To Stage or Not to Stage? Comparison of Patient-Reported Outcomes, Complications, and Discharge Disposition After Staged and Simultaneous Bilateral Posterior Total Hip Arthroplasty.

BACKGROUND: Patients who have bilateral hip arthritis can be treated with bilateral total hip arthroplasty (bTHA) in either a staged or simultaneous fashion. The goal of this study was to determine whether staged and simultaneous posterior bTHA patients differ in regard to (1) patient-reported outcome measures, (2) 90-day complication rates, and (3) discharge dispositions and cumulative lengths of stay. METHODS: Patients who (1) underwent simultaneous bTHA or staged bTHA (within 12 months) using the posterior approach, and (2) completed preoperative and 1-year postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement surveys were included in the study. A total of 266 patients (87 simultaneous bTHA and 179 staged bTHA) were included. Chart review was performed to collect patient-level variables, postoperative complications, discharge dispositions, and lengths of stay. RESULTS: Staged bTHA patients had higher Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement, Lower Extremity Activity Scale, and Veterans RAND 12-Item Health Survey physical component scores compared to simultaneous bTHA patients at 6 weeks after surgery (P = .019, .006, and .008, respectively), but these differences did not meet the minimal clinically important difference threshold for any questionnaire. Simultaneous bTHA was associated with higher rate of periprosthetic fractures (P = .034) and discharge to a location other than home (P < .001). CONCLUSIONS: There were statistically significant, but likely not clinically meaningful differences in patient-reported outcomes for staged and simultaneous bTHA patients at 6 weeks after surgery. Surgeons should be aware of the higher periprosthetic fracture risk and greater likelihood of discharge to a rehabilitation facility associated with simultaneous bTHA. Further research should aim to understand which patients may benefit most from simultaneous bTHA.

Effectiveness of oral versus intravenous tranexamic acid in primary total hip and knee arthroplasty: a randomised, non-inferiority trial.

BACKGROUND: Tranexamic acid (TXA) reduces rates of blood transfusion for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Although the use of oral TXA rather than intravenous (i.v.) TXA might improve safety and reduce cost, it is not clear whether oral administration is as effective. METHODS: This noninferiority trial randomly assigned consecutive patients undergoing primary THA or TKA under neuraxial anaesthesia to either one preoperative dose of oral TXA or one preoperative dose of i.v. TXA. The primary outcome was calculated blood loss on postoperative day 1. Secondary outcomes were transfusions and complications within 30 days of surgery. RESULTS: Four hundred participants were randomised (200 THA and 200 TKA). The final analysis included 196 THA patients (98 oral, 98 i.v.) and 191 TKA patients (93 oral, 98 i.v.). Oral TXA was non-inferior to i.v. TXA in terms of calculated blood loss for both THA (effect size=-18.2 ml; 95% confidence interval [CI], -113 to 76.3; P<0.001) and TKA (effect size=-79.7 ml; 95% CI, -178.9 to 19.6; P<0.001). One patient in the i.v. TXA group received a postoperative transfusion. Complication rates were similar between the two groups (5/191 [2.6%] oral vs 5/196 [2.6%] i.v.; P=1.00). CONCLUSIONS: Oral TXA can be administered in the preoperative setting before THA or TKA and performs similarly to i.v. TXA with respect to blood loss and transfusion rates. Switching from i.v. to oral TXA in this setting has the potential to improve patient safety and decrease costs.

Healthcare disparities: patients' perspectives on barriers to joint replacement.

