Quantification of progressive joint space narrowing in osteoarthritis of the hip: longitudinal analysis of the contralateral hip after total hip arthroplasty

OBJECTIVE: The rate of progressive joint space narrowing in the contralateral hip after total hip arthroplasty (THA) for osteoarthritis (OA) and the factors which may predispose patients to more aggressive joint space narrowing remain undefined. The current study sought to evaluate the rate and pattern of, and risk factors for, progressive joint space narrowing in the contralateral hip after THA for OA. METHODS: Each patient who underwent THA for OA in 1984-1985 was followed up longitudinally, and annual anteroposterior (AP) pelvis radiographs were obtained. The radiographic joint space width (JSW) of each contralateral hip joint was quantified, and the rates of JSW narrowing were determined. Evaluation of potential risk factors for accelerated progression of joint space narrowing included age, sex, side of surgery, weight, height, body mass index (BMI), hip pain, etiology of OA, and Kellgren/Lawrence radiographic grade. RESULTS: Ninety-nine patients and 619 AP pelvis radiographs were evaluated. The median initial JSW was 3.48 mm (interquartile range 1.55). JSW declined in a linear manner at a median rate of 0.10 mm/year. The rate of decline between baseline and followup in 20 months was predictive of the overall slope. Two subpopulations were identified. Eighty-five percent of patients maintained a slow decline in JSW (< or =0.2 mm/year), and 15% exhibited an accelerated decline in JSW (>0.2 mm/year). Kellgren/ Lawrence radiographic grade > or =2 and a diagnosis of primary OA were each associated with a more rapid decline in JSW (P = 0.006 and P = 0.02, respectively). Initial JSW, age, sex, weight, height, BMI, and hip pain were not risk factors for rapid decline in JSW. CONCLUSION: Radiographic hip JSW may be reliably quantified and followed up longitudinally using standard AP radiographs. Progression of JSW narrowing in the contralateral hip after THA for OA proceeds in a linear manner over several years. A subpopulation of patients with accelerated narrowing of contralateral JSW may be identified within 20 months, and may represent a suitable population with which to assess the potential efficacy of new disease-modifying agents.     

Gait analysis in an osteoarthritis patient with restoration of the hip joint space following contralateral total hip arthroplasty: a case report

We present the case of a patient who, after undergoing unilateral total hip arthroplasty (THA), achieved pain reduction in the contralateral hip accompanied by restoration of the radiographic joint space. We conducted gait analysis to clarify the dynamic factors affecting the natural course of osteoarthritis (OA). Our findings revealed that the patient walked with exaggerated adduction of the hip following the contralateral THA, causing substantial regeneration of joint loading.     

Long-term outcome following total hip arthroplasty: a controlled longitudinal study

OBJECTIVE: To assess long-term outcome and predictors of prognosis following total hip arthroplasty (THA) for osteoarthritis (OA). METHODS: We studied 282 patients from 2 English health districts approximately 8 years after THA, along with 295 controls selected from the general population. Baseline data were collected by interview and examination, on sex, age, comorbidity, body mass index (BMI), and Short Form 36 (SF-36) functional status, and preoperative radiographic severity of OA was graded. Functional status was reassessed at followup by postal questionnaire. Predictors of change in physical functioning were analyzed by linear regression. RESULTS: Over followup, cases who had THA reported a median improvement of 10 points in SF-36 score for physical functioning, whereas in controls there was a median deterioration of 10 points (P < 0.0001). Mental health improved by a median of 12 points in both cases and controls. Change in physical functioning was significantly worse in women and at older ages among both cases and controls. In cases, Croft grade 5 OA was associated with a physical functioning score improvement 19.4 points (95% confidence interval 7.7, 31.2) greater than the improvement in grades 0-3, but BMI was unrelated to change in physical functioning. CONCLUSION: Improvements in physical functioning following THA for OA are sustained in the long term and are more frequent in patients with more severe radiographic features preoperatively. We found no indication that patients who are overweight benefit less from THA, but further evidence is needed on the prognostic influence of more severe obesity.     

