Person:

Collins, Jamie

Background: To address both the growing burden of joint disease and the gaps in medical access in developing nations, medical relief organizations have begun to launch programs to perform total joint replacement (TJR) on resident populations in developing countries. One outcome of TJR of particular interest is physical activity (PA) since it is strongly linked to general health. This study evaluates the amount of postoperative participation in PA in low-income patients who received total joint replacement in the Dominican Republic and identifies preoperative predictors of postoperative PA level. Methods: We used the Yale Physical Activity Survey (YPAS) to assess participation in postoperative PA 1–4 years following total knee or hip replacement. We compared the amount of aerobic PA reported by postoperative TJR patients with the levels of PA recommended by the CDC and WHO. We also analyzed preoperative determinants of postoperative participation in aerobic PA in bivariate and multivariate analyses. Results: 64 patients out of 170 eligible subjects (52/128 TKR and 14/42 THR) who received TJR between 2009–2012 returned for an annual follow-up visit in 2013, with a mean treatment-to-follow-up time of 2.1 years. 43.3% of respondents met CDC/WHO criteria for sufficient participation in aerobic PA. Multivariate analyses including data from 56 individuals identified that patients who were both younger than 65 and at least two years postoperative had an adjusted mean activity dimensions summary index (ADSI) 22.9 points higher than patients who were 65 or older and one year postoperative. Patients who lived with friends or family had adjusted mean ADSI 17.2 points higher than patients living alone. Patients who had the most optimistic preoperative expectations of outcome had adjusted mean ADSI scores that were 19.8 points higher than those who were less optimistic. Conclusion: The TJR patients in the Dominican cohort participate in less PA than recommended by the CDC/WHO. Additionally, several associations were identified that potentially affect PA in this population; specifically, participants who are older than 65, recently postoperative, less optimistic about postoperative outcomes and who live alone participate in less PA.

Background: Valid measures of physical activity are critical research tools. The objective of this study was to develop a Spanish translation of the Yale Physical Activity Survey, and to provide preliminary evidence of its validity in a population of Dominican patients with lower extremity arthritis. Methods: A Dominican bilingual health care professional translated the Yale Physical Activity Survey (YPAS) from English to Spanish. Several Dominican adults reviewed the translation to ensure it was linguistically and culturally appropriate. The questionnaire was back-translated to English by a North American researcher who is fluent in Spanish. Discrepancies between the original and back-translated versions were resolved by the translator and back-translator. The Spanish translation was administered to 108 Dominican subjects with advanced hip or knee arthritis prior to (N = 44) or one to four years following (N = 64) total joint replacement. We assessed construct validity by examining the association of YPAS scores and measures of functional status and pain (WOMAC), quality of life (EQ-5D) and the number of painful lower extremity joints. Results: A higher YPAS Part II Activity Dimensions Summary Index score had weak to modest correlations with worse function and quality of life as measured with the WOMAC function scale (r = 0.21, p = 0.03), SF-36 Physical Activity Scale (r = 0.29, p = 0.004) and EQ-5D (r = 0.34, p = 0.0007). Total minutes of vigorous activity and walking had weak to modest correlation with these measures (WOMAC Function Scale (r = 0.15, p = 0.15), SF-36 Physical Activity Scale (r = 0.21, p = 0.04) and EQ-5D utility (r = 0.24, p = 0.02)). Correlations between the YPAS Part I energy expenditure score and these measures were lower (WOMAC Function Scale (r = 0.07, p = 0.49), SF-36 Physical Activity Scale (r = 0.03, p = 0.74) and EQ-5D utility (r = 0.18, p = 0.07)). Conclusions: We have developed a new Spanish translation of the Yale Physical Activity Survey and provided evidence of convergent validity in a sample of Dominican patients prior to or 1–4 years following total joint replacement.

