Influenciadeldolorlumbarenlosresultadosdelaartroplastiatotal

primariaderodillaPascualFJ,BañaE,RoyoA,RamosL,BertrandML,Guerado E

UnidaddeRodillaHospitalUniversitarioCostadelSol

Marbella(Málaga)

Introducción• Resultadosfuncionales– StatusFuncional– Índicedemasacorporal– Balancemuscular– Comorbilidadesmédicas

• Prevalencia:21– 42%– Dolorlumbar– Artroplastiatotalderodillaprimaria

• Peoresresultadosfuncionales

Staibano P,Winemaker M,Petruccelli D,deBeer J.Totaljoint arthroplasty andpreoperative low backpain.JArthroplasty.2014May;29(5):867-71

Schroer WC,Diesfeld PJ,LeMarr AR,Morton DJ,Reedy ME.Functional Outcomes After TotalKnee Arthroplasty CorrelateWith Spine Disability.JArthroplasty.2016Sep;31(9Suppl):106-9.

Introducción

Objetivos:- Primario:ResultadosFuncionales

- EscaladeFunciónyTotal- Dolor- Necesidaddeayudaparadeambular

-Secundarios:-SatisfacciónPercibida-Complicaciones

Materialymétodo

• Cohorteshistóricas:256pacientes– Dolorlumbar:65(25.4%)– Sindolorlumbar:191

• ATRprimaria• 2010– 2012• Seguimientomínimo:3años• Análisisestadísticodescriptivo

– Distribuciones– Jicuadrado,MannWhitney,Wilcoxon

yMacNemar

MaterialymétodoVariables- Edadysexo- Índicedemasacorporal- Charlson- ASA- GradoAhlbäck- Dolorlumbar- KSS

- FunciónyTotal- Dolor- Ayudas

- Satisfacción- Complicaciones

- Infección- Trombosisvenosa

profunda- Rigidez- Prótesisdolorosa

3años

n=65

n=191

Resultados

Resultados

p<0,01p <0.001

Resultados

Resultados

Resultados

P=0,083

Resultados

p =0,007

Resultados

Resultados

P=0,049

Resultados

p =0,338

p=0,646

p =0,116

p=1

p =0,604

Discusión

Total Joint Arthroplasty and Preoperative Low Back Pain

Phillip Staibano, HonsBSc(Cand) a, Mitch Winemaker, MD, FRCSC a,b,c,Danielle Petruccelli, MLIS, MSc a, Justin de Beer, MD, FRCSC a,b,c

a Hamilton Arthroplasty Group, Hamilton Health Sciences Juravinski Hospital, Hamilton, Ontario, Canadab McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canadac Department of Surgery, Hamilton Health Sciences, Hamilton, Ontario, Canada

a b s t r a c ta r t i c l e i n f o

Article history:Received 1 August 2013Accepted 3 October 2013

Keywords:total joint replacementlow back painoutcomeship arthroplastyknee arthroplastyosteoarthritis

Lower extremity osteoarthritis with concomitant low-back pain (LBP) may obscure a clinician’s ability toproperly evaluate the status of hip or knee osteoarthritis and subsequent total joint arthroplasty (TJA)candidacy. A prospective cohort study was conducted to determine prevalence and severity of preoperativeLBP among TJA patients, and the effect of TJA on alleviating LBP. Preoperative moderate to worst imaginableLBP pain on the Oswestry Disability Index (ODI) was significantly higher among hips compared to knees(28.8% vs. 16.1%, P b 0.0001). Compared to knees, hips also saw significant ODI improvement frompreoperative to one-year postoperative. TJA candidates with considerable preoperative LBP should becounselled that TJA outcomemay be impaired by the coexistence of spine disease, and that residual spine painmay continue following otherwise successful TJA.

© 2014 Elsevier Inc. All rights reserved.

It is estimated that approximately 40 million Americans sufferfrom osteoarthritis (OA), and 80% of those affected are aged55 years or more [1]. In Canada, OA is equally prevalent and affects1 in 10 individuals [2]. Among patients with end-stage disablingdegenerative hip and knee OA, total joint arthroplasty (TJA) is themost successful and cost-effective procedure to alleviate pain andimprove function and health-related quality of life [3,4]. Unfortu-nately though, there exists a subset of patients with lowerextremity OA that suffer from concomitant low back pain (LBP),and together these diagnoses may obscure a clinician’s ability toproperly evaluate the status of hip and/or knee OA and subsequentcandidacy for TJA [1,5].

Reported prevalence rates of OA with associated LBP amongarthroplasty patients vary widely, and to our knowledge there havebeen no studies to date that have compared differences among bothhip and knee arthroplasty candidates. In a review of 344 preoperativetotal hip arthroplasty (THA) patients Parvizi et al [6] have reported a49.4% prevalence rate of persistent LBP. In a similar review, Hsieh et al[7] found a 21.2% prevalence rate of LBP among patients with end-stage hip disease. In a small prospective study of 25 THA patientsBen-Galim et al [5] found that all patients within their sample had atleast moderate LBP and spinal disability prior to surgery. While

prevalence rates among THA candidates vary depending on thedefinition and grading of LBP, the link between knee OA among totalknee arthroplasty (TKA) candidates and lumbar pain has been lesswell characterized. Results of the Osteoarthritis Initiative [8] haveshown that 57.4% of participants with tibiofemoral knee OA reportedLBP which was significantly associated with increased WOMAC kneepain scores. Wolfe et al [9] found that 54.6% of patients presenting toa Rheumatology Clinic with knee OA experienced back pain. Burnettet al [10] further found that 74% of patients included in theirretrospective review of unilateral TKA reported chronic back painwhich first occurred approximately 10 years prior to TKA candidacy,and that 15% had felt that their worst back pain occurred after theonset of knee OA.

