Total+Hip+Arthroplasty+Prognosis

=__Total Hip Arthroplasty Prognosis __=



Total hip arthroplasty (THA) is a major surgery where the hip joint is replaced by a prosthesis, and knowing how likely the surgery is to succeed is important for anyone considering the surgery. Below are various aspects that have been studied and proven to be able to predict, both positive and negative, outcomes from the surgery. These aspects include; health/demographic factors, the type of surgery to be performed, what hardware to use, and what factors post-surgery can help/hurt the chances of success from the surgery.

=__Personal Factors and Health Conditions__= Patient characteristics are important in consideration of what types of patients are eligible to receive total hip arthroplasty. This systematic review by Santaguida et al., explores how patient characteristics relate to prognostic outcomes in patients with osteoarthritis. The characteristics included were age, sex, race, body weight, socioeconomic status, and work status. Although age is variably defined in the studies included in the review, it may still provide useful information for the clinician. More information on this study can be found here.
 * ===**Outcome**===

**Factor**
|| ===**Revision**=== || ===**Mortality**=== || ===**Function**=== || ===**Postoperative Pain**=== || Younger patients at higher risk for uncemented revision up to 4.5 yrs post-op Younger patients at greater risk for revision 8-15 yrs post-op || Age over 80 at greater risk of death in 30-60 day Increasing age predictor of death 90day-1y Rates increased at age > 70yrs || >70 yrs of age associated with poorer function, except WOMAC score Less improvement in function with increasing age Age over 65 led to higher admissions to ICU after sugery ||  || No difference between genders at 3 mo or 1 year post op || Men < 80yrs increased mortality rates 30-60days post op Men > 80yrs at greatest risk of death 30-60days post op Men had increased risk of mortality 90d-1yr post op || Women had poorer function than men for all outcomes Women improved less than men in function || Women experienced less post-op pain than men ||
 * Age || Age not significant for 3 mo-3yr or 1-3 yr
 * Sex || Men have greater risk
 * Weight ||  ||   || BMI negatively correlated with function ||   ||
 * Previous Surgery ||  ||   || Lower change of improved function if a previous THA had been performed in the past ||   ||
 * Before Surgery Function ||  ||   || The lower the function level of patient before surgery led to a higher increase in function after the surgery ||   ||

__**Factors Predicting Health Related Quality of Life 6 months post surgery**__
This study researched personal patient characteristics and the effects of the health related quality of life, 6 months post-surgery of total hip arthroplasty. This information can be useful for decision making of clinicians pre-surgically. Patient education and pre-surgical interventions may become more important in patients with certain characteristics. The study found that females, presense of comorbidities, contralateral hip osteoarthritis, older age, or back pain predicted less improvement in quality of life outcomes. Pre-intervention health status predicted health related quality of life. This information could be useful to encourage exercise programs pre-surgically. More information on this study can be found here.

SF-36 is a survey measuring self-assessed quality of life. An example can be found here or here.

WOMAC (Western Ontario and McMaster Universities Arthritis Index) is a questionnaire that evaluates patients with hip or knee osteoarthritis. Like the SF-36, it can be self administered and measures pain, stiffness, and functional limitations. An example can be found here.


 * ===**Studied Variables**=== || ===Health Related Quality of Life===

Measured by SF-36 and WOMAC (6months after surgery)
|| (Charlson Comorbidity Index) || Worse scores in domains of physical functioning, role physical and mental component summary scale ||
 * Pre-intervention health status || Pre-intervention WOMAC and SF-36 scores were main predictors for change after surgery. Lower scores predicted higher improvement after intervention. ||
 * Mental health status || The better pre-surgical health status, greater gains in all domains except general health ||
 * Sex || Women had lower scores in all domains of SF-36 compared to men ||
 * Contralateral OA || Worse scores in physical functioning domain. Predicted lower score gains in pain and functional limitation domains of WOMAC. ||
 * Comorbidities
 * Back pain || Worse scores in all domains except physical functioning and role physical ||
 * Age || Being older predicted worse WOMAC scores of pain domain ||
 * Level of education || No changes in domains ||
 * Waiting time until intervention || No changes in domains ||
 * Time pt remains with symptoms || No changes in domains ||
 * Patient expectations || No changes in domains ||
 * Social Support || No changes in domains ||

__Short Term Complication Rates following THA__
This chart shows patient and environment characteristics that were found to be significant predictors of complication risk. This information can be useful for patient education and anticipating risks in certain populations. More information and details of the study can be found here.

