Relationships Between Preoperative Mental Health and Improvements in Patient-Reported Outcomes After Total Hip and Knee Arthroplasty

BackgroundPoor preoperative mental health has been associated with worse outcomes after total hip (THA) and total knee arthroplasty (TKA). To fully understand these relationships, we assessed post-THA and post-TKA improvements in patient-reported mental and joint health by preoperative mental health groups.MethodsElective cases (367 THA, 462 TKA) were subgrouped by low (<25th percentile), middle (25th-74th), and high (≥75th) preoperative mental health, using Veterans RAND 12-Item Health Survey Mental Component Summary (MCS) scores. In each subgroup, we assessed the relationship between preoperative MCS and 1-year postoperative change in mental and joint health. Pairwise comparisons and multivariable regression models were applied for THA and TKA separately.ResultsMedian postoperative mental health change was +14.0 points for the low-MCS THA group, +11.1 low-TKA, +2.0 middle-THA and TKA, −4.0 high-THA, and −4.9 high-TKA (between-group differences P < .001). All MCS groups had improved median joint health scores, without significant between-group differences. Preoperative mental health was negatively associated with mental health improvements in all groups (B = −0.94 - −0.68, P < .001-P = .01) but with improvements in joint health only in the low-THA group (B = −0.74, P = .02). Improvements in mental and joint health were positively associated for low and middle (B = 0.61-0.87, P < .001), but not for high-MCS groups, with this relationship differing for the low versus high group.ConclusionPatients who have low preoperative mental health experienced greater postoperative mental health improvement and similar joint health improvement compared to patients who have high preoperative mental health. Findings can guide subgroup-targeted surgical decision-making and preoperative counseling.     

Preoperative Mental Health Influences Patient-Reported Outcome Measures and Satisfaction After Revision Total Knee Arthroplasty

BackgroundA higher prevalence of mental health conditions has been reported in patients undergoing revision total knee arthroplasty (rTKA). This study investigated the effect of preoperative mental health on patient-reported outcome measures (PROMs) and satisfaction after rTKA.MethodsA total of 245 patients who underwent rTKA in 2004-2018 were identified from our institutional joint registry. The most common indications were aseptic loosening (n = 111), infection (n = 70), and instability (n = 35). 36-item Short-Form health survey (SF-36) mental component summary (MCS) was used to stratify the cohort into: Low-MCS (SF-36 MCS <50; n = 112) and control (SF-36 MCS ≥50; n = 133) groups. Knee Society score, Oxford knee score, SF-36 physical score, and a satisfaction questionnaire were used to compare the low-MCS and control at 6 months and 2 years.ResultsAll PROMs were poorer in the low-MCS group at 6 months and 2 years. However, both groups demonstrated a comparable improvement in each PROM and a similar proportion attained the minimal clinically important difference. Fewer patients in the low-MCS group were satisfied at 2 years (72.2% vs 84.5%, P = .045). Lower preoperative SF-36 MCS was independently associated with increased odds of dissatisfaction (OR 1.037, 95% CI 1.004-1.070, P = .027). Although the change in SF-36 MCS was greater in the low-MCS group, the final value remained lower at 2 years.ConclusionWhile patients with poor mental health had inferior PROMs preoperatively and postoperatively, a similar percentage experienced a clinically meaningful improvement at 2 years. Perioperative optimization of psychological factors should still be emphasized as these patients were at a higher risk of dissatisfaction after rTKA.     

Total Knee Arthroplasty Has A Positive Effect on Patients With Low Mental Health Scores

