Aims. The aim of this study was to develop and evaluate machine-learning-based computerized adaptive tests (CATs) for the Oxford Hip Score (OHS), Oxford Knee Score (OKS), Oxford Shoulder Score (OSS), and the Oxford Elbow Score (OES) and its subscales. Methods. We developed CAT algorithms for the OHS, OKS, OSS, overall OES, and each of the OES subscales, using responses to the full-length questionnaires and a machine-learning technique called regression tree learning. The algorithms were evaluated through a series of simulation studies, in which they aimed to predict respondents’ full-length questionnaire scores from only a selection of their item responses. In each case, the total number of items used by the CAT algorithm was recorded and CAT scores were compared to full-length questionnaire scores by mean, SD, score distribution plots, Pearson’s correlation coefficient, intraclass correlation (ICC), and the Bland-Altman method. Differences between CAT scores and full-length questionnaire scores were contextualized through comparison to the instruments’ minimal clinically important difference (MCID). Results. The CAT algorithms accurately estimated 12-item questionnaire scores from between four and nine items. Scores followed a very similar distribution between CAT and full-length assessments, with the mean score difference ranging from 0.03 to 0.26 out of 48 points. Pearson’s correlation coefficient and ICC were 0.98 for each 12-item scale and 0.95 or higher for the OES subscales. In over 95% of cases, a patient’s CAT score was within five points of the full-length questionnaire score for each 12-item questionnaire. Conclusion. Oxford Hip Score, Oxford Knee Score, Oxford Shoulder Score, and Oxford Elbow Score (including separate subscale scores) CATs all markedly reduce the burden of items to be completed without sacrificing score accuracy. Cite this article: Bone Jt Open 2022;3(10):786–794

Background. The Fracture Fixation Assessment Tool score (FFATs) was developed as an objective evaluation of post-operative fracture fixation radiographs as a means of appraisal and education. The tool has proven validity, simple to use and based upon AO principles of fracture fixation. This study has been designed to assess how FFATs changes throughout the training program in the UK. Methods. The local trauma database of a district general hospital, with trauma unit status was used to identify cases. Although FFATs is designed to apply to any fracture fixation, Weber B ankle fractures were selected as common injuries, which constitute indicative cases in T&O training. Grade of the primary surgeon and supervision level were both stratified. The initial and intraoperative radiographs were anonymised and presented to the assessor who had been blinded to the identity and grade of the surgeon, for scoring using FFATs. Results. 293 fractures around the ankle were identified from the Database between 2013 and 2016. After applying the inclusion criteria of Weber B fractures operatively fixed, Specialist training registrars and consultants, there were 99 cases for evaluation. These were grouped by training experience into 4 groups. (ST3-4, ST5-6, ST7-8, Consultants) and demonstrated a trend of increasing scores with experience level with a dip in consultant scores, albeit not statistically significant due to low numbers of cases at higher training grades. Conclusions. We present our first experience of using FFATs in a uniform series of fractures in surgeons of different training grades. There is a trend to increasing scores throughout training with a dip in consultant scores likely reflecting increased complexity of cases. Implications. FFATs could prove to be an invaluable appraisal tool for teaching and mentoring surgeons in training both locally in the United Kingdom and remotely overseas

This study aims to correlate Oxford shoulder score (OSS) to EQ5D score in healthy patients presenting to a shoulder clinic with shoulder pain. OSS and EQ5D scores were collected prospectively from 101 consecutive patients presenting with shoulder pain in a shoulder clinic at one specialist centre. Patients with ASA > 2 and other significant joint arthritis were excluded from the study. Scores were collected from electronic patient records. Spearman's rho correlation of oxford shoulder scores and EQ5D scores was completed. Mean age of subjects was 51.8 (range 19.1–81.9) years, 55 of 101 subjects were men (54%). Median OSS was 26 (range 3–48) and median EQ5D score was 0.76 (range 0–0.76). Correlation for all patients was 0.624 (Sig p<0.001). This study demonstrates a strong correlation between Oxford shoulder scoring and EQ5D in a fit and well shoulder surgery clinic population. It is possible that Oxford shoulder scores may be a useful indicator of quality of life in healthy shoulder clinic patients presenting with shoulder pain

