WOMAC Domains Research Articles

Reliability and concurrent validity of 30-s and 5-time sit-to-stand tests in older adults with knee osteoarthritis.

Sit-to-stand (STS) movement is fundamental in daily life. STS tasks have been used to assess lower limb muscle strength, balance control, and functional abilities in various populations, but limited information is available on their use in older individuals with knee osteoarthritis. We here examined the intra-rater, inter-rater, and test-retest reliability of the 30-s and 5-time STS tests, and calculated the standard error of measurement (SEM) and minimal detectable change (MDC). Moreover, we explored the concurrent validity of these tests by analysing their correlation with knee muscle strength, pain, stiffness, and physical function in older adults with knee osteoarthritis. This cross-sectional study included 60 older participants diagnosed with knee osteoarthritis. Baseline demographic information and data on pain, stiffness, and physical function using the modified Western Ontario and McMaster Universities Osteoarthritis (WOMAC) were obtained. Participants performed the 30-s and 5-time STS tests as well as knee muscle strength assessment using a hand-held dynamometer. After 1week, 30 participants were reassessed to evaluate test-retest reliability. The 30-s and 5-time STS tests had excellent intra-, inter-, and test-retest reliability (intraclass correlation coefficients: 0.990-1.000, 0.996-0.999, and 0.841-0.853, respectively) with a large SEM and MDC. Both STS tests significantly correlated with knee extensor and flexor strength and all modified WOMAC domains (Pearson's correlation coefficients: 0.28-0.61, p < 0.05). The 30-s and 5-time STS tests are reliable assessment tools and correlate with knee muscle strength, pain, stiffness, and physical function in older adults with knee osteoarthritis. Key Points • The 30-s and 5-time STS test can serve as surrogate measures in various aspects of knee health, including muscle strength, pain levels, stiffness, and overall physical function, in older adults with knee osteoarthritis. • Both these STS tests are dependable tools, accessible for both experienced and inexperienced assessors to administer effectively.

Translation, Cross-Cultural Adaptation, and Validation of the Persian Version of the Harris Hip Score

BackgroundThe Harris hip score (HHS), a self-administered questionnaire, is widely used to evaluate hip pathology affecting health-related quality of life and physical function. This study’s purpose was HHS translation to Persian (HHS-Pr) and validation in patients with different hip pathologies. MethodsTranslation and cultural adaptation followed existing guidelines. Hip pathology patients (n = 151) completed the HHS, 12-Item Health Survey, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Criterion validity was determined from comparisons between the HHS measures and the different corresponding WOMAC domains. Internal consistency used Cronbach’s alpha (α), content validity the “content validity index,” and floor/ceiling effect the end-range 15%. Test-retest reliability used the intraclass correlation coefficient (subsample n = 30) at 3-7 days that compared baseline with a repeated measure. Measurement precision and change sensitivity used longitudinal assessment (subgroup n = 30) from the standard error of the measurement and minimal detectable change. ResultsCross-cultural adaptation required minor wording changes. The mean HHS-Pr was 57.77 ± 19.69. Criterion validity was significant with the WOMAC (r = −0.76) and 12-Item Health Survey Physical Component Summary (r = 0.47). Internal consistency was high before (α = 0.75) and after standardization (α = 0.86). Content validity was satisfactory (content validity index = 0.88). No floor/ceiling effects were found. Test-retest reliability (intraclass correlation coefficient = 0.85) was excellent, as was standard error of the measurement (raw score = 5.8) and minimal detectable change (raw score = 11.4). ConclusionsThe HHS-Pr demonstrated adequate validity, reliability, and sensitivity to change. These psychometric properties sufficiently measure functional status in patients with hip pathologies in a Persian-speaking population.

Comparative Effectiveness of Channa sriatus Extract Versus Glucosamine Sulphate for the Treatment of Primary Knee Osteoarthritis: A Randomised Controlled Trial

Channa striatus, an indigenous freshwater fish, has been shown to treat knee osteoarthritis, but no study has been done to compare its effectiveness with other oral therapy. This study aimed to compare the effectiveness of oral Channa striatus extract and glucosamine sulphate in knee osteoarthritis symptoms and physical function. This is a double-blind randomised controlled trial, conducted among 78 patients with primary knee osteoarthritis. Patients were assigned to receive either 500 mg/d of Channa striatus or 1,500 mg/d of glucosamine sulphate for 6 months. The main outcome measures were pain, stiffness and physical function, as assessed by the Western Ontario and Mc Master Osteoarthritis Index (WOMAC) at baseline, 3- and 6-months post-randomisation. Seventy-three patients completed the study (Channa striatus, n = 37; glucosamine sulphate, n = 37). There was no significant between-group difference in the WOMAC index. However, the within-group comparison pointed to a significant improvement in all the WOMAC domains in both groups from baseline to 6 months. The effectiveness of Channa striatus shows no difference from that of glucosamine sulphate in reducing the symptoms of knee osteoarthritis. Channa striatus could be a new alternative treatment for the management of knee osteoarthritis.

