Stable fixation of an ultra-short femoral neck-preserving hip prosthesis: a 5-year RSA, DXA, and clinical prospective outcome study of 48 patients.

BACKGROUND AND PURPOSE: We previously showed promising primary stability and preservation of bone stock with the ultra-short neck-loading hip implant in total hip arthroplasty (THA). The aim of this study was to evaluate clinical outcome, implant stability, and bone mineral density (BMD). METHODS: 50 patients were treated with the ultra-short neck Primoris hip implant at baseline and 48 were available for evaluation at 5-year follow-up. 5 different patient-reported outcome measures (PROMs) including hip-specific scores, disease-specific and generic quality of life outcome measures, and an activity score were used. Furthermore, implant stability using radiostereometric analysis (RSA) and assessment of periprosthetic BMD using dual-energy X-ray absorptiometry (DXA) were applied. RESULTS: By 1-year follow-up, all PROMs showed improvements and remained high at 5-year follow-up. After initial distal translation (subsidence) and negative rotation around the z-axis (varus tilt) the implant showed stable fixation at 5-year follow-up with no further migration beyond 12 months. In the regions of interest (ROI) 3 and 4, BMD remained stable. In ROI 2, further bone loss of 12% was found at 5-year follow-up. CONCLUSION: Clinical outcome including PROMs was satisfying throughout the 5-year follow-up period. The hip implant remains stable with both bone preservation and loss 5 years after surgery.

Patients in high- and low-revision hospitals have similar outcomes after primary knee arthroplasty: 1-year postoperative results from the Danish prospective multicenter cohort study, SPARK.

PURPOSE: It is well-known that revision rates after primary knee arthroplasty vary widely. However, it is uncertain whether hospital revision rates are reliable indicators of general surgical quality as defined by patients. The SPARK study compared primary knee arthroplasty surgery at three high-volume hospitals whose revision rates differed for unknown reasons. METHODS: This prospective observational study included primary knee arthroplasty patients (total, medial/lateral unicompartmental and patellofemoral) in two low-revision hospitals (Aarhus University Hospital and Aalborg University Hospital Farsø) and one high-revision hospital (Copenhagen University Hospital Herlev-Gentofte). Patients were followed from preoperatively (2016-17) to 1-year postoperatively with patient-reported outcome measures including Oxford Knee Score (OKS), EQ-5D-5L and Copenhagen Knee ROM (range of motion) Scale. The surgical outcomes were compared across hospitals for patients with comparable grades of radiographic knee osteoarthritis and preoperative OKS. Statistical comparisons (parametric and non-parametric) included all three hospitals. RESULTS: 97% of the 1452 patients who provided baseline data (89% of those included and 56% of those operated) responded postoperatively (90% at 1 year). Hospitals' utilization of unicompartmental knee arthroplasties differed (Aarhus 49%, Aalborg 14%, and Copenhagen 22%, p < 0.001). 28 patients had revision surgery during the first year (hospital independent, p = 0.1) and were subsequently excluded. 1-year OKS (39 ± 7) was independent of hospital (p = 0.1), even when adjusted for age, sex, Body Mass Index, baseline OKS and osteoarthritis grading. 15% of patients improved less than Minimal Important Change (8 OKS) (Aarhus 19%, Aalborg 13% and Copenhagen 14%, p = 0.051 unadjusted). Patients with comparable preoperative OKS or osteoarthritis grading had similar 1-year results across hospitals (OKS and willingness to repeat surgery, p ≥ 0.087) except for the 64 patients with Kellgren-Lawrence grade-4 (Aarhus 4-6 OKS points lower). 86% of patients were satisfied, and 92% were "willing to repeat surgery", independent of hospital (p ≥ 0.1). Hospital revision rates differences diminished during the study period. CONCLUSIONS: Patients in hospitals with a history of differing revision rates had comparable patient-reported outcomes 1 year after primary knee arthroplasty, supporting that surgical quality should not be evaluated by revision rates alone. Future studies should explore if revision rate variations may depend as much on revision thresholds and indications as on outcomes of primary surgery. LEVEL OF EVIDENCE: Level II (Prospective cohort study).

