BACKGROUND: The quality and state of satisfaction reporting after total knee replacement (TKR) is variable.
QUESTIONS/PURPOSES: The purposes of this systematic review were (1) to examine the available literature on patient satisfaction after TKR, (2) to evaluate the quality of available evidence, and (3) to identify predictors of patient satisfaction after TKR.
METHODS: A systematic review of the MEDLINE database was performed. The initial search yielded 1219 studies. The inclusion criteria were English language, clinical outcome study with primary outcome related to TKR for osteoarthritis, and patient-reported satisfaction included as an outcome measure. Studies were assessed for demographics, methodology for reporting satisfaction, and factors influencing satisfaction.
RESULTS: Two hundred eight studies, including 95,560 patients who had undergone TKR, met all inclusion and exclusion criteria; 112 (53.8%) of these studies were published in the past 3 years. Satisfaction was most commonly measured using an ordinal scale. Twenty-seven studies (13%) used a validated satisfaction survey. Eighty-three percent of studies reported more than 80% satisfaction. The most commonly reported predictor of satisfaction was post-operative patient-reported functional outcome. Pre-operative anxiety/depression was the most common pre-operative predictor of dissatisfaction.
CONCLUSION: There are numerous studies reporting patient satisfaction after TKR, and publication on the topic has been increasing over the past decade. However, the majority of studies represent lower levels of evidence and use heterogeneous methods for measuring satisfaction, and few studies use validated satisfaction instruments. In general, the majority of studies report satisfaction rates ranging from 80 to 100%, with post-operative functional outcome and relief of pain being paramount determinants for achieving satisfaction.
BACKGROUND: Elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) are effective options for the management of osteoarthritis that has not responded to conservative therapy, and they are increasing in utilization worldwide. Therefore, we sought to investigate how older age influences the outcomes of THA and TKA through a review of the current literature.
METHODS: The Embase and MEDLINE databases were examined for relevant studies that assessed the role of older age in determining the outcomes of THA and TKA. All studies except for systematic reviews and case reports were considered for inclusion. Studies were excluded if they included data on procedures other than THA and TKA or if they focused on the effect of surgical techniques and rehabilitation programs rather than age. We excluded studies if they included data on total joint arthroplasty (TJA) performed for indications other than osteoarthritis unless osteoarthritis was the diagnosis for >90% of the patient cohort. Journal references were manually searched to identify any additional articles.
RESULTS: Thirty-two articles were identified in this review. The most elderly groups in these studies were shown to experience higher mortality rates, more postoperative complications, and a longer stay in the hospital. Perioperative mortality was reported to be between 2.6% and 2.9% for nonagenarians and 1.09% and 1.54% for octogenarians. The increase in length of stay for the elderly following TJA was reported to be 0.6 to 3.1 days. Despite the increased rate of adverse events, there were gains in terms of pain relief and ability to perform activities of daily living, and overall the most elderly groups were satisfied with the THA or TKA. However, there was considerable inconsistency among studies with respect to the methodology for evaluating health-related quality of life and the level of functional ability postoperatively.
CONCLUSIONS: Although TJA is considered an effective surgery for the elderly, clinicians should be aware that the elderly are at a higher risk of greater length of stay, complications, and mortality. However, the available literature contained poor data and heterogeneous patient cohorts, and reported on a wide variety of outcomes. Further research assessing the effect of older age on TJA is warranted.
PURPOSE: This meta-analysis compared infection and revision rates in patients with rheumatoid arthritis (RA) and osteoarthritis (OA) who underwent total knee arthroplasty (TKA). Rates of superficial wound and deep periprosthetic infections were compared in the groups, as were whether revision rates associated with infectious and noninfectious causes differed in the RA and OA groups.
METHODS: Studies were included in the meta-analysis if they (1) compared infection and revision rates after primary TKA in RA and OA patients; (2) directly compared superficial wound and deep periprosthetic infection rates in RA and OA patients who underwent primary TKA; and (3) reported the actual numbers of RA and OA patients who underwent TKA and developed postoperative infection and/or required revision.
