Is routine chemoprophylaxis necessary for prevention of venous thromboembolism following knee arthroplasty in a low incidence population?

Background

Standard thromboprophylaxis guidelines have not been applied universally in regions with low incidence of deep-vein thrombosis (DVT) considering risks of chemoprophylaxis and low incidence itself. We evaluated the prevalence of DVT, efficacy and safety of chemoprophylaxis, and necessity of pharmacological prevention in a low DVT incidence population.

Methods

One hundred and forty-eight patients undergoing unilateral total knee arthroplasty (TKA) were prospectively randomized to receive either a placebo or 2.5 mg of fondaparinux once daily for 5 days. Doppler ultrasonography was performed preoperatively and 7 days after surgery. The primary efficacy outcome was prevalence of DVT up to day 7. Secondary efficacy outcome was prevalence of symptomatic venous thromboembolism (VTE) up to day 90. Primary and secondary safety outcomes were incidence of major and minor bleeding, respectively.

Results

The prevalence of total DVT was 25.7 % in placebo group and 6.8 % in fondaparinux group (p = 0.002) and the prevalence of proximal DVT was lower in both groups with no statistical difference. There was no symptomatic VTE in either group up to day 90. Although no major bleeding was developed, fondaparinux group had a significant increase of minor bleeding events (p < 0.001).

Conclusions

There remains low incidence of VTE following TKA in East Asians even without chemoprophylaxis. Although short-term fondaparinux protocol could reduce the incidence of overall DVT, its routine use seems debatable due to extremely rare proximal DVT and symptomatic PE and drug-related bleeding complication. However, modified and selective use of chemoprophylaxis would be considerable in high risk patients.     

The Rate and Mortality of Postoperative Venous Thromboembolism of Moderate Risk Surgery in Asian Patients without Thrombo-prophylaxis: Systematic Review with Meta-analysis

Background

The general gynecologic and neurologic surgeries are regard as carrying moderate risk for postoperative venous thromboembolism (VTE). This review analyzed the postoperative VTE rate of these surgeries in Asia.

Methods

Inclusion criteria were: prospective study; deep vein thrombosis (DVT) diagnosed by venography, ultrasonography, or radionucleotide scan; and no thromboprophylaxis. The pooled proportion was back calculated from Freeman–Tukey variant transformation, using a random effect model.

Results

Medline, EMBASE, Cochrane Library, and KoreaMed were searched. Fourteen studies (total population of 1,625) published from 1974 to 2008 were included. In general surgery, the pooled rate of all-sites proximal, isolated distal DVT was 13.4, 2.1, and 11.8 % (radionucleotide scan). The cancer patients carried a higher all-sites DVT rate (19.7 % radionucleotide scan and 17.4 % ultrasound). Gynecologic and neurologic surgery had 3.1 % (ultrasound) and 3.8 % (radionucleotide scan) all-sites DVT rate. For general, gynecologic, and neurologic patients, the pooled rates of symptomatic DVT were 1.5, 0.2, and 1.0 % respectively. The pooled rate of symptomatic pulmonary embolism (PE) was 0.4 % for general surgery. No patients died from PE (pooled rate 0.2 %); however, a single PE death was reported in the excluded study.

Conclusions

Postoperative symptomatic VTE was relatively low in Asia. Further study is required to stratify VTE risk and the need for thromboprophylaxis in individual patients.     

Quantitative index for deciding whether to administer preventive anticoagulant therapy in osteoarthritis patients undergoing total knee arthroplasty

Background

The 2008 American Academy of Orthopedic Surgeons recommended that surgeons assess the relative risks of venous thromboembolism and bleeding in patients undergoing total knee arthroplasty (TKA). In this situation, a quantitative index is required for deciding whether to administer preventive anticoagulant therapy for deep venous thrombosis (DVT). In this study, we investigated the risk factors for DVT after TKA.

Methods

We included 102 patients (122 knees) who underwent primary TKA for osteoarthritis of the knee between October 2007 and March 2010. DVT was evaluated using lower limb venous ultrasonography. Cutoff values for individual risk factors were determined using a receiver-operating characteristic analysis, and the patients were grouped according to the cutoff values; the odds ratios (95 % CI) were also investigated. The Wilcoxon signed-rank test and χ ² test were also used.

Results

DVT was positive in 25 knees (20.5 %). Three risk factors for DVT after TKA were identified: age 76 years or older, preoperative maximum soleus vein (MAX-SV) diameter of 6.0 mm or greater, and preoperative D-dimer value of 1.1 μg/dl or higher. The incidence of DVT was significantly higher in the group with two or more risk factors than in the group with one or no risk factors (p = 0.0001).

