-9 scores were seen in female patients (p = 0.046). No significant differences in PHQ-9 scores were found among age groups, procedures or reasons for cancellation.

CONCLUSION

Cancellation of elective orthopaedic surgery resulted in pain levels that were significantly higher than when the surgery was scheduled, leading to increased analgesic use. Additionally, significant psychosocial distress due to the cancellation was identified in some patients, particularly middle-aged women. Despite these results, confidence in the national health care system and in the treating orthopaedic surgeons was not affected.

LEVEL OF EVIDENCE

Level III.

Factors associated with poor self-reported function and quality of life in patients with end-stage knee or hip osteoarthritis immediately prior to total joint arthroplasty

INTRODUCTION

The aim was to evaluate patients' perception of function and physical and mental dimensions of health-related quality of life (HRQoL) in patients with end-stage knee or hip osteoarthritis (OA) immediately prior to surgery and to identify the factors associated with the outcomes.

MATERIAL AND METHODS

The study included 200 patients with end-stage OA (100 knee OA and 100 hip OA patients). Self-reported physical function was assessed using the Oxford Knee Score or Oxford Hip Score. Physical and mental dimensions of HRQoL were assessed using the physical and mental component summary scores of the 36-Item Short-Form Health Survey. Multivariate linear regression analysis was used to identify the sociodemographic, clinical and psychological factors associated with self-reported function and physical and mental dimensions of HRQoL.

RESULTS

End-stage knee or hip OA patients had poor function and physical dimension of HRQoL, while the mental dimension of HRQoL was not impaired. In knee OA, pain, flexion range of motion (ROM), catastrophizing, and anxiety were significantly associated with self-reported function (explained 56% of the variance), whereas catastrophizing explained 10% of the variance of the physical dimension of HRQoL. In hip OA, flexion ROM, catastrophizing and being employed were significantly associated with self-reported function (explained 44% of the variance), whereas catastrophizing and flexion ROM explained 34% of the variance of the physical dimension of HRQoL.

CONCLUSIONS

Many investigated factors were associated with poor self-reported function and HRQoL in knee and hip OA. However, the most important factors for both knee and hip OA were catastrophizing and flexion ROM.

Quantifying the Backlog of Total Hip and Knee Arthroplasty Cases: Predicting the Impact of COVID-19

BACKGROUND

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are two high-volume procedures that were delayed due to COVID-19.

QUESTIONS/PURPOSES

To help strategize an effective return to elective orthopedic surgery, we aimed to quantify the volume of THA and TKA cases delayed across the USA and estimate the time required to care for these patients when non-urgent surgery resumes.

METHODS

Population-level data was used to estimate monthly THA and TKA procedural volume from 2011 to 2017. Using linear regression, we used this data to project monthly procedural volumes for 2020 to 2023. Nine different permutations were modeled to account for variations in case delay rates (50%, 75%, 100%) and in resumption of non-urgent procedure timing. Two recovery pathways using the highest volume month as a surrogate for maximum operative capacity, and a second using the highest month + 20% were used to simulate a theoretical expansion of current capacity.

RESULTS

The projected national volume of delayed cases was 155,293 (mid-March through April; 95% CI 142,004 to 168,580), 260,806 (through May; 95% CI 238,658 to 282,952), and 372,706 (through June; 95% CI 341,699 to 403,709). The best- and worst-case scenarios for delayed cases were 77,646 (95% CI 71,002 to 84,290) and 372,706 (95% CI 341,699 to 403,709), respectively. The projected catch-up time varied between 9 and nearly 35 months for the best- and worst-case scenarios. The addition of 20% increased productivity decreased this time to between 3.21 and 11.59 months.

CONCLUSION

The COVID-19 pandemic has generated a significant backlog of THA and TKA procedures. Surgeons, administrators, and policymakers should account for these modeled estimates of case volume delays and projected demands.

Patient Perceptions of COVID-19-Related Surgical Delay: An Analysis of Patients Awaiting Total Hip and Knee Arthroplasty

BACKGROUND

COVID-19 has caused unprecedented delays in elective orthopedic surgery. Understanding patients' perceptions of the disruptions in care and their willingness to reengage the healthcare system are crucial to planning the resumption of elective care.

QUESTIONS/PURPOSES

The purpose of this study was to elicit patient perceptions about delays in total joint arthroplasty during the COVID-19 pandemic.

METHODS

We identified a consecutive series of patients who experienced COVID-19-driven delays to scheduled total hip or knee arthroplasty at an urban, academic medical center in the Southeastern United States. A 20-item survey was administered via telephone. Answers were recorded and descriptive statistics were performed. A post hoc χ-square analysis compared characteristics and outlooks of patients who did and did not immediately desire surgery.

RESULTS

Of 111 patients (64% of those identified) who met inclusion criteria and completed the survey, 96% said they felt that they were treated fairly and 90% said that the surgical delay was in their best interest; 68% reported emotional distress from the delay, but 45% reported a desire to wait longer for the pandemic to subside. Lower joint-function scores, higher pain levels, higher pain catastrophizing scores, and longer latency from personally deciding to pursue surgery were associated with the reported need for immediate surgery.

CONCLUSION

Overall, patients reported that they understood the need for elective surgical delays during the COVID-19 pandemic. However, the psychological implications they reported were not negligible. Patient preference for immediate reengagement with the healthcare system was dichotomous, with many patients favoring precautionarily furthering the delay. Understanding these preferences will help optimize elective orthopedic care during unprecedented times.

Total Joint Arthroplasty Is Associated With a Decreased Risk of Traumatic Falls: An Analysis of 499,094 Cases

INTRODUCTION

The rate of traumatic falls in the aging cohort is estimated to increase across the United States. We sought to determine whether patients with lower extremity osteoarthritis (OA) who underwent total joint arthroplasty (TJA) had a reduced risk of falling compared with those with OA who did not undergo TJA.

METHODS

The New York Statewide Planning and Research Cooperative System database was queried from 2000 to 2015 to identify 499,094 cases with primary diagnosis of hip or knee OA. Patients were stratified into 4 cohorts: group 1 (hip OA with total hip arthroplasty [THA] [N = 168,234]), group 2 (hip OA without THA [N = 22,482]), group 3 (knee OA with total knee arthroplasty [TKA] [N = 275,651]), and group 4 (knee OA without TKA [N = 32,826]). Patients were followed up longitudinally to evaluate the long-term risks of subsequent traumatic falls. Cox proportional hazards models were conducted to examine the relationship between patients' demographics and clinical characteristics and the risk of subsequent traumatic falls and reported as hazard ratios (HRs) with 95% confidence intervals (95% CIs).

RESULTS

Nineteen thousand seven hundred seventeen patients with hip OA underwent 168,234 primary THAs (88.2%), and 308,477 patients with knee OA underwent 275,651 primary TKAs (89.4%) during the period 2000 to 2015. Compared with patients without TJA, those who underwent TJA were at a decreased risk of falls (THA HR 0.56 [95% CI, 0.48 to 0.66]) and TKA HR 0.66 [95% CI, 0.57 to 0.76]). Compared with age 40 to 49 years, risk increases for ages 70 to 79 years (HR = 4.3, 95% CI: 2.8 to 6.6) and 80 years or older (HR = 5.5, 95% CI: 3.8 to 8.1).