Hospital variation in revision rates after primary knee arthroplasty was not explained by patient selection: baseline data from 1452 patients in the Danish prospective multicenter cohort study, SPARK.

PURPOSE: Revision rates following primary knee arthroplasty vary by country, region and hospital. The SPARK study was initiated to compare primary surgery across three Danish regions with consistently different revision rates. The present study investigated whether the variations were associated with differences in the primary patient selection. METHODS: A prospective observational cohort study included patients scheduled Sep 2016 Dec 2017 for primary knee arthroplasty (total, medial/lateral unicompartmental or patellofemoral) at three high-volume hospitals, representing regions with 2-year cumulative revision rates of 1, 2 and 5%, respectively. Hospitals were compared with respects to patient demographics, preoperative patient-reported outcome measures, motivations for surgery, implant selection, radiological osteoarthritis and the regional incidence of primary surgery. Statistical tests (parametric and non-parametric) comprised all three hospitals. RESULTS: Baseline data was provided by 1452 patients (89% of included patients, 56% of available patients). Patients in Copenhagen (Herlev-Gentofte Hospital, high-revision) were older (68.6 ± 9 years) than those in low-revision hospitals (Aarhus 66.6 ± 10 y. and Aalborg (Farsø) 67.3 ± 9 y., p = 0.002). In Aalborg, patients who had higher Body Mass Index (mean 30.2 kg/m2 versus 28.2 (Aarhus) and 28.7 kg/m2 (Copenhagen), p < 0.001), were more likely to be male (56% versus 45 and 43%, respectively, p = 0.002), and exhibited fewer anxiety and depression symptoms (EQ-5D-5L) (24% versus 34 and 38%, p = 0.01). The preoperative Oxford Knee Score (23.3 ± 7), UCLA Activity Scale (4.7 ± 2), range of motion (Copenhagen Knee ROM Scale) and patient motivations were comparable across hospitals but varied with implant type. Radiological classification ≥ 2 was observed in 94% (Kellgren-Lawrence) and 67% (Ahlbäck) and was more frequent in Aarhus (low-revision) (p ≤ 0.02), where unicompartmental implants were utilized most (49% versus 14 (Aalborg) and 23% (Copenhagen), p < 0.001). In the Capital Region (Copenhagen), the incidence of surgery was 15-28% higher (p < 0.001). CONCLUSION: Patient-reported outcome measures prior to primary knee arthroplasty were comparable across hospitals with differing revision rates. While radiographic classifications and surgical incidence indicated higher thresholds for primary surgery in one low-revision hospital, most variations in patient and implant selection were contrary to well-known revision risk factors, suggesting that patient selection differences alone were unlikely to be responsible for the observed variation in revision rates across Danish hospitals. LEVEL OF EVIDENCE: II, Prospective cohort study.

Patient-Reported Outcomes for Function and Pain in Total Knee Arthroplasty Patients.

BACKGROUND: Some patients undergoing total knee arthroplasty successfully manage their condition postoperatively, whereas others encounter challenges in regaining function and controlling pain during recovery at home. OBJECTIVE: The aim of this study was to use traditional statistics and machine learning to develop prediction models that identify patients likely to have increased care needs related to managing function and pain following total knee arthroplasty. METHODS: This study included 201 patients. Outcomes were changes between baseline and follow-up in the functional and pain subcomponents of the Oxford Knee Score. Both classification and regression modeling were applied. Twenty-one predictors were included. Tenfold cross-validation was used, and the regression models were evaluated based on root-mean-square error, mean absolute error, and coefficient of determination. Classification models were evaluated based on the area under the receiver operating curve, sensitivity, and specificity. RESULTS: In classification modeling, random forest and stochastic gradient boosting provided the best overall metrics for model performance. A support vector machine and a stochastic gradient boosting machine in regression modeling provided the best predictive performance. The models performed better in predicting challenges related to function compared to challenges related to pain. DISCUSSION: There is valuable predictive information in the data routinely collected for patients undergoing total knee arthroplasty. The developed models may predict patients who are likely to have enhanced care needs regarding function and pain management. Improvements are needed before the models can be implemented in routine clinical practice.

