Factors correlated with pain after total knee arthroplasty: A systematic review and meta-analysis.

MAIN OBJECTIVE: Systematically review and synthesize preoperative and intraoperative factors associated with pain after total knee arthroplasty (TKA) in patients with osteoarthritis. METHODS: Based on a peer-reviewed protocol, we searched Medline, Embase, CINAHL, Cochrane Library, and PEDro for prospective observational studies (January 2000 to February 2023) investigating factors associated with pain after TKA. The primary outcome was pain twelve months after TKA. Pain at three and six months were secondary outcomes. Multivariate random-effects meta-analyses were used to estimate mean correlation (95% CIs) between factors and pain. Sensitivity analysis was performed for each risk of bias domain and certainty of evidence was assessed. RESULTS: Of 13,640 studies, 29 reports of 10,360 patients and 61 factors were analysed. The mean correlation between preoperative factors and more severe pain at twelve months was estimated to be 0.36 (95% CI, 0.24, 0.47; P < .000; moderate-certainty evidence) for more catastrophizing, 0.15 (95% CI; 0.08, 0.23; P < .001; moderate-certainty evidence) for more symptomatic joints, 0.13 (95% CI, 0.06, 0.19; P < .001; very low-certainty evidence) for more preoperative pain. Mean correlation between more severe radiographic osteoarthritis and less pain was -0.15 (95% CI; -0.23, -0.08; P < .001; low-certainty evidence). In sensitivity analysis, the estimated correlation coefficient for pain catastrophizing factor increased to 0.38 (95% CI 0.04, 0.64). At six and three months, more severe preoperative pain was associated with more pain. Better preoperative mental health was associated with less pain at six months. CONCLUSION AND RELEVANCE: More pain catastrophizing, more symptomatic joints and more pain preoperatively were correlated with more pain, while more severe osteoarthritis was correlated with less pain one year after TKA. More preoperative pain was correlated with more pain, and better mental health with less pain at six and three months. These findings should be further tested in predictive models to gain knowledge which may improve TKA outcomes.

Factors Correlated With Physical Function 1 Year After Total Knee Arthroplasty in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis.

Importance: More than 1 in 5 patients do not experience improved physical function after total knee arthroplasty (TKA). Identification of factors associated with physical function may be warranted to improve outcomes in these patients. Objective: To identify preoperative and intraoperative factors associated with physical function at 12 months after TKA in a systematic review and meta-analysis. Data Sources: Data from January 2000 to October 2021 were searched in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Physiotherapy Evidence Database (PEDro). No language restrictions were applied. Study Selection: Prospective observational studies or randomized clinical trials on factors associated with physical function after TKA in adult patients with osteoarthritis were selected. A prespecified peer-reviewed protocol was followed. Data Extraction and Synthesis: Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline, 2 reviewers independently screened titles and abstracts and judged risk of bias using Quality in Prognosis Studies (QUIPS). Multivariate random-effects meta-analyses were performed to estimate mean correlations between factors and physical function with 95% CIs. Sensitivity analyses were conducted for each QUIPS domain. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO). Main Outcomes and Measures: The primary outcome was physical function 12 months after TKA. Secondary outcomes were physical function 3 and 6 months after TKA. All estimates are mean correlations between factors and postoperative function. Positive correlations correspond to better function. Results: Among 12 052 articles, 20 studies (including 11 317 patients and 37 factors) were analyzed. Mean correlation with higher BMI was estimated to be -0.15 (95% CI, -0.24 to -0.05; P = .33; moderate-certainty evidence), while mean correlation with better physical function was estimated to be 0.14 (95% CI, 0.02 to 0.26; P = .03; low-certainty evidence) and mean correlation with more severe osteoarthritis was estimated to be 0.10 (95% CI, 0.01 to 0.19; P = .17; high-certainty evidence). In sensitivity analyses, mean correlation with better physical function was estimated to be 0.20 (95% CI, 0.04 to 0.36; P = .02), and so perhaps a larger coefficient than in the main analysis, while mean correlations were estimated to be similar for other factors (BMI: -0.17; 95% CI, -0.28 to -0.06; P < .001; osteoarthritis severity: 0.10; 95% CI, -0.01 to 0.20; P = .05). Conclusions and Relevance: This study found that higher presurgical BMI was correlated with worse physical function (with moderate certainty) and that better physical function (low certainty) and osteoarthritis severity (high certainty) were correlated with better physical function after TKA. These findings suggest that these factors should be included when testing predictive models of TKA outcomes.