OBJECTIVE: Racial and ethnic disparities in arthroplasty utilization are evident, but the reasons are not known. We aimed to identify concerns that may contribute to barriers to arthroplasty from the patient's perspective. METHODS: We identified patients' concerns about arthroplasty by performing a mixed methods study. Themes identified during semi-structured interviews with Black and Hispanic patients with advanced symptomatic hip or knee arthritis were used to develop a questionnaire to quantify and prioritize their concerns. Multiple linear and logistic regression analyses were conducted to determine the association between race/ethnicity and the importance of each theme. Models were adjusted for sex, insurance, education, HOOS, JR/KOOS, JR, and discussion of joint replacement with a doctor. RESULTS: Interviews with eight participants reached saturation and provided five themes used to develop a survey answered by 738 (24%) participants; 75.5% White, 10.3% Black, 8.7% Hispanic, 3.9% Asian/Other. Responses were significantly different between groups (p < 0.05). Themes identified were "Trust in the surgeon" "Recovery", "Cost/Insurance", "Surgical outcome", and "Personal suitability/timing". Compared to Whites, Blacks were two-fold, Hispanics four-fold more likely to rate "Trust in the surgeon" as very/extremely important. Blacks were almost three times and Hispanics over six times more likely to rate "Recovery" as very/extremely important. CONCLUSION: We identified factors of importance to patients that may contribute to barriers to arthroplasty, with marked differences between Blacks, Hispanics, and Whites.

Survivorship and Clinical Outcomes of Primary Total Knee Arthroplasty Performed in Patients 35 Years of Age and Younger.

BACKGROUND: Total knee arthroplasties (TKAs) for patients aged ≤35 years are rare but necessary for patients who have diseases such as juvenile idiopathic arthritis, osteonecrosis, osteoarthritis, and rheumatoid arthritis. Few studies have examined the 10-year and 20-year survivorship and clinical outcomes of TKAs for young patients. METHODS: A retrospective registry review identified 185 TKAs in 119 patients aged ≤ 35 years performed between 1985 and 2010 at a single institution. The primary outcome was implant survivorship free of revision. Patient-reported outcomes were assessed at 2 time points: 2011 to 2012 and 2018 to 2019. The average age was 26 years (range, 12 to 35). Mean follow-up was 17 years (range, 8 to 33). RESULTS: Survivorship decreased from 84% (95% confidence interval [CI]: 79 to 90) at 5 years to 70% (95% CI: 64 to 77) at 10 years and to 37% (95% CI: 29 to 45) at 20 years. The most common reasons for revision were aseptic loosening (6%) and infection (4%). Risk factors for revision included increasing age at time of surgery (Hazards Ratio [HR] 1.3, P = .01) and use of constrained (HR 1.7, P = .05) or hinged prostheses (HR 4.3, P = .02). There were 86% of patients reporting that their surgery resulted in "a great improvement" or better. CONCLUSION: Survivorship of TKAs in young patients is less favorable than expected. However, for the patients who responded to our surveys, TKA demonstrated substantial pain relief and improvement in function at 17-year follow-up. Revision risk increased with older age and higher levels of constraint.

Spine or Hip First? Outcomes in Patients Undergoing Sequential Lumbar Spine or Hip Surgery.

BACKGROUND: Lumbar spine pathology frequently coexists in patients who have hip arthrosis. There is controversy on whether lumbar or hip pathology should be first addressed. The purpose of this study was to evaluate the outcomes of sequential lumbar spine (LSP) or hip arthroplasty (THA). METHODS: Using a large national database from 2010 to 2020, we reviewed the records of 241,279 patients who had concurrent hip arthritis and lumbar spine disease defined as spinal stenosis, lumbar radiculopathy, or degenerative disc disease. During the study period, 6,458 (2.7%) patients with concurrent hip/spine disease underwent sequential operative treatment of either the hip joint or lumbar spine within 2 years. The rates of subsequent surgery in either the hip or the spine, opioid requirements, and rates of hip dislocation were determined and analyzed using compared Chi-squared analyses. RESULTS: Patients undergoing THA first had lower risk of subsequent spinal procedure compared to patients who had spinal procedures first (5.7 versus 23.7%, P < .001). This disparity was maintained up to 5 years (P < .001). Opioid requirements at 1 year were highest in patients who underwent spinal procedures only (836 pills/patient) compared to any other group THA only (566 pills/patient), LSP and then THA (564 pills/patient), THA and LSP (586 pills/patient). Also, THA following LSP was associated with significantly higher rates of dislocation compared to patients undergoing THA first (3.2 versus 1.9%, P < .001). CONCLUSION: Total hip arthroplasty first in patients who have concurrent spine disease was associated with lower risk of subsequent surgery, opioid requirement, and risk of postoperative instability compared to patients having lumbar procedure first.

