Sex-based Differences in Patient Perspectives and Experiences With Shoulder, Hip, and Knee Arthroplasty.

INTRODUCTION: Sex disparities in presentation of osteoarthritis and utilization of joint replacement surgery (JRS) have been demonstrated. The role of patients' unique perspectives on JRS on their treatment decisions is poorly understood. METHODS: JRS candidates who were offered JRS but declined surgical treatment completed this survey. Survey questions included demographic information, patient experiences and current opinions around JRS, patient experiences with providers, goals and concerns, and barriers to JRS. RESULTS: More women experience barriers to undergoing JRS compared with men (53% versus 16%; P = 0.014). While both men and women indicated pain relief as their primary goal for treatment, women were significantly more likely to prioritize regaining the ability to complete daily tasks and responsibilities when compared with men (P = 0.007). Both men and women indicated that low symptom severity and nonsurgical treatment options were the reasons for not undergoing JRS (P = 0.455). Compared with men, women trended toward feeling that they were not sufficiently educated about JRS (P = 0.051). CONCLUSION: Women have unique perspectives and goals for JRS that may pose sex-specific barriers to care. A better understanding of how patients' gendered experiences affect their decision making is necessary to improve treatment of osteoarthritis and decrease disparities in care.

Psychometric testing of the British-English Long-Term Conditions Job Strain Scale, Long-Term Conditions Work Spillover Scale and Work-Health-Personal Life Perceptions Scale in four rheumatic and musculoskeletal conditions.

OBJECTIVE: The aims were to validate linguistically British-English versions of the Long-Term Conditions Job Strain Scale (LTCJSS), Long-Term Conditions Work Spillover Scale (LTCWSS) and Work-Health-Personal Life Perceptions Scale (WHPLPS) in rheumatoid arthritis, axial spondyloarthritis, osteoarthritis and fibromyalgia (FM). METHODS: The three scales were forward translated and reviewed by an expert panel prior to cognitive debriefing interviews. Participants completed a postal questionnaire. Construct validity was assessed using Rasch analysis. Concurrent validity included testing between the three scales and work (e.g., Workplace Activity Limitations Scale [WALS]) and condition-specific health scales. Two weeks later, participants were mailed a second questionnaire to measure test-retest reliability. RESULTS: The questionnaire was completed by 831 employed participants: 68% women, 53.5 (SD 8.9) years of age, with condition duration 7.7 (SD 8.0) years. The LTCJSS, LTCWSS and WHPLPS Parts 1 and 2 satisfied Rasch model requirements, but Part 3 did not. A Rasch transformation scale and Reference Metric equating scales with the WALS were created. Concurrent validity was generally good (rs = 0.41-0.85) for the three scales, except the WHPLPS Part 3. Internal consistency (Person Separation Index values) was consistent with group use in all conditions, and individual use except for the LTCWSS and WHPLSP Parts 1 and 2 in FM. Test-retest reliability was excellent, with intraclass coefficients (2,1) of 0.80-0.96 for the three scales in the four conditions. DISCUSSION: Reliable, valid versions of the British-English LTCJSS, LTCWSS and WHPLPS Parts 1 and 2 are now available for use in the UK.

Validity and Reliability of the Turkish Version of Western Ontario Osteoarthritis of the Shoulder Index.

OBJECTIVES: This study aims to adapt the Western Ontario Osteoarthritis of the Shoulder (WOOS) index specific to shoulder osteoarthritis into Turkish and to evaluate its validity and reliability. PATIENTS AND METHODS: The WOOS index was translated and culturally adapted into Turkish, systematically. It was applied to a total of 68 patients (17 males, 51 females; mean age: 61.5±8.7 years; range, 45 to 80 years) with osteoarthritis of the shoulder treated conservatively. The reliability of the scale was checked through internal consistency and test-retest methods. Internal consistency was analyzed with Cronbach alpha value. Test-retest reliability was assessed using an intraclass correlation coefficient (ICC) with 25 patients. The Western Ontario Rotator Cuff (WORC), the Shoulder Pain and Disability Index (SPADI), and the Society of American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES) scores were used to conduct concurrent validity. RESULTS: The Cronbach alpha value of the scale was found to be excellent as 0.92 (p<0.001). The ICC value was also excellent as 0.97 (p<0.001). There was an excellent positive correlation with WORC (0.847; p<0.001) and a very good positive correlation with SPADI (0.788; p<0.001). It was also negatively very good to correlate with the ASES (-0.754; p<0.001). Additionally, subsections of WOOS had a good correlation with the corresponding subsections of WORC (0.779-0.664; p<0.001). CONCLUSION: The Turkish version of the WOOS index is a valid and reliable tool and is recommended for use in the assessment of patients with osteoarthritis of the shoulder.

