Predicting short-term outcome of primary total hip arthroplasty:a prospective multivariate regression analysis of 12 independent factors

Upper-Limb High-Intensity Interval Training or Passive Heat Therapy to Optimize Cardiorespiratory Fitness Prior to Total Hip or Knee Arthroplasty: A Randomized Controlled Trial

OBJECTIVE

Preoperative exercise training, or prehabilitation, aims to optimize cardiorespiratory fitness before surgery to reduce the risk of adverse perioperative events and delayed recovery. However, traditional exercise such as walking and cycling can be difficult for people with degenerative joint diseases of the lower limbs, such as osteoarthritis. The purpose of this study was to compare the effect of three low-impact interventions on cardiorespiratory fitness, physical function, and subjective health before total hip or knee arthroplasty.

METHODS

This was a randomized controlled trial involving 93 participants with severe knee or hip osteoarthritis awaiting joint replacement surgery. Participants underwent cardiopulmonary exercise testing (to measure peak oxygen consumption [V ̇ $$ \dot{V} $$ O2 ]), then were randomized to heat therapy (Heat; 20-30 min immersed in 40°C water followed by ~15 min light-resistance exercise), high-intensity interval training (HIIT; 6-8 × 60 s intervals on a cross-trainer or arm ergometer at ~90%-100% peakV ̇ $$ \dot{V} $$ O2 ), or home-based exercise (Home; ~15 min light-resistance exercise); for up to 36 sessions (3 sessions per week for 12 weeks).

RESULTS

PeakV ̇ $$ \dot{V} $$ O2 increased by 16% across HIIT and to a greater extent than Heat (+2.5 mL × min-1 × kg-1 [95% CI: 0.5-4.4], P = 0.009) and Home (+3.2 mL × min-1 × kg-1 [1.2-5.2], P = 0.001). The anaerobic threshold increased across HIIT (+1.5 mL × min-1 × kg-1 [0.7-2.3], P < 0.001) and Heat (+1.2 mL × min-1 × kg-1 [0.4-1.9], P = 0.004), but not Home (-0.5 mL × min-1 × kg-1 [-1.3 to 0.3], P = 0.248). Subjective severity of osteoarthritis was unchanged with any intervention (P ≥ 0.250).

CONCLUSION

Heat therapy and HIIT improved indices of cardiorespiratory fitness preoperatively in patients who have difficulty performing lower-limb exercise.

Predictive Factors of Pain and Functional Outcome 5-year Following Total Hip Arthroplasty: A Prospective FORCE-TJR Cohort Study

INTRODUCTION

Previous reports have identified a number of potential predictors of pain and function after total hip arthroplasty (THA). However, the results of these studies were conflicting, and most had a short follow-up after THA. The purpose of this study is to identify factors predictive of pain and function five years after THA.

PATIENTS AND METHODS

A multi-center cohort of 7,934 primary unilateral THA patients was prospectively enrolled in Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR). Demographic data, comorbidities, and patient-reported outcome measures (PROMs) were collected pre-operatively and post-operatively at 5 years, including the Hip Injury and Osteoarthritis Outcome Score (HOOS) pain and function in daily living (ADL) scores. Multivariate logistic regression models with 95% confidence interval were used to identify independent predictors of pain and function at 5 years.

RESULTS

The patient dissatisfaction percentage was 8.2% at 5 years after THA. The multivariate regression identified the following predictive factors for the HOOS pain score at 5 years: age, educational level, insurance, smoking, race, Charlson Comorbidity Index (CCI), back pain severity, number of other lower extremity (LE) painful joints, the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain severity of the ipsilateral knee, pre-operative Short-Form Health Survey 36-item (SF-36) mental component score (MCS), and HOOS pain scores. The multivariate regression identified the following predictor factors for HOOS ADL score at 5 years: body mass index, insurance, smoking, race, back pain severity, number of other LE painful joints, KOOS pain severity of ipsilateral knee, pre-op HOOS ADL, and pre-operative SF-36 MCS and SF-36 physical component score (PCS).

CONCLUSION

Overall, 8.2% of patients were dissatisfied five years after primary THA. We have identified a number of factors that predict less improvement in pain and function 5 years after THA. These potentially modifiable factors can be targeted with preoperative patient optimization programs to improve patient outcomes and satisfaction after primary THA. Knowledge of these factors that predict less improvement in pain and function can assist the surgeon and patient during shared decision-making, and in setting appropriate patient expectations pre-operatively.