The purpose of this prospective cohort study was threefold: 1) toinvestigate the prevalence of LBP in patients with end-stage hip orknee osteoarthritis electing to undergo primary TJA, 2) to evaluatethe postoperative effectiveness of TJA in reducing LBP, and 3) todetermine whether the presence of a coexisting spinal conditionimpairs the ability of TJA to alleviate OA symptoms.

Methods

A prospective cohort study was conducted on patients withend-stage hip or knee osteoarthritis electing to undergo TJA todetermine the prevalence and severity of preoperative LBPamongst our total hip and knee arthroplasty population, andsubsequently to determine the effect of TJA on alleviating suchprevalence or severity of back pain. All patients underwentprimary unilateral TJA at one high volume academic orthopaedic

The Journal of Arthroplasty 29 (2014) 867–871

The Conflict of Interest statement associated with this article can be found athttp://dx.doi.org/10.1016/j.arth.2013.10.001.

Reprint requests: Danielle Petruccelli, MLIS, MSc, Hamilton Arthroplasty Group,HamiltonHealthSciences JuravinskiHospital,711ConcessionSt.,Hamilton,Ontario, Canada.

0883-5403/2905-0002$36.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.arth.2013.10.001

Contents lists available at ScienceDirect

The Journal of Arthroplasty

j ourna l homepage: www.arth rop lasty journa l .o rg

Staibano P,Winemaker M,Petruccelli D,deBeer J.Totaljoint arthroplastyandpreoperative low backpain.JArthroplasty.2014May;29(5):867-71

Total Joint Arthroplasty and Preoperative Low Back Pain

Phillip Staibano, HonsBSc(Cand) a, Mitch Winemaker, MD, FRCSC a,b,c,Danielle Petruccelli, MLIS, MSc a, Justin de Beer, MD, FRCSC a,b,c

a Hamilton Arthroplasty Group, Hamilton Health Sciences Juravinski Hospital, Hamilton, Ontario, Canadab McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canadac Department of Surgery, Hamilton Health Sciences, Hamilton, Ontario, Canada

a b s t r a c ta r t i c l e i n f o

Article history:Received 1 August 2013Accepted 3 October 2013

Keywords:total joint replacementlow back painoutcomeship arthroplastyknee arthroplastyosteoarthritis

Lower extremity osteoarthritis with concomitant low-back pain (LBP) may obscure a clinician’s ability toproperly evaluate the status of hip or knee osteoarthritis and subsequent total joint arthroplasty (TJA)candidacy. A prospective cohort study was conducted to determine prevalence and severity of preoperativeLBP among TJA patients, and the effect of TJA on alleviating LBP. Preoperative moderate to worst imaginableLBP pain on the Oswestry Disability Index (ODI) was significantly higher among hips compared to knees(28.8% vs. 16.1%, P b 0.0001). Compared to knees, hips also saw significant ODI improvement frompreoperative to one-year postoperative. TJA candidates with considerable preoperative LBP should becounselled that TJA outcomemay be impaired by the coexistence of spine disease, and that residual spine painmay continue following otherwise successful TJA.

© 2014 Elsevier Inc. All rights reserved.

It is estimated that approximately 40 million Americans sufferfrom osteoarthritis (OA), and 80% of those affected are aged55 years or more [1]. In Canada, OA is equally prevalent and affects1 in 10 individuals [2]. Among patients with end-stage disablingdegenerative hip and knee OA, total joint arthroplasty (TJA) is themost successful and cost-effective procedure to alleviate pain andimprove function and health-related quality of life [3,4]. Unfortu-nately though, there exists a subset of patients with lowerextremity OA that suffer from concomitant low back pain (LBP),and together these diagnoses may obscure a clinician’s ability toproperly evaluate the status of hip and/or knee OA and subsequentcandidacy for TJA [1,5].

Reported prevalence rates of OA with associated LBP amongarthroplasty patients vary widely, and to our knowledge there havebeen no studies to date that have compared differences among bothhip and knee arthroplasty candidates. In a review of 344 preoperativetotal hip arthroplasty (THA) patients Parvizi et al [6] have reported a49.4% prevalence rate of persistent LBP. In a similar review, Hsieh et al[7] found a 21.2% prevalence rate of LBP among patients with end-stage hip disease. In a small prospective study of 25 THA patientsBen-Galim et al [5] found that all patients within their sample had atleast moderate LBP and spinal disability prior to surgery. While

prevalence rates among THA candidates vary depending on thedefinition and grading of LBP, the link between knee OA among totalknee arthroplasty (TKA) candidates and lumbar pain has been lesswell characterized. Results of the Osteoarthritis Initiative [8] haveshown that 57.4% of participants with tibiofemoral knee OA reportedLBP which was significantly associated with increased WOMAC kneepain scores. Wolfe et al [9] found that 54.6% of patients presenting toa Rheumatology Clinic with knee OA experienced back pain. Burnettet al [10] further found that 74% of patients included in theirretrospective review of unilateral TKA reported chronic back painwhich first occurred approximately 10 years prior to TKA candidacy,and that 15% had felt that their worst back pain occurred after theonset of knee OA.

The purpose of this prospective cohort study was threefold: 1) toinvestigate the prevalence of LBP in patients with end-stage hip orknee osteoarthritis electing to undergo primary TJA, 2) to evaluatethe postoperative effectiveness of TJA in reducing LBP, and 3) todetermine whether the presence of a coexisting spinal conditionimpairs the ability of TJA to alleviate OA symptoms.