The influence of migration of the exeter V40 stem on patient reported outcome measures: a 2-year follow-up of 112 total hip arthroplasties using radiostereometric analysis.

PURPOSE: The cemented Exeter V40 stem is known to migrate distally. Several previous studies have reported on the extent of stem migration and its influence on clinical outcome. However, no studies have investigated the influence of stem migration on Patient Reported Outcome Measures (PROM). METHODS: One hundred and twelve total hip arthroplasties (THA) were included in a 2-year follow-up using Radiostereometric Analysis (RSA). Patients were evaluated using the Oxford Hip Score (OHS) and EQ-5D-3L PROMs. The purpose of this study was to assess the influence of stem migration, measured by Maximum Total Point Motion (MTPM), on the 2-year postoperative score (OHS and EQ-5D). Furthermore, the influence of pre-operative PROM, age, gender, acetabular component and BMI was associated with the 2-year postoperative OHS and EQ-5D scores. RESULTS: MTPM was a non-significant predictor of the 2-year postoperative OHS (regression coefficient (B) = - 2.38 (CI - 5.44; .69)) and of the 2-year postoperative EQ-5D (B = - .01 (CI - .04; .02)). The only significant predictor of the 2-year postoperative OHS and 2-year postoperative EQ-5D was gender (B = 8.71 (CI 3.52; 13.90)) and (B = .13 (CI .07; .18)), respectively. CONCLUSION: Stem migration did not significantly influence PROMs at 2 years post-operatively. Using a patient-focused approach, our results seem to corroborate results reported by previous studies, showing that slow migration of the Exeter V40 stem does not seem to influence the clinical outcome.

The Combination of Preoperative Pain, Conditioned Pain Modulation, and Pain Catastrophizing Predicts Postoperative Pain 12 Months After Total Knee Arthroplasty.

OBJECTIVES: Approximately 20% of knee osteoarthritis patients undergoing total knee arthroplasty (TKA) report chronic postoperative pain. Studies suggest that preoperative variables such as impaired descending pain control, catastrophizing, function, and neuropathic pain-like symptoms may predict postoperative pain 12 months after TKA, but the combined prediction value of these factors has not been tested. The current prospective cohort study aimed to combine preoperative risk factors to investigate the predictive value for postoperative pain 12 months after TKA. DESIGN: Prospective cohort with follow-up 12 months after surgery. PATIENTS: A consecutive sample of 131 knee osteoarthritis patients undergoing TKA. METHODS: Pain intensity, Pain Catastrophizing Scale (PCS) scores, PainDETECT Questionnaire scores, conditioned pain modulation (CPM), and Oxford Knee Score (OKS) were obtained before and 12 months after TKA. RESULTS: TKA improved pain (P < 0.001), PCS scores (P < 0.001), PainDETECT Questionnaire scores (P < 0.001), and OKSs (P < 0.001). Preoperative pain correlated with preoperative PCS scores (r = 0.38, P  <  0.001), PainDETECT scores (r = 0.53, P  <  0.001), and OKSs (r = -0.25, P  =  0.001). Preoperative PainDETECT scores were associated with preoperative PCS scores (r = 0.53, P  <  0.001) and OKSs (r = -0.25, P  =  0.002). Higher postoperative pain was correlated with high preoperative pain (r = 0.424, P  <  0.001), PCS scores (r = 0.33, P  <  0.001), PainDETECT scores (r = 0.298, P  =  0.001), and lower CPM (r = -0.18, P  =  0.04). The combination of preoperative pain, PCS score, and CPM explained 20.5% of variance in follow-up pain. PCS scores had a significant effect on pain trajectory when accounting for patient variance (t  =  14.41, P  <  0.0005). CONCLUSION: The combination of high preoperative clinical pain intensity, high levels of pain catastrophizing thoughts, and impaired CPM may predict long-term postoperative pain 12 months after surgery.

