Quality of life and functionality after total hip arthroplasty: a long-term follow-up study

Reduced survival for uncemented compared to cemented total hip arthroplasty after operatively treated acetabular fractures

BACKGROUND

Post traumatic arthritis and avascular necrosis of the femoral head are common complications after operatively treated acetabular fractures. This may cause severe disabilities for the patient, necessitating a total hip arthroplasty. Even though an arthroplasty may provide good symptomatic relief, the long-term results are more uncertain and no consensus exists according to preferred prosthetic designs. With this cohort study, we aimed to investigate the medium to long term arthroplasty survival and clinical results of total hip arthroplasty after operatively treated acetabular fractures.

METHODS

We included 52 patients treated with a secondary total hip arthroplasty at a median of 2.4 (0.1-14.1) years after an operatively treated acetabular fracture. The median age was 54 (11-82) years. Cemented arthroplasty was used for 33 patients, 10 patients had an uncemented arthroplasty and 9 patients received a hybrid arthroplasty. Average follow up was 8.0 (SD 5.0) years.

RESULTS

Ten-year revision free arthroplasty survival was 79%. Uncemented arthroplasties had a significantly worse 10-year survival of 57%. Arthroplasties performed at a centre without a pelvic fracture service also had a significantly worse 10-years survival of 51%. Cox regression showed similar results with an 8-fold increase in risk of revision for both uncemented arthroplasties and operations performed at a non-pelvic trauma centre.

CONCLUSION

Total hip arthroplasty secondary to an operatively treated acetabular fracture provides good symptomatic relief. These patients are, however, complex cases and are probably best treated at specialist centres with both pelvic trauma surgeons and arthroplasty surgeons proficient in complex revisions present.

Validación de la versión española: Expectativa y conocimiento recibido del paciente hospitalizado

Objetivo: evaluar la validez y la fiabilidad de la versión española del instrumento Expectativas y conocimiento recibido del paciente hospitalizado (ECPH/CRPH) en pacientes con osteoartritis intervenidos de artroplastia total de rodilla. Material y métodos: el proceso de validación siguió las recomendaciones internacionales: validez de contenido, validez de constructo, validez de criterio y fiabilidad. Un total de 248 pacientes que debían intervenirse de artroplastia total de rodilla en 5 hospitales públicos españoles contestaron la ECPH antes de ser hospitalizados y 220 pacientes contestaron el CRPH al darles el alta hospitalaria. Resultados: el análisis factorial confirmó las dimensiones de la escala original para el conocimiento recibido, pero no en la escala para las expectativas. La correlación de las dimensiones de la ECPH con la Escala de Opinión de la Salud de Krantz (KHOS) y la correlación de las dimensiones de la CRPH con la Escala de Acceso a la Información (AKS) indicaron la validez de criterio mostrando unas relaciones positivas. Los resultados señalaron buena fiabilidad con valores de alfa Cronbach elevados. Conclusión: el proceso de validación indica que la versión española del ECPH/CRPH es un instrumento válido y fiable para medir las expectativas y el conocimiento recibido en pacientes quirúrgicos en el contexto español.

Effect of Spinal Fusion Surgery on Total Hip Arthroplasty Outcomes: A Matched Comparison Study

BACKGROUND

Studies regarding postoperative outcomes after primary total hip arthroplasty (THA) in patients who have comorbid factors tend to focus on medical diseases. However, there is a paucity of literature examining the effect of a patient's orthopedic surgical history on outcomes after THA. Significantly, there are currently no studies on the effect of spinal fusion surgery on THA outcomes.

METHODS

A review of 82 consecutive patients who had prior spinal fusion surgery who underwent elective THA from January 1, 2006 to December 31, 2015, was conducted. A matching cohort of 82 patients was selected from the remaining THA patients to maintain a 1:1 ratio control group. This cohort of 82 patients was matched for age, gender, body mass index ±5, preoperative Oxford score ±10, total Short Form-36 score ±10, and total Western Ontario and McMaster Universities Arthritis Index (WOMAC) score ±50. Data on the same functional outcomes were prospectively collected at 6-month and 2-year follow-up for comparison.

RESULTS

Patients without spinal fusion had better outcome scores than patients with prior spinal fusion, specifically in their 6-month WOMAC scores (253.33-225.07; P = .046), their 2-year Short Form-36 total scores (79.71-69.21; P = .041), and their 2-year WOMAC scores (213.5-267.41; P = .054).

CONCLUSION

This study demonstrates that patients with prior spinal fusion had worse outcomes after THA than patients without prior spinal fusion. This has clinical significance in counseling patients with previous spinal fusion undergoing THA.

Evidence base and practice variation in acute care processes for knee and hip arthroplasty surgeries

BACKGROUND

Lack of evidence contributes to unnecessary variation in treatment costs and outcomes. This study aimed to identify from interventions historically used for total knee or hip arthroplasty (TKA, THA): i) if routine use is supported by high-level evidence; ii) whether surgeon use aligns with the evidence.

METHODS

Part 1: Systematic search of electronic library databases for systematic reviews and practice guidelines concerning seven acute-care interventions. Intervention-specific recommendations concerning routine use were extracted by assessors. Part 2: Prospective medical record audit of the acute-care received by 1900 patients involving 120 orthopaedic surgeons. Surgeon use per intervention was summarized using caterpillar plots. Surgeon-specific routine and non-routine use was defined as use in ≥ 90% and ≤ 10% of patients, respectively. Primary analysis included only surgeons contributing ≥ 10 patients.

RESULTS

Continuous passive motion (TKA): Routine use not recommended; 85.7% of surgeons did not use it routinely. Tranexamic Acid: Routine use recommended; 26.9% of surgeons used it routinely. Cryotherapy: Routine use not recommended; 45.7% of surgeons used it routinely for TKA; 31.8% used it routinely for THA. Intra-articular drainage: Routine use not recommended for TKA, but possible benefits for THA; 5.7% of surgeons used it routinely for TKA, 0.0% used it routinely for THA. Antibiotic loaded bone cement: Routine use for TKA not supported, recommendations for use for THA are inconsistent; 90.0% of surgeons used it routinely for TKA, 100.0% used it routinely for THA. Patella resurfacing (TKA): No recommendation could be made; 57.1% of surgeons routinely resurfaced the patella. Indwelling urinary catheterisation: Routine use recommended; 59.6% of surgeons used it routinely.

CONCLUSION

Recommendations for routine use or not exist for some of the acute-care interventions examined. Surgeon practices vary widely even in the presence of high-level recommendations. It is unclear whether further evidence alone would lessen unwarranted practice variation.

Ten-Year Trends and Independent Risk Factors for Unplanned Readmission Following Elective Total Joint Arthroplasty at a Large Urban Academic Hospital

BACKGROUND

Total joint arthroplasty procedures continue to provide consistent, long-term success and high patient satisfaction scores. However, early unplanned readmission to the hospital imparts significant financial risks to individual institutions as we shift away from the traditional fee-for-service payment model.

METHODS

Using a combination of our hospital's administrative database and retrospective chart reviews, we report the 30-day and 90-day readmission rates and all causes of readmission following all unilateral, primary elective total hip and knee arthroplasty procedures at a large, urban, academic hospital from 2004 to 2013.

RESULTS

In total, 1165 primary total hip (511) and knee (654) arthroplasty procedures were identified, and the 30-day and 90-day unplanned readmission rates were 4.6% and 7.3%, respectively. A multivariate regression model controlled for a variety of potential clinical and surgical confounders. Increasing body mass index levels, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each independently correlated with risk of both 30-day and 90-day unplanned readmission to our institution. Additionally, use of general anesthesia during the procedure independently correlated with risk of readmission at 30 days only, while congestive heart failure independently correlated with risk of 90-day unplanned readmission. Readmissions related directly to the surgical site accounted for 47% of the cases, and collectively totaled more than any single medical or clinical complication leading to unplanned readmission within the 90-day period.

CONCLUSION

Increasing body mass index values, general anesthesia, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each were independent risk factors for early unplanned readmission.

