Chloe E. H. Scott

Predicting dissatisfaction following total knee replacement: A PROSPECTIVE STUDY OF 1217 PATIENTS

Up to 20% of patients are not satisfied with the outcome following total knee replacement (TKR). This study investigated the pre- and post-operative predictors of dissatisfaction in a large cohort of patients undergoing TKR. We assessed 1217 consecutive patients between 2006 and 2008 both before operation and six months after, using the Short-form (SF)-12 health questionnaire and the Oxford Knee Score. Detailed information concerning comorbidity was also gathered. Satisfaction was measured at one year when 18.6% (226 of 1217) of patients were unsure or dissatisfied with their replacement and 81.4% (911 of 1217) were satisfied or very satisfied. Multivariate regression analysis was performed to identify independent predictors of dissatisfaction. Significant (p < 0.001) predictors at one year included the pre-operative SF-12 mental component score, depression and pain in other joints, the six-month SF-12 score and poorer improvement in the pain element of the Oxford Knee Score. Patient expectations were highly correlated with satisfaction. Satisfaction following TKR is multifactorial. Managing the expectations and mental health of the patients may reduce dissatisfaction. However, the most significant predictor of dissatisfaction is a painful total knee replacement.

Patient expectations of arthroplasty of the hip and knee

Patient expectations and their fulfilment are an important factor in determining patient-reported outcome and satisfaction of hip (THR) and knee replacement (TKR). The aim of this prospective cohort study was to examine the expectations of patients undergoing THR and TKR, and to identify differences in expectations, predictors of high expectations and the relationship between the fulfilment of expectations and patient-reported outcome measures. During the study period, patients who underwent 346 THRs and 323 TKRs completed an expectation questionnaire, Oxford score and Short-Form 12 (SF-12) score pre-operatively. At one year post-operatively, the Oxford score, SF-12, patient satisfaction and expectation fulfilment were assessed. Univariable and multivariable analysis were performed. Improvements in mobility and daytime pain were the most important expectations in both groups. Expectation level did not differ between THR and TKR. Poor Oxford score, younger age and male gender significantly predicted high pre-operative expectations (p < 0.001). The level of pre-operative expectation was not significantly associated with the fulfilment of expectations or outcome. THR better met the expectations identified as important by patients. TKR failed to meet expectations of kneeling, squatting and stair climbing. High fulfilment of expectation in both THR and TKR was significantly predicted by young age, greater improvements in Oxford score and high pre-operative mental health scores. The fulfilment of expectations was highly correlated with satisfaction.

Predicting dissatisfaction following total knee arthroplasty in patients under 55 years of age

AIMS Risk of revision following total knee arthroplasty (TKA) is higher in patients under 55 years, but little data are reported regarding non-revision outcomes. This study aims to identify predictors of dissatisfaction in these patients. PATIENTS AND METHODS We prospectively assessed 177 TKAs (157 consecutive patients, 99 women, mean age 50 years; 17 to 54) from 2008 to 2013. Age, gender, implant, indication, body mass index (BMI), social deprivation, range of movement, Kellgren-Lawrence (KL) grade of osteoarthritis (OA) and prior knee surgery were recorded. Pre- and post-operative Oxford Knee Score (OKS) as well as Short Form-12 physical (PCS) and mental component scores were obtained. Post-operative range of movement, complications and satisfaction were measured at one year. RESULTS Overall, 44 patients with 44 TKAs (24.9%) under 55 years of age were unsure or dissatisfied with their knee. Significant predictors of dissatisfaction on univariate analysis included: KL grade 1/2 OA (59% dissatisfied), poor pre-operative OKS, complications, poor improvements in PCS and OKS and indication (primary OA 19% dissatisfied, previous meniscectomy 41%, multiply operated 42%, other surgery 29%, BMI > 40 kg/m2 31%, post-traumatic OA 45%, and inflammatory arthropathy 5%). Poor pre-operative OKS, poor improvement in OKS and post-operative stiffness independently predicted dissatisfaction on multivariate analysis. CONCLUSION Patients receiving TKA younger than 55 years old should be informed about the increased risks of dissatisfaction. Offering TKA in KL 1/2 is questionable, with a dissatisfaction rate of 59%. Cite this article: Bone Joint J 2016;98-B:1625-34.

