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

A Systematic Review and Meta-Analysis of the Effects of Rehabilitation Using Digital Healthcare on Musculoskeletal Pain and Quality of Life

Rehabilitation using digital healthcare (DHC) has the potential to enhance the effectiveness of treatment for musculoskeletal disorders (MSDs) and associated pain by improving patient outcomes, while being cost-effective, safe, and measurable. This systematic review and meta-analysis aimed to evaluate the effectiveness of musculoskeletal rehabilitation using DHC. We searched PubMed, Ovid-Embase, Cochrane Library, and PEDro Physiotherapy Evidence Database from inception to October 28, 2022 for controlled clinical trials comparing DHC to conventional rehabilitation. We used a random-effects model for the meta-analysis, pooling the effects of DHC on pain and quality of life (QoL) by calculating standardized mean differences (SMDs) with 95% confidence intervals (CIs) between DHC rehabilitation and conventional rehabilitation (control). Fifty-four studies with 6240 participants met the inclusion criteria. The sample size ranged from 26 to 461, and the average age of the participants ranged from 21.9 to 71.8 years. The majority of the included studies focused on knee or hip joint MSD (n = 23), and the most frequently utilized DHC interventions were mobile applications (n = 26) and virtual or augmented reality (n = 16). Our meta-analysis of pain (n = 45) revealed that pain reduction was greater in DHC rehabilitation than in conventional rehabilitation (SMD: -0.55, 95% CI: -0.74, -0.36), indicating that rehabilitation using DHC has the potential to ameliorate MSD pain. Furthermore, DHC significantly improved health-related QoL and disease-specific QoL (SMD: 0.66, 95% CI: 0.29, 1.03; SMD: -0.44, 95% CI: -0.87, -0.01) compared to conventional rehabilitation. Our findings suggest that DHC offers a practical and flexible rehabilitation alternative for both patients with MSD and healthcare professionals. Nevertheless, further researches are needed to elucidate the underlying mechanisms by which DHC affects patient-reported outcomes, which may vary depending on the type and design of the DHC intervention.

Total Hip Replacement: Psychometric Validation of the Italian Version of Forgotten Joint Score (FJS-12)

BACKGROUND

One million Total Hip Replacements (THA) are thought to be performed annually. To measure prosthesis awareness throughout daily activities, the FJS-12 patient-reported outcome scale was developed. This article's goal is to undertake a psychometric validation of the Italian FJS-12 among a sample of related THA patients.

METHODS

Between January and July 2019, data from 44 patients were retrieved. The participants were required to complete the Italian version of FJS-12 and of the WOMAC at preoperative follow-up, after two weeks, 1, 3, and 6 months postoperatively.

RESULTS

The Pearson correlation coefficient between the FJS-12 and WOMAC was 0.287 (p = 0.002) at preoperative follow-up, r = 0.702 (p < 0.001) at 1 month, r = 0.516 (p < 0.001) at 3 months and r = 0.585 (p < 0.001) at 6 months. The ceiling effect surpassed the acceptable range (15%) for FJS-12 in 1 month (25.5%) and WOMAC in 6 months follow-up (27.3%).

CONCLUSIONS

The psychometric validation of the Italian version of this score for THA was executed with acceptable results. FJS-12 and WOMAC reported no ceiling and floor effects. Therefore, to distinguish between patients who had good or exceptional results following UKA, the FJS-12 could be a reliable score. Under the first four months, FJS-12 had a smaller ceiling effect than WOMAC. It is recommended to use this score in clinical research concerning the outcomes of THA.

Patient Functional Status as an Indication for Primary Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

The number of total hip arthroplasties performed per year is increasing for reasons not fully explained by a growing and aging population. The purpose of this study was to determine the role of patient functional status as an indication for surgery and determine if patients are undergoing surgery at a better functional status than in the past.

METHODS

A systematic review and meta-analysis of the MEDLINE, EMBASE, and Cochrane databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Functional status was assessed using the 36-Item Short-Form Health Survey's Physical Component Summary score. Only primary procedures were included; revisions were excluded. Articles were screened by 2 independent reviewers with conflicts resolved with a third reviewer. Meta-regression analysis was performed to determine the effect of time, patient age, and gender. Subgroup analysis was performed to compare geographic regions.

