Protocol for follow up of hip arthroplasty in the long term: effect on revision (WHISTLER study)

Total hip arthroplasty (THA) is highly successful for reducing pain and improving function, providing health‐related quality of life benefit. Demand for THA is increasing with associated increase in revision hip surgery. Hip arthroplasty surveillance (long‐term follow up) can identify asymptomatically failing THA to prepare for revision surgery, reducing potential for complications or complexity of surgery. However, it is unknown whether the surveillance of THA can be shown to improve the patient outcomes or reduce costs around revision surgery. With the current need to reduce unnecessary health consultations and to show the economic advantages of any service, the purpose of this study is to consider the relative effectiveness of hip arthroplasty surveillance on revision hip arthroplasty. This is a single‐centre, observational study in which consecutive patients undergoing aseptic revision of THA over 12 months in a large orthopaedic unit will be considered for participation. Primary outcome measures will be change in each of three valid patient‐reported scores from pre‐operatively to 12 months post‐surgery. Secondary outcomes will be the costs of treatment calculated using data obtained from the participants' hospital records and a self‐report questionnaire. An exploratory approach will be used to investigate the effect of surveillance on the outcomes of interest. A linear mixed method model will be used to study the change in scores between baseline and 12 months. The economic evaluation will be a cost–utility analysis, which compares the value of alternative interventions by attaching costs to the quality‐adjusted life years produced by each intervention.     

The importance of patient expectations in predicting functional outcomes after total joint arthroplasty

OBJECTIVE: To evaluate the relationship between patient expectations of total joint arthroplasty (TJA) and health related quality of life plus satisfaction 6 months after surgery. Methods. This prospective cohort study included patients undergoing primary total hip (THA) and knee arthroplasty (TKA). Patients were evaluated with self-report questionnaires prior to surgery and 6 months post-surgery. Medical Outcomes Study Short Form 36 (SF-36), the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), and a satisfaction scale were used to evaluate outcomes at final followup. Multivariate regression models were used to evaluate the impact of expectations on outcomes. RESULTS: There were 102 patients with THA and 89 with TKA. Mean age was 66 years. All patients achieved significant improvements in their WOMAC and SF-36 scores following surgery. Patient expectations regarding surgery were not associated with their age, gender, index joint of surgery, marital status, or race. Expectations were not correlated with pre-operative functional health status. Expectation of complete pain relief after surgery was an independent predictor of better physical function and improvement in level of pain at 6 months post-surgery. Expectation of low risk of complications from TJA was an independent predictor of greater satisfaction. CONCLUSIONS: Patient expectations were important independent predictors of improved functional outcomes and satisfaction following TJA. Greater understanding of the relationship between expectations and outcomes may improve the process of care and outcomes of TJA.     

Differences in outcomes of obese women and men undergoing primary total hip arthroplasty

OBJECTIVE: To evaluate the effect of obesity on the incidence of main complications (infection, dislocation, and revision), functional outcome, and patient satisfaction 5 years after primary total hip arthroplasty (THA), and to determine whether results differ between obese women and men. METHODS: We conducted a hospital-based prospective cohort study including patients who underwent primary THA (2,495 hips) between 1996 and 2005. We used rates and rate ratios to compare the incidence of main complications in obese and nonobese patients, and we stratified the data for sex. Functional outcome was measured using the Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index. RESULTS: The adjusted incidence rate ratio for infection (obese versus nonobese) was 4.4 (95% confidence interval [95% CI] 1.8, 10.8). Obesity substantially increased the infection rate in women (incidence rate ratio comparing obese with nonobese women 16.1; 95% CI 3.4, 75.7), whereas obesity appeared to have no effect in men (incidence rate ratio 1.0; 95% CI 0.2, 5.3). The adjusted incidence rate ratio for dislocation (obese versus nonobese) was 2.4 (95% CI 1.4, 4.2), with a higher rate increase in obese women. A total of 817 patients had a 5-year clinical followup visit. Functional outcome and satisfaction were slightly lower in obese women partly due to higher complication rates. No difference was seen in men. CONCLUSION: Primary THA is a successful intervention in obese patients, but physician and patient must be aware of increased complications, particularly in women.     