BackgroundThe purpose of this study is to determine the impact of total knee arthroplasty (TKA) on mental health.MethodsA total of 205 patients who underwent primary TKA with baseline and 1-year postoperative Short Form-12 Mental Component Score (MCS) were included in this retrospective analysis. Eighty-five (41%) patients had a preoperative MCS less than 50 points, while 120 (59%) patients had a preoperative MCS over 50 points. Two groups were assigned to the patients based on their preoperative MCS: low MCS <50 and high MCS >50.ResultsA preoperative MCS less than 50 points was predictive of greater improvement in MCS at 1 year after TKA (P < .001). Patients with low MCS improved by a mean of 10.6 points from 39.1 ± 8.6 points preoperatively to mean of 49.7 ± 10.7 points 1 year after TKA (P < .001). Patients with a high MCS decreased by a mean of 3.5 points from 60.01 ± 6.0 points preoperatively to mean of 56.6 ± 6.8 points 1 year after TKA (P < .001). This remained higher than the postoperative MCS of the patients with a low MCS, 49.7 ± 10.7 (P < .001). The patients with a high MCS had greater improvement in the Short Form-12-Physical domain (14.8 points) than the patients with a low MCS (9.2 points, P < .001).ConclusionPatients with lower baseline mental health had greater improvement in postoperative mental health following TKA than patients with higher baseline mental health. Low preoperative MCS was associated with less improvement in patient-reported outcome measures. Patients with lower baseline mental health scores before TKA benefit mentally and physically from the procedure.     

No Major Functional Benefit After Bicompartmental Knee Arthroplasty Compared to Total Knee Arthroplasty at 5-Year Follow-Up

BackgroundIn case of isolated medial and patellofemoral joint arthritis, bicompartmental knee arthroplasty (BCA) is an alternative to total knee arthroplasty (TKA). The purpose of our prospective, randomized study is to compare the clinical outcome of BCA vs TKA.MethodsEighty patients with isolated medial and patellofemoral osteoarthritis were randomly assigned to either BCA or TKA. Patients were evaluated preoperatively, 3, 6, and 12 months, and 2 and 5 years after the procedure. Knee Society Score, Oxford Knee Score, and the University of California,Los Angeles activity scores were calculated at each follow-up; Forgotten Joint Score was assessed at final follow-up.ResultsThere was an improvement in Knee Society Score, Oxford Knee Score, and the University of California,Los Angeles scores in both groups but no significant differences between both groups at any follow-up. The Forgotten Joint Score at 5-year follow-up was not significantly different either. Range of motion was significantly greater in the BCA group from 1-year follow-up onward.ConclusionOur study did not show significant differences in clinical scores between BCA and TKA; only range of motion was significantly greater in BCA. Therefore, it is questionable whether this difference justifies the complexity of BCA associated with higher risk of failure. Maybe staged patellofemoral joint arthroplasty in the presence of a well-functioning UKA is an option for BCA and an alternative to revision to TKA. Long-term studies are needed to explore the potential benefits of BCA.     

全膝关节置换术后下肢绝对长度的变化模式

目的探讨全膝关节置换术(total knee arthroplasty,TKA)术后下肢绝对长度的变化模式。方法前瞻性分析2014年1月至2017年12月56例行全膝关节置换术治疗终末期骨关节炎患者的临床资料,其中男14例,女42例;年龄为56-82岁,平均为(71.6±2.4)岁。根据术前内翻的程度将患者分为两组,内翻畸形<5°为A组,10°≥内翻畸形≥5°为B组,每组28例。术中在股骨前侧和胫骨前侧分别做标记,记录截骨前膝关节完全伸直位和安装假体后膝关节完全伸直位,分别测量截骨前及假体安装后两标记点之间的距离,两次距离的差值就是下肢绝对长度的变化值。术前及术后记录两组的下肢负重位全长X线的机械力线、膝关节活动范围、美国膝关节协会评分(knee society score,KSS)和功能评分,同时记录术后患者的满意率和对肢体长度变化的感知率。TKA术前A组膝关节活动范围(78.5±30.2)°,KSS评分(64.8±11.6)分,功能评分(62.8±9.8)分,机械轴线平均内翻(3.8±1.2)°;B组膝关节活动范围(76.4±31.4)°,KSS评分(63.4±10.4)分,功能评分(60.6±9.6)分,机械轴线平均内翻(7.4±2.3)°。结果 56例患者均获随访,随访时间6-40个月,平均(18.4±4.6)个月。所有患者未出现感染及假体松动。术后6个月时,A组膝关节活动范围(96.4±28.4)°,KSS评分(86.2±10.4)分,功能评分(83.6±9.6)分,机械轴线平均内翻(1.6±1.1)°;B组膝关节活动范围(94.6±26.6)°,KSS评分(84.8±10.2)分,功能评分(86.2±9.2)分,机械轴线平均内翻(1.8±1.2)°。两组均较术前明显改善,差异有统计学意义(P<0.05)。两组术后KSS及功能评分比较,差异无统计学意义(P>0.05)。总体来说,82.1%(46/56)的患者术后肢体绝对长度增加,其中A组为71.4%(20/28),B组为92.9%(26/28),差异有统计学意义(P<0.05)。术后能感知肢体长度有变化的患者约50.0%(28/56),其中A组为35.7%(10/28),B组为64.3%(18/28),差异有统计学意义(P<0.05)。因感觉肢体长度变化而不满意的患者约为24.2%。术后半年,感知肢体长度有变化的患者下降为14.3%(8/56),其中A组为10.7%(3/28),B组为17.9%(5/28),差异无统计学意义(P>0.05)。因感觉肢体长度有变化而不满意的患者下降为3.6%(2/56)。结论应用TKA治疗晚期骨关节炎,可明显改善功能,缓解疼痛,恢复肢体的下肢力线。但是,大多数患者置换术后肢体绝对长度会发生变化,而且这种变化的幅度和术前膝关节内翻的程度相关。术后部分患者会对这种变化有明显的感知,进而可能影响治疗总体的满意率。     

