Does Surgical Approach Affect Patient-reported Function After Primary THA?

Background

Total hip arthroplasty (THA) relieves pain and improves physical function in patients with hip osteoarthritis, but requires a year or more for full postoperative recovery. Proponents of intermuscular surgical approaches believe that the direct-anterior approach may restore physical function more quickly than transgluteal approaches, perhaps because of diminished muscle trauma. To evaluate this, we compared patient-reported physical function and other outcome metrics during the first year after surgery between groups of patients who underwent primary THA either through the direct-anterior approach or posterior approach.

Questions/purposes

We asked: (1) Is a primary THA using a direct-anterior approach associated with better patient-reported physical function at early postoperative times (1 and 3 months) compared with a THA performed through the posterior approach? (2) Is the direct-anterior approach THA associated with shorter operative times and higher rates of noninstitutional discharge than a posterior approach THA?

Methods

Between October 2008 and February 2010, an arthroplasty fellowship-trained surgeon performed 135 THAs. All 135 were performed using the posterior approach. During that period, we used this approach when patients had any moderate to severe degenerative joint disease of the hip attributable to any type of arthritis refractory to nonoperative treatment measures. Of the patients who were treated with this approach, 21 (17%; 23 hips) were lost to followup, whereas 109 (83%; 112 hips) were available for followup at 1 year. Between February and September 2011, the same surgeon performed 86 THAs. All 86 were performed using the direct-anterior approach. During that period, we used this approach when patients with all types of moderate to severe degenerative joint disease had nonoperative treatment measures fail. Of the patients who were treated with this approach, 35 (41%; 35 hips) were lost to followup, whereas 51 (59%; 51 hips) were available for followup at 1 year. THAs during the surgeon’s direct-anterior approach learning period (February 2010 through January 2011) were excluded because both approaches were being used selectively depending on patient characteristics. Clinical outcomes included operative blood loss; allogeneic transfusion; adverse events; patient-reported Veterans RAND-12 Physical (PCS) and Mental Component Summary (MCS) scores, and University of California Los Angeles (UCLA) activity scores at 1 month, 3 months, and 1 year after surgery. Resource utilization outcomes included operative time, length of stay, and discharge disposition (home versus institution). Outcomes were compared using logistic and linear regression techniques.

Results

After controlling for relevant confounding variables including age, sex, and BMI, the direct-anterior approach was associated with worse adjusted MCS changes 1 and 3 months after surgery (1-month score change, −9; 95% CI, −13 to −5; standard error, 2), compared with the posterior approach (3-month score change, −9; 95% CI, −14 to −3; standard error, 3) (both p < 0.001), while the direct-anterior approach was associated with greater PCS improvement at 3 months compared with the posterior approach (score change, 6; 95% CI, 2–10; standard error, 2; p = 0.008). There were no differences in adjusted PCS at either 1 month or 12 months, and no clinically important differences in UCLA scores. Although the PCS score differences are greater than the minimum clinically important difference of 5 points for this endpoint, the clinical importance of such a small effect is questionable. At 1 year after THA, there were no intergroup differences in self-reported physical function, although both groups had significant loss-to-followup at that time. Operative time (skin incision to skin closure) between the two groups did not differ (81 versus 79 minutes; p = 0.411). Mean surgical blood loss (403 versus 293 mL; p < 0.001; adjusted, 119 more mL; 95% CI, 79–160; p < 0.001) and in-hospital transfusion rates (direct-anterior approach, 20% [17/86] versus posterior approach, 10% [14/135], p = 0.050; adjusted odds ratio, 3.6; 95% CI, 1.3–10.1; p = 0.016) were higher in the direct-anterior approach group. With the numbers available, there was no difference in the frequency of adverse events between groups when comparing intraoperative complications, perioperative Technical Expert Panel complications, and other non-Technical Expert Panel complications within 1 year of surgery, although this study was not adequately powered to detect differences in rare adverse events.