Factors that were not found to be significant include the following: Income below 80th percentile compared to income above 20th percentile, teaching status of hospital, and rural location. Odds Ratio ||
 * Patient characteristic || Reference Group || 90 Day Complication Risk
 * Age > 75 || Age >65-75 || 1.39 ||
 * Age > 55-65 || Age >65-75 || .89 ||
 * Age < 55 || Age > 65-75 || .72 ||
 * Male Gender || Female Gender || 1.10 ||
 * Black race || White race || 1.19 ||
 * Hispanic || White race || .75 ||
 * Asian race || White race || .54 ||
 * Charlson co-morbidity ||  || 1.21 ||
 * Uncomplicated diabetes || Absence of diabetes || 1.31 ||
 * Complicated diabetes || Absence of diabetes || 1.94 ||
 * Peripheral Vascular Disease || Absence of PVD || 1.66 ||
 * Rheumatoid Arthritis || Absence of RA || 1.53 ||
 * Low volume hospital || High volume hospital || 2.00 ||
 * Intermediate volume hospital || High volume hospital || 1.33 ||
 * Low volume hospital || High volume hospital || 2.00 ||
 * Intermediate volume hospital || High volume hospital || 1.33 ||

=__Effects of Pre-Operative Exercise on Total Hip Arthroplasty Prognosis__=

In this study by Rooks et al., 108 patients were randomized to a 6 week exercise program or a 6 week education (control) program. The exercise group performed land or water based exercises three times a week for 8 weeks. The exercise session lasted 30-60 minutes and included strengthening exercises and aerobic exercise.

More information on this study can be found here.

Scores for all outcome measures of total hip arthroplasty participants (25 exercisers and 24 controls)
 * || Baseline || Pre-Operative || 8 Weeks || 26 Weeks ||
 * WOMAC function ||  ||   ||   ||   ||
 * Exercise || 29.1 ± 12.9 || 26.9 ± 11.9 || 12.8 ± 9.0 || 5.4 ± 5.8 ||
 * Control || 29.8 ± 11.2 || 33.7 ± 10.9 || 12.9 ± 8.0 || 5.3 ± 5.4 ||
 * WOMAC pain ||  ||   ||   ||   ||
 * Exercise || 8.0 ± 3.7 || 7.8 ± 4.1 || 2.6 ± 2.6 || 1.1 ± 1.7 ||
 * Control || 8.8 ± 3.2 || 9.9 ± 2.9 || 2.7 ± 2.0 || 1.0 ± 1.2 ||
 * SF-36 physical function ||  ||   ||   ||   ||
 * Exercise || 40.8 ± 18.6 || 40.4 ± 23.4 || 57.6 ± 22.0 || 81.7 ± 18.1 ||
 * Control || 44.6 ± 17.6 || 30.3 ± 17.1 || 55.1 ± 22.4 || 76.6 ± 18.6 ||
 * SF-36 pain ||  ||   ||   ||   ||
 * Exercise || 47.9 ± 20.3 || 49.5 ± 19.4 || 71.4 ± 20.1 || 79.6 ± 21.2 ||
 * Control || 43.8 ± 14.4 || 37.7 ± 17.9 || 70.8 ± 21.2 || 77.4 ± 16.3 ||
 * SF-36 role limitation physical ||  ||   ||   ||   ||
 * Exercise || 49.2 ± 41.2 || 44.6 ± 37.5 || 48.2 ± 41.9 || 83.0 ± 35.2 ||
 * Control || 50.3 ± 40.2 || 32.1 ± 39.0 || 47.2 ± 42.4 || 86.5 ± 24.4 ||
 * 1-repetition maximum, kg ||  ||   ||   ||   ||
 * Exercise || 87 ± 47 || 102 ± 49 || 80 ± 32 || 99 ± 37 ||
 * Control || 104 ± 50 || 103 ± 43 || 106 ± 51 || 117 ± 51 ||
 * Functional reach, cm ||  ||   ||   ||   ||
 * Exercise || 28.2 ± 8.1 || 30.6 ± 6.6 || 30.7 ± 6.9 || 33.5 ± 5.2 ||
 * Control || 32.0 ± 7.7 || 31.5 ± 7.1 || 32.8 ± 6.1 || 31.4 ± 7.1 ||
 * Timed up and go, seconds ||  ||   ||   ||   ||
 * Exercise || 12.39 ± 3.28 || 11.35 ± 2.35 || 11.53 ± 2.42 || 9.76 ± 1.29 ||
 * Control || 11.00 ± 2.19 || 11.3 ± 2.25 || 10.9 ± 2.83 || 9.41 ± 1.46 ||
 * Values are the mean ± SD. WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index; SF-36 = Short Form 36
 * 65% of patients in exercise group were discharged to home after inpatient treatment, the remaining 35% were discharged to inpatient rehab. 44% of the control group patients were discharged home with 56% dicharged to inpatient rehab.
 * 76% of patients in exercise group walked 50 feet on day three of inpatient stay compared to 61% in the control group.
 * __No significant differences between groups was seen at 8 or 26 weeks post-operatively for self assessed function and pain.__
 * 76% of patients in exercise group walked 50 feet on day three of inpatient stay compared to 61% in the control group.
 * __No significant differences between groups was seen at 8 or 26 weeks post-operatively for self assessed function and pain.__

