Patients follow three distinct outcome trajectories following total knee arthroplasty

Predictive Validity of the Work, Osteoarthritis, or Joint Replacement Questionnaire for Return to Work After Total Knee Arthroplasty: A 12-Month Multicenter Prospective Cohort Study

BACKGROUND

After total knee arthroplasty (TKA), a minority of working patients are dissatisfied and experience a late or no return to work (RTW). This study aimed to identify whether a predefined grouping based on self-reported ability to perform work-related activities at three months post-TKA was associated with the ability to perform work-related activities at six and 12 months and RTW at three, six, and 12 months post-TKA.

METHODS

A 12-month multicenter prospective cohort study was performed among working TKA patients intending to RTW. The Work, Osteoarthritis, or Joint Replacement questionnaire score (range, 0 to 100) was used to assess patients' ability to perform work-related activities. Patients were grouped into early-, intermediate-, and late-recovery groups at three months post-TKA. The median age of the cohort (n = 182) was 59 years [interquartile range, 55 to 62], and 52% were women. Analyses included Spearman's correlation tests, and Kaplan-Meier survival analyses.

RESULTS

The early- (n = 54) and intermediate-recovery groups (n = 68) clinically improved their ability to perform work-related activities at three and 12 months, respectively, while the late-recovery group (n = 60) did not do so until 12 months (rs = 0.6, 0.27, and 0.25, respectively). The early-recovery group returned to work earlier (median 62 [interquartile range 41 to 90] days) compared to the intermediate- (75 [46 to 115] days) and late-recovery groups (84 [58 to 116] days) and resumed 100 percent of their working hours at six months versus 12 months in the intermediate- and late-recovery groups (rs = 0.37, 0.33, 0.1 at 3, 6, and 12 months, respectively).

CONCLUSIONS

At three months post-TKA, the work, osteoarthritis, or joint replacement questionnaire can be used to distinguish early-, intermediate-, and late-recovery groups, which are associated with the ability to perform work-related activities at six and 12 months post-TKA and RTW at three and six months.

Using Two Predictive Models to Capture Two Types of Poor Outcomes in Knee Arthroplasty: A Multisite Longitudinal Cohort Study

OBJECTIVE

Poor outcome after knee arthroplasty (KA), a common major surgery worldwide, reportedly occurs in approximately 20% of patients. These patients demonstrate minimal improvement, at least moderate knee pain, and difficulty performing many routine daily activities. The purposes of our study were to comprehensively determine poor outcome risk after KA and to identify predictors of poor outcome.

METHODS

Data from 565 participants with KA in the Osteoarthritis Initiative and the Multicenter Osteoarthritis studies were used. Previously validated latent class analyses (LCAs) of good versus poor outcome trajectories of Western Ontario and McMaster Universities Arthritis Index (WOMAC) Pain and Disability were generated to describe minimal improvement and poor final outcome. The modified Escobar RAND appropriateness system was used to generate classifications of appropriate, inconclusive, and rarely appropriate. Multivariable prediction models included LCA-based good versus poor outcome, modified Escobar classifications, and evidence-driven preoperative prognostic variables.

RESULTS

Modified Escobar appropriateness classifications were nonsignificant predictors of WOMAC Pain good versus poor outcomes, indicating the methods provide independent outcome estimates. For WOMAC Pain and WOMAC Disability, approximately 34% and 45% of participants, respectively, had a high probability of either minimal improvement via "rarely appropriate" classifications or poor outcome via LCA. In multivariable prediction models, greater contralateral knee pain consistently predicted poor outcome (eg, odds ratio 1.21, 95% confidence interval 1.10-1.33).

CONCLUSION

Appropriateness criteria and LCA estimates provided combined poor outcome estimates that were approximately double the commonly reported poor outcome of 20%. Rates of poor outcome could be reduced if clinicians screened patients using appropriateness criteria and LCA predictors before surgery to optimize outcome.

Capability After Total Knee Arthroplasty for Osteoarthritis Is Strongly Associated With Preoperative Symptoms of Depression

BACKGROUND

Primary total knee arthroplasty (TKA) aims to improve the level of capability (ability to perform valued life activities) associated with knee osteoarthritis (OA). However, some evidence suggests a substantial proportion of patients remain dissatisfied with their outcomes after this procedure. We sought to better understand the association between mental health, specifically symptoms of depression, with postoperative outcomes. Symptoms of depression are shown to be common among orthopaedic populations in general and can be briefly and conveniently evaluated using the Patient Health Questionnaire-2 (PHQ-2) in a less burdensome manner compared with longer mental health surveys. This study assesses the association between preoperative depressive symptoms (PHQ-2) and levels of capability at 6 weeks and 6 months after TKA.

METHODS

We conducted a prospective cohort study involving 114 patients with knee OA across five clinics in California and Texas scheduled for TKA. Participants completed a preoperative PHQ-2 and Knee Injury and OA Outcome Score for Joint Replacement (KOOS JR) survey at 6 weeks and 6 months post-TKA. We analyzed these data using bivariate and multivariable regression.

RESULTS

Preoperative PHQ-2 scores were significantly associated with lower KOOS JR scores at 6 weeks and 6 months post-TKA. Latino/Hispanic race was also associated with lower KOOS JR scores at 6 weeks. The association between preoperative depressive symptoms and level of capability after TKA were more pronounced at 6 months compared with 6 weeks.

CONCLUSION

Preoperative symptoms of depression are strongly associated with reduced capability after TKA and can be screened for using the PHQ-2-a brief tool that can be feasibly incorporated into clinical workflows. User-friendly assessment of depressive symptoms can assist orthopaedic surgeons in identifying and addressing mental health at the outset during the management of knee OA.

