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Background: The objective of this work is to evaluate the performance of a modified quantitative Barrack Cement grading in primary THA. Previous studies demonstrated both poor intraobserver and interobserver reliability which may be due to the qualitative nature of the scale., Methods: Interobserver reliability of the Barrack Cement Grading System in its original format and then in combination with a quantitative measurement of implant/cement lengths was evaluated on 50 immediate post-operative radiographs of primary cemented arthroplasties. Intraobserver reliability was also assessed on a sub-sample of radiographs. Three evaluators with different skill levels and specialty participated: an arthroplasty surgeon, an orthopaedic resident and a radiologist. Reliability was measured using a weighted kappa coefficient for paired comparisons among the evaluators., Results: Interobserver reliability was poor (κ < 0.10) for all pairings of the Barrack System. The modified quantitative system achieved slight (κ < 0.20) to poor reliability. Intraobserver reliability was dependent on the skill and specialty of the evaluator with maximal values achieved for the experienced arthroplasty surgeon using the modified quantitative system (κ = 0.62)., Conclusion: Use of the modified scale may improve the reliability of ratings when used by individual experienced arthroplasty surgeons.

This study determined how ceramic-on-ceramic bearing THA affected joint-specific pain, function and stiffness in the first five postoperative years compared with ceramic-on-highly-crosslinked-polyethylene bearing THA. Subjects less than 61 years of age were randomized to ceramic-on-ceramic (CERAMIC) [n = 48] or ceramic-on-highly-crosslinked-polyethylene (POLYETHYLENE) [n = 44] bearing THA. Subjects were assessed using the Western Ontario McMaster Osteoarthritis Index (WOMAC) and the RAND 12-Item Health Survey (RAND-12) preoperatively, and at one and five years postoperatively. 92 subjects(50 (54%) males; average age = 52 (SD 6.6) years) were enrolled. 78 (85%) subjects returned five years postoperatively. All subjects reported improvements at one and five years in all measured indices with no group differences detected. Seven (8%) subjects experienced postoperative THA complications, none related to bearing surfaces; two subjects (POLYETHYLENE) required revision for instability. Both bearing surfaces provided excellent short-term results in younger subjects., (Crown Copyright © 2013. Published by Elsevier Inc. All rights reserved.)

Objective: Total hip replacement (THR) and total knee replacement (TKR) (arthroplasty) surgery for end-stage osteoarthritis (OA) are ideal candidates for optimization through an algorithmic care pathway. Using a comparative effectiveness study design, we compared the effectiveness of a new clinical pathway (NCP) featuring central intake clinics, dedicated inpatient resources, care guidelines and efficiency benchmarks vs. the standard of care (SOC) for THR or TKR., Methods: We compared patients undergoing primary THR and TKR who received surgery in NCP vs. SOC in a randomised controlled trial within the trial timeframe. 1,570 patients (1,066 SOC and 504 NCP patients) that underwent surgery within the study timeframe from urban and rural practice settings were included. The primary endpoint was improvement in Western Ontario and McMaster University osteoarthritis index (WOMAC) overall score over 12 months post-surgery. Secondary endpoints were improvements in the physical function (PF) and bodily pain (BP) domains of the Short Form 36 (SF-36)., Results: NCP patients had significantly greater improvements from baseline WOMAC scores compared to SOC patients after adjusting for covariates (treatment effect=2.56; 95% confidence interval (CI) [1.10-4.01]). SF-36 BP scores were significantly improved for both hip and knee patients in the NCP (treatment effect=3.01, 95% CI [0.70-5.32]), but SF-36 PF scores were not. Effects of the NCP were more pronounced in knee patients., Conclusion: While effect sizes were small compared with major effects of the surgery itself, an evidence-informed clinical pathway can improve health related quality of life (HRQoL) of hip and knee arthroplasty patients with degenerative joint disorder in routine clinical practice for up to 12 months post-operatively. CLINICALTRIALS.GOV IDENTIFIER: NCT00277186., (Copyright © 2012 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Objective: Disability from chronic illness is a major problem for society, yet the study of its determinants lacks an overall theoretical paradigm. Johnston (1996) has proposed conceptualizing disability as behavior and integrating biomedical and behavioral predictors. Dixon, Johnston, Rowley, and Pollard (2008) tested a model including constructs from the International Classification of Functioning, Disability and Health (ICF) and the theory of planned behavior (TPB) using structural equation modeling; it fitted better and explained more variance than the ICF or TPB alone. We replicated their study with a new sample from the same population (orthopedic patients awaiting joint replacement) and also tested the model after the patients had surgery., Methods: Two weeks before surgery, 342 orthopedic patients who had joint pain (most with arthritis) completed a questionnaire, with 228 completing it again 1 year after surgery. The authors tested Dixon et al.'s best-fit models cross-sectionally (before and after surgery) and assessed the goodness of fit of these imposed models to our data using structural equation modeling., Results: Findings strongly supported those of Dixon et al. Before surgery, results were very similar to Dixon et al. with all models accounting for significant variance and fitting well, but the integrated model fitted better and accounted for more variance. One year after surgery, Dixon et al.'s models showed even stronger fit to the data., Conclusions: Although behavioral and biomedical (ICF) models were supported, the integrated model provided a better explanation of disability in this population than either of these models alone and suggests biopsychosocial interventions to reduce disability., (PsycINFO Database Record (c) 2012 APA, all rights reserved.)

