Effectiveness of rehabilitation for working-age patients after a total hip arthroplasty: a comparison of usual care between the Netherlands and Germany.

BACKGROUND: Postoperative rehabilitation after primary total hip arthroplasty (p-THA) differs between the Netherlands and Germany. Aim is to compare clinical effectiveness and to get a first impression of cost effectiveness of Dutch versus German usual care after p-THA. METHODS: A transnational prospective controlled observational trial. Clinical effectiveness was assessed with self-reported questionnaires and functional tests. Measurements were taken preoperatively and 4 weeks, 12 weeks, and 6 months postoperatively. For cost effectiveness, long-term economic aspects were assessed from a societal perspective. RESULTS: 124 working-age patients finished the measurements. German usual care leads to a significantly larger proportion (65.6% versus 47.5%) of satisfied patients 12 weeks postoperatively and significantly better self-reported function and Five Times Sit-to-Stand Test (FTSST) results. German usual care is generally 45% more expensive than Dutch usual care, and 20% more expensive for working-age patients. A scenario analysis assumed that German patients work the same number of hours as the Dutch, and that productivity costs are the same. This analysis revealed German care is still more expensive but the difference decreased to 8%. CONCLUSIONS: German rehabilitation is clinically advantageous yet more expensive, although comparisons are less straightforward as the socioeconomic context differs between the two countries. TRIAL REGISTRATION: The study is registered in the German Registry of Clinical Trials (DRKS00011345, 18/11/2016).

Effectiveness of rehabilitation after a total hip arthroplasty: a protocol for an observational study for the comparison of usual care in the Netherlands versus Germany.

INTRODUCTION: Osteoarthritis is the most common joint disorder worldwide. Total hip arthroplasty (THA) is considered one of the most effective treatments for end-stage hip osteoarthritis. The number of THAs is expected to increase dramatically in the coming decades. Usual postoperative rehabilitation after primary THA differs between the German and the Dutch system. In the Netherlands, patients undergo fast-track surgery and are discharged into their home environment within a few days without receiving any aftercare. In Germany, patients stay in the hospital for about 12 days before being transferred to a rehabilitation centre for a period of 3 weeks. The superficially more cost-effective Dutch system of usual care after THA is judged critically in both countries due to suboptimal rehabilitation outcomes. The aim of this study is therefore to compare the Dutch with the German usual care rehabilitation after primary THA. It is hypothesised that the German procedure is more effective in terms of functional outcomes and patient satisfaction than the Dutch procedure and that in the long run the German approach is more cost-effective than the Dutch system. METHODS AND ANALYSIS: Medical effectiveness will be assessed at four different time points by means of patient self-reported questionnaires and functional tests. Assessments include the Hip disability and Osteoarthritis Outcome Score, Patient Acceptable Symptom State, Short Form 36, EuroQol 5 Dimensions 3 Level Questionnaire, Timed Up & Go Test and Five Times Sit-to-Stand Test. Additionally, long-term economic aspects in both countries will be assessed from a societal perspective, to get a first impression on whether cutting costs for rehabilitation, as practised in the Netherlands, really disburdens the healthcare system efficiently. ETHICS AND DISSEMINATION: The study is approved by the Institutional Review Boards of both University Medical Center Groningen (METc2015/483) and Hannover Medical School (no 2874-2015) and will be conducted according to the principles of the Declaration of Helsinki (64th, 2013). The results of the study will be published in international peer-reviewed scientific journals. Patient data will be presented anonymously in any publication or scientific journal. TRIAL REGISTRATION NUMBER: DRKS00011345; Pre-results.

Medication Use is a Better Predictor of Length of Hospital Stay in Total Hip Arthroplasty Than the American Society of Anesthetists (ASA) Score.

BACKGROUND: Length of hospital stay (LOS) greatly influences costs of total hip arthroplasty (THA). LOS is, among others, dependent on patient comorbidity. American Society of Anesthetists (ASA) scores are traditionally used as comorbidity measure, but simple medication-based measures may suffice. Therefore, the objective of the study is to determine if medication-based measures (count of medication and the medication-based index Chronic Disease Score [CDS]) have a surplus value compared to a diagnosis-based measure for comorbidity (ASA score) to predict LOS in THA. METHODS: A retrospective cohort study. THA patients from 3 hospitals were included for 2009-2013, and demographic data, comorbidity (ASA score), and medication use (count of medication and CDS) were collected. A binomial regression model was used to compare the predictive ability of the medication-based and diagnosis-based measures. RESULTS: A total of 2,282 THA patients were included. Number of medications proved a statistical significant predictor of LOS. LOS increased 6% (incidence rate ratios: 10.06 [confidence interval: 1.03-1.09]) with each medication. Neither the CDS nor the ASA score had a statistically significant relation to LOS. CONCLUSION: The medication-based measure count of medication is a better predictor for LOS in THA than the CDS and ASA score. This simple measure also appears to have more clinical relevance, as it has a higher range in scores than diagnosis-based indexes and is easily applicable.

