Associations between pre-operative radiographic osteoarthritis severity and pain and function after total hip replacement

Should We Wait for Bone-on-Bone Arthritis? Equivalent Clinical Outcomes in Patients Requiring Advanced Imaging Prior to Primary Total Hip Arthroplasty

INTRODUCTION

Plain radiographs remain the standard for diagnosing osteoarthritis (OA). Total hip arthroplasty (THA) is generally offered only for advanced OA by plain radiographs. Advanced imaging is used as an adjunct to assess OA severity in cases of progressive symptoms with less advanced OA by plain radiographs. The objective of this study was to compare outcomes following THA in patients who have advanced OA visualized by plain radiographs to patients who have less severe OA visualized by plain radiographs.

METHODS

From February 2016 to February 2020, 93 patients who had Kellgren-Lawrence (KL) grade 0 to 2 OA and underwent THA were identified. The median age was 65 years, and 55% were women. They were matched 1:3 to patients who underwent THA for KL 4 OA based on age, sex, BMI, and Charlson Comorbidity Index. The primary outcome was achievement of the Hip Injury and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) at 1 year postoperatively.

RESULTS

There was no difference between the KL 0 to 2 and KL 4 cohorts in the achievement of HOOS JR MCID (86 versus 85.6%, P = 0.922), SCB (81.7 versus 80.2%, P = 0.751), or PASS (89.2 versus 85.6%, P = 0.374). The KL 0 to 2 cohort had a similar improvement in their 2-year HOOS JR (42.5 versus 38.6, P = 0.019).

CONCLUSION

In this series, there was no difference in outcomes following primary THA between patients who have severe OA on plain radiographs (KL 4) compared to those who have less severe OA (KL 0 to 2). In the setting of severe symptoms and the absence of advanced OA on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from THA.

Can Patients Who Have Low-Grade Hip Osteoarthritis Expect the Same Outcome After Total Hip Arthroplasty Compared to Those Who Have End-Stage Osteoarthritis? - A Matched Case-Control Study

BACKGROUND

Total hip arthroplasty (THA) is an effective procedure for patients with end-stage hip osteoarthritis (OA). In addition, when hip preservation surgery is no longer indicated due to the presence of early or mild arthritic changes, THA can also be considered. Whether these patients can expect the same outcome after THA as patients who have end-stage OA remains unclear. The goal of this study was to compare the clinical outcomes after THA of patients who have low-grade OA versus a matched cohort with end-stage OA.

METHODS

This is a retrospective, single-center, multisurgeon case-control study in a high-volume referral center. Based on a cohort of 2,189 primary anterior approach THAs (1,815 patients), 50 low-grade OA cases were matched 1:1 by age, sex, and body mass index to 50 controls who have end-stage OA. Patient-reported outcome measures (PROMs) were Hip Disability and Osteoarthritis Outcome Scores and Short Form-36.

RESULTS

No significant differences in preoperative PROMs between low-grade and end-stage OA patients were found, except for 36-item Short Form Survey pain (33.0 versus 41.0; P = .045). In both groups a significant improvement of all PROMs was found postoperatively. However, all Hip Disability and Osteoarthritis Outcome Scores were significantly lower in the low-grade OA group compared to the end-stage OA group. In the group with low-grade OA, a significantly lower percentage of patients achieved the minimal clinically important difference and substantial clinical benefit after THA compared to the group with end-stage OA.

CONCLUSIONS

Patients who have low-grade OA can expect substantial clinical improvement after THA. However, the improvement is lower compared to patients who have end-stage OA. A thorough understanding of the factors that may lead to inferior clinical outcomes is imperative to improving the indications for THA in individuals who have low-grade OA.

Risk factors for pain after total hip arthroplasty: a systematic review

BACKGROUND

Approximately 23% of patients develop hip pain after total hip arthroplasty (THA). In this systematic review, we aimed to identify risk factors associated with postoperative pain after THA to optimize preoperative surgical planning.

METHODS

Six literature databases were searched for articles published from January 1995 to August 2020. Controlled trials and observational studies that reported measurements of postoperative pain with assessments of preoperative modifiable and non-modifiable risk factors were included. Three researchers performed a literature review independently.

