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Karimijashni M, Ramsay T, Beaulé PE, Poitras S. Strategies to Manage Poorer Outcomes After Hip or Knee Arthroplasty: A Narrative Review of Current Understanding, Unanswered Questions, and Future Directions. Musculoskeletal Care 2024; 22:e1921. [PMID: 39075675 DOI: 10.1002/msc.1921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 07/14/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE Although hip or knee arthroplasty is generally a successful intervention, it is documented that 15%-30% of patients undergoing arthroplasty report suboptimal outcomes. This narrative review aims to provide an overview of the key findings concerning the management of poorer outcomes after hip or knee arthroplasty. METHOD A comprehensive search of articles was conducted up to November 2023 across three electronic databases. Only studies written in English were included, with no limitations applied regarding study design and time. RESULT Efficiently addressing poorer outcomes after arthroplasty necessitates a thorough exploration of appropriate methods for assessing recovery following hip or knee arthroplasty, ensuring accurate identification of patients at risk or experiencing poorer recovery. When selecting appropriate outcome measure tools, various factors should be taken into consideration, including understanding patients' priorities throughout the recovery process, assessing psychometric properties of outcome measure tools at different time points after arthroplasty, understanding how to combine/reconcile provider-assessed and patient-reported outcome measures, and determining the appropriate methods to interpret outcome measure scores. However, further research in these areas is warranted. In addition, the identification of key modifiable factors affecting outcomes and the development of interventions to manage these factors are needed. CONCLUSION There is growing attention paid to delivering interventions for patients at risk or not optimally recovering following hip or knee arthroplasty. To achieve this, it is essential to identify the most appropriate outcome measure tools, factors associated with poorer recovery and management of these factors.
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Affiliation(s)
- Motahareh Karimijashni
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Stéphane Poitras
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
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Migliorini F, Maffulli N, Schäfer L, Simeone F, Bell A, Hofmann UK. Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) in patients who have undergone total knee arthroplasty: a systematic review. Knee Surg Relat Res 2024; 36:3. [PMID: 38212863 PMCID: PMC10782530 DOI: 10.1186/s43019-024-00210-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND The present systematic review investigated the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) of several frequent and established PROMs used to assess patients who have undergone TKA. This study was conducted according to the 2020 PRISMA statement. METHODS In September 2023, PubMed, Web of Science, and Embase were accessed with no time constraint All clinical studies investigating tools to assess the clinical relevance of PROMs used to evaluate patients having received TKA were accessed. Only studies which evaluated the MCID, PASS, or SCB were eligible. The PROMs of interest were the Forgotten Joint Score-12 (FJS-12), the Oxford Knee Score (OKS), the Knee Injury and Osteoarthritis Outcome Score (KOOS) and its related subscales activity of daily living (ADL), pain, quality of life (QoL), sports and recreational activities, and symptoms, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, the Knee Society Score (KSS) and related function score, and the Short Form-12 (SF-12) and Short Form-36 (SF-36). RESULTS Data from 29,737 patients were collected. The overall risk of bias was low to moderate. The great variability of thresholds for MCID, SCB and PASS between questionnaires but also between investigated aspects was noted, whereby MCIDs for the SF-36 appear lower than for knee-specific questionnaires. CONCLUSION Despite its critical role from a patient's perspective, the dimension of SCB is still neglected in the literature. Moreover, thresholds for the different concepts need to be condition-specific. We encourage authors to specifically report such data in future studies and to adhere to previously reported definitions to allow future comparison. Level of evidence Level IV, systematic review and meta-analysis.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy.
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, Faculty of Medicine and Psychology, University la Sapienza, 00185, Rome, Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke On Trent, ST4 7QB, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, E1 4DG, UK
| | - Luise Schäfer
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Francesco Simeone
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany
| | - Ulf Krister Hofmann
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany
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Lewis GN, Rice DA, Rashid U, McNair PJ, Kluger MT, Somogyi AA. Trajectories of Pain and Function Outcomes up to 5 to 8 Years Following Total Knee Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00128-6. [PMID: 36805116 DOI: 10.1016/j.arth.2023.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/02/2023] [Accepted: 02/11/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND There appears to be substantial variability in outcomes > 2 years following total knee arthroplasty (TKA) that is masked by whole group analyses. The goal of the study was to identify trajectories of pain and function outcomes up to 5 to 8 years post-TKA and to identify baseline factors that are associated with different trajectories of recovery. METHODS Baseline, 6-month, and 12-month pain and function data were collected in a previous study investigating predictors of outcome following primary TKA (n = 286), along with a variety of baseline predictor variables. The present study obtained pain and function data at 5 to 8 years following TKA in the same cohort (n = 201). Latent class linear mixed models were used to identify different classes of pain and functional trajectories over time. The extent to which differences across latent classes were explained by baseline predictor variables was determined. RESULTS Three classes of pain and two classes of function trajectory were identified. While most patients (84% to 93%) followed a trajectory that showed an initial rapid gain following surgery that was sustained through 5 to 8 years, both pain and function included at least one trajectory class that showed a meaningful change after 12 months. No predictor variables were significantly associated with either the pain or function classes. CONCLUSIONS Most patients follow a traditional trajectory of recovery in knee pain and function over 5 to 8 years. However, alternative trajectories are observed in an important minority of patients such that knee pain and function at 12 months after surgery does not always reflect outcomes at 5 to 8 years.
