If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Address correspondence and reprint requests to: A. Saxena, Department of Orthopaedic Surgery, The Wollongong Hospital, Wollongong, Australia. Tel: 61-2-42225000.
Total hip replacement (THR) is one of the most successful and frequently performed operations worldwide. Health-related quality of life (HRQOL) is a key outcome measure of surgery. We investigated mid-term HRQOL after THR in patients with osteoarthritis (OA).
Design
A systematic review of clinical studies published after January 2000 was performed using strict eligibility criteria. Quality appraisal and data tabulation were performed using pre-determined forms. Data were synthesised by narrative review and random-effects meta-analysis using standardised response means. Tau2 and I2 values and Funnel plots were analysed.
Results
20 studies were included. Mid-term post-operative HRQOL is superior compared to pre-operative status on qualitative and quantitative analysis. Pooled response means of total Harris Hip Score (HHS) (P < 0.00001) and combined pain (P = 0.00001) and physical function (P < 0.00001) domains of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and HHS improved markedly up to 7 years. Medical Outcomes Survey Short Form 36 shows physical functioning (PF) (P < 0.00001), bodily pain (BP) (P < 0.00001), role physical (P = 0.001), role emotional (P = 0.04), and social functioning (SF) (P = 0.03) were improved up to 7 years. General health (GH) (P = 0.29), mental health (MH) (P = 0.43), and vitality (P = 0.17) was similar. HRQOL is at least as good as reference populations in the first few years and subsequently plateaus or declines. Patient satisfaction and functional status was favourable. There was significant heterogeneity amongst all studies, but publication bias was low in pooled analysis.
Conclusion
THR confers significant mid-term HRQOL benefits across a broad range of health domains. Further studies based on consistent guidelines provided in this review are required.
Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines.
. According to the United Nations, the world's population is ageing rapidly with the number of people older than 60 years of age projected to double from 11% to 22% (2 billion) by 2050
THR achieves excellent technical outcomes with 10-year survival exceeding 95%, 25-year implant survival greater than 80%, and significant benefits for pain, mobility, and physical function
. Coupled with excellent long-term patient and prosthesis survival, increasing life expectancy will lead to more patients living for longer with their implants. In addition, a greater number of younger patients are undergoing surgery with 20% of operations being performed in those under 60 years of age
. These factors emphasise the need to analyse HRQOL beyond the early post-operative period. A thorough evaluation of surgical outcomes is also necessary for effective resource utilisation
We conducted a systematic review and meta-analysis of articles published after January 2000 on mid-term HRQOL after THR to (1) investigate post-operative HRQOL compared to respective patients' pre-operative status and reference populations, (2) outline subjective post-operative function and satisfaction, (3) clarify strengths and weaknesses of current evidence, and (4) outline guidelines for future research.
Methods
The structure of this review followed previously recommended guidelines
. Since HRQOL is not a tangible entity, a standardised method of measurement is required which is reliable, valid, responsive, sensitive, and covers all health domains
. This can be achieved by assessing disease-specific and generic HRQOL.
Disease-specific HRQOL measures aim to accurately reflect a patient's experience of a specific illness or treatment. Western Ontario and McMaster University Osteoarthritis Index (WOMAC)
Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee.
Specific or general health outcome measures in the evaluation of total hip replacement. A comparison between the Harris hip score and the Nottingham Health Profile.
The MACTAR Patient Preference Disability Questionnaire–an individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis.
Evaluating quality of life in hip and knee replacement: psychometric properties of the World Health Organization Quality of Life short version instrument.
Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
Baseline: NR Follow-up: telephone or clinical examination Repeat attempts NR
72% PR 84% RR
Follow-up: moderate QOL: Moderate
III
Abbreviations: Anx/Dep – anxiety/depression; BMI – body mass index; CVD – cerebrovascular disease; M – men; MCS – mental component summary score; NR – not recorded; P – prospective; PCS – physical component summary score; PR – participation rate; R – retrospective; Re – recorded; RE – role emotional; RP – role physical; SE – standard error; SF-12 – medical outcomes survey short form 12 questions; SF-36 – medical outcomes survey short form 36 questions; THR – total hip replacement; VT – vitality; W – women.
Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
To validate the end-point for failure in the Swedish national THR register, and to study GH after THR.
Post-op 2 yrs vs 10 yrs
2–10 yrs
10-yrs generic HRQOL is comparable to early follow-up.
Disease specific measures
NR
Generic instruments
All scores compared 10 yrs vs 2 yrs. NHP: Total score (24 vs 15), pain (25 vs 17), energy (35 vs 20), sleep (26 vs 16), physical motion (35 vs 22), emotional reaction (15 vs 7.7), and social isolation (9.2 vs 4.9) worsened with time. SF-36: Total score (60 vs 70), PF (42 vs 58), RP (41 vs 54), BP (58 vs 73), GH (62 vs 66), VT (54 vs 66), SF (77 vs 86), RE (58 vs 67), and MH (75 vs 81) were slightly worse. Please refer to original article for detailed quantitative results.
To compare the fixation of a Mallory-Head total hip prosthesis with and without cement.
Cemented vs cementless Post-op vs pre-op
Mean 6.3 ± 2.3 yrs
Broad improvements for both disease-specific and generic HRQOL. THR has a dramatic and sustained positive effect on HRQOL.
