Patricia D. Franklin

Total knee replacement outcome and coexisting physical and emotional illness

Despite widespread acceptance of total knee replacement surgery’s clinical effectiveness, variation persists in long-term functional outcome. Our aim was to quantify the relative contributions of physical and emotional coexisting conditions to the variation in improvement in 12-month post-total knee replacement physical function. Data from 165 patients who had primary total knee replacement (62% women; mean age 68 years) were evaluated. Eighty-four percent had at least one comorbid illness, with cardiovascular conditions the most prevalent (61%). Mean improvement in 12-month general function (Short Form-36 Physical Component Score) and knee-specific function (Western Ontario and McMaster Universities Osteoarthritis Index) was similar for patients with and without comorbid medical diagnoses. Adding coexisting conditions to age, gender, and baseline physical function did not improve the model’s ability to explain variation in 12-month physical function as measured by either Short Form-36 Physical Component Score or Western Ontario and McMaster Universities Osteoarthritis Index. Although coexisting medical conditions did not predict the degree of 12 month post-total knee replacement functional improvement, poorer pre-total knee replacement emotional health (Short Form-36 Mental Component Score) was associated with smaller improvements in Short Form-36 Physical Component Score and Western Ontario and McMaster Universities Osteoarthritis Index. The lack of a relationship between the presence of coexisting medical diagnoses and 12-month physical function in this study is important for patients and orthopedic surgeons. Level of Evidence: Prognostic study, Level 1 (prospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Ankle Fractures in the Elderly: Initial and Long-Term Outcomes

Background: Surgical management of ankle fractures will be an increasing part of the orthopaedic practice for aging adults. To date, there are few studies comparing outcomes after ankle fracture surgery between patients over and under 65 years. The purpose of this study was to evaluate short- and long-term outcomes after surgical treatment of isolated malleolar fractures in both the elderly and non-elderly population. Materials and Methods: Charts and radiographs were reviewed for 25 patients over age 65 and 46 patients under age 65 who underwent operative treatment of an ankle fracture during a 2-year period. Postoperative complications and need for placement in a skilled nursing facility following discharge were noted. The SF-36 and the Olerud and Molander Ankle Score were completed. Mean duration of followup in patients greater than 65 was 27 months and 24 months for patients less than or equal to 65 years. Results: Patients over 65 had a higher number of postoperative complications (40% vs. 11%, p < 0.007), and required nursing home placement more frequently than patients under 65 (p < 0.0001). At long-term followup, the data showed no significant difference in patient reported physical outcomes. Conclusion: Early postoperative outcomes after operative fixation of ankle fractures suggest significantly worse outcomes for patients over age 65. However, long-term function in the elderly was comparable to patients under age 65 in this sample. The elderly population had a significantly better mental composite score than the non-elderly.

Reduction in narcotic use after primary total knee arthroplasty and association with patient pain relief and satisfaction

We examined the prevalence of narcotic use before and after total knee arthroplasty (TKA) and its association with post-TKA pain relief and satisfaction. Data on 6364 primary, unilateral TKA patients in a national registry were analyzed. Before TKA, 24% of patients were prescribed one form of narcotic. Of these, 14% reported continued narcotic use at 12 months after TKA, whereas the majority discontinued use. Only 3% of patients who did not use narcotics before TKA had a narcotics prescription at 12 months. Patients who used narcotics before TKA were more likely to have a narcotic prescription at 12 months post-TKA, reported greater pain at 12 months, and were more likely to be dissatisfied with TKA outcome. These findings have implications for patient pre-TKA counseling.

The role of emotional health in functional outcomes after orthopaedic surgery: extending the biopsychosocial model to orthopaedics: AOA critical issues.