Background: The Alberta Hip and Knee Replacement Project developed a new evidence-based clinical pathway (NCP) for total hip (THR) and knee (TKR) replacement. The aim was to facilitate the delivery of services in a timely and cost-effective manner while achieving the highest quality of care for the patient across the full continuum of care from patient referral to an orthopedic surgeon through surgery, recovery, and rehabilitation. The purpose of this article is to provide an overview of the study design, rationale, and execution of this project as a model for health technology assessment based on comparative effectiveness of alternative clinical pathways., Methods: A pragmatic randomized controlled trial study design was used to evaluate the NCP compared with the standard of care (SOC) for these procedures. The pragmatic study design was selected as a rigorous approach to produce high quality evidence suitable for informing decisions between relevant interventions in real clinical practice. The NCP was evaluated in three of the nine regional health authorities (RHAs) in Alberta with dedicated central intake clinics offering multidisciplinary care teams, constituting 80 percent of THR and TKR surgeries performed annually in Alberta. Patients were identified in the offices of twenty orthopedic surgeons who routinely performed THR or TKR surgeries. Evaluation outcome measures were based on the six dimensions of the Alberta Quality Matrix for Health (AQMH): acceptability, accessibility, appropriateness, effectiveness, efficiency and safety. Data were collected prospectively through patient self-completed questionnaires at baseline and 3 and 12 months after surgery, ambulatory and inpatient chart reviews, and electronic administrative data., Results: The trial design was successful in establishing similar groups for rigorous evaluation. Of the 4,985 patients invited to participate, 69 percent of patients consented. A total of 3,434 patients were randomized: 1,712 to SOC and 1,722 to the NCP. The baseline characteristics of patients in the two study arms, including demographics, comorbidity as measured by CDS and exposure to pain medications, and health-related quality of life, as measured by Western Ontario and McMaster Universities Osteoarthritis Index and Short Form-36, were similar., Conclusions: The Alberta Hip and Knee Replacement Project demonstrates the feasibility and advantages of applying a pragmatic randomized controlled trial to ascertain comparative effectiveness. This is a model for health technology assessment that incorporates how clinical pathways can be effectively evaluated.

Objective: Between-participant research has shown that high negative affectivity predicts greater activity limitations and vice versa. This study examined both between- and within-participant associations of negative and positive affectivity with activity levels using ecological momentary assessment., Method: Participants were 25 people who had undergone joint replacement surgery 12 months previously. Participants made multiple reports of their activity and positive and negative affectivity over a single day using a computerized diary. Activity was also objectively recorded using an activity monitor. The following day, participants made a self-report of their activity over the measurement day and general positive and negative affectivity levels were recorded., Results: Higher self-reported walking time over the whole measurement day was associated with higher general positive affectivity but not negative affectivity. However, using ecological momentary assessment, higher diary reports of negative affectivity predicted increased activity levels while positive affectivity neither predicted nor was predicted by activity., Conclusion: These findings demonstrate the importance of within-participant methodology in detecting subtle and immediate effects of individuals' mood on behavior that may differ from findings investigating between-participant effects over longer time periods.

