Defining the Patient Acceptable Symptom State for the HOOS JR and KOOS JR After Primary Total Joint Arthroplasty

Undergoing cartilage procedures before total knee arthroplasty is not associated with worse postoperative functional outcomes, readmission rates or complication rates

PURPOSE

Patients undergoing total knee arthroplasty (TKA) with prior knee cartilage surgery have unclear outcomes in the literature. This study compared outcomes after TKA in patients with or without prior knee cartilage surgery, and we hypothesized there would be equivocal outcomes between groups.

METHODS

A retrospective matched case-control study was conducted on patients from our institution who underwent ipsilateral cartilage procedure(s) and TKA (cases) or TKA alone (controls) from 2000 to 2022. Cartilage procedures included Autologous Chondrocyte Implantation (ACI), Osteochondral Allograft (OCA) and Microfracture (MFx). Matching was performed in 1:3 (case:control) ratio for age, sex, body mass index, Charlson Comorbidity Index, pre-TKA Kellgren-Lawrence osteoarthritis grade and follow-up for knee injury and osteoarthritis outcome score for joint replacement (KOOS-JR). Mann-Whitney U and χ2 analyses were conducted, with significance being a p < 0.05. A priori power analysis required 29 patients per cohort to reach a clinically detectable difference of 11 for KOOS-JR.

RESULTS

Forty-three cases (one ACI, eight OCA and 34 MFx) and 129 controls were included after matching, with no significant demographic differences. Cases underwent TKA after cartilage surgery at a mean of 4.6 years. No significant differences existed between cases and controls for the preoperative KOOS-JR (45.2 vs. 47.8; p = 0.353), postoperative KOOS-JR (69.8 vs. 69.9; p = 0.974) or Delta KOOS-JR (30.4 vs. 26.0; p = 0.387). No significant differences existed for 90-day readmission rates (4.7% vs. 2.3%; p = 0.600) or revision TKA rates (11.6% vs. 5.4%; p = 0.177).

CONCLUSION

Patients with and without prior cartilage surgery experience similar functional outcomes, readmission rates and revision rates after TKA on the same knee. Patients who are candidates for TKA with a history of cartilage surgery may be counselled that their surgical history on that knee does not convey the risk of worse functional outcomes.

LEVEL OF EVIDENCE

Level III case-control study.

Repeat Revision Total Knee Arthroplasty Has Significantly Lower Survivorship Compared to First-Time Revisions

INTRODUCTION

Revision total knee arthroplasty (rTKA) is an increasingly common challenge for arthroplasty surgeons. Compared to first-time rTKA, re-rTKA presents additional challenges, including further compromised soft tissues and bone loss, abundant scar tissue, stemmed revision implants, and metaphyseal fixation. The goal of this study was to compare the survivorship and clinical outcomes of aseptic first-time rTKAs and re-rTKAs.

METHODS

A retrospective review of aseptic rTKAs from a single institution from 2016 to 2022 identified 850 first-time rTKAs and 178 re-rTKAs. The mean age was 67 years, 58% were women, and the mean BMI was 31. The mean operative time was longer for re-rTKAs (173 versus 160 minutes, P = 0.02), as was the hospital length of stay for the re-rTKA cohort (3.7 versus 3.2 days, P = 0.0007). Failure was defined as all-cause revision or revision for periprosthetic joint infection (PJI).

RESULTS

At 3.5 years, re-rTKAs had significantly lower survivorship free from all-cause revision than the first-time rTKA cohort (75 versus 91%, P < 0.0001). At 1.5 years, re-rTKAs had significantly lower survivorship free from revision for PJI than the first-time rTKA cohort (93 versus 98%, P = 0.003). Overall, the re-rTKA cohort had more all-cause failures (33 [19%] versus 55 [6%]; P < 0.0001) and more PJI failures (13 [7%] versus 17 [2%]; P = 0.0001). At final follow-up, the re-rTKA cohort had a significantly lower Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) (62 versus 69, P = 0.01).

CONCLUSIONS

Compared to first-time rTKA, re-rTKA has significantly decreased survivorship free from all-cause revision at 3.5 years (58 versus 43%) and revision for PJI at two years (91 versus 98%). Optimization of care for rTKA patients at centers of excellence may improve the outcomes and care of these complex patients.

Patient-reported Outcomes of Direct Anterior Approach Hip Arthroplasty After Previous Hip Arthroscopy: A Matched Case-control Study With a Minimum 5-year Follow-up

BACKGROUND

The primary aim of this study was to evaluate the impact of prior hip arthroscopy on direct anterior approach (DAA) total hip arthroplasty (THA) midterm outcomes, with a secondary analysis based on time to conversion to THA.

MATERIALS AND METHODS

Data were retrospectively reviewed for all patients who underwent THA by the DAA from 2009 to 2018. Eligible patients completed minimum 5-year follow-up patient-reported outcomes (PROs) questionnaires. Patients with a previous hip arthroscopy (THA-PA) were propensity matched in a 1:2 ratio to a control group of primary arthroplasty patients (THA-N-PA). A secondary analysis based on time to conversion to THA from the previous hip arthroscopy was conducted within the study group.

RESULTS

A total of 402 patients were included. Favorable and comparable (P>0.05) outcomes were observed at minimum 5-year follow-up for all PROs evaluated except Visual Analogue Scale pain scale, where the THA-PA group had significantly higher scores (P<0.05). Importantly, the groups reported similar complications and revision surgery rates. Furthermore, the secondary analysis found patients that converted within one year from the previous hip arthroscopy showed significantly lower patient satisfaction.

CONCLUSION

Patients with a history of hip arthroscopy who underwent THA using the DAA demonstrated comparable and sustainable outcomes across all PROs, with similar complication and revision rates to the control group at midterm follow-up. However, patients who underwent THA within one year of prior hip arthroscopy reported significantly lower satisfaction levels. Careful patient selection and indication for hip arthroscopy are essential to avoid early conversion to THA. [Orthopedics. 202x;4x(x):xx-xx.].

Periacetabular Osteotomy versus Total Hip Arthroplasty for Symptomatic Acetabular Dysplasia in Patients Aged 40 Years or Above

BACKGROUND

Patient acceptable symptomatic state (PASS) achievement, reoperation rates, and survivorship were compared between periacetabular osteotomy (PAO) for symptomatic acetabular dysplasia and total hip arthroplasty (THA) in patients aged 40 to 49 years.

METHODS

Patients aged 40 to 49 years undergoing PAO or THA were retrospectively reviewed. The PAO patients who had a body mass index (BMI) ≥ 30 or a Tönnis grade ≥ 2 were excluded. The THA patients who had a BMI ≥ 30, a Tönnis grade ≥ 3, or arthritic etiologies following slipped capital femoral epiphysis, Legg-Calve-Perthes, osteonecrosis, and/or trauma were excluded. Postoperative modified Harris Hip Score and Hip Disability and Osteoarthritis Outcome Score-Joint Replacement were collected at a minimum of 1 year following PAO and THA, respectively (mean follow-up 3.7 versus 3.2 years). Established 2-year thresholds defined PASS. Survival analysis compared procedures with an endpoint of subsequent ipsilateral surgery (excluding hardware removal). There were 103 hips (n = 42 PAO, n = 61 THA) analyzed. Sex, average age, BMI, and lateral center edge angle within the PAO group were 95.2% women, 43 years, 23.1, and 16.9 degrees, respectively, compared to 78.7% women, 45 years, 24.2, and 20.0 degrees in the THA group (P = 0.02, <0.01, 0.10, and 0.10, respectively).

RESULTS

There were 72% of PAO compared to 61% of THA patients who achieved PASS (P = 0.28). History of prior ipsilateral surgery was associated with failure to achieve PASS (37 versus 6%, P < 0.001). The rate of subsequent surgery was 5% in each cohort (P = 1.0). The mean time-to-event was 11.2 and 7.8 years in the PAO and THA cohorts, respectively. Survivorship free of reoperation was 91% at five and 8 years among PAOs and 95% at five and 8 years among THAs (P = 0.94).

CONCLUSIONS

Patients aged 40 to 49 years undergoing PAO and THA have similar PASS achievement without differences in reoperation. Both procedures are viable surgical options in quadragenarians, with high survivorship maintained at five and 8 years. Thoughtful patient and physician dialogue incorporating all management options and the patient's goals should drive surgical decision-making.

The Patient Acceptable Symptom State (PASS) has Little Utility Before Total Hip or Knee Arthroplasty

BACKGROUND

A better understanding of patient's a preoperative symptom state may assist in a more holistic evaluation of patients pursuing total joint arthroplasty (TJA). This study aimed to determine factors associated with preoperative Patient Acceptable Symptom State (PASS) scores in TJA patients and to determine the predictive ability of patient-reported outcome measures (PROMs) for achieving PASS preoperatively.

METHODS

All patients undergoing primary, elective TJA between January and October 2021 at a single institution and who had completed a preoperative PASS, preoperative Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires, and joint-specific PROMs were eligible for inclusion. Descriptive statistics and independent samples t-tests were utilized. Receiver operating characteristic curves and area under the curve analyses were created to determine threshold values for PROMs representing PASS achievement.

RESULTS

A total of 287 total hip arthroplasty (THA) patients and 378 total knee arthroplasty (TKA) patients completed PASS preoperatively, with 12.9% of THA patients and 29.6% of TKA patients reporting acceptable symptom states. The PASS responses were associated with PROMIS Physical Function (PROMIS-PF) (P < 0.001) but not Hip Dysfunction and Osteoarthritis Score, Joint Replacement (P = 0.073) scores in THA. The PASS responses were similarly associated with PROMIS-PF (P < 0.010) as well as Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (P = 0.030) scores in TKA. The Hip Dysfunction and Osteoarthritis Score, Joint Replacement and PROMIS-PF threshold values of 55.6 and 40, respectively, only weakly predicted preoperative PASS achievement in THA. The Knee Injury and Osteoarthritis Outcome Score, Joint Replacement and PROMIS-PF threshold values of 52.5 and 39, respectively, only weakly predicted preoperative PASS achievement in TKA.

CONCLUSIONS

In patients undergoing THA or TKA, 12.9 and 29.6% of patients were satisfied with their symptoms before surgery, respectively. None of the threshold values for the assessed PROMs strongly predict PASS achievement. Given that not all patients indicated for TJA reported unacceptable health states, these findings question the validity of the PASS questionnaire preoperatively.

Outcomes of Selectively Unresurfaced Patellae With a Partial Lateral Facetectomy in Primary Total Knee Arthroplasty

BACKGROUND

Not resurfacing the patella during primary total knee arthroplasty (TKA) has steadily increased as implants and techniques have improved. However, limited data exist on the acceptable arthritis severity to leave the patella unresurfaced and the subsequent effect on patient-reported outcome measures (PROMs). This study evaluated PROMs in matched cohorts of unresurfaced and resurfaced patellae, accounting for patellar osteoarthritis (OA) severity and lateral patellar facetectomies.

METHODS

A consecutive series of primary TKAs was retrospectively reviewed. There were 871 patellae selectively unresurfaced, of which 667 (76%) had an aggressive lateral facetectomy. The remaining 1,064 patellae were resurfaced. The TKAs with unresurfaced patellae were matched to TKAs with resurfaced patellae based on demographics and patellar OA severity. There were 140 TKAs in each matched group, which did not differ by demographics (P ≥ 0.33) or OA severity (P ≥ 0.99). The PROMs were compared between groups at a mean of 2.7 years (range, one to 10) at a significance level of 0.05.

RESULTS

The matched groups did not differ by postoperative knee-specific PROMs (P ≥ 0.23) nor improvement from the preoperative baseline score (P ≥ 0.19). A greater percentage of patients who had unresurfaced patellae and a lateral facetectomy achieved minimal clinically important differences for the Knee Injury and Osteoarthritis Outcome Score (94, 89, 86%) and pain with stairs (88, 85, 81%) compared to patella groups without a lateral facetectomy, despite lacking statistical significance (P ≥ 0.30). The change in PROMs for patients who had moderate to severe patello-femoral arthritis grade ≥ 2 was not different between patella groups (P ≥ 0.38).

