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Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy
Journal of Orthopaedic Science xxx (2017) 1e4
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Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original Article
Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy Yusuke Osawa a, *, Yukiharu Hasegawa b, Taisuke Seki a, Yasuhiko Takegami a, Takafumi Amano a, Naoki Ishiguro a a b
Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan Department of Hip and Knee Reconstructive Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 June 2017 Received in revised form 1 November 2017 Accepted 2 November 2017 Available online xxx
Background: There has been constant discussion about whether the clinical outcome of THA after periacetabular osteotomy (PAO) is equivalent to that after primary total hip arthroplasty (THA). However, there have been few reports about patient-reported outcomes (PRO) for those who undergo THA after PAO. We compared the pre- and postoperative PRO of patients who underwent THA after PAO and those who underwent primary THA alone. Methods: We performed a caseecontrol study. Twenty-seven patients (29 hips) underwent THA after PAO (osteotomy group); their mean age at surgery was 57.2 years, and they underwent postoperative follow-up for a mean period of 3.0 years. For the control group, after matching age, sex, and Crowe classification, we included 54 patients (58 joints) who underwent primary THA for hip dysplasia. Assessment performed preoperatively and at the last follow-up included the Harris hip score, the Short Form 36 (SF-36) for the Physical Component Summary (PCS), Mental Component Summary (MCS), and Role/Social Component Summary (RCS) domains, Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ) for pain, movement, and mental health, and the visual analog scale (VAS) score of hip pain and satisfaction. Results: The two groups demonstrated no significant difference in the preoperative Harris hip score, each domain of the SF-36, JHEQ, and the VAS score of hip pain and satisfaction. The osteotomy group demonstrated significantly poor Harris hip scores for gait and activity, and JHEQ for movement at the last follow-up. There was no significant difference in each domain of the SF-36 and the VAS score of hip pain and satisfaction at the last follow-up. Conclusion: Previous PAO affects the quality of physical function in patients who undergo subsequent THA. © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Various types of periacetabular osteotomy (PAO) are considered suitable to treat acetabular dysplasia in young adults in order to prevent the progression of osteoarthritis [1e4]. However, some patients who undergo PAO demonstrate long-term progression of osteoarthritis, thereby needing conversion to total hip arthroplasty (THA) [5e11]. Many studies have reported that the clinical
* Corresponding author. Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan. Fax: þ81 52 744 2260. E-mail address: [email protected] (Y. Osawa).
outcomes of THA after PAO are equivalent to those after primary THA [7e9]. On the other hand, several reports suggested that the therapeutic outcomes of THA after PAO are poorer than those obtained after primary THA [10,11]. There has been constant discussion about whether the clinical outcome of THA after PAO is equivalent to that after primary THA. In past reports, clinical outcomes were evaluated only by medical investigator-initiated outcomes such as the Harris Hip Score (HSS). Recently, patientreported measures of quality of life (QOL) have been found to be essential tools to assess the postoperative clinical outcomes of THA [12,13]. However, few studies on THA after PAO have evaluated patient-reported outcome (PRO). In the present study, therefore, we compared PRO of THA after PAO with those of primary THA.
https://doi.org/10.1016/j.jos.2017.11.001 0949-2658/© 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Osawa Y, et al., Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy, Journal of Orthopaedic Science (2017), https://doi.org/10.1016/j.jos.2017.11.001
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Y. Osawa et al. / Journal of Orthopaedic Science xxx (2017) 1e4
2. Materials and methods
Table 1 Patients demographics.
2.1. Patients and procedures This study was a retrospective chart review and was approved by an institutional review board. All patients provided written informed consent to participate. The study included 35 patients (37 hips) who consecutively underwent THA between April 2011 and March 2016 because of the progression of osteoarthritis after PAO. Seven patients (seven hips) who underwent concomitant intertrochanteric valgus osteotomy and one patient (one hip) who died during the follow-up period because of causes not related to surgery were excluded from the study. Thus, the final osteotomy group comprised of 27 patients (29 hips). The types of PAO included eccentric rotational acetabular osteotomy (ERAO) [14], performed for 23 hips at our institution; and rotational acetabular osteotomy (RAO) [15], performed for 6 hips at other hospitals. The patients included two men (two hips) and 25 women (27 hips), with a mean age of 57.2 years (range, 40e77 years) at the time of THA. Patients were followed-up for a mean duration of 3.0 years (range, 1e5 years). The mean age at the time of PAO was 41.1 years (range, 12e57 years). The mean interval between PAO and THA was 13.7 years (range, 3e23 years). We also selected hospital records to identify patients who underwent primary THA for osteoarthritis during the same period. We designed a case control study in which patients were matched by age (±5 years), sex, and Crowe classification. We identified 54 patients (58 hips) with no history of osteotomy who underwent primary THA for hip osteoarthritis. All THA procedures were performed by a single senior surgeon or by junior surgeons under the guidance of a senior surgeon. THA in all patients was performed using a standard posterior approach, with the patient in the lateral decubitus position. Generally cementless implants were chosen; however, in the case of poor bone quality on preoperative radiography findings and problems with fixation, cement implants were chosen instead. With regard to the type of implants used in the osteotomy group, Trident HA (Stryker Orthopedics, Mahwah, NJ) was used for 29 hips, Super Secur-Fit (Stryker Orthopedics, Mahwah, NJ) stems were used for 22 hips, Accolade II (Stryker Orthopedics, Mahwah, NJ) stems were used in three hips, and Exeter (Stryker Orthopedics, Mahwah, NJ) stems were used for four hips. For the control group, Trident HA (Stryker Orthopedics, Mahwah, NJ) was used for 58 hips, Super Secur-Fit (Stryker Orthopedics, Mahwah, NJ) stems were used for 51 hips, Accolade II (Stryker Orthopedics, Mahwah, NJ) stems were used in five hips, and Exeter (Stryker Orthopedics, Mahwah, NJ) stems were used for two hips. Regarding postoperative rehabilitation, generally, we allowed walking training and range of motion (ROM) training with full weight bearing in both groups. There were no significant differences in age, sex, body mass index, the follow-up duration or implant type between the groups (Table 1).
