Defining Failure in Primary Total Joint Arthroplasty: The Minimal Clinically Important Difference for Worsening Score

  • Tyler J. Humphrey
    Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA
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  • Akhil Katakam
    Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA

    Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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  • Christopher M. Melnic
    Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA

    Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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  • Hany S. Bedair
    Address correspondence to: Hany S. Bedair, MD, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114.
    Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA

    Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Published:December 24, 2021DOI:



      We define the value of the Minimal Clinically Important Difference for Worsening (MCID-W) for Patient-Reported Outcomes Measurement Information System Physical Function short form 10-a (PROMIS-PF-10a) score for primary total joint arthroplasty (TJA) of the hip and knee and describe the risk factors for patients scoring worse than the MCID-W.


      This retrospective study was performed using 3414 primary TJA patients. PROMIS-PF-10a scores were collected at the preoperatively and postoperatively, and patients were classified based on reaching Minimal Clinically Importance Difference for Improvement (MCID-I), MCID-W, or “no significant change” after TJA (scores betweex`n MCID-W and MCID-I). MCID-W and MCID-I values were determined by a distribution method. The association between numerous variables and scoring worse than the MCID-W of PROMIS-PF-10a was then evaluated through multiple logistic regression. A threshold for preoperative PROMIS-PF-10a score predicting decline past MCID-W was determined using the Youden index and receiver operating characteristic curve.


      The MCID-W for TJA was −1.89. Notably, increasing length of stay (odds ratio [OR] 1.073, 95% confidence interval [CI] 1.029-1.119, P < .001) and increasing preoperative PROMIS-PF-10a scores (OR 1.117, 95% CI 1.091-1.144, P < .001) were associated with increased likelihood of decline past the MCID-W of the PROMIS-PF-10a for TJA compared with patients who achieved the MCID-I. A community hospital with a dedicated joint replacement center was associated with a decreased risk for decline past the MCID-W (OR 0.601, 95% CI 0.402-0.899; P = .013).


      We described the MCID-W value (−1.89) for the PROMIS-PF-10a questionnaire for knee and hip TJA and associated patient- and hospital-level risk factors for failure after TJA. Healthcare funding initiatives should be directed toward modifiable factors associated with clinically significant worse outcomes after TJA.


