Total hip replacement in patients with osteoarthritis of the hip: improvement in pain and functional status

Free Hip Arthroplasty Templating Software - Does it Work?

Background

Preoperative planning is important for successful total hip arthroplasty (THA) and has been historically performed using acetate templates. Digital software templating has been adopted for evaluating implant size, position, and alignment. Commercial software can be expensive, but free programs exist. Detroit Bone Setter (detroitbonesetter.com, Detroit, MI) is a freely available templating program, but hasn't been validated. Our study reports this program's accuracy for templating THA.

Methods

Sixty-five patients undergoing THA between 2017 and 2022 at 2 hospitals were included. All cases were templated by the senior author or orthopaedic trauma fellow prospectively or retrospectively in a blinded fashion. Direct anterior or posterior approaches were used based on attending surgeon's preference. A student's t-test was used to compare means of templated vs actual implant sizes of femoral and acetabular components.

Results

There was no significant difference between implanted (mean [M] = 6.4, standard deviation [SD] = 2.0) and templated femoral component sizes (M = 5.7, SD = 2.1). There was a significant difference between implanted (M = 57.0, SD = 3.9) and templated acetabular component sizes (M = 53.4, SD = 3.0). Bland-Altman testing demonstrated femoral components with positive measurement bias of 0.62, indicating slight overestimation of implant size. Acetabular component size was overestimated with positive measurement bias of 3.6 mm.

Conclusions

Detroit Bone Setter is advantageous as it is freely available and supports most major company implants. It accurately templated femoral component size but consistently overestimated acetabular component size by 3.6 mm. Further studies are needed prior to recommending its routine use for templating THA when other validated methods exist. It could be used with caution when no other methods are available.

Effect of total hip arthroplasty on improving locomotive syndrome in hip disease patients: A prospective cohort study focused on total clinical decision limits stage 3

BACKGROUND

In 2020, the Japanese Orthopaedic Association established a new stage 3 in clinical decision limits (CDL) to evaluate the stage of locomotive syndrome (LS). This study focused on total CDL stage 3 with the aim of investigating indicators related to improvements in total CDL by evaluating the improvement of LS in patients who underwent total hip arthroplasty (THA).

METHODS

Of the 125 patients who underwent THA at our hospital, the subjects of the analysis were 105 patients determined to be total CDL stage 3 in an evaluation performed before THA. LS was evaluated using the stand-up test, two-step test, and 25-Question Geriatric Locomotive Function Scale (GLFS-25). Indicators related to improvements in total CDL were also investigated. All evaluation items were measured before THA and three months after THA.

RESULTS

Before THA, all subjects (n = 105) were classified as total CDL stage 3. Three months after THA, improvements in total CDL were seen in 49 subjects (46.7%). The results of stepwise multiple logistic regression analysis showed that the before THA stand-up test and GLFS-25 were significantly related to improvements in total CDL.

CONCLUSIONS

Three months after THA, improvements in LS were seen in approximately half of the subjects. The stand-up test and GLFS-25 can be used as indicators of improvement in total CDL.

DESIGN

Prospective cohort study design.

The test-retest reliability, concurrent validity, and minimal detectable change of the L test in patients with total hip arthroplasty

Background

The L test is a modified version of the timed up and go test (TUG) with an L-shaped walking path. The L test is more extensive than other performance tests, especially in turn direction and specific tasks. The study aimed to evaluate the test-retest reliability, concurrent validity, and minimal detectable change of the L test in patients with total hip arthroplasty (THA). A cross-sectional study was conducted with 33 unilateral and primary THA patients. The L test was performed twice with an interval of an hour on the same day for the test-retest reliability. Timed up and go test (TUG), five times sit to stand test (FTST), and Harris hip score (HHS) were carried out for the analysis of the concurrent validity of the L test.

