Esther Núñez

Total knee replacement and health-related quality of life: Factors influencing long-term outcomes

OBJECTIVE To evaluate health-related quality of life (HRQOL) in patients with osteoarthritis undergoing total knee replacement (TKR); identify the influence of sociodemographic, clinical, intraoperative, and postoperative variables on HRQOL; and determine patient perceptions at 7 years. METHODS We conducted a prospective study with 7 years of followup. HRQOL measures (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] and Short Form 36 [SF-36]); sociodemographic, clinical, intraoperative, inpatient, and postoperative data; patient perceptions of TKR outcomes; and physical activity at 7 years were determined. Associations were analyzed using linear regression models. RESULTS Of 146 eligible patients, 112 (86 women, mean age 67.3 years) completed followup data. There were significant differences between pre- and postoperative WOMAC pain, stiffness, and function scores (P < 0.001). Variables retained in each of the models explained 14-32% (adjusted R(2)) of variability of the WOMAC dimensions. Obesity and postdischarge complications were associated with worse scores in all WOMAC dimensions (P < 0.05). Eighty-six percent of patients were satisfied with TKR, 80% would undergo the operation again, and 56% did regular physical activity and had better WOMAC scores (P < 0.05, except for stiffness [not significant]). Mean +/- SD SF-36 scores for men and women at 7 years were 55.1 +/- 27.1 and 39.5 +/- 22.9 for physical function, 71.2 +/- 36.5 and 51.5 +/- 42.7 for physical role, 66.2 +/- 26 and 55.6 +/- 28.9 for bodily pain, and 60.7 +/- 17.1 and 50.7 +/- 21.2 for general health, respectively. CONCLUSION WOMAC dimension scores, especially pain, significantly improved at 7 years and were negatively influenced by obesity and postdischarge complications. HRQOL measures may help identify an increased risk of negative outcomes after TKR.

Health-Related Quality of Life and Direct Costs in Patients With Anterior Cruciate Ligament Injury: Single-Bundle Versus Double-Bundle Reconstruction in a Low-Demand Cohort—A Randomized Trial With 2 Years of Follow-up

PURPOSE To evaluate health-related quality of life (HRQL) in patients undergoing anterior cruciate ligament (ACL) reconstructive surgery by use of 2 procedures and to estimate the direct costs of surgery. METHODS We performed a 2-year randomized, prospective intervention study of 2 surgical ACL reconstruction techniques (anatomic single bundle [SB] v double bundle [DB]). Fifty-five consecutive outpatients, with a mean age of 30.88 years, were randomized to SB or DB ACL reconstruction. The Medical Outcomes Study 36-item Short Form Health Survey (SF-36) was used to measure HRQL (primary outcome). ACL injuries were assessed by the International Knee Documentation Committee (IKDC) score (secondary outcome). The use of medical resources and their costs were evaluated. RESULTS We included 52 patients in the final analyses (23 in the SB group and 29 in the DB group). At baseline, there were no significant differences in study variables. At 2 years of follow-up, there were no significant differences in SF-36 and IKDC scores between groups. However, compared with baseline, the SF-36 physical function, physical role, bodily pain, social function, and emotional role scores were significantly better in the SB group (P < .05), whereas only the physical function dimension score was better in the DB group (P = .047). IKDC scores at 2 years improved significantly in the SB group (P < .001) and DB group (P = .004) compared with baseline. There was a significant correlation between the SF-36 physical function, physical role, and bodily pain dimensions and the IKDC score at 2 years (P < .05). The costs were € 3,251 for the SB group and € 4,172 for the DB group. CONCLUSIONS HRQL and medical outcomes were similar between SB and DB ACL reconstruction techniques, 2 years after surgery. However, the SB technique was more cost-effective.

Prevalence of knee osteoarthritis and analysis of pain, rigidity, and functional incapacity.

