Measurement Properties of Patient-Reported Outcome Measures Used in Patients Undergoing Total Hip Arthroplasty

Strategies to Manage Poorer Outcomes After Hip or Knee Arthroplasty: A Narrative Review of Current Understanding, Unanswered Questions, and Future Directions

PURPOSE

Although hip or knee arthroplasty is generally a successful intervention, it is documented that 15%-30% of patients undergoing arthroplasty report suboptimal outcomes. This narrative review aims to provide an overview of the key findings concerning the management of poorer outcomes after hip or knee arthroplasty.

METHOD

A comprehensive search of articles was conducted up to November 2023 across three electronic databases. Only studies written in English were included, with no limitations applied regarding study design and time.

RESULT

Efficiently addressing poorer outcomes after arthroplasty necessitates a thorough exploration of appropriate methods for assessing recovery following hip or knee arthroplasty, ensuring accurate identification of patients at risk or experiencing poorer recovery. When selecting appropriate outcome measure tools, various factors should be taken into consideration, including understanding patients' priorities throughout the recovery process, assessing psychometric properties of outcome measure tools at different time points after arthroplasty, understanding how to combine/reconcile provider-assessed and patient-reported outcome measures, and determining the appropriate methods to interpret outcome measure scores. However, further research in these areas is warranted. In addition, the identification of key modifiable factors affecting outcomes and the development of interventions to manage these factors are needed.

CONCLUSION

There is growing attention paid to delivering interventions for patients at risk or not optimally recovering following hip or knee arthroplasty. To achieve this, it is essential to identify the most appropriate outcome measure tools, factors associated with poorer recovery and management of these factors.

Patient reported outcome measures (PROMs) as primary and secondary outcomes in total hip and knee arthroplasty randomized controlled trials: a systematic review

BACKGROUND

Significant heterogeneity exists regarding patient reported outcome measures (PROMs) used in total hip (THA) and knee (TKA) arthroplasty randomized controlled trials (RCTs). This study investigates the PROMs used as primary and secondary outcomes in contemporary arthroplasty RCTs.

METHODS

A literature search identified THA and TKA RCTs that were published in top ten impact factor orthopaedic journals from 2017 to 2021. Screening identified 241 trials: 76 THA, 157 TKA, and eight combined. Data were extracted to identify PROMs utilized as either primary or secondary outcomes and the time period of measurement.

RESULTS

Visual Analog Scale (VAS) Pain was the most reported primary PROM in THA (9.2%) and TKA (22.9%) trials. This was followed by Numeric Rating Scale (NRS) Pain (7.9%) and the Harris Hip score (6.6%) in THA trials and NRS Pain (4.5%) and the Knee Society score (4.5%) in TKA trials. Many THA (37.0%) and TKA (52.1%) trials did not clearly specify primary outcome time points. Only pain scales were reported at time points less than one week, while various joint-specific functional outcomes were reported at later time points. As secondary outcomes, the Harris Hip score (28.9%) was most common in THA trials and the Knee Society score (26.1%) was most common in TKA trials. Indeterminate primary or secondary outcomes were reported in 18.2% of studies.

CONCLUSIONS

Contemporary THA and TKA trials exhibit heterogeneity of PROMs as study outcomes after the first postoperative week. Our findings highlight the need for consensus in PROM reporting and better methodological reporting to improve the interpretability of RCT outcomes.

PROSPERO REGISTRATION NUMBER

CRD42022337255.

Anti-osteoporotic drug efficacy for periprosthetic bone loss after total hip arthroplasty: A systematic review and network meta-analysis

BACKGROUND

Periprosthetic bone loss following total hip arthroplasty (THA) threatens prosthesis stability. This systematic review and network meta-analysis aimed to compare the efficacy of anti-osteoporotic drugs for measures of hip function according to functional outcomes, periprosthetic femoral bone mineral density loss in each Gruen zone, and revision surgery after THA.

METHODS

The systematic search of six literature databases was conducted in December 2021 in accordance with PRISMA guidelines. Adult participants who underwent primary THA were included. A random-effects network meta-analysis was performed within a frequentist framework, and the confidence in the evidence for each outcome was evaluated using the CINeMA tool, which assessed the credibility of results from the network meta-analysis. We included 22 randomized controlled trials (1243 participants) comparing the efficacy and safety of bisphosphonates (including etidronate, clodronate, alendronate, risedronate, pamidronate, and zoledronate), denosumab, selective estrogen receptor modulator, teriparatide, calcium + vitamin D, calcium, and vitamin D. We defined the period for revision surgery as the final follow-up period.

RESULTS

Raloxifene, bisphosphonate, calcium + vitamin D, and denosumab for prosthetic hip function might have minimal differences when compared with placebos. The magnitude of the anti-osteoporotic drug effect on periprosthetic femoral bone loss varied across different Gruen zones. Bisphosphonate, denosumab, teriparatide might be more effective than placebo in Gruen zone 1 at 12 months after THA. Additionally, bisphosphonate might be more effective than placebo in Gruen zones 2, 5, 6, and 7 at 12 months after THA. Denosumab was efficacious in preventing bone loss in Gruen zones 6 and 7 at 12 months after THA. Teriparatide was likely to be efficacious in preventing bone loss in Gruen zone 7 at 12 months after THA. Raloxifene was slightly efficacious in preventing bone loss in Gruen zones 2 and 3 at 12 months after THA. Calcium was slightly efficacious in preventing bone loss in Gruen zone 5 at 12 months after THA. None of the studies reported revision surgery.