Advances in hip arthroplasty surgery: what is justified?

Total hip arthroplasty (THA) surgery has shown dramatic changes in terms of increased number of procedures and of technical development in recent years. It has been described as “the operation of the 20^th century” for the excellent results, the high satisfaction of the patients and the improvement of the quality of life.

A lot of variations have been introduced over the last few decades in THA especially in terms of indications (both in younger and older patients), techniques and devices (approaches, tissue preservation, biomaterials and industrial finishing), per-operative management (blood loss and pain control) and post-operative protocols (the so called “fast track” surgery). Looking at all these advances the emerging question is: have all of them been justified both in terms of improvement of the results for the patients and of the cost/benefit ratio from an economical point of view?

The purpose of this paper is to critically analyse the advantages and the disadvantages of the theoretically proposed “advances in hip arthroplasty” and attempt to understand which are justified of such “advances” nowadays, based on the international and the European perspective with a focus on the author’s personal clinical experience.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.170008. Originally published online at www.efortopenreviews.org

Total hip arthroplasty in patients with Paget’s disease of bone: A systematic review

AIM

To investigate the clinical and functional outcomes following total hip arthroplasty (THA) in patients with Paget’s disease.

METHODS

We carried out a systematic review of the literature to determine the functional outcome, complications and revision rates of THA in patients with Paget’s disease. Eight studies involving 358 hips were reviewed. The mean age was 70.4 years and follow-up was 8.3 years. There were 247 cemented THAs (69%), 105 uncemented THAs (29%) and 6 hybrid THAs (2%).

RESULTS

All studies reported significant improvement in hip function following THA. There were 19 cases of aseptic loosening (5%) at a mean of 8.6 years. Three cases occurred in the uncemented cohort (3%) at a mean of 15.3 years and 16 cases developed in the cemented group (6%) at a mean of 7.5 years (P = 0.2052). There were 27 revisions in the 358 cases (8%) occurring at a mean of 7 years. Six revisions occurred in the uncemented cohort (6%) at a mean of 8.6 years and 21 in the cemented cohort (9%) at a mean of 6.5 years (P = 0.5117).

CONCLUSION

The findings support the use of THA in patients with Paget’s disease hip arthropathy. The post-operative functional outcome is largely similar to other patients; however, the revision rate is higher with aseptic loosening being the most common reason for revision. Uncemented implants appear to be associated with a lower failure rate, however, there were no modern stem designs fixed using current generation cementing techniques used in the reported studies, and as such, caution is advised when drawing any conclusions.

Validation of the Mini-OAKHQOL for use in patients with osteoarthritis in Spain

The Mini-Osteoarthritis Knee and Hip Quality of Life (Mini-OAKHQOL) questionnaire osteoarthritis is specific to individuals with knee or hip osteoarthritis. The objective of this study was to perform a validation of the Mini-OAKHQOL for use in Spain in terms of its psychometric properties of reliability, validity and responsiveness. Patients with osteoarthritis from the waiting list for a joint replacement completed the OAKHQOL, Short Form 36 Health Survey and Western Ontario and McMaster Universities Osteoarthritis Index. Reliability was assessed in terms of internal consistency and test-retest data, and convergent validity using Spearman's correlation coefficient. Structural validity was investigated by confirmatory factor analysis, and Rasch analysis was used to examine the unidimensionality of the scales. Responsiveness was assessed by calculating effect sizes. Confirmatory factor analysis confirmed the five-factor model, and the results of the Rasch analyses supported the unidimensionality assumption, with infit and outfit statistics. Cronbach's alpha ranged from 0.76 to 0.89 for all except the social dimensions. Statistically significant differences were observed between patients with different degrees of disease severity on all dimensions. There was convergent validity among dimensions expected to be correlated. The OAKHQOL questionnaire showed good responsiveness, with large changes for all dimensions apart from the two social dimensions, which had small effect sizes. Results of the study support the view that the Spanish version of the Mini-OAKHQOL questionnaire is a valid instrument to measure health-related quality of life in patients with osteoarthritis of the lower limb.

Does the Timing of Pre-Operative Medical Evaluation Influence Perioperative Total Hip Arthroplasty Outcomes?

Background:

Medical evaluation pre-operatively is an important component of risk stratification and potential risk optimization. However, the effect of timing prior to surgical intervention is not well-understood. We hypothesized that total hip arthroplasty (THA) patients seen in pre-operative evaluation closer to the date of surgery would experience better perioperative outcomes.

Methods:

We retrospectively reviewed 167 elective THA patients to study the relationship between the number of days between pre-operative evaluation (range, 0-80 days) and surgical intervention. Patients’ demographics, length of stay (LOS), ICU admission frequency, and rate of major complications were recorded.

Results:

When pre-operative evaluation carried out 4 days or less before the procedure date, there was a significant reduction in LOS (3.91 vs. 4.49; p=0.03). When pre-operative evaluation carried out 11 days or less prior to the procedure date, there was a four-fold decrease in rate of intensive care admission (p=0.04). Furthermore, the major complication rate also significantly reduced (p<0.05). However, when pre-operative evaluation took place 30 days or less before the procedure date compared to more than 30 days prior, there were no significant changes in the outcomes.

Conclusion:

From this study, pre-operative medical evaluation closer to the procedure date was correlated with improved selected peri-operative outcomes. However, further study on larger patient groups must be done to confirm this finding. More study is needed to define the effect on rare events like infection, and to analyze the subsets of THA patients with modifiable risk factors that may be time-dependent and need further time to optimization.

Estimating the Societal Benefits of THA After Accounting for Work Status and Productivity: A Markov Model Approach

BACKGROUND

Demand for total hip arthroplasty (THA) is high and expected to continue to grow during the next decade. Although much of this growth includes working-aged patients, cost-effectiveness studies on THA have not fully incorporated the productivity effects from surgery.

QUESTIONS/PURPOSES

We asked: (1) What is the expected effect of THA on patients' employment and earnings? (2) How does accounting for these effects influence the cost-effectiveness of THA relative to nonsurgical treatment?

METHODS

Taking a societal perspective, we used a Markov model to assess the overall cost-effectiveness of THA compared with nonsurgical treatment. We estimated direct medical costs using Medicare claims data and indirect costs (employment status and worker earnings) using regression models and nonparametric simulations. For direct costs, we estimated average spending 1 year before and after surgery. Spending estimates included physician and related services, hospital inpatient and outpatient care, and postacute care. For indirect costs, we estimated the relationship between functional status and productivity, using data from the National Health Interview Survey and regression analysis. Using regression coefficients and patient survey data, we ran a nonparametric simulation to estimate productivity (probability of working multiplied by earnings if working minus the value of missed work days) before and after THA. We used the Australian Orthopaedic Association National Joint Replacement Registry to obtain revision rates because it contained osteoarthritis-specific THA revision rates by age and gender, which were unavailable in other registry reports. Other model assumptions were extracted from a previously published cost-effectiveness analysis that included a comprehensive literature review. We incorporated all parameter estimates into Markov models to assess THA effects on quality-adjusted life years and lifetime costs. We conducted threshold and sensitivity analyses on direct costs, indirect costs, and revision rates to assess the robustness of our Markov model results.

RESULTS

Compared with nonsurgical treatments, THA increased average annual productivity of patients by USD 9503 (95% CI, USD 1446-USD 17,812). We found that THA increases average lifetime direct costs by USD 30,365, which were offset by USD 63,314 in lifetime savings from increased productivity. With net societal savings of USD 32,948 per patient, total lifetime societal savings were estimated at almost USD 10 billion from more than 300,000 THAs performed in the United States each year.

CONCLUSIONS

Using a Markov model approach, we show that THA produces societal benefits that can offset the costs of THA. When comparing THA with other nonsurgical treatments, policymakers should consider the long-term benefits associated with increased productivity from surgery.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

Quality of life after staged revision for infected total hip arthroplasty: a systematic review

INTRODUCTION

The aim of this review was to assess (health-related) quality of life ([HR]Qol) after 1-stage or 2-stage revision for prosthetic joint infection of the hip (PJI). Additionally, we compared (HR)QoL scores with normative population scores to assess whether QoL is reduced after revision for PJI.

