Psychosocial and geriatric correlates of functional status after total hip replacement

Substantial Improvement in Self-Reported Mental Health Following Total Hip Arthroplasty Occurs Independent of Anesthetic Technique

BACKGROUND

The influence of anesthetic type on mental health after total hip arthroplasty (THA) is poorly understood. Adverse effects of general anesthesia (GA) on cognition following major non-cardiac surgery are well known, but mental health following THA is less well-studied. We hypothesized that neuraxial anesthesia (NA) would provide favorable mental health profiles compared with GA after THA.

METHODS

Prospectively collected Patient-Reported Outcomes Measurement Information System-10 (PROMIS) Global Mental Health (GMH) scores at preoperative baseline, and 1, 3, and 6 months after THA were accessed on 4,353 patients in the Pulmonary Embolism Prevention After HiP and KneE Replacement (PEPPER) Trial (ClinicalTrials.gov: NCT02810704). Anesthesia was categorized as: general (GA), neuraxial (NA), and neuraxial with peripheral block (NAP). The GMH was assessed longitudinally and compared between groups.

RESULTS

Postoperative GMH improved (P < .05) over preoperative in every anesthetic group. Groups receiving NA had higher baseline GMH scores. Improvement in GMH was diminished after GA alone and plateaued after 1 month. Adding NA or peripheral nerve block to GA conferred additional benefit to GMH improvement.

CONCLUSIONS

Patient-perceived mental health improves significantly after THA regardless of anesthetic type. Patients who have higher baseline GMH scores more commonly received NA, likely due to nonsurgical care determinants; these differences in mental wellness persisted at follow-up. Adjunctive NA or peripheral nerve block favored GMH improvement, whereas solitary GA diminished GMH improvement, which plateaued after 1 month. Substantial mental health benefits of THA may overshadow subtle differences in GMH attributable to anesthetic type.

The Outcome of Hip Arthroscopy in the Setting of Lumbar Spine Disease Is Beneficial, Yet Limited: A Systematic Review of Existing Evidence

PURPOSE

To compare hip arthroscopy outcomes in femoroacetabular impingement (FAI) patients with concurrent symptomatic lumbar spine disease to the outcomes of arthroscopic FAI patients without spine disease.

METHODS

A systematic review was performed according to PRISMA guidelines via PubMed, Cochrane, Embase, and Google Scholar databases. Studies were valid for inclusion if they had an average follow-up ≥12 months and compared patient-reported outcome measures (PROMs) in hip arthroscopy patients with and without concurrent spinal disease. Data collected included study characteristics, patient demographics, follow-up intervals, surgical indications, spinal pathology, PROMs, and reoperation rates.

RESULTS

Twelve studies were included in this systematic review. 3,107 patients who underwent hip arthroscopy were evaluated: 1,056 with coexisting lumbar spine disease (spine cohort) and 2,051 control subjects without spine disease (control cohort). The average follow-up period was 24 months. Across included studies, there were 35 instances wherein postoperative PROM scores reported by each cohort were compared. In all 35 instances, the spine cohort reported inferior postoperative PROM scores with the difference being significant (P < .05) on 23 PROMs. Collectively, 23 cases were available contrasting the proportion of each cohort to achieve the minimal clinically important difference (MCID). In 22 (95.65%) of these cases, the spine cohort achieved the MCID at a lower rate than the control cohort. There were 14 PROMs, wherein intragroup analyses were reported that compared the preoperative and postoperative score reported by the spine cohort. On all 14 PROMs, the spine cohort reported significant (P < .05) improvement after arthroscopic intervention.

CONCLUSION

FAI patients with coexisting lumbar spine pathology experience significant improvement from baseline state after arthroscopic intervention. However, the postoperative outcomes reported are inferior, and the improvement from arthroscopy was limited when compared to surgical control subjects with FAI and normal spinal anatomy.

LEVEL OF EVIDENCE

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

Identification of Potential High-Risk Patients on the Basis of PROMs in a Certified Centre for Joint Replacement (EndoProthetikZentrum) Using the Example of Hip Arthroplasty

BACKGROUND

In addition to clinical parameters, the subjective assessment by the patient to evaluate the operative outcome of an arthroplasty is becoming increasingly important. Questionnaires are used to identify patients who have not achieved the treatment goal at an early stage so that further interventions can be indicated.

MATERIAL AND METHODS

A questionnaire consisting of different PROMs was completed pre- and 3 months postoperatively by patients who had been treated with a hip arthroplasty. A standardised follow-up examination of these patients was carried out 12 to 16 weeks postoperatively, after which it was determined whether further therapy was necessary to achieve the treatment goal. Different consequences were defined for this.

RESULTS

Significant differences were found between the groups of consequences of follow-up examinations over both time points, but also when postoperative scores were considered exclusively. Furthermore, the correlations for the postoperative scores and some consequences of the clinical follow-up for the Oxford Hip Score (OHS), the OHS functional score and the Euroquol-5D show moderate effects. Thus, the collection of these postoperative scores is sufficient to identify potential high risk patients. Based on a receiver operating characteristic (ROC) analysis, threshold values could be determined for these scores, for which a follow-up examination is recommended.

CONCLUSION

Patients who could not achieve functional improvement, pain reduction and improvement in quality of life after implantation of a total hip replacement must be identified at an early stage. The results of our study show that with the help of the Oxford Hip Score and Euroquol-5D, which are answered by the patients three months postoperatively, such high risk patients can be identified. This finding is an added value for the further development of the EndoCert certification system and holistic quality assurance in arthroplasties, while the personnel and time effort remain manageable.

Dissatisfaction After Total Hip Arthroplasty Associated With Preoperative Patient-Reported Outcome Phenotypes

BACKGROUND

Patient satisfaction is indicative of the quality of care in the value-driven healthcare model. The Patient Acceptable Symptom State (PASS) is a dichotomous outcome tool measuring the highest level of symptom beyond which a patient considers him/herself well. The purpose of the present study was to identify combined preoperative phenotypes of PROMs associated with not achieving PASS at 1 year following total hip arthroplasty (THA) and to associate such phenotypes with hospital utilization parameters.

METHODS

A prospective institutional cohort of 4,034 patients who underwent primary THA for osteoarthritis (OA) with 1-year follow-up was included. Preoperative scores on Hip Disability and Osteoarthritis Outcome Score (HOOS)-pain, HOOS physical short form-(PS), and Veteran's Rand-12 (VR-12) mental component summary-(MCS) were used to develop phenotypes. Associations between preoperative 'phenotype' and 1-year PASS, discharge disposition, prolonged length of stay, 90-day readmission, and 1-year reoperation were evaluated using multivariate regression.

RESULTS

10.6% (427/4,043) reported their state as 'not satisfactory' at 1 year. The phenotypes were the only preoperative factors to demonstrate the increased likelihood of 1-year dissatisfaction. Only phenotypes with lower than average preoperative MCS demonstrated this association. Low scores in all presently measured PROMs (Pain-PS-MCS-) was associated with double the odds of 1-year dissatisfaction (P < .001), 2.43 times the odds of nonhome discharge and 2.2 times the odds of prolonged LOS.

CONCLUSIONS

Patients with lower preoperative scores across multiple PROMs have increased odds of dissatisfaction after THA; and assessing pain, function, and MCS concomitantly (as phenotypes) may support identifying patients at risk for not achieving a satisfactory outcome.

1-year trajectories of patients undergoing primary total hip arthroplasty: Patient reported outcomes and resource needs according to education level

Background

Objectives were first to evaluate by education level one-year trajectories of pain, function and general health, as well as hospital resource and medication needs in patients undergoing primary total hip arthroplasty (THA); and second, to evaluate whether outcome differences are related to existing baseline differences in health and disease severity.

Methods

We included all primary THAs from a public hospital-based prospective arthroplasty registry, performed in a high-income country 2010 to 2017. Education was classified in three levels: ≤8years of schooling (low), 9-12years (medium), and ≥13years (high). Pain and function prior to and one-year after surgery were assessed with the Western Ontario McMaster Universities score (WOMAC) and general health with the 12-item short-form health survey (SF-12).

Results

Overall 963 patients were included, 340 (35.3%) with low, 306 (31.8%) with medium, and 317 (32.9%) with high education. With increasing educational level preoperative scores for pain, function and SF-12 mental health component increased. One year after surgery improvement was observed in all education categories for WOMAC pain and function, SF-12 mental and physical component. However, absolute postoperative scores remained lower in all four domains for the low education group. After adjustment for baseline characteristics differences were much attenuated and no longer significant. There was also greater resource need in low educated patients.

