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1.  Cerebrovascular Disease Is Associated with Outcomes after Total Knee Arthroplasty: A U.S. Total Joint Registry Study 
The Journal of arthroplasty  2013;29(1):10.1016/j.arth.2013.04.003.
We assessed the association of cerebrovascular disease with patient-reported outcomes (PROs) of moderate-severe activity limitation and moderate-severe pain at 2- and 5-years after primary total knee arthroplasty (TKA) using multivariable-adjusted logistic regression. 7,139 primary and 4,234 revision TKAs were included. Compared to the patients without cerebrovascular disease, those with cerebrovascular disease had a higher odds ratio (OR) of moderate-severe limitation at 2-years and 5-years, 1.32 (95% confidence interval [CI]: 1.02, 1.72; P=0.04) and 1.83 (95% CI: 1.32, 2.55; P<0.001). No significant associations were noted with moderate-severe pain at 2-years or 5-years. In conclusion, we found that cerebrovascular disease is independently associated with pain and function outcomes after primary TKA. This should be taken into consideration when discussing expected outcomes of TKA with patients.
doi:10.1016/j.arth.2013.04.003
PMCID: PMC3783649  PMID: 23664282
Pain; Activity limitation; cerebrovascular disease; Total knee replacement; arthroplasty; joint replacement; outcomes; Patient-Reported Outcomes; Activities of Daily Living; ADLs; Function; functional limitation
2.  Are outcomes after total knee arthroplasty worsening over time? A time-trends study of activity limitation and pain outcomes 
Background
To examine whether function and pain outcomes of patients undergoing primary total knee arthroplasty (TKA) are changing over time.
Methods
The Mayo Clinic Total Joint Registry provided data for time-trends in preoperative and 2-year post-operative activity limitation and pain in primary TKA patients from 1993-2005. We used chi-square test and analysis for variance, as appropriate. Multivariable-adjusted analyses were done using logistic regression.
Results
In a cohort of 7,229 patients who underwent primary TKA during 1993-2005, mean age was 68.4 years (standard deviation (SD), 9.8), mean BMI was 31.1 (SD, 6.0) and 55% were women. Crude estimates showed that preoperative moderate-severe overall limitation were seen in 7.3% fewer patients and preoperative moderate-severe pain in 2.7% more patients in 2002-05, compared to 1992-95 (p < 0.001 for both). At 2-years, crude estimates indicated that compared to 1992-95, moderate-severe post-TKA overall limitation was seen in 4.7% more patients and moderate-severe post-TKA pain in 3.6% more patients in 2002-05, both statistically significant (p ≤ 0.018) and clinically meaningful. In multivariable-adjusted analyses that adjusted for age, sex, anxiety, depression, Deyo-Charlson index, body mass index and preoperative pain/limitation, patients had worse outcomes 2-year post-TKA in 2002-2005 compared to 1993-95 with an odds ratio (95% confidence interval (CI); p-value) of 1.34 (95% CI: 1.02, 1.76, p = 0.037) for moderate-severe activity limitation and 1.79 (95% CI: 1.17, 2.75, p = 0.007) for moderate-severe pain.
Conclusion
Patient-reported function and pain outcomes after primary TKA have worsened over the study period 1993-95 to 2002-05. This time-trend is independent of changes in preoperative pain/limitation and certain patient characteristics.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2474-15-440) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2474-15-440
PMCID: PMC4301928  PMID: 25519240
Total knee replacement; Time trends; Arthroplasty; Joint replacement; Pain; Function
3.  Increasing obesity and comorbidity in patients undergoing primary total hip arthroplasty in the U.S.: A 13-year study of time trends 
Background
Few, if any data are available are available regarding the time-trends in characteristics of patients who have undergone primary THA. Our objective was to examine the time-trends in key demographic and clinical characteristics of patients undergoing primary total hip arthroplasty (THA).
Methods
We used the data from the Mayo Clinic Total Joint Registry from 1993–2005 to examine the time-trends in demographics (age, body mass index (BMI)), medical (Deyo-Charlson index) and psychological comorbidity (anxiety, depression) and underlying diagnosis of patients undergoing primary THA. Chi-square test and analysis for variance were used. Multivariable-adjusted logistic regression (age, sex, comorbidity-adjusted) compared 1993–95 to other study periods. Odds ratio (OR) and 95% confidence interval (CI) are presented.
Results
The primary THA cohort consisted of 6,168 patients with 52% women. In unadjusted analyses, compared to 1993–95, significantly more patients (by >2-times for most) in 2002–05 had: BMI ≥ 40, 2.3% vs. 6.3%; depression, 4.1% vs. 9.8%; and anxiety, 3.4% vs. 5.7%; and significantly fewer had an underlying diagnosis of rheumatoid/inflammatory arthritis, 3.7% vs. 1.5% (p ≤ 0.01 for all). In multivariable-adjusted models, compared to 1993–95, significantly more patients in 2003–05 had (all p-values ≤ 0.01): BMI ≥ 40, OR, 2.79 (95% CI: 1.85, 4.22); Deyo-Charlson Index ≥ 3, 1.32 (1.07, 1.63); depression, 2.25 (1.66, 3.05); and anxiety, 1.71 (1.19, 2.15). Respectively, fewer patients had a diagnosis of RA/inflammatory arthritis: 0.28 (0.17, 0.46; p < 0.01). Over the 13-year study period, Deyo-Charlson index increased by 22% (0.9 to 1.1) and the mean age decreased by 0.7 years (65.0 to 64.3) (p < 0.01 for both).
Conclusions
Obesity, medical and psychological comorbidity increased and the underlying diagnosis of RA/inflammatory arthritis decreased rapidly in primary THA patients over 13-years. Our cohort characteristics are similar to previously described characteristics of national U.S. cohort, suggesting that these trends may be national rather than local trends. This is important information for policy makers to take into account for resource allocation. Studies of THA outcomes and utilization should take these rapidly changing patient characteristics into account.
doi:10.1186/1471-2474-15-441
PMCID: PMC4302153  PMID: 25519434
Total hip replacement; Time trends; Arthroplasty; Joint replacement; Diagnosis; Obesity; Comorbidity; Osteoarthritis
4.  Clinically important body weight gain following knee arthroplasty: A five-year comparative cohort study 
Arthritis care & research  2013;65(5):669-677.