METHODS

A systematic search was performed in Embase, Cochrane and Pubmed. We included articles that reported (HR)QoL questionnaires after staged revision for hip PJI with a minimum follow-up of 24 months. Methodological quality was assessed using the MINORS score.

RESULTS

The search produced 11,195 results. We selected 12 papers describing 2-stage revisions. The mean MINORS score was 9.8. Average WOMAC scores of 185 patients with a mean follow-up of 69.8 months were 73.Average Short Form 36 (SF-36) scores of 159 patients with a mean follow-up of 40.7 months were 40.4 for the physical component score (PCS) and 51.6 for the mental component score (MCS). Average Short Form 12 (SF-12) scores of 154 patients with a mean follow-up of 73.4 months were: a PCS of 35.4 and a MCS of 49.1. The WOMAC, SF-12 (PCS) and SF-36 (PCS) were respectively 12%, 26.7% and 14.8% lower, compared to normative values.

DISCUSSIONS

Patients who underwent 2-stage revision for hip PJI had substantially lower (physical component) (HR)QoL scores, but mental scores were comparable to the general population.

Three-year follow-up study of health related QOL and lifestyle indicators for Japanese patients after total hip arthroplasty

BACKGROUND

In non-Western countries including Japan, activities requiring deep flexion of the hip joint, such as seiza (kneeling with calves tucked under the thighs and buttocks resting on the heels) and using squat toilets are commonly practiced. The purpose of this study was to assess longitudinal changes in traditional health-related quality of life measures and measures of physical functions associated with lifestyle for Japanese patients pre-surgery and after total hip arthroplasty.

METHODS

Consecutive primary total hip arthroplasty patients between July 2003 and November 2006 were eligible. Patients were measured preoperatively and at 6 weeks, 1 year and 3 years postoperatively. Patients completed the EuroQol 5D, the Western Ontario and McMaster Universities Osteoarthritis Index and items related to Japanese lifestyle activities such as squatting. Changes in these scale scores across the four time points were tested, and we examined predictive factors of EuroQol 5D score at 3-year follow-up using multiple linear regression.

RESULTS

Of 1103 eligible patients, 576 completed questionnaires at all four time points. By 6 weeks post-surgery, reductions in pain and improvements in physical function and stiffness became highly significant, and improvements continued to 3 years postoperative. In contrast, improvements were far more limited for items related to Japanese lifestyle functions such as seiza and use of a Japanese squat toilet, even 3 years after surgery. Predictive factors of EQ5D at 3-year post THA were WOMAC pain and physical function, seiza, age and comorbidity measured at 3-year post THA.

CONCLUSION

The rate of improvement in QOL requiring deep flexion of the hip joint was much slower than that in QOL related to Western lifestyle. Our study suggests a need for lifestyle modification for THA patients in the other countries where kneeling and squatting are commonly performed.

Randomised controlled trial to evaluate a physiotherapy-led functional exercise programme after total hip replacement

BACKGROUND

At present, there is an insufficient evidence base to evaluate the effectiveness of physiotherapy following total hip replacement (THR). This study evaluated the effectiveness of a physiotherapy-supervised functional exercise programme between 12 and 18 weeks following THR. These time-points coincide with increased functional demand in patients.

DESIGN

Adequately powered assessor-blinded randomised controlled trial.

SETTING

Patients were recruited at a pre-operative assessment clinic and randomised following surgery.

PARTICIPANTS

Sixty-three subjects were randomised to either the usual care group (control, n=31) or the functional exercise+usual care group (n=32).

INTERVENTIONS

Patients in the functional exercise group attended a physiotherapy-supervised functional exercise class twice weekly from 12 to 18 weeks following THR. Patients in the control group followed the usual care protocol with no exercise intervention.

MAIN OUTCOME MEASUREMENT

The main outcome measurement tool was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, and the secondary outcomes included walking speed, hip abduction dynamometry, Short Form 12 physical and mental health scores, and visual analogue pain scale score.

RESULTS

At 18 weeks post surgery, WOMAC function and walking speed improved significantly more in the functional exercise group [mean difference -4.0, 95% confidence interval (CI) -7.0 to 1.0 (P<0.01); mean difference 21.9m, 95% CI 0.60 to 43.3 (P<0.04)] than the control group, but there was no significant difference in hip abductor strength.

CONCLUSION

This study demonstrated that patients who undertake a physiotherapy-led functional exercise programme between 12 and 18 weeks after THR may gain significant functional improvement compared with patients receiving usual care. Clinical trial registration number NCT01683201.

Patient Factors and Cost Associated with 90-Day Readmission Following Total Hip Arthroplasty

This study sought to identify specific costs for 90-day readmissions following total hip arthroplasty in a bundled payment system. Hospital billing records revealed 139 readmissions (8.93%) in 1781 patients. Mean costs for surgical readmissions were greater (P=0.002) compared with medical reasons, but similar for Medicare/Medicaid and private payers (P=0.975). Costs for imaging, laboratory workup, medication and transfusions, and hospital cost correlated with increasing SOI (P<0.05). Patients transferred from outside hospitals or rehabilitation had higher hospital (P=0.006) and operating room costs (P=0.001) compared to patients admitted from ED or clinic. Hospitals that care for complex patients with Medicare/Medicaid may experience increased costs for unplanned 90-day readmissions highlighting considerations for payer mix.

Personal Perspectives on Enablers and Barriers to Accessing Care for Hip and Knee Osteoarthritis

BACKGROUND

Despite increasing demand for joint replacement surgery and other health services for hip and knee osteoarthritis (OA), barriers and enablers to individual access to care are not well understood. A comprehensive understanding of drivers at all levels is needed to inform efforts for improving access.

OBJECTIVE

The aim of this study was to explore perceived barriers and enablers to receiving conservative (nonsurgical) and surgical treatment for hip and knee OA.

DESIGN

This was a qualitative study using directed content analysis.

METHODS

Semistructured telephone interviews were conducted, with 33 participants randomly sampled from an Australian population-based survey of hip and knee OA. Each interview covered factors contributing to receiving treatment for OA and perceived barriers to accessing care. Interview transcripts were coded and organized into themes.

RESULTS

Key barriers to accessing care for OA included medical opinions about saving surgery for later and the appropriate age for joint replacement. Other common barriers included difficulty obtaining referrals or appointments, long waiting times, work-related issues, and limited availability of primary and specialist care in some areas. Several participants perceived a lack of effective treatment for OA. Private health insurance was the most frequently cited enabler and was perceived to support the costs of surgical and conservative treatments, including physical therapy, while facilitating faster access to surgery. Close proximity to services and assistance from medical professionals in arranging care also were considered enablers.

CONCLUSIONS

People with hip or knee OA experience substantial challenges in accessing treatment, and these challenges relate predominantly to health professionals, health systems, and financial factors. Private health insurance was the strongest perceived enabler to accessing care for OA.

Agreements and disagreements in exercise therapy prescriptions after hip replacement among rehabilitation professionals: a multicenter survey

Background

Exercise therapy following total hip replacement (THR) is considered to be important during the initial postoperative care, but till date only a few evidence-based recommendations exist. The aim of this survey was to identify prescription standards among different rehabilitation professionals, for the exercise therapy management after THR in Germany.

Methods

The study was a cross-sectional survey. Standardized questionnaires were sent to 38 eligible rehabilitation facilities in Germany. Participating surgeons, orthopaedic physicians, physiotherapists and exercise therapists rated the optimal early weight-bearing, resistance training, key components and dose of exercise therapy, and the hip loading during exercising. The returned questionnaires were then analyzed for level of agreement (≥80 %) among respondents.