Conclusions

The inferior absolute results one year after surgery in less educated patients were largely due to older age, worse preoperative health and greater symptom severity calling for greater attention to timely and equal management, for more targeted perioperative care and increased support for the lower education group.

Does lumbar spine fusion predispose patients to future total hip replacement?

OBJECTIVE

Hip-spine syndrome has been well studied since it was first described by Offierski and MacNab in 1983. Today, strong evidence links symptoms of hip and spine pathology to postsurgical outcomes. Recent studies have reported increased rates of hip dislocation in patients previously treated with total hip arthroplasty (THA) who had undergone lumbar fusion procedures. However, the effect of this link on native hip-joint degeneration remains an area of ongoing research. The purpose of this study was to characterize the relationship between use of lumbar fusion procedures and acceleration of hip pathology by analyzing the rate of future THA in patients with preexisting hip osteoarthritis.

METHODS

This population-level, retrospective cohort study was conducted by using the PearlDiver research program. The initial patient cohort was defined by the presence of diagnosis codes for hip osteoarthritis. Patients were categorized according to use of lumbar fusion after diagnosis of hip pathology. Survival curves with respect to THA were generated by comparison of the no lumbar fusion cohort with the lumbar fusion cohort. To assess the impact of fusion construct length, the lumbar fusion cohort was then stratified according to the number of levels treated (1-2, 3-7, or ≥ 8 levels). Hazard ratios (HRs) were then calculated for the risk factors of number of levels treated, patient age, and sex.

RESULTS

A total of 2,275,683 patients matched the authors' inclusion criteria. Log-rank analysis showed no significant difference in the rates of THA over time between the no lumbar fusion cohort (2,239,946 patients) and lumbar fusion cohort (35,737 patients; p = 0.40). When patients were stratified according to number of levels treated, again no differences in the incidence rates of THA over the study period were determined (p = 0.30). Patients aged 70-74 years (HR 0.871, p < 0.001), 75-79 years (HR 0.733, p < 0.001), 80-84 years (HR 0.557, p < 0.001), and ≥ 85 years (HR = 0.275, p < 0.001) were less likely to undergo THA relative to the reference group (patients aged 65-69 years).

CONCLUSIONS

Although lumbar fusion was initially hypothesized to have a significant effect on rate of THA, lumbar fusion was not associated with increased need for future THA in patients with preexisting hip osteoarthritis. Additionally, there was no relationship between fusion construct length and rate of THA. Although lumbar fusion reportedly increases the risk of hip dislocation in patients with prior THA, these data suggest that lumbar fusion may not clinically accelerate native hip degeneration.

Effect of marital status on patient-reported outcomes following total hip arthroplasty: a matched analysis with minimum 2-year follow-up

INTRODUCTION

Mental health and patient expectation have been identified as key predictors of recovery following THA; however, there is limited literature examining the effects of social support and marital status on patient-reported outcomes (PROs).

METHODS

Data were prospectively collected and retrospectively reviewed for patients who underwent THA between July 2008 and January 2016. Patients were included if they underwent primary THA during this period and if they had documented preoperative marital status of married, divorced, or never married. Married patients were group matched to non-married patients (divorced or never married) with similar sex, age, body mass index (BMI), gender distribution, and frequency of surgical approach.

RESULTS

There were 414 married patients and 98 non-married patients who were eligible and had minimum 2-year follow-up. Mean PROs were significantly worse in the non-married group than the married group for the following measures: modified Harris Hip Score (p = 0.002), Harris Hip Score (p = 0.002), Forgotten Joint Score (p = 0.04), and the physical portions of the Veterans RAND (p = 0.025) and Short Form (p = 0.02) surveys.

CONCLUSIONS

Our study demonstrated inferior absolute PRO scores at latest follow-up for patients who were non-married compared to married following THA. These results show that while total hip replacement may still yield clinical benefit in all patients, non-married patients may ultimately achieve an inferior functional status, and expectations should be adjusted accordingly. Physicians should assess levels of psychosocial support in their patients prior to undergoing hip arthroplasty in order to optimise results.

Racial/Ethnic and Socioeconomic Disparities in Osteoarthritis Management

This article reviews the literature on racial and socioeconomic disparities in the management of osteoarthritis. Treatments investigated include arthritis education, dietary weight management, exercise/physical therapy, pharmacologic therapy with nonsteroidal antiinflammatory drugs and opioids, intra-articular steroid injections, and total joint replacement. The amount of evidence for each treatment modality varied, with the most evidence available for racial and socioeconomic disparities in total joint arthroplasty. Black patients, Hispanic patients, and patients with low socioeconomic status (SES) are less likely to undergo total joint replacement than white patients or patients with high SES, and generally have worse functional outcomes and more complications.

Systematic Review and Meta-Analysis of Tobacco Use as a Risk Factor for Prosthetic Joint Infection After Total Hip Replacement

Background

A prosthetic joint infection (PJI) is one of the possible complications after total hip arthroplasty (THA). Several studies, but not all, have reported smoking as a risk factor of PJIs in orthopaedic surgery. This study summarizes the most recent evidence using a systematic review of whether tobacco use (not only tobacco smoking) is a risk factor in developing PJIs, specifically after THA.

Methods

Ovid Medline, EMBASE, Scopus, Web of Science, and Cochrane databases were searched from inception to July 2019 to identify case-control studies that examined the PJI risk in tobacco users and tobacco nonusers undergoing THA. Publication bias was also assessed through funnel plots.

Results

Searches identified 2689 articles, and 10 of these, involving a total of 20,640 patients, met the inclusion criteria. The overall odds ratio (pooled odds ratio) to develop either a superficial infection, a deep infection, or an infection requiring revision surgery for tobacco users vs nonusers was 1.54 (95% confidence interval: 1.25-1.91) when a fixed-effect model was used and 1.56 (95% confidence interval: 1.10-2.21) when a random-effect model was used. No publication bias was observed among the identified studies.

Conclusions

The findings of the study indicated that tobacco use is associated with a higher risk of PJIs in patients undergoing THA.

Disparities in Health Care for Black Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review

Racial health disparities continue to disproportionately affect Black persons in the United States. Black individuals also have increased risk of worse outcomes associated with social determinants of health including socioeconomic factors such as income, education, and employment. This narrative review included studies originally spanning a period of approximately one decade (December 2009-December 2019) from online databases and with subsequent updates though June 2020. The findings to date suggest pervasive inequities across common conditions and injuries in physical medicine and rehabilitation for this group compared to other racial/ethnic groups. We found health disparities across several domains for Black persons with stroke, traumatic brain injury, spinal cord injury, hip/knee osteoarthritis, and fractures, as well as cardiovascular and pulmonary disease. Although more research is needed, some contributing factors include low access to rehabilitation care, fewer referrals, lower utilization rates, perceived bias, and more self-reliance, even after adjusting for hospital characteristics, age, disease severity, and relevant socioeconomic variables. Some studies found that Black individuals were less likely to receive care that was concordant with clinical guidelines per the reported literature. Our review highlights many gaps in the literature on racial disparities that are particularly notable in cardiac, pulmonary, and critical care rehabilitation. Clinicians, researchers, and policy makers should therefore consider race and ethnicity as important factors as we strive to optimize rehabilitation care for an increasingly diverse U.S. population.

The impact of BMI and smoking on risk of revision following knee and hip replacement surgery: evidence from routinely collected data

OBJECTIVE

The aim of this study was to assess the association of body mass index (BMI) and smoking with risk of revision following total knee replacement (TKR) and total hip replacement (THR).

DESIGN

Primary care data, from the Clinical Practice Research Datalink (CPRD), was linked to inpatient hospital records, from Hospital Episode Statistics Admitted Patient Care (HES APC), and covered 1997 to 2014. Parametric survival models, with BMI and smoking status included as explanatory variables, were estimated for 10-year risk of revision and mortality, and were extrapolated to estimate lifetime risk of revision.