Osteotomy Control p value group (n ¼ 29) group (n ¼ 58) Number of patients Gender (male/female) BMI Age at THA (years) Duration PAO to THA (years) Crowe classification Group I Group II Group III Group IV Follow up (years) Acetabular socket (cementless/cement) Femoral Stem (cementless/cement)
27 2/25 24.2 ± 3.6 57.2 ± 7.2 13.7 ± 6.2
54 4/50 23.6 ± 3.3 58.3 ± 7.7 e
16 11 2 0 3.0 ± 1.7 29/0
32 22 4 0 3.1 ± 1.6 58/0
0.828 1
25/4
56/2
0.092
1 0.362 0.563 e 1
BMI: Body mass index. THA: Total hip arthroplasty. PAO: Periacetabular osteotomy.
2.3. PRO evaluation PRO was evaluated using the Japanese version of the Short Form-36 (SF-36) questionnaire for health status [17,18] and the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ) [19]. We evaluated SF-36 scores for the Physical Component Summary (PCS), Mental Component Summary (MCS), and Role/Social Component Summary (RCS) domains. The JHEQ was created by the Japanese Orthopaedic Association to consider Asian lifestyle behaviors. The JHEQ consists of three components for pain, movement, and mental health. Each component is scored in a range from 0 (worst) to 28 (best). The total score ranges between 0 (worst) and 84 (best). Hip pain and patient satisfaction with their hip's condition is marked with the Visual Analog Scale (VAS): pain is rated between 0 mm (best) and 100 mm (worst), and satisfaction is rated between 0 mm (best) and 100 mm (worst). Questionnaires were administered to all patients preoperatively and at the last follow-up. 2.4. Statistical analysis Statistical analyses of the osteotomy group and the control group was performed with SPSS version 21 (IBM Corp., Armonk, NY, USA). The analyses consisted of Student's t-test for continuous variables, ManneWhitney's U test for non-continuous variables, and Fisher's exact test for categorical variables, with the level of significance set at 0.05. Data are expressed as a mean ± standard deviation or median (range). 3. Results 3.1. Clinical evaluation
2.2. Clinical evaluation We investigated the medical records of patients to determine the operative time, intraoperative blood loss, postoperative complications such as infection, dislocation, deep venous thrombosis, and nerve palsy. Hip function was evaluated using the HHS and ROM before surgery and at the last follow-up. Both HHS and ROM were assessed annually by a single senior surgeon. Leg-length discrepancy was measured using the difference in vertical distance from the inner teardrop line to the most prominent point of the lesser trochanter with postoperative anteroposterior images of the hip, according to a report by Dong et al. [16].
There was no significant difference in the preoperative HHS between the osteotomy group and control group. However, the osteotomy group had a significantly lower HHS (84.1 ± 8.1) than the control group (90.6 ± 7.4) at the last follow-up (p < 0.01) (Table 2). The gait scores in the osteotomy group and the control group were 24.7 ± 6.2 and 30.1 ± 5.1, respectively (p < 0.01). The activity scores in the osteotomy group and the control group were 11.3 ± 2.2 and 12.4 ± 1.9, respectively (p ¼ 0.035). There were no significant differences between the groups in preoperative ROM. However, at the last follow-up, flexion, abduction, external rotation and internal rotation were all significantly poorer in the osteotomy group than
Please cite this article in press as: Osawa Y, et al., Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy, Journal of Orthopaedic Science (2017), https://doi.org/10.1016/j.jos.2017.11.001