Background: The incidence of knee osteoarthritis (OA) is rising. While several risk factors have been associated with the development of knee OA, this information is not readily accessible to those at risk for osteoarthritis. Risk calculators have been developed for several prevalent chronic conditions but not for OA. Using published evidence on established risk factors, we developed an interactive, personalized knee OA risk calculator (OA Risk C) and conducted a pilot study to evaluate its acceptability and feasibility. Methods: We used the Osteoarthritis Policy (OAPol) Model, a validated, state-transition simulation of the natural history and management of OA, to generate data for OA Risk C. Risk estimates for calculator users were based on a set of demographic and clinical factors (age, sex, race/ethnicity, obesity) and select risk factors (family history of knee OA, occupational exposure, and history of knee injury). OA Risk C presents personalized risk of knee OA in several ways to maximize understanding among a wide range of users. We conducted a study of 45 subjects in a primary care setting to establish the feasibility and acceptability of the OA risk calculator. Pilot study participants were asked several questions regarding ease of use, clarity of presentation, and clarity of the graphical representation of their risk. These questions used a five-level agreement scale ranging from strongly disagree to strongly agree. Results: OA Risk C depicts information about users’ risk of symptomatic knee OA in 5 year intervals. Study participants estimated their lifetime risk at 38 %, while their actual lifetime risk, as estimated by OA Risk C, was 25 %. Eighty-four percent of pilot study participants reported that OA Risk C was easy to understand, and 89 % agreed that the graphs depicting their risk were clear and comprehensible. Conclusions: We have developed a personalized, computer-based OA risk calculator that is easy to use. OA Risk C may be utilized to estimate individuals’ knee OA risk and to deliver educational and behavioral interventions focused on osteoarthritis risk reduction.

Background: To describe the scoring methodology and MRI assessments used to evaluate the cross-sectional features observed in cases and controls, to define change over time for different MRI features, and to report the extent of changes over a 24-month period in the Foundation for National Institutes of Health Osteoarthritis Biomarkers Consortium study nested within the larger Osteoarthritis Initiative (OAI) Study. Methods: We conducted a nested case–control study. Cases (n = 406) were knees having both radiographic and pain progression. Controls (n = 194) were knee osteoarthritis subjects who did not meet the case definition. Groups were matched for Kellgren-Lawrence grade and body mass index. MRIs were acquired using 3 T MRI systems and assessed using the semi-quantitative MOAKS system. MRIs were read at baseline and 24 months for cartilage damage, bone marrow lesions (BML), osteophytes, meniscal damage and extrusion, and Hoffa- and effusion-synovitis. We provide the definition and distribution of change in these biomarkers over time. Results: Seventy-three percent of the cases had subregions with BML worsening (vs. 66 % in controls) (p = 0.102). Little change in osteophytes was seen over 24 months. Twenty-eight percent of cases and 10 % of controls had worsening in meniscal scores in at least one subregion (p < 0.001). Seventy-three percent of cases and 53 % of controls had at least one area with worsening in cartilage surface area (p < 0.001). More cases experienced worsening in Hoffa- and effusion synovitis than controls (17 % vs. 6 % (p < 0.001); 41 % vs. 18 % (p < 0.001), respectively). Conclusions: A wide range of MRI-detected structural pathologies was present in the FNIH cohort. More severe changes, especially for BMLs, cartilage and meniscal damage, were detected primarily among the case group suggesting that early changes in multiple structural domains are associated with radiographic worsening and symptomatic progression.

Background: We designed and implemented the Brigham and Women’s Wellness Initiative (B-Well), a single-arm study to examine the feasibility of a workplace program that used individual and team-based financial incentives to increase physical activity among sedentary hospital employees. Methods: We enrolled sedentary, non-clinician employees of a tertiary medical center who self-reported low physical activity. Eligible participants formed or joined teams of three members and wore Fitbit Flex activity monitors for two pre-intervention weeks followed by 24 weeks during which they could earn monetary rewards. Participants were rewarded for increasing their moderate-to-vigorous physical activity (MVPA) by 10% from the previous week or for meeting the Centers for Disease Control and Prevention (CDC) physical activity guidelines (150 min of MVPA per week). Our primary outcome was the proportion of participants meeting weekly MVPA goals and CDC physical activity guidelines. Secondary outcomes included Fitbit-wear adherence and factors associated with meeting CDC guidelines more consistently. Results: B-Well included 292 hospital employees. Participants had a mean age of 38 years (SD 11), 83% were female, 38% were obese, and 62% were non-Hispanic White. Sixty-three percent of participants wore the Fitbit ≥4 days per week for ≥20 weeks. Two-thirds were satisfied with the B-Well program, with 79% indicating that they would participate again. Eighty-six percent met either their personal weekly goal or CDC physical activity guidelines for at least 6 out of 24 weeks, and 52% met their goals or CDC physical activity guidelines for at least 12 weeks. African Americans, non-obese subjects, and those with lower impulsivity scores reached CDC guidelines more consistently. Conclusions: Our data suggest that a financial incentives-based workplace wellness program can increase MVPA among sedentary employees. These results should be reproduced in a randomized controlled trial. Trial registration Clinicaltrials.gov, NCT02850094. Registered July 27, 2016 [retrospectively registered].