=__**Comparing Components**__= The chart below is meant to provide an overview of the three main components of a THA -- the acetabular cup, the femoral component, and the articular interface -- and the variables associated with those components whose influence on prognosis have been studied. For the acetabular cup, the variables are how it's attached to the acetabulum. For the femoral component, the variables are how many pieces it comes in, how it's attached to the femur, and what it's made of. For the articular interface, the variables are how large the femoral head is and what the articular surfaces are made of.

Most prognostic studies we found were small(ish) prospective cohort designs. There were also some larger retrospective cohort designs. In either case, they tend to look at either how a single outcome relates to single variable (wear rates among different articular surfaces) or how multiple outcomes relate to a single variable (wear rate, cup loosening, and revision rate among patients with non-cemented acetabular cups). What the chart below doesn't capture, because it's not known, is how multiple variables interact to determine patient prognosis -- e.g., how cup attachment relates to the size of the femoral head relates to the materials of the articular surface relates to what the femoral stem is made from.
 * = ==**Component**== ||= ==**Advantages**== ||= ==**Disadvantages**== ||= ==**Good to know**== ||
 * ===Acetabular Cup=== ||  ||   ||   ||
 * Cemented || * Overall less risk of negative future outcomes
 * Less pain a year post-op
 * Greater mobility a year post-op ||  || No difference in wear of articular surface based on whether cup is cemented or not ||
 * Non-cemented || * In younger patients (<50 yrs) survival rate for aseptic loosening excellent at 14-yr follow-up || * In younger patients (<50 yrs), overall revision rate 80% at 14-yr follow-up ||^  ||
 * ===Femoral component=== ||  ||   ||   ||
 * Modularity ||  ||   ||   ||
 * 2 junctions || * Better at correcting femoral offset and leg length || * Increased 3rd body wear
 * Increased cost ||  ||
 * Sg. junction || * Less chance of mechanical failure ||  ||   ||
 * Cemented || * More stable initially
 * Maybe faster rehab || * Cement may loosen
 * May contribute 3rd-body debris
 * May result in osteolysis
 * Revisions more difficult ||  ||
 * Non-cemented || * Bone conserving || * Delays rehab
 * Most subsidence/distal migration will occur w/in 1st 6 mos. post-op ||  ||
 * Titanium || * Less proximal osteopenia
 * Less thigh pain ||  ||   ||
 * Cobalt chromium ||  ||   ||   ||
 * ===Articular interface=== ||  ||   ||   ||
 * Size of head || * No affect on dislocation rate || * Correlation between size of head and wear rate, and higher wear linked to higher rate of revision ||  ||
 * Metal-on-Metal ||  || * Revision rate due to loosening of femoral or acetabular components higher than Ceramic-on-Ceramic within 1st 6 mos. – 2 yrs post-op
 * Higher early revision rate due to adverse reactions to metal debris
 * Adverse tissue reactions difficult to manage because hard to spot || Study that compared short-term risks of revisions or other complications among three different articular interfaces (MOM, MPE, COC), found no differences, except for higher risk of joint infection in MOM pts compared to COC pts. ||
 * Metal-on-Polyethylene ||  ||   ||^   ||
 * Ceramic-on-Ceramic || * 10-year survival rate of implants very good
 * Revision rate due to loosening of femoral or acetabular components lower than Metal-on-Metal within 1st 6 mos. – 2 yrs post-op || * Squeaking occurs in about 6% of patients; not self-limiting ||^  ||
 * Size of head || * No affect on dislocation rate || * Correlation between size of head and wear rate, and higher wear linked to higher rate of revision ||  ||
 * Metal-on-Metal ||  || * Revision rate due to loosening of femoral or acetabular components higher than Ceramic-on-Ceramic within 1st 6 mos. – 2 yrs post-op
 * Higher early revision rate due to adverse reactions to metal debris
 * Adverse tissue reactions difficult to manage because hard to spot || Study that compared short-term risks of revisions or other complications among three different articular interfaces (MOM, MPE, COC), found no differences, except for higher risk of joint infection in MOM pts compared to COC pts. ||
 * Metal-on-Polyethylene ||  ||   ||^   ||
 * Ceramic-on-Ceramic || * 10-year survival rate of implants very good
 * Revision rate due to loosening of femoral or acetabular components lower than Metal-on-Metal within 1st 6 mos. – 2 yrs post-op || * Squeaking occurs in about 6% of patients; not self-limiting ||^  ||
 * Ceramic-on-Ceramic || * 10-year survival rate of implants very good
 * Revision rate due to loosening of femoral or acetabular components lower than Metal-on-Metal within 1st 6 mos. – 2 yrs post-op || * Squeaking occurs in about 6% of patients; not self-limiting ||^  ||
 * Revision rate due to loosening of femoral or acetabular components lower than Metal-on-Metal within 1st 6 mos. – 2 yrs post-op || * Squeaking occurs in about 6% of patients; not self-limiting ||^  ||

