Long-term follow-up of cemented total hip replacement for osteoarthritis

Two hundred twelve total hip replacements performed as a primary procedure have been followed for more than 10 years. One hundred thirty-six hips had adequate radiographic follow-up. Mechanical loosening of the acetabular and femoral component continue to be the major postoperative complications and in this series was 24 per cent. The incidence of femoral loosening has declined, however there is a continuing increase in acetabular revisions as well as an increase in bone-cement radiolucencies in relation to the acetabular component. Analysis of mechanical and technical parameters identifies those arthroplasties at increased risk of mechanical loosening, it is necessary to have two or more parameters of poor technique present before there is an increased incidence of loosening of the femoral component. Changes in stem design and cementing techniques in the early 1980s have addressed these parameters and in the mid-term have significantly decreased the incidence of mechanical failure. However we await the 10- to 15-year follow-up of these technical improvements to assess whether they will improve longevity of a biologic procedure. It is difficult to predict failure of cemented acetabular components and with longer follow-up there appears to be a steady increase in the incidence of acetabular loosening compared with a decrease in the occurrence of femoral loosening.     

OMERACT/OARSI initiative to define states of severity and indication for joint replacement in hip and knee osteoarthritis

OBJECTIVE: Time to theoretical indication of joint replacement surgery has been proposed as a primary outcome for potential structure-modifying interventions for osteoarthritis (OA). The objectives of this OMERACT/OARSI Working Group were to identify pain, physical function, and structure states that represent the progression from early to late disease for individuals with OA of the hip and knee, and to create a composite measure of these 3 domains to define states of OA severity and a surrogate measure of "need for joint replacement surgery." METHODS: For pain, focus groups and one-on-one interviews were used. For function, Rasch analysis was performed on existing indices the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS) and the Knee injury and Osteoarthritis Outcome Score (KOOS), each of which subsumes the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) questions. For structure, a comparison of existing indices (Kellgren-Lawrence, OARSI stages, and joint space width) was performed for the hip and the knee. RESULTS: For pain, key features of pain that are most distressing to people with OA from early to late disease were identified. For function, the reduction of the number of items based on the existing indices continues. For structure, the analysis is also ongoing. CONCLUSION: Preliminary results were presented at OMERACT 8; the final objective will be to combine the 3 domains (pain, function, and structure) and to create a composite index that could define states of severity and "need for total joint replacement," which could be used to evaluate treatment response to disease-modifying drugs in OA clinical trials.     

Piroxicam and naproxen in patients with osteoarthritis of the hip waiting for total hip replacement

Summary Two-hundred and fifty-two patients waiting for a total hip replacement for degenerative hip disease were randomized to two groups of nonsteroidal anti-inflammatory medication using piroxicam, 20 mg per day, and naproxen, 750 mg per day, after exclusion for severe dyspepsia or peptic ulcer, asthma, idiosyncracy, dissent, age below 50 years, Harris hip score above 50, or significant contralateral disease. A significant improvement in the pain and daily activity parameters was obtained in both groups. The effect was better in the piroxicam group one month after the commencement of the treatment, and equal in the groups later during the observation period of 2–5 months. We conclude that continuous medication is beneficial in patients with severe osteoarthritis scheduled for operation. However, the side effects of the medication have to be carefully considered and followed up.     

Determinants of willingness to pay for hip and knee joint replacement surgery for osteoarthritis

OBJECTIVES: To determine whether patients with osteoarthritis (OA) would be willing to pay for joint replacement and whether patient characteristics or health outcomes, including pain, physical function and health-related quality of life, were related to willingness to pay (WTP). METHODS: Patients who had undergone primary total hip replacement (THR) or total knee replacement (TKR) for OA completed a disease-specific questionnaire (Western Ontario and McMaster: WOMAC index), a generic measure of health status (Medical Outcome Study Short Form-36: SF-36) and an Evaluation Questionnaire to measure WTP and satisfaction with the replacement. RESULTS: Responses were obtained from 109 (77%) THR patients and 129 (72%) TKR patients. Mean age of respondents was 67 yr for THR (47% female) and 73 yr for TKR (60% female). Overall, 85% of patients responded to the WTP question. Of the THR patients, 71% were willing to pay something, 11% were not willing to pay anything and 18% did not answer the question. For TKR patients these figures were 70, 16 and 14% respectively. However, of those who responded to the WTP question, only 25% of the THR patients and 18% of the TKR patients indicated they would be willing to pay the actual current average cost of the operation in Australia (>/= A$15 000). A lower postoperative pain score (as measured by the WOMAC index) was a significant predictor of WTP for both THR and TKR patients. Income also significantly predicted WTP in THR patients but not in TKR patients. The other significant predictors for TKR patients were older age, having private health insurance and willingness to recommend joint replacement to others. CONCLUSIONS: Willingness to pay was a measure that was understandable and acceptable to patients, most of whom were willing to pay something. There was a high correlation between WTP, good health outcomes and patient satisfaction, pain relief being the dominant determinant.     

