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B. J. Levens et al.
ambulation. The research on this, however, is conicting. Several observational studies show symptomatic
relief and decrease in lateral thrust of the knee with lat-
2
eral wedged insoles. However, in several RCTs, there was
no improvement in pain scores or functional outcomes
at 6months or 2years follow-up (Maillefert etal. 2001;
Pham et al. 2004). Other therapeutic options such as
thermal modalities, transcutaneous electrical nerve
stimulation (TENS), and acupuncture are all weakly
recommended by the OARSI and lack strong consensus
among the existing guidelines. Unlike the OARSI, the
AAOS recommends strongly against acupuncture therapy (Scuderi and Insall 1992; Zhang etal. 2008).
The OARSI recommends a multimodal approach of
both pharmacological and non-pharmacological
options in treating OA.Pharmacologically, the OARSI
recommends the use of acetaminophen or paracetamol
for the treatment of mild to moderate pain in OA.The
previously recommended dose of up to 4g/day has more
recently come into question. The risk of gastrointestinal
(GI) and renal toxicity with long-term use of acetaminophen 4 g/day has been equivocal (Garcia Roderiguez
and Hernandez-Diaz 2001). For this reason, short-term
use is preferred.
As mentioned previously, damaged cartilage produces
an inammatory response in the knee joint via the
release of cytokines. These cytokines (interleukin-1B,
interleukin- 6, and tumor necrosis factor alpha) bind to
cellular receptors activating intracellular signaling pathways such as mitogen-activated protein kinase (MAPK),
nuclear factor kappa-B (NF-kB), and Janus kinasesignal transducer and activator of transcription (JAK
STAT). The activation of these pathways triggers the
production of arachidonic acid via phospholipase A2.
Arachidonic acid is further broken down by cyclooxygenase (COX) enzymes into signaling molecules
prostaglandin, leukotriene, and thromboxane, which are
responsible for the transmission of pain. Corticosteroids
bind to glucocorticoid receptors in the cell- inhibiting
activation of intracellular signaling cascade. By repressing NF-kB, MAPK, and JAK STAT, further propagation of inammatory response is prevented.
Corticosteroids also inhibit phospholipase A2 which
results in decreased production of signaling molecules
prostaglandin, leukotriene, and thromboxane. Therefore,
through repression of inammatory cascade, corticosteroids, in theory, reduce pain (Lawrence
2009; Chen etal.
2018). OARSI recommends the use of corticosteroid
injections with moderate strength of recommendation.
> Analogously, non-steroidal anti-inammatory drugs
(NSAIDs) are also strongly recommended by both
the OARSI and AAOS, but only for short-term use
due to the risk of GI discomfort. Opioids are strongly
recommended only for the management of severe
pain in exceptional circumstances (Scuderi and Insall
1992; Zhang etal. 2008).
Due to inconclusive research, the AAOS cannot recommend for or against the use of corticosteroid injections.
Based on a 2015 Cochrane review, corticosteroid injections were shown to provide a moderate short- term
improvement in pain and only small improvement in
function. These results, however, were inconclusive due
to small effect size and large degree of heterogeneity
among studies (Jüni etal. 2015).
Oral supplementation is another modality that can be used
in the treatment of osteoarthritis, albeit with variable
results and limited recommendations. The most common
supplements are glucosamine and chondroitin, which are
components of cartilage. Proponents of these compounds
as supplements purport that they stimulate synovial uid
production and improve cartilage healing (Lim etal. 2019).
When reviewed in 2005 by Cochrane, pooled analysis of
multiple RCTs found improvement in pain and function,
however, there was considerable heterogeneity among the
studies resulting in questionable outcomes. For this reason,
the OARSI only weakly recommends the use of glucosamine and/or chondroitin for symptomatic treatment of
knee OA.The AAOS strongly recommends against glucosamine based on lack of effectiveness (Scuderi and Insall
1992; Zhang etal. 2008).
Corticosteroid intra-articular injections are a commonly used noninvasive treatment modality in most
orthopedic surgery practices. First tested in a clinical
trial by Miller in 1958, corticosteroids have been used
for knee OA for over 50 years (Miller et al. 1958).
Corticosteroids have a strong anti-inammatory effect.
Viscosupplementation is another type of intraarticular injection which attempts to restore natural elements to a depleted arthritic knee. The most common
viscosupplement is hyaluronic acid (HA), a glycosaminoglycan. Hyaluronic acid is the main component of
synovial uid and acts as a lubricant and shock absorber
in the joint providing a chondroprotective effect.