Methods

A prospective cohort study was conducted on patients withend-stage hip or knee osteoarthritis electing to undergo TJA todetermine the prevalence and severity of preoperative LBPamongst our total hip and knee arthroplasty population, andsubsequently to determine the effect of TJA on alleviating suchprevalence or severity of back pain. All patients underwentprimary unilateral TJA at one high volume academic orthopaedic

The Journal of Arthroplasty 29 (2014) 867–871

The Conflict of Interest statement associated with this article can be found athttp://dx.doi.org/10.1016/j.arth.2013.10.001.

Reprint requests: Danielle Petruccelli, MLIS, MSc, Hamilton Arthroplasty Group,HamiltonHealthSciences JuravinskiHospital,711ConcessionSt.,Hamilton,Ontario, Canada.

0883-5403/2905-0002$36.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.arth.2013.10.001

Contents lists available at ScienceDirect

The Journal of Arthroplasty

j ourna l homepage: www.arth rop lasty journa l .o rg

Total Joint Arthroplasty and Preoperative Low Back Pain

Phillip Staibano, HonsBSc(Cand) a, Mitch Winemaker, MD, FRCSC a,b,c,Danielle Petruccelli, MLIS, MSc a, Justin de Beer, MD, FRCSC a,b,c

a Hamilton Arthroplasty Group, Hamilton Health Sciences Juravinski Hospital, Hamilton, Ontario, Canadab McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canadac Department of Surgery, Hamilton Health Sciences, Hamilton, Ontario, Canada

a b s t r a c ta r t i c l e i n f o

Article history:Received 1 August 2013Accepted 3 October 2013

Keywords:total joint replacementlow back painoutcomeship arthroplastyknee arthroplastyosteoarthritis

Lower extremity osteoarthritis with concomitant low-back pain (LBP) may obscure a clinician’s ability toproperly evaluate the status of hip or knee osteoarthritis and subsequent total joint arthroplasty (TJA)candidacy. A prospective cohort study was conducted to determine prevalence and severity of preoperativeLBP among TJA patients, and the effect of TJA on alleviating LBP. Preoperative moderate to worst imaginableLBP pain on the Oswestry Disability Index (ODI) was significantly higher among hips compared to knees(28.8% vs. 16.1%, P b 0.0001). Compared to knees, hips also saw significant ODI improvement frompreoperative to one-year postoperative. TJA candidates with considerable preoperative LBP should becounselled that TJA outcomemay be impaired by the coexistence of spine disease, and that residual spine painmay continue following otherwise successful TJA.

© 2014 Elsevier Inc. All rights reserved.

It is estimated that approximately 40 million Americans sufferfrom osteoarthritis (OA), and 80% of those affected are aged55 years or more [1]. In Canada, OA is equally prevalent and affects1 in 10 individuals [2]. Among patients with end-stage disablingdegenerative hip and knee OA, total joint arthroplasty (TJA) is themost successful and cost-effective procedure to alleviate pain andimprove function and health-related quality of life [3,4]. Unfortu-nately though, there exists a subset of patients with lowerextremity OA that suffer from concomitant low back pain (LBP),and together these diagnoses may obscure a clinician’s ability toproperly evaluate the status of hip and/or knee OA and subsequentcandidacy for TJA [1,5].

Reported prevalence rates of OA with associated LBP amongarthroplasty patients vary widely, and to our knowledge there havebeen no studies to date that have compared differences among bothhip and knee arthroplasty candidates. In a review of 344 preoperativetotal hip arthroplasty (THA) patients Parvizi et al [6] have reported a49.4% prevalence rate of persistent LBP. In a similar review, Hsieh et al[7] found a 21.2% prevalence rate of LBP among patients with end-stage hip disease. In a small prospective study of 25 THA patientsBen-Galim et al [5] found that all patients within their sample had atleast moderate LBP and spinal disability prior to surgery. While

prevalence rates among THA candidates vary depending on thedefinition and grading of LBP, the link between knee OA among totalknee arthroplasty (TKA) candidates and lumbar pain has been lesswell characterized. Results of the Osteoarthritis Initiative [8] haveshown that 57.4% of participants with tibiofemoral knee OA reportedLBP which was significantly associated with increased WOMAC kneepain scores. Wolfe et al [9] found that 54.6% of patients presenting toa Rheumatology Clinic with knee OA experienced back pain. Burnettet al [10] further found that 74% of patients included in theirretrospective review of unilateral TKA reported chronic back painwhich first occurred approximately 10 years prior to TKA candidacy,and that 15% had felt that their worst back pain occurred after theonset of knee OA.

The purpose of this prospective cohort study was threefold: 1) toinvestigate the prevalence of LBP in patients with end-stage hip orknee osteoarthritis electing to undergo primary TJA, 2) to evaluatethe postoperative effectiveness of TJA in reducing LBP, and 3) todetermine whether the presence of a coexisting spinal conditionimpairs the ability of TJA to alleviate OA symptoms.

Methods

A prospective cohort study was conducted on patients withend-stage hip or knee osteoarthritis electing to undergo TJA todetermine the prevalence and severity of preoperative LBPamongst our total hip and knee arthroplasty population, andsubsequently to determine the effect of TJA on alleviating suchprevalence or severity of back pain. All patients underwentprimary unilateral TJA at one high volume academic orthopaedic

The Journal of Arthroplasty 29 (2014) 867–871

The Conflict of Interest statement associated with this article can be found athttp://dx.doi.org/10.1016/j.arth.2013.10.001.

Reprint requests: Danielle Petruccelli, MLIS, MSc, Hamilton Arthroplasty Group,HamiltonHealthSciences JuravinskiHospital,711ConcessionSt.,Hamilton,Ontario, Canada.