People Prefer to Continue with Painful Activities Even if They Lead to Earlier Surgery.

BACKGROUND: The degree to which physical activity results in arthritis progression is unknown, but it probably is less than most people believe. But the belief that painful activity is harmful has notable associations both with greater pain intensity and greater activity intolerance among people seeking care for painful conditions such as osteoarthritis. If there were evidence that people not seeking care would prefer to accommodate a painful cherished activity, even if such accommodation is harmful, this might remind surgeons that many people seeking their care also hold this value. Care strategies could be designed to help people reconnect with this value by guiding them to an appropriate weighting of the potential benefits and the potential harms of painful activity. QUESTIONS/PURPOSES: (1) What degree of harm (measured as a decrease in the number of years before reconstructive surgery) are people willing to trade to continue a cherished activity? (2) What factors are associated with the chosen number of years? (3) What percentage of patients is willing to trade harm to the joint (presented as surgery 3 years earlier) to continue their cherished activity? (4) What factors are associated with the choice to trade harm for continued activity? METHODS: We performed an online, survey-based, time trade-off experiment using a crowdsourcing website that allows users to pay volunteers to complete surveys. The survey was closed when the prespecified number of surveys was obtained. The experiment measured personal and psychological factors associated with the willingness to accommodate harmful painful activity to continue cherished activities among people not currently troubled by the condition, an approach favored in trade-off studies. Large crowdsourcing survey studies may not represent the general population, but they have sufficient diversity to determine factors associated with responses. Participants (539 total, 289 men and 250 women with a mean age of 33 ± 11 years) completed validated measures of symptoms of anxiety and depression, activity tolerance, an 11-point ordinal measure of pain intensity, and three validated questionnaires addressing common misconceptions about pain. To answer our first and second questions, we calculated the harm (measured as a decrease in the number of years before reconstructive surgery) that people were willing to trade to continue their cherished activity, and then we used multiple linear regression to identify factors associated with the number of years. To answer the third and fourth questions, we calculated the percentage of patients who would choose to trade harm to the joint (surgery 3 years earlier) to continue their cherished activity and then we used multiple logistic regression to identify factors associated with the choice to trade harm for activity. RESULTS: Participants were willing to trade harm in the form of more rapid disease progression leading to surgery a mean of 4.5 ± 3.6 years earlier to continue a cherished activity. Controlling for personal and psychological factors, a greater number of years people were willing to trade was associated with slightly greater bodily pain intensity (r = 0.11; p = 0.01). Seventy-six percent (410 of 539) of participants were willing to trade harm in the form of needing surgery 3 years earlier to continue their cherished activity. Controlling for personal and psychological factors, a choice to trade earlier surgery for continued activity was associated with an income greater than USD 50,000 per year (odds ratio 2.07 [95% confidence interval 1.17 to 3.65]; p = 0.01) and greater fear of painful movement (OR 1.07 [95% CI 1.01 to 1.15]; p = 0.04). CONCLUSION: People are relatively willing to accommodate pain to continue a cherished activity, even if it causes harm. CLINICAL RELEVANCE: Musculoskeletal specialists can incorporate strategies to help people seeking care to revitalize their inherent level of willingness to accommodate painful activity. One strategy might be to attend to an appropriate weighting of the potential benefits and the potential harms of painful activity. LEVEL OF EVIDENCE: Level II, prognostic study.

Investigating the True Effect of Psychological Variables Measured Prior to Arthroplastic Surgery on Postsurgical Outcomes: A P-Curve Analysis.