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        • Singh J.A.
        • Yu S.
        • Chen L.
        • Cleveland J.D.
        Rates of total joint replacement in the United States: future projections to 2020–2040 using the national inpatient sample.
        J Rheumatol. 2019; 46: 1134-1140
        • Kurtz S.
        • Ong K.
        • Lau E.
        • Mowat F.
        • Halpern M.
        Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.
        J Bone Joint Surg Am. 2007; 89: 780-785
        • Naal F.D.
        • Impellizzeri F.M.
        • Lenze U.
        • Wellauer V.
        • von Eisenhart-Rothe R.
        • Leunig M.
        Clinical improvement and satisfaction after total joint replacement: a prospective 12-month evaluation on the patients’ perspective.
        Qual Life Res. 2015; 24: 2917-2925
      1. NIH consensus statement on total knee replacement December 8-10, 2003.
        J Bone Joint Surg Am. 2004; 86: 1328-1335
        • Katakam A.
        • Collins A.K.
        • Sauder N.
        • Shin D.
        • Bragdon C.R.
        • Chen A.F.
        • et al.
        Obesity increases risk of failure to achieve the 1-year PROMIS PF-10a minimal clinically important difference following total joint arthroplasty.
        J Arthroplasty. 2021; 36: S184-S191
        • Peters R.M.
        • van Beers L.W.A.H.
        • van Steenbergen L.N.
        • Wolkenfelt J.
        • Ettema H.B.
        • Ten Have B.L.E.F.
        • et al.
        Similar superior patient-reported outcome measures for anterior and posterolateral approaches after total hip arthroplasty: postoperative patient-reported outcome measure improvement after 3 months in 12,774 primary total hip arthroplasties using the anterior, anterolateral, straight lateral, or posterolateral approach.
        J Arthroplasty. 2018; 33: 1786-1793
        • Curtis J.R.
        • Yang S.
        • Chen L.
        • Pope J.E.
        • Keystone E.C.
        • Haraoui B.
        • et al.
        Determining the minimally important difference in the clinical disease activity index for improvement and worsening in early rheumatoid arthritis patients.
        Arthritis Care Res (Hoboken). 2015; 67: 1345-1353
        • Fiest K.M.
        • Sajobi T.T.
        • Wiebe S.
        Epilepsy surgery and meaningful improvements in quality of life: results from a randomized controlled trial.
        Epilepsia. 2014; 55: 886-892
        • Yeo F.
        • Ng C.C.
        • Loh K.W.J.
        • Molassiotis A.
        • Cheng H.L.
        • Au J.S.K.
        • et al.
        Minimal clinically important difference of the EORTC QLQ-CIPN20 for worsening peripheral neuropathy in patients receiving neurotoxic chemotherapy.
        Support Care Cancer. 2019; 27: 4753-4762
        • Florissi I.S.
        • Galea V.P.
        • Rojanasopondist P.
        • Sauder N.
        • Iban Y.E.
        • Malchau H.
        Partners arthroplasty registry: development and current findings.
        Orthop Proc. 2019; 101-B: 24
        • Cella D.
        • Riley W.
        • Stone A.
        • Rothrock N.
        • Reeve B.
        • et al.
        The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008.
        J Clin Epidemiol. 2010; 63: 1179-1194
        • Driban J.B.
        • Morgan N.
        • Price L.L.
        • Cook K.F.
        • Wang C.
        Patient-Reported Outcomes Measurement Information System (PROMIS) instruments among individuals with symptomatic knee osteoarthritis: a cross-sectional study of floor/ceiling effects and construct validity.
        BMC Musculoskelet Disord. 2015; 16: 253
        • Gershon R.C.
        • Rothrock N.
        • Hanrahan R.
        • Bass M.
        • Cella D.
        The use of PROMIS and assessment center to deliver patient-reported outcome measures in clinical research.
        J Appl Meas. 2010; 11: 304-314
      2. PROMIS.
        ([accessed 21.07.19])
        • Hung M.
        • Saltzman C.L.
        • Greene T.
        • Voss M.W.
        • Bounsanga J.
        • Gu Y.
        • et al.
        Evaluating instrument responsiveness in joint function: the HOOS JR, the KOOS JR, and the PROMIS PF CAT.
        J Orthop Res. 2018; 36: 1178-1184
        • Bruce B.
        • Fries J.
        • Lingala B.
        • Hussain Y.N.
        • Krishnan E.
        Development and assessment of floor and ceiling items for the PROMIS physical function item bank.
        Arthritis Res Ther. 2013; 15: R144
        • Fries J.F.
        • Witter J.
        • Rose M.
        • Cella D.
        • Khanna D.
        • Morgan-DeWitt E.
        Item response theory, computerized adaptive testing, and PROMIS: assessment of physical function.
        J Rheumatol. 2014; 41: 153-158
        • Canfield M.
        • Savoy L.
        • Cote M.P.
        • Halawi M.J.
