The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 5

Scientific Articles | May 01, 2004

Health-Related Quality of Life in Total Hip and Total Knee Arthroplasty: A Qualitative and Systematic Review of the Literature

Olivier Ethgen, PhD¹; Olivier Bruyère, MSc¹; Florent Richy, MSc¹; Charles Dardennes, MD¹; Jean-Yves Reginster, MD²

¹ WHO Collaborating Center for Public Health Aspects of Osteoarticular Diseases (O.E. and O.B.) and Department of Public Health, Epidemiology, and Health Economics (F.R. and C.D.), University of Liège, Belgium, CHU Sart Tilman–Bâtiment B23, 4000 Liège, Belgium. E-mail address for O. Ethgen: o.ethgen@ulg.ac.be
² Bone and Cartilage Research Unit, University of Liège, CHU Centre Ville–Bâtiment K1, Quai G. Kurth 45, 4020 Liège, Belgium

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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the WHO Collaborating Center for Public Health Aspects of Osteoarticular Diseases, Department of Public Health, Epidemiology, and Health Economics, and Bone and Cartilage Research Unit, University of Liège, Belgium

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2004 May 01;86(5):963-974

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Abstract

Background: Total hip and total knee arthroplasties are well accepted as reliable and suitable surgical procedures to return patients to function. Health-related quality-of-life instruments have been used to document outcomes in order to optimize the allocation of resources. The objective of this study was to review the literature regarding the outcomes of total hip and knee arthroplasties as evaluated by health-related quality-of-life instruments.

Methods: The Medline and EMBASE medical literature databases were searched, from January 1980 to June 2003, to identify relevant studies. Studies were eligible for review if they met the following criteria: (1) the language was English or French, (2) at least one well-validated and self-reported health-related quality of life instrument was used, and (3) a prospective cohort study design was used.

Results: Of the seventy-four studies selected for the review, thirty-two investigated both total hip and total knee arthroplasties, twenty-six focused on total hip arthroplasty, and sixteen focused on total knee arthroplasty exclusively. The most common diagnosis was osteoarthritis. The duration of follow-up ranged from seven days to seven years, with the majority of studies describing results at six to twelve months. The Short Form-36 and the Western Ontario and McMaster University Osteoarthritis Index, the most frequently used instruments, were employed in forty and twenty-eight studies, respectively. Seventeen studies used a utility index. Overall, total hip and total knee arthroplasties were found to be quite effective in terms of improvement in health-related quality-of-life dimensions, with the occasional exception of the social dimension. Age was not found to be an obstacle to effective surgery, and men seemed to benefit more from the intervention than did women. When improvement was found to be modest, the role of comorbidities was highlighted. Total hip arthroplasty appears to return patients to function to a greater extent than do knee procedures, and primary surgery offers greater improvement than does revision. Patients who had poorer preoperative health-related quality of life were more likely to experience greater improvement.

Conclusions: Health-related quality-of-life data are valuable, can provide relevant health-status information to health professionals, and should be used as a rationale for the implementation of the most adequate standard of care. Additional knowledge and scientific dissemination of surgery outcomes should help to ensure better management of patients undergoing total hip or total knee arthroplasty and to optimize the use of these procedures.

Level of Evidence: Therapeutic study, Level III-3 (systematic review of Level-III studies). See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Since the publication of the initial studies on total joint replacement by Sir John Charnley in the 1960s, both total hip and total knee arthroplasty have evolved into reliable and suitable surgical procedures to return patients to function^1,2. Total hip and total knee arthroplasty are indicated for patients with intractable pain and substantial functional disabilities who have not had acceptable relief and functional improvement after conservative treatment and who are not candidates for other, nonablative reconstructive procedures such as arthroscopy^1-4. Patients with end-stage joint deterioration due to osteoarthritis or rheumatoid arthritis constitute the largest group of patients for whom surgery is considered.

Aging of the population is driving an increase in the prevalence of arthritic disease and, consequently, the prevalence of joint failure⁵. Hence, the demand for lower-limb arthroplasty is expected to increase⁶. Additionally, the indications for surgery have been extended as a consequence of the expected potential clinical benefits and the advances in prosthetic materials. As the number of primary surgical interventions grows, the number of revisions is expected to expand as well^7,8.

The increase in health-care expenditures highlights the need for consistent evaluation of the effectiveness of medical interventions⁹. Such evaluation may inform patients, health-care providers, and health-service researchers of potential clinical and therapeutic benefits¹⁰. It may also illustrate the value of medical intervention to payers and may support and improve future health-care resources management.

The end results of surgical prosthetic intervention were traditionally assessed through measures of mortality and morbidity rates, operative complications, and the lifetime of the prosthetic materials. However, improvements in surgical and medical procedures and interventions have grown so fast that these indicators have been losing their relevance and may no longer reflect health-care efforts or benefits^11,12.

Rissanen et al.¹³ noted that the effects of total hip and total knee arthroplasty on health and health-related outcomes have been assessed with respect to numerous factors, such as economic benefits¹⁴; changes in pain, mobility, and the activities of daily life^15,16; requests for sick leave¹⁷; work disability¹⁸; and occupation¹⁹. In the past few decades, many clinical rating systems of hip and knee function have been introduced. However, little is known about their validity and reliability. A recent review claimed that properly designed reliability and validity studies were needed for the majority of commonly used rating schemes²⁰.