Objective
The impact of knee arthroplasty on subsequent body weight gain has not been fully explored. Clinically important weight gain following knee arthroplasty would pose potentially important health risks.
Methods
We used one of the largest US-based knee arthroplasty registries and a population- based control sample from the same geographic region to determine whether knee arthroplasty increases risk of clinically important weight gain of 5% or more of baseline body weight over a 5-year postoperative period.
Results
Of the persons in the knee arthroplasty sample, 30.0% gained 5% or more of baseline body weight five years following surgery as compared to 19.7% of the control sample. The multivariable adjusted (age, sex, BMI, education, comorbidity and pre-surgical weight change) odds ratio was 1.6 (95% CI, 1.2, 2.2) in persons with knee arthroplasty as compared to the control sample. Additional arthroplasty procedures during the 5-year follow-up further increased risk for weight gain (OR=2.1, 95% CI, 1.4, 3.1) relative to the control sample. Specifically among patients with knee arthroplasty, younger patients and those who lost greater amounts of weight in the 5-year pre-operative period were at greater risk for clinically important weight gain.
Conclusions
Patients who undergo knee arthroplasty are at increased risk of clinically important weight gain following surgery. Future research should develop weight loss/maintenance interventions particularly for younger patients who have lost a substantial amount of weight prior to surgery as they are most at risk for substantial postsurgical weight gain.
doi:10.1002/acr.21880
PMCID: PMC4169302  PMID: 23203539
5.  Clinically important body weight gain following total hip arthroplasty: A cohort study with five-year follow-up 
Objective
Literature examining the effects of total hip arthroplasty (THA) on subsequent body weight gain is inconclusive. Determining the extent to which clinically relevant weight gain occurs following THA has important public health implications.
Design
We used multivariable logistic regression to compare data from one of the largest US-based THA registries to a population-based control sample from the same geographic region. We also identified factors that increased risk of clinically important weight gain specifically among persons undergoing THA. The outcome measure of interest was weight gain of ≥ 5% of body weight up to 5 years following surgery.
Results
The multivariable adjusted (age, sex, BMI, education, comorbidity and pre-surgical weight change) odds ratio for important weight gain was 1.7 (95% CI, 1.06, 2.6) for a person with THA as compared the control sample. Additional arthroplasty procedures during the 5-year follow-up further increased odds for important weight gain (OR=2.0, 95% CI, 1.4, 2.7) relative to the control sample. A patient with THA had increased risk of important post-surgical weight gain of 12% (OR=1.12; 95%CI,1.08, 1.16) for every kilogram of pre-operative weight loss.
Conclusions
While findings should be interpreted with caution because of missing follow-up weight data, patients with THA appear to be at increased risk of clinically important weight gain following surgery as compared to peers. Patients less than 60 years and who have lost a substantial amount of weight prior to surgery appear to be at particularly high risk of important postsurgical weight gain.
doi:10.1016/j.joca.2012.09.010
PMCID: PMC4169300  PMID: 23047011
knee; hip; arthroplasty; obesity
6.  Time trends in the Characteristics of Patients Undergoing Primary Total Knee Arthroplasty 
Arthritis care & research  2014;66(6):897-906.
Objective
To study the time-trends in socio-demographic and clinical characteristics of patients undergoing primary total knee arthroplasty (TKA).
Methods
We used the Mayo Clinic Total Joint Registry to examine the time-trends in patient demographics (body mass index [BMI], age), underlying diagnosis, medical (Deyo-Charlson index) and psychological comorbidity (anxiety, depression) and examination findings of primary TKA patients from 1993–2005. We used chi-square test and analysis of variance.
Results
7,229 patients constituted the primary TKA cohort; 55% were women. The mean age decreased by 1.3 years (69.3 to 68.0), BMI increased by 1.7 kg/m2 (30.1 to 31.8) and Deyo-Charlson index increased by 36% (1.1 to 1.5) over the 13-year study period (p<0.001 for all). Compared to 1993–95, significantly more patients (by 2–3 times) in 2002–05 had (p<0.001 for all): BMI ≥40, 4.8% vs. 10.6%; age <50, 2.9% vs. 5.2%; Deyo-Charlson index of ≥3, 12% vs. 22.3%; depression, 4.1% vs. 14.8%; anxiety, 4.1% vs. 8.9%; and a significantly fewer had an underlying diagnosis of rheumatoid/inflammatory arthritis, 6.4% vs. 1.5%. Compared to 1993–95, significant reductions were noted in 2002–05 for the physical examination findings of (p<0.001 for all): knee joint effusion, anterior-posterior knee instability, medial-lateral knee instability, moderate-severe knee synovitis, severe limp, fair or poor muscle strength and absent peripheral pulses.
Conclusions
In this large U.S. total joint registry study, we found significant time-trends in patient characteristics, diagnosis, comorbidity and knee/limb examination findings in primary TKA patients over 13-years. These secular trends should be taken into account when comparing outcomes over time and in policy-making decisions.
doi:10.1002/acr.22233
PMCID: PMC4151514  PMID: 24249702
Total knee replacement; time trends; arthroplasty; joint replacement; diagnosis; obesity; comorbidity; osteoarthritis
7.  Medical Comorbidity is Associated with Persistent Index Hip Pain after Primary THA 
Pain medicine (Malden, Mass.)  2013;14(8):10.1111/pme.12153.
Objective
To characterize whether medical comorbidity predicts persistent moderate-severe pain after total hip arthroplasty (THA)
Methods
We analyzed the prospectively collected data from the Mayo Clinic Total Joint Registry for patients who underwent primary or revision THA between 1993–2005. Using multivariable-adjusted logistic regression analyses, we examined whether certain medical comorbidities were associated with persistent moderate-severe hip pain 2- or 5-years after primary or revision THA. Odds ratios (OR), along with 95% confidence intervals (CI) and p-value are presented.
