Persisting Pain and Poor Function after Knee or

Persisting Pain and Poor Function after Knee or Hip Joint Arthroplasty: What can learn about this epidemic? Jasvinder Singh, M. B. B. S. , M. P. H. Professor of Medicine, University of Alabama at Birmingham Staff Physician, Birmingham Veterans Affairs Medical Center Director, UAB Gout Clinic Director, UAB Cochrane Network Meta-analysis Satellite Director, Rheumatology Research, Birmingham VA Med Ctr Research Collaborator, Mayo Clinic College of Medicine THE UNIVERSITY OF ALABAMA AT BIRMINGHAM OMICS, June 2016

Disclosures • This project was funded by the orthopedic surgery division funds at the Mayo Clinic and partly by a K-12 training grant (Singh) • Research Funding • • • Patient Centered Outcomes Research Institute (PCORI) NIH: U 10 CA 149950 NIA: R 01 AG 028359, U 01 AG 18947 AHRQ: U 19 HS 021110 VA: Cooperative Studies Program CSP #G 002 Industry: Takeda, Savient • Consultant: Takeda, Savient, Regeneron, Allergan, Iroko, Merz, Bioiberica, Crealta

When do patients get Primary 1 Total Knee Arthroplasty (TKA)? • Moderate to severe pain not adequately relieved by extended course of non-surgical treatment • Clinically significant functional limitation • Radiographic evidence of joint damage • Goal of TKA • Relief of pain and • Improvement in function 1 NIH Consensus Development Conference on Total Knee replacement, December 8 -10, 2003

Projections: primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures in the United States from 2005 to 2030. Kurtz S. et. al. J Bone Joint Surg 2007: 89: 780 -785

Overview • Functional Limitation after TKA • Gender • Age • Body Mass Index • Pain and Function after TKA • Pessimism

Overview • Functional Limitation after TKA • Gender • Age • Body Mass Index • Pain and Function after TKA • Pessimism

Patient factors and Moderate to Severe Functional Limitation Post Total Knee Arthroplasty

Functional Limitation Post TKA: Predictors • Evidence regarding association of Gender, Age and BMI with functional outcomes is contradictory Yes No Gender Fitzgerald 2004; Ritter, Lutgring et al. 2008 Sharma 1996; Hawker 1998; Fortin 1999; Jones 2001; Jones 2003; Lingard 2004; Kennedy 2006 Age Lingard 2004 Hawker 1998; Fortin 1999; Jones 2001; Jones 2003; Fitzgerald 2004 BMI Hawker 1998; Winiarsky 1998; Foran 2004; Lingard 2004; Amin 2006; Krushell 2007; Naylor 2008 Sharma 1996; Jones 2001; Spicer 2001; Jones 2003; Fitzgerald 2004; Amin 2006; Bourne 2007; Nunez 2007; Naal 2008

Study Objective • To examine if Gender, Age and preoperative Body Mass Index (BMI) are significant independent predictors of functional limitation • 2 - and 5 -years after Primary TKA • 2 - and 5 -years after Revision TKA Singh JA et al. Osteoarthritis Cartilage 18(4): 515 -521. Singh JA et al. J Arthroplasty 25(7): 1091 -1095,

Study Design • All primary and revision Total Knee Arthroplasty patients at Mayo Clinic from 1993 -2005 and alive at FU • Patients responded to a mailed questionnaire or completed a questionnaire during clinic visit/telephone at 2 - and 5 years post-TKA • Pain and Function Questionnaire • have construct validity and reproducibility (Mc. Grory 1996), very similar to Knee Society Scale

Study Outcome • Limitation of 3 activities was categorized as follows: • Distance walked • 'Unlimited’ or '> 10 blocks' = None; • '5 -10 blocks ' = Mild; • '< 5 blocks '=Moderate; • 'Housebound', 'Indoors only' or 'Unable' = Severe • Using stairs • Stairs: 'Normal Up and Down’=None; • ‘'Normal Up, Down with Rail' = Mild; • 'Up and Down with Rail' = Moderate; • 'Up with Rail, Down Unable' or 'Unable ' = Severe • Rising from chair • Rise from Chair: 'Able, no arms’ = None; • 'Able, with Arms' = Mild; • 'Able with difficulty' = Moderate; • ' Unable ' = Severe • Moderate-Severe functional limitation: Moderate or Severe limitation ≥ 2 activities

Statistical Analyses • Predictor of Interest: • Gender • Age- ≤ 60, 61 -70, 71 -80, >80 • BMI, categorized per WHO (2000) classification • Normal, <25, overweight, 25 -29. 9, Obese and very obese, 30 -39. 9, extremely obese, ≥ 40 • Confounders: comorbidity (Deyo-Charlson index), ASA class, distance from medical ctr, implant fixation (primary TKA), underlying diagnosis • Multivariable logistic regression models using Generalized Estimating Equations to account for bilaterality • multivariable-adjusted odds ratios with 95% confidence intervals

Gender: We might be a little different

Gender: We might be a little different

RESULTS • Primary TKA- response rate • 65% (7, 139/10, 957) at 2 -year FU • 57% (4, 234/7, 404 ) at 5 -year FU • Revision TKA- response rate • 57% (1, 553/2, 695) at 2 -year FU • 48% (881/1, 842) at 5 -year FU

RESULTS • Clinical Characteristics • Primary TKA • Mean (SD) age, 68 (10) • 56% F • OA- 95% • BMI ≥ 25, 87% • Revision TKA • Mean (SD) age, 69 (10) years • 51% F • Loosening, wear or osteolysis -61% • BMI ≥ 25, 87%

