Predicting Early Failure in Total Knee Arthroplasty: A Critical Review of Oxinium Femoral Components

Introduction: Retrospectively, it has been shown that significant patient-reported pain 6 months following total knee arthroplasty (TKA) is associated with a 7 times greater revision rate at 5 years. Our goal is to use the FORCE-TJR registry to prospectively evaluate if postoperative pain and function scores can predict increased revision rate 5 years following TKA. Our preliminary analyses have focused on one implant reported by Australia to have a significantly high 5-year revision rate: Oxinium femoral components. Materials and Methods: FORCE-TJR matched implant catalog numbers to the international implant library to define TKA patients who received oxinium femoral components and all other implants. We defined 12-month KOOS pain and function (SF PCS) for patients with the study implant and all others (n=9187). Age, BMI, sex, pre-TKA pain, function, low back pain severity, and Charlson comorbidity index were compared for patients with moderate pain (KOOS pain\u3c75) vs. minimal pain (KOOS pain\u3e75) at 12 months postoperatively. Results: We observed that 27% of oxinium patients reported moderate pain vs. 21% of patients receiving all implants at 12 months postoperatively. Compared to patients with minimal pain, moderate pain patients had greater pre-op pain (KOOS=37 vs. 50; p\u3c 0.0002), poorer pre-op function (PCS=30 vs. 33; p\u3c0.04), and more moderate to severe low back pain (52% vs. 24%; p\u3c0.027). In addition, high 12-month pain patients had poorer 12-month function (PCS=37 vs. 45; p\u3c0.0000). Conclusion: These preliminary results indicate that moderate pain at 12-months post operatively is associated with poorer functional gain following TKA. Surgeons should recognize and potentially intervene on this group if improvement in their ultimate functional gain is desired. By continuing to follow this group of oxinium patients we will be able to determine if early pain and decreased function following TKA is associated with an increased revision rate

Direct-to-Patient PRO Collection to Support Quality Improvement in TJR

Introduction: Patient-reported outcomes (PROs) are widely used in orthopedic clinical research to evaluate quality of care. However, it is difficult to capture complete post-operative PRO data through surgeon office visits. The UK and Sweden collect post-TJR PRO measures directly from patients in their homes. We compared two US post-operative PRO collection processes- PROs in clinic at scheduled office visits and direct-to-patient collection, to evaluate timing and completeness of both approaches. Methods: At a large TJR center that has collected PROs at office visits routinely for years, post-TJR patients complete a PRO survey on a computer at follow-up clinic visits. In contrast, the national FORCE-TJR cohort manages post-operative PRO surveys across dozens of offices by sending PROs to patients directly via web-based questionnaires or scannable paper forms. We calculated post-operative PRO response rates and timing from these two approaches and compared patient physical outcomes between them. Results: In the clinic, 892 patients had TJR surgery during the study period. Of these, 392 (44%) completed post-operative surveys; 115 (29%) between 5 months and 7 months after surgery, and 85 (22%) after 7 months. Direct to patient PRO surveys were centrally distributed in month 5 after surgery. Of 11,702 TJR patients, 8283 (71%) completed the PRO survey within 5 to 9 months post-op. Of these, 90% were returned between 5 and 7 months. SF36 PCS scores were comparable between these two approaches. Discussion: While PRO collection at the office visit can support individual patient care decisions, patients return to the surgeon office at varied time points after TJR based on their recovery progress and convenience. Direct to patient PRO collection with appropriate retention processes can lead to uniform data timing and optimal completeness. Quality monitoring programs will benefit from consistent data across providers and should consider these factors in designing PRO procedures

