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BACKGROUND: Previous research has focused on the perioperative or short-term (<1 year) mortality rate of total knee arthroplasty (TKA), leaving the long-term (>1 year) mortality rate unresolved. In this study, we calculated the mortality rate up to 15 years after primary TKA. METHODS: Data from the New Zealand Joint Registry from April 1998 to December 2021 were analyzed. Patients aged 45 years or older who underwent TKA for osteoarthritis were included. Mortality data were linked with national records from births, deaths, and marriages. To determine the expected mortality rates in the general population, age-sex-specific life tables from statistics New Zealand were used. Mortality rate was presented as standardized mortality ratios (SMRs) - a comparison of relative mortality rate between the TKA and general populations. In total, 98,156 patients with a median follow-up of 7.25 years (range, 0.00 to 23.74) were included. RESULTS: Over the entire follow-up period, 22,938 patients (23.4%) had died. The overall SMR for the TKA cohort was 1.08 (95% confidence interval (CI): 1.06 to 1.09), suggesting that TKA patients have an 8% higher mortality rate compared to the general population. However, a reduction in short-term mortality rate was observed for TKA patients up to 5 years post TKA (SMR 5 years post TKA; 0.59 95% CI: 0.57 to 0.60]). On the contrary, a significantly increased long-term mortality rate was observed in TKA patients with greater than 11 years of follow-up, particularly in men over the age of 75 years (SMR 11 to 15 years post TKA for males ≥ 75 years; 3.13 [95% CI: 2.95 to 3.31]). CONCLUSION: The results suggest a reduction in short-term mortality rate for patients who undergo primary TKA. However, there is an increased long-term mortality rate particularly in men over the age of 75 years. Importantly, the mortality rates observed in this study cannot be causally attributed to TKA alone.

BACKGROUND: Patient-reported outcome measure (PROM) questionnaires in national arthroplasty registries often have low response rates leading to questions about data reliability. In Australia, the SMART (St. Vincent's Melbourne Arthroplasty Outcomes) registry captures all elective total hip (THA) and total knee (TKA) arthroplasty patients with an approximate 98% response rate for preoperative and 12-month PROM scores. This high response rate is due to dedicated registry staff following up patients who do not initially respond (subsequent responders). This study compared initial responders to subsequent responders to find differences in 12-month PROM outcomes for THA and TKA. METHODS: All elective THA and TKA patients for osteoarthritis from 2012 to 2021 captured by the SMART registry were included. In total, 1,333 THA and 1,340 TKA patients were included. The PROM scores were assessed using the Veterans-RAND 12 (VR12) and Western Ontario and McMasters Universities Arthritis Index (WOMAC) questionnaires. The primary outcome was differences in mean 12-month PROM scores between initial and subsequent responders. RESULTS: Baseline characteristics and PROM scores were similar between initial and subsequent responders. However, 12-month PROM scores varied significantly. The adjusted mean difference showed that for the WOMAC pain score, subsequent responders scored 3.4 points higher in the THA cohort and 7.4 points higher in the TKA cohort compared to initial responders. Significant differences were also found in other WOMAC and VR12 scores for both THA and TKA cohorts at the 12-month timepoint. CONCLUSION: This study found that significant differences in PROM outcomes postsurgery occurred in THA and TKA patients based on response to PROM questionnaires, suggesting that loss to follow-up in PROM outcomes should not be treated as missing completely at random (MCAR).