Disease specific measures
All outcome measures improved substantially by 3 months after surgery which is followed by continued small improvement to 1 yr. Despite a slight worsening, superior post-op HRQOL is maintained over 7 yrs. All scores provided as change scores [7 yrs; 3 months]. WOMAC: Improvements were sustained for cement: pain (−4.4 ± 2.0; −4.2 ± 1.9), stiffness (−4.0 ± 3.1; −3.7 ± 2.3), physical function (−4.7 ± 2.4; −4.2 ± 1.9); and cementless: pain (−3.6 ± 2.2; −4.3 ± 2.0), stiffness (−4.3 ± 3.1; −4.3 ± 1.9), and physical function (−4.3 ± 2.4; −4.3 ± 1.8). HHS: Scores improved markedly for both cement (44 ± 15; 41 ± 12) and cementless (46 ± 14; 41 ± 11) MACTAR improved as well for cement (−6.2 ± 2.8; −5.3 ± 2.5) and cementless: (−6.0 ± 2.6; −5.2 ± 2.2)
Generic instruments
SIP: There were substantial gains in global physical score for cement (−18 ± 12; −15 ± 11) and cementless (−17 ± 9; −14 ± 12). Please refer to original article for detailed quantitative results.
To examine HRQOL after a rotational acetabular osteotomy, primary THR, or conservative treatment.
General reference population Conservative treatment
Mean 3.9 yrs (0.5–20.0)
Generic HRQOL did not reach general population norms. Physical mobility was the main beneficiary of surgery.
Disease specific measures
NR
Generic instruments
NHP: [THR vs reference population, more than 5 yrs post-op] Energy (37 vs 27, P > 0.05), physical mobility (45 vs 10, P < 0.01), pain (31 vs 12, P > 0.05), sleep (20 vs 18, P > 0.05), emotional reaction (14 vs 8, P > 0.05), and social isolation (2 vs 3, P > 0.05) did not reach population level. No significant differences were found between THR and conservative treatment.
To investigate the long-term patient-relevant outcomes after unilateral THR for OA.
Age, sex and municipality-matched population Post-op vs pre-op
Mean 3.6 yrs (2.1–5.4)
Disease-specific and generic HRQOL improved compared to pre-op. SF-36 scores improved in almost all dimensions compared to baseline. Similar scores were attained compared to the reference population, but disease-specific HRQOL was worse. Poorer physical function than a matched reference group without hip complaints may be explained by the presence of musculoskeletal comorbidities.
Disease specific measures
WOMAC: [post-op vs pre-op] The authors re-modelled the scale so that increasing score reflected better outcomes. Pain (82 ± 20.3 vs 45 ± 17.2), stiffness (78 ± 22.2 vs 39 ± 16.3), function (74 ± 21.7 vs 38 ± 14.8) improved markedly (P < 0.0001). [THR vs general population] Pain (82 vs 87, P = 0.006) and function (74 vs 84, P < 0.0001) was not as good.
Generic instruments
SF-36: [post-op vs pre-op] PF (60 ± 25.1 vs 30 ± 19.6), RP (48 ± 44.0 vs 9 ± 21.4), BP (66 ± 26.2 vs 30 ± 16.8), VT (64 ± 24.3 vs 49 ± 20.9), SF (84 ± 22.6 vs 64 ± 26.2), RE (65 ± 42.4 vs 37 ± 42.5), and MH (78 ± 20.1 vs 70 ± 21.0) improved. GH (66 ± 22.0 vs 68 ± 19.9) was similar. There were no differences in the SF-36 subscales between patients and the reference group except PF (60 vs 71, P < 0.0001).
Function
Satisfaction: Only 4% of all patients reported that they were dissatisfied with the results of the THR.
To assess the durability and clinical outcomes of the anatomically designed, porous-coated femoral implant in a wide range of patients typically encountered in a community orthopaedic practice.
Post-op vs pre-op General reference population
Mean 11 yrs (10–12)
Substantial improvements in disease-specific and generic HRQOL. Generic HRQOL can compare to general population norms. Excellent clinical and radiographic results are obtained with the anatomically designed stem and are based on a longer follow-up interval than previous reports.
Disease specific measures:
HHS: [post-op vs pre-op] Pain (42.78 ± 8.22 vs 14.21 ± 6.89) and total score (95.98 ± 9.08 vs 42.21 ± 3.13) had dramatic improvements.
Generic instruments:
SF-36: [post-op vs pre-op] PF (M-45.8 F-2.8. vs M-73.1 F-55.9), PR (M-30.9 F-10.2 vs M-67.8 F64.9), and BP (M-33.8 F-30.9 vs M-66.9 F-64.8) benefited the most. There was a small decrease in scores in GH (M-76.1 F-74.9 vs M-70.2 F-73.9) and RE (M-86.0 F-56.1 vs M-79.8 vs F-81.9). [THR vs reference population] PF, PR, and MH scores were higher or equal to those of the general population. Quantitative results NR.
Function
All patients allowed to progress to full weight bearing on the first post-op day as balance and confidence permitted. All patients without comorbid conditions necessitating external support progressed to an unassisted limp-free gait usually within 3–6 weeks.
To assess the efficacy of the Metal-Cancellous Cementless Lubeck endoprosthesis implant with a fully coated stem in a long-term study.
Age-matched healthy population
Mean 12.8 yrs (10.1–14.9)
Generic HRQOL is similar to age-matched population norms. Metal-cancellous acetabular component was confirmed to be a reliable implant up to 15 yrs post-op.
Disease specific measures
HHS: total score (88.3), pain (33.8), activity (11.8), mobility (27.7) and function (4.8).
Generic instruments
SF-36: [THR vs reference population >70 yrs] PF (58 vs 60), RP (55 vs 62), BP (62 vs 62), GH (46 vs 46), VT (54 vs 55), SF (84 vs 83), and MH (70 vs 70) were similar.