CONCLUSION

TJA is associated with a decreased risk of long-term traumatic falls in elderly patients with the primary diagnosis of hip or knee osteoarthritis.

LEVEL OF EVIDENCE

Level III Retrospective Case-control study.

Decrease of Quality of Life, Functional Assessment and Associated Psychological Distress in Patients with Hypoallergenic Total Knee Arthroplasty

Total knee arthroplasty (TKA) is the final treatment for knee osteoarthritis, and 15-30% of patients show little or no improvement. This high percentage is related to aspects of the surgical technique, the selected implant, and specific patient characteristics. The aim of this study was to analyze whether there are differences in quality of life (QoL) and functional capacity among patients undergoing TKA with conventional implants compared to those treated with hypoallergenic oxinium implants. A pragmatic clinical study was carried out that included patients who underwent TKA between January 2013 and December 2015. During this period, 245 knees in 228 patients were treated. Eleven patients were excluded, leaving a sample of 161 conventionally treated knees, 72 knees treated with hypoallergenic implants, and one patient who received both implant types. In all patients, QoL and functional capacity were measured with the WOMAC index, the SF-12 questionnaire, and the Euro-Qol-5D L-VAS. We also assessed the psychological distress of each patient and related the findings to the functional results. The differences in QoL were tested using ANCOVA and propensity score matching (PSM) models adjusted for sex, age, weight, psychiatric history and associated complications. Patients who underwent TKA using conventional prostheses had significantly better scores on the total WOMAC index and in the pain domain (p < 0.05) than those who received hypoallergenic prostheses, but no significant differences were observed for the other domains in the ANCOVA. In contrast, with the PSM, we also found statistically significant differences in the difficulty domain of the WOMAC. Significant differences were found for the SF-12 mental health questionnaire results (p = 0.038), but the same did not occur for the physical health domain in the ANCOVA and PSM. We also found statistically significant differences in the Euro-Qol-5D index results (p = 0.041), but not in the VAS scale scores for the same questionnaire in the ANCOVA, and we did not find significant differences in either with the PSM. Patients with metal allergies and those who present psychological distress had WOMAC, SF-12, and Euro-Qol-5D results that were statistically significantly worse than those of patients who received conventional implants. Patients who underwent hypoallergic TKA had lower scores on the QoL and functional capacity scales than patients who received conventional Cr-Co implants. Additionally, patients with psychological distress had worse results on the questionnaires, and those with a metal allergy had even lower scores; the differences were statistically significant.

Knee Osteoarthritis Treatment Costs in the Medicare Patient Population

BACKGROUND

Several nonoperative options have been recommended for the treatment of knee osteoarthritis (OA), with varying degrees of evidence. Adhering to the American Academy of Orthopaedic Surgeons clinical practice guidelines has been suggested to decrease direct treatment costs by 45% in the year before knee arthroplasty, but this does not consider the cost of the entire episode of care, including the cost of surgery and postsurgery care.

OBJECTIVES

To analyze the total treatment costs after a diagnosis of knee OA, as well as the proportion of arthroplasty interventions as part of the total knee OA-related costs, and whether the total costs differed for patients who received intra-articular hyaluronic acid and/or had knee arthroplasty.

METHODS

We identified patients newly diagnosed with knee OA using the 5% Medicare data sample from January 2010 to December 2015. Patients were excluded if they were aged <65 years, had incomplete claim history, did not reside in any of the 50 states, had claim history <12 months before knee OA diagnosis, or did not enroll in Medicare Part A and Part B. The study analyzed knee OA-related costs from a payer perspective in terms of reimbursements provided by Medicare, as well as the time from the diagnosis of knee OA to knee arthroplasty for patients who had knee arthroplasty, and the time from the first hyaluronic acid injection to knee arthroplasty for those who received the injection. We compared patients who received hyaluronic acid and those who did not receive hyaluronic acid injections. Patients who received hyaluronic acid injection who subsequently had knee arthroplasty were also compared with those who did not have subsequent knee arthroplasty.

RESULTS

Of the 275,256 patients with knee OA, 45,801 (16.6%) received a hyaluronic acid injection and 35,465 (12.9%) had knee arthroplasty during the study period. The median time to knee arthroplasty was 16.4 months for patients who received hyaluronic acid versus 5.7 months for those who did not receive hyaluronic acid. Non-arthroplasty-related therapies and knee arthroplasty accounted for similar proportions of knee OA-related costs, with hyaluronic acid injection comprising 5.6% of the total knee OA-related costs. For patients who received hyaluronic acid injections and subsequently had knee arthroplasty, hyaluronic acid injection contributed 1.8% of the knee OA-related costs versus 76.6% of the cost from knee arthroplasty. Patients who received hyaluronic acid injections and did not have knee arthroplasty incurred less than 10% of the knee OA-related costs that patients who had surgery incurred.

CONCLUSION

Although limiting hyaluronic acid use may reduce the knee OA-related costs, in this study hyaluronic acid injection only comprised a small fraction of the overall costs related to knee OA. Among patients who had knee arthroplasty, those who received treatment with hyaluronic acid had surgery delayed by a median of 10.7 months and associated costs for a significant period. The ability to delay or avoid knee arthroplasty altogether can have a substantial impact on healthcare costs.

Access to hip and knee replacement surgery in patients with chronic diseases according to patient-reported pain and functional status

BACKGROUND

An increasing number of patients undergoing hip or knee replacement have chronic diseases. It has been suggested that the presence of chronic diseases may affect access to this type of surgery in the English National Health Service (NHS). We examined the access to hip and knee replacement surgery in patients with and without chronic diseases according to preoperative patient-reported pain, functional status and symptom duration.

METHODS

We analysed data of 640,832 patients who had hip or knee surgery between 2009 and 2016 in England. Multivariable regression was used to estimate the impact of 11 chronic diseases on severity of joint problems as measured on a scale from 0 to 48 by Oxford Hip (OHS) and Knee Scores (OKS) just before surgery and on likelihood of long-standing joint problems (> 5 years pre-operatively).

RESULTS

Patients with chronic diseases reported more severe joint problems than patients without (OHS differences ranged from 1.1 [95% CI 0.93, 1.2] to 2.5 [95% CI 2.3, 2.7] and OKS differences from 0.5 [95% CI 0.3, 0.7] to 2.6 [95% CI 2.4, 2.7] for the 11 chronic diseases) but the differences remain small. When analysed separately, patients with chronic diseases reported both more severe pain and poorer functional status. Six chronic diseases in hip patients and two in knee patients increased the likelihood that they had long-standing joint problems. The severity of joint problems just before surgery increased with the number of chronic diseases (OHS differences; one chronic disease (1.5 [95% CI 1.4, 1.5]) to four or more (5.8 [95% CI 5.6, 6.0])).

CONCLUSIONS

Patients with chronic diseases reported more severe joint problems immediately before hip or knee replacement surgery suggesting they have hip or knee replacement later in the course of their joint disease.