Knee osteoarthritis is one of the most prevalent health problems in our society. It accounts for 10% of all primary care visits in general medicine and 30% of outpatient appointments. The objectives of this cross-sectional descriptive study of 100 patients suffering from gonarthritis were to assess pain, functional capacity, and joint damage in patients diagnosed with knee osteoarthritis, as well as the possible repercussions for subsequent surgical treatment. Sociodemographic, clinical, and radiological data were collected, and pain and functional capacity were evaluated by using the Western Ontario and McMaster Universities Osteoarthritis Index. The majority (71) of patients were women, mean age 71 years (SD=7.84), of low educational (66%) and financial (89%) status, with mean disease duration of 11.8 years. Of the total, 87% presented with comorbidity. Radiographs revealed a varus malalignment in 31% of patients and a valgus malalignment in 17%, with bone collapse in 39% of these. The factors that most affect surgery and subsequent rehabilitation are closely linked to social status, the general state of the patient, and the radiological severity of gonarthritis. Most of the patients were obese and suffered from comorbid conditions, and some presented with psychopathology. These factors may influence surgery, and thus improvements in primary care should be made as a way of offering a simpler and more effective treatment for gonarthritis.

A therapeutic education and functional readaptation program for Spanish patients with musculoskeletal chronic diseases

Chronic musculoskeletal diseases are one of the main reasons for health consultations. They cause pain and disability and reduce the quality of life, producing restrictions on activity and considerable economic and social costs [1, 2]. Musculoskeletal diseases are usually chronic, meaning that informing patients and their families of all factors that may lead to improvements, together with their participation in the control and evolution of the disease, is essential [3, 4]. Therapeutic patient education, provided by trained health professionals, may fulfil these objectives. The therapy should be based on a set of educational activities organized to provide the patient with information on their disease and the competence (knowledge, skills and attitudes) to manage living with a chronic disease. The educational contents should be adjusted to the patients’ needs [3–5] and be designed to reorient them towards healthy lifestyles. Active learning is a dynamic system based on the idea that adults can learn autonomously, using their own experience to solve problems, and that knowledge must be reinforced by practice to reach the competence necessary to apply that knowledge practically [6]. Patients, starting with the consequences of their disease process and their own needs, interests and expectations, learn in two ways: firstly, receiving knowledge from the therapist on the relationship between the aspects of their disease and the available therapeutic resources and, secondly, experiencing these relationships themselves, which permits the acquisition of practical knowledge applicable to the solution of diseasespecific problems. This enables patients to assume at least part of the responsibility for treating their own disease autonomously [7]. Within the framework of social cognitive theory and planned change strategies, in the Rheumatology Department of the Hospital Clinic of Barcelona (Spain), a tertiary care center, we began to implement a program of Therapeutic Education and Functional Readaptation (TEFR) using active learning [8, 9]. Although this type of program has been implemented in other countries [3], the project described in this article is, to our knowledge, the first specific therapeutic education program for patients with musculoskeletal diseases in Spain. The aims of this study were to assess whether a TEFR program could reduce disability and pain and increase competence in disease self-management in patients with musculoskeletal diseases and to determine the use of health resources and the costs derived.

Well-being and obesity of rheumatoid arthritis patients

We apply the potential outcomes framework in the analysis of an observational study of rheumatoid arthritis patients, in which we compare the mean functional-health and well-being scores (SF–36) of patients who are overweight and who are not. We combine propensity score matching with multiple imputation for nonresponse. We assess the sensitivity of the conclusions with respect to the details of the propensity model and the definition of being overweight.

Role of Musculoskeletal Disorders as Concurrent Chronic Conditions: Are They Underestimated in the Discharge?

Background: Differences in recording concurrent chronic conditions (CCs) could change the weight of the influence of the different CCs on health status. Objectives: To determine the role of musculoskeletal disorders as concurrent CCs. Methods: Cross-sectional study. Discharged patients with CCs were selected by random stratification. Sociodemographic and clinical variables, health status (SF-36), type and number of self-reported and hospital discharge summary CCs were recorded. Relationships were analyzed using linear regression models. Results: In the 227 patients included, mean self-reported CCs were 6.22 (SD 3.37) and mean hospital discharge CCs were 3.1 (SD 1.95). The most-frequent self-reported CCs were hypertension 48.4%, back pain 40.4%, neck pain 39.6%, and musculoskeletal disorders 38.4%. The most frequent discharge CCs were arterial hypertensive disease 38.3%, all cancers 22.0%, ischemic heart diseases, and angina 15.9%. Musculoskeletal disorders had the greatest negative influence on SF-36 dimensions (p < 0.05). Conclusions: Musculoskeletal disorders were underestimated in the discharge summary in comparison with those reported by patients.