To review experience with THR in patients 90 yrs of age and older for the purpose of determining what measures can be taken to make surgery in this age group safer.
Post-op vs pre-op
Mean 4.1 yrs (1.8–8.1)
Disease-specific HRQOL benefits post-op. Due to the small number of patients undergoing THR, no significant conclusions can be reached concerning this group taken separately. THR in nonagenarians may allow patients to be more pain free, more active, and healthier.
To assess the long-term outcome and predictors of prognosis following THR for OA.
Age, sex and GP-matched population Post-op vs pre-op
8.5 yrs (7.1–9.9)
Generic HRQOL is improves, but not to the level of age-matched populations. Benefits for PF are sustained in the longer term, and greatest in the patients who have the most severe radiographic changes of OA before surgery.
Disease specific measures
NR
Generic instruments
SF-36: [post-op vs pre-op] PF (30 vs 20), MH (76 vs 64), and VT (50 vs 60) were superior. [THR vs reference population]: PF (30 vs 65, P < 0.0001) and VT (50 vs 60, P < 0.0001), were worse, but MH (76 vs 80, P = 0.25) was similar.
To compare general and disease-specific QOL and patient satisfaction in patients with primary and revision THR.
Primary vs revision patients
5-yrs
Functional outcome and satisfaction is lower after revision THR than after primary THR, but the difference is partly explained by older age and greater morbidity of patients undergoing revision THR.
Disease specific measures
HHS: [primary THR vs revision THR] (88.1 ± 13.1 vs 76.7 ± 18.1) WOMAC [primary THR vs revision THR]: Pain (73.3 ± 22.5 vs 66.4 ± 24.0) and function (70.0 ± 22.3 vs 61.6 ± 22.9)
Generic instruments
SF-12: [primary THR vs revision THR] PCS (41.1 ± 9.7 vs 36.5 ± 8.6) and MCS (46.6 ± 10.5 vs 46.5 ± 11.2)
Function
Satisfaction: [primary THR vs revision THR]: (8.9 vs 7.7). Satisfaction scores were high (scores ≥ 8) in 84% of primary THR patients, compared to 67% of revision THR patients.
To evaluate the QOL and functional outcome after unilateral primary THR.
Post-op vs pre-op
6, 18-months, 3, 5-yrs
Disease-specific HRQOL had significant improvement up to 18 months, after which there is a decline. HRQOL remains above the pre-op level. Results confirm the sustainability of the benefits of THR, even though there is a decline in certain SF-36 dimensions after 18 months.
Disease specific measures
HHS: The greatest change occurred between the pre-op assessment and the review at 6 months (P < 0.001). Between 6 and 18 months there was a further small, but significant improvement (P < 0.001). Following that the scores plateaued.
Generic instruments
SF-36: Mean scores of all dimensions except GH and MH improved significantly following operation and remained so throughout the entire follow-up period (P < 0.001). Between 18 months and 3 yrs there was a significant decrease in mean VT (P = 0.014), BP (P = 0.014) and changes in health scores (P < 0.001). Between the 3 and 5 yrs reviews there was a significant drop in the mean scores of PF (P < 0.001), SF (P = 0.042), BP (P = 0.042) and changes in health (P = 0.021). Quantitative results NR.
To examine the magnitude and meaningfulness of change and sensitivity of SF-36 subscales following THR.
Age and sex-matched population Post-op vs pre-op
6 months, 5 yrs
Generic HRQOL has marked improvements post-op and is comparable to an age-matched population. The SF-36 can be used to show changes for groups in physical, mental and social dimensions and in comparison with population norms.
Disease specific measures
NR
Generic instruments
SF-36: [post-op vs pre-op] PF (57.6 ± 27.3 vs 30.7 ± 20.1), RP (49.6 ± 43.2 vs 8.5 ± 20.2), BP (67.1 ± 26.0 vs 30.9 ± 17.2), VT (64.3 ± 22.4 vs 50.9 ± 20.1), SF (84.3 ± 22.3 vs 65. ± 26.2), RE (65.5 ± 42.0 vs 39.3 ± 43.6) and MH (80.6 ± 17.9 vs 69.8 ± 17.7) improved markedly. GH (63.6 ± 22.9 vs 68.8 ± 19.1) was similar. [post-op THR vs reference population] PF (74.5 ± 24.1 vs 57.6 ± 27.3) was better. GH (63.6 ± 22.9 vs 61.8 ± 22.7), VT (64.3 ± 22.4 vs 63.8 ± 22.6), and SF (84.3 ± 22.3 vs 82.7 ± 2.40) were comparable. MH (80.6 ± 17.9 vs 82.0 ± 15.6), RP (49.6 ± 43.2 vs 60.1 ± 42.4), BP (67.1 ± 26.0 vs 70.2 ± 28.0), and RE (65.5 ± 42.0 vs 77.5 ± 40.9) were slightly worse.
To examine the longitudinal changes in HRQOL over time after THR starting from before surgery. The performance of each of the dimensions of HRQOL over time with the average QOL for the general population in Taiwan was compared.
General reference population Post-op vs pre-op
3-, 6-months, 1-, 2-, 5-, 6-, 7-yrs
Dramatic improvements in disease-specific and generic HRQOL. MCS of THR patients improves rapidly after surgery and becomes higher than the average score for the general population. PCS of THR patients tends not to surpass the norm. However, since the THR patients are older than the general population, achieving the average PCS norm indicates the positive impact THR has on QOL.
