Patient expectations and their fulfilment are an important factor in determining patient-reported outcome and satisfaction of hip (THR) and knee replacement (TKR). The aim of this prospective cohort study was to examine the expectations of patients undergoing THR and TKR, and to identify differences in expectations, predictors of high expectations and the relationship between the fulfilment of expectations and patient-reported outcome measures. During the study period, patients who underwent 346 THRs and 323 TKRs completed an expectation questionnaire, Oxford score and Short-Form 12 (SF-12) score pre-operatively. At one year post-operatively, the Oxford score, SF-12, patient satisfaction and expectation fulfilment were assessed. Univariable and multivariable analysis were performed. Improvements in mobility and daytime pain were the most important expectations in both groups. Expectation level did not differ between THR and TKR. Poor Oxford score, younger age and male gender significantly predicted high pre-operative expectations (p < 0.001). The level of pre-operative expectation was not significantly associated with the fulfilment of expectations or outcome. THR better met the expectations identified as important by patients. TKR failed to meet expectations of kneeling, squatting and stair climbing. High fulfilment of expectation in both THR and TKR was significantly predicted by young age, greater improvements in Oxford score and high pre-operative mental health scores. The fulfilment of expectations was highly correlated with satisfaction

The burden of metastatic bone disease (MBD) in our Canadian cancer population continues to increase. MBD has a significant effect on patient morbidity, mortality, and health-related quality of life (HRQOL). There are various technical options used to surgically stabilize MBD lesions, surgical decision-making is variable and largely dependent on anatomic and surgeon-based factors. There is a paucity of research examining how surgical decision-making for MBD can be modified or individualized to improve quality of life (QOL) and functional outcomes, while more accurately aligning with patient-reported goals and expectations. The objective of this study was tosurvey MBD patients, support persons, physicians, and allied health care providers (HCP) with the goal of identifying 1) important contributors to HRQOL, 2) discordance in peri-operative expectations, and 3) perceived measures of success in the surgical management of MBD.

This project is a longitudinal patient-engaged research initiative in MBD. A survey was developed based on HRQOL themes in the literature and based on feedback from our patient research partners. Participants were asked to identify 1) important contributors to HRQOL and 2) perceived measures of success relevant to the surgical management of MBD. Participants were asked to rank themes from ‘extremely important’ to ‘not important at all’. Using open-ended questions, participants were asked to identify areas of improvement. Responses from the open-ended questions were analyzed by an experienced qualitative researcher using conventional content analysis. Participant's demographics were calculated using descriptive statistics. Concordance or discordance of perceived measure of success was assessed via a Chi-Square test of independence. All statistical analyses were performed using IBM SPSS® software.

Nine patients, seven support persons, 23 orthopaedic surgeons, 11 medical oncologists, 16 radiation oncologists, 16 nurses, and eight physiotherapists completed the survey. Regarding perceived measures of success, increased life expectancy (p Two main themes emerged around the timeliness of surgical care and the coordination of multidisciplinary care from patients and support persons. Patients and support persons expressed a sense of urgency in progressing to surgery/treatment, and frustration at perceived delays in treatment. Within coordination of care, patients and support persons would like clearer communication from the health care team.

There is discordance between patient/support person goals compared to physicians/HCP goals in the surgical management of MBD. Surgical decision-making and operative techniques that minimize disease progression and improve survival are important to MBD patients. Timely access to surgery/surgical consultation and improved multidisciplinary communication is important to patients. This data suggests improved peri-operative communication and education is needed for MBD patients. Furthermore, future research evaluating how modern orthopaedic surgical techniques influence survival and disease progression in MBD is highly relevant and important to patients with MBD.

Total hip arthroplasty (THA) has high rates of patient satisfaction; however patient expectations for recreational and sporting activities are not always met. Our study aimed to identify preoperative factors that predict whether patient expectations for sporting or recreational activity are met 12 months following THA. Patient reported outcome measures (PROMs) were collected prospectively from 2015-2018 at one private hospital in Sydney. Age, gender, postcode, weight, and height were recorded preoperatively. Included participants underwent primary THA by one of the investigating surgeons. Univariable and multivariable analyses were performed with an expectation fulfilment score used as the primary outcome variable. Preoperative predictor variables included: age, gender, BMI, Socio-economic Indexes for Areas (SEIFA), Oxford Hip Score, Hip Osteoarthritis Outcome Score, EQ-5D-5L and EQ Visual Analogue Scale (EQ VAS). 1019 participants were eligible and included. 13% reported that preoperative expectations of sport or recreation were not met at 12 months. Younger age, lower preoperative EQ VAS, and higher BMI were associated with failed expectations on multivariable analysis. Odds of failed expectations increased by 2% for every one year younger in age (OR= 0.98, 95% CI = 0.96 to 1.00, p=.048), by 2% for every one point lower on EQ VAS (OR=0.98, 95% CI = 0.98 to 0.99, p=.002), and by 4% for every one-point increase in BMI (OR = 1.04, 95% CI = 1.00 to 1.09, p=.042). Failure to have expectations met for sporting or recreational activity was associated with younger age, poorer general health, and high BMI. With a rise in younger patients who likely have higher physical demands, a tailored preoperative education is preferable to generic models to better manage patient expectations. Younger age, higher BMI, and poorer health may predict unmet expectations for sport and recreation after THA. Tailored education in these groups should be considered

