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Preoperative psychosocial risk factors for poor outcomes at 1 and 5 years after total knee replacement.

ABSTRACT: Background and purpose - Psychosocial factors are important risk factors for poor outcomes in the first year after total knee replacement (TKR), however their impact on long-term outcomes is unclear. We aimed to identify preoperative psychosocial risk factors for poor outcomes at 1 year and 5 years after TKR. Patients and methods - 266 patients were recruited prior to TKR surgery. Knee pain and function were assessed preoperatively and at 1 and 5 years postoperative using the WOMAC Pain score, WOMAC Function score and American Knee Society Score (AKSS) Knee score. Preoperative depression, anxiety, catastrophizing, pain self-efficacy and social support were assessed. Statistical analyses involved multiple linear regression and mixed effect linear regression. Results - Higher anxiety was a risk factor for worse pain at 1 year postoperative. No psychosocial factors were associated with any outcomes at 5 years postoperative. Analysis of change over time found that patients with higher pain self-efficacy had lower preoperative pain and experienced less improvement in pain up to 1 year postoperative. Higher pain self-efficacy was associated with less improvement in the AKSS up to 1 year postoperative but more improvement between 1 and 5 years postoperative. Interpretation - Preoperative anxiety was found to influence pain at 1 year after TKR. However, none of the psychosocial variables were risk factors for a poor outcome at 5 years post-operative, suggesting that the negative effects of anxiety on outcome do not persist in the longer-term.

SUBMITTER: Wylde V

PROVIDER: S-EPMC5560217 | biostudies-literature | 2017 Oct

REPOSITORIES: biostudies-literature

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Preoperative psychosocial risk factors for poor outcomes at 1 and 5 years after total knee replacement.

Wylde Vikki V Trela-Larsen Lea L Trela-Larsen Lea L Whitehouse Michael R MR Blom Ashley W AW

Acta orthopaedica 20170531 5

Background and purpose - Psychosocial factors are important risk factors for poor outcomes in the first year after total knee replacement (TKR), however their impact on long-term outcomes is unclear. We aimed to identify preoperative psychosocial risk factors for poor outcomes at 1 year and 5 years after TKR. Patients and methods - 266 patients were recruited prior to TKR surgery. Knee pain and function were assessed preoperatively and at 1 and 5 years postoperative using the WOMAC Pain score, W ...[more]

PMID: 28562150

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Project description:BackgroundTotal knee replacement (TKR) is a common procedure in older adults. Physical resilience may be a useful construct to explain variable outcomes. We sought to define a simple measure of physical resilience and identify risk factors for nonresilient patient outcomes.MethodsSecondary analysis of Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) cohort study, a prospective registry of total joint replacement. The analysis included 7 239 adults aged 60 or older who underwent TKR between 2011 and 2015. Measures included sociodemographic and health factors. Outcomes were categorized as physically resilient versus nonresilient based on the change from baseline to 1-year follow-up for 3 patient-reported outcomes: the physical component summary (PCS), bodily pain (BP), and vitality (VT) from the Short Form-36 subcomponent scores, at preop and 1-year postprocedure. Associations were expressed as relative risk (RR) of physically nonresilient outcomes using generalized linear regression models, with Poisson distribution and log link.ResultsAge, body mass index, and Charlson Comorbidity Index (CCI) were associated with increased risk of physically nonresilient outcomes across PCS, BP, and VT: age, per 5 years for PCS (RR = 1.18 [1.12-1.23]), BP (RR = 1.06 [1.01-1.11), and VT (RR = 1.09 [1.06-1.12]); body mass index, per 5 kg/m2, for PCS (RR = 1.13 [1.07-1.19]), BP (RR = 1.06 [1.00-1.11]), and VT (RR = 1.08 [1.04-1.11]); and CCI for PCS CCI = 1 (RR = 1.38 [1.20-1.59]), CCI = 2-5 (RR = 1.59 [1.35-1.88]), CCI ≥6 (RR = 1.55 [1.31-1.83]. Household income >$45 000 associated with lower risk for PCS (RR = 0.81 [0.70-0.93]), BP (RR = 0.80 [0.69-0.91]), and VT (RR = 0.86 [0.78-0.93]).ConclusionsWe operationalized physical resilience and identified factors predicting resilience after TKR. This approach may aid clinical risk stratification, guide further investigation of causes, and ultimately aid patients through the design of interventions to enhance physical resilience.

Project description:ObjectiveTo examine impact of pre-existing and incident problematic musculoskeletal (MSK) areas after total knee replacement (TKR) on postoperative 60-month Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain/function scores.MethodsUsing data from a randomized controlled trial of subjects undergoing TKR for osteoarthritis, we assessed problematic MSK areas in six body regions before TKR and 12, 24, 36, and 48 months after TKR. We defined the following two variables: 1) density count (number of problematic MSK areas occurring after TKR; range 0-24) and 2) cumulative density count (problematic MSK areas both before and after TKR, categorized into four levels: no preoperative areas and density count of 0-1 [reference group]; no preoperative areas and density count of 2 or more; one or more preoperative areas and density count of 0-1; and one or more preoperative areas and density count of 2 or greater). We evaluated the associations between categorized 60-month WOMAC and cumulative density count by ordinal logistic regression.ResultsAmong 230 subjects, 24% reported one or more preoperative problematic MSK area. After TKR, 75% reported a density count of 0 to 1; 25% reported a density count of 2 or more. Compared with the reference group, each cumulative density count category was associated with an increased odds of having a higher category of 60-month WOMAC pain score, as follows: 2.97 (95% confidence interval [CI], 1.48-5.98) for no preoperative problematic areas and density count of 2 or greater, 3.31 (95% CI, 1.64-6.66) for one or more preoperative problematic areas and density count of 0 to 1, and 2.85 (95% CI, 0.97-8.39) for one or more preoperative problematic areas and density count of 2 or greater. Similar associations were observed with 60-month WOMAC function score.ConclusionIn TKR recipients, the presence of problematic musculoskeletal areas beyond the index knee-preoperatively and/or postoperatively-was associated with worse 60-month WOMAC pain/function score.