CONCLUSIONS

Bisphosphonate and denosumab may be effective anti-osteoporotic drugs for preventing periprosthetic proximal femoral bone loss due to stress shielding after THA, particularly in cementless proximal fixation stems, which are the most commonly used prostheses worldwide.

Low Ceiling Effects of the Forgotten Joint Score Compared With Legacy Measures After Joint-Preserving Procedures: A Systematic Review

PURPOSE

To determine, in patients undergoing joint preservation procedures, whether the Forgotten Joint Score (FJS) compares favorably with legacy measures.

METHODS

Medical databases (including PubMed/MEDLINE and Embase databases) were queried for publications with the terms "Forgotten Joint Score" and "hip," "knee," "arthroscopy," or "ACL." Fourteen studies met the inclusion criteria. Methodologic quality was assessed through the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist, and psychometric data were evaluated for ceiling or floor effects, convergent validity, internal consistency, reliability, responsiveness, measurement invariance, and measurement error by 2 fellowship-trained orthopaedic surgeons (B.D.K. and W.T.H.).

RESULTS

Data were collected from 14 studies using the FJS after joint-preserving procedures in 911 patients (959 joints). Four studies reported strong internal consistency with an average Cronbach α of 0.92. Two studies reported responsiveness with an effect size ranging from 0.6 to 1.16. One study reported reproducibility with an interclass correlation coefficient of 0.9 (95% confidence interval, 0.8-0.9). One study reported measurement error with an minimum detectable change (MDC)individual of 32% and MDCgroup of 4.5%. Studies reported moderate to very strong convergent validity across legacy measures for hip and knee preservation surgery. Ceiling effects were favorable compared with many legacy scores for hip and knee preservation. Three studies reported the minimal clinically important difference whereas 1 study reported the patient acceptable symptomatic state for the FJS.

CONCLUSIONS

The FJS is a methodologically sound outcome measure used to evaluate patient outcomes after hip and knee preservation surgery with overall low ceiling effects compared with legacy measures.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Identifying patient subgroups with different trends of patient-reported outcomes (PROMs) after elective knee arthroplasty

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly being used to assess the effectiveness of elective total knee arthroplasty (TKA). However, little is known about how PROMs scores change over time in these patients. The aim of this study was to identify the trajectories of quality of life and joint functioning, and their associated demographic and clinical features in patients undergoing elective TKA.

METHODS

A prospective, cohort study was conducted, in which PROMs questionnaires (Euro Quality 5 Dimensions 3L, EQ-5D-3L, and Knee injury and Osteoarthritis Outcome Score Patient Satisfaction, KOOS-PS) were administered to patients at a single center undergoing elective TKA before surgery, and at 6 and 12 months after surgery. Latent class growth mixture models were used to analyze the patterns of change in PROMs scores over time. Multinomial logistic regression was used to investigate the association between patient characteristics and PROMs trajectories.

RESULTS

A total of 564 patients were included in the study. The analysis highlighted differential patterns of improvement after TKA. Three distinct PROMs trajectories were identified for each PROMs questionnaire, with one trajectory indicating the most favorable outcome. Female gender appears to be associated with a presentation to surgery with worse perceived quality of life and joint function than males, but also more rapid improvement after surgery. Having an ASA score greater than 3 is instead associated with a worse functional recovery after TKA.

CONCLUSION

The results suggest three main PROMs trajectories in patients undergoing elective TKA. Most patients reported improved quality of life and joint functioning at 6 months, which then stabilized. However, other subgroups showed more varied trajectories. Further research is needed to confirm these findings and to explore the potential clinical implications of these results.

Use of Patient-Reported Outcome Measures in Lower Extremity Research

Background

A large number of patient reported outcome measures (PROMs) have been developed for specific lower extremity orthopaedic pathologies. However, a consensus as to which PROMs are recommended for use in evaluating treatment outcomes for patients with hip, knee, ankle and/or foot pathology based on the strength of their psychometric properties is lacking.

Objective

To identify PROMs that are recommended in systematic reviews (SRs) for those with orthopaedic hip, knee, foot, and ankle pathologies or surgeries and identify if these PROMs are used in the literature.

Study design

Umbrella Review.

Methods

PubMed, Embase, Medline, Cochrane, CINAHL, SPORTDisucs and Scopus were searched for SRs through May 2022. A second search was done to count the use of PROMs in seven representative journals from January 2011 through May 2022.SRs that recommended the use of PROMs based on their psychometric properties were included in the first search. SRs or PROMs not available in the English were excluded. The second search included clinical research articles that utilized a PROM. Case reports, reviews, and basic science articles were excluded.

Results

Nineteen SRs recommended 20 PROMs for 15 lower extremity orthopaedic pathologies or surgeries. These results identified consistency between recommended PROMs and utilization in clinical research for only two of the 15 lower extremity pathologies or surgeries. This included the use of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Copenhagen Hip and Groin Outcome Score to assess outcomes (HAGOS) for those with knee osteoarthritis and groin pain, respectively.