IMPORTANCE: Discontinuation and nonpublication are established sources of avoidable waste among surgical trials, but rates of delayed completion and recruiting shortfalls remain unclear. OBJECTIVES: To examine the rate of delayed completion, incomplete enrollment, and discontinuation among randomized clinical trials in surgical populations and the duration of delays and extent of recruiting shortfalls among these trials. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study examined randomized clinical trials in surgical populations registered on ClinicalTrials.gov between January 1, 2010, and December 31, 2014. Analysis was conducted between October 27, 2021, and June 30, 2022. MAIN OUTCOMES AND MEASURES: The main outcomes were the percentages of trials completed on time or with full enrollment. Delays and recruiting shortfalls were identified by comparing projected enrollment and study timeframes prespecified at the time of registration with the actual study duration and enrollment reported on completion or discontinuation. Absolute and relative differences between planned and actual trial conduct were presented for discontinued trials and those completed with delays or recruiting shortfalls. RESULTS: In total, 2542 randomized clinical trials in surgical populations were included in the study sample, of which 370 (14.6%; 95% CI, 13.2%-15.9%) were completed both on time and with full enrollment. Approximately 1 in 5 trials (20.4%; 95% CI, 18.9%-22.0%) were completed within their planned timeframe, and 1166 trials (45.9%; 95% CI, 43.9%-47.8%) met their prespecified enrollment target. The median delay among completed trials was 12.2 months (IQR, 5.1-24.3 months) or 66.7% (IQR, 30.1%-135.8%) longer than planned. Among completed trials that did not meet their prespecified enrollment target, the median recruiting shortfall was equivalent to 31.0% (IQR, 12.7%-55.5%) of the planned study sample. A total of 546 trials (21.5%; 95% CI, 19.9%-23.1%) were discontinued.

BACKGROUND: Current predictive tools for TKA focus on clinicians rather than patients as the intended user. The purpose of this study was to develop a patient-focused model to predict health-related quality of life outcomes at 1-year post-TKA. METHODS: Patients who underwent primary TKA for osteoarthritis from a tertiary institutional registry after January 2006 were analysed. The primary outcome was improvement after TKA defined by the minimal clinically important difference in utility score at 1-year post-surgery. Potential predictors included demographic information, comorbidities, lifestyle factors, and patient-reported outcome measures. Four models were developed, including both conventional statistics and machine learning (artificial intelligence) methods: logistic regression, classification tree, extreme gradient boosted trees, and random forest models. Models were evaluated using discrimination and calibration metrics. RESULTS: A total of 3755 patients were included in the study. The logistic regression model performed the best with respect to both discrimination (AUC = 0.712) and calibration (intercept = -0.083, slope = 1.123, Brier score = 0.202). Less than 2% (n = 52) of the data were missing and therefore removed for complete case analysis. The final model used age (categorical), sex, baseline utility score, and baseline Veterans-RAND 12 responses as predictors. CONCLUSION: The logistic regression model performed better than machine learning algorithms with respect to AUC and calibration plot. The logistic regression model was well calibrated enough to stratify patients into risk deciles based on their likelihood of improvement after surgery. Further research is required to evaluate the performance of predictive tools through pragmatic clinical trials. LEVEL OF EVIDENCE: Level II, decision analysis.

BACKGROUND: Approximately 1 in 5 patients feel unsatisfied after total knee arthroplasty (TKA). Prognostic tools may aid in the patient selection process and reduce the proportion of patients who experience unsatisfactory surgery. This study uses the prognostic tool SMART Choice (Patient Prognostic Tool for Total Knee Arthroplasty) to predict patient improvement after TKA. The tool aims to be used by the patient without clinician input and does not require clinical data such as X-ray findings or blood results. The objective of this study is to evaluate the SMART Choice tool on patient decision making, particularly willingness for surgery. We hypothesise that the use of the SMART Choice tool will influence willingness to undergo surgery, especially when used earlier in the patient TKA journey. METHODS: This is a multicentred, pragmatic, randomised controlled trial conducted in Melbourne, Australia. Participants will be recruited from the St. Vincent's Hospital, Melbourne (SVHM) Orthopaedic Clinic, and the client base of HCF, Australia (private health insurance company). Patients over 45 years of age who have been diagnosed with knee osteoarthritis and considering TKA are eligible for participation. Participants will be randomised to either use the SMART Choice tool or treatment as usual. The SMART Choice tool provides users with a prediction for improvement or deterioration / no change after surgery based on utility score change calculated from the Veterans-RAND 12 (VR-12) survey. The primary outcome of the study is patient willingness for TKA surgery. The secondary outcomes include evaluating the optimal timing for tool use and using decision quality questionnaires to understand the patient experience when using the tool. Participants will be followed up for 6 months from the time of recruitment. DISCUSSION: The SMART Choice tool has the potential to improve patient decision making for TKA. Although many prognostic tools have been developed for other areas of surger

