Measures of hip function and symptoms: Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), Oxford Hip Score (OHS), Lequesne Index of Severity for Osteoarthritis of the Hip (LISOH), and American Academy of Orthopedic Surgeons (A

Does Participation in Sports Affect Osteoarthritic Progression After Periacetabular Osteotomy?

BACKGROUND

Periacetabular osteotomy (PAO) is an effective treatment for symptomatic acetabular dysplasia. However, whether postoperative participation in sports leads to progression of the Kellgren-Lawrence (KL) grade of osteoarthritis (OA) in these patients is unclear.

PURPOSE

To investigate (1) participation in sports before and after PAO and (2) whether postoperative participation in sports leads to progression of the KL grade.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The authors retrospectively reviewed data on 161 patients (183 hips) who underwent PAO for symptomatic acetabular dysplasia with preoperative KL grade 1 or 2 between 1998 and 2011. The mean age at the time of surgery was 42.0 ± 10.9 years (range, 12-64 years), and the mean follow-up duration was 100 months (range, 13-180 months). Data included participation in sports, the University of California, Los Angeles (UCLA) activity scale score, age at the time of surgery, body mass index, follow-up duration, history of treatment for developmental hip dislocations, Merle d'Aubigné-Postel score, Oxford Hip Score, center-edge angle, and KL grade. Univariate and multivariate analyses were applied to determine which factors were associated with progression to KL grade 3 or 4 after PAO.

RESULTS

The number of patients who participated in sports significantly increased from 50 (31.1%) preoperatively to 89 (55.3%) postoperatively. The mean UCLA score significantly increased from 4.7 ± 2.1 preoperatively to 5.5 ± 2.0 postoperatively. The KL grade progressed to grade 3 or 4 in 16 hips, including 4 hips that underwent conversion to total hip arthroplasty. No significant differences were found in postoperative participation in sports (89 hips [53.3%] vs 11 hips [68.8%], respectively; P = .24) and the UCLA score (5.6 ± 2.0 vs 5.1 ± 2.0, respectively; P = .30) between hips with KL grade 1 or 2 and KL grade 3 or 4. A multivariate analysis revealed that no factors, including postoperative participation in sports, were significantly associated with progression to KL grade 3 or 4.

CONCLUSION

Postoperative participation in sports after PAO did not significantly and negatively influence progression of the KL grade at midterm follow-up.

Mid-term migration of a cementless, porous acetabular cup: A 5 year Radiostereometric analysis

PURPOSE

The aim of the study was to determine the 5 year migratory and wear patterns, adverse events and clinical outcomes of a cementless, porous acetabular cup.

METHODS

RSA imaging of a cohort of 11 patients was retrospective analysed at 5 years post Total Hip Arthroplasty (THA). Changes in pain, function and symptoms of the hip at 5 years post-THA were compared to preoperative and 2 year postoperative assessments on the Harris Hip Score (HHS) and Hip dysfunction and Osteoarthritis Outcome Score (HOOS).

RESULTS

The majority of cup migration occurred up to 6 months and stabilised thereafter (6 months to 5 years, p = 0.091-0.866, Wilcoxon Signed Rank test). The direction of rotation around the 3 axes was evenly distributed among the cups between anterior-posterior rotation, internal-external rotation and increased-decreased inclination. The majority of the cups translated proximally, at an average migration of 0.36 mm (±95%CI 0.17) at 5-years post-THA. Following initial bedding in, up to 6 months, there was no detectable polyethylene wear between 6 months and 5 years. At 5 years postoperatively, a statistically significant difference was observed across all HOOS subscales in comparison to preoperative values, with higher means reported at 5 years (p < 0.001). The total mean HHS displayed a statistically significant improvement, increasing from 'poor' preoperatively to 'good' at 5 years post-THA.

CONCLUSION

Following initial migration between discharge and 6 months, the cementless porous acetabular cup demonstrated a tendency for stabilisation from 6 months up to 5 years post-THA, suggesting good mid-term fixation. Additionally, improvements in clinical outcome measures of pain, function and quality-of-life remained high following THA at 5 years post-surgery.

A pilot randomised clinical trial of physiotherapy (manual therapy, exercise, and education) for early-onset hip osteoarthritis post-hip arthroscopy

Background

Despite the increasing use of hip arthroscopy for hip pain, there is no level 1 evidence to support physiotherapy rehabilitation programs following this procedure. The aims of this study were to determine (i) what is the feasibility of a randomised controlled trial (RCT) investigating a targeted physiotherapy intervention for early-onset hip osteoarthritis (OA) post-hip arthroscopy? and (ii) what are the within-group treatment effects of the physiotherapy intervention and a health-education control group?

Methods

This study was a pilot single-blind RCT conducted in a private physiotherapy clinic in Hobart, Australia. Patients included 17 volunteers (nine women; age 32 ± 8 years; body mass index = 25.6 ± 5.1 kg/m²) who were recruited 4–14 months post-hip arthroscopy, with chondropathy and/or labral pathology at the time of surgery. Interventions included a physiotherapy treatment program that was semi-standardised and consisted of (i) manual therapy; (ii) hip strengthening and functional retraining; and (iii) health education. Control treatment encompassed individualised health education sessions. The primary outcome measure was feasibility, which was reported as percentage of eligible participants enrolled, adherence with the intervention, and losses to follow-up. The research process was evaluated using interviews, and an estimated sample size for a definitive study is offered. Secondary outcomes included the Hip disability and Osteoarthritis Outcome Score (HOOS) and the International Hip Outcome Tool (IHOT-33) patient-reported outcomes.

Results

Seventeen out of 48 eligible patients (35%) were randomised. Adherence to the intervention was 100%, with no losses to follow-up. The estimated sample size for a full-scale RCT was 142 patients. The within-group (95% confidence intervals) change scores for the physiotherapy group were HOOS-Symptoms 6 points (−4 to 16); HOOS-Pain 10 points (−2 to 22); HOOS-Activity of Daily Living 8 points (0 to 16); HOOS-Sport 3 points (−12 to 19); HOOS-Quality of Life 3 points (−7 to 13); and IHOT-33 7 points (−10 to 25). The within-group (95% confidence intervals) change scores for the control group were HOOS-Symptoms −4 points (−17 to 9); HOOS-Pain −2 points (−18 to 13); HOOS-Activity of Daily Living −7 points (−17 to 4); HOOS-Sport 4 points (−16 to 23); HOOS-Quality of Life −5 points (−18 to 9); and IHOT-33 −4 points (−27 to 19). Suggestions to improve study design included greater supervision of exercises and increased access to physiotherapy appointments.

Conclusions

Results support the feasibility of a full-scale RCT, and recommendations for an adequately powered and improved study to determine the efficacy of this physiotherapy intervention post-hip arthroscopy to reduce pain and improve function are provided.

Trial registration

Australian Clinical Trials Registry, ACTRN12614000426684

Outcomes of Hip Arthroscopy in the Older Adult: A Systematic Review of the Literature

BACKGROUND

The indications for hip preservation surgery have expanded to include treatment of hip pathology in older adults. While several studies have examined the efficacy of hip arthroscopy in the setting of osteoarthritis, there has been no review of outcomes in older adults.

PURPOSE

To review the outcomes of hip arthroscopy in older adults and identify factors associated with treatment failures.

STUDY DESIGN

Systematic review.

METHODS

PubMed, EMBASE, and the Cochrane Library were searched through March 2016 for studies reporting outcomes of primary hip arthroscopy in patients older than 40 years. Inclusion in the review was based on age, patient-reported outcome (PRO) measures, and duration of follow-up. Two authors screened the results and extracted data for use in this review. Standardized mean difference was calculated to estimate effect size for PRO scores within studies.

RESULTS

Eight studies with 401 total patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) or labral tears were included in this review. Seven of the 8 studies reported favorable PRO scores and significant postoperative improvement with moderate to large effect size. The included studies demonstrated a trend toward higher effect sizes with an increasing percentage of labral repair compared to isolated labral debridement. The complication rate was comparable to that of previous reports involving younger patients; however, the overall reoperation rate was 20.8%. Conversion to hip arthroplasty ranged from 0% to 30%, with an overall conversion rate of 18.5% at a mean time of 17.5 months following arthroscopy. The most common risk factors for conversion to arthroplasty were low preoperative PRO scores and advanced arthritis.

CONCLUSION

Hip arthroscopy appears to be a safe and efficacious treatment for labral tears and FAI in older patients who do not have significant underlying degenerative changes. However, in this population, there is a significant proportion of patients who eventually require hip arthroplasty. Outcomes may be affected by type of treatment (ie, labral debridement vs repair). Additional high-quality studies are needed to understand how these factors affect outcomes.

Comparison of Post-Operative Muscular Strength Between Gamma Nailing and Hemiarthroplasty System in Femoral Intertrochanteric Fractures

Background:

The current study focuses on the comparison of postoperative muscular strength around the hip joint of patients with femoral intertrochanteric fractures treated either by cephalo-medullary (CM) nailing or a new bipolar hip prosthesis (BHP), an especially attached device to secure displaced greater trochanteric fragment.

Methods:

Twenty patients treated with CM nailing were age- and sex- matched with a control group of 20 patients treated with BHP. Maximum isometric forces at the bilateral hip joint were measured during the follow up period. Means of 3 measurements were represented.