Lateral compartment osteoarthritis of the knee: Biomechanics and surgical management of end-stage disease

The lateral compartment is predominantly affected in approximately 10% of patients with osteoarthritis of the knee. The anatomy, kinematics and loading during movement differ considerably between medial and lateral compartments of the knee. This in the main explains the relative protection of the lateral compartment compared with the medial compartment in the development of osteoarthritis. The aetiology of lateral compartment osteoarthritis can be idiopathic, usually affecting the femur, or secondary to trauma commonly affecting the tibia. Surgical management of lateral compartment osteoarthritis can include osteotomy, unicompartmental knee replacement and total knee replacement. This review discusses the biomechanics, pathogenesis and development of lateral compartment osteoarthritis and its management.

Staged bilateral total knee replacement: changes in expectations and outcomes between the first and second operations

We explored the outcome of staged bilateral total knee replacement (TKR) for symmetrical degenerative joint disease and deformity in terms of patient expectations, functional outcome and satisfaction. From 2009 to 2011, 70 consecutive patients (41 female) with a mean age of 71.7 years (43 to 89) underwent 140 staged bilateral TKRs at our institution, with a mean time between operations of 7.8 months (2 to 25). Patients were assessed pre-operatively and at six and 12 months post-operatively using the Short Form-12, Oxford knee score (OKS), expectation questionnaire and satisfaction score. The pre-operative OKS was significantly worse before the first TKR (TKR1), but displayed significantly greater improvement than that observed after the second TKR (TKR2). Expectation level increased from TKR1 to TKR2 in 17% and decreased in 20%. Expectations of pain relief and stair-climbing were less before TKR2; in contrast, expectations of sporting and social activities were greater. Decreased expectations of TKR2 were significantly associated with younger age and high expectations before TKR1. Patient satisfaction was high for both TKR1 (93%) and TKR2 (87%) but did not correlate significantly within individuals. We concluded that satisfaction with one TKR does not necessarily translate to satisfaction following the second.

Changes in Bone Density in Metal-Backed and All-Polyethylene Medial Unicompartmental Knee Arthroplasty

BACKGROUND Proximal tibial strain in medial unicompartmental knee arthroplasty (UKA) may alter bone mineral density and cause pain. The aims of this retrospective cohort study were to quantify and compare changes in proximal tibial bone mineral density in metal-backed and all-polyethylene medial UKAs, correlating these with outcome, particularly ongoing pain. METHODS Radiographs of 173 metal-backed and 82 all-polyethylene UKAs were analyzed using digital radiograph densitometry at 0, 1, 2, and 5 years. The mean grayscale of 4 proximal tibial regions was measured and converted to a ratio: the GSRb (grayscale ratio b), where GSRb>1 represents relative medial sclerosis. RESULTS In both implants, GSRb reduced significantly to 1 year and stabilized with no differences between implants. Subgroup analysis showed less improvement in Oxford Knee Score in patients whose GSRb increased by more than 10% at 1 year (40/255) compared with patients whose GSRb reduced by more than 10% at both 1 years (8.2 vs 15.8, P=.002) and 5 years (9.6 vs 15.8, P=.022). Patients with persistently painful UKAs (17/255) showed no reduction in GSRb at 1 year compared with a 20% reduction in those without pain (P=.05). CONCLUSIONS Bone mineral density changes under medial UKAs are independent of metal backing. Medial sclerosis appears to be associated with ongoing pain.

