Impact of capsular preservation on patient-reported outcomes and complication rates in total hip arthroplasty using the direct anterior approach.

AIMS: It is not known whether preservation of the capsule of the hip positively affects patient-reported outcome measures (PROMs) in total hip arthroplasty using the direct anterior approach (DAA-THA). A recent randomized controlled trial found no clinically significant difference at one year postoperatively. This study aimed to determine whether preservation of the anterolateral capsule and anatomical closure improve the outcome and revision rate, when compared with resection of the anterolateral capsule, at two years postoperatively. METHODS: Two consecutive groups of patients whose operations were performed by the senior author were compared. The anterolateral capsule was resected in the first group of 430 patients between January 2012 and December 2014, and preserved and anatomically closed in the second group of 450 patients between July 2015 and December 2017. There were no other technical changes between the two groups. Patient characteristics, the Charlson Comorbidity Index (CCI), and surgical data were collected from our database. PROM questionnaires, consisting of the Oxford Hip Score (OHS) and Core Outcome Measures Index (COMI-Hip), were collected two years postoperatively. Data were analyzed with generalized multiple regression analysis. RESULTS: The characteristics, CCI, operating time, and length of stay were similar in both groups. There was significantly less blood loss in the capsular preservation group (p = 0.037). The revision rate (n = 3, (0.6%) in the resected group, and 1 (0.2%) in the preserved group) did not differ significantly (p = 0.295). Once adjusted for demographic and surgical factors, the preserved group had significantly worse PROMs: + 0.24 COMI-Hip (p < 0.001) and -1.6 OHS points (p = 0.017). However, the effect sizes were much smaller than the minimal clinically important differences (MCIDs) of 0.95 and 5, respectively). The date of surgery (influencing, for instance, the surgeon's age) was not a significant factor. CONCLUSION: Based on the MCID, the lower PROMs in the capsular preservation group do not seem to have clinical relevance. They do not, however, confirm the expected benefit of capsular preservation reported for the posterolateral approach. Cite this article: Bone Joint J 2022;104-B(7):826-832.

The Association Between Comorbidity and the Risks and Early Benefits of Total Hip Arthroplasty for Hip Osteoarthritis.

BACKGROUND: The changing demographics of our society will lead to an increasing number of patients presenting for orthopedic surgery with increasing comorbidity. We investigated the association between comorbidity and both the risks (complications) and benefits (improved function) of total hip arthroplasty (THA) for primary hip osteoarthritis, whilst controlling for potential confounders including age. METHODS: One thousand five hundred and eighty-four patients (67.1 ± 10.6 years; 54% men) in our tertiary care orthopedic hospital completed the Oxford Hip Score before and 12 months after THA. Comorbidity was assessed using the American Society of Anesthesiologists (ASA) grade and Charlson Comorbidity Index (CCI). Details regarding perioperative complications (hospital stay plus 18 days after discharge; mean 27 ± 3 days) were extracted from the clinic information system and graded for severity. RESULTS: For ASA1, 2, and ≥3, respectively, there were 3.1%, 3.0%, and 6.6% surgical/orthopedic complications; 3.7%, 12.5%, and 27.4% general medical complications; and 6.7%, 14.5%, and 29.8% complications of either type. ASA was associated with complication severity (P < .001). In multiple regression, increasing ASA grade (OR 1.74; 95% CI, 1.33-2.29) and age (OR 1.06; 95% CI, 1.05-1.08), both showed an independent association with increased risk of a complication; CCI explained no further significant variance. CCI, but not age, was associated with the 12-month Oxford Hip Score (beta coefficient, -0.742; 95% CI, -1.130 to -0.355; P = .002) while ASA grade explained no further variance. CONCLUSION: Greater comorbidity was associated with increased odds of a complication and (independently) slightly worse patient-rated outcome 12 months after THA. Comorbidity indices can be easily obtained for all surgical patients and may assist with preoperative counseling regarding individual risks and benefits of THA.

Could less be more when assessing patient-rated outcome in spinal stenosis?

STUDY DESIGN: Longitudinal study of the measurement properties of a brief outcome instrument. OBJECTIVE: In patients undergoing surgery for lumbar spinal stenosis, we compared the responsiveness of the Core Outcome Measures Index (COMI) with that of the condition-specific Swiss Spinal Stenosis Measure (SSM), an instrument developed to assess patients with neurogenic claudication. SUMMARY OF BACKGROUND DATA: The COMI is a validated multidimensional questionnaire for assessing the key outcomes of importance to patients with back problems. Being brief, it is associated with minimal respondent burden and high completion rates. However, for a given pathology, intuitively it may be expected to be less responsive than a condition-specific instrument. METHODS: A total of 91 patients (73±8 yr; 53% males) completed the following questionnaires before surgery: COMI, SSM, Roland Morris Disability Questionnaire, back trouble "Feeling Thermometer," pain numeric rating scale, EuroQoL-visual analogue scale. Twelve months postoperatively, 78/91 (86%) completed all the questionnaires again; they also rated the "global treatment outcome" (GTO; rated 1-5) and SSM "satisfaction with treatment result" (SSM-sat; rated 1-4), which were used as external criteria of treatment success. RESULTS: Scores for the external criteria of success (GTO/SSM-sat) correlated with the change scores (baseline to 12 mo) in COMI (r=0.57) and SSM (r=0.54) to a similar extent. Using receiver operating characteristics, with GTO or SSM-sat dichotomized as external criterion, the area under the curve was similar for the COMI change score (0.86-0.90) and the SSM (sub)scales (0.80-0.90). CONCLUSION: With either SSM-sat or GTO serving as the external criterion, COMI was as responsive as the SSM. The COMI is well able to detect important change in lumbar spinal stenosis and has the added benefit of reducing the response burden for the patient and facilitating outcome comparisons with other spinal pathologies. LEVEL OF EVIDENCE: 2.