As the field of hip arthroscopy continues to develop, functional measures and testing become increasingly important in patient selection, managing patient expectations prior to surgery, and physical readiness for return to athletic participation. The Hip Sport Test (HST) was developed to assess strength, coordination, agility, and range of motion prior to and following hip arthroscopy as a functional assessment. However, the relationship between HST and hip strength, range of motion, and hip-specific patient reported outcome (PRO) measures have not been investigated. The purpose of this study was to evaluate the correlation between the HST scores and measurements of hip strength and range of motion prior to undergoing hip arthroscopy. Between September 2009 and January 2017, patients aged 18-40 who underwent primary hip arthroscopy for the treatment of femoroacetabular impingement with available pre-operative HST, dynamometry, range of motion, and functional scores (mHHS, WOMAC, HOS-SSS) were identified. Patients were excluded if they were 40 years old, had a Tegner activity score < 7, or did not have HST and dynamometry evaluations within one week of each other. Muscle strength scores were compared between affected and unaffected side to establish a percent difference with a positive score indicating a weaker affected limb and a negative score indicating a stronger affected limb. Correlations were made between HST and strength testing, range of motion, and PROs. A total of 350 patients met inclusion criteria. The average age was 26.9 ± 6.5 years, with 34% females and 36% professional athletes. Total and component HST scores were significantly associated with measure of strength most strongly for flexion (rs = −0.20, p < 0 .001), extension (rs = −0.24, p<.001) and external rotation (rs = −0.20, p < 0 .001). Lateral and diagonal agility, components of HST, were also significantly associated with muscle strength imbalances between internal rotation versus external rotation (rs = −0.18, p=0.01) and flexion versus extension (rs = 0.12, p=0.03). In terms of range of motion, a significant correlation was detected between HST and internal rotation (rs = −0.19, p < 0 .001). Both the total and component HST scores were positively correlated with pre-operative mHHS, WOMAC, and HOS-SSS (p<.001 for all rs). The Hip Sport Test correlates with strength, range of motion, and PROs in the preoperative setting of hip arthroscopy. This test alone and in combination with other diagnostic examinations can provide valuable information about initial hip function and patient prognosis

Introduction. Clinical decision support tools are software that match the input characteristics of an individual patient to an established knowledge base to create patient-specific assessments that support and better inform individualized healthcare decisions. Clinical decision support tools can facilitate better evidence-based care and offer the potential for improved treatment quality and selection, shared decision making, while also standardizing patient expectations. Methods. Predict+ is a novel, clinical decision support tool that leverages clinical data from the Exactech Equinoxe shoulder clinical outcomes database, which is composed of >11,000 shoulder arthroplasty patients using one specific implant type from more than 30 different clinical sites using standardized forms. Predict+ utilizes multiple coordinated and locked supervised machine learning algorithms to make patient-specific predictions of 7 outcome measures at multiple postoperative timepoints (from 3 months to 7 years after surgery) using as few as 19 preoperative inputs. Predict+ algorithms predictive accuracy for the 7 clinical outcome measures for each of aTSA and rTSA were quantified using the mean absolute error and the area under the receiver operating curve (AUROC). Results. Predict+ was released in November 2020 and is currently in limited launch in the US and select international markets. Predict+ utilizes an interactive graphical user interface to facilitate efficient entry of the preoperative inputs to generate personalized predictions of 7 clinical outcome measures achieved with aTSA and rTSA. Predict+ outputs a simple, patient-friendly graphical overview of preoperative status and a personalized 2-year outcome summary of aTSA and rTSA predictions for all 7 outcome measures to aid in the preoperative patient consultation process. Additionally, Predict+ outputs a detailed line-graph view of a patient's preoperative status and their personalized aTSA, rTSA, and aTSA vs. rTSA predicted outcomes for the 7 outcome measures at 6 postoperative timepoints. For each line-graph, the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) patient-satisfaction improvement thresholds are displayed to aid the surgeon in assessing improvement potential for aTSA and rTSA and also relative to an average age and gender matched patient. The initial clinical experience of Predict+ has been positive. Input of the preoperative patient data is efficient and generally completed in <5 minutes. However, continued workflow improvements are necessary to limit the occurrence of responder fatigue. The graphical user interface is intuitive and facilitated a rapid assessment of expected patient outcomes. We have not found the use of this tool to be disruptive of our clinic's workflow. Ultimately, this tool has positively shifted the preoperative consultation towards discussion of clinical outcomes data, and that has been helpful to guide a patient's understanding of what can be realistically achieved with shoulder arthroplasty. Discussion and Conclusions. Predict+ aims to improve a surgeon's ability to preoperatively counsel patients electing to undergo shoulder arthroplasty. We are hopeful this innovative tool will help align surgeon and patient expectations and ultimately improve patient satisfaction with this elective procedure. Future research is required, but our initial experience demonstrates the positive potential of this predictive tool

Background. The ability to identify those at risk for longer inpatient stay helps providers with postoperative planning and patient expectations. Decreasing length of stay in the future will be determined by appropriate patient selection, risk stratification, and pre-operative patient optimization. The purpose of this study was to identify factors that place patients at risk for extended postoperative lengths of stay. Methods. The prospective study cohort included 2009 primary total knee arthroplasty (TKA) patients and 905 total hip arthroplasty (THA) patients. Patient comorbidities were prospectively identified and the length of stay for each patient was tracked following a primary arthroplasty. Statistical analysis was performed to correlate which comorbidities were associated with longer inpatient stays. Results. In the TKA population, gender, smoking status, venous thromboembolism history, body mass index and diabetes status were not found to be a significant predictors for length of stay. Age was found to be a factor in univariate regression testing (P<0.001). In the THA population, univariate testing showed female gender (P<0.001), smoking status (P=0.002), and age (p<0.001) to be factors, but like the TKA population venous thromboembolism history or diabetes status were not significant. In THA multivariate analysis, age (p<0.001) and female gender (p=0.018) continued to be factors, but smoking was determined to be a confounding variable. Conclusions. Age and gender were associated with a longer length of stay after THA, whereas only age was a significant factor after TKA. Development of age adjusted LOS models may help aid patient expectations and risk management