Conclusions

With suitable experience, the direct-anterior approach can be performed with expected results similar to those of the posterior approach. There may be transient and small benefits to the direct-anterior approach, including improved physical function at 3 months after surgery. However, the greater operative blood loss and greater likelihood of blood transfusions, even when the surgeon is experienced, may be a disadvantage. Given some of the kinds of bias present that we found, including loss to followup, the conclusions we present should be considered preliminary, but it appears that any benefits that accrue to the patients who had the direct-anterior approach would be transient and modest. Prospective randomized studies on the topic are needed to address the differences between surgical approaches more definitively.

Level of Evidence

Level III, therapeutic study.     

Can Preoperative Patient-reported Outcome Measures Be Used to Predict Meaningful Improvement in Function After TKA?

Background

Despite the overall effectiveness of total knee arthroplasty (TKA), a subset of patients do not experience expected improvements in pain, physical function, and quality of life as documented by patient-reported outcome measures (PROMs), which assess a patient’s physical and emotional health and pain. It is therefore important to develop preoperative tools capable of identifying patients unlikely to improve by a clinically important margin after surgery.

Questions/purposes

The purpose of this study was to determine if an association exists between preoperative PROM scores and patients’ likelihood of experiencing a clinically meaningful change in function 1 year after TKA.

Methods

A retrospective study design was used to evaluate preoperative and 1-year postoperative Knee injury and Osteoarthritis Outcome Score (KOOS) and SF-12 version 2 (SF12v2) scores from 562 patients who underwent primary unilateral TKA. This cohort represented 75% of the 750 patients who underwent surgery during that time period; a total of 188 others (25%) either did not complete PROM scores at the designated times or were lost to follow-up. Minimum clinically important differences (MCIDs) were calculated for each PROM using a distribution-based method and were used to define meaningful clinical improvement. MCID values for KOOS and SF12v2 physical component summary (PCS) scores were calculated to be 10 and 5, respectively. A receiver operating characteristic analysis was used to determine threshold values for preoperative KOOS and SF12v2 PCS scores and their respective predictive abilities. Threshold values defined the point after which the likelihood of clinically meaningful improvement began to diminish. Multivariate regression was used to control for the effect of preoperative mental and emotional health, patient attributes quantified by SF12v2 mental component summary (MCS) scores, on patients’ likelihood of experiencing meaningful improvement in function after surgery.

Results

Threshold values for preoperative KOOS and SF12v2 PCS scores were a maximum of 58 (area under the curve [AUC], 0.76; p < 0.001) and 34 (AUC, 0.65; p < 0.001), respectively. Patients scoring above these thresholds, indicating better preoperative function, were less likely to experience a clinically meaningful improvement in function after TKA. When accounting for mental and emotional health with a multivariate analysis, the predictive ability of both KOOS and SF12v2 PCS threshold values improved (AUCs increased to 0.80 and 0.71, respectively). Better preoperative mental and emotional health, as reflected by a higher MCS score, resulted in higher threshold values for KOOS and SF12v2 PCS.

Conclusions

We identified preoperative PROM threshold values that are associated with clinically meaningful improvements in functional outcome after TKA. Patients with preoperative KOOS or SF12v2 PCS scores above the defined threshold values have a diminishing probability of experiencing clinically meaningful improvement after TKA. Patients with worse baseline mental and emotional health (as defined by SF12v2 MCS score) have a lower probability of experiencing clinically important levels of functional improvement after surgery. The results of this study are directly applicable to patient-centered informed decision-making tools and may be used to facilitate discussions with patients regarding the expected benefit after TKA.

Level of Evidence

Level III, prognostic study.

     

Does Greater Knee Flexion Increase Patient Function and Satisfaction After Total Knee Arthroplasty?

