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Wu KA, Kugelman DN, Goel RK, Dilbone ES, Ryan SP, Wellman SS, Bolognesi MP, Seyler TM. How Do Patient-Reported Outcomes Correlate With Real-Time Objective Measures of Function After Total Knee Arthroplasty? A Prospective Study Using Daily Gait Metrics. J Arthroplasty 2024:S0883-5403(24)01287-7. [PMID: 39667590 DOI: 10.1016/j.arth.2024.12.007] [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: 06/27/2024] [Revised: 11/26/2024] [Accepted: 12/03/2024] [Indexed: 12/14/2024] Open
Abstract
BACKGROUND Patient-reported outcomes (PROs) are essential for evaluating patients undergoing total knee arthroplasty (TKA). While wearable technologies offer objective measures of physical function through Apple HealthKit, their relationship with PROs in TKA patients is not well understood. We investigated the association between commonly used PROs and objective measures of physical function in patients undergoing TKA. METHODS We conducted a prospective cohort study involving 152 patients undergoing unilateral TKA, assessing PROs (Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, and EuroQol Five-Dimensional Questionnaire) and objective HealthKit metrics (gait speed, step count, standing duration, steadiness, and estimated 6-minute walk test) before and at one, six, and 12 months after surgery. Pearson correlation coefficients were used to analyze the relationship between PROs and HealthKit metrics at each time point, adjusting for multiple comparisons. RESULTS Significant improvements were observed in PROs post-TKA. The Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, scores improved from 52.1 ± 11.9 preoperatively to 82.5 ± 13.2 at 12 months postoperatively (P < 0.001), and EuroQol Five-Dimensional Questionnaire scores improved from 73.9 ± 17.8 to 85.7 ± 11.6 over the same period (P < 0.001). However, correlations between PROs and HealthKit metrics were consistently low (mean r = 0.2 to 0.3) and not significant after adjusting for multiple comparisons at various operative time points. Notably, correlations among HealthKit metrics themselves remained high, indicating that objective measures were internally consistent but not strongly related to PROs. CONCLUSIONS Despite their importance in patient-centered care, PROs may not fully reflect actual physical function. Clinicians should consider incorporating objective measures, such as those provided by HealthKit, into routine assessments to obtain a more comprehensive view of patient recovery post-TKA.
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Affiliation(s)
- Kevin A Wu
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - David N Kugelman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Rahul K Goel
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Eric S Dilbone
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Adkar N, Patil M, Vaidya S, Kumbar R, Kerhalkar R, Mote G, Thareja S, Sadalagi P, Bajwa S. The Accuracy of CT-Based Three-Dimensional Templating in Predicting Implant Sizes in Patients Undergoing Robot-Assisted Total Knee Arthroplasty. Indian J Orthop 2024; 58:1388-1394. [PMID: 39324083 PMCID: PMC11420422 DOI: 10.1007/s43465-024-01244-x] [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: 12/11/2023] [Accepted: 08/10/2024] [Indexed: 09/27/2024]
Abstract
Background Computed tomography (CT) based three-dimensional templating is increasingly being used to predict implant sizes in total knee arthroplasty (TKA). However, the existing data is heterogeneous, and the majority of studies lack adequate statistical power. This study investigated whether preoperative CT-based planning in robot-assisted TKA (RA-TKA) helps in predicting the accurate size of implant used. Methods This is a single-center retrospective study of 632 consecutive RA-TKA surgeries. All surgeries were performed using a fully automatic Cuvis RA-TKA system. Cohen's Kappa (κ) coefficient was used to measure the level of agreement between the predicted and the final implant sizes. Results A total of 632 knees were operated on 384 patients. A total of 136 unilateral cases whereas 248 patients had both knees operated on. For the tibial component, in 21.7% cases a bigger implant size was used while in 11.8% cases a smaller size was used. For the femoral component, in 5.1% cases a bigger implant size was used while in 4.9% cases a smaller size was used. The agreement between the predicted and actual implant sizes was moderate for the tibial component [κ = 0.56 (95% CI: 0.51 to 0.61); p < 0.001] and almost perfect for the femoral component [κ = 0.87 (95% CI: 0.84 to 0.90); p < 0.001]. Conclusion This study suggests that planning of RA-TKA using a CT-based model can be valuable to surgeons in accurately predicting the component size for femur and to a lesser degree for tibia. Future studies should investigate the potential predictors of discordance between the predicted and actual tibial implant sizes.
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Affiliation(s)
- Neeraj Adkar
- Department of Orthopedics, SaiShree Hospital, Sr. No. 157, CTS No. 1104/3, Plot No 26, DP Road, Aundh, Pune, Maharashtra 411007 India
| | - Mangesh Patil
- Department of Orthopedics, SaiShree Hospital, Sr. No. 157, CTS No. 1104/3, Plot No 26, DP Road, Aundh, Pune, Maharashtra 411007 India
| | - Swapnil Vaidya
- Department of Orthopedics, SaiShree Hospital, Sr. No. 157, CTS No. 1104/3, Plot No 26, DP Road, Aundh, Pune, Maharashtra 411007 India
| | - Rajendra Kumbar
- Department of Orthopedics, SaiShree Hospital, Sr. No. 157, CTS No. 1104/3, Plot No 26, DP Road, Aundh, Pune, Maharashtra 411007 India
| | - Ravi Kerhalkar
- Department of Orthopedics, SaiShree Hospital, Sr. No. 157, CTS No. 1104/3, Plot No 26, DP Road, Aundh, Pune, Maharashtra 411007 India
| | - Girish Mote
- Department of Orthopedics, SaiShree Hospital, Sr. No. 157, CTS No. 1104/3, Plot No 26, DP Road, Aundh, Pune, Maharashtra 411007 India
| | - Satwik Thareja
- Department of Orthopedics, SaiShree Hospital, Sr. No. 157, CTS No. 1104/3, Plot No 26, DP Road, Aundh, Pune, Maharashtra 411007 India
| | - Prajwal Sadalagi
- Department of Orthopedics, SaiShree Hospital, Sr. No. 157, CTS No. 1104/3, Plot No 26, DP Road, Aundh, Pune, Maharashtra 411007 India
| | - Supreet Bajwa
- Hip and Knee Specialist, Wockhardt Hospital, Mumbai Central, Mumbai, India
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Londhe SB, Shetty S, Shetty V, Desouza C, Banka P, Antao N. Comparison of Time Taken in Conventional versus Active Robotic-Assisted Total Knee Arthroplasty. Clin Orthop Surg 2024; 16:259-264. [PMID: 38562637 PMCID: PMC10973624 DOI: 10.4055/cios23062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Computer- and robotic-assisted total knee replacement procedures have been shown to improve the accuracy of the implant size. It also allows dynamic confirmation of the implant and limb alignment during total knee arthroplasty (TKA). The major inhibition of the arthroplasty surgeon in adapting to the robotic-assisted TKA (RA-TKA) is the extra time spent during the registration process and milling of the bone with the robot. The aim of the study was to ascertain the extra time spent during these 2 steps as compared to the conventional TKA (C-TKA). METHODS It is a prospective study involving 30 patients each in the conventional TKA and RA-TKA operated by the same surgical team. The patients were given a choice between the C-TKA and RA-TKA and consecutive 30 cases in each group were studied by an independent observer. In the C-TKA group, the time for the application of appropriate zigs and execution of the bone cuts and soft-tissue release was recorded whereas in the RA-TKA group, the time taken for fixation of the tibial and femoral arrays and bone registration and bone milling with robot and required soft-tissue release was measured. RESULTS The preoperative patient characteristics were the same in both groups. The time taken in the C-TKA and RA-TKA groups was 24.77 ± 1.92 minutes and 25.03 ± 3.27 minutes, respectively, which is statistically insignificant (p = 0.709). CONCLUSIONS The study findings show that RA-TKA does not take additional time than C-TKA.
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Affiliation(s)
| | - Santosh Shetty
- Department of Orthopedics, CritiCare Asia Hospital, Mumbai, India
| | - Vijay Shetty
- Department of Orthopedics, CritiCare Asia Hospital, Mumbai, India
| | - Clevio Desouza
- Department of Orthopedics, CritiCare Asia Hospital, Mumbai, India
| | - Paras Banka
- Department of Orthopedics, Holy Spirit Hospital, Mumbai, India
| | - Nicholas Antao
- Department of Orthopedics, Holy Spirit Hospital, Mumbai, India
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Porsius JT, Ter Stege MHP, Selles RW, Slijper HP. Driving Factors of Recommending a Hand Surgery Clinic After Surgery. J Hand Surg Am 2024; 49:114-123. [PMID: 38099875 DOI: 10.1016/j.jhsa.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/20/2023] [Accepted: 11/01/2023] [Indexed: 02/05/2024]
Abstract
PURPOSE Since a patient's recommendation of a clinic to others is an important indicator of patient experience, more insight is needed into the underlying factors that motivate such recommendations. This retrospective cohort study assessed the relative contribution of the following: (1) patient-related characteristics, (2) treatment outcome, (3) satisfaction with treatment outcome, and (4) patients' experience with the process of care to patients' recommendation of a specific clinic after elective surgery. METHODS Patients of specialized outpatient hand surgery clinics (N = 6,895) reported the likelihood of recommending the clinic to friends or family 3-5 months after surgery by filling in the Net Promoter Score. Potential predictors of the Net Promoter Score were preoperative patient characteristics, patient-reported treatment outcomes, satisfaction with treatment outcome, and experience with several health care delivery domains. Linear regression analyses were used to examine the contribution of the predictors. RESULTS Mean age of the patients was 53 (SD, 14) years, 62.5% were women, and 62.5% were employed. Preoperative patient characteristics explained 1% of the variance in clinic recommendations. An additional 6% was explained by the treatment outcome, 21.6% by satisfaction with treatment outcome, and 33.8% by patients' experience with care delivery (total explained variance was 62.3%). The strongest independent predictors of clinic recommendations were positive experiences with the quality of the facilities and the communication skills of the physician. CONCLUSIONS Patient recommendations are more strongly driven by patients' experience with care delivery than by treatment outcome and patient characteristics. CLINICAL RELEVANCE In elective surgery, improving patient experiences is pivotal in boosting patient recommendation of the clinic.
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Affiliation(s)
- Jarry T Porsius
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Rehabilitation Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Hand and Wrist Center, Xpert Clinics, the Netherlands
| | - Marloes H P Ter Stege
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Rehabilitation Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Hand and Wrist Center, Xpert Clinics, the Netherlands.
| | - Ruud W Selles
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Rehabilitation Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Quinn J, Jones P, Randle R. Assessment of patient satisfaction following revision total knee arthroplasty. ANZ J Surg 2023; 93:995-1000. [PMID: 36881523 DOI: 10.1111/ans.18375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/27/2023] [Accepted: 02/19/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Patient satisfaction is becoming an increasingly important measure of healthcare quality. Satisfaction following RTKA is poorly described within the literature, resulting in difficulty for clinicians to manage patient expectations and obtain informed consent. METHODS We investigated postoperative satisfaction of RTKA patients by a single surgeon, using a single prosthesis, at a single institution. Patient satisfaction was assessed using structured telephone assessment questionnaires and review of orthopaedic/hospital records. The effect of patient and surgical characteristics on satisfaction was assessed using correlation coefficients and binary logistic regression in SPSS. RESULTS Two hundred and two RTKAs were performed in 178 patients between 2004 and 2015 inclusive. One hundred and twenty-four patients (143 RTKAs) were contactable to complete satisfaction assessment. Eighty-five percent of patients were satisfied and would have the RTKA again, 8% were unsure, 7% would not. Mean reported satisfaction on a numerical scale (1-10) was 8.17 (range 1-10), with 74% of patients scoring 8 or above, and 35% of patients scoring 10. The Mahomed Satisfaction Scale outcomes demonstrated a mean score of 87.7. High positive correlation was found between assessment tools. Logistic regression analysis identified factors contributing to satisfaction included ROM, OKS, BMI, and surgical time. CONCLUSION This cohort demonstrated high patient satisfaction rate following RTKA, utilizing simple and reliable outcome measurement tools. We found a high positive correlation between methods of assessment, and moderate positive correlation between satisfaction and functional outcomes. These results contribute to the understanding of satisfaction in RTKA patients, which may assist in informing patients of expected post-operative outcomes.
