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Validation of the HOOS, JR: A Short-form Hip Replacement Survey
Abstract
Background
Patient-reported outcome measures (PROMs) are increasingly in demand for outcomes evaluation by hospitals, administrators, and policymakers. However, assessing total hip arthroplasty (THA) through such instruments is challenging because most existing measures of hip health are lengthy and/or proprietary. Questions/purposesThe objective of this study was to derive a patient-relevant short-form survey based on the Hip disability and Osteoarthritis Outcome Score (HOOS), focusing specifically on outcomes after THA. Methods
We retrospectively evaluated patients with hip osteoarthritis who underwent primary unilateral THA and who had completed preoperative and 2-year postoperative PROMs using our hospital’s hip replacement registry. The 2-year followup in this population was 81% (4308 of 5351 patients). Of these, 2371 completed every item on the HOOS before surgery and at 2 years, making them eligible for the formal item reduction analysis. Through semistructured interviews with 30 patients, we identified items in the HOOS deemed qualitatively most important to patients with hip osteoarthritis. The original HOOS has 40 items, the four quality-of-life items were excluded a priori, five were excluded for being redundant, and one was excluded based on patient-relevance surveys. The remaining 30 items were evaluated using Rasch modeling to yield a final six-item HOOS, Joint Replacement (HOOS, JR), representing a single construct of “hip health.” We calculated HOOS, JR scores for the Hospital for Special Surgery (HSS) cohort and validated this new score for internal consistency, external validity (versus HOOS and WOMAC domains), responsiveness to THA, and floor and ceiling effects. Additional external validation was performed using calculated HOOS, JR scores in collaboration with the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) nationally representative joint replacement registry (n = 910). ResultsThe resulting six-item PROM (HOOS, JR) retained items only from the pain and activities of daily living domains. It showed high internal consistency (Person Separation Index, 0.86 [HSS]; 0.87 [FORCE]), moderate to excellent external validity against other hip surveys (Spearman’s correlation coefficient, 0.60–0.94), very high responsiveness (standardized response means, 2.03 [95% CI, 1.84–2.22] [FORCE]; and 2.38 [95% CI, 2.27–2.49] [HSS]), and favorable floor (0.6%–1.9%) and ceiling (37%–46%) effects. External validity was highest for the HOOS pain (Spearman’s correlation coefficient, 0.87 [95% CI, 0.86–0.89] [HSS]; and 0.87 [95% CI, 0.84–0.90] [FORCE]) and HOOS activities of daily living (Spearman’s correlation coefficient, 0.94 [95% CI, 0.93–0.95] [HSS]; and 0.94 [95% CI, 0.93–0.96] [FORCE]) domains in the HSS validation cohort and the FORCE-TJR cohort. Conclusions
The HOOS, JR provides a valid, reliable, and responsive measure of hip health for patients undergoing THA. This short-form PROM is patient relevant and efficient. Level of EvidenceLevel III, diagnostic study.
... With the healthcare practice becoming patients-centered, patient-reported outcome measures (PROMs) are growing increasingly popular in clinical care, and popular instruments, such as the HOOS-JR and KOOS-JR, are frequently used for measuring outcomes after total joint arthroplasty [1,2]. Using validated questionnaires, PROMs quantify clinical outcomes from a patient's perspective and perception by converting symptoms into numerical scores. ...
... Since standards regarding how specific PROMs should be administered can limit the contextual influence on the results, modifiable factors need to be identified. Therefore, we chose to investigate two joint-specific short-form PROMs frequently used in arthroplasty, the knee injury and osteoarthritis outcome score for joint reconstruction (KOOS-JR) and the hip disability and osteoarthritis outcome score for joint reconstruction (HOOS-JR) [1,2]. HOOS-JR and KOOS-JR scores each range from 0 to 100, with 100 indicating no difficulty with tasks and 0 indicative of extreme limitation or inability to perform tasks [1,2]. ...
... Therefore, we chose to investigate two joint-specific short-form PROMs frequently used in arthroplasty, the knee injury and osteoarthritis outcome score for joint reconstruction (KOOS-JR) and the hip disability and osteoarthritis outcome score for joint reconstruction (HOOS-JR) [1,2]. HOOS-JR and KOOS-JR scores each range from 0 to 100, with 100 indicating no difficulty with tasks and 0 indicative of extreme limitation or inability to perform tasks [1,2]. We hypothesized that patients completing the functional tasks queried on the HOOS-JR and KOOS-JR questionnaires would improve their scores, similar to the results seen after completing tasks queried on the QuickDASH [5]. ...