0883-5403/2905-0002$36.00/0 – see front matter © 2014 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.arth.2013.10.001

Contents lists available at ScienceDirect

The Journal of Arthroplasty

j ourna l homepage: www.arth rop lasty journa l .o rg

Discusión

Boyle JK,AnthonyIC,JonesBG,Wheelwright EF,Blyth MJ.Influence oflow backpain on totalknee arthroplasty outcome.Knee.2014Mar;21(2):410-4

Influence of low back pain on total knee arthroplasty outcome

J.K. Boyle, I.C. Anthony 1, B.G. Jones, E.F. Wheelwright, M.J.G. BlythOrthopaedic Research Unit, Department of Trauma and Orthopaedics, Gatehouse Building, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, United Kingdom

a b s t r a c ta r t i c l e i n f o

Article history:Received 6 May 2013Received in revised form 5 December 2013Accepted 16 December 2013

Keywords:Total knee arthroplastyLow back painFunctional outcome

Background: Preoperative pain and functional status are strong determinants of postsurgical success in total kneearthroplasty. Patients suffering chronic pain fromother coexistentmusculoskeletal problemsmay respond differ-ently postoperatively, with potentially poorer outcomes after surgery. The aim of the studywas to determine theinfluence of low back pain on the outcome of total knee replacement surgery.Methods: All patients completed Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12(both physical and mental components). Patients were divided into those with (n = 40) and without a docu-mented history of low back pain (n = 305).Results: OKS, AKSS and SF-12 physical scores were significantly worse for patients with low back pain at 24months following surgery. The mental component of the SF-12 measure demonstrated a significant improve-ment inmedianmental health post-operatively for patients with no current history of low back pain. In contrastthe group with low back pain showed no improvement in mental health scores post-operatively.Conclusion: This study demonstrates that symptomatic low back pain influences functional outcome after totalknee arthroplasty surgery and that patients with low back pain show limited or no improvement in mentalhealth post-operatively.

Level of evidence II.© 2013 Elsevier B.V. All rights reserved.

1. Introduction

Osteoarthritis (OA) is a common condition affecting older patients. Itoften exists with other co-morbidities [1]. The purpose of this investiga-tion was to determine if a history of symptomatic low back pain influ-enced the outcome of total knee arthroplasty (TKA) surgery at 2 yearpost-operative follow-up.

Surgical outcome of knee arthroplasty has been reported to be influ-enced by a wide variety of factors including high BMI, pre-operativemental health state and poor pain coping mechanisms [2–6]. In 2009Novicoff et al. [7] reported that symptomatic back pain had a significanteffect on surgical outcome in TKA revision cases in a 24 month follow-up study of 221 patients. Although almost 30% of recruited patientswere lost to follow-up, the study showed that patient-reported func-tional and quality of life outcome following revision TKA can be signifi-cantly affected by the presence of such spinal pathology. Recovery timefrom surgery was also slower in patients with back pathology.

Pre-surgical pain, pain-related behaviour and their effect on kneearthroplasty outcome are frequently featured in the literature. Patientssuffering chronic pain from other coexistent musculoskeletal problemsmay respond differently postoperatively due to psychological difficul-ties or ongoing coexistent pain [3,5,8–11]. Worse ‘pain cognitions’have been shown to be significant predictors of chronic low back painand associated disability [6,9]. Pain catastrophising, pain-related fear

of movement and increased severity of self-reported pain [8], bothpre- and postoperatively, could all influence rehabilitation followingknee arthroplasty. Lingard et al. (2004) have concluded that preopera-tive pain and functional statuswere the strongest determinants of post-surgical success of TKA [11]. Two year follow-up of 701 patients showedthat those with the lowest mental health scores and most functionallimitation were also the patients who had the poorest surgical outcomeboth 1 and 2 years post-operatively.

Function of one joint in the lower limbmust not be evaluated in iso-lation. The role of a ‘kinematic chain’ has been identified in the lowerlimb, with dysfunction at one joint being either causative or resultantof problems at another [12].

The identification of risk factors for unsatisfactory outcomeafter TKAoffers the potential for better pre-operative patient education andmorerealistic expectations of surgical outcome.

This study examines the influence of symptomatic low back pain(LBP) on the outcome of total knee arthroplasty at 2 years after surgery.

2. Methods

The effect of LBP on the outcome of TKAwas investigated in a cohortof 345 patients undergoing surgery for osteoarthritis between 2000 and2007. This was a retrospective analysis of a prospective multicentrestudy, involving two UK orthopaedic centres: Glasgow Royal Infirmaryand Nottingham City Hospital. The data used in this retrospectivestudy was a sub-analysis of data from the original prospective RCTfunded by DePuy UK (Leeds, England). The aim of the original study

The Knee 21 (2014) 410–414

E-mail address: mark.blyth@ggc.scot.nhs.uk (M.J.G. Blyth).1 Tel.: +44 141 211 4107.

0968-0160/$ – see front matter © 2013 Elsevier B.V. All rights reserved.http://dx.doi.org/10.1016/j.knee.2013.12.003

Contents lists available at ScienceDirect

The Knee

Influence of low back pain on total knee arthroplasty outcome

J.K. Boyle, I.C. Anthony 1, B.G. Jones, E.F. Wheelwright, M.J.G. BlythOrthopaedic Research Unit, Department of Trauma and Orthopaedics, Gatehouse Building, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, United Kingdom

a b s t r a c ta r t i c l e i n f o

Article history:Received 6 May 2013Received in revised form 5 December 2013Accepted 16 December 2013

Keywords:Total knee arthroplastyLow back painFunctional outcome

Background: Preoperative pain and functional status are strong determinants of postsurgical success in total kneearthroplasty. Patients suffering chronic pain fromother coexistentmusculoskeletal problemsmay respond differ-ently postoperatively, with potentially poorer outcomes after surgery. The aim of the studywas to determine theinfluence of low back pain on the outcome of total knee replacement surgery.Methods: All patients completed Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12(both physical and mental components). Patients were divided into those with (n = 40) and without a docu-mented history of low back pain (n = 305).Results: OKS, AKSS and SF-12 physical scores were significantly worse for patients with low back pain at 24months following surgery. The mental component of the SF-12 measure demonstrated a significant improve-ment inmedianmental health post-operatively for patients with no current history of low back pain. In contrastthe group with low back pain showed no improvement in mental health scores post-operatively.Conclusion: This study demonstrates that symptomatic low back pain influences functional outcome after totalknee arthroplasty surgery and that patients with low back pain show limited or no improvement in mentalhealth post-operatively.