Total hip and knee arthroplasties are effective surgical interventions for relieving pain and improving physical function caused by arthritis. Although the majority of patients substantially improve, not all reports gains or are satisfied after receiving a total joint arthroplasty. This article reviews the literature on patient outcomes after total hip and knee arthroplasties for osteoarthritis and the evidence pertaining to factors that affect these patient-centered outcomes. Mounting evidence suggests that no one patient-related or peri-operative factor clearly predicts the amount of pain relief or functional improvement that will occur following total hip or knee arthroplasty.

Objectives: To compare the preliminary rate and amount of bony ingrowth and calcar resorption between patients receiving either a standard anatomical medullary locking (AML) or a tricalcium phosphate (TCP)-coated AML femoral prosthesis and to compare preliminary clinical results., Design: A prospective, randomized, double-blind clinical trial., Setting: An acute care tertiary institution., Patients: Between January 1993 and March 1995, 92 patients underwent primary total hip arthroplasty (THA). They were randomized to 2 groups of 46--a control group or a treatment group. Of the 46 subjects enrolled in each group, no significant differences were seen preoperatively with respect to age, sex, diagnosis, clinical and radiographic assessment. Seventy-one patients were followed up for 24 months., Interventions: Insertion of either a standard AML femoral implant (control group) or a TCP-coated AML femoral implant (treatment group)., Outcome Measures: The degree of hypertrophy, calcar atrophy and the number of spot welds on standard postoperative radiographs at 6, 12 and 24 months. Clinically, assessment according to the Société internationale de chirurgie orthopédique et de traumatologie (SICOT) scale and a 100-point visual analogue scale (VAS) for pain., Results: There were no prosthetic stem revisions in either group at the 24-month follow-up. Radiographically, bony ingrowth was not significantly different in the TCP-coated stem, by chi2 analysis of the degree of hypertrophy and number of spot welds present. Also by chi2 analysis, the degree of calcar atrophy was not significantly different between groups. The mean VAS score for pain at 24 months was 12.5 for the control and 12.1 for the treatment group. No significant differences were seen in any of the clinical categories of the SICOT Scale over the 24-month interval., Conclusion: The objective of TCP-coating--to increase the rate and amount of bony ingrowth while reducing the rate of calcar resorption in non-cemented THA--was not achieved by 24 months postoperatively in our study.

Objective: Between 1994/95 and 1996/7, the healthcare system in Alberta underwent a radical transformation that saw the regionalization of service delivery and a reduction in overall healthcare funding. The aim of this study is to examine trends in utilization and associated post-operative complications and readmissions for two procedures, total hip arthroplasty (THA) and total knee arthroplasty (TKA) during this period of restructuring., Methods: This is a six-year retrospective analysis using hospital separation and healthcare insurance plan registry databases. During the study period, we looked at trends in inpatient procedure volumes, average lengths of stay, post-operative complications during the index hospital stay and readmissions within one year., Results: Over a six-year period, the age-sex standardized provincial rate of THAs increased by 18% while the rate of TKAs increased by 73%. Average lengths of stay decreased for both procedures by over 50%. The rate of procedures with at least one post-operative complication within the index episode of care decreased over the study period by 19% for THA and 21% for TKA. Readmissions due to complications of surgery increased overall by 32% for THA and 2% for TKA. Regional and sex differences were observed throughout the period., Conclusions: While the overall rate of hospitalizations has decreased in Alberta, the rates of THA and TKA procedures have increased. The lengths of stay following these procedures have, at the same time, reduced dramatically. Adverse outcomes as measured by complication rates associated with these procedures have decreased, though readmissions due to complications after surgery have increased.

The objective of this study was to examine the change in pain and physical function that occurs while waiting for major arthroplasty. Data were collected prospectively from a cohort of 313 patients who were waiting > 1 month for total hip arthroplasty or total knee arthroplasty. The WOMAC and the SF-36 health status instruments were administered at the time the patient was placed on the waiting list and again just before surgery. Minimal amounts of change in pain and physical and psychosocial function occurred for hip and knee arthroplasty patients while they waited. Overall, waiting time did not appear to have a negative impact on the amount of pain and dysfunction experienced.

