Superior responsiveness of the pain and function sections of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as compared to the Lequesne-Algofunctional Index in patients with osteoarthritis of the lower extremities

OBJECTIVE: To compare the responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and a questionnaire format of the Lequesne-Algofunctional Index in patients with OA of the lower extremities. METHODS: Longitudinal analysis of the instruments' responsiveness [standardized response mean (SRM), effect size (ES)] in ambulatory patients undergoing hip or knee arthroplasty. RESULTS: At six months 36, and at one year 40 out of 43 patients undergoing hip (N=30) or knee arthroplasty (N=13) could be examined. Both responsiveness statistics revealed the same order of responsiveness. For both indices and for both locations, the pain sections were more responsive than the function sections. However, the WOMAC scales and the WOMAC global index (hip at 12 months: SRM=2.4; knee at 12 months: SRM=2.0 ) were more responsive than the comparable Lequesne sections and Lequesne index (hip at 12 months: SRM=2.1; knee at 12 months: SRM=1.5). CONCLUSIONS: Although our results are based on a German version using a self-report format, the WOMAC scales appear to be more responsive than the Lequesne index in patients with OA of the lower extremities.     

Reliability and validity of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index in Italian patients with osteoarthritis of the knee

OBJECTIVE: The Western Ontario and McMaster Universities (WOMAC) Osteoarthritis (OA) Index is a tested questionnaire to assess symptoms and physical functional disability in patients with OA of the knee and the hip. We adapted the WOMAC for the Italian language and tested its metric properties in 304 patients with symptomatic OA of the knee. METHODS: Three hundred and four consecutive patients, attending 29 rheumatologic outpatient clinic in northern, central, and southern Italy, were asked to answer two disease-specific questionnaires (WOMAC and Lequesne algofunctional index) and one generic instrument (Medical Outcomes Study SF-36 Health Survey-MOS SF-36). A sample of 258 patients was readministered the WOMAC 7-10 days after the first visit and the structured interview, which also assessed demographic and other characteristics. Internal consistency was assessed using Cronbach's alpha, reliability using intraclass correlation coefficients (ICCs), and construct and discriminant validity using Spearman's correlations, Wilcoxon rank sum test, and Kruskal-Wallis test. RESULTS: All WOMAC subscales (pain, stiffness, and physical function) were internally consistent with Cronbach's coefficient alpha of 0.91, 0.81, and 0.84, respectively. Test-retest reliability was satisfactory with ICCs of 0.86, 0.68, and 0.89, respectively. In comparison with the SF-36, the expected correlations were found when comparing items measuring similar constructs, supporting the concepts of convergent construct validity. Very high correlations were also obtained between WOMAC scores and Lequesne OA algofunctional index. WOMAC physical function, but not WOMAC stiffness and pain subscales, was weakly associated with radiological OA severity (P=0.03). Also, WOMAC pain score was inversely correlated (P=0.01) with years of formal education. Examination of discriminant validity showed that the scores on the WOMAC and SF-36 followed hypothesized patterns: the WOMAC discriminated better among subjects with varying severity of knee problems, whereas the SF-36 discriminated better among subjects with varying levels of self-reported health status and comorbidity. CONCLUSION: The Italian version of WOMAC is a reliable and valid instrument for evaluating the severity of OA of the knee, with metric properties in agreement with the original, widely used version.     

A comparison of outcomes in osteoarthritis patients undergoing total hip and knee replacement surgery

OBJECTIVE: The aims of this study were to assess changes in physical function and quality of life with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the instrument of the Medical Outcomes Study SF-36 Health Survey (MOS SF-36), respectively, in patients undergoing hip anf knee joint replacement surgery and to compare the responsiveness of these two outcome measures 1 year after surgery. DESIGN: One hundred and ninety-four patients with osteoarthritis (OA knee 108, OA hip 86) admitted to four hospitals in Sydney were followed over a period of 1 year at 3 monthly intervals. RESULTS: WOMAC measures improved significantly after 1 year for OA hip and OA knee: there was reduction in pain of 71% and 53%, reduction of stiffness of 55% and 43% and improvement in physical function of 68% and 43%, respectively. MOS SF-36 measures in those having hip surgery improved significantly for pain (222%), physical function (247%), physical role functioning (402%), general health (110%), vitality (143%0, social functioning (169%) and mental health (114%). For those in the knee surgery group, significant improvement was seen for pain (175%), physical function (197%), physical role functioning (275%), vitality (125%) and social functioning (119%). The WOMAC was a more responsive measure than the MOS SF-36. CONCLUSION: WOMAC and MOS SF-36 detect significant and clinically meaningful changes in outcome after hip and knee replacement. WOMAC requires a smaller sample size and is more responsive in the short term. For a follow-up longer than 6 months MOS SF-36 provides additional information. The improvement in outcomes following hip joint surgery were significantly greater than those following knee surgery.     