Prevalence: Moderate-Severe Functional Limitation Primary TKA 2 -year Moderate. Severe Functional Limitation 20. 7% Primary TKA 5 -year 27. 2% Revision TKA 2 -year Revision TKA 5 -year 46. 5% 50. 5%

Primary TKA: Moderate-severe functional limitation 2 years

Primary TKA: Moderate-severe functional limitation - 5 years

Revision TKA: Moderate-severe functional limitation - 2 years

Revision TKA: Moderate-severe functional limitation - 5 years

Study Strengths/limitations • Limitations • Non-Response Bias • 57 -65% response rate • 5 -year revision TKAs, 48% • Residual confounding • Did not assess impact of change of BMI post-operatively • Strengths • Large sample size- enough patients in each BMI category • Ability to control for many confounders

Overview • Functional Limitation after TKA • Gender • Age • Body Mass Index • Pain and Function after TKA • Pessimism

Do Psychological Factors Affect Outcomes after Primary TKA? Singh JA et al. J Bone Joint Surg Br 92(6): 799 -806

Pessimistic Explanatory Style • Seligman's theory: “Causal Attribution” • that the manner in which people "explain" (i. e. , cognitively) to themselves, the reasons for the occurrence of specific, important, good or bad events in their lives (e. g. , "Why did this happen to me? ") has important ramifications. • More specifically, according to Seligman's theory, people are described as having a pessimistic attributional style who • 1) attribute the causes of adverse events in their lives to themselves (i. e. , an internal explanation, "It's me. . . "), • 2) carry the expectation that the condition will persist (i. e. , a stable explanation, ". . . happened again, as usual. . . "), and • 3) believe that it will affect other aspects of their life ( a global explanation, ". . . and now. . . I'll never get to. . . " ) can be described.

Study Objective • To examine the impact of pessimistic explanatory style on 2 -and 5 -year outcomes following Total Knee Arthroplasty (TKA)

Study Design • 894 primary TKA surgeries from 1993 -2005 in which the patients responded to Total Joint Registry routine clinical follow-up questionnaires sent to all patients @ 2 and 5 year follow-up. • construct validity and reproducibility (Mc. Grory 1996) • very similar to Knee Society Scale • Scores from the Optimism-Pessimism (PSM) scale from the Minnesota Multiphasic Personality Inventory (MMPI) completed by a subset of TKA patients a median of 16. 1 years before their TKA as a part of clinical care • Obtained for 783 primary TKA surgeries with 2 -year surveys and 443 primary TKA surgeries with 5 -year surveys.

Study Outcome • Outcomes assessed on 2 - and 5 -year clinical questionnaire: • moderate-severe pain (reference- no/mild/walking/ walking and stairs pain) • moderate-severe functional limitation = moderatesevere limitation in ≥ 2 of 3 activities (walking, climbing stairs, chair transfer; reference- no limitation, mild limitation or moderate-severe limitation in 1 activity) • Best change in knee function compared to preoperative rated as much better by patient (reference, somewhat better/same/ worse).

Statistical Analyses • Predictor of Interest: • PSM score as a categorical (score, 0 -100, tscore>60 =pessimist) • Confounders: gender, age, depression, distance from medical center • Multivariable-adjusted logistic regression models, • Odds Ratio (OR) with 95% Confidence Interval (CI) are presented • p<0. 05 was considered significant

Results • Clinical Characteristics • Primary TKA- 2 -year FU • Mean (SD) age, 69 (10); 62% F; • OA- 94% • BMI ≥ 25, 88% • Primary TKA- 5 -year FU • Mean (SD) age, 69 (9) years; 58% F • OA -92% • BMI ≥ 25, 87%

Pessimism and Moderate-Severe Pain post-PRIMARY TKA 2 -yr 5 -yr n/N (%) Odds ratio (95% CI) Pn/N (%) value Odds ratio (95% CI) No 52/533 (9. 8%) 1. 0 34/306 (11. 1%) 1. 0 Yes 35/222 (15. 8%) 2. 21 (1. 12, 4. 35) 18/126 (14. 3%) 1. 21 (0. 51, 2. 83) Pvalue Pessimist 0. 02 0. 67

Pessimism and Best Improvement in Knee Function post-PRIMARY TKA 2 -yr n/N (%) Odds ratio (95% CI) No 457/532 (85. 9%) 1. 0 Yes 173/222 (77. 9%) 0. 53 (0. 30, 0. 96) 5 -yr Pvalue n/N (%) Odds ratio (95% CI) 255/305 (83. 6%) 1. 0 100/123 (81. 3%) 1. 26 (0. 57, 2. 77) Pvalue Pessimist 0. 04 0. 57

Pessimism and Moderate-Severe Functional Limitation post-PRIMARY TKA 2 -yr n/N (%) Odds ratio (95% CI) No 136/523 (26%) 1. 0 Yes 72/220 (32. 7%) 1. 38 (0. 95, 2. 02) 5 -yr Pn/N (%) value Odds ratio (95% CI) Pvalue Pessimist 0. 09 95/298 (31. 9%) 1. 0 53/123 (43. 1%) 1. 84 (0. 98, 3. 43) 0. 06

Study Strengths/limitations • Limitations • Responder Bias • Residual confounding • Sample size small for 5 -year FU • Strengths • Large sample size- enough patients with MMPI scores • Ability to control for important confounders

Conclusions and Implications • Patients with pessimistic style had worse pain and function outcomes at 2 -years after primary TKA • Age, gender and obesity are associated with worse function outcomes at 2 - and 5 -years after primary and revision TKA • Future studies should investigate the reasons for better outcomes after TKA.

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