Results
The primary THA cohort consisted of 5,707 THAs and 3,289 THAs at 2- and 5-years, and revision THA, 2,687 and 1,627 THAs, respectively. In multivariable-adjusted logistic regression models, in the primary THA cohort, renal disease was associated with lower odds of moderate-severe hip pain (OR, 0.6; 95% CI, 0.3, 1.0) at 2-years. None of the comorbidities were significantly associated at 5-years. In the revision THA cohort, heart disease was significantly associated with higher risk (OR, 1.7; 95% CI, 1.1, 2.6) at 2-years and connective tissue disease with lower risk (OR, 0.5; 95% CI, 0.3, 0.9) of moderate-severe hip pain at 5-years follow-up.
Conclusion
This study identified new correlates of moderate-severe hip pain after primary or revision THA, a much-feared outcome of hip arthroplasty. Patients with these comorbidities should be informed regarding the increased risk or moderate-severe index hip pain, so that they can have a fully informed consent and realistic expectations.
doi:10.1111/pme.12153
PMCID: PMC3814009  PMID: 23742141
Pain; Function; functional limitation; Total hip replacement; primary; arthroplasty; joint replacement; outcomes; Patient-Reported Outcomes
8.  Patient-level clinically meaningful improvements in activities of daily living and pain after total hip arthroplasty: data from a large US institutional registry 
Rheumatology (Oxford, England)  2013;52(6):1109-1118.
Objective. To characterize patient-level clinically meaningful improvements in pain and limitation of key activities of daily living (ADLs) after primary or revision total hip arthroplasty (THA).
Methods. We analysed prospectively collected data from the Mayo Clinic Total Joint Registry to study clinically meaningful improvements in index hip pain severity and limitation in seven key ADLs (walking, climbing stairs, putting on shoes/socks, picking up objects, getting in/out of car, rising from a chair and sitting), from preoperative to 2- and 5-year post-THA.
Results. The primary THA cohort consisted of 6168 responders preoperatively, 5707 at 2 years and 3289 at 5 years postoperatively. The revision THA cohort consisted of 2063 responders preoperatively, 2682 at 2 years and 1627 at 5 years postoperatively. In the primary THA cohort, clinically meaningful pain reduction to mild or no hip pain at 2 years was reported by 94% with moderate and 91% with severe preoperative pain; respective proportions were 91% and 89% at 5-year follow-up. For revision THA, respective proportions were 84% and 77% at 2 years and 80% and 78% at 5 years. In the primary THA cohort, up to 4% with moderate and 17% with severe preoperative ADL limitation reported severe limitation in the respective activity 2 years post-primary THA; at 5 years, the respective proportions were up to 7% and 20%. Respective proportions for revision THA were up to 10% and 26% at 2 years and 13% and 30% at 5 years.
Conclusions. These comprehensive data for patient-level clinically meaningful improvements in pain and seven key ADLs can help patients set realistic goals for improvement after THA.
doi:10.1093/rheumatology/kes416
PMCID: PMC3651614  PMID: 23382362
pain; activity limitation; activities of daily living; function; functional limitation; total hip replacement; arthroplasty; joint replacement; outcomes; patient-reported outcomes; primary; revision
9.  Better Functional and Similar Pain Outcomes in Osteoarthritis compared to Rheumatoid arthritis after primary total knee arthroplasty: A cohort study 
Arthritis care & research  2013;65(12):10.1002/acr.22090.
Objective
To determine the association of the underlying diagnosis with limitation in activities of daily living (ADLs) and pain in patients undergoing primary total knee arthroplasty (TKA).
Methods
Prospectively collected data from the Mayo Clinic Total Joint Registry were used to assess the association of diagnosis with moderate-severe limitation in activities of daily living (ADLs) and moderate-severe pain and at 2- and 5-years after primary TKA using multivariable-adjusted logistic regression analyses. We calculated odds ratios (OR) and 95% confidence intervals (CI).
Results
There were 7,139 primary TKAs at 2-years and 4,234 at 5-years. In multivariable-adjusted analyses, compared to rheumatoid arthritis (RA)/inflammatory arthritis, osteoarthritis (OA) was associated with significantly lower odds ratio (OR) [95% confidence interval (CI)] of moderate-severe ADL limitation with OR of 0.5 [95% CI: 0.3, 0.8] (p=0.004) at 2-years, and 0.5 [95% CI, 0.3, 0.9] (p=0.02) at 5-years. There was no significant association of diagnosis of OA with moderate-severe pain at 2-years with OR of 1.2 [0.5, 2.7] (p=0.68) or at 5-years with OR of 1.0 [0.3, 3.7] (p=1.0).
Conclusion
We found patients with OA who underwent primary TKA had better ADL outcomes compared to patients with RA/inflammatory arthritis at 2- and 5-years. On the other hand, the pain outcomes did not differ in OA vs. RA after primary TKA. This suggests discordant effect of underlying diagnosis on pain and function outcomes after TKA. These novel findings can be used to better inform both patients and surgeons about expected pain and function outcomes after primary TKA.
doi:10.1002/acr.22090
PMCID: PMC3855298  PMID: 23925956
Total knee replacement; arthroplasty; joint replacement; patient-reported outcomes; osteoarthritis; rheumatoid arthritis
10.  Medical and psychological comorbidity predicts poor pain outcomes after total knee arthroplasty 
Rheumatology (Oxford, England)  2013;52(5):916-923.
Objective. To study comorbidity correlates of moderate to severe pain after total knee arthroplasty (TKA).
Methods. We analysed prospectively collected Total Joint Registry data to examine whether medical (heart disease, peripheral vascular disease, renal disease, chronic obstructive pulmonary disease, diabetes and CTD) and psychological (anxiety and depression) comorbidity is associated with moderate to severe pain after primary or revision TKA. Multivariable-adjusted logistic regression simultaneously adjusted for all comorbidities, age, sex, BMI, underlying diagnosis, American Society of Anesthesiologist (ASA) class, distance from medical centre and implant fixation (only for primary TKA) was used to analyse primary and revision TKA separately.