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Affiliation(s)
- Jonathan Quinn
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Peter Jones
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Ray Randle
- Gold Coast Centre for Bone and Joint Surgery, Gold Coast, Queensland, Australia
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Choong PF, Dowsey MM. Surgery for osteoarthritis. OSTEOARTHRITIS HEALTH PROFESSIONAL TRAINING MANUAL 2023:147-163. [DOI: 10.1016/b978-0-323-99269-5.00009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Londhe SB, Shetty S, Vora NL, Shah A, Nair R, Shetty V, Desouza C, Khan FS. Efficacy of the Pre-operative Three-Dimensional (3D) CT Scan Templating in Predicting Accurate Implant Size and Alignment in Robot Assisted Total Knee Arthroplasty. Indian J Orthop 2022; 56:2093-2100. [PMID: 36507208 PMCID: PMC9705650 DOI: 10.1007/s43465-022-00742-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/30/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Nearly 20% of Total knee Arthroplasty patients remain dissatisfied. This is a major concern in twenty-first century arthroplasty practice. Accurate implant sizing is shown to improve the implant survival, knee balance and patient reported outcome. Aim of the current study is to assess the efficacy of pre-operative three-dimensional (3D) CT scan templating in a robot-assisted TKA in predicting the correct implant sizes and alignment. MATERIALS AND METHODS Prospectively collected data in a single center from 30 RA-TKAs was assessed. Inclusion criterion was patients with end stage arthritis (both osteoarthritis and rheumatoid arthritis) undergoing primary TKA. Patients undergoing revision TKA and patients not willing to participate in the study were excluded. Preliminary study of ten patients had indicated almost 100% accuracy in determining the implant size and position. Sample size was estimated to be 28 for 90% reduction in implant size and position error with α error of 0.05 and beta error of 0.20 with power of study being 80. Post-operative radiographs were assessed by an independent observer with respect to implant size and position. The accuracy of femoral and tibial component sizing in the study was compared with the historic control with Chi-squared test. The p value < 0.05 was considered significant. RESULTS The pre-operative CT scan 3D templating accuracy was 100% (30 out of 30 knees) for femoral component and 96.67% (29 out of 30 knees) for tibial component. The implant position and limb alignment was accurate in 100% of patients. The accuracy of femoral component and tibial component sizing is statistically significant (Chi-squared test, p value 0.0105 and 0.0461, respectively). CONCLUSION The study results show the effectiveness of pre-operative 3 D CT scan planning in predicting the implant sizes and implant positioning. This may have a potential to improve the implant longevity, clinical outcomes and patient satisfaction.
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Affiliation(s)
- Sanjay Bhalchandra Londhe
- Orthopedic Surgeon, Criticare Asia Hospital, Teli Galli, Andheri East, Mumbai, 400069 Maharashtra India
| | - Santosh Shetty
- Orthopedic Surgeon, Criticare Asia Hospital, Teli Galli, Andheri East, Mumbai, 400069 Maharashtra India
| | - Niraj L. Vora
- Orthopedic Surgeon, Criticare Asia Hospital, Teli Galli, Andheri East, Mumbai, 400069 Maharashtra India
| | - Ashit Shah
- Orthopedic Surgeon, Criticare Asia Hospital, Teli Galli, Andheri East, Mumbai, 400069 Maharashtra India
| | - Rakesh Nair
- Orthopedic Surgeon, Criticare Asia Hospital, Teli Galli, Andheri East, Mumbai, 400069 Maharashtra India
| | - Vijay Shetty
- Orthopedic Surgeon, Criticare Asia Hospital, Teli Galli, Andheri East, Mumbai, 400069 Maharashtra India
| | - Clevio Desouza
- Orthopedic Surgeon, Holy Spirit Hospital, Andheri East, Mumbai India
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Telerehabilitation has similar clinical and patient-reported outcomes compared to traditional rehabilitation following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2022; 30:4098-4103. [PMID: 35347376 DOI: 10.1007/s00167-022-06931-6] [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: 12/14/2021] [Accepted: 03/02/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Telehealth rehabilitation (telerehab) is an increasingly popular cost-saving alternative to traditional rehabilitation after total joint arthroplasty. We compared the safety and efficacy of an institutional telerehab program to conventional "face-to-face" rehabilitation in a sample of patients undergoing total knee arthroplasty (TKA). METHODS A retrospective matched cohort study was performed. Medicare patients who utilized telerehab following unilateral TKA were matched in a 1:3 ratio to those utilizing conventional rehabilitation. Patients were matched on sex, body mass index (BMI, ± 5 kg/m2), preoperative extension (± 10 degrees), preoperative flexion (± 10 degrees), and Risk Assessment and Prediction Tool (RAPT) score (± 2 points). Ninety-day unplanned healthcare encounters, 120-day manipulations under anesthesia (MUAs), and 6-week and 3-month changes in the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), pain visual analog scale (VAS), Veterans RAND 12 (VR-12), and Lower-Extremity Activity Scale (LEAS) were compared between groups. RESULTS Eighty-two telerehab patients and 244 conventional rehab patients were included. After matching, there were no differences in 90-day unplanned healthcare encounters or 120-day MUA rates between groups. There were no differences in 6-week or 3-month changes in KOOS-JR, VAS pain, or VR-12 mental or physical sub-scores between groups. Telerehab patients had a greater improvement in LEAS score at 3 months compared to the conventional group (mean difference 1.9, P = 0.03). CONCLUSION In a matched cohort study of 326 TKA patients, telerehab patients had similar rates of unplanned healthcare encounters and MUAs and similar patient-reported outcomes compared to conventional PT patients, suggesting that telerehab can be an equally effective alternative to conventional PT following TKA. LEVEL OF EVIDENCE III.
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Total knee arthroplasty versus unicompartmental knee arthroplasty in management of anteromedial knee osteoarthritis: a randomized clinical trial. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Curtin-Bowen M, Li T, Pullman A, Businger A, Lipsitz S, Syrowatka A, Sainlaire M, Thai T, Lieberman J, Davis A, Blanchfield B, Bates DW, Dykes PC. Testing of a Risk-Standardized Complication Rate Electronic Clinical Quality Measure (eCQM) for Total Hip and/or Total Knee Arthroplasty. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2021:352-361. [PMID: 35308954 PMCID: PMC8861748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Supported by the Centers for Medicare & Medicaid Services (CMS), Brigham and Women's Hospital (BWH) has retooled the existing claims-based measures NQF1550 and NQF3493 into an electronic clinical quality measure (eCQM) to assess the risk-standardized complication rate (RSCR) following elective primary total hip (THA) and knee arthroplasty (TKA) at the clinician group level. This novel eCQM includes risk-adjustment for social determinants of health, includes all adult patients from all payers, leverages electronic health records (EHRs) rather than claims-based data, and includes both inpatient and outpatient procedures and complications which offers benefits compared to existing metrics. Following testing in two geographically different healthcare systems, the overall risk-standardized complication rate within 90 days following THA and TKA at the two sites was 3.60% (Site 1) and 3.70% (Site 2). This measure is designed for use in the Merit-Based Incentive Payment System (MIPS).
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Affiliation(s)
| | - Troy Li
- Brigham and Women's Hospital, Boston, MA
| | | | | | - Stuart Lipsitz
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | | | - Tien Thai
- Brigham and Women's Hospital, Boston, MA
| | - Jay Lieberman
- Keck School of Medicine, The University of Southern California, Los Angeles, CA
| | | | - Bonnie Blanchfield
- Brigham and Women's Hospital, Boston, MA
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - David W Bates
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Patricia C Dykes
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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De Campos Júnior LR, Sbalqueiro GN, Ayala RAR, Lopes Junior OV, Saggin PRF, Kuhn A. To Retain or Resurface the Patella in Primary Total Knee Arthroplasty: A Comparative Study. Rev Bras Ortop 2021; 56:741-746. [PMID: 34900102 PMCID: PMC8651447 DOI: 10.1055/s-0040-1721838] [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] [Received: 04/19/2020] [Accepted: 09/19/2020] [Indexed: 11/07/2022] Open
Abstract
Objective To evaluate and compare clinically and functionally patients undergoing primary total knee arthroplasty (TKA) with preservation or replacement of the patella. Methods In a cross-sectional study, the functional results were evaluated and compared, using the Western Ontario and McMaster Universities (WOMAC) and Lequesne scores, of 158 patients undergoing primary TKA (162 knees); in 81 knees the patella was submitted to arthroplasty and in 81 the joint surface of the patella was preserved. Results No significant differences were identified in terms of the Lequesne score (p = 0.585), global WOMAC score (p = 0.169), nor in terms of its subdivisions regarding stiffness (p = 0.796) and functional capacity (p = 0.190). There was a significant difference only in terms of the subdivision that evaluates pain in the WOMAC score, being lower in the group undergoing patellar arthroplasty (p = 0.036). Conclusion In the present study, there was no difference in functional assessment in patients who underwent or not patellar replacement during primary knee arthroplasty surgery. However, individuals in whom the patella was preserved reported more pain.
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Affiliation(s)
| | | | | | - Osmar Valadão Lopes Junior
- Serviço de Ortopedia e Traumatologia, Hospital São Vicente de Paulo, Passo Fundo, RS, Brasil
- Serviço de Cirurgia do Joelho, Hospital São Vicente de Paulo, Passo Fundo, RS, Brasil
| | - Paulo Renato Fernandes Saggin
- Serviço de Ortopedia e Traumatologia, Hospital São Vicente de Paulo, Passo Fundo, RS, Brasil
- Serviço de Cirurgia do Joelho, Hospital São Vicente de Paulo, Passo Fundo, RS, Brasil
| | - Andre Kuhn
- Serviço de Ortopedia e Traumatologia, Hospital São Vicente de Paulo, Passo Fundo, RS, Brasil
- Serviço de Cirurgia do Joelho, Hospital São Vicente de Paulo, Passo Fundo, RS, Brasil
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Comparison of patient reported outcome measures after single versus two-stage revision for chronic infection of total hip arthroplasty: a retrospective propensity score matched cohort study. Arch Orthop Trauma Surg 2021; 141:1789-1796. [PMID: 33783636 DOI: 10.1007/s00402-021-03810-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 02/01/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Two-stage revision is the current gold standard treatment for infected total hip arthroplasties (THA) with good clinical outcomes. Single-stage revision THA offers the advantage of only a single surgical intervention, potentially leading to improved functional outcomes. This study aimed to compare the differences in patient-reported outcome measures (PROMs) and complications between single and two-stage revision THA for chronic periprosthetic joint infection (PJI). METHODS A total of 159 consecutive revision THA patients for chronic PJI with complete pre-and post-operative patient-reported outcome measures (PROM) was investigated. A total of 46 patients with single-stage revision THA was matched to 92 patients following two-stage revision THA using propensity score matching, yielding a total of 136 propensity score-matched patients for analysis. RESULTS Single and two-stage revision THA improved PROM scores post-operatively, with significantly higher PROMs for single-stage revision THA (HOOS-PS: 50.7 vs 46.4, p = 0.04; Physical SF 10A: 42.1 vs 36.6, p < 0.001; PROMIS SF Physical: 41.4 vs 37.4, p < 0.001; PROMIS SF Mental: 52.8 vs 47.6, p < 0.001). There was no significant difference between both cohorts for reinfection rates (p = 0.81) and 90-day mortality rates (p = 1.0). CONCLUSION This study found a demonstrable functional benefit of single-stage revision compared to two-stage revision for THA with chronic periprosthetic joint infection, suggesting that single-stage revision THA may provide an effective alternative to two-stage revision in selected patients with chronic PJI. LEVEL OF EVIDENCE Level III, case-control retrospective analysis.