A composite index for total hip arthroplasty in patients with hip osteoarthritis

OBJECTIVE: We propose a composite index for considering total hip arthroplasty (THA) in hip osteoarthritis (OA). METHODS: We carried out a 3 year longitudinal study of patients with painful hip OA from 137 centers. Clinical data were collected at baseline and every 3 months; radiographs were taken at entry and each year. The decision to have surgery was made by the patient, the rheumatologist, and the surgeon, with no reference to outcome measures. Statistical analysis included discrete Cox analysis with time dependent covariates, on 3 month interval grouped data. The dependent variable was THA during the 3 months following the evaluated visit. Time dependent covariates collated at each evaluated visit included radiological joint space width (JSW), percentage decrease in JSW during the year preceding, patient's global assessment. Lequesne index, pain, and nonsteroidal antiinflammatory drug and analgesic intake. We compared 2 analyses differing in symptomatic variables entered: values obtained at a single time point vs mean values between 2 visits at a 3 month interval. Selection of the index was based on the best combination of variables to predict occurrence of THA. RESULTS: Of the 508 patients recruited for study, 42 were excluded. During the 3 year followup, 75 patients underwent THA. Symptomatic, therapeutic, and radiological variables were included in the index resulting from the 2 analyses. Based on the selected cutoff, the positive and negative predictive values for occurrence of THA in the 2 years following were 54.3 and 90.6%, respectively (single point model), and 52.9 and 86.7%, respectively (model using mean values of symptomatic variables between 2 visits). CONCLUSION: The poor positive predictive value of the composite indices obtained in this study suggests that there are other unmeasured factors determining access to surgery. On the other hand, the high negative predictive values suggest that these composite measures should be used by clinicians to determine which patients should not be referred to THA.     

Surgical treatment of hip osteoarthritis: update in total hip arthroplasty

Total hip replacement is one of the most successful procedures in orthopaedic surgery. There are two different technologies for implant fixation in total hip replacement: cemented and cementless, both can be combined, which is called Hybrid arthroplasty. Long term implant stability results in long term function. The most important factor that limits longevity of well-fixed implants is the wear of the articular surfaces. Wear of the polyethylene from the acetabulum generates particles that access the implant bone or the implant-cement-bone interface. This produces an inflammatory reaction, osteolysis and implant loosening. Polyethylene of higher resistance to wear and prosthetic articulations without polyethylene (hard on hard bearings), have been introduced to improve wear particle generation. Minimally invasive surgical techniques minimize surgical trauma to sort tissue around the hip joint, facilitating a better and more rapid recovery.     

Cost-effectiveness of total joint arthroplasty in osteoarthritis

Although total joint replacement (TJR) is a major advance in the treatment of patients with osteoarthritis, its cost-effectiveness has been questioned. We report the results of a study of the costs and benefits of TJR in consecutive osteoarthritis patients, 6 months after the surgery. Health status was measured by the Index of Well-Being. Costs of services for arthritis were determined by interview and billing records. Six months after TJR, significant improvements were seen in global health and in functional status. The average cost of care for the 6 months prior to TJR was $933. The average cost during the 6 months beginning with the TJR was $22,730 per patient--due almost entirely to costs of surgery. In general, the surgery did not change work status, probably because the mean age of the patients was 66.4 years. There were large effectiveness/cost differentials (the larger the effectiveness/cost differential, the higher the degree of cost-effectiveness [CE]). At 6 months, for all patients, the CE was associated with initial health status. The highest CE was observed in 10 patients who initially had the poorest health. TJR is more cost-effective for patients with the most to gain and less effective for those with better preoperative health status.     

The longterm outcome of osteoarthritis: rates and predictors of joint space narrowing in symptomatic patients with knee osteoarthritis