Associations between single-question Visual Analogue Scale pain score and weight-bearing and non–weight-bearing domains of Western Ontario and McMaster Universities Arthritis Index pain: data from 2 phase 3 clinical trials

Visual Analogue Scale (VAS) and the pain subscale of the Western Ontario and McMaster Universities Arthritis Index (WOMAC) are commonly used measuring tools of osteoarthritis (OA) pain. The objective of this cross-sectional study was to explore the associations between single-question VAS pain and the weight-bearing and non-weight-bearing domains of WOMAC pain. Data from 2093 patients with OA participating in 2 phase 3 clinical trials were included for post hoc analyses. Univariate Pearson correlations and comparison of r values were made using z statistics obtained using the Fisher r to z test for all items of the VAS pain scale, the WOMAC pain subscale, the weight-bearing and non-weight-bearing constructs of WOMAC pain subscale, and by subgroups of WOMAC pain quintiles and Kellgren-Lawrence grades. The correlations between VAS pain and WOMAC pain were significant (r = 0.67, P < 0.001) with a slope of 0.57 (95% confidence interval [CI]: 0.54-0.61). A similar correlation was found for weight-bearing pain (r = 0.68, P < 0.001, slope: 0.62 (95% CI: 0.59-0.65) but significantly lower for non-weight-bearing pain (r = 0.55, P < 0.001, slope: 0.49 (95% CI: 0.46-0.52). The degree of disagreement between the 2 instruments seemed to be lesser in the extreme ends of the scales, and the observed association between Kellgren-Lawrence grade and disagreement between VAS and WOMAC was driven by non-weight-bearing pain. In conclusion, VAS pain and WOMAC pain subscale correlation was found to be moderate and the VAS pain scale correlated more accurately with the WOMAC pain weight-bearing questions. This constitutes novel insight into patient with OA pain reporting.

Time to first and sustained improvement in WOMAC domains among patients with osteoarthritis receiving tanezumab

ObjectiveTo assess onset of effect in three placebo- or nonsteroidal anti-inflammatory drug (NSAID)-controlled trials of tanezumab in patients with moderate-to-severe osteoarthritis. MethodsPost-hoc nonparametric Kaplan–Meier analyses were used to estimate median time to first improvement and to sustained improvement in Western Ontario and McMaster Universities Osteoarthritis Index domain (Pain, Physical Function, Stiffness) scores across a range of improvement thresholds (0–100%, in 5% increments). Time to first improvement was defined as the first week scores met the pre-specified threshold. Time to sustained improvement was defined as the first week scores met the pre-specified threshold and were sustained (on average) for the remainder of the treatment period. ResultsAcross all domains, tanezumab-treated patients had shorter median times to first improvement (at most thresholds) and reached higher levels of improvement than placebo-treated patients. No substantial differences were observed between tanezumab doses (2.5 and 5 ​mg), or between tanezumab and NSAIDs. Most patients experiencing an event of first improvement went on to experience a sustained event. At low thresholds, sustained improvement occurred simultaneously with, or shortly after, first improvement. At higher thresholds, median time to sustained improvement was longer than median time to first improvement. ConclusionsFollowing initiation of tanezumab treatment, first improvement of osteoarthritis symptoms of 30% was evident within 2–4 weeks and sustained improvement was evident within 2–8 weeks. Time to improvement of 50% was more variable, with first and sustained events expected within 4–16 and 8–24 weeks, respectively. ClinicalTrials.gov identifiersNCT02697773; NCT02709486; NCT02528188.

Long-Term Outcomes of Single versus Multiple Courses of Viscosupplementation for Osteoarthritic Knee Pain: Real-World, Multi-Practice Experience Over a Six-Year Period.

IntroductionViscosupplementation (VS) is a safe and effective local treatment for osteoarthritis (OA) of the knee. While much research has been completed evaluating its efficacy, comparatively little research has been completed examining the effects of multiple, repeat courses of treatment versus a single course of treatment.MethodsWe retrospectively reviewed real-world data from a large cohort of patients receiving treatment for OA of the knee at 16 rehabilitation clinics. Patients were grouped based on whether they received a single course of treatment or multiple courses. Outcomes for this study included pain (measured via the visual analog scale, VAS) and functional ability (measured via the Western Ontario and McMaster Universities Arthritis Index (WOMAC)). Pain and function scores were collected at baseline (prior to treatment administration) and one week following each course of treatment.ResultsPatients receiving multiple courses of treatment saw greater improvements than those receiving a single course. For VAS, maximal improvement occurred after the fourth course (66% improvement: 1.7±1.2 vs 5.0±2.4 at baseline, p<0.0001). WOMAC scores saw maximal improvement up to the fourth course for all domains (pain: 74%: 2.5±3.3 vs 9.5±5.3, p<0.0001; stiffness: 61%: 1.3±1.0 vs 3.3±2.0, p<0.0001; function: 66%: 9.5±7.2 vs 28.3±14.1, p<0.0001). When scores from multiple courses were averaged, improvements were maintained through the fourth course for VAS (3.4±2.8) and all WOMAC domains (pain: 6.1±5.0; stiffness: 3.0±2.2; function: 23.4±17.3).DiscussionOur results indicate that multiple courses of treatment are associated with greater improvements than a single course of VS, and that these improvements continue through four courses of treatment.