Measurement properties of UCLA Activity Scale for hip and knee arthroplasty patients and translation and cultural adaptation into Danish.

Background and purpose - The UCLA Activity Scale (UCLA) is a questionnaire assessing physical activity level from 1 (low) to 10 (high) in patients undergoing hip or knee arthroplasty (HA/KA). After translation and cultural adaptation, we evaluated the measurement properties of the Danish UCLA.Patients and methods - After dual panel translation, cognitive interviews were performed among 55 HA/KA patients. An orthopedic surgeon and a physiotherapist estimated UCLA scores for 80 KA patients based on short interviews. Measurement properties were evaluated in 130 HA and 134 KA patients preoperatively and 1-year postoperatively.Results - To suit Danish patients of today, several adaptations were required. Prior to interviews, 4 patients were excluded, and 11 misinterpreted the answer options. Examiners rated the remaining 65 patients (mean age 67 years) 0.2-1.6 UCLA levels lower than patients themselves. The 130 HA and 134 KA patients (mean age 71/68 years) changed from 4.3 (SD 1.9)/4.5 (1.8) preoperatively to 6.6 (1.8)/6.2 (1.0) at 1-year follow-up. 103 (79%) HA and 89 (66%) KA patients reported increased activity. Effect sizes were large (1.2/0.96). Knee patients reaching minimal important change (MIC, ≥ 8 Oxford Knee Score points) had higher 1-year UCLA scores than patients not reaching MIC.Interpretation - Original scale development was undocumented. Content validity was questionable, and there was discrepancy between patient and examiner estimates. UCLA appears valuable for measuring change in self-reported physical activity on a group level. 4 out of 5 HA patients and 2 out of 3 KA patients were more physically active 1 year after joint replacement surgery.

Histomorphometric case-control study of subarticular osteophytes in patients with osteoarthritis of the hip.

OBJECTIVE: The objective of this cross-sectional case-control study was to determine the prevalence and size of marginal and subarticular osteophytes in patients with osteoarthritis (OA), and to compare these to that of a control group. DESIGN: We investigated femoral heads from 25 patients with OA following hip replacement surgery, and 25 femoral heads from a control group obtained post-mortem. The area and boundary length of the femoral head, marginal osteophytes, and subarticular osteophytes were determined with histomorphometry. Marginal osteophytes were defined histologically as bony projections at the peripheral margin of the femoral head, while subarticular osteophytes were defined as areas of bone that expanded from the normal curvature of the femoral head into the articular cartilage. RESULTS: The prevalence of OA patients with marginal- and subarticular osteophytes were 100 and 84%, respectively. Whereas the prevalence of the participants in the control group with marginal- and subarticular osteophytes were 56 and 28%, respectively. The area and boundary length of marginal osteophytes was (median (Interquartile range)) 165.3mm2 (121.4-254.0) mm2 and 75.1 mm (50.8-99.3) mm for patients with OA compared to 0 mm2 (0-0.5) mm2 and 0 mm (0-0.5) mm for the control group (P <  0.001). For the subarticular osteophytes, the area and boundary length was 1.0 mm2 (0-4.4) mm2 and 1.4 mm (0-6.5) mm for patients with OA compared to 0 mm2 (0-0.5) mm2 and 0 mm (0-0.5) mm for the control group (P <  0.001). CONCLUSION: As expected, both marginal- and subarticular osteophytes at the femoral head, were more frequent and larger in patients with OA than in the control group. However, in the control group, subarticular osteophytes were more prevalent than expected from the minor osteophytic changes at the femoral head margin, which may suggest that subarticular osteophytes are an early degenerative phenomenon that ultimately might develop into clinical osteoarthritis.