RESULTS

Fifty-four studies were included in the study for analysis. The most consistent association between worse pain outcomes and the female sex is poor preoperative pain or function, and more severe medical or psychiatric comorbidities. The correlation was less strong between worse pain outcomes and preoperative high body mass index value, low radiographic grade arthritis, and low socioeconomic status. A weak correlation was found between age and worse pain outcomes.

CONCLUSIONS

Preoperative risk factors that were consistently predictive of greater/server postoperative pain after THA were identified, despite the varying quality of studies that prohibited the arrival of concrete conclusions. Modifiable factors should be optimized preoperatively, whereas non-modifiable factors may be valuable to patient education, shared decision-making, and individualized pain management.

Preoperative Factors and Patient-Reported Outcomes After Total Hip Arthroplasty: Multivariable Prediction Modeling

BACKGROUND

Although total hip arthroplasty (THA) has been established as a cost-effective intervention, some patients experience ongoing pain and dissatisfaction. There is interest in predicting postoperative outcomes based on preoperative data, but the relative contribution of different preoperative factors is unclear. The study's aim was to develop multivariable prediction models for the assessment of patient-reported outcomes.

METHOD

Registry data on 1412 patients undergoing THA for osteoarthritis at two hospitals between 2013 and 2018 was used. Potential predictors included age, sex, body mass index, spoken language, education level, previous THA, American Society of Anaesthesiologists (ASA) score, lower back pain, depression/anxiety, other lower limb arthritis, number of other comorbidities, the preoperative expectation of pain and function, EuroQol Visual Analogue Scale (EQ-VAS) and preoperative OHS. Radiographic scores were also used: joint space narrowing (JSN), osteophytes, sclerosis, and an overall grade based on the Kellgren-Lawrence (KL) classification. Outcomes assessed were the patient-rated improvement, satisfaction, and OHS at six months.

RESULTS

JSN or overall KL scores were the most important predictors (P < .001) for all outcomes, with better radiographic scores associated with worse outcomes. Other predictors associated with poorer outcomes were lower back pain and lower expectation (predicting poor improvement), lower education and higher ASA (predicting lower satisfaction) and younger age, female sex, non-English speakers, lower preoperative EQ-VAS, lower education, back pain, and anxiety/depression (predicting lower OHS).

CONCLUSION

Preoperative radiological scores are an important predictor of patient-reported outcomes at six months postoperatively. Understanding the relative strengths and significance of different factors in predicting outcomes will help the clinician and patient decision-making for THA.

Osteomyelitis variolosa, an issue inherited from the past: case report and systematic review

Background

Osteomyelitis variolosa is a self-limiting disease triggered by variola virus that cannot be prevented or repaired. Smallpox has been eradicated for 40 years, and complications that remain after smallpox has been cured have become a remarkable diagnostic challenge for contemporary physicians. In this systematic review, we searched PubMed (MEDLINE), Web of Science, and Google Scholar for cases on complications, diagnosis, and treatment for osteomyelitis variolosa between January 1980 and February 2021.

Results

Ten papers and eleven finished cases, all patients from India, were included for comparison with the present case. In total, 100% of patients presented with bilateral elbow deformities, the ankle was the second most common site of lesion in 50%, and knee lesions accounted for 25% in this study. Flexion contracture, joint instability, secondary arthritis, and fracture are common complications of osteomyelitis variolosa, and most patients receive conservative treatment, while internal fixation has good results for combined fractures.

Conclusions

Although osteomyelitis variolosa is not a direct threat to the safety of patients, severe skeletal deformities can have a significant impact on quality of life. With advances in surgical techniques, clinicians are offering an increasing number of treatment options for patients with osteomyelitis variolosa. However, most importantly, smallpox has basically been removed from the historical arena, and for areas where smallpox was once endemic, physicians need to deepen the understanding of this disease again.