= **__The dangers of third-body wear and its sources__**=

There is usually a group of outliers among any cohort of THA patients who experience significantly higher wear rates than the average for their cohort.



There is persuasive evidence that these unfortunate patients are the victims of. . . junk in their joints.
 * ===Sources of Junk in a Joint=== ||
 * Bone cement ||
 * Radiopacifier particles ||
 * Bone particles ||
 * Trochanteric reattachment wires ||
 * Burnishing from loose stems ||
 * Hydroxyapatite particles ||
 * Fixation screw fretting ||
 * Neck impingement ||
 * Matte/precoat stem abrasion ||
 * Instrument scratching ||
 * Modular connection fretting ||
 * Cutting guide abrasion ||
 * Porous coating particles ||
 * Locking mechanism breakage ||
 * Microseparation impact ||
 * Assembly/impaction chipping ||

Not much can be done about junk in the joint. No techniques exist yet for quantifying the risk to patients created by third-bodies. Just know that it's a complication that a certain percentage of your patients will be confronted with.


 * ** Surgical Technique ** || ** Pros ** || ** Cons ** || ** Additional Information ** ||
 * **Anterolateral Approach** || * Maintains an intact posterior joint capsule
 * Reduced risk of dislocation compared to the posterolateral approach
 * Decreased muscle damage compared to the posterior approach || * Higher incidence of abductor weakness || * This is the surgical approach of choice because of its theoretical advantages ||
 * **Posterolateral Approach** || * Less associated nerve damage compared to the direct lateral approach || * Patients with preoperative flexion and adduction contractures are at higher risk of dislocation || * No significant difference in dislocations between posterior and lateral approaches ||
 * **Direct Lateral Approach** || * Improves access to the acetabulum compared to a more posterior approach || * More associated nerve damage compared to the posterior approach ||^  ||
 * **Minimally Invasive Surgery (MIS)** || * Decreased blood loss and operative time
 * Smaller surgical incision
 * Lower pain scores || * Increased risk of lateral femoral cutaneous nerve palsy compared to conventional procedure || * MIS and mini-incision surgeries do not show a significant difference in clinical outcomes
 * There is not a significant difference between the rate of post-operative complications between any of these operative procedure
 * Mini incision and minimally invasive are not well discriminated in most literature ||
 * **Mini Incision Surgery** ||  || * Produces Higher pain scores than MIS ||^   ||
 * **Computer Assisted Surgery (CAS)** || * Improved positioning of the acetabular component || * Increased operative time ||^  ||
 * **Femoral Neck Anteversion** ||  || * Increased femoral anteversion is coorelated with anterior dislocation after an anterior approach THA || * Femoral anteversion and hip COR are not actual surgical procedures but rather products of proper/improper component placement ||
 * **Hip Center of Rotation (COR)** ||  || * A post operative medial and posterior shift of the COR is coorelated with anterior dislocation after an anterior approach THA || * This shift in COR is due to the reaming process used to fit the acetabular component ||
 * **Femoral Neck Anteversion** ||  || * Increased femoral anteversion is coorelated with anterior dislocation after an anterior approach THA || * Femoral anteversion and hip COR are not actual surgical procedures but rather products of proper/improper component placement ||
 * **Hip Center of Rotation (COR)** ||  || * A post operative medial and posterior shift of the COR is coorelated with anterior dislocation after an anterior approach THA || * This shift in COR is due to the reaming process used to fit the acetabular component ||

