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Total hip replacement: a systematic review and meta-analysis on mid-term quality of life

Open ArchivePublished:January 31, 2014DOI:https://doi.org/10.1016/j.joca.2013.12.006

      Summary

      Objective

      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.

      Keywords

      Introduction

      Rationale

      Total hip replacement (THR) is one of the most successful surgical procedures and has been identified as the “operation of the century”
      • Learmonth I.D.
      • Young C.
      • Rorabeck C.
      The operation of the century: total hip replacement.
      . Greater than one million operations are performed every year worldwide and this is anticipated to double within the next decade
      • Pivec R.
      • Johnson A.J.
      • Mears S.C.
      • Mont M.A.
      Hip arthroplasty.
      . In the USA alone, the number of operations is projected to rise to 572,000 per year by 2030
      • Kurtz S.
      • Ong K.
      • Lau E.
      • Mowat F.
      • Halpern M.
      Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.
      . An estimated 93% of operations are performed for severe osteoarthritis (OA) with intractable pain and functional limitations
      • Pivec R.
      • Johnson A.J.
      • Mears S.C.
      • Mont M.A.
      Hip arthroplasty.
      . For these patients who are refractory to conservative measures, THR is currently the recommended and most effective treatment
      Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines.
      .
      OA is a serious public health issue with symptomatic disease prevalent in 9% of men and 11% of women
      • Oliveria S.A.
      • Felson D.T.
      • Reed J.I.
      • Cirillo P.A.
      • Walker A.M.
      Incidence of symptomatic hand, hip, and knee osteoarthritis among patients in a health maintenance organization.
      • Zhang Y.
      • Jordan J.M.
      Epidemiology of osteoarthritis.
      . It is a major cause of pain and disability
      • Cushnaghan J.
      • Coggon D.
      • Reading I.
      • Croft P.
      • Byng P.
      • Cox K.
      • et al.
      Long-term outcome following total hip arthroplasty: a controlled longitudinal study.
      . Age is one of the largest risk factors for developing OA
      • Arden N.
      • Nevitt M.C.
      Osteoarthritis: epidemiology.
      . 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
      . This will fuel an increasing incidence of OA and demand for THR
      • Badley E.M.
      • Crotty M.
      An international comparison of the estimated effect of the aging of the population on the major cause of disablement, musculoskeletal disorders.
      • Birrell F.
      • Johnell O.
      • Silman A.
      Projecting the need for hip replacement over the next three decades: influence of changing demography and threshold for surgery.
      • Fear J.
      • Hillman M.
      • Chamberlain M.A.
      • Tennant A.
      Prevalence of hip problems in the population aged 55 years and over: access to specialist care and future demand for hip arthroplasty.
      .
      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
      • Kurtz S.
      • Ong K.
      • Lau E.
      • Mowat F.
      • Halpern M.
      Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.
      • Prime M.S.
      • Palmer J.
      • Khan W.S.
      The National Joint Registry of England and Wales.
      • Smith G.H.
      • Johnson S.
      • Ballantyne J.A.
      • Dunstan E.
      • Brenkel I.J.
      Predictors of excellent early outcome after total hip arthroplasty.
      . However, these traditional indicators of surgical success may not mirror the patient's post-operative experience or healthcare efforts
      • Givon U.
      • Ginsberg G.M.
      • Horoszowski H.
      • Shemer J.
      Cost-utility analysis of total hip arthroplasties. Technology assessment of surgical procedures by mailed questionnaires.
      • O'Boyle C.A.
      Assessment of quality of life in surgery.
      • Judge A.
      • Cooper C.
      • Williams S.
      • Dreinhoefer K.
      • Dieppe P.
      Patient-reported outcomes one year after primary hip replacement in a European Collaborative Cohort.
      • Santic V.
      • Legovic D.
      • Sestan B.
      • Jurdana H.
      • Marinovic M.
      Measuring improvement following total hip and knee arthroplasty using the SF-36 health survey.
      . Patients' expectations after THR have also changed with many patients anticipating an active lifestyle in the years after surgery
      • Mahomed N.N.
      • Liang M.H.
      • Cook E.F.
      • Daltroy L.H.
      • Fortin P.R.
      • Fossel A.H.
      • et al.
      The importance of patient expectations in predicting functional outcomes after total joint arthroplasty.
      . Hence interest in patient-derived assessments of healthcare and health-related quality of life (HRQOL) has increased significantly.
      Post-operative HRQOL is now the key goal of surgery and measure of operative outcome
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      . HRQOL is so important in orthopaedics that it even constitutes a requirement for publication in some journals
      • Santic V.
      • Legovic D.
      • Sestan B.
      • Jurdana H.
      • Marinovic M.
      Measuring improvement following total hip and knee arthroplasty using the SF-36 health survey.
      . Modern series demonstrate good short-term HRQOL after THR for up to 2 years
      • Santic V.
      • Legovic D.
      • Sestan B.
      • Jurdana H.
      • Marinovic M.
      Measuring improvement following total hip and knee arthroplasty using the SF-36 health survey.
      • Ethgen O.
      • Bruyere O.
      • Richy F.
      • Dardennes C.
      • Reginster J.Y.
      Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature.
      • Montin L.
      • Suominen T.
      • Haaranen E.
      • Katajisto J.
      • Lepisto J.
      • Leino-Kilpi H.
      The changes in health-related quality of life and related factors during the process of total hip arthroplasty.
      • Lavernia C.J.
      • Alcerro J.C.
      Quality of life and cost-effectiveness 1 year after total hip arthroplasty.
      . However, mid-term HRQOL has been an important issue in THR that remains unanswered
      • Keener J.D.
      • Callaghan J.J.
      • Goetz D.D.
      • Pederson D.
      • Sullivan P.
      • Johnston R.C.
      Long-term function after Charnley total hip arthroplasty.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      .
      Despite the ageing population, the mean age of THR has not changed from 70 years in developed countries
      • Clement N.D.
      • MacDonald D.
      • Howie C.R.
      • Biant L.C.
      The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more.
      • Culliford D.J.
      • Maskell J.
      • Beard D.J.
      • Murray D.W.
      • Price A.J.
      • Arden N.K.
      Temporal trends in hip and knee replacement in the United Kingdom: 1991 to 2006.
      . 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
      • Smith G.H.
      • Johnson S.
      • Ballantyne J.A.
      • Dunstan E.
      • Brenkel I.J.
      Predictors of excellent early outcome after total hip arthroplasty.
      • Havelin L.I.
      • Fenstad A.M.
      • Salomonsson R.
      • Mehnert F.
      • Furnes O.
      • Overgaard S.
      • et al.
      The Nordic Arthroplasty Register Association: a unique collaboration between 3 national hip arthroplasty registries with 280,201 THRs.
      • Jones C.A.
      • Voaklander D.C.
      • Johnston D.W.
      • Suarez-Almazor M.E.
      The effect of age on pain, function, and quality of life after total hip and knee arthroplasty.
      . 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
      • Hirsch H.S.
      Total joint replacement: a cost-effective procedure for the 1990s.
      .