Patients' presurgical psychological profiles have been posited to predict pain and function following arthroplastic surgery of the hip and knee. Nevertheless, findings are conflicting, and this may be rooted in biased reporting that makes the determination of evidential value difficult. This ambiguity may have negative consequences for researchers and governmental agencies, as these rely on findings to accurately reflect reality. P-Curve analyses were used to establish the presence of evidential value and selective reporting in a sample of studies examining the effect of presurgical psychological predictors on outcomes following knee and hip arthroplastic surgery. A systematic search of the literature revealed 26 relevant studies. The examined sets of studies indicate that there is evidential value for the effect of depression on pain intensity and function, anxiety on pain intensity and function, pain catastrophizing on pain intensity, as well as the combined effects of all psychological predictors on pain intensity and function. The presence of evidential value was inconclusive for the effect of optimism on pain intensity. There were no signs that any results were influenced by biased reporting. The results highlight the importance of patients' psychological profiles in predicting surgical outcomes, which represent a promising avenue for future treatment approaches. PERSPECTIVE: The effects of P-hacking are difficult to detect and might be at the root of conflicting findings pertaining to the predictive properties of presurgical psychological variables on postsurgical outcomes. P-Curve analysis allows the determination of evidential value underlying these relationships and detection of P-hacking to ensure that findings are not the result of selective reporting.

Understanding the Association Between Osteoarthritis and Social Participation: The Canadian Longitudinal Study on Aging.

OBJECTIVE: The focus on disability in osteoarthritis (OA) has largely been on the ability to perform specific activities, which neglects the greater implications for social participation. We investigated the association between OA and social participation, considering activity limitations and instrumental supports as intervening variables in the association. METHODS: Data were from 21,214 respondents, ages 45-85 years, from cycle 1 of the Canadian Longitudinal Study on Aging. The questionnaire elicited information regarding self-reported doctor-diagnosed OA, difficulty with 14 activities, perceived availability and receipt of instrumental supports, and 17 social participation activities. Structural equation modeling was used. The primary outcome was social participation, and the primary predictor was OA. The intervening variables included activity limitations, received instrumental supports, and perceived instrumental supports. Latent variables were developed for intervening and social participation variables. The covariates included age, sex, body mass index, income, education, smoking, and comorbidity count. RESULTS: The mean age of the respondents was 63 years, 51% were female, and 26.5% reported having OA. Two distinct social participation indicators were identified, including social participation-diversity and social participation-intensity. When intervening variables were not considered, minimal/no association was found between OA and social participation. When intervening variables were considered, unique pathways linking OA and social participation were found. The overall negative association between activity limitations and social participation was partially direct and partially buffered by both receipt of and perceived availability of instrumental supports. In the absence of activity limitations, OA was associated with greater social participation. CONCLUSION: Enhanced social participation in people with OA who do not have activity limitations may reflect proactive steps taken by those with mild OA to maintain activity and social engagement. For those with activity limitations, findings highlight the need for interventions to mitigate limitations and draw particular attention to the importance of both provision and awareness of available instrumental supports in maintaining social participation.

Rheumatic Conditions as Risk Factors for Self-Harm: A Retrospective Cohort Study.

OBJECTIVE: To examine the risk of self-harm in rheumatic conditions. METHODS: We conducted a retrospective cohort study using data from the Clinical Practice Research Datalink. Patients with ankylosing spondylitis, fibromyalgia, osteoarthritis, or rheumatoid arthritis were identified from 1990 to 2016 and matched to patients without these conditions. Incident self-harm was defined by medical record codes following a rheumatic diagnosis. Incidence rates (per 10,000 person-years) were reported for each condition, both overall and year-on-year (2000-2016). Cox regression analysis determined risk (hazard ratio [HR] and 95% confidence interval [95% CI]) of self-harm for each rheumatic cohort compared to the matched unexposed cohort. Initial crude analysis was subsequently adjusted and stratified by age and sex. Due to nonproportionality over time, osteoarthritis was also stratified by disease duration (<1 year, ≥1 to <5 years, ≥5 to <10 years, and ≥10 years). RESULTS: The incidence of self-harm was highest in patients with fibromyalgia (HR 25.12 [95% CI 22.45-28.11] per 10,000 person-years) and lowest for osteoarthritis (HR 6.48 [95% CI 6.20-6.76]). There was a crude association with each rheumatic condition and self-harm, except for ankylosing spondylitis. Although attenuated, these associations remained after adjustment for fibromyalgia (HR 2.06 [95% CI 1.60-2.65]), rheumatoid arthritis (HR 1.59 [95% CI 1.20-2.11]), and osteoarthritis (1 to <5 years HR 1.12 [95% CI 1.01-1.24]; ≥5 to <10 years HR 1.35 [95% CI 1.18-1.54]). Age and sex were weak effect modifiers for these associations. CONCLUSION: Primary care patients with fibromyalgia, osteoarthritis, or rheumatoid arthritis (but not ankylosing spondylitis) are at increased risk of self-harm compared to people without these rheumatic conditions. Clinicians need to be aware of the potential for self-harm in patients with rheumatic conditions (particularly fibromyalgia), explore mood and risk with them, and offer appropriate support and management.