Background
Patient-reported outcome measures quantify outcomes from patients’ perspective with validated instruments. QuickDASH (Quick Disability of Arm, Shoulder and Hand, an upper extremity PROM) scores improve after completing instrument tasks, suggesting patient-reported outcome results can be modified. We hypothesized that performing lower extremity tasks on the knee injury and osteoarthritis outcome score for joint reconstruction (KOOS-JR) and hip disability and osteoarthritis outcome score for joint reconstruction (HOOS-JR) instruments would similarly improve the scores.
Methods
Forty seven hip and 62 knee osteoarthritis patients presenting to a suburban academic center outpatient osteoarthritis and joint replacement clinic were enrolled and randomized to an intervention or a control group. Inclusion criteria were age over 18 years and English competency. Patients completed a HOOS-JR or KOOS-JR instrument, completed tasks similar to those of the instrument (intervention) or the QuickDASH (control), and then repeated instruments again. Paired and unpaired t-tests were used to compare the intervention and control group scores before and after tasks.
Results
There was no significant difference in total or individual scores after task completion compared to baseline in either the HOOS-JR or the KOOS-JR groups. There was no significant difference in the scores between the intervention or control groups.
Conclusions
Disability may be less modifiable in the lower extremity than in the upper extremity, perhaps because upper extremity activities are more easily compensated by the contralateral limb, or because lower extremity activities are more frequent. Thorough evaluation of factors influencing patient-reported outcome measures is necessary before their extensive application to quality control and reimbursement models.
... A previously validated protocol was used to define and validate the French short version (6 items) and the minimal version (3 items). 13,14,15,24 Item Eligibility Assessment. Before proceeding to the item selection, 30 patients (15 men and 15 women) were randomly selected among 1000 included patients and asked to rate each of the 12 items between 1 and 3 (1 = unimportant; 2 = somewhat important; 3 = very important). ...
... The mean of these ratings was known as the ''relevance score'': Only items obtaining a mean of at least 2 and the ratings of at least 2 by two-thirds of the respondents were kept for the short version. 14,15,24 Item Reduction and Validation Process. At least 1 question from each of the 3 ACL-RSI domains-emotions; confidence in performance; and risk appraisal-had to be included in both the short and minimal versions. ...
Background
The 12-item Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) scale was developed to assess the psychological readiness of patients to return to sports after ACL reconstruction (ACLR). A short (6-item) English version was also developed, which has shown to have good reliability and validity.
Purpose/Hypothesis
We aimed to develop and validate a French version of the short ACL-RSI scale. We hypothesized that the same questions would remain in the selection as the English version and that the French version of the scale would have the same psychometric properties.
Study Design
Cohort study (diagnosis); Level of evidence, 3.
Methods
The full 12-item French ACL-RSI scale was administered to 1000 patients who had undergone ACLR surgery. Reliability (Cronbach alpha) and factor analysis of the full scale were determined. Item selection and elimination process was conducted to develop a short (6-item) version. The same methodology was used to develop the English short ACL-RSI scale. A minimal (3-item) version was also developed and assessed.
Results
Internal consistency of the full version of the French ACL-RSI was found to be high (Cronbach alpha = .95), suggesting item redundancy. The short (6-item) version was also found to have high internal consistency (Cronbach alpha = .92) and was strongly correlated with the full version ( r = 0.98). The minimal (3-item) version was also found to have high internal consistency, as well as a strong correlation with the full version ( r = 0.94).
Conclusion
The French version of the short (6-item) ACL-RSI scale was valid, discriminant, consistent, and reproducible. The minimal (3-item) version was also found to be useful and more efficient to collect the information provided by the full ACL-RSI in a French-speaking population.
... En el presente estudio, los puntajes promedio en los dominios función física, desempeño físico y dolor corporal, desempeño emocional y función social no superaron los 40 puntos en ninguno de los dos grupos (19,7), lo que confirma el impacto negativo de la OA en la calidad de vida y el funcionamiento en actividades de la vida diaria de los participantes de la prueba piloto. Estos hallazgos están en línea con lo descrito por Solís et al., 18 quienes, en un estudio realizado en Bogotá en 2787 pacientes con OA (37.82% con OAR y 21.82% con OAC), reportaron que 29.89%, 55,9%, 4.99% y 9.22% de los participantes tenían discapacidad leve, moderada, grave y total, respectivamente, y que las dimensiones más afectadas en estos pacientes fueron dolor, forma física y actividades cotidianas. ...