Results

The mean age of the participants was 74.6 ± 10.3 years. The ICC score of the L test was 0.992. Test-retest reliability was excellent. SEM95 and MDC95 values were 3.39 and 9.39, respectively. Both TUG and HHS were strongly correlated with the L test (r1 = 0.889, r2 = −0.568, p < 0.001). However, there was no significant correlation between FTST and L test (r = 0.024, p > 0.05).

Conclusions

The L test is valid and reliable performance measurement in patients with primary unilateral THA. MDC95 of the L test is an essential reference for clinicians in the rehabilitation follow-up process of THA patients.

Chronic primary or secondary non-inflammatory musculoskeletal pain is associated with disrupted sexual function and relationships: a systematic review

OBJECTIVE

Evidence points to the impact of chronic musculoskeletal pain conditions on sexual function, yet there is little systematic appraisal and synthesis of evidence examining these associations across non-inflammatory conditions. We aimed to systematically review evidence surrounding the association between chronic primary and secondary musculoskeletal pain with intimate relationships and sexual function.

METHODS

Four electronic databases were searched from 1^st January 1990 to 5^th September 2019 for cross-sectional or prospective epidemiologic and qualitative studies among cohorts with chronic primary or secondary non-inflammatory musculoskeletal pain, defined by ICD-11 classification criteria.

RESULTS

Fifty-one eligible studies were included (46 quantitative, 3 qualitative, 2 mixed-methods designs). Sample sizes ranged from 13 to 12,377 and mean age from 32.6 to 69.2 years. Cross-sectional controlled cohort studies consistently reported poorer sexual function outcomes among cohorts with pain relative to comparison groups. Of 15 studies reporting outcomes for the Female Sexual Function Index, 14 demonstrated mean scores ≤26.55 for the pain group, indicating sexual dysfunction. In four studies reporting the International Index of Erectile Function, the pain cohorts demonstrated consistently lower mean subscale scores and the erectile function subscale scores were ≤25.0, indicating erectile dysfunction. Three key themes emerged from a meta-synthesis of qualitative studies: impaired sexual function; compromised intimate relationships; and impacts of pain on sexual identity, body image and self-worth.

CONCLUSION

Sexual dysfunction and negative impacts on intimate relationships are highly prevalent among people with chronic non-inflammatory musculoskeletal pain. Consideration of these associations is relevant to the delivery of holistic, person-centred musculoskeletal pain care.

The efficacy of total hip arthroplasty on locomotive syndrome and its related physical function in patients with hip osteoarthritis

BACKGROUND

Locomotive syndrome (LS) is a predictive factor of future motor dysfunction. Our aim was to evaluate the change in the total LS grade and, its the association with the Japanese Orthopaedic Association (JOA) hip score after total hip arthroplasty (THA) among patients with hip osteoarthritis.

METHODS

This was a prospective case-control study of 72 patients who underwent primary THA. The functional outcomes were measured before, and at 6 and 12 months after THA. LS was evaluated using the following tests: stand-up test, 2-step test, and 25-question Geriatric Locomotive Function Scale (GLFS-25). In addition, factors affecting the improvement of LS grade were examined.

RESULTS

Prior to THA, 7% and 93% of patients were classified as LS grades 1 and 2. At 6 months after THA, an improvement in the total LS grade was observed in 57% of patients, with this percentage further increasing to 65% at 1 year. Only the preoperative GLFS-25 was correlated with the preoperative JOA hip scores. The postoperative GLFS-25 and the two-step test were correlated with the postoperative JOA hip scores. The preoperative functional reach test (FRT) was significantly correlated with the total LS grade improvement.

CONCLUSIONS

THA can improve the total LS grade in 65% of patients at 1 year postoperatively. Improvement was largely achieved in the first 6 months after THA, with a change from LS grade 2 to grade 1. FRT could be used an indicator of the total LS grade improvement.