Project description:BackgroundOne in five patients experience chronic pain 12 months following total knee arthroplasty (TKA). This longitudinal study used a person-centred approach to identify subgroups of patients with distinct chronic pain profiles following TKA and identified preoperative characteristics associated with these profiles.MethodsOn the day before surgery, 202 patients completed questionnaires that assessed pain, interference with functioning, fatigue, anxiety, depression and illness perceptions. Average and worst pain were assessed prior to surgery, on postoperative day 4, at 6 week and at 3 and 12 months following surgery. Using growth mixture modelling, two subgroups with distinct average and worst pain profiles were identified.ResultsPatients in the "lower average" and "lower worst" pain classes had moderate preoperative pain scores that decreased over the remaining 9 months following TKA. Patients in the "higher average" and "higher worst" pain classes had relatively higher preoperative pain scores that increased during the first three months and then decreased slightly over the remaining 9 months. Patients in the higher pain classes had higher interference with function scores; used opioids prior to surgery more often, were more likely to receive a continuous nerve block and ketamine; had higher preoperative fatigue severity and interference scores; and had worse perceptions of illness than patients in the lower pain classes.ConclusionsThese risk factors may be used to identify subgroups of patients at higher risk for more severe pain after TKA. Future studies should test whether modifying these risk factors can improve patients' outcomes after TKA.Significance statementThe present study provides a novel and original analysis of pain profiles following total knee arthroplasty that may contribute to our understanding of the transition from acute to chronic pain. Our results may be used to identify patients at higher risk for poorer outcomes based on preoperative risk factors.

Project description:ImportancePrescription opioid use is common among patients with moderate to severe knee osteoarthritis before undergoing total knee replacement (TKR). Preoperative opioid use may be associated with worse clinical and safety outcomes after TKR.ObjectiveTo determine the association of preoperative opioid use among patients 65 years and older with mortality and other complications at 30 days post-TKR.Design, setting, and participantsThis cohort study used claims data from January 1, 2010, to December 31, 2014, from a random sample of US Medicare enrollees 65 years and older who underwent TKR. Based on opioid dispensing in 360 days prior to TKR, patients were classified as continuous (≥1 opioid dispensing in each of the past 12 months) or intermittent (any dispensing of opioids in the past 12 months but not continuous use) opioid users or as opioid-naive patients (no opioids dispensed in the past 12 months). Data analyses were conducted from October 3, 2017, to November 8, 2018.Main outcomes and measuresPrimary outcomes included in-hospital mortality and 30-day post-TKR mortality, hospital readmission, and revision operation. Secondary safety outcomes at 30 days post-TKR included opioid overdose and vertebral and nonvertebral fracture. Multivariable Cox proportional hazards models estimated hazard ratios (HRs) and 95% CIs.ResultsOf 316 593 patients (mean [SD] age, 73.9 [5.8] years; 214 677 [67.8%] women) who underwent TKR, 22 895 (7.2%) were continuous opioid users, 161 511 (51.0%) were intermittent opioid users, and 132 187 (41.7%) were opioid naive. In-hospital mortality occurred in 276 patients (0.09%). At 30 days post-TKR, 828 patients (0.26%) died, 16 786 patients (5.30%) had hospital readmission, and 921 patients (0.29%) had a revision operation. All primary and secondary outcomes occurred more frequently among continuous opioid users compared with opioid-naive patients. Compared with opioid-naive patients and after adjusting for demographic characteristics, combined comorbidity score, number of different prescription medications, and frailty, continuous opioid users had greater risk of revision operations (HR, 1.63; 95% CI, 1.15-2.32), vertebral fractures (HR, 2.37; 95% CI, 1.37-4.09), and opioid overdose (HR, 4.82; 95% CI, 1.36-17.07) at 30 days post-TKR. However, after adjusting covariates, there were no statistically significant differences in in-hospital (HR, 1.18; 95% CI, 0.73-1.90) or 30-day (HR, 1.05; 95% CI, 0.73-1.51) mortality between continuous opioid users and opioid-naive patients.Conclusions and relevanceAfter adjusting for baseline risk profiles, including comorbidities and frailty, continuous opioid users had a higher risk of revision operations, vertebral fractures, and opioid overdose at 30 days post-TKR but not of in-hospital or 30-day mortality, compared with opioid-naive patients. These results highlight the need for better understanding of patient characteristics associated with chronic opioid use to optimize preoperative assessment of overall risk after TKR.

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Preoperative psychosocial risk factors for poor outcomes at 1 and 5 years after total knee replacement.

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Preoperative psychosocial risk factors for poor outcomes at 1 and 5 years after total knee replacement.

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