Changes in pain, stiffness and physical function in patients with osteoarthritis waiting for hip or knee joint replacement surgery

OBJECTIVE: Little has been reported on changes in health status in patients with osteoarthritis (OA) while waiting for hip or knee replacement surgery. In this study we assessed (1) changes in self-reported pain, stiffness and physical function in patients with OA of the hip or knee, from the decision to undergo surgery to 14 days prior to surgery, and (2) the determinants of these changes. METHODS: Among 353 baseline respondents, 170 waited >30 days for surgery, completed the Western Ontario and McMaster Universities Arthritis Index (WOMAC) before surgery and were included in the analysis of changes; 120 with OA of the hip and 50 of the knee. We analyzed changes in WOMAC scores using the paired t test and determinants of the changes using multiple linear regression. RESULTS: Patients with OA of the hip did not change on any WOMAC scale before surgery. Knee patients deteriorated with time on the WOMAC stiffness and total scales, but not on the pain or physical function subscales. In both patient categories, higher baseline WOMAC scores were associated with smaller changes on all subscales and the total score, and female sex was associated with deterioration on the pain subscale. CONCLUSIONS: Patients with OA of the hip reported no change in pain, stiffness or physical function while waiting for joint replacement surgery, whereas patients with OA of the knee deteriorated on the stiffness and total scales of the WOMAC. This suggests a difference in patient selection, referral pattern or disease development between the patient categories.     

Algo-functional assessment of knee osteoarthritis: comparison of the test-retest reliability and construct validity of the WOMAC and Lequesne indexes

OBJECTIVE: To assess and compare the test-retest reliability and the construct validity of the Lequesne and the French-Canadian version of the WOMAC indexes. DESIGN: Patients with symptomatic knee osteoarthritis (OA) fulfilling the revised criteria of the American College of Rheumatology completed both the Lequesne and the French-Canadian version of the WOMAC indexes twice at a 3-h interval. Impairment outcome measures, patients' perceived discomfort in walking and handicap were recorded. For both questionnaires, an analysis was performed item by item. Repeatability was assessed using the intraclass correlation coefficient (ICC) and the Bland and Altman method. Construct validity was investigated using the Spearman rank correlation coefficient and a factor analysis was performed. RESULTS: 88 patients were included. Eight questions of the WOMAC section C and one question of the Lequesne index had insufficient psychometric properties. Although repeatability of questionnaires was fair to excellent (0.82, 0.68, 0.74, 0.95 for the WOMAC sections A, B, C and Lequesne index respectively), construct validity could not be demonstrated. Factor analysis of the WOMAC extracted five factors which differed from the a priori triple stratification. Factor analysis of the WOMAC section C extracted two factors explaining 71% of the variance which could not be clinically characterized. For the Lequesne index, expected convergent correlations were not always achieved. Three factors were extracted by factor analysis explaining 58% of the variance. CONCLUSION: Despite their good test-retest reliability, the two composite indexes evaluated are not valid to assess the concept of functional disability induced by knee OA in a French population.     