Communication and relationship dynamics in surgical teams in the operating room: an ethnographic study.

BACKGROUND: In surgical teams, health professionals are highly interdependent and work under time pressure. It is of particular importance that teamwork is well-functioning in order to achieve quality treatment and patient safety. Relational coordination, defined as "communicating and relating for the purpose of task integration," has been found to contribute to quality treatment and patient safety. Relational coordination has also been found to contribute to psychological safety and the ability to learn from mistakes. Although extensive research has been carried out regarding relational coordination in many contexts including surgery, no study has explored how relational coordination works at the micro level. The purpose of this study was to explore communication and relationship dynamics in interdisciplinary surgical teams at the micro level in contexts of variable complexity using the theory of relational coordination. METHODS: An ethnographic study was conducted involving participant observations of 39 surgical teams and 15 semi-structured interviews during a 10-month period in 2014 in 2 orthopedic operating units in a university hospital in Denmark. A deductively directed content analysis was carried out based on the theory of relational coordination. RESULTS: Four different types of collaboration in interdisciplinary surgical teams in contexts of variable complexity were identified representing different communication and relationship patterns: 1) proactive and intuitive communication, 2) silent and ordinary communication, 3) inattentive and ambiguous communication, 4) contradictory and highly dynamic communication. The findings suggest a connection between communication and relationship dynamics in surgical teams and the level of complexity of the surgical procedures performed. CONCLUSION: The findings complement previous research on interdisciplinary teamwork in surgical teams and contribute to the theory of relational coordination. The findings offer a new typology of teams that goes beyond weak or strong relational coordination to capture four distinct patterns of relational coordination. In particular, the study highlights the central role of mutual respect and presents proposals for improving relational coordination in surgical teams.

Relationship between outcome scores and knee laxity following total knee arthroplasty: a systematic review.

Background and purpose - Instability following primary total knee arthroplasty (TKA) is, according to all national registries, one of the major failure mechanisms leading to revision surgery. However, the range of soft-tissue laxity that favors both pain relief and optimal knee function following TKA remains unclear. We reviewed current evidence on the relationship between instrumented knee laxity measured postoperatively and outcome scores following primary TKA. Patients and methods - We conducted a systematic search of PubMed, Embase, and Cochrane databases to identify relevant studies, which were cross-referenced using Web of Science. Results - 14 eligible studies were identified; all were methodologically similar. Both sagittal and coronal laxity measurement were reported; 6 studies reported on measurement in both extension and flexion. In knee extension from 0° to 30° none of 11 studies could establish statistically significant association between laxity and outcome scores. In flexion from 60° to 90° 6 of 9 studies found statistically significant association. Favorable results were reported for posterior cruciate retaining (CR) knees with sagittal laxity between 5 and 10 mm at 75-80° and for knees with medial coronal laxity below 4° in 80-90° of flexion. Interpretation - In order to improve outcome following TKA careful measuring and adjusting of ligament laxity intraoperatively seems important. Future studies using newer outcome scores supplemented by performance-based scores may complement current evidence.

A Randomized, Controlled Trial of Total Knee Replacement.