Introducción. La evaluación de los síntomas y el impacto de la osteoartritis de rodilla (OAR) y de la osteoartritis de cadera (OAC) en la capacidad funcional y la calidad de vida es prioritaria para determinar la efectividad del tratamiento y mejorar los resultados clínicos. Objetivos. Describir el proceso de traducción y adaptación cultural al español colombiano de los cuestionarios KOOS-12, KOOS-JR, HOOS-12 y HOOS-JR, presentar los resultados de su aplicación en una prueba piloto realizada para evaluar la comprensión de los ítems, y presentar los resultados obtenidos en estas versiones por pacientes con OAR y OAC en términos de funcionalidad, dolor y calidad de vida. Metodología. Estudio descriptivo. Primero, se describe el proceso de traducción y adaptación al español colombiano de los cuestionarios KOOS-12, HOOS-12, KOOS-JR, HOOS-JR. Luego, se presentan los resultados de una prueba piloto en la que las versiones en español colombiano de estos cuestionarios fueron aplicadas a 55 pacientes con OAR (n=37) y OAC (n=18). Se utilizó el coeficiente de correlación de Spearman (rho) para evaluar las correlaciones entre, por un lado, las puntuaciones obtenidas en estos instrumentos (puntaje global y por dominio) y, por el otro, las puntuaciones obtenidas en la Escala Visual Análoga (EVA) y las dimensiones del cuestionario de salud SF-36. Resultados. Las puntuaciones globales en el KOOS-12, KOOS-JR, HOOS-12 y HOOS-JR fueron 42,7, 46,5, 39,6, y 38,3, respectivamente; además, en el caso de los cuestionarios KOOS-12 y HOOS-12, la puntación en cada uno de sus dominios (dolor, función en actividades de la vida diaria y calidad de vida) nunca superó los 50 puntos. Respecto a las correlaciones entre las puntuaciones obtenidas en las dimensiones del cuestionario SF36 y los puntajes obtenidos en los cuatro cuestionarios, se observó lo siguiente: fueron muy débiles-débiles con el puntaje total KOOS-12 (rho= 0.2-0.4), a excepción de la dimensión función social (rho= 0.5); muy débiles-débiles con el puntaje KOOS-JR (rho= 0.1-0.4); moderadas-fuertes (rho= 0,5-0,8) con el puntaje total HOOS-12, a excepción de la dimensión vitalidad (rho= 0.3), y muy débiles, débiles, moderadas y fuerte con el puntaje HOOS-JR. Conclusión. De acuerdo con los resultados de la prueba piloto, es posible afirmar que las versiones traducidas y adaptadas al español colombiano de los cuestionarios KOOS-12, HOOS-12, KOOS-JR, HOOS-JR aquí presentadas podrían usarse para evaluar el impacto de la OAR y de la OAR en el país en términos de dolor, funcionalidad en actividades de la vida diaria y calidad de vida. Sin embargo, se requiere completar su proceso de validación.
... Additionally, severity of functional limitation was assessed with the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR); HOOS-JR and KOOS-JR scores are measures of joint function that range from 0 to 100, in which 0 represents total joint disability and 100 represents perfect joint health. 13,14 Severity of joint pain was assessed using the visual analog scale (VAS), which ranges from 0 to 10, in which 0 represents no pain and 10 represents worst imaginable pain. ...
Objective
Our aim was to determine the most significant barriers to total joint arthroplasty (TJA) for people living in high‐poverty communities relative to low‐poverty communities.
Methods
We created a 21‐question survey based on interviews with underrepresented minority patients with osteoarthritis targeting five barriers to TJA: trust in surgeon, recovery concerns, cost and/or insurance issues, fear of poor surgical outcomes, and timing considerations. Participants rated the importance of each barrier on a 5‐point Likert scale, dichotomized into “very or extremely important” and “not as important.” The survey was distributed at New York City clinics and nationally through an arthritis advocacy group. We used geocoding to link addresses to census tracts, defining high‐poverty communities as those with ≥20% of residents living below the poverty level. Logistic regression models assessed the association between community poverty status and rating barriers as very or extremely important, with adjustment for demographic and clinical factors.
Results
Of the 702 survey participants, 16.8% were residents of high‐poverty communities. After adjustment, participants from high‐poverty communities were more likely to rate trust in surgeon (adjusted odds ratio [aOR] 1.87, 95% confidence interval [CI] 1.24–2.82) and fear of poor surgical outcome (aOR 1.68, 95% CI 1.08–2.61) as very or extremely important.
Conclusion
People from high‐poverty communities identified lack of trust in surgeons and fear of poor surgical outcomes as more significant barriers to TJA compared to people from low‐poverty communities.
... health and was originally designed to evaluate pain, function, and activities of daily living post joint replacement surgery [21]. Similarly, the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS JR) is a survey measuring overall knee health for individuals post total knee replacement by evaluating stiffness, pain, function, and activities of daily living [22]. ...