Health-related quality of life in patients with systemic lupus erythematosus after medium to long-term follow-up of hip arthroplasty

Health-related quality of life (HRQOL) of systemic lupus erythematosus (SLE) patients with hip arthroplasty after medium to long-term follow-up has not been reported. We conducted a retrospective study for SLE patients with osteonecrosis of the femoral head (ONF). Forty-seven consecutive arthroplasties were performed in 36 patients. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Medical Outcome Survey Short Form 36 (SF-36) and Harris hip score were evaluated. Two patients died before the four-year follow-up and two patients were lost to follow-up. The remaining 43 hips in 32 patients with an average age at surgery of 35 years and an average follow-up of 12.0 years (range 4.0-25.0) were assessed. Bipolar hemiarthroplasty was performed for 18 hips in 12 patients, and total hip arthroplasty (THA) was performed for 25 hips in 20 patients. The mean WOMAC scores for pain and function at the recent followup were 90.8 +/- 8.5points and 79.0 +/- 18.3 points. Patients with THA had significantly high scores in SF-36 physical functioning (P < 0.05) and bodily pain (P < 0.03) compared to those with bipolar hemiarthroplasty. Although improvement could not reach the level of general population, the hip arthroplasty contributed to support HRQOL of SLE patients.     

Transfusion practice in hip arthroplasty--a nationwide study

Background and Objectives The optimal transfusion strategy in hip arthroplasty remains controversial despite existing guidelines. The aim of this study was to evaluate the transfusion practice in patients undergoing primary total hip arthroplasty (THA) or revision total hip arthroplasty (RTHA) in Denmark. Materials and Methods We performed a retrospective cohort study of all patients undergoing THA or RTHA in Denmark in 2008. Primary outcomes were intercentre variation in red blood cell (RBC) transfusion rates and the timing of transfusion related to surgery. Results Six thousand nine hundred thirty‐two THA patients and 1132 RTHA patients were included for analysis of which 1674 (24%) THA and 689 (61%) RTHA patients received RBC transfusion. Of these, 47% of THA and 73% of RTHA patients received transfusion on the day of surgery. Transfusion rates between centres varied from 7 to 71% and between 26 and 85% in THA and RTHA patients, respectively. Patients receiving RBC transfusion had longer length of stay and for THA patients an increased odds‐ratio (5·5) of death within 90 days. Conclusion Despite established guidelines, RBC transfusion practice in hip arthroplasty remains highly variable between Danish hospitals. The effect of RBC transfusion on outcome after hip arthroplasty should be established in prospective randomized controlled trials.     

Prospective randomised evaluation of a collagen/thrombin and autologous platelet haemostatic agent during cementless total hip arthroplasty

BackgroundTotal hip arthroplasty (THA) can be associated with substantial peri-operative blood loss which can negatively influence a patient’s clinical outcome. Few haemostatic agents have been tested in THA. The aim of this study was to determine whether the use of a collagen/thrombin/ autologous platelet haemostatic agent would result in a significant decrease of blood transfusions for patients undergoing primary THA.ResultsTransfusions were required by 5/60 (8.3%) patients in the treatment group and 7/49 (14.3%) in the control group (p=0.33). The mean number of units transfused was not significantly different between the treatment group (2.2±1.3) and the control group (1.6±0.5) (p=0.36). Haemoglobin values on post-operative days 1, 2, and 3 were significantly higher in the treatment group (p=0.002, 0.04, and 0.02, respectively). Hip Disability and Osteoarthritis Outcome Score and Short Form-12 scores were not different between the two groups.DiscussionIn relatively healthy patients undergoing primary cementless THA there was no significant difference in number of transfusions or number of units transfused. It is unlikely that we will routinely use the investigated haemostatic agent to reduce blood loss in a healthy patient undergoing THA. The product may have some benefit in patients who refuse blood transfusions, have minimal ability to increase blood volume, are undergoing total joint revision, or have markedly low pre-operative haemoglobin levels, but this needs to be demonstrated.     