RESULTS

A total of 1504 articles were identified. Data from 172 groups representing 18,644 patients recruited from 1990 to 2013 and identified from 107 articles were included. The mean preoperative Physical Component Summary score was 31.2 (95% confidence interval 30.5-31.9) with a 95% prediction interval of 22.6-39.8. The variance across studies was statistically significant (P = .000) with 97.25% true variance. Year of enrollment, age, and the percentage of females were not found to have any significant effect. There were no differences between countries.

CONCLUSION

Patients are undergoing total hip arthroplasty at a similar preoperative physical functional status as in the past. Patient age, gender, and location do not influence the functional status at which patients are indicated for surgery.

Does the Patient-Reported Outcomes Measurement Information System Correlate to Legacy Scores in Measuring Physical Health in Young Total Hip Arthroplasty Patients?

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed by the National Institutes of Health to collect outcome data in rapid dynamic fashion on electronic platforms. The potential role of PROMIS in monitoring pain and function in young total hip arthroplasty (THA) patients has been under-investigated. The purpose of this study is to investigate correlation between PROMIS Physical Function (PF) and PROMIS Pain Interference (PI) and legacy scores with similar considerations.

METHODS

We identified 298 hips who underwent primary THA over 40 months. Patients without preoperative PROMIS or legacy scores, or >50 years were excluded. Demographic data included age, gender, and body mass index. Outcome data included PF, PI, modified Harris Hip Score (mHHS), Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) domains, and Short Form 12 components. Floor/ceiling effects were considered to be significant if ≥15% of patients responded with the lowest or highest possible score. Spearman correlation (R) was performed to investigate correlation between legacy scores and PROMIS domains.

RESULTS

Mean age was 40 years, mean body mass index was 30.1 kg/m², and 55% were female. None of the patient-reported outcome measures showed any floor/ceiling effects. PI showed moderate correlation to mHHS (R = -0.60), WOMAC Pain (R = -0.62), and WOMAC PF (R = -0.60). PF showed moderate correlation to mHHS (R = 0.66) and WOMAC PF (R = 0.55). Mean PF and PI scores differed significantly from the general population mean of 50 (36.7, 65.4, respectively; both P < .001).

CONCLUSION

PROMIS is an attractive alternative to legacy scoring measures, showing moderate correlations between PROMIS physical domains and legacy PROMs of WOMAC and mHHS in young patients undergoing THA.

Is the Patient-Reported Outcome Measurement Information System Feasible in Bundled Payment for Care Improvement Total Knee Arthroplasty Patients?

BACKGROUND

Several bundled payment plans, like the Bundled Payment for Care Improvement (BPCI) initiative for total joint arthroplasty, have been introduced to decrease costs and improve clinical care. Measuring clinical outcomes with efficient, standardized methodologies is essential to determine the relative value of total joint arthroplasty care. We investigated feasibility and responsiveness of the recently developed Patient-Reported Outcomes Measurement Information System (PROMIS) in total knee arthroplasty (TKA) patients.

METHODS

We included patients with preoperative and 1-year PROMIS Physical Function (PF), Pain Interference (PI), and Depression (DEP) scores who received unilateral primary TKA. Burden was assessed using the number of questions and time required for PROMIS completion. The minimum clinically important difference was defined as 5. Floor/ceiling effects were noted if more than 15% of patients responded with the lowest/highest possible score, respectively. Wilcoxon rank-sum test was used to compare categorical data. Analysis of variance was used for PROMIS comparisons.

RESULTS

In total, 172 knees (54 BPCI) were included. Floor effects were identified for DEP at baseline (non-BPCI) and follow-up (both groups), and for PI at follow-up only (BPCI). Patients required 140 seconds and 16 questions to answer all 3 PROMIS domains. Sixty-seven percent, 60%, and 44% of knees achieved minimum clinically important difference in PI, PF, and DEP scores respectively, with no significant difference between groups. The BPCI cohort was older (P < .001) with a higher American Society of Anesthesiologists score (P = .028). There were no significant differences in scores between BPCI and non-BPCI patients.

CONCLUSION

PROMIS is feasible and time-efficient in BPCI patients undergoing primary TKA. There were no significant differences in outcomes between BPCI and non-BPCI knees.

LEVEL OF EVIDENCE

Level III.

Is the Patient-Reported Outcome Measurement Information System Feasible in Bundled Payment for Care Improvement in Total Hip Arthroplasty Patients?