Objective
Osteoarthritis management programs (OAMPs) have become a more common way to deliver patient-centered care. However, there is limited information on real-world use of these programs to guide implementation, payment policy, accessibility, and scaling in the United States. This paper describes 5-year use metrics for the Duke Joint Health Program, an OAMP embedded within a US academic health system.
Method
This analysis includes patients referred into the Program between October 2017 and April 2022. We generated descriptive statistics of referral and enrollment totals, demographics and patient-reported measures of enrollees, retention and healthcare use metrics (e.g., office visit frequency), and data capture rates for patient-reported outcomes.
Results
During the study period, 6863 patients were referred to the program and 4162 (61 %) enrolled. We observed statistically significant differences between those who did and did not enroll by age (mean difference ± SE: 2.49 ± 2.8 years), sex (70.0 % vs 67.7 % female), race (65.1 % vs 55.3 % Caucasian/White), employment status (50.0 % vs 40.2 % retired), and insurance type (53.5 % vs 47.0 % Medicare). The median (Q1, Q3) number of visits was 2 (1, 4) and ranged from 1 to 67. The median (Q1, Q3) number of days from first to last program visit was 23 (0, 84) days. Questionnaire completion rates were 72 % at baseline, 46 % at 6 weeks, 39 % at 3 months, and 40 % at 6 and 12 months.
Conclusion
Findings can guide the planning, development, and implementation of future OAMPs and inform policies to ensure programs are accessible and equitable.
... Hip and knee OA outcomes are the Hip dysfunction and Osteoarthritis Outcome for Joint Replacement and Knee injury and Osteoarthritis Outcome for Joint Replacement questionnaires, respectively, as well as the Patient-Reported Outcomes Measurement Information System 10 Global Health v1.2 short form. [70][71][72] Back and neck pain patient outcomes are assessed with the Patient-Reported Outcomes Measurement Information System Physical Function v2.0 and Pain Interference v1.1 questionnaire via Computer Adaptive Testing delivered through the patient portal in the electronic health record. [73][74][75] As the IPU model formed, case conferences were a meaningful tool for team learning and improvement. ...
Value-based health care has been accelerated by alternative payment models and has catalyzed the redesign of care delivery across the nation. Lifestyle medicine (LM) is one of the fastest growing medical specialties and has emerged as a high-value solution for root cause treatment of chronic disease. This review detailed a large integrated health care delivery system’s value transformation efforts in the nonoperative treatment of musculoskeletal (MSK) conditions by placing patient-centric, team-based, lifestyle-focused care at the foundation. With an economic and treatment imperative to reimagine care, recognizing more intervention is not always better, a collaborative approach was designed, which placed functional improvement of the patient at the center. This article described the process of implementing LM into an MSK model of care. The change management process impacted clinical, operational, and benefit plan design to facilitate an integrated care model. A new understanding of patients’ co-occurring physical impairments, medical comorbidities, and behavioral health needs was necessary for clinicians to make the shift from a pathoanatomic, transactional model of care to a biopsychosocial, longitudinal model of care. The authors explored the novel intersection of the implementation of a biopsychosocial model of care using LM principles to achieve greater value for the MSK patient population.
... Patients undergoing bilateral procedures, hemiarthroplasty, revision arthroplasty, or non-elective THA were excluded. PROMs including the hip injury and osteoarthritis, joint replacement (HOOS, JR) score and Patient-Reported Outcome Measurement Information System (PROMIS) measures of pain interference, pain intensity, mobility, physical function, global physical health, and global mental health were captured at patients' preoperative office visit and at subsequent postoperative office visits [16,17]. All patient interviews and PROM collections were performed in English. ...
Background
The influence of obesity on patient-reported outcome measures (PROMs) following total hip arthroplasty (THA) is currently controversial. This study aimed to compare PROM scores for pain, functional status, and global physical/mental health based on body mass index (BMI) classification.
Methods
Primary, elective THA procedures at a single institution between 2018 and 2021 were retrospectively reviewed, and patients were stratified into four groups based on BMI: normal weight (18.5–24.99 kg/m²), overweight (25–29.99 kg/m²), obese (30–39.99 kg/m²), and morbidly obese (> 40 kg/m²). Patient-Reported Outcome Measurement Information System (PROMIS) and Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR) scores were collected. Preoperative, postoperative, and pre/post- changes (pre/post-Δ) in scores were compared between groups. Multiple linear regression was used to assess for confounders.