More recently, the evaluation of health-related quality of life through a validated and patient-completed questionnaire has become the preferred approach. Health-related quality of life, or health status, is a broad concept representing individual responses to the physical, mental, and social effects of illness on daily living, which influence the extent to which personal satisfaction with life circumstances can be achieved²¹. It has been recognized that the assessment of outcome should focus more on the perceived health of the patients²². If clinicians are interested in going beyond the pathophysiology of the hip or knee, if they seek to perceive the broader implications of diseases and strategies implemented to counter these diseases, it is then necessary to consider outcomes that encompass several dimensions of health, as a health-related quality-of-life instrument does²³.

Many health-related quality-of-life evaluation tools have been developed to allow health researchers to approach subjective measures of health. They differ in their measurement techniques as well as in the number of domains they assess^24,25. We reviewed the literature to summarize the state of knowledge regarding the benefit of total hip and total knee arthroplasty as assessed by well-established health-related quality-of-life instruments.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

The MEDLINE and EMBASE computerized literature databases were searched, from January 1980 to June 2003, for articles that had the following terms in the title or abstract: hip arthroplasty(ies)/replacement(s), knee arthroplasty(ies)/replacement(s), quality of life, and outcome(s). Reference lists from the articles retrieved were scrutinized as well to identify any additional studies of interest. Studies were eligible for review if they matched the following inclusion criteria: (1) they were in English or French, (2) they used at least one well-validated health-related quality-of-life instrument, and (3) they had a prospective cohort study design.

A well-validated health-related quality-of-life instrument was considered to be an instrument that had the ability to assess the patient's self-reported perception of health status and that had been shown in the scientific literature to be valid, reliable, and responsive. We did not consider hip and knee-rating or scoring methods by surgeons or independent observers. The Rosser Index Matrix, which allows quality-adjusted life-years calculation but does not necessarily imply self-reporting by the patient, was regarded as a health-related quality-of-life instrument.

Results

Materials and Methods | Results | Discussion | Appendix | References

Atotal of seventy-four studies were selected for the review. Thirty-two studies investigated both total hip and total knee arthroplasty^7,26-56, twenty-six studies focused on total hip arthroplasty^57-82, and sixteen studies exclusively reported results on total knee arthroplasty^83-98.

Characteristics of the Studies

The characteristics of the studies are presented in tables in the Appendix. Sample sizes ranged from eleven to 1011 enrolled patients. The main diagnosis was osteoarthritis, and the mean age at the time of surgery ranged from forty-one to seventy-three years. The duration of follow-up ranged from seven days to seven years, but most studies described the results at six and twelve months.

Evaluation Tools

Seven generic instruments, which attempted to measure the main dimensions of health-related quality of life, and eleven specific instruments, which focused on the dimensions of health-related quality of life that are specific to arthritic diseases or total hip and total knee arthroplasty, were used. The generic evaluation tools were the Nottingham Health Profile⁹⁹, the Sickness Impact Profile¹⁰⁰, the McMaster Health Index Questionnaire¹⁰¹, the Functional Status Questionnaire¹⁰², the Medical Outcomes Study Short Form-36 (SF-36)¹⁰³, the Fifteen-Dimensional Measure of Health-Related Quality of Life¹⁰⁴, and the Schedule for the Evaluation of Individual Quality of Life¹⁰⁵. The arthritis-specific evaluation tools used were the Health Assessment Questionnaire¹⁰⁶ and its modified version¹⁰⁷; the Arthritis Impact Measurement Scale¹⁰⁸, its shortened version¹⁰⁹, and its second version¹¹⁰; the Western Ontario and McMaster University Osteoarthritis Index (WOMAC)³⁰; the Impact of Rheumatic Diseases on General Health and Lifestyle¹¹¹; and the McMaster-Toronto Arthritis Patient Function Preference Questionnaire¹¹². Interestingly, two total hip arthroplasty-specific tools (the Patient-Specific Index¹¹³ and the twelve-item Hip Score Questionnaire⁶⁴) and one total knee arthroplasty-specific tool (the twelve-item Knee Score Questionnaire⁹²) were developed and validated. The Schedule for the Evaluation of Individual Quality of Life and the McMaster-Toronto Arthritis Patient Function Preference Questionnaire are two personalized instruments. They allow the patients to nominate the domains they perceive as having the greatest impact on their health-related quality of life. In addition, six health-utility indices reflecting the preferences of the patients were used: the time trade-off technique¹¹⁴, the Rosser Index Matrix¹¹⁵, the Quality of Well-Being scale¹¹⁶, the EuroQol Five-Dimensions¹¹⁷, and the Health Utilities Mark 3¹¹⁸. A utility measure that was specifically developed for the assessment of total knee arthroplasty is the McKnee Health Utility Index⁸⁶. The number of evaluations by instruments in the seventy-four retrieved studies are provided in the Appendix. The SF-36 and the osteoarthritis-specific WOMAC were by far the most commonly used instruments. When studies used both generic and specific evaluations, the SF-36 and WOMAC combination was the most frequent, with a total of twenty-one such studies.