Disease specific measures
HHS: [5 yrs post-op vs pre-op]: Pain (41.91 ± 3.25 vs 18.07 ± 8.40), function (41.15 ± 6.91 vs 22.10 ± 8.98), and total score (92.87 ± 8.67 vs 46.79 ± 15.3) had dramatic improvements.
Generic instruments
SF-36: [5 yrs post-op vs pre-op] All domains improved markedly as shown: PF (85.43 ± 20.1 vs 41.51 ± 21.1), RP (87.60 ± 31.9 vs 14.10 ± 29.8), BP (50.14 ± 4.41 vs 44.55 ± 9.53), GH (75.06 ± 19.8 vs 52.32 ± 19.8), VT (78.47 ± 19.84 vs 59.41 ± 18.6), SF (91.07 ± 16.1 vs 50.45 ± 23.7), RE (90.08 ± 27.3 vs 38.38 ± 44.0), MH (80.60 ± 17.3 vs 66.13 ± 15.8), PCS (44.01 ± .060 vs 24.13 ± .0.51), and MCS (60.13 ± 0.85 vs 47.43 ± 0.60). [5 yrs post-op vs reference population]: RP (92.9 vs 83.7), GH (81.3 vs 69.3), VT (84.3 vs 68.3), SF (92.8 vs 86.8), RE (94.1 vs 79.4), and MH (84.9 vs 73) was better; PF (91.2 vs 92.2) was similar; and BP (49.7 vs 84.8) was worse. Please refer to original article for detailed quantitative results.
To improve knowledge about surgical technique, particularly outcomes following elective THR using the anterior surgical approach.
Different surgery populations
3, 6, 12, 24 and 36 months
Disease-specific HRQOL improves, but may decline after 6 months. The anterior approach to THR with an orthopaedic table is a safe approach, with results generalizable to surgeons with variable surgical experience.
All but 24 patients used an assistive device at discharge from hospital. Assistive devices were discontinued at a mean 21 days, however 80% of patients no longer used an assistive device by 4 days after hospital discharge.
To examine the longitudinal changes in each SF-36 subscale and explore their relationships to effective predictors in primary THR patients.
General reference population Pre-op vs post-op
3-, 6-months, 1-, 2-, 5-yrs
Generic HRQOL improves compared to pre-op, but does not quite reach population norms. Performance in all SF-36 domains except BP as well as PCS and MCS subscales improved significantly during the first 3 months after discharge and persisted for the following 5 yrs.
SF-36: [5 yrs post-op vs pre-op] PF (87.85 ± 1.78 vs 39.81 ± 3.94, P < 0.01), RP (90.28 ± 2.47 vs 12.17 ± 5.91, P < 0.01), VT (82.94 ± 1.71 vs 56.21 ± 3.26, P < 0.01), SF (94.99 ± 1.66 vs 60.88 ± 3.75, P < 0.01), and RE (95.10 ± 3.21 vs 43.64 ± 6.11, P < 0.05) had dramatic improvements whilst BP (49.84 ± 0.63 vs 42.28 ± 1.29, P > 0.05), GH (79.85 ± 1.57 vs 52.05 ± 3.17, P < 0.01), MH (83.13 ± 1.62 vs 61.95 ± 2.67, P < 0.01), PCS (43.29 ± 0.63 vs 25.76 ± 1.51, P < 0.01), and MCS (59.93 ± 0.87 vs 47.71 ± 1.53, P < 0.01) also improved. [THR vs general population] PCS did not reach population norms. Quantitative results NR. Please refer to original article for detailed quantitative results.
To compare the responsiveness over time of the HHS and the SF-36 in patients who underwent THR and assess variation in the irresponsiveness by the number of comorbid conditions.
Post-op vs pre-op
6 months, 1, 2, 5 yrs
Disease-specific and generic HRQOL improved dramatically. Disease-specific measures are more accurate for assessing immediate effects, whereas generic measures are more appropriate for revealing the long-term effects of an intervention on overall function.
Disease specific measures
HHS: [5 yrs post-op vs pre-op] Pain (41.2 vs 17.5), function (38.3 vs 19.0), and total score (88.5 vs 42.3) improved dramatically.
Generic instruments
SF-36 [5 yrs post-op vs pre-op]: PF (83.8 vs 31.5, P < 0.01) and SF (91.8 vs 47.5, P < 0.01) more than doubled. BP (53.7 vs 48.1, P > 0.05), VT (71.4 vs 45.1, P < 0.01), MH (74.3 vs 54.3, P < 0.01), GH (77.6 vs 45.7, P < 0.01), PCS (44.1 vs 22.6, P < 0.01), and MCS (54.9 vs 42.1, P < 0.01) all improved. Please refer to original article for detailed quantitative results.
To investigate the patient-relevant outcome 7 yrs after THR for OA with a focus on pain and physical function.
Age, sex and municipality-matched population Post-op vs pre-op
4, 5, 7 yrs
Disease-specific and generic HRQOL improves compared to pre-op and can be comparable to age-matched populations. Patients experience a similar health-related QOL as a reference group of a similar age and sex 7 yrs after THR except for PF where the patients score worse. THR for OA is a successful procedure, with a marked change in most of the measures from before to after surgery.
Disease specific measures
WOMAC: [7 yrs post-op vs pre-op] Pain (86 ± 16.5 vs 44 ± 16.5), stiffness (78 ± 22.1 vs 38 ± 15.9), and function (76 ± 21.1 vs 38 ± 14.8), P < 0.001 were much better for all domains. [THR vs reference population] Pain (86 ± 16.5 vs 91 ± 18.2, P = 0.05) and stiffness (78 ± 22.1 vs 89 ± 22.0, P < 0.001) were worse, but function (76 ± 21.1 vs 73 ± 23.8, P = 0.56) was similar.