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.

Modified frailty index as a predictor of the long-term functional result in patients undergoing primary total hip arthroplasty

OBJECTIVES

Total hip arthroplasty (THA) is a well-approved method for the treatment of end-stage osteoarthritis (OA). Due to rising life expectancy, elderly patients burdened with multimorbidity are subjected to THA. Some of these patients present significant depletion of physiological reserves, which is described as the frailty syndrome. This study aims to assess the influence of frailty on the THA outcomes in OA patients.

MATERIAL AND METHODS

A single-center observational study was conducted to investigate the effect of frailty measured by the modified frailty index-5 (mFI-5) and modified frailty index-11 (mFI-11) on the long-term post-THA outcomes. The analysis included 597 initially screened patients subjected to unilateral, primary THA due to hip OA. The outcomes were assessed during a follow-up visit 3 years after THA. The primary outcome measures were patient-reported (the Western Ontario and McMaster Universities Osteoarthritis Index - WOMAC) and physician-reported scales (the Harris Hip Score - HHS). The secondary outcome measures were the length of hospital stay (LOS), pain complaints, complications, and satisfaction. A correlation analysis was performed (Spearman's R).

RESULTS

Three hundred sixty-five patients met the eligibility criteria, including 57.26% women (n = 209) and 42.74% men (n = 156). The mean age was 65.11 ±12.12 years. Patients with high values of mFI-5 (r = 0.19; p < 0.05) and mFI-11 (r = 0.22; p < 0.01) achieved less satisfactory functional outcomes after THA (WOMAC). After age adjustment, mFI-11 (r = 0.17; p < 0.05) was a better predictor of functional outcome (WOMAC) than mFI-5 was (r = 0.15; p = 0.07). The mFI-5 (r = 0.25; p < 0.001) and mFI-11 (r = 0.29; p < 0.001) correlated with longer LOS.

CONCLUSIONS

The modified frailty index-5 (mFI-5) and modified frailty index-11 (mFI-11) are useful tools to identify patients subjected to THA at a high risk of poor functioning after the procedure. They can be used in preoperative counseling before obtaining informed consent to support surgical decision-making. To our knowledge, this is the first study investigating the impact of the mFI on long-term postoperative functional results in OA treated with THA.

Internal Validation of a Predictive Model for Complications After Total Hip Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is projected to increase in prevalence and associated complications will impose significant cost on the US healthcare system. The purpose of this study is to validate a predictive model for postoperative complications utilizing a novel 11-component hip-specific questionnaire encompassing preoperatively available clinical and radiographic data.

METHODS

Consecutive primary THA patients between January 2014 and January 2016 were included. Exclusion criteria included patients without questionnaire scoring variables and less than 1-year follow-up. Patients were stratified into 4 tiers based on their questionnaire score: low risk (>74), mild risk (57-73), moderate risk (41-56), and high risk (<40). A binary logistic regression was performed to determine if the questionnaire predicted complications. Receiver-operator curves were constructed to determine the threshold score below which there was a high likelihood of experiencing a complication.

RESULTS

Four hundred fifty patients were included in the final analysis with a mean (range) follow-up of 2.1 years (1.0-5.9), age of 63.1 years (25.7-9.17), and body mass index of 31.7 kg/m² (17.8-64.5). The complication rate was 13.6%. A hip questionnaire score of 73.8 conferred a 98.5% sensitivity and 98.5% negative predictive value for complications. The questionnaire score was the strongest predictor of a decreased complication likelihood (odds ratio 0.94, 95% confidence interval 0.90-0.97, P < .001). Risk tier was significantly associated with complications (low risk: 0; mild risk: 12; moderate risk: 25; and high risk: 24; P < .001).

CONCLUSION

This novel hip questionnaire demonstrated a high sensitivity and negative predictive value to identify patients at risk for postoperative complications. Future studies should attempt to prospectively validate the use of this questionnaire.

