TJR patients benefit from the surgery, regardless of their obesity status

In our analyses of 2,964 primary unilateral TKR and 2,040 primary unilateral THR patients, stratified by obesity level, we found significant improvement in pain and function 6 month after surgery across all patient groups. This was the first data of TJR outcomes in relation to obesity to emerge from a large nationally representative US cohort. The findings support that BMI should not be a deterrent to surgery to relieve hip and knee osteoarthritis symptoms. We also conclude that it remains important for surgeons to discuss potential complications associated with higher levels of obesity. Future research will consider benefits vs. risk of TJR among patients with higher BMI levels.

Li W, Ayers DC, Lewis CG, Bowen TR, Allison JJ, Franklin PD. Do functional gain and pain relief after TJR differ by patient obese status? (Accepted JBJS)

TJR patient characteristics differ between US and Switzerland: implications for cross-cultural comparison of outcomes

Analyses of pre-operative patient characteristics were performed in the following TJR cohorts: 6,680 primary TKA(US) and 823 primary TKA(Swiss); 4,647 primary THA(US) and 1,023 primary THA(Swiss). The level of functional impairment at the time of TKA and THA reflected significant, and similar, disability in both countries. Of importance, there were clinically important differences in age, education level, obesity prevalence, medical comorbidities, preoperative pain levels and emotional health between the two cohorts. We recommend that risk-adjustment for these variables will be necessary before cross-cultural comparisons of TJR outcomes can be performed.

Franklin PD, Miozzari H, Christofilopoulos P, et al. Important Patient Characteristics Differ Prior to TKA and THA Between Switzerland and the United States. BMC Musculosklet Disord Jan 11;18(1):14. doi: 10.1186/s12891-016-1372-5.

A younger TJR population does not suggest a less complex patient pool.

Younger patients report the same or greater joint-specific and global pain and decreased function pre-operatively when compared to older adults.  In addition, patients under 65 years of age are more obese and more likely to smoke as compared to older patients. Overall, younger patients pose similar risks as older patients, and have similar successful outcomes.

Ayers DC, Harrold L, Snyder B, Person S, Franklin PD. Clinical profile and disability levels of younger vs. older TKR and THR patients: results from a national research consortium. 2013 Orthopaedic Research Society Annual Meeting, San Antonio, TX.
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Patient self-reported pain and function scores are remarkably consistent across surgeons before TJR.

Despite the rapid growth in TJR utilization in the US, our analysis suggests surgeons use comparable indications for surgery. Across 150 surgeons, the mean pre-operative pain and function were similar. Overall, more than 92% of patients report significant pain and functional limitations, with the remaining patients reporting quality of life limitations. Monitoring pre-operative PROs can help patients and surgeons determine the optimal time for TJR.

Ayers DC, Li W, Harrold LR, et al. Pre-Operative Pain And Function Profiles Reflect Consistent TKR Patient Selection Among US Surgeons. Clin Orthop Relat Res; 2015 (Jan);473(1):76-81. DOI: 10.1007/s11999-014-3716-5. PMID: 24957788

TJR patients benefit from pain management information prior to surgery

After a survey of 1,609 TJR patients, we found that 33% had not received any information prior to surgery in regards to post-surgery pain management and 11% had not found the information received useful. Of importance, this lack of pain management information was associated with poorer functional outcomes at 6 months post-surgery. By contrast, patients who had received pain management information reported lower levels of pain at 2 weeks post-TJR, more use of non-medication method and less interference with daily activities as compared to patients who had not received any pain management information. The data illustrates the need to improve patient information.

Lemay CA, Lewis CG, Singh J, Franklin PD. Receipt of pain management information pre-operatively is associated with improved functional gain after elective total joint replacement. J Arthropl 2017 Jan.

Negative impact of musculoskeletal comorbidities

The burden of musculoskeletal comorbidities- specifically moderate or severe pain in the lumbar spine and non-operative hips and knees- is associated with poorer function at 6 months after surgery. Future public comparisons of PROs after TJR must be cautious to adjust for co-existing musculoskeletal conditions that can limit functional gain after successful surgery in one knee or hip.

Ayers DC, Harrold L, Li W, Snyder B, Allison JJ, Lewis C. Greater musculoskeletal pain in TKR and THR patients correlates with poorer function in a national consortium. 2013 Orthopaedic Research Society Annual Meeting, San Antonio, TX.
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Complete FORCE-TJR Bibliography


Funding Sources

List of investigators, institutions and agencies.


Funding Sources

Prime Institution Funding Agency Title
University of MA Medical School (UMMS) PCORI Patient Osteoarthritis Careplan to Inform Optimal Treatment
University of MA Medical School (UMMS) NIAMS Defining Components Of Physical Therapy Achieving Maximum Function After TKR
University of MA Medical School (UMMS) AHRQ Improving Patient-Reported Outcomes Measures for Total Joint Replacement
University of Utah AHRQ Influence of expanding bundled payment models on patient-reported outcomes, episode-of-care costs, procedure volume, and safety.
Harvard Medical School (HMS) NIAMS Use And Safety Of Opioids In Patients Undergoing Total Joint Replacement
Medical University of South Carolina PCORI Comparative Effectiveness of Pulmonary Embolism Prevention after Hip and Knee Replacement
Cornell University FDA Creating National Surveillance Infrastructure for Priority Medical Devices
Worcester Polytechnic Institute (WPI) AHRQ Mobile App For Shared Informed Decision Making In Total Joint Replacement Surgery
University of Alabama at Birmingham (UAB) AHRQ UAB Deep South Arthritis and Musculoskeletal CERTs
AcademyHealth AHRQ National Best Practices And Barriers In PRO Collection
UMass Memorial Health Center (UMMHC) UMMHC Micro RNAs In The Regulation Of Resorption And Healing Of Bone Erosions