The effect of surgical factors on early patient-reported outcome measures (PROMS) following total knee replacement
Institute of Cellular Medicine, Medical school, Newcastle University, Framlington place, Newcastle upon Tyne NE1 7RU, UK. The Bone & Joint Journal
(Impact Factor: 3.31).
08/2012; 94(8):1058-66. DOI: 10.1302/0301-620X.94B8.28786
Patient-reported outcome measures (PROMs) are increasingly being used to assess functional outcome and patient satisfaction. They provide a framework for comparisons between surgical units, and individual surgeons for benchmarking and financial remuneration. Better performance may bring the reward of more customers as patients and commissioners seek out high performers for their elective procedures. Using National Joint Registry (NJR) data linked to PROMs we identified 22,691 primary total knee replacements (TKRs) undertaken for osteoarthritis in England and Wales between August 2008 and February 2011, and identified the surgical factors that influenced the improvements in the Oxford knee score (OKS) and EuroQol-5D (EQ-5D) assessment using multiple regression analysis. After correction for patient factors the only surgical factors that influenced PROMs were implant brand and hospital type (both p < 0.001). However, the effects of surgical factors upon the PROMs were modest compared with patient factors. For both the OKS and the EQ-5D the most important factors influencing the improvement in PROMs were the corresponding pre-operative score and the patient's general health status. Despite having only a small effect on PROMs, this study has shown that both implant brand and hospital type do influence reported subjective functional scores following TKR. In the current climate of financial austerity, proposed performance-based remuneration and wider patient choice, it would seem unwise to ignore these effects and the influence of a range of additional patient factors.
Available from: Ruud W Selles
- "In the last decades there has been a shift from using only clinical outcome assessment to the development and validation of patient-reported outcome measures. For example, in the field of joint replacement surgery   and several types of surgery (such as after hip fracture, groin hernia repair and varicose vein surgery), there is an increasing focus on patient-reported outcome measures to compare HRQoL before and after treatment  . In these fields, pain and HRQoL are often considered primary outcome measures. "
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ABSTRACT: Results: For non-hospitalized UEI patients, a substantial loss in HRQoL was observed after 2.5 months which improved to the level of the general population norms by 24 months. For hospitalized UEI patients, HRQoL improved from 2.5 to 24 months but remained far below population norms. The more proximal UEI had a lower HRQoL and a slower recovery of HRQoL than distal injuries. At all time points, the proportion of UEI patients with limitations on the health domains self-care, usual activities and complaints of pain and/or discomfort was higher than in the group of all injuries. Female gender, higher age, low educational level, co-morbidity, shoulder or upper arm injury, multiple injuries and hospitalization are independent predictors for long-term loss in HRQoL.
Available from: Kirill Gromov
- "Up to 20% of the patients are not satisfied with the outcome as assessed 1 year postoperatively (Bourne et al. 2010, Klit et al. 2014) and a recent review found that 10–34% of patients had pain 3 months to 5 years after TKA (Beswick et al. 2012). Although patient-related factors (such as age, preoperative OKS and EQ5D, comorbidities, general health, depression, anxiety, and ASA) have been found to influence patient-reported outcome the most, surgical factors such as implant brand, hospital type (Baker et al. 2012), and implant alignment are also important (Choong et al. 2009, Longstaff et al. 2009). Implant malalignment following primary TKA has been reported to be the primary reason for revision in 7% of revised TKAs (Schroer et al. 2013) and it has been linked to both decreased implant survival (Ritter et al. 2011) and inferior patient-reported outcomes (Choong et al. 2009, Longstaff et al. 2009). "
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Surgeon-dependent factors such as optimal implant alignment are thought to play a significant role in outcome following primary total knee arthroplasty (TKA). Exact definitions and references for optimal alignment are, however, still being debated. This overview of the literature describes different definitions of component alignment following primary TKA for (1) tibiofemoral alignment in the AP plane, (2) tibial and femoral component placement in the AP plane, (3) tibial and femoral component placement in the sagittal plane, and (4) rotational alignment of tibial and femoral components and their role in outcome and implant survival.
We performed a literature search for original and review articles on implant positioning following primary TKA. Definitions for coronal, sagittal, and rotational placement of femoral and tibial components were summarized and the influence of positioning on survival and functional outcome was considered.
Many definitions exist when evaluating placement of femoral and tibial components. Implant alignment plays a role in both survival and functional outcome following primary TKA, as component malalignment can lead to increased failure rates, maltracking, and knee pain.
Based on currently available evidence, surgeons should aim for optimal alignment of tibial and femoral components when performing TKA.
Available from: Hemant Pandit
- "This is because clinical studies have shown that, if appropriate indications and techniques are used, UKR tends to give a faster recovery, lower costs, fewer and less severe complications and better function than a total knee replacement (TKR)   . National joint registers support these conclusions as they demonstrate that, compared with TKR, UKR has shorter inpatient stays, lower mortality , lower incidence of major complications such as infection and better outcome scores, although adjusted change scores are similar   . They do however show that UKR has a higher revision rate than TKR. "
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ABSTRACT: BACKGROUND: Obesity is considered to be a contraindication for unicompartmental knee replacement (UKR). The aim was to study the impact of BMI on failure rate and clinical outcome of the Oxford mobile bearing UKR. METHOD: Two thousand four hundred and thirty-eight medial Oxford UKRs were studied prospectively and divided into groups: BMI<25 (n=378), BMI 25 to <30 (n=856), BMI 30 to <35 (n=712), BMI 35 to <40 (n=286), and BMI 40 to <45 (n=126) and BMI≥45 (n=80). RESULTS: There was no significant difference in survival rate between groups. At a mean follow-up of 5years (range 1-12years) there was no significant difference in the Objective American Knee Society Score between groups. There was a significant (p<0.01) trend with the Oxford Knee Score (OKS) and Functional American Knee Society Scores decreasing with increasing BMI. As there was an opposite trend (p<0.01) in pre-operative OKS, the change in OKS increased with increasing BMI (p=0.048). The mean age at surgery was significantly (p<0.01) lower in patients with higher BMI. CONCLUSIONS: Increasing BMI was not associated with an increasing failure rate. It was also not associated with a decreasing benefit from the operation. Therefore, a high BMI should not be considered a contra-indication to mobile bearing UKR. LEVEL OF EVIDENCE: IV.
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