Lower Extremity Activity Scale Score Research Articles

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.

A prospective comparison of total knee arthroplasty using ultra-congruent, condylar-stabilizing, and posterior-stabilized devices implanted with kinematic alignment: better 2-year outcomes with ultra-congruent

PurposeThis study compared the 5-year results of posterior cruciate ligament (PCL)-sacrificing total knee arthroplasty (TKA) with either a post and cam posterior-stabilized (PS) device, a dished, congruent condylar-stabilizing (CS) device, or a deep-dished ultra-congruent (UC) device. The hypothesis was that the clinical and radiographic outcomes would be equivalent. CS and PS participants were part of a prospective, randomized trial, and UC participants were part of a separate prospective, non-randomized protocol that was otherwise identical. A kinematic alignment surgical technique was utilized.MethodsParticipants were assessed preoperatively, and postoperatively at 6 weeks, 6 months, and annually for 5 years by Knee Society Score (KSS), SF-36 v2, Lower Extremity Activity Scale (LEAS), and physical and radiographic evaluation. There were 116 CS/PS participants and 69 UC participants who participated in the study.ResultsTourniquet (P = .02) and operative (P = .01) times for the CS and UC groups were significantly shorter than the PS group. KSS Function scores were better for the UC group than the CS and PS groups at 6 months (P = .04) and 1 year (P = .03), and better in the UC group vs. CS at 2 years (P = .04). The KSS Pain-only score was also better in the UC compared to PS at 6 months (P = .04). There were no significant differences for the KSS Pain/Motion scores, flexion, SF-36, and LEAS scores at any time.ConclusionThese data confirm the hypothesis that there are no clinically meaningful significant differences in outcomes between the three groups at a 5-year minimum follow-up, though there is a trend toward less pain and better function at earlier visits in the UC group.Level of evidenceII.

Telerehabilitation has similar clinical and patient-reported outcomes compared to traditional rehabilitation following total knee arthroplasty.

Telehealth rehabilitation (telerehab) is an increasingly popular cost-saving alternative to traditional rehabilitation after total joint arthroplasty. We compared the safety and efficacy of an institutional telerehab program to conventional "face-to-face" rehabilitation in a sample of patients undergoing total knee arthroplasty (TKA). A retrospective matched cohort study was performed. Medicare patients who utilized telerehab following unilateral TKA were matched in a 1:3 ratio to those utilizing conventional rehabilitation. Patients were matched on sex, body mass index (BMI, ± 5kg/m2), preoperative extension (± 10 degrees), preoperative flexion (± 10 degrees), and Risk Assessment and Prediction Tool (RAPT) score (± 2 points). Ninety-day unplanned healthcare encounters, 120-day manipulations under anesthesia (MUAs), and 6-week and 3-month changes in the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR), pain visual analog scale (VAS), Veterans RAND 12 (VR-12), and Lower-Extremity Activity Scale (LEAS) were compared between groups. Eighty-two telerehab patients and 244 conventional rehab patients were included. After matching, there were no differences in 90-day unplanned healthcare encounters or 120-day MUA rates between groups. There were no differences in 6-week or 3-month changes in KOOS-JR, VAS pain, or VR-12 mental or physical sub-scores between groups. Telerehab patients had a greater improvement in LEAS score at 3months compared to the conventional group (mean difference 1.9, P = 0.03). In a matched cohort study of 326 TKA patients, telerehab patients had similar rates of unplanned healthcare encounters and MUAs and similar patient-reported outcomes compared to conventional PT patients, suggesting that telerehab can be an equally effective alternative to conventional PT following TKA. III.

Preoperative activity levels are an important indicator of postoperative activity in cementless TKAs

IntroductionIt is of interest if preoperative activity level has an impact on postoperative activity level following cementless TKA. MethodsThis review contained 127 patients who had a preoperative Lower Extremity Activity Scale (LEAS) score ≥ to 10 (active patients) and 121 patients <10 (inactive patients). ResultsPostoperatively, the results showed a difference in LEAS Activity (Active 10.5 vs. Inactive 8.7, p < 0.001). Active patients had a drop in their activity level by 1.2 on the LEAS score, yet inactive patients increased by 1.6 (p < 0.0001). ConclusionPreoperative activity levels are a good indicator for postoperative activity in cementless TKA.

