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.

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.

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.

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.

Racial/Ethnic variations in morbidity and mortality in Adult Onset Still's Disease: An analysis of national dataset.

OBJECTIVES: Adult Onset Still's Disease (AOSD) is a rare autoinflammatory disorder. There is relatively little known about the impact of social determinants of health on its outcomes. Our goal is to describe the racial/ethnic variations, morbidity and mortality of AOSD hospitalized patients in the US. MATERIALS AND METHODS: Adult US hospitalized patients between 2009-13 from a nationwide inpatient sample (NIS) database with AOSD were identified using ICD-9 code 714.2. NIS is the largest all-payer US inpatient database with approximately 8 million hospitalizations yearly. Patients with other autoimmune diseases were excluded. We used descriptive statistics to summarize patient and hospital characteristics. We performed survey-weighted logistic regression models adjusting for confounders to study our primary outcome: in-hospital mortality. RESULTS: Between 2009-13, 5,820 AOSD patients were hospitalized with a mean age of 53.6 (SE-0.61) years. 3817 (65.6%) were female, 56% white and 3% Asian. Macrophage Activating Syndrome (1.7%), Disseminated Intravascular Coagulation (DIC-1.1%) and Thrombotic Thrombocytopenic Purpura (0.4%), respectively, complicated the hospital course. There were 154 inpatient deaths in study period (mortality 2.6%). Mean age of patients who died in hospital was higher (62.4 years ± 3.1) and 13.9% were Asians. Patients of Asian origin had significantly higher odds of in-hospital death compared to whites (aOR = 6.39, 95% CI 1.77-23.1, p = 0.005). Mortality was significantly higher for patients whose hospital course was complicated by DIC (aOR = 29.69, 95% CI 5.5-160.41, p = 0.006). CONCLUSIONS: In this national sample of patients hospitalized for AOSD, we found significant variations in In-hospital mortality.

Disparities in Outcomes for Blacks versus Whites Undergoing Total Hip Arthroplasty: A Systematic Literature Review.

OBJECTIVE: Total hip replacement (THA) surgery is a successful procedure, yet blacks in the United States undergo THA less often and reflect poorer outcomes than whites. The purpose of this study is to systematically review the literature on health-related quality of life after THA, comparing blacks and whites. METHODS: A librarian-assisted search was performed in Medline through PubMed, Embase, and Cochrane Library on February 27, 2017. Original cohort studies examining pain, function, and satisfaction in blacks and whites 1 year after elective THA were included. Using the Patient/Population-Intervention-Comparison/Comparator-Outcome (PICO) process format, our population of interest was US black adults, our intervention was elective THA, our comparator was white adults, and our outcomes of interest were pain, function, and satisfaction after elective THA. The protocol was registered under the PROSPERO international register, and the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: Of the articles, 4739 were screened by title, 180 by abstract, 25 by full text, and 4 remained for analysis. The studies represented 1588 THA patients, of whom 240 (15%) were black. All studies noted more pain and worse function for blacks; although differences were statistically significant, they were not clinically significant. One study sought and identified less satisfaction for blacks after THA, and 1 study showed worse fear and anxiety scores in blacks. CONCLUSION: When measured, there are small differences in THA outcomes between blacks and whites, but most studies do not analyze/collect race. Future studies should address the effect of race and socioeconomic factors on healthcare disparities.