Bert M. Chesworth

Patient Satisfaction after Total Knee Arthroplasty: Who is Satisfied and Who is Not?

Despite substantial advances in primary TKA, numerous studies using historic TKA implants suggest only 82% to 89% of primary TKA patients are satisfied. We reexamined this issue to determine if contemporary TKA implants might be associated with improved patient satisfaction. We performed a cross-sectional study of patient satisfaction after 1703 primary TKAs performed in the province of Ontario. Our data confirmed that approximately one in five (19%) primary TKA patients were not satisfied with the outcome. Satisfaction with pain relief varied from 72–86% and with function from 70–84% for specific activities of daily living. The strongest predictors of patient dissatisfaction after primary TKA were expectations not met (10.7× greater risk), a low 1-year WOMAC (2.5× greater risk), preoperative pain at rest (2.4× greater risk) and a postoperative complication requiring hospital readmission (1.9× greater risk).Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Use of the Berg Balance Scale for Predicting Multiple Falls in Community-Dwelling Elderly People: A Prospective Study

Background and Purpose: Falls are a significant public health concern for older adults; early identification of people at high risk for falling facilitates the provision of rehabilitation treatment to reduce future fall risk. The objective of this prospective cohort study was to examine the predictive validity of the Berg Balance Scale (BBS) for 3 types of outcomes—any fall (≥1 fall), multiple falls (≥2 falls), and injurious falls—by use of sensitivity, specificity, receiver operating characteristic (ROC) curves, area under the curve, and likelihood ratios. Subjects and Methods: A sample of 210 community-dwelling older adults received a comprehensive geriatric assessment at baseline, which included the BBS to measure balance. Data on prospective falls were collected monthly for a year. The predictive validity of the BBS for the identification of future fall risk was evaluated. Results: The BBS had good discriminative ability to predict multiple falls when ROC analysis was used. However, the use of the BBS as a dichotomous scale, with a threshold of ≤45, was inadequate for the identification of the majority of people at risk for falling in the future, with sensitivities of 25% and 45% for any fall and for multiple falls, respectively. The use of likelihood ratios, maintaining the BBS as a multilevel scale, demonstrated a gradient of risk across scores, with fall risk increasing as scores decreased. Discussion and Conclusion: The use of the BBS as a dichotomous scale to identify people at high risk for falling should be discouraged because it fails to identify the majority of such people. The predictive validity of this scale for multiple falls is superior to that for other types of falls, and the use of likelihood ratios preserves the gradient of risk across the whole range of scores.

Quantifying the magnitude of risk for balance impairment on falls in community-dwelling older adults: a systematic review and meta-analysis

OBJECTIVES To evaluate and summarize the evidence linking balance impairment as a risk factor for falls in community-dwelling older adults. STUDY DESIGN AND SETTING Systematic review and meta-analysis. English language articles in MEDLINE, EMBASE, CINAHL (1988-2009), under keywords of accidental falls, aged, risk factors, and hip, radius, ulna, and humerus fractures; and bibliographies of retrieved articles. Community-dwelling older adults in a prospective study, at least 1-year duration, age more than 60 years, and samples not specific to a single disease-defined population were included. Sample size, inclusion/exclusion criteria, demographics, clinical balance measurement scale, type of fall outcome, method of fall ascertainment, length of follow-up, and odds ratio (OR) or risk ratio (RR) were extracted. Studies must have reported adjustment for confounders. Random effects meta-analysis to generate summary risk estimate was used. A priori evaluation of sources of heterogeneity was performed. RESULTS Twenty-three studies met the selection criteria. A single summary measure could not be calculated because of the nonequivalence of the OR and RR, producing an overall fall risk of RR of 1.42 (1.08, 1.85) and OR of 1.98 (1.60, 2.46). CONCLUSIONS Balance impairment imparts a moderate increase on fall risk in community-dwelling older adults. The type of fall outcome, the length of follow-up, and the balance measurement tool impact the magnitude of the association. Specific balance measurement scales were identified with associations for an increased fall risk, but further research is required to refine recommendations for their use in clinical practice.