A 5-year randomized controlled, double-blind study of glycosaminoglycan polysulphuric acid complex (Rumalon) as a structure modifying therapy in osteoarthritis of the hip and knee

OBJECTIVE: To determine the structure (disease) modifying effect of a glycosaminoglycan polypeptide association complex (GP-C; Rumalon) in patients with knee and hip osteoarthritis (OA). METHODS: Double-blind, randomized, placebo-controlled five-year study. Primary assessment criterion was change in radiographic joint space width between baseline and follow-up at 5 years. Secondary outcome criteria included Lequesne algofunctional index (LAI), pain on passive motion and consumption of non-steroidal antiinflammatory drugs (NSAIDs). The patients received 10 courses of injections of placebo or GP-C 2 ml intramuscularly in 5 years (two courses each year). Each course included 15 injections administered twice weekly. RESULTS: There were 277 patients with knee OA and 117 patients with hip OA. Control and GP-C treated groups were comparable as to sex, age, duration of disease, body weight, X-ray stage and value of LAI at the baseline. Knee joint space at 5 years decreased 0.37+/-0.08 (mean+/-standard deviation) mm for GP-C and 0.42+/-0.08 mm for placebo groups (P=0.68). Hip joint space at 5 years decreased 0.21+/-0.08 mm for GP-C and 0.22+/-0.08 mm for placebo groups (P=0.53). In a subset of patients with hip OA, Kellgren-Lawrence> or =2 and JSW> or =1 mm, there was a trend in favor of GPC for lower joint space narrowing in 5 years (P=0.11). In addition, there were no statistical differences between the treatment groups in LAI, pain on passive motion and consumption of NSAIDs. Side-effects after GP-C (14.5%) were rare, mild and not more frequent than in the placebo group (15%). CONCLUSION: We were not able to demonstrate a structure modifying effect of GP-C in OA of the hip or knee. Radiographic progression of OA in both knee and hip OA was lower than expected in both study groups.     

Cross-cultural adaptation and validation of Singapore English and Chinese versions of the Lequesne Algofunctional Index of knee in Asians with knee osteoarthritis in Singapore

OBJECTIVE: To cross-culturally adapt and validate Singapore English and Chinese versions of the Lequesne Algofunctional Index of knee in patients with knee osteoarthritis (OA) in Singapore. METHODS: Singapore English and Chinese versions were cross-culturally adapted from the source English version following standard guideline (including cognitive debriefing). Patients were asked to complete an identical, pretested questionnaire containing the Lequesne index, Short Form 36 Health Survey (SF-36), and EQ-5D twice within 6 days. Reliability was assessed using Cronbach's alpha and intraclass correlation coefficients (ICC). Dimensionality was assessed by principal component factor analysis. Construct validity was tested by item-to-scale correlations and 12 and six a priori hypotheses for convergent and divergent construct validities, respectively. RESULTS: Singapore English and Chinese Lequesne indices were well accepted by patients in pilot testing and were therefore administered to a consecutive sample of 127 English- and 131 Chinese-speaking Singaporeans with knee OA. Acceptable internal consistency was observed for activities of daily living and the global index (alpha=0.72-0.82), and the good test-retest reliability for all scales in both versions (ICC=0.66-0.94). Expected item-to-scale correlations were presented only in activities of daily living in both versions. Factor analysis yielded two factors for both versions. Convergent and divergent construct validities were supported by the presence of hypothesized correlations between the Lequesne index and SF-36 and EQ-5D scales. CONCLUSION: Both versions of the Lequesne index demonstrated acceptable reliability and validity among multiethnic Asian patients with knee OA, which suggests that it could be used as a global index in the health-related quality of life (HRQoL) measurements in Singapore and possibly other Asian countries.     

Effectiveness of hip or knee replacement surgery in terms of quality-adjusted life years and costs

BACKGROUND: Concurrent head-to-head comparisons of healthcare interventions regarding cost-utility are rare. The concept of favorable cost-effectiveness of total hip or knee arthroplasty is thus inadequately verified. PATIENTS AND METHODS: In a trial involving several thousand patients from 10 medical specialties, 223 patients who were enrolled for hip or knee replacement surgery were asked to fill in the 15D health-related quality of life (HRQoL) survey before and after operation. RESULTS: Mean (SD) HRQoL score (on a 0-1 scale) increased in primary hip replacement patients (n = 96) from 0.81 (0.084) preoperatively to 0.86 (0.12) at 12 months (p < 0.001). In revision hip replacement (n = 24) the corresponding scores were 0.81 (0.086) and 0.82 (0.097) respectively (p = 0.4), and in knee replacement (n = 103) the scores were 0.81 (0.093) and 0.84 (0.11) respectively (p < 0.001). Of 15 health dimensions, there were statistically significant improvements in moving, usual activities, discomfort and symptoms, distress, and vitality in both primary replacement groups. Mean cost per quality-adjusted life year (QALY) gained during a 1-year period was euro 6,710 for primary hip replacement, euro 52,274 for revision hip replacement, and euro 13,995 for primary knee replacement. INTERPRETATION: Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is twice that gained from hip replacement.     