Social Determinants of Health and Patient-Reported Outcomes Following Total Hip and Knee Arthroplasty in Veterans

BackgroundSocial determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age. They are associated with disparities in outcomes following total joint arthroplasty (TJA). These disparities occur even in equal-access healthcare systems such as the Veterans Health Administration (VHA). Our goal was to determine whether SDOH affect patient-reported outcome measures (PROMs) following TJA in VHA patients.MethodsPatients scheduled to undergo total hip or knee arthroplasty at VHA Hospitals in Minneapolis, MN, Palo Alto, CA, and San Francisco, CA, prospectively completed PROMs before and 1 year after surgery. PROMs included the Hip disability and Osteoarthritis Outcome Score, the Knee injury and Osteoarthritis Outcome Score, and their Joint Replacement subscores. SDOH included race, ethnicity, marital status, education, and employment status. The level of poverty in each patient’s neighborhood was determined. Medical comorbidities were recorded. Univariate and multivariate analyses were performed to determine whether SDOH were significantly associated with PROM improvement after surgery.ResultsOn multivariate analysis, black race was significantly negatively correlated with knee PROM improvement and Hispanic ethnicity was significantly negatively correlated with hip PROM improvement compared to whites. Higher baseline PROM scores and lower age were significantly associated with lower PROM improvement. Significant associations were also found based on education, gender, comorbidities, and neighborhood poverty.ConclusionMinority VHA patients have lower improvement in PROM scores after TJA than white patients. Further research is required to identify the reasons for these disparities and to design interventions to reduce them.     

Negative Association of Subclinical Hypothyroidism on Improvement in Patient-Reported Outcomes After Total Knee Arthroplasty

BackgroundThe purpose of this study is to analyze the potential influence of subclinical hypothyroidism (SCH) on improvement in patient-reported outcome measures following primary total knee arthroplasty.MethodsA prospective, comparative cohort study between 92 SCH and 90 euthyroid patients was performed. Patients were followed up to 5 postoperative years. Patient-reported outcome measure was assessed by the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire. The Knee Society Scores were used for functional evaluation, and 5-point Likert scale for patient satisfaction. The Hospital Anxiety and Depression scale was also used.ResultsAll outcome scores significantly improved from preoperative to final follow-up in both groups (P = .001). There were no significant differences between groups in Knee Society Scores (P = .057) at the final follow-up, but Western Ontario and McMaster Universities Osteoarthritis Index scores were significantly lower in the SCH group (P = .015). Likewise, the patient satisfaction rate was significant lower in the SCH group (0.010).ConclusionSCH patients have a slower functional recovery than euthyroid patients, and trended toward lower improvements in patient-reported scores. Depression was the most important negative factor. The findings of this study can provide the surgeon with an important information for better counseling the SCH patients.     

