Higher Preoperative Patient Activation Associated With Better Patient-reported Outcomes After Total Joint Arthroplasty.

BACKGROUND: Despite widely reported success associated with hip and knee replacements, some patients remain dissatisfied with their outcomes. Patient activation, an individual's propensity to engage in adaptive health behaviors, has been measured as a potentially important factor contributing to health outcomes, cost, and patient experience of care. However, to our knowledge, it has not been studied in patients undergoing total joint arthroplasties (TJAs). QUESTIONS/PURPOSES: We wanted to determine whether patients with higher activation scores would experience (1) greater resolution of pain and improved activity, (2) greater improvements in postoperative physical and mental health, and (3) greater patient satisfaction after primary THA or TKA. METHODS: We approached 174 patients and enrolled 135 who were undergoing primary THA or TKA at one of two hospitals between January 2013 and May 2014. Patient Activation Measure (PAM) scores were obtained preoperatively and patient-reported outcomes were assessed and completed for 125 patients pre- and postoperatively at the 6- or 12-month visit. We assessed pain and activity with the Hip Disability and Osteoarthritis Outcome Score (HOOS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and University of California Los Angeles (UCLA) activity scores. We measured physical and mental health by calculating SF12v2® scores and measured patient satisfaction with the Hip and Knee Satisfaction Scale (HKSS). Linear regression models were used to test the association between baseline PAM and postoperative patient-reported outcomes. RESULTS: Overall, patients with a higher baseline PAM score experienced better pain relief using the HOOS/KOOS pain scores (R2=0.311, p=0.048) and symptoms using the HOOS/KOOS symptom scores (R2=0.272, p=0.021). In addition, higher PAM scores were associated with better postoperative mental health using the SF12v2® (R2=0.057, p<0.001), but were not associated with higher physical health (R2=0.176, p=0.173). Finally, higher PAM scores were associated with having greater postoperative satisfaction after surgery using the HKSS questionnaire (R2=0.048, p=0.023). CONCLUSIONS: Higher preoperative patient activation was associated with better pain relief, decreased symptoms, improved mental health, and greater satisfaction after TJA. Future efforts should be aimed at studying if improving patient activation before surgery results in better patient-reported outcomes after elective THA or TKA. LEVEL OF EVIDENCE: Level II, prognostic study.

Trends in total knee arthroplasty implant utilization.

The incidence of total knee arthroplasty (TKA) has increased alongside our knowledge of knee physiology, kinematics, and technology resulting in an evolution of TKA implants. This study examines the trends in TKA implant utilization. Data was extracted from The Orthopedic Research Network to evaluate trends in level of constraint, fixed vs. mobile bearing, fixation, and type of polyethylene in primary TKAs. In 2012, 88% used cemented femoral and tibial implants, and 96% involved patellar resurfacing. 38% of implants were cruciate retaining, 53% posterior stabilized or condylar stabilized, 3% constrained. 91% were fixed-bearing, 7% mobile-bearing. 52% of tibial inserts were HXLPE. TKA implant trends demonstrate a preference for cemented femoral and tibial components, patellar resurfacing, fixed-bearing constructs, metal-backed tibial components, patellar resurfacing, and increased usage of HXLPE liners.

Trends in total hip arthroplasty implant utilization in the United States.

Total hip arthroplasty (THA) implant usage has evolved as experience has been gained with newer implant designs. The purpose of this study was to characterize trends in THA implant usage between 2001 and 2012. The Orthopedic Research Network, which includes 174 hospitals and ~105,000 THA, was used to evaluate trends in fixation, bearings, acetabular cup and liner, and femoral head usage. In 2012, 93% of THAs were cementless; 56% of THA bearings were metal-HXLPE; and 35% were ceramic-HXLPE. 99% of acetabular cups were modular. 61% of femoral heads were metal, 39% were ceramic, 51% were 36mm, and 28% were 32mm. THA implant usage trends favor cementless fixation, metal-on-polyethylene or ceramic-on-polyethylene bearings, modular acetabular cups, and large diameter femoral heads.