FINDINGS

TKR and THR cohorts included 10,260 and 10,961 individuals, respectively. For a change in BMI from 25 to 35, the 10-year risk of revision is expected change from 4.6% (3.3-6.4%) to 3.7% (2.6-5.1%) for TKR and 3.7% (2.8-5.1%) to 4.0% (2.8-5.7%) for THR for an otherwise average patient profile. Meanwhile, changing from a non-smoker to a current smoker is expected to change the risk of revision from 4.1% (3.1-5.5%) to 2.8% (1.7-4.7%) for TKR and from 3.8% (2.8-5.3%) to 2.9% (1.9-4.7%) for THR for an otherwise average patient profile. Estimates of lifetime risk were also similar for different values of BMI or smoking status.

CONCLUSIONS

Obesity and smoking do not appear to have a meaningful impact on the risk of revision following TKR and THR.

A history of spine surgery predicts a poor outcome after hip arthroscopy

This study compared patient reported outcomes scores (PROMs) between patients undergoing hip arthroscopy who have and have not had previous lumbar spine surgery. We aimed to determine if prior spine surgery impacts the outcome of hip arthroscopy. Data were prospectively collected and retrospectively reviewed in patients who underwent hip arthroscopy between 2010 and 2017. Twenty cases were identified for analysis and matched to a control group. Four PROMs were collected pre-operatively and between 6 months and 2 years post-operatively (mean 16.2 months): Modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports (HOS-Sports) and the 33-item International Hip Outcome Tool (iHOT-33). Patients with previous spine surgery reported significantly worse (P-value <0.001) post-operative scores on all PROMs and smaller net changes on all PROMs with the difference on the mHHS (P-value 0.007), HOS-Sport (P-value 0.009) and iHOT-33 (P-value 0.007) being significant. Subsequent analyses revealed that the type of spine surgery matters. Patients with a spine fusion reported worse post-operative scores on all PROMs compared with patients with a spine decompression surgery with the difference on the mHHS (P-value 0.001), HOS-ADL (P-value 0.011) and HOS-Sport (P-value 0.035) being significant. Overall, patients with prior decompression surgery experienced considerable improvements from hip arthroscopy whereas patients with a prior spine fusion reported poor post-operative outcomes. Given these results, it is vital that hip preservation surgeons understand the impact of the lumbar spine on the outcome of hip arthroscopy.

Improvement in mental health following total hip arthroplasty: the role of pain and function

Background

Mental health has been shown to improve after total hip arthroplasty (THA). Little is known about the role of pain and function in this context. We assessed whether change in mental health was associated with improvement in pain and function 1 year post-surgery.

Methods

This prospective study included patients enrolled in a THA registry from 2010 to 2014. We examined the mental component score (MCS) before and 1 year post-surgery, and 1-year change, in association with Western Ontario McMaster Universities (WOMAC) pain and function scores. All scores were normalized, ranging from 0 to 100 (larger score indicating better outcome). Analyses were adjusted for potential confounders.

Results

Our study included 610 participants, of which 53% were women. Descriptive statistics are as follows: the average (SD) for age (years) was 68.5 (11.8), and for BMI was 26.9 (4.9). In addition, the MCS average (SD) at baseline was 44.7 (11.2), and at 1-year after THA was 47.5 (10.5). The average change from baseline to 1-year post-THA in MCS was 2.8 (95% CI: 1.9, 3.6), for an effect size of 0.26. As for the WOMAC pain score, the average change from baseline to 1-year post-THA was 44.2 (95%CI: 42.4, 46.0), for an effect size of 2.5. The equivalent change in WOMAC function was 38.1 (95% CI: 36.2, 40.0), for an effect size of 2.0. Results from multivariable analysis controlling for covariates showed that an improvement of 10 points in the 1-year change in pain score resulted in a 0.78 point (95%: CI 0.40, 1.26) increase in the 1-year change in MCS, whereas a 10-point improvement in the 1-year change in function was associated with a 0.94 point (95% CI: 0.56, 1.32) increase.

Conclusions

Mental health significantly improved from baseline to 1-year post-THA. Greater improvement in pain and function was associated with greater improvement in mental health 1 year post-THA.

Outcomes of Hip Arthroscopy in Patients With Previous Lumbar Spine Surgery: A Matched-Pair Controlled Comparative Study With Minimum Two-Year Follow-Up

PURPOSE

The purpose of this study was to conduct a matched-pair analysis to determine the effect of prior lumbar spine surgery (LSS) on clinical outcomes of hip arthroscopy.

METHODS

Data were prospectively collected on all patients undergoing hip arthroscopy during the study period from April 2008 to December 2012. Patients were excluded if they had previous hip conditions or had undergone prior hip surgery. Patients in the LSS group (history of LSS) were matched in a 1:1 ratio to a control group (no history of LSS) according to age ±5 years, gender, body mass index categories, Tönnis grade, and labral treatment. The following outcomes were recorded in each group: modified Harris Hip Score, Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale, Hip Outcome Score-Activities of Daily Living, and visual analogue scale (VAS) score for pain, patient satisfaction, and rates for revision hip arthroscopies and conversion to total hip arthroplasty (THA).

RESULTS

During the study period, 1,405 hip arthroscopies were performed with 1,017 eligible for matching. A total of 873 (85.8%) patients had a minimum 2-year follow-up. Fifty-seven patients were matched in each group. Both groups demonstrated significant improvement in patient-reported outcome (PRO) and VAS scores. The LSS group had a lower mean for all preoperative PRO scores. There was no significant difference for the postoperative mean PRO score and change in the PRO score compared with the control group except for NAHS. The mean change in the NAHS demonstrated a greater magnitude of improvement in the LSS group. There was no significant difference between mean VAS scores, patient satisfaction, and rates for revision arthroscopy and conversion to THA between the groups.

CONCLUSIONS

Prior LSS does not adversely affect outcomes of hip arthroscopy at a minimum 2-year follow-up. These patients have lower preoperative scores but similar magnitude of improvement and revision/THA rates compared with a matched comparative group of patients without prior LSS.

LEVEL OF EVIDENCE

Level II, retrospective analysis of prospectively collected data.

Recovery after unilateral knee replacement due to severe osteoarthritis and progression in the contralateral knee: a randomised clinical trial comparing daily 2000 IU versus 800 IU vitamin D

Objective

To test whether daily high-dose vitamin D improves recovery after unilateral total knee replacement.

Methods

Data come from a 24-month randomised, double-blind clinical trial. Adults aged 60 and older undergoing unilateral joint replacement due to severe knee osteoarthritis were 6-8 weeks after surgery randomly assigned to receive daily high-dose (2000 IU) or standard-dose (800 IU) vitamin D₃. The primary endpoints were symptoms (Western Ontario and McMaster Universities Arthritis Index pain and function scores) assessed at baseline, 6, 12, 18 and 24 months in both knees, and the rate of falls over 24 months. The secondary outcomes were sit-to-stand performance, gait speed, physical activity and radiographic progression in the contralateral knee.

Results

We recruited 273 participants, 137 were randomised to receive 2000 IU and 136 were randomised to receive 800 IU vitamin D per day. 2000 IU vitamin D increased 25-hydroxyvitamin D levels to 45.6 ng/mL and 800 IU vitamin D to 37.1 ng/mL at month 24 (p<0.0001). While symptoms improved significantly in the operated knee and remained stable in the contralateral knee over time, none of the primary or secondary endpoints differed by treatment group over time. The rate of falls over 24 months was 1.05 with 2000 IU and 1.07 with 800 IU (p=0.84). 30.5% of participants in the 2000 IU and 31.3% of participants in the 800 IU group had radiographic progression in the contralateral knee over 24 months (p=0.88).

Conclusions

Our findings suggest that a 24-month treatment with daily 2000 IU vitamin D did not show greater benefits or harm than a daily standard dose of 800 IU among older adults undergoing unilateral total knee replacement.

The Influence of Arthritis in Other Major Joints and the Spine on the One-Year Outcome of Total Hip Replacement: A Prospective, Multicenter Cohort Study (EUROHIP) Measuring the Influence of Musculoskeletal Morbidity

BACKGROUND

Although arthritis in other affected major joints and back pain are known to lead to worse outcomes following total hip replacement, to our knowledge, these risk factors have not previously been operationalized as a musculoskeletal morbidity profile. The aim of this study was to measure the influence of other major joints and the spine (as grades of musculoskeletal morbidity) on the 1-year outcome of primary total hip replacement.