Results. The primary TKA cohort consisted of 7139 and 4234 TKAs (response rates 65% and 57%) and the revision TKA cohort consisted of 1533 and 881 TKAs at 2 and 5 years (response rates 57% and 48%), respectively. In the primary TKA cohort, anxiety was associated with 1.4 higher odds (95% CI 1.0, 2.0) of moderate to severe index knee pain at 2 years; at 5 years, heart disease (OR 1.7; 95% CI 1.1, 2.6), depression (OR 1.7; 95% CI 1.1, 2.5) and anxiety (OR 1.9; 95% CI 1.2, 3.1) were significantly associated with moderate to severe pain. For revision TKA, CTD (OR 0.5; 95% CI 0.2, 0.9) and depression (OR 1.8; 95% CI 1.1, 3.1) were significantly associated with moderate to severe pain.
Conclusion. This study identified medical and psychological comorbidity risk factors for moderate to severe pain after primary and revision TKA. This information can be used to provide realistic outcome expectations for patients before undergoing primary or revision TKA.
doi:10.1093/rheumatology/kes402
PMCID: PMC3630396  PMID: 23325037
pain; function; functional limitation; total knee replacement; primary; arthroplasty; joint replacement; outcomes; patient-reported outcomes
11.  Depression in primary TKA and higher medical comorbidities in revision TKA are associated with suboptimal subjective improvement in knee function 
Background
To characterize whether medical comorbidities, depression and anxiety predict patient-reported functional improvement after total knee arthroplasty (TKA).
Methods
We analyzed the prospectively collected data from the Mayo Clinic Total Joint Registry for patients who underwent primary or revision TKA between 1993–2005. Using multivariable-adjusted logistic regression analyses, we examined whether medical comorbidities, depression and anxiety were associated with patient-reported subjective improvement in knee function 2- or 5-years after primary or revision TKA. Odds ratios (OR), along with 95% confidence intervals (CI) and p-value are presented.
Results
We studied 7,139 primary TKAs at 2- and 4,234 at 5-years; and, 1,533 revision TKAs at 2-years and 881 at 5-years. In multivariable-adjusted analyses, we found that depression was associated with significantly lower odds of 0.5 (95% confidence interval [CI]: 0.3 to 0.9; p = 0.02) of ‘much better’ knee functional status (relative to same or worse status) 2 years after primary TKA. Higher Deyo-Charlson index was significantly associated with lower odds of 0.5 (95% CI: 0.2 to 1.0; p = 0.05) of ‘much better’ knee functional status after revision TKA for every 5-point increase in score.
Conclusions
Depression in primary TKA and higher medical comorbidity in revision TKA cohorts were associated with suboptimal improvement in index knee function. It remains to be seen whether strategies focused at optimization of medical comorbidities and depression pre- and peri-operatively may help to improve TKA outcomes. Study limitations include non-response bias and the use of diagnostic codes, which may be associated with under-diagnosis of conditions.
doi:10.1186/1471-2474-15-127
PMCID: PMC3990241  PMID: 24725511
Total knee arthroplasty; Knee function; Functional limitation; Primary; Arthroplasty; Joint replacement; Outcomes; Patient-reported outcomes
12.  Aseptic Tibial Debonding as a Cause of Early Failure in a Modern Total Knee Arthroplasty Design 
Background
We observed isolated tibial component debonding from the cement in one modern primary TKA design (NexGen LPS 3° tibial tray; Zimmer, Warsaw, IN, USA). This failure mechanism is sparsely reported in the literature.
Questions/Purposes
We (1) assessed survivorship of this tibial tray with special emphasis on debonding; (2) described clinical and radiographic features associated with tibial failure; and (3) compared patient and radiographic features of the failures with a matched cohort.
Methods
A total of 1337 primary TKAs were performed with a cemented NexGen LPS 3° tibial tray over an 11-year period. Twenty-five knees (1.9%) were revised for tibial debonding. BMI and radiographic alignment in the tibial debonding group were compared with a matched control group. Implant survivorship was assessed using tibial debonding as the end point.
Results
Survival free of revision from tibial debonding was 100% at 1 year and 97.8% at 5 years. The tibial failures shared a typical radiographic pattern with debonding at the cement-implant interface and subsidence into varus and flexion. We found no link between limb alignment or individual component alignment and failure because 22 of the 25 failures occurred in well-aligned knees.
Conclusions
Our standardized followup of patients undergoing TKA at routine intervals allowed us to discover a higher rate of revision resulting from tibial debonding. We have discontinued the use of this particular tibial tray for primary TKA and surveillance for patients undergoing TKA continues to be warranted.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-012-2467-4
PMCID: PMC3528903  PMID: 22790529
13.  Determinants of Direct Medical Costs in Primary and Revision Total Knee Arthroplasty 
Background
TKA procedures are increasing rapidly, with substantial cost implications. Determining cost drivers in TKA is essential for care improvement and informing future payment models.
Questions/Purposes
We determined the components of hospitalization and 90-day costs in primary and revision TKA and the role of demographics, operative indications, comorbidities, and complications as potential determinants of costs.
Methods
We studied 6475 primary and 1654 revision TKA procedures performed between January 1, 2000, and September 31, 2008, at a single center. Direct medical costs were measured by using standardized, inflation-adjusted costs for services and procedures billed during the 90-day period. We used linear regression models to determine the cost impact associated with individual patient characteristics.
Results
The largest proportion of costs in both primary and revision TKA, respectively, were for room and board (28% and 23%), operating room (22% and 17%), and prostheses (13% and 24%). Prosthesis costs were almost threefold higher in revision TKA than in primary TKA. Revision TKA procedures for infections and bone and/or prosthesis fractures were approximately 25% more costly than revisions for instability and loosening. Several common comorbidities were associated with higher costs. Patients with vascular and infectious complications had longer hospital stays and at least 80% higher 90-day costs as compared to patients without complications.