What Are the Benefits of Hip Resurfacing in Appropriate Patients? A Retrospective, Propensity Score-Matched Analysis.

Hip arthritis is one of the major causes of disability worldwide. Hip resurfacing arthroplasty (HRA) has emerged in recent years as an alternative to total hip arthroplasty (THA), but complications of HRA have limited the patient population to younger male patients with primary osteoarthritis and large hip anatomy. How the functional benefits of HRA in this population compare with those of THA is not entirely clear. The primary aim of this study was to determine whether there were differences in hip disability and patient satisfaction with surgery between these two groups at 2 years after surgery, using patient-reported outcome measures (PROMs) and subjective measures of patient satisfaction. Additionally, we sought to determine whether there were differences in post-operative discharge disposition, revision rates, or adverse events. We searched an institutional database to identify patients undergoing unilateral HRA or THA between January 2007 and July 2011 who met today's recommended criteria for HRA: younger male patients with large-enough hip anatomy to make surgery viable (a femoral head of at least 48 mm in HRA patients and, in THA patients, an acetabular shell size of 54 mm, the minimum outer shell size that could accommodate a femoral head component of 48 mm; for matching purposes, acetabular shell size in THA was used as a surrogate for the femoral head size used in HRA). We used propensity score matching to control for potentially confounding pre-operative variables and administeredtheHip Disability and Osteoarthritis Outcome Score (HOOS) survey, including its subdomains, at the 2-year mark. We also assessed differences between groups in Lower Extremity Activity Scale scores, 12-item Short Form Health Survey results, and answers regarding satisfaction with surgery. We calculated minimal detectable change, minimum clinically important change, and substantial clinical benefit using anchor-based techniques for multiple outcome measures. There were 251 patients in each group. HRA patients scored significantly higher than THA patients on the 2-year HOOS sports and recreation (92 versus 87, respectively) and on rates of overall satisfaction (94% versus 89%, respectively). The HRA group also had a greater chance of achieving minimum clinically important change (18.75 points) in the HOOS sports and recreation subdomains than the THA group (97% versus 91%). No significant difference was found in 6-month adverse event rates. HRA patients also had a significantly shorter mean hospital stay, a higher rate of discharge to home, and a lower incidence of a "significant" limp after surgery. HRA may provide a functional benefit in sports and recreation and greater satisfaction in patients who meet the current criteria for HRA. Because these benefits may be small, pre-operative counseling should focus on balancing the possible functional benefits against the longer-term risks associated with metal-on-metal bearings.

Cemented Exeter total hip arthroplasty with a 32 mm head on highly crosslinked polyethylene: Does age influence functional outcome, satisfaction, activity, stem migration, and periprosthetic bone mineral density?

