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Objective: To determine the predictors of outcome in patients with osteoarthritis 2 years after receiving total hip or knee replacement., Methods: A prospective cohort study of 222 osteoarthritis patients undergoing total hip or knee replacement in Boston and Montreal was done. Their postoperative outcomes at 6 months were previously reported. This followup reports on the outcomes after 2 years among the 165 patients (74%) who remained. The subjects were divided into 2 groups according to the median value of their preoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score. The Short Form 36-item physical function subscale and the WOMAC pain and function subscale scores were collected at baseline and at 3, 6, and 24 months postoperatively. Clinical outcomes were analyzed at 2 years, using descriptive and multiple regression analyses., Results: Improvements in pain and function at 2 years were similar to those observed at 6 months. Those subjects with the worst function and pain at the time of surgery (baseline) had comparatively worse function 2 years after surgery., Conclusion: In this comparison, the poor outcomes observed at 6 months following total joint replacement in patients with worse baseline functional status persisted after 2 years. Although there are no validated indications for when a patient should optimally have total joint replacement, these data suggest that timing of surgery may be more important than previously realized and, specifically, that performing surgery earlier in the course of functional decline may be associated with better outcome.

Objective: To determine whether patients with knee or hip osteoarthritis (OA) who have worse physical function preoperatively achieve a postoperative status that is similar to that of patients with better preoperative function., Methods: This study surveyed an observational cohort of 379 consecutive patients with definite OA who were without other inflammatory joint diseases and were undergoing either total hip or knee replacement in a US (Boston) and a Canadian (Montreal) referral center. Questionnaires on health status (the Short Form 36 and Western Ontario and McMaster Universities Osteoarthritis Index) were administered preoperatively and at 3 and 6 months postoperatively. Physical function and pain due to OA were deemed the most significant outcomes to study., Results: Two hundred twenty-two patients returned their questionnaires. Patients in the 2 centers were comparable in age, sex, time to surgery, and proportion of hip/knee surgery. The Boston group had more education, lower comorbidity, and more cemented knee prostheses. Patients undergoing hip or knee replacement in Montreal had lower preoperative physical function and more pain than their Boston counterparts. In patients with lower preoperative physical function, function and pain were not improved postoperatively to the level achieved by those with higher preoperative function. This was most striking in patients undergoing total knee replacement., Conclusion: Surgery performed later in the natural history of functional decline due to OA of the knee, and possibly of the hip, results in worse postoperative functional status.

Purpose: To study gender-specific preferences regarding timing of elective total joint replacement (TJR) surgery in patients with moderately severe osteoarthritis (OA) of the hip or knee., Patients and Methods: Focus group discussions regarding TJR surgery were conducted among 18 women and among 12 men with moderately severe OA of the hip or knee. Discussions were tape recorded, transcribed, coded for themes, and evaluated semiquantitatively and qualitatively for gender differences., Results: In general, men were more likely to choose surgery earlier in the disease than women and had higher expectations for surgical success. Women were more fearful of surgery. Women preferred to suffer arthritis pain rather than risk surgery, and indicated they would delay surgery to await better technology and to avoid disrupting caregiving roles for dependent spouses and others., Conclusion: Men and women differ in their willingness to accept continued functional decline, risks of surgery, and disruption of usual role. Gender differences may influence decisions regarding utilization of TJR.

Pharmacotherapy should play an adjunctive role to nonpharmacologic measures in the overall management of patients with symptoms due to osteoarthritis. Patients should be instructed in how to rest or unload involved joints; protect them through appropriate manipulation of their environment and appropriate methods of lifting and bending; and maintain and improve muscle strength and flexibility to ensure joint stability and prevent contractures. In most patients, acetaminophen in doses of up to 4 g/d is preferable to nonsteroidal anti-inflammatory drugs (NSAIDs) as a first-choice agent because of its lower toxicity. If NSAIDs are used, they should be prescribed initially in lower (analgesic) doses. Ibuprofen may be the preferred initial NSAID because it can be given in low doses for short durations, has been associated with lower rates of gastrointestinal tract side effects, and is inexpensive.

The management of osteoarthritis has been limited to symptomatic treatment to decrease pain and improve function without modifying the underlying disease process. New insights into the structure, physiology, and function of cartilage, however, have led to the development of promising approaches that might ultimately modify the underlying disease process. Over the past year, a number of therapeutic trials in osteoarthritis were reported in the literature. These studies provide an opportunity to review methodologic challenges in clinical trials of osteoarthritis.