Cross-cultural validity of the Animated Activity Questionnaire for patients with hip and knee osteoarthritis: a comparison between the Netherlands and Brazil

BackgroundThe Animated Activity Questionnaire (AAQ) was developed in the Netherlands to assess activity limitations in individuals with hip/knee osteoarthritis (HKOA). The AAQ is easy to implement and minimizes the disadvantages of questionnaires and performance-based tests by closely mimicking real-life situations. The AAQ has already been cross-culturally validated in six other countries. ObjectiveTo assess the cross-cultural validity, the construct validity, the reliability of the AAQ in a Brazilian sample of individuals with HKOA, and the influence of formal education on the construct validity of the AAQ. MethodsThe Brazilian sample (N = 200), mean age 64.4 years, completed the AAQ and the Western Ontario and McMaster Universities Index (WOMAC). A subgroup of participants performed physical function tests and completed the AAQ twice with a one-week interval. The Dutch sample (N = 279) was included to examine Differential Item Functioning (DIF) between the scores obtained in the Netherlands and Brazil. For this purpose, ordinal regression analyses were used to evaluate whether individuals with the same level of activity limitations from the two countries (the Dutch as the reference group) scored similarly in each AAQ item. To evaluate the construct validity, correlation coefficients were calculated between the AAQ, the WOMAC domains, and the performance-based tests. To evaluate reliability, the Cronbach's alpha coefficient, the intraclass correlation coefficient, and the standard error of measurement (SEM) were calculated. ResultsThe AAQ showed significant correlations with all the WOMAC domains and performance-based tests (rho=0.46–0.77). The AAQ showed high internal consistency (Cronbach's alpha=0.94), excellent test-retest reliability (ICC2,1 = 0.98), and small SEM (2.25). Comparing to the scores from the Netherlands, the AAQ showed DIF in two items, however, they did not impact on the total AAQ score (rho=0.99). ConclusionOverall, the AAQ showed adequate cross-cultural validity, construct validity, and reliability, which enables its use in Brazil and international/multicenter studies.

An Open label, phase II clinical study to evaluate the efficacy and safety of DPOR/JR2007 in osteoarthritis of knee

AimTo evaluate the effect of DPOR/JR2007 in patients with moderate to severe knee osteoarthritis. MethodsForty-two subjects received DPOR/2007 (1400 mg) tablets twice a day over a 12-week period. Each tablet contained 7 standardised botanical ingredients i.e. Aristolochia indica, Balsamodendron mukul, Cassia tora, Hemidesmus indicus, Withania somnifera, Pterospermum acerifolium, and Vitex negundo. Primary efficacy variable was assessment of change in Q.1 (Pain while walking on flat surface) of The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-Pain. Secondary efficacy variables consisted, change in Q.2 (Pain while going up and down the stairs) of WOMAC-Pain, WOMAC domains, Short Form-8 (SF-8) Quality of life (QoL) questionnaire, Global assessment of OA and use of rescue medication. Tumour Necrosis Factor - α (TNF-α) and Interleukin-6 (IL-6) serum levels were also measured in the study. ResultsThe mean (SD) Q.1 baseline scores of 3.5 (0.73) were significantly reduced to 2.5 (0.66) at the end of study period; p < 0.001. Similar mean reduction was reported for Q.2 and each of the WOMAC dimensions; p < 0.001 and the SF-8 scores also demonstrated significant improvement in subjects QoL; p < 0.001. For biomarker assessment, TNF-α was reduced in both sexes with significant decrease being observed in female subjects; p < 0.05. Analysis showed that serum IL-6 levels were increased in subjects but was not of clinical significance. Further, DPOR/JR2007 was well-tolerated with fewer adverse events, increased global assessment scores and minimum rescue medication usage. ConclusionDPOR/JR2007 supplementation was effective in relieving the pain and stiffness in patients with chronic knee OA and improvement was evident within 8–12 weeks. Future studies are warranted for understanding the exact mechanism of DPOR/JR2007 with respect to inflammatory cytokines.

The identification and treatment of snapping posterior tendons of the knee improves patient clinical outcomes.

To assess the most common presenting symptoms, clinical outcomes, and patient satisfaction following treatment of either snapping medial pes anserinus hamstrings or snapping lateral biceps femoris tendons. Consecutive patients with a minimum 2-year follow-up after isolated medial hamstring release for a diagnosis of medial snapping pes anserinus tendons or patients treated with primary biceps repair for lateral snapping biceps femoris tendons were evaluated. Clinical outcome scores of the following domains were collected: SF12, WOMAC score, Lysholm Knee Survey, and a simple numeric patient satisfaction score (0-10). Statistical analysis was performed with paired t-tests between preoperative and postoperative scores. At an average follow-up of 4.6years (range 2.0-8.6years) with two patients lost to follow-up, six consecutive patients (three male, three female) with seven knees were diagnosed with medial snapping pes anserinus tendons and treated with semitendinosus and gracilis tenotomies. Seven knees in seven patients (three male, four female) were diagnosed with lateral snapping biceps femoris tendons and were treated with an isolated biceps femoris repair. Nine of 13 patients were able to return to full desired activities/pre-operative level of sporting activities (4/6 medial, 5/7 lateral. Lysholm and SF-12 scores improved from preoperative to post-operative status for patients with snapping biceps femoris. Only patients undergoing primary biceps repair showed improvement across all WOMAC domains. Patients with medial hamstring tenotomy demonstrated improvement in Lysholm scores. Median postoperative satisfaction for both pathologies was 7 out of 10. Medial hamstring release for snapping pes anserinus and isolated biceps repair for lateral snapping biceps femoris yields improvement in patient satisfaction and clinical outcomes at mid-term follow-up. IV.