Tumors Constitute a Majority of Total Knee Arthroplasty in Patients <21 Years Old: A United States Nationwide Analysis.

BACKGROUND: Total knee arthroplasty (TKA) is rarely performed in patients under 21 years old, but the frequency of utilization of TKA in this population in the United States is not known. The purpose of this study was to evaluate trends in the use of TKA in patients <21 in the United States. Additionally, we aimed to determine the characteristics of these patients and the hospitals in which this procedure is performed. METHODS: We retrospectively reviewed the Kids' Inpatient Database, a national weighted sample of all inpatient hospital admissions in the United States in patients <21 years of age. We used International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes to identify patients undergoing TKA from 2000 to 2019 and determine a primary diagnosis. Descriptive statistics were calculated using the appropriate sample weights. RESULTS: The total weighted number of TKAs performed in patients <21 years from 2000 to 2019 was 1,535. There were 70.9% of TKAs performed for a primary diagnosis of tumor, and the use of TKA for malignant tumors has increased. In contrast, the use of TKA for inflammatory arthritis/juvenile idiopathic arthritis decreased significantly over the study period. The majority of TKAs were performed in urban teaching hospitals with a large bed size. CONCLUSION: Approximately 1,535 TKAs have been performed in patients <21 years from 2000 to 2019 in the United States. The majority of these procedures were performed for reconstruction after resection of a malignant tumor. The rate of TKA for inflammatory arthritis/juvenile idiopathic arthritis has decreased over the past two decades.

Outcomes After Revision Total Knee Arthroplasty From a Specific, Now-Recalled Implant System.

BACKGROUND: A specific total knee arthroplasty (TKA) implant system was recently recalled for high incidence of early polymeric wear and osteolysis. We analyzed the early outcomes of aseptic revision with these implants. METHODS: We identified 202 aseptic revision TKAs of this implant system performed at a single institution between 2010 and 2020. Revision indications included aseptic loosening (n = 120), instability (n = 55), and polymeric wear/osteolysis (n = 27). Components were revised in 145 cases (72%) and isolated polyethylene insert exchange occurred in 57 cases (28%). Kaplan-Meier and Cox proportional hazards analyses were used to determine survivorship free from all-cause rerevision and rerevision risk factors. RESULTS: At 2 and 5 years, survivorship free from all-cause rerevision was 89 and 76% in the polyethylene exchange cohort versus 92 and 84% in the component revision cohort (P = .5). At 2 and 5 years, survivorship in revision with components from the same manufacturer was 89 and 80% compared to 95 and 86% in revision with components from a different manufacturer (P = .2). Among re-revisions (n = 30), cones (37%), sleeves (7%), hinge/distal femoral replacement implants were frequently used (13%). Men had increased risk for rerevision (hazard ratio = 2.3, P = .04). CONCLUSION: In this series of aseptic revision TKAs performed on a now-recalled implant system, survivorship free from rerevision was lower than expected when components from the same manufacturer were utilized, but comparable to contemporary reports when both the components were revised with an alternative implant system. Metaphyseal fixation with cones and sleeves as well as highly constrained implants was frequently utilized at time of rerevision TKA. LEVEL OF EVIDENCE: Level IV.

Satisfaction With the Process vs Outcome of Care in Total Hip and Knee Arthroplasty.