Health Improvements

All studies described substantial improvements in the scores for physical health, such as those for pain and physical functioning. The main results from the utilities index and the SF-36 are summarized in the tables in the Appendix. Comparatively greater and faster improvements were noted with respect to the pain score^47,73-75. The greatest improvement seemed to take place within the first three to six months after surgery^{7,26,34,39,54,74,75}. Studies with longer-term follow-up described long-lasting improvement^{55,56,79,80-82}. Improvement in mental and social health was less obvious. Whereas some studies found improvement in mental health^{36,42,43,47,51,52,74,85} and social functioning^28,46, others simply suggested modest improvement^{29,54,69,71,88} or did not even provide evidence of changes in those parameters^{58,79,83,84,93}. The intuitive argument can be made that such dimensions of health-related quality of life are not related to knee and hip surgery. When improvement in health-related quality of life was found to be modest, the authors highlighted the role of comorbidities as aggravating factors in older patients. When global utility measures^{28,33,34,46,59,74,76-78,81-83,86,89,90,97,98}, personalized health-related quality-of-life instruments^{66,74,77,78,80}, or site-specific instruments were used^62-65,92, substantial improvements were also reported. Health-related quality of life following total knee arthroplasty was not assessed with personalized instruments.

Comparison with Control Groups

Wiklund and Romanus⁷¹ reported that, following total hip arthroplasty, patients experienced a quality of life that was remarkably close to or equal to that of a reference healthy group with a similar age and sex distribution. With a control group free of any major illness and matched for age, sex, and socioeconomic status with a total hip arthroplasty group, O'Boyle et al.⁸⁰ concluded that hip replacement resulted in significantly greater improvement in the health-related quality of life compared with the change in the health-related quality of life of the controls during the same period (p < 0.02). Tsuboi et al.⁵⁵ compared their patients with a group of subjects eligible for surgery but who did not undergo the surgical procedures for various reasons (personal or medical). In the group that benefited from joint replacement, the physical scores improved remarkably from one to two years postoperatively (p < 0.01) and were maintained at three to five years (p < 0.05), whereas the psychosocial scores were at the same level for up to three years postoperatively but were significantly improved at four and five years (p < 0.05). In the group treated nonoperatively, the physical scores deteriorated with persistent severity and were almost the same at baseline and five years after treatment. Additionally, the group treated operatively had significantly better social function than did the group treated nonoperatively at each one of the years of follow-up (p < 0.05).

Population Normative Values

March et al.⁴¹ found that patients treated with total hip or total knee arthroplasty reported poorer preoperative SF-36 scores for pain, physical function (limitations in performing daily physical activities), and role-physical (problems encountered with work and other daily activities due to physical health) when compared with Australian population norms for the same age-groups. Postoperatively, the biggest improvement was seen in these scores. Total hip arthroplasty caused the scores to return to normative population values. Mangione et al.⁷⁰ reported that, six months after total hip arthroplasty, the patients had scores on all SF-36 subscales that were the same as or better than the age and gender-adjusted population-based SF-36 scores. In a study of patients who had a total knee arthroplasty, van Essen et al.⁸⁵ reported that, although the scores at three months postoperatively were significantly better than the preoperative scores for physical function (p < 0.05), pain (p < 0.05), and vitality (p < 0.05), they were still lower than the age-matched population normative values. The authors suggested that this could be the consequence of either comorbidities or the time it takes for full recovery after surgery (approximately twelve months⁴⁷). Nilsdotter et al.⁶⁸ reported improvements for total hip arthroplasty patients in all SF-36 subscales (p < 0.0001) except general health. They also noted that, at twelve months postoperatively, the scores did not differ from the SF-36 general population norms. Using the WOMAC, these authors also selected an age, sex, and municipality-matched reference group without any hip symptoms. They observed that, despite a significant improvement in the pain, stiffness, and physical function dimensions of the WOMAC (p < 0.0001), the surgery group differed from the reference group with respect to the WOMAC, as the patients still reported more pain (p = 0.018), stiffness (p = 0.002), and physical dysfunction (p = 0.001) at twelve months. Using the Quality of Well-Being scale and the SF-36, Shields et al.³⁴ related that, at three and six months after total hip and total knee arthroplasty, the scores of both instruments were closer to the normative general population scores, particularly with respect to physical functioning, role-physical, and pain. Kiebzak et al.⁵⁴ reported that, although nearly all SF-36 scores increased at twelve months after surgery, differences still remained between the scores for their patients and the normative scores for the general population.