Despite the theoretical utility, research on viscosupplementation has been largely inconclusive. In a recent
meta-analysis by Jevsevar etal. of only double-blinded
RCTs with over 60 patients, there was no clinically signicant difference between HA and placebo. However,
when all literature in the analysis was included, the HA
treatment group was slightly higher than placebo
(Jevsevar etal. 2015). The OARSI found that although
HA has a delayed onset when compared with corticosteroids, it may have a prolonged duration. The strength
of this recommendation, however, is weak. Unlike the
OARSI, the AAOS strongly recommends against the
use of viscosupplementation for the conservative treatment of OA (Scuderi and Insall 1992; Zhang et al.
2008).
Osteoarthritis
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2
2.5.2 Surgical Intervention: Cemented
Total Knee Arthroplasty
When conservative treatment has failed and the patient
continues to have pain, stiffness, limited mobility, and/or
decreased quality of life, surgical management should
be considered. Several surgical options are available for
the management of OA with varying degrees of success.
For the purpose of this chapter, we will only be discussing cemented total knee arthroplasty (TKA) as a treatment for OA of the knee.
Total knee replacement is the most commonly performed operation amongst orthopedic surgeons. More
than 600,000 knee replacements are performed each
year in the United States. Primary TKA is projected to
increase by 637% by 2030in the United States (OKU
Hip and Knee 5 2017). The primary indication for TKA
is OA, which accounts for more than 94% of total procedures (Van Manen etal. 2012).
> In terms of TKA technique, cemented arthroplasty
remains the gold standard.
Scuderi and Insall describe the technique of xation of
the cement, methylmethacrylate, to the bone surface.
Fixation is achieved by the irregular conguration of
the bony surface and cement penetration into the microstructure of the cancellous bone. Prior to cementation,
pulsatile lavage assists in the removal of debris from the
bony indices allowing for adequate penetration of
cement (Scuderi and Insall 1992).
More recently, cementless TKA has emerged as
another surgical option, but further research is required
to comment on long-term durability. Cemented TKA
provides the surgeon with optimal outcomes without
relying on anatomic cuts and supplemental xation,
which is required to achieve adequate bony ingrowth in
cementless xation (Callaghan and Liu 2010). The immediate xation from cement allows for immediate, unrestricted weight-bearing and the ability to start
rehabilitation more rapidly. Although cementless TKA
was initially developed to benet younger patients, when
compared to cemented TKA in patients 60years and less,
both groups were found to have similar functional outcomes and survival rates (Franceschetti etal. 2017; Behery
et al. 2017). Cemented TKA has consistently demonstrated long-term success in multiple different survivorship studies. Scuderi and Insall found their 15-year success
rate to be around 91% in 1992. More recent studies have
shown the survivorship to be 97% at 10 and 12 years
(Falatyn et al. 1995; Ranawat et al. 1993). These longterm studies further emphasize the success of cemented
TKA as an ideal surgical treatment of OA.
2.6 Conclusion
Osteoarthritis affects millions of patients with a multifactorial genesis. Nonoperative treatment includes weight
loss, physical therapy, NSAIDs, and intra- articular injections. When nonoperative treatment is no longer effective,
surgical management with cemented TKA is a viable treatment option with proven long-term results.
Take-Home Messages
5 Osteoarthritis is a common source of knee pain and
can cause a great degree of disability.
5 The pathophysiology of osteoarthritis involves
cyclical cartilage damage predominantly due to catabolic enzymes secreted by chondrocytes and synovial macrophages.
5 The radiographic signs of osteoarthritis include
joint space narrowing, subchondral bone sclerosis,
osteophyte formation, and cystic changes. Although
present in many elderly patients, these ndings may
be asymptomatic.
5 The clinical signs of osteoarthritis are knee pain
with weight-bearing activities, morning stiffness
lasting less than 30 minutes, decreased range of
motion, and crepitus.
5 Conservative treatment is recommended for at least
6months prior to surgical intervention for osteoarthritis. The best conservative therapy involves a
combination of pharmacologic and nonpharmacologic modalities.
5 Weight loss, low impact exercise, physical therapy,
and walking aids are all strongly recommended by
either the AAOS and/or OARSI. NSAIDs, acetaminophen, and tramadol are also strongly recommended pharmacologically.