Conclusions

Development of postoperative DVT correlated significantly with the presence of the following risk factors: age 76 years or older, preoperative MAX-SV diameter of 6.0 mm or greater, and a preoperative D-dimer value of 1.1 μg/dl or higher. Considering the risk–benefit ratio, avoiding preventive anticoagulant therapy following TKA can be an option for patients with osteoarthritis with one or no risk factors.     

The necessity of pharmacological prophylaxis against venous thromboembolism in major joint arthroplasty

Purpose

Venous thromboembolism (VTE) is a recognised post-operative complication of major lower limb joint arthroplasty. Current National Institute for Health and Clinical Excellence (NICE) guidelines suggest the use of both mechanical and pharmacological prophylaxis following hip and knee replacement. Since the introduction of enhanced recovery programmes following hip and knee arthroplasty the requirement for routine pharmacological VTE prophylaxis has been questioned. The purpose of this study was to assess the efficacy of pharmacological prophylaxis against symptomatic VTE in patients undergoing hip and knee arthroplasty under an enhanced recovery programme.

Methods

Symptomatic VTE incidence was audited in 1,100 patients undergoing primary or revision total hip or knee arthroplasty at the same hospital with only mechanical prophylaxis from 2007 to 2009. Following addition of chemical prophylaxis (enoxaparin) symptomatic VTE incidence in 522 patients undergoing primary or revision total hip or knee arthroplasty from 2011 to 2012 was re-audited.

Results

In the mechanical prophylaxis group incidence of DVT was 0.73 % [95 % confidence interval (CI) 0.37–1.43 %] and incidence of pulmonary embolism (PE) 0.91 % (95 % CI 0.49–1.67 %). Following addition of pharmacological prophylaxis incidence of DVT was 0.57 % (95 % CI 0.20–1.68 %) and incidence of PE 1.15 % (95 % CI 0.53–2.48 %).

Conclusions

We found no statistically significant difference in symptomatic VTE incidence following the addition of enoxaparin. We question whether routine pharmacological prophylaxis still has a role following total hip and knee arthroplasty. Peri-operative optimisation, including post-operative analgesia and mobility, with current enhanced recovery programmes may be sufficient. As anticoagulants carry increased risk of post-operative bleeding and wound ooze, in addition to significant cost implications, their role remains controversial.     

Diabetes mellitus increases the incidence of deep vein thrombosis after total knee arthroplasty

Introduction

Many patients undergoing total knee arthroplasty (TKA) have diabetes mellitus, which may increase the risk of deep vein thrombosis (DVT) after TKA. We therefore assessed whether diabetes mellitus increased the incidence of DVT within 14 days after TKA.

Materials and methods

The incidence of DVT within 14 days of surgery was compared in diabetic and non-diabetic patients undergoing TKA in our hospital between June 2011 and February 2013. The relationships between diabetes mellitus and DVT were analyzed.

Results

Of the 358 enrolled patients, 70 (19.6 %) had diabetes and 288 (80.4 %) did not. DVT occurred within 14 days in 198 patients, 52 of 70 (74.3 %) in the diabetes group and 146 of 288 (50.7 %) in the non-diabetes group (p = 0.012). DVT of the contralateral leg was observed in 16 and 50 patients, respectively (p = 0.452). Logistic regression analysis showed that the risk of DVT was 2.71-fold higher in patients with than without diabetes mellitus (95 % CI 1.183–6.212, p = 0.018). There were no significant differences in age, gender, hypertension, BMI, duration of surgery, intra-operative blood loss, and duration of tourniquet between the two groups.

Conclusions

The incidence of DVT 14 days after TKA was significantly higher in patients with than without diabetes.     

Safety of fondaparinux to prevent venous thromboembolism in Japanese patients undergoing colorectal cancer surgery: a multicenter study

Purpose

To investigate the safety and efficacy of fondaparinux (FPX) for venous thromboembolism (VTE) prophylaxis in Japanese patients undergoing colorectal cancer surgery.

Methods

The subjects of this multicenter, open-label, prospective observational study were patients undergoing resection of the colon/rectum for colorectal cancer. All patients were given FPX 2.5 or 1.5 mg by subcutaneous injection, once daily for 4–8 days, starting 24 h after surgery. The primary endpoint was any major bleeding event and the secondary endpoint was any symptomatic VTE event.

