Improvement following total knee replacement surgery: Exploring preoperative symptoms and change in preoperative symptoms

AbstractObjectiveTo determine whether changes in preoperative osteoarthritis (OA) symptoms are associated with improvement after total knee replacement (TKR) and to identify predictors of clinically significant improvement.MethodsData on Osteoarthritis Initiative participants who were annually assessed and underwent TKR were included. T0 was the assessment prior to TKR while T−1 was the assessment prior to that. T+2 was the second assessment after TKR. We compiled data on the Western Ontario and McMaster Universities OA Index (WOMAC), OA-related symptoms, and radiographic severity. We defined clinically significant improvement as improvement in WOMAC total score ≥ to the minimal important difference (MID) (0.5 SD of mean change) between T0 and T+2 and also considered other definitions of improvement. Logistic regression models were performed to evaluate the relationship between improvement and preoperative measures.ResultsImproved (n = 211) compared to unimproved (n = 58) patients had greater worsening of their WOMAC pain (p = 0.002) and disability (p < 0.001) from T−1 to T0. Preoperative measures as predictors of improvement included higher WOMAC disability (OR = 1.08, p < 0.001), presence of chronic OA symptoms in the surgical knee (OR = 5.77, p = 0.033), absence of OA-related symptoms in the contralateral knee (OR = 9.25, p < 0.001), exposure to frequent knee bending (OR = 3.46, p = 0.040), and having a Kellgren–Lawrence x-ray grade of ≥2 in the contralateral knee (OR = 4.71, p = 0.010).ConclusionsMore than 75% of participants had improvement after TKR. Improved patients were more likely to have escalation of OA pain and disability prior to surgery than unimproved patients. Other preoperative measures predicted improvement after TKR

Widespread Pain Is Associated with Increased Risk of No Clinical Improvement After TKA in Women

Background When conservative treatments do not work, TKA may be the best option for patients with knee osteoarthritis, although a relatively large proportion of individuals do not have clinically important improvement after TKA. Evidence also suggests that women are less likely to benefit from TKA than men, but the reasons are unclear. Widespread pain disproportionately affects women and has been associated with worse outcomes after joint arthroplasty, yet it is unknown if the effect of widespread pain on TKA outcomes differs by patient gender. Questions/purposes (1) Does the association between widespread pain and no clinically important improvement in osteoarthritis-related pain and disability 2 years after TKA differ between men and women? (2) Does the use of pain medications 2 years after TKA differ between those with widespread pain and those without widespread pain before surgery? Methods Osteoarthritis Initiative () study participants were followed annually from March 2005 until October 2015. Participants who underwent TKA up to the 7-year follow-up visit with pain/disability assessment at the protocol-planned visit before TKA and at the second planned annual visit after surgery were included in the analysis. Among 4796 study participants, 391 had a confirmed TKA, including 315 with pain/disability assessment at the protocol-planned visit before TKA. Overall, 95% of participants (298) had the required follow-up assessment; 5% (17) did not have follow-up data. Widespread pain was defined based on the modified American College of Rheumatology criteria. Symptoms were assessed using the WOMAC pain (range 0 to 20; higher score, more pain) and disability (range 0 to 68; higher score, more disability) scores, and the Knee Injury and Osteoarthritis Outcome Score for pain (range 0 to 100; higher score, less pain). Improvements in pain and disability were classified based on improvement from established clinically important differences (decrease in WOMAC pain >= 1.5; decrease in WOMAC disability >= 6.0; increase in Knee Injury and Osteoarthritis Outcome Score for pain >= 9). At baseline, more women presented with widespread pain than men (45% [84 of 184] versus 32% [36 of 114]). Probability and the relative risk (RR) of no clinically important improvement were estimated using a logistic regression analysis in which participants with widespread pain and those without were compared. The analyses were done for men and women separately, then adjusted for depression and baseline outcome scores. Results Among women, preoperative widespread pain was associated with an increased risk of no clinically important improvement 2 years after TKA, based on WOMAC pain scores (13.5% versus 4.6%; RR 2.93 [95% CI 1.18 to 7.30]; p = 0.02) and the Knee Injury and Osteoarthritis Outcome Score for pain (16.5% versus 4.9%; RR 3.39 [95% CI 1.34 to 8.59]; p = 0.02). Given the lower and upper limits of the confidence intervals, our data are compatible with a broad range of disparate associations between widespread pain and lack of clinically important improvement in WOMAC pain scores (RR 0.77 [95% CI 0.22 to 2.70]; p = 0.68) and the Knee Injury and Osteoarthritis Outcome Score for pain (RR 1.37 [95% CI 0.47 to 4.00]; p = 0.57) among men, as well as clinically important improvement in WOMAC disability scores among men (RR 0.72 [95% CI 0.20 to 2.55]; p = 0.61) and women (RR 1.98 [95% CI 0.92 to 4.26]; p = 0.08). Participants presenting with widespread pain before TKA were more likely than those without widespread pain to use medication for symptoms of knee osteoarthritis most days for at least 1 month 2 years after TKA (51% [61 of 120] versus 32% [57 of 178]; mean difference, 18.8 [95% CI 7.3 to 30.1]; p < 0.01). Conclusions Widespread pain before TKA was associated with an increased risk of no clinically important improvement in knee pain 2 years postoperatively among women. Because of the small number of men with widespread pain in the sample, the results for men were inconclusive. In clinical practice, screening TKA candidates for widespread pain may be useful, and expectations of surgical outcomes may need to be tempered if patients have a concurrent diagnosis of widespread pain. Future studies should include more men with widespread pain and investigate if treatment of widespread pain before or concurrent with TKA surgery may improve surgical outcomes.12 month embargo; published online: 16 October 2019This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Relationship Between Knee Pain and Patient Preferences for Joint Replacement: Health Care Access Matters