CONCLUSIONS

Study results show that patients who had unresurfaced and resurfaced patellae have similar PROMs after TKA regardless of patello-femoral OA severity. An aggressive lateral facetectomy when leaving the patella unresurfaced may help achieve minimal clinically important differences in PROMs more frequently.

Improvement in Patient-Reported Outcomes after Revision Total Knee Arthroplasty Is Comparable to Primaries in Some Diagnoses, but Not Others

BACKGROUND

Patient-reported outcome measures (PROMs) are becoming increasingly important for reimbursement after primary total knee arthroplasty (TKA) and are likely soon to follow for revision TKA (rTKA). Therefore, as the Centers for Medicare and Medicaid Services establish criteria for minimal clinically important differences (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) metrics, it is critical to understand which patients have the greatest propensity for clinical improvement after rTKA. This study compared PROMs of rTKAs by diagnosis to a cohort of primary TKAs.

METHODS

A total of 2,308 primary and 340 aseptic rTKAs using consistent clinical protocols were retrospectively reviewed. Study data were extracted from patient health records. Modern PROMs and their associated MCID, SCB, and PASS thresholds were evaluated with P < 0.05 as significant. The mean follow-up was 27.1 months (range, one to 153).

RESULTS

Primary TKA and rTKA cohorts did not differ by demographic variables (P ≥ 0.10); however, primaries had slightly longer follow-ups (mean five months, P < 0.001). Satisfaction for cases revised for loosening (81%) and polyethylene wear/osteolysis (72%) was not different compared to primary TKAs (84%, P ≥ 0.19). The mean improvement scores for University of California, Los Angeles Activity Level and pain with level walking were not different when comparing primary TKAs to cases revised for loosening (P ≥ 0.73). Primary TKAs achieved MCID, SCB, and PASS thresholds most often (range, 60 to 90%), followed by revisions for loosening and wear/osteolysis (range, 48 to 81%); and then arthrofibrosis and instability (range, 33 to 70%; P ≤ 0.009).

CONCLUSIONS

Study results show that rTKAs for loosening and polyethylene wear/osteolysis may have comparable improvement in outcomes compared to primary TKA. Study results provide data to possibly help Centers for Medicare and Medicaid Services set rational metrics for reimbursement and set appropriate expectations.

LEVEL OF EVIDENCE

III.

Clinical Outcomes in Revision Total Knee Arthroplasty for Flexion Instability at a Mean of 3.2 Years

BACKGROUND

Flexion instability is challenging to diagnose and treat yet remains an important cause of revision total knee arthroplasty (rTKA). Previous studies report modest improvements in early patient-reported outcome measures (PROMs) following revision for flexion instability compared with other etiologies. This study evaluated outcomes after rTKA for isolated flexion instability at a mean of 3.2 years of follow-up (range, one to 12).

METHODS

Between 2011 and 2021, there were 987 consecutive rTKAs performed by five surgeons that were retrospectively reviewed. A total of 224 were revised for flexion instability, of which 170 were without concomitant diagnoses. Consistent clinical and radiographic diagnostic criteria for flexion instability were used, as previously described. The PROMs at the latest follow-up and the improvement from the pre-revision baseline were evaluated. Covariates, minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) thresholds were evaluated. Statistical significance was defined as P ≤ 0.05. The cohort was 66% women who had a mean age and body mass index (BMI) of 65 years and 33, respectively.

RESULTS

Post-revision improvement in all PROMs exceeded established MCIDs (P ≤ 0.001). Minimal clinically important difference, SCB, and PASS thresholds for the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement were achieved in 70, 55, and 49% of cases, respectively. Furthermore, 59% of patients reported their knee "sometimes" or "always" felt normal, and 52% of patients reported being "satisfied or very satisfied" at the latest follow-up. Aseptic revision-free survivorship was 90.6% (95% confidence interval, 83 to 98) out to 11.7 years. Only 1.2% of cases required a re-revision for flexion instability.

CONCLUSIONS

Although frequently a challenging diagnosis, patients and surgeons can expect clinically meaningful improvement in PROMs and low re-revision rates when undergoing revision TKA for flexion instability when using consistent and established diagnostic criteria and surgical correction techniques.

LEVEL OF EVIDENCE

III.

Low-constraint insert with a medial pivot design as a potential predictor of favourable outcomes in cruciate-retaining total knee arthroplasty: A propensity score-matched analysis

PURPOSE

The influence of polyethylene insert conformity on the outcomes of cruciate-retaining (CR) total knee arthroplasty (TKA) with a medial pivot design remains uncertain. Therefore, this study aimed to evaluate the effects of polyethylene insert conformity in CR-TKA on patient-reported outcomes.

METHODS

The data of 255 knees (FINE Total Knee System) from 255 patients were retrospectively analysed to compare outcomes for high- or low-constraint medial pivot inserts, as determined through historical controls, over an average follow-up period of 2.2 years (range, 2.0-5.5 years). Multivariate logistic regression analysis was used to identify predictors of achieving the patient-acceptable symptom state (PASS) for the Forgotten Joint Score-12 (FJS-12). Propensity score-matched cohorts for age, sex, body mass index, Kellgren-Lawrence grade, Charlson Comorbidity Index, knee flexion contracture, FJS-12 and follow-up duration were created for between-group comparison (n = 50 in each group).

RESULTS

Low-constraint insert (p = 0.031) and age (p = 0.043) were independent predictors of achieving the PASS for the FJS-12 (>33, 153/255). After successful matching, compared to the high-constraint insert, the low-constraint insert improved patient satisfaction (p = 0.029 for pain on going up or downstairs, and p = 0.047 for the function of going upstairs) and increased the likelihood of achieving the minimal clinically important difference (p = 0.019) and PASS (p = 0.025) for the FJS-12. A significant correlation was observed between the posterior tibial slope and the FJS-12 in the low-constraint insert group (p < 0.001), indicating that a greater posterior tibial slope was associated with better functional outcomes in this group.

CONCLUSIONS

Compared with high-constraint inserts, low-constraint medial pivot inserts yielded higher functional outcomes and patient satisfaction. Therefore, insert conformity may play a crucial role in CR-TKA outcomes.

LEVEL OF EVIDENCE

Level III.

Undergoing Meniscectomy Within One Year Before Primary Total Knee Arthroplasty Is Associated With Worse Postoperative Outcomes

BACKGROUND

Patients undergoing primary total knee arthroplasty (TKA) who have a history of meniscectomy have worse postoperative functional outcomes, increased rates of early postoperative complications, and higher revision rates. Despite knowing this, to the best of our knowledge, it has not been previously studied whether the timing of meniscectomy before TKA impacts functional outcomes after undergoing TKA. Compared to patients who underwent meniscectomy more than one year before TKA, do patients who have meniscectomy less than one year before TKA have significantly different postoperative outcomes?

METHODS

A retrospective cohort study was conducted at an academic medical center. Patients who did not have a history of meniscectomy (controls) were matched in a 1:3 ratio with patients who underwent meniscectomy before primary TKA (cases) based on age, sex, race, body mass index, and nonage-adjusted Charlson Comorbidity Index. The inclusion criteria consisted of patients undergoing TKA from 2013 to 2020, with a minimum of one-year follow-up for Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS-JR). The exclusion criteria comprised patients undergoing revision or conversion TKA. There were 1,767 patients in the control cohort and 589 patients in the cases cohort who were included.

RESULTS

Preoperative KOOS-JR scores did not significantly differ between the five cohorts, while postoperative KOOS-JR scores were significantly lower for patients who underwent meniscectomy less than six months before TKA and between six months and 1 year before TKA. Patients undergoing meniscectomy within six months of TKA had a significantly higher rate of aseptic revision, while patients who had a history of meniscectomy at other timeframes did not have a significantly increased rate of aseptic revision.

CONCLUSIONS

Patients undergoing TKA who had a history of meniscectomy within 1 year of the TKA may experience worse postoperative functional outcomes, and patients undergoing meniscectomy within six months of TKA may have an increased risk of revision TKA.

Does Replicating Native Hip Biomechanics Improve Patient-Reported Outcome Measures After Total Hip Arthroplasty?

BACKGROUND

Enabling technology, such as computer navigation and robotics, provides more precise implant position, which allows surgeons the ability for personalized alignment in total hip arthroplasty (THA). To date, THA implant position studies have focused on dislocation rates, rather than on patient-reported outcome measures (PROMs). This study evaluated the impact of the THA component position on clinically significant differences in PROMs.

METHODS

A total of 1,682 consecutive primary THAs were retrospectively reviewed. Acetabular and femoral component position as well as femoral offset and leg-length discrepancy (LLD) were measured on all preoperative and postoperative radiographs. Modern PROM scores were evaluated. Minimal clinically important difference (MCID), substantial clinical benefit, and patient-acceptable symptom state values were assessed for applicable PROMs. Univariate and multivariate statistical analyses were performed with P < 0.05 as significant. The mean clinical follow-up was 21.9 months (range, one to 128).

RESULTS

In multivariate analysis, the acetabular component position closer to the native hip center of rotation was associated with a greater probability of achieving the Hip disability and Osteoarthritis Outcome Score for Joint Replacement MCID, substantial clinical benefit, and patient-acceptable symptom state thresholds (P ≤ 0.008). An increase in postoperative femoral offset was associated with achieving the MCID for the University of California Los Angeles activity level and patients being 'very satisfied or satisfied' (P ≤ 0.004). The mean postoperative LLD was 3.8 mm (range, 24.5 mm short to 36.6 mm long); however, postoperative LLD was not a predictor of PROMs (P ≥ 0.167) with statistical power ≥ 87%.

CONCLUSIONS

Study results demonstrated that replicating the native center of rotation and optimizing femoral offset was associated with clinically relevant improvements in PROMs. Interestingly, in this large cohort, leg length inequality was not associated with PROMs. Further research is warranted on THA component position, including spino-pelvic parameters and PROMs.

LEVEL OF EVIDENCE

III.

Hip Resurfacing Arthroplasty in Men: A Minimum 15-Year Follow-Up Study

BACKGROUND

Hip resurfacing arthroplasty (HRA) has emerged as an alternative to total hip arthroplasty for managing osteoarthritis, particularly in younger, active men. However, long-term data on HRA outcomes in the United States remains limited.

METHODS

We retrospectively examined 472 consecutive HRA cases in 407 men performed between January 2006 and December 2008 with minimum 15-year follow-up outcomes. Patient-reported outcome measures, including the modified Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, Visual Analog Scale for pain, and University of California-Los Angeles Activity Scale, were collected. Serum metal ion levels, survivorship, and radiographic outcomes were also assessed. Kaplan-Meier survival analysis was performed to evaluate implant survivorship. The mean follow-up was 16.0 years (range, 15.0 to 18.4).

RESULTS

The overall survivorship at 15 years was 95.1%. Implants with femoral head sizes ≥ 48 mm demonstrated 95.8% survivorship, while those < 48 mm showed 91.3% survivorship. For unrevised hips, mean final follow-up scores were Hip Disability and Osteoarthritis Outcome Score for Joint Replacement 97.8 ± 5.6, modified Harris Hip Score 97.3 ± 6.4, Visual Analog Scale 0.4 ± 1.1, and University of California-Los Angeles Activity 8.0 ± 1.9. The median serum metal ion levels at the final follow-up were 2.3 μg/L for chromium and 1.7 μg/L for cobalt. There were 26 revisions that occurred, with aseptic loosening being the most common cause (n = 11).

CONCLUSIONS

This study demonstrates that HRA is a viable long-term solution for appropriately selected men with high survivorship and positive functional outcomes at a minimum 15-year follow-up.