        Patient-reported outcome measures in total joint arthroplasty: defining the optimal collection window.
        Arthroplast Today. 2020; 6: 62-67
        • van der Wees P.J.
        • Wammes J.J.
        • Akkermans R.P.
        • Koetsenruijter J.
        • Westert G.P.
        • van Kampen A.
        • et al.
        Patient-reported health outcomes after total hip and knee surgery in a Dutch University Hospital Setting: results of twenty years clinical registry.
        BMC Musculoskelet Disord. 2017; 18: 97
        • Kagan R.
        • Anderson M.B.
        • Christensen J.C.
        • Peters C.L.
        • Gililland J.M.
        • Pelt C.E.
        The recovery curve for the patient-reported outcomes measurement information system patient-reported physical function and pain interference computerized adaptive tests after primary total knee arthroplasty.
        J Arthroplasty. 2018; 33: 2471-2474
        • Cella D.
        • Eton D.T.
        • Lai J.S.
        • Peterman A.H.
        • Merkel D.E.
        Combining anchor and distribution-based methods to derive minimal clinically important differences on the functional assessment of cancer therapy (FACT) anemia and fatigue scales.
        J Pain Symptom Manage. 2002; 24: 547-561
        • Mouelhi Y.
        • Jouve E.
        • Castelli C.
        • Gentile S.
        How is the minimal clinically important difference established in health-related quality of life instruments? Review of anchors and methods.
        Health Qual Life Outcomes. 2020; 18: 136
        • Ruopp M.D.
        • Perkins N.J.
        • Whitcomb B.W.
        • Schisterman E.F.
        Youden index and optimal cut-point estimated from observations affected by a lower limit of Detection.
        Biom J. 2008; 50: 419-430
        • Holtzman J.
        • Saleh K.
        • Kane R.
        Effect of baseline functional status and pain on outcomes of total hip arthroplasty.
        J Bone Joint Surg Am. 2002; 84: 1942-1948
        • Elmallah R.D.
        • Cherian J.J.
        • Robinson K.
        • Harwin S.F.
        • Mont M.A.
        The effect of comorbidities on outcomes following total knee arthroplasty.
        J Knee Surg. 2015; 28: 411-416
        • Molto A.
        • Gossec L.
        • Meghnathi B.
        • Landewé R.B.M.
        • van der Heijde D.
        • Atagunduz P.
        • et al.
        An Assessment in SpondyloArthritis International Society (ASAS)-endorsed definition of clinically important worsening in axial spondyloarthritis based on ASDAS.
        Ann Rheum Dis. 2018; 77: 124-127
        • Campbell H.
        • Rivero-Arias O.
        • Johnston K.
        • Gray A.
        • Fairbank J.
        • Frost H.
        Responsiveness of objective, disease-specific, and generic outcome measures in patients with chronic low back pain: an assessment for improving, stable, and deteriorating patients.
        Spine (Phila Pa 1976). 2006; 31: 815-822
        • Mannion A.F.
        • Porchet F.
        • Kleinstück F.S.
        • Lattig F.
        • Jeszenszky D.
        • Bartanusz V.
        • et al.
        The quality of spine surgery from the patient’s perspective: part 2. Minimal clinically important difference for improvement and deterioration as measured with the core outcome measures index.
        Eur Spine J. 2009; 18 Suppl 3: 374-379
        • Hägg O.
        • Fritzell P.
        • Nordwall A.
        The clinical importance of changes in outcome scores after treatment for chronic low back pain.
        Eur Spine J. 2003; 12: 12-20
        • Johnston B.C.
        • Ebrahim S.
        • Carrasco-Labra A.
        • Furukawa T.A.
        • Patrick D.L.
        • Crawford M.W.
        • et al.
        Minimally important difference estimates and methods: a protocol.
        BMJ Open. 2015; 5: e007953
        • Eckhard L.
        • Munir S.
        • Wood D.
        • Talbot S.
        • Brighton R.
        • Walter W.L.
        • et al.
        Minimal important change and minimum clinically important difference values of the KOOS-12 after total knee arthroplasty.
        Knee. 2021; 29: 541-546
        • Hung M.
        • Bounsanga J.
        • Voss M.W.
        • Saltzman C.L.
        Establishing minimum clinically important difference values for the Patient-Reported Outcomes Measurement Information System Physical Function, hip disability and osteoarthritis outcome score for joint reconstruction, and knee injury and osteoarthritis outcome score for joint reconstruction in orthopaedics.
        World J Orthop. 2018; 9: 41-49
        • Engel L.
        • Beaton D.E.
        • Touma Z.
        Minimal clinically important difference: a review of outcome measure score interpretation.
        Rheum Dis Clin North Am. 2018; 44: 177-188
        • Fortin P.R.