Results
We analyzed 3,404 patients undergoing 3,903 THAs, including 919 (23.5%) normal weight, 1,374 (35.2%) overweight, 1,356 (35.2%) obese, and 254 (6.5%) morbidly obese cases. HOOS, JR scores were worse preoperatively and postoperatively for higher BMI classes, however HOOS, JR pre/post-Δ was comparable between groups. All PROMIS measures were worse preoperatively and postoperatively in higher BMI classes, though pre/post-Δ were comparable for all groups. Clinically significant improvements for all BMI classes were observed in all PROM metrics except PROMIS mental health. Regression analysis demonstrated that obesity, but not morbid obesity, was independently associated with greater improvement in HOOS, JR.
Conclusions
Obese patients undergoing THA achieve lower absolute scores for pain, function, and self-perceived health, despite achieving comparable relative improvements in pain and function with surgery. Denying THA based on BMI restricts patients from clinically beneficial improvements comparable to those of non-obese patients, though morbidly obese patients may benefit from additional weight loss to achieve maximal functional improvement.
... The modified HOOS-JR includes five items that ask participants to rate how frequently they engaged in behaviors over the past week using a 5-point Likert scale (0 = none, 1 = mild, 2 = moderate, 3 = severe, and 4 = extreme) [25]. The five items included were items two through six of the original 6-item HOOS-JR. ...
The Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) was developed as a short-form survey to measure progress after total hip arthroplasty (THA). However, the longitudinal validity of the scale structure pertaining to the modified five-item HOOS-JR has not been assessed. Therefore, the purpose of this study was to evaluate the structural validity, longitudinal invariance properties, and latent growth curve (LGC) modeling of the modified five-item HOOS-JR in a large multi-site sample of patients who underwent a THA. A longitudinal study was conducted using data from the Surgical Outcome System (SOS) database. Confirmatory factor analyses (CFAs) were conducted to assess the structural validity and longitudinal invariance across five time points. Additionally, LGC modeling was performed to assess the heterogeneity of the recovery patterns for different subgroups of patients. The resulting CFAs met most of the goodness-of-fit indices (CFI = 0.964–0.982; IFI = 0.965–0.986; SRMR = 0.021–0.035). Longitudinal analysis did not meet full invariance, exceeding the scalar invariance model (CFIDIFF = 0.012; χ2DIFF test = 702.67). Partial invariance requirements were met upon release of the intercept constraint associated with item five (CFIDIFF test = 0.010; χ2DIFF = 1073.83). The equal means model did not pass the recommended goodness-of-fit indices (CFIDIFF = 0.133; χ2DIFF = 3962.49). Scores significantly changed over time, with the highest scores identified preoperatively and the lowest scores identified at 2- and 3-years postoperatively. Upon conclusion, partial scalar invariance was identified within our model. We identified that patients self-report most improvements in their scores within 6 months postoperatively. Females reported more hip disability at preoperative time points and had faster improvement as measured by the scores of the modified five-item HOOS-JR.
... All surgeries were performed by one of 8 fellowship-trained arthroplasty surgeons. Outcomes collected include the Veterans Rand 12 (VR12) Mental and Physical Component Subscores (MCS and PCS) as well as the relevant Hip or Knee Osteoarthritis Outcome Score (HOOS or KOOS) [9,10]. Lower scores for VR12 MCS, VR12 PCS, HOOS, and KOOS (all ranges 0-100) represent more severe symptoms. ...
Background
Recovery following total joint arthroplasty is patient-specific, yet groups of patients tend to fall into certain similar patterns of recovery. The purpose of this study was to identify and characterize recovery patterns following total hip arthroplasty (THA) and total knee arthroplasty (TKA) using patient-reported outcomes that represent distinct health domains. We hypothesized that recovery patterns could be defined and predicted using preoperative data.
Methods
Adult patients were recruited from a large, urban academic center. To model postoperative responses to THA and TKA across domains such as physical health, mental health, and joint-specific measures, we employed a longitudinal clustering algorithm that incorporates each of these health domains. The clustering algorithm from multiple health domains allows the ability to define distinct recovery trajectories, which could then be predicted from preoperative and perioperative factors using a multinomial regression.
Results
Four hundred forty-one of 1134 patients undergoing THA and 346 of 921 undergoing TKA met eligibility criteria and were used to define distinct patterns of recovery. The clustering algorithm was optimized for 3 distinct patterns of recovery that were observed in THA and TKA patients. Patients recovering from THA were divided into 3 groups: standard responders (50.8%), late mental responders (13.2%), and substandard responders (36.1%). Multivariable, multinomial regression suggested that these 3 groups had defined characteristics. Late mental responders tended to be obese (P = .05) and use more opioids (P = .01). Substandard responders had a larger number of comorbidities (P = .02) and used more opioids (P = .001). Patients recovering from TKA were divided among standard responders (55.8%), poor mental responders (24%), and poor physical responders (20.2%). Poor mental responders were more likely to be female (P = .04) and American Society of Anesthesiologists class III/IV (P = .004). Poor physical responders were more likely to be female (P = .03), younger (P = .04), American Society of Anesthesiologists III/IV (P = .04), use more opioids (P = .02), and be discharged to a nursing facility (P = .001). The THA and TKA models demonstrated areas under the curve of 0.67 and 0.72.