Cross-cultural adaptation and validation of Korean Western Ontario and McMaster Universities (WOMAC) and Lequesne Osteoarthritis Indices for Clinical Research

OBJECTIVE: Our aims were to translate WOMAC and Lequesne osteoarthritis (OA) indices into Korean (KWOMAC, KLequesne) and confirm their reliability, validity, and responsiveness. DESIGN: The WOMAC and Lequesne indices were translated into Korean by three translators and translated back into English by three different translators. Fifty consecutive patients with OA were asked to rate the comprehensibility of the questions on a 4-point scale. The comprehensibility (responding with 'good' and 'very good') ranged from 78% to 99%. Test-retest was performed in another 47 patients with knee OA. The final 53 patients with knee OA, within the context of a clinical trial of two non-steroidal antiinflammatory drugs for 4 weeks, were studied to assess the internal consistency, construct validity, and responsiveness of the Korean versions. RESULTS: The test-retest reliability of the KWOMAC 3 subscales and the KLequesne yielded intraclass correlation coefficients of 0.79-0.89 and 0.87. The Cronbach standardized alphas were 0.81-0.96 and 0.75, respectively. For the construct validity, the correlation coefficients of both the KWOMAC subscales and the KLequesne with patient pain assessment and patient global assessment were between 0.30 and 0.70 and the KWOMAC subscales correlated with the KLequesne (0.41-0.55). For responsiveness, the KWOMAC and KLequesne scores significantly improved by 4-week post-treatment compared with pre-treatment; effect size values were between 0.41 and 0.69 for the KWOMAC subscales and 0.70 for the KLequesne; and the relative efficiency values of the KWOMAC subscales vs the KLequesne were between 0.87 and 0.90. CONCLUSIONS: The reliability, validity, and responsiveness of the KWOMAC and the KLequesne are confirmed.     

Responsiveness of the electronic touch screen WOMAC 3.1 OA Index in a short term clinical trial with rofecoxib

BACKGROUND: The Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index is a self-administered validated questionnaire for patients with osteoarthritis (OA) of the hip or knee. The electronic touch screen version of the WOMAC (e-WOMAC) has been previously shown to be highly correlated with the original paper format. However, whether the e-WOMAC would be suitable for monitoring the effects of drug treatment is unknown. AIM: To validate the longitudinal use of the e-WOMAC questionnaire and its ability to detect changes in WOMAC-scores induced by drug treatment in outpatient care. METHODS: Fifty-three outpatients, men and women (mean age: 64 years; SD+/-9.5), with symptomatic osteoarthritis of hip or knee were included in an open label study with rofecoxib. At three visits over 3 weeks, responsiveness of the WOMAC 3.1 regarding the three subscales, pain, stiffness and function, were compared for the original paper format and the computer touch screen format (QUALITOUCH) using a Likert scale. WOMAC scores were transformed to the 0-100 scale. ANOVA for repeated measures was used for analysis and effect sizes by subscale were compared for both formats. RESULTS: Responsiveness for all three subscales was similar between formats. In both formats, pain and stiffness were significantly reduced with rofecoxib as early as 7 days, while functional ability was significantly increased (P<0.01 for all aggregate subscale scores) with continuing improvement until the end of study. The effect sizes by subscale between Day 1 and 21 were not statistically different between the paper and the electronic version of the questionnaire and showed similar clinically meaningful improvements in WOMAC scores over 3 weeks. CONCLUSION: In this longitudinal intervention study, the e-WOMAC OA Index 3.1 showed similar responsiveness in detecting clinically meaningful changes than the original paper format.     

