Remote follow-up after total knee arthroplasty: validity of patient-reported outcome measures as a triage tool – a prospective cohort study

Anand Ramachandran; Prernaa Tyagi; Chetan Sood; Akshay Pushkar; B. Hari Krishnan; Deepak Dilip Kumar

doi:10.18203/issn.2455-4510.IntJResOrthop20263913

Authors

Anand Ramachandran Department of Orthopaedics, Armed Forces Medical College, Pune, Maharashtra, India https://orcid.org/0009-0009-4203-3875
Prernaa Tyagi Department of Orthopaedics, Armed Forces Medical College, Pune, Maharashtra, India https://orcid.org/0009-0006-4410-0849
Chetan Sood Department of Orthopaedics, Armed Forces Medical College, Pune, Maharashtra, India https://orcid.org/0000-0001-6527-473X
Akshay Pushkar Department of Orthopaedics, Armed Forces Medical College, Pune, Maharashtra, India
B. Hari Krishnan Department of Orthopaedics, Armed Forces Medical College, Pune, Maharashtra, India https://orcid.org/0000-0001-7901-8569
Deepak Dilip Kumar Department of Orthopaedics, Armed Forces Medical College, Pune, Maharashtra, India

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20263913

Keywords:

Total knee arthroplasty, Patient-reported outcome measures, Remote follow-up, Telemedicine, Knee society score, Comorbidity

Abstract

Background: Routine in-person review after total knee arthroplasty (TKA) is costly and resource-intensive. Whether remotely-collected patient-reported outcome measures (PROMs) can reproduce the clinician’s follow-up decision-not merely correlate with it-is unknown. We assessed the agreement and triage accuracy of three PROMs against the clinician-administered knee society score (KSS), and whether comorbidity should modify follow-up.

Methods: In this prospective cohort of 96 patients undergoing primary TKA for osteoarthritis, the Oxford knee score (OKS), Western Ontario and McMaster universities osteoarthritis index (WOMAC), short form (SF)-36 and KSS were recorded preoperatively, at 3 weeks and at 1 year. Agreement was assessed by Bland-Altman analysis, triage accuracy by ROC analysis against a clinician-defined suboptimal outcome (lowest-quartile 1-year KSS), and predictors by multivariable regression.

Results: Data were complete for all 96 patients (mean age 66.1 years; 72.9% comorbid; no loss to follow-up). All instruments improved by 1 year (p<0.001). Despite high PROM-KSS correlations (1-year OKS r=0.96), Bland-Altman analysis showed systematic disagreement (WOMAC bias +19.9 standardised points), so the instruments are not interchangeable. A remote OKS <28 identified the suboptimal outcome with area under the curve 0.98, sensitivity 100%, specificity 93%, negative predictive value 100% and kappa 0.88, missing no affected patient. Comorbidity count independently predicted poor outcome (adjusted odds ratio 4.0 per comorbidity, p<0.001); 1-year KSS fell stepwise across strata (p<0.001).

Conclusions: After the 3-week visit, a normal remote OKS reliably excludes a poor clinician-defined outcome, supporting a comorbidity-stratified hybrid pathway: remote follow-up for low-risk patients and in-person review for high-risk patients. External, longer-term validation is required.

References

Cross WW, Saleh KJ, Wilt TJ, Kane RL. Agreement about indications for total knee arthroplasty. Clin Orthop Relat Res. 2006;446:34-9.

Bade MJ, Kohrt WM, Stevens-Lapsley JE. Outcomes before and after total knee arthroplasty compared to healthy adults. J Orthop Sports Phys Ther. 2010;40:559-67.

Canovas F, Dagneaux L. Quality of life after total knee arthroplasty. Orthop Traumatol Surg Res. 2018;104:S41-6.

Singh S, Mehta H, Gupta S, Singh J, Bakshi AS. Comparison of clinical and radiological outcomes of total knee arthroplasty in osteoarthritic patients. Cureus. 2024;16:e60933.

Scuderi GR, Bourne RB, Noble PC, Benjamin JB, Lonner JH, Scott WN. The new Knee Society Knee Scoring System. Clin Orthop Relat Res. 2012;470:3-19.