Responsiveness of five shoulder outcome measures at follow-ups from 3 to 24 months.

BACKGROUND: To assess responsiveness of five outcome measures at four different follow-ups in patients with SLAP II lesions of the shoulder. METHODS: 119 patients with symptoms and signs, MRI arthrography and arthroscopic findings were included. The Western Ontario Shoulder Instability Index (WOSI), Oxford Instability Shoulder Score (OISS), EuroQol (EQ-5D3L), Rowe Score and Constant-Murley Score (CMS) were assessed at baseline, 3, 6, 12 and 24 months. The analysis contains both anchor-based and distribution-based methods, and hypothesis testing. RESULTS: Confidence intervals for ROC cut-off values, representing MID, for OISS, CMS and EQ-5D3L crossed zero at 3 months. Cut-off values were stable between 6- and 24-months follow-up. At 24-months ROC cut-off values (95% CI) were: Rowe 18 (13 to 24); WOSI 331 (289 to 442); OISS 9 (5 to 14); CMS 11 (9 to 15) and EQ-5D3L 0.123 (0.035 to 0.222). MID95%limit estimates were substantially higher than ROC cut-off values and MIDMEAN at all follow-ups for all instruments. The reliable change proportion (RCP) values in the improved group were highest for WOSI and the Rowe Score (ranging from 68 to 87%) and significantly lower for CMS. EQ-5D3L had the lowest values (13 to 16%). We found a moderate correlation between mean change scores of the outcome measures and the anchor, except for the EQ-5D3L. CONCLUSIONS: In patients with SLAP II-lesions the patient reported OISS and WOSI and the clinical Rowe score had best responsiveness. Our results suggest that 3 months follow-up is too early for outcome evaluation.

Predictors of chronic pain and level of physical function in total knee arthroplasty: a protocol for a systematic review and meta-analysis.

INTRODUCTION: One in five patients undergoing total knee arthroplasty (TKA) experience unchanged or worse pain and physical function 1 year after surgery. Identifying risk factors for unfavourable outcomes is necessary to develop tailored interventions to minimise risk. There is a need to review more current literature with updated methodology that addresses the limitations of earlier systematic reviews and meta-analyses. We present a Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols compliant protocol for a systematic review and meta-analysis of predictors of chronic pain and impaired function after TKA. METHODS AND ANALYSIS: This review will include prospective longitudinal observational studies, or randomised trials (including cluster and crossover designs) that report arm-wise predictors of chronic postsurgical pain or impaired physical function at 3 months, 6 months or 12 months. A comprehensive literature search of studies published between 2000 and 2019 will be performed in Medline, Embase, CINAHL, Cochrane Library and PEDro. Blinded assessment with consensus agreement will be applied for inclusion of studies, data extraction and assessment of bias risk (Quality in Prognosis Studies tool). The co-primary outcomes, pain and impaired function, at 12 months after TKA will be analysed separately. Estimates of association between each outcome and any preoperative or intraoperative factor that may predict chronic pain or impaired physical function will be extracted from the included studies, where possible. For randomised studies, results will only be extracted from TKA arms (or the first period of crossover trials). Estimates of association from the primary evidence will be synthesised narratively, and quantitatively using multivariate meta-analysis to provide 'pooled' estimates of association. Subgroup and sensitivity analyses will be performed. Certainty of evidence for each predictor will be derived from the Grading of Recommendations Assessment, Development and Evaluation framework. ETHICS AND DISSEMINATION: No ethical issues are associated with this project. The results from this review will be published in peer-reviewed journals and presented at international conferences. PROSPERO REGISTRATION NUMBER: CRD42018079069.

Sick leave and return to work after surgery for type II SLAP lesions of the shoulder: a secondary analysis of a randomised sham-controlled study.

