Determinants of outcome prior to and after total hip and knee arthroplasty

The aims of this thesis were:1. To investigate associations between radiographic OA severity, knee instability, pain and function prior to and after THA and/or TKA.2. To evaluate factors influencing physical activities in patients with end-stage hip or knee OA.3. To identify determinants of return to work after THA or TKA.The research in this thesis showed that the combination of preoperative radiographic OA severity and pain perception of the patient are important predictors for the expected postoperative pain/function outcome due to effect modification. Furthermore, the initial clinical recovery after arthroplasty surgery and preoperative scores can be used during the postoperative recovery period to identify patients at risk for an unfavourable one-year outcome. Besides, it showed that kneeinstability could be considered as an easy identifiable surrogate outcome for poor pain relief and poor function. Furthermore, pain and functional limitations were not associated with an objective technical measurement of physical activity in patients with end-stage hip or knee OA. Finally, we found that preoperative occupational information (more specifically preoperative absence from work) and work-related expectations are important predictors for return to work after THA or TKA.The research projects in this thesis were supported by an unconditional research grant from the Dutch Arthritis Society (ReumaNederland). The publication of this thesis was kindly supported by: Universiteit Leiden, Hanssen Footcare, Smith and Nephew, Lima & Link Nederland, Chipsoft.LUMC / Geneeskund

Patient expectations of sexual activity after total hip arthroplasty:A prospective multicenter cohort study

Background:  This study aimed to evaluate patients’ expectations of postoperative sexual activity (SA) after total hip arthroplasty. Methods:  A prospective multicenter cohort study of 1,271 patients managed with total hip arthroplasty was performed using patient-reported outcome measures of the Longitudinal Leiden Orthopaedics Outcomes of Osteo-Arthritis Study (LOAS). Preoperative SA expectations and their fulfillment after 1 year were assessed with the Hospital for Special Surgery expectations survey. The Hip disability and Osteoarthritis Outcome Score (HOOS) was used to measure functional status, and the Short Form-12 Mental and Physical Component Summary scores (SF-12 MCS and SF-12 PCS) and EuroQol-5 Dimensions (EQ-5D) questionnaire were used to measure health status. Two subgroups were defined preoperatively: the SA-Expecting Group and the No-SA-Expecting Group. The postoperative outcomes with regard to SA (i.e., the difference between postoperative and preoperative SA scores) were classified as “unfulfilled” (score, ≤−1), “fulfilled” (score, 0), or “exceeded” (score, ≥1). Multivariate regression analyses were used, with t tests to compare means between groups.Results: In total, 952 (74.9%) patients returned both preoperative and postoperative HSS questionnaires. Preoperatively, 605 patients (63.6%) expected to have postoperative SA. At 1 year, 43.5% of participants reported that this expectation was unfulfilled. In the No-SA-Expecting Group, 18.2% (63 of 347) regained SA, predominantly men. Postoperative SA fulfillment was related to preoperative musculoskeletal (p = 0.001) and non-musculoskeletal comorbidities (p = 0.004) and the postoperative HOOS, SF-12 PCS, SF-12 MCS, EQ-5D, and EQ-5D visual analog scale (VAS) scores (p < 0.001). Postoperative HOOS-symptoms (odds ratio [OR] 1.04; 95% confidence interval [CI], 1.02 to 1.06; p < 0.001), and HOOS-sport (OR, 1.01; 95% CI, 1.00 to 1.03; p = 0.032) were associated with postoperative SA fulfillment, as was older age (inversely; e.g., ≥76 years compared with ≤60 years: OR, 0.28; 95% CI, 0.13 to 0.62; p = 0.002). Correspondingly, for the No-SA-Expecting Group, higher age was also inversely associated with regaining postoperative SA (e.g., ≥76 years: OR, 0.07; 95% CI, 0.02 to 0.21; p < 0.001). Conclusions:  Of the patients who expected to be sexually active after surgery, 43.5% perceived this expectation to be unfulfilled; 24.3% were still sexually inactive despite most having expected a return to normal SA. Approximately one-fifth of patients who did not expect postoperative SA in fact regained SA. During preoperative consultations, surgeons should pay attention to expectation management surrounding SA

Frailty in end-stage hip or knee osteoarthritis: validation of the Groningen Frailty Indicator (GFI) questionnaire

Molecular Epidemiolog

Feasibility of collecting multiple patient-reported outcome measures alongside the Dutch arthroplasty register