The Modified painDETECT Questionnaire for Patients with Hip or Knee Osteoarthritis: Translation into Dutch, Cross-Cultural Adaptation and Reliability Assessment.

There is a growing amount of evidence that alteration in pain processing by the peripheral and central nervous system play a role in osteoarthritis pain, leading to neuropathic-like symptoms. It is essential to identify knee and hip osteoarthritis patients with a neuropathic pain profile in order to offer such patients education and additional treatment options besides conventional pain treatment. The painDETECT Questionnaire is a self-report questionnaire developed to discriminate between nociceptive and neuropathic pain. This questionnaire was modified to fit patients suffering from knee osteoarthritis. The aim of this study was to translate and cross-culturally adapt the modified painDETECT Questionnaire to the Dutch language and to provide a modified version to fit patients with hip osteoarthritis. Reliability for internal consistency, repeatability and floor and ceiling effects were subsequently assessed. A total of 278 patients were included in the reliability study and 123 patients in the repeatability analysis. The Dutch modified painDETECT Questionnaire shows good internal consistency and small relative measurement errors, represented by a good intraclass correlation coefficient. Absolute measurement error, represented by the Standard Error of Measurement, was acceptable. However, a measurement bias might be present when it comes to repeatability. To our knowledge, this study is the first to provide a Dutch modified painDETECT Questionnaire to fit hip and knee osteoarthritis patients and to assess internal consistency, reliability and agreement. International guidelines were followed in the translation process and this study has ample sample size with an adequate time interval for repeatability. Based on this study, the Dutch modified painDETECT Questionnaire seems to be fit as a discriminative tool to identify knee and hip osteoarthritis patients with a neuropathic pain profile. Whether it is also suitable as an evaluative tool to record changes over time or after an intervention remains open to further investigation.

Assessment of prosthesis alignment after revision total knee arthroplasty using EOS 2D and 3D imaging: a reliability study.

INTRODUCTION: A new low-dose X-ray device, called EOS, has been introduced for determining lower-limb alignment in 2D and 3D. Reliability has not yet been assessed when using EOS on lower limbs containing a knee prosthesis. Therefore purpose of this study was to determine intraobserver and interobserver reliability of EOS 2D and 3D knee prosthesis alignment measurements after revision total knee arthroplasty (rTKA). METHODS: Forty anteroposterior and lateral images of 37 rTKA patients were included. Two observers independently performed measurements on these images twice. Varus/valgus angles were measured in 2D (VV2D) and 3D (VV3D). Intraclass correlation coefficients and the Bland and Altman method were used to determine reliability. T-tests were used to test potential differences. RESULTS: Intraobserver and interobserver reliability were excellent for VV2D and VV3D. No significant difference or bias between the first and second measurements or the two observers was found. A significant mean and absolute difference of respectively 1.00° and 1.61° existed between 2D and 3D measurements. CONCLUSIONS: EOS provides reliable varus/valgus measurements in 2D and 3D for the alignment of the knee joint with a knee prosthesis. However, significant differences exist between varus/valgus measurements in 2D and 3D.

Does imageless computer-assisted TKA lead to improved rotational alignment or fewer outliers? A systematic review.

BACKGROUND: Computer-assisted surgery (CAS) has been developed to enhance prosthetic alignment during primary TKAs. Imageless CAS improves coronal and sagittal alignment compared with conventional TKA. However, the effect of imageless CAS on rotational alignment remains unclear. QUESTIONS/PURPOSES: We conducted a systematic and qualitative review of the current literature regarding the effectiveness of imageless CAS during TKA on (1) rotational alignment of the femoral and tibial components and tibiofemoral mismatch in terms of deviation from neutral rotation, and (2) the number of femoral and tibial rotational outliers. METHODS: Data sources included PubMed, MEDLINE, and EMBASE. Study selection, data extraction, and methodologic quality assessment were conducted independently by two reviewers. Standardized mean difference with 95% CI was calculated for continuous variables (rotational alignment of the femoral or tibial component and tibiofemoral mismatch). To compare the number of outliers for femoral and tibial component rotation, the odds ratio and 95% CI were calculated. The literature search produced 657 potentially relevant studies, 17 of which met the inclusion criteria. One study was considered as having high methodologic quality, 15 studies had medium, and one study had low quality. RESULTS: Conflicting evidence was found for all outcome measures except for tibiofemoral mismatch. Moderate evidence was found that imageless CAS had no influence on postoperative tibiofemoral mismatch. The measurement protocol for measuring tibial rotation varied among the studies and in only one of the studies was the sample size calculation based on one of the outcome measures used in our systematic review. CONCLUSIONS: More studies of high methodologic quality and with a sample size calculation based on the outcome measures will be helpful to assess whether an imageless CAS TKA improves femoral and tibial rotational alignment and tibiofemoral mismatch or decreases the number of femoral and tibial rotational outliers. To statistically analyze the results of different studies, the same measurement protocol should be used among the studies.

