St. Joseph Mercy Health System, Ypsilanti, MI, USA.
Michigan Arthroplasty Registry Collaborative Quality Initiative, Ann Arbor, MI, USA.
Clin Orthop Relat Res. 2023 Sep 1;481(9):1800-1810. doi: 10.1097/CORR.0000000000002606. Epub 2023 Mar 14.
The Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR) and Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR) scores represent pain and dysfunction as a single number ranging from 0 (extreme pain and dysfunction) to 100 (no pain or functional limitations). However, scores between 0 and 100 lack a simple interpretation because they reflect varying combinations of pain levels and dysfunction. Given that most adverse events and improvement occur within the first 90 days after surgery, a deeper understanding of the level of pain and dysfunction may reveal missed opportunities for patient care.
QUESTIONS/PURPOSES: (1) What does a given preoperative or postoperative HOOS JR and KOOS JR score indicate about pain and ability to perform daily activities? (2) How much of a change in score (that is, delta) is needed to indicate significant improvement in pain control and daily functioning?
The Michigan Arthroplasty Registry Collaborative Quality Initiative contains more than 95% of THAs and TKAs performed in Michigan. Between January 2017 and March 2019, 84,175 people in the registry underwent primary THA or TKA and were potentially eligible for this retrospective, comparative study of the first 90 postoperative days. Eighty-four percent (70,608 of 84,175) were excluded because their surgeons did not attain a target survey collection proportion of 70% and another 6% (5042) were missing covariate information or surveys, leaving 10% (8525) for analysis. The mean age and percentage of women were 65 ± 11 years and 55% (2060 of 3716), respectively, for patients undergoing THA and 67 ± 9 years and 61% (2936 of 4809), respectively, for those undergoing TKA. There were no clinically meaningful differences between patients who were analyzed and those who were excluded except for lower representation of non-White patients in the analyzed group. For interpretation, patient responses to Question 7 (pain) and Question 6 (function) from the Patient-Reported Outcomes Measurement Information System global items (PROMIS-10) were dichotomized into "much pain" (rating of pain 4 to 10 of 10) versus "less pain" (rating of ≤ 3) and "good function" (able to perform most activities) versus "poor function" (not able to perform most activities) and combined into four pain-function categories. We examined the mean preoperative and postoperative HOOS JR and KOOS JR scores for each pain-function category, adjusted for patient characteristics. We calculated the size of the delta associated with an increase to a more favorable category postoperatively (versus staying in the same or worse category) via multivariable logistic regression that controlled for patient characteristics.
Patients in the least favorable "much pain, poor function" category preoperatively had adjusted mean scores of 40 (95% confidence interval 39 to 41) for both the HOOS JR and KOOS JR. Those with mixed levels of pain and function had mean scores between 46 and 55. Those in the most favorable "less pain, good function" category had means of 60 (95% CI 58 to 62) and 59 (95% CI 58 to 61) for the HOOS JR and KOOS JR, respectively. The adjusted delta to achieve a pain level of ≤ 3 or the ability to perform most activities was 30 (95% CI 26 to 36) on the HOOS JR and 27 (95% CI 22 to 29) on the KOOS JR scales.
These adjusted means of the HOOS JR and KOOS JR provide context for understanding the levels of pain and dysfunction for individuals as well for patients reported in other studies. Potential quality improvement efforts could include tracking the proportion of patients with THA or TKA who achieved a sufficient delta to attain pain levels of ≤ 3 or the ability to perform most activities. Future studies are needed to understand pain and function represented by the HOOS JR and KOOS JR at 1 to 2 years, how these may differ by patient subgroups, and whether scores can be improved through quality improvement efforts.
Level III, therapeutic study.
髋关节和膝关节骨关节炎结局评分关节置换术（HOOS JR）和膝关节损伤和骨关节炎结局评分关节置换术（KOOS JR）评分将疼痛和功能表示为一个介于 0（极度疼痛和功能障碍）到 100（无疼痛或功能限制）的数字。然而，0 到 100 之间的分数缺乏简单的解释，因为它们反映了不同的疼痛水平和功能障碍组合。鉴于大多数不良事件和改善发生在手术后的前 90 天内，对疼痛和功能水平的更深入了解可能会发现患者护理的错失机会。
问题/目的：（1）术前或术后 HOOS JR 和 KOOS JR 评分表明疼痛和日常活动能力如何？（2）需要多少评分变化（即差值）才能表明疼痛控制和日常功能的显著改善？
密歇根关节置换登记处协作质量倡议包含密歇根州进行的超过 95%的全髋关节置换术和全膝关节置换术。在 2017 年 1 月至 2019 年 3 月期间，登记处的 84175 人接受了初次全髋关节置换术或全膝关节置换术，并有资格参加这一回顾性、比较性研究，研究时间为术后的前 90 天。84%（84175 人中有 70608 人）被排除在外，因为他们的外科医生没有达到 70%的目标调查收集比例，另有 6%（5042 人）缺失协变量信息或调查，因此 10%（8525 人）被纳入分析。接受全髋关节置换术的患者的平均年龄和女性百分比分别为 65±11 岁和 55%（2060 人中有 2060 人），接受全膝关节置换术的患者分别为 67±9 岁和 61%（2936 人中有 2936 人）。除了分析组中非白种患者的代表性较低外，接受分析的患者与被排除的患者之间没有明显的临床差异。为了便于解释，我们将患者对 PROMIS-10 全球项目问卷第 7 题（疼痛）和第 6 题（功能）的回答进行二分法，分为“疼痛严重”（疼痛评分 4 至 10 分中的 4 至 10 分）与“疼痛较轻”（评分≤3）和“功能良好”（能够进行大多数活动）与“功能不佳”（无法进行大多数活动），并将其合并为四个疼痛功能类别。我们检查了每个疼痛功能类别的术前和术后 HOOS JR 和 KOOS JR 评分，同时调整了患者特征。我们通过多变量逻辑回归计算了术后向更有利的类别增加的差值（与保持在相同或更差的类别相比）的大小，该回归控制了患者特征。
术前处于最不利的“疼痛严重，功能不佳”类别的患者调整后的 HOOS JR 和 KOOS JR 平均得分为 40（95%置信区间 39 至 41）。那些疼痛和功能水平混合的患者的平均得分在 46 到 55 之间。那些处于最有利的“疼痛较轻，功能良好”类别的患者的 HOOS JR 和 KOOS JR 平均值分别为 60（95%置信区间 58 至 62）和 59（95%置信区间 58 至 61）。在 HOOS JR 和 KOOS JR 上达到疼痛水平≤3 或能够进行大多数活动的调整后的差值为 30（95%置信区间 26 至 36）和 27（95%置信区间 22 至 29）。
这些调整后的 HOOS JR 和 KOOS JR 平均值为个体以及其他研究中报告的患者的疼痛和功能障碍水平提供了背景。潜在的质量改进工作可能包括跟踪接受全髋关节置换术或全膝关节置换术的患者中达到足够差值以达到疼痛水平≤3 或能够进行大多数活动的比例。需要进一步研究来了解 HOOS JR 和 KOOS JR 在 1 至 2 年内的疼痛和功能，并了解这些可能因患者亚组而异，以及是否可以通过质量改进工作来提高分数。
III 级，治疗性研究。