Y. Osawa et al. / Journal of Orthopaedic Science xxx (2017) 1e4 Table 2 Clinical outcomes.
Harris Hip Score (preoperative) Pain Gait Activity Total Harris Hip Score (last follow up) Pain Gait Activity Total Range of motion (preoperative) Flexion Extension Abduction Adduction External rotation Internal rotation Range of motion (last follow up) Flexion Extension Abduction Adduction External rotation Internal rotation Operative time (min) Postoperative blood loss (ml) Complications Dislocation Infection Nerve palsy Deep venous thrombosis Revision surgery Leg length discrepancy (mm)
3
Table 3 Patient-reported outcomes. Osteotomy group (n ¼ 29)
Control group (n ¼ 58)
p value
22.1 ± 6.2 18.4 ± 6.3 9.2 ± 2.4 55.1 ± 11.7
24.8 ± 7.9 18.3 ± 5.6 9.6 ± 2.1 57.2 ± 10.7
0.081 0.971 0.528 0.277
± ± ± ±
0.684 ＜0.01 0.035 ＜0.01
43.1 24.7 11.3 84.1
± ± ± ±
4.9 6.2 2.2 8.1
43.3 30.1 12.4 90.6
3.2 5.1 1.9 7.4
67.7 ± 23.3 6.1 ± 6.6 13.4 ± 8.2 14.2 ± 5.8 17.8 ± 11.6 17.8 ± 12.6
69.8 ± 22.7 7.9 ± 5.5 14.6 ± 7.4 13.2 ± 5.6 22.4 ± 10.4 12.2 ± 14.5
0.991 0.437 0.562 0.551 0.136 0.164
82.2 ± 17.3 9.9 ± 5.6 18.4 ± 5.9 15.1 ± 4.6 21.8 ± 9.2 30.2 ± 14.8 88.7 ± 22.6 391.8 ± 257.4
92.6 ± 18.8 12.3 ± 4.3 24.5 ± 6.5 15.9 ± 4.4 27.8 ± 9.9 37.4 ± 12.9 67.3 ± 15.6 302.9 ± 193.3
0.029 0.138 ＜0.01 0.432 0.018 0.041 ＜0.01 0.118
1 0 0 0 1 3.9 ± 2.8
1 0 0 0 0 2.5 ± 3.7
1 1 1 1 0.701 0.134
Osteotomy group (n ¼ 29) SF36 (preoperative) PCS 23.2 (1.7e37.1) MCS 55.4 (43.3e67.5) RCS 50.5 (10.0e66.4) SF36 (last follow up) PCS 38.3 (9.1e51.9) MCS 54.1 (21.7e71.7) RCS 49.0 (19.8e62.0) JHEQ (preoperative) Pain 9 (0e19) Movement 6.5 (0e15) Mental 13.5 (0e23) Total 29 (0e50) JHEQ (last follow up) Pain 22 (0e28) Movement 9 (0e27) Mental 19 (2e28) Total 52 (8e83)
Control group (n ¼ 58)
p value
21.0 (5.1e61.9) 54.1 (28.2e74.7) 49.9 (7.0e76.1)
0.747 0.826 0.592
43.7 (11.0e65.3) 56.1 (39.7e72.1) 49.9 (6.3e65.1)
0.064 0.843 0.512
10 (0e24) 7.5 (0e20) 12 (0e24) 28 (0e65)
0.191 0.377 0.141 0.521
25 15 21 63
0.071 0.014 0.213 ＜0.01
(7e28) (1e28) (0e28) (8e84)
SF-36: Short Form-36 item healthstatus questionnaire. PCS: Physical Component Summary. RCS: Mental Component Summary. MCS: Role/Social Component Summary. JHEQ: Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire.
There was no significant difference in the VAS pain scores preoperatively and at the last follow-up between the groups. The preoperative VAS satisfaction scores were not significantly different between the osteotomy (76, range, 13e100 mm) and control (88, range 18e100 mm) groups. Postoperative satisfaction was poorer in the osteotomy group (15, range 0e100 mm) than in the control group (7, range 0e92 mm), but the difference was not significant (p ¼ 0.086) (Table 4). 4. Discussion
in the control group. The operative time was significantly longer in the osteotomy group (88.7 ± 22.6) than in the control group (67.3 ± 15.6; p < 0.01). There were no significant differences in the postoperative blood loss between the groups. Considering complications, both groups had one case of dislocation each; however, there were no cases of infection, deep venous thrombosis, and nerve palsy in either group. Revision surgery was performed in one case (cup exchange) in the osteotomy group, and no revision surgery was performed in the control group. There was no significant difference in leg length discrepancy between the osteotomy group (3.9 ± 2.8) and control group (2.5 ± 3.7; p ¼ 0.134). 3.2. PRO evaluation There was no significant difference between the groups among the preoperative SF-36 domains. The score for the PCS domain of SF-36 at the last follow-up was poorer for the osteotomy group (38.3, range, 9.1e51.9) than for the control group (43.7, range, 11.0e65.3), but the difference was not significant (p ¼ 0.064). The postoperative SF-36 scores for MCS and RCS were not significantly different between the groups. Considering the preoperative JHEQ scores, there were no significant differences in each domain and total score. However, the total postoperative JHEQ was significantly poorer in the osteotomy group (52, range 8e83) than in the control group (63, range 8e84; p < 0.01). The movement score in the osteotomy group (9, range 0e27) was significantly poorer than that in the control group (15, range 1e28; p ¼ 0.014). The postoperative JHEQ scores for pain and mental health were not significantly different between the groups (Table 3).
Many studies have reported that the clinical outcomes of THA after PAO are equivalent to those after primary THA [7e9]. In contrast, Peters et al. reported that the outcomes of THA after PAO were significantly poorer than those of primary THA [10]. Their report demonstrated that the pain score of HHS was significantly lower in the osteotomy group. Similarly, we reported that THA after PAO had significantly poorer clinical outcomes than did primary THA, and the main reasons were poor HHS outcome scores for gait and activity [11]. We therefore considered the necessity of further evaluating patient-reported outcomes for THA after PAO. In the present study, we determined that the PRO of these patients was significantly poorer in JHEQ for movement than for patients in whom primary THA alone was performed. Few reports have evaluated the PRO of patients who undergo THA after PAO. Hartig-Andreasen et al. reported a PCS score of 44.4 and an MCS score of 58.9 for patients who underwent THA after PAO (mean follow-up, 6.4 years) [6]. The MCS score for the osteotomy group (54.1) in the present study was similar to the Table 4 Comparison of visual analog scale scores.
VAS-Pain Preoperative Last follow up VAS-Satisfaction Preoperative Last follow up
Osteotomy group (n ¼ 29)
Control group (n ¼ 58)
p value
68 (15e100) 10 (0e84)
76 (0e100) 6 (0e100)
0.331 0.544
76 (13e100) 15 (0e100)
88 (18e100) 7 (0e92)
0.129 0.086
VAS: visual analog scale.