Can obesity and physical activity predict outcomes of elective knee or hip surgery due to osteoarthritis? A meta-analysis of cohort studies

OBJECTIVE

The aim of this study was to systematically review the literature to identify whether obesity or the regular practice of physical activity are predictors of clinical outcomes in patients undergoing elective hip and knee arthroplasty due to osteoarthritis.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE AND ELIGIBILITY CRITERIA

A systematic search was performed on the Medline, CINAHL, EMBASE and Web of Science electronic databases. Longitudinal cohort studies were included in the review. To be included, studies needed to have assessed the association between obesity or physical activity participation measured at baseline and clinical outcomes (ie, pain, disability and adverse events) following hip or knee arthroplasty.

DATA EXTRACTION

Two independent reviewers extracted data on pain, disability, quality of life, obesity, physical activity and any postsurgical complications.

RESULTS

62 full papers were included in this systematic review. From these, 31 were included in the meta-analyses. Our meta-analysis showed that compared to obese participants, non-obese participants report less pain at both short term (standardised mean difference (SMD) -0.43; 95% CI -0.67 to -0.19; P<0.001) and long term post-surgery (SMD -0.36; 95% CI -0.47 to -0.24; P<0.001), as well as less disability at long term post-surgery (SMD -0.32; 95% CI -0.36 to -0.28; P<0.001). They also report fewer postsurgical complications at short term (OR 0.48; 95% CI 0.25 to 0.91; P<0.001) and long term (OR 0.55; 95% CI 0.41 to 0.74; P<0.001) along with less postsurgical infections after hip arthroplasty (OR 0.33; 95% CI 0.18 to 0.59; P<0.001), and knee arthroplasty (OR 0.42; 95% CI 0.23 to 0.78; P=0.006).

CONCLUSIONS

Presurgical obesity is associated with worse clinical outcomes of hip or knee arthroplasty in terms of pain, disability and complications in patients with osteoarthritis. No impact of physical activity participation has been observed.

PROSPERO REGISTRATION NUMBER

CRD42016032711.

Prolonged Conservative Management in Total Joint Arthroplasty: Harming the Patient?

BACKGROUND

It is important to understand the long-term consequences of postponing total joint arthroplasty until the onset of severe functional impairment. Therefore, the purpose of this investigation was to determine and compare the midterm to long-term postoperative outcomes of patients who underwent total joint arthroplasty with severe vs less severe preoperative functional impairment.

METHODS

A total of 105 primary unilateral total hip/knee arthroplasty patients were studied. Patients were divided into 2 groups-severely functionally impaired (preoperative Western Ontario and McMaster Osteoarthritis Index function ≥51 points) and functionally impaired (preoperative Western Ontario and McMaster Osteoarthritis Index function <51 points).

RESULTS

At an average of 11.2 years postoperatively, the patients who were severely functionally impaired preoperatively had worse outcomes than did the patients with less severe preoperative functional impairment.

CONCLUSION

Our data suggest that, after surgery, it is unlikely that patients who are severely functionally impaired preoperatively will ever catch up to patients who have the surgery with less severe functional impairment.

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.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

NCT01214954.

Predictors of short-term outcome to exercise and manual therapy for people with hip osteoarthritis

BACKGROUND

Physical therapy for hip osteoarthritis (OA) has shown short-term effects but limited long-term benefit. There has been limited research, with inconsistent results, in identifying prognostic factors associated with a positive response to physical therapy.

OBJECTIVES

The purpose of this study was to identify potential predictors of response to physical therapy (exercise therapy [ET] with or without adjunctive manual therapy [MT]) for hip OA based on baseline patient-specific and clinical characteristics.

DESIGN

A prognostic study was conducted.

METHODS

Secondary analysis of data from a multicenter randomized controlled trial (RCT) (N=131) that evaluated the effectiveness of ET and ET+MT for hip OA was undertaken. Treatment response was defined using OMERACT/OARSI responder criteria. Ten baseline measures were used as predictor variables. Regression analyses were undertaken to identify predictors of outcome. Discriminative ability (sensitivity, specificity, and likelihood ratios) of significant variables was calculated.

RESULTS

The RCT results showed no significant difference in most outcomes between ET and ET+MT at 9 and 18 weeks posttreatment. Forty-six patients were classified as responders at 9 weeks, and 36 patients were classified as responders at 18 weeks. Four baseline variables were predictive of a positive outcome at 9 weeks: male sex, pain with activity (<6/10), Western Ontario and McMaster Universities Osteoarthritis Index physical function subscale score (<34/68), and psychological health (Hospital Anxiety and Depression Scale score <9/42). No predictor variables were identified at the 18-week follow-up. Prognostic accuracy was fair for all 4 variables (sensitivity=0.5-0.58, specificity=0.57-0.72, likelihood ratios=1.25-1.77), indicating fair discriminative ability at predicting treatment response.

