Health status after hip or knee arthroplasty

Block-step asymmetry 5 years after large-head metal-on-metal total hip arthroplasty is related to lower muscle mass and leg power on the implant side

BACKGROUND

Metal-on-metal articulations mimic the human hip anatomy, presumably lower dislocation rates and increase the range-of-motion. This study aims to measure the muscle mass and power of both legs in patients with unilateral metal-on-metal total hip arthroplasty, and to investigate their effect on block-step test, spatio-temporal gait parameters and self-reported function.

METHODS

Twenty-eight patients (7 women), mean age 50 (28-68) years, participated in a 5-7 year follow-up. Patients had received one type unilateral large-head metal-on-metal total hip articulation, all of which were well-functioning at follow-up. Mean muscle mass was measured by the total-body Dual energy X-ray Absorption scans, and muscle power was measured in a leg extensor power rig. Block-step test and spatio-temporal gait parameters were measured with an inertial measurement unit. Self-reported function was assessed by the Hip Disability and Osteoarthritis Outcome Score.

FINDINGS

We found a significant difference between the mean muscle mass of the implant-side leg and the non-implant-side leg in hip, thigh and calf areas (P<0.008) and in mean muscle power (P=0.025). Correlations between mean muscle mass and mean muscle power were significant for both the implant-side leg (r=0.45, P=0.018) and the non-implant-side leg (r=0.51, P=0.007). The difference in mean muscle power between legs correlated with block-step test asymmetry during ascending (r=0.40, P=0.047) and descending (r=0.53, P=0.006). Correlations between self-reported function and power of the implant-side leg were not significant.

INTERPRETATIONS

Young patients have not fully regained muscle mass, muscle power and function 5-7 years after metal-on-metal total hip arthroplasty.

A non-invasive biomechanical device and treatment for patients following total hip arthroplasty: results of a 6-month pilot investigation

BACKGROUND

The purpose of the study was to examine the effect of a foot-worn biomechanical device on the clinical measurements and gait patterns of patients with total hip arthroplasty (THA).

METHODS

Nineteen patients, up to 3 months post-THA, were enrolled to the study. Patients underwent a computerized gait analysis to calculate spatiotemporal parameters and completed the Western Ontario and McMaster Universities osteoarthritis index and the SF-36 health survey. Patients then began therapy with a non-invasive foot-worn biomechanical device coupled with a treatment methodology (AposTherapy). Patients received exercise guidelines and used the device daily during their regular activities at their own environment. Follow-up examinations were conducted after 4, 12, and 26 weeks of therapy. Repeated measures ANOVA was used to evaluate changes over time. The clinical significance of the treatment effect was evaluated by computing the Cohen's effect sizes (ES statistic).

RESULTS

After 26 weeks of therapy, a significant improvement was seen in gait velocity (50.3%), involved step length (22.9%), and involved single limb support (16.5%). Additionally, a significant reduction in pain (85.4%) and improvement in function (81.1%) and quality of life (52.1%) were noted.

CONCLUSIONS

Patients following THA demonstrated a significant improvement in gait parameters and in self-assessment evaluations of pain, function, and quality of life. We recommend further RCTs to examine the effect of this therapy compared to other rehabilitation modalities following THA and compared to healthy matched controls.

TRIAL REGISTRATION

Clinical trial registration number NCT01266382.

Pre-operative psychological distress does not adversely affect functional or mental health gain after primary total hip arthroplasty

