MCID and PASS are thresholds driven from PROMS to reflect clinical effectiveness. Statistical significance can be derived from a change in PROMS, whereas MCID and PASS reflect clinical significance. Its role has been increasingly used in the world of young adult hip surgery with several publications determining the thresholds for Femoro-acetabular impingement FAI. To our knowledge MCID and PASS for patient undergoing PAO for dysplasia has not been reported.

593 PAOs between 1/2013 and 7/2023 were extracted from the Northumbria Hip Preservation Registry. Patients with available PROMS at 1year and/or 2years were included. PAOs for retroversion, residual Perthes and those combined with FO were excluded. MCID was calculated using the distribution method 0.5SD of baseline score(1). PASS was calculated using anchor method, ROC analysis performed, and value picked maximizing Youden index. A Logistic Regression analysis was performed to determine which independent variables correlated with achieving MCID and PASS.

The MCID threshold for iHOt12 was 8.6 with 83.4 and 86.3 % of patients achieved it at 1 and 2 years respectively. The PASS score at 1 and 2 year follow up was 43 and 44 respectively, with 72.6 and 75.2% achieving it at 1 and 2 year postop. At 2 years a Higher preop iHOT 12 was associated with not achieving MCID and PASS (p<0.05). Preop acetabular version was negatively correlated with achieving MCID and previous hip arthroscopy was negatively correlated with PASS.

The % of patients achieving MCID and PASS mimics that of FAI surgery (2). The negative correlation with preop iHOT12 reaffirms the importance of patient selection. The negative correlation of hip arthroscopy highlights the importance of having a high index of suspicion for dysplasia prior to hip arthroscopy and poorer outcomes of patients with mixed CAM and dysplasia pathology.

The December 2022 Sports Roundup³⁶⁰ looks at: Anterior cruciate ligament (ACL) repair with dynamic intraligamentary stabilization or anterior ACL at five years?; Femoroacetabular impingement in mild osteoarthritis: is hip arthroscopy the answer?; Steroids in Achilles tendinopathy: A randomized trial.

Aims

The aim of this study was to report the meaningful values of the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) and EuroQol visual analogue scale (EQ-VAS) in patients undergoing primary knee arthroplasty (KA).

Purpose. Various alignment philosophies for total knee arthroplasty (TKA) have been described, all striving to achieve excellent long-term implant survival and good functional outcomes. In recent years, in search of higher functionality and patient satisfaction, a shift towards more patient-specific alignment is seen. Robotics is the perfect technology to tailor alignment. The purpose of this study was to describe ‘inverse kinematic alignment’ (iKA) technique, and to compare clinical outcomes of patients that underwent robotic-assisted TKA performed by iKA versus adjusted mechanical alignment (aMA). Methods. The authors analysed the records of a consecutive series of patients that received robotic assisted TKA with iKA (n=40) and with aMA (n=40). Oxford Knee Score (OKS) and satisfaction on a visual analogue scale (VAS) were collected at a follow-up of 12 months. Clinical outcomes were assessed according to patient acceptable symptom state (PASS) thresholds, and uni- and multivariable linear regression analyses were performed to determine associations of OKS and satisfaction with 6 variables (age, sex, body mass index (BMI), preoperative hip knee ankle (HKA) angle, preoperative OKS, alignment technique). Results. The iKA and aMA techniques yielded comparable outcome scores (p=0.069), with OKS respectively 44.6±3.5 and 42.2±6.3. VAS Satisfaction was better (p=0.012) with iKA (9.2±0.8) compared to aMA (8.5±1.3). The number of patients that achieved OKS and satisfaction PASS thresholds was significantly higher (p=0.049 and p=0.003, respectively) using iKA (98% and 80%) compared to aMA (85% and 48%). Knees with preoperative varus deformity, achieved significantly (p=0.025) better OKS using iKA (45.4±2.0) compared to aMA (41.4±6.8). Multivariable analyses confirmed better OKS (β=3.1; p=0.007) and satisfaction (β=0.73; p=0.005) with iKA. Conclusions. The results of this study suggest that iKA and aMA grant comparable clinical outcomes at 12-months follow-up, though a greater proportion of knees operated by iKA achieved the PASS thresholds for OKS and satisfaction. Notably. in knees with preoperative varus deformity, iKA yielded significantly better OKS and satisfaction than aMA