Outcomes of Computer-Assisted Surgery Compared with Conventional Instrumentation in 19,221 Total Knee Arthroplasties: Results After a Mean of 4.5 Years of Follow-Up

BACKGROUND

Studies have shown improved alignment in association with the use of computer-assisted surgery (CAS) as compared with conventional instrumentation during total knee arthroplasty (TKA) but have failed to show a consistent clinical benefit. The aim of the present study was to compare the revision rates and functional outcomes following TKA performed with either CAS or conventional instrumentation. Recognizing that selection bias may arise from the preferential use of CAS in difficult or complex cases, the implant survival data and postoperative functional scores were analyzed with reference to whether the surgeon routinely performed TKA with use of CAS or conventional instrumentation.

METHODS

Revision rates and functional data in terms of the Oxford Knee Score (OKS) at 6 months, 5 years, and 10 years were obtained from the New Zealand Joint Registry (NZJR) for 19,221 TKAs performed from 2006 to 2018.These data were analyzed by comparing 2 cohorts of patients: those managed by high-volume surgeons who routinely used CAS ("routine CAS" surgeons) and those managed by high-volume surgeons who routinely used conventional instrumentation ("routine conventional" surgeons). The mean duration of follow-up was 4.5 years (range, 0 to 12 years).

RESULTS

The revision rate per 100 component-years was 0.437 for the "routine CAS" surgeons, compared with 0.440 for the "routine conventional" surgeons (p = 0.724). For patients <65 years of age, the revision rate per 100 component-years was equivalent for the "routine CAS" and "routine conventional" surgeons (0.585 compared with 0.508; p = 0.524). The OKS scores were similar at 6 months (38.88 compared with 38.52; p = 0.172), 5 years (42.26 compared with 41.77; p = 0.206), and 10 years (41.59 compared with 41.74; p = 0.893) when comparing the 2 cohorts. Surgeons who had performed >50 TKAs with use of CAS took 10 minutes longer on average than those who used conventional instrumentation (92 compared with 82 minutes; p = 0.012).

CONCLUSIONS

The present study demonstrated no difference in survivorship or functional outcome scores to support using CAS for TKA. Experienced surgeons using CAS had longer operative durations than comparable surgeons using conventional instrumentation.

LEVEL OF EVIDENCE

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

Procedural Treatments for Knee Osteoarthritis: A Review of Current Injectable Therapies

Knee osteoarthritis is a common painful degenerative condition affecting the aging Canadian population. In addition to pain and disability, osteoarthritis is associated with depression, comorbid conditions such as diabetes, and increased caregiver burden. It is predicted to cost the Canadian healthcare system $7.6 billion dollars by 2031. Despite its high cost and prevalence, controversy persists in the medical community regarding optimal therapies to treat knee osteoarthritis. A variety of medications like nonsteroidal anti-inflammatories and opioids can cause severe side effects with limited benefits. Total knee arthroplasty, although a definitive management, comes with risk such as postoperative infections, revisions, and chronic pain. Newer injectable therapies are gaining attention as alternatives to medications because of a safer side effect profile and are much less invasive than a joint replacement. Platelet-rich plasma is beginning to replace the more common injectable therapies of intra-articular corticosteroids and hyaluronic acid, but larger trials are needed to confirm this effect. Small studies have examined prolotherapy and stem cell therapy and demonstrate some benefits. Trials involving genicular nerve block procedures have been successful. As treatments evolve, injectable therapies may offer a safe and effective pathway for patients suffering from knee osteoarthritis.

The Effects of Baduanjin Qigong on Postural Stability, Proprioception, and Symptoms of Patients With Knee Osteoarthritis: A Randomized Controlled Trial

Background: Knee osteoarthritis is a common disease affecting a large number of old individuals worldwide. This study aimed to explore the effects of Baduanjin Qigong in patients with knee osteoarthritis. Methods: Fifty participants with knee osteoarthritis were randomly assigned to either an experimental group (n = 25) or a control group (n = 25). Participants in the experimental group received Baduanjin Qigong training for 12 weeks, with three sessions per week lasting 40 min per session. Participants in the control group did not receive any additional physical training. All of participants completed outcome (proprioception, postural stability, and functional ability) assessments at three time points (baseline, Week 8, 12). Results: Proprioception and Western Ontario and McMaster Universities Osteoarthritis Index function were statistically improved at eighth and 12th week of the intervention in the Baduanjin Qigong group (p < 0.05), while the control group did not have any significant changes. For postural stability at the anterior-posterior direction with eyes closed, Baduanjin Qigong group showed significant improvement compared to controls after the 12 weeks of intervention (p < 0.05). Conclusions: Regular Baduanjin Qigong practice helped the improvement of knee joint proprioception and postural stability, and reduction of pain, stiffness, and functional impairments of old adults with knee osteoarthritis. Well-designed randomized controlled trials with long-term assessment are needed. The trial was registered in Chinese Clinical Trial Registry (ChiCTR-IOR-16010042). URL: http://www.chictr.org.cn/hvshowproject.aspx?id=10550.

Clinical pathway efficiency for elective joint replacement surgeries: a case study

PURPOSE

The purpose of this paper is to define a clinical pathway for total joint replacement (TJR) surgery, estimate the effect of delays between steps of the pathway on wait time for surgery and to identify factors contributing to more efficient operations and challenges to their implementation.

DESIGN/METHODOLOGY/APPROACH

This is a case study with a mixed methods approach. The authors conducted interviews with hospital staff. Data collected in the interviews and through on-site observation were analyzed to map the TJR process and identify the steps of the care pathway. The authors extracted and analyzed data (time stamps) from 60 hospital patient records for each step in the pathway and ran a regression on the duration of the whole trajectory.

FINDINGS

There were wide variations in the delays observed between the seven steps identified. The delay between Step 1 and Step 2 was the only significant variable in predicting the total wait time to surgery. In one hospital, one delay explained 50 percent of the variation. There was misalignment between findings from the qualitative data in terms of strategies implemented to increase efficiency of the clinical pathway to the quantitative data on delays between the steps.

RESEARCH LIMITATIONS/IMPLICATIONS

The study identified the clinical pathway from the consultation with an orthopaedic surgeon to the surgery. However, it did not go beyond the surgery. Future research could investigate the relationship between specific processes and delays between steps of the process and patient outcomes, including length of stay, mobilization and functionality in activities of daily living, as well as potential complications from surgery, readmission and the services required after the patient was discharged.

PRACTICAL IMPLICATIONS

Wait times can be addressed by implementing strategies at the health system level or at the organizational level. The authors found and discuss areas where there could be efficiency gains for health care organizations.

SOCIAL IMPLICATIONS

Stakeholders in care processes are diverse and they each have their preferences in how they practice (in the case of providers) and how they perceive and wish to respond adequately to patients' needs in contexts that have different norms and approaches. The approach in this study enables a better understanding of the processes, the organizational culture and how these may affect each other.

