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Total hip arthroplasty outcomes correlate with spine disability
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E M I N A R S I N
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Available online at www.sciencedirect.com
www.elsevier.com/locate/semanthroplasty
Total hip arthroplasty outcomes correlate with spine disability William C. Schroer, MDn, Erica Diesfeld, Angela R. LeMarr, RN, Diane J. Morton, MS, and Mary E. Reedy, RN St. Louis Joint Replacement Institute, St. Louis, MO
article info
abstract
Keywords:
Functional deficits persist in a significant percentage of total hip arthroplasties (THA), leading to
total hip arthroplasty
patient dissatisfaction. Spinal stenosis is a leading cause of chronic disability and lower
spine disability
extremity weakness. Although previous studies have evaluated the potential benefit of THA
hip function
on back pain, none have reported the effects of spine disability on functional outcomes and
patient satisfaction
patient satisfaction with THA. A total of 244 primary THAs (233 patients) with minimum 2-year
outcomes
follow-up rated their satisfaction, return to activity, and standard hip outcomes using the Oxford Hip Score (OHS). History of lumbar spine pain, lumbar surgery, and daily activity limitations was documented and an Oswestry Disability Index (ODI) score was calculated. Out of 244, 151 (62%) patients reported a history of back problems: 35 patients (14%)—history of lumbar surgery, 91 (37%)—daily low back pain, and 97 (40%)—back pain that limited activity. Patients with a history of back problems had lower OHS scores than those without back pain, p ¼ 0.0001. Patients with daily low back pain or low back pain that limited activity had lower OHS scores, p o 0.0001. Increasing spine disability, as determined by ODI, correlated with poor OHS, p o 0.0001. Spine disability (ODI) was directly associated with patient dissatisfaction for pain relief (R ¼ 0.41, p o 0.0001), return to activity (R ¼ 0.34, p o 0.0001), and overall surgical results (ODI, R ¼ 0.38, p o 0.0001) at 2 years after THA. ODI correlated strongly with poor THA outcomes. In conclusion, lumbar spine disability correlated directly with poor Oxford Hip Scores. Spine disability was directly associated with THA patient dissatisfaction with pain relief, return to activity, and overall outcome of surgery. This study demonstrates that poor functional results in THA patients correlate directly with spine disability. & 2016 Elsevier Inc. All rights reserved.
1.
Introduction
Functional deficits persist for a significant number of patients after total hip arthroplasty (THA) [1]. Preoperative functional status often is an independent predictor of patient
satisfaction after THA [2,3], and poor preoperative function portends to unfavorable functional outcomes [2,4–12]. Back pain affects more than 75% of Americans over the course of their lives [13]. Spinal stenosis is a leading cause of chronic disability and lower extremity weakness in the
The authors thank Karen Steger-May, M.S., for statistical analysis. This study was funded by the St. Louis Joint Replacement Institute. Neither the authors nor the patients received anything of value for the conduction of this study. Ethical principles of research and compliance with HIPAA guidelines were followed to protect patient identity and health information privacy. n Correspondence to: St. Louis Joint Replacement Institute, SSM Health Orthopedics, 12349 DePaul Dr, Suite 100, St. Louis, MO 63044. E-mail address: [email protected] (W.C. Schroer). http://dx.doi.org/10.1053/j.sart.2016.06.015 1045-4527/& 2016 Elsevier Inc. All rights reserved.
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elderly [14,15]. Adults with low back pain are in worse physical health: 28% of adults with low back pain report limited activity whereas 10% of adults without low back pain report limited activity [16]. Spinal stenosis and osteoarthritis of the hip frequently occur in the same patient. Osteoarthritis of the hip is more prevalent in individuals with radiographic signs of spinal degeneration [17]. Previously published studies on this topic primarily have evaluated the potential benefit of joint arthroplasty on back pain [1,18,19]. No published study has evaluated the effects of spine disability on functional outcomes and patient satisfaction following THA. This study sought to determine the incidence of spine disability in THA patients, its potential association to hip outcomes, and its correlation to patient satisfaction following primary THA.
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Table 1 – Study Questionnaire Clinical history of back pain questions (1) Have you ever had surgery on your back?
(2) Do you have a history of low back problems? (3) Do you have daily back pain? (4) Does back pain limit your activity? Patient satisfaction questions (1) How much has your hip pain changed as a result of your hip surgery?
(a) Improved a lot (b) Improved a little (c) No change
(d) A little worse (e) A lot worse
(2) To what extent have you resumed your usual activities following your hip replacement?
2.