Introduction. Patient satisfaction after total hip arthroplasty (THA) has been reported to be significantly better than after total knee arthroplasty (TKA). The same has been observed for the capacity to forget during daily life activities about the operated joint. Recently a new patient reported outcome score, the Forgotten Joint Score (FJS-12) a twelve item questionaire, has been used to evaluate postoperative outcome in joint arthroplasty. A better FJS-12 score was measured in THA than in TKA objectivating the intuitive feeling that the joint was more forgotten in THA than in TKA. Hypothesis. A higher preoperative FJS-12 score is the reason for a higher postoperative FJS-12 score in THA compared to TKA. Materials and methods. FJS-12 scores were prospectively collected in 75 THA and 75 TKA preoperatively and one year postoperative. Patients were stratified according to age and BMI. Effect size of treatment was calculated using the FJS-12. Results. No preoperative difference in mean (SD) FJS-12 was observed for THA (24(17) versus TKA (22(15)). The mean (SD) postoperative FJS-12 was significantly higher for THA (79(25)) than for TKA (73(22)). Effect size of treatment was 3.4 for TKA and 3.2 for THA. Mean (SD) for men in THA (89(25)) was significantly higher than for men in TKA (74(22)). Discussion. Postoperative differences in forgotten joint feeling after THA compared to TKA can not be explained by a preoperative difference. TKA is an effective surgery as measured by the effect size of treatment. Male TKA patients have worst outcome than male THA patients. This can probably be explained by mechanical or proprioceptive differences in between both types of arthroplasty

Patient reported outcome measures (PROMs) after total knee arthroplasty (TKA) are typically used to assess longitudinal change in pain and function after total knee arthroplasty (TKA). The Patient's Knee Implant Performance (PKIP) score was developed to evaluate outcomes more broadly including function, stability, confidence, and satisfaction. Although validated in patients having a primary TKA, the PKIP has not been evaluated as an outcome measure for patients having revision TKA. This study examined patient outcomes at one year following primary and revision TKA measured using the PKIP, compared to Oxford Knee Scores. A retrospective analysis of pre-operative and one-year post-operative outcomes was completed for 39 patients (21 female) who had primary (n=27) or revision (n=12) TKA with a single surgeon between 2017 and 2020. The mean age was 69.2±7.4 years, and mean weight 87.4± 5.1kg. The change over time and correlation between the self-reported outcome measures was evaluated. There was a significant improvement in the PKIP overall score at the 12-month follow-up (32± 13 v 69± 15, p= <0.001), with no significant difference between groups (3.3 points, p=0.50). Among the PKIP sub-scores, there was a significant improvement in knee confidence (3.5±2 vs 7.7±2; p<0.001), stability (3.4±2 vs 7.4±3; p<0.001) and satisfaction (2.5±1.7 vs 6.6±3, p<0.001). Between group differences in PKIP sub-scores one year after surgery were small and non-significant. For all patients, the OKS and PKIP scores were moderately correlated before surgery (r=0.64, p=<0.05), and at 1 year after surgery (r=0.61, p= <0.001). Significant improvements in knee confidence, stability, and satisfaction one year after TKA were identified from the PKIP responses, with no significant difference between primary and revision surgery. The moderate correlation with the OKS suggests these questionnaires measure difference constructs and may provide complementary outcome information in this patient cohort

Utility score is a preference-based measure of general health state – where 0 is equal to death, and 1 is equal to perfect health. To understand a patient's smallest perceptible change in utility score, the minimal clinically important difference (MCID) can be calculated. However, there are multiple methods to calculate MCID with no consensus about which method is most appropriate. The aim of this study is to calculate MCID values for the Veterans-RAND 12 (VR12) utility score using varying methods. Our hypothesis is that different methods will yield different MCID values. A tertiary institutional registry (SMART) was used as the study cohort. Patients who underwent unilateral TKA for osteoarthritis from January 2012 to January 2020 were included. Utility score was calculated from VR12 responses using the standardised Brazier's method. Distribution and anchor methods were used for the MCID calculation. For distribution methods, 0.5 standard deviations of the baseline and change scores were used. For anchor methods, the physical and emotional anchor questions in the VR12 survey were used to benchmark utility score outcomes. Anchor methods included mean difference in change score, mean difference in 12 month score, and receiver operating characteristics (ROC) analysis with the Youden index. Complete case analysis of 1735 out of 1809 eligible patients was performed. Significant variation in the MCID estimates for VR12 utility score were reported dependent on the calculation method used. The MCID estimate from 0.5 standard deviations of the change score was 0.083. The MCID estimate from the ROC analysis method using physical or emotional anchor question improvement was 0.115 (CI95 0.08-0.14; AUC 0.656). Different MCID calculation methods yielded different MCID values. Our results suggest that MCID is not an umbrella concept but rather many distinct concepts. A general consensus is required to standardise how MCID is defined, calculated, and applied in clinical practice