OBJECTIVE: To determine the rate of progression of radiographic joint space narrowing (JSN) and the factors that predict it in symptomatic clinic patients with knee osteoarthritis (OA). METHODS: In total 1,507 patients with knee OA were studied with extended weight-bearing anterior-posterior views of the knee as part of a longitudinal study of longterm outcomes of osteoarthritis (OA). Baseline demographic and severity measurements included body mass index (BMI), pain, global severity, Health Assessment Questionnaire disability, and erythrocyte sedimentation rate. Rates and predictors of progression were obtained by Kaplan-Meier survival analyses and Cox regressions using a JSN score of 3 as "failure." RESULTS: For the 1,232 patients who had not reached the endpoint narrowing score of 3 when first evaluated, the 75th and 50th survival times (time to JSN = 3) were 11.27 and 17.84 years for those with JSN = 0 at onset, 7.41 and 12.03 years for those with JSN = 1 at onset, and 4.49 and 7.44 years for those with JSN = 2 at onset. The corresponding yearly incidence rates for the 3 initial groups were 0.017, 0.032, and 0.077. In multivariate Cox models, initial JSN, BMI, symptom duration, and global severity were predictors of progression, but only JSN was a strong predictor. BMI predicted JSN in those with JSN = 0 at onset, but not in patients with more severe disease. Although contralateral JSN predicted progression, it was only of value with initial homolateral JSN scores of 0. Assessment of homolateral osteophytes aided prediction in patients with initial JSN = 0, but was of much less help when JSN had a higher severity score. CONCLUSION: The risk of progression in clinical OA patients with radiographic abnormalities is substantial. Nonradiographic predictors of OA progression (e.g., BMI) are weak predictors of radiographic progression compared to current radiographic status. Rates of progression are greatest in those with established radiographic abnormalities. Osteophytes are of limited additional values once JSN = 2 is present. Contralateral radiographic abnormalities are useful predictors only in those with JSN = 0. Intervention studies to prevent radiographic progression probably should utilize joints where evidence of abnormality already exists. At a clinical level, current radiographic status predicts future status, with 50% of patients with JSN = 1 and 50% of patients with JSN = 2 progressing to complete joint space loss in 12.03 and 7.44 years, respectively.     

Bilateral synchronous total hip arthroplasty for end-stage arthropathy in hemophilia A patients: A retrospective study

Total hip arthroplasty (THA) has been an effective tool of advanced hemophiliac hip arthritis. There are only limited data of bilateral synchronous THA for end-stage arthropathy in hemophilia A patients.The aim of this retrospective study was to analyze clinical outcome and complication rate of bilateral THA for hemophilia A patients with end-stage arthropathy of hip and review the operative strategy.From August 2012 to July 2016, 48 hips of 24 patients with hemophilia A patients underwent THA by a single experienced chief orthopedic surgeon. Clinical and radiological evaluations were included of operation time, blood loss, the quantity of blood transfusion, clotting factor consumption, duration of hospitalization, modified Harris hip score, complication rate, and radiographic assessment.All the 24 patients successfully completed the operation, followed up for 5 to 8 years, and the mean time was 6.5 years. The average operation time was 140 minutes (range, 120–180 minutes). The average total blood loss was 225 mL (range, 150–400 mL). The mean red blood cell transfusion amount was 2.4 U (range, 0–6 U). the mean hospitalization time was 24 days (range, 16–46 days). The mean amount of clotting factor VIII used in the perioperative period for management of hemophilia A was 30,600 U (range, 18,000–52,000 U). Average modified Harris hip score increased from 46.6 (range 28–70) points preoperatively to 90.2 (range 75–98) points at final follow-up, complications were few.With excellent operative techniques and hematological management, bilateral synchronous THA for end-stage arthropathy in hemophilia A patients can provide satisfactory outcomes.     

Relevant change in radiological progression in patients with hip osteoarthritis. I. Determination using predictive validity for total hip arthroplasty

OBJECTIVE: To determine a cut-off point above which a change in joint space width (JSW) could be considered as relevant in patients with hip osteoarthritis (OA) on the basis of predicted need for subsequent total hip arthroplasty (THA). METHODS: A multicentre, prospective, longitudinal, 5-yr follow-up study was performed. A pelvic radiograph was obtained at entry and after 1 and 2 yr. For each film, the narrowest JSW was measured using a 0.1 mm graduated magnifying glass. The absolute and relative differences between baseline and 1 and 2 yr of follow-up were calculated. We determined the cut-off points above which an absolute or relative decrease in JSW between baseline and 1 and 2 yr of follow-up could be considered relevant on the basis of the predicted need for THA during the remaining years of the study. The need for THA was categorized as 'yes' or 'no'. Thereafter, for each observed change in JSW (0.1 per 0.1 mm or 1% per 1%), the sensitivity and specificity for subsequent THA were calculated. The choice of cut-off was based on maximal sensitivity and specificity, using the graphic representation of correct classification probabilities. In this way it was possible to obtain the best measured JSW threshold with maximal true positive and minimal false positive results. RESULTS: A total of 423 and 385 patients met the criteria for analysis using the decrease in JSW between baseline and 1 and 2 yr respectively. The best cut-off points were absolute decreases in JSW of 0.2 and 0.4 mm and relative decreases in JSW of 15 and 20% after 1 and 2 yr respectively, with corresponding ranges of sensitivity and specificity of 68-75 and 67-78%. CONCLUSION: This work determined the cut-off above which a change in JSW could be considered clinically relevant in patients with hip OA, on the basis of predicted subsequent need for THA. For validation, similar studies should be conducted in other countries with different health-care systems.     