BACKGROUND: More than 670,000 total knee replacements are performed annually in the United States; however, high-quality evidence to support the effectiveness of the procedure, as compared with nonsurgical interventions, is lacking. METHODS: In this randomized, controlled trial, we enrolled 100 patients with moderate-to-severe knee osteoarthritis who were eligible for unilateral total knee replacement. Patients were randomly assigned to undergo total knee replacement followed by 12 weeks of nonsurgical treatment (total-knee-replacement group) or to receive only the 12 weeks of nonsurgical treatment (nonsurgical-treatment group), which was delivered by physiotherapists and dietitians and consisted of exercise, education, dietary advice, use of insoles, and pain medication. The primary outcome was the change from baseline to 12 months in the mean score on four Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, activities of daily living, and quality of life (KOOS4); scores range from 0 (worst) to 100 (best). RESULTS: A total of 95 patients completed the 12-month follow-up assessment. In the nonsurgical-treatment group, 13 patients (26%) underwent total knee replacement before the 12-month follow-up; in the total-knee-replacement group, 1 patient (2%) received only nonsurgical treatment. In the intention-to-treat analysis, the total-knee-replacement group had greater improvement in the KOOS4 score than did the nonsurgical-treatment group (32.5 vs. 16.0; adjusted mean difference, 15.8 [95% confidence interval, 10.0 to 21.5]). The total-knee-replacement group had a higher number of serious adverse events than did the nonsurgical-treatment group (24 vs. 6, P=0.005). CONCLUSIONS: In patients with knee osteoarthritis who were eligible for unilateral total knee replacement, treatment with total knee replacement followed by nonsurgical treatment resulted in greater pain relief and functional improvement after 12 months than did nonsurgical treatment alone. However, total knee replacement was associated with a higher number of serious adverse events than was nonsurgical treatment, and most patients who were assigned to receive nonsurgical treatment alone did not undergo total knee replacement before the 12-month follow-up. (Funded by the Obel Family Foundation and others; MEDIC ClinicalTrials.gov number, NCT01410409.).

Serum 25-hydroxyvitamin D, calcium and parathyroid hormone levels in Native and European populations in Greenland.

Ca homoeostasis is important to human health and tightly controlled by powerful hormonal mechanisms that display ethnic variation. Ethnic variations could occur also in Arctic populations where the traditional Inuit diet is low in Ca and sun exposure is limited. We aimed to assess factors important to parathyroid hormone (PTH) and Ca in serum in Arctic populations. We included Inuit and Caucasians aged 50-69 years living in the capital city in West or in rural East Greenland. Lifestyle factors were assessed by questionnaires. The intake of Inuit diet was assessed from a FFQ. 25-Hydroxyvitamin D (25OHD2 and 25OHD3) levels were measured in serum as was albumin, Ca and PTH. The participation rate was 95 %, with 101 Caucasians and 434 Inuit. Median serum 25OHD (99·7 % was 25OHD3) in Caucasians/Inuit was 42/64 nmol/l (25, 75 percentiles 25, 54/51, 81) (P<0·001). Total Ca in serum was 2·33/2·29 mmol/l (25, 75 percentiles 2·26, 2·38/2·21, 2·36) (P=0·01) and PTH was 2·7/2·2 pmol/l (25, 75 percentiles 2·2, 4·1/1·7, 2·7) (P<0·001). The 69/97 Caucasians/Inuit with serum 25OHD <50 nmol/l differed in PTH (P=0·001) that rose with lower 25OHD levels in Caucasians, whereas this was not the case in Inuit. Ethnic origin influenced PTH (ß=0·27, P<0·001) and Ca (ß=0·22, P<0·001) in multivariate linear regression models after adjustment for age, sex, BMI, smoking, alcohol and diet. In conclusion, ethnic origin influenced PTH, PTH response to low vitamin D levels and Ca levels in populations in Greenland. Recommendations are to evaluate mechanisms underlying the ethnic influence on Ca homoeostasis and to assess the impact of transition in dietary habits on Ca homoeostasis and skeletal health in Arctic populations.

Knee Osteoarthritis Patients Can Provide Useful Estimates of Passive Knee Range of Motion: Development and Validation of the Copenhagen Knee ROM Scale.