Conclusions
This multidomain, longitudinal clustering analysis defines 3 distinct patterns in the recovery of THA and TKA patients, with most patients in both cohorts experiencing robust improvement, while others had equally well defined yet less optimal recovery trajectories that were either delayed in recovery or failed to achieve a desired outcome. Patients in the delayed recovery and poor outcome groups were slightly different between THA and TKA. These groups of patients with similar recovery patterns were defined by patient characteristics that include potentially modifiable comorbid factors. This research suggests that there are multiple defined recovery trajectories after THA and TKA, which provides a new perspective on THA and TKA recovery.
Level of Evidence
III.
... All patients who received an MCTT stem (ACTIS stem with a PINNACLE® Hip Solutions cup, DePuy Synthes, Warsaw, IN) were included. Preoperative and postoperative clinical assessments included the Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score Junior (HOOS JR) score, and a registryspecific hip evaluation questionnaire [22]. The procedures followed were per the Western Institutional Review Board Copernicus Group (WCG IRB, study number 1166116). ...
Background
The anterior approach for total hip arthroplasty (THA) has gained popularity in recent years. Some surgeons have been hesitant to adopt the approach due to concerns over increased complications such as intraoperative fracture, stem loosening, and stem revision. This study aims to evaluate the all-cause revision rate and survivorship of a collared, triple-tapered stem that was designed specifically for use with the anterior approach in THA to enhance outcomes and reduce adverse events.
Methodology
A retrospective outcomes review was conducted to assess survivorship and clinical outcomes for a specific proximally coated, medially collared triple-tapered (MCTT) femoral stem.
Results
In a cohort of 5,264 hips, Kaplan-Meier survivorship estimates (95% confidence interval [CI]; N with further follow-up), with survivorship defined as no revision of any component for any reason at five years after the index procedure, were 98.9% (97.8%-99.4%; 43) under the clinical assumption and 99.6% (99.4%-99.7%; 894) under the registry assumption. With survivorship defined as stem revision for any reason, survivorship estimates at five years postoperatively were 99.6% (99.3%-99.8%; 43) under the clinical assumption and 99.8% (99.7%-99.9%; 894) under the registry assumption. The mean follow-up time was 94.52 days (standard deviation [SD] 2.24, range 90.03-96.02). At five years postoperatively, the mean Harris Hip Score was 95.19, and the mean Hip Disability and Osteoarthritis Outcome Score Junior (HOOS JR) score was 98.66.
Conclusions
Our evaluation demonstrates excellent construct and stem survivorship and very low complication rates at midterm postoperative follow-up.
... PROMs were completed pre-operatively and post-operatively at 1, 3, 6, and 12 months. Patients completed the Hip Disability and Osteoarthritis Outcome for Joint Replacement (HOOS JR) survey [11] and EuroQol five-dimension fivelevel score (EQ-5D-5L) [12] on the mymobility application and iMednet (Minnetonka, MN), respectively. Patients were provided an Apple Watch ® (Apple, Cupertino, CA), which allowed them to receive reminders to complete PROMs surveys at designated time intervals. ...
Background
Patients undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA) may experience faster recovery but may also have better baseline health than those who undergo THA with the posterior approach (PA). This study aimed to compare patient-reported outcome measures (PROMs) between the DAA and PA while controlling for baseline factors.
Methods
This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform following THA. The primary outcomes were HOOS JR and EQ-5D-5L through 1 year and change from baseline. Longitudinal regression models were created to control for baseline characteristics and investigate the impact of surgical approach on PROMs.
Results
Of 1364 THAs evaluated, 731 (53.6%) were female, and 840 (61.6%) used the PA. Patients in the PA group were of similar age but had higher body mass index and comorbidity scores. Pre-operative HOOS JR and EQ-5D-5L were comparable, but higher post-operatively in the DAA group through 6 months (p = 0.03 and p = 0.005). At 1 year post-operatively, HOOS JR and EQ-5D-5L did not vary between groups (p = 0.48 and p = 0.56), nor did changes from baseline (p = 0.47 and p = 0.11). After controlling baseline characteristics, DAA was significantly associated with higher average HOOS JR through 6 months (p = 0.03) and EQ-5D-5L through 3 months (p = 0.005), but not at 12 months (p = 0.89 and p = 0.56).