BACKGROUND: Patient satisfaction, with both process of care and outcome of care, is critical for measuring the quality and value of elective procedures such as arthroplasty. The purpose of this study is to evaluate the correlation between early postoperative satisfaction with the process of care and 2-year satisfaction with the outcome of care after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: We retrospectively analyzed data from institutional arthroplasty registries. Satisfaction with the outcome of care was measured on a scale of 0-100 by a previously validated questionnaire administered 2 years postoperatively. Patient satisfaction with the process of care was measured by the Press Ganey (PG) inpatient survey, also scored 0-100. We examined the correlation between these 2 measures of satisfaction in patients who underwent primary THA or TKA. RESULTS: In total, 721 TKA patients and 760 THA patients underwent surgery and completed both the PG survey and 2-year satisfaction questionnaire. The mean age was 65.1 years with a mean body mass index of 28.8 and 56% were female. The mean PG survey score for the entire cohort was 95.6. The mean 2-year satisfaction score was 90.3. The Spearman correlation coefficient between the PG survey and the 2-year satisfaction survey was 0.23 for TKA patients (P < .001) and 0.13 for THA patients (P < .001). CONCLUSION: We found a weak correlation between the measurement of satisfaction with the process of care surrounding hip and knee arthroplasty using the PG survey and measurement of satisfaction with the outcome of care after arthroplasty using a validated 2-year satisfaction instrument.

2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty.

OBJECTIVE: To develop updated American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines for the perioperative management of disease-modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA). METHODS: We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process. RESULTS: This guideline updates the 2017 recommendations for perioperative use of disease-modifying antirheumatic therapy, including traditional disease-modifying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids. CONCLUSION: This updated guideline includes recently introduced immunosuppressive medications to help decision-making by clinicians and patients regarding perioperative disease-modifying medication management for patients with IA and SLE at the time of elective THA or TKA.

High Satisfaction and Activity Levels After Total Hip Arthroplasty in Patients Under Age 21.

BACKGROUND: With improved materials and bearing surfaces, the use of total hip arthroplasty (THA) in young patients is increasing. Functional outcomes and activity level are particularly relevant in this higher-demand patient population. There is a paucity of data on patient-reported outcomes and activity levels after THA in extremely young (<21 years old) patients. METHODS: We identified 196 patients (222 hips) who underwent THA at age <21 years at our institution from 1982 to 2018. After applying exclusion criteria, 113 of 160 (70.6%) patients (129 hips) were available for follow-up. Patient activity levels and functional outcomes were evaluated using the UCLA activity score, Forgotten Joint Score (FJS), Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and a validated 5-question satisfaction survey. Survivorship and reasons for revision were recorded. RESULTS: The mean age at surgery was 17.0 ± 2.8 years, and the mean follow-up was 13.2 years (range 2-38 years). The most common indications for THA were osteonecrosis (34%) and juvenile idiopathic arthritis (30%). The mean UCLA activity score was 5.9 ± 2.0, and 64% of patients reported a score ≥6. The mean FJS was 57.9 ± 31.0. The mean Hip Disability and Osteoarthritis Outcome Score for Joint Replacement score was 84.6 ± 16.6. Ninety percent of patients reported that they were very or somewhat satisfied with their surgery. At final follow-up, 27 of 129 (20.9%) hips had undergone revision surgery. CONCLUSION: THA performed in patients under 21 years of age with end-stage hip disease allows for high levels of activity and satisfaction postoperatively, with most patients being able to participate in moderate recreational activities. These data may be useful for surgeons in planning for and counseling extremely young patients indicated for THA.

Use of Total Hip Arthroplasty in Patients Under 21 Years Old: A US Population Analysis.

BACKGROUND: The purpose of this study is to evaluate trends in the use of total hip arthroplasty (THA) in the United States in patients under 21 years of age. Specifically, we examined the frequency of THA in this patient population over the past 2 decades, the epidemiologic characteristics of patients under 21 who underwent THA, and the characteristics of the hospitals where these procedures were performed. METHODS: We retrospectively reviewed the Kids' Inpatient Database, an inpatient US national weighted sample of hospital admissions in patients under 21 from approximately 4200 hospitals in 46 states. We queried the database using Current Procedural Terminology codes for elective and non-elective primary THA for the years 2000-2016. We utilized the International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes to determine primary diagnoses. RESULTS: The weighted total number of THAs performed in patients under 21 in the Kids' Inpatient Database increased from 347 in 2000 to 551 in 2016. The most common diagnoses were osteonecrosis, osteoarthritis, and inflammatory arthritis. The frequency of THA for osteonecrosis increased from 24% in 2000 to 38% in 2016, while the frequency of THA for inflammatory arthritis decreased from 27% in 2000 to 4% in 2016. CONCLUSION: The number of THAs in patients under 21 in the United States has increased over the past 2 decades and these procedures are increasingly performed in urban teaching hospitals. The decrease in THA for inflammatory arthritis in this population likely reflects improvements in medical management during the study period.