Impaired lymphocyte reactivity measured by immune function testing in untransplanted patients with cirrhosis.

The immune function test is an integrated measure of total mitogen-inducible CD4(+) T cell metabolic activity in the peripheral blood, and it is used to guide the dosing of immunosuppressive medications after solid organ transplantation. Recently, low CD4(+) T cell metabolic activity due to pharmacologic immunosuppression has been linked to rapidly progressive cirrhosis in hepatitis C virus (HCV)-infected liver transplant recipients. We speculate that either cirrhosis or HCV might adversely affect the CD4(+) T cell reactivity even in the absence of immunosuppressive medications. We thus performed this assay on a cohort of untransplanted hepatology patients who were not taking immunomodulatory drugs. Low mitogen-stimulated CD4(+) T cell metabolic reactivity was more commonly seen in untransplanted patients with HCV cirrhosis or with cirrhosis due to other causes but not in control patients or in those with chronic HCV in the absence of cirrhosis. The lowest mean CD4(+) T cell reactivities were seen in patients with both cirrhosis and HCV. Caution should be exercised when immune function test results are used to guide immunomodulatory therapy in transplant recipients with suspected cirrhosis, as low immune function test results may be a consequence of hepatic cirrhosis or of pharmacologic immunosuppression.

Atypia predicting prognosis for intracranial extraventricular neurocytomas.

OBJECT: The literature, at present, provides limited information about extraventricular neurocytomas (EVNs) and is almost exclusively composed of case reports or small case series. Treatment for EVNs has largely been guided by results from central neurocytoma outcome studies. The authors present an analysis of all reported intracranial EVN cases to establish if tumor histopathological features can substratify EVN into groups with differing prognosis and help guide treatment decisions. METHODS: The authors identified studies reporting histology, treatment modality, and outcomes for patients with intracranial EVN. The rates of recurrence and survival for patients were compared using Kaplan-Meier analysis. Atypical tumors, defined by MIB-1 labeling index exceeding 3% or atypical histological features, were compared with typical tumors, and patients 50 years of age or older were compared with those younger than 50 years of age. RESULTS: Eighty-five patients met the inclusion criteria, and 27% of them had an atypical histology. Typical EVNs had a better prognosis than atypical EVNs after primary treatment, with a 5-year recurrence rate of 36% compared with 68% (p < 0.001), and a 5-year mortality rate of 4% compared with 44%, respectively (p < 0.001). Age younger 50 years was associated with a better prognosis than age equal to or greater than 50 years, with a 5-year recurrence rate of 33% and 74%, respectively (p < 0.001), and a 5-year mortality rate of 4% and 52%, respectively (p < 0.001). Multivariate analysis demonstrated that atypical EVNs carried significantly increased risk for recurrence (hazard ratio [HR] 4.91, p < 0.001) and death (HR 22.91, p < 0.01). Gross-total resection was superior to subtotal resection (STR) alone in tumor control rates for typical EVNs (95% and 68%, p < 0.05), and there was a trend for adjuvant external-beam radiotherapy to benefit STR. There was suggestion of similar trends in patients with atypical EVNs. CONCLUSIONS: There are at least 2 distinct histological subtypes of EVN, with different prognostic significances. Atypia or MIB-1 labeling index greater than 3% is a significant predictor of poor prognosis for EVNs. Complete resection or more aggressive attempts at providing adjuvant therapy following STR appear to improve the prognosis for patients with EVNs. Although the authors' results are informative, there are limitations to their analysis. Given the relatively modest total number of cases reported, as well as the nature of the disaggregated analysis, the authors were not able to use formal meta-analytical methods to limit the impact of between center heterogeneity. Additionally, they were not able to control for individual differences in data analysis and presentation across the different studies included in their analysis.