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Peña P, Ortega MA, Buján J, De la Torre B. Influence of Psychological Distress in Patients with Hypoallergenic Total Knee Arthroplasty. Treatment Algorithm for Patients with Metal Allergy and Knee Osteoarthritis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:5997. [PMID: 34204981 PMCID: PMC8199888 DOI: 10.3390/ijerph18115997] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/19/2022]
Abstract
The outcome in total knee arthroplasty (TKA) depends on multiples factors, among them is the psychological condition. In addition, up 15 to 30% of the patients that undergo TKA show little or no improvement after surgery, which implies the diagnosis of a painful TKA is a challenge for the orthopedic surgeon, who must rule out a possible metal allergy (MA). It is considered an exclusion diagnosis. Due to the complex relationship between psychological condition and MA, and according to the worse results in patients treated with a hypoallergenic TKA, we asked: (1). What degree of psychological distress (PD) is present in patients who have a hypoallergenic TKA, and how does it influence the results of quality of life (QoL) and functional capacity. (2). Can we develop a new algorithm for patients with a possible MA that improves the outcomes? A pragmatic clinical study was carried out that included patients who underwent hypoallergenic TKA during three consecutive years. Quality of life and functional capacity were measured with (Western Ontario McMaster Universities Osteoarthritis Index) WOMAC index, the Short Form 12 questionnaire (SF-12) questionnaire, and the The EQ-5D-5L questionnaire essentially consists of two pages: the EQ-5D descriptive system and the EQ visual analogue scale (EQ VAS) (Euro-QoL-5D L-VAS (EQ5D)), in all patients. To assess PD, a Psychological Distress Score was developed. SPSS software was performed to statistical analysis, and Student´s test for independent variables with a p < 0.005 as statistically significant. A total of 72 anallergic TKAs in 64 patients were treated during this period; 31.3% of these patients showed features of PD before the surgery. According with the severity of the PD, 60% were classified as severe, 10% as moderate and 30% as mild. Patients with PD had statistically significant worse results on the final WOMAC, SF-12, and EQ5D questionnaires. The final scores of the physical subscale of the SF-12 and EQ5D showed better results in patients diagnosed by psychiatrist. Up to one third of the patients with hypoallergenic TKAs have PD, and their results are clearly inferior to those patients with MA without PD. When PD was diagnosed according with Psychological Distress Score, patients should be carefully assessed in order to determine if a specialist referral is recommended. According with our results, PD should be assessed either by the PCP or by us. If the PD is confirmed, a psychiatry referral is then requested for better preoperative management and treatment. We believe that this approach would lead to better TKA outcomes.
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Affiliation(s)
- Pilar Peña
- Orthopedic Surgery and Traumatology Service, Virgen de la Luz Hospital, 16002 Cuenca, Spain;
| | - Miguel A. Ortega
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain;
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Julia Buján
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain;
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Basilio De la Torre
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain
- Service of Traumatology, University Hospital Ramón y Cajal, 28034 Madrid, Spain
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14
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Begum FA, Kayani B, Magan AA, Chang JS, Haddad FS. Current concepts in total knee arthroplasty : mechanical, kinematic, anatomical, and functional alignment. Bone Jt Open 2021; 2:397-404. [PMID: 34139884 PMCID: PMC8244789 DOI: 10.1302/2633-1462.26.bjo-2020-0162.r1] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Limb alignment in total knee arthroplasty (TKA) influences periarticular soft-tissue tension, biomechanics through knee flexion, and implant survival. Despite this, there is no uniform consensus on the optimal alignment technique for TKA. Neutral mechanical alignment facilitates knee flexion and symmetrical component wear but forces the limb into an unnatural position that alters native knee kinematics through the arc of knee flexion. Kinematic alignment aims to restore native limb alignment, but the safe ranges with this technique remain uncertain and the effects of this alignment technique on component survivorship remain unknown. Anatomical alignment aims to restore predisease limb alignment and knee geometry, but existing studies using this technique are based on cadaveric specimens or clinical trials with limited follow-up times. Functional alignment aims to restore the native plane and obliquity of the joint by manipulating implant positioning while limiting soft tissue releases, but the results of high-quality studies with long-term outcomes are still awaited. The drawbacks of existing studies on alignment include the use of surgical techniques with limited accuracy and reproducibility of achieving the planned alignment, poor correlation of intraoperative data to long-term functional outcomes and implant survivorship, and a paucity of studies on the safe ranges of limb alignment. Further studies on alignment in TKA should use surgical adjuncts (e.g. robotic technology) to help execute the planned alignment with improved accuracy, include intraoperative assessments of knee biomechanics and periarticular soft-tissue tension, and correlate alignment to long-term functional outcomes and survivorship.
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Affiliation(s)
- Fahima A Begum
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK
| | - Babar Kayani
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK
| | - Ahmed A Magan
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK
| | - Justin S Chang
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK.,Department of Orthopaedic Surgery, The Princess Grace Hospital, London, UK
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15
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Ho KW, Pong G, Poon WC, Chung KY, Kwok YY, Chiu KH. Progression of health-related quality of life of patients waiting for total knee arthroplasty. J Eval Clin Pract 2021; 27:69-74. [PMID: 32202045 PMCID: PMC7891587 DOI: 10.1111/jep.13388] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/04/2020] [Accepted: 03/06/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Total knee arthroplasty (TKA) remains the surgical gold standard treatment for patients suffering from end-stage osteoarthritis (OA) of the knee. However, due to the high demand and scarce medical resources, the waiting time for surgery is astoundingly lengthy. Controversies are shown in numerous studies, on whether physical functionality and mental status decline or remain stable over the waiting period. This study aims to evaluate the progression in patients suffering from end-stage OA while on the waiting list for TKA. METHODS One hundred and twenty-seven patients suffering from end-stage OA who were on the TKA waiting list were prospectively recruited from our orthopaedics specialist clinic. They were assessed once a year for 2 years or until surgery. The Western Ontario and McMaster University Osteoarthritis Index (WOMAC), SF-36 self-rated questionnaire and 15D health-related quality of life (HRQoL) questionnaire were used as outcome measurements for functionality and disability assessment. RESULTS Patients on the waiting list for TKA showed a progressive increase in pain and disability level within the first year (P = .035). Those patients waiting for more than 2 years showed worsening HRQoL (P < .05) as time progressed. However, no significant difference was observed between the first and second years. CONCLUSIONS A decline in functionality and increase in disability were shown in follow-up assessments conducted every year. However, a plateau effect is observed with end-stage disease. This emphasizes that more active conservative management programmes should be introduced and implemented while patients are enlisted on the TKA waiting list. Moreover, timely surgical intervention can improve patients' overall function. TRIAL REGISTRATION This study involved human participants and reports health-related outcomes concerning the HRQoL in patients with end-stage OA of the knee. Thus, it was registered, retrospectively, as a clinical trial under the U.S. National Library of Medicine ClinicalTrials.gov (https://clinicaltrials.gov/) on March 4, 2018.
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Affiliation(s)
- Ki Wai Ho
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - Gerald Pong
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - Wai Chin Poon
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - Kwong Yin Chung
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Shatin, Hong Kong
| | - Yan-Yan Kwok
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Kwok Hing Chiu
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Shatin, Hong Kong
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16
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Klemt C, Tirumala V, Oganesyan R, Xiong L, van den Kieboom J, Kwon YM. Single-Stage Revision of the Infected Total Knee Arthroplasty Is Associated With Improved Functional Outcomes: A Propensity Score-Matched Cohort Study. J Arthroplasty 2021; 36:298-304. [PMID: 32778418 DOI: 10.1016/j.arth.2020.07.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Single-stage revision is an alternative to the standard 2-stage revision, potentially minimizing morbidities and improving functional outcomes. This study aimed at comparing single-stage and 2-stage revision total knee arthroplasty (TKA) for chronic periprosthetic joint infection (PJI) with regard to patient-reported outcome measures (PROMs) and complication rates. METHODS A total of 185 consecutive revision TKA patients for chronic PJI with complete preoperative and postoperative PROMs were investigated. A total of 44 patients with single-stage revision TKA were matched to 88 patients following 2-stage revision TKA using propensity score matching, yielding a total of 132 propensity score-matched patients for analysis. Patient demographics and clinical information including reinfection and readmission rates were evaluated. RESULTS There was no significant difference in preoperative PROMs between propensity score-matched single-stage and 2-stage revision TKA cohorts. Postoperatively, significantly higher PROMs for single-stage revision TKA were observed for Knee disability and Osteoarthritis Outcome Score physical function (62.2 vs 51.9, P < .01), physical function short form 10A (42.8 vs 38.1, P < .01), PROMIS SF Physical (44.8 vs 41.0, P = .01), and PROMIS SF Mental (50.5 vs 47.1, P = .02). There was no difference between propensity score-matched single-stage and 2-stage revision TKA cohorts for clinical outcomes including reinfection rates (25.0% vs 27.2%, P = .78) and 90-day readmission rates (22.7% vs 25.0%, P = .77). CONCLUSION This study illustrated that single-stage revision TKA for chronic PJI may be associated with superior patient-reported outcomes compared to 2-stage revision for the infected TKA using a variety of PROMs. Improved PROMs were not accompanied by differences in complication rates between both cohorts, suggesting that single-stage revision TKA may provide an effective alternative to 2-stage revision in patients with chronic TKA PJI.
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Affiliation(s)
- Christian Klemt
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School
| | | | - Ruben Oganesyan
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Liang Xiong
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Janna van den Kieboom
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School
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17
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The Influence of Diabetes Mellitus on Patients Undergoing Primary Total Lower Extremity Arthroplasty: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:6661691. [PMID: 33490250 PMCID: PMC7787736 DOI: 10.1155/2020/6661691] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/03/2020] [Indexed: 12/21/2022]
Abstract
Background Diabetes mellitus (DM) is a common disease that has an adverse impact on most orthopedic surgeries, and its prevalence has gradually increased in recent years. We aim to investigate the influence of DM on comorbidities and complications of patients undergoing primary total lower extremity arthroplasty. Methods PubMed, Embase, Cochrane Library, Medline, and Web of Science were systematically searched for relevant studies published before December 2019. Demographic data, comorbidities, and postoperative complications after primary total hip arthroplasties (THA) or primary total knee arthroplasties (TKA) were assessed between DM and non-DM patients. Meta-analysis was conducted using Review Manager 5.3, and forest plots were drawn for each variable. Results A total of 1,560,461 patients (215,916 patients with DM and 1,344,545 patients without DM) from 23 studies were included in this meta-analysis. The incidences of several preoperative comorbidities (hypertension (HTN), kidney disease, cardiac and cerebrovascular disease) were generally higher in patients with DM. Moreover, DM patients had a higher rate of postoperative complications (superficial and deep infection, deep vein thrombosis (DVT), and in-hospital mortality) compared to non-DM patients. Conclusions DM patients were more likely to suffer from comorbidities and had a higher risk of complications in total lower extremity arthroplasty compared to non-DM patients. It is necessary to identify DM and control hyperglycemia in the perioperative period to prevent postoperative complications in patients with DM.