The widely used Fracture Risk Assessment Tool (FRAX) estimates a 10-year probability of major osteoporotic fracture (MOF) using age, sex, body mass index, and seven clinical risk factors, including prior history of fracture. Prior fracture is a binary variable in FRAX, although it is now clear that prior fractures affect future MOF risk differently depending on their recency and site. Risk of MOF is highest in the first two years following a fracture and then progressively decreases with time – this is defined as imminent risk. Therefore, the FRAX tool may underestimate true fracture risk and result in missed opportunities for earlier osteoporosis management in individuals with recent MOF. To address this, multipliers based on age, sex, and fracture type may be applied to baseline FRAX scores for patients with recent fractures, producing a more accurate prediction of both short- and long-term fracture risk. Adjusted FRAX estimates may enable earlier pharmacologic treatment and other risk reduction strategies. This study aimed to report the effect of multipliers on conventional FRAX scores in a clinical cohort of patients with recent non-hip fragility fractures. After obtaining Research Ethics Board approval, FRAX scores were calculated both before and after multiplier adjustment, for patients included in our outpatient Fracture Liaison Service who had experienced a non-hip fragility fracture between June 2020 and November 2021. Patients age 50 years or older, with recent (within 3 months) forearm (radius and/or ulna) or humerus fractures were included. Exclusion criteria consisted of patients under the age of 50 years or those with a hip fracture. Age- and sex-based FRAX multipliers for recent forearm and humerus fractures described by McCloskey et al. (2021) were used to adjust the conventional FRAX score. Low, intermediate and high-risk of MOF was defined as less than 10%, 10-20%, and greater than 20%, respectively. Data are reported as mean and standard deviation of the mean for continuous variables and as proportions for categorical variables. A total of 91 patients with an average age of 64 years (range = 50-97) were included. The majority of patients were female (91.0%), with 73.6% sustaining forearm fractures and 26.4% sustaining humerus fractures. In the forearm group, the average MOF risk pre- and post-multiplier was 16.0 and 18.8, respectively. Sixteen percent of patients (n = 11) in the forearm group moved from intermediate to high 10-year fracture risk after multiplier adjustment. Average FRAX scores before and after adjustment in the humerus group were 15.7 and 22.7, respectively, with 25% (n = 6) of patients moving from an intermediate risk to a high-risk score. This study demonstrates the clinically significant impact of multipliers on conventional FRAX scores in patients with recent non-hip fractures. Twenty-five percent of patients with humerus fractures and 16% of patients with forearm fractures moved from intermediate to high-risk of MOF after application of the multiplier. Consequently, patients who were previously ineligible for pharmacologic management, now met criteria. Multiplier-adjusted FRAX scores after a recent fracture may more accurately identify patients with imminent fracture risk, facilitating earlier risk reduction interventions

The purpose of this study was to develop a quality appraisal tool for the assessment of laboratory basic science biomechanical studies. Materials andScore development comprised of the following phases: item identification/development, item reduction, content/face/criterion validity, weighting, test-retest reliability and internal consistency. For item identification/development, the panel was asked to independently list criteria and factors they considered important for cadaver study and generate items that should be used to appraise cadaver study quality. For content validity, the content validity ratio (CVR) was calculated. The minimum accepted content validity index (CVI) was set to 0.85. For weighting, equal weight for each item was 6.7% [15 items]. Based on these figures the panel was asked to either upscale or downscale the weight for each item ensuring that the final sum for all items was 100%. Face validity was assessed by each panel member using a Likert scale from 1–7. Strong face validity was defined as a mean score of >5. Test-retest reliability was assessed using 10 randomly selected studies. Criterion validity was assessed using the QUACS scale as standard. Internal consistency was assessed using Cronbach's alpha. Five items reached a CVI of 1 and 10 items a CVI of 0.875. For weighting five items reached a final weight of 10% and ten items 5%. The mean score for face validity was 5.6. Test-retest reliability ranged from 0.78–1.00 with 9 items reaching a perfect score. Criterion validity was 0.76 and considered to be strong. Cronbach's alpha was calculated to be 0.71 indicating acceptable internal consistency. The new proposed quality score for basic science studies consists of 15 items and has been shown to be reliable, valid and of acceptable internal consistency. It is suggested that this score should be utilised when assessing basic science studies