METHODS

The EUROHIP study consists of 1,327 patients undergoing primary total hip replacement for arthritis across 20 European orthopaedic centers. The primary outcome was the responder rate at 12 months calculated with the relative effect per patient for total hip replacement using the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. The primary predictor of interest was different combinations of arthritis of major joints and the spine grouped into 4 musculoskeletal morbidity grades: 1 (single major joint), 2 (multiple major joints), 3 (single major joint and spine), and 4 (multiple major joints and spine). The confounders adjusted for were age, sex, body mass index, living situation, years of hip pain, American Society of Anesthesiologists (ASA) class, anxiety or depression, and preoperative WOMAC subscales.

RESULTS

For this analysis, 845 patients were included with complete 12-month follow-up WOMAC scores. The mean patient age was 65.7 years, and 55.2% of patients were female.

CONCLUSIONS

The involvement of other major joints and the spine assessed as 1 of 4 musculoskeletal morbidity grades had a strong influence on the 1-year outcome after total hip replacement. The effect size was large compared with other risk factors. Even so, the majority of patients in musculoskeletal morbidity grade 4 had favorable outcomes from the surgical procedure (>74% response to surgical procedures).

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Lumbar surgery prior to total hip arthroplasty is associated with worse patient-reported outcomes

Aims

The aims of this study were to describe the prevalence of previous lumbar surgery in patients who undergo total hip arthroplasty (THA) and to investigate their patient-reported outcomes (PROMs) one year post-operatively.

Patients and Methods

Data from the Swedish Hip Arthroplasty Register and the Swedish Spine Register gathered from 2002 to 2013 were merged to identify a group of patients who had undergone lumbar surgery before THA (n = 997) and a carefully matched one-to-one control group. We investigated differences in the one-year post-operative PROMs between the groups. Linear regression analyses were used to explore the associations between previous lumbar surgery and these PROMs following THA. The prevalence of prior lumbar surgery was calculated as the ratio of patients identified with previous lumbar surgery between 2002 and 2012, and divided by the total number of patients who underwent a THA in 2012.

Results

The prevalence of lumbar surgery prior to THA in 2012 was 3.5% (351 of 10 082). Linear regression analyses showed an association with more pain (B = 4.35, 95% confidence interval (CI) 2.57 to 6.12), worse EuroQol (EQ)-5D index, (B = -0.089, 95% CI -0.112 to -0.066), worse EQ VAS (B = -6.75, 95% CI -8.58 to -4.92), and less satisfaction (B = 6.04, 95% CI 4.05 to 8.02).

Conclusion

Lumbar spinal surgery prior to THA is associated with less reduction of pain, worse health-related quality of life, and less satisfaction one year after THA. This is useful information to share in the decision-making process and may help establish realistic expectations of the outcomes of THA in patients who also have previously undergone lumbar spinal surgery. Cite this article: Bone Joint J 2017;99-B:759–65.

Rehabilitation after total joint replacement: a scoping study

PURPOSE

The evidence supporting rehabilitation after joint replacement, while vast, is of variable quality making it difficult for clinicians to apply the best evidence to their practice. We aimed to map key issues for rehabilitation following joint replacement, highlighting potential avenues for new research.

MATERIALS AND METHODS

We conducted a scoping study including research published between January 2013 and December 2016, evaluating effectiveness of rehabilitation following hip and knee total joint replacement. We reviewed this work in the context of outcomes described from previously published research.

RESULTS

Thirty individual studies and seven systematic reviews were included, with most research examining the effectiveness of physiotherapy-based exercise rehabilitation after total knee replacement using randomized control trial methods. Rehabilitation after hip and knee replacement whether carried out at the clinic or monitored at home, appears beneficial but type, intensity and duration of interventions were not consistently associated with outcomes. The burden of comorbidities rather than specific rehabilitation approach may better predict rehabilitation outcome. Monitoring of recovery and therapeutic attention appear important but little is known about optimal levels and methods required to maximize outcomes.

CONCLUSIONS

More work exploring the role of comorbidities and key components of therapeutic attention and the therapy relationship, using a wider range of study methods may help to advance the field. Implications for Rehabilitation Physiotherapy-based exercise rehabilitation after total hip replacement and total knee replacement, whether carried out at the clinic or monitored at home, appears beneficial. Type, intensity, and duration of interventions do not appear consistently associated with outcomes. Monitoring a patient's recovery appears to be an important component. The available research provides limited guidance regarding optimal levels of monitoring needed to achieve gains following hip and knee replacement and more work is required to clarify these aspects. The burden of comorbidities appears to better predict outcomes regardless of rehabilitation approach.

Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management

The diagnosis and treatment of patients who have both hip and lumbar spine pathologies may be a challenge because overlapping symptoms may delay a correct diagnosis and appropriate treatment. Common complaints of patients who have both hip and lumbar spine pathologies include low back pain with associated buttock, groin, thigh, and, possibly, knee pain. A thorough patient history should be obtained and a complete physical examination should be performed in these patients to identify the primary source of pain. Plain and advanced imaging studies and diagnostic injections can be used to further delineate the primary pathology and guide the appropriate sequence of treatment. Both the surgeon and the patient should understand that, although one pathology is managed, the management of the other pathology may be necessary because of persistent pain. The recognition of both entities may help reduce the likelihood of misdiagnosis, and the management of both entities in the appropriate sequence may help reduce the likelihood of persistent symptoms.

Predictors of physical functioning after total hip arthroplasty: a systematic review

OBJECTIVE

The objective of this systematic review of the literature was to identify the predictors of functional outcome after total hip arthroplasty (THA).

METHOD

A systematic literature search in Web of Science, CINAHL, EMBASE and PubMed was conducted on 23 June 2015. The articles were selected based on their quality, relevance and measurement of the predictive factor. The level of evidence of all studies was determined using the GRADE rating scheme.

RESULTS

The initial search resulted in 1092 citations. After application of the inclusion and exclusion criteria, 33 articles met our eligibility criteria and were graded. Included studies were classified as level of evidence low (11), moderate (17) or high (5). Of the included studies, 18 evaluated body mass index (BMI), 17 evaluated preoperative physical functions, 15 evaluated age, 15 evaluated gender and 13 evaluated comorbidity. There was strong evidence suggesting an association between BMI, age, comorbidity, preoperative physical functions and mental health with functional outcome after THA. There was weak evidence suggesting an association between quadriceps strength and education with functional outcome after THA. The evidence was inconsistent for associations with gender and socioeconomic status and functional outcome following THA. We found limited evidence suggesting that alcohol consumption, vitamin D insufficiency and allergies were predictors of functional outcome following THA.

CONCLUSIONS

We have identified multiple predictors of functional outcome after THA, which will enable general practitioners and orthopaedic surgeons to better predict the improvement in physical functioning for their patients with THA. They can use this information to provide patient-specific advice regarding the referral for THA and the expected outcomes after THA. Further research with consistent measurement tools, outcomes and duration of follow-up across studies is needed to confirm the influence of these factors.

Association Between Pain and Functional Independence in Older Adults During and After Admission to Rehabilitation After an Acute Illness or Injury

OBJECTIVES

To investigate the association between pain and functional independence in older adults during and after admission to rehabilitation after an acute illness or injury.

DESIGN

Prospective, observational cohort study.

SETTING

One community and one Veterans Affairs rehabilitation center.

PARTICIPANTS

Individuals aged 65 and older admitted for rehabilitation after an acute illness or injury (postacute rehabilitation) (N = 245; mean age 80.6, 72% male)).

MEASUREMENTS

Pain was assessed using the Geriatric Pain Measure (GPM, score 0-100). Functional independence was measured using the motor component of the Functional Independence Measure (mFIM, score 13-91). Both scores were obtained at admission; discharge; and 3-, 6-, and 9-month follow-up. In bivariate analyses, discharge GPM and persistent pain (lasting >3 months) were evaluated as predictors of mFIM score at 9 months. Applying a multilevel modeling (MLM) approach, individual deviations in GPM scores were used to predict variations in mFIM.

RESULTS

At admission, 210 participants (87.9%) reported pain (16.3% mild (GPM<30); 49.3% moderate (GPM: 30-69); 22.1% severe (GPM>70)); 21.3% reported persistent pain after discharge. The bivariate analyses did not find statistically significant associations between discharge GPM or persistent pain and mFIM score at 9 months, but in the MLM analysis, deviations in GPM were significant predictors of deviations in mFIM score, suggesting that, when individuals experienced above-average levels of pain (GPM > their personal mean GPM), they also experienced worse functional independence (mFIM < their personal mean mFIM).

