Glucosamine Revisited, Again

Our OrthoBuzz report of the “near-death” of glucosamine/chondroitin may have been premature, according to a recent study published online in the Annals of the Rheumatic Diseases. The randomized, double-blind study assigned 606 patients with knee osteoarthritis and moderate-to-severe pain to receive either glucosamine (500 mg) and chondroitin (400 mg) three times a day, or one daily dose of the COX-2 inhibitor celecoxib (200 mg).

The study was designed to discern noninferiority between the supplements and celecoxib, and the results over six months showed equivalent benefits in both groups. WOMAC measures of pain decreased by 50.1% in the supplement group and 50.2% in the celecoxib group. Both groups also showed a >50% reduction in the presence of joint swelling, and adverse events were low in both groups.

One thing readers may want to consider when mulling over these results: The study was sponsored by the manufacturer of the glucosamine/chondroitin product used in the trial, and all authors disclosed financial relationships with that manufacturer.

An additional perspective on these and other glucosamine/chondroitin findings comes from JBJS Deputy Editor for Research Tom Bauer, MD, an ultra-marathon runner who’s free of arthritis symptoms and does take glucosamine/chondroitin supplements. Dr. Bauer emphasizes the distinction between preventing osteoarthritis and treating it. “Most published studies in humans, like this recent one, have tested glucosamine/chondroitin in patients with pre-existing osteoarthritis,” he said. “It’s a tall order to expect any oral medication to induce actual restoration of the articular surface, so I’m eager to see a decent chondroprotective study of these supplements in athletes who do not have osteoarthritis.”

Coming Soon: Medicare Appropriate Use Criteria for Advanced Imaging

For most physicians, HR 4302, federal legislation signed into law on April 1, 2014, was important because it delayed until March 1, 2015 drastic SGR-imposed cuts to Medicare physician payments. While many people are wondering what the next chapter of that saga will bring as the deadline approaches, tucked away in Section 218 of HR 4302 is another provision that could have far-reaching effects on daily orthopaedic practice: a Medicare requirement tying payment for advanced diagnostic imaging to appropriate use criteria (AUC).

That section of the legislation requires providers who order advanced diagnostic imaging for Medicare patients—such as CT and MRI—to consult physician-developed AUC, and document such consultation, beginning on January 1, 2017. Beginning on January 1, 2020, 5% of the ordering clinicians deemed to be “outliers” will be subject to a prior-authorization requirement.

In the meantime, the bill requires the Centers for Medicare and Medicaid Services (CMS) to issue rules for imaging AUC, “developed or endorsed by national professional medical specialty societies or other provider-led entities,” no later than November 2015.  It also directs the Health and Human Services Secretary to identify, by April 1, 2016, clinical decision-support tools to help physicians navigate the appropriateness criteria.

The goal of appropriateness criteria is to encourage clinicians to practice evidence-based medicine for improved patient outcomes and to use limited healthcare resources more efficiently. But, like any “administrative” task appended to already-complex medical practices, AUC for diagnostic imaging are controversial.

To find out more about the development of imaging AUC and what this pending requirement might mean for orthopaedists, OrthoBuzz recently spoke with three experts:

DDavid Jevsevar, MD, MBAavid Jevsevar, MD, MBA, chair of the American Academy of Orthopaedic Surgeons’ (AAOS) Committee on Evidence-Based Quality and Value and vice-chair of orthopaedics at Dartmouth-Hitchcock Medical Center

 

AlAlexandra Page, MDexandra Page, MD, chair of the AAOS Health Care Systems Committee and an orthopaedic surgeon at Kaiser Permanente

 

Geraldine McGinty, MD, MBAGeraldine McGinty, MD, MBA, chair of the Economics Commission at the American College of Radiology (ACR) and assistant professor of radiology at Weill Cornell Medical College

 

From these interviews, three themes emerged:

  • The need for collaboration among radiologists and orthopaedists in developing imaging AUC
  • The potential benefits of imaging AUC
  • The need for imaging AUC to be as user-friendly as possible

Development through Collaboration

The AAOS has a comprehensive process for developing AUC, but collaboration with other specialty societies is essential. Ideally, AUC are developed from a peer-reviewed evidence base, but such evidence is not always available.