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18
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Peña P, Ortega MA, Buján J, De la Torre B. Decrease of Quality of Life, Functional Assessment and Associated Psychological Distress in Patients with Hypoallergenic Total Knee Arthroplasty. J Clin Med 2020; 9:E3270. [PMID: 33053865 PMCID: PMC7601743 DOI: 10.3390/jcm9103270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/26/2020] [Accepted: 10/09/2020] [Indexed: 11/16/2022] Open
Abstract
Total knee arthroplasty (TKA) is the final treatment for knee osteoarthritis, and 15-30% of patients show little or no improvement. This high percentage is related to aspects of the surgical technique, the selected implant, and specific patient characteristics. The aim of this study was to analyze whether there are differences in quality of life (QoL) and functional capacity among patients undergoing TKA with conventional implants compared to those treated with hypoallergenic oxinium implants. A pragmatic clinical study was carried out that included patients who underwent TKA between January 2013 and December 2015. During this period, 245 knees in 228 patients were treated. Eleven patients were excluded, leaving a sample of 161 conventionally treated knees, 72 knees treated with hypoallergenic implants, and one patient who received both implant types. In all patients, QoL and functional capacity were measured with the WOMAC index, the SF-12 questionnaire, and the Euro-Qol-5D L-VAS. We also assessed the psychological distress of each patient and related the findings to the functional results. The differences in QoL were tested using ANCOVA and propensity score matching (PSM) models adjusted for sex, age, weight, psychiatric history and associated complications. Patients who underwent TKA using conventional prostheses had significantly better scores on the total WOMAC index and in the pain domain (p < 0.05) than those who received hypoallergenic prostheses, but no significant differences were observed for the other domains in the ANCOVA. In contrast, with the PSM, we also found statistically significant differences in the difficulty domain of the WOMAC. Significant differences were found for the SF-12 mental health questionnaire results (p = 0.038), but the same did not occur for the physical health domain in the ANCOVA and PSM. We also found statistically significant differences in the Euro-Qol-5D index results (p = 0.041), but not in the VAS scale scores for the same questionnaire in the ANCOVA, and we did not find significant differences in either with the PSM. Patients with metal allergies and those who present psychological distress had WOMAC, SF-12, and Euro-Qol-5D results that were statistically significantly worse than those of patients who received conventional implants. Patients who underwent hypoallergic TKA had lower scores on the QoL and functional capacity scales than patients who received conventional Cr-Co implants. Additionally, patients with psychological distress had worse results on the questionnaires, and those with a metal allergy had even lower scores; the differences were statistically significant.
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Affiliation(s)
- Pilar Peña
- Orthopedic Surgery and Traumatology Service, Virgen de la Luz Hospital, 16002 Cuenca, Spain;
| | - Miguel A. Ortega
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain;
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Julia Buján
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain;
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Basilio De la Torre
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain
- Service of Traumatology, University Hospital Ramón y Cajal, 28034 Madrid, Spain
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Emara AK, Nageeb E, George J, Buttaro MA, Higuera C, Piuzzi NS. Hypovitaminosis D in lower extremity Joint Arthroplasty: A systematic review and meta-analysis. J Orthop 2020; 21:109-116. [PMID: 32255990 PMCID: PMC7114851 DOI: 10.1016/j.jor.2020.03.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/23/2020] [Indexed: 12/17/2022] Open
Abstract
The purpose of the current systematic review was to identify the prevalence of hypovitaminosis-D in LE-TJA patients; and outline the association between pre-operative hypovitaminosis and post-operative outcomes. A search of PubMed-Medline and the Cochrane-Library databases was performed for literature published before November 27th, 2019. The eighteen studies analyzed had a pooled prevalence for vitamin D insufficiency (20 - <30 ng/mL) and deficiency (<20 ng/mL) of 53.4% and 39.4%, respectively. Hypovitaminosis-D was associated with higher complication rates (p = 0.043), and a greater prevalence among septic versus aseptic revisions (p = 0.016). Therefore, pre-operative screening for hypovitaminosis-D can be beneficial in patients undergoing LE-TJA. LEVEL OF EVIDENCE Systematic Review (Level III).
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Affiliation(s)
- Ahmed K. Emara
- Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA
| | - Emmanuel Nageeb
- Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA
| | - Jaiben George
- Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA
| | - Martin A. Buttaro
- Hip Surgery Unit "Sir John Charnley", Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos Higuera
- Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA
| | - Nicolas S. Piuzzi
- Cleveland Clinic, Department of Orthopedic Surgery, 9500 Euclid Ave/A41, Cleveland, OH, 44195, USA
- Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Schwarzkopf R, Kaplan DJ, Friedlander S, Gold HT. Outcomes of a First Total Knee Arthroplasty Are Associated With Outcomes of the Subsequent Contralateral Total Knee Arthroplasty. J Arthroplasty 2020; 35:1534-1539. [PMID: 32061478 DOI: 10.1016/j.arth.2020.01.037] [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: 11/15/2019] [Revised: 01/06/2020] [Accepted: 01/14/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To determine if preoperative characteristics and postoperative outcomes of a first total knee arthroplasty (TKA) were predictive of characteristics and outcomes of the subsequent contralateral TKA in the same patient. METHODS Retrospective administrative claims data from (SPARCS) database were analyzed for patients who underwent sequential TKAs from September 2015 to September 2017 (n = 5,331). Hierarchical multivariable Poisson regression (length of stay [LOS]) and multivariable logistic regression (all other outcomes), controlling for sex, age, and Elixhauser comorbidity scores were performed. RESULTS The cohort comprised 65% women, with an average age of 66 years and an average duration of 7.3 months between surgeries (SD: 4.7 months). LOS was significantly shorter for the second TKA (2.6 days) than for the first TKA (2.8 days; P < .001). Patients discharged to a facility after their first TKA had a probability of 76% of discharge to facility after the second TKA and were significantly more likely to be discharged to a facility compared with those discharged home after the first TKA (odds ratio [OR]: 63.7; 95% confidence interval [CI]: 52.1-77.8). The probability of a readmission at 30 and 90 days for the second TKA if the patient was readmitted for the first TKA was 1.0% (OR: 3.70; 95% CI: 0.98-14.0) and 6.4% (OR: 9; 95% CI: 5.1-16.0), respectively. Patients with complications after their first TKA had a 27% probability of a complication after the second TKA compared with a 1.6% probability if there was no complication during the first TKA (OR: 14.6; 95% CI: 7.8.1-27.2). CONCLUSION The LOS, discharge disposition, 90-day readmission rate, and complication rate for a second contralateral TKA are strongly associated with the patient's first TKA experience. The second surgery was found to be associated with an overall shorter LOS, fewer readmissions, and higher likelihood of home discharge. LEVEL OF EVIDENCE Level 3-retrospective cohort study.
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Affiliation(s)
- Ran Schwarzkopf
- Departments of Population Health and Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Daniel J Kaplan
- Departments of Population Health and Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Scott Friedlander
- Departments of Population Health and Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Heather T Gold
- Departments of Population Health and Orthopedic Surgery, NYU Langone Health, New York, NY
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21
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Kayani B, Konan S, Tahmassebi J, Oussedik S, Moriarty PD, Haddad FS. A prospective double-blinded randomised control trial comparing robotic arm-assisted functionally aligned total knee arthroplasty versus robotic arm-assisted mechanically aligned total knee arthroplasty. Trials 2020; 21:194. [PMID: 32070406 PMCID: PMC7027302 DOI: 10.1186/s13063-020-4123-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 01/30/2020] [Indexed: 02/07/2023] Open
Abstract
Background Total knee arthroplasty (TKA) with mechanical alignment (MA) aims to achieve neutral limb alignment in all patients, whereas TKA with functional alignment (FA) aims to restore native, patient-specific anatomy and knee kinematics by manipulating bone resections and fine-tuning implant positioning. The objective of this study is to determine the optimal alignment technique in TKA by comparing patient satisfaction, functional outcomes, implant survivorship, complications, and cost-effectiveness in MA TKA versus FA TKA. Robotic technology will be used to execute the planned implant positioning and limb alignment with high-levels of accuracy in all study patients. Methods and analysis This prospective double-blinded randomised control trial will include 100 patients with symptomatic knee osteoarthritis undergoing primary robotic arm-assisted TKA. Following informed consent, patients will be randomised to MA TKA (the control group) or FA TKA (the investigation group) at a ratio of 1:1 using an online random number generator. Blinded observers will review patients at regular intervals for 2 years after surgery to record predefined study outcomes relating to postoperative rehabilitation, clinical progress, functional outcomes, accuracy of implant positioning and limb alignment, gait, implant stability, cost-effectiveness, and complications. A superiority study design will be used to evaluate whether FA TKA provides superior outcomes compared to MA TKA. Primary and secondary objectives will be used to quantify and draw inferences on differences in the efficacy of treatment between the two groups. Intention-to-treat and per-protocol population analysis will be undertaken. The following statistical methods will be employed to analyse the data: descriptive statistics, independent t test, paired t test, analysis of variance, Fisher exact test, chi-square test, and graphical displays. Ethical approval was obtained from the London-Surrey Research Ethics Committee, UK. The study is sponsored by University College London, UK. Discussion This is the first study to describe the use of robotic technology to achieve FA TKA, and the only existing clinical trial comparing robotic MA TKA versus robotic FA TKA. The findings of this study will enable an improved understanding of the optimal alignment technique in TKA for achieving high-levels of patient satisfaction, improving functional outcomes, increasing implant survivorship, improving cost-effectiveness, and reducing complications. Registration Clinical Trials.gov, NCT04092153. Registered on 17 September 2019.
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Affiliation(s)
- Babar Kayani
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK.
| | - Sujith Konan
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - Jenni Tahmassebi
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - Sam Oussedik
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - Peter D Moriarty
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College Hospital, 235 Euston Road, Fitzrovia, London, NW1 2BU, UK
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22
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French SR, Munir S, Brighton R. A Single Surgeon Series Comparing the Outcomes of a Cruciate Retaining and Medially Stabilized Total Knee Arthroplasty Using Kinematic Alignment Principles. J Arthroplasty 2020; 35:422-428. [PMID: 31611163 DOI: 10.1016/j.arth.2019.09.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/03/2019] [Accepted: 09/13/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) designs are developed to optimize kinematics and improve patient satisfaction. The cruciate retaining (CR) and medially stabilized (MS) TKA designs have reported good mid-term follow-up outcomes. However, reasons for consistently high rates of patient dissatisfaction following a TKA remain poorly understood. To further investigate this, we compared the short-term functional outcomes and quality of life, using patient-reported outcome measures (PROMs) and range of motion (ROM), between a CR and MS TKA. METHODS A prospective comparison was made between 2 groups (44 CR-TKAs vs 46 MS-TKAs). The Knee Injury and Osteoarthritis Outcome Score (KOOS), KOOS-12, KOOS-Short form, KOOS-Joint Replacement, Oxford Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index, UCLA Activity Scale, and EuroQuality of life - 5 Dimension were completed preoperatively and 1 year postoperatively. The Forgotten Joint Score (FJS) and Visual Analogue Scale-Satisfaction were completed at 1 year postoperatively. ROM was collected preoperatively and 1 year postoperatively. RESULTS Patients who underwent an MS-TKA scored significantly better than the CR-TKA on the FJS (MS = 79.87, CR = 63.8, P = .005), the KOOS-12 Quality of Life subscale (MS = 82.8, CR = 74.4, P = .43), and the KOOS Quality of Life subscale (MS = 82.8, CR = 74.6, P = .44). There was no difference between the groups in all assessed PROMs or ROM, preoperatively and 1 year postoperatively. CONCLUSION Patients who underwent the MS-TKA scored significantly better on the FJS and the quality of life subscale of the KOOS and KOOS-12 than those who underwent a CR-TKA. All other assessed PROMs and ROM were comparable between the 2 groups and demonstrated that both implants facilitated symptom relief and improved daily function at 1 year postoperatively. These findings suggest that at short-term follow-up, the MS device is more likely to allow a patient to "forget" that a joint has been replaced and restore their quality of life. Long-term assessment of MS-TKA design outcomes in larger cohorts is recommended.