Results

313 rehabilitation professionals from 28 clinics returned completed questionnaires and were considered eligible for analysis. Out of total respondents, 53.9 % (cemented THR) and 18.2 % (uncemented THR) recommended full weight-bearing within five days after surgery. Commencement of resistance training later than three weeks after surgery is recommended by 20.6 % (36 %) for cemented (uncemented) prosthesis. Feedback varied significantly amongst the professions. Regarding the overall objectives of rehabilitation after hip replacement, respondents agree in six out of eight requested items. Agreement concerning priorities of specific exercises was achieved in three out of twelve items. The recommended exercise therapy dose varied significantly with working experience (p = 0.02).

Conclusion

Rehabilitation professionals mainly disagreed with the exercise therapy prescriptions following the total hip replacement during the initial postoperative care in Germany.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0646-7) contains supplementary material, which is available to authorized users.

WOMAC and SF-36: instruments for evaluating the health-related quality of life of elderly people with total hip arthroplasty. A descriptive study

CONTEXT AND OBJECTIVES

Quality-of-life results have increasingly been evaluated among patients undergoing joint replacements. The objective of this study was to compare two assessment instruments for health-related quality of life (one generic and the other specific), among elderly patients undergoing total hip arthroplasty.

DESIGN AND SETTING

Cross-sectional descriptive study in a reference hospital in the region of Campinas.

METHODS

The subjects were 88 elderly outpatients aged 60 years or over who underwent primary total hip arthroplasty. Two instruments for assessing health-related quality of life were applied: the generic Medical Study 36-item Short-Form Health Survey (SF-36) and the specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Cronbach's alpha and the ceiling and floor effects of the instruments were evaluated.

RESULTS

The scores from both instruments showed that issues of a physical nature affected these elderly people's quality of life most. The pain and stiffness dimensions of WOMAC showed ceiling effects and only the functional capacity and pain dimensions of the SF-36 did not show the ceiling effect. The SF-36 presented floor effects in the dimensions of physical and emotional aspects. Cronbach's alpha was considered satisfactory in both instruments (α > 0.70).

CONCLUSIONS

The floor and ceiling effects that were observed suggest that these instruments may present some limitations in detecting changes to the majority of the SF-36 dimensions, except for functional capacity and pain, and to the pain and stiffness dimensions of WOMAC, when applied to elderly people with total hip arthroplasty.

Empowering knowledge and its connection to health-related quality of life: A cross-cultural study: A concise and informative title: Empowering knowledge and its connection to health-related quality of life

AIMS

Assess the association between patient education (i.e. empowering knowledge) and preoperative health-related quality of life, 6 months postoperative health-related quality of life, and the increase in health-related quality of life in osteoarthritis patients who underwent total hip or total knee arthroplasty.

METHOD

This is a cross-cultural comparative follow-up study using structured instruments to measure the difference between expected and received patient education and self-reported health-related quality of life (EQ-5D) in Finland, Greece, Iceland, Spain and Sweden.

RESULTS

The health-related quality of life was significantly increased 6 months postoperatively in all countries due to the arthroplasties. In the total sample, higher levels of empowering knowledge were associated with a higher health-related quality of life, both pre- and postoperatively, but not with a higher increase in health-related quality of life. On the national level, postoperative health-related quality of life was associated with higher levels of empowering knowledge in Finland, Iceland and Sweden. The increase in health-related quality of life was associated with levels of empowering knowledge for Greece.

CONCLUSIONS

Overall, it can be concluded that the level of empowering knowledge was associated with high postoperative health-related quality of life in the total sample, even though there is some variation in the results per country.

Effect of cycle ergometer and conventional exercises on rehabilitation of older patients with total hip arthroplasty: study protocol for randomized controlled trial

Background

Total hip arthroplasty (THA) is an increasingly common treatment for older patients with hip osteoarthritis. The best strategy for a physiotherapy intervention for older people after THA is not clear in the literature. The purpose of this protocol study is to test the feasibility of undertaking a full trial clinical to evaluate the effect of ergometer cycling-associated conventional exercises on functional results and health-related quality of life (HRQOL) of older patients with THA.

Methods/Design

This study protocol is a prospective, single center, randomized controlled pilot clinical trial. Older patients (≥60 years) in the postoperative phase after primary unilateral THA for hip osteoarthritis will be consecutively recruited for this study and randomly allocated to 2 treatment groups. Group I will perform cycle ergometer and conventional exercises, and group II will perform only conventional exercises. The sessions will be conducted twice a week for 8 weeks. Assessments will be made at baseline (2 weeks postoperatively: the moment that the patients receive a referral for physical therapy, which will start after suture removal), after intervention (10 weeks postoperatively), and at 6 months of follow-up (24 weeks postoperatively). The primary outcomes are the function, evaluated using the Harris Hip Score (HHS) and the Short Physical Performance Battery (SPPB). The secondary outcome is HRQOL, measured using 2 evaluation instruments: the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Data collectors will be blinded and will not have contact with participants during the interventions.

Discussion

This randomized controlled trial will provide evidence regarding the effect of this exercise therapy on physical function and quality of life in older patients after THA. If our hypothesis is correct, both interventions will be effective, but the exercises on the cycle ergometer conferring better results in function, physical performance and quality of life. The study follows Consolidated Standards of Reporting Trials (CONSORT) guidelines, and the approval of the local ethics committee has been obtained.

Trial registration

ClinicalTrials.gov: NCT01622465 (14 June 2012)

Fiber diameter and seeding density influence chondrogenic differentiation of mesenchymal stem cells seeded on electrospun poly(ε-caprolactone) scaffolds

Chondrogenic differentiation of mesenchymal stem cells is strongly influenced by the surrounding chemical and structural milieu. Since the majority of the native cartilage extracellular matrix is composed of nanofibrous collagen fibrils, much of recent cartilage tissue engineering research has focused on developing and utilizing scaffolds with similar nanoscale architecture. However, current literature lacks consensus regarding the ideal fiber diameter, with differences in culture conditions making it difficult to compare between studies. Here, we aimed to develop a more thorough understanding of how cell-cell and cell-biomaterial interactions drive in vitro chondrogenic differentiation of bone-marrow-derived mesenchymal stem cells (MSCs). Electrospun poly(ε-caprolactone) microfibers (4.3  ±  0.8 µm diameter, 90 μm(2) pore size) and nanofibers (440  ±  20 nm diameter, 1.2 μm(2) pore size) were seeded with MSCs at initial densities ranging from 1  ×  10(5) to 4  ×  10(6) cells cm(-3)-scaffold and cultured under transforming growth factor-β (TGF-β) induced chondrogenic conditions for 3 or 6 weeks. Chondrogenic gene expression, cellular proliferation, as well as sulfated glycosaminoglycan and collagen production were enhanced on microfiber in comparison to nanofiber scaffolds, with high initial seeding densities being required for significant chondrogenic differentiation and extracellular matrix deposition. Both cell-cell and cell-material interactions appear to play important roles in chondrogenic differentiation of MSCs in vitro and consideration of several variables simultaneously is essential for understanding cell behavior in order to develop an optimal tissue engineering strategy.

Adequate surgical treatment of periprosthetic femoral fractures following hip arthroplasty does not correlate with functional outcome and quality of life

PURPOSE

This study aimed to analyse functional outcome and quality of life (QoL) after surgical treatment of periprosthetic femoral fractures (PPF) following total hip arthroplasty (THA).

METHODS

This retrospective study assessed 67 patients from 2005 to 2012. Epidemiologic data, surgical details, comorbidities, deaths and postoperative complications were recorded. Functional assessment included Harris Hip Score (HHS) and range of motion (ROM); QoL was assessed using the Short-Form Health Survey of 36 questions (SF-36) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores.

RESULTS

Mean HHS was 69 ± 21 and ROM 96° ± 17°. Mean SF-36 and WOMAC scores revealed 44 ± 7.2 and 18.9 ± 19.6, respectively. The complication rate was 25.4%; 23.7% of patients died. Analysis revealed no statistical influence on final outcome as a function of fracture type or treatment strategy. Comorbidities seem to influence functional outcome.