Results

Between February 2009 and December 2010, 619 patients from 23 institutions were enrolled in this study. The median duration of FPX prophylaxis was 4 days. The incidence of major bleeding was 0.81 % [5/619, 95 % confidence interval (CI) 0.3–1.9] and the incidence of minor bleeding was 9.5 % (59/619, 95 % CI 7.3–12.1). There was no fatal bleeding or symptomatic VTE. Multivariable analysis revealed the following to be risk factors for bleeding events: preoperative platelet count <15 × 10⁴/µl [odds ratio (OR) 4.521], male sex (OR 2.078), and blood loss during surgery <50 ml (OR 2.019).

Conclusion

The administration of 2.5/1.5 mg FPX 24 h after colorectal cancer surgery is safe and effective.     

Factor Xa Inhibitors and Direct Thrombin Inhibitors Versus Low-Molecular-Weight Heparin for Thromboprophylaxis After Total Hip or Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Background

The purpose of this study is to perform a meta-analysis to compare outcomes of venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) vs other anticoagulants in patients who received total knee (TKA) or total hip arthroplasty (THA).

Incidence of symptomatic venous thrombo-embolism following shoulder surgery

Purpose

This clinical study was performed to establish the incidence of symptomatic deep vein thrombosis and pulmonary embolism after shoulder surgery as the incidence of venous thrombo-embolism complicating shoulder surgery is poorly described in literature.

Methods

We reviewed retrospectively clinical records of 920 consecutive patients who had any surgical procedure performed on their shoulder in Glan Clwyd Hospital, North Wales and a further 1,421 consecutive patients who had surgery in Morriston and Singleton Hospitals, South Wales. Patients’ records were assessed for any admissions due to proven VTE; we investigated for any radiological results suggestive of venous thrombo-embolism and for deaths in the post-operative period.

Results

We analyzed data of 2,341 patients. There was one fatal PE in this group, whereby the patient died within 48 hours following reverse shoulder replacement, and post mortem revealed massive pulmonary embolism. There were a further three cases of symptomatic, non-fatal PE. There were six cases of symptomatic DVT of lower limb. All these cases were treated successfully with anticoagulation. No upper limb DVT was identified.

Conclusion

Recent studies suggest that DVT prevalence following shoulder arthroplasty is as high as 13 %. In our study we examined occurrence of symptomatic VTE only. According to our results the prevalence of symptomatic DVT following shoulder surgery is 0.26 %, symptomatic PE 0.17 % and combined prevalence of VTE is 0.43 %. We would advise careful thought about the risk of thrombosis and use mechanical prophylaxis in shoulder surgery, especially for longer procedures. We would not recommend routine pharmacological prophylaxis unless there are additional risk factors.     

Impact of anesthesia modality and mechanical venous thromboembolism prophylaxis on the incidence of symptomatic deep venous thrombosis after TKA

Background

Venous thromboembolic events (VTE) are a common complication of total knee arthroplasty (TKA). Prior studies have discussed the utility of mechanical VTE prophylaxis as a monotherapy for low-risk TKA patients. We assess the incidence of clinically significant deep venous thrombosis (DVT) or pulmonary embolism (PE) in low-risk TKA patients who receive mechanical VTE prophylaxis and undergo spinal, epidural, or general anesthesia for their surgery.

High complication rate after total knee and hip replacement due to perioperative bridging of anticoagulant therapy based on the 2012 ACCP guideline

Introduction

An increasing amount of patients receiving total joint replacement require bridging of long-term anticoagulants. Guidelines, aimed at preventing complications, focus on thromboembolic events but not on bleeding complications. In this retrospective observational study, bleeding and thromboemoblic (TE) complications were evaluated in patients requiring perioperative heparin bridging of antithrombotic therapy during primary unilateral total hip or knee arthroplasty (THA and TKA).

Materials and methods

Between January 2011 and June 2012, we identified all patients receiving low molecular weight heparin (LMWH) bridging during THA or TKA, according to our local protocol based on the ACCP guideline. Bleeding and TE complications, interventions and patient-related outcome measurements were used for evaluation.

Results

Among 972 patients 13 patients required bridging. Twelve patients (92 %) experienced bleeding complications. An intervention was required in nine patients (69 %). Seven patients received blood transfusion (54 %). Nine patients (69 %) developed a hematoma and two patients (15 %) a periprosthetic joint infection. A total of five patients were re-admitted to hospital (39 %) and the length of stay increased in all patients. No TE complications were observed in any of these patients. One year results of this patient group seem to be good.