Preoperative psychological distress has been reported to predict poor outcome and patient dissatisfaction after total hip arthroplasty (THA). The purpose of this study was to investigate if pre-operative psychological distress was associated with adverse functional outcome after primary THR. We analysed the database of a prospective multi-centre study undertaken between January 1999 and January 2002. We recorded the Oxford Hip Score (OHS) and SF36 score preoperatively and up to five years after surgery for 1055 patients. We dichotomised the patients into the mentally distressed (Mental Health Scale score - MHS =56) and the not mentally distressed (MHS >56) groups based on their pre-operative MHS of the SF36. 762 (72.22%). Patients (595 not distressed and 167 distressed) were followed up at 5 years. Both pre and post-operative OHS and SF-36 scores were significantly worse in the distressed group (both p<0.001). However, both groups experienced statistically significant improvement in OHS and MHS, which was maximal at 1 year after surgery and was maintained over the follow up (p=0.00). There was a substantial improvement in mental distress in patients who reported mental distress prior to surgery. The results suggest that pre-operative psychological distress did not adversely compromise functional outcome gain after THA. Despite having worse absolute values both pre and post operatively, patients with mental distress did not have any less functional gain from THA as measured by improvement in OHS.

Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?

Background

There are concerns that pre-operative psychological distress might be associated with reduced patient satisfaction after total hip replacement (THR).

Methods

We investigated this in a multi-centre prospective study between January 1999 and January 2002. We dichotomised the patients into the mentally distressed (MHS ≤ 56) and the not mentally distressed (MHS > 56) groups based on their pre-operative Mental Health Score (MHS) of SF36.

Results

448 patients (340 not distressed and 108 distressed) completed the patient satisfaction survey. Patient satisfaction rate at five year was 96.66% (415/448). There was no difference in patient satisfaction or willingness to have the surgery between the two groups. None of pre-operative variables predicted five year patient satisfaction in logistic regression.

Conclusions

Patient satisfaction after surgery may not be adversely affected by pre-operative psychological distress.

Reliability and validity of the Japanese Orthopaedic Association hip score

BACKGROUND

The Japanese Orthopaedic Association (JOA) hip score has been widely used in Japan as a method to assess hip joint diseases. The JOA hip score consists of four subcategories: pain (Pain), range of motion (ROM), ability to walk (Gait), and activities of daily life (ADL). We present the first report to verify the reliability and validity of the JOA hip score.

METHODS

A total of 123 patients with osteoarthritis of a unilateral hip and 29 patients with osteonecrosis of a unilateral hip were investigated. The JOA hip score was recorded by orthopedic surgeons in their offices. On the same day, each patient answered a Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) (Japanese version 1.2) by himself or herself. The SF-36 survey measures eight subscales. The internal-consistency reliability of the JOA hip score was evaluated by Cronbach's coefficient alpha. The validity of the JOA hip score was tested by Spearman's correlation coefficients between the four subcategories of the JOA hip score and the eight SF-36 subscales.

RESULTS

When patients with osteoarthritis with conservative treatment were assessed by the JOA hip score, Cronbach's coefficient alpha was 0.70, demonstrating internal-consistency reliability. However, when the JOA hip score was used for other groups, Cronbach's coefficient alpha was <0.70, demonstrating the lack of internal-consistency reliability. Significant correlations were observed between Pain and bodily pain (r = 0.63), between Gait and physical functioning (PF) (r = 0.70), and between ADL and PF (r = 0.81), but not in any other combinations.

CONCLUSIONS

We found that the JOA hip score is a reliable system only for patients with osteoarthritis of the hip with conservative treatment. The JOA hip score is a scaling system with convergent and discriminant validity for the assessment of physical function and pain.

Lower limb biomechanics during gait do not return to normal following total hip arthroplasty

Although total hip arthroplasty (THA) is known to be a successful surgical procedure to alleviate hip pain and to improve health-related quality of life, these outcome measures in THA patients do not reach those of the general population. As a result, several investigators have assessed THA patients' gait mechanics, but most of them have ignored adjacent joints, as well as the effect that THA may have on the non-operated limb. The purpose of this investigation was to determine the effect of THA on the pelvis, hip, knee and ankle joint kinematics, as well as the hip, knee and ankle kinetics of both the operated and non-operated limbs during walking. These data were recorded for 20 patients having undergone unilateral THA and 20 healthy, matched control participants. Results revealed that the gait mechanics of THA patients did not return to normal 10.6 months, on average (+/-2.6 mo), following surgery. THA patients walked with lower operated-hip abduction moments, sagittal-plane range of motion, as well as lower generated and absorbed power, that may be consequential to pain-avoidance strategies adopted pre-operatively or to apprehensions associated with their new prosthesis. They also displayed various kinematic adaptations at the ankle joint of the operated limb and at the non-operated hip joint that may be leaving them at risk of developing other joint diseases. Further investigation is needed to confirm the reasons why THA patients' gait mechanics do not return to normal following surgery to develop better surgical techniques and/or rehabilitation programs.