Outcomes of obese and nonobese patients undergoing revision total hip arthroplasty

OBJECTIVE: To evaluate the effect of obesity on the incidence of adverse events (surgical site infection, dislocation, re-revision, or > or =1 adverse event), functional outcome, residual pain, and patient satisfaction after revision total hip arthroplasty (THA). METHODS: We conducted a university hospital-based prospective cohort study including 52 obese and 152 nonobese patients with revision THA performed between 1996 and 2006. We used incidence rates, rate ratios, and hazard ratios (HRs) to compare the incidence of events in obese and nonobese patients and in 4 body mass index (BMI) categories (<25, 25-29.9, 30-34.9, > or =35). Functional outcome and pain were measured 5 years postoperative using the Harris Hip Score. RESULTS: The incidence rate for > or =1 complication increased with rising BMI (1.8, 3.4, 10.3, and 17.9 cases/100 person-years). The increase was small between normal and overweight patients (adjusted HR 1.5, 95% confidence interval [95% CI] 0.5, 4.7), significantly greater with BMI 30-34.9 (adjusted HR 4.5, 95% CI 1.4, 14.0), and most evident with BMI > or =35 (adjusted HR 10.9, 95% CI 2.9, 41.1). The adjusted HR for surgical site infection (obese versus nonobese) was 4.1 (95% CI 1.1, 15.0) and for dislocation 3.5 (95% CI 1.3, 9.3). Eighty patients had a followup visit at 5 years. Obese patients had moderately lower functional results and higher levels of residual pain, but patient satisfaction was almost similar. CONCLUSION: Revision THA is technically challenging, particularly in obese patients, probably due to more difficult anatomic conditions. We found an increased risk of adverse events, notably surgical site infection and dislocation in these patients.     

Satisfactory cross cultural equivalence of the Dutch WOMAC in patients with hip osteoarthritis waiting for arthroplasty

BACKGROUND: Cross cultural validity is of vital importance for international comparisons. OBJECTIVE: To investigate the validity of international Dutch-English comparisons when using the Dutch translation of the Western Ontario and McMaster Universities osteoarthritis index (WOMAC). PATIENTS AND METHODS: The dimensionality, reliability, construct validity, and cross cultural equivalence of the Dutch WOMAC in Dutch and Canadian patients waiting for primary total hip arthroplasty was investigated. Unidimensionality and cross cultural equivalence was quantified by principal component and Rasch analysis. Intratest reliability was quantified with Cronbach's alpha, and test-retest reliability with the intraclass correlation coefficient. Construct validity was quantified by correlating sum scores of the Dutch WOMAC, Arthritis Impact Measurement Scales (Dutch AIMS2), Health Assessment Questionnaire (Dutch HAQ), and Harris Hip Score (Dutch HHS). RESULTS: The WOMAC was completed by 180 Dutch and 244 English speaking Canadian patients. Unidimensionality of the Dutch WOMAC was confirmed by principal component and Rasch analysis (good fit for 20/22 items). The intratest reliability of the Dutch WOMAC for pain and physical functioning was 0.88 and 0.96, whereas the test-retest reliability was 0.77 and 0.92, respectively. Dutch WOMAC pain sum score correlated 0.69 with Dutch HAQ pain, and 0.39 with Dutch HHS pain. Dutch WOMAC physical functioning sum score correlated 0.46 with Dutch AIMS2 mobility, 0.62 with Dutch AIMS2 walking and bending, 0.67 with Dutch HAQ disability, and 0.49 with Dutch HHS function. Differential item functioning (DIF) was shown for 6/22 Dutch items. CONCLUSIONS: The Dutch WOMAC permits valid international Dutch-English comparisons after correction for DIF.     