BACKGROUND: Orthopaedic surgeries include some of the highest volume surgical interventions globally; however, studies have shown that a significant proportion of patients report no clinically meaningful improvement in pain or function after certain procedures. As a result, there is increasing interest in conducting randomised placebo-controlled trials in orthopaedic surgery. However, these frequently fail to reach recruitment targets suggesting a need to improve trial design to encourage participation. The objective of this study was to systematically scope the available evidence on patient and clinician values and preferences which may influence the decision to participate in placebo surgery trial. METHODS: A systematic review was conducted via a literature search in the MEDLINE, Embase, PsycInfo, CINAHL, and EconLit databases as of 19 July 2021, for studies of any design (except commentaries or opinion pieces) based on two key concepts: patient and clinician characteristics, values and preferences, and placebo surgery trials. RESULTS: Of 3424 initial articles, we retained 18 eligible studies. Characteristics, preferences, values, and attitudes of patients (including levels of pain/function, risk/benefit perception, and altruism) and of clinicians (including concerns regarding patient deception associated with placebo, and experience/training in research) influenced their decisions to participate in placebo-controlled trials. Furthermore, some aspects of trial design, including randomisation procedures, availability of the procedure outside of the trial, and the information and consent procedures used, also influenced decisions to participate. CONCLUSION: Participant recruitment is a significant challenge in placebo surgery trials, and individual decisions to participate appear to be sensitive to preferences around treatment. Understanding and quantifying the role patient and clinician preferences may play in surgical trials may contribute to the optimisation of t

Clinical predictive tools are a topic gaining interest. Many tools are developed each year to predict various outcomes in medicine and surgery. However, the proportion of predictive tools that are implemented in clinical practice is small in comparison to the total number of tools developed. This narrative review presents key principles to guide the translation of predictive tools from academic bodies of work into useful tools that complement clinical practice. Our review identified the following principles: (1) identifying a clinical gap, (2) selecting a target user or population, (3) optimizing predictive tool performance, (4) externally validating predictive tools, (5) marketing and disseminating the tool, (6) navigating the challenges of integrating a tool into existing healthcare systems, and (7) developing an ongoing monitoring and evaluation strategy. Although the review focuses on examples in orthopaedic surgery, the principles can be applied to other disciplines in medicine and surgery.

BACKGROUND: Placebo-controlled surgical trials are recognised as the gold standard way to test the efficacy of a surgical procedure. Despite a rise in arthroscopic subacromial decompression (ASD) surgeries for the treatment of shoulder pain, only two placebo-controlled surgical trials have been conducted. These trials encountered significant recruitment challenges, threatening the external validity of findings. Difficulties with recruitment are common in clinical trials and likely to be amplified in placebo-controlled surgical trials. This mixed method feasibility trial aims to address the following questions: (i) Feasibility: What proportion of patients who have consented to undergo ASD report that they would be willing to enrol in a placebo-controlled trial for this procedure? (ii) Optimisation: Can patients' willingness to enrol in, or understanding of, such a trial be improved by supplementing written consent materials with a brief visual animation that outlines the details of the trial? And (iii) exploration: What factors influence patients stated willingness to enrol in such a trial, and how do they believe the recruitment process could be improved? METHODS: This study aims to recruit 80 patients on the waiting list for ASD. Participants will be randomised (1:1) to either view a brief video animation explaining the hypothetical placebo-controlled trial in addition to written information or to written information only. Participants in both groups will be required to state if they would be willing to opt-in to the hypothetical ASD trial after immediately being presented with the consent material and again 1 week after completion of the consent process. Patients in both groups will also be required to complete a measure of trial literacy. Twenty participants will be purposively sampled to take part in an embedded qualitative study exploring understanding of trial concepts and factors contributing to willingness to opt-in. DISCUSSION: This feasibility study will p