Conclusion

A discrepancy was found between the PROMs that were recommended by SRs and those used to assess clinical outcomes in published research. The results of this study will help to produce more uniformity with the use of PROMs that have the most appropriate psychometric properties when the reporting treatment outcomes for those with extremity pathologies.

Level of evidence

3a.

Association between VTE and antibiotic prophylaxis guideline compliance and patient-reported outcomes after total hip and knee arthroplasty: an observational study

BACKGROUND

Surgical site infection (SSI) and venous thromboembolism (VTE) are associated with high burden and cost and are considered largely preventable following total knee or hip arthroplasty (TKA, THA). The risk of developing VTE and SSI is reduced when prophylaxis is compliant with evidence-based clinical guidelines. However, the association between VTE and antibiotic prophylaxis clinical guideline compliance and patient-reported outcome measures (PROMs) after THA/TKA is unknown. This study aims to explore whether care that is non-compliant with VTE and antibiotic guideline recommendations is associated with PROMs (Oxford Hip/Knee Score and EQ-5D Index scores) at 90- and 365-days after surgery.

METHODS

This prospective observational study included high-volume arthroplasty public and private sites and consenting eligible participants undergoing elective primary THA/TKA. We conducted multiple linear regression and linear mixed-effects modelling to explore the associations between non-compliance with VTE and antibiotic guidelines, and PROMs.

RESULTS

The sample included 1838 participants. Compliance with VTE and antibiotic guidelines was 35% and 13.2% respectively. In adjusted modelling, non-compliance with VTE guidelines was not associated with 90-day Oxford score (β = - 0.54, standard error [SE] = 0.34, p = 0.112) but was significantly associated with lower (worse) 365-day Oxford score (β = - 0.76, SE = 0.29, p = 0.009), lower EQ-5D Index scores at 90- (β = - 0.02 SE = 0.008, p = 0.011) and 365-days (β = - 0.03, SE = 0.008, p = 0.002).. The changes in Oxford and EQ-5D Index scores were not clinically important. Noncompliance with antibiotic guidelines was not associated with either PROM at 90- (Oxford: β = - 0.45, standard error [SE] = 0.47, p = 0.341; EQ-5D: β = - 0.001, SE = 0.011, p = 0.891) or 365-days (Oxford score: β = - 0.06, SE = 0.41, p = 0.880 EQ-5D: β = - 0.010, SE = 0.012, p = 0.383). Results were consistent when complications were included in the model and in linear mixed-effects modelling with the insurance sector as a random effect.

CONCLUSIONS

Non-compliance with VTE prophylaxis guidelines, but not antibiotic guidelines, is associated with statistically significant but not clinically meaningful differences in Oxford scores and EQ-5D Index scores at 365 days.

Patient reported outcomes measures (PROMs) trajectories after elective hip arthroplasty: a latent class and growth mixture analysis

Background

Patient-reported outcome measures (PROMs) are an extensively used tool to assess and improve the quality of healthcare services. PROMs can be related to individual demographic and clinical characteristics in patients undergoing hip arthroplasty (HA). The aim of this study is to identify distinct subgroups of patients with unique trajectories of PROMS scores and to determine patients’ features associated with these subgroups.

Methods

We conducted a prospective, cohort study in which PROMs questionnaires (Euro Quality 5 Dimensions 3L, EQ-5D-3L, Euro-Quality-Visual-Analytic-Score, EQ-VAS, Hip disability and Osteoarthritis Outcome Score, HOOS-PS) were administered to patients undergoing elective HA pre-operatively, and at 6 and 12 months after surgery. For each measure, latent class growth analysis and growth mixture models were used to identify subgroups of patients with distinct trajectories of scores. Demografic and clinical predictors of the latent classes in growth mixture model were identified using a 3-step approach.

Results

We found three distinct trajectories for each PROM score. These trajectories indicated a response heterogeneity to the HA among the patients (n = 991). Patient’s gender, ASA score, and obesity were significantly associated with different PROMs trajectories.

Conclusions

We identified three distinct trajectories for each of the three PROMs indicators. Several demographic and clinical characteristics are associated with the different trajectories of PROMs at 6 and 12 months after HA and could be used to identify groups of patients with different outcomes following HA surgery. These findings underline the importance of patient-centered care, supporting the usefulness of integrating PROMs data alongside routinely collected healthcare records for guiding clinical care and maximizing patients’ positive outcomes.

Trial registration: Protocol version (1.0) and trial registration data are available on the platform www.clinicaltrial.gov with the identifier NCT03790267, posted on December 31, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00503-5.

Effectiveness of promotion and support for physical activity maintenance post total hip arthroplasty-study protocol for a pragmatic, assessor-blinded, randomized controlled trial (the PANORAMA trial)

Background

Total hip arthroplasty is considered an efficacious procedure for relieving pain and disability, but despite that objectively measured physical activity level remains unchanged compared to pre-surgery and is still considerably lower than that of a healthy age- and sex-matched population 6–12 months post-surgery. Since there is a graded relationship between physical activity level and functional performance, increasing physical activity may enhance the outcome of the procedure. This study aims to investigate whether promotion and support of physical activity initiated 3 months after total hip arthroplasty complementary to usual rehabilitation care can increase objective measured physical activity 6 months post-surgery.