Background: Low enrollment rates are a threat to the external validity of clinical trials. The purpose of this study was to identify factors associated with lower enrollment rates in randomized controlled trials (RCTs) involving orthopedic procedures. Methods: We performed a search in PubMed/MEDLINE for RCTs that involved any orthopedic surgical procedure, compared different intraoperative interventions, were published in English in a peer-reviewed journal between 2003 and 2014, and reported the numbers of both enrolled and eligible subjects. The primary outcome was the enrollment rate, defined as the number of enrolled subjects divided by the number of eligible subjects. We used a meta-regression to identify factors associated with lower enrollment rates. Results: The combined estimate of enrollment rate across all 393 studies meeting inclusion criteria was 90% (95% CI: 89–92%). Trials in North America had significantly lower enrollment rates compared to trials in the rest of the world (80% vs. 92%, p < 0.0001). Trials comparing operative and non-operative treatments had significantly lower enrollment rates than trials comparing two different operative interventions (80% vs. 91%, p < 0.0001). Among trials comparing operative and non-operative interventions, there was a marked difference in enrollment rate by region: 49% in North America and 86% elsewhere (p < 0.0001). Conclusions: RCTs investigating orthopedic procedures have variable enrollment rates depending on their location and the difference between the interventions being studied. North American trials that compare operative and non-operative interventions have the lowest enrollment rates. Investigators planning RCTs would be well advised to consider these data in planning recruitment efforts.

Objective To assess the responsiveness and reader time of a novel semiautomated tool to detect knee cartilage loss over 2 years in subjects with knee osteoarthritis.

Methods A total of 122 subjects from the Osteoarthritis Initiative progression cohort were selected. A reader used the software method to segment cartilage on double-echo steady-state sequence scans in the medial compartment of the femur from the baseline and 24-month visits. Change in cartilage volume (ΔV) was measured at a fixed weight-bearing (WB) location with respect to the 3-dimensional coordinate system based on cylindrical coordinates. Change was measured for 5 regions of varying WB surface area centered on the fixed point. The average change (ΔV), the SD of ΔV, and the standardized response mean (SRM) are reported.

Results The SRM was −0.52 for the largest region and decreased in magnitude as smaller regions of cartilage were probed. The average evaluation time was <20 minutes per knee compartment, split approximately evenly between a technician and a trained reader.

Conclusion The results establish that measurement of cartilage loss in a local region can be done efficiently and that the resultant measures are responsive to loss of cartilage over time. The coordinate system can potentially be used to objectively examine and establish a consistent location for all knees that is most responsive to change in cartilage volume. This technique can provide rapidly an objective quantitative measure of cartilage loss and could substantially reduce study costs for large trials and data sets.

Background: Increasing utilization of primary total knee arthroplasty (TKA) is projected to expand demand for revision TKA. Revision TKAs are procedurally complex and incur high costs on our financially constrained healthcare system. The purpose of this study was to use a case-control design to identify factors predisposing to revision TKA, particularly demographic, clinical and perioperative technical factors. Methods: We conducted a case control study to investigate patient, surgical and perioperative factors associated with greater risk of revision TKA. We included patients who received TKA at a tertiary center between 1996 and 2009. Cases (patients that had primary and revision TKA) were matched to controls (patients with primary TKA that was not revised) in a 1:2 ratio and risk of revision examined using conditional logistic regression. Results: We identified 146 cases and 290 controls. Patient factors independently associated with revision included male sex (OR 1.73; 95 % CI 1.06-2.81) and smoking (OR 2.87; 1.33-6.19). Older age was associated with decreased risk (OR 0.83 per 5-year increment; 95 % CI 0.75-0.92). Lateral release was the only technical factor associated with revision (OR 1.92; 1.07-3.43). Conclusions: In this case control study younger patient age, male gender, soft tissue release and active smoking status were associated with increased revision risk. Although we do not know whether the risk of smoking arises from short- or long-term exposure, smoking cessation prior to TKA should be considered as an intervention for decreasing revision risk.