ORIGINALITY/VALUE

Our mixed methods enabled a process mapping and the identification of factors that significantly affected the efficiency of the TJR surgery process. It combines methods from process engineering with health services and management research. To some extent, this study demonstrates that although managers can define and enforce processes, organizational culture and practices are harder to influence.

Comparative Effectiveness of Intra-Articular Hyaluronic Acid and Corticosteroid Injections on the Time to Surgical Knee Procedures

BACKGROUND

Use of intra-articular hyaluronic acid (HA) injections to manage knee osteoarthritis (OA) remains controversial because of weak and conflicting evidence. The objective was to evaluate the effectiveness of intra-articular HA injections for knee OA management.

METHODS

A nested cohort of persons with knee OA seeing a specialist was created using a 10% random sample of LifeLink Plus claims (2010-2015) to compare the risk of composite (any) knee surgical interventions, total (TKA)/unicompartmental knee arthroplasty (UKA) and TKA only among HA users and 2 comparison groups: corticosteroid (CS) users and HA/CS nonusers. A high-dimensional propensity score (hdPS) was used to match HA users with CS users and with HA/CS nonusers on background covariates. The risk of surgical interventions among HA users relative to the comparison groups was assessed using Cox proportional hazard models.

RESULTS

Among 13,849 patients, 797 were HA users, 5327 were CS users, and 7725 were HA/CS nonusers. After hdPS matching, the risk of composite surgical interventions did not differ between HA users and HA/CS nonusers (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.67-1.16) and CS users (HR, 0.89; 95% CI, 0.65-1.12). Seven of the 8 sensitivity analyses demonstrated no significant benefit among HA users compared to CS users and HA/CS nonusers. A sensitivity analysis that restricted the study cohort to those who ultimately have knee surgery showed a lower risk of surgery of HA (HR, 0.87; 95% CI, 0.79-0.95).

CONCLUSION

There were no significant differences in the risk of surgical interventions among HA users compared to HA/CS nonusers and CS users after accounting for residual confounding using an hdPS.

Effects of an over-ground exoskeleton on external knee moments during stance phase of gait in healthy adults

BACKGROUND

Physical activity and exercise is central to conservative management of knee osteoarthritis (KOA), but is often difficult for patients with KOA to maintain over the decade or more prior to surgical management. Better approaches are needed for maintaining physical function and health in this population that can also address the patho-biomechanics of the osteoarthritic knee. The objective of the study is to quantify how a lower-extremity robotic exoskeleton (dermoskeleton) modifies the external knee moments during over-ground walking in a sample of healthy adults, and to evaluate these biomechanical modifications in the context of the osteoarthritic knee.

METHOD

Motion analysis data was acquired for 13 participants walking with and without the dermoskeleton. Force plate data, external knee moment arms, and knee moments in the laboratory and tibia frames of reference were computed, as well as time-distance parameters of walking, and compared between the two conditions.

RESULTS

Although gait speed was not different, users took shorter and wider steps when walking with the dermoskeleton. Ground reaction forces and early-stance knee moment increased due to the added mass of the dermoskeleton, but the knee adduction moment was significantly reduced in late stance phase of gait. There was no effect on the knee torsional moment when measured in the anatomical frame of reference, and the late-stance knee flexion moment was invariant.

CONCLUSIONS

The dermoskeleton demonstrated favorable biomechanical modifications at the knee in healthy adults while walking. Studies are warranted to explore this technology for enabling physical activity-based interventions in patients with KOA.

Comparison of Low-, Moderate-, and High-Molecular-Weight Hyaluronic Acid Injections in Delaying Time to Knee Surgery

BACKGROUND

We compared the effectiveness of low-molecular-weight (MW) hyaluronic acid (HA) injections (LMWHA), moderate-MW HA injections (MMWHA), and high-MW HA injections (HMWHA) for prevention or delay of knee surgery in patients with knee osteoarthritis.

METHODS

An observational cohort study using LifeLink Plus claims (2006-2015) was used. The primary outcome measure of the study included all surgical interventions of the knee. The secondary outcome measures were the following: (1) unicompartmental knee arthroplasty or total knee arthroplasty and (2) total knee arthroplasty only. A high-dimensional propensity score (hdPS) using 1:1 matching was used to adjust for confounding. The likelihood of each outcome was assessed using Cox proportional hazard models.

RESULTS

A cohort of 30,417 incident HA users with knee osteoarthritis met our inclusion-exclusion criteria. There was no difference in the likelihood of composite surgical events between LMWHA users (hazard ratio, 0.939; 95% confidence interval, 0.870-1.013) and MMWHA users (hazard ratio, 1.032; 95% confidence interval, 0.952-1.119) when compared with HMWHA users in a matched hdPS analysis. However, a significantly lower likelihood for all outcome measures was demonstrated in LMWHA and MMWHA users compared with HMWHA users when hdPS was not used.

CONCLUSION

There was no significant difference in the likelihood of surgical interventions between LMWHA, MMWHA, and HMWHA users after accounting for empirically derived confounders.

Use of strong opioids for chronic pain in osteoarthritis: an insight into the Latin American reality

INTRODUCTION

Osteoarthritis is the most common cause of arthritis and one of the main causes of chronic pain. Although opioids are frequently employed for chronic pain treatment, their usage for osteoarthritis pain remains controversial due to the associated adverse effects. Most guidelines reserve their use for refractory pain in patients with hip and knee osteoarthritis. The situation is even more complex in Latin America, where the prevalence of insufficient pain treatment is high because of the limited availability and use of strong opioids. Areas covered: In this article we review the epidemiology of osteoarthritis, its socioeconomic burden, its impact as a chronic pain cause and the pharmacological treatment options, giving emphasis to the role of strong opioids, their safety and efficacy, especially in Latin American countries, where restrictions regulate their usage. Expert commentary: Usage of strong opioids is safe and effective in the short-term management of osteoarthritis with moderate to severe pain, when other pharmacological treatments are inadequate and surgery is contraindicated, provided their use adheres to existing guidelines. Educational programs for patients and physicians and further research on treating chronic pain with opioids should be implemented to reduce adverse effects and improve care quality.

Effects of preoperative walking ability and patient's surgical education on quality of life and functional outcomes after total knee arthroplasty

Objective

Prospectively analyze the effect of preoperative walking status and the patient's surgical education on functional outcomes and the three dimensions of quality of life (QoL) (pain, physical function, and mental health) after elective total knee arthroplasty (TKA).

Methods

A comparative analysis on the QoL and functional outcomes in patients who underwent total knee arthroplasty between January 2014 and June 2015. To compare effects of the patient's walking status and knowledge of the surgical procedure on QoL and functional outcomes following TKA by means of SF-36 questionnaire, CES D10, VAS, KSS, KSFS, WOMAC, as well as Friedmann and Wyman scores, 10MWT, and 30-second timed chair test, assessed before the operation and one, three, and six months after the operation.