Haemophilic; Arthropathy: Assessment of Quality of Life After Total Knee Arthroplasty

The goal of this study was to examine how the known effects of total knee arthroplasty (TKA) on clinical outcome parameters translate into improved quality of life, as measured with validated condition-specific and generic questionnaires (Knee Society Score, WOMAC, SF-12, transition questions), addressing physical, mental and social health. Eleven patients (13 knees) undergoing TKA from 1986 to 1994, with the diagnosis of severe haemophilic arthropathy of the knee, were followed-up over a 4-year period on average. TKA was found to reduce the burden of disease to levels similar to patients with osteoarthritis undergoing hip arthroplasty. Clinical and functional improvement after TKA translated into a substantial and significant increase in quality of life and patient satisfaction, found in objective as well as in patient-perceived measures. However, the physical functional ability did not reach the same level as in the corresponding population not affected by haemophilia, due to residual symptoms and impairment of other joints. Received: 30 September 1998 / Accepted: 17 March 1999     

Comparison of the responsiveness of the Harris Hip Score with generic measures for hip function in osteoarthritis of the hip

OBJECTIVE: To compare responsiveness of the Harris Hip Score with generic measures (that is, the Short Form-36 (SF-36), and a test of walking speed and pain during walking) in patients with osteoarthritis (OA) of the hip. METHOD: The first 75 cases within the population of a randomised clinical trial on manual therapy and exercise therapy were selected for secondary analysis. Experienced (self reported) recovery by the patients after treatment (five weeks) was used as an external criterion for clinically relevant improvement. Responsiveness was evaluated by comparing responsiveness ratios and receiver operating characteristic curves. RESULTS: The responsiveness ratio for the Harris Hip Score was high (1.70) compared with walking speed (0.45), pain during walking (0.66), and the subscales of the SF-36-"bodily pain" (0.42) and "physical functioning" (0.36). The area under the curve also was highest for the Harris Hip Score (0.92) compared with walking speed (0.71), pain during walking (0.73), and the SF-36 subscales-bodily pain and physical functioning (both 0.66). CONCLUSION: The Harris Hip Score is more responsive than the test of walking speed, pain, and subscales for function of the SF-36 in patients with OA of the hip. The Harris Hip Score seems to be a suitable instrument to evaluate change in hip function in patients with OA of the hip.     

Cementless total hip arthroplasty for haemophilic arthropathy: follow‐up result of more than 10 years

The improvement of prophylaxis and adequate replacement of clotting factors, the quality of life and natural history of haemophilia have been significantly improved. However, significant functional impairment is inevitable. This study was performed to evaluate over 10 years clinical and radiographic outcomes of cementless total hip arthroplasty (THA) for treatment of haemophilic hip arthropathy. Between 1995 and 2003, 27cases of cementless total hip arthroplasties were performed in 23 haemophilic patients. A total of 21 cases from 17 patients were available for follow‐up analysis over 10 years. Modified Harris hip score, the range of motion of the hip joint, perioperative coagulation factor requirements and complications associated with bleeding were evaluated as part of the clinical assessment. For the radiographic assessment, fixation of component, osteolysis, loosening and other complications were evaluated. Clinically, the mean Harris hip score improved from 57 points before the operation to 94 points at the last follow‐up. The mean flexion contracture was 10° preoperatively and 0.9° at the final follow‐up. The further flexion improved from 68.4° to 90.5° after surgery. The mean monthly requirement of factor VIII reduced from 3150 units before surgery to 1800 units at the time of the last follow‐up. There were three cases of rebleeding. In one case, a progressive haemophilic pseudotumour was found. Reoperation for any reason including revision was performed in three cases. We believe that cementless THA in patient with haemophilic hip arthropathy can bring reliable pain relief and functional improvement for longer than 10 years.     

快速康复外科理念在老年患者全髋关节置换术中的应用效果探讨

目的探讨快速康复外科(ERAS)理念在老年患者全髋关节置换术中的应用效果。方法回顾性分析该院2017-01~2019-01行全髋关节置换术的80例老年患者资料。其中接受ERAS理念指导治疗的40例患者为ERAS组,接受传统治疗方案的40例患者为对照组。比较两组术后髋关节功能Harris评分,术后疼痛视觉模拟评分(VAS)、术后并发症发生率、术后住院时间、住院费用及患者的满意度等情况。结果ERAS组术中平均出血量为(203.88±54.92)ml,对照组为(386.75±131.82)ml,差异有统计学意义(P<0.05)。ERAS组术后并发症发生率为5.00%(2/40),对照组为35.00%(14/40),差异有统计学意义(P<0.05)。ERAS组术后疼痛VAS评分下降趋势较对照组显著(P<0.05),而ERAS组术后髋关节Harris评分上升趋势较对照组显著(P<0.05)。ERAS组术后住院时间短于对照组,住院费用低于对照组,满意率高于对照组,差异有统计学意义(P<0.05)。结论在ERAS理念指导下老年患者行全髋关节置换术后髋关节功能恢复更快、更好,院外指导的完善可降低患者再入院率。     