CONCLUSION

PPF following THA are accompanied by a perceptible decline of function and remarkably high complication rates. In contrast to fracture classification and treatment type, American Society of Anesthesiologists (ASA) score predicts outcome.

Sexual Function before and after Total Hip Replacement: Narrative Review

Background

More than 1 million total hip replacements (THRs) are performed every year worldwide. Achieving decreased pain, increased mobility, and improved quality of life (QoL) are key factors in the decision to undergo THR. Sexual activity is a valued component of QoL; however, little is known about how THR affects sexual functioning or the extent to which health care providers address sexuality in THR patients.

Aim

The aim of the study was to assess the literature regarding sexuality and sexual function in patients before and after THR.

Methods

PubMed, Google Scholar, and PEDro databases were searched without search limitations from inception until December 2013 for terms relating to sexual function and THR.

Results

Sexual activity before and after a THR is an important QoL issue. In patients with end-stage hip osteoarthritis, THR has been reported to have beneficial effects in restoring sexual satisfaction and performance. While research has recently been conducted to determine the range of motion of the hip joints necessary to execute certain sexual positions, there remains a lack of validated guidelines and the risks related to sexual activity after THR is rarely discussed between patients and medical staff.

Conclusions

The ability to move comfortably is included among the many physical and psychosocial factors influencing sexual functioning. Practitioners should be encouraged to question their THR patients about sexual concerns and to provide counseling related to physical and functional aspects of sexual activity. Rehabilitation that focuses specifically on activities of daily living of sex should include sexual counseling, therapeutic exercise, and advice regarding sexual positions. Rehabilitation provided by physical therapists may help decrease pain, and facilitate greater self-awareness, self-confidence, and improved body image, all of which encourage and affirm optimal sexual health. Meiri R, Rosenbaum TY, and Kalichman L. Sexual function before and after total hip replacement: Narrative review.

Effect of early supervised progressive resistance training compared to unsupervised home-based exercise after fast-track total hip replacement applied to patients with preoperative functional limitations. A single-blinded randomised controlled trial

OBJECTIVE

To examine if 2 weekly sessions of supervised progressive resistance training (PRT) in combination with 5 weekly sessions of unsupervised home-based exercise is more effective than 7 weekly sessions of unsupervised home-based exercise in improving leg-extension power of the operated leg 10 weeks after total hip replacement (THR) in patients with lower pre-operative function.

METHOD

A total of 73 patients scheduled for THR were randomised (1:1) to intervention group (IG, home based exercise 5 days/week and PRT 2 days/week) or control group (CG, home based exercise 7 days/week). The primary endpoint was change in leg extension power at 10 week follow up. Secondary outcomes were isometric hip muscle strength, sit-to-stand test, stair climb test, 20 m walking speed and patient-reported outcome (HOOS).

RESULTS

Sixty-two completed the trial (85%). Leg extension power increased from baseline to the 10 week follow up in both groups; mean [95% CI] IG: 0.29 [0.13; 0.45] and CG: 0.26 [0.10; 0.42] W/kg, with no between-group difference (primary outcome) (P = 0.79). Maximal walking speed (P = 0.008) and stair climb performance (P = 0.04) improved more in the IG compared to CG, no other between-group differences existed.

CONCLUSIONS

In this trial, supervised PRT twice a week in addition to 5 weekly sessions of unsupervised exercise for 10 weeks was not superior to 7 weekly sessions of unsupervised home-based exercise for 10 weeks in improving the primary outcome, leg-extension power of the operated leg, at the primary endpoint 10 weeks after surgery in THR patients with lower pre-operative function.

TRIAL REGISTRATION

NCT01214954.

Chinese patients' satisfaction with total hip arthroplasty: what is important and dissatisfactory?

Through validated self-administered questionnaires, we conducted a retrospective investigation in 818 patients (1009 hips) who underwent primary THA, to collect data on overall satisfaction plus satisfaction and importance rating for 16 specific functions and issues. Overall, 8.1% patients were dissatisfied with the surgery. The top 3 important items are pain relief, squatting, and walking. The top 3 dissatisfactory items are jogging, squatting, and rising after squatting. The strongest risk factors for dissatisfaction with walking were pain (6.1×), muscle weakness(3.7×), and LLD (3.3×). The strongest risk factors for dissatisfaction with squatting were low postoperative HHS ROM (3.7×) and muscle weakness (2.6×). For Chinese patients, ROM, muscle strength and LLD are very important.

Sports participation following total hip arthroplasty

Total Hip Athroplasty (THA) is a common procedure in orthopedic surgery to address severe osteoarthritis (OA) in the hip joint. With the burgeoning "baby boomer" generation and older athletes who wish to return to competitive levels of sports, understanding how sporting activity affects THA outcomes is becoming exceptionally important. The purpose of this review is to characterize the current recommendations and risks for returning to sports after THA, as well as discuss the implications of the changing demographic and level of expectation on rehabilitation paradigms. Although the actual risks associated with participating in sports after THA are unknown, there are concerns that higher levels of physical activity after THA may increase risk for fracture, dislocation and poor long-term outcomes. Evidence surrounding the specific effect of sporting activity on wear after THA is conflicting. Newer alternatives such as metal-on-metal hip resurfacing are expected to provide better durability but there are concerns of systemic metal ions from mechanical wear, although the impact of these ions on patient health is not clear. Tracking outcomes in patients participating in higher level activities after THA presents a problem. Recently the High Activity Arthroplasty Score has been developed in response to the need to quantify higher level of physical activity and sports participation after joint arthroplasty. This measure has been shown to have a higher ceiling effect than other common outcome measures. There is little prospective evidence regarding the likelihood of poor clinical outcomes with higher level of sporting activity. There is some evidence to suggest that wear may be related to activity level, but the impact on clinical outcomes is conflicting. When advising an athlete considering returning to sport after THA, consider their preoperative activity level, current physical fitness, and specific history including bone quality, surgical approach and type of prosthesis.

LEVEL OF EVIDENCE

5.

Long-term results using the straight tapered femoral cementless hip stem in total hip arthroplasty: a minimum of twenty-year follow-up

We report the first long-term results of a prospective cohort study after total hip arthroplasty using the cementless Bicontact hip stem. Between 1987 and 1990, 250 total hip arthroplasties in 236 patients were performed using the cementless Bicontact hip stem. The average follow-up was 22.8 years (20.4-24.8) and average age at index surgery was 58.1 years. Eighty-one patients died and 9 were lost to follow-up. We noted 11 stem revisions revealing an overall Kaplan Meier survival rate of 95.0% (CI 95%: 91.1-97.2%). The average Harris Hip Score revealed 81 points (range 24-93). The Bicontact hip stem demonstrated high survival rates despite high ages and osteopenic changes, which are equivalent to other long-term reports of cementless stem fixation.

Total hip replacement: a systematic review and meta-analysis on mid-term quality of life

OBJECTIVE

Total hip replacement (THR) is one of the most successful and frequently performed operations worldwide. Health-related quality of life (HRQOL) is a key outcome measure of surgery. We investigated mid-term HRQOL after THR in patients with osteoarthritis (OA).

DESIGN

A systematic review of clinical studies published after January 2000 was performed using strict eligibility criteria. Quality appraisal and data tabulation were performed using pre-determined forms. Data were synthesised by narrative review and random-effects meta-analysis using standardised response means. Tau(2) and I(2) values and Funnel plots were analysed.

RESULTS

20 studies were included. Mid-term post-operative HRQOL is superior compared to pre-operative status on qualitative and quantitative analysis. Pooled response means of total Harris Hip Score (HHS) (P < 0.00001) and combined pain (P = 0.00001) and physical function (P < 0.00001) domains of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and HHS improved markedly up to 7 years. Medical Outcomes Survey Short Form 36 shows physical functioning (PF) (P < 0.00001), bodily pain (BP) (P < 0.00001), role physical (P = 0.001), role emotional (P = 0.04), and social functioning (SF) (P = 0.03) were improved up to 7 years. General health (GH) (P = 0.29), mental health (MH) (P = 0.43), and vitality (P = 0.17) was similar. HRQOL is at least as good as reference populations in the first few years and subsequently plateaus or declines. Patient satisfaction and functional status was favourable. There was significant heterogeneity amongst all studies, but publication bias was low in pooled analysis.