Activity levels and return to work following total knee arthroplasty in patients under 65 years of age

Aims Little is known about employment following total knee arthroplasty (TKA). This study aims to identify factors which predict return to work following TKA in patients of working age in the United Kingdom. Patients & Methods We prospectively assessed 289 patients (289 TKAs) aged ≤ 65 years who underwent TKA between 2010 and 2013. There were 148 women. The following were recorded preoperatively: age, gender, body mass index, social deprivation, comorbidities, indication for surgery, work status and nature of employment, activity level as assessed by the University of California, Los Angeles (UCLA) activity score and Oxford Knee Score (OKS). The intention of patients to return to work or to retire was not assessed pre‐operatively. At a mean of 3.4 years (2 to 4) post‐operatively, the return to work status, OKS, the EuroQol‐5 dimensions (EQ‐5D) score, UCLA activity score and Work, Osteoarthritis and joint‐Replacement (WORQ) score were obtained. Univariate and multivariate analyses were performed. Results Of 261 patients (90%) who were working before TKA, 105 (40%) returned to any job, including 89 (34%) who returned to the same job at a mean of 13.5 weeks (2 to 104) postoperatively. A total of 108 (41%) retired following TKA and 18 remained on welfare. Patients not working before the operation did not return to work. Median UCLA scores improved in 125 patients (58%) from 4 (mild activity) to 6 (moderate activity) (p < 0.001). Significant (p < 0.05) factors which were predictive of return to any work included age, heavy or moderate manual work, better post‐operative UCLA, OKS and EQ‐5D general health scores. Significant predictive factors of return to the same work included age, heavy or moderate manual work and post‐operative OKS. Multivariate analysis confirmed heavy or moderate manual work and age to independently predict a return to either any or the same work. All patients aged < 50 years who were working pre‐operatively returned to any work as did 60% of those aged between 50 and 54 years, 50% of those aged between 55 and 59 years and 24% those aged between 60 and 65 years. Conclusion If working pre‐operatively, patients aged < 50 years invariably returned to work following TKA, but only half of those aged between 50 to 60 years returned. High post‐operative activity levels and patient reported outcome measures do not predict return to work following TKA.

Activity levels and return to work after revision total hip and knee arthroplasty in patients under 65 years of age.

Aims The aim of this study was to identify predictors of return to work (RTW) after revision lower limb arthroplasty in patients of working age in the United Kingdom. Patients and Methods We assessed 55 patients aged ≤ 65 years after revision total hip arthroplasty (THA). There were 43 women and 12 men with a mean age of 54 years (23 to 65). We also reviewed 30 patients after revision total knee arthroplasty (TKA). There were 14 women and 16 men with a mean age of 58 years (48 to 64). Preoperatively, age, gender, body mass index, social deprivation, mode of failure, length of primary implant survival, work status and nature, activity level (University of California, Los Angeles (UCLA) score), and Oxford Hip and Knee Scores were recorded. Postoperatively, RTW status, Oxford Hip and Knee Scores, EuroQol‐5D (EQ‐5D), UCLA score, and Work, Osteoarthritis and Joint‐Replacement Questionnaire (WORQ) scores were obtained. Univariate and multivariate analysis was performed. Results Overall, 95% (52/55) of patients were working before their revision THA. Afterwards, 33% (17/52) RTW by one year, 48% (25/52) had retired, and 19% (10/52) were receiving welfare benefit. RTW was associated with age, postoperative Oxford Hip Score, early THA failure (less than two years), mode of failure dislocation, and contralateral revision (p < 0.05). No patient returned to work after revision for dislocation. Only age remained a significant factor on multivariate analysis (p = 0.003), with 79% (11/14) of those less than 50 years of age returning to work, compared with 16% (6/38) of those aged fifty years or over. Before revision TKA, 93% (28/30) of patients were working. Postoperatively only 7% (2/28) returned to work by one year, 71% (20/28) had retired, and 21% (6/28) were receiving welfare benefits. UCLA scores improved after 43% of revision THAs and 44% of revision TKAs. Conclusion After revision THA, age is the most significant predictor of RTW: only 16% of those over 50 years old return to work. Fewer patients return to work after early revision THA and none after revision for dislocation. After revision TKA, patients rarely return to work: none return to heavy or moderate manual work. Cite this article: Bone Joint J 2018;100‐B:1043–53.