Results:

The mean and standard deviation values (kg) of muscle strength at the non-operative/ operative side in the CM nailing group were as follows: flexion strength 9.5±4.7/8.5±4.9 (P=0.06), extension strength 6.2±3.5/5.5±3.7 (P=0.08), abduction strength at 0 degrees 7.7±3.5/6.2±2.8 (p=0.002), abduction strength at 10 degrees 5.5±2.0/4.2±2.0 (p=0.001). In the BHP group, mean and standard deviation values of muscle strength at the non-operative/ operative side were as follows: flexion strength 6.5±2.8/6.0±3.4 (P=0.08), extension strength 4.4±0.9/4.4±0.6 (P=0.83), abduction strength at 0 degrees 5.1±1.9/5.0±1.6 (p=0.12), and that at 10 degrees 4.7±1.4/4.6±1.3 (p=0.10).

Conclusion:

Our results demonstrate that CM nailing may cause a 25-30% decrease in postoperative muscle strength around the hip joint, particularly during hip abduction. With the new BHP, greater trochanter reduction is achieved allowing early weight bearing and maintaining strength in abduction. Surgeons should consider postoperative muscular strength as one of the necessary factors for selection of the appropriate surgical procedure.

Level of Evidence:

Therapeutic Level III.

Systematic review of cross-cultural adaptations of hip-specific patient-reported outcome measures in Spanish

OBJECTIVE

The aim of this study was to conduct a systematic review of the quality of the transcultural adaptation procedure and the clinimetric properties of the self-administered hip-disability functional assessment questionnaires adapted for the Spanish population.

MATERIAL AND METHOD

We searched the MEDLINE, EMBASE, CINAHL and Web of Science databases (from inception until June 2016) to locate all the scales adapted to Spanish and to analyze the different phases of the adaptation process and its psychometric properties.

RESULTS

Eight scales were identified, and were grouped into three sections, according to the type of diseases in which they can be used: a) lower limb: Lower Limb Functional Index (LLFI), Lower Extremity Functional Scale (LEFS) and Arthrosis of Membres Inférieurs et Qualité de vie (AMICAL); b) knee and/or hip: Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, Osteoarthritis Knee and Hip Quality of Life (OAKHQOL) and Hip and Knee Questionnaire (HKQ); and c) specific for hip: Hip Outcome Score (HOS) and International Hip Outcome Tool-33 (iHOT-33). The transcultural adaptation procedure was satisfactory in all cases, albeit somewhat less rigorous for the HKQ and LLFI than for the remaining questionnaires. No study evaluated all the psychometric properties.

CONCLUSION

We currently have 8 hip-disability functional assessment questionnaires adapted to Spanish with satisfactory psychometric properties. We can measure the patient's perceived impact of his or her hip disease by selecting, among the different options, those alternatives that best fit our clinical or research objectives.

Patient-reported health outcomes after total hip and knee surgery in a Dutch University Hospital Setting: results of twenty years clinical registry

Background

Patient-Reported Outcome (PRO) measurement is a method for measuring perceptions of patients on their health and quality of life. The aim of this paper is to present the results of PRO measurements in total hip and knee replacement as routinely collected during 20 years of surgery in a university hospital setting.

Methods

Data of consecutive patients between 1993 and 2014 were collected. Health outcomes were measured pre-surgery and at 3, 6, and 12 months post-surgery. Outcomes for hip replacement were measured with the Harris Hip Score (HHS) and Oxford Hip Score (OHS). Outcomes for knee replacement were measured with the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and the Knee Society Score (KSS). A Visual Analog Scale (VAS) for pain was used. Absolute and relative Minimal Clinically Important Differences (MCID) were estimated. Generalized estimating equation analysis was used for estimating mean outcomes. Trends over time were analyzed.

Results

The database contained 2,089 patients with hip replacement, and 704 patients with knee replacement. Mean HHS and OHS scores in primary hip replacement at 12 months post-surgery were 86.7 (SD: 14.5) and 41.1 (SD: 7.5) respectively. Improvements on the HHS based on absolute MCID was lower for revisions compared to primary hip replacements, with 72.4% and 87.0% respectively. Mean WOMAC and KSS scores in knee replacement at 12 months post-surgery were 21.5 (SD: 18.2) and 67.0 (SD: 26.4) respectively. Improvements based on absolute MCID were lowest for the KSS (62.6%) and highest for VAS pain (85.6%). Trend analysis showed a difference in 1 out of 24 comparisons in hip replacement and in 2 out of 9 comparisons in knee replacement.

Conclusions

The functional status of a large cohort of patients significantly improved after hip and knee replacement based on routine data collection. Our study shows the feasibility of the routine collection of PRO data in patients with total hip and knee replacement. The use of PRO data provides opportunities for continuous quality improvement.

A randomised, controlled clinical study on total hip arthroplasty using 4 different bearings: results after 10 years

PURPOSE

To compare 4 different bearings in total hip arthroplasty (THA) in a randomised controlled clinical study on clinical performance.

METHODS

393 patients with osteoarthritis of the hip or avascular necrosis were included and allocated to 1 of the head-and-cup couples zirconia-on-polyethylene (group A), metal-on-metal (group B), zirconia-on-polyethylene with the liner moulded into the shell (group C), or alumina-on-alumina (group D). In the individual case the surgeon could choose other implants if indicated.

RESULTS

299 patients were operated with the allocated prosthesis. The estimated cumulated prosthesis survival percentages and 95% confidence interval after 10 years were: group A 84.6 (75.8-93.4); group B 95.0 (89.5-100); group C 93.2 (86.7-99.7); group D 66.1 (54.5-77.7). The patients' physical function was significantly improved and remained equally good in all 4 groups, however slightly declining with ageing. The luxation rate was initially high, and equal between the groups, but was reduced by improving the surgical procedure introducing capsule repair by reinsertion of the short external hip rotators.

CONCLUSIONS

The metal-on-metal or zirconia-on-polyethylene prostheses had high 10-year survival percentages. The longevity of these bearing couples by themselves was not related to the combination of materials. The zirconia-on-polyethylene prosthesis with the liner mounted peroperatively possibly exhibited cases of backside wear which the corresponding bearing couple with moulded polyethylene (Asian) did not. The alumina-on-alumina bearing performed poorly - it was redesigned after our study initiation and later withdrawn from the market.

Mid-Term Results and Predictors of Patient-Reported Outcomes of Birmingham Hip Resurfacing

BACKGROUND

Birmingham hip resurfacing (BHR) is the only Food and Drug Administration approved resurfacing option currently available in the United States. While adequate BHR outcomes are established, there is a paucity of US-based literature demonstrating factors critical to improve patient reported outcomes (PROs). This study answers: (1) What is the implant survivorship in a large US cohort? (2) Which preoperative factors result in higher PRO scores over 5 years postoperatively?

METHODS

A retrospective 541 hip single-surgeon cohort with mean of 6.2 years follow-up (range 5-8.1) was collected. Preoperative patient/implant variables, including postoperative radiographic acetabular inclination and femoral component position, clinical outcomes, and follow-up PRO questionnaire information were collected. Validated PROs included the Hip Disability and Osteoarthritis Outcome Score (HOOS), Veterans Rand-12, and University of California Los Angeles (UCLA) activity. PROs were modeled with ordinary least squares then used to create nomograms.

RESULTS

Average patient age was 53 years with 391 (72%) males. Seven hips were revised, resulting in an overall survival of 98.8% at 5 years. Predictive modeling identified preoperative variables (sex, body mass index, smoking, and comorbidity) that had statistically significant associations with HOOS pain (P = .049), HOOS activities of daily living (P = .017), UCLA activity (P < .001), and Veterans Rand-12 physical (P < .001) PROs at latest follow-up. Nomograms predicted follow-up PROs using preoperative patient-specific variables.

CONCLUSION

This study documents excellent survival of the largest reported single-center cohort of BHRs in the United States with a mean 6.2 years follow-up. Multivariate modeling shows male nonsmokers with low body mass index, and no comorbidities will have less hip pain, better function in daily life, higher activity, and better general physical health after BHR arthroplasty.

Prospective, Longitudinal Evaluation of Gender Differences After Total Hip Arthroplasty

Temporal trends in survivorship, patient-reported outcomes, and activity levels following total hip arthroplasty were compared between 61 men and 127 women. Overall implant survivorship was excellent for both genders. Similar functional improvements were found between men and women out until 5 years. Some gender differences were observed: men had a faster time to functional recovery and higher preoperative Short-Form 12-item survey mental component scores, whereas women had a significant improvement in Short-Form 12-item survey mental component scores. Increased understanding of these differences by patients and surgeons, combined with gender-based interventions, may further advance outcomes for these patients.

Patient-reported outcomes of femoral osteotomy and total hip arthroplasty for osteonecrosis of the femoral head: a prospective case series study

Background

Patient-reported scoring systems have recently been used after surgical procedures. The purpose of this prospective study was to evaluate the patient-reported outcomes of femoral osteotomy and total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH).

