Can Neuropathic Pain Predict Response to Arthroplasty in Knee Osteoarthritis? A Prospective Observational Cohort Study
Anushka SoniK.M. LeylandAmit KiranNigel ArdenCyrus CooperVishvarani WanigasekeraIrene TraceyM K JavaidAndrew Price
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Abstract A significant proportion of patients with knee osteoarthritis (OA) continue to have severe ongoing pain following knee replacement surgery. Central sensitization and features suggestive of neuropathic pain before surgery may result in a poor outcome post-operatively. In this prospective observational study of patients undergoing primary knee arthroplasty (n=120), the modified PainDETECT score was used to divide patients, with primary knee OA, into nociceptive (<13), unclear (13–18) and neuropathic -like pain (>18) groups pre-operatively. Response to surgery was compared between groups using the Oxford Knee Score (OKS) and the presence of moderate to severe long-term pain 12 months after arthroplasty. The analyses were replicated in a larger independent cohort study (n=404). 120 patients were recruited to the main study cohort: 63 (52%) nociceptive pain; 32 (27%) unclear pain; 25 (21%) neuropathic-like pain. Patients with neuropathic-like pain had significantly worse OKS pre and post-operatively, compared to the nociceptive pain group, independent of age, sex and BMI. At 12-months post-operatively the mean OKS was 4 points lower in the neuropathic-like group compared with the nociceptive group in the study cohort (non-significant); with a difference of 5 points in the replication cohort (p<0.001). Moderate to severe long-term pain after arthroplasty at 12-months was present in 50% of the neuropathic-like pain group versus 24% in the nociceptive pain group, in the replication cohort (p<0.001). Neuropathic pain is common and targeted therapy pre, peri and post-operatively may improve treatment response.Keywords:
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BackgroundLate-stage isolated medial knee osteoarthritis can be treated with total knee replacement (TKR) or partial knee replacement (PKR). There is high variation in treatment choice and little robust evidence to guide selection. The Total or Partial Knee Arthroplasty Trial (TOPKAT) therefore aims to assess the clinical effectiveness and cost-effectiveness of TKR versus PKR in patients with medial compartment osteoarthritis of the knee, and this represents an analysis of the main endpoints at 5 years.MethodsOur multicentre, pragmatic randomised controlled trial was done at 27 UK sites. We used a combined expertise-based and equipoise-based approach, in which patients with isolated osteoarthritis of the medial compartment of the knee and who satisfied general requirements for a medial PKR were randomly assigned (1:1) to receive PKR or TKR by surgeons who were either expert in and willing to perform both surgeries or by a surgeon with particular expertise in the allocated procedure. The primary endpoint was the Oxford Knee Score (OKS) 5 years after randomisation in all patients assigned to groups. Health-care costs (in UK 2017 prices) and cost-effectiveness were also assessed. This trial is registered with ISRCTN (ISRCTN03013488) and ClinicalTrials.gov (NCT01352247).FindingsBetween Jan 18, 2010, and Sept 30, 2013, we assessed 962 patients for their eligibility, of whom 431 (45%) patients were excluded (121 [13%] patients did not meet the inclusion criteria and 310 [32%] patients declined to participate) and 528 (55%) patients were randomly assigned to groups. 94% of participants responded to the follow-up survey 5 years after their operation. At the 5-year follow-up, we found no difference in OKS between groups (mean difference 1·04, 95% CI −0·42 to 2·50; p=0·159). In our within-trial cost-effectiveness analysis, we found that PKR was more effective (0·240 additional quality-adjusted life-years, 95% CI 0·046 to 0·434) and less expensive (−£910, 95% CI −1503 to −317) than TKR during the 5 years of follow-up. This finding was a result of slightly better outcomes, lower costs of surgery, and lower follow-up health-care costs with PKR than TKR.InterpretationBoth TKR and PKR are effective, offer similar clinical outcomes, and result in a similar incidence of re-operations and complications. Based on our clinical findings, and results regarding the lower costs and better cost-effectiveness with PKR during the 5-year study period, we suggest that PKR should be considered the first choice for patients with late-stage isolated medial compartment osteoarthritis.FundingNational Institute for Health Research Health Technology Assessment Programme.