The ability to calculate quality-adjusted life-years (QALYs) for degenerative cervical myelopathy (DCM) would enhance treatment decision making and facilitate economic analysis. QALYs are calculated using utilities, or health-related quality-of-life (HRQoL) weights. An instrument designed for cervical myelopathy disease would increase the sensitivity and specificity of HRQoL assessments. The objective of this study is to develop a multi-attribute utility function for the modified Japanese Orthopedic Association (mJOA) Score. We recruited a sample of 760 adults from a market research panel. Using an online discrete choice experiment (DCE), participants rated 8 choice sets based on mJOA health states. A multi-attribute utility function was estimated using a mixed multinomial-logit regression model (MIXL). The sample was partitioned into a training set used for model fitting and validation set used for model evaluation. The regression model demonstrated good predictive performance on the validation set with an AUC of 0.81 (95% CI: 0.80-0.82)). The regression model was used to develop a utility scoring rubric for the mJOA. Regression results revealed that participants did not regard all mJOA domains as equally important. The rank order of importance was (in decreasing order): lower extremity motor function, upper extremity motor function, sphincter function, upper extremity sensation. This study provides a simple technique for converting the mJOA score to utilities and quantify the importance of mJOA domains. The ability to evaluate QALYs for DCM will facilitate economic analysis and patient counseling. Clinicians should use these findings in order to offer treatments that maximize function in the attributes viewed most important by patients

The study aimed to determine how well recorded pain levels and range of motion relate to patients' reported levels of functional ability/disability pre- and post- total hip arthroplasty. Range of motion (ROM), Oxford Hip Score (OHS) and Self-Report Harris Hip Score (HHS) were recorded pre-operatively and 3 months post-total hip arthroplasty. Pearson's correlation coefficients were calculated to determine the strength of the relationships both pre- and post-operatively between ROM (calculated using the HHS scoring system) and scores on OHS and HHS and response relating to pain from the questionnaires (question 1 HHS and questions 1, 6, 8, 10, 11 and 12 of OHS) and overall scores. Only weak relationships were found between ROM and HHS pre- (r = 0.061, n = 99, p = 0.548) and post-operatively (r = 0.373, n = 66, p = 0.002). Similar results were found for OHS, and when ROM was substituted for flexion range. In contrast, strong correlations were found between OHS pain component and HHS pre- (r = -0.753, n = 107, p<0.001) and post-operatively (r = -0.836, n = 87, p<0.001). Strong correlations were also found between the OHS pain component correlated with the HHS functional component only (HHS with score for questions relating to pain deducted) pre- (r = -0.665, n = 107, p<0.001) and post-operatively (r = -0.688, n = 87, p<0.001). Similar results were found when the HHS pain component was correlated with OHS. In orthopaedic clinical practice ROM is routinely used to assess the success or failure of arthroplasty surgery. These results suggest that this should not be done. Instead, asking the patient the level of pain that they are experiencing may be a good determinant of level of function. The results of this study may aid the development of arthroplasty scoring systems which better assess patients' functional ability

Abstract. Abstract:. Background. The dissatisfaction rate in patients operated with TKR is generally quoted to be around 20% in various registries in patients operated by multiple surgeons. The data of satisfaction rates following a TKR performed by single high volume surgeons is lacking. Aim. To study the satisfaction rate and Net Promoter Score (NPS) of consecutively operated TKR patients by a single surgeon with a minimum 1 year follow up. Methods. 860 out of 883 patients who were operated between 1st April, 2018 and 31st March, 2019 were contacted by a telephonic call. They were asked 3 questions related to their experience about the operation. The patient satisfaction, NPS and reason for dissatisfaction were assessed. Results. The overall satisfaction rate of 95.93% and a net promoter score of +96.63 was observed. When the NPS was calculated as the worst case scenario, a score of +93.70 was observed. 6 patients were unsatisfied with causes directly related to the surgery. Conclusion. TKR can have as high satisfaction rates with very high NPS in experienced surgical hands using standard techniques. These results may form a benchmark against which newer technologies can be compared