RESULTS: The rate of superficial wound infections after primary TKA was similar in the RA and OA groups (15/258 [5.8 %] vs. 77/1609 [4.7 %]; odds ratio [OR] 1.12, 95 % confidence interval [CI] 0.36-3.46; P = n.n.), but the deep infection rate was significantly higher in RA than in OA patients (229/7651 [3.0 %] vs. 642/68628 [0.9 %]; OR 2.04, 95 % CI 1.37-3.05; P < 0.001). The proportion of subjects who required revision resulting from infection after TKA was significantly higher in the RA than in the OA group (86/8201 [1.0 %] vs. 555/118755 [0.5 %]; OR 1.89, 95 % CI 1,34-2.66; P < 0.001), whereas the proportion of subjects requiring revision due to noninfectious causes did not differ significantly (46/594 [7.7 %] vs. 52/904 [5.7 %]; OR 1.22, 95 % CI 0.74-2.00; P = n.n.) CONCLUSION: Following primary TKA, RA patients had a significantly higher rate of deep periprosthetic infections than OA patients, but their superficial infection rates were similar. The revision rate due to infectious causes was significantly higher in RA than in OA patients, but their revision rates due to noninfectious causes did not differ. Therefore, the surgeon should fully explain to RA patients scheduled to undergo primary TKA that, compared to OA patients, they are more likely to experience a deep infection postsurgery.
LEVEL OF EVIDENCE: Meta-analysis Level III.
BACKGROUND: People today are living longer and want to remain active. While obesity is becoming an epidemic, the number of patients suffering from osteoarthritis (OA) is expected to grow exponentially in the coming decades. Patients with OA of the knee are progressively being restricted in their activities. Since a knee arthroplasty (KA) is a well accepted, cost-effective intervention to relieve pain, restore function and improve health-related quality of life, indications are expanding to younger and more active patients. However, evidence concerning return to sports (RTS) and physical activity (PA) after KA is sparse.
OBJECTIVES: Our aim was to systematically summarise the available literature concerning the extent to which patients can RTS and be physically active after total (TKA) and unicondylar knee arthroplasty (UKA), as well as the time it takes.
METHODS: PRISMA guidelines were followed and our study protocol was published online at PROSPERO under registration number CRD42014009370. Based on the keywords (and synonyms of) 'arthroplasty', 'sports' and 'recovery of function', the databases MEDLINE, Embase and SPORTDiscus up to January 5, 2015 were searched. Articles concerning TKA or UKA patients who recovered their sporting capacity, or intended to, were included and were rated by outcomes of our interest. Methodological quality was assessed using Quality in Prognosis Studies (QUIPS) and data extraction was performed using a standardised extraction form, both conducted by two independent investigators.
RESULTS: Out of 1115 hits, 18 original studies were included. According to QUIPS, three studies had a low risk of bias. Overall RTS varied from 36 to 89 % after TKA and from 75 to >100 % after UKA. The meta-analysis revealed that participation in sports seems more likely after UKA than after TKA, with mean numbers of sports per patient postoperatively of 1.1-4.6 after UKA and 0.2-1.0 after TKA. PA level was higher after UKA than after TKA, but a trend towards lower-impact sports was shown after both TKA and UKA. Mean time to RTS after TKA and UKA was 13 and 12 weeks, respectively, concerning low-impact types of sports in more than 90 % of cases.
CONCLUSIONS: Low- and higher-impact sports after both TKA and UKA are possible, but it is clear that more patients RTS (including higher-impact types of sports) after UKA than after TKA. However, the overall quality of included studies was limited, mainly because confounding factors were inadequately taken into account in most studies.