      Objectives

      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
      • Wright R.W.
      • Brand R.A.
      • Dunn W.
      • Spindler K.P.
      How to write a systematic review.
      and was written in accordance with the PRISMA checklist for systematic reviews and meta-analysis
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      .

      Definition and measurement of HRQOL

      HRQOL encapsulates an individual's physical, emotional and psychological health as well as social and functional status
      • Testa M.A.
      • Simonson D.C.
      Assessment of quality-of-life outcomes.
      . The assessment of these dimensions of health is necessary to evaluate broad health-related implications of OA and its treatment
      • Ethgen O.
      • Bruyere O.
      • Richy F.
      • Dardennes C.
      • Reginster J.Y.
      Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature.
      . 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
      • Testa M.A.
      • Simonson D.C.
      Assessment of quality-of-life outcomes.
      . 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)
      • Bellamy N.
      • Buchanan W.W.
      • Goldsmith C.H.
      • Campbell J.
      • Stitt L.W.
      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.
      , Harris Hip Score (HHS)
      • Garellick G.
      • Malchau H.
      • Herberts P.
      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.
      • Mahomed N.N.
      • Arndt D.C.
      • McGrory B.J.
      • Harris W.H.
      The Harris hip score: comparison of patient self-report with surgeon assessment.
      • Soderman P.
      • Malchau H.
      Is the Harris hip score system useful to study the outcome of total hip replacement?.
      , McMaster University Osteoarthritis Index (MACTAR)
      • Tugwell P.
      • Bombardier C.
      • Buchanan W.W.
      • Goldsmith C.H.
      • Grace E.
      • Hanna B.
      The MACTAR Patient Preference Disability Questionnaire–an individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis.
      , Osteoarthritis Knee and Hip Quality of Life questionnaire (OAKHQOL)
      • Rat A.C.
      • Coste J.
      • Pouchot J.
      • Baumann M.
      • Spitz E.
      • Retel-Rude N.
      • et al.
      OAKHQOL: a new instrument to measure quality of life in knee and hip osteoarthritis.
      , Merle d'Aubigne-Postel (MAP)
      • d'Aubigne R.M.
      • Postel M.
      The classic: functional results of hip arthroplasty with acrylic prosthesis.
      , and Functional Comorbidity Index (FCI)
      • Groll D.L.
      • To T.
      • Bombardier C.
      • Wright J.G.
      The development of a comorbidity index with physical function as the outcome.
      were used in this study.
      Generic HRQOL instruments are required to facilitate holistic assessment of health dimensions
      • Group W.
      Study protocol for the World Health Organisation project to develop a quality of life assessment instrument (WHOQOL).
      . Medical Outcomes 36-item Short-Form Health Survey (SF-36)
      • Ware Jr., J.E.
      • Sherbourne C.D.
      The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      , Medical Outcomes 12-item Short-Form Health Survey (SF-12)
      • Ware Jr., J.
      • Kosinski M.
      • Keller S.D.
      A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity.
      , Nottingham Health Profile (NHP)
      • McQueen D.A.
      • Long M.J.
      • Schurman 2nd, J.R.
      Selecting a subjective health status measure for optimum utility in everyday orthopaedic practice.
      , Sickness Impact Profile (SIP)
      • Bergner M.
      • Bobbitt R.A.
      • Carter W.B.
      • Gilson B.S.
      The Sickness Impact Profile: development and final revision of a health status measure.
      , and World Health Organisation (WHO) Quality of Life Short Version Instrument (WHOQOL-BREF)
      • Ackerman I.N.
      • Graves S.E.
      • Bennell K.L.
      • Osborne R.H.
      Evaluating quality of life in hip and knee replacement: psychometric properties of the World Health Organization Quality of Life short version instrument.
      were used in this study. Detailed descriptions of each instrument can be found in Table III.
      Table IQuality appraisal
      Author

      Year (study period)
      PatientsStudy designMethodological qualityPrecisionOverall
      Generic HRQOL instrumentDisease specific measuresPatient demographicsFollow-up and assessment methodsFollow-up consistencyRange/CI/SE/SD of resultsLevel of evidence
      Soderman
      • Soderman P.
      • Malchau H.
      • Herberts P.
      Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.


      2000 (1986–1995)
      1056RYES;

      NHP

      SF-36
      NOAge: 75.5 yrs, Male: 46%, BMI: NR

      OA: 89%, Revision: NR, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Sweden
      Baseline: NR

      Follow-up: mail
      100% PR

      93% RR
      Follow-up: NR

      QOL: NR
      III
      Laupacis
      • Laupacis A.
      • Bourne R.
      • Rorabeck C.
      • Feeny D.
      • Tugwell P.
      • Wong C.
      Comparison of total hip arthroplasty performed with and without cement: a randomized trial.


      2002 (1987–1992)
      250PYES;

      SIP
      YES;

      HHS

      MACTAR

      WOMAC
      Age: 64 yrs, Male: 52%, BMI: NR

      OA: 100%, Revision: 8%, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Canada
      Baseline: Re

      Follow-up: NR
      100% PR

      86% RR
      Follow-up: moderate

      QOL: wide
      I
      Kawasaki
      • Kawasaki M.
      • Hasegawa Y.
      • Sakano S.
      • Torii Y.
      • Warashina H.
      Quality of life after several treatments for osteoarthritis of the hip.


      2003 (1999–2000)
      287RYES;

      NHP
      NOAge: 54 yrs, Male: 0%, BMI: NR

      OA: 100%, Revision: NR, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Japan
      Baseline: NR

      Follow-up: NR
      51% PR

      24% RR
      Follow-up: wide

      QOL: NR
      III
      Nilsdotter
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.


      2003 (1995–1998)
      219PYES;

      SF-36
      YES;

      WOMAC
      Age: 71 yrs, Male: 45%, BMI: NR

      OA: 100%, Revision: NR, HTN: 27.8%, Diabetes: 7.1%, Smoking: NR, CVD: NR, Pulmonary disease: 0.5%, Anx/Dep: NR

      Location: Sweden
      Baseline: Re

      Follow-up: mail
      96% PR

      93% RR
      Follow-up: moderate

      QOL: moderate
      II
      Butler
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.


      2005 (1990–1992)
      107PYES;

      SF-36
      YES;

      HHS
      Age: 63.4 yrs, Male: 42%, BMI: 20.0 (M) 26.4 (F)

      OA: 76%, Revision: 1%, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: USA
      Baseline: Re

      Follow-up: clinical examination
      95% PR

      85% RR
      Follow-up: narrow

      QOL: NR
      III
      Gotze
      • Gotze C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.


