JR Scores Research Articles

Survivorship and Functional Outcomes After Complex Primary Total Knee Arthroplasty With Contemporary Rotating-Hinge Implants

Background: Initial fixed-bearing hinge designs for primary total knee arthroplasty (TKA) had high rates of aseptic loosening. There are limited data on contemporary rotating-hinge implants. Purpose: We sought to determine survivorship and functional outcomes of contemporary rotating-hinge implants used in primary TKA. Methods: Retrospective review identified 54 primary rotating-hinge TKAs implanted in 49 patients from 2014 to 2018 at a single institution. Patients identified were 76% women, the mean body mass index was 29 kg/m2, the mean age was 65 years, and the mean follow-up was 3 years. The primary diagnosis for TKA in all cases was severe instability and ligamentous compromise. Secondary diagnoses included post-traumatic osteoarthritis (11, 20%), neurologic disease (10, 19%), inflammatory arthritis (10, 19%), connective tissue disease (3, 6%), valgus deformity (16, 30%), varus deformity (2, 4%), and recurvatum (2, 4%). Preoperative, postoperative (within 6 weeks), and most recent radiographs were reviewed. In this study, we collected preoperative, 1-year, and 2-year patient-reported outcome measures (PROMs) for patients with primary rotating-hinge TKA. Patient-reported outcome measures were prospectively collected, including the Knee Injury and Osteoarthritis Outcome Survey for Joint Replacement (KOOS JR) scores and the Mental (MCS) and Physical Component Scores (PCS) of the Veterans RAND 12-Item Health Survey (VR-12). Kaplan-Meier analysis was used to determine implant survivorship. Results: Reoperation was required in 6% (3/54); indications included periprosthetic joint infection (1), peripatellar fibrosis (1), and periprosthetic femur fracture (1). At both 2 and 5 years, survivorship free from all-cause reoperation was 95% and from revision for aseptic loosening was 100%. Mean KOOS JR scores increased from 47 preoperatively to 65 at 2 years postoperatively. On radiographic review, there were no progressive radiolucent lines consistent with aseptic loosening at final follow-up. Conclusion: The findings of this single-center, multi-surgeon retrospective case series on the use of rotating-hinge implants for primary TKA suggest excellent 2-year survivorship free from reoperation and no revisions for aseptic loosening. We report modest improvement in a variety of PROMs at 1-year and 2-year follow-up. Despite improvement, clinical outcomes were poor for a primary implant. Longer-term follow-up is required to monitor the durability of primary hinges.

Comparable Outcomes Between Autologous Chondrocyte Implantation and Osteochondral Allograft Transplantation in the Setting of Patellar Realignment

PurposeThe purpose of this study was to determine clinical and functional outcomes in patients treated with autologous chondrocyte implantation (ACI) or osteochondral allograft (OCA) transplantation for chondral defects secondary to patellar instability with concomitant medial patellofemoral ligament (MPFL) reconstruction and tibial tubercle osteotomy (TTO) for patellar realignment. MethodsA retrospective review identified patients who underwent ACI or OCA transplantation with concomitant MPFL reconstruction and TTO . Patients were excluded if they did not have concomitant MPFL reconstruction and TTO, had the presence of other intra-articular pathologies, or failed to complete postoperative subjective outcome evaluations at a minimum of 2 years following surgery. Subjective outcome measures included the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), International Knee Documentation Committee (IKDC) evaluation, and Short Form Health Survey (SF-12) physical scores, collected a minimum of 2 years after surgery. Defect location, size, complications, and rate of subsequent surgery were determined. ResultsEighteen total patients were included in this study. The ACI cohort included 11 patients with 13 total defects that were treated with ACI. The OCA cohort included 7 patients with 10 total defects that were treated with OCA. This was due to a number of patients in either group having multiple cartilage defects. Twenty-three total chondral defects were compared to analyze clinical and functional outcomes following surgical correction (ACI: n=13, OCA: n=10). Five defects were noted on the femoral condyle and 18 on the patellar facets/central ridge. Defects were comparable between groups including, size measured during index-arthroscopy (ACI = 3.34 cm2, 95% CI [2.3 cm2 - 4.4 cm2] vs OCA = 4.03 cm2, 95% CI [3.1 cm2 - 5.0 cm2]; P=.351), Outerbridge classification (ACI = 54.8% grade 4 vs OCA = 60.0% grade 4; P=1.000), and AMADEUS score (ACI = 47.1 vs OCA = 58.6; P=.298). Postoperative outcomes were comparable including revision rate (ACI = 15.4% vs OCA = 10.0%; P=1.000) and 2-year IKDC scores (ACI = 74.2, 95% CI [65.2 - 83.2] vs OCA = 51.2, 95% CI [30.3 - 72.1]; P=.077). ACI did have significantly higher 2-year KOOS JR (85.1, 95% CI [76.9 - 93.3] vs 63.7, 95% CI [49.1 - 78.3]; P=.031) and SF-12 scores (54.1, 95% CI [52.0 - 56.2] vs 42.6, 95% CI [35.8 - 49.4]; P=.007) compared to OCA. ConclusionACI or OCA transplantation for chondral defects with concomitant MPFL reconstruction and TTO can be safely performed in an outpatient setting with functional and clinical outcomes being comparable. Level of EvidenceRetrospective Case Series Study (Level 3)