Clinical Characteristics and Outcomes After Anatomic Reconstruction of the Proximal Tibiofibular Joint

To assess the most common presenting symptoms, clinical outcomes, and satisfaction after anatomic reconstruction of the proximal tibiofibular joint (PTFJ) with a free semitendinosus autograft. Consecutive patients with minimum 2-year follow-up after isolated anatomic PTFJ reconstruction were retrospectively reviewed. Patients were evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and Lysholm Knee Survey score along with a simple numeric patient satisfaction score (0-10, with 10 rated as perfect). Statistical analysis was performed with paired t tests, with P < .05 considered significant. The study included 16 PTFJ reconstruction surgical procedures in 15 patients with isolated proximal tibiofibular instability verified by an examination under anesthesia (4 reconstructions in male patients vs 12 in female patients); the average age was 37.9 ± 14.6 years, with an average follow-up period of 43.2 months (range, 22-72 months). Of the 13 patients with complete follow-up, 11 (84.6%) were able to return to full desired activities and previous level of sport. Fourteen patients presented with concomitant common peroneal nerve pathology. Two patients had a subsequent complication. No patients needed an additional procedure. Significant (P < .05) improvement occurred across all WOMAC domains and in the WOMAC total score, from 31.4 (±14.9) preoperatively to 15.2 (±15.5) postoperatively. Lysholm Knee Survey scores significantly (P < .05) improved from 51.2 (±17.2) to 75.0 (±18.0). Patients' overall satisfaction was rated 7.6 (± 2.7) of10. At an average follow-up of 43.2 months, anatomic PTFJ reconstruction for isolated PTFJ instability provided improvement in clinical outcomes, a return to activities, and a low risk of complications or need for additional procedures. PTFJ reconstruction with hamstring tendon graft is a promising surgical treatment that improves patient satisfaction when conservative treatment of PTFJ instability fails. Level IV, case series.

Clinical Presentation and Outcomes Associated With Fabellectomy in the Setting of Fabella Syndrome.

Background:Clinical outcomes pertaining to isolated lateral fabellectomy in the setting of fabella syndrome are limited to small case reports at this time.Purpose:To assess the most common presenting symptoms, clinical outcomes, and satisfaction after fabella excision in the setting of fabella syndrome.Study Design:Case series; Level of evidence, 4.Methods:Consecutive patients with a minimum of 21-month follow-up after isolated fabellectomy for fabella syndrome were reviewed retrospectively. Clinical outcome scores of the following domains were collected: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and Lysholm knee survey, along with a simple numeric patient satisfaction score (range, 1-10; 10 = “very satisfied”). Statistical analysis was performed using paired t tests for all clinical outcome data.Results:A total of 11 isolated fabella excisions were included in 10 patients with isolated lateral-sided knee pain in the setting of fabella syndrome (8 males, 2 females), with a mean age of 36.9 years (range, 23-58 years) and a mean follow-up of 2.4 years (range, 21-47 months). A total of 8 patients (80%) were able to return to full desired activities, including sports. Only 5 of 11 (45%) excisions had concomitant lateral femoral condyle cartilage pathology. There were significant improvements across multiple WOMAC domains, and the WOMAC total score improved from 28.5 ± 17.6 preoperatively to 11.6 ± 10.2 postoperatively (P < .05). Lysholm scores significantly improved from 66.6 ± 23.1 preoperatively to 80.2 ± 13.9 postoperatively (P = .044). Overall patient-reported satisfaction was 8.8 ± 1.6.Conclusion:Fabella excision in the setting of fabella syndrome demonstrated improvements in clinical outcome scores, high rate of returning to preinjury level of activities, and low risk of complications or need for additional surgical procedures.

Translation, validation and cross-cultural adaptation of the Nepali version of WOMAC® LK 3.1.

Among many self-reported outcome measures, Western Ontario and McMaster Universities Arthritis Index (WOMAC) is one of the commonly used indexes for osteoarthritis patients. Despite high prevalence of musculoskeletal problems in Nepal, there is no validated tool available in the local language. Thus, this study aimed to translate the English WOMAC® into Nepali, and validate it for use in the future. Guidelines by Beaton et al were followed for translation and cross-cultural adaptation of the original WOMAC into Nepali language. Diagnosed cases of knee osteoarthritis (OA) attending the rheumatology outpatient department of National Center for Rheumatic Diseases, Kathmandu were enrolled in the study. These patients were interviewed with the Nepali version. Internal consistency was measured by Cronbach's alpha and test-retest reliability by intra-class correlation coefficient (ICC). Correlation between domains of WOMAC was tested with visual analog scale (VAS) and numerical rating scale (NRS) of pain and stiffness. The test-retest reliability was good with ICC of >0.75 for all domains and items. Internal consistency was acceptable with Cronbach's alpha scores of 0.852, 0.704 and 0.955 for pain, stiffness and physical function domains, respectively. Strong correlation was observed between WOMAC stiffness domain and VAS for stiffness and NRS for stiffness with rho (ρ) values of 0.750 and 0.759, respectively. Moderate correlation was seen between WOMAC pain and VAS for pain and NRS for pain with ρ of 0.658 and 0.584, respectively. Nepali WOMAC is a reliable and valid instrument for assessment of disease severity and its impact in Nepali-speaking patients with OA.