      2006 (1986–1990)
      201PYES;

      SF-36
      Yes;

      HHS
      Age: 59 yrs, Male: 33%, BMI: 29.7

      OA: 58%, Revision:10%, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Germany
      Baseline: NR

      Follow-up: telephone
      73% PR

      79% RR
      Follow-up: NR

      QOL: moderate
      III
      Alfonso
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.


      2007 (1998–2004)
      18RNOYES;

      HHS
      Age: 91.5 yrs, Male:24 %, BMI: NR

      OA: 50%, Revision: 6%, HTN: 64%, Diabetes: 8%, Smoking: NR, CVD: 4%, Pulmonary disease: 24%, Anx/Dep: 4%

      Location: USA
      Baseline: Re

      Follow-up: NR
      64% PR

      86% RR
      Follow-up: moderate

      QOL: NR
      IV
      Cushnaghan
      • Cushnaghan J.
      • Coggon D.
      • Reading I.
      • Croft P.
      • Byng P.
      • Cox K.
      • et al.
      Long-term outcome following total hip arthroplasty: a controlled longitudinal study.


      2007 (1993–1995)
      643PYES;

      SF-36
      NOAge: NR yrs, Male: 35%, BMI: 30% ≤ 24.5, 70% ≥ 24.6

      OA: 100%, Revision: 4%, HTN: 29.3%, Diabetes: 3.2%, Smoking: 53%, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: UK
      Baseline: Re

      Follow-up: mail
      52% PR

      85% RR
      Follow-up: narrow

      QOL: moderate
      III
      Lubbeke
      • Lubbeke A.
      • Katz J.N.
      • Perneger T.V.
      • Hoffmeyer P.
      Primary and revision hip arthroplasty: 5-year outcomes and influence of age and comorbidity.


      2007 (1996–2000)
      435PYES;

      SF-12
      YES;

      WOMAC

      HHS
      Age: 68.4 yrs, Male: 46%, BMI: 79% ≤ 30 21% ≥ 30

      OA: 77.5%, Revision: NA, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Switzerland
      Baseline: NR

      Follow-up: telephone, mail and clinical examination
      88.3% PR

      79%RR
      Follow-up: narrow

      QOL: narrow
      II
      Ng
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.


      2007 (1998–2000)
      627PYES;

      SF-36
      YES;

      HHS
      Age: 68 yrs, Male: 38%, BMI: NR

      OA: 92.5%, Revision: 2%, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Scotland
      Baseline: Re

      Follow-up: research audit nurse
      89% PR

      60–70% RR
      Follow-up: NR

      QOL: moderate
      II
      Busija
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.


      2008 (NR)
      274RYES;

      SF-36
      NOAge: 70.5 yrs, Male: 47%, BMI: NR

      OA: 100%, Revision: NR, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Sweden
      Baseline: Re

      Follow-up: NR
      93% PR

      65% RR
      Follow-up: NR

      QOL: moderate
      III
      Shi
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.


      2008 (1997–2000)
      383PYES;

      SF-36
      YES;

      HHS
      Age: 58 ± 14.67 yrs, Male: 58%, BMI: NR

      OA: 52%%, Revision: NR, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Taiwan
      Baseline: Re

      Follow-up: clinical examination
      100% PR

      58% RR
      Follow-up: NR

      QOL: wide
      II
      Bhandari
      • Bhandari M.
      • Matta J.M.
      • Dodgin D.
      • Clark C.
      • Kregor P.
      • Bradley G.
      • et al.
      Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.


      2009 (1993–2000)
      1152RNOYES;

      WOMAC
      Age: 65.3 yrs, Male:47.5 %, BMI: 28

      OA: 93%, Revision: 11%, HTN: NR, Diabetes: NR Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Canada
      Baseline: Re

      Follow-up: clinical examination
      NR% PR

      27% RR
      Follow-up: NR

      QOL: narrow
      III
      Shi
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.


      2009 (1998–2002)
      335PYES;

      SF-36
      YES;

      HHS
      Age: 59.8 yrs, Male: 56.7%, BMI: NR

      OA: 52%, Revision: NR, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Taiwan
      Baseline: Re

      Follow-up: NR
      96% PR

      41% RR
      Follow-up: NR

      QOL: moderate
      III
      Shi
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.


      2009 (1997–2000)
      335PYES;

      SF-36
      YES;

      HHS
      Age: 59.8 yrs, Male: 57.6%, BMI: NR

      OA: 52.2%, Revision: NR, HTN: 19.1%, Diabetes: 11.6%, Smoking: NR, CVD: NR, Pulmonary disease: 1.5%, Anx/Dep: NR

      Location: Taiwan
      Baseline: Re

      Follow-up: clinical examination
      100% PR

      55% RR
      Follow-up: NR

      QOL: moderate
      III
      Nilsdotter
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.


      2010 (1995–1998)
      219PYES;

      SF-36
      YES;

      WOMAC
      Age: 71 yrs, Male: 45%, BMI: NR

      OA: 100%, Revision: 0%. HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Sweden
      Baseline: Re

      Follow-up: mail
      79% PR

      88% RR
      Follow-up: NR

      QOL: moderate
      II
      Rat
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.


      2010 (1994–2003)
      3 yrs: 232

      10 yrs: 221
      PYES;

      SF-36

      NHP

      WHOQOL
      YES;

      HHS

      OAKHQOL WOMAC
      Age: 72.4 yrs, Male: NR%, BMI: NR

      OA: 100%, Revision: 0%, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: France
      Baseline: Re

      Follow-up: mail
      3 yrs:

      99% PR

      84% RR

      10 yrs:

      58% PR

      69% RR
      Follow-up: NR

      QOL: moderate
      II
      Hossain
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.


      2011 (1999–2002)
      448PYES;

      SF-36
      NOAge: 64.5 yrs, Male: 40%, BMI: NR

      OA: 80.6%, Revision: 0%, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: UK
      Baseline: Re

      Follow-up: clinical examination
      NR PR

      55% RR
      Follow-up: NR

      QOL: wide
      II
      Lavernia
      • Lavernia C.J.
      • Alcerro J.C.
      • Contreras J.S.
      • Rossi M.D.
      Patient perceived outcomes after primary hip arthroplasty: does gender matter?.


      2011 (1993–2007)
      568RYES;

      SF-36
      YES;

      WOMAC

      HHS

      MAP
      Age: 61 ± 15 yrs, Male: 41%, BMI: 28.8

      OA: 100%%, Revision: 0%, HTN: NR, Diabetes: NR, Smoking: NR, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: USA
      Baseline: Re

      Follow-up: NR
      95% PR

      98% RR
      Follow-up: narrow

      QOL: wide
      III
      Mariconda
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.


