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Rationale, aims and objectives As total joint arthroplasty ( TJA) rates rise, there is need to ensure appropriate use. Our objective was to elucidate surgeons' perspectives on appropriateness for TJA. Methods Semi-structured telephone interviews were conducted in a sample of orthopaedic surgeons that perform TJA in three Canadian Provinces. Surgeons were asked to discuss their criteria for TJA appropriateness for osteoarthritis; potential value of a decision-support tool to select appropriate candidates; and the role of other stakeholders in assessing appropriateness. Results Of 17 surgeons approached for participation, 14 completed interviews (12 males; 7 aged <50 years; 5 academic; 8 in urban practices). Surgeons agreed that pain and pain impact on patients' quality of life and function were the key criteria to assess appropriateness for TJA, but that these concepts were difficult to assess and not always congruent with structural changes on joint radiography. Some used a wider range of criteria, including their assessments of patient expectations, ability to cope and readiness for surgery. While patient age was not identified as a criterion itself, surgeons did acknowledge that appropriateness criteria may differ for younger versus older patients. Most agreed that a decision-support tool would help ensure that all elements of appropriateness are assessed in a standardized manner, albeit the ultimate decision to offer surgery must be left to the discretion of surgeons, within the context of the doctor-patient relationship. Conclusions Surgeons recognized the need for a tool to support decision making for TJA, particularly in the context of increasing surgical demand in younger patients with less severe arthritis. The work to develop and test such a decision-support tool is underway. [ABSTRACT FROM AUTHOR]

Background: While the rates of total knee arthroplasty (TKA) continue to rise worldwide, there are concerns about whether all surgeries are appropriate. Guidelines for appropriateness suggest that patients should have realistic expectations for total knee arthroplasty (TKA), and that the patient and their surgeon should agree that the potential benefits outweigh the potential harms. The objective of this study is to evaluate whether routinely collected pre- and post-TKA patient-reported outcome measures (PROMs) could be integrated into a patient decision aid to better inform these appropriateness criteria. This randomised trial will evaluate the preliminary efficacy of a tailored PROM-based patient decision aid and surgeon report (compared to usual care) for patients considering TKA on decision quality.Methods: This is a pragmatic, randomised controlled trial conducted at one site in Alberta, Canada. Adults over the age of 30 years, who have been scheduled for a TKA consultation at the Edmonton Bone and Joint Centre with a participating surgeon, who understand, speak, and read English, and can provide informed consent, are eligible to participate. Participants will be randomised to receive a PROM-based patient decision aid and surgeon report before their surgical consultation or usual care. The decision aid will provide patients with information on their expected outcomes based on the EQ-5D-5L PROM, and these estimates are individualized based on clinical and demographic characteristics. The primary outcome of this trial is decision quality. Analysis will consider outcomes intention to treat, and feasibility outcomes for implementing the trial to routine practise.Discussion: This patient decision aid and surgeon report intervention could contribute to improved treatment decision-making for patients considering total knee arthroplasty.Trial Registration (registry and Number): ClinicalTrials.gov : NCT03240913. Registered on August 1, 2017. [ABSTRACT FROM AUTHOR]

Objective: To determine the relationship between patients' preoperative readiness for total knee arthroplasty (TKA) and surgical outcome at 1 year post-TKA., Methods: This prospective cohort study recruited patients with knee osteoarthritis (OA) who were ≥30 years and were referred for TKA at 2 hip/knee surgery centers in Alberta, Canada. Those who underwent primary unilateral TKA completed questionnaires prior to TKA to assess pain using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), physical disability using the Knee Injury and Osteoarthritis Outcome Score physical function short form, perceived arthritis coping efficacy, general self-efficacy, depressed mood using the Patient Health Questionnaire 8, body mass index, comorbidities, and TKA readiness (patient acceptable symptom state; willingness to undergo TKA); these same individuals also completed the above questionnaires 1 year post-TKA to assess surgical outcomes. A good TKA outcome was defined as an individual having improved knee symptoms, measured using the Osteoarthritis Research Society International-Outcome Measures in Rheumatology responder criteria, and overall satisfaction with results of the TKA. Poisson regression with robust error estimation was used to estimate the relative risk (RR) of a good outcome for exposures, before and after controlling for covariates., Results: Of 1,272 TKA recipients assessed at 1 year post-TKA, 1,053 with data for the outcome assessed in the study were included (mean ± SD age 66.9 ± 8.8 years; 58.6% female). Most patients (87.8%) were definitely willing to undergo TKA and had "unacceptable" knee symptoms (79.7%). Among patients who underwent TKA, 78.1% achieved a good outcome. Controlling for pre-TKA OA-related disability, arthritis coping efficacy, comorbid hip symptoms, and depressed mood, definite willingness to undergo TKA and unacceptable knee symptoms were associated with a greater likelihood of a good TKA outcome, with adjusted RRs of 1.18 (95% confidence interval [95% CI] 1.04-1.35) and 1.14 (95% CI 1.02-1.27), respectively., Conclusion: Among patients who underwent TKA for knee OA, patients' psychological readiness for TKA and willingness to undergo TKA were associated with a greater likelihood of a good outcome. Incorporation of these factors in TKA decision-making may enhance patient outcomes and appropriate the use of TKA., (© 2021 American College of Rheumatology.)