Gender and BMI Differences in Physical Activity after Total Knee Replacement

Background Total knee replacement (TKR) is an effective procedure to eliminate knee pain due to osteoarthritis. However variation in functional outcome persists. Patient attributes, including age, gender, body mass index (BMI), and emotional health, influence degree of functional gain. The level of daily physical activity (PA) is important to weight management, knee OA care, and overall health. As the arthritis population becomes more overweight and inactive, it is important to understand the physical activity benefits accrued following TKR. Health promotion programs, conducted in community dwelling adults, have called attention to the use of accelerometers (step activity monitor devices) as a measure of general activity. The device, worn around the leg, gives an accurate number of daily steps (mean steps/ day), as well as, walking rate (mean steps/ minute). Unfortunately, there are limited data on the use of accelerometers in patients with knee OA. It is unknown if self-reported physical function correlates with objectively measured physical activity (e.g., steps/day) or if patient attributes influence the level of physical activity in patients with osteoarthritis before and after TKR. We hypothesized that patient physical activity at 6 months post-TKR varies with the two patients attributes, gender and body mass index (BMI). Materials and Methods A consecutive series of 89 TKR patients wore a small ankle accelerometer (StepWatch Activity Monitor/SAM; CYMA, Inc.) above the ankle of the operative leg before TKR and again at 6 months after surgery. Demographic attributes, self-reported function measured with SF36 and WOMAC, and physical activity as measured by accelerometer as quantity of steps/day and % of day inactive were recorded. Descriptive statistics and mean differences were calculated. Results Patients had a mean age of 67 years, mean BMI of 30, and 71% were women. Overall, physical activity significantly improved from a mean of 6600 steps/day before TKR to 7690 steps/day at 6 months. Women walked fewer steps/day than men before and after TKR (6,218 before, 7,150 after; a 15% increase). Non-obese patients improved steps/day, obese did not. While male reduced their inactive time after TKR, women did not. After adjusting for BMI and age, gender differences persisted in objectively measured physical activity. The number of steps/day was moderately but significant correlated with PCS and WOMAC function (r=0.28 – 0.4). Conclusions Physical activity as measured by accelerometer improved after TKR, varied with patient attributes, including gender and BMI, and was moderately correlated with self-reported function. A 15% increase in pre to post TKR patient steps/day is highly significant and contributes to the health status improvement of patients with advanced arthritis. Women‘s lower physical activity levels before surgery persists after TKR, despite significant pain relief. Physical activity differences should be considered when designing TKR patient pathways and rehabilitation programs

Integrating Patient-reported Symptoms in the Arthritis Care Record

Background For knee and hip arthritis patients, self-assessed pain and physical function are central to treatment decisions as well as to clinical and outcomes research. Both paper and electronic health records capture the clinician’s summary of the patient symptoms. Brief patient-reported arthritis symptom assessments have been broadly tested and validated in clinical research, yet have not been integrated into routine office practice. The introduction of electronic health records offers an opportunity for patient direct-entry and real-time scores of standardized symptom assessments to be included in the routine health record. Purpose To both support patient-centered health care in arthritis care and to track aggregate outcomes for longitudinal research, a comprehensive arthritis care record system was designed and implemented with the goal of integrating standardized symptom assessments and clinical metrics in an individual patient health record. Trend pain and function metrics over time, Provide real-time data to patients and clinicians to inform treatment decisions, and, Track aggregate outcomes for quality assessment and research. Study Design The data collection and management system was implemented in the Arthritis and Total Joint Center (TJC) ambulatory clinic at UMass Medical Center. The host system allows development and delivery of custom web-based surveys and serves as a database archive system with interfaces to hospital information services (HIS) and a data storage location. The survey data are divided into 21 tables representing clinical categories (e.g., pain, function, clinical diagnoses) with 259 measures, and 66 among them are used for QA reports. The patient-entered survey data are merged with the clinical data in a structured format, providing comprehensive longitudinal records for individual patients. In addition, real-time symptom trend reports are produced using query, search and analysis functions. System Use The core system was established in 2007, fully operational in 2008, and by June 2010, over 1,000,000 clinical measures had been collected from over 30,000 patients visiting the Arthritis and Total Joint Center (TJC). Among patient measures, around 400,000 measures (28,500 surveys) are related to patient self-assessed symptoms. Conclusions The system implemented in our clinic is a successful model for collecting and integrating patient symptom data with clinical data as part of a patient health record. This template is the foundation for a newly funded national research registry for comparative effectiveness in total joint replacement surgery (FORCE-TJR)

Pre-operative Emotional Health Affects Post-operative Patient Function but not Patient Satisfaction Following Primary Total Hip Arthroplasty

Introduction: Total hip (THA) and knee (TKA) arthroplasty are highly successful treatments for end-stage arthritis. However, a subset of patients experience suboptimal post-operative gain in function. 1, 2 Previous studies have shown that pre-operative emotional health influences outcomes after TKA,3 but there is limited evidence on THA patients. We hypothesized that pre-operative emotional health does not affect patient satisfaction in THA patients. Methods: A secondary analysis of an existing registry at UMass of primary THA patients between 2008 and 2011 was conducted. Baseline demographic, clinical, emotional health (SF-36 MCS), and physical health (SF-36 PCS) data were collected electronically at the pre-operative visit. Post-operative SF-36 MCS, SF-36 PCS, and satisfaction scores were collected electronically between 6 months through 2 years follow-up. Bivariate analyses and multivariate logistic regression models were used. Results: The analysis included 316 primary THA patients with mean age 62±11 years, 55% female, mean BMI 30±5, mean PCS 31±8, and mean MCS 51±11. Patients with lower baseline emotional health scores reported significantly reduced mean post-operative physical function and emotional health (p45 (indicating excellent function, national norm = 50); whereas patients with baseline MCS≥50 had a mean 17±11 point increase in post-operative PCS with 71% of these patients reporting PCS\u3e45 (p\u3c0.001). Conclusion: In THA patients, post-operative emotional health and physical health are positively correlated with baseline emotional health, however post-operative patient satisfaction remains independent of baseline emotional health

