Special article
Total knee prosthesis. Development of an objective selection tool for patients
Elaboración de un índice objetivo de selección de pacientes subsidiarios de prótesis articular de rodilla
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Development of an objective selection tool for patients" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "409" "paginaFinal" => "412" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Tomás Alcántara-Martos, Juan Carlos Rodríguez-Fernández, Antonio Evaristo Resola-García, Alberto Damián Delgado-Martínez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Tomás" "apellidos" => "Alcántara-Martos" "email" => array:1 [ 0 => "tomas.alcantara.sspa@juntadeandalucia.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Juan Carlos" "apellidos" => "Rodríguez-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Antonio Evaristo" "apellidos" => "Resola-García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Alberto Damián" "apellidos" => "Delgado-Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Cirugía Ortopédica, Rehabilitación y Medicina Preventiva, Área Sanitaria Jaén Norte, Linares, Jaén, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirugía Ortopédica, Hospital Reina Sofía, Córdoba, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Elaboración de un índice objetivo de selección de pacientes subsidiarios de prótesis articular de rodilla" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The national health systems of developed countries are engaged in a huge economic challenge. Initially, these dealt with problems that threatened life, such as infections and tumours. Once these were somehow under control, and because of the success in treating them, the life expectancy of the population has thankfully been extended. At the same time, the population expects, not only to live longer, but also to improve the quality of life.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The increase in years lived has resulted in the emergence of degenerative diseases at epidemic proportions. Thus, in the scope of orthopaedics, osteoarthritis creates havoc on the quality of life because it limits the daily activities of patients. Unlike with other degenerative diseases, such as neurological disorders, an effective solution has been found in reducing the discomfort that occurs with this disease. Prosthetic replacement of the affected joint often improves the stiffness and pain associated with it.</p><p id="par0015" class="elsevierStylePara elsevierViewall">But the increasingly high demand for them, either because more and more joints are susceptible to replacement or because, as stated above, expecting to lead a “comfortable life” is now the norm, causing a growth rate that, although it is not geometric, it is definitely arithmetic. The total number of prostheses implanted in Spain and in the world is unknown because there are no national records in all countries. The earliest hip and knee records were established in Sweden in 1975,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> and this has more than 200,000 hip replacements. In Spain, the record has only been implemented in Catalonia since 2005, and has since then collected nearly 25,000 hip and knee arthroplasties.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> In Spain, according to data from companies that produce these arthroplasties, such as Waldemar Link,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">2</span></a> it is estimated that 45,000 total knee replacement (TKR) are implanted per year, compared to 100,000 in Germany. This is a very significant problem from a healthcare management perspective, because the resources used in one area are not used in another. At a time of budgetary constraints, expenditure items that seem to increase very fast must be kept under control for the entire system to remain stable and maintained over time.</p><p id="par0020" class="elsevierStylePara elsevierViewall">On the other hand, there are no indisputable criteria regarding the surgical indication for TKR. Except in cases where a large joint destruction is observed, well documented by radiologic evidence and accompanied by permanent strong pain, the vast majority of cases involve intermittent pain with varying clinical–radiological dissociation. Therefore, the time of implantation is not fully established. It is accepted that the best time to implant is the time when all medical resources have been exhausted orally, intra-articularly and through rehabilitation. In line with this, it has been observed that the indication and implantation variability rate of the same is very high. In 2005, the <span class="elsevierStyleItalic">medical practice variability Atlas</span> analyzed knee replacements in Spain, noting that it was a process of high variability, with a standardized rate by age and sex which ranged between 2.5 and 13.49 interventions per 10,000 inhabitants-year.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Therefore, building an index that would reduce, or at least try to reduce this variability was considered useful. This would also help to establish the prosthetic indication with objectivity and fairness so that the whole population could have access to it on equal terms, and likewise, governed by general principles of beneficence and non-maleficence.</p><p id="par0030" class="elsevierStylePara elsevierViewall">An index with these characteristics should aim to meet several objectives: first, to be as simple as possible so that it can be used regularly in routine clinical practice. Without this scientific “principle of simplicity”, it is not operative and runs the risk of being relegated sooner rather than later. Second, as previously mentioned, it must be objective, so that when applied, all people have equal opportunity to access these resources, without any more requirements other than his/her medical needs, avoiding any spurious event. And thirdly, it must measure exactly that which wants to be measured. Intra- and interobserver variability should be as small as possible. This is achieved, in part, whenever the second objective is achieved. As a summary, the clarity, conciseness and accuracy criteria governing any scientific work must be met.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The aim of this work is to build a brief referral index (definitive referral index [DRI]) for patients susceptible of TKR from primary care services to Orthopaedic Surgery, so as to select those patients who need it most following fairness and objectivity criteria.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Materials and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">A survey among the members of the Spanish scientific society of Orthopaedic Surgery and Traumatology (SECOT) was performed. They were asked about the opinion they had in regard to objective criteria involved in the indication of TKR. Also, they were asked to rate how much they had to weigh each parameter involved such as age, radiographic grade and body mass index (BMI) in the final indication. They were asked to give their opinion on whether they thought other treatments had to be exhausted before indicating TKR, such as physiotherapy and intraarticular infiltration treatment with hyaluronic acid. And finally, whether they thought any other objective and non-objective criteria could be implemented in the preparation of the definitive index. Therefore, in summary, the items on which the survey was structured were: age, radiology, BMI, previous physiotherapy and previous infiltrations.