Conclusion
THA patients undergoing DAA demonstrate earlier improvements in HOOS JR and EQ-5D-5L. However, these differences may not be clinically significant and are not evident at 1-year post-operative. Patient selection and surgeon training may continue to affect outcomes by surgical approach.
... Evaluation of clinical outcomes for THA as mitigation of pain, improved quality of life and restoration of hip function are based on surveys, such as WOMAC, Harris Hip Score, SF-36, PROM-10 and HOOS [9,10]. Nevertheless, these surveys are subjective and may not be sensitive enough to detect minor changes [11,12]. ...
Introduction
Clinical gait analysis can be used to evaluate the recovery process of patients undergoing total hip arthroplasty (THA). The postoperative walking patterns of these patients can be significantly influenced by the choice of surgical approach, as each procedure alters distinct anatomical structures. The aim of this study is twofold. The first objective is to develop a gait model to describe the change in ambulation one week after THA. The secondary goal is to describe the differences associated with the surgical approach.
Materials and methods
Thirty-six patients undergoing THA with lateral (n = 9), anterior (n = 15), and posterior (n = 12) approaches were included in the study. Walking before and 7 days after surgery was recorded using a markerless motion capture system. Exploratory Factor Analysis (EFA), a data reduction technique, condensed 21 spatiotemporal gait parameters to a smaller set of dominant variables. The EFA-derived gait domains were utilized to study post-surgical gait variations and to compare the post-surgical gait among the three groups.
Results
Four distinct gait domains were identified. The most pronounced variation one week after surgery is in the Rhythm (gait cycle time: +32.9%), followed by Postural control (step width: +27.0%), Phases (stance time: +11.0%), and Pace (stride length: − 9.3%). In postsurgical walking, Phases is statistically significantly different in patients operated with the posterior approach compared to lateral (p-value = 0.017) and anterior (p-value = 0.002) approaches. Furthermore, stance time in the posterior approach group is significantly lower than in healthy individuals (p-value < 0.001).
Conclusions
This study identified a four-component gait model specific to THA patients. The results showed that patients after THA have longer stride time but shorter stride length, wider base of support, and longer stance time, although the posterior group had a statistically significant shorter stance time than the others. The findings of this research have the potential to simplify the reporting of gait outcomes, reduce redundancy, and inform targeted interventions in regards to specific gait domains.
... Given the length of the questionnaires and the level of burden completion places on both the patient and clinician, shorter versions have been created and validated. Specifically, the Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS JR) have been designed for use in joint replacement populations, encompassing pain and function in daily living domains [4,5]. In fact, collection of these PROMs has been mandated under the CMS Comprehensive Care for Joint Replacement Model [6]. ...
Background
Patients undergo total joint arthroplasty to improve function and resolve pain. Patient-reported outcome measures (PROMs) are often sought to determine the success of total joint arthroplasty but are time-consuming and patient response rates are often low. This study sought to determine whether pain numeric rating scores (NRSs) were associated with PROMs and objective mobility outcomes.
Methods
This is a retrospective review of data in patients who utilized a smartphone-based care management application prior to and following total joint arthroplasty. NRS, Hip Disability and Osteoarthritis Outcome Score, Joint Replacement and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, and objective mobility data (step counts, gait speed, and gait asymmetry) were collected preoperatively and at 30 and 90 days postoperatively. Quantile regression was performed to evaluate the correlations between NRS and PROMs.
Results
Total knee arthroplasty patients reported higher NRS than total hip arthroplasty patients postoperatively. NRS was significantly correlated with gait speed preoperatively and at 30 and 90 days postoperatively on quantile regression. Gait asymmetry was significantly associated with NRS at 30 days postoperatively. Regression results suggested significant correlations between NRS and PROMs scores; Hip Disability and Osteoarthritis Outcome Score, Joint Replacement, −0.46 (95% confidence interval: −0.48 to −0.44, P < .001) and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, -0.38 (95% confidence interval: −0.40 to −0.36, P < .001).
Conclusions
NRS is correlated with both objective and subjective measures of function in patients undergoing arthroplasty. Simple pain ratings may be a valid measurement to help predict functional outcomes when collection of traditional PROMs is not feasible.
Background
Nowadays, total hip arthroplasty (THA) is one of the most successful procedures in the field of orthopedics and trauma. The posterior approach has historically been associated with a higher rate of hip dislocation. To reduce the rate of hip dislocation in the posterior approach, most orthopedic surgeons would recommend hip precautions (HP) for their patients postoperatively based on previous theories. However, recent randomized controlled trials have shown no significant difference in hip dislocation rates with or without HP, in contrast to previous theories. Based on these, this study conducted a meta-analysis of these randomized controlled trials to try to get qualitative conclusions.
