Do Surgeon Expectations Predict Clinically Important Improvements in WOMAC Scores After THA and TKA?

BACKGROUND: Failure of THA or TKA to meet a patient's expectations may result in patient disappointment and litigation. However, there is little evidence to suggest that surgeons can consistently anticipate which patients will benefit from those interventions. QUESTIONS/PURPOSES: To determine the ability of surgeons to identify, in advance of surgery, patients who will benefit from THA or TKA and those who will not, where 'benefit' is defined as a clinically important improvement in a validated patient-reported outcomes score. METHODS: In this prospective study, eight high-volume orthopaedic surgeons completed validated THA and TKA expectations questionnaires (score 0-100, 100 being the highest expectation) as part of preoperative assessment of all their patients scheduled for a THA or TKA and enrolled in the Hospital for Special Surgery institutional registry. Enrolled patients completed the WOMAC preoperatively and at 2 years. Successful outcomes were defined as achieving the minimum clinically important difference (MCID) in WOMAC pain and function subscales. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were used to evaluate the ability of surgeons' expectation scores to identify patients likely to achieve the MCID on the WOMAC scale. Analyses were run separately for patients having THA and TKA. We enrolled 259 patients undergoing THA and 247 undergoing TKA, of whom 77% (n = 200) and 77% (n = 191) completed followup surveys 2 years after their procedures, respectively. RESULTS: Surgeons' expectation scores effectively anticipated patients who would improve after THA, but they were no better than chance in identifying patients who would achieve the MCID on the WOMAC score 2 years after TKA. For patients having THA, the areas under the ROC curve were 0.67 (95% CI, 0.53-0.82; p = 0.02) and 0.74 (95% CI, 0.63-0.85; p < 0.01) for WOMAC function and pain outcomes, respectively, indicating good accuracy. Sensitivity and specificity were maximized on WOMAC pain and function scores (sensitivity = 0.69, specificity = 0.72, both for pain and function) at an expectations score of 83 or greater of 100. Surgeons' expectations were more accurate for patients who were men, who had a BMI less than 30 kg/m2, who had more than one comorbidity, and who were older than 65 years. For patients having TKA, surgeons' expectation scores were not better than chance for identifying those who would experience a clinically important improvement on the WOMAC scale (area under ROC curve: Function = 0.51, [95% CI, 0.42-0.61], p = 0.78; Pain = 0.51, [95% CI, 0.40-0.61], p = 0.92). CONCLUSIONS: Most patients having THA and TKA achieved the MCID improvement after surgery. However, the inability of surgeons' expectation scores to discriminate accurately between patients who benefit and those who do not among patients scheduled for THA who are young, with no comorbidities, and with elevated BMIs, and among all patients scheduled for TKA, calls for surgeons to spend more time with these patients to fully understand and address their needs and expectations. Using standardized assessment tools to compare surgeons' expectations and those of their patients may help focus the surgeon-patient discussion further, and address patients' expectations more effectively. LEVEL OF EVIDENCE: Level II, therapeutic study.

Intraarticular analgesia versus epidural plus femoral nerve block after TKA: a randomized, double-blind trial.

BACKGROUND: Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic. QUESTIONS/PURPOSES: We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA. METHODS: Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded. RESULTS: The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p < 0.0001; 12-24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups. CONCLUSIONS: A continuous intraarticular infusion of ropivacaine can be recommended as a safe, effective alternative to epidural analgesia plus single-injection FNB after TKA. Improved analgesic efficacy in the group that received epidural analgesia plus single-injection FNB must be weighed against the disadvantage of a higher likelihood of knee buckling and delayed ambulation with that treatment approach. LEVEL OF EVIDENCE: Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Reproducible fixation with a tapered, fluted, modular, titanium stem in revision hip arthroplasty at 8-15 years follow-up.

