Electronic Patient-Reported Outcome Monitoring to Improve Quality of Life After Joint Replacement: Secondary Analysis of a Randomized Clinical Trial.

Importance: Although remote patient-reported outcome measure (PROM) monitoring has shown promising results in cancer care, there is a lack of research on PROM monitoring in orthopedics. Objective: To determine whether PROM monitoring can improve health outcomes for patients with joint replacement compared with the standard of care. Design, Setting, and Participants: A 2-group, patient-level randomized clinical trial (PROMoting Quality) across 9 German hospitals recruited patients aged 18 years or older with primary hip or knee replacement from October 1, 2019, to December 31, 2020, with follow-up until March 31, 2022. Interventions: Intervention and control groups received the standard of care and PROMs at hospital admission, discharge, and 12 months after surgery. In addition, the intervention group received PROMs at 1, 3, and 6 months after surgery. Based on prespecified PROM score thresholds, at these times, an automated alert signaled critical recovery paths to hospital study nurses. On notification, study nurses contacted patients and referred them to their physicians if necessary. Main Outcomes and Measures: The prespecified outcomes were the mean change in PROM scores (European Quality of Life 5-Dimension 5-Level version [EQ-5D-5L; range, -0.661 to 1.0, with higher values indicating higher levels of health-related quality of life (HRQOL)], European Quality of Life Visual Analogue Scale [EQ-VAS; range, 0-100, with higher values indicating higher levels of HRQOL], Hip Disability and Osteoarthritis Outcome Score-Physical Function Shortform [HOOS-PS; range, 0-100, with lower values indicating lower physical impairment] or Knee Injury and Osteoarthritis Outcome Score-Physical Function Shortform [KOOS-PS; range, 0-100, with lower values indicating lower physical impairment], Patient-Reported Outcomes Measurement Information System [PROMIS]-fatigue [range, 33.7-75.8, with lower values indicating lower levels of fatigue], and PROMIS-depression [range, 41-79.4, with lower values indicating lower levels of depression]) from baseline to 12 months after surgery. Analysis was on an intention-to-treat basis. Results: The study included 3697 patients with hip replacement (mean [SD] age, 65.8 [10.6] years; 2065 women [55.9%]) and 3110 patients with knee replacement (mean [SD] age, 66.0 [9.2] years; 1669 women [53.7%]). Exploratory analyses showed significantly better health outcomes in the intervention group on all PROMs except the EQ-5D-5L among patients with hip replacement, with a 2.10-point increase on the EQ-VAS in the intervention group compared with the control group (HOOS-PS, -1.86 points; PROMIS-fatigue, -0.69 points; PROMIS-depression, -0.57 points). Patients in the intervention group with knee replacement had a 1.24-point increase on the EQ-VAS, as well as significantly better scores on the KOOS-PS (-0.99 points) and PROMIS-fatigue (-0.84 points) compared with the control group. Mixed-effect models showed a significant difference in improvement on the EQ-VAS (hip replacement: effect estimate [EE], 1.66 [95% CI, 0.58-2.74]; knee replacement: EE, 1.71 [95% CI, 0.53-2.90]) and PROMIS-fatigue (hip replacement: EE, -0.65 [95% CI, -1.12 to -0.18]; knee replacement: EE, -0.71 [95% CI, -1.23 to -0.20]). The PROMIS-depression score was significantly reduced in the hip replacement group (EE, -0.60 [95% CI, -1.01 to -0.18]). Conclusions and Relevance: In this randomized clinical trial, the PROM-based monitoring intervention led to a small improvement in HRQOL and fatigue among patients with hip or knee replacement, as well as in depression among patients with hip replacement. Trial registration: Deutsches Register Klinischer Studien ID: DRKS00019916.

A comparison of joint line height after revision total knee replacement using a rotating hinge versus a condylar revision knee system.

Purpose: This retrospective study aimed to assess the effects of two differing revision total knee implants designs (condylar and rotating hinge) on joint line height. Method: The use of distal augmentation and pre and post revision radiographic joint line heights were compared in 19 condylar type knee replacements (Zimmer NexGen Legacy Constrained Condylar Knee - LCCK) and 40 LINK-Endo-rotating hinge knee replacements. Joint line and patellar heights were determined for each implant using four validated methods. For comparison within a group a two tailed paired Student's t-test was used, for comparison between the groups an unpaired, two tailed Student's t-test was used. A p value of less than 0.05 was deemed statistically significant. Results: In 15 of 19 NexGen revision knee replacements distal augments were used. No distal augments were used in the LINK-Endo RHK group. In both systems there was no tendency to elevate the joint line relative to the tibia. The joint line was distalised relative to the femur in the NexGen group and proximalised in the rotating hinge knee group. Measurements using antero-posterior radiographs were found to be the most reliable method of assessing joint line height when compared to lateral radiographs. Conclusion: Both revision knee implant systems adequately restored joint line height. In condylar type knee revision implants elevation of the joint line height may be avoided through the use of distal augmentation. We found AP radiographs to be the most reliable method of accurately assessing joint line height.

Management of Gonarthrosis with a Rotating Hinge Prosthesis: Minimum 10-Year Follow-up.