Results

There were 168 knees in 154 patients: 46.75% men and 53.24% women. 52.38% of knees had grade-III OA and 40.47% of knees had grade-IV OA. Preoperatively, SF-36 PCS was 33.2 and MCS was 35.4. Mean KSS and KSFS in females was 37.3 (16.2) and 31.5 (13.8); in males it was 49.2 (18.4) and 42.5 (15.7), respectively. Mean WOMAC scores were 64.2 in females and 56.5 in males. Mean VAS and CES D10 scores were 8.8 and 8.2 in females, and 6.9 and 6.4 in males, respectively. Post operatively at the first, third, and sixth month, significant improvements in QoL and mean SF-36, CES D10, VAS, KSS, KSFS, WOMAC, and Friedmann and Wyman scores were observed, as well as in the 10MWT and 30 s timed chair test scores. Patients with better preoperative functional activity and satisfactory understanding of TKA presented a better functional performance and achieved a good quality life (p < 0.01).

Discussion

Surgeons educate TKA candidates regarding the surgical procedure, the nature of implants, and how the procedure would affect their lifestyle and what their expectations from TKA should be. These crucial considerations should boost their confidence, enhancing their involvement and cooperation in post-surgical rehabilitation, thereby improving their QoL, functional results, and post TKA experience.

Conclusion

TKA candidates with good preoperative walking ability and understanding of knee arthroplasty have better QoL in early and late post-surgery periods. Patient's lifestyle and understanding significantly enhances the postoperative functional ability.

Cardiovascular and cerebrovascular risk with nonsteroidal anti-inflammatory drugs and cyclooxygenase 2 inhibitors: latest evidence and clinical implications

Observational studies and meta-analyses have shown that the administration of nonsteroidal anti-inflammatory drugs (NSAIDs), especially when prescribed at high doses for long periods of time, can potentially increase the risk of cardiovascular diseases. The increased thrombotic risk related to the use of NSAIDs is mainly due to their cyclooxygenase 2 selectivity. The dosage use, the formulation selected and the duration of the therapy are other factors that can significantly impact on the cardiovascular risk. In order to minimize the risk, prescription of the right drug based on the patient's features and the different safety profiles of several NSAIDs that are available on the market is key for their appropriate administration. Despite the baseline cardiovascular and gastrointestinal risk of each patient, monitoring of patients is suggested for increases in blood pressure, development of edema, deterioration of renal function, or gastrointestinal bleeding during long-term treatment with NSAIDs.

Long-term clinical benefit and cost-effectiveness of an 8-week multimodal knee osteoarthritis management program incorporating intra-articular sodium hyaluronate (Hyalgan®) injections

Background

Given the poor long-term effectiveness of focused nonsurgical knee osteoarthritis (OA) treatments, alternative therapies are needed for patients who have unsuccessfully exhausted nonsurgical options.

Methods

A telephone interview was conducted in patients who participated in a single 8-week multimodal knee OA treatment program (mean follow-up: 3.7 years, range: 2.7–4.9 years). The program consisted of five intra-articular knee injections of sodium hyaluronate (Hyalgan^®), with each injection given 1 week apart, structured physical therapy, knee bracing, and patient education. Clinical outcomes included knee pain severity, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) subscores, current medication use, and history of total knee arthroplasty. Base-case, subgroup, and sensitivity analyses were conducted to determine the incremental cost-effectiveness ratio (ICER) of the treatment program with comparisons made to historical literature controls undergoing usual care.

Results

A total of 218 patients (54%) provided long-term follow-up data. Knee pain severity decreased 60% and WOMAC subscores decreased 33%–42% compared to baseline (all p<0.001). Total knee arthroplasty was performed in 22.8% (81/356) of knees during followup. The treatment program was highly cost-effective compared to usual care with a base-case ICER of $6,000 per quality-adjusted life year (QALY). Results of subgroup analyses, one-way deterministic sensitivity analyses, and second-order probabilistic sensitivity analyses resulted in ICERs ranging from $3,996 to $10,493 per QALY. The percentage of simulations with an ICER below willingness-to-pay limits was 97.2%, 98.9%, and 99.4% for the $50,000, $100,000, and $150,000 per QALY thresholds, respectively.

Conclusion

Participation in a single 8-week knee OA treatment program, which included one cycle of five intra-articular knee injections of sodium hyaluronate given at weekly intervals, is highly cost-effective and provides clinically meaningful reductions in patient symptoms that are maintained over 3.7 years mean follow-up.

Greater pre-operative anxiety, pain and poorer function predict a worse outcome of a total knee arthroplasty

PURPOSE

Around 10-30 % of patients are dissatisfied with the results of their total knee arthroplasty (TKA). This review aimed to identify and evaluate the predictors of outcome measured by the three domains of health-related quality of life (pain, stiffness and function). The focus was on pre-operative psychological factors as related to other patient-related variables.

METHODS

A systematic search was performed using the following databases: MEDLINE, PubMed, AMED, CINAHL, PsychINFO, SciFinder, Scopus, EMBASE, Cochrane, Lilacs, Web of Science and ScienceDirect. The quality of identified studies was assessed using the Critical Appraisal Skills Programme Cohort checklist.

RESULTS

Ten studies met the eligibility criteria. From these, nine patient-related predictors of outcome were identified (depression, anxiety, age at surgery, gender (being female), medical co-morbidities, BMI, level of education, pre-operative pain severity and pre-operative knee function). Greater anxiety, pre-operative pain and function were the most significant factors to predict a poorer outcome of a TKA. The results of depression, gender (female), medical co-morbidities, BMI and level of education were variable among the included studies. There was very little evidence to support older age at operation as a predictor of poorer outcome.

CONCLUSION

Patients experiencing high levels of pain before surgery should be informed of the chances of improvement by having a TKA. A validated psychological screening tool that separates depression and anxiety is recommended as part of the pre-operative assessment stage. Patients presenting with symptoms of depression and anxiety should be identified and consulted before a TKA.

LEVEL OF EVIDENCE

II.

Preoperative Pain and Function: Profiles of Patients Selected for Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is an effective treatment to relieve pain and restore function in patients with advanced knee osteoarthritis. TKA utilization is growing rapidly, and the appropriateness of current TKA use is of great interest. We examined patient-reported preoperative pain and function profiles to understand symptom severity at the time of TKA decision.

METHODS

Data were from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement. We included patients undergoing primary, unilateral TKAs between 2011 and 2014 for osteoarthritis and had data on the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain and Short-Form 36-item Physical Component Summary (PCS) score. We compared patient profiles across groupings by symptoms: (1) little pain and high function (KOOS ≥70, PCS ≥40); (2) little pain but poor function (KOOS ≥70, PCS <40); (3) high pain but high function (KOOS <70, PCS ≥40); and (4) high pain and poor function (KOOS <70, PCS <40).

RESULTS

Of 6936 patients, 77% had high pain and poor function (group 4), 19% had high pain "or" poor function (groups 2-3), and 5% had little pain and high function before TKA (group 1). In group 1, 86% were constantly aware of their knee problem, 48% reported pain daily yet 5% experienced severe or extreme pain on stairs, and 1% pain in bed. Over half had a lot of limitations in vigorous activities. Compared with group 4, group 1 were older, less obese, more educated, and included more men and people reporting being healthy, less disabled, and happy (P < .05 for all).