Outcomes of Medial Pivot Total Knee Arthroplasty Based on Preoperative Coronal Deformity

BACKGROUND

The medial pivot total knee arthroplasty (MP-TKA) was developed to better replicate the kinematics of the healthy knee. Although outcomes of MP-TKA have been investigated, previous studies involved primarily varus preoperative deformities. The objective of this study was to determine patient outcomes using the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) following MP-TKA in relation to the type (varus/neutral/valgus) and severity (moderate/severe) of preoperative coronal deformity.

METHODS

This was a single-center retrospective cohort study of 311 knees receiving MP-TKA between April 25, 2017, and May 27, 2022, with a preoperative long leg-hip-knee-ankle angle measured by biplanar electro-optical stereo radiography. Patients were assigned to one of five varus/valgus alignment groups: neutral (0 ± 3°), moderate (3 to 15°), or severe (above 15°) preoperative coronal deformity.

RESULTS

Differences in sex were noted, while all other demographic and comorbid conditions were similar. The mean postoperative period between the date of surgery and KOOS JR collection was 17.6 months across all groups. Severe valgus knees (n = 5) had an average (mean ± SD) postoperative KOOS JR of 71.7 ± 10.6, while moderate valgus knees (n = 49) demonstrated a postoperative average KOOS JR of 72.5 ± 19.6. Neutral knees (n = 53) had an average postoperative KOOS JR of 65.2 ± 22.3, while moderate varus (n = 180) and severe varus (n = 24) had an average KOOS JR of 69.9 ± 19.1 and 73.2 ± 16.1, respectively. There was no difference noted in postoperative scores between the five deformity groups.

CONCLUSIONS

The utilization of MP-TKA in patients who have moderate and severe valgus deformity showed similar favorable outcomes when compared to neutral as well as moderate and severe varus knees. Further studies are needed to determine long-term outcomes with widespread MP-TKA use for all preoperative coronal deformities.

Stratified Comparison of Short-Term Perioperative Outcomes in Direct Anterior Versus Posterolateral Primary Total Hip Arthroplasty: A Retrospective Review

Background: It is unclear what influence patient sex and body mass index (BMI) have on perioperative outcomes following total hip arthroplasty (THA), especially regarding anterior versus posterolateral approaches. Purpose/Study Questions: We sought to compare perioperative outcomes of primary THA via direct anterior (DAA) versus posterolateral (PLA) approaches, stratified by patient sex and BMI. Methods: A retrospective review at a single institution identified 8258 patients 18 to 80 years old who underwent primary THA via DAA or PLA for osteoarthritis between February 2019 and April 2022. Patients were stratified by sex and BMI (<30 or 30-40). We compared operative times, lengths of stay (LOS), opioid consumption and prescribing patterns, and achievement of Hip Injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) across the cohorts. Results: Median operative time was 6 to 11 minutes longer for DAA than for PLA. Median LOS was shorter for DAA, with the largest difference observed in women with BMI <30 (19-hour difference) and BMI 30 to 40 (20-hour difference). In-hospital milligram morphine equivalents consumed were lower for DAA in men with BMI <30 (45 vs 53), women with BMI <30 (45 vs 53), and women with BMI 30-40 (60 vs 75). There was no difference observed in HOOS JR MCID, SCB, or PASS achievement scores at 1 year for any cohort. Conclusion: This retrospective study found longer operative times for DAA than PLA and shorter LOS in women undergoing DAA than those undergoing PLA. There were minimal clinical differences in in-hospital opioid consumption, 90-day opioid prescription patterns, and patient-reported outcome measures. These findings suggest that patient sex and BMI may have implications on case scheduling and discharge planning for primary THA. Further study is warranted.

Automated Versus Manual Femoral Component Rotation Planning in Robotic-Assisted and Conventional Total Knee Arthroplasty: A Retrospective Comparison

BACKGROUND

The purpose of this study was to determine if using automated femoral rotation planning in robotic-assisted total knee arthroplasty (RA-TKA) was associated with differences in functional outcomes compared to patients who underwent manually set femoral rotation in RA-TKA or conventional TKA (C-TKA).

METHODS

This was a retrospective multicenter study of patients who underwent TKA utilizing conventional methods with femoral component rotation set to 3° externally (C-TKA) [n = 108 knees], RA-TKA with automated femoral rotation planning intrinsic to the system (A-RA-TKA) [n = 111], and RA-TKA with femoral rotation manually set by the surgeon (M-RA-TKA) [n = 152], at least one year before follow-up. Outcome measures included the range of motion, Knee Injury and Osteoarthritis Joint Replacement (KOOS-JR), and Forgotten Joint Score (FJS). Intraoperative intercompartmental laxity measures and the rotational position of the femoral component relative to the posterior condylar axis were recorded.

RESULTS

In the A-RA-TKA group, the mean improvement in range of motion was significantly higher compared to both the M-RA-TKA and C-TKA groups (22.7 versus 9.88 and 20.6°, respectively). Significant differences in improvement in KOOS-JR were not seen, but patients in the A-RA-TKA group had significantly higher mean FJS than the M-RA-TKA and C-TKA groups (71.0 versus 52.6 and 60.5, respectively). Femoral component internal rotation was significantly greater in the M-RA-TKA group than in the A-RA-TKA group (4.27 versus 1.00°, P < 0.001). The M-RA-TKA group had a significantly higher number of highly internally rotated femoral components (> 4.5°) compared with the other groups, which was associated with significantly lower rates of achievement of FJS and KOOS-JR patient acceptable symptoms state.

CONCLUSIONS

Compared to manually set femoral rotation, the use of automated femoral rotational planning facilitates intercompartmental gap balancing and prevents over-rotation of the femoral component, which may be associated with worse functional outcomes.

Dynamic variation of tibiofemoral compression force during total knee arthroplasty: Implications for soft tissue balance and functional outcomes

BACKGROUND

Achieving precise alignment and soft tissue balance is crucial for optimal total knee arthroplasty (TKA) outcomes. We aimed to explore how tibiofemoral compression force (TFCF) varies with knee flexion and its correlation with functional outcomes.

METHODS

This prospective study included 60 patients undergoing cruciate-retaining TKA (FINE Total Knee System). Sensor-equipped trial inserts were used to measure the TFCF at 15° intervals, from full extension to 90° flexion. Patients were classified into anterior and posterior force groups based on whether the medial TFCF was higher in the anterior than in the posterior region at 60° flexion. The 2-year outcomes were assessed using the Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS-JR).

RESULTS

The total TFCF increased from 0° to 60° flexion and then decreased. The medial compressive forces were consistently higher than lateral forces. Anteromedial TFCF differed significantly between the anterior and posterior force groups at 60°, 75°, and 90° flexion. KOOS-JR scores showed a significant interaction between force type and time, with greater improvements in the anterior force group. Anteromedial TFCF at 60° flexion and KOOS-JR correlated significantly (R = 0.574).

CONCLUSION

Evaluating TFCF at multiple knee flexion angles provides valuable insights into optimising outcomes in TKA. TFCF variations, especially in the anteromedial compartment, considerably impact functional outcomes. Dynamic TFCF measurements during TKA may enhance soft tissue balance and improve outcomes. Further research is needed to validate these findings in diverse populations and with long-term follow ups.

The Mark Coventry Award: Does Matching the Native Coronal Plane Alignment of the Knee Improve Outcomes in Primary Total Knee Arthroplasty?

BACKGROUND

The coronal plane alignment of the knee (CPAK) classification system was developed to assess personalized alignment strategies, such as kinematic alignment, in total knee arthroplasty (TKA). However, CPAK has not been studied with regard to patient-reported outcome measures (PROMs). This study evaluated whether incidentally matching a patient's native preoperative CPAK classification with TKA implant position meaningfully impacted postoperative PROMs.

METHODS

A retrospective review of 2,427 primary TKAs was performed. Knees were classified using the CPAK classification on standardized preoperative and postoperative short-leg radiographs using a five-degree adjustment for the lateral distal femoral angle based on available literature. Surgeries were performed using adjusted mechanical alignment strategies with a three-degree boundary. Patients who had a matching preoperative and postoperative CPAK were compared to all other combinations. Modern PROMs and clinically important differences were analyzed utilizing univariate and multivariate analyses.

RESULTS

There were 94.5% of native knees classified as CPAK I to III, like published CPAK distributions. The distribution of postoperative CPAK classification was significantly different, with 25.6% of TKAs classified as CPAK I to III (P < 0.001), and only 11.5% (N = 266) of postoperative CPAK matched the native preoperative classification. The CPAK was not associated with preoperative (P ≥ 0.208) or postoperative PROMs (P ≥ 0.085), except CPAK I had significantly higher preoperative pain with level walking compared to CPAK III only (P = 0.027). Patients who had matching preoperative and postoperative CPAK classes demonstrated no difference in PROMs at a median of 24 months of follow-up (P ≥ 0.143). Statistical power was ≥93.9%.

CONCLUSIONS

Study results demonstrate that matching a patient's native knee coronal alignment classified by CPAK was not predictive of PROMs. This supports prior research that suggests TKA outcomes are multifactorial and related to complex interactions between implant position in three dimensions as well as soft-tissue balance and kinematics.

LEVEL OF EVIDENCE

III.

Ultracongruent Versus Posterior-Stabilized Polyethylene: No Difference in Anterior Knee Pain but Decreased Noise Generation

BACKGROUND

Noise generation and anterior knee pain can occur after primary total knee arthroplasty (TKA) and may affect patient satisfaction. Polyethylene design in cruciate-sacrificing implants could be a variable influencing these complications. The purpose of this study was to analyze the effect of polyethylene design on noise generation and anterior knee pain.

METHODS

We prospectively reviewed a cohort of patients who underwent primary TKA between 2014 and 2022 by a single surgeon using either a posterior-stabilized (PS) or ultracongruent (UC) polyethylene of the same implant design. The primary outcomes were measured through a noise generation questionnaire and the Knee Injury and Osteoarthritis Outcome Score-Patellofemoral score.

RESULTS

A total of 409 TKA procedures were included, 153 (37.4%) PS and 256 (62.6%) UC. No difference was noted in the Knee Injury and Osteoarthritis Outcome Score-Patellofemoral score between PS and UC designs (71.7 ± 26 versus 74.2 ± 23.2, P = 0.313). A higher percentage of patients in the PS cohort reported hearing (32.7% versus 22.3%, P = 0.020) or feeling noise (28.8 versus 20.3, P = 0.051) coming from their implant. No notable difference was observed in noise-related satisfaction rates. Independent risk factors of noise generation were age (OR, 0.96; P = 0.006) and PS polyethylene (OR, 1.61; P = 0.043). Noise generation was associated with decreased patient-reported outcome measure scores ( P < 0.001).

CONCLUSION

While there was no difference in anterior knee pain between PS and UC polyethylene designs, PS inserts exhibit higher rates of noise generation compared with UC. Noise generation had comparable satisfaction but was associated with decreased patient-reported outcome measure scores.

Evaluating Surgeon-influenced Factors for Total Knee Arthroplasty Value-based Reimbursement

INTRODUCTION

Clinical outcome measures used under value-based reimbursement models require risk stratification of patient demographics and medical history. Only certain perioperative patient factors may be influenced by the surgeon. The study evaluated surgeon-influenced modifiable factors associated with achieving literature-defined KOOS score thresholds to serve as the foundation of the newly established alternative payment models for total knee arthroplasties (TKA).

METHODS

We retrospectively reviewed a consecutive cohort of 4,324 patients undergoing TKA. Surgeon-influenced modifiable risk factors included thromboprophylaxis with aspirin, tourniquet use, tranexamic acid (TXA), body mass index, smoking, alcohol or illicit drug use, surgical time, length of stay (LOS), and bilateral TKA. Outcomes included complications, 90-day readmissions, discharge disposition, knee injury and osteoarthritis outcome score (KOOS) minimal clinically important difference (MCID), KOOS patient acceptable symptom state (PASS), and short form-12 (SF-12) MCID achievement. A bivariate analysis and regression were built to determine the likelihood of primary outcomes based on modifiable factors.