The EQ-5D-5L Is Superior to the -3L Version in Measuring Health-related Quality of Life in Patients Awaiting THA or TKA

As a generic measure of health-related quality of life among patients awaiting THA or TKA, the three-level version of the EQ-5D (EQ-5D-3L), which has three response levels of severity (no problems, some problems, and extreme problems/unable) to five questions, is widely used. Previous studies indicated that the ceiling effect of the EQ-5D-3L limits its application. The five-level version of the EQ-5D (EQ-5D-5L) was developed to enhance the measurement properties of the tool by adding two levels: slight problems and severe problems. However, only a few small studies have compared the EQ-5D-3L and EQ-5D-5L in patients awaiting THA and TKA. The purpose of this study was to examine the performance of the EQ-5D-3L and EQ-5D-5L among patients awaiting THA or TKA in terms of (1) response patterns, (2) convergent construct validity, (3) known-group validity, and (4) informativity and discriminatory power. This is a retrospective analysis of the Alberta Bone and Joint Health Data Repository, which recorded information on all patients receiving hip or knee arthroplasties between April 2010 and March 2017 in Alberta, Canada (n = 37,377). Patients receiving THA or TKA and who completed the EQ-5D and WOMAC at baseline (presurgery) were included in this study (n = 24,766). The EQ-5D-3L was administered to all patients in 2010, and was gradually replaced by the EQ-5D-5L between 2013 and 2016; the EQ-5D-5L reached full application in all clinics by 2017.A propensity score was used to match patients 1:1 who completed either the EQ-5D-3L or EQ-5D-5L before surgery. Response patterns have been explored using ceiling and floor effects and distribution across severity levels of each dimension. Convergent construct validity was examined using Spearman's correlation (rho) against the WOMAC. Known-group validity was examined by gender, preoperative risk factors, mental health, obesity, and WOMAC physical function score. Informativity and discriminatory power were examined using the Shannon (H') and Shannon evenness (J') indices. A total of 3446 pairs of patients awaiting THA (55% women; mean age, 66 years) and 5428 pairs of patients awaiting TKA (59% women; mean age 67 years) were included in this analysis; the study group included all patients who were kept in the propensity score matching. Ceiling and floor effects were comparable and small (less than 0.5%) for both versions; the responses across severity levels for each dimension were more evenly distributed for the EQ-5D-5L. Convergent construct validity was stronger for the EQ-5D-5L as it consistently had stronger correlations with the WOMAC overall and domain scores than the EQ-5D-3L (rho(3L-THA), -0.77 to -0.31; rho(3L-TKA), -0.71 to -0.24; rho(5L-THA), -0.71 to -0.17; rho(5L-TKA), -0.64 to -0.17; all p values < 0.001). The hypotheses of known-group analyses were confirmed for both versions. The EQ-5D-5L demonstrated stronger informativity and discriminatory power than the EQ-5D-3L, particularly for the mobility dimension (THA, H'(5L/3L)=1.66/0.37, J'(5L/3L)=0.72/0.23; TKA, H'(5L/3L)=1.66/0.41, J'(5L/3L)=0.71/0.26). This study demonstrates the superior construct validity, and informativity and discriminatory power of the EQ-5D-5L compared with the EQ-5D-3L among patients awaiting THA or TKA. Compared with the three-level version, the five-level version of the EQ-5D differentiates between patients awaiting THA and TKA much better based on their mobility, which is a key health aspect or outcome in these patients. Our findings suggest that the EQ-5D-5L is more appropriate for this population.

Preoperative Valgus Alignment Does Not Predict Inferior Outcome of Total Knee Arthroplasty.

Preoperative valgus deformity is present in an estimated 10-20% of patients undergoing total knee replacement (TKR). The objective of this study was to compare the Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores after TKR in a matched cohort of patients with preoperative valgus and varus deformities. This is a matched cohort study of 162 patients with varus native knees and 162 patients with valgus native knees who underwent TKR and were prospectively followed in our institutional registry. Patients matched were based on age, BMI, sex, and severity of preoperative knee deformity, which was classified as mild, moderate, severe varus or valgus, or no deformity. Outcomes were evaluated using the WOMAC preoperatively and at 6weeks, 3months, 6months, and 1year postoperatively. No significant difference was found between the matched varus and valgus cohorts in all WOMAC subdomain scores except for a marginally worse stiffness at 1year in patients with valgus deformity (WOMAC stiffness, 75.1 varus vs. 70.1 valgus; P=0.049). This is below the minimal clinically important difference for WOMAC scores. There was no significant difference in postoperative varus/valgus alignment between the two groups (P=0.092). We found no clinically significant difference in any of the WOMAC domains in patients with preoperative varus deformity versus valgus deformity within the first year after TKR. These findings may allow surgeons to more appropriately counsel patients with osteoarthritis with valgus deformity that they can expect similar outcomes compared to patients with varus deformity.

Reliability and validity of the 12-item WHODAS 2.0 in patients with Kashin-Beck disease.