Level of evidence II.© 2013 Elsevier B.V. All rights reserved.

1. Introduction

Osteoarthritis (OA) is a common condition affecting older patients. Itoften exists with other co-morbidities [1]. The purpose of this investiga-tion was to determine if a history of symptomatic low back pain influ-enced the outcome of total knee arthroplasty (TKA) surgery at 2 yearpost-operative follow-up.

Surgical outcome of knee arthroplasty has been reported to be influ-enced by a wide variety of factors including high BMI, pre-operativemental health state and poor pain coping mechanisms [2–6]. In 2009Novicoff et al. [7] reported that symptomatic back pain had a significanteffect on surgical outcome in TKA revision cases in a 24 month follow-up study of 221 patients. Although almost 30% of recruited patientswere lost to follow-up, the study showed that patient-reported func-tional and quality of life outcome following revision TKA can be signifi-cantly affected by the presence of such spinal pathology. Recovery timefrom surgery was also slower in patients with back pathology.

Pre-surgical pain, pain-related behaviour and their effect on kneearthroplasty outcome are frequently featured in the literature. Patientssuffering chronic pain from other coexistent musculoskeletal problemsmay respond differently postoperatively due to psychological difficul-ties or ongoing coexistent pain [3,5,8–11]. Worse ‘pain cognitions’have been shown to be significant predictors of chronic low back painand associated disability [6,9]. Pain catastrophising, pain-related fear

of movement and increased severity of self-reported pain [8], bothpre- and postoperatively, could all influence rehabilitation followingknee arthroplasty. Lingard et al. (2004) have concluded that preopera-tive pain and functional statuswere the strongest determinants of post-surgical success of TKA [11]. Two year follow-up of 701 patients showedthat those with the lowest mental health scores and most functionallimitation were also the patients who had the poorest surgical outcomeboth 1 and 2 years post-operatively.

Function of one joint in the lower limbmust not be evaluated in iso-lation. The role of a ‘kinematic chain’ has been identified in the lowerlimb, with dysfunction at one joint being either causative or resultantof problems at another [12].

The identification of risk factors for unsatisfactory outcomeafter TKAoffers the potential for better pre-operative patient education andmorerealistic expectations of surgical outcome.

This study examines the influence of symptomatic low back pain(LBP) on the outcome of total knee arthroplasty at 2 years after surgery.

2. Methods

The effect of LBP on the outcome of TKAwas investigated in a cohortof 345 patients undergoing surgery for osteoarthritis between 2000 and2007. This was a retrospective analysis of a prospective multicentrestudy, involving two UK orthopaedic centres: Glasgow Royal Infirmaryand Nottingham City Hospital. The data used in this retrospectivestudy was a sub-analysis of data from the original prospective RCTfunded by DePuy UK (Leeds, England). The aim of the original study

The Knee 21 (2014) 410–414

E-mail address: mark.blyth@ggc.scot.nhs.uk (M.J.G. Blyth).1 Tel.: +44 141 211 4107.

0968-0160/$ – see front matter © 2013 Elsevier B.V. All rights reserved.http://dx.doi.org/10.1016/j.knee.2013.12.003

Contents lists available at ScienceDirect

The Knee

Influence of low back pain on total knee arthroplasty outcome

J.K. Boyle, I.C. Anthony 1, B.G. Jones, E.F. Wheelwright, M.J.G. BlythOrthopaedic Research Unit, Department of Trauma and Orthopaedics, Gatehouse Building, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, United Kingdom

a b s t r a c ta r t i c l e i n f o

Article history:Received 6 May 2013Received in revised form 5 December 2013Accepted 16 December 2013

Keywords:Total knee arthroplastyLow back painFunctional outcome

Background: Preoperative pain and functional status are strong determinants of postsurgical success in total kneearthroplasty. Patients suffering chronic pain fromother coexistentmusculoskeletal problemsmay respond differ-ently postoperatively, with potentially poorer outcomes after surgery. The aim of the studywas to determine theinfluence of low back pain on the outcome of total knee replacement surgery.Methods: All patients completed Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12(both physical and mental components). Patients were divided into those with (n = 40) and without a docu-mented history of low back pain (n = 305).Results: OKS, AKSS and SF-12 physical scores were significantly worse for patients with low back pain at 24months following surgery. The mental component of the SF-12 measure demonstrated a significant improve-ment inmedianmental health post-operatively for patients with no current history of low back pain. In contrastthe group with low back pain showed no improvement in mental health scores post-operatively.Conclusion: This study demonstrates that symptomatic low back pain influences functional outcome after totalknee arthroplasty surgery and that patients with low back pain show limited or no improvement in mentalhealth post-operatively.

Level of evidence II.© 2013 Elsevier B.V. All rights reserved.

1. Introduction

Osteoarthritis (OA) is a common condition affecting older patients. Itoften exists with other co-morbidities [1]. The purpose of this investiga-tion was to determine if a history of symptomatic low back pain influ-enced the outcome of total knee arthroplasty (TKA) surgery at 2 yearpost-operative follow-up.

