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. 2023 Apr;9(2):e002808.
doi: 10.1136/rmdopen-2022-002808.

Patient appropriateness for total knee arthroplasty and predicted probability of a good outcome

Gillian A Hawker  1   2 , Eric Bohm  3 , Michael J Dunbar  4 , Peter Faris  5 , C Allyson Jones  6 , Tom Noseworthy  5 , Bheeshma Ravi  7 , Linda J Woodhouse  6   8 , Deborah A Marshall  5 ; BEST-Knee Study Team
Collaborators, Affiliations

Patient appropriateness for total knee arthroplasty and predicted probability of a good outcome

Gillian A Hawker et al. RMD Open. 2023 Apr.

Abstract

Objectives: One-fifth of total knee arthroplasty (TKA) recipients experience a suboptimal outcome. Incorporation of patients' preferences in TKA assessment may improve outcomes. We determined the discriminant ability of preoperative measures of TKA need, readiness/willingness and expectations for a good TKA outcome.

Methods: In patients with knee osteoarthritis (OA) undergoing primary TKA, we preoperatively assessed TKA need (Western Ontario-McMaster Universities OA Index (WOMAC) Pain Score and Knee injury and Osteoarthritis Outcome Score (KOOS) function, arthritis coping), health status, readiness (Patient Acceptable Symptom State, depressive symptoms), willingness (definitely yes-yes/no) and expectations (outcomes deemed 'very important'). A good outcome was defined as symptom improvement (met Outcome Measures in Rheumatology and Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria) and satisfaction with results 1 year post TKA. Using logistic regression, we assessed independent outcome predictors, model discrimination (area under the receiver operating characteristic curve, AUC) and the predicted probability of a good outcome for different need, readiness/willingness and expectations scenarios.

Results: Of 1,053 TKA recipients (mean age 66.9 years (SD 8.8); 58.6% women), 78.1% achieved a good outcome. With TKA need alone (WOMAC pain subscale, KOOS physical function short-form), model discrimination was good (AUC 0.67, 95% CI 0.63 to 0.71). Inclusion of readiness/willingness, depressive symptoms and expectations regarding kneeling, stair climbing, well-being and performing recreational activities improved discrimination (p=0.01; optimism corrected AUC 0.70, 0.66-0.74). The predicted probability of a good outcome ranged from 44.4% (33.9-55.5) to 92.4% (88.4-95.1) depending on level of TKA need, readiness/willingness, depressive symptoms and surgical expectations.

Conclusions: Although external validation is required, our findings suggest that incorporation of patients' TKA readiness, willingness and expectations in TKA decision-making may improve the proportion of recipients that experience a good outcome.

Keywords: Knee Osteoarthritis; Orthopedic Procedures; Osteoarthritis, Knee; Outcomes research.

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Conflict of interest statement

Competing interests: GAH has received research support as the Sir John and Lady Eaton Professor and Chair of Medicine, Department of Medicine, University of Toronto. DM has received salary and research support as a Canada Research Chair and as the Arthur J.E. Child Chair Professor. All other authors declare no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1
Participant recruitment flow chart.
Figure 2
Figure 2
Area under the receiver operating characteristic (AUROC) curves by TKA appropriateness domain. The corresponding AUROC curves and 95% CIs are as follows: TKA need (WOMAC Pain Score and KOOS-PS) 0.67 (0.63–0.71); TKA readiness and willingness (PASS knee symptoms and definite willingness and PHQ-8 depressive symptoms) 0.61 (0.57–0.64); TKA expectations (importance of four TKA outcomes: improvements in going upstairs, performing recreational activities, kneeling and psychological well-being) 0.57 (0.53–0.62); and for all appropriateness domains combined 0.70 (0.66–0.74). KOOS-PS, Knee injury and Osteoarthritis Outcome Score physical function short-form; PASS, Patient Acceptable Symptom State; PHQ-8, Patient Health Questionnaire; TKA, total knee arthroplasty; WOMAC, Western Ontario-McMaster Universities Osteoarthritis Index.
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References

    1. Sloan M, Premkumar A, Sheth NP. Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am 2018;100:1455–60. 10.2106/JBJS.17.01617 - DOI - PubMed
    1. Ravi B, Croxford R, Reichmann WM, et al. . The changing demographics of total joint arthroplasty recipients in the united states and ontario from 2001 to 2007. Best Pract Res Clin Rheumatol 2012;26:637–47. 10.1016/j.berh.2012.07.014 - DOI - PubMed
    1. Canadian Institute of Health Information . Canadian joint replacement registry (CJRR) 2021 annual report. hip and knee replacements in Canada, 2021. Available: https://www.cihi.ca/en/cjrr-annual-report-hip-and-knee-replacements-in-c...
    1. Perruccio AV, Power JD, Badley EM. Revisiting arthritis prevalence projections--it's more than just the aging of the population. J Rheumatol 2006;33:1856–62. - PubMed
    1. Wallace IJ, Worthington S, Felson DT, et al. . Knee osteoarthritis has doubled in prevalence since the mid-20th century. Proc Natl Acad Sci U S A 2017;114:9332–6. 10.1073/pnas.1703856114 - DOI - PMC - PubMed

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