Dr. Jevsevar: As much as we want AUC to be “evidence based,” there’s not a whole lot of imaging-related evidence out there. Ordering a plain radiograph of a patient who presents with symptoms of knee osteoarthritis seems self-evident and is diagnostically useful, but there’s no published evidence to support the practice. Consequently, most of the AUC already in use are based on a consensus methodology.

Dr. McGinty: The ACR’s AUC are evidence-based when there is evidence and consensus-based when there’s not. We also constantly revisit AUC in light of new evidence. When necessary, our AUC committees deploy “rapid response teams” to make sure guidelines are updated quickly and accurately.

Over the last 20 years the ACR has developed AUC for many clinical scenarios, and the process has always involved collaboration with other relevant specialties. The 24 musculoskeletal AUC that we already have established were developed in collaboration with physicians from the AAOS. Collaboration is essential because the evidence from which AUC are developed has to be representative of the specialty that’s going to use them.

Dr. Page: Cross-specialty collaboration among physicians allows us to be stronger negotiators with CMS and other large entities. My interactions with the ACR have always been with people more interested in how we can work together than in the “territorial” issues.

At Kaiser, we also collaborate with primary care doctors to establish AUC for musculoskeletal and other imaging. For example, we agree that advanced imaging is not appropriate in a primary care setting for an initial presentation of routine low back or knee pain. Collaboration helped make this an educational experience rather than an adversarial one.

Dr. Jevsevar:  With imaging, interdisciplinary input is necessary for developing AUC because we all see patients through our own lenses. AAOS representation on the ACR working groups to develop AUC ensures that both perspectives are represented. The AAOS has also successfully collaborated with primary care specialties to develop AUC for diagnosis and initial treatment of distal radius fractures, osteochondritis dissecans, and knee osteoarthritis.

AUC Benefits

The putative benefits of imaging AUC fall into two main areas: improved patient outcomes and lower health-system costs.

Dr. McGinty: Institutions and health systems that have already implemented imaging AUC have shown that they reduce costs to the system, including costs related to unnecessary imaging. We also expect that patient outcomes will improve due to decreased complications from inappropriate surgery.

Dr. Jevsevar: Imaging AUC will also help physicians measure themselves transparently. It will help identify outliers who order more imaging studies than necessary. But instead of a punitive response to that, we’re aiming for an educational response: Why is someone an outlier, and what education can we provide so that person can change behaviors?

Dr. Page: The collaborative process of developing AUC in and of itself makes us better clinicians and more empowered to provide better patient care.

Ease-of-Use Essential

All three experts whom we interviewed insisted that imaging AUC will have to be seamlessly integrated into usual clinical workflows. Extra steps that are not “automatic” will be received unhappily.

Dr. McGinty: The user-friendliness of the platform is key. Ideally, AUC filters would be embedded into the EHR system so they are seamless to the clinician. Even better would be systems that automatically track clinician adherence to AUC for reporting purposes. But for all that to happen, there will have to be ongoing collaboration with EHR vendors.

Dr. Jevsevar: Any process that’s onerous will not be good for anybody. If a procedural step is pushed to doctors, they’ll be more likely to perform it than if they have to go out and get it. I like the AAOS AUC app, but even consulting that requires an additional step. I envision an EHR-based AUC tool that will initially block a doctor from ordering an imaging study that’s not “appropriate.” Or an embedded pop-up message will remind a doctor who’s about to order an MRI or CT in a specific clinical scenario what the evidence base says.

Having said that, even if AUC are seamlessly integrated into the EHR, I don’t think they should be unreasonably rigid.  Almost all practice guidelines assume a “routine patient.” But we often see patients who are not routine, so AUC need to allow for flexibility. We’re all trying to find the right balance between providing the best care at the population and system levels and at the same time delivering the best patient-centered care to each individual.

JBJS Editor’s Choice—Better Prognoses for Aging Shoulders

We have long been taught that among people fortunate enough to survive into their 80s, 70% to 80% will have a torn rotator cuff— that it’s part of life just like degenerating lumbar discs. These figures were based on cadaveric studies, a study design that comes with a whole spectrum of issues around detection and selection bias.