Willingness to Undergo Joint Surgery Following a First-Line Intervention for Osteoarthritis: Data From the Better Management of People With Osteoarthritis Register.

OBJECTIVE: To assess the proportion of participants reconsidering their willingness to undergo surgery after 3 and 12 months. Secondary aims were to analyze and compare the characteristics of individuals willing and unwilling to undergo joint surgery for osteoarthritis (OA) before a first-line intervention, and to study the association between pain intensity, walking difficulties, self-efficacy, and fear of movement with the willingness to undergo surgery. METHODS: This was an observational study based on Swedish register data. We included 30,578 individuals with knee or hip OA who participated in a first-line intervention including education and exercise. RESULTS: Individuals willing to undergo surgery at baseline showed a higher proportion of men (40% versus 27%) and more severe symptoms and disability. Respectively, 45% and 30% of the individuals with knee and hip OA who were willing to undergo surgery at baseline became unwilling after the intervention. At the end of the study period (12 months), 35% and 19% of those with knee and hip OA, respectively, who were willing to undergo surgery at baseline became unwilling. High pain intensity, walking difficulties, and fear of movement were associated with higher odds of being willing to undergo surgery at both follow-ups, while increased self-efficacy showed the opposite association. CONCLUSION: A first-line intervention for OA is associated with reduced willingness to undergo surgery, with a greater proportion among patients with knee OA than hip OA. Due to its temporal variability, willingness to undergo surgery should be used with care to deem surgery eligibility.

Impact of comorbid conditions on disease-specific quality of life in older men and women with atrial fibrillation.

BACKGROUND: Older persons with atrial fibrillation (AF) experience significant impairment in quality of life (QoL), which may be partly attributable to their comorbid diseases. A greater understanding of the impact of comorbidities on QoL could optimize patient-centered care among older persons with AF. OBJECTIVE: To assess impairment in disease-specific QoL due to comorbid conditions in older adults with AF. METHODS: Patients aged ≥ 65 years diagnosed with AF were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. At 1 year of follow-up, the Quality of Life Disease Impact Scale-for Multiple Chronic Conditions was used to provide standardized assessment of patient self-reported impairment in QoL attributable to 34 comorbid conditions grouped in 10 clusters. RESULTS: The mean age of study participants (n = 1097) was 75 years and 48% were women. Overall, cardiometabolic, musculoskeletal, and pulmonary conditions were the most prevalent comorbidity clusters. A high proportion of participants (82%) reported that musculoskeletal conditions exerted the greatest impact on their QoL. Men were more likely than women to report that osteoarthritis and stroke severely impacted their QoL. Patients aged < 75 years were more likely to report that obesity, hip/knee joint problems, and fibromyalgia extremely impacted their QoL than older participants. CONCLUSIONS: Among older persons with AF, while cardiometabolic diseases were highly prevalent, musculoskeletal conditions exerted the greatest impact on patients' disease-specific QoL. Understanding the extent of impairment in QoL due to underlying comorbidities provides an opportunity to develop interventions targeted at diseases that may cause significant impairment in QoL.

Risk factors for limited improvement after total trapeziometacarpal joint arthroplasty.