OBJECTIVES: To compare days on sick leave and assess predictors of return to work following shoulder surgery. DESIGN: A secondary analysis of a randomised controlled trial. SETTING: Orthopaedic department. PARTICIPANTS: 114 patients with type II superior labral tear from anterior to posterior of the shoulder. INTERVENTIONS: Labral repair, biceps tenodesis or sham surgery. OUTCOME MEASURES: Sick leave was obtained from national registers for the last year before and 2 years following surgery. Total and shoulder related number of days on sick leave were obtained, using international diagnostic codes. We applied the difference-in-difference approach to compare the differences in the change in mean work days on sick leave between groups over time, backwards logistic regression and lasso regression to evaluate predictors. RESULTS: Mean total number of work days on sick leave during the 2 years after surgery was 148 (range 0-460) days. More than 80% of the sick leave days were taken by 22% of the patients. Days on sick leave classified as shoulder-related constituted 80% of the total. In all three treatment groups, the mean total number of days on sick leave doubled the year after surgery. Sham surgery and labral repair had fewer postoperative sickness absence days compared with biceps tenodesis but differences were not significant when adjusted for days of sick leave the year before surgery. Predictors of return to work at 2 years analysed by logistic regression were no sick leave (OR 8.0, 95% CI 2.4 to 26.0) and moderate symptoms of anxiety or depression (OR 0.16, 95% CI 0.05 to 0.5) at inclusion. Similar results were obtained by lasso regression but manual work was an additional predictor. CONCLUSIONS: Change in mean work days on sick leave comparing sham surgery, labral repair and biceps tenodesis, was not significantly different. Sick leave, symptoms of anxiety and depression, and manual work at inclusion predicted work status 2 years after surgery. TRIAL REGISTRATION NUMBER: NCT00586742.

Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial.

BACKGROUND: Labral repair and biceps tenodesis are routine operations for superior labrum anterior posterior (SLAP) lesion of the shoulder, but evidence of their efficacy is lacking. We evaluated the effect of labral repair, biceps tenodesis and sham surgery on SLAP lesions. METHODS: A double-blind, sham-controlled trial was conducted with 118 surgical candidates (mean age 40 years), with patient history, clinical symptoms and MRI arthrography indicating an isolated type II SLAP lesion. Patients were randomly assigned to either labral repair (n=40), biceps tenodesis (n=39) or sham surgery (n=39) if arthroscopy revealed an isolated SLAP II lesion. Primary outcomes at 6 and 24 months were clinical Rowe score ranging from 0 to 100 (best possible) and Western Ontario Shoulder Instability Index (WOSI) ranging from 0 (best possible) to 2100. Secondary outcomes were Oxford Instability Shoulder Score, change in main symptoms, EuroQol (EQ-5D and EQ-VAS), patient satisfaction and complications. RESULTS: There were no significant between-group differences at any follow-up in any outcome. Between-group differences in Rowe scores at 2 years were: biceps tenodesis versus labral repair: 1.0 (95% CI -5.4 to 7.4), p=0.76; biceps tenodesis versus sham surgery: 1.6 (95% CI -5.0 to 8.1), p=0.64; and labral repair versus sham surgery: 0.6 (95% CI -5.9 to 7.0), p=0.86. Similar results-no differences between groups-were found for WOSI scores. Postoperative stiffness occurred in five patients after labral repair and in four patients after tenodesis. CONCLUSION: Neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier: NCT00586742.

Responsiveness of outcome measures in patients with superior labral anterior and posterior lesions.

BACKGROUND: Evaluation of patients with superior labral anterior and posterior (SLAP) lesions requires outcome measures validated for the purpose. The present study aimed to evaluate the responsiveness of the Rowe score, Oxford Instability Shoulder Score (OISS), Western Ontario Shoulder Instability Index (WOSI) and EuroQol (EQ-5D and EQ-VAS) in patients treated for SLAP lesions. METHODS: Eighty-nine patients were included: 34 had arthroscopic labral repair, 28 had mini-open biceps tenodesis and 27 had physical treatment. The outcome measures were administrated before treatment and after 6 months. Responsiveness was evaluated using standardized response mean (SRM), area under receiver-operating characteristic curve (ROCAUC), reliable chance proportion (RCP) statistics and hypothesis testing. Minimal clinically important change (MCIC) estimates were reported. RESULTS: All outcome measures had high values of SRM (0.86-1.92). RCPs for the improved group were 68% to 79% for OISS, WOSI and Rowe score, and 15% to 49% for EuroQol. ROCAUC was >0.70 for all outcomes. MCIC estimates were 8 and 10 for OISS; 451 and 569 for WOSI; 17 and 18 for Rowe score; 0.39 and 0.53 for EQ-5D; and 35 and 41 for EQ-VAS. Responsiveness tested with hypotheses favours the shoulder-specific outcomes. CONCLUSIONS: OISS, WOSI and Rowe score are more responsive than EuroQol in evaluation of patients with SLAP lesions.

Evaluation of Oxford instability shoulder score, Western Ontario shoulder instability index and Euroqol in patients with SLAP (superior labral anterior posterior) lesions or recurrent anterior dislocations of the shoulder.