AB1150 Sleep health and quality of life in patients with knee osteoarthritis before and after total knee replacement

Background Studies report that sleep disturbances are often associated with chronic musculoskeletal disease. There is no agreed definition of sleep health, but some characteristics, such as sleep duration (number of hours daily) and sleep quality or satisfaction (subjective evaluation of good or poor sleep) are used to evaluate sleep health. In a previous study in patients with severe osteoarthritis awaiting total knee replacement (TKR), patients reporting good quality sleep had better health-related quality of life (HRQL) measured by the specific WOMAC and generic SF-36 questionnaires. Objectives To measure sleep health in patients included on a waiting list for TKR and 12 months after TKR. Methods Prospective study with a 12-month follow up. Sociodemographic and clinical variables were determined. Sleep health: hours of sleep and reparative sleep (RS) were examined using the question “How well do you usually sleep?” measured on a Likert scale (1=good [RS], 2=regular, 3=badly, 4=with medication/treatment (non-reparative sleep [NRS]). Function and pain were measured using the WOMAC and SF-36 questionnaires. Comparisons were made using t-tests (paired samples) and McNemars test. Linear regression models were used to analyze associations. Dependent variables: WOMAC and SF-36 pain and function dimensions; independent variables: sleep quality, age, sex, BMI, number of comorbidities, depression/anxiety. Results 105 patients (79% female, mean age 69.39 years [SD 8.3]) were included. 80% had ≥2 comorbidities (mean 2.71 [SD 1.8]), mean BMI was 33.68 (SD 6.7), 32 had depression/anxiety, and mean sleep duration was 6.63 hours (SD 1.4). 12 months after TKF there were significant improvements in WOMAC dimension scores (mean >25 points, p<0.001) and SF-36 scores (mean >19). At study inclusion, 23% reported RS with a mean sleep duration of 7.5 hours (SD 1.1) vs. 6.24 hours (SD 1.5) in NRS patients (p=0.002). 12 months after TKR, 40% of patients had RS (p=0.029). Patients with RS had better scores in all quality of life dimensions (<10 points) than those with NRS (p<0.05) at baseline and at 12 months. Multivariate analysis showed RS was independently associated with pain and function (WOMAC and SF-36) (p<0.007). Conclusions Sleep health was associated with better HRQL before and after TKR. Although more patients had RS after TKR, 60% of patients continued not to have sleep health. Although often undervalued clinically, sleep health is closely associated with the health status. Acknowledgements This work was funded by project PI/13/00948, integrated in the Plan Nacional I+D+I and cofounded by ISCIII-Subdirecciόn General de Evaluaciόn and European Regional Development Fund (ERDF). References Buysse DJ. Sleep health: can we define it? Does it matter? Sleep. 2014 Jan 1;37(1):9–17. doi: 10.5665/sleep.3298. Disclosure of Interest None declared

SAT0703 Influence of physical activity and sleep on functional capacity and pain in patients with knee osteoarthritis