Objective: To determine if severity of osteoarthritis-related knee pain is associated with a willingness to undergo total knee replacement (TKR) and whether this association is confounded or modified by components of socioeconomic status and health care coverage. MethodsCross-sectional analysis was conducted among 3,530 Osteoarthritis Initiative study participants. Logistic regression models were used to assess the effect of knee pain severity (where 0=none, 1-3=mild, 4-7=moderate, and 8-10=severe) on willingness to undergo TKR. Stratified analyses were conducted to evaluate whether socioeconomic status and health care coverage modify the effect of knee pain severity on willingness. Results: Participants with severe knee pain, compared to participants without pain, were less willing to undergo TKR (odds ratio [OR] 0.73, 95% confidence interval [95% CI] 0.57-0.93). This association was attenuated when adjusted for age, sex, comorbidity, depression, health insurance coverage, prescription medicine coverage, health care source, education, income, employment, race, and marital status (adjusted OR 0.92, 95% CI 0.68-1.24). The odds of willingness to undergo TKR were significantly lower in those with the highest level of pain, compared to those without pain, among participants without health insurance (adjusted OR 0.08, 95% CI 0.01-0.56), but not among those with health insurance (adjusted OR 1.03, 95% CI 0.73-1.38), when adjusted for demographic, clinical, health care access, and socioeconomic factors (P=0.015). However, <5% of participants were without health insurance. Conclusion: Among participants without health insurance, severe knee pain was paradoxically associated with less willingness to undergo TKR. Policies that improve access to quality health care may affect patient preferences and increase utilization of TKR surgery among vulnerable populations.NIH, a branch of the Department of Health and Human Services [N01-AR-2-2258, N01-AR-2-2259, N01-AR-2-2260, N01-AR-2-2261, N01-AR-2-2262]; Merck Research Laboratories; Novartis Pharmaceuticals Corporation; GlaxoSmithKline; Pfizer12 month embargo; Version of record online: 27 December 2016This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Does a Patient-centered Educational Intervention Affect African-American Access to Knee Replacement? A Randomized Trial.

A TKA is the most effective and cost-effective surgical option for moderate to severe osteoarthritis (OA) of the knee. Yet, black patients are less willing to undergo knee replacement surgery than white patients. Decision aids help people understand treatment options and consider the personal importance of possible benefits and harms of treatments, including TKA.NIH/National Institute of Arthritis and Musculoskeletal Skin Diseases [1-RO1-AR-054474-5, K24AR055259]12 month embargoThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Gouty Arthropathy: Review of Clinical Manifestations and Treatment, with Emphasis on Imaging

Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the articular and periarticular soft tissues, is a frequent cause of painful arthropathy. Imaging has an important role in the initial evaluation as well as the treatment and follow up of gouty arthropathy. The imaging findings of gouty arthropathy on radiography, ultrasonography, computed tomography, dual energy computed tomography, and magnetic resonance imaging are described to include findings of the early, acute and chronic phases of gout. These findings include early monosodium urate deposits, osseous erosions, and tophi, which may involve periarticular tissues, tendons, and bursae. Treatment of gout includes non-steroidal anti-inflammatories, colchicine, glucocorticoids, interleukin-1 inhibitors, xanthine oxidase inhibitors, uricosuric drugs, and recombinant uricase. Imaging is critical in monitoring response to therapy; clinical management can be modulated based on imaging findings. This review article describes the current standard of care in imaging and treatment of gouty arthropathy

Does Physical Activity Confound Race Differences in Osteoarthritis-Related Functional Limitation

Objective: This study sought to determine the extent to which physical activity confounds the relation between race and the incidence of osteoarthritis (OA)-related functional limitation. Methods: OA Initiative study participants with or at increased risk of knee OA who wore an accelerometer were included. Race was self-reported. Average time spent in moderate to vigorous physical activity (minutes per day) based on ActiGraph uniaxial accelerometer data was assessed. Functional limitation was based on the following: (1) inability to achieve a community walking speed (1.2 m/s) standard, (2) slow walking speed (<1.0 m/s), and (3) low physical functioning based on a Western Ontario and McMaster Universities OA Index (WOMAC) physical function score greater than 28 of 68. Results: African American (AA) participants (n = 226), compared with White participants (n = 1348), had a higher likelihood of developing functional limitation based on various measures. When adjusted for time in moderate to vigorous physical activity, the association between AA race and inability to walk a community walking speed slightly decreased (from relative risk [RR] 2.15, 95% confidence interval [95% CI] 1.64–2.81, to RR 1.99, 95% CI 1.51–2.61). Association between AA race and other measures of functional limitation mildly decreased (slow walking speed: from RR 2.06, 95% CI 1.40–3.01, to RR 1.82, 95% CI 1.25–2.63; low physical functioning: from RR 3.44, 95% CI 1.96–6.03, to RR 3.10, 95% CI 1.79–5.39). When further adjusted for demographic and other clinical variables, only the association between race and low physical functioning (WOMAC) significantly decreased and no longer met statistical significance. Conclusion: Greater physical activity is unlikely to completely make up for race differences in OA-related functional limitation, and other barriers to health equity need to be addressed.12 month embargo; first published: 30 July 2023This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Cumulative Disadvantage and Disparities in Depression and Pain Among Veterans With Osteoarthritis: The Role of Perceived Discrimination

Objective: Perceived discrimination is associated with chronic pain and depression and contributes to racial health disparities. In a cohort of older adult veterans with osteoarthritis (OA), our objective was to examine how membership in multiple socially disadvantaged groups (cumulative disadvantage) was associated with perceived discrimination, pain, and depression. We also tested whether perceived discrimination mediated the association of cumulative disadvantage with depression and pain. Methods: We analyzed baseline data from 270 African American veterans and 247 White veterans enrolled in a randomized controlled trial testing a psychological intervention for chronic pain at 2 Department of Veterans Affairs medical centers. Participants were age ≥50 years and self-reported symptomatic knee OA. Measures included the Everyday Discrimination Scale, the Patient Health Questionnaire Depression Scale, the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale, and demographic variables. Cumulative disadvantage was defined as the number of socially disadvantaged groups to which each participant belonged (i.e., self-reported female sex, African American race, annual income of <$20,000, and/or unemployed due to disability). We used linear regression models and Sobel’s test of mediation to examine hypotheses. Results: The mean ± SD number of social disadvantages was 1.3 ± 1.0. Cumulative disadvantage was significantly associated with higher perceived discrimination, pain, and depression (P < 0.001 for all). Perceived discrimination significantly mediated the association between cumulative disadvantage and depression symptoms (Z = 3.75, P < 0.001) as well as pain severity (Z = 2.24, P = 0.025). Conclusion: Perceived discrimination is an important psychosocial stressor that contributes to worsening OA-related mental and physical health outcomes, with greater effects among those from multiple socially disadvantaged groups.Public domain articleThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Additional file 3: of Determinants of patient preferences for total knee replacement: African-Americans and whites

Logistic regression analyses of willingness and race, stratified by sex. (DOCX 25 kb