CONCLUSION

Twenty-one percent of older adults undergoing postacute rehabilitation reported persistent pain after discharge from rehabilitation. The bivariate analysis did not find association between pain and functional independence, but MLM analysis showed that, when participants experienced more pain than their average, they had less functional independence.

Social and Behavioral Factors in Total Knee and Hip Arthroplasty

Social and behavioral factors are important determinants of health outcomes in a number of medical conditions but their role in joint arthroplasty is poorly understood. In a cohort of 20,124 hip and knee arthroplasty procedures, smoking was associated with a significantly higher risk of surgical site infections (hazard ratio 1.7, 95% CI: 1.1-2.6), whereas alcohol use was associated with a lower risk of reoperations and revisions (hazard ratio 0.7, 95% CI: 0.5-0.8). There was no association between marital status and educational attainment with the risk of complications or reoperations in total hip and knee arthroplasty.

Evaluating family function in caring for a geriatric group: Family APGAR applied for older adults by home care nurses

AIM

Family function is an essential factor affecting older adults' health. However, there has been no appropriate method to assess the family function of most older adults with fragility or poor health status. The present study aimed to explore the differences and relevance of family function estimated by home care nurses and the older adults, and to determine if nurses could represent older adults to provide the estimation.

METHODS

Study participants were 50 older adults who were aged older 65 years and were taken care of at home by well-trained nurses. The present study used the Family APGAR as the questionnaire. We compared the results evaluated by the older adults and their home care nurses. The results included the level of dysfunction and the total scores of the questionnaire. The paired t-test and McNemar-Bowker test were used for the analysis.

RESULTS

Family function could be leveled as "good," "moderate dysfunction" and "severe dysfunction" according to the scores. The family function levels estimated by nurses showed no significant differences to the patients' condition (P = 0.123 > 0.05). Comparing the total scores of the older adults with those of their own home care nurses, the results showed a moderate to nearly high correlation (R = 0.689/P < 0.001). Caring time might be the factor affecting the result.

CONCLUSIONS

The present study provides a way of helping physicians to ascertain older adults' family problems much earlier and to improve the their health status by enhancing family support. Geriatr Gerontol Int 2015; ●●: ●●-●●.

Patient-Reported Allergies Are Associated With Poorer Patient Satisfaction and Outcomes After Lower Extremity Arthroplasty: A Retrospective Cohort Study

Anecdotal evidence suggests that patient-reported allergies (PRAs) may exhibit prognostic value for patient-reported outcomes after lower extremity arthroplasty. This study's purpose was to investigate associations between PRAs, patient satisfaction and outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA). PRAs in 274 patients undergoing primary THA and 257 patients receiving primary TKA were reviewed retrospectively. Satisfaction scores, baseline Western Ontario and McMaster Universities Arthritis Index (WOMAC), 2-year postoperative WOMAC and length-of-stay (LOS) were analyzed with PRAs. Increasing number of PRAs was significantly associated with worse satisfaction scores and worse WOMAC scores for TKA and THA, and it was significantly associated with increased LOS for TKA. These results may have implications for patient counseling and risk-adjusted outcome models.

Evaluating quality of life outcomes following joint replacement: psychometric evaluation of a short form of the WHOQOL-Bref

PURPOSE

Reducing participant burden is important in health research and clinical assessment. We examined the psychometric properties of the EUROHIS-QOL 8-item index, a short version of the 26-item World Health Organisation Quality of Life questionnaire (WHOQOL-Bref), in a sample of people receiving joint replacement surgery.

METHODS

Participants (n = 1008) completed the WHOQOL-Bref at either 6, 12, 24 or 60 months after hip or knee replacement. The factor structure, differential item functioning (DIF) and unidimensionality of the EUROHIS-QOL 8-item index were examined using exploratory and confirmatory factor analyses and Rasch analyses. Convergent validity was examined using correlations with the parent measure and other patient-reported outcome measures (Oxford scores, Western Ontario and McMaster Universities Osteoarthritis Index). Discriminant validity was assessed between groups reporting high versus low pain and function, and by joint replaced.

RESULTS

The measure demonstrated high internal consistency (α = 0.86), adequate convergent (r = 0.47-0.82, p < 0.001) and discriminant validity (p < 0.001). Factor and Rasch analyses supported a unidimensional structure. However, there were also indications of multidimensionality, with support for a two-factor model focusing on general health and function, and psychosocial aspects of QOL. There was minimal evidence of DIF, with just one item evaluating energy level showing DIF for age.

CONCLUSIONS

The EUROHIS-QOL 8-item index demonstrated adequate properties as a unidimensional scale and as a two-factor scale evaluating general health and function, and psychosocial aspects of quality of life. It is low on clinical and participant burden, showed minimal ceiling effects and showed good concurrent and discriminant validity.

[Personality and comorbidity: are there "difficult patients" in hip arthroplasty?]

BACKGROUND

Concomitant disorders at the time of surgery in addition to psychological and socioeconomic patient characteristics may influence treatment outcomes in hip arthroplasty.

OBJECTIVES

To describe the impact of these factors on perioperative complications and postoperative results in terms of function, quality of life, and patient satisfaction.

MATERIALS AND METHODS

Review of relevant clinical studies, meta-analyses, and presentation of our own results.

RESULTS

Comorbidities in general, especially in combination, increase the perioperative risk profile. Socioeconomic factors (education, professional qualifications, social deprivation) in addition to psychological variables (depression, distressed personality) can have a major impact on postoperative functional outcomes and patient satisfaction.

CONCLUSIONS

It is of crucial importance to avoid inequalities in the provision of joint replacement for patients with hip osteoarthritis and co-existing risk factors. Preventive strategies should be implemented to reduce the negative impact of comorbidities on treatment outcome. Personalized communication and education may be helpful in avoiding unrealistic patient expectations before hip replacement.

A longitudinal study of quality of life and functional status in total hip and total knee replacement patients

BACKGROUND

Primary total hip and primary total knee surgeries are commonly performed to improve patients' quality of life and functional status.

AIM

This longitudinal retrospective study (N = 851) examined self-reported quality of life and functional status over the preoperative and postoperative periods: 12 months prior to surgery, one month prior to surgery and 12 months following surgery.

METHODS

A linear mixed effects model was used to analyze the changes in quality of life and functional status over the sampling period.

RESULTS

Patients in the convenience sample reported improvements in quality of life and functional status utilizing the SF-12 and Oxford Hip and Oxford Knee, although differences were noted by procedure and gender. Total hip patients tended to demonstrate greater improvement than total knee patients and males reported higher levels of physical and mental quality of life as well as functional status when compared to females. Of particular note was that mental health scores were consistently lower in both total hip and total knee replacement patients across the perioperative period and up to one year postoperative.

CONCLUSION

This study identifies an opportunity for health care providers to proactively address the mental health of total hip and total knee replacement patients throughout their joint replacement trajectory.

The role of perceived injustice in the prediction of pain and function after total knee arthroplasty

Emerging evidence suggests that the appraisal of pain and disability in terms of justice-related themes contributes to adverse pain outcomes. To date, however, research on the relation between perceived injustice and pain outcomes has focused primarily on individuals with musculoskeletal injuries. The primary aim of this study was to investigate the role of perceived injustice in the prediction of pain and disability after total knee arthroplasty (TKA). The study sample consisted of 116 individuals (71 women, 45 men) with osteoarthritis of the knee scheduled for TKA. Participants completed measures of pain severity, physical disability, perceptions of injustice, pain catastrophizing, and fear of movement before surgery, and measures of pain and disability 1 year after surgery. Prospective multivariate analyses revealed that perceived injustice contributed modest but significant unique variance to the prediction of postsurgical pain severity, beyond the variance accounted for by demographic variables, comorbid health conditions, presurgical pain severity, pain catastrophizing, and fear of movement. Pain catastrophizing contributed significant unique variance to the prediction of postsurgical disability. The current findings add to a growing body of evidence supporting the prognostic value of perceived injustice in the prediction of adverse pain outcomes. The results suggest that psychosocial interventions designed to target perceptions of injustice and pain catastrophizing before surgery might contribute to more positive recovery trajectories after TKA.

The hip-spine syndrome: how does back pain impact the indications and outcomes of hip arthroscopy?