      2011 (1985–1996)
      412RYES;

      SF-36
      YES;

      WOMAC

      HHS

      FCI
      Age: 55.3 yrs, Male: 35.2%, BMI: 27.0

      OA: 76%, Revision: 8%, HTN: NR, Diabetes: NR, Smoking: 28.8%, CVD: NR, Pulmonary disease: NR, Anx/Dep: NR

      Location: Italy
      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.
      Table IIResults of included studies
      Author (year)ObjectiveComparison groupFollow-up intervalConclusions
      HRQOL measureResults
      Soderman
      • Soderman P.
      • Malchau H.
      • Herberts P.
      Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
      (2000)
      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 yrs2–10 yrs10-yrs generic HRQOL is comparable to early follow-up.
      Disease specific measuresNR
      Generic instrumentsAll 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.
      FunctionNR
      Laupacis
      • Laupacis A.
      • Bourne R.
      • Rorabeck C.
      • Feeny D.
      • Tugwell P.
      • Wong C.
      Comparison of total hip arthroplasty performed with and without cement: a randomized trial.
      (2002)
      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 measuresAll 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 instrumentsSIP: 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.
      FunctionNR
      Kawasaki
      • Kawasaki M.
      • Hasegawa Y.
      • Sakano S.
      • Torii Y.
      • Warashina H.
      Quality of life after several treatments for osteoarthritis of the hip.
      (2003)
      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 measuresNR
      Generic instrumentsNHP: [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.
      FunctionNR
      Nilsdotter
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      (2003)
      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 measuresWOMAC: [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 instrumentsSF-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).
      FunctionSatisfaction: Only 4% of all patients reported that they were dissatisfied with the results of the THR.
      Butler
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      (2005)
      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.
      FunctionAll 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.
      Gotze
      • Gotze C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      (2006)
      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 populationMean

      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 measuresHHS: total score (88.3), pain (33.8), activity (11.8), mobility (27.7) and function (4.8).
      Generic instrumentsSF-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.
      FunctionNR
      Alfonso
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.
      (2007)
      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-opMean

      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.
      Disease specific measuresHHS [post-op vs pre-op]: total (28 vs 62)
      Generic InstrumentsNR
      FunctionNR
      Cushnaghan
      • Cushnaghan J.
      • Coggon D.
      • Reading I.
      • Croft P.
      • Byng P.
      • Cox K.
      • et al.
      Long-term outcome following total hip arthroplasty: a controlled longitudinal study.
      (2007)
      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 measuresNR
      Generic instrumentsSF-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.
      FunctionNR
      Lubbeke
      • Lubbeke A.
      • Katz J.N.
      • Perneger T.V.
      • Hoffmeyer P.
      Primary and revision hip arthroplasty: 5-year outcomes and influence of age and comorbidity.
      (2007)
      To compare general and disease-specific QOL and patient satisfaction in patients with primary and revision THR.Primary vs revision patients5-yrsFunctional 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 measuresHHS: [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 instrumentsSF-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)
      FunctionSatisfaction: [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.
      Ng
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.
      (2007)
      To evaluate the QOL and functional outcome after unilateral primary THR.Post-op vs pre-op6, 18-months, 3, 5-yrsDisease-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 measuresHHS: 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 instrumentsSF-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.
      FunctionNR
      Busija
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      (2008)
      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 yrsGeneric 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 measuresNR
      Generic instrumentsSF-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.
      FunctionNR
      Shi
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      (2008)
      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-yrsDramatic 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 measuresHHS: [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 instrumentsSF-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.
      FunctionNR
      Bhandari
      • Bhandari M.
      • Matta J.M.
      • Dodgin D.
      • Clark C.
      • Kregor P.
      • Bradley G.
      • et al.
      Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.
      (2009)
      To improve knowledge about surgical technique, particularly outcomes following elective THR using the anterior surgical approach.Different surgery populations3, 6, 12, 24 and 36 monthsDisease-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.
      Disease specific measuresWOMAC: Pain (Pre-op 75.1 ± 19.8, 3 months 96.6 ± 3.1, 6 months 90.4 ± 12.2, 1 yr 91.3 ± 13.0, 2 yrs 93.1 ± 8.3, 3 yrs 93.3 ± 1.9) scores improved over time while function scores (Pre-op – 45.3 ± 12.2, 3 months – 88.1 ± 9.9, 6 months – 83.4 ± 15.3, 1 yr – 83.4 ± 14.7, 2 yrs – 82.0 ± 13.4, 3 yrs – 77.3 ± 6.5) decline, but remain above pre-op levels.
      Generic instrumentsNR
      FunctionAll 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.
      Shi
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.
      (2009)
      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-yrsGeneric 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.
      Disease specific measuresHHS: pain [post-op] (18.15 ± 8.55), function [pre-op] (22.31 ± 9.15).
      Generic instrumentsSF-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.
      FunctionNR
      Shi
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      (2009)
      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-op6 months, 1, 2, 5 yrsDisease-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 measuresHHS: [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 instrumentsSF-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.
      FunctionNR
      Nilsdotter
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      (2010)
      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 yrsDisease-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 measuresWOMAC: [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 instrumentsSF-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.
      FunctionSatisfaction: 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).
      Rat
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      (2010)
      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 yrsAfter 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 measuresHHS: [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 instrumentsSF-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).
      FunctionWalking distance: [10 yrs vs 3 yrs] (1928 ± 2180 m vs 1346 ± 1489 m, P = 0.02).
      Hossain
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      (2011)
      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 yrsGeneric 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 measuresNR
      Generic instrumentsSF-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).
      FunctionSatisfaction: very satisfied (80.9%), somewhat satisfied (16.0%), somewhat dissatisfied (2.8%), very dissatisfied (0.2%).
      Lavernia
      • Lavernia C.J.
      • Alcerro J.C.
      • Contreras J.S.
      • Rossi M.D.
      Patient perceived outcomes after primary hip arthroplasty: does gender matter?.
      (2011)
      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 measuresHHS: [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 instrumentsSF-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.
      FunctionNR
      Mariconda
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      (2011)
      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 populationMean

