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Patient-Reported Outcomes After Total Knee Replacement Vary on the Basis of Preoperative Coexisting Disease in the Lumbar Spine and Other Nonoperatively Treated JointsThe Need for a Musculoskeletal Comorbidity Index
David C. Ayers, MD1; Wenjun Li, PhD1; Carol Oatis, PT, PhD2; Milagros C. Rosal, PhD1; Patricia D. Franklin, MD, MBA, MPH1
1 Department of Orthopedics and Physical Rehabilitation (D.C.A. and P.D.F.) and Division of Preventive and Behavioral Medicine, Department of Medicine (W.L. and M.C.R.), University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655. E-mail address for D.C. Ayers: ayersd@ummhc.org
2 Department of Physical Therapy, Arcadia University, 450 South Easton Road, Glenside, PA 19038
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Investigation performed at the Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, Worcester, Massachusetts



Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Oct 16;95(20):1833-1837. doi: 10.2106/JBJS.L.01007
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Abstract

Background: 

Although the majority of patients report substantial gains in physical function following primary total knee replacement, the degree of improvement varies widely. To understand the potential role of preoperative pain due to other musculoskeletal conditions on postoperative outcomes, we quantified bilateral knee and hip pain and low back pain before primary total knee replacement and evaluated its association with physical function at six months after total knee replacement.

Methods: 

A prospective cohort of 180 patients having primary unilateral total knee replacement reported joint-specific pain in right and left hips and knees (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] pain) as well as the low back (Oswestry Disability Index) before surgery. Participants also completed the Short Form-36 (SF-36), including the physical and mental component summary scores, before and at six months after surgery.

Results: 

Of the 180 patients, 110 (61%) were women; the mean age was 65.1 years, the mean body mass index (BMI) was 32.5 kg/m2, and mean SF-36 physical component summary score reported before the total knee replacement was 33.1. Before total knee replacement, 56.1% of the patients reported no or mild pain in the nonoperatively treated knee, hips, and low back. In addition, 22.2% of the patients had moderate to severe pain in one location; 12.8%, in two locations; and 8.9%, in three or four locations. Women reported more moderate to severe pain than men did in the nonoperatively treated knee (30% versus 11%; p < 0.004) and ipsilateral hip (26% versus 11%; p < 0.02). At six months, the mean physical component summary score was lower among patients with a greater number of preoperative locations of moderate to severe pain. After adjusting for age, sex, BMI, and SF-36 mental component summary score, moderate to severe preoperative pain in the contralateral knee (p = 0.013), ipsilateral (p = 0.014) and contralateral hip (p = 0.026), and low back (p < 0.001) was significantly associated with poorer function at six months after total knee replacement.

Conclusions: 

Preoperative musculoskeletal pain in the low back and nonoperatively treated lower extremity joints is associated with poorer physical function at six months after total knee replacement. The degree of functional improvement varies with the burden of musculoskeletal pain in other weight-bearing locations.

Level of Evidence: 

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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