CONCLUSION

Most patients undergoing TKAs had significant pain and/or poor function. Our results provide critical information given the current debate of potentially inappropriate TKA utilization in the United States.

Inadequate pain relief among patients with primary knee osteoarthritis

BACKGROUND

Despite the widespread treatments for Osteoarthritis (OA), data on treatment patterns, adequacy of pain relief, and quality of life are limited. The prospective multinational Survey of Osteoarthritis Real World Therapies (SORT) was designed to investigate these aspects.

OBJECTIVES

To analyze the characteristics and the patient reported outcomes of the Portuguese dataset of SORT at the start of observation.

METHODS

Patients ≥ 50 years with primary knee OA who were receiving oral or topical analgesics were eligible. Patients were enrolled from seven healthcare centers in Portugal between January and December 2011. Pain and function were evaluated using the Brief Pain Inventory (BPI) and WOMAC. Quality of life was assessed using the 12-Item Short Form Health Survey (SF-12). Inadequate Pain Relief (IPR) was defined as a score>4/10 on item 5 of the BPI.

RESULTS

Overall, 197 patients were analyzed. The median age was 67.0 years and 78.2% were female. Mean duration of knee OA was 6.2 years. IPR was reported by 51.3% of patients. Female gender (adjusted odds ratio - OR 2.15 [95%CI 1.1, 4.5]), diabetes (OR 3.1 [95%CI 1.3, 7.7]) and depression (OR 2.24 [95%CI 1.2, 4.3]) were associated with higher risk of IPR. Patients with IPR reported worst outcomes in all dimensions of WOMAC (p<0.001) and in all eight domains and summary components of SF-12 (p<0.001).

CONCLUSIONS

Our findings indicate that improvements are needed in the management of pain in knee OA in order to achieve better outcomes in terms of pain relief, function and quality of life.

Relationships among pain intensity, pain-related distress, and psychological distress in pre-surgical total knee arthroplasty patients: a secondary analysis

The current study aimed to examine the relationships between movement and resting pain intensity, pain-related distress, and psychological distress in participants scheduled for total knee arthroplasty (TKA). This study examined the impact of anxiety, depression, and pain catastrophizing on the relationship between pain intensity and pain-related distress. Data analyzed for the current study (N = 346) were collected at baseline as part of a larger Randomized Controlled Trial investigating the efficacy of TENS for TKA (TANK Study). Participants provided demographic information, pain intensity and pain-related distress, and completed validated measures of depression, anxiety, and pain catastrophizing. Only 58% of the sample reported resting pain >0 while 92% of the sample reported movement pain >0. Both movement and resting pain intensity correlated significantly with distress (r_s = .86, p < .01 and .79, p < .01, respectively). About three quarters to two thirds of the sample (78% for resting pain and 65% for movement pain) reported different pain intensity and pain-related distress. Both pain intensity and pain-related distress demonstrated significant relationships with anxiety, depression, and catastrophizing. Of participants reporting pain, those reporting higher anxiety reported higher levels of distress compared to pain intensity. These findings suggest that anxious patients may be particularly distressed by movement pain preceding TKA. Future research is needed to investigate the utility of brief psychological interventions for pre-surgical TKA patients.

Translation and validation of the simplified Chinese new Knee Society Scoring System

Background

The NKSS has recently been translated into Dutch version. The reliability and validity were also assessed. However, there is no Simplified Chinese version of New Society Knee Scoring System (SC-NKSS) for Chinese population.

Methods

The SC-NKSS was translated from the original English version following international guidelines. All patients undergoing total knee arthroplasty (TKA) between September 2012 and September 2013 were invited to participate in this study. Finally, a total of 105 did so. Patients (preoperative and postoperative) completed the Chinese version of NKSS, Oxford Knee Score (OKS), the Medical Outcomes General Health Survey (SF-36) and Visual analog scale (VAS). Psychometric testing of reliability, construct validity, content validity were conducted.

Results

All the 105 participants completed the questionnaires and no floor or ceiling effects were checked. Internal consistency was excellent with Cronbach’s alpha coefficient ranging from 0.71 to 0.85. Test-retest reliability was satisfactory with an intraclass correlation coefficient of 0.92 (95%confidence interval, 0.86–0.95). Construct validity was demonstrated to correlate well with the Chinese version of OKS (r =−0.78; p < 0.01), VAS (r =−0.70; p < 0.01), Physical Function (PF) (r = 0.74; p < 0.01), Body Pain (BP) (r = 0.63; p < 0.01) and General Health (GH) (r = 0.51; p < 0.01) of SF-36 domains.

Conclusion

The SC-NKSS was well accepted and demonstrated acceptable psychometric properties in mainland China.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0854-1) contains supplementary material, which is available to authorized users.

Clinical profile, level of affection and therapeutic management of patients with osteoarthritis in primary care: The Spanish multicenter study EVALÚA

OBJECTIVE

To determine the clinical profile, degree of involvement and management in patients with knee, hip or hand osteoarthritis.

MATERIAL AND METHOD

Observational study (health centers from 14 autonomous regions, n=363 primary care physicians), involving patients with clinical and/or radiological criteria for osteoarthritis from the American College of Rheumatology, consecutively selected (n=1,258). Sociodemographic variables, clinical and radiological findings, comorbidity and therapeutic management were analyzed.

RESULTS

Mean age was 68.0±9.5 years old; 77.8% were women and 47.6% obese. Distribution by location was: 84.3% knee, 23.4% hip, 14.7% hands. All patients reported pain. The most frequent radiographic Kellgren-Lawrence grade was stage 3 for knee and hip (42.9% and 51.9%, respectively), and 3 (37.2%) and 2 (34.5%) for hip. Time since onset of osteoarthritis symptoms was 9.4±7.5 years, with a mean age at onset of around 60 years old and a family history of osteoarthritis in 66.0%. The most frequent comorbidities were: hypertension (55.1%), depression/anxiety (24.7%) and gastroduodenal diseases (22.9%). A total of 97.6% of the patients received pharmacological treatment, with oral analgesics (paracetamol) (70.5%) and oral NSAIDs (67.9%) being the most frequent drugs. Bilateral osteoarthritis was present in 76.9% of patients with knee osteoarthritis, 59.3% in hip and 94.7% in hands. Female gender and time since onset were associated with bilateral knee and hip osteoarthritis.

CONCLUSIONS

The profile of the osteoarthritis patient is female, >65 years old, overweight/obese, with comorbidity, frequent symptoms and moderate radiologic involvement. Most of patients had bilateral osteoarthritis, associated with female gender and time since onset of disease. Paracetamol was the most common pharmacological treatment.

The relationship among psychological factors, neglect-like symptoms and postoperative pain after total knee arthroplasty

Neglect-like symptoms have been defined as a loss of perception of a limb, with pain and excessive effort necessary to move the limb. This phenomenon has been studied in patients with complex regional pain syndrome, but has not been assessed in patients who have undergone orthopedic procedures such as total knee arthroplasty. The authors of this study assessed neglect-like symptoms in a group of 90 patients three and six weeks after total knee arthroplasty.