Conclusions
High prosthesis costs in revision TKA represent a factor potentially amenable to cost containment efforts. Increased costs associated with demographic factors and comorbidities may put providers at financial risk and may jeopardize healthcare access for those patients in greatest need.
Level of Evidence
Level IV, economic and decision analyses. See Instructions for Authors for a complete description of levels of evidence
doi:10.1007/s11999-012-2508-z
PMCID: PMC3528929  PMID: 22864619
14.  Predictors of Activity Limitation and Dependence on Walking Aids following Primary Total Hip Arthroplasty 
Journal of the American Geriatrics Society  2010;58(12):10.1111/j.1532-5415.2010.03182.x.
OBJECTIVES
To study function outcomes and their predictors after primary total hip arthroplasty (THA).
DESIGN
Prospective Cohort Study
SETTING
Single Institution
PARTICIPANTS
All patients who underwent primary THA at our institution between 1993 and 2005 and were alive at the time of follow-up.
MEASUREMENTS
Whether sex, age, body mass index (BMI), comorbidity, anxiety, and depression predict moderate to severe activity limitation (limitation in ≥3 activities) and complete dependence on waling aids 2 and 5 years after primary THA was examined. Multivariable logistic regression adjusted for operative diagnosis, American Society of Anesthesiologists score, implant type, and distance from medical center.
RESULTS
At 2 years, 30.3% of participants reported moderate to severe activity limitation; at 5 years, 35% of participants reported moderate to severe activity limitation. Significant predictors of moderate to severe activity limitations at 2-year follow-up were female sex (odds ratio (OR)=1.2, 95% confidence interval (CI)=1.1–1.4), aged 71 to 80 (OR=2.0, 95% CI=1.6–2.5), aged 80 and older (OR=4.5, 95% CI=3.4–6.0), depression (OR=2.1, 95% CI=1.6–2.7), and BMI greater than 30. At 5-year follow-up, significant predictors were aged 71 to 80 (OR=1.7, 95% CI=1.3–2.2), older than 80 (OR=4.3, 95% CI=2.8–6.6), depression (OR=2.3, 95% CI=1.6–3.4), and BMI greater than 30.Significant predictors of complete dependence on walking aids at 2 years were female sex (OR=2.0, 95% CI=1.4–2.7), aged 71 to 80 (OR=2.4, 95% CI=1.4–4.2), older than 80 (OR=11.4, 95% CI=6.0–21.9), higher Deyo-Charlson score (OR=1.5, 95% CI=(1.1–1.2) for 5-point increase, depression (OR=2.0, 95% CI=1.2–3.4), and BMI greater than 35. Each of these factors also significantly predicted complete dependence on walking at 5-year follow-up, with similar odds ratios, except that BMI 30–34.9 was not significantly associated.
CONCLUSION
Higher BMI, depression, older age, and female sex predict activity limitation and complete dependence on walking aids 2 and 5 years after primary THA.
doi:10.1111/j.1532-5415.2010.03182.x
PMCID: PMC3850176  PMID: 21143444
Primary Total Hip Arthroplasty; THA; Predictors; Activity Limitation; Function; walking aids
15.  Diabetes: A Risk Factor for Poor Functional Outcome after Total Knee Arthroplasty 
PLoS ONE  2013;8(11):e78991.
Background
To assess the association of diabetes with postoperative limitation of activities of daily living (ADLs) after primary total knee arthroplasty (TKA).
Methodology/Principal Findings
We used the prospectively collected data from the Mayo Clinic Total Joint Registry to assess the association of diabetes and diabetes with complications with moderate-severe ADL limitation 2- and 5-years after primary TKA. Multivariable logistic regression with general estimating equations adjusted for preoperative ADL limitation, comorbidity and demographic and clinical covariates. Odds ratio (OR) and 95% confidence interval (CI) are presented. 7,139 primary TKAs at 2-years and 4,234 at 5-years constituted the cohorts. In multivariable-adjusted analyses, diabetes was associated with higher odds of moderate-severe limitation at 2- and 5-years, 1.71 (95% CI: 1.26, 2.32; P = 0.001) and 1.66 (95% CI: 1.13, 2.46; P = 0.01). Respective ORs for patients with diabetes with complications were 2.73 (95% CI: 1.47, 5.07; P = 0.001) and 2.73 (95% CI: 1.21, 6.15; P = 0.016). Sensitivity analyses that adjusted for anxiety and depression or anxiety, depression and ipsilateral hip involvement showed minimal attenuation of magnitude of the association.
Conclusions/Significance
In this large study of patients who underwent primary TKA, diabetes as well as its severity were independently associated with poorer functional outcome. Given the increasing rates of both diabetes as well as arthroplasty, more insight is needed into disease-related and treatment-related factors that underlie this higher risk of ADL limitation in patients with diabetes. Poor functional outcomes may be preventable by modifying the control of diabetes and associated comorbidity in pre- and post-arthroplasty periods.
doi:10.1371/journal.pone.0078991
PMCID: PMC3827297  PMID: 24236080
16.  Tantalum Acetabular Cups Provide Secure Fixation in THA after Pelvic Irradiation at Minimum 5-year Followup 
Background
Pelvic radiation has been commonly used to treat gastrointestinal, genitourinary, or hematopoietic malignancies. Conventional THA in these patients reportedly have high rates of fixation failure. Although secure short-term fixation reportedly occurs with trabecular metal implants following pelvic radiation, it is unclear whether the fixation is durable.
Questions/purposes
We determined the survival of trabecular metal acetabular components in patients having THA following pelvic radiation and assessed function and radiographic loosening.
Methods
We retrospectively reviewed 29 patients with prior pelvic radiation who had 34 arthroplasties using trabecular metal acetabular components from 1998 and 2005. The mean pelvic radiation dose was 6300 cGy. We collected the following data: patient demographics, surgery and implant information, clinical and radiographic followup, and tumor and radiotherapy related details. We obtained Harris hip scores (HHS) on all patients. Ten patients died of disease prior to 5 years and two patients were excluded, leaving 17 patients (22 hips) with a minimum of 5 years of clinical (mean, 78 months; median, 71; range, 57–116) and radiographic (mean, 73; median, 65; range, 51–116) followup.