Recommendations of the OARSI FDA Osteoarthritis Devices Working Group

Osteoarthritis (OA) is the most common type of arthritis and a major cause of chronic musculoskeletal pain and functional disability. While both pharmacologic and non-pharmacologic modalities are recommended in the management of OA, when patients with hip or knee OA do not obtain adequate pain relief and/or functional improvement, joint replacement surgery or other surgical interventions should be considered. Total joint arthroplasties are reliable and cost-effective treatments for patients with significant OA of the hip and knee. Evidence from cohort and observational studies has confirmed substantial improvements in pain relief with cumulative revision rates at 10 years following total hip (THA) and total knee arthroplasties (TKA) at 7% and 10%, respectively. Joint replacements have been used in most every synovial joint, although results for joints other than hip and knee replacement have not been as successful. The evolution of new device designs and surgical techniques highlights the need to better understand the risk to benefit ratio for different joint replacements and to identify the appropriate methodology for evaluating the efficacy and optimal outcomes of these new devices, designed to treat OA joints.     

Symptomatic efficacy of avocado-soybean unsaponifiables (ASU) in osteoarthritis (OA) patients: a meta-analysis of randomized controlled trials

OBJECTIVE: To evaluate the efficacy of preparations with avocado-soybean unsaponifiables (ASUs) in osteoarthritis (OA) patients using meta-analysis on randomized controlled trials (RCTs). METHOD: RCTs from systematic searches were included if they explicitly stated that hip and/or knee OA patients were randomized to either ASU or placebo. The co-primary outcome was reduction in pain and Lequesne index, leading to effect size (ES), calculated as the standardized mean difference. As secondary analysis, the number of responders to therapy was analyzed as odds ratios (ORs). Restricted maximum likelihood methods were applied for the meta-analyses, using mixed effects models. RESULTS: Four trials--all supported by the manufacturer--were included, with 664 OA patients with either hip (41.4%) or knee (58.6%) OA allocated to either 300 mg ASU (336) or placebo (328). Average trial duration was 6 months (range: 3-12 months). Though based on heterogeneous results, the combined pain reduction favored ASU (I(2) = 83.5%, ES = 0.39 [95% confidence intervals: 0.01-0.76], P=0.04). Applying the Lequesne index also favored ASU (I(2) = 61.0%, ES = 0.45 [0.21-0.70], P = 0.0003). Secondarily, the number of responders following ASU compared to placebo (OR = 2.19, P = 0.007) corresponded to a number needed to treat of six (4-21) patients. CONCLUSIONS: Based on the available evidence, patients may be recommended to give ASU a chance for e.g., 3 months. Meta-analysis data support better chances of success in patients with knee OA than in those with hip OA.     

Validation of the Western Ontario and Mcmaster University osteoarthritis index in Asians with osteoarthritis in Singapore

OBJECTIVE: To assess the reliability and validity of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) as an outcome measure in Asian patients with knee or hip osteoarthritis (OA) in Singapore. DESIGN: The WOMAC was administered twice 7 days apart to 66 consecutive English-speaking Chinese, Malay or Indian inpatients and outpatients with knee or hip OA seen at a tertiary referral centre through a structured interview, which also assessed demographic and other characteristics. Internal consistency was assessed using Cronbach's alpha, reliability using Spearman's correlations, intraclass correlations and repeatability coefficients, and relationships between WOMAC domains and known determinants of function using Spearman's correlations and the Mann-Whitney U-test. RESULTS: The WOMAC showed good internal consistency (alpha=0.70 to 0.93) and good reliability, with intraclass correlations of 0.83 to 0.90 and mean test-retest score differences of 0.02 to 0.13 points (possible range 4 points). Results of Likert scoring assessment supported the validity of the WOMAC when interpreted in the context of the close association between pain and physical function. Eight of nine a priori hypotheses relating WOMAC Pain and Physical Function scores to known determinants of function were present, supporting construct validity of this scale. CONCLUSION: The WOMAC is a valid and reliable outcome measure in Asian patients with OA in Singapore.     

Acceptability, reliability, validity and responsiveness of the Turkish version of WOMAC osteoarthritis index

