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J Knee Surg
DOI: 10.1055/a-2555-1941
Original Article

Risk Factors and Thresholds for Minimal Clinically Important Difference in Worsening after Unicompartmental Knee Arthroplasty

Perry L. Lim 
1   Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
2   Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
,
Marcos R. Gonzalez
1   Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
2   Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
,
Hany S. Bedair
1   Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
2   Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
,
Christopher M. Melnic
1   Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
2   Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
› Author Affiliations Funding None.
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Abstract

The rising demand for unicompartmental knee arthroplasty (UKA) in the United States has led to high 1-year patient satisfaction rates. However, some patients experience substantial declines in patient-reported outcome measures (PROMs) postoperatively, which we refer to as “minimal clinically important difference for worsening” (MCID-W). We sought to define MCID-W values for specific PROMs and identify risk factors associated with PROMIS Physical Function Short Form 10a (PROMIS PF-10a) declines after UKA. We conducted a retrospective study of 760 patients undergoing UKA at our institution between 2016 and 2023. Preoperative and postoperative PROMIS PF-10a, PROMIS global physical, and knee injury and osteoarthritis outcome score-physical function short-form (KOOS-PS) scores were collected. Patients were stratified upon reaching minimal clinically importance difference for improvement (MCID-I), MCID-W, or “no significant change” (score between MCID-W and MCID-I). MCID-W and MCID-I values were determined using a distribution-based method. Logistic regression was performed to identify risk factors for scoring below MCID-W. We established the following MCID-I and MCID-W thresholds: PROMIS PF-10a (+3.00 and −1.64), KOOS-PS (+6.25 and −3.42), and PROMIS Global-Physical (+2.72 and −1.55). Bivariate analysis revealed differences in terms of revision (p = 0.02), reoperation (p = 0.03), postoperative complications (p = 0.002), deep venous thrombosis (DVT; p < 0.001), and pneumonia (p = 0.01) between cohorts. Body mass index >35 (odds ratio [OR] = 2.49), postoperative complications (OR = 5.09), pneumonia (OR = 22.39), DVT (OR = 9.27), and preoperative PROMIS PF-10a scores (OR = 1.07) were risk factors for scoring below the MCID-W threshold, whereas age > 80 (OR = 2.89) and preoperative PROMIS PF-10a scores (OR = 1.05) were risk factors for failing to achieve MCID-I. Our study established MCID-W values for pivotal PROMs after primary UKAs. We found that 8.8% of patients scored below MCID-W, highlighting the need to improve patient selection and perioperative care in UKA.

Keywords

unicompartmental knee arthroplasty - patient-reported outcome measures - minimal clinically important difference - PROMIS PF-10a

Investigation Performed At

The investigation was performed at the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA and Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA.


Note

[Supplementary Table S1] and [S2] are available in the online version only.


Supplementary Material



Publication History

Received: 12 November 2024

Accepted: 10 March 2025

Accepted Manuscript online:
11 March 2025

Article published online:
11 April 2025

© 2025. Thieme. All rights reserved.