Methods

Forty-two symptomatic ONFH patients with asymptomatic contralateral hip underwent either transtrochanteric anterior rotational osteotomy (ARO) or THA as a primary operation. Of these, 20 patients whose contralateral hips remained asymptomatic at the final follow-up (more than 1 year postoperatively) were recruited to participate in this study. Nine patients were treated with ARO (ARO group) and 11 patients were treated with THA (THA group). Both the Oxford hip score (OHS) and the short form 36 (SF-36) were evaluated preoperatively and at the final follow-up.

Results

The preoperative OHS was 29.1 ± 10.9 and 21.9 ± 9.6 points in the ARO and THA groups, which significantly improved to 38.4 ± 9.4 and 40.3 ± 5.1 points at the final follow-up, respectively. The preoperative physical component summary score was 30.8 ± 12.8 and 17.8 ± 14.5 points in the ARO group and THA groups, which significantly improved to 44.5 ± 10.6 and 43.3 ± 10.4 points at the final follow-up, respectively. The preoperative mental component summary score was 48.0 ± 8.5 and 48.6 ± 11.3 points in the ARO and THA groups, both of which remained unchanged at the final follow-up.

Conclusions

The short-term patient-reported outcomes of this study suggested that both ARO and THA for ONFH resulted in significantly improved postoperative hip joint function.

Pain and Function Recovery Trajectories following Revision Hip Arthroplasty: Short-Term Changes and Comparison with Primary Hip Arthroplasty in the ADAPT Cohort Study

Background and Purpose

Patients report similar or better pain and function before revision hip arthroplasty than before primary arthroplasty but worse results are reported after revision surgery than after primary surgery. The trajectory of post-operative recovery during the first months and any differences by type of surgery have received little attention. We explored the trajectories of change in pain and function after revision hip arthroplasty to 12-months post-operatively and compare them with those observed after primary hip arthroplasty.

Methods

This study is a prospective cohort study of patients undergoing primary (n = 80 with 92% for an indication of osteoarthritis) and revision (n = 43) hip arthroplasties. WOMAC pain and function scores and walking speed were collected pre-operatively, at 3 and 12-months post-operatively. Multilevel regression models were used to chart and compare the trajectories of change (0–3 months and 3–12 months) between types of surgery.

Results

The improvements in pain and function following revision arthroplasty occurred within the first 3-months with no evidence of further change beyond this initial period. While the pattern of recovery was similar to the one observed after primary arthroplasty, improvements in the first 3-months were smaller after revision compared to primary arthroplasty. Patients listed for revision surgery reported lower pre-operative pain levels but similar post-operative levels compared to those undergoing primary surgery. At 12-months post-operation patients who underwent a revision arthroplasty had not reached the same level of function achieved by those who underwent primary arthroplasty.

Conclusion

The post-operative improvements in pain and function are larger following primary hip arthroplasty than following revision hip arthroplasty. Irrespectively of surgery type, most of the improvements occur in the first three post-operative months. More research is required to identify whether the recovery following revision surgery could be improved with specific post-operative interventions.

Predictors of physical functioning after total hip arthroplasty: a systematic review

OBJECTIVE

The objective of this systematic review of the literature was to identify the predictors of functional outcome after total hip arthroplasty (THA).

METHOD

A systematic literature search in Web of Science, CINAHL, EMBASE and PubMed was conducted on 23 June 2015. The articles were selected based on their quality, relevance and measurement of the predictive factor. The level of evidence of all studies was determined using the GRADE rating scheme.

RESULTS

The initial search resulted in 1092 citations. After application of the inclusion and exclusion criteria, 33 articles met our eligibility criteria and were graded. Included studies were classified as level of evidence low (11), moderate (17) or high (5). Of the included studies, 18 evaluated body mass index (BMI), 17 evaluated preoperative physical functions, 15 evaluated age, 15 evaluated gender and 13 evaluated comorbidity. There was strong evidence suggesting an association between BMI, age, comorbidity, preoperative physical functions and mental health with functional outcome after THA. There was weak evidence suggesting an association between quadriceps strength and education with functional outcome after THA. The evidence was inconsistent for associations with gender and socioeconomic status and functional outcome following THA. We found limited evidence suggesting that alcohol consumption, vitamin D insufficiency and allergies were predictors of functional outcome following THA.

CONCLUSIONS

We have identified multiple predictors of functional outcome after THA, which will enable general practitioners and orthopaedic surgeons to better predict the improvement in physical functioning for their patients with THA. They can use this information to provide patient-specific advice regarding the referral for THA and the expected outcomes after THA. Further research with consistent measurement tools, outcomes and duration of follow-up across studies is needed to confirm the influence of these factors.

Dual-Mobility Articulations for Patients at High Risk for Dislocation

BACKGROUND

The purpose of this study was to evaluate the performance of dual-mobility articulations in patients at high risk for dislocation after revision total hip arthroplasty.

METHODS

We reviewed the results of 36 consecutive revision total hip arthroplasties performed on patients considered high risk for instability. Indications for inclusion included abductor insufficiency, recurrent instability, failure of constrained liner, or inadequate intraoperative stability when trialing.

RESULTS

At a minimum of 2 years, there were 4 (11.1%) repeat revisions including both dual-mobility liners that were cemented into an acetabular shell and 2 for deep infection treated with a 2-stage exchange. There was one dislocation that was successfully closed reduced but no revisions for recurrent instability. The mean Harris hip score improved from 45 to 90 points (P < .001).

CONCLUSION

Dual-mobility articulations are associated with a low rate of failure with no revisions for instability in this challenging group of patients.

Long-Term Survival of the Native Hip After a Minimally Displaced, Nonoperatively Treated Acetabular Fracture

BACKGROUND

Few studies have evaluated the long-term results for nonoperatively treated acetabular fractures. The purpose of this study was to describe the long-term survival of the native acetabulum as well as the clinical and radiographic outcome for patients with nonoperatively treated acetabular fractures.

METHODS

All patients with acetabular fractures are prospectively registered in our acetabular fracture database and followed up at regular intervals for up to 20 years. We identified 236 patients (237 fractures) who had been treated nonoperatively between 1994 and 2004; 51 patients with incomplete data were excluded. For the survival analysis, 186 fractures with an average follow-up of 9 years (range, 1 to 20 years) were included. For the long-term clinical outcome, 104 patients with an average follow-up of 12.1 years (range, 9 to 20 years) were included.

RESULTS

The 10-year survival of the native hips was 94% (111 hips were at risk). Eighty-nine percent of the patients had a good or excellent Harris hip score, and 88% had a good or excellent Merle d'Aubigné and Postel score. The most important negative predictor for clinical outcome and survival of the hip was a fracture step-off of ≥2 mm measured in the obturator oblique radiograph.

CONCLUSIONS

Nonoperative treatment of minimally displaced acetabular fractures yields good to excellent long-term results. For patients with a questionable indication for fracture surgery, oblique radiographs (Judet views) are a helpful tool in the decision-making process, as a fracture step-off of ≥2 mm is a strong predictor for a poor clinical and radiographic result at 10 years.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Prospective evaluation of short and mid-term outcomes of total hip arthroplasty using the Accolade™ stem

PURPOSE

Cementless press-fit total hip arthroplasty (THA) with the Accolade stem (Stryker AccoladeTM TMZF, Mahwah, New Jersey) has demonstrated variable implant survivorship and outcomes. The purpose of this study was to analyse the: 1) implant survivorship; 2) complications; 3) functional outcomes; 4) overall quality of life; and 5) patient expectations and satisfaction following THA with this particular press-fit stem.

METHODS

A prospectively collected database of 222 patients who underwent THA at 7 institutions between 2006 and 2009 using the Accolade stem (Stryker Inc. Mahwah, New Jersey) was evaluated. Harris Hip Score (HHS) and SF-12 were used to assess the outcomes at 2- and 5-year follow-up. Kaplan-Meier survivorship was calculated at 5 years of follow-up.

RESULTS

The 5-year aseptic and all-cause survivorship rates were 99.4% (95% CI, 96.3 to 99.9%) and 97.9% (95% CI, 94.6 to 99.2%), respectively. At 2 and 5 years postoperatively, the patients demonstrated a mean HHS of approximately 89 points and 92 points, respectively. The mental and physical components of the SF-12 mean score increased with the physical component having a more marked increase. The mental and physical components of the SF-12 score increased to a mean of 46 and 45 points at 2 and 5 years, respectively. At 2-year follow-up, over 90% of patients were satisfied with their outcome in a majority of areas surveyed.

DISCUSSION

Our results suggest that the use of this press-fit construct results in tremendous improvements in functional and quality of life outcomes, along with excellent survivorship at short- and mid-term follow-up.

RM Pressfit® cup: good preliminary results at 5 to 8 years follow-up for 189 patients

AIM

The RM Classic® cup shows very good results. The RM Pressfit® cup has an equatorial pressfit; it is a monoblock implant without metalback. The aim of this study was to evaluate retrospectively the survival of this implant, monitoring patients for at least 5 years in all consecutive cases operated in our centre.

METHODS

Between February 2006 and December 2008, our department performed 189 consecutive nonselected primary total hip arthroplasties using the RM® Pressfit cup, and all of these were included in the study. The operative technique involved an anterolateral approach. The latest follow-up evaluation was performed at a minimum of 5 years after the index arthroplasty.