The association between comorbidity and length of hospital stay and costs in total hip arthroplasty patients: a systematic review.

We performed a systematic review on the relationship between comorbidity and length of hospital stay (LOS) and hospital costs (HC). Electronic databases were systematically searched for relevant studies, conducting methodological quality assessment and best-evidence synthesis: 317 articles were identified, 10 of which fit the inclusion criteria; nine studies determined the relationship between comorbidity and LOS, with eight reporting a positive correlation; five studies were considered to be of high quality, four of which found a positive correlation; two studies analyzed the relationship between comorbidity and HC and reported significantly higher HC for patients with comorbidities, and were considered to be of high quality. In conclusion, there is limited evidence that patient comorbidity has a positive correlation with LOS and HC.

Cross-cultural adaptation of the Dutch Short Musculoskeletal Function Assessment questionnaire (SMFA-NL): internal consistency, validity, repeatability and responsiveness.

The purpose of this study was to translate and culturally adapt the Dutch version of the Short Musculoskeletal Function Assessment questionnaire (SMFA-NL) and to investigate the internal consistency, validity, repeatability and responsiveness of the translated version. The original SMFA was first translated and culturally adapted from English into Dutch according to a standardised procedure and subsequently tested for clinimetric quality. The study population consisted of 162 patients treated for various musculoskeletal injuries or disorders at the departments of Orthopedics and Traumatology. All respondents filled in the SMFA-NL and the SF-36 and a region-specific questionnaire. To determine repeatability, 87 respondents filled in the SMFA-NL for a second time after a time interval of three to four weeks. To determine responsiveness, 29 respondents who were treated for their injury within three months before the first assessment filled in the SMFA-NL for a second time after two to three months. The following analyses were performed to evaluate clinimetric quality of the SMFA-NL: factor analysis and Cronbach's alpha (internal consistency), floor and ceiling effects, Spearman's Rho (construct validity), intraclass correlation coefficients and the Bland & Altman method (repeatability), and standardised response means (SRM) (responsiveness). Factor analysis demonstrated four subscales of the SMFA-NL. Both the newly identified subscales of the SMFA-NL and the conventional subscales of the SMFA showed good internal consistency. No floor and some ceiling effects were found. Construct validity was good, as high correlations were found between the subscales of the SMFA-NL and the respective subscales of the SF-36 and the region-specific questionnaires. Repeatability of the SMFA-NL subscales was high, with no systematic bias between first and second assessment. Responsiveness of the SMFA-NL was moderate, as small to moderate SRMs were found. We successfully translated and culturally adapted a Dutch version of the Short Musculoskeletal Function Assessment questionnaire (SFMA-NL). This study shows that the SMFA-NL is a valid, reliable and moderately responsive method for the assessment of functional status of patients who have a broad range of musculoskeletal disorders. Furthermore, it will allow for comparison between different patient groups as well as for cross-cultural comparisons.

Compensatory trunk movements in patients with hip osteoarthritis: accuracy and reproducibility of a body-fixed sensor-based assessment.

This study examined the accuracy and reproducibility of a body-fixed sensor-based assessment for quantifying frontal plane angular movements of the (upper) thorax and pelvis of patients with hip osteoarthritis at different walking speeds. To evaluate accuracy, the angular movements of sensors attached to the thorax and pelvis of three patients were compared with results based on an optical motion analysis system. Accuracy was high, with small and consistent mean differences (<1.0 degree) and corresponding standard deviations (<1.3 degrees) between optical motion analysis system and body-fixed sensor data. To evaluate reproducibility, angular trunk movements were assessed twice in 15 patients. Reproducibility was high (intraclass correlation coefficients ranged from 0.86 to 0.97), and the values of the mean differences between the test and retest were small, with the 95% confidence interval containing zero. This body-fixed sensor-based assessment is an accurate and reproducible method for quantifying frontal plane compensatory trunk movements during gait of patients with hip osteoarthritis at different walking speeds.

Reliability and validity of the short questionnaire to assess health-enhancing physical activity (SQUASH) in patients after total hip arthroplasty.