Please cite this article in press as: Osawa Y, et al., Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy, Journal of Orthopaedic Science (2017), https://doi.org/10.1016/j.jos.2017.11.001
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Y. Osawa et al. / Journal of Orthopaedic Science xxx (2017) 1e4
previously reported score, although the PCS score (38.3) indicated poor outcome in this domain. However, direct comparisons are not reliable, because their study did not have a control group. In addition, the mean time interval from PAO to THA was shorter in the previous study (3.3 years) than in the present study, while the mean age at the time of THA was higher in the present study than in the previous study (40.5 years). Many studies have reported that factors such as leg length discrepancy, ROM, abductor muscle strength, and dislocation affect patients' postoperative PRO after THA [20e23]. In the present study, leg length discrepancy and the dislocation rate were not significantly different between the groups. Conversely, postoperative recovery of ROM was poorer for patients in the osteotomy group than for those in the control group, which could have been because of hard soft tissue adhesion due to previous PAO. Fujita et al. reported that postoperative ROM was an important factor for postoperative QOL because Asian lifestyles need deep hip flexion for activities such as sitting straight and using Japanese toilets [23]. Similarly, the postoperative walking ability was poorer for patients in the osteotomy group than for those in the control group because many patients in this group limped compared with those in the control group. Therefore, we should consider conversion to THA before walking ability and ROM become worse in patients who underwent PAO previously. Considering the surgical technique, morphological changes in the acetabulum such as large osteophyte, acetabular sclerosis, and defect were reported to make it difficult to perform surgical techniques [5e11]. We have reported that socket positioning of safe zone was significantly poorer in THA after PAO than primary THA [11]. In addition, previous reports suggested that the socket tends to be positioned superolaterally in THA after PAO [9]. The surgical technique of positioning the socket in the anatomical hip center was challenging because acetabular bone defects were severe in patients who underwent THA after PAO compared with those who underwent primary THA [8,9,11]. However, we should position the socket as appropriately as possible because a high hip center may affect the postoperative walking ability and ROM [24,25]. The present study has some limitations. First, the number of patients in the study group (n ¼ 29) was small. It is suitable that far more patients should be investigated. Second, multiple types of implants were used in the current study, and there were slight differences in the implant type, cement or cementless stem, between the groups. However, revision surgery was performed for one case in the osteotomy; therefore, implants are considered to have little effect on the short-term clinical outcomes. Third, we could not investigate abductor muscle strength. RAO and ERAO are relatively invasive procedures for the abductor muscle; therefore, these osteotomies may lead to poor recovery of abductor muscle strength and gait ability postoperatively [22]. In conclusion, PRO of JHEQ for movement were significantly poorer for THA after PAO than for primary THA. Although PAO may be a successful form of joint preservation surgery in many patients, greater care should be paid to increase their quality of physical function after surgery. Conflict of interest All authors state that they have no conflicts of interest. References [1] Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year followup of Bernese periacetabular osteotomy. Clin Orthop Relat Res 2008 Jul;466(7): 1633e44.
[2] Kaneuji A, Sugimori T, Ichiseki T, Fukui K, Takahashi E, Matsumoto T. Rotational acetabular osteotomy for osteoarthritis with acetabular dysplasia: conversion rate to total hip arthroplasty within twenty years and osteoarthritis progression after a minimum of twenty years. J Bone Jt Surg Am 2015 May;97(9):726e32. [3] Yasunaga Y, Ochi M, Yamasaki T, Shoji T, Izumi S. Rotational acetabular osteotomy for pre- and early osteoarthritis secondary to dysplasia provides durable results at 20 years. Clin Orthop Relat Res 2016 Oct;474(10): 2145e53. [4] Hasegawa Y, Iwase T, Kitamura S, Kawasaki M, Yamaguchi J. Eccentric rotational acetabular osteotomy for acetabular dysplasia and osteoarthritis: follow-up at a mean duration of twenty years. J Bone Jt Surg Am 2014 Dec;96(23):1975e82. [5] Parvizi J, Burmeister H, Ganz R. Previous Bernese periacetabular osteotomy does not compromise the results of total hip arthroplasty. Clin Orthop Relat Res 2004 Jun;423(6):118e22. [6] Hartig-Andreasen C, Stilling M, Søballe K, Thilleman TK, Troelsen A. Is cup positioning challenged in hips previously treated with periacetabular osteotomy? J Arthroplasty 2014 Apr;29(4):763e8. [7] Amanatullah DF, Stryker L, Schoenecker P, Taunton MJ, Clohisy JC, Trousdale RT, Sierra RJ. Similar clinical outcomes for THAs with and without prior periacetabular osteotomy. Clin Orthop Relat Res 2015 Feb;473(2): 685e91. [8] Ito H, Takatori Y, Moro T, Oshima H, Oka H, Tanaka S. Total hip arthroplasty after rotational acetabular osteotomy. J Arthroplasty 2015 Mar;30(3): 403e6. [9] Fukui K, Kaneuji A, Sugimori T, Ichiseki T, Matsumoto T. Does rotational acetabular osteotomy affect subsequent total hip arthroplasty? Arch Orthop Trauma Surg 2015 Mar;135(3):407e15. [10] Peters CL, Beck M, Dunn HK. Total hip arthroplasty in young adults after failed triple innominate osteotomy. J Arthroplasty 2001 Feb;16(2):188e95. [11] Osawa Y, Hasegawa Y, Seki T, Amano T, Higuchi Y, Ishiguro N. Significantly poor outcomes of total hip arthroplasty after failed periacetabular osteotomy. J Arthroplasty 2016 Sep;31(9):1904e9. [12] Al-Taki MM, Masri BA, Duncan CP, Garbuz DS. Quality of life following proximal femoral replacement using a modular system in revision THA. Clin Orthop Relat Res 2011 Feb;469(2):470e5. [13] Rahman WA, Greidanus NV, Siegmeth A, Masri BA, Duncan CP, Garbuz DS. Patients report improvement in quality of life and satisfaction after hip resurfacing arthroplasty. Clin Orthop Relat Res 2013 Feb;471(2):444e53. [14] Hasegawa Y, Iwase T, Kitamura S, Yamauchi K, Sakano S, Iwata H. Eccentric rotational acetabular osteotomy for acetabular dysplasia: follow-up of one hundred and thirty-two hips for five to