RESULTS

Bilateral TKA was associated with a higher odds ratio (OR) for home discharge (OR = 5.40, P < 0.001), KOOS MCID (OR = 2.60, P < 0.001), PASS (OR = 2.4, P ≤ 0.001), and SF-12 PCS MCID achievement (OR = 3.21, P < 0.001). Similarly, LOS was inversely associated with KOOS MCID (OR = 0.88, P = 0.002) and PASS (OR = 0.81, P < 0.001) but directly associated with home discharge (OR = 2.5, P ≤ 0.001) in-hospital complications (OR = 1.50, P < 0.001) and 90-day readmissions (OR = 1.23, P = 0.005). The KOOS MCID and PASS achievement was positively influenced by TXA (OR = 1.33, P = 0.008; OR = 1.29, P = 0.020) use and negatively influenced by aspirin use (OR = 0.68, P = 0.013; OR = 0.73, P = 0.040). In-hospital opioid use was an independent risk factor for not achieving SF-12 MCS MCID (OR = 0.56, P = 0.006).

CONCLUSION

In this study, modifiable perioperative variables, such as TXA, aspirin use, opioid use, LOS, and bilateral TKA, were found to markedly increase quality metrics threshold achievement and should be considered as risk variables in the current value-based care models. Future studies should investigate the effect of modifiable risk factors on quality metrics to build new risk adjustment tools that incentivize patient perioperative optimization.

Time-dependent, patient-centered perceptions of quality measures for total joint arthroplasty: a cross-sectional, choice modeling study

BACKGROUND

As value-based care arrangements continue to assess quality of care and costs, comprehensive and patient-centered definitions of quality of care are required. While patient-reported outcome measures are increasingly integrated into quality assessments following total joint arthroplasty (TJA), patient perceptions of quality paired with the phase of surgical care has not been described. The purpose of this study was to assess how TJA patients perceive measures of quality of care and assess if these perceptions change based on the phase of care.

METHODS

Patients who had undergone a TJA within the past two years or had a scheduled TJA within the next 6 months completed a questionnaire designed using best-worst scaling, a method used to measure individuals' priorities by asking participants to make repeated selections of the best and worst items in a series of subsets of items. Subanalyses were calculated to compare each phase of care (preoperative, short term postoperative, and long term postoperative).

RESULTS

A total of 153 patients completed the questionnaire; 36 were preoperative, 55 were short term postoperative, and 62 were long term postoperative. Patients placed the highest value on improving activities of daily living (β = 1.03, CI = 0.90-1.16), decreasing pain (β = 0.65, CI = 0.53-0.76), and avoiding re-intervention (β = 0.64, CI = 0.52-0.76). Decreasing pain ranked as a higher priority preoperatively compared to short term postoperatively, and subsequently increased in priority again after 6 months. Avoiding reintervention was less important to patients preoperatively compared to postoperatively. Avoiding complications was more important to patients preoperatively compared to postoperatively.

CONCLUSIONS

Matching outcome assessments with how patients assess their quality of care throughout the TJA recovery process can inform phase-specific quality improvement initiatives and value definitions. Activities of daily living should be measured across phases of care and into long-term recovery. TJA value dashboards should align with these patient-driven perceptions of quality.

LEVEL OF EVIDENCE

Level III, cohort study.

Rotating Hinge Revision Total Knee Arthroplasty Provides Greater Arc of Motion Gains for Patients Who Have Severe Arthrofibrosis

BACKGROUND

Arthrofibrosis is a common postoperative total knee arthroplasty (TKA) complication that results in limited range of motion (ROM). There is limited literature on outcomes after revision TKA (rTKA) for arthrofibrosis based on preoperative ROM restriction. The aims of this study were to: (1) examine ROM trajectory after rTKA for arthrofibrosis patients who have severe versus nonsevere limitations; (2) compare ROM gains and final arc of motion (AOM) between severe and nonsevere cohorts; (2a) compare ROM gain in a severe cohort treated with a rotating hinge (RH) versus a non-RH (NRH) construct; and (3) assess the impact of arthrofibrosis severity on patient-reported outcome measures.

METHODS

Patients were divided into 2 groups: group A had preoperative ROM < 70° (severe), and group B had preoperative ROM > 70° (non-severe). Patients were assessed clinically using AOM gain, absolute ROM, Knee injury and Osteoarthritis Outcomes Score for Joint Replacement, lower extremity activity scale, and pain scores. Postoperative gains in AOM were compared between both groups.

RESULTS

A total of 56 rTKAs (group A (severe): n = 36, group B (non-severe): n = 20) were performed for patients who have postoperative fibrosis. Group B had better ROM at the 1-year time point (group B: 95.9 ± 22.5 degrees versus group A: 83.2 ± 25.7 degrees). Group A had significantly better improvement in absolute AOM than group B (31.1 ± 20.9 versus 11.4 ± 25.0 degrees, P < 0.01). The RH group demonstrated significantly better absolute AOM gain than the NRH group (41.3 ± 19.4 versus 18.3 ± 15.2 degrees, P < 0.001). However, there were no significant differences in patient-reported outcome measures between groups A and B or between RH and NRH groups at the final follow-up.

CONCLUSIONS

Final ROM achieved between severe and nonsevere arthrofibrosis groups was similar, and patients who have severe arthrofibrosis can expect greater absolute ROM gains and similar functional outcomes than nonsevere arthrofibrosis patients. The RH rTKAs provided greater AOM gains for patients who have severe arthrofibrosis, with equivalent functional outcomes to non-RH implants. For severe arthrofibrosis patients, RH designs provided twice the overall ROM gain; however, longer follow-up is necessary to determine whether RH designs have inferior overall implant survivorship.

Should We Wait for Bone-on-Bone Arthritis? Equivalent Clinical Outcomes in Patients Requiring Advanced Imaging Before Primary Total Hip Arthroplasty

BACKGROUND

Plain radiographs remain the standard for diagnosing osteoarthritis (OA). Total hip arthroplasty (THA) is generally offered only for advanced OA by plain radiographs. Advanced imaging is used as an adjunct to assess OA severity in cases of progressive symptoms with less advanced OA by plain radiographs. The objective of this study was to compare outcomes following THA in patients who have advanced OA visualized by plain radiographs to patients who have less severe OA visualized by plain radiographs.

METHODS

From February 2016 to February 2020, 93 patients who had Kellgren-Lawrence (KL) grade 0 to 2 OA and underwent THA were identified. The median age was 65 years, and 55% were women. They were matched 1:3 to patients who underwent THA for KL 4 OA based on age, sex, body mass index, and Charlson Comorbidity Index. The primary outcome was achievement of the Hip Injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) minimum clinically important difference, substantial clinical benefit, and patient-acceptable symptom state at 1 year postoperatively.

RESULTS

There was no difference between the KL 0 to 2 and KL 4 cohorts in the achievement of HOOS JR minimum clinically important difference (86 versus 85.6%, P = .922), substantial clinical benefit (81.7 versus 80.2%, P = .751), or patient-acceptable symptom state (89.2 versus 85.6%, P = .374). The KL 0 to 2 cohort had a similar improvement in their 2-year HOOS JR (42.5 versus 38.6, P = .019).

CONCLUSIONS

In this series, there was no difference in outcomes following primary THA between patients who have severe OA on plain radiographs (KL 4) compared to those who have less severe OA (KL 0 to 2). In the setting of severe symptoms and the absence of advanced OA on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from THA.

Clinical relevance of patient-reported outcome measures in patients who have undergone total hip arthroplasty: a systematic review

INTRODUCTION

In orthopaedic research, it is crucial to determine changes that are statistically significant and clinically meaningful. One approach to accomplish this is by calculating the Minimal Clinically Important Difference (MCID), the Clinically Important Differences (CID), the Minimum Detectable Change (MDC), the Minimal Important Change (MIC), and the Patient Acceptable Symptom State (PASS) values. These tools assist medical professionals in comprehending the patient's viewpoint, enabling them to establish treatment objectives that align with patients' desires and expectations. The present systematic review investigated the MCID, MIC, CID, MDC, and PASS of the most used PROMs to assess patients who have undergone THA.

METHODS

This systematic review followed the 2020 PRISMA guidelines. Web of Science, Embase, and PubMed were accessed in March 2024 without time constraints or additional filters. All the clinical investigations which evaluated data tools (MCID, MIC, CID, MDC, and PASS) to assess the clinical relevance of PROMs in THA were accessed. Articles in Spanish, Italian, German, and English were eligible. Studies with levels of evidence I to III were eligible.

RESULTS

Data from 100,824 patients were collected. All relevant demographic data were analysed and summarised. In addition, the MCID, MIC, CID, MDC and PASS of the COMI, HOOS, SF-36, OHS, Oxford-12, PROMIS-PF, SF-12, and WOMAC scores for THA were determined.

CONCLUSION

Current evidence recommends to collect MCIDs based on anchors routinely. These values should be used as complementary tools to determine the clinical effectiveness of a treatment instead of solely relying on statistically significant improvements.

LEVEL OF EVIDENCE

Level IV, systematic review and meta-analysis.

Trends in Preoperative Outcome Measures From 2013 to 2021 in Patients Undergoing Primary Total Joint Arthroplasty

INTRODUCTION

The prevalence of total joint arthroplasty (TJA) continues to increase exponentially. Patient-reported outcome measures (PROMs) are used to define clinical and quality-of-life improvement and for reimbursement. Temporal trends of preoperative PROMs and specifically how COVID-19 has affected these PROMs is lacking. This study evaluated preoperative PROMs over time, whether medical factors affected preoperative PROMs, and what correlations the COVID-19 pandemic had with these trends in PROMs.

METHODS

A total of 3,014 patients who underwent primary total hip total hip arthroplasty or total knee arthroplasty from 2013 to 2021 were retrospectively reviewed for covariates and preoperative PROMs. Commonly reported preoperative PROMs were evaluated in univariate and multivariate models.

RESULTS

Preoperative activity level steadily increased from 2015 to 2021 for THAs and steadily increased from 2015 to 2019 for TKAs, followed by a decrease in 2020. Preoperative KOOS JR scores increased from 2016 to 2019 and then decreased in 2020 and 2021. Preoperative knee pain with level walking and climbing stairs steadily increased from 2013 to 2019, with additional increases in 2020. The COVID-19 era was significantly associated with higher activity levels for THAs, higher levels of pain with level walking, and lower KOOS JR scores. Preoperative PROM scores demonstrated correlations with postoperative PROM scores, which differed from that during the COVID era (rho range 0.105 to 0.391) at a mean of 2.0 years postoperatively.

DISCUSSION

Surgical delays because of COVID-19 were associated with increased preoperative disability as evidenced by lower activity levels. Aside from this pandemic era, patient activity levels increased over time, indicating that modern TJA patients are more active preoperatively and likely to demand higher levels of function after surgery. Additional studies should evaluate the clinical effect of these statistically significant findings. Providers should consider the trends in preoperative PROMs over time when counseling patients on expectations after TJA.

Worse Patient-Reported Outcomes and Spino-Pelvic Parameters After Total Hip Arthroplasty for Rapidly Progressive Osteoarthritis of the Hip Compared to Osteoarthritis: A Propensity-Matched Cohort Study

BACKGROUND

This study aimed to assess the association between the disease process of hip osteoarthritis and total hip arthroplasty (THA) outcomes; this is a critical issue, as rapid progression has been postulated to be responsible for patient dissatisfaction after THA.

METHODS

This retrospective case-control study included 255 patients who underwent THA and completed a mean follow-up duration of 42.1 months (range, 24.0 to 77.0). We classified patients into those who had (n = 26) and did not have (n = 229) rapidly progressive osteoarthritis of the hip (RPOA), defined as a narrowing rate of joint space ≥ 2 mm yearly or a ≥ 50% loss within 12 months, excluding any other cause of a destructive arthropathy. Propensity score-matched cohorts for age, sex, body mass index, and spino-pelvic measures were created, and the outcomes were compared between the 2 groups.