The Effect of Joint Line Elevation on Patient-Reported Outcomes After Contemporary Revision Total Knee Arthroplasty

BackgroundJoint line elevation in revision total knee arthroplasty (rTKA) is considered a risk factor for inferior outcomes, engendering a dogmatic protocol of joint line restoration. However, this precedent is based on historical data using rudimentary revision systems and unvalidated outcome measures. This study’s purpose was to evaluate the effect of joint line height elevation on validated patient-reported outcome measures (PROMs) using modern revision implants.MethodsA total of 327 rTKAs performed at a single institution were reviewed. Surgical technique prioritized flexion-extension gap balancing and accepted joint line elevation if necessary to achieve a balanced flexion space. Radiographic measurements included changes in joint line height (from preoperative and calculated “intended” anatomic/native) and change in posterior condylar offset. Prospectively collected PROMs were evaluated using multivariate regression.ResultsThe mean joint line elevation from preoperative and “intended” to postoperative joint line was 4.9 ± 5.7 mm and 7.2 ± 6.6 mm, respectively. The mean increase in posterior condylar offset was 1.0 ± 4.6 mm. Patients within ±5 mm of preoperative joint line height were 3.88× more likely to achieve the substantial clinical benefit for Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (P = .004). An increase from intended joint line height >5 mm was not associated with differences in any other PROMs (P ≥ .165).ConclusionsIn contemporary rTKA, recreating the joint line within 5 mm of preoperative improves knee-specific health outcomes. These data support approximating native joint line height as a viable technique to optimize flexion gap balance and subsequent patient outcomes in rTKA.Level of EvidenceLevel III retrospective cohort study.     

Self-Directed Home Exercises vs Outpatient Physical Therapy After Total Knee Arthroplasty: Value and Outcomes Following a Protocol Change

BackgroundThe need for outpatient physical therapy (OPPT) has been questioned following primary total knee arthroplasty (TKA). Recent studies have suggested that similar outcomes may be possible with self-directed home exercise programs (HEP) compared to OPPT, which can be costly to both the patient and healthcare system. The aim of the present study is to compare the safety, efficacy, and health economics of formal OPPT with self-directed home exercises after TKA following a protocol change.MethodsA single-surgeon, retrospective study of 520 consecutive patients undergoing primary unilateral TKA from 2016 to 2018 was performed. All 251 TKAs performed in 2016 were routinely prescribed OPPT, while all 269 TKAs in 2017 completed a self-directed HEP alone for 2 weeks. At their 2-week visit, OPPT was prescribed if patients had less than 90° range of motion or per patient request. Financial data of postdischarge costs were collected for all patients. Multivariate logistic regression evaluated for variables associated with failure of the HEP program.ResultsOverall, 65.8% (177/269) of patients in the HEP group did not require OPPT. There was no significant difference in percentage of patients whose range of motion was less than 90° at 2-week follow-up between OPPT and HEP (14% vs 11.9%, P = .467). Between OPPT and HEP, there were no differences in manipulation under anesthesia (3.2% vs 3%, P = .883). On average, patients who received OPPT incurred an increase in average cost of $1340.87 and $1893.42 for Medicare and private insurer patients, respectively. We did not identify any significant risk factors for failing HEP.ConclusionComparable outcomes were demonstrated between patients receiving HEP compared to OPPT with a substantial cost saving. While a portion of patients still require formal OPPT, the majority do not. Surgeons should consider an initial trial of HEP with close follow-up in order to limit unnecessary costs associated with OPPT.     

The Benefit in Patient-Reported Outcomes After Total Knee Arthroplasty was Comparable Across Income Quartiles