Results
All implants were in place in the surviving patients. The mean HHS improved from 36 preoperatively to 80 at latest followup. There were no reoperations for any reason, and we observed no implant loosening or migration at final followup in surviving or deceased patients.
Conclusions
Tantalum trabecular metal acetabular components restored function and provided durable reconstruction in patients undergoing THA following prior pelvic radiation. We observed no clinical or radiographic failures at a minimum 5-year followup.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-012-2382-8
PMCID: PMC3462848  PMID: 22576931
17.  Total Knee Arthroplasty in Morbidly Obese Patients Treated with Bariatric Surgery: A Comparative Study 
The Journal of arthroplasty  2012;27(9):1696-1700.
Our objective was to compare outcomes (anesthesia time, total operative time, tourniquet time, duration of hospital stay, 90-day complication rate and transfusion rates) of patients with total knee arthroplasty (TKA) who underwent bariatric surgery before or after TKA. One-hundred-twenty-five patients were included: TKA before bariatric surgery (group 1; n=39); TKA within two years of bariatric surgery (group 2; n=25); and TKA more than 2 years after bariatric surgery (group 3; n=61). Patients with TKA more than 2 years after bariatric surgery had shorter anesthesia, total operative and tourniquet times than other groups; differences were significant between groups. Ninety-day complication and transfusion rates approached but did not meet statistical significance. Ninety-day complication rates and duration of hospital stay did not differ significantly between the three groups.
doi:10.1016/j.arth.2012.03.005
PMCID: PMC3413743  PMID: 22554730
Total knee arthroplasty; morbidly obese; bariatric surgery; outcomes
18.  Patients with osteoarthritis and avascular necrosis have better functional outcomes and those with avascular necrosis worse pain outcomes compared to rheumatoid arthritis after primary hip arthroplasty: a cohort study 
BMC Medicine  2013;11:210.
Background
This study was conducted to assess whether patient-reported outcomes (PROs) differ by the underlying diagnosis (rheumatoid arthritis (RA)/inflammatory arthritis, osteoarthritis (OA), avascular necrosis of bone (AVN), other) in patients undergoing primary total hip arthroplasty (THA).
Methods
We used prospectively collected data to assess the association of diagnosis with index hip function and pain. Moderate-severe activity limitation and moderate-severe pain were assessed at two- and five-year follow-up after primary THA using multivariable-adjusted logistic regression analyses. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.
Results
There were 5,707 primary THAs at two-years and 3,289 at five-years, 51% were women and the mean age was 65 years. The underlying diagnosis was RA in 3%, OA in 87%, AVN in 7% and other in 3%. In multivariable-adjusted analyses, compared to RA, diagnoses of OA and AVN were significantly associated with lower odds of moderate-severe activities of daily living limitations with an OR (95% CI) of 0.5 (0.3 to 0.8) (P = 0.01) and 0.4 (0.2 to 0.8) (P = 0.01), respectively, at two-years, but not at five-years, 0.7 (0.4 to 1.4) (P = 0.36) and 0.9 (0.4 to 1.8) (P = 0.78), respectively. At two-years, neither OA nor AVN were significantly associated with higher odds of moderate-severe pain (1.6 (0.6 to 4.5) (P = 0.40) and 2.8 (0.9 to 8.5) (P =0 0.06)), respectively. At five-years, AVN was associated with higher odds of moderate-severe pain with OR 4.1 (1.2 to 14.1) (P = 0.02), but not OA, 2.1 (0.7 to 6.5) (P = 0.22).
Conclusions
We found that patients with OA and AVN had better functional outcomes and those with AVN worse pain outcomes after primary THA, compared to patients with RA/inflammatory arthritis. Insights into mediators of these relationships are needed to better understand these associations.
doi:10.1186/1741-7015-11-210
PMCID: PMC3850929  PMID: 24063410
Total hip replacement; Diagnosis; Osteoarthritis; Rheumatoid arthritis; Avascular necrosis; Pain; Function; Arthroplasty; Joint replacement; Patient-reported outcomes; Risk factors
19.  Ninety-day Mortality in Patients Undergoing Elective Total Hip or Total Knee Arthroplasty 
The Journal of arthroplasty  2012;27(8):1417-1422.e1.
Using an institutional Joint Registry, we studied frequency, trends and predictors of mortality following elective total hip or knee arthroplasty (THA/TKA). Of the 12,727 and 12,484 patients who underwent THA and TKA respectively, all-cause mortality rates at 7-, 30- and 90-days were as follows: THA, 0.1%, 0.2% and 0.5%; TKA 0.1%. 0.2% and 0.4%, respectively. Statistically significant downward time-trend in 90-day mortality was noted after TKA (p=0.02), but not after THA (p=0.41). In multivariable-adjusted analyses of THA patients, older age, higher comorbidity index, and prior cardiac disease were significantly associated with higher 90-day mortality. In TKA patients, older age, male gender, ASA class of 3-4, and higher comorbidity index were associated with higher 90-day all-cause mortality. Optimization of disease management may reduce postoperative mortality after THA/TKA.
doi:10.1016/j.arth.2012.03.008
PMCID: PMC3413788  PMID: 22554727
20.  Operative diagnosis for revision total hip arthroplasty is associated with patient-reported outcomes (PROs) 
Background
Little is known about the impact of the reason for revision total hip arthroplasty (THA) on the outcomes following revision THA. In this study, our objective was to assess the association of operative diagnosis with patient-reported outcomes (PROs) after revision THA.
Methods
We used prospectively collected data from the Mayo Clinic Total Joint Registry that collects pre- and post-operative pain and function outcomes using a validated Hip questionnaire, on all revision THAs from 1993–2005. We used logistic regression to assess the odds of moderate-severe index hip pain and moderate-severe limitation in activities of daily living (ADLs) 2- and 5-years after revision THA. We calculated odds ratios (OR) and 95% confidence intervals (CIs).