OBJECTIVE: To explore the ways in which people talk about knee osteoarthritis and how this may influence engagement in physical activity and activity-based interventions as recommended by clinical practice guidelines. DESIGN: A qualitative synthesis using discourse analysis methods. METHODS: Systematic review methods were used to identify qualitative studies exploring the perceptions of people with knee osteoarthritis, their carers, and/or clinicians. Methodological quality was evaluated through the use of the Critical Appraisal Skills Programme. Raw quotes extracted from each study were analyzed with inductive discourse analysis. RESULTS: A search of five electronic databases from inception until August 2019 yielded 778 articles. Sixty-two articles from 56 studies were included, reporting data (1,673 direct quotes) from people with knee osteoarthritis, carers, and clinicians in 16 countries. Two overarching discourses were identified-impairment and participation. The overarching impairment discourse prevailed in all participant groups and study settings. In this discourse, knee osteoarthritis was likened to a machine that inevitably wore down over time and required a doctor to repair. The overarching participatory discourse almost always coexisted alongside an impairment discourse. According to this discourse, a "busy body" was perceived as "healthy," and people could remain active despite knee osteoarthritis. CONCLUSION: The prevailing impairment discourse may potentially discourage people from using knees that have passed their "use-by date" and increase reliance on doctors to repair joint damage. Consistent with recommendations in clinical practice guidelines, a participatory discourse may provide an alternative way of communicating that may encourage people with knee osteoarthritis to continue to engage in physical activity by focusing on what they can do, rather than what they cannot do.

Osteoarthritis is a highly prevalent and disabling disease, causing a significant individual and socioeconomic burden worldwide. Until now, there has been a dearth of research exploring the impact of osteoarthritis in global Indigenous communities. Osteoarthritis has a similar risk factor profile to many chronic diseases that disproportionately affect Indigenous peoples. In this editorial, we argue that osteoarthritis and associated mobility restrictions play a central role in the chronic disease profile of Indigenous peoples. We present a call to action for clinicians and health care providers, researchers and policymakers to begin to recognise the interrelated nature of osteoarthritis and chronic disease. We have an opportunity to change the way we do business, to improve access to culturally secure osteoarthritis care and the health and wellbeing of Indigenous communities.

Objective: Patient satisfaction is considered an important outcome measure after total knee replacement, but the construct is complex. There is large variation both in how satisfaction is measured and estimates of the proportion of people who are satisfied after surgery. The aim of this systematic review was to i) evaluate the proportion of people reported to be satisfied after total knee replacement for osteoarthritis; and ii) assess the content validity of the utilised satisfaction measures. Methods: We searched four literature databases with search phrases ‘Total Knee Arthroplasty’ OR ‘Total Knee Replacement’ AND ‘Patient satisfaction’ for studies that measured satisfaction at least 6 month post-unilateral primary total knee replacement for knee osteoarthritis. Identified studies were assessed for risk of bias, and studies at high risk of bias were excluded (PROSPERO: CRD42017058936). Meta-analysis was not appropriate due to the heterogeneity in satisfaction instruments, thus satisfaction scores were described. The content validity of satisfaction questionnaires was assessed using the COnsensus-based Standards for the selection of health status Measurement Instruments criteria. Results: The present review found heterogeneity in the satisfaction questions used, as well as the satisfaction estimates from the various studies. Only two satisfaction instruments were relevant for a Total Knee Replacement population and both failed assessment for content validity due to lack of patient involvement during development and testing in accordance with the COnsensus-based Standards for the selection of health status Measurement Instruments criteria. Conclusion: Future research should focus on qualitative methods to elicit patients' perspectives of satisfaction to build theoretical understanding.

Osteoarthritis is a debilitating condition as well as a growing global health problem, and total knee arthroplasty (TKA) is an effective treatment for advanced disease. Unplanned 30-day hospital readmission is an indicator of complications, which is a significant financial burden on healthcare systems. We reviewed the literature to better understand the patient-related factors associated with unplanned 30-day readmission following TKA. MEDLINE and EMBASE were searched for studies reporting on patient-related risk factors for unplanned 30-day readmission following primary or revision TKA for any indication. The impact of specific medical comorbidities on increasing the risk of 30-day readmission following TKA is quite well established. The following comorbidities are strongly associated with readmission: bleeding disorder, diabetes, chronic kidney disease and dialysis, chronic immunosuppressant use and history of cancer. Other significant comorbidities include: dementia; depression; haematological (coagulopathy and anaemia), cardiovascular (atrial fibrillation, cardiovascular disease, coronary artery disease and congestive heart failure), respiratory (chronic obstructive pulmonary disease) and liver diseases; and cerebrovascular accident/transient ischaemic attack (but only in revision TKA patients). The influence of variation in sex, age and body mass index each demonstrate a more complex pattern. A systematic review and meta-analysis is required to quantify the impact of the various patient-related factors on 30-day readmission following TKA. Clinicians can use this information in preoperative decision-making.