Efficacy of bed exercise in elderly patients after total hip arthroplasty: A retrospective study of 539 patients

The purpose of this study was to observe the necessity of bed exercise therapy in the rehabilitation of elderly patients after hip replacement and to analyze whether bed exercise therapy has an impact on patients’ psychological scores, hip function and postoperative complications. From January 2018 to January 2021, a total of 539 patients with end-stage femoral head necrosis or hip osteoarthritis were retrospectively analyzed. According to the method of postoperative rehabilitation exercise, patients were divided into 2 groups: Group A (routine gait) and Group B (bed exercise). There was no significant difference in general information between the 2 groups. There was no significant difference in baseline pain scores between patients in Group A and Group B (25.2 ± 9.6 vs 24.8 ± 10.4, P = .429). However, at 5 weeks post-operatively, the pain scores of patients in Group A were significantly higher than those in Group B (38.6 ± 7.7 vs 34.1 ± 8.1, P = .016). At 17 weeks post-operatively, the difference between Group A and Group B remained (40.9 ± 6.9 vs 37.5 ± 7.5, P = .041). Similar to the pain score, the hip function score compared between the 2 groups was significantly different at 5 weeks (39.7 ± 8.4 in Group A, 45.9 ± 9.2 in Group B, P < .001) and 17 weeks post-operatively (41.5 ± 7.6 in Group A, 47.2 ± 8.8 in Group B, P < .001). At 17 weeks post-operatively, between the 2 groups, only the range of motion (ROM) of abduction showed no significant difference. Patients in Group B exhibited a better ROM in any other movement posture. The results showed that compared with Group A, bed exercise rehabilitation training could reduce the incidence of deep venous thrombosis. This study demonstrates that bed exercise can improve the hip function and quality of life of elderly patients with total hip arthroplasty (THA) at an early postoperative stage. It can reduce the incidence of deep venous thrombosis of the lower limbs after surgery. For these patients, systematic bed exercise rehabilitation training is recommended in the early postoperative period.     

Sex differences in hip osteoarthritis: results of a longitudinal study in 508 patients

OBJECTIVE: To evaluate sex differences in the clinical and structural presentation, and natural history of hip OA. METHODS: A multicentre, prospective, longitudinal, five year follow up study of 508 patients (302 women, 206 men, mean age 63 (7) years) with painful hip OA. Data collected were baseline demographics, symptomatic, therapeutic, and structural variables; symptomatic variables and changes in joint space width (JSW) during the first year's follow up; requirement for total hip arthroplasty (THA) between the end of the first and fifth years. Statistical analysis: evaluation of sex differences (a) at baseline, in the main characteristics of hip OA using multivariate logistic regression; (b) during the first year of follow up, in the radiological progression of the disease; (c) during the five years of follow up, in the requirement for THA using Kaplan-Meier curves and the log rank test, and of the parameters related to THA, using a multivariate Cox analysis. RESULTS: At entry, women presented more frequently than men with polyarticular OA (mean (SD) articular score 306 (162) v 235 (127)), and superomedial migration of the femoral head (40% v 19%), and had more severe symptomatic disease (patient's overall assessment 46 (23) v 40 (26)). The change in JSW did not differ between women and men after one year, but a greater proportion of women had rapid structural progression (OR=2.34, 95% CI 1.1 to 5.2). THA was performed more often in women. Multivariate analysis suggested that the decision to perform surgery was related more closely to the symptomatic and structural severity of the disease than to the sex of the patient. CONCLUSION: Hip OA in women is more frequently part of a polyarticular OA, and displays greater symptomatic and structural severity.     