      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 measuresWOMAC: [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 instrumentsSF-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.
      FunctionSatisfaction: 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.
      Table IIIOutline of HRQOL scoring systems
      SystemComponents
      WOMAC
      • Bellamy N.
      • Buchanan W.W.
      • Goldsmith C.H.
      • Campbell J.
      • Stitt L.W.
      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.
      24 items measuring three subscales. Higher scores indicate worse outcome.
      PainWalking, stairs, bed, sitting, lying, standing
      StiffnessAfter waking and later in the day
      Physical functionStairs, rising from sitting, standing, bending, walking, shopping, socks, bathing, toilet, household duties
      HHS
      • Garellick G.
      • Malchau H.
      • Herberts P.
      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.
      10-items measuring four conceptual domains. Higher scores indicate better outcome.
      PainSeverity, effect on activities, pain medication
      FunctionDaily activities and gait assessment
      Absence of deformityHip flexion, adduction, internal rotation, extremity length discrepancy
      Range of motionHip flexion, abduction, external and internal rotation, and adduction
      MACTAR
      • Tugwell P.
      • Bombardier C.
      • Buchanan W.W.
      • Goldsmith C.H.
      • Grace E.
      • Hanna B.
      The MACTAR Patient Preference Disability Questionnaire–an individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis.
      19 items assessing physical function. Higher effect size indicate better outcome.
      OAKHQOL
      • Rat A.C.
      • Coste J.
      • Pouchot J.
      • Baumann M.
      • Spitz E.
      • Retel-Rude N.
      • et al.
      OAKHQOL: a new instrument to measure quality of life in knee and hip osteoarthritis.
      43 items assessing five dimensions. Higher scores indicate better outcome.
      Physical activity, mental health, pain, social support, social activities
      FCI
      • Groll D.L.
      • To T.
      • Bombardier C.
      • Wright J.G.
      The development of a comorbidity index with physical function as the outcome.
      18 items assessing burden of comorbidities on physical function.
      Arthritis, osteoporosis, asthma, chronic obstructive pulmonary disease, angina, congestive heart failure, myocardial infarction, neurological disease, stroke or TIA, peripheral vascular disease, diabetes, upper gastrointestinal disease, depression, anxiety or panic disorders, visual impairment, hearing impairment, degenerative disc disease, obesity and/or BMI
      SF-36
      • Ware Jr., J.E.
      • Sherbourne C.D.
      The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.
      SF-12
      • Ware Jr., J.
      • Kosinski M.
      • Keller S.D.
      A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity.
      36 (or 12) items measuring eight conceptual domains or dimensions of health. Higher scores indicate better outcome.
      General health (GH)Measurement of perceived overall health, including past and present health
      Physical functioning (PF)Indicates level of limitations in lifting, bending, kneeling, or walking moderate distance
      Bodily pain (BP)Represents the intensity, frequency, and duration of bodily pain and limitations in normal activities due to pain
      Mental health (MH)Measures the emotional, cognitive, and intellectual status of the patient
      Role physical (RP)Measures the degree in performing of usual activities for age and social status
      Role emotional (RE)Measures personal feeling of job performance at work or other activities
      Vitality (VT)Measures feeling of energy, fatigue, and tiredness
      Social functioning (SF)Indicates ability to develop and maintain mature social relationships.
      Note: Both SF-36 and SF-12 surveys can provide two summary measures – Physical Component Score (PCS) and Mental Component Score (MCS)
      NHP
      • McQueen D.A.
      • Long M.J.
      • Schurman 2nd, J.R.
      Selecting a subjective health status measure for optimum utility in everyday orthopaedic practice.
      38 yes/no statements on health problems covering six dimensions of subjective health. Higher scores indicate worse outcome.
      Physical mobilityOnly 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,
      PainPain at night, unbearable pain, pain on movement, pain on walking, pain on standing, constant pain, pain with stairs, pain on sitting
      SleepRequire sleeping tablets, early morning wakening, awake most of the night, takes a long time to get to sleep, insomnia
      Energy levelTiredness, everything is an effort, easily run out of energy
      Emotional reactionsFeeling 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 isolationFeeling lonely, difficult to make contact with people, feels close to no one, feel like a burden to people, difficulty interacting with people
      SIP
      • Bergner M.
      • Bobbitt R.A.
      • Carter W.B.
      • Gilson B.S.
      The Sickness Impact Profile: development and final revision of a health status measure.
      12 items assessing physical and psychological domains. Higher scores indicate worse outcome.
      PhysicalAmbulation, mobility, body care, movement
      PsychosocialSocial interaction, communication, alertness behaviour, emotional behaviour, sleep, eating, home management, reaction, pastimes, employment
      WHOQOL-BREF
      • Ackerman I.N.
      • Graves S.E.
      • Bennell K.L.
      • Osborne R.H.
      Evaluating quality of life in hip and knee replacement: psychometric properties of the World Health Organization Quality of Life short version instrument.
      Physical healthActivities of daily living, medication dependence, energy and fatigue, mobility, pain and discomfort, sleep and rest, work capacity
      PsychologicalBodily image and appearance, negative feelings, positive feelings, self-esteem, spirituality, thinking, learning
      Social relationshipsPersonal relationships, social support, sexual activity
      EnvironmentFinancial resources, freedom, safety, security, health and social care, home environment, opportunities for acquiring new information and skills, participation in opportunities for recreation, pollution, transport

      Selection criteria

      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.

