C. Tilbury

Return to work after total hip and knee arthroplasty: a systematic review

OBJECTIVES The aim of this study was to describe work status and time to return to work in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) and to determine which factors are associated with work status. METHODS A systematic search strategy in various databases through April 2013 was performed. All clinical studies concerning patients undergoing THA or TKA providing quantitative information on work status before and after surgery were eligible for inclusion. Extracted were study characteristics, data on work status and determinants of return to work. The methodological quality was evaluated in three quality aspects (selection bias, information bias and statistical analysis bias). RESULTS Nineteen studies published between 1986 and 2013 were selected (4 on THA, 14 on TKA and 1 on THA and TKA). These studies included 3872 patients with THA and 649 patients with TKA. The proportions of patients returning to work ranged from 25 to 95% at 1-12 months after THA and from 71 to 83% at 3-6 months after TKA. The average time to return to work varied from 1.1 to 13.9 weeks after THA and from 8.0 to 12.0 weeks after TKA. Factors related to work status after THA and TKA included sociodemographic, health and job characteristics. Overall, the methodological quality of the studies was moderate to low. CONCLUSION The majority of patients who are employed before THA and TKA return to work postoperatively. Comparisons of work status and the rate and speed of return to work between studies in THA and TKA are hampered by large variations in patient selection and measurement methods, underpinning the need for more standardization.

Outcome of total hip arthroplasty, but not of total knee arthroplasty, is related to the preoperative radiographic severity of osteoarthritis: A prospective cohort study of 573 patients

Background and purpose — There is no consensus on the impact of radiographic severity of hip and knee osteoarthritis (OA) on the clinical outcome of total hip arthroplasty (THA) and total knee arthroplasty (TKA). We assessed whether preoperative radiographic severity of OA is related to improvements in functioning, pain, and health-related quality of life (HRQoL) 1 year after THA or TKA. Patients and methods — This prospective cohort study included 302 THA patients and 271 TKA patients with hip or knee OA. In the THA patients, preoperatively 26% had mild OA and 74% had severe OA; in the TKA patients, preoperatively 27% had mild OA and 73% had severe OA. Radiographic severity was determined according to the Kellgren and Lawrence (KL) classification. Clinical assessments preoperatively and 1 year postoperatively included: sociodemographic characteristics and patient-reported outcomes (PROMs): Oxford hip/knee score, hip/knee injury and osteoarthritis outcome score (HOOS/KOOS), SF36, and EQ5D. Change scores of PROMs were compared with mild OA (KL 0–2) and severe OA (KL 3–4) using a multivariate linear regression model. Results — Adjusted for sex, age, preoperative scores, BMI, and Charnley score, radiographic severity of OA in THA was associated with improvement in HOOS “Activities of daily living”, “Pain”, and “Symptoms”, and SF36 physical component summary (“PCS”) scale. In TKA, we found no such associations. Interpretation — The decrease in pain and improvement in function in THA patients, but not in TKA patients, was positively associated with the preoperative radiographic severity of OA.

Can Optimism, Pessimism, Hope, Treatment Credibility and Treatment Expectancy Be Distinguished in Patients Undergoing Total Hip and Total Knee Arthroplasty?

Objectives The constructs optimism, pessimism, hope, treatment credibility and treatment expectancy are associated with outcomes of medical treatment. While these constructs are grounded in different theoretical models, they nonetheless show some conceptual overlap. The purpose of this study was to examine whether currently available measurement instruments for these constructs capture the conceptual differences between these constructs within a treatment setting. Methods Patients undergoing Total Hip and Total Knee Arthroplasty (THA and TKA) (Total N = 361; 182 THA; 179 TKA), completed the Life Orientation Test-Revised for optimism and pessimism, the Hope Scale, the Credibility Expectancy Questionnaire for treatment credibility and treatment expectancy. Confirmatory factor analysis was used to examine whether the instruments measure distinct constructs. Four theory-driven models with one, two, four and five latent factors were evaluated using multiple fit indices and Δχ2 tests, followed by some posthoc models. Results The results of the theory driven confirmatory factor analysis showed that a five factor model in which all constructs loaded on separate factors yielded the most optimal and satisfactory fit. Posthoc, a bifactor model in which (besides the 5 separate factors) a general factor is hypothesized accounting for the commonality of the items showed a significantly better fit than the five factor model. All specific factors, except for the hope factor, showed to explain a substantial amount of variance beyond the general factor. Conclusion Based on our primary analyses we conclude that optimism, pessimism, hope, treatment credibility and treatment expectancy are distinguishable in THA and TKA patients. Postdoc, we determined that all constructs, except hope, showed substantial specific variance, while also sharing some general variance.