Orthopaedic surgery successfully restores physical function and relieves pain in millions of Americans each year. In fact, orthopaedic surgery to treat arthritis of the knee and hip and lumbar spine conditions is among the top five surgical procedures by cost and volume in the United States. Despite the overwhelming success of orthopaedic procedures, functional improvement after surgery varies widely. Poor functional outcomes have been correlated with poor emotional health, such as anxiety, depression, poor coping skills, and poor social support1,2. The variation in functional outcomes exists despite state-of-the-art surgical techniques and is independent of postoperative complications. Furthermore, suboptimal functional outcomes associated with poor emotional health have been reported in a variety of orthopaedic specialties, including spine surgery, trauma care and/or fracture repair, rotator cuff repair, sports-related surgery (e.g., anterior cruciate ligament [ACL] reconstruction), total hip replacement, total knee replacement, and hand and upper extremities surgery. It is well established that the emotional health of the patient influences the outcome of many common orthopaedic surgeries.

Vertebral Artery Anatomy : A Review of Two Hundred Fifty Magnetic Resonance Imaging Scans

Study Design. The aim of this study is to characterize the anatomy of vertebral arteries using magnetic resonance imaging scans of 250 consecutive patients. Objectives. To document the prevalence of midline vertebral artery (VA) migration in a subgroup of patients presenting with neck pain, radiculopathy, or myelopathy and to identify the course of the VA through the TFs. Summary of Background Data. Knowledge of VA anomalies and their respective prevalence may help surgeons decrease the incidence of iatrogenic injury to this artery. Methods. In this retrospective review of 281 consecutive patients, who had an magnetic resonance imaging for axial neck pain, radiculopathy, or myelopathy, anatomic measurements were obtained from C2 to C7. Results. The observed VA anomalies can be classified into following 3 main groups: (1) intraforaminal anomalies-midline migration, (2) extraforaminal anomalies, and (3) arterial anomalies. Midline migration of the VA was identified in 7.6% (19/250) of patients. The etiology can be degenerative or traumatic. It is important to note that the pattern of medial migration was clockwise rotation from caudal to cephalad and was present in all of our patients with anomalous arteries. Additionally, at C6, only 92% (460/500) of VAs were located within their respective transverse foramens and hypoplastic VAs were identified in 10% (25/250) of patients. Conclusion. Anomalies that must be considered before surgery include interforamenal anomalies, extraforamenal anomalies, and arterial anomalies. The intraforaminal anomalies involve midline migration, which places the VA at direct risk during corpectomy. Extraforaminal anomalies are related to VAs entering the transverse foramen at a level other than C6, which can increase the risk of injury during the anterior approach to the cervical spine. Arterial anomalies can be fenestrated, hypoplastic, or absent. These raise concern with the ability to maintain cerebral perfusion in the setting of damage to one of the VAs with the presence of contralateral arterial abnormality.

Incorporating Patient-reported Outcomes in Total Joint Arthroplasty Registries: Challenges and Opportunities

BackgroundTotal joint arthroplasty (TJA) registries traditionally have focused on implant longevity and rates of revision surgery. Registries would benefit from the addition of standardized patient-reported outcomes (PROs) such as pain relief and improved physical function. However, PROs have not been routinely adopted, and their incorporation into TJA registries presents challenges.Questions/purposesWe review current PRO use by existing national registries, challenges to integrating PROs in national registries, lessons from national registries that have integrated PROs, and suggestions to guide future adoption of PROs.MethodsWe conducted a literature search of papers addressing PRO use in national knee and hip arthroplasty registries, resulting in 15 articles. These publications were supplemented by discussions with thought leaders from international registries.Where Are We Now?Some national TJA registries are collecting PROs and valuable research is emerging. However, challenges exist, such as selecting suitable PROs, selection bias in countries without government-mandated participation for all hospitals, and challenges with missing data.Where Do We Need to Go?The ideal system will incorporate PROs into TJA registries. In so doing, it will be important to choose suitable PROs and develop innovative methods to collect PROs to ensure complete data and sustainability.How Do We Get There?New methods are required to meet the challenges related to registry design, logistics of PRO collection, and registry cost and sustainability. Modifications to the traditional hospital- and implant-centric design and new procedures to collect complete data from both patients and clinicians may be necessary. For instance, England and Wales, New Zealand, and Sweden developed methods to collect PROs after TJA directly from patients and a US TJA registry collects PROs as the primary outcome. Finally, to assure long-term sustainability, PRO data must be valuable to multiple stakeholders, including patients, clinicians, researchers, and policy makers.