BACKGROUND: Osteoarthritis (OA) is one of the most common chronic joint diseases and a leading cause of pain and disability in Australia. A National Osteoarthritis Strategy (the Strategy) was developed to outline a national plan to achieve optimal health outcomes for people at risk of, or with, OA. OBJECTIVE: This article focuses on the theme of advanced care of patients with OA within the Strategy. DISCUSSION: The Strategy was developed in consultation with a leadership group, thematic working groups, an implementation advisory committee, multisectoral stakeholders and the public. This Strategy identified three priorities in advanced care for osteoarthritis. In brief, these include surgical decision making, referral for evidence-informed non-surgical alternatives and surgical services. A set of goals within these priority areas and strategies was also proposed by the working group in consultation with stakeholders nationwide. Peak arthritis bodies and major healthcare professional associations currently endorse the Strategy.

Background Approximately 12–20% of those with osteoarthritis (OA) in Australia who undergo total knee replacement (TKR) surgery do not report any clinical improvement. There is a need to develop prediction tools for use in general practice that allow early identification of patients likely to undergo TKR and those unlikely to benefit from the surgery. First-line treatment strategies can then be implemented and optimised to delay or prevent the need for TKR. The identification of potential non-responders to TKR may provide the opportunity for new treatment strategies to be developed and help ensure surgery is reserved for those most likely to benefit. This statistical analysis plan (SAP) details the statistical methodology used to develop such prediction tools. Objective To describe in detail the statistical methods used to develop and validate prediction models for TKR surgery in Australian patients with OA for use in general practice. Methods This SAP contains a brief justification for the need for prediction models for TKR surgery in general practice. A description of the data sources that will be linked and used to develop the models, and estimated sample sizes is provided. The planned methodologies for candidate predictor selection, model development, measuring model performance and internal model validation are described in detail. Intended table layouts for presentation of model results are provided. Conclusion Consistent with best practice guidelines, the statistical methodologies outlined in this SAP have been pre-specified prior to data pre-processing and model development.

Background: The value of involving consumers and community members in every stage of the research process is gaining recognition as an important consideration in the wider research landscape. The National Health and Medical Research Council (NHMRC) has provided general recommendations for involving consumers and community members in research, although the translation of these recommendations into tangible actions has not yet been well defined. In light of these recommendations, many research institutions are now seeking to incorporate the voices of consumers and community members in their research practices. Methods: The consumer and community involvement framework described in this paper incorporates the NHMRC’s recommendations to produce a four-tiered model where consumer participants nominate their level of involvement depending on their research interests and preferred level of commitment. In ascending order, the tiers are: Consumer Subscriber, Document Reviewer, Research Buddy and Consumer Advocate. The success of this framework depends upon the implementation of effective governance and access to appropriate infrastructure. A Consumer and Community Advisory Group and a designated Consumer and Community Liaison Officer will take responsibility for ensuring appropriate interactions between consumers, researchers, and the research center’s executive team. The framework aims to apply suitable support structures in place to manage expectations and minimize barriers to effective involvement, whilst ensuring that consumer contributions are appropriately valued and incorporated in the research. Discussion: Involving consumers and community members in the research process is an important step towards developing and delivering effective, person-centered health care. While consumer and community involvement offer researchers invaluable perspectives on their research program, it provides an opportunity for consumers and community members to be actively involved in health