REVISION HIP ARTHROPLASTY IN PATIENTS WITH SEVERE SICKLE-CELL DISEASE: CHALLENGES AND EARLY OUTCOMES

Total hip arthroplasty (THA) has proved to be an effective treatment modality for sickle-cell hip arthropathy (mosaic-like dense bone due to infarcts). However, mode of failure, survival rates and challenges associated with revision hip arthroplasty in sickle-cell disease patients are mostly unknown.We retrospectively evaluated prospectively collected data from all patients with sickle-cell disease who underwent revision hip arthroplasty from 2016. Patient, surgery, medical and surgical complications related data were collected. The pinnacle and reclaim revision system with gription augments (JJ) was used in all patients. Pre-op and post-op clinical outcome data (both objective and subjective, HOOS Jr and OHS) were recorded. Cumulative success rates were recorded with re-revision surgery as an end point.We performed fifteen revision THAs on 13 patients (mean follow up of 6.6 years). The mean age of the patients was 48 years (range, 30–59). At final follow-up, a statistically significant improvement of mean OHS and HOOS JR scores eas found in all patients. reported (OHS: 34.0 and HOOS JR: 77.7). Cumulative success rate was 100% for re-revision for all reasons at 6 years. Five intensive care unit (ITU) admissions, two vaso-occlusive sickle cell crises, one transfusion-related complication and one acute chest syndrome (ACS) were recorded. On admission, the mean percentage of HbS was 75.25% (64.6–86.4%).Revision arthroplasty in sickle-cell disease patients poses increased risks, with medical and surgical challenges. However, with careful preparation, planning and a multi-disciplinary team approach, revision arthroplasty can result in excellent clinical outcomes and excellent functional scores in the majority of patients in the short and mid-term.

Smoking cessation prior to elective total joint arthroplasty results in sustained abstinence postoperatively.

Tobacco use is a well-documented modifiable risk factor for perioperative complications. To determine the tobacco abstinence rates of patients who made cessation efforts prior to a total joint arthroplasty (TJA) procedure. A retrospective evaluation was performed on 88 self-reported tobacco users who underwent TJA between 2014-2022 and had tobacco cessation dates within 3 mo of surgery. Eligible patients were contacted via phone survey to understand their tobacco use pattern, and patient reported outcomes. A total of 37 TJA patients participated. Our cohort was on average 61-years-old, 60% (n = 22) women, with an average body mass index of 30 kg/m2. The average follow-up time was 2.9 ± 1.9 years. A total of 73.0% (n = 27) of patients endorsed complete abstinence from tobacco use prior to surgery. Various cessation methods were used perioperatively including prescription therapy (13.5%), over the counter nicotine replacement (18.9%), cessation programs (5.4%). At final follow up, 43.2% (n = 16) of prior tobacco smokers reported complete abstinence. Patients who were able to maintain cessation postoperatively had improved Patient-Reported Outcomes Measurement Information System (PROMIS)-10 mental health scores (49 vs 58; P = 0.01), and hip dysfunction and osteoarthritis outcome score for joint replacement (HOOS. JR) scores (63 vs 82; P = 0.02). No patients in this cohort had a prosthetic joint infection or required revision surgery. We report a tobacco cessation rate of 43.2% in patients undergoing elective TJA nearly 3 years postoperatively. Patients undergoing TJA who were able to remain abstinent had improved PROMIS-10 mental health scores and HOOS. JR scores. The perioperative period provides clinicians a unique opportunity to assist active tobacco smokers with cessation efforts and improve postoperative outcomes.

Comparison of Patients Based on Their Self-Selected Discharge Pathway after Total Knee Arthroplasty at an Ambulatory Surgical Center.