Rotator cuff injuries represent a significant burden to the health care system, affecting more than 30% of the population over the age of sixty. Despite the advanced surgical techniques that are available, poor results are sometimes seen in a subset of patients receiving surgical treatment for their rotator cuff disease. The reasons for this failure of treatment remain unclear, particularly if the surgery was ‘technically’ successful. An increasing body of evidence has demonstrated a strong correlation between pre-operative psychological factors and functional outcome following several orthopaedic procedures. This association, however, has not been fully demonstrated or effectively investigated in the context of rotator cuff treatment. The main objective for this study was to conduct a systematic review to determine the impact of psychosocial factors on the outcome of treatment in patients with rotator cuff disease. A systematic search was conducted of Medline, CINAHL, and PsychInfo databases for articles published from database inception until September 2018. The titles and abstracts were screened for all of the studies obtained from the initial search. Inclusion and exclusion criteria were applied, and a full text review was conducted on those studies meeting the eligibility criteria. A total of 1252 studies were identified. Following removal of duplicates and application of the inclusion and exclusion criteria, 46 studies underwent a full-text review. Ten studies were included in the final analysis. A total of 1,206 patients, with a mean follow-up of 13 months, were included. Three studies examined patient expectations prior to treatment. All three found that higher expectations prior to treatment led to a significantly improved outcome following both operative and non-operative treatment. Three studies assessed the association between pre-operative general psychological measures and post-operative pain and function. All three studies found patients with worse pre-operative general psychological scores demonstrated increased post-operative pain. Two of the studies also found a negative association with post-operative function, while one of the studies found no association with post-operative function. Three studies assessed the impact of pre-operative anxiety and depression on outcomes following surgical treatment of rotator cuff disease. Only one of the studies found a negative association with post-operative pain and function. The remaining two studies found no association between anxiety or depression and any outcomes following surgery. Finally, one study examined the impact of general distress on outcomes following the surgical treatment of rotator cuff disease and found no association with post-operative levels of pain or function. The results of this systematic review indicate that there is somewhat conflicting and contradictory evidence within the literature. Overall, however, there does appear to be an association between pre-operative psychological factors and post-operative function and pain, in that higher levels of pre-operative psychological dysfunction are predictive of poorer function and increased pain following the treatment of rotator cuff disease

Background. Total knee arthroplasty (TKA) is a routine, cost-effective treatment for end-stage arthritis. While the evidence for good-to-excellent patient-reported outcomes and objective clinical data is present, approximately 20% of patients continue to be dissatisfied with results of their surgery. Dissatisfaction is strongly correlated with unmet patient expectations, and these patients may experience a higher cost of care due to recurring office and emergency visits. Therefore, this survey asked a large group of United States (U.S) and international surgeons to prioritize areas of opportunity in primary TKA. Specifically, we compared surgeon responses regarding: 1) the top 5 areas needing improvement; which were stratified by: 2) surgeons' years of experience; and 3) surgical case volume. Methods. A total of 418 orthopaedic surgeons were surveyed. Two hundred U.S. surgeons and 218 international surgeons participated from 7 different countries including: The United Kingdom (40), France (40), Germany (43), Italy (40), Spain (38), and Australia (17). To participate, surgeons had to be board certified, in practice for 2 years, spend 60% of their time in clinical practice, and perform a minimum of 25 joint arthroplasties per year. Surgeons were asked to choose the top 5 areas of improvement for TKA from a list of 17 attributes including clinical and functional outcomes, procedural workflow and economic variables. Surgeons were able to specify additional options if needed. Results were stratified by annual case volume (25 to 50; 51 to 100; greater than 100 cases) and years of experience (1 to 10; 11 to 20; greater than 20). Single-tail proportion tests were used to compare results between cohorts, where an alpha of 0.05 was set as significant. Results. The most frequently identified opportunity in both groups was functional outcomes, selected by 63% of U.S. surgeons (p=0.001) compared to 71% of international surgeons (p=0.002). In the U.S. cohort, this was followed by cost (47%), which was not identified in the top 5 choices for international surgeons. Cost was followed by implant survivorship (45%), patient satisfaction (42%), and accuracy/precision (39%). In the international cohort, implant survivorship (57%), dynamic joint balancing (40%), accuracy/precision (39%), and patient satisfaction rates (35%) were noted. When stratified by years of experience and case volume, the top area for improvement remained functional outcomes for U.S. and International groups. Conclusion. The responses in the international survey demonstrate that functional outcomes, implant survivorship and costs had greater perceived potential for improvement, compared to the specific targeting of post-operative patient satisfaction. Functional outcomes remained a top area for improvement, regardless of years of experience or case volume. As a result, enhancing functional outcomes and implant survivorship may ultimately address patient satisfaction, by more consistently meeting patient expectations. These results serve as baseline data to help guide future improvements in knee arthroplasty