Methods

The trial is designed as a pragmatic, parallel group, two-arm, assessor-blinded, superiority, randomized (1:1), controlled trial with post intervention follow-up 6 and 12 months after total hip arthroplasty. Home-dwelling, independent, and self-reliant patients with hip osteoarthritis are provisionally enrolled prior to surgery and re-screened about 2–3 months post-surgery to confirm eligibility. Baseline assessment is conducted 3 months post-surgery. Subsequently, patients (n=200) are randomized to either a 3-month, multimodal physical activity promotion/education intervention or control (no further attention). The intervention consists of face-to-face and telephone counselling, patient education material, pedometer, and step-counting journal. The primary outcome is objectively measured physical activity, specifically the proportion of patients that complete on average ≥8000 steps per day 6 months post-surgery. Secondary outcomes include core outcomes (i.e., physical function, pain, and patient global assessment) and health-related quality of life. Furthermore, we will explore the effect of the intervention on self-efficacy and outcome expectations (i.e., tertiary outcomes).

Discussion

By investigating the effectiveness of a pedometer-driven, face-to-face, and telephone-assisted counselling, behavior change intervention in complementary to usual rehabilitation, we hope to deliver applicable and generalizable knowledge to support physical activity after total hip arthroplasty and potentially enhance the outcome of the procedure.

Trial registration

www.clinicaltrials.govNCT04471532. Registered on July 15, 2020.

Use of computerised adaptive testing to reduce the number of items in patient-reported hip and knee outcome scores: an analysis of the NHS England National Patient-Reported Outcome Measures programme

OBJECTIVE

Over 160 000 participants per year complete the 12-item Oxford Hip and Knee Scores (OHS/OKS) as part of the NHS England Patient-Reported Outcome Measures (PROMs) programme. We used a modern computational approach, known as computerised adaptive testing (CAT), to simulate individually tailored OHS and OKS assessment, with the goal of reducing the number of questions a patient must complete without compromising measurement accuracy.

METHODS

We fit the 2018/2019 PROMs data to an item response theory (IRT) model. We assessed IRT model assumptions alongside reliability. We used parameters from the IRT model with data from 2017/2018 to simulate CAT assessments. Two simulations were run until a prespecified SE of measurement was met (SE=0.32 and SE=0.45). We compared the number of questions required to meet each cut-off and assessed the correlation between the full-length and CAT administration.

RESULTS

We conducted IRT analysis using 40 432 OHS and 44 714 OKS observations. The OHS and OKS were both unidimensional (root mean square error of approximation 0.08 and 0.07, respectively) and marginal reliability 0.91 and 0.90. The CAT, with a precision limit of SE=0.32 and SE=0.45, required a median of four items (IQR 1) and two items (IQR 1), respectively, for the OHS, and median of four items (IQR 2) and two items (IQR 0) for the OKS. This represents a potential 82% reduction in PROM length. In the context of 160 000 yearly assessments, these methodologies could result in the omission of some 1 280 000 redundant questions per year, which equates to 40 000 hours of patient time.

CONCLUSION

The application of IRT to the OHS and OKS produces an efficient and substantially reduced CAT. We have demonstrated a path to reduce the burden and potentially increase the compliance for these ubiquitous outcome measures without compromising measurement accuracy.

Can minimal clinically important differences in patient reported outcome measures be predicted by machine learning in patients with total knee or hip arthroplasty? A systematic review

OBJECTIVES

To systematically review studies using machine learning (ML) algorithms to predict whether patients undergoing total knee or total hip arthroplasty achieve an improvement as high or higher than the minimal clinically important differences (MCID) in patient reported outcome measures (PROMs) (classification problem).

METHODS

Studies were eligible to be included in the review if they collected PROMs both pre- and postintervention, reported the method of MCID calculation and applied ML. ML was defined as a family of models which automatically learn from data when selecting features, identifying nonlinear relations or interactions. Predictive performance must have been assessed using common metrics. Studies were searched on MEDLINE, PubMed Central, Web of Science Core Collection, Google Scholar and Cochrane Library. Study selection and risk of bias assessment (ROB) was conducted by two independent researchers.

RESULTS

517 studies were eligible for title and abstract screening. After screening title and abstract, 18 studies qualified for full-text screening. Finally, six studies were included. The most commonly applied ML algorithms were random forest and gradient boosting. Overall, eleven different ML algorithms have been applied in all papers. All studies reported at least fair predictive performance, with two reporting excellent performance. Sample size varied widely across studies, with 587 to 34,110 individuals observed. PROMs also varied widely across studies, with sixteen applied to TKA and six applied to THA. There was no single PROM utilized commonly in all studies. All studies calculated MCIDs for PROMs based on anchor-based or distribution-based methods or referred to literature which did so. Five studies reported variable importance for their models. Two studies were at high risk of bias.

DISCUSSION

No ML model was identified to perform best at the problem stated, nor can any PROM said to be best predictable. Reporting standards must be improved to reduce risk of bias and improve comparability to other studies.