Patients and methods
Demographic and clinical data for patients undergoing primary THA between June 1, 2010 and June 1, 2012 were obtained through retrospective review. The study was IRBapproved. Overall, 428 patients were identified who met eligibility criteria. A questionnaire was mailed with a letter explaining the purpose of the study and to invite volunteer participation. The questionnaire was completed and returned for 244 THAs (233 patients). Spine questions detailed history of back problems, including prior back surgery, and determined the Oswestry Disability Index (ODI), the most commonly applied spine-specific patient outcome measurement [20,21] (Table 1). Postoperative hip pain and function were determined by the Oxford Hip Score (OHS). Variables previously described to correlate with THA outcomes such as age, gender, BMI, and ASA, were compared with OHS. New variables including the presence of back problems and spine disability, as measured by the ODI, similarly were compared to OHS to determine the association between spine disability and hip outcomes. Finally, patient satisfaction with pain relief, function, and overall outcome was determined from three questions (Table 1). Spine disability (ODI) scores were modeled statistically against these satisfaction results. Statistical analysis of demographic data utilized Wilcoxon t-test for quantitative measures and Chi square analysis for categorical measures. Comparisons of categorical variables to OHS were made with Wilcoxon’s t-test, p o 0.05 for significance. For continuous characteristics, the Spearman Correlation Coefficient was used for a linear association between the characteristic and the OHS value, with significance R 4 0.20.
3.
Results
Out of 244, 151 (62%) THA patients reported a history of back problems. In all, 35 patients (14%) reported history of lumbar surgery, 91 (37%) reported daily low back pain, and 97 (40%) reported back pain that limits activity. Compared to patients without a history of back problems, patients with back problems had worse OHS (21.8 vs. 17.2, p ¼ 0.001), patients with daily back pain had worse OHS (23.9 vs. 17.7, p o 0.0001),
(a) A lot (b) Moderately (c) Somewhat
(d) A little (e) Not at all
(3) In general, how would you rate the outcome of your hip surgery? (a) Excellent (b) Very good (c) Good
(d) Fair (e) Poor
and patients with activity-limiting pain had inferior OHS (24.3 vs. 17.2, p o 0.0001). A history of spine surgery was not associated with OHS (Fig. 1). The mean ODI score of all patients was 16.1, but was 26.1 in the 151 THA patients with a history of back problems. Patients categorized with minimal spine disability, ODI o 20, had a mean OHS of 16.8 (IQR: 12.0–19.0). Patients with moderate spine disability, ODI: 20–39, had a mean OHS of 22.5 (IQR: 15.0–28.0). Patients with severe spine disability, ODI ¼ 40 or more, had a mean OHS of 30.6 (IQR: 20.5–41.0), p o 0.0001. Covariates associated with OHS included the Oswestry Disability Index (ODI), R ¼ 0.46, p o 0.0001 (Fig. 2) and ASA level, p o 0.0001. Several patient variables were not associated with hip outcomes as determined by the OHS: gender, p ¼ 0.45; age, R ¼ 0.07, p ¼ 0.25; BMI, R ¼ 0.10, p ¼ 0.11. When asked to rate satisfaction with THA on pain relief, return to activity, and outcome of surgery, patients of 18 hips (7%) reported no improvement in pain or worsening of their hip pain following THA, 16 hips (7%) reported little to no return to usual activities following THA, and 23 hips (10%) rated their THA outcome as fair or poor. Overall dissatisfaction with THA outcome correlated strongly with spine disability, ODI, R ¼ 0.38, p o 0.0001. Patients with increased hip pain after surgery had a higher level of spine disability (ODI), R ¼ 0.41, p o 0.0001. Patients with difficulty returning to usual activities following THA had a higher ODI, R ¼ 0.34, p o 0.0001 (Fig. 3).
4.
Discussion
Patient dissatisfaction following primary total hip arthroplasty (THA) has been shown between 7% and 15%, with many patients experiencing persistent pain and limited function [3,22,23]. Previously published hip outcomes studies
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Figure 1 – Graph depicting the mean and interquartile range of the Oxford Hip Score (OHS) for each spine condition question. have reported the patient’s preoperative functional status as the primary factor affecting postoperative function [2,8–10]. Several studies have specifically demonstrated that poor preoperative walking capacity is directly associated with worse THA outcomes [6,11]. While limited walking capacity is expected with lower extremity osteoarthritis, other coexistent disease also affects function [5]. Spinal stenosis causes chronic disability with lower extremity weakness and has been postulated to impede total joint function [6,15,24]. The results of this study indicate that poor THA outcomes and patient dissatisfaction correlate directly with the incidence and severity of lumbar spine disability. Back pain affects more than 75% of Americans over the course of their lives [13], and spinal stenosis is a leading cause of chronic disability and lower extremity weakness in the elderly [15,25]. In the current study of 244 THAs, 62% (151) reported a history of back problems; 14% (35) reported previous back surgery, 37% (91) reported daily low back pain, and 40% (97) reported lumbar pain that limited activity. Similar rates of lumbar pain have been reported by Parvisi et al. [1] with 49.4% of THA patients reporting lumbar pain, and Staibano et al. [19] with 28.8% of THA patients reporting daily back pain. However, both of these studies differ from the current study in their analysis of the