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Affiliation(s)
- Sofie R French
- Research Department, Australian Institute of Musculoskeletal Research, Wollstonecraft, New South Wales, Australia
| | - Selin Munir
- Research Department, Australian Institute of Musculoskeletal Research, Wollstonecraft, New South Wales, Australia
| | - Roger Brighton
- Orthopaedic Department, Westmead Private Hospital, Westmead, New South Wales, Australia
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23
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Dion CAB, Howard JL, Lanting BA, McAuley JP. Does Recession of the Posterior Cruciate Ligament Influence Outcome in Total Knee Arthroplasty? J Arthroplasty 2019; 34:2383-2387. [PMID: 31326243 DOI: 10.1016/j.arth.2019.05.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/19/2019] [Accepted: 05/29/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND For a PCL-retaining (posterior cruciate ligament) total knee arthroplasty (TKA) to function suitably, proper soft tissue balancing, including PCL recession, is required. Yet, when the recession of the PCL is needed, there is still a debate as to whether a cruciate-retaining (CR) TKA should be converted to a posterior-stabilized TKA due to the concern of instability and poorer clinical outcomes. The purpose of this study is to determine whether recession of the PCL adversely affects clinical outcomes in patients who undergo CR TKA. METHODS CR TKAs of the same design performed by the senior author (J.M.) were identified between December 2006 and July 2015. Clinical outcome measurements were collected and included the Western Ontario and McMaster Universities Osteoarthritis Index score, the Knee Society Clinical Rating System, Short Form-12 Physical Composite Score/Mental Health Composite Score, and revision rates. RESULTS There were no significant differences in clinical outcome when the PCL was retained, partially recessed, or completely released during PCL-retaining TKA (Western Ontario and McMaster Universities Osteoarthritis Index: P = .54, Knee Society Clinical Rating System: P = .42, Short Form-12 Mental Health Composite Score: P = .89, Short Form-12 Physical Composite Score: P = .527). CONCLUSION This study presents evidence of similar clinical outcomes when the PCL is retained or released during PCL-retaining TKA, provided attention is paid to appropriate soft tissue balancing. CR TKA undergoing partial or complete release of the PCL should not routinely be converted to a posterior-stabilized knee design. LEVEL OF EVIDENCE Level II, Prognostic study.
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Affiliation(s)
- Charles-Antoine B Dion
- Division of Orthopaedic Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - James L Howard
- Division of Orthopaedic Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Brent A Lanting
- Division of Orthopaedic Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - James P McAuley
- Division of Orthopaedic Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
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24
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Malahias MA, Gu A, Addona J, Nocon AA, Carli AV, Sculco PK. Different clinical outcomes on the second side after staged total knee replacement. A systematic review. Knee 2019; 26:530-536. [PMID: 31078392 DOI: 10.1016/j.knee.2019.04.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/12/2019] [Accepted: 04/14/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The clinical outcomes of the contralateral side in staged bilateral total knee arthroplasty (BTKA) are relatively unknown. The purpose of this study was to answer: 1) Does the second-operated knee in a staged BTKA result in inferior clinical and functional outcomes? 2) Is the duration of time between the first- and the second-operated knee defined in a consistent fashion in the literature? 3) Does the time interval between TKAs influence clinical outcomes? METHODS Two reviewers independently conducted a systematic search of the literature using different databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Five of the seven included studies reported significantly inferior postoperative clinical outcomes for the second-operated knee compared with the first-operated knee. There was no difference in the overall major complication rate between first- and second-operated TKA (2.4% and 1.2% respectively). Based on the literature reviewed, there is no consensus on the optimal time interval between the stages. Most studies, which investigated the impact of different intervals on the outcomes of the second-operated knee, concluded that the differences in outcomes with different intervals were not significant. CONCLUSIONS Current literature suggests that the second-operated knee, in patients undergoing staged BTKAs, might have inferior clinical outcomes when compared with the first-operated knee.
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Affiliation(s)
- Michael-Alexander Malahias
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Alex Gu
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Jacqueline Addona
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Allina A Nocon
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Alberto V Carli
- Adult Reconstruction & Joint Replacement, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Peter K Sculco
- The Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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25
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Doiron-Cadrin P, Kairy D, Vendittoli PA, Lowry V, Poitras S, Desmeules F. Feasibility and preliminary effects of a tele-prehabilitation program and an in-person prehablitation program compared to usual care for total hip or knee arthroplasty candidates: a pilot randomized controlled trial. Disabil Rehabil 2019; 42:989-998. [DOI: 10.1080/09638288.2018.1515992] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Patrick Doiron-Cadrin
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montréal, Québec, Canada
- Orthopaedic Clinical Research Unit, Centre-intégré-universitaire-de-santé-et-de-services-sociaux Est-de-l’île-de Montréal, Maisonneuve-Rosemont Hospital Research Centre, University of Montreal, Montréal, Québec, Canada
| | - Dahlia Kairy
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montréal, Québec, Canada
- Centre for Interdisciplinary Research in Rehablitation of Greater Montreal, Montréal, Québec, Canada
| | - Pascal-André Vendittoli
- Orthopaedic Clinical Research Unit, Centre-intégré-universitaire-de-santé-et-de-services-sociaux Est-de-l’île-de Montréal, Maisonneuve-Rosemont Hospital Research Centre, University of Montreal, Montréal, Québec, Canada
- Department of Surgery, University of Montreal, Montreal, Canada
| | - Véronique Lowry
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montréal, Québec, Canada
- Orthopaedic Clinical Research Unit, Centre-intégré-universitaire-de-santé-et-de-services-sociaux Est-de-l’île-de Montréal, Maisonneuve-Rosemont Hospital Research Centre, University of Montreal, Montréal, Québec, Canada
| | - Stéphane Poitras
- School of rehabilitation sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - François Desmeules
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montréal, Québec, Canada
- Orthopaedic Clinical Research Unit, Centre-intégré-universitaire-de-santé-et-de-services-sociaux Est-de-l’île-de Montréal, Maisonneuve-Rosemont Hospital Research Centre, University of Montreal, Montréal, Québec, Canada
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26
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Arslan A, Çuglan B, Özkurt B, Utkan A, Korkmaz MF, Koca TT, Sevimli R. Is it Possible to Recover Cardiac Functions After Total Knee Arthroplasty? Open Orthop J 2018; 12:261-268. [PMID: 30123375 PMCID: PMC6062906 DOI: 10.2174/1874325001812010261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/21/2018] [Accepted: 06/21/2018] [Indexed: 11/22/2022] Open
Abstract
Background Patients suffering from knee osteoarthritis lead a less active life than their healthy peers. It is well known that insufficient physical activity is the most common cause of chronic diseases. However, there is not enough research to enlighten the effect of increased functional capacity on cardiac functions after Total Knee Arthroplasty (TKA). This study aimed to investigate whether the orthopedic surgeons can predict that the patients will be healthier after TKA in terms of cardiac functions or not? Methods 109 patients who underwent TKA were prospectively followed for one year. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and short form 36 (SF-36) surveys, BMI measures, average step count per day, the six-minute walking test (6MWT), the Five-Times-Sit-to-Stand Test (FTSST) and Doppler echocardiography were performed both in the preoperative and postoperative period. Results After TKA, there was a substantial improvement in terms of WOMAC and SF36 survey scores. The average step count increased from 2199.6±690.8 steps/day to 4124.3±1638.8 steps/day. 6MWT and FTSST improved significantly as well. The average brisk walking time was 174.23±95.11 minutes/week. The means of early and late mitral inflow velocity ratios (E/A and Em/Am ratios) increased from 0.71±0.12 to 0.77±0.13 and from 0.66±0.13 to 0.76± 0.15 at the first year follow-up visit, respectively (p<0.001). Conclusion In the first year, objective physical capacity measures increased together with the expected improvements in disease-specific and generic measures. After TKA, left ventricular diastolic functions may be considered to have recovered in the light of the healing signs via echocardiography.
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Affiliation(s)
- Aydın Arslan
- Department of Orthopaedics and Traumatology, Elite İstanbul Medical Center,Istanbul Gelisim University,Istanbul,Turkey
| | - Bilal Çuglan
- Department of Cardiology, Silivri Medical Park Hospital,Bahcesehir University,Istanbul,Turkey
| | - Bülent Özkurt
- Department of Orthopaedics and Traumatology, Ankara Numune Research and Training Hospital, SBU,Ankara,Turkey
| | - Ali Utkan
- Department of Orthopaedics and Traumatology, Ankara Numune Research and Training Hospital, SBU,Ankara,Turkey
| | - Mehmet Fatih Korkmaz
- Department of Orthopaedics and Traumatology, Ankara Numune Research and Training Hospital, SBU,Ankara,Turkey
| | - Tuba Tülay Koca
- Department of Orthopaedics and Traumatology,Turgut Ozal Medical Center,Malatya,Turkey
| | - Resit Sevimli
- Department of Orthopaedics and Traumatology, Ankara Numune Research and Training Hospital, SBU,Ankara,Turkey
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27
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Ilfeld BM, Ball ST, Gabriel RA, Sztain JF, Monahan AM, Abramson WB, Khatibi B, Said ET, Parekh J, Grant SA, Wongsarnpigoon A, Boggs JW. A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty. Neuromodulation 2018; 22:653-660. [PMID: 30024078 PMCID: PMC6339601 DOI: 10.1111/ner.12790] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/19/2018] [Accepted: 04/09/2018] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA). METHODS For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total. RESULTS In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported. CONCLUSIONS This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Scott T Ball
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.,The Outcomes Research Consortium, Cleveland, OH, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Amanda M Monahan
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Jesal Parekh
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Stuart A Grant
- Duke University Medical Center, Duke University, Durham, NC, USA
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28
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Perez JL, Mosher ZA, Watson SL, Sheppard ED, Brabston EW, McGwin G, Ponce BA. Readability of Orthopaedic Patient-reported Outcome Measures: Is There a Fundamental Failure to Communicate? Clin Orthop Relat Res 2017; 475:1936-1947. [PMID: 28374349 PMCID: PMC5498383 DOI: 10.1007/s11999-017-5339-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 03/27/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are increasingly used to quantify patients' perceptions of functional ability. The American Medical Association and NIH suggest patient materials be written at or below 6th to 8th grade reading levels, respectively, yet one recent study asserts that few PROMs comply with these recommendations, and suggests that the majority of PROMs are written at too high of a reading level for self-administered patient use. Notably, this study was limited in its use of only one readability algorithm, although there is no commonly accepted, standard readability algorithm for healthcare-related materials. Our study, using multiple readability equations and heeding equal weight to each, hopes to yield a broader, all-encompassing estimate of readability, thereby offering a more accurate assessment of the readability of orthopaedic PROMS. QUESTIONS/PURPOSES (1) What proportion of orthopaedic-related PROMs and orthopaedic-related portions of the NIH Patient Reported Outcomes Measurement Information System (PROMIS®) are written at or below the 6th and 8th grade levels? (2) Is there a correlation between the number of questions in the PROM and reading level? (3) Using systematic edits based on guidelines from the Centers for Medicare and Medicaid Services, what proportion of PROMs achieved American Medical Association and NIH-recommended reading levels? METHODS Eighty-six (86) independent, orthopaedic and general wellness PROMs, drawn from commonly referenced orthopaedic websites and prior studies, were chosen for analysis. Additionally, owing to their increasing use in orthopaedics, four relevant short forms, and 11 adult, physical health question banks from the PROMIS®, were included for analysis. All documents were analyzed for reading grade levels using 19 unique readability algorithms. Descriptive statistics were performed using SPSS Version 22.0. RESULTS The majority of the independent PROMs (64 of 86; 74%) were written at or below the 6th grade level, with 81 of 86 (94%) written at or below the 8th grade level. All item banks (11 of 11) and short forms (four of four) of the PROMIS® were written below the 6th grade reading level. The median reading grade level of the 86 independent PROMs was 5.0 (interquartile range [IQR], 4.6-6.1). The PROMIS® question banks had a median reading grade level of 4.1 (IQR, 3.5-4.8); the Adult Short Forms had a median reading grade level of 4.2 (IQR, 4.2-4.3) There was no correlation appreciated between the median reading grade level and the number of questions contained in a PROM (r = -0.081; p = 0.460). For PROMs above NIH-recommended levels, following edits, all (five of five) achieved NIH reading level goals and three (three of five) achieved American Medical Association goals. Editing of these PROMs improved readability by 4.3 median grade level (before, 8.9 [IQR, 8.4-9.1], after 4.6 [IQR, 4.6-6.4], difference of medians, 4.3; p = 0.008). CONCLUSIONS Patient literacy has great influence on healthcare outcomes, and readability is an important consideration in all patient-directed written materials. Our study found that more than 70% of PROMs commonly used in orthopaedics, and all orthopaedic-related portions of the PROMIS® are written at or below the most stringent recommendations (≤ 6th grade reading level), and more than 90% of independent PROMs and all PROMIS® materials are written at or below an 8th grade level. Additionally, the use of the Centers for Medicare and Medicaid Services guidelines for editing high reading level PROMs yields satisfactory results. CLINICAL RELEVANCE Fears of widely incomprehensible PROMs may be unfounded. Future research to identify the most appropriate readability algorithm for use in the healthcare sector, and revalidation of PROMs after readability-improving edits is warranted.