5 Although frequently used in practice, the research
behind intra-articular injections such as corticosteroids and HA is equivocal and therefore based on
only weak to moderate recommendation.
5 When conservative treatment measures have been
exhausted, total knee arthroplasty is an ideal surgical treatment for symptomatic relief.
5 Cemented TKA remains the gold standard for treat-
ment with excellent long-term survivorship.
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Cementless vs cemented Tibial xation in primary total knee
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Brown GA (2013) AAOS clinical practice guideline: treatment of
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Osteoarthritis andOther
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Indications forTotal Knee
Arthroplasty: AnEast African
Perspective
SeidMohammedYasin
Contents
3.1 Osteoarthritis – 24
3.1.1 Introduction – 24
3.1.2 Risk Factors – 24
3.1.3 Pathology – 25
3.1.4 Clinical Features – 25
3.1.5 Laboratory Findings – 25
3.1.6 Radiologic Features – 25
3.1.7 Management – 25
3.1.8
Indications forTotal Knee Arthroplasty – 26
23
3
3.2 Total Knee Arthroplasty inEast (and Sub-Saharan)
Africa – 30
References – 31
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2022
E. Hansen, K.-D. Kühn (eds.), Essentials of Cemented Knee Arthroplasty,
https://doi.org/10.1007/978-3-662-63113-3_3
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S. M. Yasin
3.1 Osteoarthritis
5 Repetitive stress on a joint (e.g., frequent kneeling
3.1.1 Introduction
> Osteoarthritis (OA) is a disease characterized by
3
degeneration of cartilage and its underlying bone
within a joint. It has traditionally been subdivided
into either primary (idiopathic) or secondary forms
considering its etiology.
and prolonged squatting)
5 Decreased bone density
5 Knee malalignment
5 Muscle weakness
5 Meniscal injuries
5 Other arthritic conditions
5 Joint laxity
Primary osteoarthritis is the most common type of
arthritis and one of the commonest reasons for disability worldwide (Kim etal. 2011). It has been estimated
that ~7.5% of people over 55 years of age have some
knee pain and disability and that ~2% have severe problems. Radiographic evidence of OA occurs in the majority of people of 65 years of age and in about 80% of
those aged over 75 years (Arden and Nevitt 2006).
About 13% of women and 10% of men aged 60years
and older have symptomatic knee OA (Zhang and Jordan 2010).
> OA of the knee is more prevalent and more severe in
women, especially after the age of 55years, as compared to males.
The prevalence of OA in Africa has not been investigated much. One such study showed that in rural Nigeria, for instance, 1 out of every 5 adults aged ≥40 have
symptomatic knee OA (Akinpelu etal. 2011), indicating
that the condition is quite rampant in the region.
OA of the knee is particularly important not only for
its high prevalence rate compared with other types of
OA but also for its presentation at an earlier age and its
ongoing increase in incidence in line with the prevalence
of aging and obesity.
Total knee arthroplasty (TKA), when indicated, is a
very effective way of managing advanced OA as it
improves quality of life through improving function and
alleviation of pain (Katchy etal. 2018).
3.1.2 Risk Factors
OA is multifactorial and develops through a complex
interplay of constitutional and mechanical factors.
Genetic predisposition has been blamed to contribute to
the development of primary knee OA.In both genders,
knee OA within parents, brothers, or sisters was a signicant predictor for symptomatic knee OA in the investigated person (Klussmann etal. 2010).
Aging is known to be an established risk factor for
OA.The strong association between age and osteoarthritis may best be explained by age-related changes in
the matrix composition and a decrease in chondrocyte
function as well as increased responsiveness to stimuli.
These changes can interfere with continued internal
remodeling, maintenance of the tissue, and loss of cartilage (Hinton etal. 2002).
Obesity, on the other hand, is generally taken as a
major risk factor for the occurrence of symptomatic
knee OA.This correlation has been supported by numerous publications.
5 It has been shown that every 5kg of weight gain
results in a 36% increase in the risk of knee OA.
5 On the other hand, another study has reported that
5.1 kg weight reduction over a 10-year period
decreased the likelihood of women developing symp-
tomatic knee OA by 50%, revealing the presence of a
strong correlation between obesity and OA (Bliddal
etal. 2014).
