Age-Related Decline in Patient-Reported Outcomes 2 and 5 Years Following Total Hip Arthroplasty

Excellent Results of Large-Diameter Ceramic-on-Ceramic Bearings in Total Hip Arthroplasty at Minimum Ten-Year Follow-up

AIMS

This study reports the minimum 10 year results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head (LDH) ceramic-on-ceramic (CoC) bearing.

METHODS

Of the 276 THAs included in this study, 237 (85%) were available for review at a mean of 10.5 years (range, 10 to 12) postoperatively. There were eleven deaths that occurred during the follow-up. Reoperations, implant revisions, adverse events, clinical outcomes, radiographic evaluation, and whole blood metal ion levels were assessed at the last follow-up.

RESULTS

After a minimum of 10 years, implant survivorship was 98.7%. There were three revisions (1.3%): one for insufficient acetabular cup primary fixation, one traumatic periprosthetic acetabular fracture, and one probable deep chronic infection. No dislocation or ceramic implant fracture was observed. The mean University of California at Los Angeles (UCLA) activity score, Western Ontario and McMaster Universities Osteoarthritis Index score, and Forgotten Joint Score were 5.6 (2 to 10), 90.1 (9 to 100), and 79.2 (4 to 100), respectively. In the 10 years following implantation, at least 43% of patients reported hearing a squeaking noise from the prosthesis. All patients who had squeaking hips were satisfied with the surgery. The mean titanium level was 2.2 μg/L (1.1 to 5.6). No progressive radiolucent lines, osteolysis, or implant loosening signs were observed at the last radiographic evaluation.

CONCLUSION

A LDH CoC THA provides outstanding long-term (minimum 10 year) implant survivorship with unrestricted activity while avoiding implant impingement, liner fracture, and hip instability. Functional outcomes, satisfaction, and joint perception were excellent. Although the incidence of squeaking was high, it did not affect patient satisfaction or function. The systemic titanium levels were low, related to unavoidable passive corrosion of implant surfaces, and did not reveal any indirect signs of trunnionosis.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Incidence of periprosthetic joint infection after primary total hip arthroplasty is underestimated: a synthesis of meta-analysis and bibliometric analysis

The American Musculoskeletal Society updated the diagnostic criteria for periprosthetic joint infection (PJI) in 2011 and 2018. However, the overall incidence of PJI since the introduction of these new standards has not been assessed. In order to fill this knowledge gap, a single-group meta-analysis was conducted using articles obtained from several databases, focusing on the incidence of PJI after primary total hip arthroplasty (THA). Our study revealed a significant difference in the incidence of PJI reported by different national or regional databases. Moreover, most cases of PJI were found to be underestimated. This highlights the crucial need for standardized diagnostic criteria and monitoring methods to accurately identify and track cases of PJI. Furthermore, a bibliometric analysis was conducted to provide a comprehensive overview of the current state of research on PJI after THA. This analysis explored the most productive countries, organizations, journals, and individuals in this research area. Additionally, it identified the research trends and hotspots of the last decade, highlighting the advancements and areas of focus in this field. By conducting these analyses, the study aims to contribute to the understanding of PJI after THA and provide valuable insights for clinicians, researchers, and policymakers involved in the management of this condition.

Prioritisation of patients awaiting hip and knee arthroplasty: Lower pre-operative EQ-5D is associated with greater improvement in quality of life and joint function

INTRODUCTION

The COVID-19 pandemic has led to unprecedented delays for those awaiting elective hip and knee arthroplasty. Current demand far exceeds available resource, and therefore it is integral that healthcare resource is fairly rationed to those who need it most. We therefore set out to determine if pre-operative health-related quality of life assessment (HRQoL) could be used to triage arthroplasty waiting lists.

METHODS

Data regarding demographics, perioperative variables and patient reported outcome measures (PROMs) (pre-operative and 1-year post-operative EuroQOL five dimension (EQ-5D-3L) and Oxford hip and knee scores (OHS/OKS) were retrospectively extracted from electronic patient health records at a large university teaching hospital. Patients were split into two equal groups based on pre-operative EQ-5D TTO scores and compared (Group1 [worse HRQoL] = -0.239 to 0.487; Group2 [better HRQoL] = 0.516-1 [best]).

RESULTS

513 patients were included. Patients in Group1 had significantly greater improvement in post-operative EQ-5D-3L scores compared to Group2 (Median 0.67 vs. 0.19; p < 0.0001), as well as greater improvement in OHS/OKS (Mean 22.4 vs. 16.4; p < 0.0001). Those in Group2 were significantly less likely to achieve the EQ-5D-3L minimum clinically important difference (MCID) attainment (OR 0.13, 95%CI 0.07-0.23; p < 0.0001) with a trend towards lower OHS/OKS MCID attainment (OR 0.66, 95%CI 0.37-1.19; p = 0.168). There was no clinically significant difference in length of stay (Median 3-days both groups), and no statistically significant difference in adverse events (30 days and 1 year readmission/reoperation).