Kinematic Gait Analysis After Primary Total Hip Replacement: A Systematic Review: Gait After Total Hip Replacement: A Systematic Review

Total hip replacement (THR) is a surgical procedure indicated for patients affected by severe hip osteoarthritis. Although this technique has proved to be effective in relieving pain and restoring function, gait limitations may persist following this procedure. The objective of this systematic review was to evaluate gait kinematics after THR and compare the results with those of the pre-operative state and with healthy control individuals. PubMed/MEDLINE, Embase, Web of Science, CENTRAL and Scopus databases were searched until December 2019. Methodological quality and internal validity score of each study were assessed using the PEDro and the Newcastle-Ottawa scales. In all, ten studies met our inclusion criteria. Following THR, statistically significant improvements were seen in dynamic hip and knee range of motion of both the affected and the contralateral limb, single-limb support time symmetry, step length, stride length, walking speed and gait pattern. However, deficits were observed in all the previous parameters, as well as in hip adduction angle in comparison with healthy subjects. In conclusion, gait patterns improve after THR in comparison with the pre-operative state, although there are deficits relative to healthy individuals.

Does total hip replacement affect sexual quality of life?

Background

Total Hip Replacement (THR) is an effective treatment for end-stage hip osteoarthritis. Since the introduction of total joint replacement, the effect on the Sexual Quality of Life (SQoL) following THR has been addressed in scant studies. The aim of our study was to systematically review the literature, to summarise effects of THR on patients’ SQoL.

Methods

We searched PubMed, EMBASE and PsycINFO between January 1970 and February 9th, 2015 with search terms including Total Hip, Osteoarthritis, SQoL, and THR. Eligible studies were identified and two independent authors extracted data including details of SQoL, study quality and risk of bias.

Results

There were 12 eligible studies, which included a total of 2099 patients with an age range of 20–85 years. The methodological quality of ten studies was rated as low, and of two as moderate. Amongst the majority of patients, SQoL improved after surgery, both in terms of physical-functional and psychosocial well-being. However, changes between pre-operative and postoperative SQoL ranged extensively: for example, Sexual Dysfunction Δ 8–51 % and Sexual Activity (SA) Δ 0–77 %. Three studies reported that some patients never resumed SA again after surgery.

Conclusion

In over 40 years of THR treatment, scant studies have examined the effect of THR on patients’ SQoL. This review suggests that SQol improves after THR, although the magnitude of effects varies highly. However, the quality of the supporting evidence was rated as low to moderate. This suggests a need for more high quality evidence about the effects of THR on SQoL.

Test-retest reliability of Common Mental Disorders Questionnaire (CMDQ) in patients with total hip replacement (THR)

Background

The Common Mental Disorders Questionnaire (CMDQ) is used to assess patients’ mental health. It has previously been shown to provide a sensitive and specific instrument for general practitioner setting but has so far not been tested in hospital setting or for changes over time (test-retest). The aim of this study is, by means of a test-retest method, to investigate the reliability of the instrument over time with total hip replacement (THR) patients.

Methods

Forty-nine hip osteoarthritis patients who had undergone THR answered the questionnaire twelve months after their operation. Fourteen days later they completed it again. Covering emotional disorder, anxiety, depression, concern, somatoform disorder and alcohol abuse, the questionnaire consists of 38 items with six subscales, each of which has between 4 to 12 items. A five-point Likert scale (from 0–4) is used.

Results

For each of the 38 questions, a quadratic-weighted Kappa coefficient of 0.42 (0.68 – 0.16) to 0.98 (1.00 – 0.70) was found. A Cronbach’s alpha of 0.94 for all the questions indicated high internal consistency.

Conclusion

The results showed a moderate to almost perfect reliability of CMDQ of this specific population.

Trial registration

Current Controlled Trials: NCT01205295

The impact of total joint arthroplasty on sexual function in young, active patients

There is limited information regarding sexual function following total hip (THA) and knee arthroplasty (TKA). A multicenter study of 806 THA, 542 TKA, and 181 control patients less than 60 years of age was conducted using an independent survey center to question subjects about their sexual function. Only 1.3% of THA and 1.6% of TKA patients stated they were not sexually active due to their operation. No significant differences were noted in sexual function based on the bearing surface, femoral head size, or use of surface replacement arthroplasty in the hip cohort. Multivariate analysis revealed no difference in the percentage of patients sexually active following a THA or TKA (OR 1.19, P=0.38). Most young active patients return to sexual activity after hip and knee arthroplasty.