> The pathogenetic role of obesity has been identied
to be beyond just a mechanical load on prone joints,
in that excess adipose tissue produces humoral fac-
tors, altering articular cartilage metabolism. The
leptin system has also been postulated to be the link
between OA and obesity. These premises may explain
the observed prevalence of OA in non-weight-bearing
joints such as hand joints of obese subjects (Heidari
2011).
Risk Factors for OA of the Knee with Dierent
Degrees of Contributions
5 Genetic predisposition
5 Old age
5 Female sex
5 Overweight and obesity
5 Knee injury
Niu etal. (2009) examined the effect of obesity on knee
OA and came up with the following conclusion: Obesity
increases the incidence of OA but its contribution to the
progression of an already established knee OA may not
be as signicant. However, this conclusion has so far
been an area of debate in the literature.
Occupations that involve knee-straining work activities such as excessive kneeling and squatting or lifting and
Osteoarthritis andOther Indications forTotal Knee Arthroplasty: AnEast African Perspective
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3
carrying loads were found to be associated with
symptomatic knee osteoarthritis (Klussmann et al.
2010).
> Other important risk factors include asymmetric
mechanical loading, infectious and noninfectious
arthritic conditions as well as presence of meniscal
injuries.
Regarding sports activities, there are conicting conclusions among different literatures, some of them regarding sports as risk factors, some others considering them
protective against OA, while the rest regarding them as
having no effect. In general, evidence show that heavy
and repetitive sports could pose some risk of OA
whereas moderate exercises are chondroprotective.
The lifetime risk of developing symptomatic knee
OA (i.e., developing the condition by age 85 years) is
estimated to be 44.7%, irrespective of sex, race, and level
of education. The risk increased in the presence of history of trauma and raised BMI/ obesity (Murphy etal.
2008).
3.1.3 Pathology
> The central pathologic features of OA are the loss of
hyaline articular cartilage and changes in the sub-
chondral bone.
The pathogenesis is directly linked to an increase in
water content of the articular cartilage with a decrease
in proteoglycan content. Collagenase levels increase,
thereby disrupting maintained collagen. Proteolytic
enzymes and inammatory cytokines, on the other
hand, will increase and end up in an arthritic, painful
joint (Martin etal. 2011).
Pathophysiology of the arthritic knee is also known
to be related to changes in the autonomic nervous system, blood and lymph ow, fascial tension, limitations
in range of motion, and relationships of the length and
tension of the muscles around the knee (Van Manen
etal. 2012).
descending stairs, palpable effusion, xed-exion deformity, restricted-exion range of motion, and crepitus
predicted knee OA at sensitivity of 94% and specicity
of 93%.
3.1.5 Laboratory Findings
> Complete blood count (CBC), erythrocyte sedimenta-
tion rate (ESR), and C-reactive protein (CRP) levels
in OA are usually normal.
Synovial uid is of noninammatory type. In suspected
cases of knee OA, synovial uid level of anti-CCP can
be used for the differentiation of OA from RA (Heidari
etal. 2010).
3.1.6 Radiologic Features
Radiologic appearance of an osteoarthritic knee exhibits attestations for progressive destruction of the articular cartilage like joint space narrowing and reparative
processes such as osteophyte formation and subchondral sclerosis.
Subchondral cysts, though taken as one of the cardinal radiological features of OA, are absent in most
patients with established OA.Audrey etal. (2014) have
documented that subchondral cysts were only present in
30.6% of their study population while narrowed joint
space, osteophytes, and subchondral sclerosis were
found to be present in 99.5%, 98.1%, and 88.3% of all
radiographs in their series, respectively.
Radiologic features are also used for the classication of OA in an attempt to give an idea of severity of
the arthritic process and joint degeneration. Kellgren
and Lawrence in 1957 came up with a radiologic classication of OA, which has later been endorsed by the
WHO and continued to be one of the most accepted
radiologic classications of OA to date (. Table 3.1;
. Figs.3.1, 3.2, and 3.3).
3.1.7 Management
3.1.4 Clinical Features
Common symptoms and signs of knee OA include persistent pain, reduced function, crepitus, and swelling.
The swelling could result from effusion or could even be
secondary to bony enlargement in late presentations.
According to Peat et al. (2007), together with
expected demographic features such as age, sex, and
body mass index, absence of whole leg pain, difculty in
In obese patients with primary OA of the knee, weight
loss is the most important strategy to relieve symptoms,
including pain, and to check disease progression through
breaking the vicious cycle of events: reduced activity
(because of pain and heavyweight), further weight gain,
and decreased muscle strength, leading to further articular damage.