RESULTS

The mean follow-up was 6.5 years (5-8 years). We had preoperative information for 186 of the 189 patients. 102 patients were seen in consultation (54.0%), 46 (24.3%) patients were contacted by phone, 37 (19.6%) patients died, and 4 patients (2.1%) were lost for unknown reasons. Of the 189 arthroplasties, 6 (3.2%) required revision; 4 (2.1%) for infection, 1 (0.5%) for significant haematoma with persistent deglobulisation and 1 (0.5%) for periprosthetic calcification during the 5 to 8 years following the operation. No hip was revised because of aseptic loosening. The mean annual wear rate based on the last follow-up at 5 years minimum was 0.065 mm per year. We observed no migration, 1 femoral loosening and no acetabular loosening.

CONCLUSIONS

Our study finds a good survival rate which is compatible with the 94% at 20 years with RM Classic®. These results are suggestive but must be confirmed with long-term studies.

Comparison of tissue transglutaminase 2 and bone biological markers osteocalcin, osteopontin and sclerostin expression in human osteoporosis and osteoarthritis

Osteoporosis (OP) and osteoarthritis (OA) are the most common joint diseases, with a high incidence in the elderly population. OP is characterized by trabecular bone remodeling and reabsorption, whereas articular cartilage and subchondral bone remodeling are major features of OA. Although classically considered as independent or even conflicting processes, clinical coexistence of OP and OA was recently described. Transglutaminase 2 (TG2) expression is considered a biomarker of OA, but its role in osteoporotic bone remodeling is still uncertain. We investigated TG2 and bone biological markers (Osteocalcin, Osteopontin, and Sclerostin) in osteoporotic and osteoarthritic osteocartilagineous tissue (n = 54) and human chondrocyte cultures in vitro by immunohistochemistry, immunofluorescence and RT-PCR. Histomorphometric evaluation of bone trabecular remodeling was also performed. In cartilage, TG2 expression was faint in control and OP and significantly less than in OA and OP + OA chondrocytes; the opposite was found for Osteocalcin, whereas Osteopontin and Sclerostin expression was similar. In the subchondral trabecular bone, osteocytes/osteoblasts TG2 expression was slight and similar comparing control, OP, OA, and OP + OA group, whereas Osteocalcin and Osteopontin expression was lower in OP compared to control, OA and OP + OA. Increased TG2 and reduced Osteocalcin expression were maintained in human osteoarthritic chondrocytes in vitro. Histomorphometric analysis confirmed reduced trabecular bone mass in OP and OP + OA compared with OA patients. TG2 represented a suitable biomarker of osteoarthritic chondrocyte activation, whereas osteocalcin and osteopontin characterized osteoporotic osteocyte/osteoblast changes; differences were lost in OP + OA patients, suggesting careful consideration when coexistence of the two diseases occurs.

The effectiveness of supplementary arm and upper body exercises following total hip arthroplasty for osteoarthritis in the elderly: a randomized controlled trial

OBJECTIVE

To determine whether arm and upper body exercises in addition to the standard rehabilitation programme improve outcomes after hip arthroplasty.

DESIGN

Prospective, parallel, randomized, controlled trial.

SETTING

Orthopaedic and rehabilitation departments.

SUBJECTS

A total of 70 patients >60 years of age, who underwent hip replacement, out of 98 eligible candidates after exclusion criteria were implemented.

INTERVENTIONS

The study group took part in the supplementary arm and upper body exercise programme to be compared with the standard rehabilitation programme group.

MAIN OUTCOME

The primary outcome was a Harris Hip Score. Secondary outcomes were: Hand grip strength and Medical Outcomes Study 36-Item Short-Form Health Survey. Outcomes were assessed preoperatively, two weeks after surgery and at 12 weeks follow-up.

RESULTS

In the intervention group, significant improvements were found: in functional ability - Harris Hip Score after two (mean difference = 4.7 points) and 12 (mean difference = 5.85 points) weeks; in muscle strength - handgrip for both hands (mean difference for dominant hand = 4.16 and for the other hand = 2.8) after 12 weeks; and in role-physical dimension SF-36 Health Survey (mean difference = 6.42 points) after 12 weeks.

CONCLUSION

Results of this study indicate that arm and upper body exercises in addition to the standard rehabilitation programme improve outcomes 12 weeks after hip arthroplasty.

Validation of the HOOS, JR: A Short-form Hip Replacement Survey

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly in demand for outcomes evaluation by hospitals, administrators, and policymakers. However, assessing total hip arthroplasty (THA) through such instruments is challenging because most existing measures of hip health are lengthy and/or proprietary.

QUESTIONS/PURPOSES

The objective of this study was to derive a patient-relevant short-form survey based on the Hip disability and Osteoarthritis Outcome Score (HOOS), focusing specifically on outcomes after THA.

METHODS

We retrospectively evaluated patients with hip osteoarthritis who underwent primary unilateral THA and who had completed preoperative and 2-year postoperative PROMs using our hospital's hip replacement registry. The 2-year followup in this population was 81% (4308 of 5351 patients). Of these, 2371 completed every item on the HOOS before surgery and at 2 years, making them eligible for the formal item reduction analysis. Through semistructured interviews with 30 patients, we identified items in the HOOS deemed qualitatively most important to patients with hip osteoarthritis. The original HOOS has 40 items, the four quality-of-life items were excluded a priori, five were excluded for being redundant, and one was excluded based on patient-relevance surveys. The remaining 30 items were evaluated using Rasch modeling to yield a final six-item HOOS, Joint Replacement (HOOS, JR), representing a single construct of "hip health." We calculated HOOS, JR scores for the Hospital for Special Surgery (HSS) cohort and validated this new score for internal consistency, external validity (versus HOOS and WOMAC domains), responsiveness to THA, and floor and ceiling effects. Additional external validation was performed using calculated HOOS, JR scores in collaboration with the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) nationally representative joint replacement registry (n = 910).

RESULTS

The resulting six-item PROM (HOOS, JR) retained items only from the pain and activities of daily living domains. It showed high internal consistency (Person Separation Index, 0.86 [HSS]; 0.87 [FORCE]), moderate to excellent external validity against other hip surveys (Spearman's correlation coefficient, 0.60-0.94), very high responsiveness (standardized response means, 2.03 [95% CI, 1.84-2.22] [FORCE]; and 2.38 [95% CI, 2.27-2.49] [HSS]), and favorable floor (0.6%-1.9%) and ceiling (37%-46%) effects. External validity was highest for the HOOS pain (Spearman's correlation coefficient, 0.87 [95% CI, 0.86-0.89] [HSS]; and 0.87 [95% CI, 0.84-0.90] [FORCE]) and HOOS activities of daily living (Spearman's correlation coefficient, 0.94 [95% CI, 0.93-0.95] [HSS]; and 0.94 [95% CI, 0.93-0.96] [FORCE]) domains in the HSS validation cohort and the FORCE-TJR cohort.

CONCLUSIONS

The HOOS, JR provides a valid, reliable, and responsive measure of hip health for patients undergoing THA. This short-form PROM is patient relevant and efficient.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Movement-Pattern Training to Improve Function in People With Chronic Hip Joint Pain: A Feasibility Randomized Clinical Trial

Study Design Feasibility randomized clinical trial. Background Rehabilitation may be an appropriate treatment strategy for patients with chronic hip joint pain; however, the evidence related to the effectiveness of rehabilitation is limited. Objectives To assess feasibility of performing a randomized clinical trial to investigate the effectiveness of movement-pattern training (MPT) to improve function in people with chronic hip joint pain. Methods Thirty-five patients with chronic hip joint pain were randomized into a treatment (MPT) group or a control (wait-list) group. The MPT program included 6 one-hour supervised sessions and incorporated (1) task-specific training for basic functional tasks and symptom-provoking tasks, and (2) strengthening of hip musculature. The wait-list group received no treatment. Primary outcomes for feasibility were patient retention and adherence. Secondary outcomes to assess treatment effects were patient-reported function (Hip disability and Osteoarthritis Outcome Score), lower extremity kinematics, and hip muscle strength. Results Retention rates did not differ between the MPT (89%) and wait-list groups (94%, P = 1.0). Sixteen of the 18 patients (89%) in the MPT group attended at least 80% of the treatment sessions. For the home exercise program, 89% of patients reported performing their home program at least once per day. Secondary outcomes support the rationale for conduct of a superiority randomized clinical trial. Conclusion Based on retention and adherence rates, a larger randomized clinical trial appears feasible and warranted to assess treatment effects more precisely. Data from this feasibility study will inform our future clinical trial. Level of Evidence Therapy, level 2b-. J Orthop Sports Phys Ther 2016;46(6):452-461. Epub 26 Apr 2016. doi:10.2519/jospt.2016.6279.

Longitudinal assessment of MRI in hip osteoarthritis using SHOMRI and correlation with clinical progression

PURPOSE

To assess the evolution of MR imaging findings in normal volunteers and subjects with hip osteoarthritis (OA) over 1.5 years described by the semi-quantitative Scoring Hip OA with MRI (SHOMRI) scoring system and their correlation with the evolution of clinical parameters.