INTRODUCTION: Fifty per cent of patients consent for total knee replacement (TKR) with unrealistic expectations about what it involves and can achieve. A framework is needed to help surgeons identify key knowledge gaps and misconceptions that can be targeted during the informed consent process. In this qualitative study, we explored knowledge gaps and misconceptions by asking patients to reflect on their expectations along the TKR journey. METHODS: Eligible adults were ≥18 years, 12-month post-TKR and had completed a validated expectations questionnaire pre-TKR as part of a joint replacement registry. To capture a variety of perspectives, people with a range of pre-TKR expectation scores were invited. In interviews, participants reflected on anticipated and actual experiences and unexpected experiences they had along the way. Transcripts were analysed through inductive thematic analysis. Recruitment ceased when thematic saturation was reached. ETHICS APPROVAL: Ethical approval for this study was granted by the St Vincent's Hospital Melbourne Ethics Committee (LRR 077/18). RESULTS: In the final sample (n = 20; 50% female; median age = 72 years; contralateral TKR = 11), all participants described instances where their anticipated and actual experiences diverged, including high expectations of improvements in pain/function (pre-surgical optimism), lacking awareness about anaesthetic procedures (perioperative misunderstandings), feeling unprepared for the length of the recovery period (post-operative misestimations) and trying to make sense of ongoing functional limitations (long-term misattributions). DISCUSSION AND CONCLUSION: These findings are captured in a preliminary framework of therapeutic misconception. Although future research is needed to test this framework prospectively in larger, more generalisable samples, surgeons can consider these key knowledge gaps and misconceptions when consenting for TKR.

Introduction: Fifty per cent of patients consent for total knee replacement (TKR) with unrealistic expectations about what it involves and can achieve. A framework is needed to help surgeons identify key knowledge gaps and misconceptions that can be targeted during the informed consent process. In this qualitative study, we explored knowledge gaps and misconceptions by asking patients to reflect on their expectations along the TKR journey. Methods: Eligible adults were ≥18 years, 12-month post-TKR and had completed a validated expectations questionnaire pre-TKR as part of a joint replacement registry. To capture a variety of perspectives, people with a range of pre-TKR expectation scores were invited. In interviews, participants reflected on anticipated and actual experiences and unexpected experiences they had along the way. Transcripts were analysed through inductive thematic analysis. Recruitment ceased when thematic saturation was reached. Ethics Approval: Ethical approval for this study was granted by the St Vincent's Hospital Melbourne Ethics Committee (LRR 077/18). Results: In the final sample (n = 20; 50% female; median age = 72 years; contralateral TKR = 11), all participants described instances where their anticipated and actual experiences diverged, including high expectations of improvements in pain/function (pre-surgical optimism), lacking awareness about anaesthetic procedures (perioperative misunderstandings), feeling unprepared for the length of the recovery period (post-operative misestimations) and trying to make sense of ongoing functional limitations (long-term misattributions). Discussion and Conclusion: These findings are captured in a preliminary framework of therapeutic misconception. Although future research is needed to test this framework prospectively in larger, more generalisable samples, surgeons can consider these key knowledge gaps and misconceptions when consenting for TKR.

INTRODUCTION: Resistant Gram-positive organisms, such as methicillin-resistant staphylococci, account for a significant proportion of infections following joint replacement surgery. Current surgical antimicrobial prophylaxis guidelines recommend the use of first-generation or second-generation cephalosporin antibiotics, such as cefazolin. Cefazolin, however, does not prevent infections due to these resistant organisms; therefore, new prevention strategies need to be examined. One proposed strategy is to combine a glycopeptide antibiotic with cefazolin for prophylaxis. The clinical benefit and cost-effectiveness of this combination therapy compared with usual therapy, however, have not been established. METHODS AND ANALYSIS: This randomised, double-blind, parallel, superiority, placebo-controlled, phase 4 trial will compare the incidence of all surgical site infections (SSIs) including superficial, deep and organ/space (prosthetic joint) infections, safety and cost-effectiveness of surgical prophylaxis with cefazolin plus vancomycin to that with cefazolin plus placebo. The study will be performed in patients undergoing joint replacement surgery. In the microbiological sub-studies, we will examine the incidence of SSIs in participants with preoperative staphylococci colonisation (Sub-Study 1) and incidence of VRE acquisition (Sub-Study 2). The trial will recruit 4450 participants over a 4-year period across 13 orthopaedic centres in Australia. The primary outcome is the incidence of SSI at 90 days post index surgery. Secondary outcomes include the incidence of SSI according to joint and microorganism and other healthcare associated infections. Safety endpoints include the incidence of acute kidney injury, hypersensitivity reactions and all-cause mortality. The primary and secondary analysis will be a modified intention-to-treat analysis consisting of all randomised participants who undergo eligible surgery. We will also perform a per-protocol analysis. ETHICS AND DISS