Elective primary total hip arthroplasty in octogenarians

BACKGROUND: Total hip arthroplasty (THA) has resulted in decreased pain and increased function in people with end-stage hip arthritis for several decades. In elderly people, THA has been used most often following femoral neck fracture. However, with life spans increasing and people remaining healthy and active well into their eighties, arthroplasty surgeons are now performing primary THA as an elective procedure in octogenarians. The aim of this study was to demonstrate the efficacy of elective total hip arthroplasty in patients aged 80 years or older with end-stage hip arthritis. METHODS: Forty patients (46 THAs), aged 80 or older at the time of surgery, were identified for this study. Clinical assessment included amount of hip pain, limp, and use of assistive devices for ambulation at most recent follow-up. Radiographic assessment included implant stability, heterotopic bone formation, and osteolysis. Medical and hip-related complications, reoperations, and revisions were recorded from medical records. RESULTS: Eleven patients (27.5%) suffered a medical complication and six patients (15%) had a hip-related complication, all of which were treated and were not life threatening. Clinically, 80% were pain free and 70% walked without assistance at an average 4-year follow-up. Radiographically, all implants were stable without osteolysis. No components had been revised; however, four patients had undergone a reoperation, three for recurrent dislocation. CONCLUSIONS: Elective total hip arthroplasty is a safe and effective treatment for end-stage osteoarthritis of the hip in the elderly patient. However, the procedure is not without risk. Complications, often related to preexisting comorbidities, do occur, but mortality rates are low.     

Tenascin-C levels in pseudosynovial fluid of loose hip prostheses

OBJECTIVE: Aseptic loosening is one of the most important problems that can occur after total hip arthroplasty (THA). In this study, we analysed levels of large tenascin-C (TN-C) variants and compared them in pseudosynovial fluid from patients with aseptic loosening after THA with those in synovial fluid from patients undergoing primary THA (control). METHODS: Pseudosynovial fluid samples (n = 24) were obtained by aspiration at the time of revision THA performed due to aseptic loosening. Synovial fluid samples (n = 12) were obtained by aspiration at the time of primary THA. Expression of TN-C splice variants was examined using immunoblotting. TN-C levels were measured using an enzyme-linked immunosorbent assay (ELISA) system that we developed previously. RESULTS: Western blotting showed the presence of large TN-C variants in pseudosynovial fluid of artificial joints with loosening. TN-C levels were approximately three times higher in pseudosynovial fluid of loose artificial joints (median 151.9 ng/mL) than in synovial fluid controls (median 50.1 ng/mL) (p = 0.035). CONCLUSION: Levels of TN-C including large variant subunits are elevated in pseudosynovial fluid of loose artificial joints, indicating that TN-C is a useful novel biochemical marker of loose hip prostheses.     

Outcome of total hip replacement for avascular necrosis in systemic lupus erythematosus