Objective. Wearable sensors have enabled objective functional data collection from patients before total knee replacement (TKR) and at clinical follow-ups post-surgery whereas traditional evaluation has solely relied on self-reported subjective measures. The timed-up-and-go (TUG) test has been used to evaluate function but is commonly measured using only total completion time, which does not assess joint function or test completion strategy. The current work employs machine learning techniques to distinguish patient groups based on derived functional metrics from the TUG test and expose clinically important functional parameters that are predictive of patient recovery. Methods. Patients scheduled for TKR (n=70) were recruited and instrumented with a wearable sensor system while performing three TUG test trials. Remaining study patients (n=68) also completed three TUG trials at their 2, 6, and 13-week follow-ups. Many patients (n=36) have also participated up to their 26-week appointment. Custom developed software was used to segment recorded tests into sub-activities and extract 54 functional metrics to evaluate op/non-operative knee function. All preoperative TUG samples and their standardized metrics were clustered into two unlabelled groups using the k-means algorithm. Both groups were tracked forward to see how their early functional parameters translated to functional improvement at their three-month assessment. Test total completion time was used to estimate overall functional improvement and to relate findings to existing literature. Patients that completed their 26-week tests were tracked further to their most recent timepoint. Results. Preoperative clustering separated two groups with different test completion times (n=46 vs. n=22 with mean times of 13s vs. 22s). Of the faster preoperative group, 63% of patients maintained their time, 26% improved, and 11% worsened whereas of the slower preoperative group, 27% maintained, 64% improved, and 9% worsened. The high improvement group improved their times by 4.9s (p<0.01) between preoperative and 13-week visits whereas the other group had no significant change. Test times were different between both groups preoperatively (p<0.001) and at 6 (p=0.01) and 13 (p=0.03) weeks but not at 26 weeks (p=0.67). The high improvement group reached an overall improvement of 9s (p<0.01) at 26 weeks whereas the low improvement group still showed no improvement greater than the TUG minimal detectable change of 2.2s (1.8s, p<0.01)[1]. Test sub-activity times for both groups at each timepoint can be seen in Figure 1. Conclusions. This work has demonstrated that machine learning has the potential to find patterns in preoperative functional parameters that can predict functional improvement after surgery. While useful for assigning labels to the distinguished clusters, test completion time was not among the top distinguishable metrics between groups at three months which highlights the necessity for these more descriptive performance metrics when analyzing patient recovery. It is expected that these early predictions will be used to realistically adjust patient expectations or highlight opportunities for physiotherapeutic intervention to improve future outcomes. For any figures or tables, please contact the authors directly

Significance. In spite of evidence that total knee replacement (TKR) surgery is effective, numerous studies have demonstrated that approximately 20 percent of patients who have undergone TKR surgery are not satisfied. This relatively high rate of patients who are not satisfied is the result of unmet patient expectations. The strongest predictor of dissatisfaction after TKR is unmet expectations (RR = 10.7, Bourne, Chesworth, et al, 2010). This is confirmed by Dunbar, Richardson, and Robertsson (2013): “Unmet expectation seems to be a major cause of unsatisfactory outcomes and satisfaction is most strongly correlated with relief of pain, followed by improvement in physical function.” Objective: To develop patient reported outcome (PRO) recovery graphs for knee function, activity level, and pain relief to be used as a shared decision making tool for total knee replacement surgery. Methods. A proprietary joint arthroplasty database of patient reported outcomes (PROs) was analyzed to determine the recovery curve means and standard deviations of four PROs at six time points: pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years post-operatively for total knee replacement surgery. The recovery graphs are stratified by percentile (10%, 26%, 50%, 75%, and 90%) The PROs analyzed were: (1) European quality of life (EQ-5D); Oxford Knee Score (OKS); (3) Lower Extremity Activity Scale (LEAS); and (4) Likert Pain Scale (LPS). The minimum clinically important difference (MCID) was calculated using a distribution method where the MCID equals one half the standard deviation of the score change, MCID = σΔ/2. The LEAS and LPS are used to measure patients’ expectations for pain relief and activity improvement. Prior to discussing surgery, patients are asked to report their pre-operative pain and activity levels and to specify their expected pain relief and activity improvement one year after surgery. Results. EQ-5D: MCID 0.086, mean pre-op 0.695, 1 year post op 0.845, mean change 0.150 (1.74 MCIDs). Oxford Knee Score: MCID 4.55, mean pre-op 25.7, 1 year post op 39.7, mean change 14.0 (3.08 MCIDs). Lower Extremity Activity Scale: MCID 1.61, mean pre-op 9.08, 1 year post op 10.82, mean change 1.74 (1.08 MCIDs). Likert Pain Scale: MCID 1.26, mean pre-op 5.98, 1 year post op 1.41, mean change −4.57 (3.63 MCIDs). Stratified recovery graphs for Oxford Knee Score, Lower Extremity Activity Scale, and Likert Pain Scale are attached. Conclusions. Pain relief (3.63 MCIDs) and improved knee function (3.08 MCIDs) will be the most dramatic improvements for patients undergoing total knee replacement surgery. Stratified recovery graphs can be used as a shared decision making tool to manage both realistic and unrealistic expectations. The recovery graphs delineate the time course for rehabilitation. Patients typically do not exceed their pre-operative activity level until three months after surgery