The purpose of this study was to determine whether high flexion leads to improved benefits in patient satisfaction, perception, and function after total knee arthroplasty (TKA). Data were collected on 122 primary TKAs. Patients completed a Total Knee Function Questionnaire. Knees were classified as low (≤110°), mid (111°-130°), or high flexion (>130°). Correlation between knee flexion and satisfaction was not statistically significant. Increased knee flexion had a significant positive association with achievement of expectations, restoration of a “normal” knee, and functional improvement. In conclusion, although the degree of postoperative knee flexion did not affect patient satisfaction, it did influence fulfillment of expectations, functional ability, and knee perception. This suggests that increased knee flexion, particularly more than 130°, may lead to improved outcomes after TKA.     

Implant Survival,Knee Function,and Pain Relief After TKA: Are There Differences Between Men and Women?

Background  

As efforts continue to improve the results of TKA, the potential influence of sex and gender on long-term survival of implants, knee function, pain relief, and patient satisfaction remains relevant, particularly given the increased incidence of osteoarthritis of the knee in women and reports that women derive equal benefit from TKA.     

What Host Factors Affect Aseptic Loosening After THA and TKA?

Background

Aseptic loosening is the most common cause for revisions after lower-extremity total joint arthroplasties, however studies differ regarding the degree to which host factors influence loosening.

Questions/purpose

We performed a systematic review to determine which host factors play a role in the development of clinical and/or radiographic failure from aseptic loosening after (1) THA and (2) TKA.

Methods

Two searches on THA and TKA, respectively, using four electronic databases (EMBASE, CINAHL Plus, PubMed, and Scopus) were conducted. We identified a total of 209 reports that encompassed nine potential host factors affecting aseptic loosening. Inclusion criteria for consideration of scientific clinical reports were that 20 or more patients were involved, with more than 1-year followup, with at least three studies pertaining to each factor, and at least six of the Methodological Index for Non-randomized Studies criteria met, and with raw data for odds ratio (OR) calculations. Twenty-one studies (16 THA studies with 45,779 hips and five TKA studies with 288 knees, respectively) were used to calculate weighted OR and CIs (using the random effects theory) and study heterogeneity for four different host factors in THAs (male sex, high activity level, obesity defined as BMI ≥ 30 kg/m², and current or former tobacco use) and one factor in TKA (BMI ≥ 30 kg/m²), which were placed in a forest plot.

Results

For THA, male sex (OR, 1.39; 95% CI, 1.22–1.58; p = 0.001) and high activity level (University of California Los Angeles [UCLA] activity score ≥ 8 points; OR, 4.24; 95% CI, 2.46–7.31; p = 0.001) were associated with aseptic loosening. However, obesity (OR, 1.01; 95% CI, 0.73–1.40; p = 0.96), and tobacco use (OR, 1.96; 95% CI, 0.43–8.97; p = 0.39) were not associated with an increased risk of aseptic loosening after THA with the numbers available. For TKA, we found no host factors associated with loosening. In particular, obesity (BMI ≥ 30 kg/m²) was not associated with aseptic loosening with the numbers available (OR, 2.28; 95% CI, 0.60–8.62; p = 0.22).

Conclusions

Patients undergoing a lower-extremity total joint arthroplasty who engage in impact sports should be counseled regarding their potential increased risk of aseptic loosening; however, given the weak evidence available, we believe that higher-level studies are necessary to clearly define the risk factors, particularly with newer-generation constructs.

Level of Evidence

Level IV, therapeutic study.     

Outcome of Total Knee Arthroplasty After High Tibial Osteotomy: Does Malalignment Jeopardize the Results when Using a Posterior-Stabilized Arthroplasty?

Background

The controversy regarding the outcome of total knee arthroplasties after high tibial osteotomy may relate to malalignment secondary to overcorrection after high tibial osteotomy (HTO) [1, 2] and to the type of arthroplasty itself (posterior-stabilized arthroplasty or posterior cruciate ligament-retaining prosthesis).

Questions/Purpose

We asked two questions: (1) Would a posterior-stabilized arthroplasty provide sufficient constrain and improve pain and function in patients with severe malalignment due to a previous HTO? (2) Will malalignment of the previous HTO jeopardize the long-term results of a total knee reconstruction with a posterior-stabilized implant?