BackgroundFew studies have assessed how socioeconomic status (SES) influences patient-reported outcomes (PROMs) after total knee arthroplasty (TKA). This study evaluated the impact of patient median ZIP code income levels on PROMs after TKA.MethodsWe retrospectively reviewed patients at our institution undergoing primary, unilateral TKA from 2017 to 2020. Patients who did not have one-year postoperative PROMs were excluded. Patients were stratified based on the quartile of their home ZIP code median income from United States Census Bureau data. There were 1,267 patients included: 98 in quartile 1 (median income ≤ $46,308) (7.7%); 126 in quartile 2 (median income $46,309-$57,848) (10.0%); 194 in quartile 3 (median income $57,849-$74,011) (15.7%); and 849 in quartile 4 (median income ≥ $74,012) (66.4%). We collected baseline demographic data, 2-year outcomes, and PROMs preoperatively, as well as at 12 weeks and one year, postoperatively.ResultsThe Knee Injury and Osteoarthritis Outcome Score for Joint Replacement was significantly higher in quartile 4 preoperatively (P < .001), 12 weeks postoperatively (P < .001), and one year postoperatively (P < .001). There were no significant differences in delta improvements of Knee Injury and Osteoarthritis Outcome Score for Joint Replacement from preoperative to 12 weeks or one year postoperatively. There were no significant differences in lengths of stay, discharge dispositions, readmissions, or revisions.ConclusionPatients from lower income areas have slightly worse knee function preoperatively and worse outcomes following TKA. However, improvements in PROMs throughout the first year postoperatively are similar across income quartiles, suggesting that patients from lower income quartiles achieve comparable therapeutic benefits from TKA.Level III EvidenceRetrospective Cohort Study.     

Achieving Deep Flexion After Primary Total Knee Arthroplasty

Total knee arthroplasty patients often have difficulty performing activities involving flexion beyond 130°. The NexGen LPS Flex (Zimmer Inc, Warsaw, Ind) mobile bearing implant accommodates up to 155° of flexion. Two hundred eighteen total knee arthroplasties were performed using this implant on 125 patients over a 2-year period with a minimum of 5 years follow-up. All data were collected prospectively. Forty-four percent of preoperative cases had full flexion (ie, 140° active flexion and ability to kneel with thigh/calf contact for 1 minute). Five-year data showed an average flexion of 140° ± 11.5° and flexion greater than 140° in 103 knees (68%). There were no differences in patellofemoral pain levels, complications, or Knee Society scores despite our patients having, on average, an increase in flexion and function.     

Causes of Instability After Total Knee Arthroplasty

The purpose of the present study was to characterize the underlying causes that lead to instability after total knee arthroplasty (TKA). We reviewed 83 revision TKAs (79 patients) performed for instability. After detailed analysis of patient's history, physical examination, operative report and radiographs, we identified six categories: flexion/extension gap mismatch, component malposition, isolated ligament insufficiency, extensor mechanism insufficiency, component loosening, and global instability. Twenty-five knees presented with multi-factorial instability. When these knees were classified according to the most fundamental category, each category above included 24, 12, 11, 10, 10 and 16 knees respectively. The unstable TKA may result from a variety of distinct etiologies which must be identified and treated at the time of revision. The revision TKA could be tailored to the specific causes.     

Functional Outcome of Total Knee Arthroplasty After Periprosthetic Distal Femoral Fracture

A prospective matched cohort study was performed to compare functional outcomes between 28 patients with periprosthetic femoral fractures and 28 with primary total knee arthroplasties (TKA). The mean follow-up was 6.7 years (range, 5–9). Radiographic osteopenia was a predisposing factor, but not notching, body mass index, or preinjury knee scores or motion. At last follow-up, the Knee Society scores, knee motion, Womac, and SF-12 were significantly lower in the fracture group, and were significantly decreased compared to the preinjury status. We found that periprosthetic distal femoral fracture after TKA worsens functional outcomes at the medium term, but arthroplasty complication and survival rates were similar in both groups.     

Chronic Thrombocytopenia and In-Hospital Outcomes After Primary Total Hip and Knee Arthroplasty