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The data obtained were treated statistically. Cronbach's alpha coefficient was calculated, and once the index was built, it was applied to 41 patients, repeating measurements with the same investigator and with a different one in order to determine the internal and external validity of the test through the intraclass correlation coefficient (ICC).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">49 responses were obtained. The questions and the means of each response are indicated in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The questionnaire included open questions to indicate objective and non-objective criteria that could contribute to the final preparation of the index. Given its lengthiness and lack of statistical impact, they are not discussed in this text.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Cronbach's alpha coefficient was 0.774 at 95% confidence and ICC, with the same confidence interval to measure the internal validity of the tool, was 99.8%, and 99.5% for external validity.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">The fewest possible criteria had to be used in the design of the index, and these would need to measure what really needed to be measured, i.e., the need for a TKR in a concise and precise manner, having failed other oral, articular and physiotherapy treatments. Besides these criteria, the lack of subjectivity criteria is of paramount significance.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Thus, age meets the latter, because a TKR performed in a young person is associated with future follow-up processes, which ideally should be avoided, as it is not a final prosthetic implantation. Moreover, implantation in the very elderly, with their potentially fewer remaining years of life, can make a scarce resource less profitable, even more in certain age groups.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Kellgren and Lawrence radiological criteria<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">4</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), within the limitations of its variability, inter- and even intraobserver is a parameter that cannot be left out of an index like this. This variability, although low, is remarkable because other parameters are totally objective, without any variability. The reason for introducing it has to do with being a criterion which is always taken into account. TKR implantation is inconceivable without performing an X-ray.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">BMI is a useful indicator of intra- and postoperative complications of TKR, among others. Although conflicting studies including this idea<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">5</span></a> have been recently published, its justification by the authors is based on the great technical perfection achieved with the procedure, which has contributed to overcoming the difficulties inherent in obesity. However, other studies<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">6</span></a> have found worse results in the short term. Additionally, a meta-analysis<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">7</span></a> of the University of Amsterdam shows that: knee surgery carries a higher number of infections in obese patients than in non-obese, the rate of reoperation for infection debridement is higher in obese than in non-obese patients, and rejection and removal of the prosthesis was higher in obese patients, requiring a greater number of reoperations. The risk of patellar implant rupture in the months or years following surgery increases with the degree of obesity, and also, the more significant obesity is, the more difficult and complex is the surgery. To indicate a TKR under the Andalusian Public Health System,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> this parameter along with age are the only ones considered in the general recommendations for the implantation of a TKR regarding the guide for the proper use of knee arthroplasty in patients with osteoarthritis.</p><p id="par0085" class="elsevierStylePara elsevierViewall">It is well established that due to the potential risk of infections and general morbidity associated with the surgical procedure, all conservative treatments prior to performing surgery criterion must have been exhausted. In this sense, the implementation of a well-established rehabilitation programme including exercises over a period of time can help improve the pain and stiffness associated with osteoarthritis, contributing to delaying the prosthetic procedure. In December 2014, the <span class="elsevierStyleItalic">European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis</span> established a protocol to manage gonalgia due to knee osteoarthritis that included both physical therapy as well as hyaluronic acid infiltration.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">9</span></a> New studies are constantly showing that these parameters are improved by using various physical and rehabilitative techniques,<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">10,11</span></a> so their use in patients with knee osteoarthritis should be considered.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Finally, intraarticular treatment should also be tested as conservative procedure before surgery. The hyaluronic acid therapy arose as a result of trying to avoid the first corticosteroid injections due to their potential side effects both local and systemic. This therapy improved the rheological and friction properties of the joint, with virtually no side effects, according to a meta-analysis published in 2004.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">12</span></a> Another review paper calls into question these results,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">13</span></a> although the authors acknowledge that the quality of the work reported was very low. In 2006, the evidence-based Cochrane medical database<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a> and another review which followed,<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> also reported good results in controlling the symptoms of knee osteoarthritis, with very few side effects.</p><p id="par0095" class="elsevierStylePara elsevierViewall">A new intra-articular treatment with platelet-rich plasma has recently emerged, but there are only a few studies evaluating its efficacy. Among these few studies, some report good results,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">16</span></a> even better than the hyaluronic acid when compared with each other.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">17</span></a> But because of its cost and the complexity of its production process, this procedure should not be considered as first-line treatment.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a> Taking into account the above, and the survey results obtained, the construction of the DRI should be as follows (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Considering the maximum possible score for each item, the DRI would have a maximum score of 14. This index has the advantage of including a flexible referral cut-off, which may vary depending on the degree of restriction to be implemented. But an index of 10 or higher can be considered as appropriate and, depending on how it filters throughout time, it could be adjusted more accurately.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Cronbach's alpha coefficient measures the reliability of a measuring instrument through a set of items and is expected to measure the same theoretical dimension and, in addition, that these items are highly correlated. The nearer it gets to 1, the more reliable it is, and above 0.7 is considered acceptable.