Early Recovery Outcomes in Patients Undergoing Total Hip Arthroplasty Through a Posterior Approach With Modified Postoperative Precautions.

BACKGROUND: Recent data suggest that a modified, more lenient set of precautions after total hip arthroplasty (THA) performed through the posterolateral approach may safely allow more patient movement and exercise in the immediate postoperative period. We hypothesize that 1) patients undergoing THA given modified precautions will demonstrate a fast-track return to functional activity and 2) wrist-based activity trackers will provide valuable information on postoperative activity levels. METHODS: We prospectively enrolled patients undergoing THA. Patients were given a wrist-based, commercially available activity tracker to wear 1 week preoperatively and 6 weeks postoperatively. Postoperative hip precautions included only the avoidance of the "leg-shaving" position of combined hip flexion, adduction, and internal rotation. Linear mixed models were used to analyze the change in steps and Hip Disability and Osteoarthritis Outcome Score-Junior (HOOS)-JR data. Pearson correlation coefficients were used to describe the relationship between average steps and HOOS-JR scores over time. RESULTS: Eighty-two patients were enrolled. Seventy-four percent returned to work by week 4. Seventy-six percent of left THA patients returned to driving by week 4. At 6 weeks, 23% of survey respondents were taking pain medication and 26% were using assistive devices. Average daily steps were 1098 at week 1, 2491 at week 2, 4130 at week 3, 4850 at week 4, 5712 at week 5, and 6069 at week 6. A significant correlation (R: -0.981) was found between increased weekly steps and improved HOOS-JR scores after THA (P < .001). CONCLUSION: Defining expected recovery timelines for patients undergoing THA helps surgeons counsel their patients preoperatively. Our study demonstrates an expected pathway for recovery after THA by using modified precautions that will be more clearly outlined with ongoing clinical data analysis.

Joint Replacements in Individuals With Skeletal Dysplasias: One Institution's Experience and Response to Operative Complications.

BACKGROUND: Skeletal dysplasias are a heterogeneous group of >400 genetic disorders characterized by abnormal bone growth. Many individuals experience joint pain and limitation, coming to require joint replacement much earlier than the average-statured population. In addition, prosthesis survival rate is less in the dysplastic population. The purpose of this study is to identify risk factors for surgery and provide recommendations to improve surgical outcomes. METHODS: This a retrospective review of 29 individuals with a skeletal dysplasia who had 64 joint replacements between April 1985 and January 2019 at a single institution. We collected demographics, physical examination, medical history, imaging studies, surgical indication, and complications. RESULTS: Spondyloepiphyseal dysplasia was the most common skeletal dysplasia (7), followed by pseudoachondroplasia (4) and multiple epiphyseal dysplasia (4). Average age of the cohort was 40.6 years (range 14-64). Hip arthroplasty (34) was the most commonly performed surgery. The majority of arthroplasties (75%) required custom components. Complication rate was 37.3%, most commonly pulmonary embolism (3) and pneumonia (3). Most complications (81.8%) occurred in individuals with either a pre-existing cardiopulmonary comorbidity or lumbar/sacral deformity. Body mass index did not correlate with complication severity (R = -0.042, P = .752) or rate (R = 0.006, P = .963). CONCLUSION: Surgical complications are highest in patients with pre-existing cardiopulmonary conditions. Body mass index does not predict complications in this cohort. Preoperative evaluations for individuals with skeletal dysplasias should include comprehensive work-up of spine issues and extraskeletal systems that present an operative risk. Intraoperative protocol should include special consideration for placement on the table, airway maintenance, and spinal cord monitoring in select cases.