BackgroundThere is a lack of data on the influence of chronic thrombocytopenia (cTCP) on clinical outcomes following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Limited studies mainly focused on postoperative heparin-induced TCP from single centers with small sample sizes. This study aims to describe the characteristics, trend, and outcomes of cTCP in patients undergoing THA and TKA from a nationally reprehensive perspective.MethodsWe identified THA and TKA patients with and without cTCP from the 2005 to 2015 Nationwide Inpatient Sample. Annual percent changes were calculated to reflect cTCP trends. Multivariable regression and propensity score analyses were conducted to investigate the association of cTCP and mortality, preoperative complications, cost as well as length of stay.ResultsIn total, 578,278 and 1,237,331 patients underwent primary THA and TKA, respectively. Proportion of cTCP annually increased by 6.95% in THA and 6.66% in TKA. Patients with cTCP were associated with higher risk of medical (odds ratio [OR] 2.00, 95% confidence interval [CI] 1.89-2.11) and surgical complications (OR 2.72, 95% CI 2.55-2.90) in THA, and higher risk of mortality (OR 1.68, 95% CI 1.22-2.31), medical (OR 1.94, 95% CI 1.85-2.03) and surgical complications (OR 2.55, 95% CI 2.38-2.73) in TKA. Additionally, higher cost and longer length of stay were observed in patients with cTCP for both surgical procedures.ConclusionPatients with cTCP had higher risk of mortality for TKA, more perioperative complications for both TKA and THA. Further studies are warranted to improve the preoperative management and to prevent worse outcomes associated with cTCP.     

Stiffness After Revision Total Knee Arthroplasty

Stiffness after a revision total knee arthroplasty (TKA) is a disabling complication that has largely been overlooked in the literature. This study attempts to define the prevalence of stiffness after revision TKA and to determine the risk factors that may lead to its development. Thirty-two knees (4.0%) presented with stiffness that we defined as a range of motion less than 90°. Risk factors were found to be poor preoperative range of motion, stiffness as primary indication for revision, younger age, shorter interval between index primary and revision TKA, presence of well-fixed components at the time of revision, postoperative wound drainage, and lower Charlson index. Because of the challenges of treating stiffness, efforts should be invested in preventing this complication.     

Predictors of Patient-Reported Pain and Functional Outcomes Over 10 Years After Primary Total Knee Arthroplasty: A Prospective Cohort Study

Background

This study aimed at identifying preoperative predictors of patient-reported outcomes after total knee arthroplasty (TKA) and at investigating their association with the outcomes over time.

Intraoperative Medial Pivot Affects Deep Knee Flexion Angle and Patient-Reported Outcomes After Total Knee Arthroplasty

The aim of this study was to evaluate the relationship between clinical results including patient-reported outcomes and intraoperative knee kinematic patterns after total knee arthroplasty (TKA). A cross-sectional survey of forty consecutive medial osteoarthritis patients who had a primary TKA using a CT-based navigation system was conducted. Subjects were divided into two groups based on intraoperative kinematic patterns: a medial pivot group (n = 20) and a non-medial pivot group (n = 20). Subjective outcomes with the new Knee Society Score and clinical outcomes were evaluated. The functional activities, patient satisfaction and the knee flexion angle of the medial pivot group were significantly better than those of the non-medial pivot group. An intraoperative medial pivot pattern positively influences deep knee flexion and patient-reported outcomes.     

Good Postoperative Flexion Angle Improves Knee Function and Improvement of Flexion Angle Increases Patient Satisfaction After Total Knee Arthroplasty

BackgroundTotal knee arthroplasty (TKA) is a well-established procedure for treating knee joint diseases. However, the postoperative range of motion (ROM) varies and is an important indicator of TKA success. Recently, patient-reported outcome measures (PROMs) and patient satisfaction have drawn attention. However, the relationship between ROM and knee function obtained by PROM and satisfaction is not well understood.MethodsWe retrospectively reviewed the data of 375 patients who underwent 500 primary TKA procedures. We measured the ROM before and after surgery. Knee joint function was evaluated using the Knee Injury Osteoarthritis Outcome Score, a PROM, and patients were classified into good function and poor function groups. Patient satisfaction was evaluated on a 5-graded scale as overall satisfaction, and patients were divided into a satisfied or a dissatisfied group according to the obtained scores. ROM was compared between the 2 groups, then significantly different factors were analyzed using multiple logistic regression analysis. Moreover, cut-off points of ROM for obtaining good function and patient satisfaction were determined using ROC curve analysis.ResultsThe postoperative flexion angle had a significant effect on knee function (P < .001). The cut-off value of the postoperative flexion angle for good knee function was 120°. The improvement in flexion angle had a significant effect on patient satisfaction (P = .004). The cut-off value for the improvement in the flexion angle was 5°.ConclusionThe postoperative flexion angle had a significant effect on knee function and improvement in the flexion angle had a significant effect on patient satisfaction.