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> In the case of the DRI, it obtained 0.774, very close to good. The low number of responses obtained may be an element of bias, not only of selection but also for the statistical result. In connection with the ICC, excellent values are found for internal and external validity (0.995 and 0.991 at 95% confidence, respectively). This is because the parameters that constitute the index are objective and, therefore, there is no variation in the results. Only the radiological degree can vary somewhat, justifying tenths.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Because, above all, objectivity was the target so that the intra- and interobserver consistency was present, other criteria such as pain or disability were not incorporated. First, because the questionnaires measuring these are more complex the more theoretically accurate they pretend to be, but never achieve leaving no trace of subjectivity, and that is precisely what index was trying to avoid since its design. Both pain and disability are assumed, otherwise the patient would not seek medical help.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Finally, it should be clearly stressed that this index is a filter for referral queries related to Orthopaedic Surgery in general terms, so as to select the patients that are most in need of this, always limited, resource. Therefore, it cannot be, in any way, an absolute criterion for the indication of arthroplasty. Particular conditions may always appear which may make the index irrelevant because the final indication is always a consequence of the doctor–patient relationship, and from it the supreme condition arises.</p><p id="par0120" class="elsevierStylePara elsevierViewall">On the other hand, and contrary to what the index name suggests, this work is not intended to be “definitive”, its purpose is rather to be a first step to further investigate the issue and improve it from a scientific point of view. The means by which this study has been carried out have been few and hence its possible limitations, but it is expected to be a good starting point.</p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion, the first index of referral (DRI) has been obtained to help primary care services and other services to select patients for referral to Orthopaedic Surgery, patients who most require arthroplasty following criteria of equity and objectivity.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-12" "fechaAceptado" => "2015-01-15" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Alcántara-Martos T, Rodríguez-Fernández JC, Resola-García AE, Delgado-Martínez AD. Elaboración de un índice objetivo de selección de pacientes subsidiarios de prótesis articular de rodilla. Med Clin (Barc). 2015;145:409–412.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BMI: body mass index; TKR: total knee replacement.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Considers age and radiological deterioration objective and decisive parameter to implant TKR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Radiology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">What weight would it have from 0 to 10 on aggregate in the indication? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.62 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">In relation to age, rate from 0 to 10 the most appropriate intervals to perform an arthroplasty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.64 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55–65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.64 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65–75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.67 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.73 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Should there be an age limit?<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40.8% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Is obesity an objective parameter indicating a TKR? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">In relation to weight, rate from 0 to 10 the different sections that are most suitable for TKR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">BMI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25–30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30–35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.82 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.76 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Should physiotherapy be performed before TKR?<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Should infiltration treatment be tried? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1038335.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The highest response rate among those who answered yes was 22.4% (84 years).</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The highest response rate among those who answered yes was 42.9% (6 months).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Questions and responses mean in the survey conducted among members of the Spanish Society of Orthopaedic Surgery and Traumatology.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gonartrosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Radiographic findings \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Absence of osteophytes, narrowing or cysts \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Inconclusive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Osteophytes only \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Minimum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Small osteophytes, moderate narrowing of the joint interline, there may be cysts and sclerosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clear moderately sized osteophytes and narrowing of the joint interline \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Serious \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Large osteophytes and severe narrowing of the joint interline \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1038334.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Kellgren and Lawrence radiographic criteria.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">BMI: body mass index.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Age (years)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>55–65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>65–75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>75–85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>>85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contraindication \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Radiology (Kellgren and Lawrence Index)</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Grade 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Grade 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Grade 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Grade 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">BMI</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>≤25 (normal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>25–30 (overweight) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>30–35 (obesity) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>>35 (morbid obesity) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Physiotherapy</span> (><span class="elsevierStyleItalic">6 months)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Infiltration with hyaluronic acid</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; 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