MATERIALS AND METHODS

Hip MRI studies of 18 subjects with [Kellgren-Lawrence (KL) score = 2/3; mean age = 54.4 ± 11.2 years; 27.8% women] and 36 controls without radiographic OA [KL = 0/1; mean age = 43.7 ± 12.8 years; 50.0% women] were assessed at baseline and after 1.5 years by using SHOMRI, and their clinical status was evaluated by using Harris Hip Score and Hip Disability and Osteoarthritis Outcome Score (HOOS). Imaging and clinical parameters at baseline and their change over time were compared between groups using Mann-Whitney U and Fisher׳s exact tests. Spearman׳s rank correlations and generalized linear models adjusted for age, sex, BMI, and KL were used to assess associations between imaging and clinical findings.

RESULTS

At baseline, OA subjects had significantly higher SHOMRI total scores than controls [median (IQR): 12.5 (6-19.5) vs. 7 (4-13.5); p = 0.024]. Over 1.5 years, only the progression rate of subchondral cysts was significantly higher in OA subjects than in controls (16.7% vs. 0.0%; p = 0.033), while no significant differences were found for any of the other SHOMRI subscales. Baseline bone-marrow edema pattern (BMEP) was significantly associated with worsening pain (HOOS subscale; p = 0.018) and hip-related quality of life (HOOS subscale; p = 0.044). Progression of subchondral cysts was significantly associated with worsening symptoms other than pain (HOOS subscale, p = 0.030). Baseline KL did not significantly correlate with worsening of any clinical symptoms (each, p > 0.05).

CONCLUSION

In this relatively young study population without or with mild to moderate radiographic hip OA, only minimal differences were found between groups regarding the progression of hip abnormalities as assessed by SHOMRI over 1.5 years. However, BMEP predicted clinical worsening and subchondral cyst progression was associated with worsening symptoms. Although longer follow-up periods are required, this suggests that SHOMRI is a useful tool to monitor hip abnormalities and their progression longitudinally.

Salvage of Monoblock Metal-on-Metal Acetabular Components Using a Dual-Mobility Bearing

BACKGROUND

Large-diameter, monoblock acetabular components have been used for both hip resurfacing arthroplasty and metal-on-metal (MoM) total hip arthroplasty (THA). If revision is required, one solution is to retain the shell and use a dual-mobility bearing.

METHODS

We reviewed the results of 25 revision THAs including 11 hip resurfacing arthroplasty and 14 MoM THAs where a monoblock acetabular component was mated to a dual-mobility bearing.

RESULTS

At a mean of 29 months, there was one failure, an intraprosthetic dislocation of the dual-mobility bearing. There was a significant decrease in serum metal ion levels postoperatively.

CONCLUSION

Retention of a well-fixed, monoblock MoM acetabular shell and mating it to a dual-mobility bearing in the setting of revision surgery seems to be a reasonable, low-morbidity option at short-term follow-up in appropriately positioned cups.

Nurse staffing and the work environment linked to readmissions among older adults following elective total hip and knee replacement

OBJECTIVE

To examine the effect of nurse staffing and the work environment on 10- and 30-day unplanned readmissions for US Medicare patients following elective total hip and knee replacement.

DESIGN

A cross-sectional analysis of secondary data.

SETTING

Acute care hospitals in California, Florida, New Jersey and Pennsylvania, during 2006.

PARTICIPANTS

Medicare patients (n = 112 017) admitted to an acute care hospital for an elective total hip or knee replacement.

MAIN OUTCOME MEASURES

The adjusted odds ratio (OR) of experiencing an unplanned readmission within 10 and 30 days of discharge following an elective total hip or knee replacement.

RESULTS

Our sample included 112 017 Medicare patients in 495 hospitals. Nearly 6% of the patients were readmitted within 30 days; more than half of whom were rehospitalized within 10 days. Adjusted for patient and hospital characteristics, patients had 8% higher odds of 30-day readmission and 12% higher odds of 10-day readmission, for each additional patient per nurse. Patients cared for in the best work environments had 12% lower odds of 30-day readmission.

CONCLUSIONS

Readmission outcomes following major joint replacement are associated with hospital nursing care. Attention to nurse work conditions may be central to improving readmissions in this postoperative Medicare population.

Are Range of Motion Measurements Needed When Calculating the Harris Hip Score?

BACKGROUND

Often the patient-reported outcome (PRO) component of the Harris Hip Score (HHS) is completed, but the physician-assessed range of motion (ROM) component is not. The PRO component only is called a modified Harris Hip Score (mHHS). The purpose of this study was to determine if a statistically significant or clinically meaningful difference existed when calculating the HHS with and without the physician-reported ROM portion.

METHODS

Included patients had complete HHS data (both physician and PRO components). Surgical procedure (primary or revision) was recorded for each subject. American Society of Anesthesiologists score was divided into low and high groups. Body mass index was divided into 4 categories. The study used a repeated measures design.

RESULTS

Data on 483 patients were collected between 12 and 60 months postoperatively (mean follow-up: 32.5 months, mean age: 55.9 ± 13.5 years). A mean difference of 4 points existed between the 2 groups: HHS group average score was 84.56 ± 13.18, and mHHS group average score was 88.74 ± 13.77. American Society of Anesthesiologists score, body mass index, and surgical type demonstrated a significant interaction with the HHS calculation method (P < .001). Primary total joint patients demonstrated a greater difference between the 2 scoring methods compared with revision patients.

CONCLUSION

No clinically meaningful difference in outcomes was found between the mHHS and the HHS. The calculation of the HHS is dependent on the inclusion of the ROM measurement. However, the small point difference between the HHS and mHHS indicates that the mHHS is still useful as an accurate determinant of patient clinical outcome, and ROM assessment is not essential.

The History of Patient-Reported Outcomes in Rheumatology

The rheumatology community began incorporating patient-reported outcomes in the early 1980s, helping shift the care of chronic diseases from a narrower biomedical model to a broader biopsychosocial model of health. Early efforts were focused primarily in clinical trials and clinical research, but over the last decade there has been increasing use in routine rheumatology clinical care. More than 250 valid and reliable scales to assess domains of importance to patients with rheumatic conditions have been developed. The approach to measurement continues to be refined. Rheumatology has much to be proud of in contributions to the important field of patient-reported outcomes.

Responsiveness and ceiling effects of the Forgotten Joint Score-12 following total hip arthroplasty

OBJECTIVES

To assess the responsiveness and ceiling/floor effects of the Forgotten Joint Score -12 and to compare these with that of the more widely used Oxford Hip Score (OHS) in patients six and 12 months after primary total hip arthroplasty.

METHODS

We prospectively collected data at six and 12 months following total hip arthroplasty from 193 patients undergoing surgery at a single centre. Ceiling effects are outlined with frequencies for patients obtaining the lowest or highest possible score. Change over time from six months to 12 months post-surgery is reported as effect size (Cohen's d).

RESULTS

The mean OHS improved from 40.3 (sd 7.9) at six months to 41.9 (sd 7.2) at 12 months. The mean FJS-12 improved from 56.8 (sd 30.1) at six months to 62.1 (sd 29.0) at 12 months. At six months, 15.5% of patients reached the best possible score (48 points) on the OHS and 8.3% obtained the best score (100 points) on the FJS-12. At 12 months, this percentage increased to 20.8% for the OHS and to 10.4% for the FJS-12. In terms of the effect size (Cohen's d), the change was d = 0.10 for the OHS and d = 0.17 for the FJS-12.

CONCLUSIONS

The FJS-12 is more responsive to change between six and 12 months following total hip arthroplasty than is the OHS, with the measured ceiling effect for the OHS twice that of the FJS-12. The difference in effect size of change results in substantial differences in required sample size if aiming to detect change between these two time points. This has important implications for powering clinical trials with patient-reported measures as the primary outcome.Cite this article: Dr D. F. Hamilton. Responsiveness and ceiling effects of the Forgotten Joint Score-12 following total hip arthroplasty. Bone Joint Res 2016;5:87-91. DOI: 10.1302/2046-3758.53.2000480.

Trajectories of Pain and Function after Primary Hip and Knee Arthroplasty: The ADAPT Cohort Study

Background and Purpose

Pain and function improve dramatically in the first three months after hip and knee arthroplasty but the trajectory after three months is less well described. It is also unclear how pre-operative pain and function influence short- and long-term recovery. We explored the trajectory of change in function and pain until and beyond 3-months post-operatively and the influence of pre-operative self-reported symptoms.

Methods

The study was a prospective cohort study of 164 patients undergoing primary hip (n = 80) or knee (n = 84) arthroplasty in the United Kingdom. Self-reported measures of pain and function using the Western Ontario and McMaster Universities Osteoarthritis index were collected pre-operatively and at 3 and 12 months post-operatively. Hip and knee arthroplasties were analysed separately, and patients were split into two groups: those with high or low symptoms pre-operatively. Multilevel regression models were used for each outcome (pain and function), and the trajectories of change were charted (0–3 months and 3–12 months).