Validity of patient-reported comorbidities before total knee and hip arthroplasty in patients older than 65 years

Obtaining preoperative medical histories in elderly patients can be challenging, and tools have been developed to aid in history gathering. The purpose of this study is to determine the agreement between patient- and physician-reported histories before total knee or hip arthroplasty. Three hundred eighty-two patients older than 65 years completed a preoperative morbidity assessment form preoperatively. Sensitivity, specificity, κ, and agreement were calculated for each dichotomous response. Diabetes (κ = 0.77) and lung disease (κ = 0.68) had substantial agreement. Fourteen comorbidities ranged from slight to moderate agreement. Osteoarthritis and peripheral vascular disease had no agreement. These results highlight the incongruence between patient- and physician-reported comorbidities and emphasizes the need for detailed histories by health care professionals for medically complicated elderly patients preoperatively.

Prediction of functional outcome at six months following total hip arthroplasty

BACKGROUND

Recovery of function such as the ability to walk without an assistive device after total hip arthroplasty (THA) is not always automatic.

OBJECTIVE

This study investigated whether predetermined variables could be used to identify patients who might have functional limitations at 6 months following THA.

DESIGN

A prospective, observational cohort design was used.

METHOD

Demographics and baseline measures, including age, sex, and preoperative Lower Extremity Functional Scale (LEFS) score, were collected 1 to 3 weeks prior to surgery from 40 participants who were scheduled to undergo THA. Six weeks after surgery, a second LEFS score was recorded along with each participant's body mass index and the THA procedure performed; walking speed and balance also were assessed at this time using the 10-Meter Walk Test, the Timed "Up & Go" Test, and the Functional Reach Test. At 6 months following surgery, each participant's functional outcome was determined from the final LEFS score and the need for an assistive device. Classification and regression tree (CART) analyses and logistic regression were used to establish which of the variables could predict outcome at 6 months.

RESULTS

Body mass index, sex, and age were identified by CART analysis as predictors to classify participants who did not reach successful outcome status. Logistic regression revealed that sex (female) was the only individual variable that predicted outcome at 6 months. Walking speed was the only performance variable identified as a predictor for outcome using CART analysis.

LIMITATIONS

Only a limited number of variables were observed due to the small sample size.

CONCLUSION

It is possible to identify those patients who are at risk for an unsuccessful outcome through the use of variables such as body mass index, age, and sex.

Patient anxiety and concern as predictors for the perceived quality of treatment and patient reported outcome (PRO) in orthopaedic surgery

BACKGROUND

Previous studies have shown that patients' anxiety and dissatisfaction are predictors for increased postoperative pain and reduced efficacy of pain treatment. However, it remains to be shown whether patient anxiety and concern are predictors for the perceived quality of treatment and patient reported outcome (PRO).The aim of this study is to investigate whether there is a correlation between preoperative anxiety and concern, and the perceived quality of postoperative treatment and outcome. The hypothesis is that anxious and concerned patients are less satisfied with treatment and have a poorer outcome.

METHODS/DESIGN

This study is designed as a prospective follow-up study and has the aim of investigating the correlation between patient anxiety and concern, patients' perceived quality of treatment and outcome. This correlation will be detected using five questionnaires: CMD-SQ (Common Mental Disorders Screening Questionnaire), EuroQol 5 Dimensions (EQ-5D), Short form 12 (SF-12), "What is your evaluation of the patient progress in the Department of Orthopaedic Surgery?" (HVOK), Questionnaire for patients who have had hip surgery (RCS) and Oxford Hip Score (OHS) or Oxford Shoulder Score (OSS). The patients will complete the above mentioned questionnaires preoperatively in the outpatient department, and postoperatively just before discharge from the inpatient department, and 12 and 52 weeks after the operation. The study includes a reliability test of CMD-SQ regarding this specific population and tested by means of a Kappa. A total of 500 hip- and shoulder-patients will be included from October 2010 till October 2011.