ObjectivesOur primary aim was to describe migration of the Exeter stem with a 32 mm head on highly crosslinked polyethylene and whether this is influenced by age. Our secondary aims were to assess functional outcome, satisfaction, activity, and bone mineral density (BMD) according to age.Patients and MethodsA prospective cohort study was conducted. Patients were recruited into three age groups: less than 65 years (n = 65), 65 to 74 years (n = 68), and 75 years and older (n = 67). There were 200 patients enrolled in the study, of whom 115 were female and 85 were male, with a mean age of 69.9 years (sd 9.5, 42 to 92). They were assessed preoperatively, and at three, 12 and, 24 months postoperatively. Stem migration was assessed using Einzel-Bild-Röntgen-Analyse (EBRA). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), EuroQol-5 domains questionnaire (EQ-5D), short form-36 questionnaire (SF-36,) and patient satisfaction were used to assess outcome. The Lower Extremity Activity Scale (LEAS), Timed Up and Go (TUG) test, and activPAL monitor (energy expelled, time lying/standing/walking and step count) were used to assess activity. The BMD was assessed in Gruen and Charnley zones.ResultsMean varus/valgus tilt was -0.77⁰ and axial subsidence was -1.20 mm. No significant difference was observed between age groups (p ⩾ 0.07). There was no difference according to age group for postoperative WOMAC (p ⩾ 0.11), HHS (p ⩾ 0.06), HOOS (p ⩾ 0.46), EQ-5D (p ⩾ 0.38), patient satisfaction (p ⩾ 0.05), or activPAL (p ⩾ 0.06). Patients 75 years and older had a worse SF-36 physical function (p = 0.01) and physical role (p = 0.03), LEAS score (p < 0.001), a shorter TUG (p = 0.01), and a lower BMD in Charnley zone 1 (p = 0.02).ConclusionExeter stem migration is within normal limits and is not influenced by age group. Functional outcome, patient satisfaction, activity level, and periprosthetic BMD are similar across all age groups.Cite this article: N. D. Clement, M. Bardgett, K. Merrie, S. Furtado, R. Bowman, D. J. Langton, D. J. Deehan, J. Holland. Cemented Exeter total hip arthroplasty with a 32 mm head on highly crosslinked polyethylene: Does age influence functional outcome, satisfaction, activity, stem migration, and periprosthetic bone mineral density? Bone Joint Res 2019;8:275–287. DOI: 10.1302/2046-3758.86.BJR-2018-0300.R1.

Age-Related Decline in Patient-Reported Outcomes 2 and 5 Years Following Total Hip Arthroplasty

BackgroundPatient-reported outcome measures (PROMs) help assess therapeutic effectiveness. This study assessed the effect of advanced age on the Hip Disability and Osteoarthritis Outcome Score (HOOS) and Lower Extremity Activity Scale (LEAS) after total hip arthroplasty (THA). MethodsA prospective cohort of patients underwent primary THA at our institution between May 2007 and December 2011. Exposure was age at the time of surgery and outcomes were HOOS and LEAS scores 2 and 5 years postsurgery. We used a multivariable longitudinal generalized estimating equation to elucidate the effect of age on PROM scores. ResultsOur analysis of 3700 THA patients (mean age, 66 years; 56.4% female) demonstrated a decline in scores by age for the LEAS, HOOS Activities of Daily Living, and HOOS Sport and Recreation domains. There was also association between age and HOOS Symptoms and HOOS Quality of Life domains, but not between age and the HOOS Pain domain. Critical ages at which the relationship between age and outcome changed was 63 years for the HOOS Pain, Symptom, Activities of Daily Living, and Quality of Life domains, and 72 years for the HOOS Sport and Recreation domain and the LEAS. ConclusionPatients undergoing THA at older ages reported lower activity and sports and recreation scores than younger patients, but similar pain, symptoms, and quality of life scores. This knowledge can help physicians guide patients’ expectations before THA. Our findings also indicate that PROM scores should be age adjusted when used for quality or value comparisons between hospitals or physicians.

Safety and Efficacy of Percutaneous Injection of Lipogems Micro-Fractured Adipose Tissue for Osteoarthritic Knees.

The aim of this study was to evaluate the safety and efficacy of using autologous, micro-fractured, minimally manipulated adipose tissue in patients with refractory knee osteoarthritis (OA). A total of 17 subjects (26 knees) with a median age of 72 years (range: 54-78 years) and a history of knee OA (Kellgren-Lawrence, grade of 3 or 4) underwent treatment with ultrasound-guided injection of micro-fractured adipose tissue. Micro-fractured fat was obtained using a minimal manipulation technique in a closed system (Lipogems), without the addition of enzymes or any other additives. The study subjects were clinically evaluated using the numerical pain rating scale (NPRS), the 100-point Knee Society Score (KSS) with its functional component (FXN), and the lower extremity activity scale (LEAS) at 6 weeks, 6 months, and 12 months following this procedure. When compared with baseline, significant improvements were noted in the mean values of NPRS, FXN, and LEAS at 6 weeks, 6 months, and 12 months. The mean KSS significantly improved at 6 weeks and 12 months. In particular, the average KSS score improved from 74 to 82, the FXN score improved from 65 to 76, and the LEAS score improved from 36 to 47. These values were significantly greater than the previously published minimal clinically important difference described for KSS and FXN in patients who underwent total knee arthroplasty for primary OA. No serious adverse events were reported. The injection of autologous, micro-fractured, minimally manipulated adipose tissue appears to be a safe and effective treatment option for patients with refractory, severe (grade 3 or 4) knee OA. This study demonstrated significant improvements in pain, quality of life, and function for at least 12 months in this study population. This intervention may represent a nonsurgical treatment option to avoid knee joint replacement in this population; however, further investigation is needed.

