Using Surgical Appropriateness Criteria to Examine Outcomes of Total Knee Arthroplasty in a United States Sample

Abstract

Objective We determined outcomes for patients classified as appropriate, inconclusive or inappropriate for total knee arthroplasty (TKA) using a modified version of a validated appropriateness algorithm. Outcome measurement was conceptualized as short-term postoperative change attributable primarily to surgery and rehabilitation (two-months) and as longer term post-operative change and recovery (one- and two-year). Methods Pre-operative and yearly post-operative WOMAC Function, KOOS Symptoms and KOOS Pain scores were examined for persons undergoing primary TKA in the Osteoarthritis Initiative. Multi-group two-piece latent growth curve modeling was used to determine differences in outcome variable changes for each group from pre- to two-months post-surgery as well as over a two-year post-operative period. Results Data from 167 persons with primary TKA were examined. Prevalence rates of appropriate, inconclusive and inappropriate judgments were 47.9%, 20.8%, and 31.3%, respectively. The inappropriate group showed no change at two months following surgery while appropriate and inconclusive groups had substantial improvement in all outcomes. One-year and two-year post-operative recovery outcomes were not significantly different among the three groups. Conclusion The inappropriate group was unchanged two months after surgery and, on average, improved by 2.3 WOMAC Function points from pre-surgery to one year following surgery based on our models. Appropriate and inconclusive groups improved by an average of 19.8 WOMAC Function points at one year post-surgery. These data provide a compelling case for consensus building efforts to define eligibility criteria for TKA with the goals of reducing variation in patient selection and optimizing both change over time and final outcomes.

Preoperative Pain and Function: Profiles of Patients Selected for Total Knee Arthroplasty

“…While deciding whether TKR is appropriate for a patient is based on clinical assessment as well as patient symptoms, our data highlight the patients’ significant symptoms and profiles at the time they elected TKR. In contrast, using the modified-RAND definition of inappropriate surgical intervention criteria developed by Escobar 6 , Riddle et al 7, 29 found using OAI data that 44% of TKRs were classified as appropriate, 22% were classified as inconclusive, and 34% as inappropriate use. However, in another recent study where Ghomrawi et al also used Escobar’s criteria 27 , they found approximately 8% classified as inappropriate TKR use, 12% uncertain, and 81% as appropriate.…”

“…Surgeons and patients must balance delays in surgery timing with the fact that patients had lower pain relief and smaller functional improvement than were patients considered appropriate for TKRs 8, 35 . It is worth noting that using the modified Escobar’s appropriateness criteria, Riddle et al 29 recently found that the group classified as having inconclusive use of TKR had very similar pre-operative scores as the group classified as having appropriate TKR use on WOMAC physical function, KOOS symptoms, and KOOS pain scales‥…”

Women Demonstrate More Pain and Worse Function Before THA but Comparable Results 12 Months After Surgery

“…A good patient outcome after orthopaedic surgery is usually dependent, among other things, on an appropriate indication for surgery [34,37]. However, there is currently no consensus on objective indications for THA; most experts consider the severity of pain and disability to be important [33], but there is little agreement regarding the actual severity of symptoms that indicates the need for surgery [11].…”

Association between activity limitations and pain in patients scheduled for total knee arthroplasty

“…Researchers have attempted to use other measures such as the KOOS Pain and Function subscales to aid in the assessment of TKA appropriateness, but the KOOS Sport and Recreational Activity subscale has not been explored in this capacity [35]. The use of computerized adaptive testing may be a potential option for overcoming the limitations of the WOMAC for measuring a wide range of activity and function limitations for persons considering TKA.…”