Outpatient total knee arthroplasty (TKA) is being performed more frequently in ambulatory surgical centers (ASCs) to decrease the cost of care. Discharge pathways include 23-hour observation (OBSERVATION) or same-day discharge home (HOME), which differ in postoperative medical supervision. Few studies allow patients to self-select their discharge pathway. This study compared patient variables between self-selected OBSERVATION or HOME discharge after TKA at an ASC. We hypothesized that age, sex, and distance lived from the ASC would differ between discharge pathways. Clinical and patient-reported outcomes were explored.A chart review identified 130 patients with TKA at an ASC between November 2017 and December 2019. Patients self-selected OBSERVATION or HOME during a preoperative physician visit. Patient variables obtained from the electronic medical record were age, sex, race/ethnicity, marital status, body mass index, diabetic status, American Society of Anesthesiologists (ASA) class, distance lived from the ASC, anesthesia type, procedure time, and time in the postanesthesia recovery unit. Clinical outcomes (knee range of motion, infection rate, and reoperation rate) and patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS, JR]; Oxford Knee Score [OKS]) were collected at either 6 or 12 weeks postsurgery. Variables were compared between groups.Pathway selection was n = 70 OBSERVATION and n = 60 HOME, and all patients completed their self-selected discharge pathway. Age and proportion of females were significantly higher in OBSERVATION than in HOME (61.3 ± 3.5 vs. 58.5 ± 5.4 years, 85.7 vs. 65.0%, respectively; p < 0.05). Distance lived from the ASC tended to be greater in OBSERVATION than HOME (22.1 ± 24.6 vs. 15.3 ± 10.1 miles, p = 0.056). Across groups, clinical outcomes were favorable (i.e., >88% met the 6-week knee flexion milestone, 1.9% infection rate, and 3.1% manipulation under anesthesia), and the preoperative to 12-week postoperative change in KOOS, JR and OKS scores met the minimal clinically important difference.Older age, female sex, and farther distance lived from the ASC may influence patients to select OBSERVATION over HOME discharge following TKA at an ASC. No robust differences were found in early outcomes.

Patient-Reported Outcomes of Total Hip Arthroplasty at an Ambulatory Surgery Center Versus a Hospital-Based Center.

The utilization of ambulatory surgery centers (ASCs) and same-day discharge (SDD) from hospital-based centers (HBCs) after total hip arthroplasty (THA) continues to increase. There remains a paucity of literature directly comparing patient-reported outcomes by surgery site. We sought to compare outcomes between patients undergoing THA at an ASC versus HBC while controlling for medical comorbidities. Patients undergoing primary THA with SDD (postoperative day 0) from a single HBC (1,015 patients) or stand-alone ASC (170 patients) from December 2020 to 2021 were identified. Patient demographics, comorbidities, and 90-day complications were collected. Hip Osteoarthritis Outcome Score (HOOS JR), VR-12, and procedural satisfaction scores were collected preoperatively and at 3, 6, and 12 months. Patients were matched by age and American Society of Anesthesiologists (ASA). Chi-squared analysis was conducted to compare categorical variables, and a Wilcoxon rank-sum test was used for continuous variables. Linear regression models were conducted considering age, sex, and presence of comorbidities. Patients undergoing THA at an ASC had markedly higher VR-12 Physical Component Scores at all time points and improved VR-12 Mental Component Scores at preoperative visit and 6 months. These patients had increased procedural satisfaction at 3 months, although there was no difference at 1 year. No notable difference was observed in 90-day complication rates between groups. After matching by age and ASA, each group had 170 patients. In the matched analysis, preoperative HOOS JR scores were markedly lower in the HBC group. However, there was no notable difference in HOOS JR scores, change in HOOS JR scores, and procedural satisfaction, at any postoperative time point. No notable difference was observed in patient-reported outcomes at any time point for SDD after THA performed at an ASC or an HBC when controlling for age and comorbidities. This study suggests noninferiority of stand-alone ASCs for outpatient THA, regarding patient satisfaction and patient-reported outcomes.

The influence of body mass index on patient-reported outcome measures following total hip arthroplasty: a retrospective study of 3,903 Cases.

The influence of obesity on patient-reported outcome measures (PROMs) following total hip arthroplasty (THA) is currently controversial. This study aimed to compare PROM scores for pain, functional status, and global physical/mental health based on body mass index (BMI) classification. Primary, elective THA procedures at a single institution between 2018 and 2021 were retrospectively reviewed, and patients were stratified into four groups based on BMI: normal weight (18.5-24.99kg/m2), overweight (25-29.99kg/m2), obese (30-39.99kg/m2), and morbidly obese (> 40kg/m2). Patient-Reported Outcome Measurement Information System (PROMIS) and Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) scores were collected. Preoperative, postoperative, and pre/post- changes (pre/post-Δ) in scores were compared between groups. Multiple linear regression was used to assess for confounders. We analyzed 3,404 patients undergoing 3,903 THAs, including 919 (23.5%) normal weight, 1,374 (35.2%) overweight, 1,356 (35.2%) obese, and 254 (6.5%) morbidly obese cases. HOOS, JR scores were worse preoperatively and postoperatively for higher BMI classes, however HOOS, JR pre/post-Δ was comparable between groups. All PROMIS measures were worse preoperatively and postoperatively in higher BMI classes, though pre/post-Δ were comparable for all groups. Clinically significant improvements for all BMI classes were observed in all PROM metrics except PROMIS mental health. Regression analysis demonstrated that obesity, but not morbid obesity, was independently associated with greater improvement in HOOS, JR. Obese patients undergoing THA achieve lower absolute scores for pain, function, and self-perceived health, despite achieving comparable relative improvements in pain and function with surgery. Denying THA based on BMI restricts patients from clinically beneficial improvements comparable to those of non-obese patients, though morbidly obese patients may benefit from additional weight loss to achieve maximal functional improvement.