Effects of home-based prehabilitation on pre- and postoperative outcomes following total hip and knee arthroplasty

The aim of this study was to determine the effectiveness of home-based prehabilitation on pre- and postoperative outcomes in participants awaiting total knee (TKA) and hip arthroplasty (THA). A systematic review with meta-analysis of randomized controlled trials (RCTs) of prehabilitation interventions for TKA and THA. MEDLINE, CINAHL, ProQuest, PubMed, Cochrane Library, and Google Scholar databases were searched from inception to October 2022. Evidence was assessed by the PEDro scale and the Cochrane risk-of-bias (ROB2) tool. A total of 22 RCTs (1,601 patients) were identified with good overall quality and low risk of bias. Prehabilitation significantly improved pain prior to TKA (mean difference (MD) -1.02: p = 0.001), with non-significant improvements for function before (MD -0.48; p = 0.06) and after TKA (MD -0.69; p = 0.25). Small preoperative improvements were observed for pain (MD -0.02; p = 0.87) and function (MD -0.18; p = 0.16) prior to THA, but no post THA effect was found for pain (MD 0.19; p = 0.44) and function (MD 0.14; p = 0.68). A trend favouring usual care for improving quality of life (QoL) prior to TKA (MD 0.61; p = 0.34), but no effect on QoL prior (MD 0.03; p = 0.87) or post THA (MD -0.05; p = 0.83) was found. Prehabilitation significantly reduced hospital length of stay (LOS) for TKA (MD -0.43 days; p < 0.001) but not for THA (MD, -0.24; p = 0.12). Compliance was only reported in 11 studies and was excellent with a mean value of 90.5% (SD 6.82). Prehabilitation interventions improve pain and function prior to TKA and THA and reduce hospital LOS, though it is unclear if these effects enhance outcomes postoperatively.

Measurement properties of PROMIS short forms for pain and function in patients receiving knee arthroplasty

BACKGROUND

While there are a few studies on measurement properties of PROMIS short forms for pain and function in patients with knee osteoarthritis, nothing is known about the measurement properties in patients with knee arthroplasty. Therefore, this study examined the measurement properties of the German Patient-Reported Outcomes Measurement Information System (PROMIS) short forms for pain intensity (PAIN), pain interference (PI) and physical function (PF) in knee arthroplasty patients.

METHODS

Short forms were collected from consecutive patients of our clinic's knee arthroplasty registry before and 12 months post-surgery. Oxford Knee Score (OKS) was the reference measure. A subsample completed the short forms twice to test reliability. Construct validity and responsiveness were assessed using scale-specific hypothesis testing. For reliability, Cronbach's alpha, intraclass correlation coefficients, and agreement using standard error of measurement (SEM_agr) were used. Agreement was used to determine standardised effect sizes and smallest detectable changes (SDC90). Individual-level minimal important change (MIC) was calculated using a method of adjusted prediction.

RESULTS

Of 213 eligible patients, 155 received questionnaires, 143 returned baseline questionnaires and 119, 12-month questionnaires. Correlations of short forms with OKS were large (│r│ ≥ 0.7) with slightly lower values for PAIN, and specifically for men. Cronbach's alpha values were ≥ 0.84 and intraclass correlation coefficients ≥ 0.90. SEM_agr were around 3.5 for PAIN and PI and 1.7 for PF. SDC90 were around 8 for PAIN and PI and 4 for PF. Follow-up showed a relevant ceiling effect for PF. Correlations with OKS change scores of around 0.5 to 0.6 were moderate. Adjusted MICs were 7.2 for PAIN, 3.5 for PI and 5.7 for PF.

CONCLUSION

Our results partly support the use of the investigated short forms for knee arthroplasty patients. The ability of PF to differentiate between patients with high perceived recovery is limited. Therefore, the advantages and disadvantages should be strongly considered within the context of the intended use.

Cross-validation of good versus poor self-reported outcome trajectory types following knee arthroplasty

OBJECTIVE

To determine whether good versus poor outcome trajectories and predictors of poor outcome obtained in a derivation study could be replicated in an independent sample of persons undergoing knee arthroplasty (KA).

METHODS

We used data from TRIO-POPULAR, a prospective cohort study of 926 participants who underwent KA in the United Kingdom. The participants were assessed preoperatively and 6-weeks, 6- and 12-months postoperatively. The Oxford Knee Score was the primary outcome and a variety of pre-operative predictors of outcome were selected. The outcome measure and the predictors were selected to most closely align with a previously published derivation study of good versus poor outcome. Confirmatory two-piece latent class growth curve analyses were used to model outcome and regression was used to identify predictors of outcome class.

RESULTS

Trajectories for the Oxford Knee Scores from TRIO-POPULAR replicated trajectories for WOMAC Pain and Function scores from the previously published derivation study. Multivariable predictors of poor outcome were pain catastrophizing (odds ratio = 1.125, 95% CI = 1.048, .206, p = 0.001) and comorbidity (odds ratio = 1.134, 95%CI = 1.049, 1.227, p = 0.002. Pain catastrophizing also predicted poor outcome in the derivation study.

CONCLUSIONS

Good and poor outcome trajectories replicated those found in the previously published derivation study. Our model-based method produces stable outcome trajectories despite using data from different countries and participants with substantively different characteristics. Predictors of poor outcome were somewhat inconsistent between the cross-validation and derivation studies. Pain catastrophizing was the only consistent poor outcome predictor.