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  • References

  • 1 Liddle AD, Pandit H, Judge A, Murray DW. Patient-reported outcomes after total and unicompartmental knee arthroplasty: a study of 14,076 matched patients from the National Joint Registry for England and Wales. Bone Joint J 2015; 97-B (06) 793-801
    Search in Google Scholar
  • 2 Price AJ, Rees JL, Beard DJ, Gill RHS, Dodd CAF, Murray DM. Sagittal plane kinematics of a mobile-bearing unicompartmental knee arthroplasty at 10 years: a comparative in vivo fluoroscopic analysis. J Arthroplasty 2004; 19 (05) 590-597
    Search in Google Scholar
  • 3 Liddle AD, Judge A, Pandit H, Murray DW. Adverse outcomes after total and unicompartmental knee replacement in 101,330 matched patients: a study of data from the National Joint Registry for England and Wales. Lancet 2014; 384 (9952): 1437-1445
    Search in Google Scholar
  • 4 Ong PH, Pua YH. A prediction model for length of stay after total and unicompartmental knee replacement. Bone Joint J 2013; 95-B (11) 1490-1496
    Search in Google Scholar
  • 5 Murray DW, Liddle AD, Judge A, Pandit H. Bias and unicompartmental knee arthroplasty. Bone Joint J 2017; 99-B (01) 12-15
    Search in Google Scholar
  • 6 Badawy M, Espehaug B, Indrekvam K, Havelin LI, Furnes O. Higher revision risk for unicompartmental knee arthroplasty in low-volume hospitals. Acta Orthop 2014; 85 (04) 342-347
    Search in Google Scholar
  • 7 Longo UG, De Salvatore S, Candela V. et al. Unicompartmental knee arthroplasty: minimal important difference and patient acceptable symptom state for the forgotten joint score. Medicina (Kaunas) 2021; 57 (04) 324
    Search in Google Scholar
  • 8 Freigang V, Rupp M, Pfeifer C. et al. Patient-reported outcome after patient-specific unicondylar knee arthroplasty for unicompartmental knee osteoarthritis. BMC Musculoskelet Disord 2020; 21 (01) 773
    Search in Google Scholar
  • 9 Humphrey TJ, Katakam A, Melnic CM, Bedair HS. Defining failure in primary total joint arthroplasty: the minimal clinically important difference for worsening score. J Arthroplasty 2022; 37 (04) 630-636.e1
    Search in Google Scholar
  • 10 Salimy MS, Paschalidis A, Dunahoe JA, Bedair HS, Melnic CM. MGB Arthroplasty Patient-Reported Outcomes Writing Committee. Patient-reported outcomes following revision total hip arthroplasty demonstrate less improvement and significantly higher rates of worsening compared to primaries. J Arthroplasty 2023; 38 (11) 2410-2414
    Search in Google Scholar
  • 11 Salimy MS, Paschalidis A, Dunahoe JA. Patients consistently report worse outcomes following revision total knee arthroplasty compared to primary total knee arthroplasty. J Arthroplasty 2023; 39 (02) 459-465
    Search in Google Scholar
  • 12 Canfield M, Savoy L, Cote MP, Halawi MJ. Patient-reported outcome measures in total joint arthroplasty: defining the optimal collection window. Arthroplast Today 2019; 6 (01) 62-67
    Search in Google Scholar
  • 13 Kagan R, Anderson MB, Christensen JC, Peters CL, Gililland JM, Pelt CE. The recovery curve for the patient-reported outcomes measurement information system patient-reported physical function and pain interference computerized adaptive tests after primary total knee arthroplasty. J Arthroplasty 2018; 33 (08) 2471-2474
    Search in Google Scholar
  • 14 Cella D, Eton DT, Lai JS, Peterman AH, Merkel DE. Combining anchor and distribution-based methods to derive minimal clinically important differences on the functional assessment of cancer therapy (FACT) anemia and fatigue scales. J Pain Symptom Manage 2002; 24 (06) 547-561
    Search in Google Scholar
  • 15 Cella D, Riley W, Stone A. et al; PROMIS Cooperative Group. The patient-reported outcomes measurement information system (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008. J Clin Epidemiol 2010; 63 (11) 1179-1194
    Search in Google Scholar
  • 16 Mouelhi Y, Jouve E, Castelli C, Gentile S. How is the minimal clinically important difference established in health-related quality of life instruments? Review of anchors and methods. Health Qual Life Outcomes 2020; 18 (01) 136
    Search in Google Scholar
  • 17 Ruopp MD, Perkins NJ, Whitcomb BW, Schisterman EF. Youden Index and optimal cut-point estimated from observations affected by a lower limit of detection. Biom J 2008; 50 (03) 419-430
    Search in Google Scholar