RESULTS

After successfully matching RPOA (n = 25) and non-RPOA patients (n = 50), there were significant differences in minimum clinically important difference (P = .009 for European Quality of Life 5-Dimension, and P < .001 for low back pain), patient acceptable symptom state (P = .015 for European Quality of Life 5-Dimension, and P < .001 for Hip Disability and Osteoarthritis Outcome Score Joint Replacement score), patient satisfaction (P = .028), and T1 pelvic angle as an indicator of global sagittal spinal deformity (P = .017). There was a correlation between T1 pelvic angle and low back pain in the RPOA group (R = 0.628, P < .001).

CONCLUSIONS

Patients who exhibited RPOA before undergoing THA showed worse patient-reported outcomes compared with those who did not have rapid progression. Our study highlights the critical role of the disease process in influencing THA outcomes, advocating for a paradigm shift toward more meticulous preoperative evaluations, including global spinal deformity, standardized diagnostic criteria, and tailored interventions.

Defining the Patient Acceptable Symptom State (PASS) for PROMIS After Total Ankle Replacement

BACKGROUND

Although patient-reported outcomes (PROs), such as the Patient-Reported Outcomes Measurement Information System (PROMIS), are a key element of evaluating success after total ankle replacement (TAR), many do not explicitly state a key factor of postoperative success: is the patient satisfied with their outcome after TAR? The patient acceptable symptom state (PASS) represents the symptom threshold beyond which patients consider themselves well. This study aimed to establish the PROMIS thresholds for the PASS in a primary cohort of TAR patients.

METHODS

This single-institution study included 127 primary TAR patients with preoperative and 2-year postoperative PROMIS scores. At 2 years postoperatively, patients answered 2 PASS anchor questions (Satisfaction, Delighted-Terrible scale) with Likert-scale responses. PASS thresholds with 95% confidence intervals (CIs) were calculated from PROMIS scores using an anchor-based method. Using a bootstrapping technique with 1,000 iterations, the Youden index was calculated to determine the best specificity and sensitivity coordinates to maximize their combination. Finally, preoperative variables associated with the likelihood of achieving the PASS were assessed.

RESULTS

There was a strong association between PASS thresholds and PROMIS domains, especially Pain Interference (PASS threshold of <56.0, area under the receiver operating characteristic curve [AUC] = 0.940), Pain Intensity (<48.4, AUC = 0.936), and Physical Function (>44.7, AUC = 0.883). The likelihood of achieving the PASS was not affected by age, race, gender, American Society of Anesthesiologists (ASA) class, body mass index, or severity of ankle deformity. Patients with worse preoperative Physical Function and Global Mental Health scores were less likely to meet the PASS threshold for Physical Function postoperatively (p = 0.028 and 0.041).

CONCLUSIONS

The ability to reach the PASS after TAR was most strongly associated with postoperative PROMIS pain scores. However, PASS thresholds were generally poorer than population means. This demonstrates that patients do not need to reach normal pain or physical function levels to have an acceptable symptom state after TAR.

LEVEL OF EVIDENCE

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

Factors associated with the progression of sagittal spinal deformity after total hip arthroplasty: a propensity score-matched cohort study

PURPOSE

The functional interaction between the hip and spine in patients undergoing total hip arthroplasty (THA) is clinically significant, as it impacts post-operative outcomes. Therefore, this study aimed to identify factors associated with the progression of sagittal spinal deformity and assess the association with patient-reported outcomes.

METHODS

This retrospective case-control study included 200 patients who underwent primary THA and completed a mean follow-up duration of 42.2 months (range, 24.0-78.0). We employed a multivariate logistic regression to identify variables predictive of a post-THA sagittal vertical axis (SVA) ≥ 50 mm, which was indicative of a spinal sagittal imbalance. Propensity score-matched cohorts for age, sex, body mass index, follow-up duration, hip flexion contracture, developmental dysplasia, pelvic incidence (PI), and SVA were created, and the outcomes were compared between the two groups.

RESULTS

PI (odds ratio 1.39; 95% confidence interval 1.04-1.86, p = 0.033) was associated with an SVA ≥ 50 mm. After successfully matching patients with (n = 50) and without (n = 50) an SVA ≥ 50 mm, the minimum clinically important difference showed significant differences between the 50 matched pairs (p = 0.016 for EuroQol-5D, p = 0.003 for Hip Disability and Osteoarthritis Outcome Score Joint Replacement, and p < 0.001 for low back pain).

CONCLUSION

PI is associated with the development of a positive sagittal spinal malalignment post-THA. This finding can assist surgeons in managing patient expectations and in optimising outcomes. Feasible strategies are warranted to minimise the risk of spinal deformity progression post-THA.

Defining the patient acceptable symptom state using PROMIS following reconstruction of the progressive collapsing foot deformity

BACKGROUND

The patient acceptable symptom state (PASS) represents the threshold beyond which patients are satisfied with their outcome. This study aimed to define PASS thresholds for progressive collapsing foot deformity (PCFD) reconstruction using Patient-Reported Outcomes Measurement Information System (PROMIS) scores and anchor question responses.

METHODS

This retrospective study consisted of 109 patients who underwent flexible PCFD reconstruction, had preoperative and 2-year postoperative PROMIS scores, and 2-year postoperative anchor question responses. ROC curve analyses were performed to quantify PASS thresholds.

RESULTS

PASS thresholds for the PROMIS Physical Function (PF) and Pain Interference (PI) domains were found to be lower and higher, respectively, than population norms. Furthermore, patients with higher preoperative PROMIS PF scores or lower preoperative PROMIS PI scores had a significantly higher likelihood of achieving the PASS thresholds.

CONCLUSION

In addition to guiding future outcomes research, these results may help surgeons optimize treatment for PCFD and better manage patient expectations.

LEVEL OF EVIDENCE

III, retrospective cohort study.

What Are the Diagnosis-Specific Thresholds of Minimal Clinically Important Difference and Patient Acceptable Symptom State in Hip Disability and Osteoarthritis Outcome Score After Primary Total Hip Arthroplasty?

BACKGROUND

This study aimed to determine the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) thresholds for Hip Disability and Osteoarthritis Outcome Score (HOOS) pain, physical short form (PS), and joint replacement (JR) 1 year after primary total hip arthroplasty stratified by preoperative diagnosis of osteoarthritis (OA) versus non-OA.

METHODS

A prospective institutional cohort of 5,887 patients who underwent primary total hip arthroplasty (January 2016 to December 2018) was included. There were 4,184 patients (77.0%) who completed a one-year follow-up. Demographics, comorbidities, and baseline and one-year HOOS pain, PS, and JR scores were recorded. Patients were stratified by preoperative diagnosis: OA or non-OA. Minimal detectable change (MDC) and MCIDs were estimated using a distribution-based approach. The PASS values were estimated using an anchor-based approach, which corresponded to a response to a satisfaction question at one year post surgery.

RESULTS

The MCID thresholds were slightly higher in the non-OA cohort versus OA patients. (HOOS-Pain: OA: 8.35 versus non-OA: 8.85 points; HOOS-PS: OA: 9.47 versus non-OA: 9.90 points; and HOOS-JR: OA: 7.76 versus non-OA: 8.46 points). Similarly, all MDC thresholds were consistently higher in the non-OA cohort compared to OA patients. The OA cohort exhibited similar or higher PASS thresholds compared to the non-OA cohort for HOOS-Pain (OA: ≥80.6 versus non-OA: ≥77.5 points), HOOS-PS (OA: ≥83.6 versus non-OA: ≥83.6 points), and HOOS-JR (OA: ≥76.8 versus non-OA: ≥73.5 points). A similar percentage of patients achieved MCID and PASS thresholds regardless of preoperative diagnosis.

CONCLUSIONS

While MCID and MDC thresholds for all HOOS subdomains were slightly higher among non-OA than OA patients, PASS thresholds for HOOS pain and JR were slightly higher in the OA group. The absolute magnitude of the difference in these thresholds may not be sufficient to cause major clinical differences. However, these subtle differences may have a significant impact when used as indicators of operative success in a population setting.

Does Approach Matter in Robotic-Assisted Total Hip Arthroplasty? A Comparison of Early Reoperations Between Direct Anterior and Postero-Lateral Approach

BACKGROUND

There is no consensus on whether direct anterior approach (DAA) or postero-lateral approach (PLA) total hip arthroplasty (THA) confers a lower risk of postoperative complications. Robotic assistance in THA results in a more consistently accurate component position compared to manual THA. The objective of this study was to compare rates of dislocation, reoperation, revision, and patient-reported outcome measures between patients undergoing DAA and PLA robotic-assisted primary THA.

METHODS

We identified 2,040 consecutive robotic-assisted primary THAs performed for primary osteoarthritis, using DAA (n = 497) or PLA (n = 1,542) between 2017 and 2020. The mean follow-up was 18 months. Kaplan-Meier analysis estimated survivorship free of dislocation, reoperation, and revision. Achievement of patient acceptable symptom state and minimum clinically important difference were used to compare changes in the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) and Visual Analog Scale.

RESULTS

Dislocation was rare in this series (14 in 2,040, 0.7%), including 1 of 497 (0.2%) in the DAA cohort and 13 of 1,542 (0.8%) in the PLA cohort (P = .210). There was no difference in 2-year reoperation-free survivorship (97.8 versus 98.6%, P = .59) or revision-free survivorship (98.8 versus 99.0%, P = .87) at any time point. After controlling for age, sex, and body mass index, there was no difference in dislocation, reoperation, or revision. At 6-week follow-up, after controlling for age, sex, and body mass index, patients in the DAA cohort had higher odds of achieving HOOS JR minimum clinically important difference (odds ratio = 2.01, P = .012) and HOOS JR patient acceptable symptom state (odds ratio = 1.72, P = .028). There were no differences in patient-reported outcome measures by 3 months.

CONCLUSIONS

For robotic-assisted primary THA, DAA may confer enhanced early (<6 weeks) functional recovery compared to the PLA, but there was no significant difference in postoperative dislocation, reoperation, or revision rates.

Functional Articulating Antibiotic Spacers for Chronic Native Septic Knee Arthritis

Background

Semipermanent functional spacers are now utilized for prosthetic joint infection in an attempt to avoid another surgery with 2-stage treatment. This study evaluates the results of metal-on-polyethylene articulating spacers for the treatment of chronic native septic knee arthritis.

Methods

This is a retrospective review of 18 patients treated with metal-on-polyethylene articulating antibiotic spacers constructed with all-polyethylene tibial components or with polyethylene inserts (PIs) with Steinmann pins or screws for chronic native knee infection. Demographic information, spacer construct type, prior knee surgery, complications, infecting organisms, infection eradication, and functional results were analyzed.

Results

Of 18, 8 (44%) spacers were all-polyethylene tibial components and 10 (56%) were PI. Of 18 patients, 5 (28%) experienced spacer complications. Of 18 patients, 12 (67%) underwent a second reimplantation surgery (mean 106 days), while 6 (33%) retained their spacer (average duration 425 days). The PI group performed better in Knee Injury and Osteoarthritis Outcome score for Joint Replacement according to minimum clinically important difference and patient acceptable symptom state (PASS) criteria. The overall reimplantation group achieved Knee Injury and Osteoarthritis Outcome score for Joint Replacement PASS criteria and minimum clinically important difference criteria, while the maintained articulating spacer group did not achieve PASS criteria; however, they did reach minimum clinically important difference.

Conclusions

Functional articulating spacers are a viable treatment for chronic, native knee septic arthritis. The PI patient group had a greater improvement in Knee Injury and Osteoarthritis Outcome score for Joint Replacement scores and had no significant difference in reimplantation rate as the all-polyethylene tibial components patient group. Both planned 2-stage reimplantation and longer-term spacer retention show promising results for this difficult clinical problem.