UNLABELLED: Although generally considered successful, total hip arthroplasty (THA) can yield suboptimal results in terms of pain and function in up to one forth of patients suffering from hip osteoarthritis (OA). A thorough understanding of the determinants of patient-reported pain and function following THA can help plan interventions directed at improving surgical results. Previously published systematic reviews do not permit to confidently identify the determinants of THA outcomes because of unsatisfactory methodological designs. Therefore, we aimed to answer: (1) which preoperative factors are most consistently associated with postoperative patient-reported pain and function up to 2 years following primary unilateral THA for hip OA. Medline, Pubmed, Embase and CINAHL were screened from their respective inception dates until April 2015 using a combination of keywords and MESH terms. Criteria for inclusion were: (1) participants with primary unilateral THA for hip OA followed for at least 3 months with a maximal follow-up of 2 years; (2) validated disease-specific patient-reported outcome measures assessing pain and/or disability; (3) identification of determinants obtained via multivariate analyses. Methodological quality was assessed using a modified version of the methodology checklist for prognostic studies. Twenty-two manuscripts were included. Mean score of the methodological quality was 81.0±10.3% (66.7% to 100%). Among socioeconomic determinants, a lower educational level was significantly related to worse pain and function (3 out of 3 studies evaluating the relationship). Clinical determinants of poor outcomes included preoperative levels of pain and physical function (9 out of 12 studies), higher body mass index (6 out of 10 studies), presence/greater level of comorbidities (7 out of 8), worse general health (4 out of 4 studies) and lower radiographic OA severity (3 out of 4 studies). Study heterogeneity limited the pooled assessment of the strength of associations between the preoperative variables and THA outcomes. Studies with moderate-to-high methodological quality allowed to identify 6 preoperative variables consistently associated with medium term pain and function following THA. This knowledge may assist the management of patients at risk of poor results. Further research is required to clarify the force of associations between determinants and THA outcomes.
LEVEL OF EVIDENCE: Level II. Systematic review of cohort studies.
BACKGROUND: This systematic review examines which patient related factors influence functional and clinical outcomes after total hip arthroplasty (THA) in patients with hip osteoarthritis (OA).
METHODS: We performed a systematic review according to the PRISMA guidelines. We searched databases and trial registries for prospective studies including OA patients who underwent primary THA. Studies with preoperative measurements on predictors, with at least 1 year follow-up were included. Risk of bias and confounding was assessed for two domains: follow-up rate and looking at independent effects.
RESULTS: Thirty-five studies were included (138,039 patients). Only nine studies (29 %) had low risk of bias for all domains thus suggesting an overall low quality of evidence. Studies were heterogeneous in the predictors tested and in the observed directions of the associations. Overall, preoperative function (13 studies (37 %), 2 with low risk of bias) and radiological OA (6 studies (17 %), 1 with low risk of bias) were predictors with the most consistent findings. Worse preoperative function and more severe radiological OA were associated with larger postoperative improvement. However, these patients never reached the level of postoperative functioning as patients with better preoperative function or less severe radiological OA. For age, gender, comorbidity, pain and quality of life the results of studies were conflicting. For BMI, some studies (n = 5, 2 with low risk of bias) found worse outcomes for patients with higher BMI. However, substantial improvement was still achieved regardless of their BMI.
CONCLUSION: There is not enough evidence to draw succinct conclusions on preoperative predictors for postoperative outcome in THA, as results of studies are conflicting and the methodological quality is low. Results suggest to focus on preoperative function and radiological osteoarthritis to decide when THA will be most effective. The present mapping of current evidence on the relationship between patient related factors and outcomes provides better information compared to individual studies and may help to set patient expectations before surgery. In addition, these findings may contribute to discussions on how to achieve the best possible postoperative outcome for specific patient groups.
TRIAL REGISTRATION: This systematic review was registered in Prospero, registration number RD42014009977 .
Many of the mooted risk factors associated with periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) remain controversial and are not well characterized. Online and manual searches were performed using Medline, Embase, Chinese National Knowledge Infrastructure and the Cochrane Central Database from January 1980 to March 2014). For inclusion, studies had to meet the quality assessment criteria of the CONSORT statement, and be concerned with evaluation of risk factors for PJI after TJA. Two reviewers extracted the relevant data independently and any disagreements were resolved by consensus. Fourteen studies were included in this meta-analysis. The following significant risk factors for PJI were identified: body mass index (both continuous and dichotomous variables); diabetes mellitus; corticosteroid therapy; hypoalbuminaemia; history of rheumatoid arthritis; blood transfusion; presence of a wound drain; wound dehiscence; superficial surgical site infection; coagulopathy; malignancy, immunodepression; National Nosocomial Infections Surveillance Score ≥2; other nosocomial infection; prolonged operative time; and previous surgery. Factors that were not significantly associated with PJI were: cirrhosis; hypothyroidism; urinary tract infection; illicit drug abuse; alcohol abuse; hypercholesterolaemia; hypertension, ischaemic heart disease; peptic ulcer disease; hemiplegia or paraplegia; dementia; and operation performed by a staff surgeon (vs a trainee). Strategies to prevent PJI after TJA should focus, in particular, on those patients at greatest risk of infection according to their individual risk factors.