Predicting outcomes in patients undergoing intra-articular corticosteroid hip injections

OBJECTIVE

To investigate the associations between clinical, procedural, and radiographic factors and outcomes of steroid hip injections, including long-term and immediate pain reduction, time to arthroplasty, time to reinjection, and the total number of injections.

MATERIALS AND METHODS

All intra-articular anesthetic and steroid injections of the hip under fluoroscopic guidance between January 2014 and March 2016 were retrospectively reviewed. Hip radiographs were scored using the Kellgren-Lawrence (KL) and Osteoarthritis Research Society International (OARSI) scores. Immediate pain relief and response were evaluated using a change in visual analog scale and OMERACT-OARSI criteria respectively. Long-term pain relief was evaluated at 2‑7 months after injection by reviewing the medical records. Correlation between patient characteristics, procedural variations, and radiographic factors with injection outcomes was analyzed by using linear and logistic regression models.

RESULTS

Of 361 injections, 79.8% showed an immediate pain response and 32.7% had subjective long-term pain relief (> 2 months). There was no significant correlation between immediate pain relief and response with long-term pain relief and other outcomes. Older age and higher KL score, OARSI-central joint space narrowing (JSN), and inferior acetabular osteophyte were correlated with long-term pain relief (p = 0.01‑0.03). Higher KL and OARSI grades, particularly JSN, were significantly correlated with increased immediate pain relief and total number of injections but decreased time to arthroplasty. Baseline pain positively correlated with immediate pain response (p < 0.001).

CONCLUSIONS

Older patients with higher grades of radiographic OA and high baseline pain were good candidates for steroid injections, particularly for those patients awaiting hip arthroplasty.

The Outcomes of Nonoperative Management of Patients With Hip and Knee Osteoarthritis Triaged to a Physiotherapy-Led Clinic at Minimum 5-Year Follow-Up and Factors Associated With Progression to Surgery

BACKGROUND

The purpose of this study is to determine outcomes of a nonoperative treatment service for hip and knee osteoarthritis (OA), the "Joint Clinic," at minimum 5-year follow-up, and investigate factors that may influence progression to joint replacement surgery.

METHODS

This is an observational cohort study of 337 patients with hip (n = 151, 45%) or knee OA (n = 186, 55%) seen at the Joint Clinic, at 5-7 years of follow-up. Kaplan-Meier survival curves were used to determine survivorship of the affected joint and Cox regression used to determine factors associated with time to surgery.

RESULTS

At mean 6-year follow up, 188 (56%) patients had undergone or were awaiting total joint arthroplasty, 127 (38%) were still being managed nonoperatively, and 22 (7%) had died without having surgery. Patients with hip OA were more likely to have required surgery (111/151, 74%) than patients with knee OA (77/186, 41%) (chi-square = 33.6, P < .001). The 7-year surgery-free survival for hip OA was 23.7% and knee OA 55.9% (P < .001). Factors associated with increased likelihood of surgery were joint affected (hip, hazard ratio [HR] 2.80), Kellgren-Lawrence (KL) grade (KL 3, HR 2.02; KL 4, 4.79), and Oxford Hip/Knee Score (HR 1.34 for each 5 points worse at baseline).

CONCLUSION

More than 50% of the patients referred to secondary care with mild-moderate knee OA may not need surgery at 7 years. Patients with hip OA and those with severe radiographic changes are more likely to require surgery and should not be delayed if there is not an adequate response to conservative measures.

Osteoarthritis

Osteoarthritis is a leading cause of disability and source of societal cost in older adults. With an ageing and increasingly obese population, this syndrome is becoming even more prevalent than in previous decades. In recent years, we have gained important insights into the cause and pathogenesis of pain in osteoarthritis. The diagnosis of osteoarthritis is clinically based despite the widespread overuse of imaging methods. Management should be tailored to the presenting individual and focus on core treatments, including self-management and education, exercise, and weight loss as relevant. Surgery should be reserved for those that have not responded appropriately to less invasive methods. Prevention and disease modification are areas being targeted by various research endeavours, which have indicated great potential thus far. This narrative Seminar provides an update on the pathogenesis, diagnosis, management, and future research on osteoarthritis for a clinical audience.