Total joint replacement in osteoarthritis

Surgical approaches have been developed for most of the sites of osteoarthritis, including the carpal metacarpal and first metatarsal phalangeal joint, the hips, knees, shoulders, ankles and elbows. This chapter will address surgical options for advanced osteoarthritis of the hips and knees and will focus primarily on total hip and knee replacement.     

Effects of total hip replacement on quality of life in patients with osteoarthritis and in patients with rheumatoid arthritis

Summary The effects of total hip replacement (THR) on quality of life were investigated in 62 patients with osteoarthrosis (OA) and 35 patients with rheumatoid arthritis (RA). Patients eligible for a first hip joint replacement were enrolled consecutively and examined at home before the operation and 3, 6, and 12 months after surgery.The IRGL (Influence of Rheumatic Diseases on Health and Lifestyle), a Dutch version of the AIMS (Arthritis Impact Measurement Scales), was used to operationalize quality of life in a questionnaire.Pain and mobility scores showed significant improvement among both OA and RA patients. The general mood of the OA patients also improved significantly, but the RA group showed only a favourable tendency in this respect. The interference of OA in several areas of life almost disappeared, whereas the impact of RA was only slightly reduced. There was no discernible effect on the social dimension in either group. A single THR apparently solves the main problem of most OA patients, but only one of a number of joint problems for most RA patients. The IRGL is complex and time-consuming and contains irrelevant scales. Its multidimensional evaluation of the quality of life is more informative than a purely somatic evaluation.     

全膝关节表面置换治疗老年严重膝骨关节炎的临床体会

目的作者报道了用全膝关节表面置换治疗老年性严重膝骨关节炎的临床体会。方法我院自１９９６年３月～１９９８年４月对１０例６０岁以上的严重膝骨关节炎的患者进行了全膝关节表面置换,均采用进口非限制性膝关节假体。结果经过６～３０个月随访,采用ＨＳＳ膝关节评分系统,术后所有患者在关节疼痛、功能及活动度均有明显改善,没有１例发生感染及深静脉栓塞。结论全膝关节表面置换对老年性严重膝骨关节炎治疗效果满意。     

Living with severe osteoarthritis while awaiting hip and knee joint replacement surgery

Objectives: To explore the lived experiences of patients with severe osteoarthritis (OA) of the hip or knee joint while awaiting joint replacement surgery. Methods: An exploratory qualitative approach using phenomenology was adopted for the purpose of the study. Unstructured interviews were carried out on a sample of six patients who had been referred to the National Health Service waiting list for a primary hip or knee replacement. The participants were invited to share their experiences and concerns relating to how they were coping with end‐stage OA of their hip or knee joint. Interviews were digitally recorded and transcribed verbatim. Narrative data were analysed using Giorgi's (1985) procedural steps to reveal themes which recurred in the participants' stories. Results: Six themes emerged from the data, central to the experience of living with severe OA. They were: coping and living with pain; not being able to walk; coping with everyday activities; body image; advice and support available; and the effect of their disease upon family, friends and helpers. There were also a number of sub‐themes associated with each major theme. Conclusions: This study suggests that there is an absence of generic support, guidance and information relating to the management of symptoms of OA for individuals awaiting hip and knee replacement surgery. Patients awaiting hip and knee joint replacement surgery often have difficulty in managing their symptoms. Support in general appears to be dependent on the availability of resources in the primary care setting. Potential patients who are fortunate to know or meet someone who has undergone a similar procedure learn from the experience of exchanging information between themselves, along with coping strategies in the management of their symptoms. Copyright © 2008 John Wiley & Sons, Ltd.     