Is Shared Decision-making Associated with Better Patient-reported Outcomes? A Longitudinal Study of Patients Undergoing Total Joint Arthroplasty

BACKGROUND

Although shared decision-making (SDM) has knowledge and satisfaction benefits for patients and is promising, we lack data demonstrating that SDM is associated with better patient-reported functional outcomes. Such data would support the integration and prioritization of SDM into all aspects of orthopaedic care.

QUESTIONS/PURPOSES

(1) Is a measure of SDM before total joint arthroplasty associated with better patient-reported outcome measures (PROMs) 1 year postoperatively? (2) What is the relationship between the measure of SDM and two measures of patient experience (patient rating of the provider and patient likelihood of recommending the provider) at 1 year postoperatively?

METHODS

In this observational longitudinal survey-based study, patients receiving an initial THA or TKA from a large, multispecialty medical group in the Midwestern United States were surveyed after they were scheduled for surgery and again at 12 months after their procedure. The three-item collaboRATE measure of SDM was added to existing patient surveys of PROMs. However, the surgeons and their department had no organized approach to SDM during this time. The surveys also included the Oxford knee or hip score and two validated measures of patient experience (patient rating of the provider and whether a patient would recommend the provider). Of the 2779 eligible primary joint arthroplasties that occurred from April 23, 2018 to May 1, 2019, 48% (1334 procedures; 859 TKAs and 485 THAs) of the patients responded to both the preoperative and 12-month postoperative surveys. Most of the patients who were included in the analytic sample were white (93%; 1255 of 1344), with only 3% (37) using Medicaid benefits at the time of surgery. Differences between responders and nonresponders were present and explored in an analysis. Patient responses were analyzed in regression models to estimate the association between preoperative collaboRATE scores and the Oxford knee or hip scores, and patient experience measures 12 months postoperatively.

RESULTS

There was a moderate, positive association between preoperative collaboRATE scores and the Oxford scores at 12 months, after adjustment for potential confounders such as patient age and preoperative functional score (β = 0.58; 95% CI 0.14-1.02; p = 0.01). Similarly, patients with preoperative collaboRATE scores had marginally higher patient experience scores at 12 months postoperatively (β = 0.14; 95% CI 0.05-0.24; p = 0.003) and were more likely to recommend their surgeon (OR 1.43; 95% CI 1.11-1.84; p = 0.005). The patient experience measures were also modestly correlated with collaboRATE scores in cross-sectional associations, both preoperatively and at 12 months postoperatively (0.29 ≤ r ≤ 0.54; p < 0.01).

CONCLUSION

The association between preoperative collaboRATE scores and Oxford hip or knee scores suggests that SDM could be one tool to encourage better outcomes. Although previous studies have shown that SDM can improve patient experience, the lack of a strong correlation in our study suggests that PROMs and experience measures are separate domains, at least partly. Improving preoperative SDM between the surgeon and patient might help improve surgical outcomes for patients undergoing TKA and THA.

LEVEL OF EVIDENCE

Level II, therapeutic study.

The Patient-Specific Combined Target Zone for Morpho-Functional Planning of Total Hip Arthroplasty

Background Relevant criteria for total hip arthroplasty (THA) planning have been introduced in the literature which include the hip range of motion, bony coverage, anterior cup overhang, leg length discrepancy, edge loading risk, and wear. The optimal implant design and alignment depends on the patient’s anatomy and patient-specific functional parameters such as the pelvic tilt. The approaches proposed in literature often consider one or more criteria for THA planning. but to the best of our knowledge none of them follow an integrated approach including all criteria for the definition of a patient-specific combined target zone (PSCTZ). Questions/purposes (1) How can we calculate suitable THA implant and implantation parameters for a specific patient considering all relevant criteria? (2) Are the resulting target zones in the range of conventional safe zones? (3) Do patients who fulfil these combined criteria have a better outcome score? Methods A method is presented that calculates individual target zones based on the morphology, range of motion and load acting on the hip joint and merges them into the PSCTZ. In a retrospective analysis of 198 THA patients, it was calculated whether the patients were inside or outside the Lewinnek safe zone, Dorr combined anteversion range and PSCTZ. The postoperative Harris Hip Scores (HHS) between insiders and outsiders were compared. Results 11 patients were inside the PSCTZ. Patients inside and outside the PSCTZ showed no significant difference in the HHS. However, a significant higher HHS was observed for the insiders of two of the three sub-target zones incorporated in the PSCTZ. By combining the sub-target zones in the PSCTZ, all PSCTZ insiders except one had an HHS higher than 90. Conclusions The results might suggest that, for a prosthesis implanted in the PSCTZ a low outcome score of the patient is less likely than using the conventional safe zones by Lewinnek and Dorr. For future studies, a larger cohort of patients inside the PSCTZ is needed which can only be achieved if the cases are planned prospectively with the method introduced in this paper. Clinical Relevance The method presented in this paper could help the surgeon combining multiple different criteria during THA planning and find the suitable implant design and alignment for a specific patient.