Body Mass Index Is Associated With All-cause Mortality After THA and TKA

BACKGROUND

Both obesity and underweight are associated with a higher risk of mortality in adulthood, but the association between mortality after arthroplasty and extreme ranges of body mass index (BMI) have not been evaluated beyond the first year.

QUESTIONS/PURPOSES

The purpose of this study was to investigate the association between BMI and all-cause mortality after TKA and THA.

METHODS

Data from two arthroplasty registries, the St Vincent's Melbourne Arthroplasty (SMART) Registry from Australia and the Kaiser Permanente Total Joint Replacement Registry (KPTJRR) from the United States, were used to identify patients aged ≥ 18 years undergoing elective TKAs and THAs between January 1, 2002, and December 31, 2013. Same-day bilateral THA and hemiarthroplasties were excluded. All-cause mortality was recorded from the day of surgery to the end of the study (December 31, 2013). Data capture was complete for the SMART Registry. No patients were lost to followup in the KPTJRR cohort and 2959 (5%) THAs and 5251 (5%) TKAs had missing data. Cox proportional hazard regression was used to estimate the all-cause mortality associated with six BMI categories: underweight (< 18.5 kg/m), normal weight (18.5-24.9 kg/m), overweight (25.0-29.9 kg/m), obese class I (30.0-34.9 kg/m), obese class II (35.0-39.9 kg/m), and obese class III (> 40 kg/m). For TKA, the SMART cohort had a median followup of 5 years (range, 0-12 years) and the KPTJRR cohort had a median followup of 4 years (range, 0-12 years). For THA, the SMART cohort had a median followup of 5 years (range, 0-12 years) and the KPTJRR cohort had a median followup of 4 years (range, 0-12 years).

RESULTS

In both the Australian and US cohorts, being underweight (Australia: hazard ratio [HR], 3.72; 95% confidence interval [CI], 1.94-7.08; p < 0.001 and United States: HR, 1.88; 95% CI, 1.33-2.64; p < 0.001) was associated with higher all-cause mortality after TKA, whereas obese class I (Australia: HR, 0.66; 95% CI, 0.47-0.92; p = 0.015; United States: HR, 0.71; 95% CI, 0.66-0.78; p < 0.001) or obese class II (Australia: HR, 0.54; 95% CI, 0.35-0.82; p = 0.004; United States: HR, 0.73; 95% CI, 0.66-0.81; p < 0.001) was associated with lower mortality when compared with normal-weight patients. In the US cohort, being overweight was also associated with a lower risk of mortality (HR, 0.76; 95% CI, 0.71-0.82; p < 0.001). In the US cohort, being underweight had a higher risk of mortality after THA (HR, 2.09; 95% CI, 1.65-2.64; p < 0.001), whereas those overweight (HR, 0.73; 95% CI, 0.67-0.80; p < 0.001), obese class I (HR, 0.68; 95% CI, 0.62-0.75; p < 0.001), or obese class II (HR, 0.71; 95% CI, 0.62-0.81; p < 0.001) were at a lower risk of mortality after THA when compared with normal-weight patients. In patients undergoing THA in the Australian cohort, we observed no association between BMI and risk of death.

CONCLUSIONS

We found that even severe obesity is not associated with a higher risk of death after arthroplasty. Patients should be informed of this when considering surgery. Clinicians should be cautious when considering total joint arthroplasty in underweight patients without first considering their nutritional status.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The Influence of Radiological Severity and Symptom Duration of Osteoarthritis on Postoperative Outcome After Total Hip Arthroplasty: A Prospective Cohort Study

BACKGROUND

We aimed to investigate the influence of preoperative radiological severity and symptom duration of hip osteoarthritis (OA) on the postoperative functional outcome, quality of life, as well as abductor muscle strength after total hip arthroplasty (THA).