A Comparison of Clinical Outcomes After Total Knee Arthroplasty in Patients Who Have and Do Not Have Self-Reported Nickel Allergy: Matched and Unmatched Cohort Comparisons

BackgroundThe impact of a preoperative self-reported nickel allergy in patients undergoing primary total knee arthroplasty (TKA) remains unclear. The aim of this study was to compare the revision rates and outcomes of patients who have a self-reported nickel allergy undergoing primary TKA to patients who do not have a self-reported nickel allergy. MethodsOver 5 years, a total of 284 TKAs in patients who have and 17,735 in patients who do not have a self-reported nickel allergy were performed. Revision rates and differences in preoperative and postoperative patient-reported outcome measures, including Knee Osteoarthritis Outcome Score Joint Replacement (KOOS JR), Visual Analog Scale, Lower Extremity Activity Scale, and the Patient-Reported Outcomes Measurement Information System Mental and Physical Scores, were compared. ResultsSurvivorship free of all-cause revision at 1 year was similar for patients who have and do not have a self-reported nickel allergy (99.5% [95% CI (confidence interval): 98.6 to 100.0] versus 99.3% [95% CI: 99.1 to 99.4]), P = .49). Patients who have a self-reported nickel allergy undergoing primary TKA had no difference in KOOS JR, Visual Analog Scale, or Lower Extremity Activity Scale scores at 6 weeks and 1 year and slightly worse Patient-Reported Outcomes Measurement Information System mental and physical scores at 6 weeks compared to patients who did not have an allergy. Matched analysis revealed no difference in 6-week or 1-year KOOS, JR scores between patients who did and did not have a self-reported nickel allergy when stratified by implant class (nickel-free versus standard cobalt-chromium) (P = .113 and P = .415, respectively). ConclusionsPatients who have a self-reported nickel allergy can be advised that, on average, their clinical outcome scores will improve similarly to patients who do not have a self-reported nickel allergy, and revision rates will be similar.

Stepping Up Recovery: Integrating Patient-reported Outcome Measures and Wearable Technology for Rehabilitation Following Knee Arthroplasty.

Improvement after knee arthroplasty (KA) is often measured using patient-reported outcome measures (PROMs). However, PROMs are limited due to their subjectivity. Therefore, wearable technology is becoming commonly utilized to objectively assess physical activity and function. We assessed the correlation between PROMs and step/stair flight counts in total (TKA) and partial knee arthroplasty (PKA) patients.Analysis of a multicenter, prospective, longitudinal cohort study investigating the collection of average daily step and stair flight counts, was performed. Subjects (N = 1,844 TKA patients and N = 489 PKA patients) completed the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and provided numerical rating scale pain scores pre- and postoperatively. Only patients who reported living in a multilevel home environment (N = 896 TKA patients and N = 258 PKA patients) were included in analysis of stair flight counts. Pearson correlation coefficients were calculated to determine correlations between variables.Among TKA patients, pain scores demonstrated a negative correlation to mean step counts at preoperative (r = -0.14, p < 0.0001) and 1-month follow-up (r = -0.14, p < 0.0001). Similar negative correlations were true for pain and stair flight counts at preoperative (r = -0.16, p < 0.0001) and 1-month follow-up (r = -0.11, p = 0.006). KOOS JR scores demonstrated weak positive correlations with mean step counts at preoperative (r = 0.19, p < 0.0001) and 1-month postoperative (r = 0.17, p < 0.0001). Similar positive correlations were true for KOOS JR scores and stair flight counts preoperatively (r = 0.13, p = 0.0002) and at 1-month postoperatively (r = 0.10, p = 0.0048). For PKA patients, correlations between pain and KOOS JR with step/stair counts demonstrated similar directionality.Given the correlation between wearable-generated data and PROMs, wearable technology may be beneficial in evaluating patient outcomes following KA. By combining subjective feedback with the objective data, health care providers can gain a holistic view of patients' progress and tailor treatment plans accordingly.

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

The prevalence of total joint arthroplasty (TJA) continues to increase exponentially. Patient-reported outcome measures (PROMs) are used to define clinical and quality-of-life improvement and for reimbursement. Temporal trends of preoperative PROMs and specifically how COVID-19 has affected these PROMs is lacking. This study evaluated preoperative PROMs over time, whether medical factors affected preoperative PROMs, and what correlations the COVID-19 pandemic had with these trends in PROMs. A total of 3,014 patients who underwent primary total hip total hip arthroplasty or total knee arthroplasty from 2013 to 2021 were retrospectively reviewed for covariates and preoperative PROMs. Commonly reported preoperative PROMs were evaluated in univariate and multivariate models. Preoperative activity level steadily increased from 2015 to 2021 for THAs and steadily increased from 2015 to 2019 for TKAs, followed by a decrease in 2020. Preoperative KOOS JR scores increased from 2016 to 2019 and then decreased in 2020 and 2021. Preoperative knee pain with level walking and climbing stairs steadily increased from 2013 to 2019, with additional increases in 2020. The COVID-19 era was significantly associated with higher activity levels for THAs, higher levels of pain with level walking, and lower KOOS JR scores. Preoperative PROM scores demonstrated correlations with postoperative PROM scores, which differed from that during the COVID era (rho range 0.105 to 0.391) at a mean of 2.0 years postoperatively. Surgical delays because of COVID-19 were associated with increased preoperative disability as evidenced by lower activity levels. Aside from this pandemic era, patient activity levels increased over time, indicating that modern TJA patients are more active preoperatively and likely to demand higher levels of function after surgery. Additional studies should evaluate the clinical effect of these statistically significant findings. Providers should consider the trends in preoperative PROMs over time when counseling patients on expectations after TJA.