**__Effects of Home Exercise Program Compliance__**
From the study //Effects of a home program on strength, walking speed, and function after total hip replacement// by Jan, M.-H., J.-Y. Hung, et al

12 Week Daily Exercise Program: Exercises A-F (2 x 10 reps) and a 30 minute walk at comfortable pace


Jan, M.-H., J.-Y. Hung, et al. (2004)

__Results__
Jan, M.-H., J.-Y. Hung, et al. (2004)
 * Outcome Measures |||| Exercise Groups ||  ||   |||| Control Group ||
 * |||| High Compliance |||| Low Compliance ||  ||   ||
 * || Pre || Post || Pre || Post || Pre || Post ||
 * Strength (Nm) ||  ||   ||   ||   ||   ||   ||
 * Operated side ||  ||   ||   ||   ||   ||   ||
 * Abductors || 54.2±17.1 || 64.9±17.8* || 52.4±20.7 || 54.8±21.6 || 55.7±17.7 || 52.0±21.0 ||
 * Flexors || 49.2±20.0 || 57.5±22.3* || 48.9±18.2 || 48.4±14.8 || 54.2±22.5 || 50.8±21.2 ||
 * Extensors || 70.1±21.4 || 79.6±20.9* || 72.0±24.8 || 70.5±28.1 || 74.8±31.1 || 72.5±24.2 ||
 * Nonoperated side ||  ||   ||   ||   ||   ||   ||
 * Abductors || 60.5±18.1 || 67.1±17.5* || 61.5±16.1 || 63.7±21.1 || 63.3±20.1 || 62.3±23.1 ||
 * Flexors || 56.4±19.7 || 67.4±15.8* || 59.3±18.3 || 60.8±20.6 || 62.3±20.0 || 59.5±21.2 ||
 * Extensors || 84.8±23.8 || 91.9±30.1* || 82.4±16.5 || 85.3±32.5 || 87.4±38.7 || 87.1±23.8 ||
 * Walking speed (m/min) ||  ||   ||   ||   ||   ||   ||
 * Level-free || 63.8±6.3 || 71.9±11.3* || 64.1±8.9 || 64.7±9.2 || 66.1±13.2 || 62.6±10.8 ||
 * Level-fast || 85.0±11.4 || 98.6±17.8* || 88.5±6.4 || 89.7±14.7 || 85.8±15.0 || 81.0±7.8 ||
 * Grass-free || 63.0±13.5 || 78.6±18.1* || 61.5±16.9 || 65.0±15.1 || 61.9±12.4 || 59.0±14.1 ||
 * Grass-fast || 78.7±9.1 || 95.4±10.6* || 76.3±8.7 || 74.2±9.0 || 78.6±12.6 || 73.8±7.2 ||
 * Sponge-free || 57.1±7.6 || 62.2±14.6* || 56.5±8.7 || 55.2±13.8 || 57.0±11.4 || 51.6±13.8 ||
 * Functional score || 11.7±0.8 || 13.1±0.6* || 12.4±1.2 || 12.7±1.7 || 12.4±1.1 || 12.0±1.4 ||

====Compliance was measured by a daily record kept by the patient. Muscle strength measurements were taken bilaterally using the Cybex 6000 Isokinetic Dynamometer. Patients who reported high compliance rate with the home exercise program exhibited increased muscle strength, functional score, and walking speed across variable surfaces. Patients reporting low compliance with the home program show slight increase in most of the outcome measures (excluding flexor/extensor strength on the operated side and walking speed over grass-fast and sponge surfaces. The control group (not instructed to participate in exercise program) decreased in all outcome measurements====

__**Conclusion**__:
====Patients who participate in daily home exercise programs after a THA are more likely to increase hip strength bilaterally, have faster walking speeds, and a greater functional score. Higher values in these areas indicate a better prognosis the patient.==== = = =Videos that may be beneficial for you:=

=__Prognosis__:= [] [] []

=__Success story__:= [|http://www.youtube.com/user/DePuyVideos?v=x_nqkC2gyHQ&feature=pyv&ad=17755347952&kw=total%20hip%20replacement%20surgery&utm_source=google&utm_medium=cpc&utm_campaign=Knee%2FHip+-+YouTube&utm_term=total%20hip%20replacement%20surgery&utm_content=Hip+-+Hip+Replacement+Total|mkwid|s7gPzc0Cl|pcrid|17755347952]

__**Materials**__: []

__**The surgery itself**__: []

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