DISCUSSION

If a correlation between patient anxiety and concern, patients' perceived quality of treatment and patient reported outcome is found, it will be recommended to screen all hip- and shoulder-patients for anxiety and concern preoperatively. Besides, it would be relevant to carry out investigations of possible interventions towards anxious and concerned patients.

TRIAL REGISTRATION

Current Controlled Trials: NCT01205295.

Recovery in mechanical muscle strength following resurfacing vs standard total hip arthroplasty - a randomised clinical trial

OBJECTIVES

To evaluate the effect of resurfacing vs standard total hip replacement on post-surgery hip and knee muscle strength recovery in a prospective randomised controlled trial at the Department of Orthopaedics, University Hospital, Odense, Denmark.

METHODS

Forty-three patients were randomised into (A) standard total hip arthroplasty (S-THA) and (B) resurfacing total hip arthroplasty (R-THA). Pre-surgery assessment and follow-up were conducted (8, 26 and 52 wks). Maximal isometric muscle strength (Nm) and between-limb asymmetry for the knee extensors/flexors, hip adductors/abductors, hip extensors/flexors were analysed.

RESULTS

Maximal knee extensor and hip abductor strength were higher in S-THA than R-THA at 52 wks post-surgery (P ≤ 0.05) and hip extensors tended to be higher in S-THA at 52 wks (P = 0.06). All muscle groups showed substantial between-limb strength asymmetry (7-29%) with the affected side being weakest (P ≤ 0.05) and hip flexors being most affected. Asymmetry was present in half of the muscle groups at 26 wks (P ≤ 0.05), and remained present for the hip flexors and hip adductors at 52 wks (P ≤ 0.05).

CONCLUSIONS

R-THA patients showed an attenuated and delayed recovery in maximal lower limb muscle strength (in 2/6 muscle groups) compared to S-THA. Notably, the attenuated strength recovery following R-THA was most markedly manifested in the late phase (1 yr) of post-surgical recovery, and appeared to be due to the detachment of the lower half of the gluteus maximus muscle rather than implant design per se. Thus, the present data failed to support the hypothesis that R-THA would result in an enhanced strength rehabilitation compared to S-THA. Further, between-limb asymmetry remained present for hip flexors and adductors after 52 wks.

TRIAL REGISTRATION

NCT01229293.

Intraoperative muscle damage in total hip arthroplasty

Tenderness in the medial and posterior thigh is sometimes observed during the early postoperative period after total hip arthroplasty (THA). In this study, the possible correlations of preoperative hip range of motion, surgical approach, and limb lengthening with postoperative muscle strain injury in THA were investigated. Sixty primary THA patients given the posterolateral approach or direct-lateral approach were examined. For comparison of the muscle strain injury in the 2 groups, we used magnetic resonance imaging. There were significant differences in postoperative thigh pain between cases in the posterolateral group with reduction of internal rotation and those with no reduction, and between cases in the direct-lateral group with reduction of external rotation and those with no reduction.

MRI findings of gluteus minimus muscle damage in primary total hip arthroplasty and the influence on clinical outcome

INTRODUCTION

The influence of surgical trauma on gluteus minimus muscle in total hip arthroplasty (THA) and the impact on functional outcome has been hardly investigated up to now. Potential risks of minimus damage during the approach or femoral preparation is due to its attachment to the anterior facet of the greater trochanter. Possible trauma-associated functional deficits of minimus muscle may result in reduced abduction force or in an unstable hip joint. The aim of the present study was to assess the pre- and post-operative gluteus minimus muscle (tendon defects and fatty atrophy) in patient with anterolateral minimally invasive and modified lateral approach by means of magnetic resonance imaging (MRI) and to investigate the associated impact on functional outcome.