benefit of THA on back pain, reporting more than half of patients experienced improvement in back pain following primary THA. Causation of back pain in patients with hip arthritis has been termed the Hip-Spine Syndrome [1,18,19]. Alternatively, the current study evaluated the association of lumbar spine pain and disability on the outcomes and function of a fully recovered THA. Low back pain has previously been shown to impact standardized arthritis outcome measures. The Western Ontario MacMaster (WOMAC) score, a validated instrument that assesses pain and function in osteoarthritis of the hip and knee, is negatively affected by back pain [26]. Previously, poor preoperative WOMAC scores were associated with less improvement in pain and function following THA [4]. Similarly, the current study demonstrated significantly worse OHS in patients with a history of back problems; 17.2 for patients without back problems compared with 21.8 in patients reporting back problems, p ¼ 0.001 (Fig. 1). Questions from the OHS, as well as most hip and knee functional
outcome tools, determine a patient’s ability to walk, but are unable to differentiate if compromised function is due to hip or spine pathology. Studies reporting back pain results, including the current report, could be criticized because back pain is an inherently vague and non-specific diagnosis. Therefore, the current study used the Oswestry Disability Index (ODI), the most commonly applied standardized spine disability measure [20]. Few arthroplasty studies have analyzed an association of joint replacement and spine disability. Staibano et al. employed the ODI as an outcome measure of joint replacement surgery and found that THA correlated with improvement in ODI scores from preoperative values. No association was seen following TKA [19]. Alternatively, in the current study, the ODI was determined 2 or more years after THA and used as a patient-specific variable to determine its association with THA outcomes. The mean ODI was 16.1 for all 244 THA, and increased to 26.1 for the 151 patients with a history of back problems. Patients with minimal spine disability had excellent OHS (16.8), while patients with moderate or severe spine disability had significantly worse hip outcomes, OHS of 22.5 and 30.6, respectively, p o 0.0001. In the current study, only the patients’ comorbid medical history (ASA) and spine disability (ODI) correlated with poor OHS. Age, gender, and BMI were not associated with hip outcomes. This contrasts with previous reports that poor THA function correlates with increasing age, BMI, and female gender [4,27,28]. Consistent with previous studies, patient health (ASA level) correlated with THA outcomes [29]. Increasing spine disability, as measured with the continuous variable, ODI score, was directly associated with poor OHS, R ¼ 0.46, p o 0.0001 (Fig. 2). This is the first study to report that increasing spine disability, ODI, is associated with worsening hip outcomes in fully recovered THA patients. An extensive number of studies have documented that the primary determinant of poor postoperative THA function is limited preoperative function [2,4–12]. Several studies concluded that surgery performed later in the natural history of functional decline due to hip OA may result in worse postoperative functional status [2,4,7,8]. Further reports document an association between limited preoperative walking capacity and poor THA outcomes [6,8,11]. Alternatively, the poor
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Figure 2 – Graph depicting the linear relationship between Oswestry Disability Index (ODI) score and the OHS. preoperative functional status and postoperative limitations may be the result of alternative co-existent disease that is limiting function [5,24,30]. In the current study, the majority of patients had a history of back problems and increased
Figure 3 – Graphs depicting the mean and interquartile range of the ODI score and patient responses to each of the three patient satisfaction questions.
disability as determined by the ODI. Spine disability leads to lower extremity weakness, limits walking capacity, and has been postulated to impede total joint function [6,15,24]. The current study demonstrates that poor THA functional outcomes were directly associated with spine disability. Together, these points infer that the limited preoperative functional status, which determines poor postoperative THA function, is the result of co-existent spine disability rather than strictly worsening hip OA. As an outcome measure, satisfaction incorporates numerous intrinsic and extrinsic factors to the individual patient experience surrounding arthroplasty surgery [31]. With regard to THA, persistent pain and poor function lead to dissatisfaction [1,24,31]. In the current study, the continuous variable for spinal disability (ODI) was compared to the outcomes of three standardized patient satisfaction questions (Table 1). A direct association was found between ODI and poor patient satisfaction with regards to pain relief, return to activity, and overall satisfaction with surgery (Fig. 3). These results expand the association of back problems and spine disability with poor hip outcomes to a direct correlation of lumbar spine disability and patient dissatisfaction following THA. Previous reports have hypothesized an association between spine problems, hip pain, and THA dissatisfaction [1,18,24]; but to our knowledge, this is the first study that demonstrated the correlation between increased spine disability and patient dissatisfaction after primary THA. This study has several limitations. It is a retrospective review of primary THA conducted through a volunteer response mailing. Individuals who voluntarily participate in a study may not be representative of the entire selected population, potentially creating a selection bias. Two factors obviate this concern: first, more than half (244 of 428, 57%) of the eligible THA population responded to the mailing; second, an analysis of demographic data for patients who responded and those who did not respond demonstrated no statistical differences (Table 2). In addition, this study employed a single outcome measure, the Oxford Hip Score [32,33]. This measure was chosen because it is patient derived, does not require previous evaluation or physical examination, has been shown to be reproducible, and could be self-administered through a mailing. As a consequence, this study does not contain