Results

Hip: Most improvement occurred within the first 3 months following hip surgery and patients with worse pre-operative scores had greater changes. The mean changes observed between 3 and twelve months were statistically insignificant. One year after surgery, patients with worse pre-operative scores had post-operative outcomes similar to those observed among patients with less severe pre-operative symptoms. Knee: Most improvement occurred in the first 3 months following knee surgery with no significant change thereafter. Despite greater mean change during the first three months, patients with worse pre-operative scores had not ‘caught-up’ with those with less severe pre-operative symptoms 12 months after their surgery.

Conclusion

Most symptomatic improvement occurred within the first 3 months after surgery with no significant change between 3–12 months. Further investigations are now required to determine if patients with severe symptoms at the time of their knee arthroplasty have a different pre-surgical history than those with less severe symptoms and if they could benefit from earlier surgical intervention and tailored rehabilitation to achieve better post-operative patient-reported outcomes.

Arthroscopic Management of Dysplastic Hip Deformities: Predictors of Success and Failures With Comparison to an Arthroscopic FAI Cohort

BACKGROUND

Reports regarding arthroscopy for mild hip dysplasia have conflicting results.

HYPOTHESIS

Arthroscopy for borderline/mild hip dysplasia would lead to improved outcomes but be inferior to arthroscopy for femoroacetabular impingement (FAI).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 88 hips (77 patients, 71% female; mean age, 33.9 years) with dysplastic radiographic findings were retrospectively reviewed at a mean follow-up of 26.0 months after hip arthroscopy. Specific procedures included labral repair (76%), labral debridement (23%), capsular repair/plication (82%), and femoral osteochondroplasty (72%). Radiographic parameters included lateral center-edge angle, neck-shaft angle, Tönnis angle, extrusion index, femoral head lateralization, and break in the Shenton line. Pre- and postoperative function were evaluated prospectively with the modified Harris Hip Score (mHHS), 12-Item Short Form Health Survey, and visual analog scale for pain. The results of the dysplastic cohort were compared with an age-matched cohort of 231 hips without radiographic dysplasia that underwent arthroscopic FAI correction during the study period (mean follow-up, 22.7 months).

RESULTS

The mean lateral center-edge angle was 20.8° (range, 8.7°-24.5°), and the mean Tönnis angle was 11.0° (range, 0°-22.2°). At the time of final follow-up, the dysplastic cohort demonstrated a mean mHHS of 81.3 with a mean 15.6-point improvement in mHHS, compared with 88.4 and 24.4 points, respectively, in the FAI cohort (P = .00044). The dysplastic cohort had 60.9% good/excellent results and 32.2% failures, compared with 81.2% good/excellent results and 10.5% failures for the FAI cohort (P < .01). Failure was defined as an mHHS ≤70 or eventual pelvic/femoral osteotomy or total hip arthroplasty. Dysplastic hips that underwent capsular plication and labral repair had greater good/excellent results (73%) and mean latest mHHS (85), as well as lower failure rates (18%) compared with the remainder of the dysplastic cohort (P < .05). Grade 4 chondral defects were predictive of lower scores (P = .02). There were no other statistically significant differences for outcomes regarding sex, age, or radiographic parameters (P > .05). There were no iatrogenic subluxations/dislocations.

CONCLUSION

Arthroscopic management of mild to moderate acetabular dysplasia had inferior good/excellent results and higher failure rates when compared with an FAI cohort; therefore, isolated arthroscopic procedures in this population should be cautiously considered. These results were independent of patient sex. Labral repair and capsular plication resulted in better clinical outcomes in this mildly dysplastic cohort.

The current practice of handling and reporting missing outcome data in eight widely used PROMs in RCT publications: a review of the current literature

Purpose

Patient-reported outcome measures (PROMs) are designed to assess patients’ perceived health states or health-related quality of life. However, PROMs are susceptible to missing data, which can affect the validity of conclusions from randomised controlled trials (RCTs). This review aims to assess current practice in the handling, analysis and reporting of missing PROMs outcome data in RCTs compared to contemporary methodology and guidance.

Methods

This structured review of the literature includes RCTs with a minimum of 50 participants per arm. Studies using the EQ-5D-3L, EORTC QLQ-C30, SF-12 and SF-36 were included if published in 2013; those using the less commonly implemented HUI, OHS, OKS and PDQ were included if published between 2009 and 2013.

Results

The review included 237 records (4–76 per relevant PROM). Complete case analysis and single imputation were commonly used in 33 and 15 % of publications, respectively. Multiple imputation was reported for 9 % of the PROMs reviewed. The majority of publications (93 %) failed to describe the assumed missing data mechanism, while low numbers of papers reported methods to minimise missing data (23 %), performed sensitivity analyses (22 %) or discussed the potential influence of missing data on results (16 %).

Conclusions

Considerable discrepancy exists between approved methodology and current practice in handling, analysis and reporting of missing PROMs outcome data in RCTs. Greater awareness is needed for the potential biases introduced by inappropriate handling of missing data, as well as the importance of sensitivity analysis and clear reporting to enable appropriate assessments of treatment effects and conclusions from RCTs.

Electronic supplementary material

The online version of this article (doi:10.1007/s11136-015-1206-1) contains supplementary material, which is available to authorized users.

Junk in the joint: A trend for arthroscopic debridement to improve outcomes following closed reduction of traumatic hip dislocation

Purpose

To determine whether arthroscopic debridement following closed reduction of traumatic hip dislocation is associated with less persistent pain and functional impairment than closed reduction alone.

Methods

Retrospective comparative study, consisting of telephone interview, 2–14 years postinjury. Subjects were 15 patients aged 18 years or older at time of injury who received closed reduction of traumatic hip dislocation with arthroscopy (seven patients) or without arthroscopy (eight patients) at a level 1 trauma center between 2000 and 2012. The exposure was arthroscopic removal of intra-articular loose bodies following closed reduction. The primary outcome was the American Academy of Orthopaedic Surgeons® Hip & Knee Outcomes Questionnaire.

Results

Among the patients who received arthroscopy, the mean Hip & Knee Core Scale standardized score (0–100) was 98 (SD 2), as compared to 86 (SD 29) among patients who did not. These scores showed a statistical trend toward less pain and improved function in the arthroscopy group (p = 0.069). No patients in the arthroscopy group had scores below the average among healthy people, as compared to three of eight (38%) in the control group.

Conclusions

Patients who underwent arthroscopic debridement in addition to closed reduction had nonsignificant improvements in pain, stiffness, swelling, and functional impairment as compared to those who received closed reduction alone. Though not significant, these results warrant further study to determine whether arthroscopy is indicated for all patients suffering traumatic hip dislocation.

Level of Evidence

IV

Posterior wall acetabulum fracture-dislocation with subsequent ipsilateral pipkin IV fracture-dislocation: How many hits can a hip take?

The treatment of acetabulum fractures is a technically-demanding task for orthopaedic trauma surgeons. The treatment of femoral head fractures associated with acetabulum fractures, pipkin IV fractures, presents difficulty as usually the femoral head fracture requires treatment through an anterior approach and the acetabulum fracture, which is commonly a posterior wall fracture, requires treatment through a posterior approach. Recently, surgical dislocation of the hip has become an accepted option for treatment of these fractures as it allows treatment of the femoral head fracture and posterior wall acetabulum fracture through one approach. However, dual anterior and posterior approaches are acceptable. We present 15 year follow up of an 18 year old female who underwent open reduction internal fixation of a posterior wall acetabulum fracture through a Kocher–Langenbeck approach. Four months later the patient sustained a second fracture dislocation of the same hip, this time a femoral head fracture with an associated posterior wall acetabulum fracture that was treated with a Kocher–Langenbeck approach for the revision acetabulum and a approach for the femoral head fracture. At fifteen years the patient had a Merle d'Aubigne score of 15 and a Harris hip score of 71. She was gainfully employed and subjectively happy with her surgical result. While treatment of pipkin IV fracture dislocations can be treated through a surgical dislocation of the hip, dual surgical approaches are a viable option in certain cases.

Hip joint motion and gluteal muscle activation differences between healthy controls and those with varying degrees of hip osteoarthritis during walking

PURPOSE

Compare gluteal muscle activation patterns and three-dimensional hip joint movements among those with severe hip osteoarthritis (OA), moderate OA and a healthy group during walking.

SCOPE

20 individuals with severe OA, 20 with moderate OA and 20 healthy individuals were recruited. Three-dimensional hip motion and surface electromyograms from gluteus maximus and medius were collected during treadmill walking at a self-selected speed. Angular displacement characteristics were calculated for three-dimensional hip motions. Principal component analysis extracted amplitude and temporal features from electromyographic waveforms. Analysis of Variance models and student t-tests using Bonferroni corrections determined between group differences in these gait features (α = 0.05).

CONCLUSIONS

Sagittal plane hip range of motion was significantly reduced with increasing severity of OA (p < 0.05) where as frontal and transverse plane range of motion was reduced in the severe OA group only (p < 0.05). Activation patterns of gluteus medius and maximus did not differ between the healthy group and those with moderate hip OA (p > 0.05). Individuals with severe OA walking with more prolonged gluteus maximus activation and prolonged and less dynamic gluteus medius activation compared to the other two groups (p < 0.05). This study highlights the changing function of the hip joint during walking with increasing hip OA severity.