Symptomatic venous thromboembolism (SVTE) is a potentially significant complication which may occur following injury or surgery. Recent NICE guidelines, and clinical targets have all focused on decreasing in hospital death from acquired SVTE. Despite these guidelines there are no large studies investigating the risk factors for or incidence of SVTE in acute trauma admission. Data from a prospective series of 9167 consecutive patients with a diagnosis of fractured neck of femur (NOF) at a single institution was used to construct a risk score for SVTE. Twenty three factors were screened with pairwise analysis. The cohort had an event rate of 1.4%. A multiple logistic regression model was used to construct a risk score and correct for confounding variables from nine significant factors identified by the pairwise analysis. Four factors; length of stay; chest infection; cardiac failure and transfusion were used to produce the final risk score. The score was statistically significant (p< 0.0001) and highly predictive (ROC analysis, AUC=0.76) of SVTE. The score was separately validated in two cohorts from different Level 1 trauma centres. In one prospective consecutive cohort of 1000 NOF patients all components of the Nottingham SVTE score were found to be individually statistically significant (p< 0.0045). The score was further validated in a separate cohort of 3200 patients undergoing elective hip surgery. The score was found to be statistically significantly predictive of SVTE as a whole, and three of the four components were individually predictive in this patient cohort. Balancing risks and benefits for thromboprophylaxis is key to reducing the risk of thromboembolic events, minimising bleeding and other complications associated with the therapy. Our study of 13,367 prospective patients is the largest of its type and we have successfully constructed and validated a scoring system that can be used to inform patient treatment decisions

While clinically important improvements in Oxford Shoulder Scores have been defined for patients with general shoulder problems or those undergoing subacromial decompression, no threshold has been reported for classifying improvement after shoulder replacement surgery. This study aimed to establish the minimal clinically important change (MCIC) for the Oxford Shoulder Score in patients undergoing primary total shoulder replacement (TSR). Patient-reported outcomes data were sourced from the Australian Orthopaedic Association National Joint Replacement Registry Patient-Reported Outcome Measures Program. These included pre- and 6-month post-operative Oxford Shoulder Scores and a rating of patient-perceived change after surgery (5-point scale ranging from ‘much worse’ to ‘much better’). Two anchor-based methods (using patient-perceived improvement as the anchor) were used to calculate the MCIC: 1) mean change method; and 2) predictive modelling, with and without adjustment for the proportion of improved patients. The analysis included 612 patients undergoing primary TSR who provided pre- and post-operative data (58% female; mean (SD) age 70 (8) years). Most patients (93%) reported improvement after surgery. The MCIC derived from the mean change method was 6.8 points (95%CI 4.7 to 8.9). Predictive modelling produced an MCIC estimate of 11.6 points (95%CI 8.9 to 15.6), which reduced to 8.7 points (95%CI 6.0 to 12.7) after adjustment for the proportion of improved patients. For patient-reported outcome measures to provide valuable information that can support clinical care, we need to understand the magnitude of change that matters to patients. Using contemporary psychometric methods, this analysis has generated MCIC estimates for the Oxford Shoulder Score. These estimates can be used by clinicians and researchers to interpret important changes in pain and function after TSR from the patient's perspective. We conclude that an increase in Oxford Shoulder Scores of at least 9 points can be considered a meaningful improvement in shoulder-related pain and function after TSR