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Abstract Background Knee osteoarthritis is a common and often disabling disorder, which has been related to knee‐straining work. However, exposure response relations are uncertain and there are few prospective studies. We studied prospectively if incident knee osteoarthritis is associated with cumulative exposure as an airport baggage handler, lifting on average 5000 kg/d. Methods The study is based on the Copenhagen Airport Cohort, a historical cohort of male baggage handlers and a reference group of unskilled men from the greater Copenhagen area, followed from 1990 to 2012. Cumulative years of employment as a baggage handler was based on information from company employment and union registers. Outcome was first hospital admission with a discharge diagnosis of knee osteoarthritis and/or knee replacement, ascertained from the Danish National Patient Register. Results The cohort contained 3442 baggage handlers and 65 511 workers in the reference group. The unadjusted incidence rate ratio (IRR) of knee osteoarthritis increased steeply with cumulative years as a baggage handler. Although the exposure‐response pattern became weaker and statistically nonsignificant ( P ≈ .10) when adjusting for age, the risk of knee osteoarthritis was still increased in baggage handlers at the highest exposure level. Additional analyses showed that the association between age and osteoarthritis was stronger for baggage handlers (IRR = 2.09; 95% CI: 1.68‐2.60) than for referents (IRR = 1.58; 95% CI: 1.53‐1.63), indicating that knee osteoarthritis occurred at a younger age among baggage handlers than in the reference group. Conclusions The results of this prospective cohort study support that long‐term heavy lifting increases the risk of knee osteoarthritis.
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Gender disparities in total knee arthroplasty utilization may be due to differences in perceptions and expectations about total knee arthroplasty outcomes. This study evaluates the impact of a decision aid on perceptions about total knee arthroplasty and decision-making parameters among patients with knee osteoarthritis.Patients with moderate to severe knee osteoarthritis viewed a video about knee osteoarthritis treatments options, including total knee arthroplasty, and received a personalized arthritis report. An adapted version of the Western Ontario and McMaster Universities Osteoarthritis Index was used to assess pain and physical function expectations following total knee arthroplasty before/after the intervention. These scores were compared to an age- and gender-adjusted means for a cohort of patients who had undergone total knee arthroplasty. Decision readiness and conflict were also measured.At baseline, both men and women had poorer expectations about post-operative pain and physical outcomes compared with observed outcomes of the comparator group. Following the intervention, women's mean age-adjusted expectations about post- total knee arthroplasty pain outcomes improved (Pre: 27.0; Post: 21.8 [p =0.08; 95% CI -0.7, 11.0]) and were closer to observed post-TKA outcomes; whereas men did not have a significant change in their pain expectations (Pre: 21.3; Post: 19.6 [p = 0.6; 95% CI -5.8, 9.4]). Women also demonstrated a significant improvement in decision readiness; whereas men did not. Both genders had less decision conflict after the intervention.Both women and men with osteoarthritis had poor estimates of total knee arthroplasty outcomes. Women responded to the intervention with more accurate total knee arthroplasty outcome expectations and greater decision readiness. Improving patient knowledge of total knee arthroplasty through a decision aid may improve medical decision-making and reduce gender disparities in total knee arthroplasty utilization.
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Abstract Objective: To identify associating risk factors to total knee arthroplasty and to follow-up pain and function for up to 5 years after completing
initial comprehensive rehabilitation. Design: Naturalistic, observational cohort study with exploratory analyses of the impact of knee arthroplasty. Rehabilitation lasting 3 to 6
weeks was provided for 205 patients in a rehabilitation clinic setting. The main outcome measures were the Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC) and the Short Form 36 Health Survey. Results: At group level, knee pain and function in patients without arthroplasty remained overall stable from mean=50.6, resp. 51.8 points at
baseline to 53.3, resp. 52.7 points at the 5-year follow-up on the WOMAC (scale 0-100). In the course of knee osteoarthritis, 23.4% (n=48) of the patients
significantly deteriorated in pain and function and was referred for knee arthroplasty. Total knee arthroplasty was associated with female sex
(odds ratio=3.04), educated at university level (odds ratio=3.25), minus 1 comorbidity (odds ratio=1.41), and a decrease of 10 (of 100 possible) points
on the WOMAC factor ascending/descending stairs (odds ratio=1.51). Conclusions: Highly educated women with a lower number of comorbidities and higher disability to manage stairs were more likely to receive total
knee arthroplasty. Keywords Knee osteoarthritis; Rehabilitation; Arthroplasty; Knee replacement