Patients and Methods

We retrospectively reviewed 25 posterior-stabilized TKAs in 25 patients with severe valgus deformity after HTO (ranging from 10° to 20° of valgus) and compared the results with a series of matched 25 posterior-stabilized TKAs in 25 patients with normocorrection after HTO ranging from 5° of valgus to 5° of varus. Clinical, operative, and radiographic data were reviewed. Minimum follow-up was 10 years after the arthroplasty (average, 15 years; range, 10–20 years).

Results

All the knees had standard posterior-stabilized total knee arthroplasty implants. Patients with an overcorrected HTO were more likely to require a soft tissue release to balance the knee. However, Average Knee Society and Function Score improved, respectively, from 48 to 85 and from 50 to 90 points in the severely overcorrected group, versus, respectively, 50 to 89 and 52 to 97 in the normocorrected group, but the range of mobility was superior for patients with normal alignment. Fifteen-year survivorship after the arthroplasty comparison showed no significant difference between the two groups (one revision in each group).

Conclusions

Patients with an overcorrected HTO are more likely to require a soft tissue release to balance the knee. However, both groups show improvements in function and pain. With a posterior-stabilized arthroplasty, the degree of deformity has no impact on the longevity of the TKA.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-013-9344-x) contains supplementary material, which is available to authorized users.     

Does Calipered Kinematically Aligned TKA Restore Native Left to Right Symmetry of the Lower Limb and Improve Function?

Background

Kinematically aligned total knee arthroplasty (KA TKA) strives to restore the native left to right symmetry of the lower limb; however, the reproducibility of achieving this target is unknown. The present study determined the proportion of patients with left to right symmetry and the improvement in patient-reported function after calipered KA TKA.

Does Ramosetron Reduce Postoperative Emesis and Pain after TKA?

Background  

Current pain management protocols involving many anesthetic and analgesic drugs reportedly provide adequate analgesia after TKA. However, control of emetic events associated with the drugs used in current multimodal pain management remains challenging.     

Whose Transplant Function Fails After Ureteral Revision Following Kidney Transplantation?

Background

Kidney transplantation is associated with ureteral complications in about 5% of cases. While many reasons for ureteral complications are known, it is currently unknown whether transplant outcomes are affected by operative revision of the transplanted ureter. In a retrospective analysis, we compared patients with versus without loss of transplant function after operative revision for a ureteral complication.

Patients and methods

Between 1997 and 2005, a total of 43 ureteral complications occurred in 636 patients (6.8%) after kidney transplantation. Thirty-one of 43 patients underwent open operative revision of the transplant ureter. One patient died from suicide. The remaining 30 patients were analyzed for clinical parameters and transplant outcome.

Results

At median 5-year follow-up, 18/30 patients (60%) had functioning transplants and 12/30 (40%) had returned to dialysis. Various parameters such as number of mismatches, ischemia times, number of previous transplantations, and interval from transplantation to occurrence of ureteral complication as well as posttransplant and postrevision serum creatinine values showed no influence on transplant outcomes.

Conclusions

In our retrospective analysis, transplant outcome was not affected by specific parameters associated with operative revision of the transplant ureter.     

Are Barbed Sutures Associated With 90-day Reoperation Rates After Primary TKA?

Background

Studies have suggested that barbed sutures for wound closure in TKAs are an acceptable alternative to standard methods. However others have observed a higher risk of wound-related complications with barbed sutures.

Questions/Purposes

(1) Do 90-day TKA reoperation rates differ between patients undergoing a barbed suture arthrotomy closure compared with a traditional interrupted closure? (2) Do the 90-day reoperation rates of wound-related, deep infection, and arthrotomy failure complications differ between barbed suture and traditional closures?