Generic instruments
SF-36: [7 yrs post-op vs pre-op] PF (54 ± 27.2 vs 31 ± 19.4, P < 0.001), RP (45 ± 44.6 vs 9 ± 21.1, P = 0.001), BP (63 ± 28.1 vs 31 ± 15.8, P < 0.0001), MH (79 ± 19.1 vs 70 ± 21.2, P = 0.03), and VT (59 ± 46.4 vs 49 ± 20.2, P = 0.003) improved. SF (62 ± 23.8 vs 63 ± 26.4, P < 0.0001) and GH (63 ± 22.4 vs 68 ± 19.8, P < 0.0001) were worse. RE (81 ± 23.2 vs 37 ± 43.5, P = 0.10) remained similar. [THR vs reference population] THR achieves similar BP (63 ± 28.1 vs 69 ± 26.9, P = 0.19), GH (63 ± 22.4 vs 62 ± 25.0, P = 0.94), SF (62 ± 23.8 vs 65 ± 21.8, P = 0.36), RE (81 ± 23.2 vs 79 ± 24.7, P = 0.53), and MH (79 ± 19.1 vs 72 ± 43.0, P = 0.90) scores. PF (54 ± 27.2 vs 69 ± 31.3, P = 0.01), RP (45 ± 44.6 vs 60 ± 46.0, P = 0.05) and VT (59 ± 46.4 vs 72 ± 43.0, P = 0.05) were worse.
Function
Satisfaction: 96% of patients were satisfied in general at the 7 yrs follow-up, and 97% were satisfied with their pain relief and improved physical function. Walking ability>3 km [THR vs reference population] (59% vs 70%, P = 0.15).
To compare QOL scores 3 and 10 yrs after THR for OA with age and sex-adjusted QOL scores in a general population, and to determine factors associated with QOL after surgery.
Sex and GP-matched population 3 yrs and 10 yrs
3, 10 yrs
After THR, impaired HRQOL persists over time despite substantial improvement in condition. Comorbidities, environmental factors and the presence of painful locations other than the THR location are the main factors associated with post-op QOL. Pre-op QOL is predictive of QOL at 3 yrs but not 10 yrs after surgery.
Disease specific measures
HHS: [10 yrs vs 3 yrs] total score (47.9 ± 11.3 vs 41.4 ± 13.2, P = 0.002) continues to improve over time. WOMAC: [10 yrs vs 3 yrs]: Function (52 ± 26 vs 66 ± 21, P < 0.0001) and pain (57 ± 26 vs 70 ± 21, P < 0.0001) worsens. OAKHQOL [10 yrs vs 3 yrs]: Physical activities (44 ± 26 vs 57 ± 24, P < 0.0001), MH (61 ± 26 vs 72 ± 22, P < 0.0001), pain (54 ± 32 vs 66 ± 25, P = 0.003), and social support (65 ± 28 vs 58 ± 28, P = 0.08) improved and social activities (59 ± 29 vs 64 ± 30, P = 0.22) remained similar.
Generic instruments
SF-36: At 3 yrs, PF (37.1 ± 22.2), MH (55.3 ± 19.3), pain (34.0 ± 15.3), and SF (62.7 ± 23.2). NHP: At 3 yrs, Physical abilities (48.8 ± 20.8), emotional reaction (73.9 ± 27.8), pain (291 ± 25.9), and social isolation (83.7 ± 25.1). WHOQOL-BREF: HRQOL scores significantly lower than reference population at 3 and 10 yrs (P < 0.05).
Function
Walking distance: [10 yrs vs 3 yrs] (1928 ± 2180 m vs 1346 ± 1489 m, P = 0.02).
To investigate the effect pre-op MH-assessed as psychological distress has on patient satisfaction after THR.
Post-op vs pre-op Untreated controls
5 yrs
Generic HRQOL improves. 5 yrs patient satisfaction after THR is very high and although patients with pre-op mental distress report less pain relief, they remain no less satisfied than those without any mental distress. Perception of improvement in QOL similar in both groups of patients.
Disease specific measures
NR
Generic instruments
SF-36: Patients reported a very good improvement in their QOL, with 85.3% responding that they had experienced a great or more than imagined improvement, and 10.7% responding that they had experienced a moderate improvement in their QOL. Patient results in non-distressed were higher than distressed in all subscales (P < 0.01) (non-distressed vs distressed): PF (21 vs 13), SF (50 vs 26), VT (44 vs 26), RE (59 vs 15), RP (11 vs 5).
Function
Satisfaction: very satisfied (80.9%), somewhat satisfied (16.0%), somewhat dissatisfied (2.8%), very dissatisfied (0.2%).
To determine if there is a gender difference in patient-perceived functional measures and range of motion in primary THR.
Male vs female Post-op vs pre-op
Mean 5.6 yrs (2–16)
Disease-specific and generic HRQOL improve in all domains compared to pre-op. Both genders had improvements in all outcome measures after surgery.
Disease specific measures
HHS: [post-op vs pre-op] Scores more than double for males (84.3 ± 13.9 vs 40.1 ± 14.4) and females (82.7 ± 13.3 vs 36.5 ± 14.8). MAP: [post-op vs pre-op] Male – (14.4 ± 5.00 vs 10.4 ± 3.03) Female – (14.7 ± 4.51 vs 9.37 ± 3.05) WOMAC [post-op vs pre-op]: All domains improved. Male – function (9.03 ± 12.9 vs), pain (1.90 ± 3.72 vs), and stiffness (0.75 ± 1.40 vs 3.34 ± 2.41). Female – function (8.24 ± 12.5 vs), pain (1.44 ± 3.19 vs), and stiffness (0.62 ± 1.37 vs3.81 ± 2.46).