The effect of an orthopedic trauma room on after-hours surgery at a level one trauma center

Purpose: The purpose of this study is to examine the effect of establishing a dedicated operating room for unscheduled orthopedic cases and to evaluate a group of patients with isolated femur fractures. The frequency of after-hours surgery and the impact of patients who present with acute orthopedic injuries are reviewed. Methods: A retrospective review of all orthopedic cases from the operating room scheduling system at a level-one trauma center was undertaken from October 2003 to September 2005. Before October 2004, unscheduled cases were placed on a shared add-on list, and no special priority was given to orthopedic cases. Additionally, a subset of adult patients with isolated femoral shaft fractures was identified to evaluate time from admission to surgery, operative time, frequency of transfer of care between surgeons, and total length of hospital stay. Results: The number of orthopedic cases was 1799 in fiscal year 2004 (FY04) and 2046 in FY05, an increase of 14%. Overall, the hospital experienced an increase in level-one trauma activations from 1450 in FY04 to 1580 in FY05 (8.2%), and an increase in the number operative trauma cases from 447 to 494 (9.5%). Cases after 7:00 pm declined from 197 in FY04 to 165 in FY05, a decrease of 16%. Cases between midnight and 7:00 am declined from 63 in FY04 to 35 in FY05, a decrease of 44%. For the subset of femur fracture patients, transfer of care to another operating surgeon occurred 4.5 times more frequently. The median delay between admission and surgery increased from 5.7 hours to 10.9 hours. Median case duration increased from 106 to 127 minutes. Conclusions: It is possible to dramatically decrease the occurrence of after-hours orthopedic surgery in a level-one trauma center through the use of a dedicated room for unscheduled orthopedic trauma cases. Benefits include less frequent activation of after-hours operating room resources, fewer disruptions to the OR schedule and office hours, and more frequent fracture care by orthopedic traumatologists. The impact of a longer delay between admission and surgical treatment and more frequent transfer of care between surgeons deserves further evaluation.

Integrating Patient-reported Outcomes Into Orthopaedic Clinical Practice: Proof of Concept From FORCE-TJR

BackgroundGood orthopaedic care requires a knowledge of the patient’s history of musculoskeletal pain and associated limitations in daily function. Standardized measures of patient-reported outcomes (PROs) can provide this information. Integrating PROs into routine orthopaedic patient visits can provide key information to monitor changes in symptom severity over time, support shared clinical care decisions, and assess treatment effectiveness for quality initiatives and value-based reimbursement.Where Are We Now?Although standardized, validated PRO surveys are routinely used in clinical and comparative effectiveness research, they are not consistently or efficiently collected in clinical practice.Where Do We Need to Go?Ideally, PROs need to be collected directly from patients before their surgeon visit so the data are readily available to the surgeon and patient at the time of the office visit. In addition, PROs should be integrated in the electronic health record to monitor patient status over time.How Do We Get There?PRO integration in clinical practice requires minor modifications to the office flow, some additional staff to facilitate collection, and the technical infrastructure to score, process, and store the responses. We document successful office procedures for collecting PROs in one busy orthopaedic clinic and some suggested methods to extend this model to the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) consortium of 121 surgeons where the process is centralized and staff obtained consent to send the PRO directly to the patient’s home. Both methods are options for the broader adoption of office-based PROs.