BACKGROUND: Knee arthroplasty does not always require extensive long-term follow-up. If knee range of motion (ROM) could be assessed reliably by patients, some follow-up visits might be replaced by patient-reported outcome measures, and this additional information could be reported directly to registers. We developed and tested the validity and reliability of a simple scale for patients to self-report their passive knee ROM. METHODS: Through an iterative process, we created a 2-item scale with 11 illustrations of knee motion in 15° increments. The validity and reliability was tested in knee osteoarthritis and arthroplasty patients at different treatment stages, many with poor ROM. Patient estimates were compared to passive goniometer measurements performed blindly by a physiotherapist and a junior orthopedic surgeon. RESULTS: The mean difference between 100 patients' (70.9 years) estimates and goniometer measurements was -0.7° (standard deviation, 12.3°) for flexion and 1.1° (standard deviation, 11.6°) for extension, both not significant. Correlation was 0.79 and 0.63, and kappa values at retest were 0.84 and 0.66. For flexion < 110°, sensitivity of patient estimates was 88% and specificity was 88%. For a limit of 100°, values were 95% and 81%. For extension deficits >10°, sensitivity was 78% and specificity 70%. Values were 100% and 66% for a 15° limit. CONCLUSION: The Copenhagen Knee ROM Scale is a patient-friendly and feasible alternative to passive ROM measurement for registers, research, and selected clinical use. This scale appears reliable and valid compared to reports of similar tools, and patient estimates are better correlated to goniometer measurements.

Prospective psychometric characterization of hip and knee arthroplasty patients.

BACKGROUND: Psychiatric conditions and psychopharmacological treatments have been demonstrated to be important risk-factors for prolonged hospital length of stay, readmission and morbidity, following fast-track total hip (THA) and total knee arthroplasty (TKA). AIMS: The aim of the study was to provide a detailed description of the preoperative psychiatric characteristics of a well-defined patient population undergoing THA and TKA, using the 90-item Symptom Checklist (SCL-90-R). METHODS: A pre-surgical population of 2183 patients completed the full SCL-90-R prior to THA/TKA from 2015 to 2016. The SCL-90-R scale and total scores of the pre-surgical sample were compared to the scores of an age- and gender stratified Danish sample of healthy controls. A Mokken scalogram analysis was conducted to assess the scalability of the SCL-90-R in both samples. RESULTS: The Mokken analysis yielded acceptable scalability coefficients above 0.30 in all subscales of the SCL-90-R except psycoticism (0.28). There was no clinically significant difference (effect size = <0.50) in the SCL-90-R total score between the pre-surgical and the healthy controls samples, although pre-surgical patients had lower mean scores compared to the healthy controls in all subscales except somatization (effect size = -0.22). CONCLUSION: The Mokken analysis demonstrated that the SCL-90-R and its subscales express valid measures of psychopathology in our surgical sample. The psychiatric profile of the pre-surgical patient sample indicates that patients undergoing THA/TKA are not more burdened by psychiatric symptoms than a healthy control group with the exception of symptoms relating to somatization.

Safety Aspects of Postanesthesia Care Unit Discharge without Motor Function Assessment after Spinal Anesthesia: A Randomized, Multicenter, Semiblinded, Noninferiority, Controlled Trial.

BACKGROUND: Postanesthesia care unit (PACU) discharge without observation of lower limb motor function after spinal anesthesia has been suggested to significantly reduce PACU stay and enhance resource optimization and early rehabilitation but without enough data to allow clinical recommendations. METHODS: A multicenter, semiblinded, noninferiority randomized controlled trial of discharge from the PACU with or without assessment of lower limb motor function after elective total hip or knee arthroplasty under spinal anesthesia was undertaken. The primary outcome was frequency of a successful fast-track course (length of stay 4 days or less and no 30-day readmission). Noninferiority would be declared if the odds ratio (OR) for a successful fast-track course was no worse for those patients receiving no motor function assessment versus those patients receiving motor function assessment by OR = 0.68. RESULTS: A total of 1,359 patients (98.8% follow-up) were available for analysis (93% American Society of Anesthesiologists class 1 to 2). The primary outcome occurred in 92.2% and 92.0%, corresponding to no motor function assessment being noninferior to motor function assessment with OR 0.97 (95% CI, 0.70 to 1.35). Adverse events in the ward during the first 24 h occurred in 5.8% versus 7.4% with or without motor function assessment, respectively (OR, 0.77; 95% CI, 0.5 to 1.19, P = 0.24). CONCLUSIONS: PACU discharge without assessment of lower limb motor function after spinal anesthesia for total hip or knee arthroplasty was noninferior to motor function assessment in achieving length of stay 4 days or less or 30-day readmissions. Because a nonsignificant tendency toward increased adverse events during the first 24 h in the ward was discovered, further safety data are needed in patients without assessment of lower limb motor function before PACU discharge.