Detecting differences across multiple instances of code clones

Clone detectors find similar code fragments (i.e., instances of code clones) and report large numbers of them for industrial systems. To maintain or manage code clones, developers often have to in-vestigate differences of multiple cloned code fragments. However, existing program differencing techniques compare only two code fragments at a time. Developers then have to manually combine several pairwise differencing results. In this paper, we present an approach to automatically detecting differences across multiple clone instances. We have implemented our approach as an Eclipse plugin and evaluated its accuracy with three Java software systems. Our evaluation shows that our algorithm has precision over 97.66% and recall over 95.63 % in three open source Java projects. We also conducted a user study of 18 developers to evaluate the use-fulness of our approach for eight clone-related refactoring tasks. Our study shows that our approach can significantly improve de-velopers ’ performance in refactoring decisions, refactoring details, and task completion time on clone-related refactoring tasks. Au-tomatically detecting differences across multiple clone instances also opens opportunities for building practical applications of code clones in software maintenance, such as auto-generation of appli-cation skeleton, intelligent simultaneous code editing

Clonepedia: Summarizing code clones by common syntactic context for software maintenance

No Full Tex

A Web-Based Treatment Decision Support Tool for Patients With Advanced Knee Arthritis: Evaluation of User Interface and Content Design

BACKGROUND: Data-driven surgical decisions will ensure proper use and timing of surgical care. We developed a Web-based patient-centered treatment decision and assessment tool to guide treatment decisions among patients with advanced knee osteoarthritis who are considering total knee replacement surgery. OBJECTIVE: The aim of this study was to examine user experience and acceptance of the Web-based treatment decision support tool among older adults. METHODS: User-centered formative and summative evaluations were conducted for the tool. A sample of 28 patients who were considering total knee replacement participated in the study. Participants\u27 responses to the user interface design, the clarity of information, as well as usefulness, satisfaction, and acceptance of the tool were collected through qualitative (ie, individual patient interviews) and quantitative (ie, standardized Computer System Usability Questionnaire) methods. RESULTS: Participants were older adults with a mean age of 63 (SD 11) years. Three-quarters of them had no technical questions using the tool. User interface design recommendations included larger fonts, bigger buttons, less colors, simpler navigation without extra next page click, less mouse movement, and clearer illustrations with simple graphs. Color-coded bar charts and outcome-specific graphs with positive action were easiest for them to understand the outcomes data. Questionnaire data revealed high satisfaction with the tool usefulness and interface quality, and also showed ease of use of the tool, regardless of age or educational status. CONCLUSIONS: We evaluated the usability of a patient-centered decision support tool designed for advanced knee arthritis patients to facilitate their knee osteoarthritis treatment decision making. The lessons learned can inform other decision support tools to improve interface and content design for older patients\u27 use

Racial Differences in the Effectiveness of Total Knee Arthroplasty (TKA) on Postoperative Pain and Function

Objective: African Americans are less likely than Caucasians to perceive TKA as an effective treatment option. We examined post-TKA pain and function by race, with and without adjusting for demographic and clinical factors on determining racial differences. Methods: We analyzed data from FORCE-TJR, a national cohort of TJR patients. Patients had primary and unilateral TKA surgeries 07/01/2011-12/31/2014, and completed surveys on demographic and clinical information, including a pre- and 6-month postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS). The KOOS pain and function scores ranged from 0-100 (higher=better). We examined baseline, 6-month, and 6-month change in pain and function by race, and estimated the association between race and outcomes, adjusting for demographic and clinical factors. Results: Analyses included 5028 white (63% female, 65% income\u3e45k; mean age of 67. BMI of 31) and 270 black patients (80% female, 39% income\u3e45k; mean age of 63, BMI of 34). At baseline, black compared with white patients reported worse knee pain (mean: 39vs.48), and poorer function (mean: 46vs.54). While all patients reported significant gains at 6-month post-surgery, black patients had lower postoperative pain (mean: 71vs.82) and function scores (mean: 73vs.84) than white patients. Although not statistically significant, black patients on average had lower 6-month change than white patients in pain -1.9 (95%CI: -4.4, 0.6) and function -1.6 (95%CI: -3.9, 0.7). Adjusting for covariates, racial differences were significantly more pronounced in change in pain -5.5 (95%CI: -8.3, -2.7) and function -5.6 (95%CI: -8.2, -3.0). Conclusions: TKAs were as effective in reducing pain and improving functions in blacks as in whites. Adjusting for certain demographic and clinical factors can impact assessment of racial differences and the effectiveness of TKA on postoperative outcomes, as black patients were very different from white patients on these important factors