Determinants of return to work 12 months after total hip and knee arthroplasty

Introduction A substantial number of patients undergoing total hip or knee arthroplasty (THA or TKA) do not or only partially return to work. This study aimed to identify differences in determinants of return to work in THA and TKA. Methods We conducted a prospective, observational study of working patients aged <65 years undergoing THA or TKA for osteoarthritis. The primary outcome was full versus partial or no return to work 12 months postoperatively. Factors analysed included preoperative sociodemographic and work characteristics, alongside the Hip Disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS), and Oxford Hip and Knee Scores. Results Of 67 THA and 56 TKA patients, 9 (13%) and 10 (19%), respectively, returned partially and 5 (7%) and 6 (11%), respectively, did not return to work 1 year postoperatively. Preoperative factors associated with partial or no return to work in THA patients were self-employment, absence from work and a better HOOS Activities of Daily Living (ADL) subscale score, whereas only work absence was relevant in TKA patients. Type of surgery modified the impact of ADL scores on return to work. Conclusions In both THA and TKA, absence from work affected return to work, whereas self-employment and better preoperative ADL subscale scores were also associated in THA patients. The impact of ADL scores on return to work was modified by type of surgery. These results suggest that strategies aiming to influence modifiable factors should consider THA and TKA separately.

No associations between self-reported knee joint instability and radiographic features in knee osteoarthritis patients prior to Total Knee Arthroplasty: A cross-sectional analysis of the Longitudinal Leiden Orthopaedics Outcomes of Osteo-Arthritis study (LOAS) data

BACKGROUND To describe the prevalence of self-reported knee joint instability in patients with pre-surgery knee osteoarthritis (OA) and to explore the associations between self-reported knee joint instability and radiological features. METHODS A cross-sectional study including patients scheduled for primary Total Knee Arthroplasty (TKA). Self-reported knee instability was examined by questionnaire. Radiological features consisted of osteophyte formation and joint space narrowing (JSN), both scored on a 0 to three scale. Scores >1 are defined as substantial JSN or osteophyte formation. Regression analyses were provided to identify associations of radiological features with self-reported knee joint instability. RESULTS Two hundred and sixty-five patients (mean age 69years and 170 females) were included. Knee instability was reported by 192 patients (72%). Substantial osteophyte formation was present in 78 patients (41%) reporting and 33 patients (46%) not reporting knee joint instability. Substantial JSN was present in 137 (71%) and 53 patients (73%), respectively. Self-reported knee instability was not associated with JSN (relative to score 0, odds ratios (95% CI) of score 1, 2 and 3 were 0.87 (0.30-2.54), 0.98 (0.38-2.52), 0.68 (0.25-1.86), respectively) or osteophyte formation (relative to score 0, odds ratios (95% CI) of score 1, 2 and 3 were 0.77 (0.36-1.64), 0.69 (0.23-1.45), 0.89 (0.16-4.93), respectively). Stratified analysis for pain, age and BMI showed no associations between self-reported knee joint instability and radiological features. CONCLUSION Self-reported knee joint instability is not associated with JSN or osteophyte formation.

Patients’ pre-operative general and specific outcome expectations predict postoperative pain and function after total knee and total hip arthroplasties

Abstract Background and aims Previous studies have suggested there is an association between preoperative expectations about the outcome and outcomes of total knee and total hip arthroplasty (TKA/THA). However, expectations have been rarely examined on their clinical relevance relative to other well-known predictive factors. Furthermore expectations can be measured on a more generic level (e.g. does one expect their symptoms to improve after surgery) or on a more specific level (e.g. does one expect to be able to squat again after surgery). Aim of this study was to examine whether patients’ general and specific preoperative outcome expectations predict function and pain 12-months after TKA/THA, when assessed as one of the candidate predictive variables alongside other relevant clinical and sociodemographic variables. Moreover, we explored whether a more generic or a more specific assessment of expectations would better predict outcome. Methods A prospective cohort study on consecutive TKA/THA patients, with assessments done preoperatively and 12-months postoperative. Primary outcomes were the knee injury and osteoarthritis outcome score (KOOS) and hip injury and osteoarthritis outcome score (HOOS) activities of daily living (ADL) and pain subscale scores at 12-months. The pain subscales consist of nine-(KOOS) and 10-(HOOS) items and the ADL of 17 items. Patients’ preoperative outcome expectations were measured with the credibility expectancy questionnaire (CEQ), which contains three items scored on a 0–9 scale and sum score 0–27 and the Hospital for Special Surgery expectations surveys (HSS expectation surveys) for 17(TKA) or 18(THA) outcomes on 0–4 scale. Other candidate predictors: preoperative pain and function as measured with HOOS/KOOS, sex, age, education level, body mass index, Kellgren/Lawrence score, preoperative mental health and treatment credibility as measured with CEQ. Eight prediction models were constructed using multivariate linear regression analysis with a backward selection procedure. Results The 146 TKA patients included in this study had a mean age of 66.9 years (SD 9.2) and 69% was female. The 148 THA patients had a mean age 67.2 (SD 9.5) and 57% was female. Mean outcomes: postoperative HOOS-ADL 84.3 (SD 16.6), pain 88.2 (SD 15.4), KOOS-ADL 83.9 (SD 15.8) and pain 83.6 (SD 17.1). CEQ-expectancy median was in THA 23 (IQR 21;24) and TKA 23 (IQR 20;24). HSS-expectation surveys function was for THA 21.0 (18.0;24.0) and 19.0 (14.0;22.0) in TKA. Patients’ outcome expectations were consistently part of the combination of variables that best predicted outcomes for both TKA/THA 1-year post-operatively. Expectations alone explained between 17.0 and 30.3% of the variance in outcomes. The CEQ expectancy subscale explained more variance of postoperative function in TKA and of function and pain in THA as compared to the HSS expectation surveys. Conclusions In planning of surgical treatment, orthopedic surgeons should take a range of variables into account of which the patient’s expectations about outcome of surgery is one. The CEQ expectancy subscale predicted outcomes slightly better as the HSS expectation surveys, but differences in predictive value of the two measurements were too small to prefer between the two. Future studies are advised to replicate these findings and externally validate the models presented.