Age-Related Functional Decline Following Total Knee Arthroplasty: Risk Adjustment is Mandatory

BackgroundPatient-reported outcome measures (PROMs) are being used increasingly to determine the success of total knee arthroplasty (TKA). Our goal is to investigate whether advanced age is associated with lower PROM scores. MethodsWe used our hospital’s TKA registry to examine the relationship between age and PROMs in all patients 50-90 years of age who underwent unilateral or simultaneous bilateral primary TKA between 2007 and 2011 with a primary diagnosis of osteoarthritis. All 5 domains of the Knee Injury and Arthritis Outcomes Score (KOOS) and the Lower Extremity Activity Scale (LEAS) at baseline, 2 years, and 5 years were collected. The association between age and PROM score was assessed by piecewise linear regression using generalized estimating equations, adjusting for demographics, comorbidity, and baseline score. ResultsSignificant nonlinear relationships among age, KOOS subdomains, and LEAS were found. The placement of the age spline knot was at 70 years for KOOS Symptom and 68 years for KOOS Pain, KOOS Activities of Daily Living (ADL), and LEAS. The KOOS Symptom domain showed a significant worsening between 2-year and 5-year follow-up (P < .05) as patients got older. ConclusionWe found an age-related decline in KOOS Pain, KOOS Symptom, KOOS ADL, and LEAS scores. The best fitting spline knots were at 68 (KOOS Pain, KOOS ADL, and LEAS) and 70 years (KOOS Symptoms), respectively. This demonstrates that there is a critical age at which functional decline begins regardless of the quality of the TKA surgery. Our findings will help surgeons accurately guide patient expectations after TKA based on age. Level of EvidenceLevel II, prognostic study.

The Effect of Prior Hip Arthroscopy on Patient-Reported Outcomes After Total Hip Arthroplasty: An Institutional Registry–Based, Matched Cohort Study

BackgroundA significant number of patients who undergo hip arthroscopy will subsequently undergo total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA), although limited evidence exists regarding effects of prior hip arthroscopy on the outcomes of these procedures. MethodsOf 5091 patients who underwent hip arthroscopy, we identified 69 patients who underwent subsequent THA (46) or HRA (23). Patients were matched to patients with no history of hip arthroscopy. Preoperative and 2-year postoperative Hip disability and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-12, Lower Extremity Activity Scale score, and satisfaction surveys were compared. ResultsPatients who underwent THA with history of arthroscopy had lower postoperative Hip disability and Osteoarthritis Outcome Score Pain (82 ± 16 vs 93 ± 9, P = .003), Stiffness (85 ± 16 vs 93 ± 15, P = .01), Sports and Recreation (71 ± 22 vs 88 ± 18, P = .003), Quality-of-Life (65 ± 22 vs 86 ± 11, P < .0001), WOMAC Pain (86 ± 16 vs 93 ± 15, P = .03), WOMAC Stiffness (80 ± 21 vs 88 ± 17, P = .05), and Short Form-12 Physical Component Scores (48 ± 11 vs 54 ± 6, P = .008). They were less likely to be “very satisfied” after arthroplasty (71% vs 89%, P = .0008). ConclusionHip arthroscopy before hip arthroplasty is associated with slightly lower results in several patient-reported outcomes. These results are relevant when assessing patients for hip arthroscopy and when counseling prospective arthroplasty patients with history of arthroscopy.