While clinically important improvements in Oxford Shoulder Scores have been defined for patients with general shoulder problems or those undergoing subacromial decompression, no threshold has been reported for classifying improvement after shoulder replacement surgery. This study aimed to establish the minimal clinically important change (MCIC) for the Oxford Shoulder Score in patients undergoing primary total shoulder replacement (TSR). Patient-reported outcomes data were sourced from the Australian Orthopaedic Association National Joint Replacement Registry Patient-Reported Outcome Measures Program. These included pre- and 6-month post-operative Oxford Shoulder Scores and a rating of patient-perceived change after surgery (5-point scale ranging from ‘much worse’ to ‘much better’). Two anchor-based methods (using patient-perceived improvement as the anchor) were used to calculate the MCIC: 1) mean change method; and 2) predictive modelling, with and without adjustment for the proportion of improved patients. The analysis included 612 patients undergoing primary TSR who provided pre- and post-operative data (58% female; mean (SD) age 70 (8) years). Most patients (93%) reported improvement after surgery. The MCIC derived from the mean change method was 6.8 points (95%CI 4.7 to 8.9). Predictive modelling produced an MCIC estimate of 11.6 points (95%CI 8.9 to 15.6), which reduced to 8.7 points (95%CI 6.0 to 12.7) after adjustment for the proportion of improved patients. For patient-reported outcome measures to provide valuable information that can support clinical care, we need to understand the magnitude of change that matters to patients. Using contemporary psychometric methods, this analysis has generated MCIC estimates for the Oxford Shoulder Score. These estimates can be used by clinicians and researchers to interpret important changes in pain and function after TSR from the patient's perspective. We conclude that an increase in Oxford Shoulder Scores of at least 9 points can be considered a meaningful improvement in shoulder-related pain and function after TSR

Patients' perspective and experience is heavily modulated by their understanding of their pre-operative disability along with their overall coping strategy and life philosophy. Given that evidence-based practice is relying on patient-reported outcomes more and more, the orthopaedic community must be diligent in differentiating patients that may have the same objective outcome but vary widely on a patient-reported subjective basis. In clinical practice, patient selection is often a sensitive, experience-based decision process that screens for catastrophization, recognizing that certain patients will not benefit from a simple surgery. It is well appreciated that patient's catastrophization can affect their subjective outcome but there is little reported literature on this abstract concept. The study set out to determine if post-operative outcomes correlated with pre-operative catastrophization scales. This current study set out to look at a cohort of complex consecutive foot and ankle cases and describe the relationship between Patient Catastrophizing Score (PCS) and multiple functional outcomes that are used commonly in foot and ankle specifically (SF-12 & FAOS). The PCS has three subcategory rumination, helplessness and magnification. A single institution undertook recruitment in consecutive patients within three surgeon's practice. In the end, 46 patients were found to be eligible in the study with an average age of 54.72 ± 14.41 years-old, a majority female 30 / 46 (65.22%), a minority employed at the pre-operative visit 19/46 (41%) and with an average BMI of 26.2 ± 5.56. We found that the mental component of the SF12 had a statistically significant negative effect with the rumination score (r=−1.03) (p = 0.01) and the helplessness score (r=−1.05) (0.001). There was no statistically significant effect for the physical component of the SF-12. Looking at the FAOS Pain component, it correlated was significantly with the PCS rumination (Multivariate : r= −7.6 (p=0.002) Univariate: r=−2 (0.03)) and helplessness (Multivariate : r=−6.73 (p=0.01) Univariate: r=−1.5 (p=0.03)). Otherwise the FAOS ADL component showed correlation as well with the PCS rumination (Multivariate: r=−4.67 (p=0.02) Univariate : r=−1.85 (p=0.01)), helplessness (Multivariate r=−5.89 (p = 0.01) Univariate r=−1.81 (p = 0.001)) and total score (Multivariate : r=3.74 (p=0.02) Univariate r=−0.75 (p=0.01)). The FAOS Quality of life component was statistically significant for the rumination score (Univariate r=−11.59) (p < 0.05) and the helplessness score (Univariate r=−9.65) (p = 0.002) also the PCS total (Univariate r=8.54) (p = 0.0003). As layed out in our hypothesis, this study did show an association between an increase patient catastrophizing score pre-operatively and a worse outcome in the following scores: Mental component of SF12, FAOS Pain, FAOS ADL and FAOS Quality of life components. This is an association and no causality can be proven within the limits of this current pilot study, but remains alarming. In elective surgeries, catastrophization should be screened for using the PCS form and potentially modulated pre-operatively with the help of allied health therapist while a patient is on the waitlist