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Affiliation(s)
- Gwyn N Lewis
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - David A Rice
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand; Waitematā Pain Services, Te Whatu Ora Waitematā, Auckland, New Zealand
| | - Usman Rashid
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Peter J McNair
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Michal T Kluger
- Waitematā Pain Services, Te Whatu Ora Waitematā, Auckland, New Zealand; Department of Anaesthesiology and Perioperative Medicine, Te Whatu Ora Waitematā, Auckland, New Zealand; Department of Anaesthesiology, Faculty of Medicine and Health Sciences, University of Auckland, New Zealand
| | - Andrew A Somogyi
- Discipline of Pharmacology, School of Biomedicine, University of Adelaide, Australia; Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, Australia
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Goh GS, Tarabichi S, Baker CM, Qadiri QS, Austin MS. Should We Aim to Help Patients "Feel Better" or "Feel Good" After Total Hip Arthroplasty? Determining Factors Affecting the Achievement of the Minimal Clinically Important Difference and Patient Acceptable Symptom State. J Arthroplasty 2023; 38:293-299. [PMID: 35964857 DOI: 10.1016/j.arth.2022.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/04/2022] [Accepted: 08/07/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Recent attempts have been made to use preoperative patient-reported outcome measure (PROM) thresholds as prior authorization criteria based on the assumption that patients who have higher baseline scores are less likely to achieve the minimal clinically important difference (MCID). This study aimed to identify factors affecting the achievement of MCID and patient acceptable symptom state (PASS) after total hip arthroplasty (THA), and to determine the overlap between the two outcomes. METHODS We identified 3,581 primary, unilateral THAs performed at a single practice in 2015-2019. PROMs including Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) and 12-item Short Form Health Survey were collected preoperatively and 1-year postoperatively. The likelihood of attaining PASS according to attainment of MCID was assessed. Multivariable regression was used to identify independent predictors of MCID and PASS. RESULTS In total, 79.8% achieved MCID and 73.6% achieved PASS for HOOS-JR. Approximately 1 in 7 patients who achieved MCID did not eventually achieve PASS. Worse preoperative HOOS-JR (odd ratio 0.933) was associated with MCID attainment. Better preoperative HOOS-JR (odd ratio 1.015) was associated with PASS attainment. Men, lower body mass index, better American Society of Anesthesiologists score, and better preoperative 12-item Short Form Health Survey mental score were predictors of MCID and PASS. Age, race, ethnicity, Charlson Comorbidity Index, and smoking status were not significant predictors. CONCLUSION Preoperative PROMs were associated with achieving MCID and PASS after THA, albeit in opposite directions. Clinicians should strive to help patients "feel better" and "feel good" after surgery. Preoperative PROMs should not solely be used to prioritize access to care.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Colin M Baker
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Qudratullah S Qadiri
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew S Austin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Goh GS, Baker CM, Tarabichi S, Clark SC, Austin MS, Lonner JH. The Paradox of Patient-Reported Outcome Measures: Should We Prioritize "Feeling Better" or "Feeling Good" After Total Knee Arthroplasty? J Arthroplasty 2022; 37:1751-1758. [PMID: 35436528 DOI: 10.1016/j.arth.2022.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The use of preoperative patient-reported outcome measure (PROM) thresholds for patient selection in arthroplasty care has been questioned recently. This study aimed to identify factors affecting achievement of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) after total knee arthroplasty (TKA) and determine the overlap between the two outcomes. METHODS We identified 1,239 primary, unilateral TKAs performed at a single institution in 2015-2019. PROMs including the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and 12-item Short Form Health Survey (SF-12) were collected preoperatively and 1-year postoperatively. The likelihood of attaining PASS as per attainment of MCID was assessed. A multivariable regression was used to identify predictors of MCID and PASS. RESULTS In total, 71.3% achieved MCID and 75.5% achieved PASS for KOOS-JR. Only 7.7% achieved MCID but not PASS, whereas almost twice this number did not achieve MCID but did achieve PASS (11.9%). Poorer preoperative KOOS-JR (OR 0.925), better SF-12 physical (OR 1.025), and mental (OR 1.027) were associated with MCID attainment. In contrast, better preoperative KOOS-JR (OR 1.030) and SF-12 mental (OR 1.025) were associated with PASS attainment. Age, gender, race, ethnicity, body mass index, Charlson index, American Society of Anesthesiologists classification, and smoking status were not significant predictors. CONCLUSION Preoperative PROMs were associated with achieving MCID and PASS after TKA, albeit some positively and some negatively. In the era of value-based care, clinicians should not only strive to help patients "feel better" but also ensure that patients "feel good" after surgery. This study does not support the use of PROMs in prioritizing access to care.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Colin M Baker
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Sean C Clark
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Matthew S Austin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Jess H Lonner
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Wylde V, Penfold C, Rose A, Bradshaw E, Whitehouse MR, Blom AW. Ten-Year Results of the Triathlon Knee Replacement: A Cohort Study. Cureus 2021; 13:e15211. [PMID: 34178530 PMCID: PMC8221002 DOI: 10.7759/cureus.15211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Studies evaluating the outcomes of different brands of knee prostheses are important to monitor patient outcomes and generate evidence to aid decisions around the choice of implant. The Triathlon® prosthesis (Stryker, Limerick, Ireland), one of the most commonly used total condylar knee prosthesis, is designed to provide greater knee motion and the potential for longer implant survivorship. The aim of this cohort study was to evaluate outcomes and survivorship of the Triathlon total knee replacement (TKR) up to 10 years post-operative. Methods Two-hundred sixty-six (266) patients listed for a Triathlon TKR in one orthopaedic hospital were recruited. Assessments were conducted preoperatively and then at three months and one, two, three, five, seven, and 10 years after surgery. Outcomes assessed included pain, function, knee-related quality of life (QoL), satisfaction, kneeling ability, activity levels, American Knee Society Score, complications, and survivorship. Results Large improvements in patient-reported outcomes were observed in the first three months after surgery, followed by small improvement up to one year post-operative, and then outcomes plateaued up to 10 years post-operative. Satisfaction with overall outcome ranged from 79%-94% over the duration of follow-up. Activity levels and kneeling ability were similar before and after surgery. There was a large improvement in the median American Knee Society score in the first three months post-operative, followed by a small but gradual improvement to 10 years post-operative. Survivorship was 95.4% (95% confidence interval 91.8-97.5%) at 10 years post-operative. Conclusions This study found that the Triathlon TKR results in excellent outcomes and survivorship to 10 years post-operative.