A Crosswalk Between UCLA and Lower Extremity Activity Scales

The University of California, Los Angeles (UCLA) activity scale and the Lower Extremity Activity Scale (LEAS) are the two most-widely used and rigorously developed scales for assessing activity level in patients having joint replacement. However, the two scales are not convertible, and the level of correlation between the two is not clear. Creating a crosswalk between these scales; that is, a concordance table to convert scores from one scale to the other and vice versa, will help compare results from existing studies using either scale, and pool those results for meta-analyses. It also will facilitate pooling data from multiple registries and data sources. To create a crosswalk between the UCLA and the LEAS activity scales for patients having THA or TKA. Preoperative and 2-year postoperative UCLA and LEAS scores for a cohort of patients undergoing primary TKA or THA at the Hospital for Special Surgery between May 2007 and December 2011 were matched from two registries. The scales were self-administered by patients. Three hundred sixty-four patients having TKAs (67% women; mean age, 67years) and 403 having THA (66% women; mean age, 66years) had both scores available. The equipercentile equating method was used to create the crosswalk. The standard response mean was used to assess responsiveness of the converted versus actual UCLA and LEAS scores from baseline to 2years. Crosswalk validation also included comparing the area under the receiver operating characteristic curve of the actual and converted scores to evaluate their ability to discriminate different levels of function measured using the Hip dysfunction and Osteoarthritis Outcome Score activities of daily living subscale for patients having THA and the Knee injury and Osteoarthritis Outcome Score activities of daily living subscale for patients having TKA. Difference between scores was assessed using the inequality test. For patients having TKA, converted mean scores (UCLA to LEAS, 9.5±3.0; LEAS to UCLA, 4.7±2.1) were not different from the actual scores (UCLA, 4.8±2.1; LEAS, 9.4±2.9). Standard response means for the converted scores (UCLA to LEAS, 0.47; LEAS to UCLA, 0.52) were not different from those of the actual scores (UCLA, 0.48; LEAS, 0.56). The areas under the receiver operating characteristic curve also were not different for actual and converted scores for THA and TKA. We have developed and validated a crosswalk to easily convert UCLA to LEAS scores (and vice versa) for THA and TKA. Reproducing the crosswalk for other lower extremity conditions or surgical procedures may extend its utility to studies assessing activity in patients having these conditions or procedures.

The Effect of Comorbidities on Outcomes following Total Knee Arthroplasty.

To enhance the success of total knee arthroplasty (TKA), clinicians must identify factors that may impede functional recovery. Multiple comorbidities may affect outcomes, and our purpose was to identify the role of overall disease burden, as well as individual comorbidities, on post-TKA outcomes. We prospectively reviewed 283 TKA patients (172 women, 111 men). Preexisting comorbidities were weighted using the Charlson comorbidity index (CCI). Patients were divided into four groups: CCI score of 0 to 1, 2, 3, or 4 or more and followed up at 6 weeks, 3 months, 1 year, and annually until 5 years. The most prevalent comorbidities were also individually assessed at these follow-ups. The effect of these on outcomes was evaluated using the Knee Society Score (KSS), Short Form 36 (SF-36), and lower extremity activity scale (LEAS). Patients who had lower CCI scores had significant improvements in KSS at 2- and 5-year follow-up (+34 and +38 points, respectively; p < 0.01). CCI scores of 0 to l demonstrated significantly greater improvement in the SF-36 physical component score (PCS) at final follow-up (+16 points; p < 0.05) and higher LEAS scores at 2 years postoperatively (p = 0.001), compared with the remaining cohorts. Endocrine disease and hypertension yielded significantly lower KSS at follow-up (-5 and -5 points, respectively; p < 0.05). Patients who had hypertension or gastrointestinal disease had significantly lower SF-36 PCS at final follow-up compared with those who did not (45 vs. 48 points and 47 vs. 49 points; p < 0.035 and 0.041, respectively), as well as lower activity scores (11 vs. 12 points for both comorbidities; p < 0.05). Patients who had cardiovascular disease had significantly lower SF-36 MCS (53 vs. 56 points, respectively; p = 0.03) at 4 years postoperatively than those without, as well as lower activity scores (11 vs. 12 points, respectively; p = 0.024). Patients who have lower CCIs may have improved activity and functional levels following TKA. Hypertension, cardiovascular disease, endocrine disease, and gastrointestinal disease may correlate with poorer functional and activity outcomes postoperatively.