CONCLUSIONS

A pre-operative EQ-5D-3L cut-off of ≤0.487 for hip and knee arthroplasty prioritisation may help to maximise clinical utility and cost-effectiveness in a limited resource setting post COVID-19.

Early postoperative relationship between patient-reported outcome measures and gait biomechanical factors after total hip arthroplasty

BACKGROUND

Patient-reported outcome measures (PROMs) have recently been considered as indicating clinical outcomes after total hip arthroplasty (THA). Although various factors are reportedly associated with post-THA and PROMs, the relationship with gait parameters, which are objective assessment factors after THA, remains unclear.

RESEARCH QUESTION

What is the relationship between PROMs and gait biomechanical factors four weeks after THA?

METHODS

Forty-five patients (six men and 39 women) who underwent THA were included. Three-dimensional gait analysis was performed four weeks post-THA; joint angle, internal moment, and power of the lower extremity at the first and second peaks of the vertical component of the floor reaction force were assessed for the operated side. PROMs were evaluated using the Japanese Orthopedic Association Hip Disease Evaluation Questionnaire (JHEQ). The relationship between the JHEQ score and extracted gait parameters was analyzed using gender and gait speed as control factors.

RESULTS

For the JHEQ sub-domain, movement was positively correlated with the internal knee extension moment values at the first peak (r = 0.347). There was no significant correlation between JHEQ and the internal hip abduction moment value at the first peak. Mental status was negatively correlated with the hip flexion angle value at the second peak (r = -0.373), and positively correlated with the hip flexion moment value (r = 0.348). Total JHEQ scores and mental status were negatively correlated with the power of hip flexion value at the second peaks, respectively (r = -0.316, -0.444).

SIGNIFICANCE

The results of this study may provide recovery guidelines to be used as an index for gait assessment in the early post-THA period. Further studies are needed to verify whether gait parameters can improve PROMs in the early post-THA period.

Participation in a Preoperative Patient Education Session Is a Significant Predictor of Better WOMAC Total Index Score and Higher EQ-5D-5L Health Status Index 1 Year After Total Knee and Hip Arthroplasties: A Retrospective Observational Study

OBJECTIVE

The aim of the study was to investigate whether patient-specific factors, preoperative patient-reported outcome measures, and participation in a preoperative patient education session significantly predict 1-yr Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score and EuroQol 5 Dimensions 5 Levels (EQ-5D-5L) health status index of patients who underwent total hip or knee arthroplasties within an enhanced rehabilitation program.

DESIGN

This is a retrospective observational cohort study. The inclusion criteria were met by 676 (373 total hip arthroplasties and 303 total knee arthroplasties) patients. Two multiple regression models were carried out to estimate the contributions of nine potential predictors.

RESULTS

Younger age (P = 0.006), higher preoperative EQ-5D-5L index (P = 0.004), lower patient clinical complexity level (P = 0.001), lower preoperative WOMAC total score (P < 0.001), preoperative patient education session (P = 0.004), and submitting for total hip arthroplasty (P < 0.001) were significant predictors of better 1-yr WOMAC total score. Higher preoperative EQ-5D-5L index (P < 0.001), lower patient clinical complexity level classification (P < 0.001), lower preoperative WOMAC total score (P = 0.009), preoperative patient education session (P = 0.04), and submitting for total hip arthroplasty (P = 0.01) were significant predictors of higher 1-yr EQ-5D-5L health status index.

CONCLUSIONS

Better baseline patient-reported outcome measure scores, less comorbidities, younger age, submitting for total hip arthroplasty, and attending a preoperative patient education session were significant predictors of better WOMAC total scores and higher EQ-5D-5L health status index 1 yr after total hip or total knee arthroplasties.

Association of global sagittal spinal deformity with functional disability two years after total hip arthroplasty

BACKGROUND

The relationship between spinopelvic alignment and functional disability after total hip arthroplasty (THA) has not been fully elucidated despite the growing recognition of its importance on patient-reported outcome measures. Therefore, our aim was to assess the effect of global sagittal spinal deformity on post-operative disability.

METHODS

This analysis was based on 208 cases of THA, with functional disability measured at a follow-up of 2 years. The Hip Disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR), ranging from a scale of 0 (complete joint disability) to 100 (perfect joint health), was used to divide eligible patients into two groups, namely with and without disability, using a score of 70 as the cut-off. The following factors were compared between the two groups using multivariate analysis: age, sex, body height, body mass index, spinopelvic parameters, and surgeon experience. To identify the cut-off value of the parameters for predicting disability (HOOS-JR < 70/100), we used the receiver-operating characteristic curve.