Objective: To determine whether women have worse functional status than men at the time of laminectomy for degenerative spinal stenosis or total joint arthroplasty for degenerative arthritis of the hip and knee., Methods: Consecutive patients undergoing laminectomy for degenerative lumbar spinal stenosis or unilateral, primary hip or knee arthroplasty for advanced degenerative arthritis were recruited. Functional status was measured with self-administered questionnaires. We compared preoperative functional status scores of men and women, using linear regression models that adjusted for age, comorbid conditions, work status, education, living arrangement, and body mass index. We also compared the rates of in-hospital complications and 6-month followup functional status scores for men and women., Results: Women had much worse functional status than men prior to laminectomy for spinal stenosis (P < 0.01) and prior to total hip arthroplasty (P < 0.001) and total knee arthroplasty (P < 0.0001). These differences persisted after statistical adjustment for demographic and clinical characteristics. Women had comparable or greater functional improvement following surgery and experienced a similar number of complications compared with men., Conclusions: The observed gender differences in functional status prior to major orthopedic surgery indicate that women are operated on at a more advanced stage in the course of their disease. These results are not due to gender differences in demographic or clinical characteristics of the patients, and cannot be justified by differences between men and women in the outcome of surgery. The role of patient preferences and differential access to these procedures should be explored in future studies.

Objective: To evaluate the efficacy of continuous passive motion (CPM) in the postoperative management of patients undergoing total knee arthroplasty., Design: A randomized controlled single-blind trial of CPM plus standardized rehabilitation vs standard rehabilitation alone., Setting: A referral hospital for arthritis and musculoskeletal care., Patients: Consecutive patients with end-stage osteoarthritis or rheumatoid arthritis undergoing primary total knee arthroplasty who had at least 90 degrees of passive knee flexion. One hundred fifty-four patients were eligible and 102 patients agreed to participate and were randomized. Ninety-three patients completed the study protocol., Intervention: Continuous passive motion machines programmed for rate and specified arc of motion within 24 hours of surgery with range increased daily as tolerated with standardized rehabilitation program compared with standardized rehabilitation program alone., Main Outcome Measures: Primary outcomes were pain, active and passive knee range of motion, swelling (or circumference), quadriceps strength at postoperative day 7, as well as complications, length of stay, and active and passive range of motion and function at 6 weeks., Results: Use of CPM increased active flexion and decreased swelling and the need for manipulations but did not significantly affect pain, active and passive extension, quadriceps strength, or length of hospital stay. At 6 weeks there were no differences between the two groups in either range of motion or function. In this series, use of CPM resulted in a net savings of $6764 over conventional rehabilitation in achieving these results., Conclusion: For the average patient undergoing total knee arthroplasty, CPM is more effective in improving range of motion, decreasing swelling, and reducing the need for manipulation than is conventional therapy and lowers cost.

Although total joint replacement (TJR) is a major advance in the treatment of patients with osteoarthritis, its cost-effectiveness has been questioned. We report the results of a study of the costs and benefits of TJR in consecutive osteoarthritis patients, 6 months after the surgery. Health status was measured by the Index of Well-Being. Costs of services for arthritis were determined by interview and billing records. Six months after TJR, significant improvements were seen in global health and in functional status. The average cost of care for the 6 months prior to TJR was $933. The average cost during the 6 months beginning with the TJR was $22,730 per patient--due almost entirely to costs of surgery. In general, the surgery did not change work status, probably because the mean age of the patients was 66.4 years. There were large effectiveness/cost differentials (the larger the effectiveness/cost differential, the higher the degree of cost-effectiveness [CE]). At 6 months, for all patients, the CE was associated with initial health status. The highest CE was observed in 10 patients who initially had the poorest health. TJR is more cost-effective for patients with the most to gain and less effective for those with better preoperative health status.

A prospective descriptive study was done on the direct and indirect costs to ambulatory patients with rheumatoid arthritis and osteoarthritis, stratified at study entry by level of function. Measures of health status over a 1-year period were taken. On a yearly basis, in 1979 dollars, patients spent an average of $147 for arthritis medications, aids, and devices, and $207 for outpatient visits. A small number were hospitalized and incurred an average charge of $245, and an additional $84 for physician fees. In addition to direct monetary costs, patients averaged 6.8 days of restricted activity costs, patients averaged 6.8 days of restricted activity per month, in some cases so severe as to confine patients to bed for an average of 1.3 days per month. Among students and working patients, 2.5 work-days per month were lost due to arthritis, and 30% reported that they were unemployed or retired because of impaired health. Functional capacity and specific diagnosis on entry to the study were the most important determinants of arthritis-related expenditures. Both direct and indirect costs varied considerably from the observed average. Twenty percent of patients incurred no costs for arthritis-related purchases, 42+ had no costs for outpatient visits, and 93% had no inpatient costs. Yet for some patients, the financial burden was very high.