A study on overweight and obese older adults with
knee OA estimated that every pound of lost weight
26
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. Table 3.1 Radiologic grading of OA (adapted from
Kellgren and Lawrence 1957)
Grade Radiologic ndings
0 No radiological ndings of osteoarthritis
3
I Doubtful joint space narrowing and possible
osteophytic lipping
II Denite osteophytes and possible joint space
narrowing
III Moderate multiple osteophytes, denite narrowing of
joint space, small pseudocystic areas with sclerotic
walls, and possible deformity of bone contour
IV Large osteophytes, marked joint space narrowing,
severe sclerosis, and denite deformity of bone
contour
Intra-articular corticosteroid injections, on the other
hand, reduce knee pain for at least 1 week. They are
taken as short-term management options for chronic
osteoarthritic conditions (Hepper etal. 2009).
> Hyaluronic acid (HA) injections have a longer term
effect in pain control compared with corticosteroids
(Bellamy etal. 2006).
The use of glucosamine and chondroitin sulfate for
symptomatic knee OA has not been supported by
most publications despite the ongoing controversy
regarding their patient-reported benets. All metaanalyses showed that the overall effect of these agents
compared to placebo was not statistically signicant.
3.1.8 Indications forTotal Knee
Arthroplasty
resulted in a fourfold reduction in the load exerted on
the knee per step during daily activities, which appears
to be clinically meaningful (Bliddal etal. 2014).
The AAOS recommends self-management, exercise,
and integrated healthcare programs for patients with
knee OA.
> Professionally guided weight loss programs should be
incorporated including diet modication and specic
exercise programs which do not cause further stress
on the knee and its overlying cartilage.
The Framingham knee osteoarthritis study showed a
greater than 50% reduction in primary knee OA with a
decrease in body mass index of 2 or more (Felson etal.
1987).
Aquatic exercise, gait aids, cognitive behavioral therapy with an exercise component, and self-management
programs were the recommended non-pharmacologic
options. Moreover, for the rst time, mind–body exercises (Tai Chi and Yoga) have recently been recommended
as core treatment options for individuals with knee OA.
Topical non-steroidal anti-inammatory drugs
(NSAIDs) were strongly recommended for use in knee
OA patients with no comorbidities. High-quality evidence involving a large number of patients showed modest benets over the course of 12 weeks (Bannuru etal.
2019).
As an initial drug treatment plan, a trial of acetaminophen with other non-pharmaceutical treatments
has been recommended before adding NSAIDs, considering the overall cost of NSAIDs and their side effects
(Wegman etal. 2004). However, AAOS does not recommend acetaminophen anymore claiming to have found
no benets for it compared to placebo.
> Common diseases that cause knee damage requiring
arthroplasty are osteoarthritis, chronic rheumatoid
arthritis, and osteonecrosis, while contraindications
for knee arthroplasty include purulent arthritis and
tuberculosis (Tateishi 2001).
Osteoarthritis, as an indication for surgery, is responsible for majority of TKAs done worldwide. In the
USA, one population-based study identied OA to
have accounted for 94%–97% of TKA operations
(Singh etal. 2010). A search for a similar study in East
African countries resulted in almost no data to be
mentioned. The only paper identied was from Kenya,
by Kigera and Kimpiatu (2015), which showed that
osteoarthritis was the indication for surgery in 96% of
TKAs in their series. Other African countries like Nige-
ria and Malawi have studies that reported that OA
accounted for 100% and 99% of the indications for
TKA, respectively (Davies et al. 2019; Katchy etal.
2018).
Knee deformities can be taken both as predisposing
conditions for OA and consequences of OA marking
severity of the condition and hence necessitating
TKA. Analysis of 68 consecutive TKAs performed in
Nigeria showed that 26.47% of replaced knees had valgus before surgery, with a mean angle of 22.07°±5.73°,
whereas 17.65% had varus knees with a mean angle of
14.69° ± 2.84°, and 11.77% knees were found to have
exion deformities with a mean angle of 10.2°±1.32°.
The rest of 44.11% knees had no deformities (Katchy
etal. 2018).