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Affiliation(s)
- Vikki Wylde
- Musculoskeletal Research Unit, University of Bristol, Bristol, GBR
| | - Chris Penfold
- Musculoskeletal Research Unit, University of Bristol, Bristol, GBR
| | - Alice Rose
- Musculoskeletal Research Unit, University of Bristol, Bristol, GBR
| | | | | | - Ashley W Blom
- Musculoskeletal Research Unit, University of Bristol, Bristol, GBR
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Bonnefoy-Mazure A, Lübbeke A, Miozzari HH, Armand S, Sagawa Y, Turcot K, Poncet A. Walking Speed and Maximal Knee Flexion During Gait After Total Knee Arthroplasty: Minimal Clinically Important Improvement Is Not Determinable; Patient Acceptable Symptom State Is Potentially Useful. J Arthroplasty 2020; 35:2865-2871.e2. [PMID: 32646679 DOI: 10.1016/j.arth.2020.05.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 05/01/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is the operation of choice in patients with end-stage knee osteoarthritis (OA). Up to 1 in 5 patients still encounter functional limitations after TKA, partly explaining patient dissatisfaction. Which gait ability to target after TKA remains unclear. To determine whether Minimal Clinical Important Improvement (MCII) or Patient Acceptable Symptom State (PASS) values could be derived from gait parameters recorded in patients with TKA. And, if so, to define those values. METHODS In this ancillary study, we retrospectively analyzed gait parameters of patients scheduled for a unilateral TKA between 2011 and 2013. We investigated MCII and PASS values for walking speed and maximal knee flexion using anchor-based methods: 5 anchoring questions based on perceived body function and patients' satisfaction. RESULTS Over the study period, 79 patients performed a clinical gait analysis the week before and 1 year after surgery, and were included in the present study. All clinical and gait parameters improved 1 year after TKA. Nevertheless, changes in gait outcomes were not associated with perceived body function or patients' satisfaction, precluding any MCII estimation in gait parameters. PASS values, however, could be determined as 1.2 m/s for walking speed and 50° for maximal knee flexion. CONCLUSION In this study, we found that MCII and PASS values are not necessarily determinable for gait parameters after TKA in patients with end-stage OA. Using anchor questions based on perceived body function and patient's satisfaction, MCII could not be defined while PASS values were potentially useful. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Alice Bonnefoy-Mazure
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals, Geneva University, Geneva, Switzerland; Faculty of Medicine, Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Anne Lübbeke
- Faculty of Medicine, Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Hermes H Miozzari
- Faculty of Medicine, Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphane Armand
- Willy Taillard Laboratory of Kinesiology, Geneva University Hospitals, Geneva University, Geneva, Switzerland; Faculty of Medicine, Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Yoshimasa Sagawa
- Laboratoire d'Exploration Fonctionnelle Clinique du Mouvement, CHU de Besançon, Besançon, France; Centre d'Investigation Clinique, INSERM CIC 1431, CHU de Besançon, Besançon, France
| | - Katia Turcot
- Faculty of Medicine, Department of Kinesiology, Laval University, Quebec, Quebec, Canada; Centre for Interdisciplinary Research in Rehabilitation and Social Integration (CIRRIS), Quebec, Quebec, Canada
| | - Antoine Poncet
- Clinical Research Center, Faculty of Medicine, University of Geneva, Geneva, Switzerland; Division of Clinical Epidemiology, Department of Health and Community Medicine, University Hospitals of Geneva, Geneva, Switzerland
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Which Preoperative Factors are Associated with Not Attaining Acceptable Levels of Pain and Function After TKA? Findings from an International Multicenter Study. Clin Orthop Relat Res 2020; 478:1019-1028. [PMID: 32039954 PMCID: PMC7170689 DOI: 10.1097/corr.0000000000001162] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although TKA is a common and proven reliable procedure for treating end-stage knee osteoarthritis, a minority of patients still do not achieve satisfactory levels of pain relief and functional improvement. Even though several studies have attempted to identify patients at risk of having poor clinical outcomes, few have approached this issue by considering the outcome of the patient-acceptable symptom state (PASS), defined as the value on a patient-reported outcome measure scale above which the patient deems their current symptom state acceptable. QUESTIONS/PURPOSES (1) What is the proportion of patients who do not attain the PASS in pain and function at 1 year after TKA? (2) Which preoperative patient factors are associated with not achieving the PASS in pain at 1 year after TKA? (3) Which preoperative patient factors are associated with not achieving the PASS in function at 1 year after TKA? METHODS This retrospective study is a secondary analysis of the 1-year follow-up data from a prospective, international, multicenter study of a single TKA system. Inclusion criteria for that study were patients diagnosed with primary osteoarthritis or post-traumatic arthritis and who were able to return for follow-up for 10 years; exclusion criteria were infection, osteomyelitis, and failure of a previous joint replacement. Between 2011 and 2014, 449 patients underwent TKA at 10 centers in five countries. At 1 year, 13% (58 of 449) were lost to follow-up, 2% could not be analyzed (eight of 449; missing 1-year KOOS), leaving 85% (383 of 449) for analysis here. The primary outcomes were not surpassing evidence-derived PASS thresholds in the Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain and Activities in Daily Living (ADL) sub-scores. Multivariate binary logistic regressions considering preoperative demographic, radiographic, and patient-reported outcome measure data were constructed using a forward stepwise elimination algorithm to reach the simplest best-fit regression models. RESULTS At 1 year after TKA, 38% of the patients (145 of 383) did not reach the PASS in KOOS Pain, 36% (139 of 383) did not reach the PASS in KOOS ADL, and 29% (110 of 383) did not achieve the PASS in either KOOS Pain or ADL. After controlling for potentially confounding variables such as gender, age, BMI, and comorbidity scores, we found that men (odds ratio 2.09; p = 0.01), and patients with less-than-advanced radiographic osteoarthritis (OR 2.09; p = 0.01) were strongly associated with not achieving the PASS in pain. After controlling for the same potentially confounding variables, we found that patients with less-than-advanced radiographic osteoarthritis (OR 2.09; p = 0.01) were also strongly associated with not achieving the PASS in function. CONCLUSIONS We found that patients with less severe osteoarthritis were much less likely to attain the PASS in pain and function at 1 year after TKA, and that men were much less likely to achieve the PASS in pain at 1 year after TKA. Based on these findings, surgeons should strongly consider delaying surgery in patients who present with less-than-severe osteoarthritis, with increased caution in men. Surgeons should counsel their patients on their expectations and their chances of achieving meaningful levels of pain and functional improvement. Future regional and national registry studies should assess the true proportion of patients attaining PASS in pain and function after TKA and confirm if the preoperative factors identified in this study remain significant in larger, more diverse patient populations. LEVEL OF EVIDENCE Level III, therapeutic study.