Introduction. A better understanding of the rate of improvement associated with aTSA and rTSA is critical to establish accurate patient expectations for treatment to reduce pain and restore function; more realistic patient expectations pre-operatively may lead to greater patient satisfaction post-operatively. To this end, this study quantifies the rate of improvement in outcomes of aTSA and rTSA using 5 different scoring metrics for 1641 patients with one platform shoulder arthroplasty system. Methods. 1641 patients (mean age: 69.3yrs) were treated by 14 orthopaedic surgeons using one platform shoulder system (Exactech, Inc). 729 patients received aTSA (65.3yrs; 384F/345M) for treatment of degenerative arthritis and 912 patients received rTSA (72.5yrs; 593F/319M) for treatment of CTA/RCT/OA. Each patient was scored pre-operatively and at various follow-up intervals (3 months, 6months, annually, etc) using the SST, UCLA, ASES, Constant, and SPADI metrics; active abduction, active forward flexion, and active/passive external rotation were also measured. 4439 total follow-up reports were analyzed (1851 and 2588 rTSA). Improvements in outcome using each metric score were calculated and normalized on a 100 point scale. The rate of improvement was analyzed using a 40 point moving filter treadline and with a 3rd order polynomial treadline over the entire range of follow-up. Results. aTSA and rTSA outcomes with each scoring metric improved in the majority of patients, where less than 5% of reports had negative improvement in each metric after 6 months follow-up. (Figure 1) Similarly, motion improved in the majority of aTSA patients, where less than 8% of reports had negative improvement after 6 months follow-up. rTSA patients had a higher percentage of reports with negative improvement in motion after 6 months followup, where <12% of patients had negative improvement in active abduction and forward flexion while <20% patients had negative improvement in active external rotation. The pattern of improvement for each metric was similar for both aTSA and rTSA, where the SST metric demonstrated the largest improvement and the Constant metric demonstrated the smallest improvement for aTSA (Figure 2) and rTSA (Figure 3). Differences in improvement between aTSA and rTSA were observed, with rTSA associated with a larger magnitude of improvement in both the Constant score and active forward flexion and with aTSA associated with larger improvement in external rotation. Finally, full improvement was reached between 12 and 24 months for both aTSA and rTSA patients where the rate of improvement associated with rTSA patients was generally 30% larger than aTSA patients during the first 12 months. Discussion and Conclusions. This database analysis of over 1600 patients demonstrates the reliability of improvements in outcomes achieved with both aTSA and rTSA using a single platform shoulder system. Future work should attempt to better understand the impact of pre-operative diagnosis, patient age/gender/BMI, and also the role of rehabilitation on the rate of improvement with each prosthesis type; additional follow-up time is required to confirm these results

Introduction. Patients-reported outcome measures (PROMs) have been reported as the important methods to evaluate clinical outcomes in total knee arthroplasty (TKA). The patient satisfaction score in Knee Society Score (KSS-2011) has been used in the recent literatures. Patient satisfaction was subjective parameter, and would be affected by multiple factors including psychological factors and physical conditions at not only affected joint but also elsewhere in the body. The question was raised regarding the consistency of patient satisfaction score in KSS-2011 to other PROMs. The purpose of this study was to investigate the correlation of patient satisfaction in KSS-2011 to other categories in KSS-2011 and to other PROMs including Forgotten Joint Score (FJS-12), EuroQol-5 Dimensions (EQ-5D) and 25-questions in Geriatric Locomotive Function Scale (GLFS-25). Material & Method. 83 patients over 65 years old with osteoarthritic knees were involved in this study. All patients underwent CR-TKAs (Persona CR. R. ). The means and ranges of demographics were as follows: age; 74.5 years old (65–89), Hip-Knee-Ankle (HKA) angle; 12.4 (−6.2–22.5) in varus. We asked patients to fulfill the questionnaire including KSS-2011, FJS-12, EQ-5D and GLFS-25 at 1-year postoperative follow-up visit. KSS-2011 consisted of 4 categories of questions; patient satisfaction (PS), symptoms, patient expectations (PE), functional activities (FA). We evaluated the correlation of PS to other PROMs using simple linear regression analyses (p<0.001). Results. The means and standard deviations of 1-year postoperative scores were as follows: PS; 28.5 ± 7.0, symptoms; 19.1 ± 4.3, PE; 11.2 ± 2.9, FA; 71.5 ± 16.6, FJS-12; 51.5 ± 18.6, EQ5D; 0.69 ± 0.10, GLFS-25; 25.7 ± 16.9. PSs were moderately positively correlated to other categories in KSS-2011(correlation coefficient (r): symptoms; 0.69, PE; 0.73, FA; 0.69). PSs were positively correlated to both FJS-12 and EQ5D (r: FJS-12; 0.72, EQ-5D; 0.67) and negatively correlated to GLFS-25(r; −0.74). Discussions. Patient satisfaction score positively correlated to the symptoms, patient expectation and functional activities in KSS-2011 with moderately high correlation coefficient. This meant the better pain relief and functional outcome improved patient satisfaction. Although there had be reported preoperative higher expectation would lead to poor patient satisfaction postoperatively, we interestingly found positive correlation between patient satisfaction and expectation at 1 year after TKA. Patient with the higher satisfaction tended to expect more in the future, on the other hand, unsatisfied patient with residual pain and/or poor function would resign themselves to the present status and reduced their expectation in our patient population. We have found patient satisfaction score in KSS-2011 significantly correlated to FJS-12 and GLFS-25 with strong correlation coefficient. This meant patient satisfaction could be considered consist to other PROMS in relatively younger patient with better functional status in this study. Conclusion. The patient satisfaction score in KSS-2011 was found to be consistent with moderately high correlations coefficient to other categories in KSS-2011 and other PROMs including FJS-12, EQ-5D, GLFS-25 at 1 year after (CR)-TKA. For any figures or tables, please contact authors directly