BACKGROUND: Having an estimate of the measurement error of self-report questionnaires is important both for assessing follow-up results after treatment and when planning intervention studies. Specific questionnaires have been evaluated for patients with shoulder instability, but not in particular for patients with SLAP (superior labral anterior posterior) lesions or recurrent dislocations. The aim of this study was to evaluate the agreement, reliability, and validity of two commonly questionnaires developed for patients with shoulder instability and a generic questionnaire in patients with SLAP lesions or recurrent anterior shoulder dislocations. METHODS: Seventy-one patients were included, 33 had recurrent anterior dislocations and 38 had a SLAP lesion. The patients filled in the questionnaires twice at the same time of the day (± 2 hours) with a one week interval between administrations. We tested the Oxford Instability Shoulder Score (OISS) (range 12 to 60), the Western Ontario Shoulder Instability Index (WOSI) (0 to 2100), and the EuroQol: EQ-5D (-0.5 to 1.0) and EQ-VAS (0 to 100). Hypotheses were defined to test validity. RESULTS: ICC ranged from 0.89 (95% CI 0.83 to 0.93) to 0.92 (0.87 to 0.95) for OISS, WOSI, and EQ-VAS and was 0.66 (0.50 to 0.77) for EQ-5D. The limits of agreement for the scores were: -7.8 to 8.4 for OISS; -339.9 to 344.8 for WOSI; -0.4 to 0.4 for EQ-5D; and -17.2 and 16.2 for EQ-VAS. All questionnaires reflect the construct that was measured. The correlation between WOSI and OISS was 0.73 and ranged from 0.49 to 0.54 between the shoulder questionnaires and the generic questionnaires. The divergent validity was acceptable, convergent validity failed, and known group validity was acceptable only for OISS. CONCLUSION: Measurement errors and limitations in validity should be considered when change scores of OISS and WOSI are interpreted in patients with SLAP lesions or recurrent shoulder dislocations. EQ-5D is not recommended as a single outcome.

Long-term results after SLAP repair: a 5-year follow-up study of 107 patients with comparison of patients aged over and under 40 years.

PURPOSE: The aims of this prospective cohort study were to assess the long-term results after isolated superior labral repair and to determine whether the results were associated with age. METHODS: One hundred seven patients underwent repair of isolated SLAP tears. There were 36 women and 71 men with a mean age of 43.8 years (range, 20 to 68 years). Mean follow-up was 5.3 years (range, 4 to 8 years). Of the patients, 62 (57.9%) were aged 40 years or older. Follow-up examinations were performed by an independent examiner; 102 patients (95.3%) had a 5-year follow-up. RESULTS: The Rowe score improved from 62.8 (SD, 11.4) preoperatively to 92.1 (SD, 13.5) at follow-up (P < .001). Satisfaction was rated excellent/good for 90 patients (88%) at 5 years. There was no significant difference in the results for patients aged 40 years or older and those aged under 40 years. Difficulty with postoperative stiffness and pain was reported by 14 patients (13.1%). CONCLUSIONS: Our results suggest that long-term outcomes after isolated labral repair for SLAP lesions are good and independent of age. Postoperative stiffness was registered in 13.1% of the patients. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Reliability, agreement and validity of the 1988 version of the Rowe Score.

BACKGROUND: The aim of this study was to evaluate reliability, agreement, and validity of the 1988 version of the Rowe score in patients with superior glenoid labrum lesions (SLAP) or recurrent anterior dislocations. METHODS: Thirty-eight patients with SLAP lesions and 33 with anterior recurrent dislocations were independently tested twice by 2 experienced clinicians with the 1988 version of the Rowe score. In addition, the patients completed disease specific and generic questionnaires--the Western Ontario Shoulders Instability Index (WOSI), Oxford Instability Shoulder Score (OISS), and EuroQol (EQ-5D and EQ-VAS)--at both test days. RESULTS: No significant differences between clinicians and test days were detected for the Rowe score. Limits of agreement of the total score varied from -17.9 to 20.5. For the categorical score (total units), there were significant differences between the 2 examiners (P < .001). The ICC 2.1 was acceptable (>.70) for the total score. No floor or ceiling effects were observed for the total score, but considerable floor and/or ceiling effects were detected for some of the domains. Discriminant validity was acceptable, but content, construct, or convergent validity was not acceptable. CONCLUSION: Results using the 1988 version of the Rowe score should be critically interpreted.

[Non-traumatic shoulder pain]. / Atraumatiske skulderlidelser.