Age Effect

Using the Nottingham Health Profile for patients over the age of eighty years who had a total knee arthroplasty, Birdsall et al.⁹³ found that all dimensions, except social isolation, were substantially improved at three months after intervention (p < 0.05). At twelve months, the improvement in energy, emotional reactions, sleep, and physical mobility was maintained (p = 0.001). Interestingly, the authors randomly selected a gender-matched group of younger patients between sixty-five and seventy-five years of age who also had had a primary total knee arthroplasty. This younger group also showed significant improvement in all dimensions, except social isolation, at three months (p < 0.05), which was maintained at twelve months. By comparing the Nottingham Health Profile scores before and after surgery for the two groups, the authors found that the very elderly patients complained of less pain but worse mobility before surgery than did the younger group (p < 0.05). March et al.⁴¹ divided their study population into three different age-groups (fifty-five to sixty-four years, sixty-five to seventy-four years, and seventy-five years or older) and reported that total knee and total hip arthroplasty were successful in restoring health and well-being regardless of the age-range. McGuigan et al.⁵¹ split their study population into two age-groups at sixty-five years of age and found that the younger patients had better scores (p < 0.05) than did the older patients on all scales except physical function, pain, health perception, and health change. Nilsdotter and Lohmander⁷³ proceeded in the same way. In a comparison of two age-groups of patients (those older than and those younger than seventy-two years), they showed that patients who were older than seventy-two years and had a total hip arthroplasty had a degree of improvement (expressed in points) similar to that experienced by those younger than seventy-two years, in all dimensions except for physical function. However, the older patients did not reach the same absolute level of SF-36 health status after total hip arthroplasty as the younger ones did. The age of the patient seems to be more important for the improvement in physical function than for the improvement in the pain score. McGuigan et al.⁵¹ and Nilsdotter and Lohmander⁷³ proposed that multiple comorbidities in older patients may explain the fact that overall health-related quality of life is still more deteriorated after surgery in an older age-group. Kiebzak et al.⁵⁴ concluded that an age of more than sixty-five years did not preclude substantial improvement in SF-36 scores. Heck et al.⁹⁶ conducted a regression analysis and noted that older age was positively associated with better physical health as expressed by the SF-36 physical component score. Donell et al.⁹⁸ studied four age-groups (fifty-one to sixty, sixty-one to seventy, seventy-one to eighty, and eighty-one to ninety years) and noted that, despite significant preoperative differences among the age-groups, i.e., those between eighty-one and ninety years of age had worse scores (p = 0.0208), there were no differences postoperatively between the groups. Moreover, differences in health-related quality-of-life gains between each group were not significant. In addition, the authors warned against the computation of quality-adjusted life years, which are likely to discriminate against the elderly for whom life expectancy is shorter, as age should not be considered as a barrier to surgery. Jones et al.³⁶ investigated the effect of total hip and total knee arthroplasty in very old patients by comparing two age-groups (those who were more than eighty years old and those who were younger). Patients who were eighty years of age or older had substantial improvements in the WOMAC and SF-36 scores that were comparable with those of patients who were fifty-five to seventy-nine years of age.

Gender Effect

Van Essen et al.⁸⁵ noted a difference between men and women. Whereas men showed a significant amelioration in physical function and bodily pain (p < 0.05), women manifested significant improvement in bodily pain, vitality, role-emotional, and mental health scores (p < 0.05). According to the authors, such findings underline the importance of considering the psychosocial aspect of a patient's general health. McGuigan et al.⁵¹ noted that male gender was associated with a greater improvement after surgery with respect to social function, physical role function, mental health, energy, and pain scores than was female gender. In studies on total hip arthroplasty, Nilsdotter et al.^68,73 found no gender-related differences in preoperative and postoperative SF-36 and WOMAC scores, except for preoperative pain scores for both questionnaires, for which women had worse scores than men⁷³. Brodie and Sloman⁵⁸, using the Arthritis Impact Measurement Scale, noted that men were more mobile than women both before and after surgery. Kiebzak et al.⁵⁴ revealed that men scored slightly higher preoperatively than women did on all SF-36 subscales. These differences were maintained twelve months postoperatively.

Total Hip Arthroplasty Compared with Total Knee Arthroplasty

Liang et al.³³ found no significant differences between patients who had a total hip or total knee arthroplasty with regard to the mean change in the Quality of Well-Being Scale. McGuigan et al.⁵¹ reported that patients who had a total hip arthroplasty scored higher than did those who had a total knee arthroplasty in all scales of the SF-36 except for the health-change score. However, the authors moderated their findings because of the important difference in the demographic data between the two populations and suggested that such a difference in outcome highlighted the need to take demographic variables into account when reporting health-related quality-of-life data following total joint replacement. In a comparison of the outcomes after total hip and total knee arthroplasty, Ritter et al.⁵² found substantial improvement in all dimensions of the SF-36, except for general health, at six, twelve, and twenty-four months, with no significant difference between patients who had a total hip arthroplasty and those who had a total knee arthroplasty. Hozack et al.⁵⁰, using the SF-36, showed that patients who have a total hip arthroplasty manifest better restoration in both absolute level and change from baseline for physical function, social function, pain, and energy scores. Although the authors remarked that patients who had a total knee arthroplasty were older and heavier than the patients who had a total hip arthroplasty, the SF-36 scores were identical preoperatively. Kiebzak et al.²⁷ also observed that improvement after total hip arthroplasty was notably greater than that after total knee arthroplasty. Patients who had a total hip arthroplasty recorded substantially increased SF-36 scores for all dimensions, whereas patients who had a total knee arthroplasty improved only with respect to physical functioning, role-physical, pain, and vitality scores. In a later study, Kiebzak et al.⁵⁴ confirmed that patients treated with total hip arthroplasty had significantly higher scores at twelve months postoperatively on all SF-36 domains (p < 0.04). Bayley et al.⁴² noted that patients who had a total hip replacement tended to report lower scores for function preoperatively and greater improvement after surgery. Their scores returned to normative values for pain and role-emotional dimensions, and they did better than population norms with respect to social function, role-physical mental health, and vitality. On the other hand, the scores for patients who had a total knee arthroplasty returned to population norms only for social function and mental health and were below normative values for the other dimensions. Rissanen et al.⁷ noted that the health-related quality-of-life scores increased substantially more after total hip arthroplasty than after total knee arthroplasty, even after adjustment for age and preoperative scores. Using the WOMAC, Aarons et al.²⁶ found that patients who had a total knee arthroplasty had a smaller improvement in pain scores than those who had a total hip arthroplasty. Bachmeier et al.³⁹ reported greater improvement in the SF-36 scores (except role-emotional) and the WOMAC scores for patients who had a total hip arthroplasty than for those who had a total knee arthroplasty. Very similar results on the SF-36 and the WOMAC were found by March et al.⁴⁴. Mainard et al.⁴³ confirmed that patients who have a total hip arthroplasty have better and earlier gain than do those who have a total knee arthroplasty in terms of health-related quality of life as assessed by the Nottingham Health Profile and the Arthritis Impact Measurement Scale-2. Surprisingly, many other studies that included both total hip and total knee arthroplasty groups did not present comparative results.