OBJECTIVE: To describe the short and medium term results of total hip arthroplasty (THA) for avascular necrosis in patients with systemic lupus erythematosus (SLE). METHODS: Nineteen patients with SLE and avascular necrosis of the femoral head (AVNFH), who underwent 26 THA were retrospectively reviewed with a minimum followup of 2 years. To determine whether these patients had results similar to those of patients with other conditions, we formed a control group of 19 patients who had 29 THA. They were matched for age, sex, and followup to the patients with SLE. Controls had THA for juvenile rheumatoid arthritis (n = 7), osteoarthritis (5), adult onset rheumatoid arthritis (8), developmental dysplasia of the hip (4), and other diagnoses (5). Outcome measures included a 10 point visual analog scale (VAS) for pain, the Harris hip score, and the SF-36 self-administered health outcome questionnaire. We used the methods of Delee, Harris, and Engh for radiological assessment. RESULTS: Mean age at surgery was 46 years (range 21-71 years) and average followup was 4 years, 7 months (range 1 yr 9 mo to 9 yrs 6 mo), similar in both groups. Technical problems, mostly consisting of small, nonpropagating cracks of the calcar in uncemented stems, were encountered in 4 SLE hips and 1 control hip. Six complications were noted in the SLE group, including 2 early, nonrecurrent dislocations, 1 patient with thigh pain for 1 year, 1 pericarditis, 1 sick-sinus syndrome, and 1 urinary tract infection. There was one case of urinary tract infection in the control group. One SLE patient developed a low grade prosthetic infection and underwent successful revision 2 years after primary surgery. Clinical outcome measures had similar scores in the 2 groups: average VAS pain score = 2.00 in SLE hips (maximum 10) and 1.97 in control hips; mean Harris hip score = 86.7 in SLE patients (maximum 100) and 81.9 in controls; average SF-36 score = 63.4 in SLE patients (maximum 100) and 60.5 in controls. There was no radiological evidence of implant loosening in controls; there was 1 asymptomatic cup migration in the SLE group. CONCLUSION: In the short and medium term, patients with SLE and AVN had good results after THA. Results were similar in patients who had hip replacement for other diagnoses. Less favorable clinical outcomes of hip replacement have been reported in young patients who have AVN of other etiology (e.g., alcoholic, post-traumatic), but this was not the case in our young patients who had AVN and SLE. Thus, AVNFH and SLE should not constitute a contraindication to hip replacement.     

Clinical outcomes and patient satisfaction following total joint replacement in haemophilia – 23‐year experience in knees,hips and elbows

Summary. Joint replacement surgery is an available option for end‐stage haemophilic arthropathy. However, reports with long‐term follow‐up are limited. Moreover, patient satisfaction in this setting has never been measured. We share our institution’s experience with joint arthroplasty in haemophilic arthropathy and report on clinical outcomes and patient satisfaction. Between 1985 and 2007, 65 consecutive joints in 45 patients (mean age: 48.6; range: 22–83) underwent joint replacement surgery. Of these, 40 total knee replacements in 31 patients, 18 total hip replacements in 16 patients and 6 total elbow replacements in 3 patients were included. Average follow‐up was 10.7 years (2.4–24.3). Charts were reviewed retrospectively and patients were asked to return for clinical assessment and completion of questionnaires. According to the Knee Society clinical score, postoperative results were good to excellent in 83% of knees. According to the Harris Hip Score, results were good to excellent in 31% of hips. According to the Mayo Elbow Performance Score, results were good to excellent in 83% of elbows. Complication rates are higher than in the non‐haemophilic population, while prosthesis survival rates are lower. Patient satisfaction with pain relief is higher than satisfaction with functional improvement. For 88% of joints, patients are willing to have the same operation again. This study confirms previous knowledge on the role of total joint arthroplasty in haemophilic arthropathy. Despite high complication rates and modest functional outcomes, the operations are valuable for achieving pain relief. In general, patients find that risks are outweighed by the benefits.     

Total hip or knee replacement for osteoarthritis: Mid‐ and long‐term quality of life

Objective

To compare quality of life (QOL) scores 3 and 10 years after total hip arthroplasty (THA) or total knee arthroplasty (TKA) for osteoarthritis with QOL scores in a general population, and to determine factors associated with QOL after surgery.

Methods

Data were obtained from 2 multicenter cohorts of patients with THA or TKA: 232 patients were recruited during 2003 (3‐year cohort) and 221 patients were recruited during 1994 (10‐year cohort). Preoperative data (QOL, radiograph results) and followup data (demographics, comorbidities, pain locations, environmental factors, and QOL) were collected. QOL data for the general population were obtained from a 2003 population‐based survey.

Results

A total of 195 and 89 patients for the 3‐ and 10‐year cohorts, respectively, were followed up; the mean age at followup was 73 years. For both of the cohorts, physical functioning and role‐physical or role‐emotional QOL scores were lower than those for a general population with comparable age. Scores for pain, mental health, and social dimensions were lower than those for the reference population for only the 10‐year cohort. For both cohorts, increased number of comorbidities, painful locations other than THA or TKA location, and unfavorable environmental factors were associated with impaired QOL. Low preoperative QOL scores were predictive of impaired QOL at followup for only the 3‐year cohort.