      Study selection

      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
      • Wright J.G.
      • Swiontkowski M.F.
      • Heckman J.D.
      Introducing levels of evidence to the journal.
      . These were derived from previously described guidelines
      • Wright R.W.
      • Brand R.A.
      • Dunn W.
      • Spindler K.P.
      How to write a systematic review.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      . 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
      • Rucker G.
      • Schwarzer G.
      • Carpenter J.R.
      • Schumacher M.
      Undue reliance on I(2) in assessing heterogeneity may mislead.
      and I2 statistic for statistical heterogeneity
      • Higgins J.P.
      • Thompson S.G.
      • Deeks J.J.
      • Altman D.G.
      Measuring inconsistency in meta-analyses.
      . 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
      • Cushnaghan J.
      • Coggon D.
      • Reading I.
      • Croft P.
      • Byng P.
      • Cox K.
      • et al.
      Long-term outcome following total hip arthroplasty: a controlled longitudinal study.
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      • Soderman P.
      • Malchau H.
      • Herberts P.
      Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Gotze C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      • Lavernia C.J.
      • Alcerro J.C.
      • Contreras J.S.
      • Rossi M.D.
      Patient perceived outcomes after primary hip arthroplasty: does gender matter?.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      • Laupacis A.
      • Bourne R.
      • Rorabeck C.
      • Feeny D.
      • Tugwell P.
      • Wong C.
      Comparison of total hip arthroplasty performed with and without cement: a randomized trial.
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.
      • Kawasaki M.
      • Hasegawa Y.
      • Sakano S.
      • Torii Y.
      • Warashina H.
      Quality of life after several treatments for osteoarthritis of the hip.
      • Lubbeke A.
      • Katz J.N.
      • Perneger T.V.
      • Hoffmeyer P.
      Primary and revision hip arthroplasty: 5-year outcomes and influence of age and comorbidity.
      • Bhandari M.
      • Matta J.M.
      • Dodgin D.
      • Clark C.
      • Kregor P.
      • Bradley G.
      • et al.
      Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.
      (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
      • Cushnaghan J.
      • Coggon D.
      • Reading I.
      • Croft P.
      • Byng P.
      • Cox K.
      • et al.
      Long-term outcome following total hip arthroplasty: a controlled longitudinal study.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Soderman P.
      • Malchau H.
      • Herberts P.
      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 C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.
      • Kawasaki M.
      • Hasegawa Y.
      • Sakano S.
      • Torii Y.
      • Warashina H.
      Quality of life after several treatments for osteoarthritis of the hip.
      • Lubbeke A.
      • Katz J.N.
      • Perneger T.V.
      • Hoffmeyer P.
      Primary and revision hip arthroplasty: 5-year outcomes and influence of age and comorbidity.
      . Five studies were excluded from pooled analysis due to poor study quality (Table I)
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.
      • Bhandari M.
      • Matta J.M.
      • Dodgin D.
      • Clark C.
      • Kregor P.
      • Bradley G.
      • et al.
      Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.
      . 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)
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Lavernia C.J.
      • Alcerro J.C.
      • Contreras J.S.
      • Rossi M.D.
      Patient perceived outcomes after primary hip arthroplasty: does gender matter?.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      • Laupacis A.
      • Bourne R.
      • Rorabeck C.
      • Feeny D.
      • Tugwell P.
      • Wong C.
      Comparison of total hip arthroplasty performed with and without cement: a randomized trial.
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.
      . 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
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Gotze C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      • Laupacis A.
      • Bourne R.
      • Rorabeck C.
      • Feeny D.
      • Tugwell P.
      • Wong C.
      Comparison of total hip arthroplasty performed with and without cement: a randomized trial.
      • Kawasaki M.
      • Hasegawa Y.
      • Sakano S.
      • Torii Y.
      • Warashina H.
      Quality of life after several treatments for osteoarthritis of the hip.
      • Lubbeke A.
      • Katz J.N.
      • Perneger T.V.
      • Hoffmeyer P.
      Primary and revision hip arthroplasty: 5-year outcomes and influence of age and comorbidity.
      . SF-36 with WOMAC and/or HHS scores was the most common HRQOL assessment combination
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Gotze C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      • Lavernia C.J.
      • Alcerro J.C.
      • Contreras J.S.
      • Rossi M.D.
      Patient perceived outcomes after primary hip arthroplasty: does gender matter?.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.
      . 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
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.
      • Bhandari M.
      • Matta J.M.
      • Dodgin D.
      • Clark C.
      • Kregor P.
      • Bradley G.
      • et al.
      Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.
      .
      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
      • Wright R.W.
      • Brand R.A.
      • Dunn W.
      • Spindler K.P.
      How to write a systematic review.
      . This was not achieved in 11 studies
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      • Gotze C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.
      • Kawasaki M.
      • Hasegawa Y.
      • Sakano S.
      • Torii Y.
      • Warashina H.
      Quality of life after several treatments for osteoarthritis of the hip.
      • Lubbeke A.
      • Katz J.N.
      • Perneger T.V.
      • Hoffmeyer P.
      Primary and revision hip arthroplasty: 5-year outcomes and influence of age and comorbidity.
      • Bhandari M.
      • Matta J.M.
      • Dodgin D.
      • Clark C.
      • Kregor P.
      • Bradley G.
      • et al.
      Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.
      with five studies having a RR of 27–58%
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.
      • Bhandari M.
      • Matta J.M.
      • Dodgin D.
      • Clark C.
      • Kregor P.
      • Bradley G.
      • et al.
      Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.
      . Patients who do not participate in HRQOL assessment or are lost to follow-up are more likely to be more ill and have a worse HRQOL
      • Cushnaghan J.
      • Coggon D.
      • Reading I.
      • Croft P.
      • Byng P.
      • Cox K.
      • et al.
      Long-term outcome following total hip arthroplasty: a controlled longitudinal study.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      . 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
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      • Soderman P.
      • Malchau H.
      • Herberts P.
      Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      • Lavernia C.J.
      • Alcerro J.C.
      • Contreras J.S.
      • Rossi M.D.
      Patient perceived outcomes after primary hip arthroplasty: does gender matter?.
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.
      • Kawasaki M.
      • Hasegawa Y.
      • Sakano S.
      • Torii Y.
      • Warashina H.
      Quality of life after several treatments for osteoarthritis of the hip.
      • Bhandari M.
      • Matta J.M.
      • Dodgin D.
      • Clark C.
      • Kregor P.
      • Bradley G.
      • et al.
      Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.
      and only one randomised controlled trial was present in this review
      • Laupacis A.
      • Bourne R.
      • Rorabeck C.
      • Feeny D.
      • Tugwell P.
      • Wong C.
      Comparison of total hip arthroplasty performed with and without cement: a randomized trial.
      . 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
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Laupacis A.
      • Bourne R.
      • Rorabeck C.
      • Feeny D.
      • Tugwell P.
      • Wong C.
      Comparison of total hip arthroplasty performed with and without cement: a randomized trial.
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.
      • Lubbeke A.
      • Katz J.N.
      • Perneger T.V.
      • Hoffmeyer P.
      Primary and revision hip arthroplasty: 5-year outcomes and influence of age and comorbidity.
      . Since the strength of evidence cannot exceed that of included studies, it is limited and is a major contributor to bias within studies.

      Results of individual studies

      Disease-specific quality of life measures

      Results of disease-specific scoring systems were recorded in 15 studies
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Gotze C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      • Lavernia C.J.
      • Alcerro J.C.
      • Contreras J.S.
      • Rossi M.D.
      Patient perceived outcomes after primary hip arthroplasty: does gender matter?.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      • Laupacis A.
      • Bourne R.
      • Rorabeck C.
      • Feeny D.
      • Tugwell P.
      • Wong C.
      Comparison of total hip arthroplasty performed with and without cement: a randomized trial.
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.
      • Lubbeke A.
      • Katz J.N.
      • Perneger T.V.
      • Hoffmeyer P.
      Primary and revision hip arthroplasty: 5-year outcomes and influence of age and comorbidity.
      • Bhandari M.
      • Matta J.M.
      • Dodgin D.
      • Clark C.
      • Kregor P.
      • Bradley G.
      • et al.
      Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.
      (Table II).
      Most of these studies indicate that post-operative WOMAC and HHS scores were superior up to 16 years compared to baseline
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Lavernia C.J.
      • Alcerro J.C.
      • Contreras J.S.
      • Rossi M.D.
      Patient perceived outcomes after primary hip arthroplasty: does gender matter?.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      • Laupacis A.
      • Bourne R.
      • Rorabeck C.
      • Feeny D.
      • Tugwell P.
      • Wong C.
      Comparison of total hip arthroplasty performed with and without cement: a randomized trial.
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.
      . 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
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.
      . Compared to a reference population, results vary. Two authors report poorer scores in all WOMAC domains
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      , and one author reports superior WOMAC pain and stiffness domains with similar physical function
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      .
      Figure thumbnail gr2
      Fig. 2Post-operative vs pre-operative disease-specific HRQOL.