Primary Compared with Revision Arthroplasty

Hozack et al.⁵⁰ established that, even though no significant preoperative differences appeared in any health dimensions of the SF-36, physical function was significantly higher in the group that had a primary total hip arthroplasty than in the group that had a revision (p < 0.01). The other scores were comparable for the two subgroups. When comparing changes between the preoperative scores and those at the time of follow-up, the group that had a primary total hip arthroplasty showed better improvement in physical function (p = 0.03) and overall health perception (p = 0.02). The authors did not report results concerning differences between primary and revision total knee arthroplasty.

Prosthesis and Procedure Effects

Rorabeck et al.^77,78 performed a randomized clinical trial comparing cemented and cementless total hip replacements. A striking improvement, with no difference between the cemented and cementless groups, was found with use of the Sickness Impact Profile. Nevertheless, a decline appeared at four years after surgery in both groups compared with the two-year results. According to the authors, this could be due to the aging of the study population and, thus, to a decrease in their general health status rather than to a specific deterioration in hip function. With the WOMAC and the McMaster-Toronto Arthritis Patient Function Preference Questionnaire, dramatic and long-lasting improvements were observed with no differences between cemented and cementless implants. With the time trade-off technique, total hip arthroplasty was shown to be unquestionably effective whatever type of prosthesis was used. Lavernia et al.⁹⁷ prospectively followed patients who had a unilateral total knee arthroplasty and those who had a bilateral total knee arthroplasty. They reported no difference in the Quality of Well-Being scores. Garellick et al.⁷⁹ randomized patients who were having a total hip arthroplasty to management with a Charnley or a Spectron prosthesis. They noted long-lasting improvement for all items except social isolation. Laupacis et al.^74,81 also followed a randomized cohort of patients who had a hip replacement with a Mallory-Head prosthesis inserted either with or without cement. The patients had improvements across a wide array of dimensions of health-related quality of life that were maintained during the seven years of follow-up, although they appeared to decrease slightly between the first and seventh years. Despite use of randomization, Garellick et al.⁷⁹ and Laupacis et al.^74,81 did not report any comparative results with respect to the type of prosthesis.

Osteoarthritis Compared with Rheumatoid Arthritis

With use of the Impact of Rheumatic Diseases on General Health and Lifestyle questionnaire to assess the effects after total hip replacement, Borstlap et al.⁶⁹ described substantial amelioration on both the pain and mobility scales in the group that had osteoarthritis. Mental health (anxiety, cheerfulness, and depression) and self-care were also improved. The impact of the disease on several activities of daily living was attenuated. However, no amelioration in the social dimension was noted. In the group that had rheumatoid arthritis, significant improvement was reported only with respect to the mobility (p = 0.0005) and pain (p = 0.001) scores. The authors matched the patients in the osteoarthritis group and the rheumatoid arthritis group for gender only. Matching for age was not possible given that patients with osteoarthritis were definitely older. Both groups improved in terms of health-related quality of life, but amelioration was less pronounced in the group with rheumatoid arthritis. Using the Health Assessment Questionnaire and on the basis of a five-year follow-up period, Kirwan et al.⁵⁶ assessed disability in four groups: patients with osteoarthritis who had a total hip or total knee arthroplasty and patients with rheumatoid arthritis who had a total hip or total knee arthroplasty. They reported improvements in all four groups but noted that patients with osteoarthritis did better than those with rheumatoid arthritis. Drewett et al.⁸³ reported similar results after total knee arthroplasty for patients with osteoarthritis and those with rheumatoid arthritis. In a study that focused exclusively on patients with rheumatoid arthritis, Kageyama et al.⁴⁹ found relatively small improvements with respect to the scores on the Modified Health Assessment Questionnaire. For patients with osteoarthritis, total hip and total knee arthroplasty can relieve a major local disorder in the lower limb. In comparison, for patients with rheumatoid arthritis, these interventions may provide limited restoration in health status because of disabilities in the upper extremities.