PURPOSE

Many patients presenting with hip disease also have coexisting lumbar spine disease (LSD). At present there is a paucity of literature examining the effect of arthroscopic hip surgery in patients with coexisting LSD. The purpose of this systematic review was to examine the relationship between the hip and lumbar spine to determine whether low back pain impacts the indications and outcomes for surgical intervention of the hip.

METHODS

A systematic review of the literature was performed by a search of PubMed using the following search terms: (1) hip, back, and motion; (2) hip, back, and pain; and (3) hip, lumbar spine, and pain. Two reviewers searched for relevant articles that met established inclusion criteria. We excluded review articles, technique articles, articles reporting on the same patient population, and articles without reported patient data. Kinematic data pertaining to the hip for patients with low back pain was collected. Preoperative and postoperative data were collected for patients treated for hip disease in the setting of LSD.

RESULTS

After examining 2,020 references and abstracts, 15 articles were selected for this review. Patients with low back pain consistently demonstrated decreased hip range of motion compared with controls. Patients undergoing hip surgery with coexisting LSD showed improvement in the modified Harris Hip Score (mHHS), Harris Hip Score (HHS), Visual Analog Scale (VAS), SF-36 scores, and the Owestry Disability Index.

CONCLUSIONS

Patients with low back pain frequently have limited or altered hip range of motion, and these patients routinely improve after surgical intervention for hip disease. Surgical intervention for hip disease should be considered in the context of low back pain and LSD.

LEVEL OF EVIDENCE

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

Education attainment is associated with patient-reported outcomes: findings from the Swedish Hip Arthroplasty Register

BACKGROUND

Age, sex, and medical comorbidities may be associated with differences in patient-reported outcome scores after THA. Highest level of education may be a surrogate for socioeconomic status, but the degree to which this is associated with patient-reported outcomes after THA is not known.

QUESTIONS/PURPOSES

We investigated the national Swedish Hip Arthroplasty Register for the association of education attainment on patient-reported outcomes 1 year after THA; specifically, we evaluated level of education attainment against health-related quality of life (HRQoL), pain reduction, and satisfaction with treatment 1 year after THA.

METHODS

All THAs for osteoarthritis performed from 2005 through 2007 with complete patient-reported outcome measures (representing 49% of the THAs performed for this diagnosis) were selected from the Swedish Hip Arthroplasty Register. These cases were merged with national databases containing education attainment, marital status, and comorbidities (n = 11,464; mean age of patients, 64 years). The patient-reported outcome measure protocol included the HRQoL measure EuroQol five-dimension scale (EQ-5D), a VAS for pain, the Charnley classification survey, and a VAS addressing THA satisfaction. Linear regression analyses determined the association of preoperative patient factors with patient-reported outcomes.

RESULTS

High education attainment was associated with higher HRQoL (EQ-5D index ß(high) = 0.03 ± 0.01; EQ VAS ß(high) = 2.6 ± 0.5) after THA, whereas those with low and medium education were at risk for lower HRQoL. High education was associated with less pain after treatment (ß(high) = -3.3 ± 0.05). Individuals with low or medium education were at risk for less satisfaction with THA (p < 0.001).

CONCLUSIONS

Our results suggest clinicians should support patients with low and medium education to a greater extent. Identification of patients who will benefit most from THA and educating those at risk for poorer outcomes, like patients with low and medium education, ultimately may improve patient satisfaction, HRQoL, pain, and the cost utility of THA.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Medical comorbidity is associated with persistent index hip pain after total hip arthroplasty

OBJECTIVE

To characterize whether medical comorbidity predicts persistent moderate-severe pain after total hip arthroplasty (THA).

METHODS

We analyzed the prospectively collected data from the Mayo Clinic Total Joint Registry for patients who underwent primary or revision THA between 1993 and 2005. Using multivariable-adjusted logistic regression analyses, we examined whether certain medical comorbidities were associated with persistent moderate-severe hip pain 2 or 5 years after primary or revision THA. Odds ratios (ORs), along with 95% confidence intervals (CIs) and P value, are presented.

RESULTS

The primary THA cohort consisted of 5,707 THAs and 3,289 THAs at 2 and 5 years, and revision THA, 2,687 and 1,627 THAs, respectively. In multivariable-adjusted logistic regression models, in the primary THA cohort, renal disease was associated with lower odds of moderate-severe hip pain (OR 0.6; 95% CI 0.3, 1.0) at 2 years. None of the comorbidities were significantly associated at 5 years. In the revision THA cohort, heart disease was significantly associated with higher risk (OR 1.7; 95% CI 1.1, 2.6) at 2 years and connective tissue disease with lower risk (OR 0.5; 95% CI 0.3, 0.9) of moderate-severe hip pain at 5-year follow-up.

CONCLUSION

This study identified new correlates of moderate-severe hip pain after primary or revision THA, a much-feared outcome of hip arthroplasty. Patients with these comorbidities should be informed regarding the risk of moderate-severe index hip pain, so that they can have a fully informed consent and realistic expectations.

Effect of pre-operative neuromuscular training on functional outcome after total knee replacement: a randomized-controlled trial

Background

Total Knee Replacement (TKR) is the standard treatment for patients with severe knee osteoarthritis (OA). Significant improvement in pain and function are seen after TKR and approximately 80% of patients are very satisfied with the outcome. Functional status prior to TKR is a major predictor of outcome after the intervention. Thus, improving functional status prior to surgery through exercise may improve after surgery outcome. However, results from several previous trials testing the concept have been inconclusive after surgery.

Methods/design

In a randomized controlled trial (RCT) we will test the effect of a pre-operative neuromuscular trainingprogram versus an attention control program on lower extremity function – before and after surgery. We will enroll 80 participants, aged between 55–90 years, who are scheduled for TKR. In this single-blinded RCT, the intervention group will receive a minimum of 8 and a maximum of 24 training sessions plus 3 educational sessions of the knee school. The control group will receive the 3 educational sessions only. Assessments are performed immediately before and after the intervention (before surgery), at 6 weeks, 3 months and 12 months (after surgery).

The primary outcome will include the Chair Stand Test as a measure of leg strength and reaction time. Secondary outcomes are knee function and pain assessed with the self-reported Knee Injury and Osteoarthritis Outcome Score (KOOS). All measurements will be carried out by a specially trained physical therapist, blinded to group allocation.

Discussion

To our knowledge this is the first single-blinded RCT to test the effect of pre-operative neuromuscular training plus knee school against knee school alone – on knee function and pain, assessed immediately after the interventions prior to surgery and repeatedly after surgery.

Trial registration

Clinical Trials NCT00913575

Determining who should be referred for total hip and knee replacements

Total hip and total knee replacements (THR and TKR respectively), the definitive treatments for end-stage arthritis, are both safe and extremely successful in relieving pain and improving function. However, physicians who care for patients with chronic hip and knee arthritis are often the 'gatekeepers' to total joint replacement (TJR) procedures as they select patients for referral to an orthopaedic surgeon to be considered for arthroplasty. Currently, no evidence-based criteria exist to guide physicians in this decision-making process, and this situation raises the possibility that conscious or unconscious biases may influence referral patterns, potentially leading to systematic inequities regarding which patients are eventually offered TJR. This article reviews why TJRs are particularly important procedures, and highlights common misperceptions among physicians regarding TJR risk assessment. This article also underscores the benefits of ongoing discussion regarding TJR with all patients with moderate-to-severe chronic hip or knee pain and disability.

Predictors of mortality following primary hip and knee replacement in the aged. A single-center analysis of 1,998 primary hip and knee replacements for primary osteoarthritis

BACKGROUND AND PURPOSE

High age is associated with increased postoperative mortality, but the factors that predict mortality in older hip and knee replacement recipients are not known.

METHODS

Preoperative clinical and operative data on 1,998 primary total hip and knee replacements performed for osteoarthritis in patients aged ≥ 75 years in a single institution were collected from a joint replacement database and compared with mortality data. Average follow-up was 4.2 (2.2-7.6) years for the patients who survived. Factors associated with mortality were analyzed using Cox regression analysis, with adjustment for age, sex, operated joint, laterality, and anesthesiological risk score.

RESULTS

Mortality was 0.15% at 30 days, 0.35% at 90 days, 1.60% at 1 year, 7.6% at 3 years, and 16% at 5 years, and was similar following hip and knee replacement. Higher age, male sex, American Society of Anesthesiologists risk score of > 2, use of walking aids, preoperative walking restriction (inability to walk or ability to walk indoors only, compared to ability to walk > 1 km), poor clinical condition preoperatively (based on clinical hip and knee scores or clinical severity of osteoarthritis), preoperative anemia, severe renal insufficiency, and use of blood transfusions were associated with higher mortality. High body mass index had a protective effect in patients after hip replacement.