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Affiliation(s)
- Jorge L Perez
- Division of Orthopaedic Surgery, Department of Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Zachary A Mosher
- Division of Orthopaedic Surgery, Department of Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Shawna L Watson
- Division of Orthopaedic Surgery, Department of Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Evan D Sheppard
- Division of Orthopaedic Surgery, Department of Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Eugene W Brabston
- Division of Orthopaedic Surgery, Department of Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Gerald McGwin
- Division of Orthopaedic Surgery, Department of Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA
| | - Brent A Ponce
- Division of Orthopaedic Surgery, Department of Surgery, University of Alabama at Birmingham, 1313 13th Street South, Birmingham, AL, 35205, USA.
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29
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Kulshrestha V, Datta B, Kumar S, Mittal G. Outcome of Unicondylar Knee Arthroplasty vs Total Knee Arthroplasty for Early Medial Compartment Arthritis: A Randomized Study. J Arthroplasty 2017; 32:1460-1469. [PMID: 28065624 DOI: 10.1016/j.arth.2016.12.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 12/01/2016] [Accepted: 12/12/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND With increasing number of patients with early osteoarthritis of knee opting for total knee arthroplasty (TKA), there has been increase in patients dissatisfied with surgical outcomes. It is being presumed that offering unicondylar knee arthroplasty (UKA) to them would improve outcomes. METHODS Primary objective of our study was to look for any difference in patient-reported outcome and function at 2-year follow-up in patients undergoing UKA as compared to TKA. Our study was a randomized study with parallel assignment conducted at a high-volume specialized arthroplasty center. Eighty patients with bilateral isolated medial compartment knee arthritis were randomized into simultaneous 2-team bilateral TKA (n = 40) and UKA (n = 40) group. We finally analyzed 36 patients in each group. Main outcome measure was improvement in Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS) and High Activity Arthroplasty Score (HAAS) obtained at 2-year follow-up. RESULTS Improvement in KOS-ADLS and HAAS at 2 years was similar (P = .2143 and .2010) in both groups. Performance as assessed with Delaware index was also similar. Length of hospital stay was less in UKA group (6.6 days as against 5.4 days). Complications and readmission rates were more in TKA group (nil in UKA group; 08 in TKA group). CONCLUSION At 2-year follow-up, UKA provides similar improvement in patient-reported outcomes, function, and performance as compared to TKA when performed in patients with early arthritis. However, UKA patients have shorter hospital stay and fewer complications.
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Affiliation(s)
- Vikas Kulshrestha
- Joint Replacement Centre, Army Hospital Research & Referral, New Delhi, India
| | - Barun Datta
- Joint Replacement Centre, Army Hospital Research & Referral, New Delhi, India
| | - Santhosh Kumar
- Department Of Orthopaedics, Air Force Hospital, Jorhat, India
| | - Gaurav Mittal
- Joint Replacement Centre, Army Hospital Research & Referral, New Delhi, India
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30
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Effects of a tele-prehabilitation program or an in-person prehabilitation program in surgical candidates awaiting total hip or knee arthroplasty: Protocol of a pilot single blind randomized controlled trial. Contemp Clin Trials Commun 2016; 4:192-198. [PMID: 29736482 PMCID: PMC5935896 DOI: 10.1016/j.conctc.2016.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/23/2016] [Accepted: 10/03/2016] [Indexed: 01/22/2023] Open
Abstract
Background The accessibility for total joint arthroplasty often comes up against long wait lists, and may lead to deleterious effects for the awaiting patients. This pilot single blind randomized controlled trial aims to evaluate the impact of a telerehabilitation prehabilitation program before a hip or knee arthroplasty compared to in-person prehabilitation or to usual wait for surgery. Methods/design Thirty-six patients on a wait list for a total hip or knee arthroplasty will be recruited and randomly assigned to one of three groups. The in-person prehabilitation group (n = 12) will receive a 12-week rehabilitation program (2 sessions/week) including education, exercises of the lower limb and cardiovascular training. Patients in the tele-prehabilitation group (n = 12) will receive the same intervention using a telecommunication software. The control group (n = 12) will be provided with the hospital's usual documentation before surgery. The Lower Extremity Functional Scale (LEFS) will be the primary outcome measure taken at baseline and at 12 weeks. Secondary measures will include self-reported function and quality of life as well as performance tests. A mixed-model, 2-way repeated-measure ANOVA will be used to analyse the effects of the rehabilitation programs. Discussion This pilot study is the first to evaluate the feasibility and the impact of a telerehabilitation prehabilitation program for patients awaiting a total joint arthroplasty. The results of this pilot-RCT will set the foundations for further research in the fields of rehabilitation and tele-medicine for patients suffering from lower limb osteoarthritis. Trial registration ClinicalTrials.gov: NCT02636751.
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Key Words
- ANOVA, Analysis of variance
- Arthroplasty
- FRSQ, Fonds de recherche du Québec – Santé
- GRS, Global Rating Scale
- Hip
- ICC, Intraclass correlation coefficient
- Knee
- LEFS, Lower Extremity Functional Scale
- Prehabilitation
- RCT, Randomized clinical trial
- SF-36, The Short Form (36) Health Survey
- SPW, Self-paced Walk
- ST, Stair Test
- THA, Total hip arthroplasty
- TJA, Total joint arthroplasty
- TKA, Total knee arthroplasty
- TUG, Timed Up and Go
- Telemedicine
- WOMAC, Western Ontario & McMaster Universities Osteoarthritis Index
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31
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Graff C, Hohmann E, Bryant AL, Tetsworth K. Subjective and objective outcome measures after total knee replacement: is there a correlation? ANZ J Surg 2016; 86:921-925. [PMID: 27561210 DOI: 10.1111/ans.13708] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 04/27/2016] [Accepted: 07/03/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Although various methods for quantifying outcomes following total knee replacement (TKR) are used, there are few studies of the relationships between patient reported scores and functional tests. This paper aims to assess the relationships between commonly used outcome scores after TKR through a prospective cohort study. METHODS Twenty-four patients who had undergone unilateral TKR were assessed using four patient-reported outcome scores as well as objective measurements of knee laxity, quadriceps muscle strength and the Timed Up and Go Test. All scores and measures were correlated using the Pearson product moment correlation coefficient using the lower one-sided 95% confidence interval. A level of significance of P < 0.05 was selected. RESULTS The Timed Up and Go Test was the only objective measure to demonstrate a statistically significant correlation (r = -0.557 to -0.770, P = 0.0001-0.005) with patient-reported scores. CONCLUSION A comprehensive assessment of outcomes after TKR requires both subjective and objective assessments. Walking ability and speed are important to the TKR patient and are representative of their pain and function.
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Affiliation(s)
- Christy Graff
- Musculoskeletal Research Unit, Central Queensland University, Rockhampton, Queensland, Australia.
| | - Erik Hohmann
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Adam L Bryant
- Musculoskeletal Research Unit, Central Queensland University, Rockhampton, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Kevin Tetsworth
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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32
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Blom AW, Artz N, Beswick AD, Burston A, Dieppe P, Elvers KT, Gooberman-Hill R, Horwood J, Jepson P, Johnson E, Lenguerrand E, Marques E, Noble S, Pyke M, Sackley C, Sands G, Sayers A, Wells V, Wylde V. Improving patients’ experience and outcome of total joint replacement: the RESTORE programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BackgroundTotal hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.ObjectiveTo undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.MethodsWe used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.ResultsSystematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.ConclusionsThe RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.Study registrationCurrent Controlled Trials ISRCTN52305381.FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley W Blom
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Neil Artz
- School of Health Professions, Faculty of Health and Human Sciences, Plymouth University, Plymouth, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Paul Dieppe
- Medical School, University of Exeter, Exeter, UK
| | - Karen T Elvers
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Jeremy Horwood
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Jepson
- School of Sport, Exercise and Rehabilitation Sciences, Birmingham, UK
| | - Emma Johnson
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Elsa Marques
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sian Noble
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mark Pyke
- North Bristol NHS Trust, Bristol, UK
| | | | - Gina Sands
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Victoria Wells
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Vikki Wylde
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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Thompson SM, Salmon LJ, Webb JM, Pinczewski LA, Roe JP. Construct Validity and Test Re-Test Reliability of the Forgotten Joint Score. J Arthroplasty 2015; 30:1902-5. [PMID: 26027525 DOI: 10.1016/j.arth.2015.05.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 04/21/2015] [Accepted: 05/05/2015] [Indexed: 02/01/2023] Open
Abstract
Consecutive patients undergoing knee arthroplasty completed questionnaires: FJS, Knee Injury and Osteoarthritis Outcome Score (KOOS) and WOMAC Score (mean 39 months after surgery), and were mailed a repeat questionnaire after 4 to 6 weeks. The test-retest reliability was almost perfect for the FJS (ICC = 0.97), and the FJS subdomains (ICC > 0.8). Convergent construct validity of the FJS was correlated with the KOOS Subscores of Quality of Life (0.63, P = 0.001), Symptom (0.33, P = 0.001), Pain (0.68, P = 0.001) and ADL (0.66, P = 0.001) and the Total WOMAC (0.70, P = 0.001). The FJS demonstrates high test-retest reliability and construct validity compared to the Normalised WOMAC and KOOS Subscales. The FJS does not demonstrate the ceiling effect of the WOMAC or KOOS pain scores so may have greater discriminatory ability following TKR.