Predictors of Health-Related Quality-of-Life Improvements

McGuigan et al.⁵¹ used multiple regression analysis to determine the relative effect of sex, age, and preoperative scores on the postoperative scores for each of the scales of the SF-36. Their analysis failed to indicate a predictive relationship between preoperative and postoperative scores for any scales. Sharma et al.⁸⁸ predicted physical function outcome (SF-36) at three months after total knee arthroplasty. They showed that, among all of the baseline variables considered in their model, psychosocial variables (SF-36 social functioning scale, role-emotional scale, and motivation) most strongly predicted physical functional outcome. In a study of total knee arthroplasty, Heck et al.⁹⁶ also performed multiple regression analysis to determine the improvement in the SF-36 physical component score from baseline to up to two years of follow-up. The set of potential predictors they used was particularly large and included patient factors, surgeon factors, and process variables. The maximum likelihood for improvement in the SF-36 physical component score was seen in patients who had a total knee arthroplasty in a hospital in which at least fifty operations per year were performed on Medicare patients; who had better mental health status at baseline; who had the surgery performed on Monday, Friday, or Saturday; who were older; who were treated with a posterior cruciate ligament-sparing device; and who had a higher preoperative physical function score on the WOMAC scale. Hopman et al.⁶¹ tried to determine which patient characteristics, process-of-care variables (medications, prosthetic devices, etc.), and structure variables (physician or surgeon) were associated with a change in the health-related quality of life. Female gender, treatment with a hybrid prosthesis, and increased preoperative disability and loss of motion were associated with positive changes. The successful cessation of smoking and a higher preoperative weight, as well as a higher anesthetic risk, were also predictors of positive changes. Rissanen et al.⁴⁷ addressed the effect of patient demographic variables. In patients who had a total hip arthroplasty, those with a higher level of education reported greater improvement in all models (p < 0.001). Age had no impact, and male gender was associated with improvement in mobility and pain scores. In patients who had a total knee arthroplasty, gender and education were not significantly related to changes in health-related quality of life except for mobility. Older patients had less gain in the mobility score (p < 0.01) and in the Fifteen-Dimensional Measure of Health-Related Quality of Life score (p < 0.001). MacWilliam et al.⁷⁵ investigated the distributions in the change on the SF-36 pain and physical functioning scores. They observed that approximately 16% of the patients reported no change in pain or increased pain at six months, and approximately 24% of the patients reported no change in physical function or decreased physical function at six months. Then they identified three categories of risk factors for poor outcomes: demographic characteristics, medical history, and preoperative functional status. African-American ethnicity, a low level of education, and each additional comorbidity were associated with a decrease in the change in the pain score (p < 0.01) and the change in the physical function score (p < 0.01). Interestingly, they also reported that patients with low preoperative scores were found to have lower scores postoperatively in comparison with patients with high preoperative scores (p < 0.01). Fortin et al.³² separately assessed patients who had total hip arthroplasty and those who had total knee arthroplasty to determine the predictors for pain (WOMAC pain score) and function (WOMAC and SF-36 physical function scores) at six months postoperatively. In all models, the baseline score was always the most important predictor of the six-month score, as was also reported by Nilsdotter and Lohmander⁷³. Patients with poorer preoperative function and pain remained worse postoperatively. In patients who had a total knee arthroplasty, those who were more highly educated reported better function and reduced pain, and comorbidity, assessed according to the Comorbidity Illness Rating Scale¹¹⁹, was found to be negatively associated with the postoperative SF-36 physical function score. Fortin et al.⁵³ extended their study to twenty-four months of follow-up and confirmed that preoperative subscale scores were always the best predictor of outcome at twenty-four months. Mahomed et al.³⁸ explored the role of patient expectation on postoperative outcome and showed that the expectation of complete pain relief was an independent predictor of greater improvement in the pain score (WOMAC) and physical functioning score (SF-36 and WOMAC) (p < 0.05). The authors also reported that, for the WOMAC pain score and the WOMAC and SF-36 physical function scores, the most significant predictors of the postoperative scores were the respective preoperative baseline scores (p < 0.001).

Weight Effect

Using the Rosser Index Matrix, Chan and Villar⁷⁶ studied three groups of patients who had a total hip arthroplasty: those who were not obese (a body mass index of <25), those who were mildly obese (a body mass index between 25 and 29.9), and those who were moderately obese (a body mass index between 30 and 39.9). Improvements were reported for all groups, but the authors noted that there was no difference in health-related quality of life after surgery among the three groups at one and three years. Despite the fact that the results were based on a body mass index of <40, the authors concluded that obesity does not influence the benefits of total hip arthroplasty and that, consequently, patients should not be denied surgery on the basis of their body weight alone. Using the Nottingham Health Profile, Deshmukh et al.⁹⁵ showed that total knee arthroplasty led to a definite and prompt improvement in the patients' quality of life and that the body mass index made no substantial unique contribution to the short-term outcome. Using a large data set, including 592 patients who had a total hip arthroplasty and 1011 patients who had a total knee arthroplasty, and the SF-36 and the WOMAC scores, Stickles et al.⁴⁵ studied five groups based on body mass index (a score of <25, 25 to 30, 30 to 35, 35 to 40, and >40). At the one-year follow-up, they found that obese patients who had had a total hip or total knee arthroplasty were as satisfied with the outcome as were their peers who were not obese. Additionally, there were no differences in the changes in the SF-36 physical and mental component summary scores as well as in the WOMAC global score among the different body-mass-index groups. However, this does not suggest that obesity does not have an effect on outcome after total hip or total knee arthroplasty because, as the body mass index increased, the risk of having difficulty ascending and descending stairs at one year increased and the postoperative WOMAC global score and SF-36 physical component summary score decreased. The authors stated that it will remain impossible to assess the effect of obesity on total hip and total knee arthroplasty outcomes until a standardized definition of obesity has been adopted by the orthopaedic community.