Objective: To assess the relationship between comorbidities and amount of improvement in pain and physical function in recipients of total knee arthroplasty (TKA) for knee osteoarthritis (OA)., Design: Prospective cohort study., Setting: Two provincial central intake hip and knee centres in Alberta, Canada., Participants: 1051 participants (278 in 6-minute walk test (6MWT) subset), ≥30 years of age with primary knee OA referred for consultation regarding elective primary TKA; assessed 1 month prior and 12 months after TKA., Primary and Secondary Outcome Measures: Pre-post TKA change in knee OA pain (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), physical function (Knee injury and Osteoarthritis Outcome Score (KOOS) Physical Function Short-Form) and 6MWT walking distance; and the reporting of an acceptable symptom state (Patient Acceptable Symptom State (PASS)) at 12 months after TKA., Results: Mean participant age was 67 years (SD 8.8), 59% were female and 85% reported at least one comorbidity. Individuals with a higher number of comorbidities had worse pre-TKA and post-TKA scores for pain, physical function and 6MWT distance. At 12-month follow-up, mean changes in pain, function and 6MWT distance, and proportion reporting a PASS, were similar for those with and without comorbidities. In multivariable regression analysis, adjusted for potential confounders and clustering by surgeon, no specific comorbidities nor total number of comorbidities were associated with less improvement in pain, physical function or 6MWT distance at 12 months after TKA. Patients with diabetes (OR 0.64, 95% CI 0.44 to 0.94) and a higher number of lower extremity troublesome joints (OR 0.85, 95% CI 0.76 to 0.96) had lower odds of reporting a PASS., Conclusion: For individuals with knee OA, comorbid conditions do not limit improvement in pain, physical function or walking ability after TKA, and most conditions do not impact achieving an acceptable symptom state., Competing Interests: Competing interests: GAH has received research support as the Sir John and Lady Female Eaton Professor and Chair of Medicine, Department of Medicine, University of Toronto; DAM was supported through a Canada Research Chair in Health Systems and Services Research (2008–2018) and is currently supported as the Arthur J.E. Child Chair in Rheumatology; all other authors declare no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Our aim was to assess prior use of core recommended non-surgical treatment among patients with knee osteoarthritis (OA) scheduled for total knee arthroplasty (TKA), and to assess potential patient-level correlates of underuse, if found., Methods: This was a cross-sectional study of patients undergoing TKA for primary knee OA at 2 provincial central intake hip and knee clinics in Alberta, Canada. Standardized questionnaires assessed sociodemographic characteristics, social support, coexisting medical conditions, OA symptoms and coping, and previous non-surgical management. Multivariable logistic regression was used to assess the patient-level variables independently associated with receipt of recommended non-surgical knee OA treatment, defined as prior use of pharmacotherapy for pain, rehabilitation strategies (exercise or physiotherapy), and weight loss if overweight or obese (body mass index ≥ 25 kg/m 2 )., Results: There were 1273 patients included: mean age 66.9 years (SD 8.7), 39.9% male, and 44.1% had less than post-secondary education. Recommended non-surgical knee OA treatment had been used by 59.7% of patients. In multivariable modeling, the odds of having received recommended non-surgical knee OA treatment were significantly and independently lower among individuals who were older (OR 0.97, 95% CI 0.95-0.99), male (OR 0.33, 0.25-0.45), and who lacked post-secondary education (OR 0.70, 0.53-0.93)., Conclusion: In a large cross-sectional analysis of knee OA patients scheduled for TKA, 40% of individuals reported having not received core recommended non-surgical treatments. Older individuals, men, and those with less education had lower odds of having used recommended non-surgical OA treatments.

Objectives: Increasingly, there is emphasis on identifying and initiating treatment of osteoarthritis (OA) in the early phases of the disease. This study aimed to identify the perceived barriers and facilitators to managing clients with early knee OA and the contextual factors affecting implementation of care by physical therapists (PTs)., Design: Qualitative study using in-depth semistructured interviews with 33 PTs. The interviews were audio-recorded, transcribed verbatim and analysed inductively using thematic analysis., Setting: Canada., Participants: A purposive sample of PTs who managed clients with knee symptoms and/or diagnosed knee OA in community/outpatient settings in three provinces in Canada (Ontario, Alberta, British Columbia)., Results: Factors that affected physical therapy management of early knee OA were identified at four levels: the community, healthcare system, healthcare provider and client level. Some healthcare provider factors acted primarily as enablers of management, such as PTs' confidence in their ability to manage perceived early knee OA, PTs' beliefs about consequences of OA and the PT scope of practice. However, the study illuminated a range of modifiable factors that can act as barriers to management. These factors included access to services in the community and healthcare system; healthcare provider factors such as time, access to evidence and physician's role in referrals and messaging; and client factors related to client characteristics (eg, general health, socioeconomic status), engagement in management and beliefs about OA., Conclusion: These findings provide us with a basis to begin to address specific barriers and to optimise care for early knee OA., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)