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Affiliation(s)
- Simon M Thompson
- North Sydney Orthopaedic and Sports Medicine Centre, The Mater Clinic, Suite 2, Wollstonecraft NSW, Australia
| | - Lucy J Salmon
- North Sydney Orthopaedic and Sports Medicine Centre, The Mater Clinic, Suite 2, Wollstonecraft NSW, Australia
| | - Justin M Webb
- North Sydney Orthopaedic and Sports Medicine Centre, The Mater Clinic, Suite 2, Wollstonecraft NSW, Australia
| | - Leo A Pinczewski
- North Sydney Orthopaedic and Sports Medicine Centre, The Mater Clinic, Suite 2, Wollstonecraft NSW, Australia
| | - Justin P Roe
- North Sydney Orthopaedic and Sports Medicine Centre, The Mater Clinic, Suite 2, Wollstonecraft NSW, Australia
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Halawi MJ. Outcome Measures in Total Joint Arthroplasty: Current Status, Challenges, and Future Directions. Orthopedics 2015; 38:e685-9. [PMID: 26270754 DOI: 10.3928/01477447-20150804-55] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 10/27/2014] [Indexed: 02/03/2023]
Abstract
Total joint arthroplasty (TJA) is the most commonly performed surgical procedure for the treatment of advanced degenerative joint diseases. Numerous outcome measures for TJA have been developed, which can be reported by physicians, patients, or both. Although outcome tools were traditionally centered on morbidity, mortality, and implant survival, the focus has evolved over recent years to joint-specific, disease-specific, activity-specific, general well-being, and quality of life assessments. However, despite the importance of outcome measures in a time of growing demand for TJA and increased government scrutiny fueled by high implant costs, there remains no "gold standard" method to assess the impact of TJA. The aim of this review is to evaluate the currently available literature on outcome measures in joint arthroplasty, highlighting the strengths and limitations of commonly used instruments. Because outcomes are influenced by a multitude of intangible factors, there is an increasing role for assessing patient satisfaction as a simple way to account for the complex aspects of care. Strategies including proper patient selection and establishing realistic expectations preoperatively are critical to optimizing outcomes. In an era of increasing public scrutiny, the current state of conflicting results and variable correlations among outcome measures implores the need for a standardized system that should incorporate a metric for patient satisfaction adjusted for preoperative expectations.
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MESH Headings
- Arthroplasty, Replacement, Hip/standards
- Arthroplasty, Replacement, Hip/trends
- Arthroplasty, Replacement, Knee/standards
- Arthroplasty, Replacement, Knee/trends
- Forecasting
- Humans
- Male
- Middle Aged
- Osteoarthritis, Hip/surgery
- Osteoarthritis, Knee/surgery
- Patient Outcome Assessment
- Patient Satisfaction
- Patient Selection
- Quality of Life
- Treatment Outcome
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Weick J, Bawa HS. The potential utility of patient-reported range of motion after total knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:193. [PMID: 26417577 PMCID: PMC4560710 DOI: 10.3978/j.issn.2305-5839.2015.07.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/16/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Jack Weick
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, USA
| | - Harpreet S Bawa
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine and Biological Sciences, Chicago, Illinois 60637, USA
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Abstract
Objectives A lack of connection between surgeons and patients in evaluating
the outcome of total knee arthroplasty (TKA) has led to the search
for the ideal patient-reported outcome measure (PROM) to evaluate
these procedures. We hypothesised that the desired psychometric properties
of the ideal outcome tool have not been uniformly addressed in studies describing
TKA PROMS. Methods A systematic review was conducted investigating one or more facets
of patient-reported scores for measuring primary TKA outcome. Studies
were analysed by study design, subject demographics, surgical technique,
and follow-up adequacy, with the ‘gold standard’ of psychometric
properties being systematic development, validity, reliability,
and responsiveness. Results A total of 38 articles reported outcomes from 47 different PROMS
to 85 541 subjects at 26.3 months (standard deviation 30.8) post-operatively.
Of the 38, eight developed new scores, 20 evaluated existing scores,
and ten were cross-cultural adaptation of existing scores. Only
six of 38 surveyed studies acknowledged all ‘gold standard’ psychometric
properties. The most commonly studied PROMS were the Oxford Knee
Score, New Knee Society Score, Osteoarthritis Outcome Score, and
Western Ontario and McMaster Universities Osteoarthritis Index. Conclusions A single, validated, reliable, and responsive PROM addressing
TKA patients’ priorities has not yet been identified. Moreover,
a clear definition of a successful procedure remains elusive. Cite this article: Bone Joint Res 2015;4:120–127
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Affiliation(s)
- P N Ramkumar
- Hospital for Special Surgery, 535 E 70th St, Bellaire Building, Suite 9-11, New York 10021, USA
| | - J D Harris
- Houston Methodist Orthopedics and Sports Medicine, 6550 Fannin Street, Smith Tower, Suite 2511 Houston, Texas 77030, USA
| | - P C Noble
- Houston Methodist Orthopedics and Sports Medicine, 6550 Fannin Street, Smith Tower, Suite 2511 Houston, Texas 77030, USA
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Besalduch-Balaguer M, Aguilera-Roig X, Urrútia-Cuchí G, Puntonet-Bruch A, Jordan-Sales M, González-Osuna A, Celaya-Ibáñez F, Colomina-Morales J. Level of response to telematic questionnaires on health-related quality of life on total knee replacement. Rev Esp Cir Ortop Traumatol (Engl Ed) 2015. [DOI: 10.1016/j.recote.2015.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Mayr HO, Reinhold M, Bernstein A, Suedkamp NP, Stoehr A. Sports activity following total knee arthroplasty in patients older than 60 years. J Arthroplasty 2015; 30:46-9. [PMID: 25304937 DOI: 10.1016/j.arth.2014.08.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 07/19/2014] [Accepted: 08/15/2014] [Indexed: 02/01/2023] Open
Abstract
In a retrospective study with a population over 65 years, sports activity was conducted 6 years after cruciate retaining (CR) total condylar knee arthroplasty (TKA) with rotating platform (RP). Eighty-one Patients (71.8±5.4years) were examined at follow-up 6.4±0.9 years postoperative. Sport was practiced 5.3 hours every week in mean. Patients were active in sports 3.5times per week. Twenty-five percent performed high impact sports, 47% medium impact sports and 52% low impact sports at follow-up. In KOOS sports 60±28 was reached, in WOMAC 12.1±15.1. It can be concluded that in this population 50% of patients were active in medium and low impact sport 6 years after surgery. However, a quarter of patients were also active in high impact sports.
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Affiliation(s)
- Hermann O Mayr
- Department of Orthopaedic and Trauma Surgery, Freiburg University, Germany
| | - Maik Reinhold
- OCM Clinic of Orthopaedic and Trauma Surgery, Munich, Germany
| | - Anke Bernstein
- Department of Orthopaedic and Trauma Surgery, Freiburg University, Germany
| | - Norbert P Suedkamp
- Department of Orthopaedic and Trauma Surgery, Freiburg University, Germany
| | - Amelie Stoehr
- OCM Clinic of Orthopaedic and Trauma Surgery, Munich, Germany
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Level of response to telematic questionnaires on Health Related Quality of Life on total knee replacement. Rev Esp Cir Ortop Traumatol (Engl Ed) 2014; 59:254-9. [PMID: 25435294 DOI: 10.1016/j.recot.2014.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 10/23/2014] [Accepted: 10/27/2014] [Indexed: 11/22/2022] Open
Abstract
UNLABELLED Questionnaires measuring health-related quality of life are difficult to perform and obtain for patients and professionals. Computerised tools are now available to collect this information. The objective of this study was to assess the ability of patients undergoing total knee replacement to fill in health-related quality-of-life questionnaires using a telematic platform. MATERIAL AND METHODS Ninety eight consecutive patients undergoing total knee arthroplasty were included. Participants were given an access code to enter the website where they had to respond to 2 questionnaires (SF8 and the reduced WOMAC), and 3 additional questions about the difficulty in completing the questionnaires. RESULTS A total of 98 patients agreed to participate: 45 males and 53 females (mean age 72.7 years). Fourteen did not agree to participate due to lack of internet access. Of the final 84 participants, 50% entered the website, and only 36 answered all questions correctly. Of the patients who answered the questionnaire, 80% were helped by a relative or friend, and 22% reported difficulty accessing internet. CONCLUSION The use of telematic systems to respond to health-related quality of life questionnaires should be used cautiously, especially in elderly population. It is likely that the population they are directed at is not prepared to use this type of technology. Therefore, before designing telematics questionnaires it must be ensured that they are completed properly.
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Postoperative range of motion does not correlate with patient reported outcome scores in Asians after total knee arthroplasty. J Arthroplasty 2014; 29:2285-8. [PMID: 24656638 DOI: 10.1016/j.arth.2014.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 02/02/2014] [Accepted: 02/13/2014] [Indexed: 02/01/2023] Open
Abstract
Activities in Asian cultures require greater knee flexion. However, this study hypothesized that post-operative range of motion (ROM) does not correlate with patient reported outcome scores at 2years. 292 TKAs were evaluated at a public hospital in Singapore from January 2006 to May 2009. The relationship between ROM and outcome scores was examined using a multiple linear regression model with Generalized Estimating Equation (GEE) allowing adjustment for confounders and repeated TKAs within a patient. Analysis did not yield statistically significant results when patients' post-op ROM was correlated with outcome scores at 2years. Lack of post op ROM does not translate into poorer outcome scores and dissatisfaction. Doctors can now counsel patients who are concerned about a lack of ROM after TKA.
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Noiseux NO, Callaghan JJ, Clark CR, Zimmerman MB, Sluka KA, Rakel BA. Preoperative predictors of pain following total knee arthroplasty. J Arthroplasty 2014; 29:1383-7. [PMID: 24630598 PMCID: PMC4065835 DOI: 10.1016/j.arth.2014.01.034] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 01/27/2014] [Accepted: 01/31/2014] [Indexed: 02/01/2023] Open
Abstract
Total knee arthroplasty has provided dramatic improvements in function and pain for the majority of patients with knee arthritis, yet a significant proportion of patients remain dissatisfied with their results. We performed a prospective analysis of 215 patients undergoing TKA who underwent a comprehensive array of evaluations to discover whether any preoperative assessment could predict high pain scores and functional limitations postoperatively. Patients with severe pain with a simple knee range-of-motion test prior to TKA had a 10 times higher likelihood of moderate to severe pain at 6 months. A simple test of pain intensity with active flexion and extension preoperatively was a significant predictor of postoperative pain at 6 months after surgery. Strategies to address this particular patient group may improve satisfaction rates of TKA.