MATERIALS AND METHODS

Thirty-eight patients [average age, 64 years (35-80); BMI, 28 kg/m(2) (19-35)] with primary coxarthrosis were prospectively enrolled in the study. A cementless hip prosthesis was implanted either via a minimally invasive anterolateral or a modified direct lateral approach. Patients were clinically and radiologically (MRI) examined preoperatively, 3, and 12 months postoperatively. Additionally, the Harris hip score, a pain score (NRS 0-10) and a satisfaction score (1-6) were recorded. To test the function of the abductor muscles the Trendelenburg's sign and the abductor muscle strength were evaluated. MRI evaluation includes the assessment of tendon defects and fatty atrophy of the minimus muscle.

RESULTS

Tendon defects and fatty atrophy were seen in nearly 50% of the patients after THA. Harris hip-, pain-, and satisfaction scores did not correlate with the MR findings. There was also no impact on the abduction strength or the Trendelenburg's sign. Furthermore, the frequency of minimus damage was neither influenced by age, gender, BMI nor by the applied approach.

CONCLUSION

Muscle atrophy and tendon defects of the minimus muscle appear frequently after THA without any favored relation to the lateral or anterolateral approach. The extent of injured minimus muscle has a minor impact on the clinical outcome particularly not on the abduction strength within the first postoperative year. The main function of the gluteus minimus is rather the centralization of the femoral head in the joint during the gait cycle than hip abduction and stabilization of the pelvis. The use of a straight stem with the associated need for lateral femoral preparation may be a risk factor for minimus tendon damage. Therefore, the surgeon should pay special attention to the prevention of surgical trauma to the gluteus minimus muscle during femoral preparation.

Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty

To assess the potential recovery rate of a minimally invasive total hip replacement technique with minimal soft tissue disruption, an accelerated rehabilitation protocol was implemented with weightbearing as tolerated on the day of surgery. One hundred consecutive patients were enrolled in this prospective study. Ninety-seven patients (97%) met all the inpatient physical therapy goals required for discharge to home on the day of surgery; 100% of patients achieved these goals within 23 hours of surgery. Outpatient therapy was initiated in 9% of patients immediately, 62% of patients by 1 week, and all patients by 2 weeks. The mean time to discontinued use of crutches, discontinued use of narcotic pain medications, and resumed driving was 6 days postoperatively. The mean time to return to work was 8 days, discontinued use of any assistive device was 9 days, and resumption of all activities of daily living was 10 days. The mean time to walk (1/2) mile was 16 days. Furthermore, there were no readmissions, no dislocations, and no reoperations. Therefore, a rapid rehabilitation protocol is safe and fulfills the potential benefits of a rapid recovery with minimally invasive total hip arthroplasty.

Effects of a late-phase exercise program after total hip arthroplasty: a randomized controlled trial

OBJECTIVE

To investigate the effects of a late-phase exercise program for patients who underwent total hip arthroplasty (THA) 4 to 12 months earlier.

DESIGN

A single-blind, randomized controlled trial.

SETTING

Exercises were performed in subjects' homes. Exercise instruction and measurements taken before and after the trial were performed in an outpatient research and treatment center.

PARTICIPANTS

Convenience sample of 34 adults 4 to 12 months post-THA randomly allocated to experimental or control groups. Twenty-eight subjects completed the study.

INTERVENTION

An 8-week, hip-exercise intervention, during which the control group received basic isometric and active range of motion exercises; the experimental group received strength and postural stability exercises.

MAIN OUTCOME MEASURES

Score on the 12-Item Hip Questionnaire; fear of falling; hip flexor, extensor, abductor, and knee extensor muscle torque; and postural stability in single stance.

RESULTS

There was a statistically significant improvement in all measures of self-perceived function, muscle strength (hip flexors, 24.4%; hip extensors, 47.8%; hip abductors, 41.2%; knee extensors, 23.4%), and postural stability (36.8%) in the experimental group and no significant change in the control group. Neither group had statistically significant changes in fear of falling measures.