Validation of the Spanish version of the Goodman score in total hip arthroplasty

Purpose

Currently, patient-reported outcome measures (PROMs) are the standard instruments used to compare arthroplasty results. Goodman et al. recently published a well-constructed scale with excellent psychometric properties that can be quickly administered. The main objective of our study was to translate, culturally adapt, and validate a Spanish version of the Goodman questionnaire in patients who underwent total hip arthroplasty (THA).

Methods

The original Goodman scale was translated into Spanish and cross-culturally adapted. Then, the data from this version were tested for psychometric quality. We designed a cross-sectional study for data collection. This study enrolled 2 institutions. Patients who underwent hip replacement due to primary osteoarthritis secondary to dysplasia between 1 January 2018 and 31 December 2019 were included. A total of 153 patients were contacted twice to record the Goodman and Oxford hip scales (OHS) to assess the validity of the questionnaire. Reliability was tested using the Cronbach’s alpha, Concordance using 3 test: intraclass correlation coefficient (ICC), Lin's concordance correlation coefficient (CCC), and the Bradley-Blackwood F test. The spearman correlation was used to asses correlation between the OHS and the Spanish-adapted Goodman scale.

Results

The overall satisfaction after THA was reported to be “very satisfied” by 137 patients (75%), and only 14 patients reported some degree of dissatisfaction (6%). The improvement in quality of life was reported to be “more than I ever dreamed possible” by 41% patients. Cronbach’s alpha was acceptable, reaching a coefficient of 0.95 (95% confidence interval, 0.82–1). No statistical difference (t test, p = 0.55) was found in the original version, with great internal validity. Test re-test concordance was optimal among the 3 tests used. A moderate correlation was found between the OHS and the Spanish-adapted Goodman scale.

Conclusion

The Spanish version of the Goodman questionnaire in THA is a reliable, consistent, and feasible scale to evaluate patient satisfaction and improvement in the quality of life in Spanish speakers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02653-6.

Patient-Reported Outcomes Measurement Information System Validation in Hip Arthroscopy: A Shift Towards Reducing Survey Burden

Background The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to provide measures of patient-reported symptoms and healthcare outcomes across a variety of conditions in an easily accessible manner. The purpose of this study was to validate PROMIS against traditional legacy measures in patients undergoing hip arthroscopy for femoral acetabular impingement (FAI). Methodology Outcome measures collected pre- and post-operatively included PROMIS Pain Interference (PI) and Physical Function (PF), modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living and Sport (HOS-ADL and HOS-Sport), Nonarthritic Hip Score (NAHS), and Visual Analog Scale (VAS). Pearson's correlation coefficients were calculated between each outcome measure. Results Strong correlations were observed between the PROMIS PF T-Score and the mHHS (r = 0.64-0.83, p < 0.0001), HOS-ADL (r = 0.54-0.81, p < 0.0001), HOS-Sport (r = 0.55-0.74, p < 0.0001), and NAHS (r = 0.61-0.78, p < 0.0001) measurement tools. PROMIS Computer Adaptive Testing PI T-Score and VAS also demonstrated a strong correlation (r = 0.64-0.80, p < 0.0001). Conclusions PROMIS PF scores correlate strongly with mHHS, HOS-ADL, HOS-Sport, and NAHS scores at all time points. Likewise, PROMIS PI scores correlate strongly with VAS pain scores. On average, patients completing PROMIS need to fill out only four or five questions. This study supports the use of PROMIS as an efficient, valid outcome tool for patients with FAI undergoing hip arthroscopy.

Systematic review and meta-analysis of measurement properties of the Hip disability and Osteoarthritis Outcome Score - Physical Function Shortform (HOOS-PS) and the Knee Injury and Osteoarthritis Outcome Score - Physical Function Shortform (KOOS-PS)

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate all evidence on measurement properties of the Hip disability and Osteoarthritis Outcome Score - Physical function Shortform (HOOS-PS) and the Knee Injury and Osteoarthritis Outcome Score - Physical function Shortform (KOOS-PS).

DESIGN

This study was conducted according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline for systematic reviews of PROMs. MEDLINE, EMBASE, The Cochrane Library, CINAHL and PsychINFO through February 2019 were searched. Eligible studies evaluated patients with hip or knee complaints and described a measurement property, interpretability, feasibility, or the development of either the HOOS-PS or KOOS-PS.

RESULTS

Twenty-three studies were included. For both questionnaires, the content validity was found inconsistent and the quality evidence was moderate for a sufficient reliability and high for an insufficient construct validity. The HOOS-PS had a high quality evidence of sufficient structural validity and internal consistency (pooled Cronbach's alpha 0.80; n = 3761) and low quality evidence of sufficient measurement error and indeterminate responsiveness. Concerning the KOOS-PS, the quality evidence was high for an insufficient responsiveness, moderate for an inconsistent structural validity and internal consistency and low for an inconsistent measurement error.

CONCLUSIONS

The inconsistent evidence for content validity implies that scores on the HOOS-PS and KOOS-PS may inadequately reflect physical functioning. Furthermore, there is evidence for insufficient construct validity and responsiveness in patients with knee osteoarthritis receiving conservative treatment. Using the HOOS-PS or KOOS-PS as outcome measurement instruments for comparing outcomes, measuring improvements or benchmarking in patients with hip or knee complaints or undergoing arthroplasty should only be done with great caution.