Aims. To compare the functional outcome, health-related quality of life (HRQoL), and satisfaction of patients who underwent primary total hip arthroplasty (THA) and a single debridement, antibiotics and implant retention (DAIR) procedure for deep infection, using either the transgluteal or the posterior surgical approach for both procedures. Methods. The study was registered at clinicaltrials.gov (ID: NCT03161990) on 15 May 2017. Patients treated with a single DAIR procedure for deep infection through the same operative approach as their primary THA (either the transgluteal or the posterior approach) were identified in the Norwegian Arthroplasty Register and given a questionnaire. Median follow-up after DAIR by questionnaire was 5.5 years in the transgluteal group (n = 87) and 2.5 years in the posterior approach group (n = 102). Results. Patients in the posterior approach group were less likely to limp after the DAIR procedure (17% vs 36% limped all the time; p = 0.005), had a higher mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score (80 vs 71; p = 0.013), and were more likely to achieve a patient acceptable symptom state for the WOMAC function score (76% vs 55%; p = 0.002). In a multivariable analysis, the point estimate for the increase in WOMAC function score using the posterior approach was 10.2 (95% CI 3.1 to 17.2; p = 0.005), which is above the minimal clinically important improvement. The patients in the posterior approach group also reported better mean HRQoL scores and were more likely to be satisfied with their hip arthroplasty (77% vs 55%; p = 0.001). Conclusion. In patients treated with a single, successful DAIR procedure for deep infection of a primary THA, the use of the posterior approach in both primary surgery and DAIR was associated with less limping, better functional outcome, better HRQoL, and higher patient satisfaction compared with cases where both were performed using the transgluteal approach. The observed differences in functional outcome and patient satisfaction were clinically relevant. Cite this article: Bone Joint J 2020;102-B(12):1662–1669

Integrated Regional Orthopaedic (MSK) Assessment clinics (ROAC) are now mandated in many provinces for the assessment and triage of patients referred for total joint arthroplasty (TJA). Their introduction underscores the lack of means for Primary Care Physicians (PCP) to appropriately refer patients for surgical consideration. Thus, problems arise when patients who are clear candidates for surgery are subject to a significant extra step in the care pathway by attending a ROAC while those who have insufficient problems are also seen, contributing to costs and crowding the access portal. We postulated that a patient reported outcome measure, decision aid combined with a validated grading of a weight bearing knee X-ray would provide an inexpensive yet effective tool to significantly improve the referral process for Knee OA (compared with the current mechanism). To date we have enrolled two hundred and forty-five consenting patients to the study, all referred by their PCP to the ROAC with a diagnosis of symptomatic Knee Osteoarthritis. All patients were evaluated as per the current ROAC protocol which included a medical history, physical examination and an X-ray (standing AP, lateral and patella-femoral skyline). Prior to the visit, subjects were sent a copy of a patient decision aid, Oxford Knee Score (OKS) and requested to answer whether their current clinical status described as Patient Acceptable Symptom State (PASS2) was acceptable. All radiographs were analyzed and scored for OA severity using the validated grading from 0 – 13. Of the 245 cases, 200 completed OKS and PASS2 uestionnaires and had standing X-rays for evaluation (only 120 completed the decision aid and these were left out of this report). Of the 200 included cases, 104 were referred from the ROAC to see a surgeon. In analysis, we found that a self-reported PASS 2 answer NO and an AP X-ray graded at 6 or above predicted over 75% of those patients that were referred. This represents a 3.4 greater likelihood of referral using this simple analysis. The OKS did not modify this prediction. Thus, use of a validated grading of a standing AP X-ray along with a response, ‘readiness for surgery’ indicated 75% of patients appropriate for surgical consideration. Patients with less severe gradings are likely being unnecessarily referred to ROAC leading to overuse of scarce resources, crowding the access and adding to costs, others, who score higher, are being needlessly delayed. The ability to discreetly screen for the best possible candidates should be a continued focus of ROAC and will lead to improved use of expensive resources, overall patient care and satisfaction and the provision of tools to the PCP for appropriate referral

Aims

The aim of this study was to report the implant survival and patient-reported outcome measures (PROMs) in a consecutive series of patients aged less than 50 years at the time of arthroplasty using the Birmingham Hip Resurfacing system (BHR), with a minimum follow-up of ten years.