However, in the January 21, 2015 issue of The Journal, Keener et al. provide us with much more reliable data regarding the progression of asymptomatic rotator cuff tears in a population of 224 subjects. The cohort included people with an asymptomatic rotator cuff tear in one shoulder and pain due to rotator cuff disease in the contralateral shoulder. As determined by ultrasound, 118 had full thickness tears, and 56 had partial thickness tears. Importantly, the study also included 50 controls with no ultrasound evidence of rotator cuff tear in one shoulder and painful cuff disease in the contralateral shoulder. Researchers followed the cohort for a mean of more than 5 years.

The good news is that neither age nor gender was found to be related to the risk of tear enlargement. Tear enlargement occurred in 49% of all the shoulders at a median of 2.8 years, and the risk of enlargement was 4.2 times and 1.5 times higher in subjects with full thickness tears, relative to controls and those with partial thickness tears, respectively. Both tear type and tear enlargement were associated with the onset of “new pain,” further assuring us that following our rotator cuff patients clinically is a sound and cost-efficient strategy.

What I found most interesting is that progressive muscular degeneration in the supraspinatus muscle belly, as detected by ultrasound, was associated with tear enlargement. This strengthens our recommendations—to our patients and ourselves—to engage in rotator cuff strengthening as a part of overall resistance training for lifelong maintenance of function and preservation of muscle mass.

So…. to protect our cuff integrity and for innumerable other reasons, back to the gym we go.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

What’s New in Primary Bone Tumors

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from studies cited in the December 17, 2014 Specialty Update on primary bone tumors:

Chondrosarcoma

–MicroRNA-145, an inhibitor of cell growth, was expressed at abnormally low levels in chondrosarcoma, lending credence to the hypothesis that underexpression of microRNA-145 plays a role in cancer development.

–Osteoclasts enhance the ability of chondrosarcoma to invade bone, but that invasion that can be partially halted by zoledronic acid.

–There is increased activity of the glycolysis-associated enzyme lactate dehydrogenase-A (LDHA) in chondrosarcoma.

–Density and location of new blood-vessel formation may be an important prognostic factor in chondrosarcoma.

–Conditional survival in patients with chondrosarcoma improves with each year of survival, but even patients who survive ten years after diagnosis cannot be considered cured.

Chordoma

–Variants of T transcription factor play a role in the pathophysiology of familial and sporadic chordoma.

–In patients with primary sarcomas of the spine, proton radiation plus surgery yielded local control rates of 85% at eight years.

Osteosarcoma

–Expression of the glucose transporter Glut-1 correlated with worse outcomes in patients with osteosarcoma.

–Secondary malignant neoplasms were found in 2.1% of long-term survivors of osteosarcoma.

–Use of fluorescence-guided surgery in a mouse model of osteosarcoma allowed reduction in the amount of residual tumor and improved disease-free survival.

–Among patients with high-grade osteosarcoma with soft-tissue extension, four parameters—tumor location, intracapsular extension, Huvos grade, and alkaline phosphatase level—may help predict which individuals will eventually develop metastases.

–In 45 patients with local recurrence but no metastases, the 10-year survival rate was 13%; most local recurrences were in soft tissue, not bone.

–Mid-therapy PET imaging may be useful to physicians in assessing response to chemotherapy.

Ewing Sarcoma

–Twenty-one percent of Ewing sarcoma samples had deletions of the STAG2 gene, and patients with STAG2 deletions had more aggressive tumors.

Soft-Tissue Sarcoma

–Among patients who also had surgery, intensity-modulated radiation therapy (IMRT) was associated with a lower local recurrence rate compared to conventional external-beam radiation.

–Six-month progression-free survival was 58% among 91 patients in a phase-II clinical trial of a hypoxia-activated cytotoxic agent (TH-302) used with doxorubicin.

–In a follow-up protocol comparison, radiography was noninferior to CT in terms of overall survival rate and disease-free survival.

–Ninety-five percent of 867 soft-tissue sarcoma patients who developed a recurrence did so within 8.6 years, raising questions about the usefulness of following patients beyond 10 years.

Reconstruction

–Due to high complication rates, intercalary allograft reconstruction after tumor resection should be reserved for defects of 15 cm or less, and plate-and-screw fixation should be used rather than intramedullary-nail fixation.