Surgical outcome of knee arthroplasty has been reported to be influ-enced by a wide variety of factors including high BMI, pre-operativemental health state and poor pain coping mechanisms [2–6]. In 2009Novicoff et al. [7] reported that symptomatic back pain had a significanteffect on surgical outcome in TKA revision cases in a 24 month follow-up study of 221 patients. Although almost 30% of recruited patientswere lost to follow-up, the study showed that patient-reported func-tional and quality of life outcome following revision TKA can be signifi-cantly affected by the presence of such spinal pathology. Recovery timefrom surgery was also slower in patients with back pathology.

Pre-surgical pain, pain-related behaviour and their effect on kneearthroplasty outcome are frequently featured in the literature. Patientssuffering chronic pain from other coexistent musculoskeletal problemsmay respond differently postoperatively due to psychological difficul-ties or ongoing coexistent pain [3,5,8–11]. Worse ‘pain cognitions’have been shown to be significant predictors of chronic low back painand associated disability [6,9]. Pain catastrophising, pain-related fear

of movement and increased severity of self-reported pain [8], bothpre- and postoperatively, could all influence rehabilitation followingknee arthroplasty. Lingard et al. (2004) have concluded that preopera-tive pain and functional statuswere the strongest determinants of post-surgical success of TKA [11]. Two year follow-up of 701 patients showedthat those with the lowest mental health scores and most functionallimitation were also the patients who had the poorest surgical outcomeboth 1 and 2 years post-operatively.

Function of one joint in the lower limbmust not be evaluated in iso-lation. The role of a ‘kinematic chain’ has been identified in the lowerlimb, with dysfunction at one joint being either causative or resultantof problems at another [12].

The identification of risk factors for unsatisfactory outcomeafter TKAoffers the potential for better pre-operative patient education andmorerealistic expectations of surgical outcome.

This study examines the influence of symptomatic low back pain(LBP) on the outcome of total knee arthroplasty at 2 years after surgery.

2. Methods

The effect of LBP on the outcome of TKAwas investigated in a cohortof 345 patients undergoing surgery for osteoarthritis between 2000 and2007. This was a retrospective analysis of a prospective multicentrestudy, involving two UK orthopaedic centres: Glasgow Royal Infirmaryand Nottingham City Hospital. The data used in this retrospectivestudy was a sub-analysis of data from the original prospective RCTfunded by DePuy UK (Leeds, England). The aim of the original study

The Knee 21 (2014) 410–414

E-mail address: mark.blyth@ggc.scot.nhs.uk (M.J.G. Blyth).1 Tel.: +44 141 211 4107.

0968-0160/$ – see front matter © 2013 Elsevier B.V. All rights reserved.http://dx.doi.org/10.1016/j.knee.2013.12.003

Contents lists available at ScienceDirect

The Knee

Discusión

Schroer WC,Diesfeld PJ,LeMarr AR,Morton DJ,Reedy ME.Functional Outcomes After TotalKneeArthroplasty CorrelateWith Spine Disability.JArthroplasty.2016Sep;31(9Suppl):106-9.

Primary Arthroplasty

Functional Outcomes After Total Knee Arthroplasty Correlate WithSpine Disability

William C. Schroer, MD *, Paul J. Diesfeld, PA-C, Angela R. LeMarr, RN, Diane J. Morton, MS,Mary E. Reedy, RNSSM Health Orthopedics, St. Louis Joint Replacement Institute, St. Louis, Missouri

a r t i c l e i n f o

Article history:Received 27 October 2015Received in revised form28 April 2016Accepted 6 June 2016Available online 23 June 2016

Keywords:total knee arthroplastyknee functionKnee Society scoreOxford Knee Scorespine disabilitylow back pain

a b s t r a c t

Background: Despite pain resolution in most patients after total knee arthroplasty (TKA), poor functionpersists in approximately 20% of patients and frequently is associated with patient dissatisfaction.Lumbar spine problems are a leading cause of functional disability. This study sought to determine theassociation between lower knee function scores and history of spine disability.Methods: Prospective demographic, health, and knee-specific data were collected for 1156 consecutiveTKAs from July 2010 to July 2012. A spine questionnaire and Oswestry Disability Index (ODI) score wereobtained from 691 knees.Results: Of 691 patients, 371 (54%) with TKA had daily back pain or back pain that limited activity. OxfordKnee Score was significantly worse in patients with vs without back problems preoperatively (36.9/34.8;P ¼ .0006) and postoperatively (20.2/17.0; P < .0001), but not for improvement (16.7/17.8; P ¼ .10). KneeSociety (KS) pain scores were similar regardless of spine history. KS function scores were lower in pa-tients with vs without back problems preoperatively (42.3/47.0; P ¼ .0005), postoperatively (69.0/79.8;P < .0001), and for improvement (25.8/32.9; P < .0001). Lower KS function was associated with femalegender, age, health, preoperative function, and ODI. ODI was associated with Oxford Knee Score(R ¼ 0.57) and KS function score (R ¼ 0.54).Conclusion: Knee function scores were significantly worse in patients with a history of back problemsand directly associated with ODI score. KS function scores indicated that TKA patients with back prob-lems had worse function before and after TKA with less improvement. Poor TKA outcomes and dissat-isfaction may reflect poor knee function, spine disability, or both. Awareness of coexisting spine disabilityshould guide patient expectations and evaluation of TKA outcomes.

© 2016 Published by Elsevier Inc.