The use of tapered, fluted, modular, distally fixing stems has increased in femoral revision surgery. The goal of this retrospective study was to assess mid-term to long-term outcomes of this implant. Seventy-one hips in 70 patients with a mean age of 69 years were followed for an average of 10 years. Preoperative HHS averaged 50 and improved to 87 postoperatively. Seventy-nine percent hips had Paprosky type 3A or more bone-loss. All stems osseointegrated distally (100%). Two hips subsided >5mm but achieved secondary stability. Sixty-eight percent hips had evidence of bony reconstitution and 21% demonstrated diaphyseal stress-shielding. One stem fractured near its modular junction and was revised with a mechanical failure rate of 1.4%. Distal fixation and clinical improvement were reproducibly achieved with this stem design.

Fibrin sealants or cell saver eliminate the need for autologous blood donation in anemic patients undergoing primary total knee arthroplasty.

INTRODUCTION: Reducing allogeneic blood transfusions remains a challenge in total knee arthroplasty. Patients with preoperative anemia have a particularly high risk for perioperative blood transfusions. MATERIALS AND METHODS: 176 anemic patients (Hb < 13.5 g/dl) undergoing total knee replacement were prospectively evaluated to compare the effect of a perioperative cell saver (26 patients), intraoperative fibrin sealants (5 ml Evicel, Johnson & Johnson Wound Management, Ethicon, Somerville, NJ) (45 patients), preoperative autologous blood donation (PABD) (21 patients), the combination of fibrin sealants and preoperative autologous blood donation (44) and no intervention (40 patients) on perioperative blood loss and transfusion requirements. RESULTS: All protocols resulted in significant reduction of allogeneic blood transfusions. Transfusion rates were similar with the use of PABD (19%), Evicel (18%), and cell saver (19%), all significantly lower than the control group (38 %, p < 0.05). Combining Evicel with PABD resulted in significantly higher wastage of autologous units (p < 0.05) with no significant reduction in allogeneic transfusion rate (14%). The use of fibrin sealant resulted in a significant reduction of blood loss compared to the PABD group (603 vs. 810 ml, p < 0.005) as well as the control group (603 vs. 822 ml, p < 0.005). CONCLUSIONS: While PABD proved to be the most cost-effective treatment option in anemic patients, fibrin sealants and cell saver show similar reduction in allogeneic transfusion rates compared to controls. The combination of fibrin sealants and PABD is not cost-effective and increases the number of wasted units.

Low vitamin D status does not adversely affect short-term functional outcome after total hip arthroplasty.

We prospectively measured functional performances (Western Ontario and McMaster Universities Osteoarthritis Index, Short Form-36, 2-minute walk test, and timed get-up-and-go test) of patients who underwent total hip arthroplasty (THA) and had serum vitamin D levels tested during the preoperative evaluation. Of 219 patients, 102 (46.6%) had low vitamin D levels (25-hydroxyvitamin D<30 ng/mL). Low vitamin D status did not adversely affect short-term function at 6 weeks after THA. In addition, there was no association between serum vitamin D levels and the within-patient changes of scores of each outcome measurement. Because this 6-week period is generally adequate to correct vitamin D deficiency, orthopedic surgeons can safely perform THA without delay. Nevertheless, because vitamin D deficiency impairs bone quality, patients with low vitamin D levels should be treated once identified.

Does vitamin D status affect the attainment of in-hospital functional milestones after total hip arthroplasty?

Our study aims to identify the prevalence of low vitamin D status in patients undergoing total hip arthroplasty (THA) and to evaluate the association between serum vitamin D level and the attainment of in-hospital functional milestones. We collected data from patients who underwent THA and had preoperative serum vitamin D (serum 25-hydroxy vitamin D) levels measured. From 200 patients, 79 (39.5%) had low serum vitamin D (serum 25-hydroxy vitamin D <32 ng/mL). There were no associations between serum vitamin D level and the attainment of in-hospital functional milestones as well as length of hospital stay or perioperative complications after THA. Because low vitamin D status did not compromise the short-term functional outcomes after THA, surgery need not be delayed, but low vitamin D levels should be corrected once identified.