Methods

A retrospective analysis of a longitudinally maintained institutional primary TKA database was conducted on all TKAs performed between April 2011 and September 2015. We compared 884 primary TKAs, where the arthrotomy was closed with a barbed suture, with 1598 primary TKAs closed with the standard interrupted suture. After barbed sutures were introduced at our institution in 2012, the majority of surgeons gradually switched to barbed suture closures, with many using them exclusively by the end of the data collection period. We confirmed in-person followups and available data past 90 days for 97.4% (1556 of 1598) of the knees in patients with standard sutures and 94.8% (838 of 884) of the knees in patients with barbed sutures. Our primary endpoint was all-cause 90-day reoperation; our secondary endpoints considered: wound-related reoperation, as defined by previous studies; deep infection per Musculoskeletal Infection Society guidelines; and arthrotomy failure, defined intraoperatively as an opening or dehiscence through the previous arthrotomy closure. T tests and chi-square analyses were used to determine differences between the suture cohorts, and bivariate logistic regression was used to determine associations with our 90-day reoperation outcomes.

Results

With the numbers available, there was no association between suture type and 90-day all-cause reoperation (odds ratio [OR], 1.70; 95% CI, 0.82–3.53; p = 0.156). Suture type was not associated with wound-related reoperation (OR, 2.73; 95% CI, 0.97–7.69; p = 0.058). A 0.6% (five of 884) arthrotomy failure rate was observed in the barbed cohort while no (0 of 1598) arthrotomy failures were noted in the traditional group (p = 0.003). Deep infections were rare in both groups (two of 884 barbed sutures, 0 of 1598 standard sutures) and could not be compared.

Conclusions

Although we saw no difference in overall and wound-related 90-day reoperation rates by suture type with the numbers available, we observed a higher frequency in our secondary question of arthrotomy failures when barbed sutures are used for arthrotomy closure during TKA. Given the widespread use of this closure technique, our preliminary pilot results warrant further investigation in larger multicenter cohorts.

Level of Evidence

Level III, therapeutic study.

     

Does Disability Correlate With Impairment After Hand Injury?

Background

Any loss or deviation in body function and structure is considered impairment, whereas limitations on activities are fundamental to the definition of disability. Although it seems intuitive that the two should be closely related, this might not be the case; there is some evidence that psychosocial factors are more important determinants of disability than are objective impairments. However, the degree to which this is the case has been incompletely explored.

Questions/purposes

The purpose of this study was to determine if disability (as measured by the Disabilities of the Arm, Shoulder and Hand [DASH] and the Michigan Hand Questionnaire [MHQ]) and pain intensity correlate with impairment (as measured by the American Medical Association [AMA] impairment guide). Secondary study questions addressed the effect of pain intensity and symptom of depression on predicting disability.

Methods

Impairment and disability were evaluated in a sample of 107 hand-injured patients a mean of 11 months after injury. Impairment rating was performed prospectively. From the patients who came for therapy, they were invited to fill out the questionnaire and evaluated for impairment rating. Response variables of DASH, MHQ, and visual analog scale pain intensity values were collected at the same setting. Other explanatory variables included demographic, injury-related, and psychological factors (symptoms of depression measured with the Beck Depression Inventory). Initial bivariate and multivariate analyses were performed to determine correlations of disability and pain to impairment rating and other exploratory variables.

Results

Disability as measured by the DASH showed intermediate correlation with AMA impairment (r = 0 .38, beta = 0.36, p = 0.000). Together with gender, it accounted for only 22% of the variability in DASH scores. Similarly, MHQ score correlated with impairment rating (r = −0.24, beta = −0.23, p < 0.05). However, together with age, injured hand accounted for only 19% of the variability in MHQ scores. However, pain intensity did not correlate with impairment (r = −0.46, p > 0.05). Interestingly, pain intensity did correlate with the time passed from surgery but it was correlated with symptom of depression (r² = 0.10, beta = 0.33, p = 0.001).

Conclusions

The limited correlation between impairment and disability emphasizes the importance of factors other than pathophysiology in human illness behavior. These may include physical (pain, dominant injured hand) and conditional factors (time since surgery) or psychological factors such as depression and adapting; all mentioned can be considered as personal factors that may be different in each patient. So considering personal difference and any other condition except the impairment alone can help to better plan interventions and also diminish disability level.

Level of Evidence

Level III, therapeutic study.