Source of the study: University of Auckland, Auckland, New Zealand and University of Otago, Christchurch, New Zealand. The Oxford Knee Score (OKS) is a 12-item questionnaire used to track knee arthroplasty outcomes. Validation of such patient reported outcome measures is typically anchored to a single question based on patient ‘satisfaction’, however risk of subsequent revision surgery is also an important outcome measure. The OKS can predict subsequent revision risk within two years, however it is not known which item(s) are the strongest predictors. Our aim was to identify which questions were most relevant in the prediction of subsequent knee arthroplasty revision risk. . All primary TKAs (n=27,708) and UKAs (n=8,415) captured by the New Zealand Joint Registry between 1999 and 2019 with at least one OKS response at six months, five years or ten years post-surgery were included. Logistic regression and receiver operating characteristics (ROC) curves were used to assess prediction models at six months, five years and ten years. Q1 ‘overall pain’ was the strongest predictor of revision within two years (TKA: 6 months, odds ratio (OR) 1.37; 5 years, OR 1.80; 10 years, OR 1.43; UKA: 6 months, OR 1.32; 5 years, OR 2.88; 10 years, OR 1.85; all p<0.05). A reduced model with just three questions (Q1, Q6 ‘limping when walking’, Q10 ‘knee giving way’) showed comparable or better diagnostic ability with the full OKS (area under the curve (AUC): TKA: 6 months, 0.77 vs. 0.76; 5 years, 0.78 vs. 0.75; 10 years, 0.76 vs. 0.73; UKA: 6 months, 0.80 vs. 0.78; 5 years: 0.81 vs. 0.77; 10 years, 0.80 vs. 0.77). The three questions on overall knee pain, limping when walking, and knee ‘giving way’ were the strongest predictors of subsequent revision within two years. Attention to the responses for these three key questions during follow-up may allow for prompt identification of patients most at risk of revision

A large proportion of wait times for primary total knee (TKA) and hip (THA) arthroplasty is the time from primary care referral to surgical consultation. To our knowledge, no study has investigated whether a referral Oxford Knee or Hip Score (OKHS) could be used to triage non-surgical referrals appropriately. The primary purpose of the current study was to determine if a referral OKHS has the predictive ability to discriminate when a knee or hip referral will be deemed conservative as compared to surgical by the surgeon during their first consultation, and to identify an OKHS cut-off point that accurately predicts when a primary TKA or THA referral will be deemed conservative. We retrospectively reviewed all consecutive primary TKA and THA consultations from a single surgeon's tertiary, high volume practice over a three-year period. Patients with a pre-consultation OKHS, BMI < 4 1, and no absolute contraindication to TJR were included. Consultation knees/hips were categorized into two groups based on surgeon's decision, those that were offered TJR during their first consolation (surgical) versus those that were not (conservative). Baseline demographic data and OKHS were abstracted. Variables of interest were compared between cohorts using the exact chi-square test and Wilcoxon rank-sum test. Spearman's rank correlation coefficients were used to measure association between pre-consult OKHS and the surgeon's decision. A receiver operator characteristic (ROC) curve analysis was used to calculate the area under the curve (AUC) and to identify a cut-off point for the pre-operative OKHS that identified whether or not a referral was deemed conservative. TKA and THA referrals were analyzed separately. The study included 1,436 knees (1,016 patients) with a median OKS of 25 (IQR 19–32) and 478 hips (388 patients) with a median OHS of 22 (IQR 16–29). Median pre-consultation OKHS demonstrated clinically and statistically significant differences between the surgical versus conservative cohorts (p 32 (sensitivity=0.997, NPV=0.992) and for hips is OHS >34 (sensitivity=0.997 NPV=0.978). ROC analysis identified severable potential lower OKHS thresholds, depending on weight of prioritization of sensitivity, specificity, and NPV. Referral OKS and OHS demonstrate good ability to discriminate when a primary TKA or THA referral will be deemed non-surgical versus surgical at their first consultation in a single surgeon's practice. Multiple potential effective OKHS thresholds can be applied as a tool to decrease wait times for primary joint arthroplasty. However, a cost analysis would aid in identifying the optimal cut-off score, and these findings need to be externally validated before they can be broadly applied