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Wylde V, Penfold C, Rose A, Blom AW. Variability in long-term pain and function trajectories after total knee replacement: A cohort study. Orthop Traumatol Surg Res 2019; 105:1345-1350. [PMID: 31594730 DOI: 10.1016/j.otsr.2019.08.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/25/2019] [Accepted: 08/22/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Previous research suggests that patient-reported outcomes plateau by one year after total knee replacement (TKR). Analysis of trajectories to date has predominately been based on changes in median/mean scores over the first post-operative year, rather than variability in trajectory patterns over the longer-term. The aim was to evaluate variability in long-term pain and function trajectories after TKR. HYPOTHESIS There will be variability in long-term pain and function trajectories after TKR. PATIENTS AND METHODS In all, 266 patients undergoing a Triathlon® TKR because of osteoarthritis were recruited from one orthopaedic centre. Participants completed the WOMAC Pain and Function scales preoperatively and then at 3 months, 1 year, 2 years, 3 years, 5 years and 7 years post-operative. Longitudinal analyses evaluated patterns of clinically meaningful change. RESULTS Most patients had an improvement in pain and function during the first year post-operative; improvement was greatest in the first 3 months. By 1-year post-operative, 8% of patients had no change or a worsening of pain and 21% for function. Thereafter, approximately 15% of patients improved and 15% worsened between each assessment time. For those patients who had no change in symptoms from pre-operative to 1-year post-operative, one third had further improvement between 1 and 2 years post-operative. DISCUSSION This study identified clinically meaningful variability in long-term outcomes after TKR, which could be discussed with patients to ensure they have realistic expectations of their outcome. Further research is needed to evaluate determinants of this variability and whether patients who will do poorly can be identified early in their recovery pathway. LEVEL OF EVIDENCE IV, prospective cohort study.
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Affiliation(s)
- Vikki Wylde
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK.
| | - Chris Penfold
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Alice Rose
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Wylde V, Kunutsor SK, Lenguerrand E, Jackson J, Blom AW, Beswick AD. Is social support associated with patient-reported outcomes after joint replacement? A systematic review and meta-analysis. THE LANCET. RHEUMATOLOGY 2019; 1:e174-e186. [PMID: 35072110 PMCID: PMC7612240 DOI: 10.1016/s2665-9913(19)30050-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Identifying prognostic factors for outcomes after joint replacement could improve the provision of stratified care. This systematic review evaluated whether social support is a prognostic factor for better patient-reported outcomes after total hip replacement (THR) and total knee replacement (TKR). METHODS MEDLINE, Embase and PsycINFO were searched from inception to April 2019. Cohort studies evaluating the association between social support and patient-reported outcomes at three months or longer after THR or TKR were included. Data were extracted from study reports. Study quality was assessed using the QUIPS tool. Data were synthesized using meta-analysis and narrative synthesis. The review was registered on PROSPERO (CRD42016041485). FINDINGS Searches identified 5,810 articles and 56 studies with data from 119,165 patients were included. In meta-analysis, the presence of social support had a beneficial effect on long-term post-operative WOMAC (mean difference 2.88; 95% CIs 1.30; 4.46) and Oxford Knee Score (0.29; 0.12, 0.45). Social support measured using a validated questionnaire was found to be associated with WOMAC pain (0.04; 0.00, 0.08) but not WOMAC function (-0.01; -0.12, 0.11). The presence of social support had a positive association with some SF-36 subscales but not others. For all outcomes, results of narrative synthesis were inconsistent. INTERPRETATION There is evidence that social support is a prognostic factor for some outcomes after joint replacement. Development and evaluation of complex interventions to improve social support and social integration is warranted. FUNDING This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol.