REVIEW REGISTRATION

PROSPERO number CRD42017069539.

Patient-reported outcomes: Which ones are most relevant?

The use of patient-reported outcome measures (PROs) in research and clinical use in orthopedic trauma surgery has increased dramatically over the past decades, and this trend will continue in the future. This review aimed to provide insight into the way PROs can best be identified, reviewed, selected, and used in orthopedic trauma studies and patient care. Selection of instruments for a specific (research) question starts with a systematic literature review for identifying the mostly used instruments. From this list, the instruments that are most suitable for the intended use are selected. Readability, usability, and costs should be considered at this stage. For the selected instruments, the next step is to search the literature systematically in order to determine if the measurement properties of these instruments meet the quality standard as outlined by the COSMIN group. Instruments need to be valid for the targeted condition, intervention as well as population. If not available in the primary language of the targeted population, the instrument requires translation according to a state of the art procedure and validation in the new language. Reporting guidelines like the SPIRIT-PRO and CONSORT-PRO are available in order to guide the reporting of PROs in study protocol and outcome reports, respectively. Using Core Outcome Sets improves the validity of results of clinical research and increases the feasibility of conducting meta-analyses. If the standards and procedures as outlined above are used, the use of PROs will contribute to improved patient care and clinical research.

Editorial Commentary: Proximal Hamstring Tendon Injuries: Is the Research Hamstrung by the Use of Poor Outcome Measures?

Proximal hamstring tendon injuries are uncommon injuries, and there are few high-quality studies of surgical procedures in the literature. Increasing standardization of outcome measures with the use of validated, injury-specific, patient-reported outcome measures will improve research in this area. This will allow better assessment of novel surgical techniques.

Patient-reported outcome measures for hip-related pain: a review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018

Hip-related pain is a well-recognised complaint among active young and middle-aged active adults. People experiencing hip-related disorders commonly report pain and reduced functional capacity, including difficulties in executing activities of daily living. Patient-reported outcome measures (PROMs) are essential to accurately examine and compare the effects of different treatments on disability in those with hip pain. In November 2018, 38 researchers and clinicians working in the field of hip-related pain met in Zurich, Switzerland for the first International Hip-related Pain Research Network meeting. Prior to the meeting, evidence summaries were developed relating to four prioritised themes. This paper discusses the available evidence and consensus process from which recommendations were made regarding the appropriate use of PROMs to assess disability in young and middle-aged active adults with hip-related pain. Our process to gain consensus had five steps: (1) systematic review of systematic reviews; (2) preliminary discussion within the working group; (3) update of the more recent high-quality systematic review and examination of the psychometric properties of PROMs according to established guidelines; (4) formulation of the recommendations considering the limitations of the PROMs derived from the examination of their quality; and (5) voting and consensus. Out of 102 articles retrieved, 6 systematic reviews were selected and assessed for quality according to AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Two showed moderate quality. We then updated the most recent review. The updated literature search resulted in 10 additional studies that were included in the qualitative synthesis. The recommendations based on evidence summary and PROMs limitations were presented at the consensus meeting. The group makes the following recommendations: (1) the Hip and Groin Outcome Score (HAGOS) and the International Hip Outcome Tool (iHOT) instruments (long and reduced versions) are the most appropriate PROMs to use in young and middle-aged active adults with hip-related pain; (2) more research is needed into the utility of the HAGOS and the iHOT instruments in a non-surgical treatment context; and (3) generic quality of life measures such as the EuroQoL-5 Dimension Questionnaire and the Short Form Health Survey-36 may add value for researchers and clinicians in this field. We conclude that as none of the instruments shows acceptable quality across various psychometric properties, more methods studies are needed to further evaluate the validity of these PROMS—the HAGOS and iHOT—as well as the other (currently not recommended) PROMS.

Translation, Cross-Cultural Adaptation, and Psychometric Properties of the Polish Version of the Hip Disability and Osteoarthritis Outcome Score (HOOS)

Background and Objectives: This study aimed to translate the Hip disability and Osteoarthritis Outcome Score (HOOS) into the Polish language, to determine its validity and reliability, and to assess its main psychometric properties. Materials and Methods: A total of 332 hip osteoarthritis (OA) subjects were recruited to the study group and 90 healthy subjects to the control group. The study consisted of the HOOS translation and the assessment of the discriminative power, internal consistency, and the potential floor and ceiling effects followed by the determination of the construct validity and test-retest reliability. The analysis was performed using Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and SF-36 questionnaires. Results: The translation process consisted of forward translation, reconciliation, backward translation, review, harmonization, and proofreading. The hip OA patients reported a reduced HOOS score when compared to the control subjects. The discriminant validity of the questionnaire was confirmed. A Cronbach’s alpha of 0.97 was found, indicating a high internal consistency. The HOOS showed a significant correlation with the SF-36 and WOMAC, which ranged from r = −0.93, p-value < 0.05 for WOMAC total score to r = 0.92, and p-value < 0.05 for WOMAC daily living. No floor or ceiling effects were found. A very high intraclass correlation coefficient (ICC) was found (0.93–0.97) for the total score and the individual domains of the HOOS. Conclusions: The Polish HOOS is valid and reliable for evaluating the outcomes of hip OA patients in Poland. This questionnaire may be used with confidence for clinical and research purposes.