BACKGROUND: Trapeziometacarpal (TMC) osteoarthritis can be painful and cause disability for patients. Total joint replacement of the TMC joint provides a pseudo arthrosis with good restoration of the thumb motion and pain relief in most patients. But there is also a risk of no improvement following the operation. The purpose of this study was to identify patients at risk of no clinically important improvement following operative treatment of osteoarthritis of the TMC joint. METHODS: We included 287 consecutive patients (225 women, 62 men) treated with total joint replacement of the TMC joint due to osteoarthritis with a mean age of 58.9 years (range 41-80) in a prospective cohort study. We collected information preoperatively and 12 months postoperatively on disabilities of the arm, shoulder and hand score (DASH), grip strength and pain at rest and activity on a visual analogue scale (VAS). RESULTS: We found a statistically significant improvement in DASH from 42.0 to 15.9 (p < 0.001), VAS at rest from 3.5 to 0.6 (p < 0.001), VAS at activity from 7.9 to 2.5 (p < 0.001) and grip strength from 21.6 kg to 27.6 kg (p < 0.001) 12 months after the operation, when analysed as a group. There was an increased risk of no clinically important improvement in hand function for patients with preoperative high preoperative grip strength. Also, we found an increased risk of no clinically important improvement in female patients when using VAS as outcome. CONCLUSION: However, we were unable to detect one isolated preoperative predictor as indicator of successful result after operative treatment of TMC osteoarthritis, and as so it was not possible to establish a clinical valid tool for patient selection before surgery. Informed consent was obtained from all patients for being included in the study. The study needed no approval from The Regional Committee of Biomedical Research Ethics as the data was collected, as part of our normal pre- and postoperative clinical pathway, but the study is part of an outcome study of the results after total joint arthroplasty (TJA) of the TMC joint registered in Clinicaltrials.gov (NCT01554748). TRIAL REGISTRATION: Clinicaltrials.gov (NCT01554748). Registered 15 March 2012.

A narrative review and content analysis of functional and quality of life measures used to evaluate the outcome after TSA: an ICF linking application.

BACKGROUND: Total shoulder arthroplasty (TSA) is considered as the standard reconstructive surgery for patients suffering from severe shoulder pain and dysfunction caused by arthrosis. Multiple patient-reported outcome measures (PROMs) have been developed and validated that can be used to evaluate TSA outcomes. When selecting an outcome measure both content and psychometric properties must be considered. Most research to date has focused on psychometric properties. Therefore, the current study aims to summarize what PROMs are being used to assess TSA outcomes, to classify the type of measure (International society for quality of life (ISOQOL) using definitions of functioning, disability, and health (FDH), quality of life (QoL) and health-related quality of life (HRQoL)) and to compare the content of these measures by linking them to the International Classification of Functioning, Disability and Health (ICF) framework. METHODS: A literature review was performed in three databases including MEDLINE, EMBASE, and CINAHL to identify PROMs that were used in TSA studies. Meaningful concepts of the identified measures were extracted and linked to the relevant second-level ICF codes using standard linking rules. Outcome measures were classified as being FDH, HRQoL or QoL measures based on the content analysis. RESULT: Thirty-five measures were identified across 400 retrieved studies. The most frequently used PROM was the American Shoulder and Elbow Society score accounting for 21% (246) of the total citations, followed by the single item pain-related scale like visual analog scale (17%) and Simple Shoulder Test (12%). Twelve PROMs with 190 individual items fit inclusion criteria for conceptual analysis. Most codes (65%) fell under activity and participation categories. The top 3 most predominant codes were: sensation of pain (b280; 13%), hand and arm use (d445; 13%), recreational activity (d920; 8%). Ten PROMs included in this study were categorized as FDH measures, one as HRQoL measure, and one as unknown. CONCLUSIONS: Our study demonstrated that there is an inconsistency and lack of clarity in conceptual frameworks of identified PROMs. Despite this, common core constructs are evaluated. Decision-making about individual studies or core sets for outcome measurement for TSA would be advanced by considering our results, patient priorities and measurement properties.

Playing sport injured is associated with osteoarthritis, joint pain and worse health-related quality of life: a cross-sectional study.