METHODS

In this prospective cohort study, we studied 250 patients. Preoperatively, we evaluated the function with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and quality of life with euroqol-5D (EQ-5D). At 1 year after THA, the same scores and also hip abductor muscle strength were measured in 222 patients. We divided the cohort twice, first according to the radiological OA severity [Kellgren-Lawrence classification (KL)] and then according to the OA symptom duration. We investigated whether the preoperative KL class and symptom duration influenced the 1-year WOMAC (primary outcome measure) or EQ-5D and abductor muscle strength (secondary outcome measures).

RESULTS

The crude results showed that KL class and symptom duration had no influence (P = .90 and P = .20, respectively) on the 1-year WOMAC. Younger age, male gender, and lower body mass index were associated with a better function. Regarding 1-year EQ-5D, the crude results showed that body mass index and KL class had no influence (P = .83 and P = .39, respectively). The adjusted results showed that only age and gender influenced the postoperative EQ-5D. No influence of the tested factors was found on the 1-year abductor muscle strength.

CONCLUSION

Preoperative radiological OA severity and symptom duration had no influence on the outcome of THA and should probably not affect the decision about timing the operative intervention.

LncRNA DANCR involved osteolysis after total hip arthroplasty by regulating FOXO1 expression to inhibit osteoblast differentiation

Background

Aseptic loosening of artificial hip joint is a major complication affecting the long-term use of the artificial hip joint, and is the main cause of joint replacement failure. However, the mechanism of aseptic loosening of THR has not yet cleared. The aim of this study was to investigate the underlying mechanism of DANCR in osteoblast differentiation (OD).

Methods

We detected the expressions of DANCR and FOXO1 in clinical samples and mesenchymal stem cells (MSCs) by qRT-PCR and western blotting. The effects of polymethylmethacrylate (PMMA) on OD of MSCs were examined by alkaline phosphatase (ALP) activity and Alizarin Red S (ARS) staining. The expressions of OD markers were measured by qRT-PCR and western blotting. The mechanism of DANCR in OD was detected by RNA pull-down, RNA immunoprecipitation (RIP) assay and ubiquitination assays.

Results

Compared with the surrounding normal tissues, DANCR expression was up-regulated and FOXO1 expression was down-regulated in periprosthetic tissues. PMMA suppressed ALP activity, increased DANCR expression, and decreased the expressions of FOXO1, Runx2, Osterix (Ostx) and osteocalcin (OCN). ARS staining showed that PMMA inhibited the OD of MSCs. Knockdown of DANCR attenuated the inhibitory effect of PMMA on OD. Knockdown of FOXO1 could reverse the effect of si-DANC. RNA pull-down and RIP assay implicated that DANCR bound to FOXO1. Ubiquitination assay indicated that si-DANCR could repress Skp2-mediated ubiquitination of FOXO1.

Conclusion

LncRNA DANCR could inhibit OD by regulating FOXO1 expression.

Predictors of response to prefabricated foot orthoses or rocker-sole footwear in individuals with first metatarsophalangeal joint osteoarthritis

BACKGROUND

Osteoarthritis of the first metatarsophalangeal joint (1st MTPJ OA) is a common and disabling condition commonly managed with footwear and orthotic interventions. The objective of this study was to identify factors associated with a successful treatment response in people with 1st MTPJ OA provided with prefabricated orthoses or rocker-sole footwear as part of a randomised clinical trial.

METHODS

People with 1st MTPJ OA (n = 88) who participated in a randomised trial were allocated to receive prefabricated foot orthoses (n = 47) or rocker-sole footwear (n = 41) and completed a baseline questionnaire including information on demographics, anthropometrics, general health, pain characteristics (including the Foot Health Status Questionnaire [FHSQ] and Foot Function Index [FFI]) and perceptions of the interventions, and a clinical assessment of foot posture, range of motion, radiographic severity and in-shoe plantar pressures. Adherence was documented using diaries. At 12 weeks, participants documented their perception of improvement on a 15-point scale. Those reporting at least moderate improvement on this scale were classified as 'responders'.

RESULTS

There were 29 responders (62%) in the orthoses group and 16 responders (39%) in the rocker-sole group. In the orthoses group, responders had greater baseline pain severity while walking, a higher FFI difficulty score, and wore their orthoses more frequently. In the rocker-sole group, responders had a higher FFI stiffness score and greater radiographic severity. However, the accuracy of these variables in identifying responders in each group was modest (62 and 53%, respectively).