Double metal tibial blocks augmentation in total knee arthroplasty

Severe uncontained tibial bone defects occurring during total knee arthroplasty are challenging, and which treatment method is the best remains unknown. In this study, clinical and radiographic outcomes of double metal blocks augmentation were examined. Between 2004 and 2012, double metal blocks augmentation was carried out in 17 patients with severe asymmetric uncontained tibial bone defects. The first block was attached to the tibial tray with screws, and then the second block was cemented to the first block. Out of 17 patients, 13 (8 primary, 5 revision) were available for final follow-up at a median of 69 months (range 24-99). For clinical assessment, range of motion and Knee Society score were evaluated preoperatively and annually thereafter. At the final follow-up, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford knee, Short Form-36, Lower extremity functional scale, and Lower extremity activity scale scores were evaluated. Radiographic assessment for radiolucent lines at the block-cement-bone interfaces and signs of failure was performed annually using fluoroscopy and standard radiographs. Range of motion and Knee Society score were significantly improved post-operatively. Other clinical outcomes were favourable. Radiolucent lines were seen on fluoroscopy in three knees, but no sign of failure, such as loosening, collapse, or instability, was observed at the final follow-up. Double metal blocks augmentation is a favourable and useful method, which does not cause mechanical failure or protrusion of the prosthetic because of its modularity, to manage severe asymmetric uncontained proximal tibial bone defects >15 mm in total knee arthroplasty. Case series, Level IV.

Venous thromboembolism in amyotrophic lateral sclerosis: a prospective study.

To prospectively assess the incidence of both symptomatic and asymptomatic venous thromboembolism (VTE) in patients with amyotrophic lateral sclerosis (ALS) and to identify risk factors. Fifty outpatients with ALS were recruited consecutively and prospectively evaluated with bilateral venous duplex ultrasonography (VDU) of the proximal leg veins at enrollment and 6 and 12 months. The primary outcome measure was clinically important VTE, defined as asymptomatic proximal deep vein thrombosis (DVT) by screening VDU, symptomatically proven DVT or pulmonary embolism (PE), or fatal PE. For each patient, person-days of follow-up were recorded from enrollment until the date of VTE, death, loss to follow-up, or final 12-month visit. During the 1-year follow-up period, VTE was detected in 4 patients (1 symptomatic DVT, 1 symptomatic PE, and 2 asymptomatic DVTs) over 13,011 person-days of follow-up, representing an 11.2% 1-year incidence. Subjects with leg-onset ALS or significant leg weakness had a 1-year VTE incidence rate of 35.8% and 35.5%, respectively. VTE risk was significantly increased for those patients with decreased lower extremity Revised ALS Functional Rating Scale subscore (p = 0.03), decreased Lower Extremity Activity Scale score (p = 0.02), and decreased average lower limb Medical Research Council scale strength score (p = 0.03). Our data suggest that clinically important VTE is common in patients with ALS, particularly those with leg weakness and reduced mobility. Given these results, the potential benefits of routine VTE screening and primary prophylaxis in high-risk patients with ALS with leg weakness should be explored in future studies. In the meantime, physicians should have a low threshold for considering VTE in patients with ALS with leg weakness.