Generic instruments
SF-36: [post-op vs pre-op] Both males – PF (59.7 ± 27.1 vs 23.1 ± 20.7), BP (67.0 ± 28.4 vs 38.6 ± 21.5), SF (79.2 ± 26.1 vs 53.7 ± 31.2), PCS (42.4 ± 10.9 vs 28.3 ± 7.21) and females – PF (53.6 ± 28.3 vs 23.1 ± 20.7), BP (63.1 ± 27.9 vs 31.3 ± 21.5), SF (77.1 ± 26.8 vs 42.5 ± 33.4), PCS (40.8 ± 11.4 vs25.7 ± 7.39) and improvements in all domains.
To evaluate patients undergoing THR > 11 yrs ago have severe functional impairment, and to identify possible outcome predictors of long-term HRQOL and hip function after THR.
Age-matched population
Mean 16 ± 3.6 yrs
Disease-specific and generic HRQOL is worse compared to age-matched populations. Patients who had undergone THR have impaired long-term self-reported physical QOL and hip functionality, but they still perform physically better than untreated patients with advanced hip OA. Post-surgical satisfaction is high.
Disease specific measures
WOMAC: [THR vs reference population] Total score (28.8 ± 20 vs 3.1 ± 7), function (23.6 ± 16 vs 1.8 ± 5), stiffness (1.2 ± 2 vs 0.4 ± 1), and pain (3.8 ± 4 vs 0.8 ± 2) (P < 0.05 for all domains) was worse. HHS [THR vs reference population]: total (74.8 ± 17 vs 94 ± 82, P < 0.05). FCI: 3.6 ± 1.9 pre-op
Generic instruments
SF-36: [65–74 yrs THR patients vs reference population]: Scores were worse in all domains (P < 0.05): PF (44.1 ± 26 vs 71.7 ± 24), RP (50.0 ± 42 vs 65.9 ± 38), BP (48.5 ± 20 vs 67.6 ± 26), GH (41.2 ± 16 vs 55.4 ± 19), VT (49.1 ± 16 vs 59.3 ± 19), SF (57.6 ± 22 vs 75.8 ± 23), RE (65.3 ± 42 vs 73.5 ± 34), MH (54.5 ± 13 vs 64.7 ± 19), PCS (35.3 ± 10 vs 42.7 ± 9), MCS (44.8 ± 9 vs 45.8 ± 9). Please refer to original article for detailed quantitative results.
Function
Satisfaction: 96% of patients were satisfied with the outcome of the surgery, and 96.8% said that they would undergo the same procedure again
Abbreviations: M – men; NR – not recorded; P – prospective; QOL – quality of life; R – retrospective; Re – recorded; RE – role emotional; RP – role physical; SF-12 – medical outcomes survey short form 12 questions; SF-36 – medical outcomes survey short form 36 questions; VT – vitality; W – women.
Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee.
Specific or general health outcome measures in the evaluation of total hip replacement. A comparison between the Harris hip score and the Nottingham Health Profile.
The MACTAR Patient Preference Disability Questionnaire–an individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis.
38 yes/no statements on health problems covering six dimensions of subjective health. Higher scores indicate worse outcome.
Physical mobility
Only walk indoors, difficult to bend, unable to walk, trouble with stairs, difficult to reach for things, difficult to dress, hard to stand for long times, needs help walking outside,
Pain
Pain at night, unbearable pain, pain on movement, pain on walking, pain on standing, constant pain, pain with stairs, pain on sitting
Sleep
Require sleeping tablets, early morning wakening, awake most of the night, takes a long time to get to sleep, insomnia
Energy level
Tiredness, everything is an effort, easily run out of energy
Emotional reactions
Feeling down, anhedonia, feeling on edge, day seems to drag, easily lose temper, feel like losing control, ruminating at night, feel like life is not worth living, wake up feeling depressed
Social isolation
Feeling lonely, difficult to make contact with people, feels close to no one, feel like a burden to people, difficulty interacting with people
Evaluating quality of life in hip and knee replacement: psychometric properties of the World Health Organization Quality of Life short version instrument.
Personal relationships, social support, sexual activity
Environment
Financial resources, freedom, safety, security, health and social care, home environment, opportunities for acquiring new information and skills, participation in opportunities for recreation, pollution, transport
Studies considered for review had the following pre-determined inclusion criteria: (1) all patients over 18 years of age, (2) OA as the primary indication for surgery, (3) THR as a primary procedure, (4) mid-term outcomes with a mean or final post-operative follow-up of at least 3 years, (5) disease-specific and/or generic HRQOL data recorded. These studies were restricted according to the following report characteristics: (1) published after January 2000, (2) English language, and (3) original research only. The search period was restricted to be more representative of modern post-operative outcomes.
Information sources and search strategy
On December 2012 a literature search was conducted using MeSH keyword search on PubMed (MEDLINE) for all studies published after January 2000 (Fig. 1). Strict inclusion criteria for study characteristics were applied as described above. An additional manual search of OVID (MEDLINE) and EBSCOhost (EMBASE) as well as reference lists of each included study was conducted to identify studies not covered by the initial MeSH Keyword search. All identified articles were retrieved from the aforementioned databases.