Results
For the 2- and 5-year cohorts, the operative diagnosis was loosening/wear/osteolysis in 73% and 75%; dislocation/bone or prosthesis fracture/instability or non-union in 17% and 15%; and failed prior arthroplasty with components removed/infection in 11% and 11%, respectively. In multivariable-adjusted analyses that included preoperative ADL limitations, compared to patients with loosening/wear/osteolysis, patients with dislocation/fracture/instability/non-union had OR of 2.2 (95% CI, 1.3-3.5; p = 0.002) for overall moderate-severe ADL limitation and those with failed prior arthroplasty/infection had OR of 1.6 (95% CI, 1.0-2.8; p = 0.06). At 5-years, ORs were lower and differences were no longer significant. Moderate-severe pain did not differ significantly by diagnosis, at 2- or 5-years in multivariable adjusted analyses, with one exception, i.e. failed prior arthroplasty/infection had a trend towards significance with odds ratio of 1.9 (95% CI, 0.9-3.8; p = 0.07).
Conclusions
Operative diagnosis is independently associated with ADL limitations, but not pain, at 2-years after revision THA. Patients should be informed of the risk of poorer short-term outcomes based on their diagnosis.
doi:10.1186/1471-2474-14-210
PMCID: PMC3722075  PMID: 23866848
Total hip replacement; Arthroplasty; Joint replacement; Patient-reported outcomes; Diagnosis
21.  Ipsilateral lower extremity joint involvement increases the risk of poor pain and function outcomes after hip or knee arthroplasty 
BMC Medicine  2013;11:144.
Background
Poor pain and function outcomes are undesirable after an elective surgery such as total hip or knee arthroplasty (THA/TKA). Recent studies have indicated that the presence of contralateral joint influences outcomes of THA/TKA, however the impact of ipsilateral knee/hip involvement on THA/TKA outcomes has not been explored. The objective of this study was to assess the association of ipsilateral knee/hip joint involvement on short-term and medium-term pain and function outcomes after THA/TKA.
Methods
In this retrospective study of prospectively collected data, we used the data from the Mayo Clinic Total Joint Registry to assess the association of ipsilateral knee or hip joint involvement with moderate to severe pain and moderate to severe activity limitation at 2-year and 5-year follow-up after primary and revision THA and TKA using multivariable-adjusted logistic regression analyses.
Results
At 2 years, 3,823 primary THA, 4,701 primary TKA, 1,218 revision THA and 725 revision TKA procedures were studied. After adjusting for multiple covariates, ipsilateral knee pain was significantly associated with outcomes after primary THA (all P values <0.01): (1) moderate to severe pain: at 2 years, odds ratio (OR), 2.3 (95% confidence interval (CI) 1.5 to 3.6); at 5 years, OR 1.8 (95% CI 1.1 to 2.7); (2) moderate to severe activity limitation: at 2 years, OR 3.1 (95% CI 2.3 to 4.3); at 5 years, OR 3.6 (95% CI 2.6 to 5.0). Ipsilateral hip pain was significantly associated with outcomes after primary TKA (all P values <0.01): (1) moderate to severe pain: at 2 years, OR 3.3 (95% CI 2.3 to 4.7); at 5 years, OR 1.8 (95% CI 1.1 to 2.7); (2) moderate to severe activity limitation: at 2 years, OR 3.6 (95% CI 2.6 to 4.9); at 5 years, OR 2.2 (95% CI 1.6 to 3.2). Similar associations were noted for revision THA and TKA patients.
Conclusions
To the best of our knowledge, this is the first study showing that the presence of ipsilateral joint involvement after THA or TKA is strongly associated with poor pain and function outcomes. A potential way to improve outcomes is to address ipsilateral lower extremity joint involvement.
doi:10.1186/1741-7015-11-144
PMCID: PMC3681648  PMID: 23738845
Arthroplasty; Ipsilateral; Joint replacement; Outcomes; Risk factors; Total hip replacement; Total knee replacement
22.  Income and patient-reported outcomes (PROs) after primary total knee arthroplasty 
BMC Medicine  2013;11:62.
Background
To assess whether income is associated with patient-reported outcomes (PROs) after primary total knee arthroplasty (TKA).
Methods
We used prospectively collected data from the Mayo Clinic Total Joint Registry to assess the association of income with index knee functional improvement, moderate to severe pain and moderate to severe activity limitation at 2-year and 5-year follow-up after primary TKA using multivariable-adjusted logistic regression analyses.
Results
There were 7, 139 primary TKAs at 2 years and 4, 234 at 5 years. In multivariable-adjusted analyses, at 2-year follow-up, compared to income > US$45, 000, lower incomes of ≤ US$35, 000 and > US$35, 000 to 45, 000 were associated (1) significantly with moderate to severe pain with an odds ratio (OR) 0.61 (95% CI 0.40 to 0.94) (P = 0.02) and 0.68 (95% CI 0.49 to 0.94) (P = 0.02); and (2) trended towards significance for moderate to severe activity limitation with OR 0.78 (95% CI 0.60 to 1.02) (P = 0.07) and no significant association with OR 0.96 (95% CI 0.78 to 1.20) (P = 0.75), respectively. At 5 years, odds were not statistically significantly different by income, although numerically they favored lower income. In multivariable-adjusted analyses, overall improvement in knee function was rated as 'better' slightly more often at 2 years by patients with income in the ≤ US$35, 000 range compared to patients with income > US$45, 000, with an OR 1.9 (95% CI 1.0 to 3.6) (P = 0.06).
Conclusions
We found that patients with lower income had better pain outcomes compared to patients with higher income. There was more improvement in knee function, and a trend towards less overall activity limitation after primary TKA in lower income patients compared to those with higher incomes. Insights into mediators of these relationships need to be investigated to understand how income influences outcomes after TKA.
doi:10.1186/1741-7015-11-62
PMCID: PMC3641978  PMID: 23497272
arthroplasty; income; joint replacement; patient-reported outcomes; risk factor; total knee replacement
23.  Surgical Technique: Porous Tantalum Reconstruction for Destructive Nonprimary Periacetabular Tumors 
Background
Large bone loss and frequently irradiated existing bone make reconstructing metastatic and other nonprimary periacetabular tumors challenging. Although existing methods are initially successful, they may fail with time. Given the low failure rates of porous tantalum acetabular implants in other conditions with large bone loss or irradiated bone, we developed a technique to use these implants in these neoplastic cases where others might fail.