Intermediate Outcome of a Cruciate-retaining Tibia

The use of an all-polyethylene tibia in total knee arthroplasty is being revisited as a means to decrease backside polyethylene wear and lessen cost. The Depuy Sigma all-polyethylene tibia (Depuy Orthopedics, Warsaw, Indiana) has been reported with good outcomes at a greater than 10-year interval, whereas the Biomet AGC I beam design (Biomet, Warsaw, Indiana) has had a high failure rate at an early interval. This is a retrospective review of another design. One hundred seventy patients (190 cruciate-retaining total knee replacements) with a Scorpio (Stryker, Mahwah, New Jersey) all-polyethylene implant and tibia were identified in the authors' registry. This implant was chosen for all octogenarians deemed fit for a cruciate-retaining knee and a few septuagenarians who were deemed likely to remain inactive postoperatively for reasons other than knee arthritis. Mean follow-up was 38 months (range, 24-83 months). Mean patient age was 83.1 years (range, 72.7-93.8 years). Twenty-seven patients (29 knees) were lost to follow-up. Nineteen patients (24 knees) died before 24-month follow-up; all implants were in place, and no deaths were associated with the index procedure. Fifty-one patients (55 knees) were followed by telephone interview only and 75 patients (81 knees) by an office visit with radiograph analysis. One tibia revision was performed 2 months postoperatively for an implant placed in extension and varus. No infections, component wear, radiolucent lines, or impending revisions of the remaining cohort occurred. Lower Extremity Activity Scale scores ranged from 2 to 10 (mean score, 6.8), which demonstrated success even in patients with an active lifestyle. This previously unreported design is a promising all-polyethylene tibia alternative for total knee arthroplasty in older patients.

Recovery expectations of hip resurfacing compared to total hip arthroplasty: A matched pairs study

Expectations of higher activity levels associated with hip resurfacing arthroplasty (HRA) may be driving better outcomes in this group compared to total hip arthroplasty (THA). Previous studies evaluated patient expectations before consulting with the surgeon, although these expectations were likely unrealistic and would change after the consultation. We compared HRA and THA patient expectations after consultation with the surgeon. In a prospective registry setting, patients awaiting HRA were matched to THA patients by age, sex, and a preoperative Lower Extremity Activity Scale score (range 1-18, with 18 indicating levels of highest activity). Patients completed preoperatively a validated 18-item expectations survey. Mean overall expectation scores were first compared. Exploratory factor analysis (EFA) was then performed to determine if the grouping of individual expectations items represented meaningfully different underlying factors in the 2 groups. We matched 123 pairs. The mean ± SD expectation scores were similar (85.2 ± 15.5 for HRA and 87.3 ± 13.9 for THA; P = 0.249). The EFA showed that HRA and THA patients shared the common expectations of pain relief and improvement in daily activities (9 items) and eliminating pain medications, the need for a cane, and improving sexual activity (3 items). THA patients perceived the remaining 6 items as an overall third expectation of participation in higher-level activities. However, HRA patients perceived a fourth expectation of normal range of motion (2 items) independent of the other higher-level activities (4 items). Even after consulting with a surgeon, patients' expectations differed between HRA and THA patients regarding higher-level activities. More counseling for patients seeking hip arthroplasty is therefore needed.

A Short Tapered Stem Reduces Intraoperative Complications in Primary Total Hip Arthroplasty

While short-stem design is not a new concept, interest has surged with increasing utilization of less invasive techniques. Short stems are easier to insert through small incisions. Reliable long-term results including functional improvement, pain relief, and implant survival have been reported with standard tapered stems, but will a short taper perform as well? We compared short, flat-wedge, tapered, broach-only femoral stems to standard-length, double-tapered, ream and broach femoral stems in terms of intraoperative complications, short-term survivorship, and pain and function scores. We retrospectively reviewed the records of 606 patients who had 658 THAs using a less invasive direct lateral approach from January 2006 to March 2008. Three hundred sixty patients (389 hips) had standard-length stems and 246 (269 hips) had short stems. Age averaged 63 years, and body mass index averaged 30.7 kg/m(2). We recorded complications and pain and function scores and computed short-term survival. Minimum followup was 0.8 months (mean, 29.2 months; range, 0.8-62.2 months). We observed a higher rate of intraoperative complications with the standard-length stems (3.1%; three trochanteric avulsions, nine femoral fractures) compared with the shorter stems (0.4%; one femoral fracture) and managed all complications with application of one or more cerclage cables. There were no differences in implant survival, Harris hip score, and Lower Extremity Activity Scale score between groups. Fewer intraoperative complications occurred with the short stems, attesting to the easier insertion of these devices. While longer followup is required, our early results suggest shortened stems can be used with low complication rates and do not compromise the survival and functional outcome of cementless THA. Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Relationship Between Demographic Variables and Preoperative Pain and Disability in 5945 Total Joint Arthroplasties at a Single Institution