Following the search, two reviewers independently performed the first stage of screening titles and abstracts. Studies were excluded if they did not meet eligibility criteria. If the information required to determine eligibility was not in the abstract, a second stage screen was run after data extraction. Consensus for studies to be included was achieved by discussion between the two reviewers based on the pre-determined selection criteria mentioned above. Reviewers were not blinded to any study characteristics including journal, authors and study institution.
Data items and extraction
All data items were pre-determined and specified as shown in Table I, Table II. Data extraction was then performed in two parts by two reviewers using standardised pilot forms. Study quality was first assessed using sample size, study design, use of both disease-specific and generic HRQOL measures, follow-up consistency and variability of results (Table I). Overall level of evidence applicable to orthopaedic surgery was also assessed
. Secondly, HRQOL results of the studies reviewed were tabulated (Table II).
Synthesis of results
The generic inverse variance method using a random-effects model was used to estimate the standardised response mean for continuous data across studies. The pooled response means (estimated overall mean difference [95% confidence interval (CI)]) are expressed on Forest plots. Low quality studies were analysed, but excluded from the pooled response means analysis. Disease-specific HRQOL instruments were pooled together and likewise generic HRQOL instruments were pooled together. Some studies split HRQOL data by characteristics such as gender and cement or cementless procedures. These separate results were pooled together to avoid any bias and allow inclusion in meta-analysis. In order to perform sub-group analyses to elicit outcomes for specific health domains, similar health domains within each instrument were pooled together. Where necessary, HRQOL results were corrected by multiplying by (−1) to ensure that all positive HRQOL scales have the same direction of effect. The consistency of results across studies was assessed by the Tau2 statistic for clinically relevant heterogeneity
. A P-value <0.05 was considered significant for pooled response means. All statistical analysis was performed on Review Manager (RevMan) [Windows] version 5.1 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011).
Risk of bias
The risk of bias in individual studies was assessed by a qualitative review based on study quality and data tabulated in Table I. Risk of bias across studies was analysed by Tau2 and I2 statistic as well as Funnel plots to assess for publication bias (Figs. 4 and 5). Outliers were annotated on the Funnel plots. These analyses of risk of bias facilitate more accurate interpretation of the qualitative and quantitative findings of this review by allowing assessment of strength of evidence and effects of bias on the findings.
Results
Study selection
After careful systematic selection, 20 studies were selected for review
Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
(Fig. 1). Meta-analysis was performed on pre-operative HRQOL scores compared to post-operative scores at the time of final follow-up for both disease-specific and generic HRQOL instruments. Heterogeneous data prevented complete meta-analysis and precluded analysis of comparisons with reference populations. Key factors were statistical (no pre-operative data, data not expressed as mean ± standard deviation (SD), etc.) and methodological (specific follow-up time point not given for the respective HRQOL score, use of different HRQOL scoring systems that could not be amalgamated, etc.) inconsistencies. Hence nine studies were excluded completely from meta-analysis
Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
. Key factors considered were sample size, response rates (RR) and overall level of evidence. Therefore a limited meta-analysis was performed with pooled results of six studies (mostly level of evidence II/III)
. Complete standardised response means without pooled analysis are shown in the Supplementary Figure.
Study characteristics and risk of bias within studies
THR was performed on patients with a primary diagnosis of OA (mean/median age: 54–91.5 years). The number of patients in each study was small with less than 500 patients in 15 studies which is a source of bias
. Where a generic HRQOL instrument is not used there may be inadequate assessment of HRQOL according to the WHO's HRQOL definition, but this was only in two studies
Mean or median follow-up period of included studies ranged between 3 and 12.8 years. The follow-up consistency was variable. According to previous guidelines, a RR of >85% (loss to follow-up <15%) is considered ideal for treatment received analyses
. Thus inclusion of the above studies for qualitative and meta-analysis is likely to skew HRQOL results positively. There was a relatively wide SD, range or CI amongst studies, and reflects the inexact subjective nature of HRQOL.
Study design limited the strength of evidence of included articles. Seven studies were retrospective
Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
. This may reflect the ethical dilemma of denying patients surgery when technical outcomes are excellent. Only eight level I or II studies were included in this review
. The pooled response means of total HHS [3.59 [2.27, 4.91], P < 0.00001, Fig. 2(A)], and combined WOMAC and HHS pain [2.33 [1.59, 3.08], P = 0.00001, Fig. 2(B)] and physical function [2.31 [1.46, 3.16], P < 0.00001, Fig. 2(C)] scores demonstrated marked benefits for a follow-up of between 3.6 and 7 years. Some studies described improvements on WOMAC and HHS until 12–18 months with a subsequent plateau effect where there were no further significant gains
Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
. Physical functioning (PF), role physical, and bodily pain (BP) experienced the greatest improvements. On quantitative analysis, SF-36 PF [1.16 [0.70, 1.63], P < 0.00001, Fig. 3(B)], BP [1.23 [0.75, 1.72], P < 0.00001, Fig. 3(C)], role physical [1.00 [0.40, 1.60], P = 0.001, Fig. 3(E)], role emotional [0.56 [0.02, 1.10], P = 0.04, Fig. 3(F)] and social functioning (SF) [0.42 [0.04, 0.81], P = 0.03, Fig. 3(H)] were improved over a follow-up period of 3.6–7 years. General health (GH) [−0.28 [−0.80, 0.24], P = 0.29, Fig. 3(A)], mental health (MH) [0.20 [−0.30, 0.70], P = 0.43, Fig. 3(D)] and vitality [0.36 [−0.15, 0.87], P = 0.17, Fig. 3(G)] domains remained similar. SIP scores mirror these benefits
. Some studies suggest that after a period of 1–3 years, BP, vitality, and PF may begin to decline, but disease condition and HRQOL appears to remain above pre-operative levels
Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
. Busija et al. report worse physical function, role physical, BP and role emotional domains, but similar GH, vitality, social function and MH at 5 years
. NHP scores at 5 years show THR patients have similar energy, pain, sleep, and emotional reaction, and worse physical mobility compared to conservatively treated and control populations
. Although walking distance and the number of outdoor daily walks decreases from 3 to 10 years, the amount of domestic assistance required and the number of people who use walking sticks decreases
. Hossain et al. report that 60.5% of patients were very satisfied with their ability to do house/garden work and 53.2% were very satisfied with their ability to do recreational activities
. Common predictors of worse outcome in these studies were female sex, older age, and pain reported at other sites. Better baseline PF, hypertension (HTN), living alone, and no post-operative employment may also influence HRQOL.