A 12-item short form of the Hip disability and Osteoarthritis Outcome Score (HOOS-12): tests of reliability, validity and responsiveness

OBJECTIVE

To evaluate reliability, validity and responsiveness of HOOS-12, a 12-item short form of the 40-item Hip disability and Osteoarthritis Outcome Score (HOOS). HOOS-12 provides Pain, Function and Quality of Life (QOL) scale scores and a summary hip impact score.

DESIGN

Data from 1,273 FORCE-TJR hip osteoarthritis (OA) patients who completed HOOS before and six and 12 months after total hip replacement (THR) were analyzed. HOOS-12 includes a pain frequency item and three items measuring pain during increasingly difficult (sitting/lying, walking, stairs) activities; function items about standing, rising from sitting, getting in/out of a car, and walking on an uneven surface; and the 4-item HOOS QOL scale. Percent computable scale scores, floor and ceiling effects, internal consistency reliability, validity (scale correlations, tests of known groups validity using one-way analysis of variance (ANOVA)), and responsiveness (effect sizes (ES), standardized response means (SRM)) were compared for HOOS-12, full-length HOOS, HOOS-PS and HOOS, JR.

RESULTS

Internal consistency reliability was above 0.70 for all HOOS-12 scales and above 0.90 for the HOOS-12 Summary score. Validity and responsiveness of HOOS-12 Pain, Function and QOL scales were satisfactory and reached similar conclusions as comparable full-length HOOS scales. The HOOS-12 Summary score was highly responsive in discriminating between groups who differed in global ratings of post-THR change in physical capabilities and had high ES and SRM standardized response means.

CONCLUSIONS

HOOS-12 was a reliable and valid alternative to HOOS in THR patients with moderate to severe OA and provided three domain-specific and summary hip impact scores with substantially reduced respondent burden.

Relationship Between PROMIS Computer Adaptive Tests and Legacy Hip Measures Among Patients Presenting to a Tertiary Care Hip Preservation Center

BACKGROUND

Legacy hip outcome measures may be burdensome to patients and sometimes yield floor or ceiling effects. Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) allow for low-burden data capture and limited ceiling and floor effects.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine whether the PROMIS CAT domains demonstrate correlation against commonly used legacy patient-reported outcome measures in a population of patients presenting to a tertiary care hip preservation center. The authors hypothesized the following: (1) PROMIS CAT scores based on physical function (PF), pain interference (PIF), pain behavior, and pain intensity would show strong correlation with the following legacy scores: modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), Hip Outcome Score (HOS) Sports and Activities of Daily Living subscales, and Veterans RAND-6D (VR-6D) utility measure. (2) The mental and physical health portions of the VR-6D legacy measure would show weak correlation with mental- and psychosocial-specific PROMIS elements-depression, anxiety, fatigue, sleep, and ability to participate in social roles and activities. (3) All PROMIS measures would exhibit fewer floor and ceiling effects than legacy scores.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Prospective data were collected on 125 patients in the hip preservation clinics. Enrollees completed legacy scores (visual analog scale for pain, mHHS, iHOT-12, HOS, and VR-6D) and PROMIS CAT questionnaires (PF, PIF, pain behavior, anxiety, depression, sleep, social roles and activities, pain intensity, fatigue). Spearman rank correlations were calculated, with r_s values of 0 to 0.3 indicating negligible correlation; 0.3 to 0.5, weak correlation; 0.5 to 0.7, moderately strong correlation; and >0.7, strong correlation. Floor and ceiling effects were evaluated.

RESULTS

As anticipated, the PF-CAT yielded strong correlations with the iHOT-12, mHHS, HOS-Sports, HOS-Activities of Daily Living, and VR-6D, with r_s values of 0.76, 0.71, 0.81, 0.87, and 0.71, respectively. The PIF-CAT was the only pain score to show moderately strong to strong correlation with all 14 patient-reported outcome measures. A strong correlation was observed between the VR-6D and the social roles and activities CAT ( r_s = 0.73). The depression CAT had a significant floor effect at 19%. No additional floor or ceiling effect was present for any other legacy or PROMIS measure.

CONCLUSION

The PF-CAT shows strong correlation with legacy patient-reported outcome scores among patients presenting to a tertiary care hip preservation center. The PIF-CAT also correlates strongly with legacy and PROMIS measures evaluating physical and mental well-being. PROMIS measures are less burdensome and demonstrate no floor or ceiling effects, making them a potential alternative to legacy patient-reported outcome measures for the hip.

Update on the epidemiology, risk factors and disease outcomes of osteoarthritis

Osteoarthritis (OA) is the most frequent form of arthritis and a leading cause of pain and disability worldwide. OA can affect any synovial joint, although the hip, knee, hand, foot and spine are the most commonly affected sites. Knowledge about the occurrence and risk factors for OA is important to define the clinical and public health burden of the disease to understand mechanisms of disease occurrence and may also help to inform the development of population-wide prevention strategies. In this article, we review the occurrence and risk factors for OA and also consider patient-reported outcome measures that have been used for the assessment of the disease.