The purpose of this study was to check the reliability and validity of the 12-item Chinese version of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for the assessment of disability in patients with Kashin-Beck disease (KBD). We recruited 219 patients with KBD from the high-risk KBD area in the Shaanxi province, using stratified multistage random sampling. We assessed each patient using the Chinese version of the 12-item WHODAS 2.0 and the Western Ontario and McMaster Universities Index of Osteoarthritis (WOMAC). Statistical evaluations of the instruments consisted of Cronbach's alpha, intraclass correlation coefficient (ICC), confirmatory factor analysis (CFA), and Pearson's correlation coefficient. Cronbach's alpha and ICC for the six domains ranged from 0.704 to 0.906 and 0.690 to 0.852, respectively. A six-factor structure fits the data well (CFI=0.967, TLI=0.944, RMSEA=0.08). Regarding convergent validity, the four domains of the 12-item WHODAS 2.0 (getting around, self-care, life activity, and participation) showed moderate-to-strong correlation for all three domains of the WOMAC (0.428<|r|<0.804). Regarding divergent validity, the two domains of the 12-item WHODAS 2.0 (understanding and communication, and getting along with people) showed weak correlation for the three domains of WOMAC (0.182<|r|<0.295). The Chinese version of 12-item WHODAS 2.0 questionnaire is a reliable and valid instrument when administered to KBD patients.

Age, Sex, Body Mass Index, Education, and Social Support Influence Functional Results After Total Knee Arthroplasty.

Introduction:Total knee arthroplasty (TKA) is an effective treatment for knee osteoarthritis. Patient-reported outcome after TKA is influenced by multiple patient-related factors. The aim of this study was to prospectively evaluate preoperative patient-related factors and to compare the self-reported outcomes 1 year after TKA among groups differing by age, sex, body mass index (BMI), education, and social support level.Methods:314 patients, who underwent TKA in Vilnius Republican University Hospital between the end of 2012 and the middle of 2014, were included in a study. The preoperative and 12-month follow-up measurements were obtained using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-12 (SF-12). Differences between patient groups according to gender, age, BMI, level of education, and level of social support were analyzed.Results:At 12-month follow-up men demonstrated better results than women in WOMAC (P = .003) and SF-12 both domains (P < .05). Patients with a higher social support demonstrated higher scores in physical function according to SF-12 (P = .008). Better preoperative WOMAC and SF-12 scores were a predictor of better outcome 1 year after surgery. There was no difference in postoperative scores in different age, BMI, and education groups according to WOMAC and SF-12.Conclusion:There is no difference in self-reported functional outcome between patient groups differing in age, BMI, and education. Men and socially supported patients demonstrate better postoperative functional results 12 months after TKA. Better preoperative knee function and overall physical and mental function are predictors of better outcome 1 year after TKA. Age and obesity should not be limiting factors when considering who should receive this surgery.

Increasing comorbidity is associated with worsening physical function and pain after primary total knee arthroplasty

BackgroundPrevious studies suggested that pre-operative comorbidity was a risk factor for worse outcomes after TKA. To our knowledge, studies have not examined whether postoperative changes in comorbidity impact pain and function outcomes longitudinally. Our objective was to examine if increasing comorbidity postoperatively is associated with worsening physical function and pain after primary total knee arthroplasty (TKA).MethodsWe performed a retrospective chart review of veterans who had completed Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-36 (SF36) surveys at regular intervals after primary TKA. Comorbidity was assessed using a variety of scales: validated Charlson comorbidity index score, and a novel Arthroplasty Comorbidity Severity Index score (Including medical index, local musculoskeletal index [including lower extremity and spine] and TKA-related index subscales; higher scores are worse ), at multiple time-points post-TKA. We used mixed model linear regression to examine the association of worsening comorbidity post-TKA with change in WOMAC and SF-36 scores in the subsequent follow-up periods, controlling for age, length of follow-up, and repeated observations.ResultsThe study cohort consisted of 124 patients with a mean age of 71.7 years (range 58.6–89.2, standard deviation (SD) 6.9) followed for a mean of 4.9 years post-operatively (range 1.3–11.4; SD 2.8). We found that post-operative worsening of the Charlson Index score was significantly associated with worsening SF-36 Physical Function (PF) (beta coefficient (ß) = -0.07; p < 0.0001), SF-36 Bodily Pain (BP) (ß = -0.06; p = 0.002), and WOMAC PF subscale (ß = 0.08; p < 0.001; higher scores are worse) scores, in the subsequent periods. Worsening novel medical index subscale scores were significantly associated with worsening SF-36 PF scores (ß = -0.03; p = 0.002), SF-36 BP (ß = -0.04; p < 0.001) and showed a non-significant trend for worse WOMAC PF scores (ß = 0.02; p = 0.11) subsequently. Local musculoskeletal index subscale scores were significantly associated with worsening SF-36 PF (ß = -0.05; p = 0.001), SF-36 BP (ß = -0.04; p = 0.03) and WOMAC PF (ß = 0.06; p = 0.01) subsequently. None of the novel index subscale scores were significantly associated with WOMAC pain scores. TKA complications, as assessed by TKA-related index subscale, were not significantly associated with SF-36 or WOMAC domain scores.ConclusionsIncreasing Charlson index as well as novel medical and local musculoskeletal index subscale scores (from novel Arthroplasty Comorbidity Severity Index) post-TKA correlated with subsequent worsening of physical function and pain outcomes post-TKA. Further studies should examine which comorbidity management could have the greatest impact on these outcomes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-016-1261-y) contains supplementary material, which is available to authorized users.