Waiting Time for Surgery

Williams et al.⁴⁰ addressed the issue generated by lengthy waiting lists for total hip and total knee arthroplasty. Preoperatively, there was no relationship between the WOMAC and SF-36 scores and the waiting time. Postoperatively, the authors noted marked improvements for all scores and noticed that the waiting time did not appear to have an impact on postoperative outcome. Using the same instruments in a study of total hip arthroplasty, Nilsdotter and Lohmander⁷³ did not find any effect of waiting time on the postoperative outcome. They observed improvement in the scores for general health and pain during the waiting time and suggested that it could be considered as an example of regression to the mean, in the sense that patients might be expected to be at their worst when the decision is made to put them on the waiting list. Using the WOMAC, the SF-36, and the Health Utilities Mark 3, Mahon et al.⁵⁹ prospectively followed the health-related quality of life and the mobility of patients from the time of referral for total hip arthroplasty rather than from the first visit to a surgeon. They found that there was no association between the time that the patients waited and the postoperative health-related quality of life and mobility. They also reported that the more disabled patients had surgery sooner and benefited from broader health-related quality-of-life and mobility gains than did patients who waited longer. Patients who waited more than six months experienced clinically important losses in health-related quality of life and mobility during the wait.

Cost-Effectiveness

When overall health improvement was used to assess the effectiveness of total joint arthroplasty, the hip and knee procedures had similar results^33,120. Liang et al.³³ reported that total joint arthroplasty was far more cost-effective among patients who had the most to gain (those with lower preoperative scores). Lavernia et al.⁹⁷ concluded that total knee arthroplasty is a cost-effective procedure and compares most favorably with other medical and surgical interventions. Comparing the cost-effectiveness of unilateral and bilateral arthroplasty, they showed that, although bilateral arthroplasty was significantly more expensive (p = 0.01), there were no significant differences in the Quality of Well-Being scores and cost per quality-adjusted life years at any of the assessment intervals (p < 0.05). They also observed that the cost per quality-adjusted life year decreased as a function of time; the large values found for the first three months were probably due to the relatively long rehabilitation process after total knee arthroplasty. Rissanen et al.⁷ compared the cost-effectiveness of total hip and total knee arthroplasty as well as that associated with three age-groups (sixty years of age or younger, sixty-one to seventy years, and more than seventy years of age). The cost-effectiveness ratio demonstrated a greater efficiency for the hip procedures. In addition, total hip arthroplasty for patients younger than seventy years and total knee arthroplasty for those younger than sixty years were more cost-effective than for other patient groups. Total knee arthroplasty in the oldest group was the least cost-effective intervention.

Discussion

Materials and Methods | Results | Discussion | Appendix | References

Total hip and total knee arthroplasty were found to be quite effective in terms of health-related quality of life. Most of the health dimensions, except occasionally the social dimension, were improved. Age should not be considered an obstacle to surgery. Men seem to gain more from the intervention, which is consistent with the fact that, generally, men report less disability than women¹²¹. When improvement was found to be modest, the role of comorbidities was highlighted. Total hip arthroplasty seems to return the patient to function to a greater extent than total knee arthroplasty does, and primary surgery offers greater improvement than revision does. Patients reporting poorer preoperative health-related quality of life were more likely to experience greater improvement.

Seven studies were not included. One study did not consider the same cohort of patients before and after the intervention¹³. One study did not apply a health-related quality-of-life instrument; rather, the authors validated a battery of their own self-reported scales¹²². One study examined arthroplasty in general and did not focus on total knee procedures¹²³. Four studies assessed preoperative health-related quality of life retrospectively, either by using preoperative data in the patient's medical record¹²⁴ or by asking the patients to remember their health status before the intervention^125-127. Lingard et al.⁸⁷ and others¹²⁸ have demonstrated that recall data are not a reliable proxy for prospectively collected data^87,128. This should be kept in mind to avoid any overestimation or underestimation of the effectiveness of arthroplasty given that the preoperative status appears to be a strong predictor of the outcome after surgery^32,53.

Most of the studies were based on data retrieved from surgeon-based or hospital-based recruited cohorts. The findings may have limited value for generalization because of limited patient representation²². Outcome may differ depending on surgeon experience or hospital volume^129-132. However, studies that investigated a community-based population³⁵ or enrolled patients from multiple orthopaedic surgeons^39,45,73,75 or countries⁹⁴ described results with more general value, which confirmed the findings of single-surgeon studies.