Tranexamic Acid Does Not Reduce the Risk of Transfusion in Rheumatoid Arthritis Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Patients with rheumatoid arthritis (RA) receive transfusions more often than patients with osteoarthritis following lower extremity total joint arthroplasty (TJA), but mitigating factors are not described. Tranexamic acid (TXA) is widely used to reduce blood loss in patients undergoing TJA, but its effect on transfusion rates in patients with RA has not been studied. METHODS: We retrospectively reviewed data from a prospectively collected cohort of patients with RA undergoing TJA. Disease activity measured by Clinical Disease Activity Index, patient-reported outcome measures, and serologies was obtained. Baseline characteristics were summarized and compared. Transfusion requirements and TXA usage were obtained from chart review. Logistic regression was used to determine factors associated with transfusion in RA patients undergoing TJA. RESULTS: The cohort included 252 patients, mostly women with longstanding RA and end-stage arthritis requiring TJA. In multivariate analysis, 1 g/dL decrease in baseline hemoglobin (odds ratio [OR] = 0.394, 95% confidence interval [CI] [0.232, 0.669], P = .001), 1-minute increase in surgical duration (OR = 1.022, 95% CI [1.008, 1.037], P = .003), and 1-point increase in Clinical Disease Activity Index (OR = 1.079, 95% CI [1.001, 1.162]) were associated with increased risk of transfusion. TXA use was not associated with decreased risk of postoperative transfusion. CONCLUSIONS: Preoperative health optimization should include assessment and treatment of anemia in RA patients before TJA, as preoperative hemoglobin level is the main risk factor for postoperative transfusion. Increased disease activity and increased surgical time were independent risk factors for postoperative transfusion but are less modifiable. While TXA did not decrease transfusion risk in this population, a prospective trial is needed to confirm this. LEVEL OF EVIDENCE: IV.

Assessment of a Satisfaction Measure for Use After Primary Total Joint Arthroplasty.

BACKGROUND: Patient satisfaction after total hip (THA) and total knee arthroplasty (TKA) is a core outcome selected by the Outcomes Measurement in Rheumatology. Up to 20% of THA/TKA patients are dissatisfied. Improving patient satisfaction is hindered by the lack of a validated measurement tool that can accurately measure change. METHODS: The psychometric properties of a proposed satisfaction instrument, consisting of 4 questions rated on a Likert scale, scored 1-100, were tested for validity, reliability, and sensitivity to change using data collected between 2007 and 2011 in an arthroplasty registry. RESULTS: We demonstrated construct validity by confirming our hypothesis; satisfaction correlated with similar constructs. Satisfaction correlated moderately with pain relief (TKA ρ = 0.61, THA ρ = 0.47) and function (TKA ρ = 0.65, THA ρ = 0.51) at 2 years; there was no correlation with baseline/preoperative pain/function values, as expected. Overall Cronbach's alpha >0.88 confirmed internal consistency. Test-retest reliability with weighted kappa ranged 0.60-0.75 for TKA and 0.36-0.56 for THA. Hip disability and Osteoarthritis Outcome Score/Knee injury and Osteoarthritis Outcome Scores quality of life improvement (>30 points) corresponds to a mean satisfaction score of 93.2 (standard deviation, 11.5) after THA and 90.4 (standard deviation, 13.8) after TKA, and increasing relief of pain and functional improvement increased the strength of their association with satisfaction. The satisfaction measure has no copyright and is available free of cost and represents minimal responder burden. CONCLUSION: Patient satisfaction with THA/TKA can be measured with a validated 4-item questionnaire. This satisfaction measure can be included in a total joint arthroplasty core measurement set for total joint arthroplasty trials.

Validation of the Hip Disability and Osteoarthritis Outcome Score and Knee Injury and Osteoarthritis Outcome Score Pain and Function Subscales for Use in Total Hip Replacement and Total Knee Replacement Clinical Trials.

