Patient-specific instrumentation does not improve radiographic alignment or clinical outcomes after total knee arthroplasty: A meta-analysis

Background and purpose: Patient-specific instrumentation (PSI) for total knee arthroplasty (TKA) has been introduced to improve alignment and reduce outliers, increase efficiency, and reduce operation time. In order to improve our understanding of the outcomes of patient-specific instrumentation, we conducted a meta-analysis. Patients and methods: We identified randomized and quasi-randomized controlled trials (RCTs) comparing patient-specific and conventional instrumentation in TKA. Weighted mean differences and risk ratios were determined for radiographic accuracy, operation time, hospital stay, blood loss, number of surgical trays required, and patient-reported outcome measures. Results: 21 RCTs involving 1,587 TKAs were included. Patient-specific instrumentation resulted in slightly more accurate hip-knee-ankle axis (0.3°), coronal femoral alignment (0.3°, femoral flexion (0.9°), tibial slope (0.7°), and femoral component rotation (0.5°). The risk ratio of a coronal plane outlier (\u3e 3° deviation of chosen target) for the tibial component was statistically significantly increased in the PSI group (RR = 1.64). No significance was found for other radiographic measures. Operation time, blood loss, and transfusion rate were similar. Hospital stay was significantly shortened, by approximately 8 h, and the number of surgical trays used decreased by 4 in the PSI group. Knee Society scores and Oxford knee scores were similar. Interpretation: Patient-specific instrumentation does not result in clinically meaningful improvement in alignment, fewer outliers, or better early patient-reported outcome measures. Efficiency is improved by reducing the number of trays used, but PSI does not reduce operation time

Probabilities of TKR patients achieving their goals

Introduction: Prospective total knee replacement patients often enquire about the likelihood that surgery will resolve their knee pain, enable them to walk “normally”, and to resume activities important to them. However, considerable variability exists in patient outcomes, which makes it difficult for clinicians to accurately answer these questions, and for patients to make informed decisions. In this study five patient-centred outcomes were explored: pain resolution, walk without limping, perform usual work, ability to kneel, and satisfaction. Significance: The goal of this paper was not to create a fully predictive framework of outcomes after TKR, but to focus on patient-centred goals using only easily measured baseline factors to see if doing this might be achievable and potentially useful in terms of discussion of expectations in shared decision making for surgery. The added value of personalising each outcome, as opposed to providing all patients with a generic probability, was also assessed from the statistical models. Method: Data from 470 patients was used in multivariable logistic regression analyses to identify independent significant predictors for each goal. Predictors assessed were age, gender, body mass index, preoperative knee function, physical health status and mental health status. Results: The likelihood of achieving a desirable outcome varied across goals examined. Whilst 82% of patients were able to walk without a consistent limp, only 32% could kneel with ease. Furthermore, we identified a consistent pattern where patients with greater preoperative knee function and mental health, had improved odds for attaining each goal. Preoperative physical health and body mass also had some predictive utility. Conclusion: We found that when assessing the merits of undergoing total knee replacement, consideration of a patient’s pre-operative knee function and mental health allows a more accurate prediction of the benefit they may achieve