OBJECTIVE: To identify the preoperative patient-related characteristics predicting inpatient recovery of functioning and/or length of hospital stay after elective primary total hip arthroplasty.
DESIGN: A search was conducted of the electronic databases MEDLINE, EMBASE and CINAHL from inception through April 2014. Observational studies were selected for systematic review if they identified clinically relevant preoperative prognostic factors and reported an association between inpatient recovery of physical functioning and/or length of hospital stay. Study participants were adults undergoing an elective primary total hip arthroplasty.
RESULTS: Fourteen studies were included, a total of 199,410 individual total hip arthroplasty procedures. Two studies investigated inpatient recovery of physical functioning, no strong level of evidence was found for a relationship between functional recovery and any of the preoperative predictors. Twelve studies investigated the length of hospital stay and reported 19 preoperative prognostic factors. A strong level of evidence suggested that higher scores on the American Society of Anaesthesiologists assessment (OR 3.34 to 6.22, +0.20 days), increased number of comorbidities (RR of 1.10, +0.59 to 1.61 days), presence of heart disease, (RR of 1.59, +0.26 days), and presence of lung disease (RR of 1.30, +0.34 days) were associated with longer lengths of hospital stay following total hip arthroplasty.
CONCLUSION: For the prediction of inpatient recovery of physical functioning no factors with a strong level of evidence were found. For length of stay there was a strong level of evidence for the American Society of Anaesthesiologists score, number of comorbidities, and presence of heart or lung disease.
OBJECTIF: L'indice de masse corporelle (IMC) est largement reconnu comme un facteur pronostique dans plusieurs opérations; Cependant, la relation entre l'IMC et les résultats après arthroplastie totale du genou (PTG) est largement débattue. Nous avons cherché à évaluer l'effet de l'IMC à différentes valeurs de coupure sur les résultats suivants primaires TKA.
METHODES: bases de données électroniques (PubMed / Medline, CENTRAL, Embase et Web of Science) ont été systématiquement cherché des études portant sur l'association entre l'IMC et les résultats suivants primaires TKA. Deux enquêteurs examinés indépendamment des études d'éligibilité, ont évalué la qualité des études utilisant l'échelle Newcastle-Ottawa et extrait les données. Une méta-analyse a été réalisée en utilisant le logiciel Review Manager.
RÉSULTATS: Vingt-huit articles, dont un total de 20,988 PTG ont été identifiés. La postopératoires Knee Society Score est apparu à la tendance ((2) IMC ≥ 30 kg / m) patients inférieur chez les obèses que chez les non-obèses patients (IMC <30 kg / (2) m). La méta-analyse a montré que la révision avec suivi ≥5 ans, une infection, une infection superficielle et la thrombose veineuse profonde se sont produites statistiquement plus fréquemment chez les patients obèses, alors qu'une infection profonde est survenue statistiquement plus fréquemment chez les obèses morbides (IMC ≥ 40 kg / m (2)) les patients que chez les patients non obèses. Aucune différence de descellement aseptique avec un suivi ≥5 ans, l'embolie pulmonaire et les taux de mortalité périopératoire ont été trouvées entre les patients obèses et non obèses.
CONCLUSIONS: Les patients ayant un IMC ≥ 30 kg / m (2) sont à un risque plus élevé de scores inférieurs fonctionnels et développer des complications suivantes primaires TKA. Il semble raisonnable d'encourager les patients obèses à perdre du poids avant sélective TKA.