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

Primary total knee arthroplasty (TKA) aims to improve the level of capability (ability to perform valued life activities) associated with knee osteoarthritis (OA). However, some evidence suggests a substantial proportion of patients remain dissatisfied with their outcomes after this procedure. We sought to better understand the association between mental health, specifically symptoms of depression, with postoperative outcomes. Symptoms of depression are shown to be common among orthopaedic populations in general and can be briefly and conveniently evaluated using the Patient Health Questionnaire-2 (PHQ-2) in a less burdensome manner compared with longer mental health surveys. This study assesses the association between preoperative depressive symptoms (PHQ-2) and levels of capability at 6 weeks and 6 months after TKA. We conducted a prospective cohort study involving 114 patients with knee OA across five clinics in California and Texas scheduled for TKA. Participants completed a preoperative PHQ-2 and Knee Injury and OA Outcome Score for Joint Replacement (KOOS JR) survey at 6 weeks and 6 months post-TKA. We analyzed these data using bivariate and multivariable regression. Preoperative PHQ-2 scores were significantly associated with lower KOOS JR scores at 6 weeks and 6 months post-TKA. Latino/Hispanic race was also associated with lower KOOS JR scores at 6 weeks. The association between preoperative depressive symptoms and level of capability after TKA were more pronounced at 6 months compared with 6 weeks. Preoperative symptoms of depression are strongly associated with reduced capability after TKA and can be screened for using the PHQ-2-a brief tool that can be feasibly incorporated into clinical workflows. User-friendly assessment of depressive symptoms can assist orthopaedic surgeons in identifying and addressing mental health at the outset during the management of knee OA.

Preoperative Symptoms of Depression are Associated With Worse Capability 6-weeks and 6-months After Total Hip Arthroplasty for Osteoarthritis

BackgroundSymptoms of depression have been associated with greater incapability following total hip arthroplasty (THA). A brief, 2-question, measure of symptoms of depression – the Patient Health Questionnaire-2 (PHQ-2) – may be sufficient to measure associations with the magnitude of incapability during recovery from THA. This study investigated whether preoperative symptoms of depression (measured with the PHQ-2) correlated with levels of incapability 6 weeks and 6 months after THA, accounting for demographic and clinical factors. MethodsWe performed a prospective cohort study across 5 centers and recruited 101 patients undergoing THA, of whom 90 (89%) completed follow-up. Patients completed demographics, a preoperative 2-item (PHQ-2) measure of symptoms of depression, and the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) at 6-weeks and 6-months postoperatively. Negative binomial regression models determined factors associated with HOOS JR at 6 weeks and 6 months, accounting for potential confounders. ResultsAccounting for potential confounding factors, we found that higher preoperative PHQ-2 scores (reflecting greater symptoms of depression) were associated with lower HOOS JR scores (reflecting a greater level of hip disability) at both 6 weeks (regression coefficient = −0.67, P < .001) and 6 months (regression coefficient = −1.9, P < .001) after THA. ConclusionsSymptoms of depression on a 2-question preoperative questionnaire are common, and greater symptoms of depression are associated with reduced capability within the first year following THA. These findings support the prioritization of routine mental health assessments before THA. Measuring mindset using relatively brief instruments will be important considering the current shift toward implementing self-reported measures of health status in clinical practice and incorporating them within alternative payment models.

Staged Bilateral Total Knee Arthroplasty: Differing Results Comparing the First and Second Knees

BackgroundPatients often prefer one knee over the other following staged bilateral total knee arthroplasty (BTKA). Our study compared patient-reported outcomes scores of each knee following BTKA and identified factors that may contribute to the identified discrepancies. MethodsAll patients who underwent staged BTKA between July 2014 and August 2022 were identified. The patient-reported outcomes were collected preoperatively and at 2 weeks, 6 weeks, 1 year, and 2 years postoperatively. Each knee’s results were compared using paired t-tests and McNemar tests. Preoperative Kellgren-Lawrence Grade (KLG), postoperative range of motion (ROM), reoperation rates, and manipulations under anesthesia (MUAs) were collected. Results were stratified based on time between TKAs (< 3 months, 3 to 12 months, 1 to 2 years, and > 2 years). ResultsThere were 911 patients who underwent staged BTKA, with a mean 4.1-year follow-up. The ROM, patient satisfaction, MUAs, and reoperations were not significantly different between knees. Comparing the KLG of the first and second knees, 71% had the same KLG for both knees, 21% had a lower KLG, and 7% of the second knees had a higher KLG. The first knee had greater pain reduction (−10.6 at 2 weeks, −27.4 at 6 weeks) compared to the second (9.3 at 2 weeks, −8.1 at 6 weeks) (P < .0001) and better improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score (8.5 at 2 weeks, 16.9 at 6 weeks) compared to the second (−5.8 at 2 weeks, 5.0 at 6 weeks) (P < .0001). The 1-year outcomes between first and second knees, or recovery curves, were not different when stratifying by time between TKAs. ConclusionsThe second knee in a staged BTKA has less delta improvement in KOOS JR and pain scores at early follow-up, likely due to higher starting KOOS JR and Patient-Reported Outcomes Measurement Information System scores, despite similar final patient satisfaction and clinical outcome measures. Lower KLG in the second total knee arthroplasty (TKA) may contribute to these findings. An MUA after the first TKA is highly predictive of an MUA after the second TKA.