BACKGROUND: Sports participants are faced with the decision to continue or cease play when injured. The implications of playing sport while injured on joint health and health-related quality of life (HRQoL) has not been investigated. The purpose of this study was to investigate the relationship between having played sport while injured and HRQoL, osteoarthritis, and persistent joint pain; and compare findings in elite and recreational cricketers. METHODS: The Cricket Health and Wellbeing Study cohort was used for this study. Inclusion criteria were: age ≥ 18 years, played ≥1 cricket season. Questionnaire data collected included a history of playing sport injured, SF-8 (physical (PCS) and mental (MCS) component scores), physician-diagnosed osteoarthritis, and persistent joint pain (most days of the last month). Multivariable linear regressions and logistic regressions were performed. Continuous covariates were handled using fractional polynomials. Models were adjusted for age, sex, cricket-seasons played, playing status, joint injury, and orthopaedic surgery. All participants (n = 2233) were included in HRQoL analyses, only participants aged ≥30 years (n = 2071) were included in osteoarthritis/pain analyses. RESULTS: Of the 2233 current and former cricketers (mean age: 51.7 SD 14.7, played 30 IQR 24 cricket seasons, 60% were current cricketers, 62% played recreationally; median PCS: 51.4 IQR 9.0; MCS: 54.3 IQR 8.6) 1719 (77%) had played sport while injured. People who had played sport injured reported worse adjusted PCS (Effect(95% CI): - 1.78(- 2.62, - 0.93) and MCS (- 1.40(- 2.25, - 0.54), had greater odds of osteoarthritis (adjusted OR(95% CI): 1.86(1.39, 2.51) and persistent joint pain (2.34(1.85, 2.96)), compared to people who had not played sport injured. Similar relationships were observed regarding PCS, osteoarthritis and pain in elite and recreational subgroups. Playing injured was only related to worse MCS scores for elite cricketers (- 2.07(- 3.52, - 0.63)); no relationship was observed in recreational cricketers (- 0.70(- 1.79, 0.39)). CONCLUSION: Cricketers that had played sport injured had impaired HRQoL, increased odds of osteoarthritis and persistent joint pain, compared to those who had not played sport injured. Playing sport injured was only related to impaired mental-components of HRQoL in elite cricketers. The long-term impact of playing while injured on musculoskeletal health, should be considered when advising athletes on their ability to compete following injury.

Quality-Adjusted Life-Years Lost Due to Physical Inactivity in a US Population With Osteoarthritis.

OBJECTIVE: One-half of the 14 million persons in the US with knee osteoarthritis (OA) are not physically active, despite evidence that physical activity (PA) is associated with improved health. We undertook this study to estimate both the quality-adjusted life-year (QALY) losses in a US population with knee OA due to physical inactivity and the health benefits associated with higher PA levels. METHODS: We used data from the Osteoarthritis Initiative and the Centers for Disease Control and Prevention to estimate the proportions of a US population with knee OA ages ≥45 years that are inactive, insufficiently active, and active, and the likelihood of a shift in their PA level. We used the OA Policy Model, a computer simulation of knee OA, to determine QALYs lost due to inactivity and to measure potential benefits of increased PA (comorbidities averted and QALYs saved). RESULTS: Among 13.7 million persons with knee OA, a total of 7.5 million QALYs, or 0.55 QALYs per person, were lost due to inactivity or insufficient PA relative to activity over their remaining lifetimes. Black Hispanic women experienced the highest losses, at 0.76 QALYs per person. Women of all races/ethnicities had ~20% higher loss burdens than men. According to our model, if 20% of the inactive population were instead active, 95,920 cases of cancer, 222,413 of cardiovascular disease, and 214,725 of diabetes mellitus would potentially be averted, and 871,541 potential QALYs would be saved. CONCLUSION: Physical inactivity leads to substantial QALY losses in a US population with knee OA. Increases in the activity levels in even a fraction of this population may have considerable collateral health benefits, potentially averting cases of cancer, cardiovascular disease, and diabetes mellitus.

Influence of Depressive Symptoms on the Clinical Outcomes of Total Ankle Arthroplasty.

Many studies have reported the relevance of depression on clinical outcomes after knee or hip arthroplasty. However, no study has investigated this relationship in total ankle arthroplasty (TAA). This study aimed to study the relationship between depressive symptoms and clinical outcomes after TAA. This retrospective comparative study investigated 40 patients who underwent TAA for end-stage ankle arthritis. Depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression Scale and Patient Health Questionnaire-9. Preoperative and postoperative clinical outcomes were compared using the visual analog scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores by classifying the subjects into depressive and nondepressive groups. The mean follow-up duration was 24.3 ± 7.3 (range 14 to 37) months. There were 13 and 27 subjects in the depressive and nondepressive groups, respectively. There were no significant differences in the baseline characteristics and preoperative VAS and AOFAS scores between them. The postoperative VAS score was significantly higher in the depressive group (3.1 ± 2.4) than in the nondepressive group (1.4 ± 2.3; p < .001). The postoperative AOFAS scores in the depressive and nondepressive groups were 89.3 ± 13.4 and 95.0 ± 8.1, respectively, showing a significantly superior result in the latter group (p < .001). The clinical outcomes after TAA were poorer in the patients with depressive symptoms than in those without. Depressive symptoms are patient-specific factors or independent predictors that show less improvement after TAA. Therefore, clinical considerations of these symptoms are essential before TAA.