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Affiliation(s)
- V Wylde
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
| | - S K Kunutsor
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
| | - E Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
| | - J Jackson
- Histopathology Department, Royal Devon and Exeter Hospital, Exeter, UK
| | - A W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
| | - A D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
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11
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Filbay SR, Judge A, Delmestri A, Arden NK. Evaluating Patients' Expectations From a Novel Patient-Centered Perspective Predicts Knee Arthroplasty Outcome. J Arthroplasty 2018; 33:2146-2152.e4. [PMID: 29544972 PMCID: PMC6005343 DOI: 10.1016/j.arth.2018.02.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/25/2018] [Accepted: 02/07/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND One-in-five patients are dissatisfied following knee arthroplasty and <50% have fulfilled expectations. The relationship between knee-arthroplasty expectations and surgical outcome remains unclear. PURPOSE Are expectations regarding the impact of pain on postoperative life predictive of one-year outcome? Does the impact of pain on preoperative quality of life (QOL) influence this relationship? METHODS Longitudinal cohort of 1044 uni-compartmental (43%) or total knee-arthroplasty (57%) (UKA or TKA) patients, aged mean 69 ± 9 years. Preoperatively, patients reported the impact of pain on QOL and expected impact of pain on life one-year post-arthroplasty. One-year postoperative outcomes: non-return to desired activity, surgical dissatisfaction, not achieving Oxford Knee Score minimal important change (OKS <MIC). Logistic regression including covariates was performed for all patients and subgroups (better vs worse pre-operative pain-related QOL; UKA vs TKA). RESULTS Expecting moderate-to-extreme pain (vs no pain) predicted non-return to activity (odds ratio [95% confidence interval], 2.3 [1.3, 4.1]), dissatisfaction (4.0 [1.7, 9.3]), OKS <MIC (3.1 [1.5, 6.3]). Expecting mild pain (vs no pain) predicted worse outcomes for patients with better preoperative pain-related QOL (non-return to activity: 2.7 [1.5, 4.8], OKS <MIC: 2.5 [1.1, 5.5]). Expecting moderate-to-extreme pain (vs. no pain) predicted worse outcomes for patients with worse preoperative pain-related QOL (non-return to activity: 2.4 [1.1, 5.5], dissatisfaction: 5.0 [1.7, 14.8], OKS <MIC: 3.4 [1.4, 8.6]). The odds of a poor outcome in people with worse expectations was higher for UKA patients. CONCLUSIONS Expecting a worse outcome predicted surgical dissatisfaction, less clinical improvement and non-return to desired activity. Patients expecting a more optimistic outcome relative to preoperative status achieved better surgical outcomes.
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Affiliation(s)
- Stephanie R Filbay
- Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis, Nuffield, Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Rd, Oxford UK OX3 7LD
| | - Andrew Judge
- Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Musculoskeletal Research Unit, University of Bristol, School of Clinical Sciences, Bristol BS10 5NB, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, UK; MRC Lifecourse Southampton General Hospital University of Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Antonella Delmestri
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Rd, Oxford UK OX3 7LD
| | - Nigel K Arden
- Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Rd, Oxford UK OX3 7LD
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12
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Escobar A, García Pérez L, Herrera-Espiñeira C, Aizpuru F, Sarasqueta C, Gonzalez Sáenz de Tejada M, Quintana JM, Bilbao A. Total knee replacement: Are there any baseline factors that have influence in patient reported outcomes? J Eval Clin Pract 2017; 23:1232-1239. [PMID: 28548313 DOI: 10.1111/jep.12765] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 04/07/2017] [Accepted: 04/07/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND There is conflicting evidence about what factors influence outcomes after total knee replacement (TKR). The objective is to identify baseline factors that differentiate patients who achieve both, minimal clinically important difference (MCID) and a patient acceptable symptom state (PASS) in pain and function, measured by WOMAC, after TKR from those who do not attain scores above the cutoff in either of these dimensions. METHODS One-year prospective multicentre study. Patients completed WOMAC, SF-12, EQ-5D, expectations, other joint problems and sociodemographic data while in the waiting list, and 1-year post-TKR. Dependent variable was a combination of MCID and PASS in both dimensions (yes/no). Univariate analysis was performed to identify variables associated. Exploratory factor analysis (EFA) was performed to study how these variables grouped into different factors. RESULTS Total sample comprised 492 patients. Mean (SD) age was 71.3 (6.9), and there were a 69.7% of women. Of the total, 106 patients did not attain either MCID or PASS in either dimension, and 230 exceeded both thresholds in both dimensions. In the univariate analysis, 13 variables were associated with belonging to one group or another. These 13 variables were included in EFA; 3 factors were extracted: expectations, mental health, and other joints problems. The percentage of variance explained by the 3 factors was 80.4%. CONCLUSION We have found 2 modifiable baseline factors, expectations and mental health, that should be properly managed by different specialist. Indication of TKR should take into account these modifiable factors for improving outcomes after TKR.
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Affiliation(s)
- A Escobar
- Research Unit, Hospital Universitario Basurto, Bilbao, Spain.,Research Associate, Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Spain
| | - L García Pérez
- Planning and Evaluation Service, Canary Islands Health Service, Tenerife, Spain.,Research Associate, Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Spain
| | - C Herrera-Espiñeira
- Hospital Virgen de las Nieves, Granada, Spain.,Research Associate, Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Spain
| | - F Aizpuru
- Research Unit, Hospital Universitario Araba, Vitoria-Gasteiz, Spain.,Research Associate, Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Spain
| | - C Sarasqueta
- Research Unit, Hospital Universitario Donostia, San Sebastian, Spain.,Research Associate, Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Spain
| | - M Gonzalez Sáenz de Tejada
- Research Unit, Hospital Universitario Basurto, Bilbao, Spain.,Research Associate, Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Spain
| | - J M Quintana
- Research Unit, Hospital of Galdakao-Usansolo, Galdakao, Spain.,Research Associate, Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Spain
| | - A Bilbao
- Research Unit, Hospital Universitario Basurto, Bilbao, Spain.,Research Associate, Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Spain
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13
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Warner SC, Richardson H, Jenkins W, Kurien T, Doherty M, Valdes AM. Neuropathic pain-like symptoms and pre-surgery radiographic severity contribute to patient satisfaction 4.8 years post-total joint replacement. World J Orthop 2017; 8:761-769. [PMID: 29094006 PMCID: PMC5656491 DOI: 10.5312/wjo.v8.i10.761] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 06/20/2017] [Accepted: 08/16/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate a comprehensive range of factors that contribute to long-term patient satisfaction post-total joint replacement (TJR) in people who had undergone knee or hip replacement for osteoarthritis.
METHODS Participants (n = 1151) were recruited from Nottinghamshire post-total hip or knee replacement. Questionnaire assessment included medication use, the pain-DETECT questionnaire (PDQ) to assess neuropathic pain-like symptoms (NP) and TJR satisfaction measured on average 4.8 years post-TJR. Individual factors were tested for an association with post-TJR satisfaction, before incorporating all factors into a full model. Data reduction was carried out using LASSO and receiver operator characteristic (ROC) curve analysis was used to quantify the contribution of variables to post-TJR satisfaction.