Introduction. The aim of this study was to evaluate the effects of posterior tibial slope (PTS) and posterior condylar offset (PCO) on patient-reported pain and function one year after TKA. Methods. A total of 500 patients from 11 clinics in 6 countries were enrolled into a prospective, multicenter study. All patients were indicated for primary TKA for OA and received components from a single manufacturer. All liners were made from vitamin-E stabilized, highly crosslinked (95 kGy) polyethylene; 54.7% were posterior stabilized (PS) and the remaining were cruciate-retaining. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was administered at the one-year follow-up visit. The KOOS pain and activities in daily life (ADL) sub-scores were dichotomized and served as the primary outcomes. Dichotomization was done with the patient acceptable symptom state (PASS), defined by previous studies as the value of the PROM above which patients deem their state as acceptable (84.5 points for KOOS pain and 83.0 points for KOOS ADL). Plain lateral radiographs were taken and assessed for PTS (Figure 1) and PCO (Figure 2). PTS was categorized as above (excessive flexion), within (ideal), or below (extension) the safe zone of 0° − 7° of flexion. PCO increases or decreases of greater than 3mm were compared against no change (≤ 3mm). Each of the two sagittal positioning metrics was tested against the KOOS pain and ADL PASS at one year. Results. 396 patients (80.3% of eligible) had completed the one-year visit. A total of 297 (75%) achieved the PASS in KOOS pain and 277 (70%) achieved the PASS in KOOS ADL (Figure 3). PTS was closely associated with the likelihood of achieving the PASS in KOOS pain (p < 0.001) and ADL (p = 0.005) in univariate tests (Kruskal-Wallis). It was also independently predictive of achieving the PASS in multivariable models controlling for sex, body mass index, preoperative health state, and age. In a binary logistic regression for achieving the PASS in KOOS pain, a PTS < 0° (extension) was 6.3 times less likely to achieve the PASS compared to the ideal PTS (0°–7° of flexion) (p=0.004; OR=0.16). Overly flexed tibial components (>7°) were equally likely to achieve the PASS in KOOS pain as components with an ideal PTS (p=0.091). A separate model assessing independent predictors of achieving the PASS in KOOS ADL, patients with extension were 4.8 times less likely to achieve the PASS compared to those with an ideal PTS (p=0.012; OR=0.21), while patients with excessive flexion were equally likely to achieve the PASS in KOOS ADL as patients with an ideal PTS (p=0.077). When considering the patients with a PTS > 7° (excessive flexion), PCO decrease was associated with a lower chance of achieving the PASS in KOOS ADL (p = 0.022). When considering the patients with a PTS < 0° (extension), PCO increase was associated with a lower chance of achieving the PASS in KOOS pain (p = 0.031). Conclusions. The most influential sagittal positioning parameter affecting patient outcomes at one year after TKA was PTS. PTS had a significant, independent effect on all PROMs one year after TKA. Surgeons should be more cautious to avoid tibial component extension rather than excessive flexion. We recommend replicating the native PCO and targeting a PTS of 0°–7° of flexion. For any figures or tables, please contact authors directly

Purpose. Patient expectations of total knee arthroplasty (TKA) can be managed through education. E-learning is the application of information technology to education. Providing information to patients at the place and time of their choosing, e-learning has the potential to broaden the reach of existing services for patients. This study evaluated whether an e-learning tool could affect whether patients felt their expectations were met and whether they were satisfied with surgery one year following primary TKA. Method. We recruited consecutive patients with osteoarthritis and randomized them to either standard patient education (n=207), or to our standard patient education plus a new e-learning tool (n=209). Preoperative measures were completed following the patients’ Pre-Admission clinic (PAC) visit and prior to accessing the e-learning tool. Postoperative patient reported outcome measures (PROMs) were completed at six weeks, three months and one year after TKA. We used the Postoperative Expectation Questionnaire to measure the degree to which patient expectations had been met and the Patient Acceptable Symptom State (PASS) question to measure patient satisfaction at one year postoperative. We collected several PROMs for descriptive purposes including: new Knee Society Knee Scoring System (KSS); (Pre-Op and Post-Op versions), Knee injury and Osteoarthritis Outcome Score (KOOS), the Medical Outcomes Study 12-Item Short Form Health Survey, version 2 (SF-12), Hospital Anxiety and Depression Scale (HADS), Pain Catastrophizing Scale (PCS), University of California at Los Angeles (UCLA) Activity Score, and the Social Role Participation Questionnaire (SRPQ). Results. Both groups were similar with respect to their preoperative PROMs. Preoperative patient satisfaction was low, with few patients satisfied with their present state prior to TKA and similar between groups (14% intervention group, 11% control group). At one year postoperatively, the risk that expectations of patients were not met was 21.8% in the control group and 21.4% in the intervention group for a risk difference of 1.3% (95% CI −7.8% to 10.4%, p = 0.78). The proportion of patients satisfied with their TKA at one year postoperative was similar in the intervention group 78.6% and the control group 78.2%, and the risk difference 0.6% (95% CI −8.4% to 9.6%) was not statistically significant (p = 0.78). At one year postoperative we found significant postoperative between-group differences in favour of the control group for the new KSS symptoms score and the functional activities score. We also found that control patients had less anxiety, lower scores for rumination, magnification, and helplessness than intervention patients on the PCS. Conclusion. Patients randomized to the e-learning tool had significantly better KSS symptom scores and functional activities scores as well as lower anxiety and helplessness scores but they did not have a reduced risk of expectations not being met or an improved overall satisfaction with their TKA

We compared the incidence of pseudotumours after large head metal-on-metal (MoM) total hip arthroplasty (THA) with that after conventional metal-on-polyethylene (MoP) THA and assessed the predisposing factors to pseudotumour formation.