Conclusion

This study shows an alarmingly high complication rate in patients receiving LMWH bridging during elective TKA or THA surgery. All complications seem to be caused by, or secondary to bleeding. Patients need to be consulted about the risk of bleeding complications, and the risk of bleeding needs to be balanced over the risk of TE complications.     

The Incidence and Economic Burden of In-Hospital Venous Thromboembolism in the United States

Background

Venous thromboembolism (VTE) is a potentially preventable and costly complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The in-hospital incidence and economic burden of VTE following total joint arthroplasty (TJA) in the United States is unknown. The aim of this study was to examine this issue.

Prophylaxis of Venous Thromboembolism with Low Molecular Weight Heparin in Bariatric Surgery: a Prospective, Randomised Pilot Study Evaluating Two Doses of Parnaparin (BAFLUX Study)

Background

The optimal dose of low molecular weight heparin (LMWH) to prevent venous thromboembolism (VTE) after bariatric surgery remains controversial. The aim of this multicentre, open-label, pilot study was to evaluate the efficacy and safety of two different doses of the LMWH parnaparin administered to patients undergoing bariatric surgery.

Methods

Patients were randomised to receive 4,250 IU/day (group A) or 6,400 IU/day (group B) of parnaparin s.c. for 7–11 days. Bilateral colour Doppler ultrasound of the lower limb was performed before surgery and at the end of the treatment period. The primary efficacy outcome was a composite of asymptomatic and symptomatic deep vein thrombosis, symptomatic pulmonary embolism and death from any cause during treatment. The primary safety endpoint was major and clinically relevant non-major bleeding.

Results

A total of 258 patients underwent randomization; 8 subjects were excluded following the safety analysis. One hundred thirty-one patients [106 females; mean age, 40.3 years (standard deviation (SD) ±9.6); mean body mass index (BMI), 44.6 kg/m² (SD ±5.4)] were assigned to group A and 119 patients [93 females; mean age, 41.5 years (SD ±9.9); mean BMI, 44.2 kg/m² (SD ±5.4)] were assigned to group B. The rate of the primary efficacy outcome was 1.5 % (two cases; 95 % confidence interval (CI), 0.2–6.0 %) in group A as compared with 0.8 % (one case; 95 % CI, 0.4–5.3 %) in group B (p?=?ns). The composite incidence of major bleeding and clinically relevant non-major bleeding was 6.1 % (eight cases; 95 % CI, 2.9–12.1 %) in group A and 5.0 % (six cases; 95 % CI, 2.1–11.1 %) in group B (p?=?ns).

Conclusions

A parnaparin dose of 4,250 IU/day seems suitable for VTE prevention in patients undergoing bariatric surgery.     

The Incidence of Pulmonary Embolism and Deep Vein Thrombosis After Knee Arthroplasty in Asians Remains Low: A Meta-analysis

Background

While Western literature has mostly reported the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) after TKA with chemoprophylaxis, the Asian literature still has mostly reported the incidence without chemoprophylaxis. This may reflect a low incidence of DVT and PE in Asian patients, although some recent studies suggest the incidence after TKA in Asian patients is increasing. Moreover, it is unclear whether the incidence of DVT and PE after TKA is similarly low among different Asian countries.

Questions/purposes

We therefore determined the overall incidence of symptomatic PE and DVT without chemoprophylaxis after TKA in the Asian population, determined whether the incidence had a tendency to increase over time in Asia, and compared the incidence of symptomatic PE and DVT among Asian countries through a meta-analysis.

Methods

We searched the PubMed, Embase, Cochrane Library, Web of Science, and Google Scholar websites for prospective studies published between 1996 and 2011. A total of 1947 patients from 18 studies were reviewed for meta-analysis.

Results

The incidence of symptomatic PE was 0.01%. The incidences of overall DVT, proximal DVT, and symptomatic DVT were 40.4%, 5.8% and 1.9%, respectively. We found no difference in incidence of symptomatic PE among Asian countries and no trends in changes of the incidence over time.

Conclusions

The incidence of symptomatic PE and DVT after TKA without prophylaxis is low in Asian countries and has not changed over time, despite Westernizing lifestyles and an aging populace. Further investigation with large randomized studies is necessary to confirm our findings and identify risk factors predisposing to DVT.     