  • 18 Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KDJ. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not?. Clin Orthop Relat Res 2010; 468 (01) 57-63
    Search in Google Scholar
  • 19 Wylde V, Learmonth I, Potter A, Bettinson K, Lingard E. Patient-reported outcomes after fixed- versus mobile-bearing total knee replacement: a multi-centre randomised controlled trial using the Kinemax total knee replacement. J Bone Joint Surg Br 2008; 90 (09) 1172-1179
    Search in Google Scholar
  • 20 van der Wees PJ, Wammes JJG, Akkermans RP. et al. Patient-reported health outcomes after total hip and knee surgery in a Dutch University Hospital Setting: results of twenty years clinical registry. BMC Musculoskelet Disord 2017; 18 (01) 97
    Search in Google Scholar
  • 21 Goldberg B, Deckey DG, Verhey JT. et al. Changes over a decade in patient-reported outcome measures and minimal clinically important difference reporting in total joint arthroplasty. Arthroplast Today 2023; 20: 101096
    Search in Google Scholar
  • 22 Goh GS, Tarabichi S, Baker CM, Qadiri QS, Austin MS. Should we aim to help patients “feel better” or “feel good” after total hip arthroplasty? determining factors affecting the achievement of the minimal clinically important difference and patient acceptable symptom state. J Arthroplasty 2023; 38 (02) 293-299
    Search in Google Scholar
  • 23 Humphrey TJ, Salimy MS, Duvvuri P, Melnic CM, Bedair HS, Alpaugh K. A matched comparison of the rates of achieving the minimal clinically important difference following conversion and primary total hip arthroplasty. J Arthroplasty 2023; 38 (09) 1767-1772
    Search in Google Scholar
  • 24 Seetharam A, Deckard ER, Ziemba-Davis M, Meneghini RM. The AAHKS clinical research award: are minimum two-year patient-reported outcome measures necessary for accurate assessment of patient outcomes after primary total knee arthroplasty?. J Arthroplasty 2022; 37 (8S): S716-S720
    Search in Google Scholar
  • 25 Piuzzi NS. Cleveland Clinic O. M. E. Arthroplasty Group. Patient-reported outcomes at 1 and 2 years after total hip and knee arthroplasty: what is the minimum required follow-up?. Arch Orthop Trauma Surg 2022; 142 (09) 2121-2129
    Search in Google Scholar
  • 26 Rosinsky PJ, Chen JW, Shapira J, Maldonado DR, Lall AC, Domb BG. Mid-term patient-reported outcomes of hip arthroplasty after previous hip arthroscopy: a matched case-control study with a minimum 5-year follow-up. J Am Acad Orthop Surg 2020; 28 (12) 501-510
    Search in Google Scholar
  • 27 Berliner JL, Brodke DJ, Chan V, SooHoo NF, Bozic KJ. Can preoperative patient-reported outcome measures be used to predict meaningful improvement in function after TKA?. Clin Orthop Relat Res 2017; 475 (01) 149-157
    Search in Google Scholar
  • 28 Katakam A, Collins AK, Sauder N. et al. Obesity increases risk of failure to achieve the 1-year PROMIS PF-10a minimal clinically important difference following total joint arthroplasty. J Arthroplasty 2021; 36 (7S): S184-S191
    Search in Google Scholar
  • 29 Calabro L, Clement ND, MacDonald D, Patton JT, Howie CR, Burnett R. Venous thromboembolism after total knee arthroplasty is associated with a worse functional outcome at one year. Bone Joint J 2021; 103-B (07) 1254-1260
    Search in Google Scholar
  • 30 Mantilla CB, Horlocker TT, Schroeder DR, Berry DJ, Brown DL. Frequency of myocardial infarction, pulmonary embolism, deep venous thrombosis, and death following primary hip or knee arthroplasty. Anesthesiology 2002; 96 (05) 1140-1146
    Search in Google Scholar
  • 31 Parvizi J, Smith EB, Pulido L. et al. The rise in the incidence of pulmonary embolus after joint arthroplasty: is modern imaging to blame?. Clin Orthop Relat Res 2007; 463 (463) 107-113
    Search in Google Scholar
  • 32 Johnston BC, Ebrahim S, Carrasco-Labra A. et al. Minimally important difference estimates and methods: a protocol. BMJ Open 2015; 5 (10) e007953
    Search in Google Scholar
  • 33 Hung M, Bounsanga J, Voss MW, Saltzman CL. Establishing minimum clinically important difference values for the patient-reported outcomes measurement information system physical function, hip disability and osteoarthritis outcome score for joint reconstruction, and knee injury and osteoarthritis outcome score for joint reconstruction in orthopaedics. World J Orthop 2018; 9 (03) 41-49
    Search in Google Scholar