Miralles-Muñoz FA, Gonzalez-Parreño S, Martinez-Mendez D, Gonzalez-Navarro B, Ruiz-Lozano M, Lizaur-Utrilla A, et al. A validated outcome categorization of the Knee Society Score for total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2022;30:1266-72.

Hansjee S, Giebaly DE, Shaarani SR, Haddad FS. Follow-up after arthroplasty surgery: a changing landscape. Bone Joint J. 2022;104-B:1104-9.

Hendricks TJ, Chong ACM, Cusick RP. The cost of routine follow-up in total joint arthroplasty and the influence of these visits on treatment plans. Kans J Med. 2018;11:59-66.

Sharareh B, Schwarzkopf R. Effectiveness of telemedical applications in postoperative follow-up after total joint arthroplasty. J Arthroplasty. 2014;29:918-22.

Beard DJ, Harris K, Dawson J, Doll H, Murray DW, Carr AJ, et al. Meaningful changes for the Oxford hip and knee scores after joint replacement surgery. J Clin Epidemiol. 2015;68:73-9.

Strickland LH, Murray DW, Pandit HG, Jenkinson C. Development of a patient-reported outcome measure (PROM) and change measure for use in early recovery following hip or knee replacement. J Patient Rep Outcomes. 2020;4:91.

Dowsey MM, Choong PFM. The utility of outcome measures in total knee replacement surgery. Int J Rheumatol. 2013;2013:506518.

Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1:307-10.

Wang Y, Yin M, Zhu S, Chen X, Zhou H, Qian W. Patient-reported outcome measures used in patients undergoing total knee arthroplasty. Bone Joint Res. 2021;10:203-17.

von Elm E, Altman DG, Egger M, Pocock SJ, Götzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453-7.

Williams DP, Blakey CM, Hadfield SG, Murray DW, Price AJ, Field RE. Long-term trends in the Oxford knee score following total knee replacement. Bone Joint J. 2013;95-B:45-51.

Clement ND, Weir D, Deehan D. Meaningful values in the Short Form Health Survey-36 after total knee arthroplasty. Bone Joint Res. 2022;11:477-83.

Walker LC, Clement ND, Bardgett M, Weir D, Holland J, Gerrand C, et al. The WOMAC score can be reliably used to classify patient satisfaction after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2018;26:3333-41.

Lo LWT, Suh J, Chen JY, Liow MHL, Allen JC, Lo NN, et al. Early postoperative pain after total knee arthroplasty is associated with subsequent poorer functional outcomes and lower satisfaction. J Arthroplasty. 2021;36:2466-72.

Yap YYW, Edwards KL, Soutakbar H, Fernandes GS, Scammell BE. Oxford knee score 1 year after TKR for osteoarthritis with reference to a normative population: what can patients expect? Osteoarthr Cartil Open. 2021;3:100143.

Elmallah RDK, Cherian JJ, Robinson K, Harwin SF, Mont MA. The effect of comorbidities on outcomes following total knee arthroplasty. J Knee Surg. 2015;28:411-6.

Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373-83.

Kahn TL, Soheili A, Schwarzkopf R. Outcomes of total knee arthroplasty in relation to preoperative patient-reported and radiographic measures. Geriatr Orthop Surg Rehabil. 2013;4:117-26.

Kiran A, Bottomley N, Biant LC, Javaid MK, Carr AJ, Cooper C, et al. Variations in good patient-reported outcomes after total knee arthroplasty. J Arthroplasty. 2015;30:1364-71.

Youden WJ. Index for rating diagnostic tests. Cancer. 1950;3:32-5.

Hajian-Tilaki K. Sample size estimation in diagnostic test studies of biomedical informatics. J Biomed Inform. 2014;48:193-204.

Zhang H, Zhou Y. Concept verification of a remote automatic scoring system for evaluating knee function after total knee arthroplasty. J Knee Surg. 2021;34:464-70.

Small SR, Bullock GS, Khalid S, Barker K, Trivella M, Price AJ. Current clinical utilisation of wearable motion sensors for the assessment of outcome following knee arthroplasty: a scoping review. BMJ Open. 2019;9:e033832.