The influence of body mass index (BMI) in the stair climbing function in patients with knee osteoarthritis (OA) and healthy people

Purpose: Evidences show that obesity is a great risk factor in the development of knee osteoarthritis (OA). In addition, they also demonstrate that individuals with higher body mass index (BMI) have greater pain and more severe OA. However, the association between the different categories of BMI and functional activities, such as ascending and descending stairs, remains unclear. Therefore, the aim of this study was to evaluate and to compare the results obtained in the Stair Climbing Test, as well as the items corresponding to this functional activity in WOMAC questionnaire in individuals with knee OA (OAG) and healthy (CG), categorized by BMI (normal, overweight and obese). Methods: Patients with knee OA were selected based on the American College of Rheumatology criteria (ACR) and classified by the Kellgren and Lawrence scale. One hundred and sixteen participants (82 with knee OA and 34 healthy), with a mean age of 53.44 ± 8.151 years (OAG); 55.90 ± 7.135 (CG) years, were classified by body mass index (BMI) among normal: 18.5–24.9; overweight: 25.0–29.9 and obese ≥30 kg/m2. All participants answered the WOMAC (Western Ontario and McMaster Universities), a self-applied questionnaire. For the present study, it was considered the final score of the activities “ascending stairs” and “descending stairs” from the “physical function” of WOMAC domain; thus, the amounts were considered worse as higher the score achieved. In addition, the participants performed the Stair Climbing Test. The test should be performed as quickly as possible by the patients, and the total test time was timed in seconds; whereas, longer times indicated physical function more compromised. Initially, data were checked for normality by the Kolmogorov–Srmirnov test. To compare the categories of BMI (normal x overweight x obese) was applied one-way ANOVA test and post-hoc Bonferroni to identify statistical differences. For comparison between groups (control x OA) was used independent t test. For all analyzes we adopted a significance level of 5% (p ≤ 0.05). Results: The results of this study are shown in Table 1, as mean ± SD. For the Stair Climbing test, when it was compared the BMI categories, participants of CG categorized as obese had statistically higher values than those categorized as overweight and normal (p = 0,0073). In the comparison among groups, the OAG had statistically higher values compared to the CG only in the normal category (p < 0.0034). For the item “ascending stairs” in the WOMAC questionnaire, the category “obese” had statistically higher values compared to “overweight” and “normal” in CG (p < 0.0001), and compared to overweight in OAG (p = 0,0051). Comparing the groups, there were statistically higher values in OAG compared to CG in the categories “normal” (p = 0.0004) and “overweight” (p < 0.0001). For the item “descending stairs” in the WOMAC, the category “obese” also showed statistically higher values compared to “overweight” and “normal” in CG (p < 0.0001), and compared to “overweight” in OAG (p = 0.0030). Comparing the groups, it was discovered that the OAG had statistically higher values compared to CG in the categories “normal” (p = 0.0006) and “overweight” (p = 0.0007). Conclusions: It can be concluded that besides the functional impairment caused by OA, high BMI can also have a functional affect in some activities, such as ascending and descending stairs, observed in patients with OA, but mainly in healthy people.Tabled 1Table 1. Mean and standard deviation values of Stair Climbing Test, WOMAC “Ascending Stairs” and WOMAC “Descending Stairs” for CG and OAG in BMI categories (normal, overweight and obese)Stair Climbing TestNormalOverweightObesep valueCG (n = 34)10.301 ± 1.086 (n=14)10.368 ± 1.686 (n=10)12.193 ± 1.343∗Statistically significant difference compared with normal,#Statistically significant difference compared to overweight (n=10)0.0073OAG (n = 82)12.065 ± 1.962£statistically significant difference compared to GC (n = 18)12.272 ± 4.772 (n = 30)14.563 ± 4.814 (n = 34)0.0605p value0.00340.25100.1788WOMAC “Ascending Stairs”NormalOverweightObesep valueCG (n = 34)0.000 ± 0.000 (n = 14)0.222 ± 0.4410 (n = 10)1.800 ± 1.033∗Statistically significant difference compared with normal,#Statistically significant difference compared to overweight (n = 10)<0.0001OAG (n = 82)1.765 ± 1.147£statistically significant difference compared to GC (n = 18)1.533 ± 0.8193£statistically significant difference compared to GC (n = 30)2.324 ± 0.9761#Statistically significant difference compared to overweight (n = 34)0.0051p value0.0004<0.00010.2392WOMAC “Descending Stairs”NormalOverweightObesep valueCG (n = 34)0.200 ± 0.4140 (n = 14)0.222 ± 0.4410 (n = 10)1.800 ± 1.033∗Statistically significant difference compared with normal,#Statistically significant difference compared to overweight (n = 10)<0.0001OAG (n = 82)1.882 ± 1.269£statistically significant difference compared to GC (n = 18)1.400 ± 0.932£statistically significant difference compared to GC (n = 30)2.324 ± 1.007#Statistically significant difference compared to overweight (n = 34)0.0030p value0.00060.00070.2416∗ Statistically significant difference compared with normal# Statistically significant difference compared to overweight£ statistically significant difference compared to GC Open table in a new tab

Validation of the HOOS, JR: A Short-form Hip Replacement Survey.