NIVEAU DE PREUVE: étude Prognostic, niveau III.
BACKGROUND: Aseptic loosening is the most common cause for revisions after lower-extremity total joint arthroplasties, however studies differ regarding the degree to which host factors influence loosening.
QUESTIONS/PURPOSE: We performed a systematic review to determine which host factors play a role in the development of clinical and/or radiographic failure from aseptic loosening after (1) THA and (2) TKA.
METHODS: Two searches on THA and TKA, respectively, using four electronic databases (EMBASE, CINAHL Plus, PubMed, and Scopus) were conducted. We identified a total of 209 reports that encompassed nine potential host factors affecting aseptic loosening. Inclusion criteria for consideration of scientific clinical reports were that 20 or more patients were involved, with more than 1-year followup, with at least three studies pertaining to each factor, and at least six of the Methodological Index for Non-randomized Studies criteria met, and with raw data for odds ratio (OR) calculations. Twenty-one studies (16 THA studies with 45,779 hips and five TKA studies with 288 knees, respectively) were used to calculate weighted OR and CIs (using the random effects theory) and study heterogeneity for four different host factors in THAs (male sex, high activity level, obesity defined as BMI ≥ 30 kg/m2, and current or former tobacco use) and one factor in TKA (BMI ≥ 30 kg/m2), which were placed in a forest plot.
RESULTS: For THA, male sex (OR, 1.39; 95% CI, 1.22-1.58; p = 0.001) and high activity level (University of California Los Angeles [UCLA] activity score ≥ 8 points; OR, 4.24; 95% CI, 2.46-7.31; p = 0.001) were associated with aseptic loosening. However, obesity (OR, 1.01; 95% CI, 0.73-1.40; p = 0.96), and tobacco use (OR, 1.96; 95% CI, 0.43-8.97; p = 0.39) were not associated with an increased risk of aseptic loosening after THA with the numbers available. For TKA, we found no host factors associated with loosening. In particular, obesity (BMI ≥ 30 kg/m2) was not associated with aseptic loosening with the numbers available (OR, 2.28; 95% CI, 0.60-8.62; p = 0.22).
CONCLUSIONS: Patients undergoing a lower-extremity total joint arthroplasty who engage in impact sports should be counseled regarding their potential increased risk of aseptic loosening; however, given the weak evidence available, we believe that higher-level studies are necessary to clearly define the risk factors, particularly with newer-generation constructs.
LEVEL OF EVIDENCE: Level IV, therapeutic study.
The quality and state of satisfaction reporting after total knee replacement (TKR) is variable.
QUESTIONS/PURPOSES:
The purposes of this systematic review were (1) to examine the available literature on patient satisfaction after TKR, (2) to evaluate the quality of available evidence, and (3) to identify predictors of patient satisfaction after TKR.
METHODS:
A systematic review of the MEDLINE database was performed. The initial search yielded 1219 studies. The inclusion criteria were English language, clinical outcome study with primary outcome related to TKR for osteoarthritis, and patient-reported satisfaction included as an outcome measure. Studies were assessed for demographics, methodology for reporting satisfaction, and factors influencing satisfaction.
RESULTS:
Two hundred eight studies, including 95,560 patients who had undergone TKR, met all inclusion and exclusion criteria; 112 (53.8%) of these studies were published in the past 3 years. Satisfaction was most commonly measured using an ordinal scale. Twenty-seven studies (13%) used a validated satisfaction survey. Eighty-three percent of studies reported more than 80% satisfaction. The most commonly reported predictor of satisfaction was post-operative patient-reported functional outcome. Pre-operative anxiety/depression was the most common pre-operative predictor of dissatisfaction.
CONCLUSION:
There are numerous studies reporting patient satisfaction after TKR, and publication on the topic has been increasing over the past decade. However, the majority of studies represent lower levels of evidence and use heterogeneous methods for measuring satisfaction, and few studies use validated satisfaction instruments. In general, the majority of studies report satisfaction rates ranging from 80 to 100%, with post-operative functional outcome and relief of pain being paramount determinants for achieving satisfaction.