RESULTS After data reduction, the best fitting model for post-TJR satisfaction included various measures of pain, history of revision surgery, smoking, pre-surgical X-ray severity, WOMAC function scores and various comorbidities. ROC analysis of this model gave AUC = 0.83 (95%CI: 0.80-0.85). PDQ scores were found to capture much of the variation in post-TJR satisfaction outcomes: AUC = 0.79 (0.75-0.82). Pre-surgical radiographic severity was associated with higher post-TJR satisfaction: ORsatisfied = 2.06 (95%CI: 1.15-3.69), P = 0.015.
CONCLUSION These results highlight the importance of pre-surgical radiographic severity, post-TJR function, analgesic medication use and NP in terms of post-TJR satisfaction. The PDQ appears to be a useful tool in capturing factors that contribute to post-TJR satisfaction.
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Affiliation(s)
- Sophie C Warner
- Academic Rheumatology, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Nottingham NG5 1PB, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester and National Institute for Health Research, Leicester Cardiovascular Biomedical Research Unit, Leicester LE3 9QP, United Kingdom
| | - Helen Richardson
- Academic Rheumatology, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Nottingham NG5 1PB, United Kingdom
| | - Wendy Jenkins
- Academic Rheumatology, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Nottingham NG5 1PB, United Kingdom
| | - Thomas Kurien
- Arthritis Research UK Pain Centre, Nottingham NG5 1PB, United Kingdom
- Academic Division of Trauma and Orthopaedics, Queens Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Michael Doherty
- Academic Rheumatology, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Nottingham NG5 1PB, United Kingdom
- Arthritis Research UK Pain Centre, Nottingham NG5 1PB, United Kingdom
| | - Ana M Valdes
- Academic Rheumatology, University of Nottingham, Clinical Sciences Building, Nottingham City Hospital, Nottingham NG5 1PB, United Kingdom
- Arthritis Research UK Pain Centre, Nottingham NG5 1PB, United Kingdom
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14
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Fransen M, Nairn L, Bridgett L, Crosbie J, March L, Parker D, Crawford R, Harmer AR. Post-Acute Rehabilitation After Total Knee Replacement: A Multicenter Randomized Clinical Trial Comparing Long-Term Outcomes. Arthritis Care Res (Hoboken) 2017; 69:192-200. [PMID: 27868384 DOI: 10.1002/acr.23117] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 09/20/2016] [Accepted: 10/04/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To evaluate the long-term benefit of providing a post-acute, outpatient group exercise program for patients following primary total knee replacement (TKR) surgery for osteoarthritis. METHODS A multicenter randomized clinical trial was conducted in 12 Australian public and private hospital centers. A total of 422 participants, ages 45-75 years, were randomly allocated prior to hospital discharge to the post-acute group exercise program or to usual care and were assessed at 6 weeks, 6 months, and 12 months after surgery. The main outcomes were operated knee pain and activity limitations at 12 months using the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. Secondary outcomes included health-related quality of life (Short Form 12 health survey), knee extension and flexion strength, stair-climb power, 50-foot walk speed, and active knee range of motion. RESULTS While both allocation groups achieved significant improvements in knee pain and activity limitations over the 12-month followup period, there were no significant differences in these main outcomes, or in the secondary physical performance measures, between the 2 treatment allocations. Twelve months after TKR, 69% and 72% of participants allocated to post-acute exercise and usual acute care, respectively, were considered to be treatment-responders. While population normative values for self-report measures of pain, activity limitation, and health-related quality of life were attained 12 months after TKR, marked deficits in physical performance measures remained. CONCLUSION Providing access to a post-acute group exercise program did not result in greater reductions in long-term knee pain or activity limitations than usual care. Patients undergoing primary TKR retain marked physical performance deficits 12 months after surgery.
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Affiliation(s)
| | | | | | - Jack Crosbie
- University of Sydney, New South Wales, Australia
| | - Lyn March
- University of Sydney, New South Wales, Australia
| | - David Parker
- Sydney Orthopaedic Research Institute, Chatswood, New South Wales, Australia
| | - Ross Crawford
- Queensland University of Technology, Brisbane, Queensland, Australia
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15
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Usiskin IM, Yang HY, Deshpande BR, Collins JE, Michl GL, Smith SR, Klara KM, Selzer F, Katz JN, Losina E. Association between activity limitations and pain in patients scheduled for total knee arthroplasty. BMC Musculoskelet Disord 2016; 17:378. [PMID: 27585441 PMCID: PMC5009694 DOI: 10.1186/s12891-016-1233-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 08/23/2016] [Indexed: 11/17/2022] Open
Abstract
Background Historically, persons scheduled for total knee arthroplasty (TKA) have reported severe pain with low demand activities such as walking, but recent data suggests that TKA recipients may have less preoperative pain. Little is known about people who elect TKA with low levels of preoperative pain. To better understand current TKA utilization, we evaluated the association between preoperative pain and difficulty performing high demand activities, such as kneeling and squatting, among TKA recipients. Methods We used baseline data from a randomized control trial designed to improve physical activity following TKA. Prior to TKA, participants were categorized according to Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain scores: Low (0–25), Medium (26–40), and High (41–100). Within each group, limitations in both low demand and high demand activities were assessed. Results The sample consisted of 202 persons with a mean age of 65 (SD 8) years; 21 %, 34 %, and 45 % were categorized in the Low, Medium, and High Pain groups, respectively. Of the Low Pain group, 60 % reported at least one of the following functional limitations: limited flexion, limp, limited walking distance, and limitations in work or housework. While only 12 % of the Low Pain group reported at least moderate pain with walking on a flat surface, nearly all endorsed at least moderate difficulty with squatting and kneeling. Conclusions A substantial number of persons scheduled for TKA report Low WOMAC Pain (≤25) prior to surgery. Persons with Low WOMAC Pain scheduled for TKA frequently report substantial difficulty with high demand activities such as kneeling and squatting. Studies of TKA appropriateness and effectiveness for patients with low WOMAC Pain should include measures of these activities. Trial registration Identifier NCT01970631; Registered 23 October 2013.