      Generic HRQOL instruments

      Results of generic HRQOL instruments were recorded in 18 studies
      • Cushnaghan J.
      • Coggon D.
      • Reading I.
      • Croft P.
      • Byng P.
      • Cox K.
      • et al.
      Long-term outcome following total hip arthroplasty: a controlled longitudinal study.
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      • Soderman P.
      • Malchau H.
      • Herberts P.
      Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Gotze C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      • Lavernia C.J.
      • Alcerro J.C.
      • Contreras J.S.
      • Rossi M.D.
      Patient perceived outcomes after primary hip arthroplasty: does gender matter?.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      • Laupacis A.
      • Bourne R.
      • Rorabeck C.
      • Feeny D.
      • Tugwell P.
      • Wong C.
      Comparison of total hip arthroplasty performed with and without cement: a randomized trial.
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.
      • Kawasaki M.
      • Hasegawa Y.
      • Sakano S.
      • Torii Y.
      • Warashina H.
      Quality of life after several treatments for osteoarthritis of the hip.
      • Lubbeke A.
      • Katz J.N.
      • Perneger T.V.
      • Hoffmeyer P.
      Primary and revision hip arthroplasty: 5-year outcomes and influence of age and comorbidity.
      (Table II).
      SF-36 scores were equal to or better compared to patients' pre-operative state in most or all domains for up to 10 years
      • Cushnaghan J.
      • Coggon D.
      • Reading I.
      • Croft P.
      • Byng P.
      • Cox K.
      • et al.
      Long-term outcome following total hip arthroplasty: a controlled longitudinal study.
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.
      . 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
      • Laupacis A.
      • Bourne R.
      • Rorabeck C.
      • Feeny D.
      • Tugwell P.
      • Wong C.
      Comparison of total hip arthroplasty performed with and without cement: a randomized trial.
      . 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
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Soderman P.
      • Malchau H.
      • Herberts P.
      Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
      • Ng C.Y.
      • Ballantyne J.A.
      • Brenkel I.J.
      Quality of life and functional outcome after primary total hip replacement. A five-year follow-up.
      .
      Figure thumbnail gr3
      Fig. 3Post-operative vs pre-operative generic HRQOL (SF-36).
      Figure thumbnail gr4
      Fig. 4Funnel plots of post-operative vs pre-operative disease-specific HRQOL.
      Figure thumbnail gr5
      Fig. 5Funnel plots of post-operative vs pre-operative generic HRQOL SF-36.
      THR confers mid-term benefits that allow patients to have comparable or superior HRQOL relative to a reference population (Table II)
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Gotze C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      • Lavernia C.J.
      • Alcerro J.C.
      • Contreras J.S.
      • Rossi M.D.
      Patient perceived outcomes after primary hip arthroplasty: does gender matter?.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      • Kawasaki M.
      • Hasegawa Y.
      • Sakano S.
      • Torii Y.
      • Warashina H.
      Quality of life after several treatments for osteoarthritis of the hip.
      . All SF-36 domains are shown to be similar or superior to reference populations by a number of authors at 3, 5, 11 and 13 years
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Gotze C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      • Lavernia C.J.
      • Alcerro J.C.
      • Contreras J.S.
      • Rossi M.D.
      Patient perceived outcomes after primary hip arthroplasty: does gender matter?.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      . However, these improvements may be time-limited and a plateau is reached at 3 years
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      . 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
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      . 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
      • Kawasaki M.
      • Hasegawa Y.
      • Sakano S.
      • Torii Y.
      • Warashina H.
      Quality of life after several treatments for osteoarthritis of the hip.
      .

      Functional status and satisfaction

      Functional status and satisfaction was assessed in eight studies
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      • Lubbeke A.
      • Katz J.N.
      • Perneger T.V.
      • Hoffmeyer P.
      Primary and revision hip arthroplasty: 5-year outcomes and influence of age and comorbidity.
      • Bhandari M.
      • Matta J.M.
      • Dodgin D.
      • Clark C.
      • Kregor P.
      • Bradley G.
      • et al.
      Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.
      .
      Between 84% and 97% of patients were satisfied with the outcome of surgery up to 7 years' follow-up after THR (Table II)
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      • Lubbeke A.
      • Katz J.N.
      • Perneger T.V.
      • Hoffmeyer P.
      Primary and revision hip arthroplasty: 5-year outcomes and influence of age and comorbidity.
      . Up to 95% of patients were satisfied with their ability to practice leisure activities and 96.8% would undergo the same procedure again
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      . Nilsdotter et al. reported that 97% were satisfied with the level of pain relief and improved physical function
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      . At least 80% of patients progressed to an unassisted limp-free gait by 3–6 weeks
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      • Bhandari M.
      • Matta J.M.
      • Dodgin D.
      • Clark C.
      • Kregor P.
      • Bradley G.
      • et al.
      Outcomes following the single-incision anterior approach to total hip arthroplasty: a multicenter observational study.
      , and at 3.6 years, 42% had unlimited walking distance and only 33% used walking assistance
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      . 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
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      . 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
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      .

      Predictors of post-operative QOL

      Four studies investigate predictors of mid-term post-operative HRQOL
      • Cushnaghan J.
      • Coggon D.
      • Reading I.
      • Croft P.
      • Byng P.
      • Cox K.
      • et al.
      Long-term outcome following total hip arthroplasty: a controlled longitudinal study.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      . 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
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      • Soderman P.
      • Malchau H.
      • Herberts P.
      Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.
      . HRQOL was favourable when compared to before surgery
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Busija L.
      • Osborne R.H.
      • Nilsdotter A.
      • Buchbinder R.
      • Roos E.M.
      Magnitude and meaningfulness of change in SF-36 scores in four types of orthopedic surgery.
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.
      , but increasing age appears to be a predictor of worse outcome when compared to younger patients
      • Nilsdotter A.K.
      • Petersson I.F.
      • Roos E.M.
      • Lohmander L.S.
      Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      . 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
      • Alfonso D.T.
      • Howell R.D.
      • Strauss E.J.
      • Di Cesare P.E.
      Total hip and knee arthroplasty in nonagenarians.
      .

      Long-term post-operative QOL

      Long-term post-operative HRQOL is also important. Even though only five studies had follow-up data of 10 or more years
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Soderman P.
      • Malchau H.
      • Herberts P.
      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 C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      , 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
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      • Soderman P.
      • Malchau H.
      • Herberts P.
      Outcome after total hip arthroplasty: part I. General health evaluation in relation to definition of failure in the Swedish National Total Hip Arthoplasty register.
      . Butler et al. report all domains on SF-36 except for BP, GH and role emotion improve markedly at 11 years
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      . HRQOL is worse on SF-36 at 10 years
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      and both HHS and SF-36 at 16 years
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      . 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
      • Gotze C.
      • Tschugunow A.
      • Gotze H.G.
      • Bottner F.
      • Potzl W.
      • Gosheger G.
      Long-term results of the metal-cancellous cementless Lubeck total hip arthroplasty: a critical review at 12.8 years.
      . 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
      • Nilsdotter A.K.
      • Isaksson F.
      Patient relevant outcome 7 years after total hip replacement for OA – a prospective study.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.
      .