RESULTS

The disability (30 hips) and control (178 hips) groups showed a significant difference in pre-operative body height (p = 0.020), T1 pelvic angle divided by pelvic incidence (T1PA/PI; p = 0.018), PI minus lumbar lordosis (p = 0.027), post-operative HOOS-JR (p = 0.010), patient satisfaction (p = 0.033), and the modified Harris Hip Score (p = 0.038). On multivariate analysis, the following factors were associated with persistent disability: T1PA/PI > 0.2 (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.19-4.14; p <  0.001) and height < 148 cm equivalent to legal standards as short stature (OR, 1.26; 95% CI, 1.09-1.48; p = 0.011). The cut-off value of pre-operative T1PA/PI was > 0.19, with a sensitivity of 95% and specificity of 85%. Post-operative satisfaction (p <  0.001), HOOS-JR (p = 0.023), and EuroQol 5-Dimension (p = 0.041) differed between the two groups when the pre-operative cut-off value was chosen as 0.2.

CONCLUSIONS

A T1PA/PI > 0.2 was associated with greater disability after THA. Clinicians should be aware that patient-related factors, including global spinal deformities, particularly in patients with a short stature, can influence THA outcomes at 2 years postoperatively.

The AAHKS Clinical Research Award: No Evidence for Superior Patient-Reported Outcome Scores After Total Hip Arthroplasty With the Direct Anterior Approach at 1.5 Months Postoperatively, and Through a 5-Year Follow-Up

BACKGROUND

The direct anterior approach to total hip arthroplasty (THA) may result in superior early postoperative patient-reported outcome measures (PROMs). This study compared PROMs between THA patients treated with the direct anterior or posterolateral approach between 1.5 months and 5 years, using literature-derived patient acceptable symptom state (PASS) and minimal clinically important improvement (MCII) thresholds.

METHODS

A propensity score match of 93 direct anterior patients to 93 posterolateral patients from a multicenter US collaboration (6 centers, 398 patients) was performed. The Harris Hip Score (HHS), the Short-Form 36, and a Numerical Rating Scale for Pain were collected preoperatively, postoperatively (mean days: 47), and at 1, 3, and 5 years. The proportion of patients reaching the HHS PASS, Pain MCII, and Function MCII in the direct anterior and posterolateral groups was compared using binary logistic regressions, controlling for age, gender, body mass index, and Charnley score.

RESULTS

Direct anterior patients were less likely to reach the HHS PASS at the postoperative visit (P = .015; odds ratio = 0.454), but not at later visits (P > .082). Direct anterior patients had no difference from posterolateral patients in their tendency to reach the Pain MCII postoperatively or at 1 year (P > .090). The direct anterior patients were less likely to reach the Function MCII at the postoperative visit (P = .011; odds ratio = 0.422), but not at 1 year (P = .958).

CONCLUSION

No evidence was found of superior early postoperative PROM scores in THA patients treated with the direct anterior approach. No PROM differences were found at or beyond 1 year, indicating that patients reach similar final symptom states, regardless of surgical approach.

Clinical Characteristics of Patients with Type 2 Diabetes Mellitus Receiving a Primary Total Knee or Hip Arthroplasty

AIM

The purpose of this study is to explore clinical characteristics of patients with T2DM receiving a primary knee (TKA) or hip (THA) arthroplasty to patients without T2DM receiving a TKA or THA and patients with T2DM with no history of osteoarthritis (OA).

METHODS

The study included a retrospective database review of 500 consecutive primary TKA or THA identified with ICD-9 codes and 100 consecutive T2DM patients. Patients who received a TKA or THA were screened for inclusion and exclusion and divided into with or without T2DM groups. A comparison group of patients with T2DM only without arthroplasty was screened to exclude patients with a history of OA or arthroplasty. All groups were compared based on demographic and relevant comorbidity differences. OA characteristics, including OA and previous arthroplasty of the involved and contralateral joints, were compared between patients with and without T2DM receiving a TKA or THA. Finally, patients with T2DM with and without TKA or THA were compared for T2DM differences.

RESULTS

Study results found that among those receiving a primary arthroplasty, patients with T2DM were more likely to be obese and older and reported cardiovascular, urinary, dyslipidemia, and peripheral neuropathy than those with T2DM. Among the T2DM individuals, those receiving an arthroplasty surgery were older and obese and more likely to report peripheral neuropathy; however, those with T2DM with no OA were more likely to report atherosclerosis and cardiovascular disease. Within the arthroplasty subgroup of individuals with T2DM, those requiring antidiabetic medication were 4.5 times more likely to have contralateral OA or arthroplasty.

CONCLUSIONS

The results of this study suggest that patients with T2DM requiring a primary arthroplasty are a unique subgroup that requires careful considerations as they are often older, have obesity, and specific comorbidities predisposing to worse postoperative outcomes than their non-T2DM arthroplasty counterparts. Therefore, clinical practice and future studies must consider strategies that would limit OA and arthroplasty management delays while accounting for comorbidities and patient characteristics.