BACKGROUND: Total hip replacement (THR)/total knee replacement (TKR) studies do not uniformly measure patient centered domains, pain, and function. We aim to validate existing measures of pain and function within subscales of standard instruments to facilitate measurement. METHODS: We evaluated baseline and 2-year pain and function for THR and TKR using Hip disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS), with primary unilateral TKR (4796) and THR (4801). Construct validity was assessed by correlating HOOS/KOOS pain and activities of daily living (ADL), function quality of life (QOL), and satisfaction using Spearman correlation coefficients. Patient relevant thresholds for change in pain and function were anchored to improvement in QOL; minimally clinically important difference (MCID) corresponded to "a little improvement" and a really important difference (RID) to a "moderate improvement." Pain and ADL function scores were compared by quartiles using Kruskal-Wallis. RESULTS: Two-year HOOS/KOOS pain and ADL function correlated with health-related QOL (KOOS pain and Short Form 12 Physical Component Scale ρ = 0.54; function ρ = 0.63). Comparing QOL by pain and function quartiles, the highest levels of pain relief and function were associated with the most improved QOL. MCID for pain was estimated at ≥20, and the RID ≥29; MCID for function ≥14, and the RID ≥23. The measures were responsive to change with large effect sizes (≥1.8). CONCLUSION: We confirm that HOOS/KOOS pain and ADL function subscales are valid measures of critical patient centered domains after THR/TKR, and achievable thresholds anchored to improved QOL. Cost-free availability and brevity makes them feasible, to be used in a core measurement set in total joint replacement trials.

Living in immigrant communities does not impact total knee arthroplasty outcomes: experience from a high-volume center in the United States.

BACKGROUND: Community characteristics such as poverty affect total knee arthroplasty (TKA) outcomes. However, it is unknown whether other community factors such as immigrant proportion (IP) also affect outcomes. Our objective was to determine the association of neighborhood IP on preoperative (pre-op) and 2-year postoperative (post-op) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function after elective TKA. METHODS: Patients in a high volume institutional TKA registry between May 2007 and February 2011 were retrospectively analyzed. Demographics, pre-op and 2-year post-op WOMAC pain and function scores, and geocodable addresses were obtained. Patient-level variables were linked to US Census Bureau census tract data. The effect of patient and neighborhood-level factors on WOMAC scores were analyzed using linear mixed effects models. RESULTS: 3898 TKA patients were analyzed. Pre-op and 2-year post-op WOMAC pain and function scores were between 2.75-4.88 WOMAC points worse in neighborhoods with a high IP (≥ 40%) compared to low IP (< 10%). In multivariable analyses, these differences were not statistically significant. Women had worse pre-op and 2-year post-op WOMAC scores (all p ≤ 0.04), but this difference was not influenced by neighborhood IP (all pinteraction NS). CONCLUSIONS: Patients living in high (≥40%) IP neighborhoods do not have worse pre-op or 2-year post-op pain and function outcomes after TKA compared to those living in low (< 10%) IP neighborhoods. Although sex differences favoring males are notable, these differences are not associated with IP. High neighborhood IP do not appear to affect outcomes after TKA.

Causes of Revision in Young Patients Undergoing Total Hip Arthroplasty.

BACKGROUND: The purpose of this study was to identify reasons for revision of total hip arthroplasty (THA) in patients who underwent primary THA at or before the age of 35 years. We hypothesized that the reasons for revision in younger patients would be different from the general older population of patients undergoing THA because of the differences in diagnoses, complexity of deformities, and differences in activity level. METHODS: Data for 108 hips in 82 patients who underwent primary THA at our institution before the age of 35 years from 1982-2007 and subsequently underwent revision THA were reviewed. Operative reports and clinic notes were reviewed to determine baseline characteristics, reason for revision, timing of revision, and components revised. RESULTS: The mean age at index surgery was 25.4 years, and mean time from index to revision surgery was 10.1 years. The most common preoperative diagnoses included avascular necrosis, juvenile idiopathic arthritis, developmental dysplasia of the hip, and posttraumatic arthritis. The most common reasons for revision were acetabular loosening (30.1%), femoral loosening (23.7%), and polyethylene wear (24.7%). 8.3% of patients underwent primary THA with highly cross-linked polyethylene, while the remainder of the patients underwent THA when conventional polyethylene was used. There was no statistically significant association between which component(s) were revised and initial fixation (ie cemented or uncemented prosthesis) (P = .26). CONCLUSION: Causes of revision in this population appear to differ from the general THA population. In young patients, acetabular loosening, femur loosening, and polyethylene wear were the most common causes of revision. Instability and infection were less common compared with literature reports of causes of revision in older patients. Findings in this study may be useful in counseling young patients undergoing THA, though results were likely influenced by the use of conventional rather than highly cross-linked polyethylene in this cohort.