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Table 2 – Patient Demographics Variable Gender Male Female Age (y) BMI (kg/m2)
Responders (n ¼ 244)
84 160 67 7 10.2 31 7 5.9
Non-Responders (n ¼ 184)
(34%) (66%) (40–94) (17–51)
76 108 65 7 13 32 7 8
(41%) (59%) (31–92) (19–60)
p Value
0.15 0.14 0.43
Side Left hip Right hip
103 (42%) 141 (58%)
81 (44%) 103 (56%)
0.71
ASA level I II III
9 (4%) 125 (51%) 110 (45%)
3 (2%) 80 (43%) 101 (55%)
0.08
preoperative evaluation outcomes for subsequent comparison. Alternative THA outcome measures were not feasible with our study design. These factors prevent direct comparison of preoperative and postoperative function scores. Preoperative functional limitations in patients with poor postoperative OHS and/or ODI scores can only be inferred. Finally, categorization of pain specific to hip or spine is difficult. Patients may not be able to discriminate hip or spine pain separate from one another [19]. Furthermore, the self-administered hip and spine functional outcome tools employed in this study may not reliably differentiate between pathologies. Overall, the Oswestry Disability Index (ODI) correlated strongly with poor outcomes after THA. Moderate and severe lumbar spine disability directly correlated with worse Oxford Hip Scores. Spine disability was directly associated with THA patient dissatisfaction with pain relief, return to activity, and overall outcome of surgery. This study demonstrated that decreased functional results in THA patients are directly associated with increased spine disability. [34]
r e f e r e n c e s
[1] Parvizi J, Pour AE, Hillibrand A, et al. Back pain and total hip arthroplasty. Clinical Orthopaedics and Related Research 2010;468:1325–30. [2] Mancuso CA, Jout J, Salvati EA, Sculco TP. Fulfillment of patients’ expectations for total hip arthroplasty. The Journal of Bone and Joint Surgery. American Volume 2009;91:2073–8. [3] Mancuso CA, Salvati EA, Johanson NA, et al. Patients’ expectations and satisfaction with total hip arthroplasty. The Journal of Arthroplasty 1997;12:387–96. [4] Fortin PR, Clarke AE, Joseph L, et al. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis and Rheumatism 1999;42:1722–8. [5] Greenfield S, Apolone G, McNeil BJ, Cleary PD. The importance of co-existent disease in the occurrence of postoperative complications and one-year recovery in patients undergoing total hip replacement. Comorbidity and outcomes after hip replacement. Medical Care 1993;31:141–54. [6] Holtzman J, Saleh K, Kane R. Effect of baseline functional status and pain on outcomes of total hip arthroplasty. The
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Journal of Bone and Joint Surgery. American Volume 2002;84:1942–8. Johansson HR, Bergschmidt P, Skripitz R, et al. Impact of preoperative function on early postoperative outcome after total hip arthroplasty. Journal of Orthopaedic Surgery (Hong Kong) 2010;18:6–10. Johnsson R, Thorngren KG. Function after total hip replacement for primary osteoarthritis. International Orthopaedics 1989;13:221–5. Mancuso CA, Sculco TP, Salvati EA. Patients with poor preoperative functional status have high expectations of total hip arthroplasty. The Journal of Arthroplasty 2003;18: 872–8. Montin L, Leino-Kilpi H, Suominen T, Lepisto J. A systematic review of empirical studies between 1966 and 2005 of patient outcomes of total hip arthroplasty and related factors. Journal of Clinical Nursing 2008;17:40–5. Roder C, Staub LP, Eggli S, et al. Influence of preoperative functional status on outcome after total hip arthroplasty. The Journal of Bone and Joint Surgery. American Volume 2007;89:11–7. Vissers MM, Bussmann JB, Verhaar JA, et al. Recovery of physical functioning after total hip arthroplasty: systematic review and metal-analysis of the literature. Physical Therapy 2011;91:615–29. Centers for Disease Control and Prevention. Prevalence of disabilities and associated health conditions among adults, United States, 1999. Morbidity and Mortality Weekly Report 2001;50:120–7. Institute of Medicine of the National Academies Report. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, DC: The National Academies Press; 2011 [p. 62]. Pivec R, Johnson AJ, Naziri Q, et al. Lumbar spinal stenosis impairs function following total knee arthroplasty. The Journal of Knee Surgery 2013;26:59–64. National Center for Health Statistics. Health, United States, 2006. With chartbook on trends in the health of Americans. Hyattsville, MD; 2006 www.cdc.gov/nchs/data/hus/hus06.pdf. Horvath G, Koroknai G, Acs B, et al. Prevalance of low back pain and lumbar spine degenerative disorders. Questionnaire survey and clinical-radiological analysis of a representative Hungarian population. International Orthopaedics 2010;34: 1245–9. Ben-Galim P, Ben-Galim T, Rand N, et al. Hip-spine syndrome: the effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip. Spine 2007;32: 2099–102.