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Affiliation(s)
- Ilana M Usiskin
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BC-4016, Boston, MA, 02115, USA
| | - Heidi Y Yang
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BC-4016, Boston, MA, 02115, USA
| | - Bhushan R Deshpande
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BC-4016, Boston, MA, 02115, USA
| | - Jamie E Collins
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BC-4016, Boston, MA, 02115, USA
| | - Griffin L Michl
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BC-4016, Boston, MA, 02115, USA
| | - Savannah R Smith
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BC-4016, Boston, MA, 02115, USA
| | - Kristina M Klara
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BC-4016, Boston, MA, 02115, USA
| | - Faith Selzer
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BC-4016, Boston, MA, 02115, USA
| | - Jeffrey N Katz
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BC-4016, Boston, MA, 02115, USA
| | - Elena Losina
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, BC-4016, Boston, MA, 02115, USA.
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16
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Wang L, Lee M, Zhang Z, Moodie J, Cheng D, Martin J. Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised controlled trials. BMJ Open 2016; 6:e009857. [PMID: 26839013 PMCID: PMC4746481 DOI: 10.1136/bmjopen-2015-009857] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES The clinical impact of preoperative physiotherapy on recovery after joint replacement remains controversial. This systematic review aimed to assess the clinical impact of prehabilitation before joint replacement. DESIGN We searched PubMed, Embase and Cochrane CENTRAL up to November 2015 for randomised controlled trials comparing prehabilitation versus no prehabilitation before joint replacement surgery. Postoperative pain and function scores were converted to Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function subscales (0-100, high scores indicate worse outcome). Random effects meta-analysis was performed to calculate weighted mean differences (WMD, 95% CI), subgrouped by hip and knee surgery. PRIMARY AND SECONDARY OUTCOMES Postoperative pain and function scores, time to resume activities of daily living, quality of life, length of hospital stay, total cost, patient satisfaction, postoperative complications, any adverse events and discontinuations. RESULTS Of 22 studies (1492 patients), 18 had high risk of bias. Prehabilitation slightly reduced pain scores within 4 weeks postoperatively (WMD -6.1 points, 95% CI -10.6 to -1.6 points, on a scale of 0-100), but differences did not remain beyond 4 weeks. Prehabilitation slightly improved WOMAC function score at 6-8 and 12 weeks (WMD -4.0, 95% CI -7.5 to -0.5), and time to climbing stairs (WMD -1.4 days, 95% CI -1.9 to -0.8 days), toilet use (-0.9 days, 95% CI -1.3 to -0.5 days) and chair use (WMD -1.2 days, 95% CI -1.7 to -0.8 days). Effects were similar for knee and hip surgery. Differences were not found for SF-36 scores, length of stay and total cost. Other outcomes of interest were inadequately reported. CONCLUSIONS Existing evidence suggests that prehabilitation may slightly improve early postoperative pain and function among patients undergoing joint replacement; however, effects remain too small and short-term to be considered clinically-important, and did not affect key outcomes of interest (ie, length of stay, quality of life, costs).
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Affiliation(s)
- Li Wang
- Centre for Medical Evidence, Decision Integrity and Clinical Impact (MEDICI), University of Western Ontario, London, Ontario, Canada
- Chinese Cochrane Centre, West China Hospital, Sichuan University, Chengdu, China
- Michael G DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Myeongjong Lee
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Chungju, South Korea
| | - Zhe Zhang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jessica Moodie
- Centre for Medical Evidence, Decision Integrity and Clinical Impact (MEDICI), University of Western Ontario, London, Ontario, Canada
| | - Davy Cheng
- Centre for Medical Evidence, Decision Integrity and Clinical Impact (MEDICI), University of Western Ontario, London, Ontario, Canada
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
| | - Janet Martin
- Centre for Medical Evidence, Decision Integrity and Clinical Impact (MEDICI), University of Western Ontario, London, Ontario, Canada
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology & Biostatistics, University of Western Ontario, London, Ontario, Canada
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17
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Krause ML, Crowson CS, Bongartz T, Matteson EL, Michet CJ, Mason TG, Persellin ST, Gabriel SE, Davis JM. Determinants of Disability in Rheumatoid Arthritis: A Community-Based Cohort Study. Open Rheumatol J 2015; 9:88-93. [PMID: 26862353 PMCID: PMC4740964 DOI: 10.2174/1874312901409010088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 08/04/2015] [Accepted: 08/28/2015] [Indexed: 11/22/2022] Open
Abstract
Longitudinal care of a community-based cohort of patients with rheumatoid arthritis (RA) was evaluated retrospectively. Candidate determinants of disability included visual analog scales (VAS) for patient global assessment and pain, comorbidities, and medications. The outcome was the 'patient-acceptable symptom state' for disability as defined by the Health Assessment Questionnaire (HAQ) disability index, using a cutoff of <1.04. Two-sample t tests and multivariable logistic regression were used to determine odds ratios (OR) for associations between predictor variables and disability. Out of a total of 99 patients, 28 (28%) patients had HAQ ≥1.04 at their last visit. The greatest odds of not attaining the patient-acceptable symptom state in a multivariable model was associated with corticosteroids (OR: 5.1; p=0.02), antidepressants (OR: 5.3; p=0.02), and female sex (OR: 6.5; p=0.05). In the era of biologic therapy, female sex, corticosteroids, and antidepressants remain profound determinants of disability highlighting the need to understand the underlying mechanisms.