ten years. J Bone Jt Surg Am 2002 Mar;84(3):404e10. [15] Ninomiya S. Rotational acetabular osteotomy for the severely dysplastic hip in the adolescent and adult. Clin Orthop Relat Res 1989 Oct;247(10):127e37. [16] Dong N, Yang C, Li SQ, Gao YH, Liu JG, Qi X. Effect of preoperative leg length discrepancy on functional outcome and patient satisfaction after total hip arthroplasty in cases of osteonecrosis of the femoral head. J Arthroplasty 2016 Dec;31(12):2789e94. [17] Ware Jr JE, Sherbourne CD. The MOS 36-item short-form health survey (SF36). I. Conceptual framework and item selection. Med Care 1992 Jun;30(6): 473e83. [18] Fukuhara S, Bito S, Green J, Hsiao A, Kurokawa K. Translation, adaptation, and validation of the SF-36 Health Survey for use in Japan. J Clin Epidemiol 1998 Nov;51(11):1037e44. [19] Matsumoto T, Kaneuji A, Hiejima Y, Sugiyama H, Akiyama H, Atsumi T, Ishii M, Izumi K, Ichiseki T, Ito H, Okawa T, Ohzono K, Otsuka H, Kishida S, Kobayashi S, Sawaguchi T, Sugano N, Nakajima I, Nakamura S, Hasegawa Y, Fukuda K, Fujii G, Mawatari T, Mori S, Yasunaga Y, Yamaguchi M. Japanese orthopaedic Association hip disease evaluation questionnaire (JHEQ): a patient-based evaluation tool for hip-joint disease. The subcommittee on hip disease evaluation of the clinical outcome committee of the Japanese orthopaedic Association. J Orthop Sci 2012 Jan;17(1):25e38. [20] Mahmood SS, Mukka SS, Crnalic S, Sayed-Noor AS. The influence of leg length discrepancy after total hip arthroplasty on function and quality of life: a prospective cohort study. J Arthroplasty 2015 Sep;30(9):1638e42. [21] Forsythe ME, Whitehouse SL, Dick J, Crawford RW. Functional outcomes after nonrecurrent dislocation of primary total hip arthroplasty. J Arthroplasty 2007 Feb;22(2):227e30. [22] Mahmood SS, Mukka SS, Crnalic S, Wretenberg P, Sayed-Noor AS. Association between changes in global femoral offset after total hip arthroplasty and function, quality of life, and abductor muscle strength. Acta Orthop 2016 Feb;87(1):36e41. [23] Fujita K, Makimoto K, Mawatari M. Three-year follow-up study of health related QOL and lifestyle indicators for Japanese patients after total hip arthroplasty. J Orthop Sci 2016 Mar;21(2):191e8. 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Please cite this article in press as: Osawa Y, et al., Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy, Journal of Orthopaedic Science (2017), https://doi.org/10.1016/j.jos.2017.11.001
Contents lists available at ScienceDirect
Journal of Orthopaedic Science journal homepage: http://www.elsevier.com/locate/jos
Original Article
Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy Yusuke Osawa a, *, Yukiharu Hasegawa b, Taisuke Seki a, Yasuhiko Takegami a, Takafumi Amano a, Naoki Ishiguro a a b
Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan Department of Hip and Knee Reconstructive Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 1 June 2017 Received in revised form 1 November 2017 Accepted 2 November 2017 Available online xxx
Background: There has been constant discussion about whether the clinical outcome of THA after periacetabular osteotomy (PAO) is equivalent to that after primary total hip arthroplasty (THA). However, there have been few reports about patient-reported outcomes (PRO) for those who undergo THA after PAO. We compared the pre- and postoperative PRO of patients who underwent THA after PAO and those who underwent primary THA alone. Methods: We performed a caseecontrol study. Twenty-seven patients (29 hips) underwent THA after PAO (osteotomy group); their mean age at surgery was 57.2 years, and they underwent postoperative follow-up for a mean period of 3.0 years. For the control group, after matching age, sex, and Crowe classification, we included 54 patients (58 joints) who underwent primary THA for hip dysplasia. Assessment performed preoperatively and at the last follow-up included the Harris hip score, the Short Form 36 (SF-36) for the Physical Component Summary (PCS), Mental Component Summary (MCS), and Role/Social Component Summary (RCS) domains, Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ) for pain, movement, and mental health, and the visual analog scale (VAS) score of hip pain and satisfaction. Results: The two groups demonstrated no significant difference in the preoperative Harris hip score, each domain of the SF-36, JHEQ, and the VAS score of hip pain and satisfaction. The osteotomy group demonstrated significantly poor Harris hip scores for gait and activity, and JHEQ for movement at the last follow-up. There was no significant difference in each domain of the SF-36 and the VAS score of hip pain and satisfaction at the last follow-up. Conclusion: Previous PAO affects the quality of physical function in patients who undergo subsequent THA. © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
1. Introduction Various types of periacetabular osteotomy (PAO) are considered suitable to treat acetabular dysplasia in young adults in order to prevent the progression of osteoarthritis [1e4]. However, some patients who undergo PAO demonstrate long-term progression of osteoarthritis, thereby needing conversion to total hip arthroplasty (THA) [5e11]. Many studies have reported that the clinical
* Corresponding author. Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan. Fax: þ81 52 744 2260. E-mail address: [email protected] (Y. Osawa).
outcomes of THA after PAO are equivalent to those after primary THA [7e9]. On the other hand, several reports suggested that the therapeutic outcomes of THA after PAO are poorer than those obtained after primary THA [10,11]. There has been constant discussion about whether the clinical outcome of THA after PAO is equivalent to that after primary THA. In past reports, clinical outcomes were evaluated only by medical investigator-initiated outcomes such as the Harris Hip Score (HSS). Recently, patientreported measures of quality of life (QOL) have been found to be essential tools to assess the postoperative clinical outcomes of THA [12,13]. However, few studies on THA after PAO have evaluated patient-reported outcome (PRO). In the present study, therefore, we compared PRO of THA after PAO with those of primary THA.
https://doi.org/10.1016/j.jos.2017.11.001 0949-2658/© 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Osawa Y, et al., Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy, Journal of Orthopaedic Science (2017), https://doi.org/10.1016/j.jos.2017.11.001
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2. Materials and methods
Table 1 Patients demographics.