Introduction. Hip arthroplasty is considered common to patients aged 65 and over however, both Jennings, et al., (2012) and Bergmann (2016) found THA patients are substantially younger with more patients expecting to return to preoperative activity levels. With heavier, younger, and often more active patients, devices must be able to support a more demanding loading-regime to meet patient expectations. McClung (2000) demonstrated that obese patients can display lower wear-rates with UHMWPE bearing resulting from post-operative, self-induced reduced ambulatory movement, thus questioning if obese kinematics and loading are indeed the worst-case. Current loading patterns used to test hip implants are governed by ISO 14242-1 (2014). This study aimed to characterize a heavy and active population (referred to as HA) and investigate how the gait profile may differ to the current ISO profile. Method. A comprehensive anthropometric data set of 4082 men (Gordon, CC., et.al., 2014) was used to characterize a HA population. Obese and HA participants were classed as BMI ≥30 however HA participants were identified by applying anthropometric ratios indicative of lower body fat, namely “waist to height” (i.e. WHtR <0.6) and “waist to hip” (i.e. WHpR <0.9). Findings. Of 491 obese participants 61 were identified as HA (i.e. BMI> 30, WHpR<0.9; WHtR<0.6) (Figure 1). These characteristics were validated against a population of elite rugby players that were found to be a true reflection of HA patients (Figure 2). Combining the Army and Rugby populations resulted in a weight of 123kg for the 95. th. percentile, which based on 3× body weight (as referenced in ISO14242-1) would equate to a peak simulator load of 3620N. Conclusion. Characterization of a HA population was successfully defined as clinically obese by BMI, but with WHtR and WHpR associated with lower body fat. The author was unable to identify gait characteristics of a HA population through existing literature. Future Work. A gait-lab based study will be used to compare literature-based kinematics of obese subjects to those of HA subjects. A worst-case gait cycle can then be established for standard walking and other activities and translated into hip simulator parameters for HA patients

Purpose. Patient expectations influence post-treatment outcomes, both surgical and non-surgical. Existing studies evaluate the technical aspects of interventions and functional outcomes but fail to take into account patient expectations. This retrospective analysis of prospectively collected multi-center data aims to explore the relationship between pre-operative expectations and post-operative outcomes and satisfaction in lumbar and cervical spine surgery. The authors hypothesized that expectations dramatically affect spine patient satisfaction independent of functional outcomes. Method. Patient data from lumbar and cervical spine patients collected prospectively using a patient health survey system was analyzed. The study included patients who underwent operative intervention (decompression with or without fusion) with at least a 3-month period of follow-up. Pre-operative expectations were measured using the MODEMS expectation survey. Post-operative satisfaction and fulfillment of expectations were measured using the MODEMS satisfaction survey. Post-operative functional outcomes were measured using the ODI and SF-36. Multi-variate ordinal logistic regression modeling was used to examine predictors of post-operative satisfaction. Multi-variate linear regression modeling was used to examine predictors of functional outcomes. Results. 402 patients were included in the study. Significant predictors of increased satisfaction include: higher fulfillment of expectations regarding work (p=0.003) and pain relief (p=0.008), greater post-operative SF-36 (p=0.04), and lower pre-operative expectations regarding ability to exercise (p=0.03). Lumbar spine patients were more satisfied than cervical-spine patients. Significant predictors of better post-operative function include: higher expectations regarding sleep (p<0.0002), fulfillment of expectations regarding work (p<0.0001), sleep (p=0.03), and daily activities (p=0.02). Cervical spine patients had better functional outcomes (p=0.006). Conclusion. This study showed that pre-operative expectations and their fulfillment influence post-operative satisfaction in lumbar and cervical spine patients. This underlines the importance of taking pre-operative expectations into account in order to obtain an informed choice based on patient preferences

In years past, the most common reason for revision following knee replacement was polyethylene wear. A more recent study indicates that polyethylene wear is relatively uncommon as a cause for total knee revision counting for only 10% or fewer of revisions. The most common reason for revision currently is aseptic loosening followed closely by instability and infection. The time to revision was surprisingly short. In a recent series only 30% of knees were greater than 5 years from surgery at the time of revision. The most common time interval was less than 2 years. This is likely because of the higher incidence of infection and instability that occurs most commonly at a relatively early time frame. Evaluation of a painful total knee should take into account these findings. All total knees that are painful within 5 years of surgery should be assumed to be infected until proven otherwise. Therefore, virtually all should be aspirated for cell count, differential, and culture. Alpha-defensin is also available in cases in which a patient may have been on antibiotics within a month or less, as well as cases in which diagnosis is a challenge for some reason. Instability can be diagnosed with physical exam focusing on mid-flexion instability which can be usually determined with the patient seated and the knee in mid-flexion, with the foot flat on the floor at which point sagittal plane laxity can be discerned. This is also frequently associated with symptoms of giving way and recurring effusions and difficulty descending stairs. A new phenomenon of tibial de-bonding has been described, which can be a challenge to diagnose. Radiographs can appear normal when loosening occurs between the implant and the cement mantle. This seems to be more common with the use of higher viscosity cement. Obviously this is technique dependent since good results have been reported with the use of high viscosity cement. Component malposition can cause stiffness and pain and relatively good results have been reported by component revision when malrotation has been confirmed with CT scan. When infection, instability and loosening are not present, extra-articular causes should be ruled out including lumbar spine, vascular compromise, complex regional pain syndromes and fibromyalgia, and peri-articular causes such as bursitis, tendonitis, tendon impingement among others. One of the most common causes of pain following total knee is unrealistic patient expectations. Performing total knee replacement in early stages of arthritis with only mild to moderate symptoms and radiographic changes has been associated with persistent pain and dissatisfaction. It may be prudent to obtain the immediate preoperative x-rays to determine if early intervention was undertaken and patients have otherwise normal appearing total knee x-rays and a negative work up. A recent study indicated that this was likely a cause or a major contributing factor to persistent pain following otherwise a well performed knee replacement. A national multicenter study of the appropriateness of indications for TKA also indicated that early intervention was a major cause of persistent pain, dissatisfaction, and failure to improve following total knee replacement