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Affiliation(s)
- Nicolas O. Noiseux
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - John J. Callaghan
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - Charles R. Clark
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA
| | - M. Bridget Zimmerman
- College of Public Health, Department of Biostatistics, University of Iowa, Iowa City, IA
| | - Kathleen A. Sluka
- College of Medicine, Department of Physical Therapy and Rehabilitation, University of Iowa, Iowa City, IA
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de Souza Leão MG, Santos Santoro E, Lima Avelino R, Inoue Coutinho L, Campos Granjeiro R, Orlando Junior N. Quality-of-life assessment among patients undergoing total knee arthroplasty in Manaus. Rev Bras Ortop 2014; 49:194-201. [PMID: 26229799 PMCID: PMC4511687 DOI: 10.1016/j.rboe.2014.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 04/09/2013] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE this study had the aim of assessing the quality of life among patients undergoing total knee arthroplasty (TKA). For this, the SF-36 and WOMAC questionnaires respectively were used to make comparisons with preoperative values. METHODS a prospective observational cohort study was conducted, with blinded analysis on the results from 107 TKAs in 99 patients, between June 2010 and October 2011. The present study included 55 knees/patients, among whom 73% were female and 27% were male. The patients' mean age was 68 years. The SF-36 and WOMAC questionnaires (which have been validated for the Portuguese language) were applied immediately before and six months after the surgical procedure. RESULTS the statistical and graphical analyses indicated that the variables presented normal distribution. From the data, it was seen that all the indices underwent positive changes after the surgery. CONCLUSIONS despite the initial morbidity, TKA is a very successful form of treatment for severe osteoarthritis of the knee (i.e. more than two joint compartments affected and/or Ahlback classification greater than 3), from a functional point of view, with improvement of the patients' quality of life, as confirmed in the present study. This study presented evidence level IV (description of case series), with analysis on the results, without a comparative study.
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Affiliation(s)
| | - Erika Santos Santoro
- Orthopedics and Traumatology Service, Fundação Hospital Adriano Jorge, Manaus, AM, Brazil
| | - Rafael Lima Avelino
- Orthopedics and Traumatology Service, Fundação Hospital Adriano Jorge, Manaus, AM, Brazil
| | - Lucas Inoue Coutinho
- Orthopedics and Traumatology Service, Fundação Hospital Adriano Jorge, Manaus, AM, Brazil
| | | | - Nilton Orlando Junior
- Orthopedics and Traumatology Service, Fundação Hospital Adriano Jorge, Manaus, AM, Brazil
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Leão MGDS, Santos Santoro E, Lima Avelino R, Inoue Coutinho L, Campos Granjeiro R, Orlando Junior N. Avaliação da qualidade de vida em pacientes submetidos à artroplastia total do joelho em Manaus. Rev Bras Ortop 2014. [DOI: 10.1016/j.rbo.2013.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Badawy M, Espehaug B, Indrekvam K, Engesæter LB, Havelin LI, Furnes O. Influence of hospital volume on revision rate after total knee arthroplasty with cement. J Bone Joint Surg Am 2013; 95:e131. [PMID: 24048562 DOI: 10.2106/jbjs.l.00943] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The number of total knee replacements has substantially increased worldwide over the past ten years. Several studies have indicated a correlation between high hospital procedure volume and decreased morbidity and mortality following total knee arthroplasty. The purpose of the present study was to evaluate whether there is a correlation between procedure volume and the risk of revision following total knee arthroplasty with use of hospital volume data from the Norwegian Arthroplasty Register. METHODS Thirty-seven thousand, three hundred and eighty-one total knee arthroplasties that were reported to the Norwegian Arthroplasty Register from 1994 to 2010 were used to examine the annual procedure volume per hospital. Hospital volume was divided into five categories according to the number of procedures performed annually: one to twenty-four (low volume), twenty-five to forty-nine (medium volume), fifty to ninety-nine (medium volume), 100 to 149 (high volume), and ≥150 (high volume). Cox regression (adjusted for age, sex, and diagnosis) was used to estimate the proportion of procedures without revision and the risk ratio (RR) of revision. Analyses were also performed for two commonly used prosthesis brands combined. RESULTS The rate of prosthetic survival at ten years was 92.5% (95% confidence interval, 91.5 to 93.4) for hospitals with an annual volume of one to twenty-four procedures and 95.5% (95% confidence interval, 94.1 to 97.0) for hospitals with an annual volume of ≥150 procedures. We found a significantly lower risk of revision for hospitals with an annual volume of 100 to 149 procedures (relative risk = 0.73 [95% confidence interval, 0.56 to 0.96], p = 0.03) and ≥150 procedures (relative risk = 0.73 [95% confidence interval, 0.54 to 1.00], p = 0.05) compared with hospitals with an annual volume of one to twenty-four procedures. Similar results were found when we analyzed two commonly used prosthesis brands. CONCLUSIONS In the present study, there was a significantly higher rate of revision knee arthroplasties at low-volume hospitals as compared with high-volume hospitals.
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Affiliation(s)
- Mona Badawy
- Kysthospital in Hagavik, Hagaviksbakken 25, 5217 Hagavik, Norway. E-mail address for M. Badawy: . E-mail address for K. Indrekvam:
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Roth JS, Buehler KC, Shen J, Naughton M. Patient factors predict functional outcomes after cruciate retaining TKA: a 2-year follow-up analysis. J Arthroplasty 2013; 28:1321-6. [PMID: 23523205 DOI: 10.1016/j.arth.2013.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 11/29/2012] [Accepted: 01/04/2013] [Indexed: 02/01/2023] Open
Abstract
We analyzed preoperative patient characteristics and postoperative functional outcomes to identify the most predictive preoperative characteristics of postoperative functional outcome for Cruciate Retaining (CR) TKA. In a prospective, multicenter study, 307 knees with minimum 2-year follow-up were first divided into groups based on 2-year functional performance. Logistic regression then determined SF-36 General Health Score (GHS) to be the most predictive preoperative patient characteristic. Subsequently, a second analysis was performed using preoperative SF-36 GHS to stratify patients into groups. Statistical significance was achieved in both analyses by gender, BMI and hypertension. Statistical significance was achieved in a single analysis by age, preoperative narcotic use, preoperative metabolic medication usage, preoperative pulmonary disease and preoperative use of medication for anxiety or depression.
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Affiliation(s)
- Justin S Roth
- Department of Orthopaedic Surgery, Riverside County Regional Medical Center, Moreno Valley, California 92555, USA
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47
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Abstract
Total joint arthroplasty (TJA) continues to be one of the most successful surgical interventions in medicine. Demand is growing rapidly, placing an increasingly heavy cost burden on national health systems. Despite the popularity of these surgeries, high-quality cost-effectiveness studies evaluating TJA are few in number. This article summarizes the current literature on value in arthroplasty, identifying the various factors affecting costs and outcomes, and suggesting how policy makers can influence utilization of TJA to further improve value to society.
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Culliton SE, Bryant DM, Overend TJ, MacDonald SJ, Chesworth BM. The relationship between expectations and satisfaction in patients undergoing primary total knee arthroplasty. J Arthroplasty 2012; 27:490-2. [PMID: 22115761 DOI: 10.1016/j.arth.2011.10.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 10/07/2011] [Indexed: 02/01/2023] Open
Abstract
The objective of this literature review was to examine the relationship between expectations and satisfaction in patients undergoing primary total knee arthroplasty (TKA). Five databases were searched from inception to July 2011. Five studies were eligible on the following inclusion criteria: primary TKA, diagnosis of knee osteoarthritis, presurgery outcome measures, a measure of patient expectations and satisfaction, multivariate analysis of the relationship between expectations and satisfaction reported separately for TKA recipients, and English language. Preoperative expectations did not correlate with postoperative satisfaction. However, postoperative satisfaction was predicted by how well postoperative expectations were met after surgery. Therefore, patient education programs for managing expectations should span part of the postoperative recovery period.
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Affiliation(s)
- Sharon E Culliton
- Health and Rehabilitation Sciences Program, Faculty of Health Sciences, The University of Western Ontario, London, ON, Canada
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Na SE, Ha CW, Lee CH. A new high-flexion knee scoring system to eliminate the ceiling effect. Clin Orthop Relat Res 2012; 470:584-93. [PMID: 22125252 PMCID: PMC3254737 DOI: 10.1007/s11999-011-2203-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 11/15/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Various scoring systems document improvement after TKA, but most are associated with a ceiling effect that may fail to distinguish between patients having different levels of knee function after TKA. We therefore developed a new scoring system for patients with higher levels of flexion to eliminate ceiling effects observed with current systems. QUESTIONS/PURPOSES The purposes of this study were (1) to determine whether the high-flexion knee score eliminates the ceiling effect, (2) to assess the validity and responsiveness of the high-flexion knee score, and (3) to determine whether the high-flexion knee score can aid in differentiation of the knee status of patients at the ceiling level. METHODS We prospectively studied 165 patients with 201 well-functioning knees who had undergone primary TKA. We obtained Knee Society scores, WOMAC scores, Feller scores, SF-36 scores, and high-flexion knee scores for all patients. The high-flexion knee score includes items that reflect knee function in the high functional range, such as sitting on or rising from the floor, squatting, or kneeling. We determined the ceiling effects and score distributions of various scoring systems. We performed a convergent validity test of the high-flexion knee score by correlation analysis with these various scoring systems. Responsiveness of the high-flexion knee score was assessed by correlation analysis of changes in various scoring systems. To determine whether the high-flexion knee score can aid in differentiation of knee status of patients at the ceiling level, relative responsiveness of the various scores in the ceiling versus below the ceiling range was determined. RESULTS The high-flexion knee score showed no ceiling effect, whereas the other systems did. Addition of the high-flexion knee score to the other scoring systems eliminated these ceiling effects and resulted in more normalized score distributions. The high-flexion knee score correlated (r = -0.77) with WOMAC in postoperative scores, and it also correlated with the changes in WOMAC (r = -0.69) and SF-36 physical functioning (r = 0.62). The correlation of WOMAC score with SF-36 physical function score was lower in patients at the ceiling level of the Knee Society knee score and Knee Society function score, compared with the correlation at below-ceiling range, whereas the high-flexion knee score maintained a correlation with the SF-36 physical function score, even at the ceiling level of the Knee Society knee score and Knee Society function score. CONCLUSIONS Compared with other systems, the high-function knee score appears valid for evaluating the knee status in the high-flexion range. Our data suggest the high-flexion knee score differentiates among the knee status in the high-function range. Furthermore, the high-function knee score eliminates the ceiling effect of the currently used scoring tools, and thus may be useful when combined with other scoring systems. LEVEL OF EVIDENCE Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sang-Eun Na
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710 Republic of Korea
| | - Chul-Won Ha
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710 Republic of Korea
| | - Choong-Hee Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710 Republic of Korea
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Wang W, Geller JA, Kim A, Morrison TA, Choi JK, Macaulay W. Factors affecting response rates to mailed preoperative surveys among arthroplasty patients. World J Orthop 2012; 3:1-4. [PMID: 22470843 PMCID: PMC3302048 DOI: 10.5312/wjo.v3.i1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 10/28/2011] [Accepted: 01/01/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify factors that affect patient response rates to preoperative functional surveys in hip and knee arthroplasty patients.
METHODS: From May 2008 to March 2009, 247 patients were scheduled more than 4 wk in advance for hip or knee arthroplasty by one of two participating surgeons at our center. A personalized questionnaire comprised of the Short Form 12 (SF-12) and Western Ontario and McMaster Universities (WOMAC) Index was mailed to patients at random time points ranging from 7 to 101 d prior to surgery. Nine independent factors were documented prospectively, including age, gender, ethnicity, marital status, type of surgery, surgeon, days prior to surgery (DPS) of survey mailing, WOMAC score and SF-12 score. The date of the completed survey receipt was also documented. For non-responders, the surveys were completed with the research team at the hospital upon admission. Multivariate regression and χ2 analysis were performed with Statistical Analysis Software software.
RESULTS: DPS was the only factor that affected patient response. Mailing surveys 26 d to 31 d prior to surgery dates led to a peak response rate of 80% that was significantly higher (P < 0.023) than response rates for patients who were mailed their surveys ≤ 16 d (62.5%), 17 d to 25 d (70%) or ≥ 32 d prior to surgery (55%). No other factors, including preoperative WOMAC and SF-12 scores, significantly influenced response behavior.
CONCLUSION: The DPS was independently the most significant predictor of response rates for pre-operative functional data among patients scheduled for hip and knee arthroplasty.
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