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Affiliation(s)
| | - Cynthia S Crowson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research
| | - Tim Bongartz
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric L Matteson
- Division of Rheumatology, Department of Medicine;; Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Sherine E Gabriel
- Division of Rheumatology, Department of Medicine;; Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John M Davis
- Division of Rheumatology, Department of Medicine
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18
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Individual patient monitoring in daily clinical practice: a critical evaluation of minimal important change. Qual Life Res 2014; 24:607-16. [PMID: 25252608 DOI: 10.1007/s11136-014-0809-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2014] [Indexed: 01/01/2023]
Abstract
PURPOSE In daily practice, physicians translate knowledge from clinical trials to practice, to improve health in individual patients. To help interpret meaningful change on disease outcome measures, the concept of minimal important change (MIC) was conceived. The objective of this study was to investigate whether MIC values are suited for individual patient monitoring. METHODS Three main elements of the MIC concept were evaluated: (1) MIC values for improvement and deterioration were determined, and the amount of misclassification present in quantifying minimal change was analyzed. (2) Discordance between change categories (improved, unchanged, deteriorated), defined by the MIC values, and patients' satisfaction with their health was inspected. (3) Discordance between change categories, defined by MIC values, and patients' willingness to alter therapy was inspected. RESULTS MIC value analysis was based on 469 patients with RA seen in daily practice. The chance of falsely classifying health change of an individual patient was high (false-positive range 19-30 % and false-negative range 43-72 %). Of patients classified as improved, 24 % were not satisfied with their health and 69 % were not willing to change therapy. Of patients classified as deteriorated, 54 % were satisfied with their health and 57 % were not willing to change therapy. CONCLUSIONS The misclassification in the quantification of change and high proportions of discordance between change categories defined by MIC cutoff values and patients' satisfaction and willingness to alter therapy indicate that MIC values as such are not suited for individual patient monitoring.
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19
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Escobar A, Riddle DL. Concordance between important change and acceptable symptom state following knee arthroplasty: the role of baseline scores. Osteoarthritis Cartilage 2014; 22:1107-10. [PMID: 24971868 DOI: 10.1016/j.joca.2014.06.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 05/27/2014] [Accepted: 06/10/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the influence of baseline score on concordance between the Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS) estimates obtained on persons following total knee arthroplasty (TKA). DESIGN Patients scheduled for TKA in 15 hospitals in Spain were recruited and provided pre-operative and 1-year postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain and Function scores. 1 year following surgery, patients completed questionnaires that determined the importance of any changes in status since surgery as well as the extent of satisfaction with the 1-year outcome. Kappa (κ) was used to determine the extent of concordance between MCID and PASS measures for the entire sample and after splitting the sample based on quartiles of the baseline WOMAC scores. RESULTS A total of 923 patients participated in the study. The extent of concordance between MCID and PASS without regard to baseline score was κ = 0.41 (95% Confidence Interval (CI) = 0.36, 0.47) for WOMAC Function and after stratifying baseline scores into quartiles, κ = 0.72 (95%CI = 0.68, 0.77). Similar estimates were obtained for WOMAC Pain. CONCLUSIONS Baseline score has substantial influence on the extent of concordance between MCID and PASS for patients undergoing TKA. Clinicians should account for baseline score when interpreting either MCID or PASS and the extent to which these measures agree. These findings have potential to influence the interpretation of outcome following TKA.
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Affiliation(s)
- A Escobar
- Research Unit, Hospital Universitario Basurto, Avda. Montevideo 18, 48013 Bilbao, Spain; Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
| | - D L Riddle
- Departments of Physical Therapy and Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA.
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Oleske DM, Bonafede MM, Jick S, Ji M, Hall JA. Electronic health databases for epidemiological research on joint replacements: considerations when making cross-national comparisons. Ann Epidemiol 2014; 24:660-5. [PMID: 25088754 DOI: 10.1016/j.annepidem.2014.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 05/17/2014] [Accepted: 06/10/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to examine the rate of primary knee, hip, or shoulder replacement among persons with osteoarthritis (OA) of the knee by gender and age comparing two nations in similar periods using electronic health records, but with different health-care systems. METHODS Two electronic health care databases of anonymized information were used to construct cohorts of adults with OA of the knee from the United Kingdom (UK) and the United States. Patients were required to have activity in the database at least 6 months before the first diagnosis of knee OA ("index diagnosis") in the study period to ensure that the patient samples were eligible for medical evaluation. The outcomes (numerator) measured were primary knee, hip, or shoulder replacement or the composite of primary knee, hip, or shoulder replacement. The denominator was the person-time at risk computed from time from the date of the index diagnosis to the date of each outcome separately or to the end of the database period if no outcome was documented. RESULTS There were 93,146 subjects in the UK and 1,468,217 in the United States who were aged 18+ years and met the study eligibility criteria. The composite joint replacement rate (hip, knee, or shoulder) ranged from 11.89 per 100 person-years (PY) in the Unites States to 4.13 per 100 PY in the UK Primary knee replacements rates ranged from 10.38 per 100 PY in the Unites States to 3.40 per 100 PY in the UK and occurred at a somewhat higher rate in males than females in both countries. Both primary hip and shoulder replacement rates were higher in the Unites States than in the UK (hip: 1.19 per 100 PY and 0.76 per 100 PY; shoulder: 0.19 per 100 PY and 0.03 per 100 PY, respectively). The median time to a primary hip or knee replacement in the UK was approximately twice as long as in the Unites States. CONCLUSIONS Knee replacements are not an uncommon event in persons with knee OA occurring throughout the adult life span, with the rate steeply rising in both sexes until aged 75 years. Although the pattern of the age-specific joint replacement rates was similar between sexes, the magnitude of the rates was markedly lower in the UK.
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Affiliation(s)
- Denise M Oleske
- Global Surveillance and Pharmacoepidemiology, AbbVie, North Chicago, IL.
| | | | - Susan Jick
- The Boston Collaborative Drug Surveillance Program, The Boston University School of Public Health, Lexington, MA
| | - Ming Ji
- Medical Safety Evaluation, AbbVie, North Chicago, IL
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