OBJECTIVE: To evaluate the acceptability, reliability, validity and responsiveness of the Turkish version of Western Ontario and McMaster Universities (WOMAC) osteoarthritis (OA) index in physiotherapy outpatient practice in Turkey. METHOD: Data were obtained from 72 patients with OA of the knee. They were asked to answer two disease-specific questionnaires (WOMAC LK 3.1 and Lequesne-Algofunctional Index of Severity for the knee) and one generic instrument (Medical Outcomes study SF-36 Survey-SF-36). Acceptability was assessed in terms of refusal rate, rates of missing responses, and administration time. Reliability was assessed using Cronbach's alpha. Content validity was assessed by examining the floor and ceiling effects, and skew of the distributions. Convergent and divergent validity was assessed by examining the Pearson's correlation coefficients. Responsiveness was determined by examining effect size (ES), standardized response means (SRM) and P values generated using Wilcoxon's test. RESULTS: The overall response rate was 100%. Alpha values for all WOMAC subscales exceeded the value of 0.70 at both baseline and follow-up assessments. Frequency distributions of scores were symmetrical. Subscales had negligible floor and ceiling effects. Both pain and physical function subscales were fairly correlated with the subscales measuring similar constructs of SF-36, whereas they were weakly correlated with other dimensions of SF-36. A good correlation was obtained between WOMAC total and Lequesne index. The pain and physical function subscales of WOMAC index were the most responsive subscales. CONCLUSION: The Turkish WOMAC OA index is acceptable, valid, reliable and responsive for use in Turkish patients with knee OA.     

Comparative analysis of patient-centered outcome of total hip and knee arthroplasty

AIM: The aim of the present study was a comparative investigation of the functional improvement reported by patients suffering from primary osteoarthritis of the knee or hip undergoing total joint replacement and assessed at 3 months. METHOD: In a prospective, controlled clinical trial, 56 patients with primary osteoarthritis of the hip and 59 patients with primary osteoarthritis of the knee undergoing total joint replacement were assessed at two measuring times (day of admission = t1 and 3-month follow-up = t2) using the XSMFA-D (Extra Short Musculoskeletal Function Assessment Questionnaire--German version), WOMAC (Western Ontario and McMasters Universities) arthrosis index and FFb-H OA (Function Assessment Questionnaire Hannover Osteoarthritis). The statistical analysis included effect sizes as standardised response mean, t-test and covariance analysis. RESULTS: Both groups of patients demonstrated significant improvements of the musculoskeletal functions measured. The effect sizes between baseline scores and 3-month follow-up scores range from 0.4 to 2.0 and can be considered as large effects. The covariance analysis showed significant differences between patients with osteoarthritis of the hip and knee for almost every score examined. Patients with hip replacement showed large improvements. A significant influence of the presurgery baseline score on the 3-month score was found consistently. Further analysis showed that patients with medium or strong degrees of disability according to the Function index of the XSMFA-D showed the strongest effects of change at 3 months. However, their scores at t2 were less than the scores of the less disabled patients at t1. CONCLUSION: We conclude that patients with hip replacement show more improvement 3 months after the surgery than patients with knee replacement. Furthermore, it was seen that patients who were more disabled before surgery achieved more improvement than the less-disabled patients. However, they did not achieve the level of the less disabled patients. Thus, the recommendation that total joint replacement should be performed as late as possible should be reviewed.     

Should aggregate scores of the Medical Outcomes Study 36-item Short Form Health Survey be used to assess quality of life in knee and hip osteoarthritis? A national survey in primary care

OBJECTIVE: To assess the relevance of using the aggregate physical component score (PCS) and mental component score (MCS) of the Medical Outcomes Study 36-item Short Form Health Survey (SF-36) for patients with knee and hip osteoarthritis (OA). METHODS: We conducted a cross-sectional national survey in a primary care setting in France. A total of 1474 general practitioners enrolled 4183 patients with hip or knee OA. Construct validity of PCS and MCS was assessed by convergent and divergent validity and factor analysis. RESULTS: Records of 4133 patients (98.8%) were analyzed (2540 knee, 1593 hip OA). PCS mean scores were 32.0+/-8.4 and 31.8+/-8.4 and MCS scores 47.1+/-11.0 and 46.8+/-11.1, for knee and hip OA, respectively. Acceptable convergent and divergent validity was observed, and correlation between PCS and MCS mean scores was low (r=0.14). However, factor analysis performed on the eight subscale scores failed to support the use of PCS and MCS aggregate scores. It extracted two factors which were similar for both OA types and differed from the a priori stratification. Scores for two subscales usually attributed to MCS - emotional role and social functioning - were shared between factors, and scores for another subscale - general health perception - usually belonging to the PCS was in the mental component factor. CONCLUSIONS: Our results suggest that aggregate scores from the PCS and MCS of the SF-36 as they are currently defined may not be optimal for used in hip and knee OA patients to assess health-related quality of life.     