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[19] Staibano P, Winemaker M, Petruccelli D, deBeer J. Total joint arthroplasty and preoperative low back pain. The Journal of Arthroplasty 2014;29:867–71. [20] McCormick JD, Werner BC, Shimer AL. Patient-reported outcome measures in spine surgery. The Journal of the American Academy of Orthopaedic Surgeons 2013;21:99–107. [21] Tomkins-Lane CC, Battie MC. Validity and reproducibility of self-report measures of walking capacity in lumbar spinal stenosis. Spine 2010;35:2012–97. [22] Anakwe RE, Jenkins PJ, Moran M. Predicting dissatisfaction after total hip arthroplasty: a study of 850 patients. The Journal of Arthroplasty 2011;26:209–13. [23] Harris IA, Harris AM, Naylor JM, et al. Discordance between patient and surgeon satisfaction after total joint arthroplasty. The Journal of Arthroplasty 2013;28:722–7. [24] Ayers D, Harrold L, Li W, et al. Greater musculoskeletal pain in TKR and THR patients correlates with poorer function in a national consortium. Annual Meeting of the Orthopaedic Research Society; 2013 [scientific poster]. [25] Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from US national surveys, 2002. Spine 2006;31:2724–7. [26] Wolfe F. Determinants of WOMAC function, pain and stiffness scores: evidence for the role of low back pain, symptom counts, fatigue and depression in osteoarthritis, rheumatoid arthritis and fibromyalgia. Rheumatology 1999;38:355–61. [27] Holtzman J, Saleh K, Kane R. Gender differences in functional status and pain in a Medicare population
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undergoing elective total hip arthroplasty. Medical Care 2002;40:461–70. Kennedy DM, Hanna SE, Stratford PW, et al. Preoperative function and gender predict pattern of functional recovery after hip and knee arthroplasty. The Journal of Arthroplasty 2006;21:559–66. MacWilliam CH, Yood MU, Verner JJ, McCarthy BD, Ward RE. Patient-related risk factors that predict poor outcome after total hip replacement. Health Services Research 1996;31: 623–38. Ayers D, Harrold L, Li W, et al. Greater musculoskeletal pain in TKR and THR patients correlates with poorer function in a national consortium. Annual Meeting of the Orthopaedic Research Society 2013 [scientific poster]. Noble PC, Conditt MA, Cook KF, Mathis KB. Patient expectations affect satisfaction with total knee arthroplasty. Clinical Orthopaedics and Related Research 2006;452:35–43. Dawson J, Fitzpatrick R, Carr A, Murray DW. Questionnaire on the perceptions of patients about total hip replacement. The Journal of Bone and Joint Surgery. British Volume 1996;78:185–90. Murray DW, Fitzpatrick R, Rogers K, et al. The use of the Oxford hip and knee scores. The Journal of Bone and Joint Surgery. British Volume 2007;89:1010–4. Jones CA, Beaupre LA, Johnston DW, Suarez-Almazor ME. Total joint arthroplasties: current concepts of patient outcomes after surgery. Clinics in Geriatric Medicine 2005;21: 527–41.
E M I N A R S I N
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T H R O P L A S T Y
27 (2016) 2–7
Available online at www.sciencedirect.com
www.elsevier.com/locate/semanthroplasty
Total hip arthroplasty outcomes correlate with spine disability William C. Schroer, MDn, Erica Diesfeld, Angela R. LeMarr, RN, Diane J. Morton, MS, and Mary E. Reedy, RN St. Louis Joint Replacement Institute, St. Louis, MO
article info
abstract
Keywords:
Functional deficits persist in a significant percentage of total hip arthroplasties (THA), leading to
total hip arthroplasty
patient dissatisfaction. Spinal stenosis is a leading cause of chronic disability and lower
spine disability
extremity weakness. Although previous studies have evaluated the potential benefit of THA
hip function
on back pain, none have reported the effects of spine disability on functional outcomes and
patient satisfaction
patient satisfaction with THA. A total of 244 primary THAs (233 patients) with minimum 2-year
outcomes
follow-up rated their satisfaction, return to activity, and standard hip outcomes using the Oxford Hip Score (OHS). History of lumbar spine pain, lumbar surgery, and daily activity limitations was documented and an Oswestry Disability Index (ODI) score was calculated. Out of 244, 151 (62%) patients reported a history of back problems: 35 patients (14%)—history of lumbar surgery, 91 (37%)—daily low back pain, and 97 (40%)—back pain that limited activity. Patients with a history of back problems had lower OHS scores than those without back pain, p ¼ 0.0001. Patients with daily low back pain or low back pain that limited activity had lower OHS scores, p o 0.0001. Increasing spine disability, as determined by ODI, correlated with poor OHS, p o 0.0001. Spine disability (ODI) was directly associated with patient dissatisfaction for pain relief (R ¼ 0.41, p o 0.0001), return to activity (R ¼ 0.34, p o 0.0001), and overall surgical results (ODI, R ¼ 0.38, p o 0.0001) at 2 years after THA. ODI correlated strongly with poor THA outcomes. In conclusion, lumbar spine disability correlated directly with poor Oxford Hip Scores. Spine disability was directly associated with THA patient dissatisfaction with pain relief, return to activity, and overall outcome of surgery. This study demonstrates that poor functional results in THA patients correlate directly with spine disability. & 2016 Elsevier Inc. All rights reserved.