Patients Requiring Both Total Hip Arthroplasty and Lumbar Spinal Fusion Have Lower Hip Functional Outcome Scores: A Matched Case-Control Study

BACKGROUND

While patients who undergo both lumbar spinal fusion (LSF) and total hip arthroplasty (THA) have increased complication rates compared to patients who have not undergone LSF, there is a paucity of literature evaluating THA functional outcomes in patients with a history of LSF. This study was conducted to determine whether patients undergoing THA with a history of LSF have inferior functional outcomes compared to patients having no history of LSF.

METHODS

A retrospective matched case-control study was conducted at an academic center. Patients who underwent both THA and LSF (cases) were matched with controls who underwent THA without LSF. Inclusion criteria required a minimum of 1-year follow-up for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement [HOOS-JR]. Following propensity matching for age, sex, race, body mass index, and comorbidities, 291 cases and 1,164 controls were included, with no demographic differences.

RESULTS

Patients who underwent both THA and LSF had a significantly lower preoperative HOOS-JR (47 versus 50; P < .001), postoperative HOOS-JR (77 versus 85; P < .001), a significant lower rate of achieving the patient acceptable symptom state (55 versus 67%; P < .001), with no significant difference in delta HOOS-JR (34 versus 34; P = .834). When comparing patients undergoing THA before LSF or LSF before THA, no differences existed for preoperative HOOS-JR (50 versus 47; P = .304), but patients undergoing THA before LSF had lower postoperative HOOS-JR scores (74 versus 81; P = .034), a lower-delta HOOS-JR (27 versus 35; P = .022), and a lower rate of reaching the HOOS-JR minimal clinically important difference (62 versus 76%; P = .031).

CONCLUSIONS

Patients who have a history of LSF experience a similar improvement in hip function when undergoing THA compared to patients who do not have a history of LSF. However, due to lower preoperative function, they may have a lower postoperative functional outcome ceiling. Additionally, patients undergoing THA before LSF have worse hip functional outcomes than patients undergoing LSF before THA.

Clinical Significance Thresholds in Primary and Revision Latarjet Procedures With Comparable Outcome Achievements

BACKGROUND

Given the variability across populations and settings, defining the MCID and the PASS for the Rowe and ASOSS scores and patients undergoing primary and revision Latarjet it is essential to have accurate benchmarks relevant to these groups when interpreting clinical results.

PURPOSE

To determine the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) thresholds for the visual analog scale (VAS) for pain during sports, Athletic Shoulder Outcome Scoring System (ASOSS), and Rowe scores after primary and revision Latarjet procedures for treatment of shoulder instability.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Between January 2018 and January 2020, a retrospective review of 149 patients undergoing primary Latarjet (n = 82) and revision Latarjet (n = 67) to treat shoulder instability was performed in a single institution. Patient-reported outcome measures were collected preoperatively and 1 year postoperatively. The delta was defined as the change between the pre- and postoperative scores. Distribution-based and anchored-based approaches were used to estimate the MCID and the PASS, respectively. The optimal cutoff point and the percentage of patients achieving those thresholds were also calculated.

RESULTS

The distribution-based MCIDs after primary Latarjet were 1.1, 7.5, and 9.6 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the MCID thresholds were 93.9%, 98.7%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds after primary Latarjet were ≤1, ≥90, and ≥85 for the VAS, Rowe, and ASOSS scores, respectively. The percentages of patients who achieved PASS thresholds were 82.9%, 89%, and 86.5% for the VAS, Rowe, and ASOSS scores, respectively. The distribution-based MCIDs after revision Latarjet were 0.6, 6.2, and 3.4 for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved MCID thresholds were 89.3%, 100%, and 100% for the VAS, Rowe, and ASOSS scores, respectively. The PASS thresholds were ≤3, ≥87, and ≥86 after revision Latarjet for the VAS, Rowe, and ASOSS scores, respectively. The rates of patients who achieved the PASS thresholds were 88%, 88%, and 91% for the VAS, Rowe, and ASOSS, respectively.

CONCLUSION

This study identified useful values for the MCID and PASS thresholds in VAS, Rowe, and ASOSS scores after primary and revision Latarjet procedures for treating shoulder instability. Most patients achieved MCID and PASS benchmarks, indicating successful primary and revision Latarjet procedure outcomes. These metrics can serve as valuable parameters when analyzing parameters in future studies and have the potential to enhance patient care by optimizing treatment strategies and surgical decision making.

Diagnosis-Specific Thresholds of the Minimal Clinically Important Difference and Patient Acceptable Symptom State for KOOS After Total Knee Arthroplasty

UPDATE

This article was updated on May 1, 2024 because of a previous error, which was discovered after the preliminary version of the article was posted online. The byline that had read "Ahmed K. Emara, MD 1 *, Ignacio Pasqualini, MD 1 *, Alison K. Klika, MS 1 , Melissa N. Orr, BS 1 , Pedro J. Rullán, MD 1 , Nicolas S. Piuzzi, MD 1 , and the Cleveland Clinic Arthroplasty Group†" now reads "Ahmed K. Emara, MD 1 *, Ignacio Pasqualini, MD 1 *, Yuxuan Jin, MS 1 , Alison K. Klika, MS 1 , Melissa N. Orr, BS 1 , Pedro J. Rullán, MD 1 , Nicolas S. Piuzzi, MD 1 , and the Cleveland Clinic Arthroplasty Group†".

BACKGROUND

Literature-reported minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds for patient-reported outcome measures demonstrate marked variability. The purpose of this study was to determine the minimal detectable change (MDC), MCID, and PASS thresholds for the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subdomain, Physical Function Short Form (PS), and Joint Replacement (JR) among patients with osteoarthritis (OA) who underwent primary total knee arthroplasty (TKA).

METHODS

A prospective cohort of 6,778 patients who underwent primary TKA was analyzed. Overall, 1-year follow-up was completed by 5,316 patients for the KOOS Pain, 5,018 patients for the KOOS PS, and 4,033 patients for the KOOS JR. A total of 5,186 patients had an OA diagnosis; this group had an average age of 67.0 years and was 59.9% female and 80.4% White. Diagnosis-specific MDCs and MCIDs were estimated with use of a distribution-based approach. PASS values were estimated with use of an anchor-based approach, which corresponded to a response to a satisfaction question at 1 year postoperatively.

RESULTS

The MCID thresholds for the OA group were 7.9 for the KOOS Pain, 8.0 for the KOOS PS, and 6.7 for the KOOS JR. A high percentage of patients achieved the MCID threshold for each outcome measure (KOOS Pain, 95%; KOOS PS, 88%; and KOOS JR, 94%). The MDC 80% to 95% confidence intervals ranged from 9.1 to 14.0 for the KOOS Pain, 9.2 to 14.1 for the KOOS PS, and 7.7 to 11.8 for the KOOS JR. The PASS thresholds for the OA group were 77.7 for the KOOS Pain (achieved by 73% of patients), 70.3 for the KOOS PS (achieved by 68% of patients), and 70.7 for the KOOS JR (achieved by 70% of patients).

CONCLUSIONS

The present study provided useful MCID, MDC, and PASS thresholds for the KOOS Pain, PS, and JR for patients with OA. The diagnosis-specific metrics established herein can serve as benchmarks for clinically meaningful postoperative improvement. Future research and quality assessments should utilize these OA-specific thresholds when evaluating outcomes following TKA. Doing so will enable more accurate determinations of operative success and improvements in patient-centered care.

LEVEL OF EVIDENCE

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

Establishing the Minimal Clinically Important Difference and Patient Acceptable Symptom State Thresholds Following Arthroscopic Capsular Release for the Treatment of Idiopathic Shoulder Adhesive Capsulitis

PURPOSE

To determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) threshold for the visual analog scale (VAS), Constant, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores following arthroscopic capsular release for the treatment of idiopathic shoulder adhesive capsulitis.

METHODS

A retrospective review of prospective collected data was performed in patients undergoing arthroscopic capsular release for the treatment of idiopathic adhesive capsulitis at a single institution from January 2018 through January 2019. Patient-reported outcome measures were collected preoperatively and 6 months' postoperatively. Delta was defined as the change between preoperative and 6 months' postoperative scores. Distribution-based and anchored-based (response to a satisfaction question at 1 year) approaches were used to estimate MCIDs and PASS, respectively. The optimal cut-off point where sensitivity and specificity were maximized (Youden index) and the percentage of patients achieving those thresholds were also calculated.

RESULTS

Overall, a total of 100 patients without diabetes who underwent arthroscopic capsular release and completed baseline and 6-month patient-reported outcome measures were included. The distribution-based MCID for VAS, Constant, SANE, and ASES were calculated to be 1.1, 10.1, 9.3, and 8.2, respectively. The rate of patients who achieved MCID thresholds was 98% for VAS, 96% for Constant, 98% for SANE, and 99% for ASES. The PASS threshold values for VAS, Constant, and ASES were ≤2, ≥70, ≥80, and ≥80, respectively. The rate of patients who achieved PASS thresholds was 84% for VAS, 84% for Constant, 89% for SANE, and 78% for ASES.

CONCLUSIONS

In patients without diabetes and idiopathic adhesive capsulitis, high rates of MCID and PASS thresholds can be achieved with arthroscopic anteroinferior capsular release LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

A Retrospective Study on the Feasibility of Using Low-burden Patient-reported Pain Scores to Track Recovery and Outcomes After Total Joint Replacement

Background

Patients undergo total joint arthroplasty to improve function and resolve pain. Patient-reported outcome measures (PROMs) are often sought to determine the success of total joint arthroplasty but are time-consuming and patient response rates are often low. This study sought to determine whether pain numeric rating scores (NRSs) were associated with PROMs and objective mobility outcomes.

Methods

This is a retrospective review of data in patients who utilized a smartphone-based care management application prior to and following total joint arthroplasty. NRS, Hip Disability and Osteoarthritis Outcome Score, Joint Replacement and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, and objective mobility data (step counts, gait speed, and gait asymmetry) were collected preoperatively and at 30 and 90 days postoperatively. Quantile regression was performed to evaluate the correlations between NRS and PROMs.

Results

Total knee arthroplasty patients reported higher NRS than total hip arthroplasty patients postoperatively. NRS was significantly correlated with gait speed preoperatively and at 30 and 90 days postoperatively on quantile regression. Gait asymmetry was significantly associated with NRS at 30 days postoperatively. Regression results suggested significant correlations between NRS and PROMs scores; Hip Disability and Osteoarthritis Outcome Score, Joint Replacement, -0.46 (95% confidence interval: -0.48 to -0.44, P < .001) and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, -0.38 (95% confidence interval: -0.40 to -0.36, P < .001).

Conclusions

NRS is correlated with both objective and subjective measures of function in patients undergoing arthroplasty. Simple pain ratings may be a valid measurement to help predict functional outcomes when collection of traditional PROMs is not feasible.

Defining Patient-relevant Thresholds and Change Scores for the HOOS JR and KOOS JR Anchored on the Patient-acceptable Symptom State Question

BACKGROUND

When evaluating the results of clinical research studies, readers need to know that patients perceive effect sizes, not p values. Knowing the minimum clinically important difference (MCID) and the patient-acceptable symptom state (PASS) threshold for patient-reported outcome measures helps us to ascertain whether our interventions result in improvements that are large enough for patients to care about, and whether our treatments alleviate patient symptoms sufficiently. Prior studies have developed the MCID and PASS threshold for the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) anchored on satisfaction with surgery, but to our knowledge, neither the MCID nor the PASS thresholds for these instruments anchored on a single-item PASS question have been described.

QUESTIONS/PURPOSES

(1) What are the MCID (defined here as the HOOS/KOOS JR change score associated with achieving PASS) and PASS threshold for the HOOS JR and KOOS JR anchored on patient responses to the single-item PASS instrument? (2) How do patient demographic factors such as age, gender, and BMI correlate with MCID and PASS thresholds using the single-item PASS instrument?