Platelet-Rich plasma Injection Management for Ankle osteoarthritis study (PRIMA): protocol of a Dutch multicentre, stratified, block-randomised, double-blind, placebo-controlled trial.

INTRODUCTION: Platelet-rich plasma (PRP) is a potentially efficacious treatment for ankle osteoarthritis (OA), but its use has not been examined in high-quality studies. Systematic reviews show that PRP injections significantly decrease pain and improve function in patients with knee OA. Ankle OA is more common than hip or knee OA in the young active population; with a prevalence of 3.4%.PRP injections in ankle OA are shown to be safe and improve quality of life over time, but no randomised controlled trial has been conducted. Our randomised controlled trial will evaluate the efficacy of PRP injections for symptom reduction and functional improvement, compared with placebo, in the treatment of ankle (talocrural) OA. METHODS AND ANALYSIS: We will conduct the Platelet-Rich plasma Injection Management for Ankle OA study: a multicentre, randomised, placebo-controlled trial. One hundred patients suffering from ankle OA will be randomised into two treatment groups: PRP injection or placebo (saline) injection. Both groups will receive two injections of PRP or placebo at an interval of 6 weeks. Primary outcome is the American Orthopaedic Foot and Ankle Society score at 26 weeks. Secondary outcomes determined at several follow-up moments up to 5 years, include Ankle Osteoarthritis Score, Foot and Ankle Outcome Score, pain subscale of (0-40), Visual Analogue Scale score (0-100), Ankle Activity Score (0-10), subjective patient satisfaction Short Form Health Survey-36, Global Attainment Scaling and the EuroQol-5 dimensions-3 levels utility score. A cost-effectiveness analysis will be performed at 1 year. ETHICS AND DISSEMINATION: The study is approved by the Medical Ethics Review Committee Amsterdam Medical Center, the Netherlands (ABR 2018-042, approved 23 July 2018) and registered in the Netherlands trial register (NTR7261). Results and new knowledge will be disseminated through the Dutch Arthritis Association (ReumaNederland), Dutch patient federation, conferences and published in a scientific peer-reviewed journal. TRIAL REGISTRATION NUMBER: NTR7261.

Patient-Reported Outcome Measures and Health-Related Quality-of-Life Scores of Patients Undergoing Anatomic Total Shoulder Arthroplasty.

BACKGROUND: Health-related quality-of-life (HRQoL) scores are required for cost-effectiveness and health-care value analysis. We evaluated HRQoL scores and patient-reported outcome measures (PROMs) in patients with advanced glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty to establish values of HRQoL scores that can be used for cost-effectiveness and value analysis and to assess relationships between HRQoL scores and shoulder and upper-extremity PROMs. METHODS: We analyzed 145 patients (145 shoulders) with glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty; 93 patients had 1-year follow-up. Preoperative and postoperative functional outcomes were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) for shoulder pain and function. Health utility was assessed with the EuroQol-5 Dimensions (EQ-5D), Short Form-6 Dimensions (SF-6D), and VAS Quality of Life (VAS QoL). HRQoL score validity was determined through correlations between the PROMs and HRQoL scores. The responsiveness of HRQoL scores was measured through the effect size and the standardized response mean. RESULTS: There were significant improvements in all PROMs and HRQoL scores (p < 0.001) at 1 year after the surgical procedure. The changes in VAS QoL and EQ-5D were significantly correlated (weak to moderate) with the changes in all PROMs except the SST, demonstrating comparably acceptable validity. The VAS QoL had a large effect size (1.833) and standardized response mean (1.603), and the EQ-5D also had a large effect size (1.163) and standardized response mean (1.228), demonstrating responsiveness. The effect sizes of all PROMs were larger than those of the HRQoL scores. The change in SF-6D had only a moderate effect size and standardized response mean and was not significantly correlated with the change in any of the PROMs. CONCLUSIONS: PROMs and HRQoL scores are not interchangeable, and studies of the cost-effectiveness and value of shoulder arthroplasty should incorporate both shoulder and upper-extremity PROMs and HRQoL scores. The findings of this study provide data on HRQoL scores that are specific to the treatment of advanced glenohumeral osteoarthritis with anatomic total shoulder replacement and can be used for future cost-effectiveness and value analysis studies. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Health and Quality of Life Outcomes Among Patients Undergoing Surgery for End-Stage Ankle Arthritis.