CONCLUSION

THR confers significant mid-term HRQOL benefits across a broad range of health domains. Further studies based on consistent guidelines provided in this review are required.

Causes and frequency of unplanned hospital readmission after total hip arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is a beneficial and cost-effective procedure for patients with osteoarthritis. Recent initiatives to improve hospital quality of care include assessing unplanned hospital readmission rates. Patients presenting for THA have different indications and medical comorbidities that may impact rates of readmission.

QUESTIONS/PURPOSES

This study measured (1) the unplanned hospital readmission rate in primary THA, revision THA, and antibiotic-spacer staged revision THA to treat infection. Additionally, we determined (2) the medical and surgical causes of readmission; and (3) the risk factors associated with unplanned readmission.

METHODS

A total of 1415 patients (988 primary THA, 344 revision THA, 82 antibiotic-spacer staged revision THA to treat infection) from a single institution were included. All hospital readmissions within 90 days of discharge were reviewed. Patient demographics and medical comorbidities were included in a Cox proportional hazards model to assess risk of readmission.

RESULTS

The overall unplanned readmission rate was 4% at 30 days and 7% at 90 days. At 90 days, primary THA (5%) had a lower unplanned readmission rate than revision THA (10%, p < 0.001) and antibiotic-spacer staged revision THA (18%, p < 0.001). Medical diagnoses were responsible for almost one-fourth of unplanned readmissions, whereas over half of surgical readmissions were the result of dislocation, surgical site infection, and postoperative hematoma. Type of procedure, hospital stay greater than 5 days, cardiac valvular disease, diabetes with end-organ complications, and substance abuse were each associated with increased risk of unplanned readmission.

CONCLUSIONS

Higher rates of unplanned hospital readmissions in revision THA rather than primary THA suggest that healthcare quality measures that incorporate readmission rates as a proxy for quality of care should distinguish between primary and revision procedures. Failure to do so may negatively impact tertiary referral hospitals that often care for patients requiring complex revision procedures.

Health-related quality of life and functionality after reverse shoulder arthroplasty

BACKGROUND

Modern semiconstrained reverse shoulder arthroplasty (RSA) has shown a great improvement in function and range of motion (ROM) in different etiologies, including revision surgery, sequelae of fractures, or tumors. Few studies have evaluated RSA for primary glenohumeral osteoarthritis, massive rotator cuff tear, or cuff tear arthropathy excluding any other shoulder disease, and data on patients' quality of life after this surgery are lacking.

METHODS

In this prospective cohort study, 80 patients were evaluated after an RSA for either primary osteoarthritis, massive rotator cuff tear, or cuff tear arthropathy with the Constant-Murley score (CMS), ROM, and Short Form Health Survey (SF-36). A radiologic assessment was performed preoperatively and postoperatively in 62 of these patients.

RESULTS

At a mean 5-year follow-up, the cumulative survival rate was 97.3% and significant improvements in the CMS and ROM were observed when compared with the baseline values. The CMS was 93.2% of the sex- and age-matched normal values. The postoperative SF-36 scores showed no significant differences compared with normative data. Younger patients and subjects with worse preoperative conditions achieved the greatest benefit after RSA. The length of follow-up was found to be associated with the severity of scapular notching.

CONCLUSIONS

This study introduces new predictors for surgical outcomes, and it shows that patients who had undergone RSA a mean of 5 years earlier exhibit similar functionality and health-related quality of life with respect to healthy controls. Physicians should consider these results when discussing the outcomes of this surgery with patients.

LEVEL OF EVIDENCE

Level IV, Case series, treatment study.

Exclusion of patients with sequential primary total joint arthroplasties from arthroplasty outcome studies biases outcome estimates: a retrospective cohort study

OBJECTIVE

Total joint arthroplasty (TJA) outcome studies have largely focused on recipients of a single primary TJA, which may bias outcome estimates.

DESIGN

This retrospective cohort study utilized health administrative databases from Ontario, Canada, to assemble a cohort that received a first primary elective hip or knee TJA for osteoarthritis (OA) between 2002 and 2009 (index TJA). Characteristics of TJA recipients at their index TJA were compared for those who did vs did not go on to receive one or more subsequent primary, elective hip/knee TJAs (multiple TJAs - yes/no) over a 2-year follow-up period. Cox proportional hazards, censored on death, was used to examine the relationship of receipt of multiple TJAs (yes/no) on rates of surgical complications for the index TJA, controlling for confounders.

RESULTS

Among 97,374 eligible patients, 19,856 (20.4%) received a second primary elective TJA procedure within 2 years. In bivariate analyses, recipients of multiple primary TJAs were significantly more likely than single TJA recipients to be female, younger, with fewer co-morbidities (P < 0.0001), and to experience surgical complications with the index surgery, including early revision (P < 0.0001). Controlling for patient differences, receipt of >1 primary TJAs over 2 years was independently and significantly associated with lower odds of having experienced a surgical complication following the index arthroplasty (adjusted HR 0.65, 95%CI 0.59-0.72).

CONCLUSIONS

One in five patients receiving their first elective primary hip or knee TJA received a second hip/knee TJA within 2 years. Our results indicate that exclusion of this large subsample of TJA recipients from TJA outcomes studies over-estimates surgical risks and may underestimate patient-reported benefits.

Primary total hip arthroplasty: health related quality of life outcomes

PURPOSE

The health related quality of life (HRQoL) outcomes of total hip arthroplasty (THA) present a pertinent and clinically important problem in modern orthopaedics. Our goal was to report and compare the health-related outcomes after THA in respect to type of fixation in patients with hip osteoarthritis (H-OA) one year after operation.

METHODS

A total of 145 patients with H-OA who received THA were evaluated. Uncemented and cemented subjects were evaluated using generic measures, i.e. the EQ-5D questionnaire, and the disease-specific measures designed by the authors, i.e. the Total Hip Arthroplasty Questionnaire (THAQ). Obtained data was statistically processed at the level of pain, functionality and general health perception. Patient-reported outcomes were measured differences between pre-operative measures and those at one-year follow-up visit.

RESULTS

Significant improvement in health outcomes was reached in both groups regardless of the type of fixation (p < 0.001). Uncemented fixation exhibited better results for EQ-5DINDEX, pain (p = 0.004) and self-care on EQ-5D (p = 0.043), as well as increased magnitude of change for functionality on THAQ (p = 0.002). However, additional analysis of the subset did not reveal a significant difference between cemented vs. uncemented groups with regard to function on THAQ, but the significant difference on self-care and pain dimensions of EQ-5D remained.

CONCLUSIONS

Uncemented endoprosthesis generally achieved better short-term outcomes in some dimensions. However, painless mobility has been restored in most of the patients, regardless of the fixation type. Both methods reached good clinical outcomes in their respective domains; therefore, we would emphasise prevention of osteoarthritis and the quality of care as the more important predictors of good clinical outcomes.

The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis

OBJECTIVE

To examine whether total joint arthroplasty of the hip and knee reduces the risk for serious cardiovascular events in patients with moderate-severe osteoarthritis.

DESIGN

Propensity score matched landmark analysis.

SETTING

Ontario, Canada.

PARTICIPANTS

2200 adults with hip or knee osteoarthritis aged 55 or more at recruitment (1996-98) and followed prospectively until death or 2011.

MAIN OUTCOME MEASURE

Rates of serious cardiovascular events for those who received a primary total joint arthroplasty compared with those did not within an exposure period of three years after baseline assessment.