Background Knee osteoarthritis (OA) is a degenerative disease in which pain and functional disability progression tend to increase with reducing the health-related quality of life (HRQOL). Factors related to healthy lifestyles, such as physical activity and sleep, are known to have restorative benefits on function and pain in these patients. A previous study found that patients with reparative sleep achieved better WOMAC and SF-36 HRQOL questionnaire dimension scores. Objectives To determine the influence of physical activity and sleep on functional capacity and pain in patients with long-term knee OA. Methods Cross-sectional study. Sociodemographic and clinical variables, physical activity (PA) (regular physical exercise ≥3 times a week ≥30 minutes per session (PE) and sitting ≤6 hours/day [S]) and sleep quality/reparative sleep (RS) were determined using the question: How do you usually sleep? (1=well [RS], 2=regular, 3=badly, 4 =with medication/treatment [NRS]). Functional capacity and pain were evaluated using the WOMAC (specific) and SF-36 (generic) HRQOL questionnaires. Associations were analysed using multiple regression models. Results 453 patients (84.3% female), mean age 69.73 (8.4), BMI 35.27 [SD 6.3], comorbidities 2.43 (SD 1.5), 78.6% with obesity (BMI 33.68 [SD 6.7]), depression/anxiety in 36.4%, PE 60.5%, S 72.2% and PA 48.6%, were included. 22.5% reported RS. Bivariate analysis showed patients with PA and those with RS had better functional capacity and less pain intensity (>10, p>0.001, in both WOMAC and SF-36). The four multiple regression showed that patients with PA and SR had better scores, both in functional capacity (dependent variables, WOMAC and SF-36) and pain (dependent variables, WOMAC and SF-36), p<0.006. Age, gender, number of comorbidities and obesity were included in the models as potential confounders. Obesity was associated with worse function and more pain in the four models (p<0.05). Being female and greater comorbidity were associated with poorer functional capacity and pain assessed by the SF-36. Conclusions Physical activity and sleep were associated with less pain and better functional capacity, suggesting these variables should be determined systematically in clinical practice due to their significant relationship with HRQOL. Obesity was negatively associated with function and pain. There was also a negative relationship between female gender and comorbidity according to the SF-36. Differences in generic and specific questionnaires mean they should be used together to provide more detailed information. Acknowledgements This work was funded by project PI/13/00948, integrated in the Plan Nacional I+D+I and cofounded by ISCIIISubdirecciόn General de Evaluaciόn and European Regional Development Fund (ERDF). References Uthman OA, van der Windt DA, Jordan JL, Dziedzic KS, Healey EL, Peat GM, et al. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. BMJ. 2013;347:f5555. Abad VC, Sarinas PS, Guilleminault C. Sleep and rheumatologic disorders. Sleep Med Rev 2008;12:211–28. Disclosure of Interest None declared

THU0624 Sleep Quality in Patients with Severe Knee Osteroarthritis

Background Sleep disturbance is closely related to chronic musculoskeletal diseases. Reports suggest 55% of patients aged >55 years sleep <6 hours (15%) with deficient or poor quality sleep (29%), insomnia (56%) and diagnosed sleep disorders (18%). Osteoarthritis (OA) is one of the most prevalent of these diseases. Older adults with OA have poorer health, worse sleep quality, more limitations in activities of daily living and more pain compared with persons without OA. The prevalence of night joint pain and sleep problems increase with the severity of OA, which negatively impacts the quality of life. Objectives To determine whether sleep quality is associated with the health status in patients with severe knee OA. Methods Cross-sectional observational study. Consecutive patients with severe knee OA on a waiting list for arthroplasty were included. Sociodemographic and clinical variables were determined. Patients were asked the number of hours they usually sleep and about sleep quality (whether sleep was restorative) in the previous ≥6 months, using the question: How do you usually sleep? (by Likert scale: 1=good, 2=fair, 3=poor and 4=with medication). The health status was assessed using specific and generic health-related quality of life questionnaires (HRQOL) (WOMAC and SF-36, respectively). Data analysis: Multiple linear regression models were used to analyse the association between health and sleep quality (dichotomized as 1: reparative sleep (RS)=1 and non-reparative sleep (NRS)=2,3,4). Dependent variables were: total WOMAC scores (TW), SF-36 physical component (PC) and mental component (MC). Independent variables were: sleep quality, age, gender, BMI, severity OA number of comorbidities and depression/anxiety. Results 142 patients, (84% female, mean age 68.5 (SD 8.6), mean BMI 33.9 (SD 4.1), mean comorbidities 5.1 (SD 3.6) were included. The most-frequent comorbidities were hypertension 63.8%, back pain 47.5%, depression/anxiety 38.6%. Patients with RS (27%) slept a mean of 7.6 (SD 1) hours vs 6.6 (SD 1.4) hours in those with NRS (p<0.001). There was no association with the MC. Mean TW scores were 49.8 (SD 16.1) for patients with RS vs. 59.3 (SD 16.4) for patients with NRS (p=0.003). Mean PC scores were 36.1 (SD 9.5) for RS and 31.8 (SD 8.4) for NRS (p=0.009). Mean MC scores were 46.2 (SD 13.1) and 43.8 (SD 13.6) (p=0.343) for RS vs. NRS, respectively. Separate regression models showed RS was associated with better TW scores (p=0.002), with other variables not being significant, and that RS was associated with better PC scores (p=0.012) and female sex, the number of comorbidities and anxiety/depression were associated with worse PC scores (p=0.013 and p=0.004, respectively). Conclusions Reparative sleep is associated with a better health status in OA patients on a waiting list for TKA. References Parmelee PA et al. Sleep disturbance in osteoarthritis: linkages with pain, disability and depressive symptoms. Arthritis Care Res 2015;67(3):358 Acknowledgement This work has been funded by the project PI/13/00948, integrated in the Plan Nacional I+D+I and co-funded by ISCIII-Subdirecciόn General de Evaluaciόn and European Regional Development Fund (ERDF). Disclosure of Interest None declared