OBJECTIVE: To evaluate the efficacy of Mindfulness-Based Stress Reduction (MBSR) in improving pain and physical function following total joint arthroplasty (TJA). DESIGN: Two-group, parallel-group, randomised controlled trial, conducted between September 2012 and May 2017. SETTING: Single centre study conducted at a University-affiliated, tertiary hospital. INTERVENTION: People with arthritis scheduled for TJA, with a well-being score <40 (Short Form-12 Survey) were randomly allocated to a pre-surgery eight-week MBSR program or treatment as usual (TAU). OUTCOME MEASURES: Self-reported joint pain and function at 12 months post-surgery, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were knee stiffness and global improvement (WOMAC); physical and psychological well-being (Veterans RAND 12-item Health Survey); self-efficacy (Arthritis Self-Efficacy Scale); and mindfulness (5-Factor Mindfulness Questionnaire). RESULTS: 127 participants were randomised; 65 to MBSR and 62 to TAU, of which 45 participants allocated to the intervention and 56 participants allocated to usual care proceeded to surgery and 100 (99%) completed primary outcome measures. Greater improvements in knee pain (mean difference, -10.3 points, 95% CI -19.0 to -1.6; P = 0.021) and function (mean difference, -10.2 points, 95% CI -19.2 to -1.3; P = 0.025) at 12 months post-surgery were observed in the MBSR group compared to the TAU group. A between group difference in global scores (-9.5 points, 95% CI -17.9 to -1.1; P = 0.027) was also observed. No other differences in secondary outcomes were observed. CONCLUSION: MBSR improves post-surgery pain and function in people with psychological distress undergoing TJA. Further research is required to examine potential barriers to broader implementation and uptake.

BACKGROUND: Osteoarthritis is a debilitating condition as well as a growing global health problem, and total knee arthroplasty is an effective treatment for advanced stages of disease. Unplanned 30-day hospital readmission is an indicator of complications, which is a significant financial burden on healthcare systems. The objective is to perform a systematic review of patient-related factors associated with unplanned 30-day readmission following total knee arthroplasty. This information will inform future strategies to improve health outcomes after knee arthroplasty surgery. METHODS: MEDLINE and EMBASE will be systematically searched using a comprehensive search strategy. Studies of higher quality than case series will be included, in order to optimise the quality of the findings of this review. We will include studies reporting on patient-related risk factors for unplanned 30-day readmission following primary or revision total knee arthroplasty for any indication. Case series will be excluded, as will studies reporting exclusively on intraoperative, clinician, hospital, and health system risk factors. The reference lists of selected papers will then be screened for any additional literature. Two reviewers will independently apply stringent eligibility criteria to titles, abstracts, and full texts of studies identified in the literature search. They will then extract data from the final list of selected papers according to an agreed-upon taxonomy and vocabulary of the data to be extracted. Assessment of risk of bias and quality of evidence will then take place. Finally, the effect size of each identified risk factor will be determined; meta-analysis will be performed where adequate data is available. DISCUSSION: The findings of this review and subsequent meta-analysis will aid clinicians as they seek to understand the risk factors for 30-day readmission following total knee arthroplasty. Clinicians and patients will be able to use this information to align expectati