Illness perceptions of people with chronic hip pain: A qualitative investigation

Background: Chronic hip pain is one of the leading causes of global disability. It can lead to significant physical and functional impairments, sleep disturbances and psychological distress. The biomedical model of illness is insufficient to explain persistent hip pain as it fails to consider biopsychosocial components strongly associated to musculoskeletal pain and disability. In particular, negative illness perceptions can lead to emotional distress, and progressive pain and disability. In this context, the Common Sense Model links illness perceptions with behavioural and emotional responses to manage health threats. To date, in-depth illness perceptions of people with persistent hip pain have not been investigated. Purpose: The purpose of this study was to explore illness perceptions, coping strategies and care seeking history of patients experiencing chronic hip pain within the Common Sense Model. Methods: This was a cross-sectional qualitative study with a deductive framework analysis approach. It was conducted between 2016 and 2017 as the initial stage of a prospective intervention study for hip pain management. Patients with chronic hip pain were referred to this study by two orthopaedic surgeons from a private clinic in Perth, Western Australia. Sixteen patients (µ age = 51 [SD 10.7]) participated in face-to-face interviews following a semi-structured interview guide based on Leventhal's Common Sense Model. This included seven key categories of beliefs: interpretation, identity, cause, consequences, time line, controllability, and action and appraisal. The seven categories were applied onto the framework analysis comprised of six steps: familiarisation, application of the framework, indexing, charting, mapping and interpretation of the data. Results: Four key themes emerged: 1. Discrepancies between what patients believed to be the cause(s) of their hip pain and how health professionals explained their symptoms based on the biomedical model (e.g. patients believed their pain was the result of exercise-related injuries that could be treated whilst health professionals interpreted altered hip alignment and aging as the cause); 2. Illness perceptions informed by pathoanatomical explanations provided by health professionals negatively impacted emotional state and behavioural responses (e.g. patients reported that medical imaging revealed extensive structural hip damage, leading to fear, anxiety or frustration); 3. Differentiation between strategies to “fix the damage” to their hip and “control the symptoms” (e.g. patients described unsuccessful attempts to “fix their hip” through physiotherapy, stem cell injections, or tried to “control their symptoms” through activity-avoidance, acupuncture, cortisone injections; but many believed hip replacement was the only solution); and 4. The negative impact of hip pain on the ability to exercise and sleep and the consequences to their psychosocial health (e.g. patients exercised to maintain psychosocial health but this strategy was compromised by pain). Conclusion(s): People with chronic hip pain presenting for surgical consultation have illness perceptions that are heavily influenced by a pathoanatomical framework which negatively affects emotional and behavioural responses. Implications: The recognition of illness perceptions and their role in perpetuating disability, avoidance and distress is important for clinicians treating chronic hip pain. Clinicians can play an important role in minimising patients' disability and distress by positively modifying illness perceptions

Factors influencing return to work after hip and knee arthroplasty

Background: A substantial proportion of patients undergoing lower limb arthroplasty are of working age. This study aims to identify when patients return to work (RTW) and if they return to normal hours and duties, and to identify which factors influence postoperative RTW. The hypothesis is that there is no difference in time of RTW between the different types of surgery, and no difference in time of RTW based on the physical demands of the job. Materials and methods: Consecutive patients aged \u3c 65 years who had undergone unilateral primary total hip arthroplasty (THA), total knee arthroplasty (TKA), or medial unicompartmental knee arthroplasty (UKA) from 2015 to 2017 were sent a questionnaire. Quantitative questions explored timing and nature of RTW, and qualitative questions explored factors influencing timing of RTW. Results: There were 116 patients (64 male, 52 female) with an average age of 56 years. Thirty-one patients were self-employed and 85 were employees. Of these patients, 58 had undergone THA, 31 had undergone TKA, and 27 had undergone UKA. One hundred and six (91%) patients returned to work. Patients returned to work after (mean) 6.4 weeks (THA), 7.7 weeks (TKA), and 5.9 weeks (UKA). Time of RTW was not significantly influenced by type of surgery (p = 0.18) (ns). There was a non-significant correlation between physical demands of the work versus time of RTW (p = 0.28) (ns). There was a significantly earlier time of RTW if flexible working conditions were resumed (p = 0.003). Active recovery, motivation, necessity and job flexibility enabled RTW. The physical effects of surgery, medical restrictions and work factors impeded RTW. Conclusion: The time of RTW was not significantly influenced by the type of operation or by the physical demands of the job. Patients returned to work 5.9–7.7 weeks after hip/knee arthroplasty. Rehabilitation, desire, and necessity promoted RTW. Pain, fatigue and medical restrictions impeded RTW. Level of evidence: 3