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) is increasingly used to assess patient health. The Bundled Payment for Care Improvement (BPCI) initiative for total hip arthroplasty (THA) was introduced to decrease costs and improve clinical care. We investigated differences between BPCI and non-BPCI THA patients and their PROMIS scores, along with its feasibility and responsiveness in these populations.

METHODS

We included all consecutive patients receiving unilateral primary THA who also had preoperative and one-year postoperative PROMIS physical function (PF), PROMIS pain interference (PI), and PROMIS depression (DEP) scores. Demographics and PROMIS scores were compared. Test burden was assessed using the number of questions and time required for PROMIS completion. The minimum clinically important difference was defined as 5. Floor and ceiling effects were noted if more than 15% of patients responded with the lowest or highest possible score, respectively. Wilcoxon rank-sum test was used to compare categorical data. ANOVA was used for PROMIS comparisons.

RESULTS

290 hips (86 BPCI, 30%) were included. The BPCI cohort was older (P < .001) with a higher American Society of Anesthesiologists physical status classification system (P = .0045). There were significant differences in baseline scores of PF and DEP between BPCI and non-BPCI (P = .046 and P = .048, respectively). Both groups showed significant improvement at follow-up in all scores (all P < .001). Significantly more non-BPCI patients achieved minimum clinically important difference at follow-up in PI and PF (P = .047 and P = .023, respectively). Floor effects were identified for DEP at baseline and follow-up and for PI at follow-up only.

CONCLUSION

PROMIS is feasible and time-efficient in BPCI patients undergoing primary THA. There were significant differences between BPCI and non-BPCI hips.

LEVEL OF EVIDENCE

Level III.

PROMIS Versus Legacy Patient-Reported Outcome Measures in Patients Undergoing Surgical Treatment for Symptomatic Acetabular Dysplasia

BACKGROUND

No previous study has investigated how the Patient-Reported Outcomes Measurement Information System (PROMIS) performs compared with legacy patient-reported outcome measures in patients with symptomatic acetabular dysplasia treated with periacetabular osteotomy (PAO).

PURPOSE

To (1) measure the strength of correlation between the PROMIS and legacy outcome measures and (2) assess floor and ceiling effects of the PROMIS and legacy outcome measures in patients treated with PAO for symptomatic acetabular dysplasia.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

This study included 220 patients who underwent PAO for the treatment of symptomatic acetabular dysplasia. Outcome measures included the Hip disability and Osteoarthritis Outcome Score (HOOS) pain, HOOS activities of daily living (ADL), modified Harris Hip Score (mHHS), PROMIS pain, and PROMIS physical function subsets, with scores collected preoperatively and/or postoperatively at a minimum 12-month follow-up. The change in mean scores from preoperatively to postoperatively was calculated only in a subgroup of 57 patients with scores at both time points. Distributions of the PROMIS and legacy scores were compared to evaluate floor and ceiling effects, and Pearson correlation coefficients were calculated to evaluate agreement.

RESULTS

The mean age at the time of surgery was 27.7 years, and 83.6% were female. The mean follow-up time was 1.5 years. Preoperatively, neither the PROMIS nor the legacy measures showed significant floor or ceiling effects. Postoperatively, all legacy measures showed significant ceiling effects, with 15% of patients with a maximum HOOS pain score of 100, 29% with a HOOS ADL score of 100, and 21% with an mHHS score of 100. The PROMIS and legacy instruments showed good agreement preoperatively and postoperatively. The PROMIS pain had a moderate to strong negative correlation with the HOOS pain (r = -0.66; P < .0001) and mHHS (r = -0.60; P < .0001) preoperatively and the HOOS pain (r = -0.64; P < .0001) and mHHS (r = -0.64; P < .0001) postoperatively. The PROMIS physical function had a moderate positive correlation with the HOOS ADL (r = 0.51; P < .0001) and mHHS (r = 0.49; P < .0001) preoperatively and a stronger correlation postoperatively with the HOOS ADL (r = 0.56; P < .0001) and mHHS (r = 0.56; P < .0001).

CONCLUSION

We found good agreement between PROMIS and legacy scores preoperatively and postoperatively. PROMIS scores were largely normally distributed, demonstrating an expanded ability to capture variability in patients with improved outcomes after treatment.