The provision of preoperative and postoperative physical therapy in elderly people with hip and knee osteoarthritis undergoing primary joint replacement surgery

Background:Although the value of physical therapy (PT) in the rehabilitation of patients undergoing THA and TKA is generally acknowledged, little is known on the actual extent of its delivery and contents. This study aimed to describe the use, characteristics, and determinants of preoperative and postoperative PT in THA and TKA. Methods:One thousand and five patients who underwent THA or TKA in four hospitals in the preceding 7-22 mo were invited to complete a survey on referral, setting, duration, and content regarding preoperative and postoperative PT as well as their current level of physical functioning (Hip Disability and Osteoarthritis Outcome [HOOS] and Knee Injury and Osteoarthritis Outcome Score [KOOS]) and quality of life (Short Form-36 [SF-36]). The association between patients’ characteristics (age and sex), hospital stay, and time since surgery on the one side and the provision of PT on the other and between PT usage and physical function and quality of life were analyzed by multivariable logistic and linear regression analyses. Results:In total, 210 of the 522 responders (54% THA and 46% TKA) patients had preoperative PT (40%; 44%>12 wk; 38% ≥2 times per week) and 514 postoperative PT (99%; 47% ≥12 wk; 67% ≥2 times per week). The most frequently reported interventions (>60% of patients) preoperatively were aerobic exercises and walking stairs and postoperatively, aerobic, muscle strengthening and range of motion exercises, walking stairs, and gait training. Regarding preoperative PT, female sex was the only factor associated with its provision. Moreover, the hospital was related to the proportion of referrals made by the orthopaedic surgeon, and a longer follow-up time since surgery was associated with a lower rate of provision of physical modalities. For postoperative PT, the hospital was associated with duration of PT and the provision of passive exercises, whereas older age was associated with fewer referrals by orthopaedic surgeons and treatment duration less than 12 wk, and female sex was associated with a treatment duration longer than 12 wk. A longer duration of postoperative PT was only associated with a worse physical quality of life, whereas preoperative PT use and the frequency of postoperative PT were not associated with any aspect of the patients’ current health status. Conclusions:Almost all patients undergoing THA or TKA received postoperative PT, whereas fewer than half had preoperative PT. There was considerable variation in the provision of preoperative and postoperative PT in part associated with patient and hospital characteristics and time since surgery, warranting the need for more prospective research into potential practice variation.

AB0844 Determinants of Returning to Work 12 Months After Total Joint Surgery: Differences Between Total Hip Arthroplasty and Total Knee Arthroplasty