BACKGROUND:

Persistent postoperative pain has a significant relationship with patient health and satisfaction.

OBJECTIVES:

To investigate the prevalence and association of neglect-like symptoms (NLS) and other psychological factors on postoperative pain in patients following total knee arthroplasty (TKA). NLS are defined as the loss of perception of the limb with pain and excessive effort required to move the limb. The authors hypothesized that NLS were an important contributor to postoperative pain.

METHODS:

The factors influencing pain were investigated using a longitudinal study with assessments at three and six weeks postsurgery. The relationships among demographic factors (age, body weight, body mass index), psychological factors (State-Trait Anxiety Inventory and Pain Catastrophizing Scale [PCS]) and NLS with postoperative pain were investigated in 90 patients after TKA. The associations among motor functions (muscle strength of knee extension, range of motion), sensory functions (joint position sense and two-point discrimination in the thigh) and NLS were also investigated.

RESULTS:

At three and six weeks after surgery, 36% and 19% of patients, respectively, experienced NLS. In hierarchical multiple regression analysis, NLS and PCS scores were significantly associated with postoperative pain, while joint position sense and range of motion were significantly associated with NLS.

CONCLUSIONS:

These results suggest that facilitation of sensory integration is important in rehabilitation after TKA because NLS appears to result from impaired sensory integration. The association of PCS scores with postoperative pain and NLS suggests the need to provide appropriate postoperative education to reduce persistent negative thoughts regarding future pain.

Quality of life in patients with knee osteoarthritis: a commentary on nonsurgical and surgical treatments

Knee osteoarthritis (OA) has a significant negative impact on health-related quality of life (HRQoL). Identification of therapies that improve HRQoL in patients with knee OA may mitigate the clinical, economic, and social burden of this disease. The purpose of this commentary is to report the impact of knee OA on HRQoL, describe the change in HRQoL attributable to common knee OA interventions, and summarize findings from clinical trials of a promising therapy. Nonsurgical therapies do not reliably modify HRQoL in knee OA patients given their general inability to alleviate physical manifestations of OA. Surgical knee OA interventions generally result in good to excellent patient outcomes. However, there are significant barriers to considering surgery, which limits clinical utility. Therapies that most effectively control OA-related pain with a low risk: benefit ratio will likely have the greatest benefit on HRQoL with greater rates of patient adoption. Initial clinical trial findings suggest that less invasive joint unloading implants hold promise in bridging the therapeutic gap between nonsurgical and surgical treatments for the knee OA patient.

Health care subsidy and outcomes of total knee arthroplasty in Asians

Singapore has a nonmodified universal health care system in which the government ensures affordable health care in the public health system, largely through a system of compulsory savings, subsidies, and price controls. Patients seeking treatment via the public health system may also choose for nonsubsidized options, with the benefits of being able to choose a surgeon, better privacy, and shorter time to surgery. To the authors' knowledge, few studies have reported the effect of health care subsidies on total knee arthroplasty outcomes. The purpose of this study was to assess whether patients receiving a health care subsidy had good outcomes or fared worse than their paying counterparts after undergoing conventional total knee arthroplasty. The authors retrospectively reviewed 369 patients who underwent total knee arthroplasty between 2006 and 2010. Patients were stratified into 2 groups: nonsubsidized (n=95) and subsidized patients (n=274). Outcome measures, such as range of motion, function score, knee score, Oxford Knee Questionnaire, and the Short Form 36 questionnaire, were compared between the groups at 6-month and 2-year follow-up. Subsidized patients had good postoperative outcomes, and no significance differences existed in outcome scores and range of motion between the 2 groups at 6-month and 2-year follow-up except in the mean function score, where patients in the nonsubsidized group did better (P=.019). Subsidized patients had good outcomes and did not fare worse than nonsubsidized patients after conventional total knee arthroplasty, except for their knee function score.

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

Background

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

Methods

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

Results

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

Conclusions

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

Conservative management of symptomatic knee osteoarthritis: a flawed strategy?

Conservative management of medial compartment knee osteoarthritis (OA) is a misleading term used to describe the application of medical, orthotic, and/or rehabilitative therapies exclusive of surgical interventions. The implication of this nomenclature is that these therapies offer satisfactory symptom relief, alter disease progression, and have limited side effects. Unfortunately, conservative therapeutic options possesses few, if any, characteristics of an ideal treatment, namely one that significantly alleviates pain, improves knee function, and reduces medial compartmental loading without adverse side effects. As uncompensated mechanical loading is a primary culprit in the development and progression of knee OA, we propose that the therapeutic perspective of conservative treatment should shift from pharmacological treatments, which have no influence on joint loading, minimal potential to alter joint function, substantial associated risks, and significant financial costs, towards minimally invasive load absorbing therapeutic interventions. A safe and effective minimally invasive medical device specifically engineered for symptomatic relief of medial knee OA by limiting joint contact forces has the potential to reduce the clinical and economic knee OA burden. This review characterizes the current standard of care recommendations for conservative management of medial compartment knee OA with respect to treatment efficacy, risk profile, and economic burden.

Clinical and economic burden of revision knee arthroplasty

Surgery is indicated for symptomatic knee osteoarthritis (OA) when conservative measures are unsuccessful. High tibial osteotomy (HTO), unicompartmental knee arthroplasty (UKA), and total knee arthroplasty (TKA) are surgical options intended to relieve knee OA pain and dysfunction. The choice of surgical intervention is dependent on several factors such as disease location, patient age, comorbidities, and activity levels. Regardless of surgical treatment, complications such as infection, loosening or lysis, periprosthetic fracture, and postoperative pain are known risks and are indications for revision surgery. The clinical and economic implications for revision surgery are underappreciated. Over 55,000 revision surgeries were performed in 2010 in the US, with 48% of these revisions in patients under 65 years. Total costs associated with each revision TKA surgery have been estimated to be in excess of $49,000. The current annual economic burden of revision knee OA surgery is $2.7 billion for hospital charges alone. By 2030, assuming a 5-fold increase in the number of revision procedures, this economic burden will exceed $13 billion annually. It is appealing to envision a therapy that could delay or obviate the need for arthroplasty. From an actuarial standpoint, this would have the theoretical downstream effect of substantially reducing the number of revision procedures. Although no known therapies currently meet these criteria, such a breakthrough would have a tremendous impact in lessening the clinical and economic burden of knee OA revision surgery.

The association between radiographic severity and pre-operative function in patients undergoing primary knee replacement for osteoarthritis

OBJECTIVE

To determine the association between radiographic osteoarthritis (OA) and pre-operative function in patients undergoing primary knee replacement.

METHODS

Single centre study examining pre-operative outcomes in a consecutive series of 525 patients who underwent primary knee replacement for OA between January 2006 and December 2007. Pre-operative data included: demographics, American Society of Anaesthesiologists (ASA) status and OA in the contralateral knee. The International Knee Society (IKS) rating and Short Form-12 (SF-12) were recorded for each patient. Pre-operative radiographs were read by a single observer for Kellgren and Lawrence (K&L) grading and Osteoarthritis Research Society International (OARSI) atlas features. Multiple linear regression was used to assess the strength of associations between radiographic OA severity and function, adjusting for clinically relevant variables.