Using the Lequesne questionnaires for patients with hip and knee disabilities in daily routine to reflect the quality of outcome in rehabilitation

AIM: Studies in rehabilitation research put great value on patients' self-assessment. Patients with hip or knee diseases who need an orthopaedic rehabilitation suffer mainly pain, reduction of walking distance and other disabilities that impact on the activities of daily life. The Lequesne scores for the hip and knee are an indicator to show the degree of disabilities. The aim of the study was to prove that the Lequesne indices are reliable instruments for the individual to express the outcome of rehabilitation. We tested the Lequesne indices in daily clinical work, in the handling and in the acceptance. METHOD: Since May 1999 the rehabilitation center Bad Eilsen uses the Lequesne questionnaires as self-report questionnaire instruments for patients with hip and knee disabilities. 145 patients with hip and 122 patients with knee diseases filled in the questionnaires correctly and handed them back. RESULTS: The Lequesne indices are able to show developments in both directions; improvement as well as change for the worse. The Lequesne questionnaires are helpful to complete the common clinical parameters. CONCLUSION: Using the Lequesne questionnaires as a self-report instrument in our daily routine we are able to obtain a good reflection of individual health condition and the quality of outcome in rehabilitation.     

Health-related quality of life and costs in patients with osteoarthritis on waiting list for total knee replacement

OBJECTIVES: To determine: (1) health-related quality of life (HRQL) in patients with severe osteoarthritis (OA) on a waiting list (WL) for total knee replacement (TKR) and to compare it with general Spanish reference population values (RPVs); (2) the influence of sociodemographic and clinical variables on HRQL dimensions and (3) the use and cost of resources related to knee OA. METHODS: Cross-sectional study. HRQL was measured by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Medical Outcomes Study 36 Item Short Form Health Survey (SF-36) questionnaires. Sociodemographic and disease characteristics, body mass index, pharmacological treatment and the cost and use of economic resources related to knee OA during the 6-months previous to baseline were recorded. Relationships were analyzed using linear regression models. RESULTS: One hundred consecutive outpatients (71 female, mean age 71+/-6.89 years, mean disease duration 11.84+/-10.52 years) were included. Patients showed worse HRQL measured by SF-36 than the reference population, mainly in physical function, physical role and bodily pain dimensions (P<0.05). A low number of visits to physicians were recorded (mean 0.62+/-1.04). Total mean direct medical costs were 200.24 euro (95%CI 167.08-233.40) and total mean direct non-medical costs were 1234.87 euro (95%CI 812.74-1657.00). CONCLUSIONS: The HRQL of patients on a WL is worse than that of the reference population. The main costs of these patients were on non-medical resources, mainly due to functional limitations and loss of autonomy. The results suggest little compliance with knee OA management guidelines.     

Effectiveness of hip or knee replacement surgery in terms of quality-adjusted life years and costs

Background?Concurrent head-to-head comparisons of healthcare interventions regarding cost-utility are rare. The concept of favorable cost-effectiveness of total hip or knee arthroplasty is thus inadequately verified.

Patients and methods?In a trial involving several thousand patients from 10 medical specialties, 223 patients who were enrolled for hip or knee replacement surgery were asked to fill in the 15D health-related quality of life (HRQoL) survey before and after operation.

Results?Mean (SD) HRQoL score (on a 0–1 scale) increased in primary hip replacement patients (n = 96) from 0.81 (0.084) preoperatively to 0.86 (0.12) at 12 months (p < 0.001). In revision hip replacement (n = 24) the corresponding scores were 0.81 (0.086) and 0.82 (0.097) respectively (p = 0.4), and in knee replacement (n = 103) the scores were 0.81 (0.093) and 0.84 (0.11) respectively (p < 0.001). Of 15 health dimensions, there were statistically significant improvements in moving, usual activities, discomfort and symptoms, distress, and vitality in both primary replacement groups. Mean cost per quality-adjusted life year (QALY) gained during a 1-year period was € 6,710 for primary hip replacement, € 52,274 for revision hip replacement, and € 13,995 for primary knee replacement.

Interpretation?Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is twice that gained from hip replacement.