Although most patients consistently report pain relief after totalknee arthroplasty (TKA), functional deficits persist for a significantnumber of patients, which have been associated with patient

dissatisfaction [1]. Functional limitations following TKA have beenreported to correlate with patient variables of increasing age, bodymass index (BMI), health status, female gender, and poor preop-erative knee function [2-5].

According to the Centers for Disease Control and Prevention, the2 leading causes of chronic pain in the United States are low backpain (28.1%) and knee pain (19.5%) [6]. Spinal stenosis and osteoar-thritis of the knee frequently occur in the same patient. Osteoar-thritis of the knee ismoreprevalent in individualswith radiographicsigns of spinal degeneration [7]. In addition, adults with low backpain often are inworse physical health: 28% of adults with low backpain reported limited activity compared with 10% of adults withoutlow back pain [8]. Despite the frequent association of knee and backosteoarthritis and the reported functional limitations in back painpatients, published knee outcome reports have not included vari-ables accounting for low back pain or spine disability.

This institutional review boardeapproved study was funded by the St. Louis JointReplacement Institute. Neither the authors nor the patients received anything ofvalue for the conduction of this study. Ethical principles of research and compliancewith Health Insurance Portability and Accountability Act (HIPAA) guidelines werefollowed throughout the study to protect all patients' personal identifying infor-mation.

One or more of the authors of this paper have disclosed potential or pertinentconflicts of interest, which may include receipt of payment, either direct or indirect,institutional support, or association with an entity in the biomedical field whichmay be perceived to have potential conflict of interest with this work. For fulldisclosure statements refer to http://dx.doi.org/10.1016/j.arth.2016.06.015.* Reprint requests: William C. Schroer, MD, SSM Health Orthopedics, St. Louis

Joint Replacement Institute, 12349 DePaul Drive, Suite 100, St. Louis, MO 63044.

Contents lists available at ScienceDirect

The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal .org

http://dx.doi.org/10.1016/j.arth.2016.06.0150883-5403/© 2016 Published by Elsevier Inc.

The Journal of Arthroplasty 31 (2016) S106eS109

Primary Arthroplasty

Functional Outcomes After Total Knee Arthroplasty Correlate WithSpine Disability

William C. Schroer, MD *, Paul J. Diesfeld, PA-C, Angela R. LeMarr, RN, Diane J. Morton, MS,Mary E. Reedy, RNSSM Health Orthopedics, St. Louis Joint Replacement Institute, St. Louis, Missouri

a r t i c l e i n f o

Article history:Received 27 October 2015Received in revised form28 April 2016Accepted 6 June 2016Available online 23 June 2016

Keywords:total knee arthroplastyknee functionKnee Society scoreOxford Knee Scorespine disabilitylow back pain

a b s t r a c t

Background: Despite pain resolution in most patients after total knee arthroplasty (TKA), poor functionpersists in approximately 20% of patients and frequently is associated with patient dissatisfaction.Lumbar spine problems are a leading cause of functional disability. This study sought to determine theassociation between lower knee function scores and history of spine disability.Methods: Prospective demographic, health, and knee-specific data were collected for 1156 consecutiveTKAs from July 2010 to July 2012. A spine questionnaire and Oswestry Disability Index (ODI) score wereobtained from 691 knees.Results: Of 691 patients, 371 (54%) with TKA had daily back pain or back pain that limited activity. OxfordKnee Score was significantly worse in patients with vs without back problems preoperatively (36.9/34.8;P ¼ .0006) and postoperatively (20.2/17.0; P < .0001), but not for improvement (16.7/17.8; P ¼ .10). KneeSociety (KS) pain scores were similar regardless of spine history. KS function scores were lower in pa-tients with vs without back problems preoperatively (42.3/47.0; P ¼ .0005), postoperatively (69.0/79.8;P < .0001), and for improvement (25.8/32.9; P < .0001). Lower KS function was associated with femalegender, age, health, preoperative function, and ODI. ODI was associated with Oxford Knee Score(R ¼ 0.57) and KS function score (R ¼ 0.54).Conclusion: Knee function scores were significantly worse in patients with a history of back problemsand directly associated with ODI score. KS function scores indicated that TKA patients with back prob-lems had worse function before and after TKA with less improvement. Poor TKA outcomes and dissat-isfaction may reflect poor knee function, spine disability, or both. Awareness of coexisting spine disabilityshould guide patient expectations and evaluation of TKA outcomes.

© 2016 Published by Elsevier Inc.

Although most patients consistently report pain relief after totalknee arthroplasty (TKA), functional deficits persist for a significantnumber of patients, which have been associated with patient

dissatisfaction [1]. Functional limitations following TKA have beenreported to correlate with patient variables of increasing age, bodymass index (BMI), health status, female gender, and poor preop-erative knee function [2-5].

According to the Centers for Disease Control and Prevention, the2 leading causes of chronic pain in the United States are low backpain (28.1%) and knee pain (19.5%) [6]. Spinal stenosis and osteoar-thritis of the knee frequently occur in the same patient. Osteoar-thritis of the knee ismoreprevalent in individualswith radiographicsigns of spinal degeneration [7]. In addition, adults with low backpain often are inworse physical health: 28% of adults with low backpain reported limited activity compared with 10% of adults withoutlow back pain [8]. Despite the frequent association of knee and backosteoarthritis and the reported functional limitations in back painpatients, published knee outcome reports have not included vari-ables accounting for low back pain or spine disability.

This institutional review boardeapproved study was funded by the St. Louis JointReplacement Institute. Neither the authors nor the patients received anything ofvalue for the conduction of this study. Ethical principles of research and compliancewith Health Insurance Portability and Accountability Act (HIPAA) guidelines werefollowed throughout the study to protect all patients' personal identifying infor-mation.