One‐year change in radiographic joint space width in patients with unilateral joint space narrowing: Data from the osteoarthritis initiative

Objective

To examine the rate of joint space width (JSW) loss in both knees of patients with unilateral medial joint space narrowing (JSN) at baseline.

Methods

Cases were selected from a pool of 2,678 subjects enrolled in the Osteoarthritis Initiative cohort. Inclusion criteria for the present study were unilateral medial JSN, bilateral frequent knee pain, and body mass index (BMI) ≥25 kg/m². Baseline and 1‐year fixed flexion radiographs of both knees were read (blinded to time point) using an automated algorithm for minimum JSW and JSW at 4 fixed locations in the medial compartment.

Results

Sixty‐seven participants met the inclusion criteria: 43 women and 24 men, with mean ± SD age 60 ± 9 years and mean ± SD BMI 31 ± 4 kg/m². Thirty‐seven subjects (55%) had ≥1 definite tibiofemoral osteophyte. The average progression in no‐JSN knees was comparable with that in JSN knees (approximately ?0.2 mm/year). However, JSW change was more variable in no‐JSN knees, resulting in standardized response means (SRMs; the mean/SD) of approximately ?0.24 in no‐JSN knees versus approximately ?0.41 in JSN knees on average at the 4 fixed locations, and SRMs of ?0.24 and ?0.35, respectively, for minimum JSW. Young age and high BMI were associated with increased progression, especially in JSN knees.

Conclusion

JSN and no‐JSN knees progressed at a comparable rate, but a wider distribution of JSW change in no‐JSN knees resulted in a poorer sensitivity to change in these knees.

     

Quadriceps muscle wasting persists 5 months after total hip arthroplasty for osteoarthritis of the hip: a pilot study

Aims: To determine whether additional muscle fibre wasting of the ipsilateral vastus lateralis muscle occurs in the early postoperative period after total hip arthroplasty for osteoarthritis of the hip and whether there is an improvement in preoperative measures of quadriceps muscle thickness, strength, pain and function over a 5‐month postoperative period. Methods: Twelve patients had ipsilateral needle quadriceps biopsy for muscle morphology and bilateral quadriceps muscle thickness ultrasound preoperatively, 5 days and 4 weeks postoperatively and a further muscle thickness measurement at 5 months. Seven additional patients and five age‐matched control subjects had bilateral quadriceps muscle ultrasound thickness preoperatively, 6 weeks and 5 months postoperatively, with assessment of quadriceps muscle dynamometry, pain scores and Timed Up and Go (TUG) test. Results: Preoperatively, all 19 patients demonstrated significant atrophy of the ipsilateral compared with the contralateral quadriceps muscle (P = 1.8 × 10^–7) on muscle ultrasound, which persisted at 5 months follow up (P = 0.009). Muscle morphology preoperatively showed type 2A and 2B muscle fibre atrophy on needle muscle biopsy, with further atrophy of all three fibre types (P = 0.029) at 5 days postoperatively associated with a fibre type shift from type 1 to 2A fibres (P = 0.0011) at 1 month. There was improvement in hip pain postoperatively and a significant improvement in the TUG test (P = 0.007). However, there was no improvement in muscle strength on dynamometry. Conclusions: There is significant ipsilateral quadriceps atrophy and weakness with 2A and 2B fibre atrophy preoperatively in patients with osteoarthritis of the hip with exacerbation and further atrophy of all three fibre types 5 days postoperatively. Postoperative follow up showed that the reduction in ipsilateral quadriceps muscle thickness persisted at 5 months despite physical rehabilitation. Patients did note significant improvement in pain postoperatively and improvement on functional assessment with the TUG test. Other therapeutic strategies may have to be developed to reverse disuse muscle atrophy. (Intern Med J 2001; 31: 7–14)     

Performance of an automated computer-based scoring method to assess joint space narrowing in rheumatoid arthritis: a longitudinal study