BACKGROUND: The use of hinged designs is usually reserved for severe deformities or instability in contemporary total knee arthroplasty (TKA). Results have been mixed with some authors reporting relatively high incidences of complications. The aim of this study is to present the results of primary TKA performed with a hinged prosthesis with a minimum 10-year follow-up. We also examined the factors that influence survivorship of this prosthesis. METHODS: A total of 238 primary TKA procedures were performed using hinged prostheses. Indications included osteoarthritis, rheumatoid arthritis, posttraumatic deformity, and arthritis. Clinical outcomes were assessed using the Hospital for Special Surgery score. Radiologic assessment was performed at each follow-up. Survivorship was calculated based on the Kaplan-Meier method. All complications were documented. RESULTS: Mean follow-up was 13.5 years (standard deviation [SD], 3.4). Mean flexion at final review was 118° (SD, 20°). Fifty-four percent and 20% reported excellent and good functional scores, respectively. Survivorship was 94% at 13.5 years in patients over 60 years of age and 77% in patients less than 60 years of age. Survivorship in patients with preoperative varus deformity was 96% and that in valgus knees was 79%. CONCLUSIONS: The results of this study suggest that when rotating hinges are used for primary TKA, the best results are achieved in patients over 60 years old. The indications for this design in the setting of primary TKA include significant deformities, severe bone loss, and ligamentous laxity.

Complication rates after total ankle arthroplasty in one hundred consecutive prostheses.

INTRODUCTION: Total ankle arthroplasty is increasingly used as an alternative to arthrodesis to treat advanced ankle arthritis. However, the outcomes and postoperative complications are poorly described. PATIENTS AND METHODS: Between March 2005 and May 2010 114 S.T.A.R. prostheses were implanted by one surgeon at our institution. We retrospectively analysed the demographics, clinical outcomes and radiographic characteristics of 100 ankle prostheses (97 patients). RESULTS: The average follow up was 36 months. The average preoperative AOFAS score of 36.87 (22-58) significantly increased to 75.99 postoperative. A total of 87 % of the patients reported a better life quality. Twenty-seven ankles incurred complications after primary surgery, and 21 prostheses required revision surgery, including four patients who required arthrodesis. CONCLUSION: Our study shows a high satisfaction rate after total ankle replacement and clear pain relief. Patients with a body mass Index higher than 30 showed a higher rate of complications. Compared with ankle fusion, the rates of complications are comparable.

Three-year follow up utilizing tantal cones in revision total knee arthroplasty.

There still is no consensus on the treatment of choice in revision knee arthroplasty associated with severe femoral and/or tibial bone loss. A total of 44 patients underwent revision knee arthroplasty procedures using porous tantalum cones (TM cones) to reconstruct tibial and/or femoral bone defects. At latest follow up after 37 months (32-48), 38 patients remained in the study. Tibial and femoral bone loss was categorized according to the AORI-Classification. The average preoperative KSS improved from 34 (range, 6-90) to 63 points (range, 7-90 points). The VAS improved from 7.5 to 4.8. Two patients required a re-revision due to aseptic loosening. There was no correlation between the different types of knee prosthesis implanted. Our study shows favourable clinical and radiological outcomes using TM cones in managing significant bone loss in revision total knee surgery.

Medium-term follow-up of a modular tapered noncemented titanium stem in revision total hip arthroplasty: a single-surgeon experience.

We report a single-surgeon experience with a noncemented modular revision shaft (Modular Prosthesis; LINK, Hamburg, Germany) with clinical and radiographic results of 63 patients after 10 years. The Harris Hip Score improved from 51 to 84 points. Intraoperative complications included 11 fractures. Four patients had postoperative femoral fractures. Further shaft revisions were necessary: 1 subsidence, 1 late fracture, 1 late deep infection. Sixty-eight percent of cases showed revision defects as graded 3° by Mallory; 95 % did not show signs of loosening or subsidence; 38 patients showed adequate bone remodeling in the shaft and proximal femur; 21 patients showed excellent recovery of preoperative osteolytic areas, and 5 patients did not show signs of remodeling. The Modular Prosthesis stem shows adequate fixation and tendency toward satisfactory bone remodeling after 10 years.

Secondary Patellar Resurfacing after Primary Bicondylar Knee Arthroplasty did Not Meet Patients' Expectations.

Secondary patella resurfacing is a controversial procedure which is applied in patients with anterior knee pain after a bicondylar knee arthroplasty (with unresurfaced patella). A group of 46 patients were submitted to this procedure and their satisfaction, range of motion and pain improvement was evaluated. 52.2% of the patients were satisfied with the procedure, with an improvement in pain (Visual Analogue Scale) of 65% and an improvement in range of motion in 56,5%, with roundabout half of the patients having no resolution to their complaints. Whilst an improvement was not achieved in all patients, as it was initially hypothesised, this procedure should be considered when a revision knee arthroplasty is performed with an unresurfaced patella.

Patterns of osseointegration and remodeling in femoral revision with bone loss using modular, tapered, fluted, titanium stems.

Radiographic signs of osseointegration with the use of fluted, tapered, modular, titanium stems in revision hip arthroplasty with bone loss have not been previously categorized. Serial radiographs of 64 consecutive hips with mean follow-up of 6.2 years were retrospectively reviewed. Bone loss was classified as per Paprosky classification, osseointegration was assessed according to a modified system of Engh et al, and Harris Hip Score was used to document pain and function. Seventy-four percent of the hips had type 3 or 4 bone loss. All stems were radiographically osseointegrated. Early minor subsidence was seen in 6.2% of the hips; definite bony regeneration, 73% of the hips; and stress shielding, 26% of the hips. These osseointegration patterns were different from those described for extensively porous-coated cobalt-chromium stems and had a bearing on the evaluation of fixation of these stems.