In addition, most of the results came from observational studies instead of randomized controlled studies^133,134. As far as we know, no study has fully investigated the effectiveness of total hip and total knee arthroplasty compared with nonoperative care. However, this question brings up ethical considerations. With the current state of knowledge, would it be ethical to randomize highly disabled patients to nonoperative care? Few studies made the distinction between surgical patterns (an anterior compared with a posterior approach or a procedure performed with or without cement). Yet studies in which the patients were randomized with respect to different prosthetic types^33,74,77,78 have failed to demonstrate a significant effect of different surgical procedures on the health-related quality of life.

When the outcomes of total hip and total knee arthroplasty are evaluated, numerous factors other than the surgery itself should be taken into account. Comorbidities, rehabilitation therapy, use of medications, psychological profile, and social support are factors likely to influence the success or failure of an operation as expressed in terms of health-related quality of life. This latter point highlights the need for more predictive and explanatory modeling.

Many studies have described the results between three and twenty-four months. Prosthetic failures and complications mainly occur more than two years postoperatively. Patients undergoing arthroplasty of a lower limb are generally elderly. In the elderly, comorbidity and overall functional decline are common. Surgery may substantially relieve a specific complaint but may not enhance overall health-related quality of life in the long run; however, studies with long-term follow-up have described long-lasting improvement in health-related quality of life^55,56,79-82.

Patients who report a poorer health-related quality of life preoperatively are more likely to experience greater improvement after surgery. Their mediocre preoperative health status certainly offers more chances for improvement^33,61. Nevertheless, patients with lower function preoperatively failed to reach a level of function postoperatively that was similar to that achieved in patients with better preoperative function^32,53,135. Individuals who already have high preoperative scores may have a smaller opportunity to benefit from surgery³³. Patients with a poor preoperative score can derive the most gain in health-related quality of life, but it could be the result of the fact that they have more room for improvement on fixed-ended scales (the ceiling effect)⁴⁸.

Responsiveness is among the most important criteria when choosing an instrument^136,137. Highly responsive scales require a smaller sample size and allow comparison of different types of total hip or total knee arthroplasty, where the differences between types of prostheses are expected to be much smaller than the changes before and after surgery⁶³. Further research is needed to determine the preferred index for assessing responsiveness.

A longer waiting time may not necessarily jeopardize the potential improvements that patients can achieve with surgery^40,59,73. The opposite could also be argued⁴⁰. If more disabled patients can achieve substantial relief, then disproportionately long waiting times impose an avoidable burden of pain and disability^138,139. Shortening the waiting times and prioritizing patients in terms of severity would serve to reduce the burden of waiting for surgery. The years without disability and pain that are lost while waiting for a total joint arthroplasty are not regained after surgery⁷³.

To manage the waiting list, a patient's perception of his or her overall symptom burden and ability to tolerate delayed pain relief should be considered along with information derived from clinical judgments^73,140,141. Several studies have suggested that the SF-36 and the WOMAC may assist the surgeon in placing the patient on the waiting list for surgery^40,73. In a study of patients who had a total hip arthroplasty, the scores on the WOMAC pain and physical function scales at twelve months postoperatively were not predicted by the preoperative radiographic grade of osteoarthritis⁶⁸. This suggests that the symptoms and not the radiographic grade should drive the decision for surgery. The practice of delaying total hip arthroplasty until severe radiographic changes are evident should therefore be questioned, and more attention should be paid to the patient's self-perception of health status. Nevertheless, use of health-related quality-of-life data to manage the time on the waiting list may also allow the patients to overestimate their pain or disability in order to have the surgery as soon as possible. Using health-related quality-of-life instruments as an aid for managing the waiting list deserves further research.

Nevertheless, the lack of awareness of effective interventions for arthritis has been pointed out^134,142-144. This may have prevented both patients and health professionals from implementing likely effective surgical interventions¹⁴³. For example, recent reports have stressed the underuse of hip and knee arthroplasty^145,146.

On the basis of a qualitative study on the unwillingness of patients to consider total joint arthroplasty for the treatment of arthritis, Hudak et al.¹⁴⁷ pointed out that a lack of information and misperceptions may lead a patient to defer the decision to have an arthroplasty or may preclude it altogether. Some authors have called for the need for both patients and health professionals to be informed and up-to-date on the beneficial outcome expected from surgery^134,148. Coyte et al.¹⁴⁹ also stressed the need to increase the consistency of informed clinical knowledge to optimize the allocation of health-care resources. Failure to diffuse outcomes research data may impede clinical progress and may expose patients to suboptimal care¹⁵⁰. Health-related quality-of-life data can play a major role in providing and disseminating relevant health-status information and can be used as a rationale to improve the management of health-care resources.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

Tables showing the characteristics of the studies, the health-related quality-of-life instruments assessed in this review, and the evolution of utility scores and specific component scores of the SF-36 are available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

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Topics

hip region ; hip joint ; osteoarthritis ; pain ; arthroplasty ; hip replacement arthroplasty ; knee replacement arthroplasty ; quality of life ; health-related quality of life ; sf-36

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Olivier Ethgen, Olivier Bruyère, Florent Richy, Charles Dardennes, Jean-Yves Reginster; Health-Related Quality of Life in Total Hip and Total Knee ArthroplastyA Qualitative and Systematic Review of the Literature. The Journal of Bone & Joint Surgery. 2004 May;86(5):963-974.

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