Knee arthroplasty in the young patient: survival in a community registry

Operative options for the younger patient with an arthritic knee remain controversial. We prospectively followed 1047 patients 55 years old or younger who underwent knee arthroplasty in a community joint registry over a 14-year period. Patients were implanted with 1047 joints of three predominant designs by 48 surgeons in four hospitals associated with a community joint registry. The mean age for this cohort was 49.8 years, and 62.8% (657/1047) of the patients were female. There were a total of 73 revisions performed, 5.6% (37/653) in women and 9.2% (36/394) in men. Cemented TKAs performed best, with a cumulative revision rate of 15.5%, compared to 32.3% in unicompartmental knee arthroplasty (UKA) patients and 34.1% in cementless designs. Men had a higher cumulative revision rate than women, 31.9% compared to 20.6%. Adjusting for implant type and gender, there was no difference in cumulative revision rate based on diagnosis (OA versus other) or age group (< or = 40, 41-45, 46-50, 51-55 years) or between cruciate-retaining and -substituting designs. Eighty five percent of cemented TKA implants survived at 14 years in the population under 55 years of age in this community registry. Cementless designs and UKA increased revision risk independently.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Gait in the early days after total knee and hip arthroplasty: a comparison

PURPOSE

To evaluate whether gait after Total Knee Arthroplasty (TKA) is different from gait after Total Hip Arthroplasty (THA) in the early days following surgical intervention.

METHOD

The gait was studied in water, thus exploiting its buoyancy force. Twenty consecutive patients underwent TKA and twenty consecutive patients underwent THA. The mean age was 70.2 years (SD 6.9). Twenty age-matched volunteers were the control group.

RESULTS

At the beginning TKA and THA patients had the same speed and the same step length. At day 15 there was a speed difference in favour of THA patients (t = - 2.245, df 38, p = 0.031). Likewise, the step length was longer in THA patients (t = -2.293 df 38, p = 0.027). In contrast to TKA patients, THA patients were unbalanced, having a longer stance phase on the non-operated leg and a longer swing on the contralateral one.

CONCLUSIONS

Gait strategies were completely different after TKA and THA interventions. TKA patients were balanced over their feet and they appeared more cautious and more concerned about gait quality than moving quickly. By contrast, THA patients were unbalanced, having a longer stance phase on the non-operated leg and a longer swing on the contralateral one. However, their speed gain was higher.

Evolution of disability in adults with hip arthroplasty: a national longitudinal study

OBJECTIVE

To describe disability in individuals with hip arthroplasty and its evolution over 2 years compared with that in the general population, and to compare the degree of disability between subjects with recent and older hip arthroplasty.

METHODS

We selected a national representative sample of 16,945 subjects from the 1999 French population census. This sample, interviewed in 1999 and 2001 about their level of disability, included 527 subjects with hip arthroplasty (i.e., representing 424,000 individuals in the French noninstitutionalized population): 145 who underwent the procedure between 1999 and 2001 (recent hip arthroplasty) and 382 with an older hip arthroplasty.