Introduction. The systematic effects of joint replacement in rheumatoid arthritis (RA) patients are that inflamed synovium and pathological articular cartilage has dissipated. Expectations of total knee arthroplasty (TKA) are reduction of inflammatory cytokines, decreased disease activity and improvement of drug efficacy and ADL. Remission of rheumatoid arthritis is defined as having a Disease Activity Score DAS28 (ESR) of less than 2.6 and Health Assessment Questionnaire (HAQ) – Disability Index, less than 0.5. Purpose. We investigated whether TKA could reduce disease activity and improve ADL, and subsequent remission levels of DAS and HAQ or not. Material and Methods. We analyzed the Knee Society Score (KSS), KOOS score and DAS28 in 15 patients, 23 rheumatoid arthritic knees at pre-operation and 1 year after operation. Preoperatively patients had used non-steroidal anti-inflammatory drugs, prednisolone, disease-modifying anti-rheumatic drugs including methotrexate. TKA (Zimmer NexGen LPS Flex Knee implants and Stemmed Tibial component with stem) was performed with the modified gap technique or modified anatomical technique using original tensor with synovectomy. Results. Preoperative and postoperative KSS are 45.7±18.1 and 88.7±17.7 (P<0.01) respectively, and function scores were 40.1±21.7 and 74.8±24.0 (P<0.01) respectively (Figure 1). Preoperative and postoperative KOOS score (%) were ‘pain’ 50.6±37.8 and 95.4±19.3 (P<0.01), ‘symptom’ 56.6±32.8 and 94.7±18.6 (P<0.01), ‘ADL’ 60.6±27.9 and 89.5±32.4 (P<0.01), ‘QOL’ 28.4±32.1 and 63.6 ±22.9 (P<0.01) and ‘sport’ 20.56±29.52 and 47.10±33.9(P=0.06), respectively (Figure 2). Preoperative and postoperative DAS28(CRP) were 4.48±1.08 and 3.58±1.11(P<0.01), and DAS28 (ESR) were 4.90±1.02 and 4.13±0.99 (P=0.02) (Figure 3). Discussion. Each scores except ‘sport’ and DAS28 (ESR) improved statistically 1 year after operation. Function score, ‘ADL’ and ‘QOL’ scores also improved. HAQ score includes 2 categories related to walking ability and TKA was expected to improve the HAQ score, although the HAQ score is highly affected by upper arm function. The ‘sport’ score did not improve because almost all patients did not do sports preoperatively and postoperatively. DAS28 (ESR) and DAS28 (CRP) correlate strongly, but in this study there were statistical discrepancies in improvement. This might be because age, sex, disease duration, and existence of rheumatoid factors, anti-cyclic citrullinated peptide antibody and DLA-DRB1 shared epitope have been shown to influence ESR. DAS28 improved by a little less than 1.0, but there was limited control of disease activity. It was reported that the average DAS 28 didn't drop below 3.2 in 3 years follow-up after TKA. In this study we did not assess depending on preoperative disease activity, but it was reported that TKA had a systematic effect on severe or moderate RA activity, not low disease activity

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

Purpose. With growing attention being paid to quality and cost effectiveness in healthcare, outcome evaluations are becoming increasingly important. This determination can be especially difficult in reverse shoulder arthroplasty (RSA) given the complex pathology and extensive disabilities in this patient population. Several different scoring systems have been developed and validated for use in various shoulder pathologies. The purpose of this study was to assess the use three outcome scores in a population of patients undergoing RSA. We aim to demonstrate the validity of three outcome scores in patients undergoing RSA, and to determine if one score or a combination of scores is superior to others. Methods. Using a database of patients treated with RSA, we assessed preoperative and postoperative Constant Scores, American Shoulder and Elbow Surgeons (ASES) scores, and subjective shoulder values (SSV) in 148 shoulders. The outcomes at each scoring period were described and the scores were compared to one another as well as to active range of motion using linear regression modeling. Results. There were no significant differences in the mean improvement of any of the scores. All of the outcome scales improvements were correlated with each other and improvement in forward elevation but not with external rotation. Using multivariate regression analysis all 3 outcome measures were able to predict 38.9% of the variation in improvement in functional outcomes (forward elevation). This was only slightly greater than that provided by improvements in the outcome variable CS alone (36.7%). Conclusion. The three shoulder outcome scores evaluated, regardless of whether they were patient reported or physician based, appear to appropriately reflect improvements after RSA with equal validity. The objective physician assessed Constant score had the strongest correlation with function of the arm, and use of a combination of all 3 outcome scores does not increase the ability to predict range of motion compared to using the Constant Score alone