Comparing Patient Outcomes After THA and TKA: Is There a Difference?

Both primary total hip (THA) and knee (TKA) arthroplasty relieve pain, restore function, and increase mobility. Despite these successes, there is controversy as to whether THA or TKA provides greater or similar improvement. We therefore compared primary THA and TKA patient results in terms of (1) willingness to have surgery again; (2) WOMAC change score; (3) whether expectations were met; and (4) satisfaction. Patients undergoing primary THA were more willing to undergo their surgery again (THA 96%, TKA 89%), demonstrated greater WOMAC change scores, more frequently reported their expectations were met (THA 78%, TKA 70%), and expressed greater overall satisfaction (THA 89%, TKA 81%). In addition, patients undergoing THA expressed higher satisfaction with pain reduction while performing activities (ie, walking, stairs, and sitting/lying) and their ability to perform daily activities (ie, stairs, transportation, getting up, lying in bed, and light domestic duties) when compared with patients undergoing TKA. Our data suggest primary THA offers superior short-term outcomes when compared with primary TKA.Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

The Impact of Morbid Obesity on Patient Outcomes After Total Knee Arthroplasty

Five hundred fifty patients who underwent primary total knee arthroplasty between 1987 and 2004 with a primary diagnosis of osteoarthritis and 1-year outcome data (Western Ontario and McMaster Osteoarthritis Index [WOMAC]) were evaluated. Patients were stratified into body mass index categories based on the World Health Organization classification of obesity. Patients were dichotomized into a class III morbidly obese group and a non-morbidly obese group. Independent t test and multivariable linear regression were used to determine if a difference existed in the 1-year WOMAC outcome between morbidly obese patients and all other patients. Although 1-year outcomes were worse for morbidly obese patients (P < .05), they showed greater improvement in function compared with non-morbidly obese patients. Morbid obesity does not affect 1-year outcomes in patients who have had a total knee arthroplasty.

Medial opening wedge high tibial osteotomy: A prospective cohort study of gait, radiographic, and patient-reported outcomes

OBJECTIVE To evaluate the effect of medial opening wedge high tibial osteotomy on gait, radiographic, and patient-reported outcomes over a 2-year postoperative period in patients with varus alignment and medial compartment knee osteoarthritis, and to identify significant predictors of outcome. METHODS We used an observational cohort study design and prospectively administered 3-dimensional quantitative gait analysis, hip to ankle weight-bearing radiographs, and patient-reported outcomes preoperatively and 6, 12, 18, and 24 months postoperatively. Observed changes with 95% confidence intervals (95% CIs) were calculated. Multivariate linear regression and cluster analysis were used to evaluate associations between patient characteristics and 2-year outcomes in dynamic knee joint load (external knee adduction moment during gait) and Knee Injury and Osteoarthritis Outcome Scores (KOOS). RESULTS A total of 126 patients (mean age 47.48 years) were included in the study. Mean changes suggested clinically important improvements in malalignment (change in mechanical axis angle 8.04 degrees [95% CI 7.16 degrees , 8.93 degrees ]), medial compartment load during gait (change in knee adduction moment -1.38 [95% CI -1.53, -1.22] percentage body weight x height), and all KOOS domain scores (change in pain 23.19 [95% CI 19.49, 26.89] KOOS points). A small (13%) increase in knee adduction moment was observed from 6 to 24 months postoperatively. Few preoperative clinical and/or gait characteristics assessed at baseline were significantly associated with 2-year outcomes. CONCLUSION A medial opening wedge high tibial osteotomy with correction to approximately neutral alignment produces substantial and clinically important changes in dynamic knee joint load and patient-reported measures of pain, function, and quality of life 2 years postoperatively. Changes in knee adduction moment observed in the first 2 years postoperatively should be explored as potential predictors of longer-term success and subgroups of patients with poor outcomes.