全髋关节置换术治疗强直性脊柱炎并髋关节强直的临床疗效分析

目的探讨人工全髋关节置换术治疗强直性脊柱炎并髋关节强直的技术要点及临床疗效。方法2011-03~2014-03对确诊为强直性脊柱炎并髋关节强直的患者17例(32髋)行人工全髋关节置换术,平均随访25.4(13~35)个月,对比手术前、后及末次随访时关节疼痛、关节屈曲畸形矫正度、关节总活动度及Harris评分改善情况。结果术前14例患者(27髋)髋关节呈屈曲挛缩畸形平均(35.42±3.15)°,术后平均(4.63±2.12)°,术后较术前明显改善(P0.01);术前关节总活动度(屈曲+后伸+内收+外展+内旋+外旋)平均(5.81±3.32)°,术后平均(152.47±3.76)°,术后较术前明显改善(P0.01);术前Harris评分平均(27.73±6.41)分,术后平均(82.31±6.58)分,术后较术前明显改善(P0.01);术前患者重度疼痛3例,中度疼痛6例,轻度疼痛8例,术后轻度疼痛7例,无中重度疼痛;无坐骨神经损伤、骨折、感染并发症出现,术后1例患者出现髋关节前脱位,给予手法复位、皮肤牵引后未再脱位。结论全髋关节置换术治疗强直性脊柱炎并髋关节强直能迅速解除患者疼痛,改善关节功能,恢复生活自理能力,是一种安全、有效的治疗方法。     

The prevalence of radiographic femoroacetabular impingement in younger individuals undergoing total hip replacement for osteoarthritis

Femoroacetabular impingement (FAI) has been suggested as a major cause of primary hip osteoarthritis (PHOA). We assessed the prevalence of FAI detected radiographically in a cohort that underwent total hip replacement (THR) for PHOA. Two radiologists independently assessed the retrospective preoperative radiographs (AP pelvis and lateral) of 82 subjects <55 years of age scheduled for THR. Subjects were categorized as: definite FAI, no FAI, and not possible to exclude FAI. Definite FAI was present in 36 % of subjects. FAI is common in young subjects undergoing THR for PHOA.     

Evaluation by explicit criteria of the use of total hip joint replacement

OBJECTIVE: To evaluate the appropriateness of the use of total hip replacement (THR) using explicit criteria developed by an expert panel. METHODS: Patients with a diagnosis of osteoarthritis who were undergoing THR in five public hospitals in Spain were included consecutively in the study during a 1-yr period. The appropriateness of the indication was judged by explicit criteria developed using a mutidisciplinary approach. Complications were measured 3 months after surgery. One year after discharge, pain, functional limitation and general health were measured. RESULTS: After evaluation of 583 patients, 82 (13.6%) were considered to have undergone inappropriate procedures, and for 279 (46.2%) patients indication for the procedure was considered uncertain. Differences were found in the rate of appropriateness among some centres. One year after discharge, the perception of general health was slightly better in those patients who had been judged to have undergone an appropriate procedure. CONCLUSIONS: The study identified a moderate percentage of inappropriately performed THR. When considered together with those cases that were judged to have uncertain indications, the results indicate that further studies should be done to identify patients who may have an inadequate benefit:risk ratio from this procedure.     

Age and waiting time as predictors of outcome after total hip replacement for osteoarthritis