CONCLUSION

The response to prefabricated orthoses or rocker-sole footwear in people with 1st MTPJ OA is related to measures of increased pain and disease severity. However, the overall classification accuracy associated with these factors is not sufficient for identifying individuals who are most likely to benefit from these interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12613001245785.

Differences in presentation, progression and rates of arthroplasty between hip and knee osteoarthritis: Observations from an osteoarthritis cohort study-a clear role for conservative management

Aim

To describe the natural progression and the rates of arthroplasty of a cohort of hip and knee osteoarthritis (OA) patients.

Methods

An observational study of 247 consecutive patients who attended an OA clinic between May 2008 and August 2009. Follow‐up survey was conducted from July 2014 to December 2014, with the primary end point being joint replacement surgery.

Results

One hundred and sixty‐seven patients had knee OA and 80 patients had hip OA. When adjusted for other variables (age, gender, body mass index, Kellgren‐Lawrence stage, symptom duration, presence of OA elsewhere and pain score), patients with hip OA demonstrated 86% increased hazard of surgery compared to knee OA patients (95% CI increase of 19% to 193%). At 6 years after initial consultation, 67% of patients with knee OA did not require a knee replacement surgery, while 40% (30, 51) of hip OA patients did not undergo surgery (95% CI: 59–74%). Overall at 6 years, 58% of patients (95% CI: 51–64%) did not undergo joint replacement surgery.

Conclusion

Knee and hip OA patients appear to behave differently, with hip OA patients more likely to undergo arthroplasty. There is a significant number of both hip OA and knee OA patients who did not require arthroplasty at the end of 6 years, suggesting a major role for conservative therapy.

Central sensitization as a determinant of patients' benefit from total hip and knee replacement

Background

Discrepancies exist between osteoarthritic joint changes and pain severity before and after total hip (THR) and knee (TKR) replacement. This study investigated whether the interaction between pre‐operative widespread hyperalgesia and severity of radiographic osteoarthritis (OA) was associated with pain severity before and after joint replacement.

Methods

Data were analysed from 232 patients receiving THR and 241 receiving TKR. Pain was assessed pre‐operatively and at 12 months post‐operatively using the WOMAC Pain Scale. Widespread hyperalgesia was assessed through forearm pressure pain thresholds (PPTs). Radiographic OA was evaluated using the Kellgren and Lawrence scheme. Statistical analysis was conducted using multilevel models, and adjusted for confounding variables.

Results

Pre‐operative: In knee patients, there was weak evidence that the effect of PPTs on pain severity was greater in patients with more severe OA (Grade 3 OA: ß = 0.96 vs. Grade 4: ß = 4.03), indicating that in these patients higher PPTs (less widespread hyperalgesia) was associated with less severe pain. In hip patients, the effect of PPTs on pain did not differ with radiographic OA (Grade 3 OA: ß = 3.95 vs. Grade 4: ß = 3.67).

Post‐operative: There was weak evidence that knee patients with less severe OA who had greater widespread hyperalgesia benefitted less from surgery (Grade 3 OA: ß = 2.28; 95% CI −1.69 to 6.25). Conversely, there was weak evidence that hip patients with more severe OA who had greater widespread hyperalgesia benefitted more from surgery (Grade 4 OA: ß = −2.92; 95% CI −6.58 to 0.74).

Conclusions

Widespread sensitization may be a determinant of how much patients benefit from joint replacement, but the effect varies by joint and severity of structural joint changes.

Significance

Pre‐operative widespread hyperalgesia and radiographic osteoarthritis (OA) severity may influence how much patients benefit from joint replacement. Patients undergoing knee replacement with less severe OA and greater widespread hyperalgesia benefitted less from surgery than patients with less hyperalgesia. Patients undergoing hip replacement with more severe OA and greater widespread hyperalgesia benefitted more than patients with less hyperalgesia.