INTERPRETATION

Postoperative mortality is low in healthy old joint replacement recipients. Comorbidities and functional limitations preoperatively are associated with higher mortality and warrant careful consideration before proceeding with joint replacement surgery.

What predicts 36-item health survey version 2 after total hip arthroplasty

OBJECTIVE

To identify the factors having the greatest effect on the Medical Outcomes Study 36-Item Short-Form Health Survey, version 2 (SF-36v2) score after total hip arthroplasty (THA).

DESIGN

Retrospective review.

SETTING

Private 150-bed hospital.

PARTICIPANTS

Patients (N=659) who underwent initial THA for osteoarthritis (OA) of the hip between April 2007 and January 2009. A total of 138 patients who fulfilled the inclusion criteria were seen at the first follow-up, while 108 patients were included in the second follow-up; all 30 patients excluded at the second follow-up underwent contralateral THA between follow-ups. The average time ± SD from surgery to first follow-up was 195.1±67.7 days, and that to second follow-up was 443.0±108.5 days. Patients' average age ± SD was 61.1±9.9 years at first follow-up and 61.3±10.3 years at second follow-up. Women accounted for 85.5% of patients at first follow-up and 85.2% at second follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Eight subscales of the SF-36v2, age, sex, body mass index, complications, living alone, contralateral hip OA, range of hip joint motion, walking aids, and preoperative mental health (MH) values from the SF-36v2.

RESULTS

Canonical correlation analysis showed that contralateral hip OA had a major effect on the SF-36v2 score at the first follow-up. At the second follow-up, excluding the 30 patients who had undergone contralateral THA, physical function measured by the SF-36v2 was strongly affected by age, and other items were strongly affected by preoperative MH.

CONCLUSIONS

When using the SF-36v2 as an assessment scale after THA, adjustments should be made for contralateral hip OA. Moreover, age and preoperative MH should also be considered.

Acute delirium and poor compliance in total hip arthroplasty patients with substance abuse disorders

From the joint registry of 2831 primary total hip arthroplasties (2351 patients) performed between 1998 and 2003, we identified 15 patients (16 hips) who had a documented history of substance abuse disorders at the time of the index surgery. The patients included 13 men (14 hips) and 2 women (2 hips), with the mean age of 49 years (range, 29-65 years). On the basis of the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 13 patients had alcohol abuse disorders, 1 had amphetamine abuse disorder, and 1 had heroin abuse disorder. We found high rates of postoperative substance withdrawal delirium and psychosis (46%), late complication (25%), and lost to follow-up (27%) in these patients. Because patients with substance abuse disorders have unexpected perioperative psychotic episodes, poor compliance, and a tendency to not follow medical advice after surgery and show early discontinuation of follow-up, we suggest that surgeons should work with other medical professionals and carefully perform total hip arthroplasty in such patients.

Aggregate health burden and the risk of hospitalization in older persons post hip replacement surgery

BACKGROUND

We sought to understand the association between aggregate health burden-chronic conditions, functionally limiting health problems and mental well-being-and the likelihood of hospitalization among older persons post hip replacement surgery.

METHODS

Eight hundred and twenty-eight Medicare recipients from three U.S. states completed a questionnaire 3 years postsurgery. Using administrative data (Medicare Provider Analysis and Review), participants were prospectively followed for 12 months postquestionnaire to capture hospitalizations. Using logistic regression, demographic, socioeconomic, and behavioral characteristics and medical comorbidities were considered as predictors. Subsequently, musculoskeletal (MSK) functional and geriatric problems were added as predictors, then mental well-being and activity limitations. Path analysis was employed to elucidate interrelationships between these predictors, investigating whether mediated effects through mental well-being and activity limitations were operational.

RESULTS

Mean age was 76 years (range: 67-96); 63% were women; 23% had ≥1 hospitalization(s). When medical comorbidity, MSK limitations, and geriatric problems were considered, each was independently associated with hospitalization (odds ratios: 1.3, 1.1, 1.2, respectively). When mental well-being and activity limitations were added, these variables were predictive of hospitalization (odds ratios: 1.2, 1.1, respectively), while MSK limitations and geriatric problems were no longer predictive. Path analysis results suggested that the influence of medical comorbidity and MSK and geriatric problems were mediated through mental well-being and activity limitations.

CONCLUSIONS

Several health domains predict hospitalization, beyond and including medical comorbidity. Efforts aimed at delaying/minimizing hospitalizations in this population should consider an array of domains for potentially targeted intervention. These findings can serve as a baseline against which future research can assess the impact of changes to the health care system.

Effect of psychopathology on patient-perceived outcomes of total knee arthroplasty within an indigent population

BACKGROUND

Factors other than surgical technique and implants impact patient outcomes following a total knee arthroplasty. The purpose of this study was to analyze the effects of psychopathology on the rate of improvement following total knee arthroplasty in an indigent population.

METHODS

One hundred and fifty-four consecutive indigent patients undergoing a primary total knee arthroplasty for arthritis were enrolled and available for follow-up. Patients were classified as having psychopathology on the basis of the presence of somatization, depression, and/or a panic or anxiety disorder as assessed with the Patient Health Questionnaire. Outcome measures were completed preoperatively and one year postoperatively. Univariate analyses, controlled for sex and age, were used to compare the rates of improvement in patients who exhibited psychopathology with the rates in those without psychopathology.

RESULTS

Fifty-four patients (35%) were diagnosed with at least one Axis-I psychological disorder. The psychopathology group showed significantly lower Short Form-36 mental component summary scores both at baseline and one year postoperatively (p < 0.001 for both). The psychopathology group also reported significantly higher levels of perceived disability at baseline on the Pain Disability Questionnaire (p < 0.001) and worse scores on the Western Ontario and McMaster Universities Osteoarthritis Index (p = 0.004); however, the improvement on both of these scales did not differ significantly between the two groups (p > 0.05). The Knee Society Score differed significantly between the two groups at both baseline and the one-year follow-up evaluation (p = 0.003 and p = 0.001, respectively), but there was no significant difference in the total rate of improvement between the two comparison groups (p > 0.05).

CONCLUSIONS

Not only is there a high prevalence of psychopathology in the indigent population, but psychopathology may result in lower patient-perceived outcome scores at one year after a total knee arthroplasty. Even though outcome scores may be worse for patients with psychopathology, our study showed that these patients still benefit, with the same degree of improvement in function.

Does vitamin D status affect the attainment of in-hospital functional milestones after total hip arthroplasty?

Our study aims to identify the prevalence of low vitamin D status in patients undergoing total hip arthroplasty (THA) and to evaluate the association between serum vitamin D level and the attainment of in-hospital functional milestones. We collected data from patients who underwent THA and had preoperative serum vitamin D (serum 25-hydroxy vitamin D) levels measured. From 200 patients, 79 (39.5%) had low serum vitamin D (serum 25-hydroxy vitamin D <32 ng/mL). There were no associations between serum vitamin D level and the attainment of in-hospital functional milestones as well as length of hospital stay or perioperative complications after THA. Because low vitamin D status did not compromise the short-term functional outcomes after THA, surgery need not be delayed, but low vitamin D levels should be corrected once identified.

[Primary hip replacement: first year results and predictive factors of poor outcome]

OBJECTIVE

To evaluate the results of total hip arthroplasty in patients with osteoarthritis and to identify predictors of poor functional outcome.

MATERIAL AND METHODS

A prospective observational study in patients operated on in 2006 with total hip arthroplasty in 4 hospitals in Guipúzcoa, followed up for 1 year.

OUTCOME VARIABLES

pain, physical function, complications, mortality, quality of life by WOMAC and SF-12 (at 0, 3, 6 and 12 months) and «Poor functional outcome» at one year (last quartile of the WOMAC in function area). Logistic regression was performed to examine predictors of poor functional outcome.

RESULTS

A total of 166 patients were followed up. The incidence of systemic and local complications was 6.3% and 14.5%, respectively, 4.3% readmissions and no deaths related to surgery. Close to 40 points improvement in pain, stiffness and WOMAC functional limitation, mainly in the first 3 months after surgery. A similar trend was seen, but lower in the physical and mental component of the SF12 (12 and 8 points, respectively). The previous score on the WOMAC function area and the physical component of SF-12, and the existence of any complications, are predictors of poor functional recovery.