Validity, responsiveness, and perceptions of clinical utility of the Canadian Occupational Performance Measure when used in a sub-acute setting

Purpose: The validity, responsiveness, and clinical utility of the Canadian Occupational Performance Measure was investigated when used in a sub-acute setting.Materials and Methods: Fifty older adults (mean age 78.2 years, Standard Deviation = 7.2; 64% female) completed the Canadian Occupational Performance Measure, Functional Independence Measure and the Short-Form 36 Health Questionnaire. The Canadian Occupational Performance Measure was correlated with the Functional Independence Measure and Short-Form 36 Health Questionnaire and the admission and discharge Canadian Occupational Performance Measure Performance and Satisfaction scores were compared for significant differences. Qualitative interviews with were completed with six older adults and six occupational therapists to explore the utility of the Canadian Occupational Performance Measure.Results: The Canadian Occupational Performance Measure Satisfaction scale was significantly associated with the Functional Independence Measure and Short-Form 36 Health Questionnaire. Significant differences were found between the admission and discharge Canadian Occupational Performance Measure Performance and Satisfaction scale scores. From both the clients' and therapists' perspectives, four key qualitative themes emerged: (1) "Likes" about the Canadian Occupational Performance Measure; (2) Effects on practice; (3) Utility; and (4) Future use.Conclusions: This study provides evidence of the Canadian Occupational Performance Measure's validity, responsiveness and clinical utility when used in a sub-acute setting.Implications for rehabilitationThe Canadian Occupational Performance Measure appears able to effectively evaluate the outcomes of occupational therapy interventions, including in sub-acute rehabilitation settings. It is an individualized outcome measure where clients are responsible for measuring their own progress and meaningful outcomes from therapy.Evidence of the Canadian Occupational Performance Measure's convergent validity, predictive validity and responsiveness to change was found which contributes to the body of knowledge of its psychometric properties.From a qualitative perspective, the Canadian Occupational Performance Measure was found to improve clinical decision making, facilitating client engagement, formulating clear treatment goals and making therapy more meaningful for clients.

Total Ankle Replacement for Osteoarthritis Following Pilon Fracture of the Tibia

BACKGROUND

Outcomes for total ankle replacement (TAR) performed for osteoarthritis following pilon fracture are underreported. We compared the outcomes between different indications for TAR.

METHODS

Patient-reported outcome measures (PROMs) for TAR performed from 2006 to 2014 by a single surgeon were reviewed. Foot and Ankle Outcome Score (FAOS), SF-36, comorbidities, self-reported body mass index (BMI), and patient satisfaction scores were reviewed. Data were collected preoperatively and at 1 and 2 years postoperatively. Clinical notes and radiographs highlighted the indication for TAR. The following subgroups were created: osteoarthritis (OA), rheumatoid arthritis (RA), pilon fracture (PF), ankle fracture (AF), and posttraumatic arthritis without previous fracture (PTOA). PROMs were available for 173 TARs: 89 (51.4%) for OA, 36 (20.8%) for AF, 21 (12.1%) for RA, 15 (8.7%) for PF, and 12 (6.9%) for PTOA. The pilon fracture group were the youngest and had the highest BMI (mean, 56.5 years; mean BMI, 31.6 kg/m²). No difference was found in number of reported comorbidities ( P > .05).

RESULTS

Significant improvement in FAOS scores was seen in all subgroups from preoperatively to 1 year ( P = .01, .05, and .03). SF-36 had similar results for all subgroups with improvement in all parameters by 2 years. Significant improvement in role physical and role emotional domains was seen by 1 year following TAR ( P = .018 and P = .042). Patient satisfaction scores were similar in each group. There was no major difference in any of the reported outcomes between subgroups by 2 years postoperatively.

CONCLUSION

We found similar outcomes for patients who underwent TAR after pilon fracture compared to other indications.

LEVEL OF EVIDENCE

Level III, comparative study.

Fourteen Year Follow-Up of Randomized Clinical Trials of Active Robotic-Assisted Total Hip Arthroplasty

BACKGROUND

Active robotic total hip arthroplasty (THA) has been used clinically for over 20 years, but long-term results have never been studied. The aims of this study are to determine whether active robotic THA improves clinical outcomes and results in fewer revisions over a long-term follow-up.

METHODS

Patients from 2 US Food and Drug Administration clinical trials (1994-1998 and 2001-2006) who had undergone THA using either an active robotic system or a traditional manual technique were examined to determine if any differences existed in radiographic analysis and patient pain and function using the University of California, Los Angeles; visual analog scale; Health Status Questionnaire (HSQ) pain; HSQ role physical; HSQ physical functioning; Harris pain scores; and the total Western Ontario and McMaster Universities Osteoarthritis Index scores at a mean follow-up of 14 years.