Radiographic Severity of Arthritis Affects Functional Outcome in Total Ankle Replacement (TAR)

BACKGROUND

It has been previously demonstrated that radiographic severity of arthritis predicts outcome following knee replacement. In certain circumstances, patients may undergo arthroplasty without severe radiographic disease. An example may be the patient with significant chondral damage unsuccessfully treated with arthroscopy. This patient may proceed to joint replacement when their radiographs would not normally merit such intervention. We investigated whether these findings were also applicable to total ankle replacements (TARs).

METHODS

We retrospectively reviewed a single-surgeon, single-implant series of 178 TARs in 170 patients. Of them, 124 patients who took part in the hospital joint registry with a minimum 2-year follow-up were included for this study. The radiographic severity of arthritis was graded using the Kellgren-Lawrence classification. Preoperative weight-bearing radiographs were reviewed for severity of arthritis by 2 blinded observers: the first author and an independent colleague from the radiology department. Patients were grouped into 4 subgroups based on degree of severity of radiographic grading for arthritis-A, B, C, and D (for grades 1, 2, 3, and 4 grades, respectively). Data collected included Foot and Ankle Outcome Score (FAOS; pain, function, and stiffness), MOS 36-item Short-Form Health Survey (SF-36) scores, and patient satisfaction scores collected prospectively and at 1 and 2 years postoperation.

RESULTS

Groups were similar in terms of demographic data (P > .1) and preoperative FAOS scores (P > .89) for pain, function and stiffness. Group D had the biggest improvement in all domains of FAOS. This reached significance in each domain when compared to group C. No significant differences were demonstrated in SF-36 scores. Overall, 91.1% of patients in group D were satisfied at 2 years, compared with 50.0% of patients in groups A, B, and C (P < .001). In addition, 93.9% of patients in group D felt that their quality of life had been improved by the surgery, compared to 47% of patients with groups A, B, and C (P < .001). Further, 77.3% of patients from group D said they would have the operation again, vs only 52.2% of patients with grade III or less (P = .014). Patients who were "very satisfied" or "somewhat satisfied" postoperatively had an average Kellgren-Lawrence (KL) grade of 3.9 preoperatively. In contrast the "very dissatisfied" and "somewhat dissatisfied" patients had an average KL grade of 2.9 (P < .05).

CONCLUSION

Although this study does not explain all of the dissatisfaction in TAR, radiologic severity is an important factor that surgeons must consider when planning how best to treat their patients. There may be a different pathophysiology in this patient group that is not well served by arthroplasty.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Women demonstrate more pain and worse function before THA but comparable results 12 months after surgery

BACKGROUND

Many studies report differences in patient-reported outcome measures (PROMs) for men and women undergoing total hip arthroplasty (THA). Few studies have evaluated whether these are explained by corresponding differences in important preoperative factors.

QUESTIONS/PURPOSES

(1) Are there differences between men and women in PROM scores preoperatively and 12 months after THA? (2) Do baseline differences in comorbidity, age, body mass index (BMI), and mental health status explain these differences in PROM scores?

METHODS

Preoperatively, 300 patients completed the Oxford Hip Score (OHS), WOMAC, and SF-12; 261 (86%) of them (129 women, 64 ± 11 years; 132 men, 66 ± 10 years) completed the same questionnaires 12 months postoperatively and also rated the acceptability of their current symptoms and change in general health.

RESULTS

Preoperatively, women showed worse scores than men in the OHS (-1.9; 95% confidence interval, -3.6 to -0.3) and WOMAC (-6.3; -10.9 to -1.7). At 12 months postoperatively, the absolute scores for all PROMs were not significantly different. After controlling for BMI, age, comorbidity, SF-12 mental health scores, and sociodemographic characteristics, the baseline differences remained.

CONCLUSIONS

Surgeons may be more reluctant to operate on women than men because they perceive that, because of their worse baseline status, women are likely to have worse outcomes; however, given that we found no evidence for differences in patient-reported outcomes at 12 months, these suspicions would appear to be unfounded. Women and men can be expected to benefit to a similar extent from THA.

LEVEL OF EVIDENCE

Level III, therapeutic study.