DISCUSSION

The improvement experienced after the surgery is already very important before the third month. The functional and physical status before surgery and possible complications of surgery are significant determinants of the results.

Health burden in chronic disease: multimorbidity is associated with self-rated health more than medical comorbidity alone

OBJECTIVES

To investigate the association between multimorbidity-a construct comprising several health domains (medical comorbidity, musculoskeletal, physical and social functional status, mental health, and geriatric problems)-and overall self-rated health (SRH), an important chronic disease health outcome. We investigate whether medical comorbidity effects are mediated through other health domains and whether these domains have independent effects on SRH.

STUDY DESIGN AND SETTING

Medicare recipients (n=958) completed a questionnaire 3 years post primary total hip replacement surgery. Self-reported sociodemographic characteristics, SRH, and health domain statuses were ascertained. Probit regressions and path analyses were used to evaluate the independent effects of the health domains on SRH and the interrelationships between domains and to quantify direct and mediated effects.

RESULTS

All domains were independently associated with SRH. Medical comorbidity explained 11.7% of the variance in SRH, and all other health domains explained 27.3%. The impact of medical comorbidity was largely direct (only 21.5% mediated through other domains). Medical comorbidity minimally explained the variance in other domain scores.

CONCLUSION

SRH has multiple determinants. This finding suggests that an exclusive focus on any one domain in health research may limit the researchers' ability to understand health outcomes for which SRH is predictive.

Smoking and outcomes after knee and hip arthroplasty: a systematic review

OBJECTIVE

Studies have suggested higher rates of perioperative and postoperative complications in smokers compared to nonsmokers. The objective of this systematic review was to assess the association of smoking and postoperative outcomes following total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

A search of 6 databases (The Cochrane Library, Scopus, Proquest Dissertation abstracts, CINAHL, Ovid Medline, and Embase) was performed by a Cochrane librarian. All titles and abstracts were screened by 2 independent reviewers with expertise in performing systematic reviews. Studies were included if they were fully published reports that included smoking and any perioperative or postoperative clinical outcome in patients with TKA or THA.

RESULTS

A total of 21 studies were included for the review, of which 6 provided multivariable-adjusted analyses, 14 univariate analyses, and one statistical modeling. For most outcomes, results from 1-2 studies could be pooled. Current smokers were significantly more likely to have any postoperative complication (risk ratio 1.24, 95% CI 1.01 to 1.54) and death (risk ratio 1.63, 95% CI 1.06 to 2.51) compared to nonsmokers. Former smokers were significantly more likely to have any post-operative complication (risk ratio 1.32, 95% CI 1.05 to 1.66) and death (risk ratio 1.69, 95% CI 1.08 to 2.64) compared to nonsmokers.

CONCLUSION

This systematic review found that smoking is associated with significantly higher risk of postoperative complication and mortality following TKA or THA. Studies examining longterm consequences of smoking on implant survival and complications are needed. Smoking cessation may improve outcomes after THA or TKA.

Predictors of activity limitation and dependence on walking aids after primary total hip arthroplasty

OBJECTIVES

To study function outcomes and their predictors after primary total hip arthroplasty (THA).

DESIGN

Prospective cohort study.

SETTING

Mayo Clinic.

PARTICIPANTS

All patients who underwent primary THA at the Mayo Clinic between 1993 and 2005 and were alive at the time of follow-up.

MEASUREMENTS

Whether sex, age, body mass index (BMI), comorbidity, anxiety, and depression predict moderate to severe activity limitation (limitation in ≥3 activities) and complete dependence on waling aids 2 and 5 years after primary THA was examined. Multivariable logistic regression adjusted for operative diagnosis, American Society of Anesthesiologists score, implant type, and distance from medical center.

RESULTS

At 2 years, 30.3% of participants reported moderate to severe activity limitation; at 5 years, 35% of participants reported moderate to severe activity limitation. Significant predictors of moderate to severe activity limitations at 2-year follow-up were female sex (odds ratio (OR)=1.2, 95% confidence interval (CI)=1.1-1.4), aged 71 to 80 (OR=2.0, 95% CI=1.6-2.5), aged 80 and older (OR=4.5, 95% CI=3.4-6.0), depression (OR=2.1, 95% CI=1.6-2.7), and BMI greater than 30.0. At 5-year follow-up, significant predictors were aged 71 to 80 (OR=1.7, 95% CI=1.3-2.2), older than 80 (OR=4.3, 95% CI=2.8-6.6), depression (OR=2.3, 95% CI=1.6-3.4), and BMI greater than 30.0.Significant predictors of complete dependence on walking aids at 2 years were female sex (OR=2.0, 95% CI=1.4-2.7), aged 71 to 80 (OR=2.4, 95% CI=1.4-4.2), older than 80 (OR=11.4, 95% CI=6.0-21.9), higher Deyo-Charlson score (OR=1.5, 95% CI=(1.1-1.2) for 5-point increase, depression (OR=2.0, 95% CI=1.2-3.4), and BMI greater than 35.0. Each of these factors also significantly predicted complete dependence on walking at 5-year follow-up, with similar odds ratios, except that BMI of 30.0 to 34.9 was not significantly associated.

CONCLUSION

Higher BMI, depression, older age, and female sex predict activity limitation and complete dependence on walking aids 2 and 5 years after primary THA.

Predicting the Longer-term Outcomes of Total Hip Replacement

Objective.

The objective of this study was to identify the patient-level predictors (age, sex, body mass index, mental health, and comorbidity) for a sustained functional outcome at a minimum 1 year of followup after total hip replacement (THR).

Methods.

We reviewed data from our registry on 636 consecutive patients from 1998 to 2005. Demographic data and the outcome scores of the Western Ontario McMaster University Osteoarthritis Index (WOMAC) and Medical Outcomes Study Short-form 36 (SF-36) scores were extracted from the database. Longitudinal regression modeling was performed to identify the predictive factors of interest. Fourteen percent of patients were missing outcomes data at 1 year of followup.

Results.

The mean followup in our cohort was 3.3 years (range 1–6 yrs) and there were no revisions for aseptic loosening performed during this time. Mean clinical outcome scores were found to be relatively constant for the 6 years after surgery. Older age, year of followup, and greater comorbidity were identified as negative prognostic factors for a sustained functional outcome following THR (p < 0.05).

Conclusion.

Understanding of longterm surgical outcomes should be appropriately used to set realistic patient expectations of surgery.

Social, educational, and occupational predictors of total hip replacement outcome

OBJECTIVE

There is limited evidence on social, educational, and occupational factors as predictors of response to total hip replacement (THR). We aimed to analyze these factors in a large population-based setting.

METHOD

Patients of the Dresden Hip Surgery Registry were recruited and the pre and post (6 months) operative functional status was assessed using the global Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) score (0-100 points). Non-response was defined a gain of <20 points in WOMAC score over a 6 months period and was analyzed with respect to six socioeconomic parameters. Multiple logistic regression modeling was applied to adjust for age, sex, BMI, co-morbidity, and preoperative functional status.

RESULTS

Data from 1007 patients (mean age 61 years, STD 13; 55% women) were included. The average preoperative WOMAC score was 45.8 which increased to 84.4 after surgery. 38.2%, 36.6%, and 25.3% of the patients attended school for 8, 9, and 12 years, respectively. 54.1% were retired, 26.9% worked full time, and 6.7% received a disability pension. A 14.8% of the patients did not achieve a gain of > or =20 points in WOMAC score and were classified as non-responders. After control for confounders, significantly increased risks of non-response were found for widowed patients compared to singles [odds ratio (OR) 4.30, 1.45-12.71], those who lived alone (OR 1.70, 1.02-2.85), and patients with a disability pension compared to those who worked full time (OR 5.81, 2.33-14.46). The risk of non-response decreased with increasing length of school education (12 vs 8 years: OR 0.49, 0.27-0.89). Compared to workers, employees (OR 0.55, 0.33-0.90) and self-employed patients (OR 0.41, 0.18-0.94) showed significantly decreased risks of non-response.

CONCLUSION

Socioeconomic parameters are independent predictors of response to THR. This can help to improve the health service by identifying subgroups which need special attention in order to increase the response rate.