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Results of total joint arthroplasty and joint preserving surgery in younger patients evaluated by alternative outcome measures

Jakob Klit
Danish Medical Journal 2014, 61 (4): B4836
24814600

BACKGROUND: Knee and hip OA is the clinical and pathological outcome of a functional and structural failure of the joint, resulting in pain and physical dysfunction. Despite the similarity in clinical presentation the pathogenesis seems to differ. Where knee OA is associated with obesity and trauma, hip OA is associated with FAI covering three fundamentally different hip deformities, including acetabular dysplasia; all hypothesized to initiates OA development. Where PAO is used worldwide as a joint-preserving procedure in acetabular dysplasia, TKA and THA are the treatment of choice of end stage OA. Traditional main outcomes are clinically objective surgeon-reported endpoints. Patient perceived outcomes are known to differ from these and PROMs are now recommended as the core set of outcomes. When evaluating the outcome in younger patients, this high demanding group can show ceiling-effects of the scores. The overall aim of this thesis was to investigate the consequences of PAO, TKA, and THA in younger patients evaluated by alternative outcomes in relation to satisfaction, fulfillment of expectations, symptoms of depression, the socioeconomic effects, and abilities in sex-life; to improve patient information prior to PAO, TKA and THA surgery.

MATERIAL AND METHODS: This PhD thesis is based on three studies. Study I is a cross-sectional survey of preserved hip joints with a mean follow-up of ten years after PAO. One hundred patients (121 PAO's) were eligible for inclusion. An inquiry to the National Patient registry identified 36 of PAO's (in 35 patients) being converted to THA. The 61 remaining patients (80 preserved hip joints) were asked to participate in this questionnaire based follow-up. Fifty-five patients (70 preserved hip-joints) accepted and constituted the study population. All patients received a questionnaire concerning aspects of functional ability, patient satisfaction, expectations, and quality of life following PAO. Both Study II and Study III are prospective multicenter cohort studies. Consecutive patients less than 60 years of age scheduled for (study II) unilateral or bilateral simultaneous primary TKA or (study III) scheduled for unilateral or bilateral simultaneous primary THA or HR were eligible for inclusion. Study II consisted of 115 primary TKA patients; 103 unilateral and 12 simultaneous, and Study III consisted of 136 primary THA patients; 86 unilateral THA, six simultaneous bilateral THA, and 44 HR. The study groups received a paper-format questionnaire within one month before surgery and at three, six, and 12 months postoperatively.

RESULTS: Study I showed a high willingness to undergo PAO again with the experience and knowledge they have today and improvements were seen in all quality of life parameters except for ability in sex-life for males. Study II showed significantly improvements in joint function and HRQoL. Satisfaction and fulfillment of expectations do, however, not fully mirror the observed significant improvements in knee function and HRQoL. Patients with a depression preoperatively experience an inferior result evaluated by OKS and SF-36 PCS and MCS, but not concerning satisfaction, work-life, income or sex-life. In general TKA surgery in younger patients cannot be expected to change relation to work or annual income. Patients stay sexually active after TKA, but a decrease in frequency and a negative affection of sexual practice should be expected. Study III showed significantly improvements in joint function and HRQoL and a high degree of satisfaction and fulfillment of expectations. Only patients with major complications were not willing to repeat. THA surgery in younger patients cannot be expected to change the patient's relation to work or annual income. Patients stay sexually active after THA, and female patients experiences positive changes.

CONCLUSION: Based on the findings in this thesis PAO patients are satisfied with the outcome at medium to long-term follow-up, and lasting improvements is seen in the patients' sex life, ability to do sports, and social life. TKA and THA are reliable surgical procedures in younger patients. In addition to significantly improving joint function and HRQoL, patients' stay employed and sexually active postoperatively. However, a decrease in frequency of sexual activities and negative affection of sexual practice patterns should be anticipated following TKA surgery, THA surgery have a positive influence on female THA patients sex-life.

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