Inflammatory Arthritis Is a Risk Factor for Multiple Complications After Total Hip Arthroplasty: A Population-Based Comparative Study of 68,348 Patients.

BACKGROUND: Patients with inflammatory arthritis (IA) are likely at higher risk of postoperative complications following total hip arthroplasty (THA), from the underlying disease, the degree of articular deformity, and immunosuppressive medications. The purpose of this study was to perform a comparative study of the risk of complications after THA between IA and osteoarthritis. METHODS: A national private insurance database was used to select patients undergoing unilateral primary THA. Patients were categorized to the inflammatory cohort if they had a diagnosis of IA and treatment with an IA-specific medication within the year before surgery. Patients with no diagnosis of IA were considered osteoarthritis. Risk of Centers for Medicare and Medicaid Services-reportable complications and 90-day readmission was compared between cohorts using multivariate logistic regression controlling for age, gender, length of stay, comorbidities, and corticosteroid use. RESULTS: A total of 68,348 patients were included; 2.12% met criteria for IA. Patients with IA were found to have higher risk of transfusion (odds ratio [OR], 1.29; P < .01), mechanical complications (OR, 1.35; P = .01), infection (OR, 1.96; P < .01), and 90-day readmission (OR, 1.35; P < .01). There were no differences in risk of venous thromboembolism or medical complications. CONCLUSION: Patients with IA have significantly higher risk of transfusion, mechanical complications, infection, and readmission following THA. Efforts should be made to optimize their health and medications before THA to minimize their complication risk. Additionally, hospitals should receive commensurate resources to maintain access to THA for patients with IA who are prone to higher resource utilization. LEVEL OF EVIDENCE: III.

Diagnosing Prosthetic Joint Infections in Patients With Inflammatory Arthritis: A Systematic Literature Review.

BACKGROUND: Patients with inflammatory arthritis (IA) are at increased risk of prosthetic joint infections (PJI), yet differentiating between septic and aseptic failure is a challenge. The aim of our systematic review is to evaluate synovial biomarkers and their efficacy at diagnosing PJI in patients with IA. METHODS: A comprehensive literature search was performed in the following databases from inception to January 2018: Ovid MEDLINE, Ovid EMBASE, and the Cochrane Library. Searches across the databases retrieved 367 results. Two of 5 reviewers independently screened a total of 298 citations. Discrepancies were resolved by a third reviewer. Twenty articles fit our criteria, but due to methodological differences findings could not be pooled for meta-analysis. For 5 studies, raw data were provided, pooled, and used to derive optimal diagnostic cut points. RESULTS: Our final analysis included 1861 non-IA patients, including 426 patients with PJI, and 90 IA patients of whom 26 had PJI. There was a significant difference among the 4 groups for serum C-reactive protein (CRP), erythrocyte sedimentation rate, and synovial CRP, polymorphonuclear neutrophil percent, white blood cells, interleukin (IL)-6, IL-8, and IL-1b. Polymorphonuclear neutrophil percent had the highest sensitivity (95.2%) and specificity (85.0%) to detect infections with an optimum threshold of 78%. CONCLUSION: While levels of synovial white blood cells, IL-6, IL-8, and serum CRP appear higher in patients with IA, there is overlap with those who are not infected. Further studies are needed to explore diagnostic tests that will better detect PJI in patients with IA.