BACKGROUND: Despite recognized benefits of regular physical activity on musculoskeletal fitness as well as general health, little is known about the physical activity behavior of patients after Total Hip Arthroplasty (THA). So far, no physical activity questionnaire has been validated in this category of patients. As the Short Questionnaire to Assess Health-enhancing physical activity (SQUASH) has been shown to be a fairly reliable and valid tool to gauge the physical activity behavior of the general Dutch adult population, we measured the reliability and relative validity of this tool in patients after THA. METHODS: 44 patients (17 men and 27 women, mean age 71 +/- 8 years) completed the SQUASH twice with an in-between period of 2 to 6 weeks (mean 3.7). Reliability was determined by calculating the Spearman correlation coefficient between the activity scores of the separate questions as well as the total activity scores from both administrations. Additionally, a Bland & Altman analysis was performed for the total activity scores. Relative validity was determined using the Actigraphaccelerometer, worn by 39 patients (15 men and 24 women, mean age 70 +/- 8 years) for a 2-week period following the second questionnaire, as a criterion measure. RESULTS: Spearman's correlation coefficient for overall reliability was 0.57. It varied between 0.45 and 0.90 for the separate questions. No systematic biases between readings were found. The Spearman correlation between Actigraph readings and total activity score was 0.67. It was 0.56 for total minutes of activity, 0.20 for time spent in light intensity activity, 0.40 for moderate activity and 0.35 for vigorous activity. Systematic bias was found between the SQUASH and the Actigraph. CONCLUSION: The SQUASH can be considered to be a fairly reliable tool to assess the physical activity behavior of patients after THA. Validity was found to be comparable with those of other questionnaires, and as it is short and easy to fill in, it may prove to be a useful tool to assess physical activity in this particular subset of the population. However, the considerable systematic bias found in this study illustrates the need for further analysis of the validity of the SQUASH.

Effectiveness of computer-navigated minimally invasive total hip surgery compared to conventional total hip arthroplasty: design of a randomized controlled trial.

BACKGROUND: Moderate to severe osteoarthrosis is the most common indication for Total Hip Arthroplasty (THA). Minimally Invasive Total Hip Surgery (MIS) and computer-navigated surgery were introduced several years ago. However, the literature lacks well-designed studies that provide evidence of superiority of computer-navigated MIS over a conventional THA technique. Hence, the purpose of this study is to compare (cost)effectiveness of computer-navigated MIS with a conventional technique for THA. It is our hypothesis that computer-navigated MIS will lead to a quicker recovery during the early postoperative period (3 months), and to an outcome at least as good 6 months postoperatively. We also hypothesize that computer-navigated MIS leads to fewer perioperative complications and better prosthesis positioning. Furthermore, cost advantages of computer-navigated MIS over conventional THA technique are expected. METHODS/DESIGN: A cluster randomized controlled trial will be executed. Patients between the ages of 18 and 75 admitted for primary cementless unilateral THA will be included. Patients will be stratified using the Charnley classification. They will be randomly allocated to have computer-navigated MIS or conventional THA technique. Measurements take place preoperatively, perioperatively, and 6 weeks and 3 and 6 months postoperatively. Degree of limping (gait analysis), self-reported functional status and health-related quality of life (questionnaires) will be assessed preoperatively as well as postoperatively. Perioperative complications will be registered. Radiographic evaluation of prosthesis positioning will take place 6 weeks postoperatively. An evaluation of costs within and outside the healthcare sector will focus on differences in costs between computer-navigated MIS and conventional THA technique. DISCUSSION: Based on studies performed so far, few objective data quantifying the risks and benefits of computer-navigated MIS are available. Therefore, this study has been designed to compare (cost) effectiveness of computer-navigated MIS with a conventional technique for THA. The results of this trial will be presented as soon as they become available.

Joint recovery programme versus usual care: an economic evaluation of a clinical pathway for joint replacement surgery.

OBJECTIVE: The objective of the present study was to determine the incremental cost-effectiveness of a clinical pathway for patients undergoing joint replacement, the Joint Recovery Programme (JRP), as compared with usual care. The existing care process was revised to contain costs and shorten waiting lists by facilitating patient flows and improve healthcare efficiency. METHODS: The study design was a before-after trial. In total, 160 patients undergoing total hip and total knee replacement, aged 28 to 87 years (mean age, 64.4 years), were treated either according to the Joint Recovery Programme (a standardized care process with patient education and rehabilitation in groups) or usual care. Both groups were followed for 1 year. Costs were studied from a societal perspective. Outcomes included functional level (Harris Hip score and American Knee Society score) and generic quality of life (EuroQol). RESULTS: The results indicate that the Joint Recovery Programme resulted in a significant cost saving when compared with usual care mainly as a result of a considerable (>50%) reduction in length of hospital stay. The average cost saving per patient amounted to $1261 in the total hip replacement group and $3336 in the total knee replacement group. At the same time, both functional level and quality of life were higher in the JRP group. CONCLUSIONS: Clinical pathway dominates usual care and is a highly cost-effective approach to contain costs related to joint replacement surgery without adverse consequences for patients.