AB1146 The Relationship Between Function and the Periarticular Knee Structure Measured by Ultrasound in Obese Patients with Knee Osteoarthritis on a Waiting List for Total Knee Replacement

Background An increasing number of obese patients are candidates for total knee replacement (TKR). However, objective criteria for decision making in these patients are lacking. We hypothesized that quantification of the periarticular knee structure in elderly obese patients on a waiting list for TKR could provide additional information/indicators for decision-making. Objectives To evaluate the influence of the anthropometric properties and periarticular structures of the knee as assessed by ultrasound imaging on functional capacity in obese patients with knee osteoarthritis on a waiting list for TKR. Methods Cross-sectional observational study. Sociodemographic and anthropometric variables, body mass index (BMI), comorbidities and physical activity (regular physical exercise ≥3 times per week for ≥30 minutes per session and remaining seated ≤6 hours per day) were collected. Function was measured using the Timed Up and Go (TUG) test (functional mobility and balance) (categorized as 13.5/>13.5 seconds). Periarticular knee structures were evaluated using ultrasound (subcutaneous fat thickness [distance from the skin to the fascia, in mm], quadriceps/rectus femoris thickness [distance between the fascia and the femur, in mm]). Statistical analysis: Multivariate logistic regression model was used to discover the combination of variables which best explained function. The goodness of fit of the classification of the predictive model was assessed using a receiver operating characteristic (ROC) curve. Results 54 patients, (41 female, mean age 69.9 years (SD 7), mean BMI 35.7 (SD 4), 58% with >2 comorbidities, 51.9% physically active) were studied. Mean TUG was 15.5 seconds (SD 8) (50% TUG >13.5 seconds). Mean subcutaneous fat thickness was 25.1 mm (SD 11), and mean quadriceps/rectus femoris thickness was 37.4 mm. (SD 9). Multivariable analysis identified age >75 years (OR 11.10 [11.4–86.9] p=0.024), and subcutaneous fat thickness (OR 1.09 [1.09–1.2] p=0.013) as predictors of worse TUG scores. The area under the ROC curve was 0.71. Conclusions Periarticular fat, but not the BMI, was an independent predictor of a greater reduction in functional mobility in these patients. This suggest that exercises to maintain and improve function could improve the functional status of patients on a waiting list, and delay TKR. Ultrasound is useful to determine objective measures of function in these patients. References Villareal DT, et al. Physical frailty and body composition in obese elderly men and women. Obesity Res 2004;12 (6):913-20. Núñez M, et al. Good quality of life in severely obese total knee replacement patients: a case-control study.Obes Surg. 2011 Aug;21(8):1203-8. Katz JN. Appropriateness of Total Knee Arthroplasty. Editorial Arthritis Rheumatol 2014;66(8): 1979–1981.doi: 10.1002/art.38688. Acknowledgements This work has been funded by the project PI13/00948, integrated in the Plan Nacional I+D+I and co-funded by ISCIII-Subdirecciόn General de Evaluaciόn and European Regional Development Fund (ERDF). Disclosure of Interest None declared