2.1. Patients and procedures This study was a retrospective chart review and was approved by an institutional review board. All patients provided written informed consent to participate. The study included 35 patients (37 hips) who consecutively underwent THA between April 2011 and March 2016 because of the progression of osteoarthritis after PAO. Seven patients (seven hips) who underwent concomitant intertrochanteric valgus osteotomy and one patient (one hip) who died during the follow-up period because of causes not related to surgery were excluded from the study. Thus, the final osteotomy group comprised of 27 patients (29 hips). The types of PAO included eccentric rotational acetabular osteotomy (ERAO) [14], performed for 23 hips at our institution; and rotational acetabular osteotomy (RAO) [15], performed for 6 hips at other hospitals. The patients included two men (two hips) and 25 women (27 hips), with a mean age of 57.2 years (range, 40e77 years) at the time of THA. Patients were followed-up for a mean duration of 3.0 years (range, 1e5 years). The mean age at the time of PAO was 41.1 years (range, 12e57 years). The mean interval between PAO and THA was 13.7 years (range, 3e23 years). We also selected hospital records to identify patients who underwent primary THA for osteoarthritis during the same period. We designed a case control study in which patients were matched by age (±5 years), sex, and Crowe classification. We identified 54 patients (58 hips) with no history of osteotomy who underwent primary THA for hip osteoarthritis. All THA procedures were performed by a single senior surgeon or by junior surgeons under the guidance of a senior surgeon. THA in all patients was performed using a standard posterior approach, with the patient in the lateral decubitus position. Generally cementless implants were chosen; however, in the case of poor bone quality on preoperative radiography findings and problems with fixation, cement implants were chosen instead. With regard to the type of implants used in the osteotomy group, Trident HA (Stryker Orthopedics, Mahwah, NJ) was used for 29 hips, Super Secur-Fit (Stryker Orthopedics, Mahwah, NJ) stems were used for 22 hips, Accolade II (Stryker Orthopedics, Mahwah, NJ) stems were used in three hips, and Exeter (Stryker Orthopedics, Mahwah, NJ) stems were used for four hips. For the control group, Trident HA (Stryker Orthopedics, Mahwah, NJ) was used for 58 hips, Super Secur-Fit (Stryker Orthopedics, Mahwah, NJ) stems were used for 51 hips, Accolade II (Stryker Orthopedics, Mahwah, NJ) stems were used in five hips, and Exeter (Stryker Orthopedics, Mahwah, NJ) stems were used for two hips. Regarding postoperative rehabilitation, generally, we allowed walking training and range of motion (ROM) training with full weight bearing in both groups. There were no significant differences in age, sex, body mass index, the follow-up duration or implant type between the groups (Table 1).
Osteotomy Control p value group (n ¼ 29) group (n ¼ 58) Number of patients Gender (male/female) BMI Age at THA (years) Duration PAO to THA (years) Crowe classification Group I Group II Group III Group IV Follow up (years) Acetabular socket (cementless/cement) Femoral Stem (cementless/cement)
27 2/25 24.2 ± 3.6 57.2 ± 7.2 13.7 ± 6.2
54 4/50 23.6 ± 3.3 58.3 ± 7.7 e
16 11 2 0 3.0 ± 1.7 29/0
32 22 4 0 3.1 ± 1.6 58/0
0.828 1
25/4
56/2
0.092
1 0.362 0.563 e 1
BMI: Body mass index. THA: Total hip arthroplasty. PAO: Periacetabular osteotomy.
2.3. PRO evaluation PRO was evaluated using the Japanese version of the Short Form-36 (SF-36) questionnaire for health status [17,18] and the Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire (JHEQ) [19]. We evaluated SF-36 scores for the Physical Component Summary (PCS), Mental Component Summary (MCS), and Role/Social Component Summary (RCS) domains. The JHEQ was created by the Japanese Orthopaedic Association to consider Asian lifestyle behaviors. The JHEQ consists of three components for pain, movement, and mental health. Each component is scored in a range from 0 (worst) to 28 (best). The total score ranges between 0 (worst) and 84 (best). Hip pain and patient satisfaction with their hip's condition is marked with the Visual Analog Scale (VAS): pain is rated between 0 mm (best) and 100 mm (worst), and satisfaction is rated between 0 mm (best) and 100 mm (worst). Questionnaires were administered to all patients preoperatively and at the last follow-up. 2.4. Statistical analysis Statistical analyses of the osteotomy group and the control group was performed with SPSS version 21 (IBM Corp., Armonk, NY, USA). The analyses consisted of Student's t-test for continuous variables, ManneWhitney's U test for non-continuous variables, and Fisher's exact test for categorical variables, with the level of significance set at 0.05. Data are expressed as a mean ± standard deviation or median (range). 3. Results 3.1. Clinical evaluation
2.2. Clinical evaluation We investigated the medical records of patients to determine the operative time, intraoperative blood loss, postoperative complications such as infection, dislocation, deep venous thrombosis, and nerve palsy. Hip function was evaluated using the HHS and ROM before surgery and at the last follow-up. Both HHS and ROM were assessed annually by a single senior surgeon. Leg-length discrepancy was measured using the difference in vertical distance from the inner teardrop line to the most prominent point of the lesser trochanter with postoperative anteroposterior images of the hip, according to a report by Dong et al. [16].