Correlation of the Caprini Score and Venous Thromboembolism Incidence Following Primary Total Joint Arthroplasty—Results of a Single-Institution Protocol

Background

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis, is a serious complication after total joint arthroplasty (TJA). Risk assessment models are increasingly used to provide patient-specific risk stratification. A recently implemented protocol mandates calculation of a Caprini Score for all surgical patients at our institution. We investigated the accuracy of the Caprini Score in predicting VTE events following TJA.

Modifiable factors delaying early discharge following primary joint arthroplasty

Aims

Recent NHS reforms have incentivised reduction in length of stay, with the UK department of health expecting health trusts to reduce bed days and ultimately reduce overall costs. The aim of this study was to identify avoidable causes for protracted hospital admission following total hip arthroplasty (THA) or total knee arthroplasty (TKA) within a fast-track unit.

Methods

During a 6-month period, 535 consecutive patients underwent primary THA or TKA under the care of a single surgeon. All patients with a post-operative stay of greater than 72 h were identified, and reasons for delayed discharge were determined.

Results

The majority of arthroplasty patients were discharged within 3 days post-operatively. Twenty-one per cent of THA patients and 25 % of TKA patients remained as inpatients for greater than 72 h. For the THA population, this equates to 43 % of bed days used by 21 % of patients, and for the TKA population, 44 % of bed days were used by 25 % of patients. The major factor within both groups for delayed discharge was attributed to inadequate social support.

Conclusions

Delayed discharge can never be totally prevented. This unit aims to develop improvement in social work provision, with a greater focus on pre-admission discharge planning to reduce the number of delayed discharges and ultimately reduce the cost burden of joint replacement surgery. It is not conducive with the ethos of fast-track arthroplasty to only identify social circumstances upon admission.     

Low risk of thromboembolic complications after fast-track hip and knee arthroplasty

Background and purpose

Pharmacological prophylaxis can reduce the risk of deep venous thrombosis (DVT), pulmonary embolism (PE), and death, and it is recommended 10–35 days after total hip arthroplasty (THA) and at least 10 days after total knee arthroplasty (TKA). However, early mobilization might also reduce the risk of DVT and thereby the need for prolonged prophylaxis, but this has not been considered in the previous literature. Here we report our results with short-duration pharmacological prophylaxis combined with early mobilization and reduced hospitalization.

Patients and methods

1,977 consecutive, unselected patients were operated with primary THA, TKA, or bilateral simultaneous TKA (BSTKA) in a well-described standardized fast-track set-up from 2004–2008. Patients received DVT prophylaxis with low-molecular-weight heparin starting 6–8 h after surgery until discharge. All re-admissions and deaths within 30 and 90 days were analyzed using the national health register, concentrating especially on clinical DVT (confirmed by ultrasound and elevated D-dimer), PE, or sudden death. Numbers were correlated to days of prophylaxis (LOS).

Results

The mean LOS decreased from 7.3 days in 2004 to 3.1 days in 2008. 3 deaths (0.15%) were associated with clotting episodes and overall, 11 clinical DVTs (0.56%) and 6 PEs (0.30%) were found. The vast majority of events took place within 30 days; only 1 death and 2 DVTs occurred between 30 and 90 days. During the last 2 years (854 patients), when patients were mobilized within 4 h postoperatively and the duration of DVT prophylaxis was shortest (1–4 days), the mortality was 0% (95% CI: 0–0.5). Incident cases of DVT in TKA was 0.60% (CI: 0.2–2.2), in THA it was 0.51% (CI: 0.1–1.8), and in BSTKA it was 0% (CI: 0–2.9). Incident cases of PE in TKA was 0.30% (CI: 0.1–1.7), in THA it was 0% (CI: 0–1.0), and in BSTKA it was 0% (CI: 0–2.9).

Interpretation

The risk of clinical DVT, and of fatal and non-fatal PE after THA and TKA following a fast-track set-up with early mobilization, short hospitalization, and short duration of DVT prophylaxis compares favorably with published regimens with extended prophylaxis (up to 36 days) and hospitalization up to 11 days. This calls for a reconsideration of optimal duration of chemical thromboprophylaxis.Total hip and knee arthroplasty (THA and TKA) are associated with perioperative risks including deep venous thrombosis (DVT) and pulmonary embolism (PE)—both of which are manifestations of venous thromboembolism (VTE)—possibly leading to a post-thrombotic syndrome (PTS) or death. The mechanisms underlying VTE are not fully understood (Malone 1977, Malone and Agutter 2006). Immobility with long hospitalization after surgery may be a contributory factor (Heit et al. 2001, Seddighzadeh et al. 2007, Sharma et al. 2007).The recent evidence-based guidelines for DVT prophylaxis according to the American College of Chest Physicians consist of at least 10 days of prophylaxis after TKA and THA, and preferably up to 35 days after THA (Geerts et al. 2008). The incidence of DVT has been found to have decreased over time, possibly as a result of increased and earlier mobilization (Xing et al. 2008). We therefore present our data on DVT, PE, and death after TKA, bilateral simultaneous TKA (BSTKA), and THA with a fast-track set-up with short DVT prophylaxis, early mobilization, and short hospitalization.     