Conclusion

THA or TKA can improve QOL, but the benefits may be time limited. Addressing environmental factors and treating comorbidities and pain in locations other than the arthroplasty location could have mid‐ and long‐term effects on the QOL of patients with THA or TKA.     

Association of hospital and surgeon volume of total hip replacement with functional status and satisfaction three years following surgery

OBJECTIVE: To evaluate whether hospital volume and surgeon volume of total hip replacements (THRs) are associated with patient-reported functional status and satisfaction with surgery 3 years postoperatively. METHODS: We performed a population-based cohort study of a stratified random sample of Medicare beneficiaries who underwent elective primary or revision THR in Ohio, Pennsylvania, or Colorado in 1995. The primary outcomes were the self-reported Harris hip score and a validated scale measuring satisfaction with the results of surgery. Both outcomes were assessed 3 years postoperatively. Hospital volume was defined as the aggregate number of elective primary and revision THRs performed on Medicare beneficiaries in the hospital in 1995. High-volume hospitals were defined as those in which >100 such procedures are performed annually, and low-volume centers were defined as those in which 12 procedures per year. CONCLUSION: Hospital volume and surgeon volume have little effect on 3-year functional outcome following THR, after adjusting for patient sociodemographic and select clinical characteristics. However, satisfaction with primary THR is greater among patients who underwent surgery in high-volume centers, and satisfaction with revisions is greater among patients whose operations were performed by higher-volume surgeons. Referring clinicians should incorporate these findings into their discussion of referral choices with patients considering THR. Conclusions regarding the effect of volume on longevity of the implants must await longer-term followup studies. Finally, further research is warranted to better understand the association between hospital and surgeon procedure volume and patient satisfaction with surgery.     

80岁以上股骨颈骨折髋关节置换术围手术期安全性和疗效观察

目的评价高龄（≥80岁）股骨颈骨折患者接受髋关节置换术围手术期的安全性和有效性。方法1997年11月至2007年11月,应用全髋关节置换术（11例）或半髋关节置换术（67例）治疗78例≥80岁股骨颈骨折患者,对其术前危险因素、围手术期并发症和术后2周临床效果等临床资料进行回顾性分析。结果本组患者平均年龄（83．7±3．59）岁,其中GardenⅢ型骨折42例、GardenⅣ型骨折36例。术前应用美国麻醉医师协会分级标准评价,80．8％为高危患者;采用统计死亡率和并发症发生率的生理学和手术严重程度评分系统预测主要并发症发生32例,术后实际发生24例,观察值与预测值之间无统计学差异（p=0．205）,全髋关节置换组与半髋关节置换组均无统计学差异;术后2周疼痛缓解满意率为96．2％,76．9％的患者独立或辅助下自行室内活动。结论在高龄股骨颈骨折患者,围手术期针对生理状况及手术操作的可改变指标进行有效的干预措施,采取髋关节置换术,可获得安全、有效的临床结果。     

Ethnic differences in the relationship between obesity and joint pain and function in a joint arthroplasty population

OBJECTIVE: We investigated the influence of obesity on joint pain and function in Asians as compared to Caucasians with degenerative hip and knee arthritis. METHODS: We surveyed 1983 patients (1876 Caucasians and 107 Asians) undergoing primary hip or knee replacement surgery. Relevant covariates including demographic data, body mass index (BMI), sex, comorbidities, education, and ethnicity were recorded. Pain and joint functional status were assessed at baseline and at 1-year followup with the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain and function scores. RESULTS: Asian patients presented for surgery at a significantly younger age and lower mean BMI, and reported greater pain and dysfunction than Caucasian patients. Multivariate linear regression modeling showed that for every level of BMI, Asian patients reported greater levels of joint pain and dysfunction. At a BMI of 30 kg/m2, this translated to a 16.6% higher WOMAC score (p < 0.001). CONCLUSION: Among patients with endstage osteoarthritis, at every level of BMI, joint pain and dysfunction are greater in Asians than in Caucasians. This difference is likely mediated through both mechanical and inflammatory effects.