In the presence of radiologic evidence for end-stage
degenerative knee joint disease, Osteoarthritis Research
Society International (OARSI) recommends TKA for
OA when there is a continued pain despite an attempt of
Osteoarthritis andOther Indications forTotal Knee Arthroplasty: AnEast African Perspective
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a
27
3
b
. Fig. 3.1 a, b Mild OA in a 62-year-old Ethiopian woman (Kellgren stage I)
a 6-month course of nonoperative treatment (Zhang
etal. 2008). Besides, the decision to pursue TKA should
put the age and body habitus of the patient into consideration, since the outcome has been variable when TKA
was performed for younger and obese individuals in different literatures. This guideline is also applicable for
other degenerative joint diseases.
According to Hardorn and Holmes (1997), follow-
up of indications for TKA surgeries shows that patients
below the age of 60 are less likely to be considered for a
TKA and most surgeons want their obese patients to
lose weight before surgery.
An additional factor identied to be among determi-
nants of considering candidates for surgery, as several
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S. M. Yasin
3
. Fig. 3.2 Moderately advanced OA in a 67-year-old Ethiopian man (Kellgren stage II)
studies (summarized by O’Connor and Hooten 2011)
have documented, is the presence of an unconscious
bias on provider recommendations of TKA for male
patients with moderate OA as compared to females with
similar conditions.
Despite the numerous researches on the subject and
several trials to come up with specic indications for
TKA in patients with advanced knee OA, yet there is no
consensus on when exactly to do TKA in the disease
progress.
However, in the literature review performed by
Dieppe et al. (1999), it was concluded that despite the
lack of evidence-based indications for TKA in knee OA,
daily pain and an attendant X-ray evidence of loss of
joint space are taken as key indications for TKA in a
consensus-style approach. A high patient motivation was
also cited as a common factor contributing to the decision to go ahead with surgery, whereas co- morbidities
and technical difculties were common factors against it.
X-ray features can assist decision-making when both
operative and nonoperative options are on the table for
a particular patient. But it is wise to note that radio-
graphic appearance of the diseased knee may not always
correlate with the degree of pain and disability the
patient complains of. It is not uncommon to see patients
with comparably affected bilateral knee X-rays, while
symptoms are asymmetrical.
McAlindon etal. (1993) have been able to show that
radiographic score does not make signicant independent contribution to prediction of disability. Quadriceps
weakness has rather been found to be the most important factor, signaling the need for a thorough patient
evaluation and exhaustion of nonoperative options
before coming to a conclusion that TKA is the solution.
The Knee Osteoarthritis Grading System (KOGS) is
a radiological grading system of degenerative arthritis
of the knee. It is relatively easier to use and has the ability to evaluate all three compartments of the knee to aid
the surgeon’s decision on the type and timing of knee
arthroplasty. Oosthuizen et al. (2018) have regarded
KOGS as the rst and valid tri-compartmental grading
system that can help in decision-making regarding the
type and timing of knee arthroplasties based on the preoperative OA status.
Osteoarthritis andOther Indications forTotal Knee Arthroplasty: AnEast African Perspective
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3
. Fig. 3.3 Advanced OA in a 72-year-old Ethiopian woman (Kellgren stage III)
The Delphi consensus technique used by Hardorn
and Holmes (1997), trying to derive surgical priorities in
knee and hip replacement surgeries using clinical parameters can also be taken as an assistive guide while making decisions (.
Table3.2).
Even though this technique, also referred to as “New
Zealand priority criteria,” has been in use for several
years in different institutions, its ability to accurately
determine those patients who are most in need of joint
replacement surgery has been questioned by Coleman
etal. (2005) after comparing it with other scoring systems for disability from musculoskeletal diseases such as
the Western Ontario and McMasters Universities
Arthritis Index (WOMAC) and the Musculoskeletal
Function Assessment (MFA). Its use, hence, should be
assisted with other radiologic parameters like KOGS to
minimize subjectivity in decision-making.
. Table 3.2 Summary of New Zealand priority criteria for
major joint replacement
Pain (40%) Pain severity scored 0–20
Functional
activity (20%)
Movement and
deformity (20%)
Other factors
(20%)
a
Patients are scored from 0 to 100 on a scale that describes
different levels of severity in four domains: pain, function,
joint damage and other factors
a
Pain occurrence scored 0–20
Walking difculty 0–10
Other functional impairment 0–10
Pain on active/passive motion 0–10
Other abnormalities including loss of
movement and radiographic change 0–10
Other joints affected 0–10
Ability to work, act as a caregiver, and
live independently 0–10
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