Balance Impairment as a Risk Factor for Falls in Community-Dwelling Older Adults Who Are High Functioning: A Prospective Study

Background Screening should have simple and easy-to-administer methods that identify impairments associated with future fall risk, but there is a lack of literature supporting validation for their use. Objective The aim of this study was to evaluate the independent contribution of balance assessment on future fall risk, using 5 methods to quantify balance impairment, for the outcomes “any fall” and “any injurious fall” in community-dwelling older adults who are higher functioning. Design This was a prospective cohort study. Methods A sample of 210 community-dwelling older adults (70% male, 30% female; mean age=79.9 years, SD=4.7) received a comprehensive geriatric assessment at baseline, which included the Berg Balance Scale to measure balance. Information on daily falls was collected for 12 months by each participants monthly submission of a falls log calendar. Results Seventy-eight people (43%) fell, of whom 54 (30%) sustained an injurious fall and 32 (18%) had recurrent falls (≥2 falls). Different balance measurement methods identified different numbers of people as impaired. Adjusted relative risk (RR) estimates for an increased risk of any fall were 1.58 (95% confidence interval [CI]=1.06, 2.35) for self-report of balance problems, 1.58 (95% CI=1.03, 2.41) for one-leg stance, and 1.46 (95% CI=1.02, 2.09) for limits of stability. An adjusted RR estimate for an increased risk of an injurious fall of 1.95 (95% CI=1.15, 3.31) was found for self-report of balance problems. Limitations The study was a secondary analysis of data. Conclusions Not all methods of evaluating balance impairment are associated with falls. The number of people identified as having balance impairment varies with the measurement tool; therefore, the measurement tools are not interchangeable or equivalent in defining an at-risk population. The thresholds established in this study indicate individuals who should receive further comprehensive fall assessment and treatment to prevent falls.

Intratester and Intertester Reliability of Goniometric Measurement of Passive Lateral Shoulder Rotation

Measurement of lateral rotation range of motion (ROM) is frequently performed during shoulder evaluation. The purpose of this study was to determine the intratester and intertester reliability of goniometric measurement of passive lateral rotation ROM of the shoulder. Two experienced PTs performed the testing in a randomized block design. They were blinded to all clinical information and to their goniometric readings. Passive lateral rotation ROM of the shoulder was assessed in 34 patients with a variety of shoulder pathologies. Patients were placed in the supine position with the arm abducted approximately 20 degrees to 30 degrees. A standard goniometer, placed along the joint axis by the therapist, was red by an independent assistant. Intraclass correlation coefficients (ICCs) and their associated 95% confidence intervals were calculated. Intratherapist ICCs (0.88 and 0.93) and intertherapist ICCs (0.85 and 0.80) were high. These findings suggest that reliable measures of passive lateral rotation ROM of the shoulder can be obtained from patients with shoulder pathology using standard goniometry and by placing the patient in a supine position.

Cost effectiveness of revision total knee arthroplasty.

Total knee arthroplasty now exceeds total hip arthroplasty as the most commonly performed joint replacement. Projections suggest the need for revision knee arthroplasty in the future will produce an immense economic burden. The excellent cost effectiveness of primary knee arthroplasty has been well established. This article explores the cost effectiveness of revision knee arthroplasty, and makes a comparison of costs between different international health care systems. While revision knee arthroplasty is more costly, technically difficult, and complicated than primary knee arthroplasty, it is still a cost effective means of improving function, pain relief, and quality of life. The role of national arthroplasty registries will be important in guiding decision making toward reducing the requirements for revision surgery.Level of Evidence: Prognostic study, level II-1 (prospective study). See Guidelines for Authors for complete description of levels of evidence.

The relationship between expectations and satisfaction in patients undergoing primary total knee arthroplasty.

The objective of this literature review was to examine the relationship between expectations and satisfaction in patients undergoing primary total knee arthroplasty (TKA). Five databases were searched from inception to July 2011. Five studies were eligible on the following inclusion criteria: primary TKA, diagnosis of knee osteoarthritis, presurgery outcome measures, a measure of patient expectations and satisfaction, multivariate analysis of the relationship between expectations and satisfaction reported separately for TKA recipients, and English language. Preoperative expectations did not correlate with postoperative satisfaction. However, postoperative satisfaction was predicted by how well postoperative expectations were met after surgery. Therefore, patient education programs for managing expectations should span part of the postoperative recovery period.