Second-Generation Versus First-Generation Cementless Tapered Wedge Femoral Stems

Clinical outcomes of a new second-generation proximally coated, tapered wedge cementless stem were compared with those of its predecessor regarding (1) all-cause implant survivorship; (2) objective and subjective outcomes; (3) complications; and (4) radiographic features. Patients who underwent a primary total hip arthroplasty with the second-generation stem (68 hips) were compared with those who received the first-generation stem (136 hips) at a mean follow-up of 3.5 years. Although the first-generation stem was designed in the traditional manner, the second-generation stem was shortened to accommodate all surgical approaches and designed using a computed tomography scan-based database to enhance fit. The second-generation stem had survivorship, functional, and subjective outcomes similar to those of the first-generation stem.

Effects of sensorimotor training volume on recovery of sensorimotor function in patients following lower limb arthroplasty

Background

Sensorimotor function is degraded in patients after lower limb arthroplasty. Sensorimotor training is thought to improve sensorimotor skills, however, the optimal training stimulus with regard to volume, frequency, duration, and intensity is still unknown. The aim of this study, therefore, was to firstly quantify the progression of sensorimotor function after total hip (THA) or knee (TKA) arthroplasty and, as second step, to evaluate effects of different sensorimotor training volumes.

Methods

58 in-patients during their rehabilitation after THA or TKA participated in this prospective cohort study. Sensorimotor function was assessed using a test battery including measures of stabilization capacity, static balance, proprioception, and gait, along with a self-reported pain and function. All participants were randomly assigned to one of three intervention groups performing sensorimotor training two, four, or six times per week. Outcome measures were taken at three instances, at baseline (pre), after 1.5 weeks (mid) and at the conclusion of the 3 week program (post).

Results

All measurements showed significant improvements over time, with the exception of proprioception and static balance during quiet bipedal stance which showed no significant main effects for time or intervention. There was no significant effect of sensorimotor training volume on any of the outcome measures.

Conclusion

We were able to quantify improvements in measures of dynamic, but not static, sensorimotor function during the initial three weeks of rehabilitation following TKA/THA. Although sensorimotor improvements were independent of the training volume applied in the current study, long-term effects of sensorimotor training volume need to be investigated to optimize training stimulus recommendations.

Trial registration

Clinical trial registration number: DRKS00007894

Satellite Cells CD44 Positive Drive Muscle Regeneration in Osteoarthritis Patients

Age-related bone diseases, such as osteoarthritis and osteoporosis, are strongly associated with sarcopenia and muscle fiber atrophy. In this study, we analyzed muscle biopsies in order to demonstrate that, in osteoarthritis patients, both osteophytes formation and regenerative properties of muscle stem cells are related to the same factors. In particular, thanks to immunohistochemistry, transmission electron microscopy, and immunogold labeling we investigated the role of BMP-2 in muscle stem cells activity. In patients with osteoarthritis both immunohistochemistry and transmission electron microscopy allowed us to note a higher number of CD44 positive satellite muscle cells forming syncytium. Moreover, the perinuclear and cytoplasmic expression of BMP-2 assessed by in situ molecular characterization of satellite cells syncytia suggest a very strict correlation between BMP-2 expression and muscle regeneration capability. Summing up, the higher BMP-2 expression in osteoarthritic patients could explain the increased bone mineral density as well as decreased muscle atrophy in osteoarthrosic patients. In conclusion, our results suggest that the control of physiological BMP-2 balance between bone and muscle tissues may be considered as a potential pharmacological target in bone-muscle related pathology.

Scoring hip osteoarthritis with MRI (SHOMRI): A whole joint osteoarthritis evaluation system

BACKGROUND

To develop a semi-quantitative MR-based hip osteoarthritis (OA) evaluation system (Scoring hip osteoarthritis with MRI, SHOMRI), and to test its reproducibility and face validity.

METHODS

The study involved 98 subjects with informed consent. Three-Tesla MR imaging of hip was performed in three planes with intermediate-weighted fat saturated FSE sequences. Two radiologists assessed cartilage loss, bone marrow edema pattern, subchondral cyst in 10 subregions, and assessed labrum in 4 subregions. In addition, presence or absence of ligamentum teres integrity, paralabral cysts, intra-articular body, and effusion in the hip joint were analyzed using the SHOMRI system. The reproducibility was assessed with intra-class correlation coefficient (ICC), Cohen's Kappa values and percent agreement. SHOMRI scores were correlated with radiographic Kellgren-Lawrence (KL) and OARSI atlas gradings, and clinical parameters, the hip osteoarthritis outcome score (HOOS) and hip range of motion (ROM), using Spearman's rank correlation and ordinal logistic regression.

RESULTS

ICC values were in the excellent range, 0.91 to 0.97. Cohen's Kappa values and percent agreement ranged from 0.55 to 0.79 and 66 to 99%, respectively. SHOMRI demonstrated significant correlations with KL and OARSI gradings as well as with clinical parameters, HOOS and ROM (P < 0.05). Among the SHOMRI features, subchondral cyst and bone marrow edema pattern showed the highest correlation with HOOS and ROM.

CONCLUSION

SHOMRI demonstrated moderate to excellent reproducibility and significant correlation with radiographic gradings and clinical parameters.

A cross-sectional study of perceived injustice and disability in hip osteoarthritis

OBJECTIVE

To determine the correlation among severity of hip osteoarthritis, disability, and Perceived injustice.

MATERIAL AND METHODS

A cohort of 46 participants with unilateral hip osteoarthritis underwent hip range of motion measurements and completed the Injustice Experience Questionnaire (IEQ), the Hip Disability and Osteoarthritis Outcome Score (HOOS), and a Croft radiological grading of osteoarthritis severity.

RESULTS

The mean age of the cohort was 62.7±10.4 years, and the cohort included 27 females. The mean duration of symptoms was 46.9±20.6 months. The means of each of the five subscales of the HOOS were as follows: Pain, 62.3±9.4; Other Symptoms, 56.7±9.6; Function in Activities of Daily Living (ADL), 58.2±6.7; Function in Sport and Recreation (Sport/Rec), 58.1±6.7; and Hip-Related Quality of Life (QOL) 59.9±7.5. The combined mean hip range of motion (abduction, adduction, flexion, extension, external rotation, internal rotation) was 215.9±10.9 degrees. The mean IEQ score (Perceived injustice) was 12.0±1.7. Of the available factors, only QOL, hip range of motion, and the Croft radiological osteoarthritis grade predicted Perceived injustice scores, with an R-squared of 0.81 in multiple regression analysis.

CONCLUSION

In this cohort of patients with unilateral osteoarthritis, more severe disease (as measured by restricted range of motion and radiological severity) was highly correlated with higher levels of Perceived injustice. Perceived injustice may thus reflect an appropriate response to the severity of the disease and is thus more likely a result of the disease process and subsequent disability rather than a cause of disability.

OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for hip osteoarthritis

The ability to assess the efficacy and effectiveness of an intervention for the treatment of hip osteoarthritis (OA) requires strong clinical trial methodology. This consensus paper provides recommendations based on a narrative literature review and best judgment of the members of the committee for clinical trials of hip OA. We provide recommendations on clinical trial design, outcome measures, including structural (radiography), and patient and physician global assessments, performance based measures, molecular markers and experimental endpoints including MRI imaging. This information can be utilized by sponsors of trials for new therapeutic agents for hip OA.

How is the experience of pain measured in older, community-dwelling people with osteoarthritis? A systematic review of the literature

The objective of the study was to perform a systematic review to identify and appraise outcome measures and measures of pain that are used to assess the experience of pain by older people with osteoarthritis, and to assess whether these measures are effective at capturing the multidimensional nature of the experience of this pain. A systematic review of five electronic databases from January 1996 to March 2013 was done. Inclusion criteria were cohort/observational and cross-sectional studies; specific diagnosis of OA; employed outcome measures of pain and/or health and/or quality of life which included questions about pain; and considered older adults. Articles were reviewed for methodological quality using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. A total of 14 publications met the inclusion criteria, and 11 discrete studies were included in the review. The studies used 21 different outcome measures, utilizing 13 measures of pain. Sensory, affective and cognitive dimensions of pain were captured by the measures, albeit studies predominantly measured intensity or severity alone. Measures of pain used in epidemiological studies do not adequately capture the multidimensional nature of the experience of pain in osteoarthritis. There is a fraught complexity in the multidimensionality of the experience of pain in osteoarthritis, and studies exploring osteoarthritis pain in older people should attempt to capture this multidimensionality by employing multiple valid and reliable outcome measures that capture specific dimensions of the pain experience.

Preliminary validation of the Review of Musculoskeletal System (ROMS) questionnaire

BACKGROUND

Measurement of clinical outcomes is necessary to define best practice. It requires a validated tool that can be easily applied as part of clinical practice. We present the preliminary validation of a brief self-reported Review of Musculoskeletal System (ROMS) questionnaire that captures functional limitations due to musculoskeletal problems and other medical and emotional conditions.

METHODS

Data were derived from a clinical outcomes database (Orthopaedic Minimal Data Set [OrthoMiDaS]) that combines patient-reported data collected as part of routine care and secondary data extracted from electronic medical records. The study utilized 82,873 encounters collected from 24,116 consecutive patients with problems in the upper and lower extremities. In addition to the ROMS, the study used version 2 of the Short Form-12 (SF-12v2), the Penn Shoulder Score (PSS), the Hip disability and Osteoarthritis Outcome Score (HOOS), and the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaires. Fifteen cross-sectional samples were used to evaluate the floor and ceiling effects as well as the construct and content validity. Five longitudinal cohorts were used to measure test-retest reliability and responsiveness. Standard statistical tests were applied.