There was no significant difference in the preoperative HHS between the osteotomy group and control group. However, the osteotomy group had a significantly lower HHS (84.1 ± 8.1) than the control group (90.6 ± 7.4) at the last follow-up (p < 0.01) (Table 2). The gait scores in the osteotomy group and the control group were 24.7 ± 6.2 and 30.1 ± 5.1, respectively (p < 0.01). The activity scores in the osteotomy group and the control group were 11.3 ± 2.2 and 12.4 ± 1.9, respectively (p ¼ 0.035). There were no significant differences between the groups in preoperative ROM. However, at the last follow-up, flexion, abduction, external rotation and internal rotation were all significantly poorer in the osteotomy group than
Please cite this article in press as: Osawa Y, et al., Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy, Journal of Orthopaedic Science (2017), https://doi.org/10.1016/j.jos.2017.11.001
Y. Osawa et al. / Journal of Orthopaedic Science xxx (2017) 1e4 Table 2 Clinical outcomes.
Harris Hip Score (preoperative) Pain Gait Activity Total Harris Hip Score (last follow up) Pain Gait Activity Total Range of motion (preoperative) Flexion Extension Abduction Adduction External rotation Internal rotation Range of motion (last follow up) Flexion Extension Abduction Adduction External rotation Internal rotation Operative time (min) Postoperative blood loss (ml) Complications Dislocation Infection Nerve palsy Deep venous thrombosis Revision surgery Leg length discrepancy (mm)
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Table 3 Patient-reported outcomes. Osteotomy group (n ¼ 29)
Control group (n ¼ 58)
p value
22.1 ± 6.2 18.4 ± 6.3 9.2 ± 2.4 55.1 ± 11.7
24.8 ± 7.9 18.3 ± 5.6 9.6 ± 2.1 57.2 ± 10.7
0.081 0.971 0.528 0.277
± ± ± ±
0.684 ＜0.01 0.035 ＜0.01
43.1 24.7 11.3 84.1
± ± ± ±
4.9 6.2 2.2 8.1
43.3 30.1 12.4 90.6
3.2 5.1 1.9 7.4
67.7 ± 23.3 6.1 ± 6.6 13.4 ± 8.2 14.2 ± 5.8 17.8 ± 11.6 17.8 ± 12.6
69.8 ± 22.7 7.9 ± 5.5 14.6 ± 7.4 13.2 ± 5.6 22.4 ± 10.4 12.2 ± 14.5
0.991 0.437 0.562 0.551 0.136 0.164
82.2 ± 17.3 9.9 ± 5.6 18.4 ± 5.9 15.1 ± 4.6 21.8 ± 9.2 30.2 ± 14.8 88.7 ± 22.6 391.8 ± 257.4
92.6 ± 18.8 12.3 ± 4.3 24.5 ± 6.5 15.9 ± 4.4 27.8 ± 9.9 37.4 ± 12.9 67.3 ± 15.6 302.9 ± 193.3
0.029 0.138 ＜0.01 0.432 0.018 0.041 ＜0.01 0.118
1 0 0 0 1 3.9 ± 2.8
1 0 0 0 0 2.5 ± 3.7
1 1 1 1 0.701 0.134
Osteotomy group (n ¼ 29) SF36 (preoperative) PCS 23.2 (1.7e37.1) MCS 55.4 (43.3e67.5) RCS 50.5 (10.0e66.4) SF36 (last follow up) PCS 38.3 (9.1e51.9) MCS 54.1 (21.7e71.7) RCS 49.0 (19.8e62.0) JHEQ (preoperative) Pain 9 (0e19) Movement 6.5 (0e15) Mental 13.5 (0e23) Total 29 (0e50) JHEQ (last follow up) Pain 22 (0e28) Movement 9 (0e27) Mental 19 (2e28) Total 52 (8e83)
Control group (n ¼ 58)
p value
21.0 (5.1e61.9) 54.1 (28.2e74.7) 49.9 (7.0e76.1)
0.747 0.826 0.592
43.7 (11.0e65.3) 56.1 (39.7e72.1) 49.9 (6.3e65.1)
0.064 0.843 0.512
10 (0e24) 7.5 (0e20) 12 (0e24) 28 (0e65)
0.191 0.377 0.141 0.521
25 15 21 63
0.071 0.014 0.213 ＜0.01
(7e28) (1e28) (0e28) (8e84)
SF-36: Short Form-36 item healthstatus questionnaire. PCS: Physical Component Summary. RCS: Mental Component Summary. MCS: Role/Social Component Summary. JHEQ: Japanese Orthopaedic Association Hip-Disease Evaluation Questionnaire.