      Discussion

      Summary of evidence and interpretation

      Recent studies establish a positive impact of THR on HRQOL
      • Santic V.
      • Legovic D.
      • Sestan B.
      • Jurdana H.
      • Marinovic M.
      Measuring improvement following total hip and knee arthroplasty using the SF-36 health survey.
      • Montin L.
      • Suominen T.
      • Haaranen E.
      • Katajisto J.
      • Lepisto J.
      • Leino-Kilpi H.
      The changes in health-related quality of life and related factors during the process of total hip arthroplasty.
      . Even though systematic and scoping reviews have previously been published
      • Ethgen O.
      • Bruyere O.
      • Richy F.
      • Dardennes C.
      • Reginster J.Y.
      Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature.
      • Jones C.A.
      • Pohar S.
      Health-related quality of life after total joint arthroplasty: a scoping review.
      • Vissers M.M.
      • Bussmann J.B.
      • Verhaar J.A.
      • Arends L.R.
      • Furlan A.D.
      • Reijman M.
      Recovery of physical functioning after total hip arthroplasty: systematic review and meta-analysis of the literature.
      , 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
      • Ethgen O.
      • Bruyere O.
      • Richy F.
      • Dardennes C.
      • Reginster J.Y.
      Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature.
      . Prosthetic failures and complications also mainly occur after 2 years which is detrimental to HRQOL
      • Ethgen O.
      • Bruyere O.
      • Richy F.
      • Dardennes C.
      • Reginster J.Y.
      Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature.
      . 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
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      . 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
      • Mariconda M.
      • Galasso O.
      • Costa G.G.
      • Recano P.
      • Cerbasi S.
      Quality of life and functionality after total hip arthroplasty: a long-term follow-up study.
      . 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
      • Ritter M.A.
      • Thong A.E.
      • Davis K.E.
      • Berend M.E.
      • Meding J.B.
      • Faris P.M.
      Long-term deterioration of joint evaluation scores.
      . 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
      • Keener J.D.
      • Callaghan J.J.
      • Goetz D.D.
      • Pederson D.
      • Sullivan P.
      • Johnston R.C.
      Long-term function after Charnley total hip arthroplasty.
      . 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
      • Keener J.D.
      • Callaghan J.J.
      • Goetz D.D.
      • Pederson D.
      • Sullivan P.
      • Johnston R.C.
      Long-term function after Charnley total hip arthroplasty.
      , 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
      • Robertsson O.
      • Dunbar M.
      • Pehrsson T.
      • Knutson K.
      • Lidgren L.
      Patient satisfaction after knee arthroplasty: a report on 27,372 knees operated on between 1981 and 1995 in Sweden.
      • Rees J.L.
      • Dawson J.
      • Hand G.C.
      • Cooper C.
      • Judge A.
      • Price A.J.
      • et al.
      The use of patient-reported outcome measures and patient satisfaction ratings to assess outcome in hemiarthroplasty of the shoulder.
      . 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
      • Hudak P.L.
      • Clark J.P.
      • Hawker G.A.
      • Coyte P.C.
      • Mahomed N.N.
      • Kreder H.J.
      • et al.
      “You're perfect for the procedure! Why don't you want it?” Elderly arthritis patients' unwillingness to consider total joint arthroplasty surgery: a qualitative study.
      • Hawker G.A.
      • Wright J.G.
      • Coyte P.C.
      • Williams J.I.
      • Harvey B.
      • Glazier R.
      • et al.
      Differences between men and women in the rate of use of hip and knee arthroplasty.
      . HRQOL outcomes data are important to avoid exposing patients to suboptimal care. They also plays a major role in providing and disseminating relevant health status information that can be used as a rationale to improve healthcare resource utilisation
      • Ethgen O.
      • Bruyere O.
      • Richy F.
      • Dardennes C.
      • Reginster J.Y.
      Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature.
      • Peterson M.G.
      • Hollenberg J.P.
      • Szatrowski T.P.
      • Johanson N.A.
      • Mancuso C.A.
      • Charlson M.E.
      Geographic variations in the rates of elective total hip and knee arthroplasties among Medicare beneficiaries in the United States.
      . This is especially important given the burgeoning demand for THR.
      The excellent technical outcomes of surgery are well-established and the focus is now about improving HRQOL. The effect of an ageing population and increasing life expectancy with a relatively stable age at the time of surgery, combined with excellent long-term prosthetic survival means patients will live with their implants for a longer time. Prolonged HRQOL benefits are also particularly relevant for the greater numbers of younger patients being considered for surgery. Hence maintaining high standards of HRQOL in the mid-term should be a critical measure of successful outcome.
      Patients expect improvements in physical function after surgery to be able to lead an active lifestyle
      • Mahomed N.N.
      • Liang M.H.
      • Cook E.F.
      • Daltroy L.H.
      • Fortin P.R.
      • Fossel A.H.
      • et al.
      The importance of patient expectations in predicting functional outcomes after total joint arthroplasty.
      and realistic expectations also aid their recovery
      • Mahomed N.N.
      • Liang M.H.
      • Cook E.F.
      • Daltroy L.H.
      • Fortin P.R.
      • Fossel A.H.
      • et al.
      The importance of patient expectations in predicting functional outcomes after total joint arthroplasty.
      • Rat A.C.
      • Guillemin F.
      • Osnowycz G.
      • Delagoutte J.P.
      • Cuny C.
      • Mainard D.
      • et al.
      Total hip or knee replacement for osteoarthritis: mid- and long-term quality of life.
      . Our findings allow patients to have accurate expectations on not just physical and functional, but also emotional and mental welfare after surgery. This review demonstrates that there is increasing evidence showing worthwhile gains in regards to mid-term HRQOL after THR. Surgeons, patients, and their families can be more confident about the mid-term HRQOL benefits of undergoing THR when it is required.

      Review limitations

      The primary limitation of this review is that only a limited meta-analysis could be performed. We have attributed this to the clinical and methodological heterogeneity between studies. As a result, the large proportion of studies unable to be included for meta-analysis means the quantitative results may be skewed. Nevertheless, the magnitude and significance of the quantitative results, as well as the very low Tau2 and I2 values, supports the results of qualitative analysis showing that THR is effective at improving HRQOL.
      The findings of this review should be interpreted with caution. There were six studies which had very low RR
      • Shi H.Y.
      • Mau L.W.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Responsiveness of the Harris Hip Score and the SF-36: five years after total hip arthroplasty.
      • Hossain M.
      • Parfitt D.J.
      • Beard D.J.
      • Darrah C.
      • Nolan J.
      • Murray D.W.
      • et al.
      Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?.
      • Shi H.Y.
      • Chiu H.C.
      • Chang J.K.
      • Wang J.W.
      • Culbertson R.
      • Khan M.M.
      Evaluation and prediction of health-related quality of life for total hip replacement among Chinese in Taiwan.
      • Shi H.Y.
      • Khan M.
      • Culbertson R.
      • Chang J.K.
      • Wang J.W.
      • Chiu H.C.
      Health-related quality of life after total hip replacement: a Taiwan study.
      • Butler J.B.
      • Lansky D.
      • Duwelius P.J.
      Prospective evaluation of total hip arthroplasty with a cementless, anatomically designed, porous-coated femoral implant: mean 11-year follow-up.