CONCLUSIONS

An exercise program emphasizing weight bearing and postural stability significantly improved muscle strength, postural stability, and self-perceived function in patients 4 to 12 months after THA.

Preventing chronic ectopic bone-related pain and disability after hip replacement surgery with perioperative ibuprofen. A multicenter, randomized, double-blind, placebo-controlled trial (HIPAID)

Postoperative ectopic bone formation affects about 40% of people undergoing elective hip replacement surgery. Despite clear evidence that a short course of perioperative nonsteroidal anti-inflammatory drugs (NSAIDs) can substantially reduce the occurrence of ectopic bone, the use of NSAID-based prophylactic therapy is uncommon in Australia or New Zealand. In part, this reflects surgeons' uncertainty about the importance of ectopic bone as a cause of impaired long-term outcome, and in part, concerns about possible increased risk for gastrointestinal complications and excess wound bleeding in patients undergoing orthopedic surgery. To address this uncertainty, a multicenter randomized controlled clinical trial is being conducted amongst 1000 patients undergoing elective total hip replacement (or revision) surgery. Patients are randomly allocated to 14 days of treatment with either 1200 mg ibuprofen (a commonly used NSAID) or matching placebo commencing within 24 h of surgery. Treatment outcomes will be assessed 6-12 months later. The primary outcome will be self-reported pain and physical function. Secondary outcomes include quality of life and physical performance measures. Patient recruitment has commenced in more than 20 orthopedic centers throughout Australia and New Zealand and will be complete by the end of October 2003. The prevention of chronic ectopic bone-related pain and disability after hip replacement surgery with anti-inflammatory drugs study (HIPAID) has been designed to provide precise and reliable information about the overall balance of risks and benefits associated with a short 14-day perioperative course of ibuprofen among individuals undergoing elective total hip replacement surgery.

The painful total hip replacement

Total hip replacement is one of the most common and successful orthopaedic procedures. However, evaluation and treatment of the painful total hip replacement is one of the most difficult challenges for the arthroplasty surgeon. The differential diagnosis includes causes that are intrinsic and extrinsic to the hip. A thorough history and physical examination provide the basis for a focused, efficient workup of the painful total hip replacement. The temporal onset, duration, severity, site, and character of the pain all provide important clues in determining the cause of the painful total hip replacement. The physical examination should focus on tests and maneuvers that reproduce the patient's symptoms. Laboratory tests and radiographic evaluation are used selectively as indicated by the history and physical examination findings. With a careful and thorough evaluation, the cause of the painful total hip replacement can be determined in most patients, and the appropriate treatment can be initiated.

Comparison of patient and doctor responses to a total hip arthroplasty clinical evaluation questionnaire

BACKGROUND

Surgeons traditionally undertake a prospective evaluation of patients undergoing total hip arthroplasty in order to determine outcomes. The validity of doctor-derived data is questionable because of the potential for interobserver error, reporting bias, and differences between the perceptions of doctors and patients. Also, the use of doctor-derived data necessitates the use of costly outpatient services. Consequently, there are likely to be benefits associated with the use of patient-derived clinical evaluation data. However, few studies have focused on whether data obtained from the patient and doctor differ.

METHODS

The agreement between patient and doctor responses on a sixteen-item total hip arthroplasty clinical evaluation questionnaire completed at more than 2900 clinical assessments was determined. Data from repeated assessments performed preoperatively and postoperatively enabled stratified analyses that were used to examine reasons for disagreement and factors influencing agreement. Agreement was measured with use of the kappa coefficient.

RESULTS

For twelve of the sixteen items, the patient responses had acceptable agreement with the doctor responses. Some important differences between patient-derived and doctor-derived data were found. If the patient had other joint or health problems, had a revision total hip arthroplasty, or reported mild or moderate pain, there was a greater chance of reduced agreement on the pain items. Younger patients demonstrated better agreement with doctors than older patients did.