Background: An increasing number of medical relief organizations have launched programs to perform total joint replacements in the developing world. There is a paucity of data on the clinical outcomes of these procedures. We documented pre- and post-operative pain and functional status in a group of low income Dominicans who underwent total hip or knee replacement performed by an American relief organization. Methods: In March 2009 and 2010, we surveyed patients participating in Operation Walk Boston, a medical relief organization that provides total joint replacements to patients in the Dominican Republic. Questionnaires included the Western Ontario and McMaster University Osteoarthritis (WOMAC) Index scales and the Short-Form 36 (SF-36) scales for physical activity and mental health. Scores were transformed to a 0 - 100 point scale (100 is best). Results: 81 individuals (mean age 61 years, 60% female) completed the pre-operative questionnaires. Twenty eight of the 35 who completed preoperative forms in 2009 also completed follow up forms in 2010 (follow-up rate 80%). Patients reported poor pre-operative WOMAC function (mean = 33.6, sd = 22.0) and WOMAC pain (mean = 38.4, sd = 22.9) scores preoperatively. Mean post-operative WOMAC pain and function scores were 86.4 (sd = 13.1) and 88.1 (sd = 11.4) respectively. Improvement in pain and function was similar for patients undergoing hip (n=11) and knee (n=17) replacements. Conclusion: Total joint replacement was effective in relieving pain and restoring function in this program. These results are useful for comparison to outcomes in developed countries and for establishing benchmarks for future programs.

Background: Arthroscopic surgery is a common treatment for knee osteoarthritis (OA), particularly for symptomatic meniscal tear. Many patients with knee OA who have arthroscopies go on to have total knee arthroplasty (TKA). Several individual studies have investigated the interval between knee arthroscopy and TKA. Our objective was to summarize published literature on the risk of TKA following knee arthroscopy, the duration between arthroscopy and TKA, and risk factors for TKA following knee arthroscopy. Methods: We searched PubMed, Embase, and Web of Science for English language manuscripts reporting TKA following arthroscopy for knee OA. We identified 511 manuscripts, of which 20 met the inclusion criteria and were used for analysis. We compared the cumulative incidence of TKA following arthroscopy in each study arm, stratifying by type of data source (registry vs. clinical), and whether the study was limited to older patients (≥ 50) or those with more severe radiographic OA. We estimated cumulative incidence of TKA following arthroscopy by dividing the number of TKAs among persons who underwent arthroscopy by the number of persons who underwent arthroscopy. Annual incidence was calculated by dividing cumulative incidence by the mean years of follow-up. Results: Overall, the annual incidence of TKA after arthroscopic surgery for OA was 2.62% (95% CI 1.73–3.51%). We calculated the annual incidence of TKA following arthroscopy in four separate groups defined by data source (registry vs. clinical cohort) and whether the sample was selected for disease progression (either age or OA severity). In unselected registry studies the annual TKA incidence was 1.99% (95% CI 1.03–2.96%), compared to 3.89% (95% CI 0.69–7.09%) in registry studies of older patients. In unselected clinical cohorts the annual incidence was 2.02% (95% CI 0.67–3.36%), while in clinical cohorts with more severe OA the annual incidence was 4.13% (95% CI 1.81–6.44%). The mean and median duration between arthroscopy and TKA (years) were 3.4 and 2.0 years. Conclusions: Clinicians and patients considering knee arthroscopy should discuss the likelihood of subsequent TKA as they weigh risks and benefits of surgery. Patients who are older or have more severe OA are at particularly high risk of TKA. Electronic supplementary material The online version of this article (10.1186/s12891-017-1765-0) contains supplementary material, which is available to authorized users.