OBJECTIVE: To investigate in a prospective study the relationship between age, pre-operative status, waiting time and post-operative outcome in patients assigned for unilateral total hip replacement (THR) due to osteoarthritis (OA). METHOD: One hundred and forty-eight patients (mean age 71 yr) with primary OA of the hip were investigated pre-operatively and 3, 6 and 12 months post-operatively with the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). For 56 of the patients an additional evaluation was made when they were placed on the waiting list. RESULTS: One hundred and twenty-four patients fulfilled the study criteria (age 50 yr or over and unilateral THR for OA during the study period). Before surgery there were no differences in the WOMAC or SF-36 subscales (except mental health) between patients aged over and under 72 yr. Post-operatively, the younger patients reached a better score than the older patients. There were no differences in pre-operative status or post-operative outcome between the patients who had been on the waiting list more than and less than 3 months. Most pain relief after hip replacement was obtained by 3 months, while it took at least 1 yr to reach the full benefit in improved function. Ninety per cent of the patients had improved by at least 10 points on a 100-point scale for pain and function at 12 months. CONCLUSION: The age of the patients assigned for THR did not determine their pre-operative status. However, younger patients gained more function post-operatively than older patients and reached higher absolute mean SF-36 values, except for pain. An average difference in time on the waiting list of 3 months did not result in a difference in post-operative outcome. At least 1 yr is required for the average OA patient to gain the full benefit of the THR.     

Health status in patients awaiting hip replacement for osteoarthritis

BACKGROUND: Hip osteoarthritis is a major cause of pain and disability, especially in the elderly. As part of a study investigating factors that could be associated with advanced osteoarthritis of the hip, we compared the health status of patients awaiting arthroplasty for hip osteoarthritis with controls. We further investigated the interaction of hip osteoarthritis with other variables (age, gender, social class and concurrent pain) in relation to health status. METHODS: A case-control study was performed in two English health districts (Portsmouth and North Staffordshire) during 1993-1995. A total of 611 patients (210 men and 401 women) listed for hip replacement because of osteoarthritis over an 18-month period formed the case group and were compared with an equal number of controls selected from the general population and individually matched for age, gender and general practice. Cases and controls completed a structured interviewer-administered questionnaire, which included queries about their medical condition, occupation (from which a measure of social class was derived), and general health status using the SF36. RESULTS: Physical function (t=32.1, P<0.001), social function (t=16.8, P<0.001) and perceived general health (t=4.1, P<0.001) were worse in the case group, but energy/vitality and mental health showed little difference between cases and controls. Cases were more likely to report knee pain than controls, but case-control status was not associated with pain in the fingers or shoulders, or with social class. However, differences in physical and social function between cases and controls did vary with socio-demographic factors and concurrent knee pain status. CONCLUSION: Patients awaiting hip-replacement because of osteoarthritis were more likely to be restricted in their physical and social life than adults in the general population, but mental state and vitality appear unimpaired in this group. This contrasts with findings from other chronic pain disorders. Manual social class is not linked to being on a waiting list for osteoarthritic hip replacement but does add to the burden on health status, particularly social functioning in those with osteoarthritis of the hip.     

Radiographic osteoarthritis of the hip joint in Turkey

The prevalence of hip osteoarthritis (OA) varies greatly across different geographic areas. Limited data exist about the prevalence of radiographic hip OA in the Turkish population. The aim of this study was to estimate the prevalence of radiographic hip OA in Turkey utilizing a random sample. That sample consisted of radiographs filed at the Department of Urology, Gazi University Hospital, Ankara, and included patients aged 25 years and older (range 25-97 years). Plain supine abdominal radiographs and intravenous pyelographies were evaluated using the Kellgren and Lawrence (K&L) grading system. Evaluations were made of 1,248 hips in 682 patients (205 women and 477 men). Overall, 8.8% of the hips evaluated had radiographic hip OA (K&L grade 2 or higher). Both hips were visible in 566 patients. Of those patients 11.7% had radiographic hip OA in either one or both hips (9.4% of women and 12.6% of men), and 51.5% of whom had bilateral findings. Prevalence increased with age and was 1.9%, 16.1%, and 21.5% for age ranges 25-39, 40-54, and 55 years and older, respectively. Patients aged 40 years and older had significantly more radiographic hip OA than those younger than 40 years (P<0.001). Men had a higher frequency than women after the age of 40 years, but this did not reach statistical significance. In most patients radiographic findings indicated only mild disease. Three patients had grade 3 disease and only one patient (aged 68 years) had grade 4 disease. Among patients aged 40 years or older. 1.1% had grade 3 or 4 disease. These findings suggest that K&L grade 2 OA changes emphasizing osteophytes at hip joints are not uncommon in the Turkish population, especially among those aged 40 years and older. However, frequency of moderate or severe radiographic hip OA may be low.