CONCLUSIONS

Patients' perceptions of symptoms and outcomes after total hip arthroplasty are relatively similar to those of their doctor. There is minimum risk of misinterpreting outcomes data by replacing doctor-completed questionnaires with patient-completed questionnaires in uncomplicated total hip arthroplasty cases. For patients with comorbid joint problems or other health problems, and for those reporting substantial pain, direct physician involvement in the evaluation of pain is recommended. The selective use of patient-completed questionnaires has the potential to substantially reduce the costs of outcomes evaluation programs by minimizing doctor input. Pending revision of some of the items, the use of this patient-completed questionnaire is advocated.

Outcomes of total hip arthroplasty: a study of patients one year postsurgery

STUDY DESIGN

Ex post facto research using prospective analysis of differences between the involved hip and uninvolved hip.

OBJECTIVES

To assess outcomes of total hip arthroplasty (THA) by comparing range of motion (ROM), muscle strength, and postural stability in the surgical hip to those of the uninvolved hip 1 year postsurgery. An additional objective was to assess degree of relationship among ROM, strength, and postural stability impairments to a measure of self-assessed function.

BACKGROUND

Most patients who have THA receive physical therapy that consists mainly of self-care instructions and an exercise protocol that emphasizes mobility during the acute phase of recovery. But, outcomes of THA 1 year postsurgery indicate that current physical therapy programs used during the acute phase of recovery do not effectively restore physical and functional performance.

METHODS AND MEASURES

Subjects consisted of 11 women and 4 men (mean age +/- standard deviation = 62 +/- 8 years) with unilateral THA performed 1 year prior to data collection. Assessment variables consisted of self-assessment of function and measures of postural stability, muscle strength, and hip ROM. The 12-Item Hip Questionnaire was used for self-assessment of function. Three separate repeated measures MANOVA were used to compare the involved side to the uninvolved side in measures of postural stability, strength, and ROM. The Spearman's rho was used to assess degree of association between the subjects' score of self-assessed function and impairments in strength and postural stability.

RESULTS

Measures of postural stability were significantly lower (P < or = 0.01) on the side of the replaced hip. Differences in strength values between the involved and uninvolved sides were not statistically significant. Correlations between scores of self-assessed function and hip abductor and knee extensor strength were statistically significant (r = 0.56, P < or = 0.03). Self-assessed function was not significantly correlated to postural stability impairments.

CONCLUSION

The brief postsurgical rehabilitation program received by patients with THA may not be sufficient. A second phase of rehabilitation implemented 4 months or more after surgery that emphasizes weight bearing and postural stability may be advisable.

Effects of task-specific training on walking and sit-to-stand after total hip replacement

Twenty subjects with total hip replacement (THR) who were still experiencing movement problems at an average of 12.7 months post-operation undertook a six week outpatient program based on task-specific training of functional activities. All subjects demonstrated improved performance of walking and sit-to-stand after the training period. Specifically, scores on the ratings of occurrence of critical biomechanical components of the two tasks increased. In addition, step lengths of both legs, stride length and peak weight on the side of the most recent THR during the extension phase of sit-to-stand all improved significantly. This descriptive study suggests that task-specific training may assist individuals to improve performance of walking and sit-to-stand even if undertaken many months after a THR.

Determinants of health-related quality of life following elective total hip replacement

This study examined the patient perspective of surgical success through the measurement of health-related quality of life (HRQOL), in order to identify the patient characteristics and process issues associated with postoperative changes in health status. Patients completed the RAND 36-item Health Survey 1.0 (SF-36) prior to surgery and at 6 months following surgery. Baseline patient demographic and clinical information were collected from the medical record and were used to develop models of change in HRQOL for 68 patients. While many patients improved, a number experienced no change or even a decline in HRQOL in the postoperative period. Factors associated with change in HRQOL are presented. The findings suggest that factors associated with change in health status can be systematically assessed, which may lead to the development of interventions aimed at those patient characteristics or process issues that impact on HRQOL.