Patient satisfaction and patient-reported outcomes do not vary by BMI class in total hip arthroplasty.

Obesity has been identified as a risk factor for postoperative complications in patients undergoing total hip arthroplasty (THA). This study aimed to investigate patient-reported outcomes, pain, and satisfaction as a function of body mass index (BMI) class in patients undergoing THA. 1736 patients within a prospective observational study were categorized into BMI classes. Pre- and postoperative Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR), satisfaction, and pain scores were compared by BMI class using one-way ANOVA. Healthy weight patients reported the highest preoperative HOOS JR (56.66 ± 13.35) compared to 45.51 ± 14.45 in Class III subjects. Healthy weight and Class III patients reported the lowest (5.65 ± 2.01) and highest (7.06 ± 1.98, p < 0.0001) preoperative pain, respectively. Changes in HOOS JR scores from baseline suggest larger improvements with increasing BMI class, where Class III patients reported an increase of 33.7 ± 15.6 points at 90days compared to 26.1 ± 17.1 in healthy weight individuals (p = 0.002). Fewer healthy weight patients achieved the minimal clinically important difference (87.4%) for HOOS JR compared to Class II (96.5%) and III (94.7%) obesity groups at 90days postoperatively. Changes in satisfaction and pain scores were largest in the Class III patients. Overall, no functional outcomes varied by BMI class postoperatively. Patients of higher BMI class reported greater improvements following THA. While risk/benefit shared decision-making remains a personalized requirement of THA, this study highlights that utilization of BMI cutoff may not be warranted based on pain and functional improvement.

Hip Resurfacing in the Setting of Retained Proximal Femoral Instrumentation or Complex Deformity

AbstractTotal hip arthroplasty (THA) in the setting of significant retained femoral instrumentation or complex proximal femoral deformity may be challenging and published reports of THA in this setting reveal sobering results. Hip resurfacing arthroplasty (HRA) is an alternative to THA and may avoid complex hardware removal or deformity correction at the time of hip arthroplasty. Twenty-three patients who underwent elective HRA in the setting of significant proximal femoral deformity and/or retained femoral instrumentation were identified from a prospectively maintained registry. Pre- and postoperative Lower Extremity Assessment Scores (LEAS), modified Harris Hip Scores (mHHS), Hip Disability and Osteoarthritis Outcome Scores for Joint Replacement (HOOS, JR) scores, Visual Analog Scale (VAS) pain levels, and metal ion levels were obtained. Median (interquartile range [IQR]) follow-up was 5.03 (2.07 − 7.91) years, and no patients had undergone revision surgery at their latest follow-up. The mean (standard deviation [SD]) surgical duration was 94.40 (12.00) minutes, and postoperative length of stay was 1.74 (1.80) days. There were no intraoperative complications, and all patients were discharged home. Median (IQR) postoperative LEAS, VAS pain scale, mHHS, and HOOS, JR scores were 13.00 (9.25 − 13.00), 2.50 (0.75 − 10.00), 92.60 (92.40 − 100.00), and 92.34 (85.26 − 100.00), respectively. Fourteen patients completed postoperative serum metal ion level testing at a mean (SD) of 4.24 (2.85) years, where cobalt and chromium levels were 1.22 (0.36) and 2.01 (0.80) parts per billion, respectively. HRA is a viable option for patients with significant proximal femoral deformity or retained instrumentation, and excellent results at mid-term follow-up can be achieved utilizing this strategy in this complex patient population.

What Are the Underlying Mental Health Constructs Associated With Level of Capability in People With Knee and Hip Osteoarthritis?