1.
Introduction
Functional deficits persist for a significant number of patients after total hip arthroplasty (THA) [1]. Preoperative functional status often is an independent predictor of patient
satisfaction after THA [2,3], and poor preoperative function portends to unfavorable functional outcomes [2,4–12]. Back pain affects more than 75% of Americans over the course of their lives [13]. Spinal stenosis is a leading cause of chronic disability and lower extremity weakness in the
The authors thank Karen Steger-May, M.S., for statistical analysis. This study was funded by the St. Louis Joint Replacement Institute. Neither the authors nor the patients received anything of value for the conduction of this study. Ethical principles of research and compliance with HIPAA guidelines were followed to protect patient identity and health information privacy. n Correspondence to: St. Louis Joint Replacement Institute, SSM Health Orthopedics, 12349 DePaul Dr, Suite 100, St. Louis, MO 63044. E-mail address: [email protected] (W.C. Schroer). http://dx.doi.org/10.1053/j.sart.2016.06.015 1045-4527/& 2016 Elsevier Inc. All rights reserved.
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elderly [14,15]. Adults with low back pain are in worse physical health: 28% of adults with low back pain report limited activity whereas 10% of adults without low back pain report limited activity [16]. Spinal stenosis and osteoarthritis of the hip frequently occur in the same patient. Osteoarthritis of the hip is more prevalent in individuals with radiographic signs of spinal degeneration [17]. Previously published studies on this topic primarily have evaluated the potential benefit of joint arthroplasty on back pain [1,18,19]. No published study has evaluated the effects of spine disability on functional outcomes and patient satisfaction following THA. This study sought to determine the incidence of spine disability in THA patients, its potential association to hip outcomes, and its correlation to patient satisfaction following primary THA.
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Table 1 – Study Questionnaire Clinical history of back pain questions (1) Have you ever had surgery on your back?
(2) Do you have a history of low back problems? (3) Do you have daily back pain? (4) Does back pain limit your activity? Patient satisfaction questions (1) How much has your hip pain changed as a result of your hip surgery?
(a) Improved a lot (b) Improved a little (c) No change
(d) A little worse (e) A lot worse
(2) To what extent have you resumed your usual activities following your hip replacement?
2.
Patients and methods
Demographic and clinical data for patients undergoing primary THA between June 1, 2010 and June 1, 2012 were obtained through retrospective review. The study was IRBapproved. Overall, 428 patients were identified who met eligibility criteria. A questionnaire was mailed with a letter explaining the purpose of the study and to invite volunteer participation. The questionnaire was completed and returned for 244 THAs (233 patients). Spine questions detailed history of back problems, including prior back surgery, and determined the Oswestry Disability Index (ODI), the most commonly applied spine-specific patient outcome measurement [20,21] (Table 1). Postoperative hip pain and function were determined by the Oxford Hip Score (OHS). Variables previously described to correlate with THA outcomes such as age, gender, BMI, and ASA, were compared with OHS. New variables including the presence of back problems and spine disability, as measured by the ODI, similarly were compared to OHS to determine the association between spine disability and hip outcomes. Finally, patient satisfaction with pain relief, function, and overall outcome was determined from three questions (Table 1). Spine disability (ODI) scores were modeled statistically against these satisfaction results. Statistical analysis of demographic data utilized Wilcoxon t-test for quantitative measures and Chi square analysis for categorical measures. Comparisons of categorical variables to OHS were made with Wilcoxon’s t-test, p o 0.05 for significance. For continuous characteristics, the Spearman Correlation Coefficient was used for a linear association between the characteristic and the OHS value, with significance R 4 0.20.
3.