METHODS

Between July 2020 and September 2021, a total of 10,970 patients underwent one primary unilateral THA or TKA and completed at least one of the three surveys (preoperative HOOS or KOOS JR, 1-year postoperative HOOS or KOOS JR, and 1-year postoperative single-item anchor) at one large, academic medical center. Of those, only patients with data for all three surveys were eligible, leaving 13% (1465 total; 783 THAs and 682 TKAs) for analysis. Despite this low percentage, the overall sample size was large, and there was little difference between completers and noncompleters in terms of demographics or baseline patient-reported outcome measure scores. Patients undergoing bilateral total joint arthroplasty or revision total joint arthroplasty and those without all three surveys at 1 year of follow-up were excluded. A receiver operating characteristic curve analysis, leveraging a 1-year, single-item PASS (that is, "Do you consider that your current state is satisfactory?" with possible answers of "yes" or "no") as the anchor was then used to establish the MCID and PASS thresholds among the 783 included patients who underwent primary unilateral THA and 682 patients who underwent primary unilateral TKA. We also explored the associations of age at the time of surgery (younger than 65 years or 65 years and older), gender (men or women), BMI (< 30 or ≥ 30 kg/m 2 ), and baseline Patient-Reported Outcome Measure Information System-10 physical and mental component scores (< 50 or ≥ 50) for each of the MCID and PASS thresholds through stratified analyses.

RESULTS

For the HOOS JR, the MCID associated with the PASS was 23 (95% CI 18 to 31), with an area under the receiver operating characteristic curve of 0.75, and the PASS threshold was 81 (95% CI 77 to 85), with an area under the receiver operating characteristic curve of 0.81. For the KOOS JR, the MCID was 16 (95% CI 14 to 18), with an area under the receiver operating characteristic curve of 0.75, and the PASS threshold was 71 (95% CI 66 to 73) with an area under the receiver operating characteristic curve of 0.84. Stratified analyses indicated higher change scores and PASS threshold for younger men undergoing THA and higher PASS thresholds for older women undergoing TKA.

CONCLUSION

Here, we demonstrated the utility of a single patient-centered anchor question, raising the question as to whether simply collecting a postoperative PASS is an easier way to measure success than collecting preoperative and postoperative patient-reported outcome measures and then calculating MCIDs and the substantial clinical benefit.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Cementless medial pivot design demonstrates equal or better outcomes compared to cementless cruciate-retaining design following total knee arthroplasty

Introduction

Traditional total knee arthroplasty (TKA) designs fail to reproduce physiologic knee kinematics, which can contribute to patient dissatisfaction. In an attempt to restore more normal knee kinematics, the medial pivot (MP) design may improve knee function and stability as well as patient satisfaction. A limited number of studies have compared postoperative outcomes of exclusively cementless Cruciate-Retaining (CR) TKAs to cementless MP TKAs. We aimed to compare: (1) 90-day, 1-year, and 2-year complications and revisions, (2) preoperative and postoperative range of motion (ROM), (3) Knee Injury and Osteoarthritis Outcome (KOOS-JR), and (4) visual analog scale (VAS) pain scores at 3-month, 6-month, 1-year, and 2-years.

Methods

A retrospective analysis was performed to identify all patients who had previously undergone a TKA at our institution and compare a cementless CR system to a cementless MP design. Categorical variables, including demographics, comorbidities, and complications utilized Chi-square tests in bivariable analysis. Continuous variables, such as age, were compared using Student's t-tests. Significance was defined as p < 0.05.

Results

Cementless CR and cementless MP cohorts showed low profiles of postoperative complications and favorable patient-reported outcome measures (PROMs). The MP cohort had lower VAS pain at 1-year (1.70 vs. 3.76, p < 0.001) and 2-years (1.43 vs. 2.60, p < 0.001) and higher ROM at 3-months (118 vs. 100, p < 0.001), 6-months (113 vs. 103, p < 0.0001), and 1-year (117 vs. 110, p = 0.02), respectively.

Conclusion

This study is the first comparison of postoperative outcomes between a cementless CR TKA and cementless MP TKA designs. Implant design and fixation type are vital components influencing patient satisfaction after TKA. Pain scores and range of motion favored the cementless MP cohort in comparison to the cementless CR cohort.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Clinical outcomes and return to dance after total hip arthroplasty or hip resurfacing in professional dancers

Aims

Professional dancers represent a unique patient population in the setting of hip arthroplasty, given the high degree of hip strength and mobility required by their profession. We sought to determine the clinical outcomes and ability to return to professional dance after total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA).

Methods

Active professional dancers who underwent primary THA or HRA at a single institution with minimum one-year follow-up were included in the study. Primary outcomes included the rate of return to professional dance, three patient-reported outcome measures (PROMs) (modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), and Lower Extremity Activity Scale (LEAS)), and postoperative complications.

Results

A total of 49 hips in 39 patients (mean age 56 years (SD 13); 80% female (n = 39)) were included. Mean follow-up was 4.9 years (SD 5.1). Of these 49 hips, 37 THAs and 12 HRAs were performed. In all, 96% of hips returned to professional dance activities postoperatively. With regard to PROMs, there were statistically significant improvements in mHHS, HOOS-JR, and LEAS from baseline to ≥ one year postoperatively. There were complications in 7/49 hips postoperatively (14%), five of which required revision surgery (10%). There were no revisions for instability after the index procedure. Two complications (5.4%) occurred in hips that underwent THA compared with five (42%) after HRA (p = 0.007), though the difference by procedure was not significantly different when including only contemporary implant designs (p = 0.334).

Conclusion

Active professional dancers experienced significant improvements in functional outcome scores after THA or HRA, with a 96% rate of return to professional dance. However, the revision rate at short- to mid-term follow-up highlights the challenges of performing hip arthroplasty in this demanding patient population. Further investigation is required to determine the results of THA versus HRA using contemporary implant designs in these patients.

One-Year Postoperative Patient-Reported Outcome Measures Are Associated With Three-Year to Five-Year Postoperative Satisfaction in Total Knee Arthroplasty

BACKGROUND

Over the past couple of decades, the definition of success after total knee arthroplasty (TKA) has shifted away from clinician-rated metrics and toward the patient's subjective experience. Therefore, understanding the aspects of patient recovery that drive 3-year to 5-year satisfaction after TKA is crucial. The aims of this study were to (1) determine the 1-year postoperative factors, specifically patient-reported outcome measures (PROMs) that were associated with 3-year and 5-year postoperative satisfaction and (2) understand the factors that drive those who are not satisfied at 1 year postoperatively to become satisfied later in the postoperative course.

METHODS

This was a retrospective study of 402 TKA patients who were gathered prospectively and presented for their 1-year follow-up. Demographics were collected preoperatively and patient-reported outcomes were collected at 1, 3, and 5 years postoperatively. Logistic regressions were used to identify the factors at 1 year that were associated with 3-year and 5-year satisfaction.

RESULTS

Associations between 1-year PROMs with 3-year satisfaction were observed. Longer term satisfaction at 5 years was more closely associated with EuroQol 5 Dimension Mobility, Activity Score, and Numerical Rating Scale Satisfaction. Of those who were not satisfied at 1 year, EuroQol 5 Dimension Mobility, Knee Disability Osteoarthritis Outcome Score Function in Sport and Recreation, and Satisfaction were associated with becoming satisfied at 3 years.

CONCLUSION

The 1-year PROMs were found to be associated with satisfaction at 3 to 5 years after TKA. Importantly, many of the PROMs that were associated with 3-year to 5-year satisfaction, especially in those who were not originally satisfied at 1 year, were focused on mobility and activity level.

The Impact of Social Determinants of Health on Outcomes and Complications After Total Knee Arthroplasty: An Analysis of Neighborhood Deprivation Indices

BACKGROUND

Social determinants of health (SDOH) are important factors in the delivery of orthopaedic care. The purpose of this study was to investigate the relationship between outcomes following total knee arthroplasty (TKA) and both the Social Vulnerability Index (SVI) and the Area Deprivation Index (ADI).

METHODS

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database was utilized to identify TKA cases for inclusion. Demographic characteristics and medical history were documented. The SVI, its subthemes, and the ADI were analyzed. Outcome data included length of stay, discharge disposition, postoperative change in the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR), 90-day incidences of emergency department (ED) visits, readmission, death, deep venous thrombosis (DVT) and/or pulmonary embolism (PE), periprosthetic fracture, implant failure, periprosthetic joint infection (PJI), and all-cause reoperation. Database cross-referencing was completed to document aseptic and septic revisions beyond 90 days postoperatively. Bivariate quartile-stratified and multivariable analyses were used to associate deprivation metrics with outcomes.

RESULTS

A total of 19,321 TKA cases met inclusion criteria. Baseline patient characteristics varied among the SVI and/or ADI quartiles, with patients of non-White race and with a greater number of comorbidities noted in higher deprivation quartiles. Higher SVI and/or ADI quartiles were correlated with an increased rate of discharge to a skilled nursing facility (p < 0.05). A higher SVI and/or ADI quartile was associated with increased incidences of ED visits and readmissions postoperatively (p < 0.05). DVT and/or PE and long-term aseptic revision were the complications most strongly associated with higher deprivation metrics. Upon multivariable analysis, greater length of stay and greater incidences of ED visits, readmissions, DVT and/or PE, and aseptic revision remained significantly associated with greater deprivation based on multiple metrics.

CONCLUSIONS

Greater deprivation based on multiple SVI subthemes, the composite SVI, and the ADI was significantly associated with increased length of stay, non-home discharge ED visits, and readmissions. The SVI and the ADI may be important considerations in the perioperative assessment of patients who undergo TKA.

LEVEL OF EVIDENCE

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

Scaled TelePhysical Therapy Program a Promising Option for Post-acute Care of Lower-Extremity Arthroplasty Patients

Background

Post-acute care for orthopedic surgery patients continues to evolve with the reduction in hospital length of stay (LOS), shift to ambulatory surgery, increased number of surgeries, and focus on value-based care.

Purpose

We sought to examine outcomes of a cohort of lower-extremity arthroplasty patients receiving telephysical therapy (TelePT) according to hospital LOS, as a means of exploring the viability of TelePT as a value-based discharge option.

Methods

A retrospective review was conducted of patients who participated in our institution's HSS@Home TelePT program after undergoing primary unilateral hip or knee arthroplasty, unicondylar knee replacement, or hip resurfacing. Demographic data and outcomes such as hospital LOS, number of days between discharge and TelePT evaluation, number of TelePT visits, number of re-admissions, Hip dysfunction and Osteoarthritis Outcome (HOOS Jr.) or Knee injury and Osteoarthritis Outcome (KOOS Jr.) scores, and patient satisfaction scores were collected. Patients were divided into categories based on hospital LOS to help determine the versatility of program.

Results

In the 2814 patients included, we observed an average of 4.1 TelePT visits; 1% of patients were readmitted within 90 days, and 97% of patients were satisfied or highly satisfied. There was no difference in HOOS or KOOS Jr. scores at each follow-up time point, except for the 6-month HOOS Jr. scores.

Conclusion

This retrospective study suggests that TelePT may be a viable option for care of lower-extremity arthroplasty patients in the post-acute setting, regardless of hospital LOS. As a discharge option, it may meet the needs of select patients to fill a gap in providing value-based care.

Two-Year Outcomes of Novel Dual-Mobility Implant in Primary Total Hip Arthroplasty

Introduction

Dual-mobility (DM) implants for total hip arthroplasty (THA) have gained popularity due to their potential to reduce hip instability and dislocation events that may lead to revision surgery. These implants consist of a femoral head articulated within a polyethylene liner, which articulates within an outer acetabular shell, creating a dual-bearing surface. Our study aimed to report our observations on the survivorship of a novel DM implant for primary total hip arthroplasty at two years.