There was no significant difference in the VAS pain scores preoperatively and at the last follow-up between the groups. The preoperative VAS satisfaction scores were not significantly different between the osteotomy (76, range, 13e100 mm) and control (88, range 18e100 mm) groups. Postoperative satisfaction was poorer in the osteotomy group (15, range 0e100 mm) than in the control group (7, range 0e92 mm), but the difference was not significant (p ¼ 0.086) (Table 4). 4. Discussion
in the control group. The operative time was significantly longer in the osteotomy group (88.7 ± 22.6) than in the control group (67.3 ± 15.6; p < 0.01). There were no significant differences in the postoperative blood loss between the groups. Considering complications, both groups had one case of dislocation each; however, there were no cases of infection, deep venous thrombosis, and nerve palsy in either group. Revision surgery was performed in one case (cup exchange) in the osteotomy group, and no revision surgery was performed in the control group. There was no significant difference in leg length discrepancy between the osteotomy group (3.9 ± 2.8) and control group (2.5 ± 3.7; p ¼ 0.134). 3.2. PRO evaluation There was no significant difference between the groups among the preoperative SF-36 domains. The score for the PCS domain of SF-36 at the last follow-up was poorer for the osteotomy group (38.3, range, 9.1e51.9) than for the control group (43.7, range, 11.0e65.3), but the difference was not significant (p ¼ 0.064). The postoperative SF-36 scores for MCS and RCS were not significantly different between the groups. Considering the preoperative JHEQ scores, there were no significant differences in each domain and total score. However, the total postoperative JHEQ was significantly poorer in the osteotomy group (52, range 8e83) than in the control group (63, range 8e84; p < 0.01). The movement score in the osteotomy group (9, range 0e27) was significantly poorer than that in the control group (15, range 1e28; p ¼ 0.014). The postoperative JHEQ scores for pain and mental health were not significantly different between the groups (Table 3).
Many studies have reported that the clinical outcomes of THA after PAO are equivalent to those after primary THA [7e9]. In contrast, Peters et al. reported that the outcomes of THA after PAO were significantly poorer than those of primary THA [10]. Their report demonstrated that the pain score of HHS was significantly lower in the osteotomy group. Similarly, we reported that THA after PAO had significantly poorer clinical outcomes than did primary THA, and the main reasons were poor HHS outcome scores for gait and activity [11]. We therefore considered the necessity of further evaluating patient-reported outcomes for THA after PAO. In the present study, we determined that the PRO of these patients was significantly poorer in JHEQ for movement than for patients in whom primary THA alone was performed. Few reports have evaluated the PRO of patients who undergo THA after PAO. Hartig-Andreasen et al. reported a PCS score of 44.4 and an MCS score of 58.9 for patients who underwent THA after PAO (mean follow-up, 6.4 years) [6]. The MCS score for the osteotomy group (54.1) in the present study was similar to the Table 4 Comparison of visual analog scale scores.
VAS-Pain Preoperative Last follow up VAS-Satisfaction Preoperative Last follow up
Osteotomy group (n ¼ 29)
Control group (n ¼ 58)
p value
68 (15e100) 10 (0e84)
76 (0e100) 6 (0e100)
0.331 0.544
76 (13e100) 15 (0e100)
88 (18e100) 7 (0e92)
0.129 0.086
VAS: visual analog scale.
Please cite this article in press as: Osawa Y, et al., Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy, Journal of Orthopaedic Science (2017), https://doi.org/10.1016/j.jos.2017.11.001
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Y. Osawa et al. / Journal of Orthopaedic Science xxx (2017) 1e4
previously reported score, although the PCS score (38.3) indicated poor outcome in this domain. However, direct comparisons are not reliable, because their study did not have a control group. In addition, the mean time interval from PAO to THA was shorter in the previous study (3.3 years) than in the present study, while the mean age at the time of THA was higher in the present study than in the previous study (40.5 years). Many studies have reported that factors such as leg length discrepancy, ROM, abductor muscle strength, and dislocation affect patients' postoperative PRO after THA [20e23]. In the present study, leg length discrepancy and the dislocation rate were not significantly different between the groups. Conversely, postoperative recovery of ROM was poorer for patients in the osteotomy group than for those in the control group, which could have been because of hard soft tissue adhesion due to previous PAO. Fujita et al. reported that postoperative ROM was an important factor for postoperative QOL because Asian lifestyles need deep hip flexion for activities such as sitting straight and using Japanese toilets [23]. Similarly, the postoperative walking ability was poorer for patients in the osteotomy group than for those in the control group because many patients in this group limped compared with those in the control group. Therefore, we should consider conversion to THA before walking ability and ROM become worse in patients who underwent PAO previously. Considering the surgical technique, morphological changes in the acetabulum such as large osteophyte, acetabular sclerosis, and defect were reported to make it difficult to perform surgical techniques [5e11]. We have reported that socket positioning of safe zone was significantly poorer in THA after PAO than primary THA [11]. In addition, previous reports suggested that the socket tends to be positioned superolaterally in THA after PAO [9]. The surgical technique of positioning the socket in the anatomical hip center was challenging because acetabular bone defects were severe in patients who underwent THA after PAO compared with those who underwent primary THA [8,9,11]. However, we should position the socket as appropriately as possible because a high hip center may affect the postoperative walking ability and ROM [24,25]. The present study has some limitations. First, the number of patients in the study group (n ¼ 29) was small. It is suitable that far more patients should be investigated. Second, multiple types of implants were used in the current study, and there were slight differences in the implant type, cement or cementless stem, between the groups. However, revision surgery was performed for one case in the osteotomy; therefore, implants are considered to have little effect on the short-term clinical outcomes. Third, we could not investigate abductor muscle strength. RAO and ERAO are relatively invasive procedures for the abductor muscle; therefore, these osteotomies may lead to poor recovery of abductor muscle strength and gait ability postoperatively [22]. In conclusion, PRO of JHEQ for movement were significantly poorer for THA after PAO than for primary THA. Although PAO may be a successful form of joint preservation surgery in many patients, greater care should be paid to increase their quality of physical function after surgery. Conflict of interest All authors state that they have no conflicts of interest. References [1] Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year followup of Bernese periacetabular osteotomy. Clin Orthop Relat Res 2008 Jul;466(7): 1633e44.
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Please cite this article in press as: Osawa Y, et al., Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy, Journal of Orthopaedic Science (2017), https://doi.org/10.1016/j.jos.2017.11.001