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Predicting the Outcome of Total Knee Arthroplasty
Elizabeth A. Lingard, BPhty, MPhil, MPH1; Jeffrey N. Katz, MD, MS2; Elizabeth A. Wright, PhD2; Clement B. Sledge, MD2
1 School of Surgical and Reproductive Sciences, The Medical School, University of Newcastle upon Tyne NE2 4HH, England. E-mail address: liz.lingard@nuth.northy.nhs.uk
2 Robert B. Brigham Arthritis and Musculoskeletal Research Center (J.N.K. and E.A.W.) and Department of Orthopaedic Research (C.B.S.), Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115
View Disclosures and Other Information
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Stryker Howmedica. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. Also, a commercial entity (Stryker Howmedica) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Kinemax Outcomes Group includes: William Gillespie, Colin Howie, Ian Annan, Alastair Gibson, and Judith Lane (Princess Margaret Rose Hospital, Edinburgh, Scotland); Ian Pinder, David Weir, Nigel Brewster, and Karen Bettinson (Freeman Hospital, Newcastle upon Tyne, England); Maurice Needhoff and Roz Jackson (King's Mill Centre, Mansfield, England); Tim Wilton and Peter Howard (Derbyshire Royal Infirmary, Derby, England); Ian Forster, Paul Szyprt, Chris Moran, David Whitaker, Mike Bullock, and Zena Hinchcliffe; (Queen's Medical Centre, Nottingham, England); Ian Learmonth, John Newman, Chris Ackroyd, George Langkamer, Robert Spencer, Mark Shannon, Evert Smith, John Dixon, and Sarah Whitehouse (Avon Orthopedic Centre, Bristol, England); Clement Sledge, Frederick Ewald, Robert Poss, John Wright, Scott Martin, John Kwon, and Yvette Valderamma (Brigham and Women's Hospital, Boston, Massachusetts); Steven Harwin and Michael Lichardi (Beth Israel Medical Center, New York, NY); Mark Mehlhoff, Linda Weiler, and Tom Cahalan (Physician's Clinic of Iowa, Cedar Rapids, Iowa); Richard Cronk and Allyson Sandago (Neuromuscular and Joint Center, Corvallis, Oregon); Stephen Rackemann and Emma McLaughlin (The Knee Centre, Gold Coast, Queensland, Australia); and Peter Lewis, Robert Bauze, Gordon Morrison, Tom Stevenson, and Jane Stirling (Queen Elizabeth Hospital, Adelaide, South Australia, Australia).
Investigation performed at Brigham and Women's Hospital, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Oct 01;86(10):2179-2186
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Background: The relief of pain and the restoration of functional activities are the main outcomes of primary total knee arthroplasty for the treatment of osteoarthritis. This paper examines the preoperative predictors of pain and functional outcome at one and two years following total knee arthroplasty.

Methods: Patients were recruited for a prospective observational study of primary total knee arthroplasty for the treatment of osteoarthritis from centers in the United States, the United Kingdom, and Australia. Research assistants recruited the patients and collected the clinical history and physical examination data preoperatively and at three, twelve, and twenty-four months postoperatively. The Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Short Form-36 (SF-36), and demographic data were obtained by self-administered patient questionnaires.

Results: We recruited 860 patients and obtained one-year WOMAC data on 759 patients (88%) and two-year data on 701 (82%). The mean age was seventy years, and 59% of the patients were female. Using hierarchical regression models, we found that the most significant preoperative predictors of worse scores on the pain and function domains of the WOMAC scale and on the physical functioning domain of the SF-36 at one and two years postoperatively were low preoperative scores, a higher number of comorbid conditions, and a low SF-36 mental health score. After adjusting for these predictors, we found that the functional status of the patients from the United Kingdom was significantly worse than that of the patients from the other countries and the difference was clinically important at both the one-year and two-year follow-up examination (p < 0.0005). The mean WOMAC pain scores for the three countries were not significantly different at one year, and, although they were significantly different at two years (p = 0.025), the difference was not clinically important.

Conclusions: Patients who have marked functional limitation, severe pain, low mental health score, and other comorbid conditions before total knee arthroplasty are more likely to have a worse outcome at one year and two years postoperatively. After adjusting for these predictors, it was found that patients from the United Kingdom had significantly worse functional outcomes but similar pain relief compared with those from the United States and Australia.

Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.

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    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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