Using a prospective institutional registry, 5945 total joint arthroplasty patients were evaluated for the following preoperative variables: sex, age, living situation, pain (visual analog scale), and activity level (lower extremity activity scale). Univariate analysis was performed with χ 2, t test, and Pearson correlation coefficient. Patient age was inversely correlated with visual analog scale and lower extremity activity scale scores ( P < .0001). Whereas total hip arthroplasty was performed as equally in women and men, total knee arthroplasty was more frequent in women. Women were more likely to live alone, experience severe pain, and have limited activity ( P < .0001). Patients who lived alone were more likely to experience severe pain or limited activity ( P < .0001). Women and patients who live alone experience more pain and disability before surgery, potentially placing them at risk for inferior surgical outcomes.

Factors That Impact Expectations Before Total Knee Arthroplasty

This study examined the effect of patient attributes on expectations before total knee arthroplasty (TKA). A total of 1943 patients completed an Expectations Survey before TKA. Demographics, surgical history, baseline Medical Outcomes Study Short Form 36 (SF-36) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lower Extremity Activity Scale score were obtained. On univariate analysis, expectations (mean score, 77.6) correlated with SF-36 General Health, age, SF-36 Vitality, KOOS Quality-of-Life, and Lower Extremity Activity Scale. Living alone and history of joint arthroplasty were associated with significantly lower expectations, whereas male sex and white race were associated with higher expectations. On multivariate regression analysis, age, living situation, history of joint arthroplasty, SF-36 General Health, and KOOS Quality-of-Life remained significant predictors of expectations. Our results suggest that high, possibly unrealistic, expectations of TKA are common and should be moderated to maintain patient satisfaction.

Patterns of Functional Improvement After Revision Knee Arthroplasty

Despite the increase in the number of total knee arthroplasty revisions, outcomes of such surgery and their correlates are poorly understood. The aim of this study was to characterize patterns of functional improvement after revision total knee arthroplasty over a two-year period and to investigate factors that affect such improvement patterns. Three hundred and eight patients in need of revision surgery were enrolled into the study, conducted at seventeen centers, and 221 (71.8%) were followed for two years. Short Form-36 (SF-36), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Lower-Extremity Activity Scale (LEAS) scores were collected at baseline and every six months for two years postoperatively. A piecewise general linear mixed model, which models correlation between repeated measures and estimates separate slopes for different follow-up time periods, was employed to examine functional improvement patterns. Separate regression slopes were estimated for the zero to twelve-month and the twelve to twenty-four-month periods. The slopes for zero to twelve months showed significant improvement in all measures in the first year. The slopes for twelve to twenty-four months showed deterioration in the scores of the WOMAC pain subscale (slope = 0.67 +/- 0.21, p < 0.01) and function subscale (slope = 1.66 +/- 0.63, p < 0.05), whereas the slopes of the other measures had plateaued. A higher number of comorbidities was consistently the strongest deterrent of functional improvement across measures. The modes of failure of the primary total knee arthroplasty were instrument-specific predictors of outcome (for example, tibial bone lysis affected only the SF-36 physical component score [coefficient = -5.46 +/- 1.91, p < 0.01], while malalignment affected both the SF-36 physical component score [coefficient = 5.41 +/- 2.35, p < 0.05] and the LEAS score [coefficient = 1.42 +/- 0.69, p < 0.05]). Factors related to the surgical technique did not predict outcomes. The onset of worsening pain and knee-specific function in the second year following revision total knee arthroplasty indicates the need to closely monitor patients, irrespective of the mode of failure of the primary procedure or the surgical technique for the revision. This information may be especially important for patients with multiple comorbidities.