RESULTS

The propensity score matched cohort consisted of 153 matched pairs of participants with moderate-severe arthritis. Over a median follow-up period of seven years after the landmark date (start of the study), matched participants who underwent a total joint arthroplasty during the exposure period were significantly less likely than those who did not to experience a cardiovascular event (hazards ratio 0.56, 95% confidence interval 0.43 to 0.74, P<0.001). Within seven years of the exposure period the absolute risk reduction was 12.4% (95% confidence interval 1.7% to 23.1%) and number needed to treat was 8 (95% confidence interval 4 to 57 patients).

CONCLUSIONS

Using a propensity matched landmark analysis in a population cohort with advanced hip or knee osteoarthritis, this study found a cardioprotective benefit of primary elective total joint arthroplasty.

The effects of nonsteroidal anti-inflammatory drugs on clinical outcomes, synovial fluid cytokine concentration and signal transduction pathways in knee osteoarthritis. A randomized open label trial

OBJECTIVE

We investigated the effects of celecoxib, diclofenac, and ibuprofen on the disease-specific quality of life, synovial fluid cytokines and signal transduction pathways in symptomatic knee osteoarthritis (OA).

DESIGN

Ninety patients scheduled for a total knee arthroplasty (TKA) were randomized to six groups that were treated with low and high dosages of celecoxib, diclofenac or ibuprofen. At the time of the first admission (T0) and at surgery (T1 = 14 days after beginning of the nonsteroidal anti-inflammatory drugs (NSAIDs)), samples of knee synovial fluid were obtained from each patient for analysis. During the surgery the synovial tissue was harvested from the knee of patients. The Western Ontario and McMaster universities (WOMAC) score was used to evaluate the patient disease-specific quality of life at T0 and T1. Microarray tests performed at T0 and T1 were used to evaluate the effects of NSAIDs on Tumor necrosis factor (TNF)-alpha, Interleukin-6 (IL-6), IL8 and Vascular endothelial growth factor (VEGF) concentration in the synovial fluid. Western blot assays evaluated the effects of NSAIDs on MAP kinase (MAPK) signal transduction pathway in the synovial membrane.

RESULTS

NSAID treatment induced a statistically significant improvement in the WOMAC score and a statistically significant decrease in the IL-6, VEGF and TNF-alpha concentration in the synovial fluid. Higher dosages of NSAIDs provided a greater improvement in the disease-specific quality of life of patients and lower concentrations of pro-inflammatory cytokines in the synovial fluid. Inhibition of MAPKs was noted after NSAID treatment.

CONCLUSION

Short-term NSAID treatment improves the patient disease-specific quality of life with a parallel decrease in pro-inflammatory synovial fluid cytokine levels in knee OA. Signal transduction pathways may be involved in regulating the anti-inflammatory effects of NSAIDs. ClinicalTrial.gov: NCT01860833.

Change in quality of life and cost/utility analysis in open stage-related surgical treatment of elbow stiffness

The goals of this study were to examine the improvement in quality of life achieved after open surgical treatment of elbow stiffness and to verify the cost/utility ratio of surgery. Thirty-three patients (22 men and 11 women) underwent surgery. The etiologies of elbow stiffness were posttraumatic conditions (n=26), primary osteoarthritis (n=5), and rheumatoid arthritis (n=2). Surgery included 14 ulnohumeral arthroplasties, 6 ulnohumeral arthroplasties associated with radiocapitellar replacement, 5 ulnohumeral arthroplasties associated with radial head replacement, and 8 total elbow arthroplasties. All patients were evaluated pre- and postoperatively with the Mayo Elbow Performance Score, the Mayo Elbow Performance Index, the modified American Shoulder and Elbow Surgeons score, the Quick Disabilities of the Arm, Shoulder and Hand score, and the Short Form 36 after a mean follow-up of 26 months. Possible variables affecting clinical outcome and quality of life improvement were assessed. The cost/utility ratio was evaluated as diagnosis-related group reimbursement per quality-adjusted life year. Mayo Elbow Performance Scores and modified American Shoulder and Elbow Surgeons scores increased, on average, by 43 and 41 points, respectively (P<.0001). Quick Disabilities of the Arm, Shoulder and Hand scores decreased, on average, by 44 points (P<.0001). The improvement in the SF-36 physical and mental component summary score was 7.6 and 7, respectively (P=.0001 and .0018). The cost/utility ratio ranged between 670 and 817 Euro/quality-adjusted life year. A significant correlation was found between pain score and quality of life improvement. An inverse correlation emerged between pre- and postoperative quality of life score. The current study shows that open surgery significantly improves quality of life and elbow function. Selecting the surgical procedure that most effectively reduces pain appears to be the most relevant variable responsible for quality of life improvement. Surgery shows a satisfactory cost/utility ratio, justifying a health spending increase to reduce the social costs resulting from lingering elbow stiffness.

Influence of surgical experience in the learning curve of a new approach in hip replacement: anterior mini-invasive vs. standard lateral

There is conflicting evidence regarding the potential benefit of minimally invasive surgery for total hip arthroplasty (THA), especially during the 'learning curve' of individual surgeons. Sixty patients who underwent THA between January and December 2010 were evaluated. The aim was to assess the anterior mini-invasive (MI) approach performed in 30 patients during the learning curve of a single experienced hip surgeon compared with the results of 30 patients operated upon through a standard lateral approach by the same surgeon. Operation and hospitalisation times, blood loss, number of transfusions, peri-operative complications and femoral/acetabular component placement were monitored. Harris Hip Score (HHS) and Hip Disability and Osteoarthritis Outcome Score (HOOS) were analysed before and 12 months after surgery. Pain Visual Analogue Scale (VAS) was also recorded 1 week and 1 month after surgery. Hospitalisation, blood loss, number of transfusions and VAS score 1 week postoperatively were significantly lower and operative time was significantly longer in the anterior MI approach. Similar functional outcomes 1 year after surgery, component positioning and complication rates were observed in both groups. The results suggest that anterior MI approach is a safe procedure during the learning curve of an experienced hip surgeon.

Evaluation of patient satisfaction with physical therapy following primary THA

Physical therapy following total hip arthroplasty (THA) is intended to maximize a patient's range of motion and function and improve the quality of life. No universally accepted standard of care exists for physical therapy among physicians or therapists. However, it may be crucial to enhance efforts to more fully elucidate contributing parameters that affect patient experiences. The purpose of this study was to evaluate various factors contributing to patient satisfaction with postoperative physical therapy. One hundred consecutive patients (110 hips) who underwent THA were prospectively surveyed for satisfaction with postoperative physical therapy. All surveys were filled out anonymously by the patients, and investigators were blinded to clinical outcomes and who was surveyed. Seventy-six percent of patients reported being satisfied with their rehabilitation experiences. Factors, including patient age and sex, duration of therapy, number of patients per session, continuity of care with the same therapist, amount of hands-on time spent with the therapist, number of patients per session, and total number of sessions completed, were significantly correlated with patient satisfaction. Co-pay amount did not significantly affect patient satisfaction. These factors may be underappreciated by physicians and physical therapists. To maximize patient satisfaction with physical therapy, physicians should identify institutions whose therapists are willing to spend adequate hands-on time during one-on-one or small-group sessions while maintaining the greatest possible continuity of care with a single provider.

The changing demographics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007

BACKGROUND

The rates of total joint arthroplasty (TJA) of the hip and knee have increased in North America over the last decade. While initially designed for elderly patients (>70 years of age), several reports suggest that an increasing number of younger patients are undergoing joint replacements. This suggests that more people are meeting the indication for TJA earlier in their lives. Alternatively, it might indicate a broadening of the indications for TJA.

METHODS

We used the administrative databases available at the Healthcare Cost and Utilization Project (HCUP) and the Institute for Clinical Evaluative Sciences (ICES) to determine the rates of TJA of the hip and knee in the United States, and Ontario, Canada, respectively. We determined the crude rates of THA and TKA in both areas for four calendar years (2001, 2003, 2005 and 2007). We also calculated the age- and sex-standardised rates of THA and TKA in both areas for each time period. We compared the age distribution of TJA recipients between the US and Ontario, and within each area over time.

