Cleveland Clinic, Cleveland, Ohio.
J Bone Joint Surg Am. 2023 Feb 15;105(4):286-292. doi: 10.2106/JBJS.22.00645. Epub 2022 Dec 19.
Pain and function, as reflected by patient-reported outcome measures (PROMs), can influence improvement after total knee arthroplasty (TKA) and can reflect the extent of patient access to orthopaedic surgical care. We aimed to (1) categorize patients according to pain and function PROM phenotypes, (2) identify patient characteristics associated with poor preoperative pain and function, and (3) assess relationships between baseline characteristics and PROM phenotypes.
A prospective cohort of 14,079 TKAs was enrolled. Demographics, comorbidities, surgical details, and preoperative PROMs were collected. Outcomes included preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) Pain (P) and Physical Function (PS) subscores, stratified by demographics. Patients were then categorized into 4 PROM phenotypes defined on the basis of the cohort medians: above or equal to the median for both pain and function scores (P+PS+), below the median for both pain and function (P-PS-), above or equal to the median for pain but below the median for function (P+PS-), and below the median for pain but above or equal to the median for function (P-PS+). Descriptive statistics and multivariable regression analyses were calculated.
The largest PROM phenotype was P-PS- (39.4%), followed by P+PS+ (38.9%). The cohort with discordantly poor function but high pain scores (less pain) was the smallest cohort (9.9%). Preoperative KOOS-Pain and KOOS-PS scores at or below the 25th percentile were independently associated with younger age, female sex, higher body mass index (BMI), non-White race, current smoking, lower education, non-commercial insurance, and higher Charlson Comorbidity Index (CCI). Multivariate logistic regression showed that patients in the P+PS+ category were older (odds ratio [OR] = 1.56), were more likely to be male (OR = 2.00), had a lower BMI (OR = 0.67), had more education (OR = 1.63), had a lower CCI, and were less likely to be Black (OR = 0.80) or Other (OR = 0.62) race, be a current smoker (OR = 0.62), and have commercial insurance (OR = 0.74), compared with the P-PS- phenotype.
Younger age, obesity, non-White race, female sex, current or recent smoking, non-commercial insurance, and higher CCI were associated with worse pre-TKA PROMs and poor pain-function phenotype combinations. Such a pattern may indicate barriers to TKA access among these patient populations leading to advanced levels of impairment at the time of treatment.
Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
疼痛和功能（反映在患者报告的结果测量中，即 PROM）可影响全膝关节置换术（TKA）后的改善，并反映患者获得骨科手术护理的程度。我们的目的是：（1）根据疼痛和功能 PROM 表型对患者进行分类；（2）确定与术前疼痛和功能不良相关的患者特征；（3）评估基线特征与 PROM 表型之间的关系。
前瞻性纳入了 14079 例 TKA 患者。收集了人口统计学、合并症、手术细节和术前 PROM。结果包括根据人口统计学分层的膝关节损伤和骨关节炎结果评分（KOOS）疼痛（P）和躯体功能（PS）子评分，以及术前 KOOS 疼痛和 PS 评分低于第 25 百分位的患者。然后，根据队列中位数将患者分为 4 种 PROM 表型：疼痛和功能评分均高于或等于中位数（P+PS+）、疼痛和功能评分均低于中位数（P-PS-）、疼痛评分高于或等于中位数但功能评分低于中位数（P+PS-）、疼痛评分低于中位数但功能评分高于或等于中位数（P-PS+）。计算了描述性统计和多变量回归分析。
最大的 PROM 表型是 P-PS-（39.4%），其次是 P+PS+（38.9%）。功能表现较差但疼痛评分较高（疼痛较轻）的患者比例最小（9.9%）。术前 KOOS 疼痛和 PS 评分低于或等于第 25 百分位与年龄较小、女性、较高的体重指数（BMI）、非白种人、当前吸烟、较低的教育程度、非商业保险和较高的 Charlson 合并症指数（CCI）独立相关。多变量逻辑回归显示，P+PS+组患者年龄较大（优势比[OR] = 1.56）、更可能为男性（OR = 2.00）、BMI 较低（OR = 0.67）、受教育程度较高（OR = 1.63）、CCI 较低、不太可能为黑种人（OR = 0.80）或其他种族（OR = 0.62）、当前或近期吸烟（OR = 0.62）、且拥有商业保险（OR = 0.74），与 P-PS-表型相比。
年龄较小、肥胖、非白种人、女性、当前或近期吸烟、非商业保险和较高的 CCI 与 TKA 前 PROM 较差和疼痛功能表型组合不良相关。这种模式可能表明这些患者群体在接受治疗时存在 TKA 获得障碍，导致其在治疗时出现更严重的功能障碍。
预后 III 级。请参阅作者说明，以获取完整的证据水平描述。