        • Clarke A.E.
        • Joseph L.
        • Liang M.H.
        • Tanzer M.
        • Ferland D.
        • et al.
        Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery.
        Arthritis Rheum. 1999; 42: 1722-1728<1722::AID-ANR22>3.0.CO;2-R
        • Katz J.N.
        • Barrett J.
        • Mahomed N.N.
        • Baron J.A.
        • Wright R.J.
        • Losina E.
        Association between hospital and surgeon procedure volume and the outcomes of total knee replacement.
        J Bone Joint Surg Am. 2004; 86: 1909-1916
        • Bozic K.J.
        • Maselli J.
        • Pekow P.S.
        • Lindenauer P.K.
        • Vail T.P.
        • Auerbach A.D.
        The influence of procedure volumes and standardization of care on quality and efficiency in total joint replacement surgery.
        J Bone Joint Surg Am. 2010; 92: 2643-2652
        • Jeschke E.
        • Citak M.
        • Günster C.
        • Matthias Halder A.
        • Heller K.D.
        • Malzahn J.
        • et al.
        Are TKAs performed in high-volume hospitals less likely to undergo revision than TKAs performed in low-volume hospitals?.
        Clin Orthop Relat Res. 2017; 475: 2669-2674
        • Ricciardi B.F.
        • Liu A.Y.
        • Qiu B.
        • Myers T.G.
        • Thirukumaran C.P.
        What is the association between hospital volume and complications after revision total joint arthroplasty: a large-database study.
        Clin Orthop Relat Res. 2019; 477: 1221-1231
        • Berliner J.L.
        • Brodke D.J.
        • Chan V.
        • SooHoo N.F.
        • Bozic K.J.
        John Charnley Award: preoperative patient-reported outcome measures predict clinically meaningful improvement in function after THA.
        Clin Orthop Relat Res. 2016; 474: 321-329
        • Memtsoudis S.G.
        • Della Valle A.G.
        • Besculides M.C.
        • Esposito M.
        • Koulouvaris P.
        • Salvati E.A.
        Risk factors for perioperative mortality after lower extremity arthroplasty: a population-based study of 6,901,324 patient discharges.
        J Arthroplasty. 2010; 25: 19-26
        • Mori C.
        • Beun S.
        • Bailey A.
        Bone up your program: certification process for the total knee replacement and total hip replacement center.
        Orthop Nurs. 2012; 31: 287-293
      3. Blue Distinction specialty care.
        ([accessed 21.07.23])
        • Bourne R.B.
        • Chesworth B.M.
        • Davis A.M.
        • Mahomed N.N.
        • Charron K.D.
        Patient satisfaction after total knee arthroplasty: who is satisfied and who is not?.
        Clin Orthop Relat Res. 2010; 468: 57-63
        • Zhang S.
        • Chong M.
        • Lau B.P.H.
        • Ng Y.H.
        • Wang X.
        • Chua W.
        Do patients with diabetes have poorer improvements in patient-reported outcomes after total knee arthroplasty?.
        J Arthroplasty. 2021; 36: 2486-2491
        • Postler A.E.
        • Beyer F.
        • Wegner T.
        • Lützner J.
        • Hartmann A.
        • Ojodu I.
        • et al.
        Patient-reported outcomes after revision surgery compared to primary total hip arthroplasty.
        Hip Int. 2017; 27: 180-186
        • Wylde V.
        • Blom A.W.
        • Whitehouse S.L.
        • Taylor A.H.
        • Pattison G.T.
        • Bannister G.C.
        Patient-reported outcomes after total hip and knee arthroplasty: comparison of midterm results.
        J Arthroplasty. 2009; 24: 210-216
        • Klasan A.
        • Putnis S.E.
        • Yeo W.W.
        • Fritsch B.A.
        • Coolican M.R.
        • Parker D.A.
        Advanced age is not a barrier to total knee arthroplasty: a detailed analysis of outcomes and complications in an elderly cohort compared with average age total knee arthroplasty patients.
        J Arthroplasty. 2019; 34: 3135-3136
        • Zak S.G.
        • Lygrisse K.
        • Tang A.
        • Meftah M.
        • Long W.J.
        • Schwarzkopf R.
        Primary total hip arthroplasty outcomes in octogenarians.
        Bone Jt Open. 2021; 2: 535-539
        • Lee S.H.
        • Kim D.H.
        • Lee Y.S.
        Is there an optimal age for total knee arthroplasty?: a systematic review.
        Knee Surg Relat Res. 2020; 32: 60
        • Chen W.
        • Ke X.
        • Wang X.
        • Sun X.
        • Wang J.
        • Yang G.
        • et al.
        Prevalence and risk factors for postoperative delirium in total joint arthroplasty patients: a prospective study.
        Gen Hosp Psychiatry. 2017; 46: 55-61
        • Bohl D.D.
        • Sershon R.A.
        • Fillingham Y.A.
        • Della Valle C.J.
        Incidence, risk factors, and sources of sepsis following total joint arthroplasty.
        J Arthroplasty. 2016; 31: 2875-2879.e2