Objectives: The demand for total knee arthroplasty (TKA) is increasing. Differentiating who will derive a clinically meaningful improvement from TKA from others is a key challenge for orthopaedic surgeons. Decision aids can help surgeons select appropriate candidates for surgery, but their uptake has been low. The aim of this study was to explore the barriers and facilitators to decision aid uptake among orthopaedic surgeons. Design: A qualitative study involving face-to-face interviews. Questions were constructed on the Theoretical Domains Framework to systematically explore barriers and facilitators. Setting: One tertiary hospital in Australia. Participants: Twenty orthopaedic surgeons performing TKA. Outcome measures: Beliefs underlying similar interview responses were identified and grouped together as themes describing relevant barriers and facilitators to uptake of decision aids. Results: While prioritising their clinical acumen, surgeons believed a decision aid could enhance communication and patient informed consent. Barriers identified included the perception that one’s patient outcomes were already optimal; a perceived lack of non-operative alternatives for the management of end-stage osteoarthritis, concerns about mandatory cut-offs for patient-centred care and concerns about the medicolegal implications of using a decision aid. Conclusions: Multifaceted implementation interventions are required to ensure that orthopaedic surgeons are ready, willing and able to use a TKA decision aid. Audit/ feedback to address current decision-making biases such as overconfidence may enhance readiness to uptake. Policy changes and/or incentives may enhance willingness to uptake. Finally, the design/implementation of effective non-operative treatments may enhance ability to uptake by ensuring that surgeons have the resources they need to carry out decisions.

BACKGROUND: A patient- and surgeon-Delphi-derived Outcome Measures in Rheumatology (OMERACT) draft core domain set for total joint arthroplasty (TJR) trials was recently developed. Our objective was to obtain further patient stakeholder endorsement of draft core domain set for TJR clinical trials. METHODS: We surveyed two patient groups: (1) OMERACT patient partners; and (2) patients who had undergone hip or knee TJR. Patients received an introductory email with explanations about the core domain set and instructions to rate the core domains, i.e., important aspects, of OMERACT TJR clinical trial draft core domain set. Rating was on a nominal scale, where 1-3 indicated a domain of limited importance, 4-6 an important, but not critical domain, and 7-9 a critical domain. We used Mann-Whitney test (a non-parametric test) to compare the distribution of ratings between the two groups. RESULTS: Thirty one survey participants from the OMERACT patient partner group and 118 knee/hip TJR patients responded with response rates of 66 and 80%, respectively. Majority of the survey respondents were female, 87 vs. 53%, and were 55 years or older, 57 vs. 94%. Median (interquartile range [IQR]) scores for six core domains by OMERACT and knee/hip TJR patient groups were, respectively: pain, 8 [8, 9] and 9 [8, 9]; function, 9 [8, 9] and 9 [8, 9]; patient satisfaction, 8 [8, 9] and 8 [7, 9]; revision surgery, 7 [7, 8] and 7 [5, 9]; adverse events, 8 [7, 9] and 8 [6, 9]; and death, 9 [6, 9] and 9 [4, 9]. No statistically significant differences in rating were noted for any of the six core domains between the two groups (p ≥ 0.31). Among the additional domains, ratings for patient participation did not differ by group (p = 0.98), but ratings for cost were significantly different (p = 0.005). Patients provided qualitative feedback regarding core domains, and did not propose any modifications to the draft core domain set. CONCLUSIONS: Two separate patient stakeholder groups endorsed the OME

BACKGROUND: With the evolution of total hip joint replacement techniques, there has been a trend towards minimally invasive surgery. The anterior approach (AA) to total hip arthroplasty has been widely associated with less soft tissue damage. The aim of our study was to compare clinical and 1-year functional outcomes for AA hip arthroplasty versus a posterior approach (PA). METHOD: We retrospectively reviewed 92 (50 anterior and 42 posterior) total hip replacements performed at our centre between 2006 and 2011. Clinical outcomes were recorded from hospital medical records and clinical audit system. Range of motion analysis, Harris hip score (HHS) and Short Form-12 score were recorded pre-operatively and at the 12-month follow-up marks. Additionally, we reviewed operative time, length of stay, discharge destination, complications, return to theatre and readmission rates. RESULTS: The results of our study revealed significantly shorter average hospital length of stay for the AA versus PA (4.2 versus 6.0 days, P = 0.004). Interestingly, our study also showed significantly shorter operating time with the AA (83.0 versus 91.8 min, P = 0.048) and lower return to theatre rates (0 versus 9.5%, P = 0.026). Finally, multivariate analysis showed AA to be associated with higher HHS and pre-operative body mass index to be associated with lower HHS at 12-month post-operation (P = 0.02 and <0.001, respectively). CONCLUSIONS: Our study showed improved HHS at 12 months as well as reduced hospital length of stay, operating time and return to theatre with an AA when compared with a PA.