BACKGROUND: There is little research investigating which aspects of health-related quality of life change following ankle arthrodesis and total ankle replacement surgery. The objective of this study was to report on statistically and clinically relevant changes in multiple dimensions of health-related quality of life among patients undergoing ankle replacement or fusion surgery. METHODS: This study was based on a prospective sample of ankle arthrodesis and total ankle replacement patients. Participants complete the Ankle Osteoarthritis Scale, EuroQoL's EQ-5D-3L, the Patient Health Questionnaire-9, and the pain intensity, interference with enjoyment of life, and general activity pain instrument. Instruments were completed preoperatively and postoperatively. Multivariate regression models were used to measure the change in health-related quality of life outcomes, adjusting for demographic, clinical, and health service utilization. RESULTS: Participants achieved statistically significant improvements in health-related quality of life in each domain of measurement. The majority of participants reported clinically significant improvement in pain. Mild depressive symptoms were common, and clinically significant improvement in depression symptoms occurred in 22% of patients. Gains in health were more pronounced among participants reporting the worst preoperative health in all domains quality of life measured. CONCLUSIONS: Pain showed a clinically important improvement among 64% of participants whereas 22% reported a clinically meaningful improvement in their depression symptoms postoperatively. Clinically significant gains in health-related quality of life were not experienced by all participants in all dimensions. Further research is warranted to better understand the failure of some patients to improve in dimensions of health studied. LEVEL OF EVIDENCE: Level III, comparative study.

Psychological well-being in patients with aneurysms-osteoarthritis syndrome.

Aneurysms-osteoarthritis syndrome (AOS) is characterized by arterial aneurysms and dissection in combination with early-onset osteoarthritis, which can impact quality of life. We describe the subjective quality of life and investigate anxiety and depression in 28 AOS patients aged 15-73 years. Three questionnaires were used: 36-Item Short Form Survey (SF-36), hospital anxiety and depression scale (HADS) and Rotterdam disease specific questionnaire. Results of the SF-36 and HADS were compared to a reference Dutch cohort and the SF-36 questionnaire also to patients with Marfan syndrome. Compared to the general population, AOS patients scored significantly lower on the following SF-36 domains: physical functioning, vitality, social functioning, bodily pain, and general health. Physical functioning was also lower than in Marfan patients. Patients with AOS scored higher on the HADS depression scale, while anxiety did not show a significant difference compared to the general population. No difference in SF-36 and HADS domain scores were found between patient with and without orthopaedic symptoms and patients with or without previous aortic surgery. Additionally, we found that patients' worries for their future and heredity of their disease are important factors for anxiety, which should be addressed in clinical practice.

The commercial pig as a model of spontaneously-occurring osteoarthritis.

BACKGROUND: Preclinical osteoarthritis models where damage occurs spontaneously may better reflect the initiation and development of human osteoarthritis. The aim was to assess the commercial pig as a model of spontaneous osteoarthritis development by examining pain-associated behaviour, joint cartilage integrity, as well as the use of porcine cartilage explants and isolated chondrocytes and osteoblasts for ex vivo and in vitro studies. METHODS: Female pigs (Large white x Landrace x Duroc) were examined at different ages from 6 weeks to 3-4 years old. Lameness was assessed as a marker of pain-associated behaviour. Femorotibial joint cartilage integrity was determined by chondropathy scoring and histological staining of proteoglycan. IL-6 production and proteoglycan degradation was assessed in cartilage explants and primary porcine chondrocytes by ELISA and DMMB assay. Primary porcine osteoblasts from damaged and non-damaged joints, as determined by chondropathy scoring, were assessed for mineralisation, proliferative and mitochondrial function as a marker of metabolic capacity. RESULTS: Pigs aged 80 weeks and older exhibited lameness. Osteoarthritic lesions in femoral condyle and tibial plateau cartilage were apparent from 40 weeks and increased in severity with age up to 3-4 years old. Cartilage from damaged joints exhibited proteoglycan loss, which positively correlated with chondropathy score. Stimulation of porcine cartilage explants and primary chondrocytes with either IL-1ß or visfatin induced IL-6 production and proteoglycan degradation. Primary porcine osteoblasts from damaged joints exhibited reduced proliferative, mineralisation, and metabolic capacity. CONCLUSION: In conclusion, the commercial pig represents an alternative model of spontaneous osteoarthritis and an excellent source of tissue for in vitro and ex vivo studies.