Methods

We conducted a retrospective, multicenter study to assess the clinical outcomes of patients undergoing a THA with a novel DM implant (OR3O acetabular system™, Smith & Nephew, Inc., Memphis, TN) from January 2020 to September 2021. Patient demographics, surgical information, and survivorship data were collected from medical records for patients with a minimum of two years of follow-up. Primary outcomes included overall implant survivorship at two years as well as aseptic survivorship, revision rates of the DM acetabular shell, and average time to revision. Patient-reported outcomes were collected in the form of HOOS JR.

Results

A total of 250 hips in 245 patients had a minimum two-year follow-up. Primary osteoarthritis (80%) was the most common indication for index THA. The average aseptic survivorship of the DM acetabular components at two years for the cohort was 98.4% and survivorship of the acetabular implants overall was 97.6%. There were a total of four (1.6%) aseptic revisions of the DM acetabular component. Reasons for aseptic acetabular revision included one case of instability, one intraprosthetic dislocation, one periprosthetic acetabular fracture, and one malpositioned acetabular cup resulting in impingement. The mean time of follow-up was 893.9 days. Eighty-seven patients had preoperative and two-year HOOS JR available. HOOS JR improved by an average of 38.5 points.

Conclusion

This novel DM acetabular implant demonstrates excellent survivorship at two years follow-up with low rates of instability and intraprosthetic dislocation and no episodes of metal-on-metal corrosion. Use of the DM implant demonstrated clinically relevant improvements in patient-reported outcomes at two years.

Effect of Patient Characteristics on the Minimal Clinically Important Difference and Patient Acceptable Symptom State Thresholds After Arthroscopic Bankart Repair

BACKGROUND

There is scarce literature on clinically significant values after arthroscopic Bankart repair (ABR).

PURPOSE

To determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) thresholds at 1 year for the Rowe and Athletic Shoulder Outcome Scoring System (ASOSS) scores after ABR and to determine the effect of patient characteristics on these metrics after ABR.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of patients undergoing ABR from a single institution between January 2017 and January 2020 was performed. Patients with at least 1 episode of instability and a minimum follow-up of 12 months were included. The exclusion criteria were as follows: bony defects of >20% on the anteroinferior portion of the glenoid based on a preoperative computed tomography scan; engaging Hill-Sachs lesions at 90° of abduction and 90° of external rotation based on an arthroscopic examination; previous surgery on the same shoulder; multidirectional instability or concomitant repair of full-thickness rotator cuff tears; superior labral anterior to posterior lesions; posterior labral tears; or humeral avulsion of the glenohumeral ligament lesions. Patient-reported outcome measures were collected both preoperatively and 1-year postoperatively. Delta was defined as the change between preoperative and 1-year postoperative scores. Distribution-based (one-half the standard deviation of the difference between pre- and postoperative outcome scores) and anchored-based approaches (response to a satisfaction question at 1 year) were used to estimate the MCID and the PASS, respectively. The optimal cutoff point, where sensitivity and specificity were maximized, and the percentage of patients achieving those thresholds were also calculated.

RESULTS

Overall, 190 patients were included. The distribution-based MCID for the Rowe and ASOSS scores were calculated to be 8.2 and 8.7, respectively. The rate of patients who achieved MCID thresholds was 96% for the Rowe and 96% for ASOSS scores. The PASS threshold for the Rowe and ASOSS scores were ≥80 and ≥90, respectively. The rate of patients who achieved PASS scores after ABR were 86% and 83%, respectively. The MCID and PASS values showed great variability based on sex (men: 8.5 and ≥85 for Rowe / 8.9 and ≥90 for ASOSS, respectively, vs women: 6.7 and ≥73 for Rowe / 8.1 and ≥75 for ASOSS), age (≥21: 8.4 and ≥80 / 9.2 and ≥90 vs <21: 7.8 and ≥75 / 7.7 and ≥85), sports participation (sports: 8.8 and ≥85 / 9.5 and ≥90 vs no sports: 8.1 and ≥75 / 8.6 and ≥80), and type of athlete (competitive: 8.4 and ≥85 / 8.9 and ≥87 vs recreational: 7.5 and ≥73 / 8.1 and ≥68).

CONCLUSION

This study identified the MCID and PASS thresholds for the Rowe and ASOSS scores at 1 year after ABR. However, these values showed great variability when accounting for different patient characteristics such as sex, age, sports participation, and type of athlete, highlighting the importance of considering individual patient-specific characteristics for optimal treatment decision-making and ensuring treatment success tailored to each patient's unique needs and expectations.

Mid-Term Outcomes of a Modern Zweymüller Monolithic Femoral Stem in Primary Total Hip Arthroplasty

Background: Prosthetic hip replacement is a widely practiced surgical procedure with excellent results. Hip stems based on the Zweymüller design have a long history and their philosophy focuses on achieving long-term stability promoting physiological load transfer. The aim of this study is to evaluate outcomes, survivorship, and complication rates in a cohort of patients treated with this stem. Methods: A retrospective review was conducted to identify patients who underwent primary THA with Zweymüller stems. A total of 86 hips (43%) were implanted in men, and 114 hips (57%) in women. The mean follow-up time was 5.4 years. Patient charts were reviewed for adverse events occurring after primary THA as well as for revision and indication for revision. Patients still implanted with the hip stem were asked to complete the HOOS JR survey. Results: Ten hips (5.0%) were lost to follow up. The mean HOOS JR score at final evaluation was 96.3 points (range, 60.0–100.0). Two revisions were performed during the study for femoral stem loosening due to a periprosthetic Vancouver B2 fracture and for multiple hip dislocations. Conclusions: The Zweymüller design hip stem showed excellent survivorship and favorable clinical outcomes at a mean follow-up of 5.4 years.

Mid-Term Outcomes of a Modern Zweymüller Monolithic Femoral Stem in Primary Total Hip Arthroplasty

Background: Prosthetic hip replacement is a widely practiced surgical procedure with excellent results. Hip stems based on the Zweymüller design have a long history and their philosophy focuses on achieving long-term stability promoting physiological load transfer. The aim of this study is to evaluate outcomes, survivorship, and complication rates in a cohort of patients treated with this stem. Methods: A retrospective review was conducted to identify patients who underwent primary THA with Zweymüller stems. A total of 86 hips (43%) were implanted in men, and 114 hips (57%) in women. The mean follow-up time was 5.4 years. Patient charts were reviewed for adverse events occurring after primary THA as well as for revision and indication for revision. Patients still implanted with the hip stem were asked to complete the HOOS JR survey. Results: Ten hips (5.0%) were lost to follow up. The mean HOOS JR score at final evaluation was 96.3 points (range, 60.0–100.0). Two revisions were performed during the study for femoral stem loosening due to a periprosthetic Vancouver B2 fracture and for multiple hip dislocations. Conclusions: The Zweymüller design hip stem showed excellent survivorship and favorable clinical outcomes at a mean follow-up of 5.4 years.

Rasch Analysis of Joint Replacement Version for Hip Disability and Osteoarthritis Outcome in Individuals With Advanced Osteoarthritis of Hip Awaiting Total Hip Arthroplasty Surgery

OBJECTIVE

The objective of this study was to examine measurement properties of the Joint replacement version for Hip Disability and Osteoarthritis Outcome Score (HOOS-JR) using Rasch analysis in patients with osteoarthritis of hip (HOA).

DESIGN

Cross-sectional clinical measurement SETTING: Patient outcomes database at a tertiary care hospital PARTICIPANTS: Convenience sampling of patients with HOA scheduled for total hip arthroplasty (N=327) OUTCOME MEASURES AND ANALYSIS: The data for pre-surgery assessments for patients with HOA were extracted from an existing database. Variables extracted included HOOS-JR scores, demographic information (age, sex), health-related data, and anthropometric variables. The assumptions of Rasch model such as the test of fit, fit residuals, ordering of item thresholds, factor structure, DIF, internal consistency and Pearson separation index were examined for the HOOS-JR scores.

RESULTS

The HOOS-JR showed adequate overall fit to the Rasch model, logically ordered response thresholds, no floor or ceiling effects, and high internal consistency (Cronbach's alpha of 0.91). The HOOS-JR did not satisfy the assumption of unidimensionality, albeit the violation of this assumption was marginal (6.12% over 5%). Person-item threshold distribution (difference between person and item means were equal to 0.92 which was less than 1 logit unit) confirmed that the HOOS-JR scores were well targeted.

CONCLUSIONS

Given that the violation of unidimensionality for HOOS-JR was marginal, we recommend further studies to validate this finding. Results broadly support the use of HOOS-JR for assessing hip health in patients with HOA.

Establishing the Minimal Clinically Important Difference and Patient Acceptable Symptomatic State following Patellofemoral Inlay Arthroplasty for Visual Analog Scale Pain, Western Ontario and McMaster Universities Arthritis Index, and Lysholm Scores

BACKGROUND

The purposes of the study were to define the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after patello-femoral inlay arthroplasty (PFA) and to identify factors predictive for the achievement of clinically important outcomes (CIOs).

METHODS

A total of 99 patients who underwent PFA between 2009 and 2019 and had a minimum of 2-year postoperative follow-up were enrolled in this retrospective monocentric study. Included patients had a mean age of 44 years (range, 21 to 79). The MCID and PASS were calculated using an anchor-based approach for the visual analog scale (VAS) pain, Western Ontario and McMaster Universities Arthritis Index (WOMAC), and Lysholm patient-reported outcome measures. Factors associated with CIO achievement were determined using multivariable logistic regression analyses.

RESULTS

The established MCID thresholds for clinical improvement were -2.46 for the VAS pain score, -8.5 for the WOMAC score, and + 25.4 for the Lysholm score. Postoperative scores corresponding to the PASS were <2.55 for the VAS pain score, <14.6 for the WOMAC score, and >52.5 points for the Lysholm score. Preoperative patellar instability and concomitant medial patello-femoral ligament reconstruction were independent positive predictors of reaching both MCID and PASS. Additionally, inferior baseline scores and age were predictive of achieving MCID, whereas superior baseline scores and body mass index were predictive of achieving PASS.

CONCLUSION

This study determined the thresholds of MCID and PASS for the VAS pain, WOMAC, and Lysholm scores following PFA implantation at 2-year follow-up. The study demonstrated a predictive role of patient age, body mass index, preoperative patient-reported outcome measure scores, preoperative patellar instability, and concomitant medial patello-femoral ligament reconstruction in the achievement of CIOs.

LEVEL OF EVIDENCE

Prognostic Level IV.

Survivorship and Clinical Outcomes of Primary Total Knee Arthroplasty Performed in Patients 35 Years of Age and Younger

BACKGROUND

Total knee arthroplasties (TKAs) for patients aged ≤35 years are rare but necessary for patients who have diseases such as juvenile idiopathic arthritis, osteonecrosis, osteoarthritis, and rheumatoid arthritis. Few studies have examined the 10-year and 20-year survivorship and clinical outcomes of TKAs for young patients.

METHODS

A retrospective registry review identified 185 TKAs in 119 patients aged ≤ 35 years performed between 1985 and 2010 at a single institution. The primary outcome was implant survivorship free of revision. Patient-reported outcomes were assessed at 2 time points: 2011 to 2012 and 2018 to 2019. The average age was 26 years (range, 12 to 35). Mean follow-up was 17 years (range, 8 to 33).

RESULTS

Survivorship decreased from 84% (95% confidence interval [CI]: 79 to 90) at 5 years to 70% (95% CI: 64 to 77) at 10 years and to 37% (95% CI: 29 to 45) at 20 years. The most common reasons for revision were aseptic loosening (6%) and infection (4%). Risk factors for revision included increasing age at time of surgery (Hazards Ratio [HR] 1.3, P = .01) and use of constrained (HR 1.7, P = .05) or hinged prostheses (HR 4.3, P = .02). There were 86% of patients reporting that their surgery resulted in "a great improvement" or better.

CONCLUSION

Survivorship of TKAs in young patients is less favorable than expected. However, for the patients who responded to our surveys, TKA demonstrated substantial pain relief and improvement in function at 17-year follow-up. Revision risk increased with older age and higher levels of constraint.