OBJECTIVE: To compare the diagnostic performance of a computer-based method for measuring joint space width with the Sharp joint space narrowing (JSN) scoring method in patients with rheumatoid arthritis (RA). METHODS: A random sample of patients with early RA, for whom sequential hand radiographs and Sharp scores were available, was selected from the National Data Bank for Rheumatic Diseases. Hand joint space width was measured using an automated, computer-based method in random order and with blinding for clinical information. We constructed a receiver operating characteristic curve and compared the diagnostic performance of the computer-based and Sharp methods based on the areas under the curve. RESULTS: One hundred twenty-nine patients with early RA who underwent serial radiography were included. Changes in the computer-based and Sharp methods were highly correlated (r = 0.75, P < 0.001). The computer-based method was significantly more discriminant than the Sharp JSN subscale. The area under the curve of the computer-based method was 0.96 (95% confidence interval [95% CI] 0.94, 0.99) compared with 0.93 (95% CI 0.89, 0.96) for the Sharp subscale (P = 0.024). At the most discriminant cutoff, specificity of the computer-based method was 88.4% compared with 81.4% for the Sharp subscale (P = 0.11); sensitivity was 87.6% for the computer-based method compared with 82.2% for Sharp subscale (P = 0.19). The signal-to-noise ratio for the computer-based method was 83% compared with 70% for the Sharp subscale (P = 0.013). CONCLUSION: The computer-based method for measuring joint space width is more discriminant than the semiquantitative Sharp JSN subscale.     

Detection of radiographic joint space narrowing in subjects with knee osteoarthritis: longitudinal comparison of the metatarsophalangeal and semiflexed anteroposterior views

OBJECTIVE: Although recent protocols for standardized knee radiography afford highly reproducible radioanatomic alignment of the joint and measurement of joint space width (JSW) in repeat radiographs acquired on the same day, the sensitivity of these techniques to joint space narrowing (JSN) over time in subjects with knee osteoarthritis (OA) is unknown. The present study was undertaken to compare the metatarsophalangeal (MTP) view and the semiflexed anteroposterior (AP) view with respect to sensitivity to JSN in knee OA. METHODS: In 49 subjects with definite knee OA, 2 MTP radiographs and 1 semiflexed AP radiograph were obtained at baseline. Each examination was repeated 14 months later. In MTP views, minimum JSW and the distance between the anterior and posterior margins of the medial tibial plateau (intermargin distance [IMD], an indicator of parallel alignment of the tibial plateau and the x-ray beam) were measured with a pair of calipers and a magnifying lens fitted with a graticule. JSW in semiflexed AP views was measured by digital image analysis. RESULTS: The mean of within-knee standard deviations of JSW in the baseline MTP examinations (n = 52 OA knees) was 0.24 mm (coefficient of variation 5.8%). Although IMDs in the 2 baseline MTP views were very highly correlated (+0.88), IMDs in the serial examinations were only moderately correlated (+0.45). Serial MTP views showed a small increase in mean JSW over 14 months that was not significantly greater than zero (mean +/- SD +0.09 +/- 0.66 mm; P not significant). In contrast, concurrent semiflexed AP examinations showed a marginally significant decrease in mean JSW (-0.09 +/- 0.31 mm; P = 0.10). CONCLUSION: These results demonstrate that evidence of the short-term reproducibility of a radiographic protocol is an insufficient basis on which to predict the quality of its longitudinal performance.     

Long‐term outcome following total hip arthroplasty: A controlled longitudinal study

Objective

To assess long‐term outcome and predictors of prognosis following total hip arthroplasty (THA) for osteoarthritis (OA).

Methods

We studied 282 patients from 2 English health districts ～8 years after THA, along with 295 controls selected from the general population. Baseline data were collected by interview and examination, on sex, age, comorbidity, body mass index (BMI), and Short Form 36 (SF‐36) functional status, and preoperative radiographic severity of OA was graded. Functional status was reassessed at followup by postal questionnaire. Predictors of change in physical functioning were analyzed by linear regression.

Results

Over followup, cases who had THA reported a median improvement of 10 points in SF‐36 score for physical functioning, whereas in controls there was a median deterioration of 10 points (P < 0.0001). Mental health improved by a median of 12 points in both cases and controls. Change in physical functioning was significantly worse in women and at older ages among both cases and controls. In cases, Croft grade 5 OA was associated with a physical functioning score improvement 19.4 points (95% confidence interval 7.7, 31.2) greater than the improvement in grades 0–3, but BMI was unrelated to change in physical functioning.

Conclusion

Improvements in physical functioning following THA for OA are sustained in the long term and are more frequent in patients with more severe radiographic features preoperatively. We found no indication that patients who are overweight benefit less from THA, but further evidence is needed on the prognostic influence of more severe obesity.