LIMITATIONS

The short-term follow-up limits the interpretation of results, and the low number of identified responders may have resulted in possible overfitting of the predictor model.

CONCLUSIONS

The authors were unable to identify baseline variables in patients with hip OA that indicate those most likely to respond to treatment due to low discriminative ability. Further validation studies are needed to definitively define the best predictors of response to physical therapy in people with hip OA.

[More muscle mass in men: explanatory model for superior outcome after total hip arthroplasty]

BACKGROUND

Men show better functional results after total hip arthroplasty (THA). The aim of this study was a patient-specific analysis of the hip joint muscles in comparison to the joint geometry.

METHODS

In this study 93 computed tomography (CT) scans of the pelvis (45 men, 48 women) were analyzed to determine hip joint geometry and the volume of the gluteus medius (GMV), gluteus maximus (GXV) and tensor fasciae latae (TFL) muscles. The abduction muscle volumes were analyzed with respect to patient-specific adduction moments.

RESULTS

The absolute total volume of the hip muscular system (TMV) was larger in men than in women (1913 ccm vs. 1479 ccm; p <0.0001). Men exhibited a more progressive increase of muscle volume as the adduction moment increases.

CONCLUSIONS

Men have a greater abduction muscle mass in order to balance adduction moments occurring in the hip joint and therefore have more muscle mass to compensate the inevitable intraoperative muscle damage during THA. This argument supports the extraordinary importance of muscle sparing surgical techniques in women.

Recovery and prediction of physical functioning outcomes during the first year after total hip arthroplasty

OBJECTIVES

To investigate recovery of physical functioning in patients during the first year after total hip arthroplasty (THA), and to predict postoperative walking distance outcomes from preoperative measures.

DESIGN

A longitudinal prospective design was used. Data were analyzed by repeated-measures analysis of variance and multivariate regression analyses.

SETTING

Two hospitals.

PARTICIPANTS

Patients with hip osteoarthritis were consecutively included and assessed preoperatively (n=88), at 3 months (n=88), and at 12 months (n=64) after THA.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Physical functioning was assessed by objective measures-the 6-minute walk test (6MWT), stair climbing test, Index of Muscle Function, figure-of-eight, and active hip range of motion-and the subjective measures by Harris Hip Score and Hip dysfunction and Osteoarthritis Outcome Score.

RESULTS

In objective measures, improvements were found from preoperatively to 3 months in 6MWT (P<.01) and stair climbing test (P<.05) scores, while all measures had improved from 3 to 12 months (P≤.001). In contrast, all the subjective measures showed substantial improvements at 3 months, but small further improvements from 3 to 12 months (P<.001). Age, sex, preoperative 6MWT distance, and hip range of motion predicted 6MWT outcomes at 3 and 12 months (P≤.01).

CONCLUSIONS

The objective measures of physical functioning improved gradually during the first postoperative year, while the subjective measures showed large early improvements, but little further improvements. Younger age, male sex, and better scores of walking distance and hip flexibility before surgery predicted better score in walking distance at both 3 and 12 months after surgery.

Low vitamin D status does not adversely affect short-term functional outcome after total hip arthroplasty

We prospectively measured functional performances (Western Ontario and McMaster Universities Osteoarthritis Index, Short Form-36, 2-minute walk test, and timed get-up-and-go test) of patients who underwent total hip arthroplasty (THA) and had serum vitamin D levels tested during the preoperative evaluation. Of 219 patients, 102 (46.6%) had low vitamin D levels (25-hydroxyvitamin D<30 ng/mL). Low vitamin D status did not adversely affect short-term function at 6 weeks after THA. In addition, there was no association between serum vitamin D levels and the within-patient changes of scores of each outcome measurement. Because this 6-week period is generally adequate to correct vitamin D deficiency, orthopedic surgeons can safely perform THA without delay. Nevertheless, because vitamin D deficiency impairs bone quality, patients with low vitamin D levels should be treated once identified.