One or more of the authors of this paper have disclosed potential or pertinentconflicts of interest, which may include receipt of payment, either direct or indirect,institutional support, or association with an entity in the biomedical field whichmay be perceived to have potential conflict of interest with this work. For fulldisclosure statements refer to http://dx.doi.org/10.1016/j.arth.2016.06.015.* Reprint requests: William C. Schroer, MD, SSM Health Orthopedics, St. Louis

Joint Replacement Institute, 12349 DePaul Drive, Suite 100, St. Louis, MO 63044.

Contents lists available at ScienceDirect

The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal .org

http://dx.doi.org/10.1016/j.arth.2016.06.0150883-5403/© 2016 Published by Elsevier Inc.

The Journal of Arthroplasty 31 (2016) S106eS109

Primary Arthroplasty

Functional Outcomes After Total Knee Arthroplasty Correlate WithSpine Disability

William C. Schroer, MD *, Paul J. Diesfeld, PA-C, Angela R. LeMarr, RN, Diane J. Morton, MS,Mary E. Reedy, RNSSM Health Orthopedics, St. Louis Joint Replacement Institute, St. Louis, Missouri

a r t i c l e i n f o

Article history:Received 27 October 2015Received in revised form28 April 2016Accepted 6 June 2016Available online 23 June 2016

Keywords:total knee arthroplastyknee functionKnee Society scoreOxford Knee Scorespine disabilitylow back pain

a b s t r a c t

Background: Despite pain resolution in most patients after total knee arthroplasty (TKA), poor functionpersists in approximately 20% of patients and frequently is associated with patient dissatisfaction.Lumbar spine problems are a leading cause of functional disability. This study sought to determine theassociation between lower knee function scores and history of spine disability.Methods: Prospective demographic, health, and knee-specific data were collected for 1156 consecutiveTKAs from July 2010 to July 2012. A spine questionnaire and Oswestry Disability Index (ODI) score wereobtained from 691 knees.Results: Of 691 patients, 371 (54%) with TKA had daily back pain or back pain that limited activity. OxfordKnee Score was significantly worse in patients with vs without back problems preoperatively (36.9/34.8;P ¼ .0006) and postoperatively (20.2/17.0; P < .0001), but not for improvement (16.7/17.8; P ¼ .10). KneeSociety (KS) pain scores were similar regardless of spine history. KS function scores were lower in pa-tients with vs without back problems preoperatively (42.3/47.0; P ¼ .0005), postoperatively (69.0/79.8;P < .0001), and for improvement (25.8/32.9; P < .0001). Lower KS function was associated with femalegender, age, health, preoperative function, and ODI. ODI was associated with Oxford Knee Score(R ¼ 0.57) and KS function score (R ¼ 0.54).Conclusion: Knee function scores were significantly worse in patients with a history of back problemsand directly associated with ODI score. KS function scores indicated that TKA patients with back prob-lems had worse function before and after TKA with less improvement. Poor TKA outcomes and dissat-isfaction may reflect poor knee function, spine disability, or both. Awareness of coexisting spine disabilityshould guide patient expectations and evaluation of TKA outcomes.

© 2016 Published by Elsevier Inc.

Although most patients consistently report pain relief after totalknee arthroplasty (TKA), functional deficits persist for a significantnumber of patients, which have been associated with patient

dissatisfaction [1]. Functional limitations following TKA have beenreported to correlate with patient variables of increasing age, bodymass index (BMI), health status, female gender, and poor preop-erative knee function [2-5].

According to the Centers for Disease Control and Prevention, the2 leading causes of chronic pain in the United States are low backpain (28.1%) and knee pain (19.5%) [6]. Spinal stenosis and osteoar-thritis of the knee frequently occur in the same patient. Osteoar-thritis of the knee ismoreprevalent in individualswith radiographicsigns of spinal degeneration [7]. In addition, adults with low backpain often are inworse physical health: 28% of adults with low backpain reported limited activity compared with 10% of adults withoutlow back pain [8]. Despite the frequent association of knee and backosteoarthritis and the reported functional limitations in back painpatients, published knee outcome reports have not included vari-ables accounting for low back pain or spine disability.

This institutional review boardeapproved study was funded by the St. Louis JointReplacement Institute. Neither the authors nor the patients received anything ofvalue for the conduction of this study. Ethical principles of research and compliancewith Health Insurance Portability and Accountability Act (HIPAA) guidelines werefollowed throughout the study to protect all patients' personal identifying infor-mation.

One or more of the authors of this paper have disclosed potential or pertinentconflicts of interest, which may include receipt of payment, either direct or indirect,institutional support, or association with an entity in the biomedical field whichmay be perceived to have potential conflict of interest with this work. For fulldisclosure statements refer to http://dx.doi.org/10.1016/j.arth.2016.06.015.* Reprint requests: William C. Schroer, MD, SSM Health Orthopedics, St. Louis

Joint Replacement Institute, 12349 DePaul Drive, Suite 100, St. Louis, MO 63044.

Contents lists available at ScienceDirect

The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal .org

http://dx.doi.org/10.1016/j.arth.2016.06.0150883-5403/© 2016 Published by Elsevier Inc.

The Journal of Arthroplasty 31 (2016) S106eS109

Limitaciones

• Naturalezaretrospectiva

• Escaladevaloracióndeldolorlumbarpreypostartroplastia

• Testcalidaddevida

ConclusionesPresenciadedolorlumbarpreoperatorioenartroplastiatotalderodillaprimaria• PeorespuntuacionespostquirúrgicasKSSFunciónyKSSTotal(p<0,001)

• Mayornecesidaddeayudaparadeambularal4ºaño(p=0,007)

• Norelaciónestadísticamentesignificativacon– PTRdolorosa– Satisfacción percibida– Complicaciones

Gracias