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Patient-reported outcome measures (PROMs) are being used increasingly in total knee arthroplasty (TKA). We conducted a systematic review aimed at identifying psychometrically sound PROMs by appraising their measurement properties. Studies concerning the development and/or evaluation of the measurement properties of PROMs used in a TKA population were systematically retrieved via PubMed, Web of Science, Embase, and Scopus. Ratings for methodological quality and measurement properties were conducted according to updated COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. Of the 155 articles on 34 instruments included, nine PROMs met the minimum requirements for psychometric validation and can be recommended to use as measures of TKA outcome: Oxford Knee Score (OKS); OKS–Activity and Participation Questionnaire (OKS-APQ); 12-item short form Knee Injury and Osteoarthritis Outcome (KOOS-12); KOOS Physical function Short form (KOOS-PS); Western Ontario and McMaster Universities Arthritis Index-Total Knee Replacement function short form (WOMAC-TKR); Lower Extremity Functional Scale (LEFS); Forgotten Joint Score (FJS); Patient’s Knee Implant Performance (PKIP); and University of California Los Angeles (UCLA) activity score. The pain and function subscales in WOMAC, as well as the pain, function, and quality of life subscales in KOOS, were validated psychometrically as standalone subscales instead of as whole instruments. However, none of the included PROMs have been validated for all measurement properties. Thus, further studies are still warranted to evaluate those PROMs. Use of the other 25 scales and subscales should be tempered until further studies validate their measurement properties. Cite this article: Bone Joint Res 2021;10(3):203–217.
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Many patients with osteoarthritis (OA) of the knee and/or hip undergo total joint replacement (TJR) because of severely progressed symptoms.To determine patient and disease characteristics associated with undergoing TJR in participants with recent-onset knee and/or hip OA.Participants with hip or knee pain from the nationwide prospective Cohort Hip and Cohort Knee (CHECK) study were included.The outcome measure was total hip arthroplasty (THA) or total knee arthroplasty (TKA) during 6 years of follow-up. Joint-dependent characteristics were compared using generalised estimating equations (GEE). Multivariable models were built for both subgroups. Differences in symptomatic and radiographic progression were determined between baseline and 2-year follow-up (T2).The knee subgroup included 751 participants (1502 knees), and there were 538 participants in the hip subgroup (1076 hips). Nineteen participants (22 knees) underwent TKA and 53 participants (62 hips) THA. Participants who underwent TKA had higher baseline body mass index, painful knee flexion, and higher Kellgren and Lawrence scores. Participants who underwent THA had painful internal hip rotation and showed more severe radiographic OA features. Participants who underwent TKA or THA showed more rapid symptomatic and radiographic OA progression at T2.In patients with recent-onset knee or hip pain, radiographic OA features already exist and a substantial number of patients fulfil existing criteria for knee and hip OA. A trend was observed in rapid progression of radiographic and symptomatic OA severity among patients with TKA and THA. Early detection of OA by the GP is important in managing knee and hip OA.
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Previous studies have reported lower implant survival rates, residual pain, and higher patient dissatisfaction rates following knee arthroplasty in younger knee arthroplasty patients. We aimed to assess the real-world effectiveness of knee arthroplasty in a prospective non-selected cohort of patients aged 65 years or less with 2-year follow-up.In total, 250 patients (272 knees) aged 65 years or less were enrolled into this prospective cohort study. Patient-reported outcome measures were used to assess the outcome.The mean Oxford Knee Score and all Knee Injury and Osteoarthritis Outcome Score subscales increased significantly (p < 0.001) from preoperative situation to the 2-year follow-up. Significant increase (p < 0.001) in physical activity was detected in High-Activity Arthroplasty Score and RAND-36 Physical Component Score (PCS). Pain was also significantly (p < 0.001) relieved during the follow-up. Total disappearance of pain was rare at 2 years. Patients with milder (Kellgren-Lawrence grade 2) osteoarthritis were less satisfied and reported poorer patient-reported outcome measure than those with advanced osteoarthritis (Kellgren-Lawrence grade 3-4). There was no difference in the outcome (any patient-reported outcome measure) between patients who underwent total knee arthroplasty and those who received unicondylar knee arthroplasty.We found that measured with a wide set of patient-reported outcome measures, both total knee arthroplasty and unicondylar knee arthroplasty resulted in significant pain relief, as well as improvement in physical performance and quality of life in patients aged 65 years or less. Real-world effectiveness of these procedures seems to be excellent. 15% of patients still had residual symptoms and were dissatisfied with the outcome at 2 years after the operation.
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