Results
Out of 244, 151 (62%) THA patients reported a history of back problems. In all, 35 patients (14%) reported history of lumbar surgery, 91 (37%) reported daily low back pain, and 97 (40%) reported back pain that limits activity. Compared to patients without a history of back problems, patients with back problems had worse OHS (21.8 vs. 17.2, p ¼ 0.001), patients with daily back pain had worse OHS (23.9 vs. 17.7, p o 0.0001),
(a) A lot (b) Moderately (c) Somewhat
(d) A little (e) Not at all
(3) In general, how would you rate the outcome of your hip surgery? (a) Excellent (b) Very good (c) Good
(d) Fair (e) Poor
and patients with activity-limiting pain had inferior OHS (24.3 vs. 17.2, p o 0.0001). A history of spine surgery was not associated with OHS (Fig. 1). The mean ODI score of all patients was 16.1, but was 26.1 in the 151 THA patients with a history of back problems. Patients categorized with minimal spine disability, ODI o 20, had a mean OHS of 16.8 (IQR: 12.0–19.0). Patients with moderate spine disability, ODI: 20–39, had a mean OHS of 22.5 (IQR: 15.0–28.0). Patients with severe spine disability, ODI ¼ 40 or more, had a mean OHS of 30.6 (IQR: 20.5–41.0), p o 0.0001. Covariates associated with OHS included the Oswestry Disability Index (ODI), R ¼ 0.46, p o 0.0001 (Fig. 2) and ASA level, p o 0.0001. Several patient variables were not associated with hip outcomes as determined by the OHS: gender, p ¼ 0.45; age, R ¼ 0.07, p ¼ 0.25; BMI, R ¼ 0.10, p ¼ 0.11. When asked to rate satisfaction with THA on pain relief, return to activity, and outcome of surgery, patients of 18 hips (7%) reported no improvement in pain or worsening of their hip pain following THA, 16 hips (7%) reported little to no return to usual activities following THA, and 23 hips (10%) rated their THA outcome as fair or poor. Overall dissatisfaction with THA outcome correlated strongly with spine disability, ODI, R ¼ 0.38, p o 0.0001. Patients with increased hip pain after surgery had a higher level of spine disability (ODI), R ¼ 0.41, p o 0.0001. Patients with difficulty returning to usual activities following THA had a higher ODI, R ¼ 0.34, p o 0.0001 (Fig. 3).
4.
Discussion
Patient dissatisfaction following primary total hip arthroplasty (THA) has been shown between 7% and 15%, with many patients experiencing persistent pain and limited function [3,22,23]. Previously published hip outcomes studies
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Figure 1 – Graph depicting the mean and interquartile range of the Oxford Hip Score (OHS) for each spine condition question. have reported the patient’s preoperative functional status as the primary factor affecting postoperative function [2,8–10]. Several studies have specifically demonstrated that poor preoperative walking capacity is directly associated with worse THA outcomes [6,11]. While limited walking capacity is expected with lower extremity osteoarthritis, other coexistent disease also affects function [5]. Spinal stenosis causes chronic disability with lower extremity weakness and has been postulated to impede total joint function [6,15,24]. The results of this study indicate that poor THA outcomes and patient dissatisfaction correlate directly with the incidence and severity of lumbar spine disability. Back pain affects more than 75% of Americans over the course of their lives [13], and spinal stenosis is a leading cause of chronic disability and lower extremity weakness in the elderly [15,25]. In the current study of 244 THAs, 62% (151) reported a history of back problems; 14% (35) reported previous back surgery, 37% (91) reported daily low back pain, and 40% (97) reported lumbar pain that limited activity. Similar rates of lumbar pain have been reported by Parvisi et al. [1] with 49.4% of THA patients reporting lumbar pain, and Staibano et al. [19] with 28.8% of THA patients reporting daily back pain. However, both of these studies differ from the current study in their analysis of the benefit of THA on back pain, reporting more than half of patients experienced improvement in back pain following primary THA. Causation of back pain in patients with hip arthritis has been termed the Hip-Spine Syndrome [1,18,19]. Alternatively, the current study evaluated the association of lumbar spine pain and disability on the outcomes and function of a fully recovered THA. Low back pain has previously been shown to impact standardized arthritis outcome measures. The Western Ontario MacMaster (WOMAC) score, a validated instrument that assesses pain and function in osteoarthritis of the hip and knee, is negatively affected by back pain [26]. Previously, poor preoperative WOMAC scores were associated with less improvement in pain and function following THA [4]. Similarly, the current study demonstrated significantly worse OHS in patients with a history of back problems; 17.2 for patients without back problems compared with 21.8 in patients reporting back problems, p ¼ 0.001 (Fig. 1). Questions from the OHS, as well as most hip and knee functional
outcome tools, determine a patient’s ability to walk, but are unable to differentiate if compromised function is due to hip or spine pathology. Studies reporting back pain results, including the current report, could be criticized because back pain is an inherently vague and non-specific diagnosis. Therefore, the current study used the Oswestry Disability Index (ODI), the most commonly applied standardized spine disability measure [20]. Few arthroplasty studies have analyzed an association of joint replacement and spine disability. Staibano et al. employed the ODI as an outcome measure of joint replacement surgery and found that THA correlated with improvement in ODI scores from preoperative values. No association was seen following TKA [19]. Alternatively, in the current study, the ODI was determined 2 or more years after THA and used as a patient-specific variable to determine its association with THA outcomes. The mean ODI was 16.1 for all 244 THA, and increased to 26.1 for the 151 patients