RESULTS

Subjects with hip arthroplasty reported more difficulty in bending forward (odds ratio [OR] 4.5, 95% confidence interval [95% CI] 3.1-6.6), climbing stairs (OR 2.2, 95% CI 1.5-3.1), walking >300 meters (OR 1.6, 95% CI 1.03-2.6), dressing (OR 2.9, 95% CI 2.1-4.2), and getting in and out of a chair (OR 2.5, 95% CI 1.7-3.6) than the general population. However, the evolution in disability was similar to that of the general population. Compared with subjects with older hip arthroplasty, those with recent hip arthroplasty reported more difficulty walking >300 meters (OR 2.7, 95% CI 1.3-5.6), washing (OR 2.9, 95% CI 1.6-5.4), dressing (OR 2.2, 95% CI 1.2-4.2), and getting in and out of a chair (OR 2.1, 95% CI 1.1-3.9).

CONCLUSION

This study describes the potential future disability in the more elderly population, with implications for health-related planning.

Pain and overall health status in older people with hip and knee replacement: a population perspective

OBJECTIVE

To investigate the health-related quality of life and presence of hip or knee pain according to whether or not people had had previous hip or knee arthroplasty.

STUDY DESIGN AND SETTING

Cross-sectional survey representing randomly selected sample of 5500 elderly (65+) people. Pain prevalence rates obtained from standard screening questions. Standard pain severity ratings obtained for each hip and knee.

RESULTS

People with a past arthroplasty had worse health status compared to other people (p < 0.001 for all but two SF-36 dimensions). Hip or knee pain was more prevalent amongst people with past hip or knee replacement than amongst those without (62.5% versus 36.5% respectively; following adjustment for age and sex: Mantel-Haenszel combined odds ratio = 2.90, 95% CI 2.30-3.68, p < 0.001). More replaced knee joints were symptomatic than replaced hip joints (OR = 1.62, p = 0.022).

CONCLUSIONS

Elderly people with a past hip or knee arthroplasty have significantly greater health and social care needs than other people--especially those related to pain and mobility. This may reflect the generalised nature of the underlying disease process.

Revision in previously satisfied knee arthroplasty patients is the result of their call on the physician, not on pre-planned follow-up: a retrospective study of 181 patients who underwent revision within 2 years

BACKGROUND

Degree of satisfaction with a knee arthroplasty is said to be correlated to reduced pain and better function. During a validation of the Swedish Knee Arthroplasty Register in 1997, previously operated patients were asked how satisfied they were with their knee. A subgroup of "satisfied" patients was identified who underwent revision within 2 years of having expressed satisfaction. Our aim was to study the revision diagnosis, to determine whether the problem leading to revision had been discovered as a result of routine follow-up, and also to find out when the symptoms leading to revision had started.

METHODS

We retrospectively studied the medical records of 181 patients (181 knees), with a median age of 74 (31-88) years. 68% were women and the median time between primary operation and revision was 8 (3-21) years.

RESULTS

Aseptic loosening (74/181) was the most common diagnosis. 2 cases were revised as a result of routine follow-up. 44% of the medical records included reports of pain in the replaced knee prior to answering the satisfaction questionnaire.

INTERPRETATION

Few patients were admitted to knee revision surgery due to medical findings discovered during routine follow-up. The term "satisfaction" must be interpreted with care, as it seems to have a more complex meaning for the patients than absence of knee pain.

Long-term results of total knee arthroplasty in young patients with rheumatoid arthritis

Forty-seven cemented total knee arthroplasties in 32 patients with rheumatoid arthritis who were 55 years or younger (average, 43) were followed until death or a minimum of 15 years. The average follow-up was 18 years. There were 6 revisions; 5 of 6 revisions had severe polyethylene wear and osteolysis. All revisions occurred after 17 years (range, 17-23). Three of these had fracture of the tibial component associated with polyethylene wear through; the remaining 2 had loose tibial and femoral components. One patient sustained a distal femoral periprosthetic fracture requiring revision of the total knee. Cemented total knee arthroplasty in the young patient with rheumatoid arthritis is reliable and durable at an average 18 years of follow-up with an estimated survivorship of 100% at 15 years and 93.7% at 20 years.