Hip abductor deficiency (HAD) associated with hip arthroplasty can be a chronic, painful condition that can lead to abnormalities in gait and instability of the hip. HAD is often confused with trochanteric bursitis and patients are often delayed in diagnosis after protracted courses of therapy and steroid injection. A high index of suspicion is subsequently warranted. Risk factors for HAD include female gender, older age, and surgical approach. The Hardinge approach is most commonly associated with HAD because of failure of repair at the time of index surgery or subsequent late degenerative or traumatic rupture. Injury to the superior gluteal nerve at exposure can also result in HAD and is more commonly associated with anterolateral approaches. Multiple surgeries, chronic infection, and chronic inflammation from osteolysis or metal debris are also risk factors especially as they can result in bone stock deficiency and direct injury to muscle. Increased offset and/or leg length can also contribute to HAD, especially when both are present. Physical exam demonstrates abductor weakness with walking and single leg stance. There is often a palpable defect over the greater trochanter and palpation in that area usually elicits significant focal pain. Note may be made of multiple incisions. Increased leg length may be seen. Radiographs may demonstrate avulsion of the greater trochanter or significant osteolysis. Significant polyethylene wear or a metal-on-metal implant should be considered as risk factors, as well as the presence of increased offset and/or leg length. Ultrasound or MRI are helpful in confirming the diagnosis but false negatives and positive results are possible. Treatment is difficult, especially since most patients have failed conservative management before diagnosis of HAD is made. Surgical options include allograft and mesh reconstruction as well as autologous muscle transfers. Modest to good results have been reported, but reproducibility is challenging. In the case of increased offset and leg length, revision of the components to reduce offset and leg length may be considered. In the case of significant instability, abductor repair may require constrained or multi-polar liners to augment the surgical repair. HAD is a chronic problem that is difficult to diagnose and treat. Detailed informed consent appropriately setting patient expectations with a comprehensive surgical plan is required if surgery is to be considered. Be judicious when offering this surgery

Significance. In spite of evidence that total knee replacement (TKR) surgery is effective, numerous studies have demonstrated that approximately 20 percent of patients who have undergone TKR surgery are not satisfied. This relatively high rate of patients who are not satisfied is the result of unmet patient expectations. The strongest predictor of dissatisfaction after TKR is unmet expectations (RR = 10.7, Bourne, Chesworth, et al, 2010). This is confirmed by Dunbar, Richardson, and Robertsson (2013): “Unmet expectation seems to be a major cause of unsatisfactory outcomes and satisfaction is most strongly correlated with relief of pain, followed by improvement in physical function.” Hypothesis: One year post-operative pain relief and activity level expectations can be measured pre-operatively and used for shared decision making. Methods. A web–based system for prospectively collecting patient reported outcomes (PROs) has been developed. The data set for total hip/knee replacement surgery includes: (1) European quality of life, EQ-5D; Oxford Hip Score/Oxford Knee Score; (3) Lower Extremity Activity Scale (LEAS); and (4) Pain Likert Scale (PLS). The EQ-5D was selected as the health related quality of life (HRQL) general outcome measure because it has been adopted by multiple international joint replacement registries (Swedish Hip Arthroplasty Register, Norwegian Arthroplasty Register, United Kingdom National Joint Registry). The EQ-5D can be used to calculate quality adjusted life years (QALYs) for economic and/or comparative effectiveness analyses. The OHS/OKS questionnaires are used by the United Kingdom National Joint Registry and the New Zealand Joint Registry. The LEAS and PLS are used to measure patient's expectations for pain relief and functional improvement by asking patients to report their pre-operative pain and activity level before surgery and asking patients to report their pain and activity level expectations one year after surgery. Results. The LEAS change (one-year post-operative activity level minus pre-operative activity level) mean and standard deviation are 1.45 and 3.18. The LEAS minimum clinically important difference (MCID) is 1.59. The mean LEAS change is 0.91 MCIDs. The PLS change (one-year post-operative pain score minus pre-operative pain score) mean and standard deviation are −4.57 and 2.85. The PLS MCID is 1.43. The mean PLS change is −3.2 MCIDs. The z statistic for expected change is z = (Δ. expect. – μ. Δ. )/σ. Δ. The probability of realizing an expected activity level change greater than or equal to 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 is 68%, 56%, 43%, 31%, 21%, 13%, 7.6%, 4.0%, 2.0%, 0.9%, and 0.4%, respectively. The probability of realizing an expected pain change greater than or equal to 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 is 95%, 90%, 82%, 71%, 58%, 44%, 31%, 20%, 11%, 6.0%, and 2.8%, respectively. Conclusions. Dramatic improvement in activity level is unlikely. However, 86 percent of patients can expect clinically significant pain relief defined by pain relief greater than the MCID. Shared decision making should discuss unrealistic expectations prior to proceeding with surgery