with a history of back problems. Patients with minimal spine disability had excellent OHS (16.8), while patients with moderate or severe spine disability had significantly worse hip outcomes, OHS of 22.5 and 30.6, respectively, p o 0.0001. In the current study, only the patients’ comorbid medical history (ASA) and spine disability (ODI) correlated with poor OHS. Age, gender, and BMI were not associated with hip outcomes. This contrasts with previous reports that poor THA function correlates with increasing age, BMI, and female gender [4,27,28]. Consistent with previous studies, patient health (ASA level) correlated with THA outcomes [29]. Increasing spine disability, as measured with the continuous variable, ODI score, was directly associated with poor OHS, R ¼ 0.46, p o 0.0001 (Fig. 2). This is the first study to report that increasing spine disability, ODI, is associated with worsening hip outcomes in fully recovered THA patients. An extensive number of studies have documented that the primary determinant of poor postoperative THA function is limited preoperative function [2,4–12]. Several studies concluded that surgery performed later in the natural history of functional decline due to hip OA may result in worse postoperative functional status [2,4,7,8]. Further reports document an association between limited preoperative walking capacity and poor THA outcomes [6,8,11]. Alternatively, the poor
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Figure 2 – Graph depicting the linear relationship between Oswestry Disability Index (ODI) score and the OHS. preoperative functional status and postoperative limitations may be the result of alternative co-existent disease that is limiting function [5,24,30]. In the current study, the majority of patients had a history of back problems and increased
Figure 3 – Graphs depicting the mean and interquartile range of the ODI score and patient responses to each of the three patient satisfaction questions.
disability as determined by the ODI. Spine disability leads to lower extremity weakness, limits walking capacity, and has been postulated to impede total joint function [6,15,24]. The current study demonstrates that poor THA functional outcomes were directly associated with spine disability. Together, these points infer that the limited preoperative functional status, which determines poor postoperative THA function, is the result of co-existent spine disability rather than strictly worsening hip OA. As an outcome measure, satisfaction incorporates numerous intrinsic and extrinsic factors to the individual patient experience surrounding arthroplasty surgery [31]. With regard to THA, persistent pain and poor function lead to dissatisfaction [1,24,31]. In the current study, the continuous variable for spinal disability (ODI) was compared to the outcomes of three standardized patient satisfaction questions (Table 1). A direct association was found between ODI and poor patient satisfaction with regards to pain relief, return to activity, and overall satisfaction with surgery (Fig. 3). These results expand the association of back problems and spine disability with poor hip outcomes to a direct correlation of lumbar spine disability and patient dissatisfaction following THA. Previous reports have hypothesized an association between spine problems, hip pain, and THA dissatisfaction [1,18,24]; but to our knowledge, this is the first study that demonstrated the correlation between increased spine disability and patient dissatisfaction after primary THA. This study has several limitations. It is a retrospective review of primary THA conducted through a volunteer response mailing. Individuals who voluntarily participate in a study may not be representative of the entire selected population, potentially creating a selection bias. Two factors obviate this concern: first, more than half (244 of 428, 57%) of the eligible THA population responded to the mailing; second, an analysis of demographic data for patients who responded and those who did not respond demonstrated no statistical differences (Table 2). In addition, this study employed a single outcome measure, the Oxford Hip Score [32,33]. This measure was chosen because it is patient derived, does not require previous evaluation or physical examination, has been shown to be reproducible, and could be self-administered through a mailing. As a consequence, this study does not contain
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Table 2 – Patient Demographics Variable Gender Male Female Age (y) BMI (kg/m2)
Responders (n ¼ 244)
84 160 67 7 10.2 31 7 5.9
Non-Responders (n ¼ 184)
(34%) (66%) (40–94) (17–51)
76 108 65 7 13 32 7 8
(41%) (59%) (31–92) (19–60)
p Value
0.15 0.14 0.43
Side Left hip Right hip
103 (42%) 141 (58%)
81 (44%) 103 (56%)
0.71
ASA level I II III
9 (4%) 125 (51%) 110 (45%)
3 (2%) 80 (43%) 101 (55%)
0.08
preoperative evaluation outcomes for subsequent comparison. Alternative THA outcome measures were not feasible with our study design. These factors prevent direct comparison of preoperative and postoperative function scores. Preoperative functional limitations in patients with poor postoperative OHS and/or ODI scores can only be inferred. Finally, categorization of pain specific to hip or spine is difficult. Patients may not be able to discriminate hip or spine pain separate from one another [19]. Furthermore, the self-administered hip and spine functional outcome tools employed in this study may not reliably differentiate between pathologies. Overall, the Oswestry Disability Index (ODI) correlated strongly with poor outcomes after THA. Moderate and severe lumbar spine disability directly correlated with worse Oxford Hip Scores. Spine disability was directly associated with THA patient dissatisfaction with pain relief, return to activity, and overall outcome of surgery. This study demonstrated that decreased functional results in THA patients are directly associated with increased spine disability. [34]
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