–Thirty-six patients who received frozen orthotopic autograft during reconstruction demonstrated a 10-year autograft survival rate of 80%.

–Patients who underwent pelvic reconstruction had a higher infection rate (26%), compared with those who did not undergo pelvic reconstruction (15%).

JBJS Classics: Correlating Lumbar MRIs with Clinical Findings

JBJS-Classics-logoEach month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.

In 1989, a group of sixty-seven asymptomatic individuals with no history of back pain or sciatica underwent magnetic resonance scans of the lumbar spine. In a landmark 1990 JBJS study, Boden et al. reported that three neuroradiologists who had no clinical knowledge of the patients interpreted the images as being substantially abnormal in 28% of the cohort (19 individuals). More specifically, a herniated nucleus pulposus was identified in 24 % of these asymptomatic subjects. These “magnetic-resonance positive” findings were more prevalent in older subjects; abnormal MRI findings were identified in 57% of those aged 60 to 80 years.

Boden et al. concluded that so many MRI findings of substantial abnormalities in asymptomatic people “emphasized the dangers of predicating a decision to operate on the basis of diagnostic tests—even when a state-of-the-art modality is used—without precise correlation with clinical signs and symptoms.”

However, despite the findings of Boden et al., during the last five years of the 1990s, Medicare claims showed a 40% increase in spine-surgery rates, a 70% increase in fusion-surgery rates, and a two-fold increase in use of spinal implants. Although spine-fusion surgery has a well-established role in treating certain spinal diseases, a 2007 systematic review of several randomized trials indicated that the benefits of fusion surgery were limited when treating degenerative lumbar discs with back pain alone. This review suggested the need for more thorough selection of surgical candidates, which was a caution also implied by Boden et al.

Although the three neuroradiologists in the Boden et al. study largely agreed on the absence or presence of abnormal findings on the MRIs, in 2014 Fu et al. reported on the interrater and intrarater agreements by four reviewers of MRI findings from the lumbar spine of 75 subjects. Even though this study used standardized evaluation criteria, there was significant variability in both interrater and intrarater agreement among the reviewers. As the Boden et al. study did 25 years ago, this study demonstrated the diagnostic limitations of MRI interpretation for lumbar spinal diseases.

In 2001, JBJS published a paper by Borenstein et al. that was a seven-year follow-up study among the same asymptomatic subjects studied by Boden et al. Borenstein et al. found that the original 1989 scans of the lumbar spine were not predictive of the future development or duration of low back pain. This led Borenstein et al. to conclude—as Boden et al. did—that “clinical correlation is essential to determine the importance of abnormalities on magnetic resonance images.”

Many important subsequent studies were inspired by the original findings of Boden et al. in JBJS. Most of them emphasize that for lumbar-spine diagnoses, an MRI is only one (albeit important) piece of data; that interpretation of MRIs is variable; and that all imaging information must be correlated to the specific patient’s clinical condition.

Several studies and national surveys indicate that approximately a quarter of US adults report having had back pain during the past 3 months, making this a common clinical complaint. But the findings of Boden, et al. and subsequent studies remind us that surgery is not always the appropriate treatment.

Daisuke Togawa, MD, PhD

JBJS Deputy Editor

Med Students Cite Importance of—and Obstacles to—Care Coordination

The 9th annual Epocrates Future Physicians of America Survey from athenahealth polled more than 1,400 medical students about clinical teamwork, among other topics. A whopping 96% of respondents said that collaborating with “extended care teams”—members of which might include nurses, PAs, and medical staff—is important or very important to the delivery of high-quality care. Forty-three percent cited fragmented care as the number-one risk factor for compromised patient safety, with cost of care and medication non-compliance coming in a distant second and third, respectively. And, apparently aware of the shift toward financial incentives for better outcomes arising from team-based care, 67% rated care coordination as important or very important for a physician’s financial success.

However, 57% of respondents cited inadequate cross-team communication as the number-one barrier to coordinated care, with a lack of interoperability among current EHR systems cited by 42% as the primary hurdle. On a more positive note, the survey found that 86% of respondents felt that their medical training prepared them for patient-centered care, a model that stresses patient and family involvement in shared decision-making.