Thresholds for the Oxford Hip Score after total hip replacement surgery: a novel approach to postoperative evaluation.

BACKGROUND: This is a prospective cohort study to define the thresholds to distinguish patients with a satisfactory or unsatisfactory outcome after total hip replacement (THR) based on patient-reported outcome measures (PROMs) including the Oxford Hip Score (OHS), and using patient satisfaction and patient-perceived function as global transition items. The thresholds are intended to be used as a tool in the process of determining which patients are in need of postoperative outpatient evaluation. METHODS: One hundred and three THR patients who had completed a preoperative questionnaire containing the OHS questionnaire were invited to complete the same questionnaire and supplementary questions at a mean of 6 (4-9) months after surgery. Correlations between outcome measures and anchors were calculated using Pearson's correlation coefficient. Thresholds were established by receiver operating characteristic (ROC) analysis, using multiple anchors. RESULTS: Significant correlations were found between outcome measures and anchors. Thresholds were determined for outcome measures coupled with satisfaction, patient-perceived function and a combination thereof using a cut-off of 50 and 70. CONCLUSIONS: We have established a set of thresholds for Oxford scores that may help determine which THR patients are in need of postoperative evaluation. These thresholds can be implemented in clinical practice. LEVEL OF EVIDENCE: Level 3.

Absence of a Tourniquet Does Not Affect Fixation of Cemented TKA: A Randomized RSA Study of 70 Patients.

We aimed to determine whether not using a tourniquet in cemented TKA would affect migration of the tibial component measured by radiosterometric analysis (RSA). Seventy patients were randomized into a tourniquet group and a non-tourniquet group and using model-based RSA, the migration of the tibial component was analyzed. Primary and secondary outcome measures were maximum total point motion (MTPM) and translations and rotations. Follow-up period was 2 years. The tibial component was well fixated in both groups and no significant difference in migration between the two groups was detected (P=0.632). Mean MTPM (SD) was 0.47 mm (0.16) in the tourniquet group and 0.45 mm (0.21) in the non-tourniquet group. Absence of tourniquet indicates that stable fixation of the tibial component can be achieved in cemented TKA.

Three Year RSA Evaluation of Vitamin E Diffused Highly Cross-linked Polyethylene Liners and Cup Stability.

Vitamin E diffusion into highly cross-linked polyethylene (E-XLPE) is a method for enhancing oxidative stability of acetabular liners. The purpose of this study was to evaluate in vivo penetration of E-XLPE using radiostereometric analysis (RSA). Eighty-four hips were recruited into a prospective 10-year RSA. This is the first evaluation of the multicenter cohort after 3-years. All patients received E-XLPE liners (E1, Biomet) and porous-titanium coated cups (Regenerex, Biomet). There was no difference (P=0.450) in median femoral head penetration into the E-XLPE liners at 3-years comparing cobalt-chrome heads (-0.028mm; inter-quartile range (IQR) - 0.065 to 0.047) with ceramic heads (-0.043mm, IQR - 0.143to0.042). The 3-year follow-up indicates minimal E-XLPE liner penetration regardless of head material and minimal early cup movement.