The rapidly ageing population and increasing life expectancy necessitates consideration of HRQOL after THR in the elderly. Mean or median age of patients was greater than 70 years in six studies
Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
. Discretion is required when operating in nonagenarians, but due to impaired vision and poor balance being possible confounding influential factors, HRQOL in this age group is unclear
Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
, these results may be used to extrapolate our mid-term findings to long-term HRQOL. All health domains on NHP and SF-36 appear to decline progressively from 2 years to 10 years post-operatively
Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
. Gotze et al. report that at 12 years, SF-36 scores are similar to population norms in those greater than 70 years of age, but worse than population norms in those less than 60 years of age in all domains except GH and social function
. The small number of studies and conflicting data means more studies on long-term HRQOL are required.
Risk of bias across studies
Statistical (Tau2 range: 0.0–0.0) and clinically relevant heterogeneity (I2 range: 0–0%) was minimal amongst studies included for pooled analysis. However, overall qualitative analysis demonstrates significant heterogeneity between studies. Key factors contributing to heterogeneity include a wide variation of implants such as surgical approach, bearing surface and fixation method, different patient demographics such as age, different follow-up times, and use of different HRQOL instruments.
We aimed to minimise reporting bias by conducting a full and comprehensive search of the literature using both electronic and manual search techniques. All identified articles were retrieved. Relatively good symmetry was found on funnel plot analysis of studies included for pooled response means indicating low levels of publication bias. Two studies were identified as outliers which skewed the results positively in some subgroups
, most of these studies demonstrated a broad range of benefits on HRQOL up to 2 years after surgery. There are many factors which can influence mid-to-long-term HRQOL that are not reflected in these studies. In particular, comorbidities, medication use, psychological profile, and social support factors impact HRQOL outcomes and are likely to worsen with time
. Furthermore, we considered the use of a disease-specific and/or generic HRQOL instrument as critical to assess the full definition of HRQOL and an analysis of each study's quality was also undertaken. To our knowledge, this is the first systematic review and meta-analysis on mid-term HRQOL outcomes after THR.
It is reported that disease-specific measures may be more accurate for assessing immediate effects of treatment and generic measures may be more appropriate for revealing the long-term effects of THR on overall function
. This review demonstrates superior post-operative disease-specific and generic HRQOL compared to baseline as illustrated by both qualitative and quantitative analysis. The relationship between positive disease-specific and generic HRQOL physical domains demonstrates that hip functionality, which is reflected by disease-specific scores such as WOMAC and HHS, is critical to general function
. Hip-specific HRQOL benefits greatly from surgery. Quantitative analysis showed all health domains on SF-36 were superior or similar to baseline over follow-up of up to 7 years. PF, BP, and role physical domains all demonstrated large benefits. These benefits for physical and functional domains of health are some of the key objectives of surgery. In addition, role emotional and SF domains' improvements support significant psychosocial benefit from THR even though this may not be a primary goal of surgery. The lack of improvement in GH may reflect the fact that THR alone is unlikely to directly improve a patient's present health status related to their comorbidities. Some studies also indicated a gradual plateauing or decline in HRQOL after the first few years. This is can be attributed to ageing or an increasing number of comorbidities and multiple sites of OA
. However, HRQOL remains above pre-operative levels. Hence our study indicates there are persistent mid-term HRQOL benefits after THR.
HRQOL matched or exceeded reference populations within the first 3 years. Subsequently, there were mixed results demonstrating either a plateau effect of sustained improvements or decline to worse HRQOL compared to the same reference population. However, we found studies made comparisons to healthy and younger populations, often without correcting for important comorbidities such as musculoskeletal disease (Table II). A previous study by Keener et al. raised this issue when comparing results to reference populations since unfair comparisons are often made when the reference population does not accurately represent the THR patient cohort
. Considering that patients being considered for THR often carry multiple comorbidities and reference populations are healthier in general, and do not have medical conditions affecting physical function such as OA
, HRQOL should not be expected to exceed such reference populations. By reaching HRQOL levels of reference populations, our findings indicate a very strong benefit of THR.
HRQOL instruments often do not account for patient satisfaction which is an important outcome of surgery
. We found the vast majority of patients were satisfied with the results of their surgery as well as their ability to undertake activities of daily living. Effective pain relief and HRQOL and functional improvements following surgery means many patients would be willing to undergo surgery again. These excellent results reflect the HRQOL benefits conferred by THR.
Studies show that lack of information and misperceptions can lead patients to defer or preclude THR as an option to treat their OA which may contribute to the inappropriate underutilisation of THR
01039-X&id=gr1.jpg){kind=link}
01039-X&id=gr2.jpg){kind=link}
01039-X&id=gr3.jpg){kind=link}
01039-X&id=gr4.jpg){kind=link}
01039-X&id=gr5.jpg){kind=link}