Mental health characteristics such as negative mood, fear avoidance, unhelpful thoughts regarding pain, and low self-efficacy are associated with symptom intensity and capability among patients with hip and knee osteoarthritis (OA). Knowledge gaps remain regarding the conceptual and statistical overlap of these constructs and which of these are most strongly associated with capability in people with OA. Further study of these underlying factors can inform us which mental health assessments to prioritize and how to incorporate them into whole-person, psychologically informed care. (1) What are the distinct underlying factors that can be identified using statistical grouping of responses to a multidimensional mental health survey administered to patients with OA? (2) What are the associations between these distinct underlying factors and capability in knee OA (measured using the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS JR]) and hip OA (measured using Hip Disability and Osteoarthritis Outcome Score, Joint Replacement [HOOS JR]), accounting for sociodemographic and clinical factors? We performed a retrospective cross-sectional analysis of adult patients who were referred to our program with a primary complaint of hip or knee pain secondary to OA between October 2017 and December 2020. Of the 2006 patients in the database, 38% (760) were excluded because they did not have a diagnosis of primary osteoarthritis, and 23% (292 of 1246) were excluded owing to missing data, leaving 954 patients available for analysis. Seventy-three percent (697) were women, with a mean age of 61 ± 10 years; 65% (623) of patients were White, and 52% (498) were insured under a commercial plan or via their employer. We analyzed demographic data, patient-reported outcome measures, and a multidimensional mental health survey (the 10-item Optimal Screening for Prediction of Referral and Outcome-Yellow Flag [OSPRO-YF] assessment tool), which are routinely collected for all patients at their baseline new-patient visit. To answer our first question about identifying underlying mental health factors, we performed an exploratory factor analysis of the OSPRO-YF score estimates. This technique helped identify statistically distinct underlying factors for the entire cohort based on extracting the maximum common variance among the variables of the OSPRO-YF. The exploratory factor analysis established how strongly different mental health characteristics were intercorrelated. A scree plot technique was then applied to reduce these factor groupings (based on Eigenvalues above 1.0) into a set of distinct factors. Predicted factor scores of these latent variables were generated and were subsequently used as explanatory variables in the multivariable analysis that identified variables associated with HOOS JR and KOOS JR scores. Two underlying mental health factors were identified using exploratory factor analysis and the scree plot; we labeled them "pain coping" and "mood." For patients with knee OA, after accounting for confounders, worse mood and worse pain coping were associated with greater levels of incapability (KOOS JR) in separate models but when analyzed in a combined model, pain coping (regression coefficient -4.3 [95% confidence interval -5.4 to -3.2], partial R 2 0.076; p < 0.001) had the strongest relationship, and mood was no longer associated. Similarly, for hip OA, pain coping (regression coefficient -5.4 [95% CI -7.8 to -3.1], partial R 2 0.10; p < 0.001) had the strongest relationship, and mood was no longer associated. This study simplifies the multitude of mental health assessments into two underlying factors: cognition (pain coping) and feelings (mood). When considered together, the association between capability and pain coping was dominant, signaling the importance of a mental health assessment in orthopaedic care to go beyond focusing on unhelpful feelings and mood (assessment of depression and anxiety) alone to include measures of pain coping, such as the Pain Catastrophizing Scale or Tampa Scale for Kinesiophobia, both of which have been used extensively in patients with musculoskeletal conditions. Level III, prognostic study.

Gluteal Tendinopathy Is Associated With Lower Patient-Reported Outcome Measures in Total Hip Arthroplasty With a Posterior Approach: A Prospective Cohort Study of 1,538 Patients

BackgroundGluteal tendinopathy (GT) is found in 20 to 25% of patients undergoing total hip arthroplasty (THA). Despite this, there is a scarcity of literature assessing the association between GT and THA outcomes. The aim of this study was to evaluate whether intraoperative diagnosis of GT negatively affected postoperative outcomes. MethodsConsecutive patients undergoing primary THA for osteoarthritis via a posterior approach over 5 years were recruited in a prospective study. Gluteal tendinopathy was assessed and graded at the time of surgery, but not repaired. A total of 1,538 (93%) completed the patient-reported outcome measures (PROMs) at 1 year after surgery and were included in the analysis. The PROMs included the Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR), and EuroQol 5-Dimension, and were collected preoperatively and one year after THA. ResultsThe gluteal tendons were graded as 4 distinct grades: normal (n = 1,023, 66%), tendinopathy but no tear (n = 337, 22%), partial thickness tear (n = 131, 9%), and full thickness tear (n = 47, 3%). The occurrence of GT was associated with age, body mass index, and sex. There was no significant difference in baseline OHS or HOOS JR scores according to GT grade. As GT grade increased, lower median 1-year OHS (P = .001) and HOOS JR (P = .016) were observed. This association was confirmed by linear regression analysis with 1-year OHS (B = 0.5, 95% CI = −0.9 to −0.1, P = .011) when controlled for age and sex. ConclusionsGluteal tendinopathy was commonly observed and was associated with inferior 1-year PROMs in patients undergoing THA via posterior approach. Increasing degree of tendinopathy was a negative prognostic factor for outcomes and patient satisfaction. Level of EvidenceLevel 2 (High quality prospective cohort study).