Cemented total hip arthroplasty following acetabular fracture

Aims To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture. Patients and Methods Between 1992 and 2016, 49 patients (33 male) with mean age of 57 years (25 to 87) underwent cemented THA at a mean of 6.5 years (0.1 to 25) following acetabular fracture. A total of 38 had undergone surgical fixation and 11 had been treated non‐operatively; 13 patients died at a mean of 10.2 years after THA (0.6 to 19). Patients were assessed pre‐operatively, at one year and at final follow‐up (mean 9.1 years, 0.5 to 23) using the Oxford Hip Score (OHS). Implant survivorship was assessed. An age and gender‐matched cohort of THAs performed for non‐traumatic osteoarthritis (OA) or avascular necrosis (AVN) (n = 98) were used to compare complications and patient‐reported outcome measures (PROMs). Results The mean time from fracture to THA was significantly shorter for patients with AVN (2.2 years) or protrusio (2.2 years) than those with post‐traumatic OA (9.4 years) or infection (8.0 years) (p = 0.03). Nine contained and four uncontained defects were managed with autograft (n = 11), bulk allograft (n = 1), or trabecular metal augment (n = 1). Initial fracture management (open reduction and internal fixation or non‐operative), timing of THA (>/< one year), and age (>/< 55 years) had no significant effect on OHS or ten‐year survival. Six THAs were revised at mean of 12 years (5 to 23) with ten‐year all‐cause survival of 92% (95% confidence interval 80.8 to 100). THA complication rates (all complications, heterotopic ossification, leg length discrepancy > 10 mm) were significantly higher following acetabular fracture compared with atraumatic OA/AVN and OHSs were inferior: one‐year OHS (35.7 versus 40.2, p = 0.026); and final follow‐up OHS (33.6 versus 40.9, p = 0.008). Conclusion Cemented THA is a reasonable option for the sequelae of acetabular fracture. Higher complication rates and poorer PROMs, compared with patients undergoing THA for atraumatic causes, reflects the complex nature of these cases.

Survival analysis of the Wallis interspinous spacer used as an augment to lumbar decompression

Abstract Object: The Wallis fixed interspinous spacer may augment traditional decompression in the treatment of lumbar spinal stenosis. The aim of this study was to determine factors influencing survival of the Wallis interspinous spacer and to identify specific modes and predictors of failure. Methods: We performed a retrospective cohort study of 244 Wallis interspinous spacers implanted in 195 consecutive patients with a mean age of 56 years (range 21–87) to augment single or multi-level decompression. We examined patient demographics, indications for surgery, surgical techniques and pathology on magnetic resonance imaging (MRI). A Kaplan-Meier survival analysis was performed. Results: Median follow-up was 4.5 years (range 2–8). Sixteen patients were lost to follow-up. Repeat MRI was performed in 98 patients (50%). A recurrent stenosis was found in 21% of patients (41/195) and occurred at a similar incidence at the level of the spacer and at adjacent spinal levels. Revision decompression was performed in 19 patients (10%) at 2.8 ± 1.8 years (range 6 months-6 years) with implant removal in 15 and conversion to fusion in 4 patients. No specific patient factors or pre-operative MRI findings predicted failure. Five-year survival was 91% (95% CI: 79–96%). Conclusions: The Wallis implant is generally implanted without complication when used as an adjunct to decompression with a good medium term survival. Though disc heights were maintained, the Wallis spacer did not however appear to reduce the incidence of recurrent spinal or foraminal stenosis from that expected from decompression alone.