Implementation of patient-reported outcome measures in U.S. Total joint replacement registries: rationale, status, and plans

BACKGROUND In the U.S. and abroad, the use of patient-reported outcome measures to evaluate the impact of total joint replacement surgery on patient quality of life is increasingly common. Analyses of patient-reported outcomes have documented substantial pain relief and functional gain among the vast majority of patients managed with total joint replacement. In addition, postoperative patient-reported outcomes are useful to identify persistent pain and suboptimal outcomes in the minority of patients who have them. The leaders of five U.S. total joint replacement registries report the rationale, current status, and vision for the use of patient-reported outcome measures in U.S. total joint replacement registries. METHODS Surgeon leaders of the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement registry, American Joint Replacement Registry, California Joint Replacement Registry, Michigan Arthroplasty Registry Collaborative Quality Initiative, and Virginia Joint Registry report the rationale supporting the adoption of patient-reported outcome measures, factors associated with the selection and successful implementation of patient-reported outcome measures, and barriers to complete and valid data. RESULTS U.S. registries are at varied stages of implementation of preoperative surveys and postoperative total joint replacement outcome measures. Surgeon leaders report unified rationales for adopting patient-reported outcome measures: to capture data on pain relief and functional gain following total joint replacement as well as to identify suboptimal implant performance. Key considerations in the selection of a patient-reported outcome measure include its ability to measure both joint pain and physical function while limiting any burden on patients and surgeons related to its use. Complete patient-reported outcomes data will be associated with varied modes of survey completion, including options for home-based completion, to ensure consistent timing and data capture. CONCLUSIONS The current stage of implementation of patient-reported outcome measures varies widely among U.S. registries. Nonetheless, evidence from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement registry supports the feasibility of successful implementation of patient-reported outcome measures with careful attention to the selection of the outcome measure, mode and timing of postoperative administration, and minimization of any burden on the patient and surgeon.

Patient-reported outcomes after total knee replacement vary on the basis of preoperative coexisting disease in the lumbar spine and other nonoperatively treated joints: the need for a musculoskeletal comorbidity index.

BACKGROUND Although the majority of patients report substantial gains in physical function following primary total knee replacement, the degree of improvement varies widely. To understand the potential role of preoperative pain due to other musculoskeletal conditions on postoperative outcomes, we quantified bilateral knee and hip pain and low back pain before primary total knee replacement and evaluated its association with physical function at six months after total knee replacement. METHODS A prospective cohort of 180 patients having primary unilateral total knee replacement reported joint-specific pain in right and left hips and knees (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] pain) as well as the low back (Oswestry Disability Index) before surgery. Participants also completed the Short Form-36 (SF-36), including the physical and mental component summary scores, before and at six months after surgery. RESULTS Of the 180 patients, 110 (61%) were women; the mean age was 65.1 years, the mean body mass index (BMI) was 32.5 kg/m², and mean SF-36 physical component summary score reported before the total knee replacement was 33.1. Before total knee replacement, 56.1% of the patients reported no or mild pain in the nonoperatively treated knee, hips, and low back. In addition, 22.2% of the patients had moderate to severe pain in one location; 12.8%, in two locations; and 8.9%, in three or four locations. Women reported more moderate to severe pain than men did in the nonoperatively treated knee (30% versus 11%; p < 0.004) and ipsilateral hip (26% versus 11%; p < 0.02). At six months, the mean physical component summary score was lower among patients with a greater number of preoperative locations of moderate to severe pain. After adjusting for age, sex, BMI, and SF-36 mental component summary score, moderate to severe preoperative pain in the contralateral knee (p = 0.013), ipsilateral (p = 0.014) and contralateral hip (p = 0.026), and low back (p < 0.001) was significantly associated with poorer function at six months after total knee replacement. CONCLUSIONS Preoperative musculoskeletal pain in the low back and nonoperatively treated lower extremity joints is associated with poorer physical function at six months after total knee replacement. The degree of functional improvement varies with the burden of musculoskeletal pain in other weight-bearing locations.