Despite Greater Improvement in Pain and Function Among Obese Patients Shortly After Total Knee Arthroplasty, There is No Difference in Patient-Reported Outcomes and Satisfaction Between Body Mass Index Classes at 1 Year Postoperatively

BackgroundAlthough obesity may be associated with an increased risk of perioperative and postoperative complications after total knee arthroplasty (TKA), body mass index (BMI) cutoffs for TKA patient selection remain a controversial topic. This study aimed to investigate patient-reported outcomes, satisfaction, and pain among BMI classes at 3 months and 1 year following TKA. MethodsA total of 2,365 patients were categorized into Centers for Disease Control BMI classes according to preoperative values. The BMI distribution over the cohort demonstrated 7 underweight, 340 healthy weight, 731 overweight, 666 Class I, 391 Class II, and 230 Class III obesity. Preoperative and postoperative Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), satisfaction, and pain scores were compared by BMI class by Analysis of Variance with pairwise comparisons. ResultsPreoperative KOOS JR scores and satisfaction scores were both significantly greater for healthy weight patients compared to Class III patients (P < .0001). However, KOOS JR, satisfaction, and pain did not vary by BMI class postoperatively. Changes in scores from baseline suggest larger improvements with increasing BMI class, where Class III patients reported the greatest improvements in KOOS JR (23.24 ± 15.67, P < .0001) and pain scores (−3.56 ± 2.65, P < .0001) at 90 days. Significantly greater improvement with increasing BMI was also present at 1-year postoperatively for KOOS JR scores. A total of 85.8% of Class III patients reached the Minimal Clinically Important Difference for KOOS JR at 90 days compared to 76.8% of the healthy weight group (P = .03). Differences between BMI groups in the proportion reaching Minimal Clinically Important Difference at 1 year were not significant. ConclusionsPatients of higher BMI reported greater and earlier improvements in satisfaction, knee function, and pain following TKA. Shared decision-making remains paramount to preoperative surgical evaluation. However, rationing of this surgical intervention based on BMI alone may not be warranted.

Survivorship, complications, and outcomes following distal femoral replacement for neoplastic indications

BackgroundDistal femoral replacements (DFRs) are excellent treatment options for limb salvage procedures in patients who have bone loss secondary to neoplasm. Multiple studies report adequate survivorship and complication rates following DFR implantation, primarily for non-neoplastic indications. However, current literature regarding neoplasm-specific reports is often limited by sample size, survivorship, and patient reported outcome measurements. Therefore, we sought to examine patients who received a DFR for a neoplastic indication at multiple tertiary academic centers. Specific outcomes analyzed included: (1) revision-free survival, (2) medical/surgical complications, and (3) Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR). MethodsAll patients who underwent a DFR for a neoplastic indication were retrospectively reviewed. A total of 29 knees were included for various neoplastic indications. Outcomes of interest included: post-operative thromboses, pneumonia, dislocations, periprosthetic joint infections (PJIs), aseptic loosening, osteolysis, emergency department visits, inpatient readmissions, and revision surgeries. Patient-reported outcome measure (PROM) collected included: Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR). ResultsRevision-free survivorship was 72.4 % at 23 months with radiographic follow-up. PJI was the most common post-operative complication, affecting 3 knees (10.3 %). The mean number of emergency department visits and inpatient readmissions averaged less than one per patient (0.63 and 0.41, respectively). KOOS JR scores improved markedly among from baseline to final follow-up (44.1–57.8). ConclusionThe use of DFR led to satisfactory medium-term clinical outcomes with an acceptable complication rate for this challenging group of patients. The marked improvement in patient satisfaction for this patient population gives a promising outlook for patients who will undergo this procedure in the future and can guide patient-provider regarding surgical expectations.

The influence of mental health on early outcomes following total hip arthroplasty.

Poor mental health is difficult to recognize and as a result, its association with recovery from total joint arthroplasty is difficult to assess. The purpose of this study was to investigate the relationship between overall mental health scores and outcomes in the early postoperative period following unilateral total hip arthroplasty (THA). This is a retrospective review of prospectively collected data involving 142 patients who underwent primary unilateral THA. Independent variables included patient demographics and preoperative Patient-Reported Outcomes Measurement Information System (PROMIS), Global Physical Health (GPH) and Global Mental Health (GMH) and Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) scores as well as diagnoses of depression or anxiety. Dependent variables included length of stay (LOS), disposition at discharge, narcotic consumption until discharge, 6-week postoperative GPH, GMH and HOOS JR scores and magnitude of change compared to preoperative scores. Preoperative GMH and postoperative outcomes were compared using Pearson correlation coefficient, independent t-tests, Pearson's Chi-Square test, and univariate logistic regression. Patients with preoperative GMH scores below the 25% quartile were less likely to be discharged home and resulted in lower GPH, GMH and HOOS JR scores at 6-week follow-up compared to patients with preoperative GMH scores in the top 25% quartile. However, patients with low preoperative GMH scores demonstrated a greater magnitude of improvement in both the GPH and GMH scores compared to patients in the top 25% quartile. There was no difference in opioid consumption or LOS between either groups. When comparing patients with and without depression/anxiety, no difference was seen in any of the outcomes measured. Unilateral THA offers significant improvements in both physical and mental function to patients with hip osteoarthritis and poor mental health, though overall scores remain lower than in those with better mental health.