Patient-reported outcome measures (PROMs) are increasingly in demand for outcomes evaluation by hospitals, administrators, and policymakers. However, assessing total hip arthroplasty (THA) through such instruments is challenging because most existing measures of hip health are lengthy and/or proprietary. The objective of this study was to derive a patient-relevant short-form survey based on the Hip disability and Osteoarthritis Outcome Score (HOOS), focusing specifically on outcomes after THA. We retrospectively evaluated patients with hip osteoarthritis who underwent primary unilateral THA and who had completed preoperative and 2-year postoperative PROMs using our hospital's hip replacement registry. The 2-year followup in this population was 81% (4308 of 5351 patients). Of these, 2371 completed every item on the HOOS before surgery and at 2 years, making them eligible for the formal item reduction analysis. Through semistructured interviews with 30 patients, we identified items in the HOOS deemed qualitatively most important to patients with hip osteoarthritis. The original HOOS has 40 items, the four quality-of-life items were excluded a priori, five were excluded for being redundant, and one was excluded based on patient-relevance surveys. The remaining 30 items were evaluated using Rasch modeling to yield a final six-item HOOS, Joint Replacement (HOOS, JR), representing a single construct of "hip health." We calculated HOOS, JR scores for the Hospital for Special Surgery (HSS) cohort and validated this new score for internal consistency, external validity (versus HOOS and WOMAC domains), responsiveness to THA, and floor and ceiling effects. Additional external validation was performed using calculated HOOS, JR scores in collaboration with the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) nationally representative joint replacement registry (n = 910). The resulting six-item PROM (HOOS, JR) retained items only from the pain and activities of daily living domains. It showed high internal consistency (Person Separation Index, 0.86 [HSS]; 0.87 [FORCE]), moderate to excellent external validity against other hip surveys (Spearman's correlation coefficient, 0.60-0.94), very high responsiveness (standardized response means, 2.03 [95% CI, 1.84-2.22] [FORCE]; and 2.38 [95% CI, 2.27-2.49] [HSS]), and favorable floor (0.6%-1.9%) and ceiling (37%-46%) effects. External validity was highest for the HOOS pain (Spearman's correlation coefficient, 0.87 [95% CI, 0.86-0.89] [HSS]; and 0.87 [95% CI, 0.84-0.90] [FORCE]) and HOOS activities of daily living (Spearman's correlation coefficient, 0.94 [95% CI, 0.93-0.95] [HSS]; and 0.94 [95% CI, 0.93-0.96] [FORCE]) domains in the HSS validation cohort and the FORCE-TJR cohort. The HOOS, JR provides a valid, reliable, and responsive measure of hip health for patients undergoing THA. This short-form PROM is patient relevant and efficient. Level III, diagnostic study.

Validation of the KOOS, JR: A Short-form Knee Arthroplasty Outcomes Survey.

Medicare is rapidly moving toward using patient-reported outcome measures (PROMs) for outcomes assessment and justification of orthopaedic and other procedures. Numerous measures have been developed to study knee osteoarthritis (OA); however, many of these surveys are long, disruptive to clinic flow, and result in incomplete data capture and/or low followup rates. The Knee injury and Osteoarthritis Outcome (KOOS) physical function short-form (KOOS-PS), while shorter, ignores pain, which is a primary concern of patients with advanced knee OA. Our objective was to derive and validate a short-form survey focused on the patient with end-stage knee OA undergoing TKA. Using our hospital's knee replacement registry, we retrospectively identified 2291 patients with knee OA who underwent primary unilateral TKA and had completed preoperative and 2-year postoperative PROMs. We assessed 30 items from the 42-item KOOS that were quantitatively most difficult for patients to perform before TKA and qualitatively most relevant to patients with end-stage knee OA. Rasch analysis identified the KOOS, JR, a seven-item instrument, representing a single dimension, which we define as "knee health" because it reflects aspects of pain, symptom severity, and activities of daily living (ADL) including movements or activities that are directly relevant and difficult for patients with advanced knee OA. We assessed the internal consistency, external validity (versus KOOS and WOMAC domains), responsiveness, and floor and ceiling effects of the KOOS, JR. External validation was performed using calculated KOOS, JR scores in collaboration with a nationally representative joint replacement registry, the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR). Internal consistency for the KOOS, JR was high (Person Separation Index, 0.84; and 0.85 [FORCE]), external validity against other validated knee surveys was excellent (Spearman correlation coefficient, ρ 0.54-0.91), particularly for the KOOS pain (ρ 0.89 [95% CI, 0.88-0.91] Hospital for Special Surgery [HSS]; and 0.91 [95% CI, 0.90-0.93] [FORCE]) and KOOS ADL (ρ 0.87 [95% CI, 0.85-0.88] [HSS]; and 0.84 [95% CI, 0.81-0.87] [FORCE]). The KOOS, JR responsiveness (standardized response means, 1.79 [95% CI, 1.70-1.88] [HSS]; and 1.70 [95% CI, 1.54-1.86] [FORCE]) was high and floor 0.4-1.2%) and ceiling (18.8-21.8%) effects were favorable. The new short knee PROM, the KOOS, JR, provides a single score representing "knee health" as it combines pain, symptoms, and functional limitations in a single score. This short-form PROM is patient-relevant and efficient. Level III, diagnostic study.