BACKGROUND: Shoulder pain (usually non-traumatic) is the third most common cause of consultations for musculoskeletal pain in primary health care. This article discusses challenges within diagnostics and treatment of non-traumatic shoulder pain. MATERIAL AND METHODS: The article is based on literature identified through a non-systematic search in PubMed and the Cochrane library. RESULTS: One clinical test alone is generally not sufficient to make a pathoanatomical diagnosis. The incidence of degenerative changes in the normal population makes it difficult to interpret diagnostic images. MR is mainly indicated as part of a preoperative assessment and upon a specific indication. For diagnosis of the rotator cuff, ultrasound is as good as MR. Clinical studies do not show clear effects of specific treatment. This may be caused by methodological weaknesses of the trials evaluated and that patient characteristics and placebo effects contribute to the diagnosis. Injection with glucocorticoids seems to be well founded in patients with adhesive capsulate (frozen shoulder). With subacromial pain, supervised physical exercise and surgical treatment have similar effects, but there is not sufficient evidence to recommend particular treatments for rupture. INTERPRETATION: Non-traumatic shoulder pain is usually diagnosed adequately from the medical history and a combination of clinical tests; conservative treatment is most often adequate. When diagnostic imaging is required, ultrasound should be the first choice.

Efficacy of labral repair, biceps tenodesis, and diagnostic arthroscopy for SLAP lesions of the shoulder: a randomised controlled trial.

BACKGROUND: Surgery for type II SLAP (superior labral anterior posterior) lesions of the shoulder is a promising but unproven treatment. The procedures include labral repair or biceps tenodesis. Retrospective cohort studies have suggested that the benefits of tenodesis include pain relief and improved function, and higher patient satisfaction, which was reported in a prospective non-randomised study. There have been no completed randomised controlled trials of surgery for type II SLAP lesions. The aims of this participant and observer blinded randomised placebo-controlled trial are to compare the short-term (6 months) and long-term (2 years) efficacy of labral repair, biceps tenodesis, and placebo (diagnostic arthroscopy) for alleviating pain and improving function for type II SLAP lesions. METHODS/DESIGN: A double-blind randomised controlled trial are performed using 120 patients, aged 18 to 60 years, with a history for type II SLAP lesions and clinical signs suggesting type II SLAP lesion, which were documented by MR arthrography and arthroscopy. Exclusion criteria include patients who have previously undergone operations for SLAP lesions or recurrent shoulder dislocations, and ruptures of the rotator cuff or biceps tendon. Outcomes will be assessed at baseline, three, six, 12, and 24 months. Primary outcome measures will be the clinical Rowe Score (1988-version) and the Western Ontario Instability Index (WOSI) at six and 24 months. Secondary outcome measures will include the Shoulder Instability Questionnaire (SIQ), the generic EuroQol (EQ-5 D and EQ-VAS), return to work and previous sports activity, complications, and the number of reoperations. DISCUSSION: The results of this trial will be of international importance and the results will be translatable into clinical practice. TRIAL REGISTRATION: [ClinicalTrials.gov NCT00586742].

Treatment of labral tears with associated spinoglenoid cysts without cyst decompression.

BACKGROUND: The treatment of symptomatic spinoglenoid cysts has varied from observation, needle aspiration, and open excision to arthroscopic decompression. The purpose of the present study was to prospectively assess whether labral repair alone would lead to cyst resolution and pain relief. METHODS: Forty-two patients with a posterosuperior labral tear and a ganglion cyst at the spinoglenoid notch were treated with arthroscopic débridement of the glenoid rim and labral repair, either with a resorbable tack or a suture anchor. Patients ranged in age from twenty-three to sixty-eight years. Seven patients had clinical and/or radiographic evidence of atrophy of the infraspinatus muscle; one had atrophy of both the infraspinatus and the teres minor muscles, while two had atrophy of the teres minor muscle. All patients had postoperative magnetic resonance imaging performed twice, at an average of fifteen months and again at an average of forty-three months postoperatively. The clinical outcome, including the Rowe score, was assessed for all patients at a median of forty-three months postoperatively. RESULTS: In thirty-seven (88%) of the forty-two patients, the cysts had resolved completely. In five patients, a cyst was still present but with a clear reduction in size. These five patients had remission of pain and were satisfied with the shoulder function. Three patients with preoperative muscular atrophy without fatty infiltration regained normal appearing muscle, while the seven with preoperative fatty changes continued to demonstrate those changes postoperatively. The median Rowe score improved from 61.5 points preoperatively to 98.0 points at the time of follow-up. Thirty-one patients assessed the result of treatment as excellent; nine, as good; and two, as fair. CONCLUSIONS: Most spinoglenoid cysts resolve, and patient satisfaction can be expected to be high after labral fixation without cyst decompression.