Ergebnisse und Komplikationen der Behandlung periprothetischer Femurfrakturen mit einem winkelstabilen Plattensystem

Background

Locked plate devices offer advantages in the treatment of periprosthetic femur fractures associated with fixed total hip or total knee arthroplasty. The purpose of this study was to evaluate the early results and complications with a locked plate system (NCB-DF®).

Patients and methods

A total of 31 patients (mean age 76 years, 7 males, 24 females) with a femur fracture above a fixed total knee arthroplasty (TKA, n=12) or a total hip arthroplasty (THA, n=19) were treated with a locked plate.

Results

There were 11 complications necessitating revision: 6 implant failures, 2 in patients with a THA and 4 in patients with a TKA, 4 hematomas and 1 infection and 2 patients died. After 6 months all fractures had healed securely but a secondary correction was necessary in one patient.

Conclusion

Fixation of periprosthetic femur fractures with a locked plate system provided satisfactory results in patients with a THA, however, the relatively high implant failure rate in fractures above a stable TKA is a cause for concern.     

Do Surgeon Expectations Predict Clinically Important Improvements in WOMAC Scores After THA and TKA?

Background

Failure of THA or TKA to meet a patient’s expectations may result in patient disappointment and litigation. However, there is little evidence to suggest that surgeons can consistently anticipate which patients will benefit from those interventions.

Questions/purposes

To determine the ability of surgeons to identify, in advance of surgery, patients who will benefit from THA or TKA and those who will not, where ‘benefit’ is defined as a clinically important improvement in a validated patient-reported outcomes score.

Methods

In this prospective study, eight high-volume orthopaedic surgeons completed validated THA and TKA expectations questionnaires (score 0–100, 100 being the highest expectation) as part of preoperative assessment of all their patients scheduled for a THA or TKA and enrolled in the Hospital for Special Surgery institutional registry. Enrolled patients completed the WOMAC preoperatively and at 2 years. Successful outcomes were defined as achieving the minimum clinically important difference (MCID) in WOMAC pain and function subscales. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were used to evaluate the ability of surgeons’ expectation scores to identify patients likely to achieve the MCID on the WOMAC scale. Analyses were run separately for patients having THA and TKA. We enrolled 259 patients undergoing THA and 247 undergoing TKA, of whom 77% (n = 200) and 77% (n = 191) completed followup surveys 2 years after their procedures, respectively.

Results

Surgeons’ expectation scores effectively anticipated patients who would improve after THA, but they were no better than chance in identifying patients who would achieve the MCID on the WOMAC score 2 years after TKA. For patients having THA, the areas under the ROC curve were 0.67 (95% CI, 0.53–0.82; p = 0.02) and 0.74 (95% CI, 0.63–0.85; p < 0.01) for WOMAC function and pain outcomes, respectively, indicating good accuracy. Sensitivity and specificity were maximized on WOMAC pain and function scores (sensitivity = 0.69, specificity = 0.72, both for pain and function) at an expectations score of 83 or greater of 100. Surgeons’ expectations were more accurate for patients who were men, who had a BMI less than 30 kg/m², who had more than one comorbidity, and who were older than 65 years. For patients having TKA, surgeons’ expectation scores were not better than chance for identifying those who would experience a clinically important improvement on the WOMAC scale (area under ROC curve: Function = 0.51, [95% CI, 0.42–0.61], p = 0.78; Pain = 0.51, [95% CI, 0.40–0.61], p = 0.92).

Conclusions

Most patients having THA and TKA achieved the MCID improvement after surgery. However, the inability of surgeons’ expectation scores to discriminate accurately between patients who benefit and those who do not among patients scheduled for THA who are young, with no comorbidities, and with elevated BMIs, and among all patients scheduled for TKA, calls for surgeons to spend more time with these patients to fully understand and address their needs and expectations. Using standardized assessment tools to compare surgeons’ expectations and those of their patients may help focus the surgeon-patient discussion further, and address patients’ expectations more effectively.

Level of Evidence

Level II, therapeutic study.