Description of Technique
After local tumor curettage, a large uncemented tantalum shell (sometimes with tantalum augments) was fixed to remaining bone using numerous screws. When substantial medial bone loss was present, an antiprotrusio cage was placed over the top of the cup and secured to remaining ilium and ischium.
Patients and Methods
We retrospectively reviewed 20 patients who underwent THAs for neoplastic bone destruction with the described technique. Their mean age was 60 years (range, 22–80 years). We recorded pain and ambulatory status, pain medication use, and Harris hip scores. We assessed for progressive radiolucent lines and component migration on followup radiographs. Eleven of the 20 patients died at a mean of 17 months after surgery. The minimum followup for surviving patients was 26 months (mean, 56 months; range, 26–85 months).
Results
Harris hip scores improved from a mean 32 preoperatively to a mean 74 postoperatively. We observed no cases of progressive radiolucent lines or component migration. Complications included one perioperative death, two superficial infections, one deep vein thrombosis, and one dislocation.
Conclusion
Our initial experience has made tantalum reconstruction our preferred method for dealing with major periacetabular neoplastic bone loss. Additional studies comparing this technique with alternatives are required.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-011-2117-2
PMCID: PMC3254739  PMID: 21989784
24.  Reinfection after two-stage revision for periprosthetic infection of total knee arthroplasty 
International Orthopaedics  2011;36(1):65-71.
Purpose
Limited data exist regarding the long-term results or risk factors for failure after two-stage reimplantation for periprosthetic knee infection. The purpose of this retrospective review was to investigate infection-free implant survival and identify variables associated with reinfection after this procedure. Furthermore, a staging system was evaluated as a possible prognostic tool for patients undergoing two-stage reimplantation of infected total knee arthroplasty (TKA).
Methods
In this level II, retrospective prognostic study, 368 patients with infected TKA treated with a two-stage revision protocol at our institution between 1998 and 2006 were reviewed. Patients who developed recurrent infection and an equal number of patients randomly selected for the control group were analysed for risk factors associated with treatment failure.
Results
At the most recent follow-up, 58 (15.8%) patients had developed reinfection after the two-stage reimplantation. The median time to reinfection was 1,303 days (3.6 years), with follow-up time ranging from six to 2,853 days (7.8 years). The strongest positive predictors of treatment failure included chronic lymphoedema [hazard ratio (HR) = 2.28, 95% confidence interval (CI) 1.16–4.48; p = 0.02),and revision between resection and definitive reimplantation (HR = 2.13, 95% CI 1.20–3.79; p = 0.01, whereas patients treated with intravenously administered Cefazolin had a significant reduction in recurrent infection rate (HR = 0.48, 95% CI 0.25–0.90; p = 0.02).
Conclusions
Our findings should be of help in counselling patients regarding their prognosis when faced with two-stage exchange for infected TKA and provide a basis for future comparisons.
doi:10.1007/s00264-011-1267-x
PMCID: PMC3251662  PMID: 21553042
25.  Cardiac and Thromboembolic Complications and Mortality in Patients Undergoing Total Hip and Total Knee Arthroplasty 
Annals of the Rheumatic Diseases  2011;70(12):2082-2088.
Objective
Study 90-day cardiac and thromboembolic complications and all-cause mortality following total hip or knee arthroplasty (THA/TKA).
Method
In a population-based cohort of all Olmsted County residents who underwent a THA or TKA between 1994 and 2008, we assessed 90-day occurrence and predictors of cardiac complications (myocardial infarction, cardiac arrhythmia or congestive heart failure), thromboembolic complications (deep venous thrombosis (DVT) or pulmonary embolism (PE)) and mortality.
Results
Among the Olmsted County THA and TKA cohorts, 90-day complication rates were as follows: cardiac, 15.8% and 6.9%; thromboembolic, 4.9% and 4.0%; and mortality, 0.7% and 0.4%, respectively. Unadjusted frequency of cardiac/thromboembolic events differed by history of prior respective event. In multivariable-adjusted logistic regression analyses, ASA class III–IV (OR, 6.1, 95% CI:1.6, 22.8) and higher Deyo-Charlson comorbidity score (OR, 1.2, 95% CI:1.0,1.4) were significantly associated with odds of 90-day cardiac event post-THA in patients with no known prior cardiac event. In those with known prior cardiac disease, ASA class III–IV (OR, 4.4, 95% CI:2.0, 9.9), male gender (OR, 0.5, 95% CI:0.3,0.9) and history of thromboembolic disease (OR, 3.2; 95% CI:1.4,7.0) were significantly associated with odds of cardiac complication 90-day post-THA. No significant predictors of thromboembolism were found in THA patients.
In TKA patients with no prior cardiac history, age >65 years (OR, 4.1, 95% CI:1.2, 14.0), and ASA class III–IV (OR, 2.8, 95% CI:1.1,6.8) and in TKA patients with known cardiac disease, ASA class III–IV (OR, 3.2, 95% CI:1.8,5.7) was significantly associated with odds of 90-day cardiac event. In TKA patients with no prior thromboembolic disease, male gender (OR, 0.5, 95% CI:0.2,0.9) and higher Charlson index (OR, 1.2, 95% CI:1.1,1.3) and in patients with known thromboembolic disease, higher Charlson index score (OR, 1.1, 95% CI:1.1,1.4) was associated with odds of 90-day thromboembolic event.
Conclusion
Older age, higher comorbidity, higher ASA class and prior history of cardiac/thromboembolic disease was associated with an increased risk of 90-day cardiac and thromboembolic complications.
doi:10.1136/ard.2010.148726
PMCID: PMC3315837  PMID: 22021865
Cardiac; Thromboembolic; Total Hip Arthroplasty; Total Knee Arthroplasty; Mortality

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