The survey also asked students about their awareness of accountable care organizations (ACOs). According to the American College of Physicians, “the core purpose of an Accountable Care Organization is to provide accessible, effective, team-based integrated care.” Yet, according to the survey, 65% of medical students feel they don’t know enough about ACOs. That’s down from 72% in last year’s survey, but it’s still a sizable proportion. Another 39% admitted that they are unsure about the purpose or structure of ACOs.

In two miscellaneous findings that reveal ambivalence among medical students regarding the personal versus technological in medical practice, 99% of respondents said they would prefer a face-to-face office visit over a virtual encounter for an initial patient interaction, while at the same time 97% said they would encourage patients to use remote monitoring devices such as those now available for tracking weight, physical-activity levels, blood sugar, and vital signs.

Most Med Students to Sidestep Private Practice, but Ortho Residents Seek Independence

If you’re a physician in private practice, there may be very few doctors following in your footsteps, according to results from athenahealth’s 9th annual Epocrates Future Physicians of America Survey.

Among medical students who responded to the survey, 73% said they plan to seek employment through a hospital or large group practice; a mere 10% said they hope to join a private practice, down from 17% the previous year. One reason for the employed practice-setting preference: med students feel their training doesn’t prepare them for the challenges of running a business. Fifty-seven percent expressed dissatisfaction with their education in practice management, and 65% reported feeling unprepared for the exigencies of billing and coding.

When asked about their “top concerns,” 60% of respondents cited a desire for work-life balance as number one. That, along with an apparent aversion to the administrative hassles of private practice, helps explain this year’s findings.

However, when OrthoBuzz asked members of the JBJS Resident Advisory Board to comment on these findings, another side of the story emerged. Daniel Hatch, MD, a fifth-year resident at Penn State Hershey Orthopaedics, said, “I am a huge proponent of private-practice medicine and hope to join a private-practice group when I am done with training, but I too feel the pull toward employed positions with guaranteed high salaries for the first few years and large signing bonuses.  But I am looking for more autonomy and control in the decision-making related to my practice.”

Orrin Franko, MD, a chief resident at UC San Diego, concurred: “Personally, I desire the independence of private practice and do not fear the inevitable challenges I will face by running a business—but I am in the small minority,” he said.  “I have seen first-hand the personal satisfaction, financial success, and independence of private-practice surgeons, and I desire that for myself.  I hope that more of my colleagues feel the same way.  Otherwise, I feel we are at risk of losing control over our specialty to large hospital systems and payors.”

For Benjamin Service, MD, a resident at Orlando Health, the choice is “not simply academic versus private practice versus hospital employed…due to the variation in orthopedic practices.” Dr. Service agrees with the survey’s findings about subpar private-practice preparedness. “US medical schools are severely lacking in educating their students on debt management, finance, asset protection, and practice management,” he said.  “It is obvious that many students would not initially consider private practice due to this gap in our education.”

What do you think? Please let us know by clicking the “Leave a comment” button.

Revised JBJS LOE Table Improves Clinical Usefulness and Transparency

Since 2003, JBJS has assigned level-of-evidence (LOE) ratings to all clinical articles, based on a system developed by the UK’s Centre for Evidence-Based Medicine (CEBM). The CEBM updated its rating system in 2011, and The Journal has revised its LOE guidance in ways that largely but not entirely reflect the CEBM update.

In an editorial in the January 7, 2015 JBJS, Editor-in-Chief Dr. Marc Swiontkowski and Associate Editor for Evidence-Based Orthopaedics Dr. Robert Marx note that the revised JBJS LOE table still divides studies by type and that “much of the ranking criteria remain the same.” However, the rows and columns have been transposed and a column focused on specific clinical questions has been added. The clinical-question column—which poses queries such as “Does this treatment help?”—can guide busy clinicians quickly and efficiently to the best available evidence about their immediate situation.

In addition, guidance in the new table’s footnotes permits flexibility to grade studies upward if there is a dramatic effect size or downward on the basis of small effect size or study-quality issues such as imprecision. Overall, the revised table clarifies and makes more transparent The Journal’s LOE-assignment process.