RESULTS

The floor and ceiling effects of the ROMS questionnaire in patients with shoulder, hip, and knee problems ranged from 1.3% to 8.5%. Construct-validity tests confirmed convergent and divergent validity of the ROMS. The tests also justified its additional value when the ROMS was used with joint-specific tools. When measuring test-retest reliability of the ROMS scales, intraclass correlation ranged from 0.80 to 0.90 at approximately one week and from 0.71 to 0.87 at approximately four weeks. Responsiveness of the ROMS was greater than that of the SF-12 and less than that of the joint-specific questionnaires.

CONCLUSIONS

The ROMS is compatible with routine clinical process and has good psychometric properties in patients with shoulder, hip, and knee disorders. It can be used as a primary outcome tool for large observational studies and can supplement more specific tools in controlled studies.

CLINICAL RELEVANCE

The ROMS was developed as a tool to measure and monitor the clinical status of the musculoskeletal system in a population of patients during and after treatment as well as over time.

Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis

The objective of this study is to compare the clinical, radiographic and surgical outcomes among patients undergoing primary THA performed via the anterior versus posterior approach. We searched numerous sources and eventually included 17 studies, totaling 2302 participants. In terms of post-operative pain and function, the anterior approach was significantly favored in 4 studies at short-term follow-up. Pooled estimates showed a significant difference in favor of the anterior approach in terms of length of stay and dislocations. Current evidence comparing outcomes following anterior versus posterior THA does not demonstrate clear superiority of either approach. Until more rigorous, randomized evidence is available, we recommend choice of surgical approach for THA be based on patient characteristics, surgeon experience and surgeon and patient preference.

A phase II trial for the efficacy of physiotherapy intervention for early-onset hip osteoarthritis: study protocol for a randomised controlled trial

Background

Early-onset hip osteoarthritis is commonly seen in people undergoing hip arthroscopy and is associated with increased pain, reduced ability to participate in physical activity, reduced quality of life and reduced range of motion and muscle strength. Despite this, the efficacy of non-surgical interventions such as exercise therapies remains unknown. The primary aim is to establish the feasibility of a phase III randomised controlled trial investigating a targeted physiotherapy intervention for people with early-onset hip osteoarthritis. The secondary aims are to determine the size of treatment effects of a physiotherapy intervention, targeted to improve hip joint range and hip-related symptoms in early-onset hip osteoarthritis following hip arthroscopy, compared to a health-education control.

Methods

This protocol describes a randomised, assessor- and participant-blind, controlled clinical trial. We will include 20 participants who are (i) aged between 18 and 50 years; (ii) have undergone hip arthroscopy during the past six to 12 months; (iii) have early-onset hip osteoarthritis (defined as chondrolabral pathology) at the time of hip arthroscopy; and (iv) experience hip-related pain during activities. Primary outcome will be the feasibility of a phase III clinical trial. Secondary outcomes will be (i) perceived global change score; (ii) hip-related symptoms (measured using the Hip disability and Osteoarthritis Outcome Score (HOOS) pain subscale, activity subscale, and sport and recreation subscale); (iii) hip quality of life (measured using the HOOS quality of life subscale and International Hip Outcome tool; (iv) hip muscle strength and (v) hip range of motion. The physiotherapy intervention is semi-standardised, including joint and soft tissue mobilisation and stretching, hip and trunk muscle retraining and functional and activity-specific retraining and education. The control intervention encompasses individualised health education, with the same frequency and duration as the intervention. The trial primary end-point is the conclusion of the 12-week intervention, and follow-up measures will be collected at the 12-week post-baseline assessment.

Discussion

The findings of this study will provide guidance regarding the feasibility of a full-scale phase III randomised controlled trial, prior to its undertaking.

Trial registration

The trial protocol was registered with the Australian Clinical Trials Registry (number: 12614000426684) on 17 April 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-014-0543-7) contains supplementary material, which is available to authorized users.

Radiographic Hip Involvement in Ankylosing Spondylitis: Factors Associated with Severe Hip Diseases

Objective.

To determine the factors associated with severe radiographic hip involvement in patients with ankylosing spondylitis (AS).

Methods.

A cross-sectional retrospective study was performed. The patients were classified into 3 groups based on the Bath Ankylosing Spondylitis Radiology Hip Index (BASRI-hip): minimal hip disease, moderate hip disease, and severe hip disease. Demographic, clinical, radiographic, and laboratory data were collected and analyzed. To identify factors associated with severe hip disease, ordinal regression analyses were performed.

Results.

A total of 256 patients were involved in the study. There were differences in the age at onset, delay in diagnosis, bilateral hip involvement, sacroiliitis, Schober’s index, and occiput-to-wall distance among the 3 groups (p < 0.05). The patients with severe hip disease had lower C-reactive protein and erythrocyte sedimentation rate levels than did the minimal group (p < 0.05). The functional status based on the Bath Ankylosing Spondylitis Functional Index and the Harris Hip Score showed significant differences (p < 0.05). The results of the ordinal regression analyses showed that bilateral hip involvement, sacroiliitis, delay in diagnosis, age at onset, and spinal involvement were associated with a higher BASRI-hip (p < 0.05).

Conclusion.

Bilateral hip involvement, severe sacroiliitis, longer delay in diagnosis, early disease onset, and spinal involvement are associated with severe hip disease in patients with AS. The severity of hip involvement is associated with the functional status in AS.

Unipolar hemiarthroplasty versus bipolar hemiarthroplasty in patients with displaced femoral neck fractures: a four-year follow-up of a randomised controlled trial

PURPOSE

The treatment of choice for a displaced femoral neck fracture in the most elderly patients is a cemented hemiarthroplasty (HA). The optimal design, unipolar or bipolar head, remains unclear. The possible advantages of a bipolar HA are a better range of motion and less acetabular wear. The aim of this study was to evaluate hip function, health related quality of life (HRQoL), surgical outcome and acetabular erosion in a medium-term follow-up.

METHODS

One hundred and twenty patients aged 80 or more with a displaced fracture of the femoral neck (Garden III and IV) were randomised to treatment with a cemented Exeter HA using a unipolar or a bipolar head. All patients were able to walk independently, with or without aids, before surgery. Follow-ups were performed at four, 12, 24 and 48 months postoperatively. Assessments included HRQoL (EQ-5D index score), hip function (Harris hip score [HHS]) and radiological acetabular erosion.

RESULTS

The mean EQ-5D index score was generally higher among the patients with bipolar hemiarthroplasties at the follow-ups with a significant difference at 48 months: unipolar HAs 0.59 and bipolar HAs 0.70 (p = 0.04). There was an increased rate of acetabular erosion among the patients with unipolar hemiarthroplasties at the early follow-ups with a significant difference at 12 months (unipolar HAs 20% and bipolar HAs 5%, p = 0.03). At the later follow-ups the incidence of acetabular erosion accelerated in the bipolar group, and there were no significant differences between the groups at the 24- and 48-month follow-ups. There was no difference in HHS or reoperation rate between the groups at any of the follow-ups.

CONCLUSION

The bipolar HAs seem to result in better HRQoL beyond the first two years after surgery compared to unipolar HAs. Bipolar HAs displayed a later onset of acetabular erosion compared to unipolar HAs.

Total hip arthroplasty through the mini-incision (Micro-hip) approach versus the standard transgluteal (Bauer) approach: a prospective, randomised study

PURPOSE

To compare outcome after total hip arthroplasty (THA) through the mini-incision approach versus the standard transgluteal approach.

METHODS

80 women and 63 men aged 33 to 89 (mean, 62) years with primary osteoarthritis of the hip were randomised to undergo unilateral THA through a mini-incision approach (Micro-hip, n=55) or standard, lateral, transgluteal approach (Bauer, n=88). Levels of haemoglobin, haematocrit, serum creatine kinase, and C-reactive protein, length of hospital stay, mobilisation, and any complication were recorded. Visual analogue scale (VAS) for pain was assessed. Hip function was assessed using the Harris Hip Score and the Oxford Hip Score, whereas general health was assessed using the EQ-5D general health questionnaire. The cup inclination and varus/valgus of the stem position were measured using a goniometer.

RESULTS

The Micro-hip group achieved a significantly lower mean incision length (9.3 vs. 13.4 cm, p<0.001), mean surgical time (60 vs. 68 minutes, p=0.021), mean reduction in haemoglobin level (2.1 vs. 2.8 g/dl, p<0.001), and mean VAS for pain from hour 6 to day 6 (all p<0.05). One patient in the Micro-hip group developed early aseptic loosening of the cup and underwent revision surgery at month 4. Three patients in the Bauer group and one patient in the Micro-hip group sustained intra-operative nondisplaced fractures of the proximal femur, which were fixed with cerclages. Two patients in the Microhip group developed deep vein thrombosis during week 1.

CONCLUSION

THA through the Micro-hip approach achieved faster pain relief.