RESULTS

The crude and standardised rates of THA and TKA increased over time in both the US and Ontario. The crude rates of THA were higher in the US in 2001 and 2003, but were not significantly different from the rate in Ontario in 2005 and 2007. The crude rates of TKA were consistently higher in the US for all time periods. In addition, the US consistently had more THA and TKA recipients in 'younger' age categories (<60 years of age). While the age- and sex-standardised rates of TKA were greater in the US in all time periods, the relative increase in rates from 2001 to 2007 was greater in Ontario (US - 59%, Ontario - 73%). For both the US and Ontario, there was a significant shift in the demographic of THA and TKA recipients to younger patients (p < 0.0001).

CONCLUSIONS

The utilisation of primary hip and knee arthroplasty has increased substantially in both the US and Ontario in the period from 2001 to 2007. This increase has been predominantly in knee replacements. The demographics of joint replacement recipients has become younger, with substantial increases in the prevalence of patients <60 years old amongst TJA recipients, and significant increases in the incidence of TJA in these age groups in the general population, in both the US and Ontario.

The effect of functional movement ability on the quality of life after total hip replacement

AIMS AND OBJECTIVES

To analyse in detail the relationship between the movement and generic health-related quality of life (HRQoL) indicators and the subjective feeling of health of the patients, as well as the objective movement parameters measured by the surgeon and the patient's opinion about the success of the total hip replacement (THR).

BACKGROUND

We have only limited information about the effect of mobility function improvement on the HRQoL several years after THR. We have recently found that after THR postoperative health awareness is influenced mainly by cardiovascular diseases, but the effects of the movement parameters on the subsequent feelings of well-being were not examined.

DESIGN

Retrospective longitudinal study.

METHODS

This study involved 109 patients who had had THR. The patients' health status and objective and subjective mobility function at the time of operation and five years later were evaluated using questionnaires (including EQ-5D and WOMAC scores) and the hospital database.

RESULTS

All components of EQ-5D and WOMAC had significantly improved by Year 5 in patients who experienced a complete recovery after the operation, but not the mobility and pain components of EQ-5D for those patients who felt an improvement only in their subjective mobility function. The surgeon-assessed parameters and use of walking aids showed a similar distribution in patients who considered themselves to be healthy or only moderately sick five years after THR.

CONCLUSION

Successful THR significantly improves the feeling of well-being and the mobility function of patients even five years after the operation. In individual cases, however, other subjective and objective factors, but not the mobility function, have a major influence on the HRQoL.

RELEVANCE TO CLINICAL PRACTICE

Five years after successful THR, nursing care has to focus not only on the further improvement of the mobility but on strengthening the subjective feeling of the patient's well-being and health.

Estimating risk in Medicare patients with THA: an electronic risk calculator for periprosthetic joint infection and mortality

BACKGROUND

Although risk factors for periprosthetic joint infection (PJI) and mortality after total hip arthroplasty (THA) have been identified, interactions between specific patient risk factors are poorly understood. Therefore, it is difficult for surgeons to counsel patients on their individual risk of PJI or mortality after THA.

QUESTIONS/PURPOSES

We evaluated the interaction between patient clinical and demographic factors on the risk of PJI and mortality after THA and developed an electronic risk calculator for estimating the patient-specific risk of PJI and mortality in Medicare patients with THA.

METHODS

We used the Medicare 5% sample claims database to calculate the risk of PJI within 2 years and mortality within 90 days after THA in 53,252 Medicare patients with primary THAs between 1998 and 2009. Logistic regression using 29 comorbid conditions, age, sex, race, and socioeconomic status were used as inputs to develop an electronic risk calculator to estimate patient-specific risk of PJI and mortality after THA.

RESULTS

The overall 2-year risk of PJI and 90-day risk of mortality after primary THA were 2.07% and 1.30%, respectively. White women aged 70 to 74 years with alcohol abuse, depression, electrolyte disorder, peptic ulcer disease, urinary tract infection, rheumatologic disease, preoperative anemia, cardiopulmonary (cardiac arrhythmia, congestive heart failure, ischemic heart disease, chronic pulmonary disease) comorbidities, and peripheral vascular disease were at highest risk for PJI. White women aged 65 to 69 years with electrolyte disorder, hemiplegia/paraplegia, hypertension, hypothyroidism, metastatic tumor, preoperative anemia, coagulopathy, cardiopulmonary (congestive heart failure, chronic pulmonary disease) and psychiatric (psychoses, depression) comorbidities, malignancies, and peripheral vascular disease were at highest risk for mortality. An electronic risk calculator was developed to estimate the risk of PJI and mortality in Medicare patients with THA.

CONCLUSIONS

This electronic risk calculator can be used to counsel Medicare patients regarding their patient-specific risks of PJI and mortality after THA.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Evaluation of the method for analyzing chromium, cobalt and titanium ion levels in the blood following hip replacement with a metal-on-metal prosthesis

High-resolution inductively coupled plasma mass spectrometry (HR-ICP-MS) can be used to measure metal ion levels in whole blood, although the accuracy and repeatability of this method is not yet known in the clinical setting. In this study, chromium, cobalt and titanium ion levels were measured in three whole blood samples, each collected at the same moment from 101 patients undergoing total hip arthroplasty with a metal-on-metal (MoM) bearing. The first sample (purge sample) had direct contact with the metal needle used during insertion of the catheter, whereas the second sample (reference sample) and the third sample (reserve sample) did not. The absolute difference between reference samples and reserve samples was greater than the limit of quantification of the HR-ICP-MS device for all three ions (0.84 versus 0.35 µg/L for chromium, 0.74 versus 0.07 for cobalt, and 0.88 versus 0.70 µg/L for titanium), although the levels were very small in most cases, they exceeded the clinical significant threshold in 19 to 31% of the cases. No clinically significant difference was observed between reference samples and purge samples. Therefore, HR-ICP-MS is a clinically acceptable method to evaluate metal ion levels in blood following hip replacement with an MoM prosthesis, and it is not necessary to discard the purge sample to obtain repeatable results.

Tenotomy versus tenodesis in the treatment of the long head of biceps brachii tendon lesions

Background

The superiority of tenotomy vs. tenodesis for surgery on lesions of the long head of the biceps brachii tendon is still under debate. Indeed, high-quality evidence is lacking, mainly because of methodological problems, such as retrospective design, population sample size or lack of patient randomization.

Methods/Design

The study will be a two-center, double-blind, randomized, controlled trial to compare patients treated with biceps tenotomy or tenodesis for lesions of the long head of the biceps brachii tendon over a 2-year follow-up period. The study participants will be 128 adults with biceps brachii tendinopathy and supraspinatus tendon tears. The primary end point will be the postoperative difference in the Constant-Murley score (CMS) between the 2 groups at the two-year follow-up. A comparison of the mean improvement with standard age- and gender-related CMS will be performed. The secondary end point will be evaluation of the postoperative general health of patients, as evaluated with Short Form 36 (SF-36) scores. The number and severity of complications associated with use of the different surgical techniques will be assessed.

Discussion

This study will be the first randomized and appropriately powered clinical trial to directly compare tenotomy and biceps tenodesis. The results of this study will help to establish clinical practice guidelines for patients suffering from lesions of the long head of the biceps brachii tendon, providing important information to patients and health care providers about the possible complications, outcome predictors and effectiveness of the targeted interventions.

Trial Registration

Current Controlled Trials ISRCTN38839558

Patient satisfaction after total knee and hip arthroplasty

Patient satisfaction is an important outcome measurement in TKA/THA surgery. Patient satisfaction can be evaluated from 2 perspectives, determinants of satisfaction and components of satisfaction.(5) In total joint arthroplasty, improvements in satisfaction can be achieved by examining these perspectives. Patient satisfaction is one of the many PROMs used in orthopedic surgery and is an integral part of the growing sentiment to evaluate surgery from the patient's perspective as well as from the surgeon's. The importance of measuring outcomes from the patient perspective is integral to today's patient-centered models of care.