Total hip arthroplasty (THA) is among the most successful interventions in all of medicine and has recently been termed “The Operation of the Century”. Charnley originally stated that “Objectives must be reasonable. Neither surgeons nor engineers will ever make an artificial hip joint that will last 30 years and at some time in this period enable the patient to play football.” and he defined an appropriate patient as generally being over 65 years of age. Hip rating scales developed during this time were consistent with this approach and only required relief of pain and return to normal activities of daily living to achieve a perfect score. Since this time, however, hip arthroplasty has been applied to high numbers of younger, more active individuals and patient expectations have increased. One recent study showed that in spite of a good hip score, only 43% of patients had all of their expectations completely fulfilled following THA. The current generation metal-metal hip surface replacement arthroplasty (SRA) has been suggested as an alternative to standard THA which may offer advantages to patients including retention of more native bone, less stress shielding, less thigh pain due to absence of a stem, less limb length discrepancy, and a higher activity level. A recent technology review by the AAOS determined that currently available literature was inadequate to verify any of these suggested potential benefits. The potential complications associated with SRA have been well documented recently. The indications are narrower, the implant is more expensive, the technique is more demanding and less forgiving, and the results are both highly product and surgeon specific. Unless a clinical advantage in the level of function of SRA over THA can be demonstrated, continued enthusiasm for this technique is hard to justify. To generate data on the level of function of younger more active arthroplasty patients, a national multicenter survey was conducted by an independent university medical interviewing center with a long track record of conducting state and federal medical surveys. All patients were under 60, high demand (pre-morbid UCLA score > 6) and had received a cementless stem with an advanced bearing surface or an SRA at one of five major total joint centers throughout the country. The detailed questionnaire quantified symptoms and function related to employment, recreation, and sexual function. Patients with SRA had a higher incidence of noises emanating from the hip than other bearing surfaces although this was transient and asymptomatic. SRA patients were much more likely to have less thigh pain than THA, less likely to limp, less likely to perceive a limb length difference, more likely to run for exercise, and more likely to run longer distances. In another study of over 400 THA and SRA patients at two major academic centers, patients completed pain drawings that revealed an equivalent incidence of groin pain between THA and SRA, but an incidence of thigh pain in THA that was three times higher than in SRA in young active patients. While some or most of the observed advantages of SRA over THA may be attributable to some degree of selection bias, the inescapable conclusion is that SRA patients are demonstrating clinical advantages that warrants continued utilization and investigation of this procedure

Introduction & aims. Satisfaction following total knee replacement (TKR) surgery remains suboptimal at around 80%. Prediction of factors influencing satisfaction may help manage expectations and thus improve satisfaction. We investigated preoperative variables that estimate the probability of achieving a successful surgical outcome following TKR in several outcomes important to patients. Method. 9 pre-operative variables (easily obtained on initial consultation) of 591 unilateral TKRs were selected for univariant then multivariant analyses. These variables included Oxford Knee Score (OKS), age, sex, BMI, ASA score, pain score, mobility aids, SF12 PCS & SF12 MCS. Using the relative predictive strengths of these variables we modeled the probabilities a successful result would be achieved for 6 patient reported outcomes at 3 and 12 months following surgery. These were ‘Excellent/good OKS’, ‘Mild/no pain’, ‘Walking without/at first a limp’, ‘No/little interference with normal work’, ‘Kneeling with little/no difficulty’ and ‘Satisfaction with surgery’. Results. Pre-operative OKS was the most useful single predictor, having impact at three months and/or one year on all outcomes examined, except kneeling. SF12 MCS affected pain scores, pain with usual activity, and limp at three months and/or one year. At three months, BMI, age, gender, ASA and pain also influenced one or more of 6 post-operative outcomes studied. After inputting pre-operative OKS, adding other predictors did not significantly improve the statistical model. Conclusions. Our model provides objective probability estimates based on the outcomes of our previous TKRs, which we can use to give specific objective information to prospective TKR patients regarding their likely postoperative trajectory. We hope this will modulate patient expectations, assist preparation for their surgical experience and in turn increase satisfaction

Stiffness remains one of the most common, and challenging post-operative complications after TKA. The exact definition of stiffness varies, and patient expectations of post-operative motion vary as well. Pre-operative motion and diagnosis (such as post-traumatic arthritis) can influence post-operative motion, and careful patient counseling about expectations is important. Post-operative stiffness should be evaluated by ruling out infection, evaluating rehabilitation efforts, and careful physical and radiographic examination. Manipulation under anesthesia (MUA) in selected cases can be helpful. The author generally prefers to perform MUA between the 6- and 8-week mark post-operatively. Careful technique is required to minimised the risk of fracture or soft tissue injury. For more chronic stiffness, revision may be indicated, especially if an etiology is identified pre-operatively (for example, an excessively thick patellar resurfacing, an oversized femoral component, gross malrotation, etc.). CT scanning can be helpful for pre-operative evaluation and planning. During revision, thorough synovectomy and release of contractures and ligamentous balancing is performed as required. Careful attention to gap balancing, component rotation, and sizing is critical. Patients should be counseled that the results of revision for stiffness are mixed and somewhat unpredictable unless a clear etiology was found intra-operatively (for example, a grossly oversized femoral component). More frequent post-operative office visits may be helpful to guide rehabilitation progress in these challenging cases