RESULTS

Lateral tibiofemoral osteophyte grade was an independent predictor of pre-operative function as determined by the functional sub-scale of the IKS in patients undergoing primary knee replacement (coefficient=2.58, p=0.033). No associations were evident between pre-operative function and modified K&L, joint space narrowing, Ahlbäck attrition and coronal plane deformity. Other statistically significant predictors of poorer pre-operative function included: advancing age, female gender, knee pain and poorer SF-12 mental component summary scores which including osteophyte grade accounted for 24.6% of the variation in functional scores, (r=0.496).

CONCLUSION

Osteophytes in the lateral compartment of the knee were associated with pre-operative function in patients with advanced knee OA. Further studies are required which examine individual radiographic features specifically in patients with advanced knee OA to determine their relationship to pre-operative pain and function.

Orthopaedic podiatry triage: process outcomes of a skill mix initiative

Background. The Orthopaedic Podiatry Triage Clinic (OPodTC) is a ‘skill mix’ model of care developed in Queensland Health to address the problem of lengthy waiting times for orthopaedic surgery on foot and ankle pathologies. It is based on the recognition that many orthopaedic surgery referrals can be identified early and treated conservatively with podiatry, averting the need for more costly and invasive surgical interventions. The model is collaborative and relies on screening and triage by the podiatrist, rather than delegation by the orthopaedic surgeon. Methods. Screening and triage through OPodTC was trialled at three Queensland Health hospital facilities during 2009 and 2010 to improve service timeliness. Patients identified by the OPodTC podiatrist as suitable for conservative management were provided with non-surgical podiatry interventions and discharged if appropriate. Those identified as still requiring surgical intervention after the benefit of interim conservative treatment provided by the podiatrist (or who chose to remain on the list) were returned to their previous place on the orthopaedic waiting list. This paper presents a summary and description of waiting list changes in association with this trial. Results. The OPodTC intervention resulted in a reduction in the non-urgent category of the waiting list across the three hospitals of between 23.3% and 49.7%. Indications from wait-list service data demonstrated increased timeliness and improved patient flow, which are core goals of these skill mix initiatives. Conclusions. This study highlights the potential of screening and triage functions in the skill mix debate. In this example, conservative treatment options were considered first, suitable patients did not have to wait long periods to receive timely and appropriate interventions, and those for whom surgery was indicated, were provided with a more targeted service. What is known about the topic? Shifting and delegation of tasks is a key issue in current global debate on models of care. Discussion regarding the mix and shifting of tasks in podiatry and orthopaedic surgery has been limited in Australia, and the appropriate measurement of outcomes and processes is a point for discussion. What does this paper add? This paper describes such an initiative in podiatry and orthopaedic surgery. It describes a skill mix initiative based on triage and screening rather than delegation. It reflects benefits of including waiting lists as a process measure. What are the implications for practitioners? Support for triage-oriented skill mix collaboration in Podiatry and Orthopaedic Surgery.

Relationship between demographic variables and preoperative pain and disability in 5945 total joint arthroplasties at a single institution

Using a prospective institutional registry, 5945 total joint arthroplasty patients were evaluated for the following preoperative variables: sex, age, living situation, pain (visual analog scale), and activity level (lower extremity activity scale). Univariate analysis was performed with χ(2), t test, and Pearson correlation coefficient. Patient age was inversely correlated with visual analog scale and lower extremity activity scale scores (P < .0001). Whereas total hip arthroplasty was performed as equally in women and men, total knee arthroplasty was more frequent in women. Women were more likely to live alone, experience severe pain, and have limited activity (P < .0001). Patients who lived alone were more likely to experience severe pain or limited activity (P < .0001). Women and patients who live alone experience more pain and disability before surgery, potentially placing them at risk for inferior surgical outcomes.

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

Background

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

Methods

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

Results

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

Conclusions

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

Clinical and economic consequences of the treatment gap in knee osteoarthritis management

Osteoarthritis affects 27 million American adults of all ages and is a leading cause of disability in middle-aged and older adults. Initial management of knee osteoarthritis symptoms utilizes conservative care although long-term efficacy is poor. Arthroplasty and high tibial osteotomy may be considered for patients with severe pain or disability. We hypothesize that a distinct treatment gap exists for the patient with symptomatic knee osteoarthritis who is unresponsive to conservative care (including simple surgical treatments) yet refuses to undergo or is not an appropriate candidate for more invasive surgical procedures. This treatment gap represents a protracted period in which the patient experiences debilitating pain, reduced quality of life, and a significant financial burden. Approximately 3.6 million Americans linger in the knee osteoarthritis treatment gap and this number will grow to about 5 million people by 2025. The typical knee osteoarthritis treatment gap extends 20 years although the younger osteoarthritis patient is faced with the treatment gap throughout the majority of their adult life. There is great need for a safe, effective, and cost effective treatment option for patients with moderate to severe osteoarthritis that enjoys high patient acceptance.

Variability of indication criteria in knee and hip replacement: an observational study

Background

Total knee (TKR) and hip (THR) replacement (arthroplasty) are effective surgical procedures that relieve pain, improve patients' quality of life and increase functional capacity. Studies on variations in medical practice usually place the indications for performing these procedures to be highly variable, because surgeons appear to follow different criteria when recommending surgery in patients with different severity levels. We therefore proposed a study to evaluate inter-hospital variability in arthroplasty indication.

Methods

The pre-surgical condition of 1603 patients included was compared by their personal characteristics, clinical situation and self-perceived health status. Patients were asked to complete two health-related quality of life questionnaires: the generic SF-12 (Short Form) and the specific WOMAC (Western Ontario and Mcmaster Universities) scale. The type of patient undergoing primary arthroplasty was similar in the 15 different hospitals evaluated.

The variability in baseline WOMAC score between hospitals in THR and TKR indication was described by range, mean and standard deviation (SD), mean and standard deviation weighted by the number of procedures at each hospital, high/low ratio or extremal quotient (EQ_5-95), variation coefficient (CV_5-95) and weighted variation coefficient (WCV_5-95) for 5-95 percentile range. The variability in subjective and objective signs was evaluated using median, range and WCV_5-95. The appropriateness of the procedures performed was calculated using a specific threshold proposed by Quintana et al for assessing pain and functional capacity.

Results

The variability expressed as WCV_5-95 was very low, between 0.05 and 0.11 for all three dimensions on WOMAC scale for both types of procedure in all participating hospitals. The variability in the physical and mental SF-12 components was very low for both types of procedure (0.08 and 0.07 for hip and 0.03 and 0.07 for knee surgery patients). However, a moderate-high variability was detected in subjective-objective signs. Among all the surgeries performed, approximately a quarter of them could be considered to be inappropriate.

Conclusions

A greater inter-hospital variability was observed for objective than for subjective signs for both procedures, suggesting that the differences in clinical criteria followed by surgeons when indicating arthroplasty are the main responsible factors for the variation in surgery rates.