Notably, The Journal has decided to depart from the CEBM update in two important ways. We will not follow the CEBM’s policy of reserving Level-I designation for systematic reviews, believing that certain high-quality original research also merits Level-I status. In addition, because economic and population-health decisions play an increasingly important role in orthopaedic surgery today, we have retained economic studies in our table, while the CEBM eliminated such research from its update.

Finally, the editorial reminds readers that “a higher LOE does not necessarily reflect the clinical importance of a given study.” Ultimately, each reader is responsible for deciding what constitutes the best external evidence for his or her specific clinical question.

Please let us know what you think about the revised LOE table by clicking the “Leave a comment” button.

“Fat Hormone” Associated with Cartilage Thinning

In a recent Annals of Rheumatic Diseases study, Australian researchers reported that levels of circulating leptin—a hormone that influences body weight and regulates some inflammatory processes—are negatively associated with changes in knee-cartilage thickness.

This prospective cohort study of 163 randomly selected patients (mean age of 63) used MRI to assess knee-cartilage thickness and radioimmunoassay to measure serum leptin levels at baseline and again after an average of 2.7 years. Cross-sectionally, leptin levels were negatively associated with cartilage thickness at femoral, medial tibial, lateral tibial, and patellar sites, after researchers adjusted for age, sex, BMI, and disease status. Longitudinally, baseline levels and changes in leptin over time were associated with greater differences in tibial-cartilage thickness.

The authors speculate that leptin may have a catabolic effect on cartilage that contributes to the development of osteoarthritis (OA), and that decreases in leptin levels associated with weight loss may help explain the clinical improvement in patients with knee OA who lose weight.

JBJS Supplement Cites New Findings from International Device Registries

Surgeons performed more than 1.1 million joint replacements in the US in 2011. That same year, the International Consortium of Orthopaedic Registries (ICOR) was launched to help close gaps in evidence and data collection related to orthopaedic implants. The ICOR network now consists of more than 70 stakeholders and more than 30 orthopaedic registries representing 14 nations.

The December 17, 2014 edition of The Journal contains an online supplement with 14 articles highlighting the achievements of international registries and the findings from 12 ICOR-initiated registry studies. The first article in the supplement (National and International Postmarket Research and Surveillance Implementation) summarizes the findings from the 12 registry studies. The second article (A Distributed Health Data Network Analysis of Survival Outcomes) provides an overview of the data extraction processes and analytic strategies used in the studies.

Key findings from the 12 studies contained in the supplement:

There were no differences in revision risk when metal-on-HXLPE (highly cross-linked polyethylene) implants with larger and smaller femoral head sizes were compared.

Non-cross-linked polyethylene was not associated with significantly worse revision outcomes when compared with metal-on-HXLPE.

Large-head-size metal-on-metal implants were associated with increased risk of revision after two years, compared with metal-on-HXLPE implants.

Use of ceramic-on-ceramic implants with a smaller head size was associated with a higher revision risk compared with metal-on-HXLPE implants and ceramic-on-ceramic implants with head sizes >28 mm.

When compared with hybrid fixation, cementless fixation was associated with an approximately 58% higher risk of revision surgery in patients aged 75 years or older.

Mobile-bearing, non-posterior-stabilized knee designs presented a 40% higher risk of failure than that found with fixed-bearing, non-posterior-stabilized designs.

Compared with fixed-bearing posterior-stabilized knee prostheses, patients who received mobile bearings had an 85% higher chance of revision within the first postoperative year.

Fixed non-posterior-stabilized (cruciate-retainin0 TKA performed better (with or without patellar resurfacing) than did fixed posterior-stabilized (cruciate-substituting) TKA.

Reported revision rates of TKA and THA among pediatric and young-adult patients is currently similar to that for older patients, but the dearth of data makes it incumbent on registries to continue collecting and analyzing data relevant to younger populations.

This systematic review and meta-analysis concluded that surgeons performing a primary THA should use an implant that outperforms benchmarks established by the UK’s National Institute for Health and Care Excellence (NICE).

Among 19 registry reports and 1052 articles examined, only one report and two studies mentioned patient-reported outcome measures (PROMs) and minimum clinically important differences in connection with revision rates after TKA or THA.

Successful collection of PROM data is possible with careful attention to selection of outcome measure(s) and minimizing the data-collection burden on physicians and patients.

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