Background The majority of the patients undergoing Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) returns to work postoperatively, but the absolute number of patients who do not return to work remains substantial. Little is known about factors limiting return to work1, Objectives To identify factors related to return to work after THA and TKA one year postoperatively. Methods This one-year prospective cohort study included patients who were assessed preoperatively and one-year postoperatively, aged 65 years or younger, and who provided information on their work status. Assessments included a questionnaire and/or telephone interview on work status. The outcome of return to work was divided into full return to work vs. partial or no return to work. Potential determinants included the following preoperative characteristics: physical hip/knee-job demands (classified into light, medium or heavy), the amount of working hours a week, self-employement, sick leave duration, granted disability benefits, presence of work adaptions and expectations of returning to work. Logistic regression analyses were employed to determine factors associated partial/no return to work in all patients, controlling for type of surgery (THA or TKA). Results Sixty-seven THA patients (mean age 56 years; SD 6.6, 33 females (49%)) and 56 TKA patients (mean age 56 years; SD 5.7, 31 females (55%)) were included. The mean amount of work hours a week preoperatively was 32 hours (SD 12.5) in THA patients and 31 hours (SD 12.3) in TKA patients. 53/67 THA patients (79%) and 40/56 TKA patients (71%) returned to work fully one-year post-operatively (same mean amount of work hours), whereas 5/67 THA patients (7%) and 7/56 TKA patients (13%) did not return to work at all and 9/67 THA patients (13%) and 9/56 TKA patients (16%) returned to work but less hours than preoperatively (mean decrease of work hours per week -17 hours (SD 11.5, P=0.002) in THA and -16 hours (SD 12.4, P=0.005) in TKA) The THA patients who returned to work partially or not had a lower educational level (P=0.006), were more often self-employed (P=0.009) and were more often absent from work due to hip complaints preoperatively than those fully returning to work (P=0.002). In the TKA group of patients there were no significant differences in characteristics of patients returning to work fully or not. In the multivariable logistic regression analyses, being self-employed (OR 7.4, 95%, CI 1.5-35.8), preoperative absence from work (OR 10.8, 95% CI 2.8-4.8) and working more hours preoperatively (OR 1.03, 95% CI 0.99-1.1) were factors significantly associated with partial/no return to work. Conclusions Self-employment, working more hours and being absent from work preoperatively remained determinants for partial/no return to work after correcting for type of prothesis. These findings underline the need to study return to work after THA and TKA separately. References C.Tilbury, et al., Return to work after total hip and knee arthroplasty: a systematic review. Rheumatology. (Oxford) 53(3), 512 (2014). Acknowledgements This study was funded by the Anna Fonds/NOREF Disclosure of Interest None declared

THU0437 Return to Work after Total Hip and Knee Arthroplasty: Results from A Prospective Cohort Study

Background A substantial proportion of patients undergoing Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) is of working age at the time of surgery. Although it is found that the majority of working patients return to work after surgery, the literature on duration until return to work and the impact of surgery on the amount of working hours in patients undergoing THA or TKA is scanty. Objectives The aim of this study was to measure duration until return to work and the impact of surgery on working hours in patients undergoing THA or TKA. Methods This study on work was part of a prospective cohort study on the outcomes of THA and TKA surgeries. This study included patients under 65 years of age, undergoing THA or TKA, who provided information on their work status before and one year after surgery. Assessments included a questionnaire on work status (yes/no), working hours per week and time to return to work. Comparisons of working hours before and after surgery were done with the Wilcoxon signed-rank test. Results Seventy-five of 122 THA (62%) and 70 of 120 TKA patients (59%) who were under 65 years had a paid job before surgery. The mean numbers of working hours per week were 32.3 (SD 13.4) in the THA group and 31.0 (SD 12.6) in the TKA group. Absence of work in relation to hip-or knee complaints during the year before surgery was reported by 19 (25%) and 19 (27%) of the employed patients with THA and TKA, respectively. The employment rates one year postoperatively were 66/75 (88%) after THA and 60/70 (86%) after TKA. The mean time to return to work was 12.5 (SD 7.5) and 12.9 (SD 7.8) weeks after THA and TKA, respectively. After 1 year, 17/66 (30%) of the patients with THA and 19/60 (32%) of patients with TKA worked less hours postoperatively as compared to preoperatively. In these patients, the number of working hours decreased significantly, with a mean difference of -14.4 hours (95% CI -19.5; -9.8) in the THA group and of -14.7 hours (95% CI -20.7; -9.4) in the TKA group (both p=0.002, Wilcoxon signed-rank test). Conclusions The majority of patients who had a paid job before surgery returned to work after THA and TKA, after approximately 12 weeks. Thirty % of the patients who returned to work, worked less hours than preoperatively. Given the increasing numbers of working patients undergoing THA or TKA more research into patients who do not return or decrease their working hours is needed. References Tilbury C. et al. Rheumatology 2013 Nov 23. [Epub ahead of print] Kuijer PP et al. J Occup Rehabil 2009;19(4):375-381. Kievit A.J. et al. Journal of Arthroplasty 2014; 10.1016 Acknowledgements Special thanks to the Annafonds|NOREF for their financial support. Disclosure of Interest : C. Tilbury Grant/research support: Anna Fonds/NOREF, C. Leichtenberg: None declared, R. Tordoir: None declared, M. Holtslag: None declared, S. Verdegaal: None declared, R. Nelissen: None declared, T. Vliet Vlieland: None declared DOI 10.1136/annrheumdis-2014-eular.2940