RESULTS

The ROBODOC group had statistically significant higher HSQ pain and Harris pain scores and lower Western Ontario and McMaster Universities Osteoarthritis Index scores. There was no statistically significant difference in probability of a revision for wear between the groups (χ² = 1.80; P = .179), and no revisions for loosening in either group.

CONCLUSION

Prior studies have demonstrated improved implant fit and alignment with the use of this active robot system. This long-term study now shows no failures for stem loosening at a mean follow-up of 14 years and small but potentially important improvements in clinical outcomes in the robot group.

The ShortMAC: Minimum Important Change of a Reduced Version of the Western Ontario and McMaster Universities Osteoarthritis Index

Study Design Clinical measurement study; secondary analysis of randomized clinical trial data. Background A 12-item shortened version (ShortMAC) of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a condition-specific, patient-reported osteoarthritis index, has been derived, published, and validated. The minimum important change (MIC) of the ShortMAC has not been reported or compared with the traditional 24-item WOMAC. Objectives To investigate the MIC of the 12-item ShortMAC and the traditional 24-item WOMAC across 3 levels of patient-perceived global change. Methods The Management of OsteoArthritis Trial cohort of 206 consecutive patients with knee or hip osteoarthritis was assessed at the initial visit and after 9 weeks of physical therapy (n = 155) or usual medical care (n = 51). The global rating of change instrument, assessed at the 9-week visit, provided the anchor. The MIC was calculated using receiver operating characteristic curve methodology for the ShortMAC and the traditional WOMAC, across 3 levels of patient-perceived change (small, medium, and large change) defined by the global rating of change. Results The MICs for the ShortMAC and traditional WOMAC (both transformed to a scale from 0 to 100) were 7.9 and 9.8 points for small change, 8.4 and 9.8 points for medium change, and 12.1 and 10.1 points for large change, respectively. The MICs of the pain and function subscales are also reported for small, medium, and large changes. Conclusion The lower point estimates for the MIC of the ShortMAC compared with that of the traditional WOMAC, using conventional definitions of MIC and half the number of items, indicate greater efficiency for use in clinical trials and reduced patient burden. J Orthop Sports Phys Ther 2018;48(2):81-86. Epub 21 Oct 2017. doi:10.2519/jospt.2018.7676.

Minimally invasive periacetabular osteotomy using a modified Smith-Petersen approach: technique and early outcomes

AIMS

Periacetabular osteotomy is an effective way of treating symptomatic hip dysplasia. We describe a new minimally invasive technique using a modification of the Smith-Peterson approach. We performed a prospective, longitudinal cohort study to assess for any compromise in acetabular correction when using this approach, and to see if the procedure would have a higher complication rate than that quoted in the literature for other approaches. We also assessed for any improvement in functional outcome.

PATIENTS AND METHODS

From 168 consecutive patients (189 hips) who underwent acetabular correction between March 2010 and March 2013 we excluded those who had undergone previous pelvic surgery for DDH and those being treated for acetabular retroversion. The remaining 151 patients (15 men, 136 women) (166 hips) had a mean age of 32 years (15 to 56) and the mean duration of follow-up was 2.8 years (1.2 to 4.5). In all 90% of cases were Tönnis grade 0 or 1. Functional outcomes were assessed using the Non Arthritic Hip Score (NAHS), University of California, Los Angeles (UCLA) and Tegner activity scores.

RESULTS

The mean pre-operative lateral centre-edge angle was 14.2° (-5° to 30°) and the mean acetabular index was 18.4° (4° to 40°). Post-operatively these were 31° (18° to 46°) and 3° (-7° to 29°), respectively, a significant improvement in both (p < 0.001). Allogenic blood transfusion was required in two patients (1.2%). There were no major nerve or vascular complications, and no wound infections. At the time of last follow-up, we noted a significant improvement in functional outcome scores: UCLA improved by 2.31 points, Tegner improved by 1.08 points, and the NAHS improved by 25.4 points (p < 0.001 for each). Hypermobility and longer duration of surgery were significant negative predictors for a good post-operative UCLA score, while residual retroversion was a positive predictor of post-operative UCLA score.

CONCLUSION

We have found this approach to be safe and effective, facilitating early recovery from surgery. Cite this article: Bone Joint J 2017;99-B:22-8.

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.