Background: As utilization rates for total joint arthroplasty increase, there is a hesitancy to perform this surgery on very old patients. The objective of this prospective study was to compare pain, functional, and health-related quality-of-life outcomes after total hip and total knee arthroplasty in an older patient group (> or =80 years) and a representative younger patient group (55-79 years)., Methods: In an inception community-based cohort within a Canadian health care system, 454 patients who received primary total hip arthroplasty (n = 197) or total knee arthroplasty (n = 257) were evaluated within a month prior to surgery and 6 months postoperatively. Pain, function, and health-related quality of life were evaluated with the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index and the 36-Item Short-Form Health Survey (SF-36)., Results: There were no age-related differences in joint pain, function, or quality-of-life measures preoperatively or 6 months postoperatively. Furthermore, after adjusting for potential confounding effects, age was not a significant determinant of pain or function. Although those in the older and younger groups had comparable numbers of comorbid conditions and complications, those in the older group were more likely to be transferred to a rehabilitation facility than younger patients. Regardless of age, patients did not achieve comparable overall physical health when matched with the general population for age and sex., Conclusions: With increasing life expectancy and elective surgery improving quality of life, age alone is not a factor that affects the outcome of joint arthroplasty and should not be a limiting factor when considering who should receive this surgery.

This study was conducted to determine the impact of health status on waiting time for major joint arthroplasty in a universal publicly funded health system. Data were collected prospectively from a cohort of 553 patients waiting for total hip or total knee arthroplasty. The WOMAC and SF-36 health status instruments were administered at the time the patient was placed on the waiting list. The outcome measure was length of waiting time. Multivariate analyses found increased body mass index and decreased social function as the only determinants of waiting time. This model explained only 4% of the variance in waiting time. The association between health status and waiting time for arthroplasties appears to be small. These findings suggest that major joint arthroplasty is not prioritized on the basis of burden of illness.

Objective: To quantify the magnitude of change seen with pain, function, and quality of life outcomes 6 months after total hip and knee arthroplasties (THA, TKA) within a community based cohort of a regional health district., Methods: An inception cohort of 504 patients who received primary THA (228) or TKA (276) was prospectively followed. All patients resided in the community and were assessed within one month prior to surgery and 6 months postoperatively. Health related quality of life measures were evaluated with the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index and the Medical Outcome Survey Short Form SF-36. Perioperative factors were extracted from medical charts. Health services utilization data were collected from regional health databases., Results: Over 75% of patients reported improvement in joint-specific pain and function, regardless of the type of joint replaced. Other health dimensions such as social function, bodily pain, physical function, vitality, and general health showed significant improvement after surgery. Those psychosocial dimensions with modest changes had baseline values comparable to age and sex adjusted normal values; whereas, bodily pain and physical function, which had large changes, had values lower than the normal values. Ninety-one percent of patients receiving THA were satisfied with their surgery, whereas 77% were satisfied with their TKA. The average length of stay was 7 days and the in-hospital complication rate was 0.34 per patient., Conclusion: Large improvements were reported for pain and function after joint arthroplasties, while small to moderate changes were seen in other areas related to quality of life. Patients with hip arthroplasties showed greater improvement in pain and function and were more satisfied with their outcomes than patients with knee arthroplasties. Although pain and function show large improvements, bodily pain and physical function were less than the values reported in the general population.

Objective: To describe a method of reducing the costs of implants in hip and knee arthroplasty., Design: Implant costs were compared before and after the implementation of a 2-year contract with implant vendors, providing increased volume for decreased implant cost. An additional 20% of arthroplasties could be done outside the contract for research or special purposes., Setting: A regional health authority involving 2 acute care hospitals., Method: Costs were obtained for 942 hip and knee arthroplasties performed in 1993/94 and compared with costs of 1656 hip and knee arthroplasties performed in 1996/97., Outcome Measures: Implant cost and number of joint arthroplasty procedures performed., Results: A 40% decrease in the cost per implant for primary knee arthroplasty and an 18% decrease in the cost per implant for primary hip arthroplasty were achieved. A rebate, calculated as a percentage of volume used, was received from the vendor to support general orthopedic research and education. A new contract for 3 years has recently been signed with 3 vendors designated as primary vendors for 80% of the volume., Conclusion: The vendor-contract economic strategy effectively reduced the cost of hip and knee arthroplasty and may be useful at other centres looking for cost reduction methods that maintain adequate patient care and support clinical research and education.