Background: Compliance rates with patient-reported outcome measures (PROMs) collected alongside arthroplasty registries vary in the literature. We described the feasibility of a routinely collected set PROMs alongside the Dutch Arthroplasty Register. Methods: The longitudinal Leiden Orthopaedics Outcomes of OsteoArthritis Study is a multicenter (7 hospitals), observational study including patients undergoing total hip or total knee arthroplasty (THA or TKA). A set of PROMs: Short Form-12, EuroQol 5 Dimensions, Hip/Knee injury and Osteoarthritis Outcome Score, Oxford Hip/Knee Score was collected preoperatively and at 6, 12, 24 months, and every 2 years thereafter. Participation rates and response rates were recorded. Results: Between June 2012 and December 2014, 1796 THA and 1636 TKA patients were invited, of whom 1043 THA (58%; mean age 68 years [standard deviation, SD: 10]) and 970 TKA patients (59%; mean age 71 years [SD 9.5]) participated in the study. At 6 months, 35 THA/38 TKA patients were lost to follow-up. Response rates were 90% for THA (898/1000) and 89% for TKA (827/932) participants. At 1 and 2 years, 8 and 18 THA and 17 and 11 TKA patients were lost to follow-up, respectively. The response rates among those eligible were 87% (866/992) and 84% (812/972) for THA and 84% (771/917) and 83% (756/906) for TKA patients, respectively. The 2-year questionnaire was completed by 78.5% of the included THA patients and by 77.9% of the included TKA patients. Conclusions: About 60% of patients undergoing THA or TKA complete PROMs preoperatively, with more than 80% returning follow-up PROMs. To increase the participation rates, more efforts concerning the initial recruitment of patients are needed.Clinical epidemiolog

Are pain, functional limitations and quality of life associated with objectively measured physical activity in patients with end-stage osteoarthritis of the hip or knee?

Objectives: Physical activity is promoted in patients with hip or knee osteoarthritis (OA), yet little is known about its relationship with symptoms, functional limitations and Quality of Life (QoL). We investigated if OA-associated pain, functional limitations and QoL are associated with objectively measured physical activity in patients with end-stage hip/knee OA. Methods: Cross-sectional study including patients scheduled for primary total hip/knee arthroplasty. Patients wore an accelerometer (Activ8) with physical activity assessed over waking hours, and expressed as number of activity daily counts (ADC) per hour, %time spent on physical activity i.e. walking, cycling or running (%PA), and %time spent sedentary (%SB). Pain, functional limitations and joint-specific and general QoL were assessed with the Hip disability/Knee Injury and Osteoarthritis Outcome Score (HOOS/KOOS) and the Short Form (SF)-12. Multivariate linear regression models with the three to Z-scores transformed parameters of physical activity as dependent variables and adjusted for confounding, were conducted. Results: 49 hip and 48 knee OA patients were included. In hip and knee OA patients the mean number of ADC, %PA and %SB were 18.79 ± 7.25 and 21.19 ± 6.16, 14 ± 6.4 and 15 ± 5.0, and 66 ± 10.5 and 68 ± 8.7, respectively. In hip OA, better joint-specific and general QoL were associated with more ADC, (β 0.028; 95%CI:0.007–0.048, β0.041; 95%CI:0.010–0.071). Also, better general QoL was associated with the %PA (β 0.040, 95%CI:0.007–0.073). No other associations were found. Conclusion: Whereas QoL was associated with physical activity in hip OA, pain and functional limitations were not related to objectively measured physical activity in patients with end-stage hip or knee OA

Occupational advice for Patients undergoing Arthroplasty of the Lower limb: An intervention development and feasibility study (The OPAL Study)

Background Hip and knee replacements are regularly performed for patients who work. There is little evidence about these patients’ needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively. Objective(s) To develop an occupational advice intervention to support early recovery to usual activities including work which is tailored to the requirements of patients undergoing hip and knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks Design An intervention mapping (IM) approach was used to develop the intervention. The research methods employed were: rapid evidence synthesis; qualitative interviews with patients and stakeholders; prospective cohort study; survey of clinical practice; modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the IM process. Setting Orthopaedic departments within NHS secondary care. Participants Patients in work, and intending to return to work following primary elective hip and knee replacement surgery; healthcare professionals and employers. Interventions Occupational advice intervention. Main outcome measures Development of an occupational advice intervention. Fidelity of the developed intervention when delivered in a clinical setting. Patient and clinician perspectives of the intervention. Preliminary assessments of intervention effectiveness and cost. Results A cohort study (154 patients), 110 stakeholder interviews, survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, personalized return to work plan and co-ordination from the healthcare team to support the delivery of 13 patient and 20 staff performance objectives (POs). To support delivery, a range of tools (e.g. occupational checklists, patient workbooks, employer information), roles (e.g. return-to-work coordinator) and training resources were created. Feasibility was assessed in 21 of the 26 patients recruited from 3 NHS trusts. Adherence with the defined performance objectives was 75% for patient POs and 74% for staff POs. The intervention was generally well received although the short timeframe available for implementation and concurrent research evaluation led to some confusion amongst patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff. Limitations Implementation and uptake of the intervention was not standardized and was limited by the study timeframe. Evaluation of the intervention involved a small number of patients which limited the ability to assess it. Conclusions The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention Future work The intervention warrants a randomised controlled trial to assess its clinical and cost effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure adoption is sustained. Funding This project was funded by the NIHR Health Technology Assessment programme (project number 15/28/02) Trial Registrations International Standard Randomised Controlled Trials Number Trial ID: ISRCTN27426982 International prospective register of systematic reviews (PROSPERO) Registration: CRD4201604523

Frailty Questionnaire Is Not a Strong Prognostic Factor for Functional Outcomes in Hip or Knee Arthroplasty Patients

Orthopaedics, Trauma Surgery and Rehabilitatio

RETURN TO WORK AFTER TOTAL HIP AND KNEE ARTHROPLASTY: RESULTS FROM A PROSPECTIVE COHORT STUDY

Optimising joint reconstruction management in arthritis and bone tumour patient