From a previous randomised controlled trial which compared large head (38 mm to 60 mm) cementless MoM THA with conventional head (28 mm) cementless MoP THA, 93 patients (96 THAs: 41 MoM (21 males, 20 females, mean age of 64 years, standard deviation (sd) 4) and 55 MoP (25 males, 30 females, mean age of 65 years, sd 5) were recruited after a mean follow-up of 50 months (36 to 64).

The incidence of pseudotumours, measured using a standardised CT protocol was 22 (53.7%) after MoM THA and 12 (21.8%) after MoP THA. Women with a MoM THA were more likely to develop a pseudotumour than those with a MoP THA (15 vs 7, odds ratio (OR) = 13.4, p < 0.001). There was a similar incidence of pseudotumours in men with MoM THAs and those with MoP THAs (7 vs 5, OR = 2.1, p = 0.30). Elevated cobalt levels (≥ 5 microgram/L) were only associated with pseudotumours in women with a MoM THA. There was no difference in mean Oxford and Harris hip scores between patients with a pseudotumour and those without.

Contrary to popular belief, pseudotumours occur frequently around MoP THAs. Women with a MoM THA and an elevated cobalt level are at greatest risk. In this study, pseudotumours had no effect on the functional outcome after either large head MoM or conventional MoP THA.

Cite this article: Bone Joint J 2015;97-B:1481–7.

The April 2014 Research Roundup³⁶⁰ looks at: scientific writing needed in orthopaedic papers; antiseptics and osteoblasts; thromboembolic management in orthopaedic patients; nicotine and obesity in post-operative complications; defining the “Patient Acceptable Symptom State”; and cheap and nasty implants of poor quality.

Objectives. To define Patient Acceptable Symptom State (PASS) thresholds for the Oxford hip score (OHS) and Oxford knee score (OKS) at mid-term follow-up. Methods. In a prospective multicentre cohort study, OHS and OKS were collected at a mean follow-up of three years (1.5 to 6.0), combined with a numeric rating scale (NRS) for satisfaction and an external validation question assessing the patient’s willingness to undergo surgery again. A total of 550 patients underwent total hip replacement (THR) and 367 underwent total knee replacement (TKR). Results. Receiver operating characteristic (ROC) curves identified a PASS threshold of 42 for the OHS after THR and 37 for the OKS after TKR. THR patients with an OHS ≥ 42 and TKR patients with an OKS ≥ 37 had a higher NRS for satisfaction and a greater likelihood of being willing to undergo surgery again. Conclusions. PASS thresholds appear larger at mid-term follow-up than at six months after surgery. With- out external validation, we would advise against using these PASS thresholds as absolute thresholds in defining whether or not a patient has attained an acceptable symptom state after THR or TKR. Cite this article: Bone Joint Res 2014;3:7–13

The December 2013 Knee Roundup³⁶⁰ looks at: Conflict of interest and hyaluronic acid; Will time indeed tell in microfracture?; Contralateral knee pain and joint replacement outcomes; Patient satisfaction and knee replacement?; Hope in the cytokines for painful TKRs?; Pain severity, cytokines and osteoarthritis?; Quadriceps weakness and pain; and spontaneous osteonecrosis of the knee

We obtained information from the Elective Orthopaedic Centre on 1523 patients with baseline and six-month Oxford hip scores (OHS) after undergoing primary hip replacement (THR) and 1784 patients with Oxford knee scores (OKS) for primary knee replacement (TKR) who completed a six-month satisfaction questionnaire.

Receiver operating characteristic curves identified an absolute change in OHS of 14 points or more as the point that discriminates best between patients’ satisfaction levels and an 11-point change for the OKS. Satisfaction is highest (97.6%) in patients with an absolute change in OHS of 14 points or more, compared with lower levels of satisfaction (81.8%) below this threshold. Similarly, an 11-point absolute change in OKS was associated with 95.4% satisfaction compared with 76.5% below this threshold. For the six-month OHS a score of 35 points or more distinguished patients with the highest satisfaction level, and for the six-month OKS 30 points or more identified the highest level of satisfaction. The thresholds varied according to patients’ pre-operative score, where those with severe pre-operative pain/function required a lower six-month score to achieve the highest levels of satisfaction.

Our data suggest that the choice of a six-month follow-up to assess patient-reported outcomes of THR/TKR is acceptable. The thresholds help to differentiate between patients with different levels of satisfaction, but external validation will be required prior to general implementation in clinical practice.