Methods
Randomized controlled trials of HP after THA up to July 28, 2023, were searched in 3 databases, PubMed, Embase, and the Cochrane Library. Data extraction and literature quality assessment were performed by 2 independent authors and extracted hip dislocation, hip disability and Osteoarthritis Outcome Score, joint replacement (HOOS JR) scores over 6 weeks, and time to discontinuation of mobility aids. Stata software and Revman software were used to perform this meta-analysis.
Results
Following screening, 3 papers with a total of 1215 participants were included in the analysis. This meta-analysis showed that there was no statistically significant difference in hip dislocation rates with or without HP after THA undergoing the posterior approach and that the without HP group instead showed better outcomes in terms of HOOS JR scores and time to discontinuation of mobility aids.
Conclusion
THA with a posterior approach does not require hip precautions.
Background
Patients who undergo a second THA at least 1 year after the first one may experience different recovery courses after each THA. It is unknown what the clinically relevant improvements and healthcare utilization are after each THA in patients undergoing contralateral THA > 1 year apart.
Questions/purposes
(1) Do patient-reported outcome measures (PROMs) differ at baseline and 1 year after THA for the first and second hip arthroplasty? (2) Does the likelihood of achieving minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds differ for the first and second hip arthroplasty? (3) Does utilization of healthcare within 90 days of THA, using discharge disposition, length of stay (LOS), and 90-day readmission risk as proxies, differ between the first and second hip arthroplasty?
Methods
Between January 2016 and December 2021, a total of 14,023 primary THAs for hip osteoarthritis were performed at a large tertiary academic center, and data from each were longitudinally maintained in an institutional database. In this retrospective study, we excluded nonelective (n = 265), simultaneous bilateral (n = 89), staged bilateral < 1 year apart (n = 1856), unilateral THAs (n = 7541), and those who were lost prior to the minimum study follow-up of 1 year or had incomplete data sets (n =3618), leaving 654 contralateral THAs > 1 year apart (327 patients) for analysis here. The median (range) patient age was 64 years (26 to 88) at the time of the first THA and 66 years (27 to 88) at the second THA. The mean (IQR) time from first THA to second THA was 696 days (488 to 1008). In all, 62% (204 of 327) of patients were women, and 89% (286 of 321) were White. The median (range) BMI was 29 kg/m ² (first THA 16 to 60, second THA 18 to 56) at both THAs. PROMs were obtained preoperatively and at 1 year after each of the THAs and included Hip Disability and Osteoarthritis Outcome Score pain (HOOS-pain), physical function (HOOS-PS), and joint replacement (HOOS-JR) scores, as well as the Veterans Rand 12-Item Health Survey mental component summary score. Each was scored from 0 to 100, with higher scores representing better patient perceived outcomes. A distribution-based method was used to calculate the MCID thresholds (HOOS-pain 8.35, HOOS-PS 9.47, and HOOS-JR 7.76), while an anchor-based method was utilized for the PASS thresholds (HOOS-pain 80.6, HOOS-PS 83.6, and HOOS-JR 83.6). Healthcare utilization outcomes included discharge disposition, LOS, and 90-day readmission rates.
Results
Patients had slightly lower baseline PROM scores in all HOOS subdomains before the first THA compared with the second THA (median HOOS-pain 38 versus 42, p < 0.001; HOOS-PS 54 versus 58, p < 0.001; HOOS-JR 43 versus 47, p < 0.001). The difference between baseline and 1-year postoperative scores was slightly larger in all HOOS subdomains after the first THA (median HOOS-pain difference 52 versus 50, p < 0.001; HOOS-PS difference 38 versus 31, p < 0.001; HOOS-JR difference 42 versus 39, p < 0.001). There was no difference in the percentage of patients achieving the MCID in HOOS-pain (97% versus 97%; p = 0.93), HOOS-PS (92% versus 88%; p = 0.17), and HOOS-JR (96% versus 94%; p = 0.18) between the first and second THAs. Although there was also no difference in the percentage of patients achieving PASS thresholds in HOOS-pain (81% versus 77%; p = 0.11), HOOS-PS (82% versus 79%; p = 0.055), and HOOS-JR (71% versus 71%; p = 0.39) between the first and second THAs, considerably fewer patients were reaching the PASS threshold in both THAs. After the second THA, slightly more patients were discharged home (95% versus 91%; p = 0.03) and had a very slightly shorter LOS (1.28 versus 1.35 days; p < 0.001). There was no difference in 90-day readmission rates between the first and second THA (4% versus 5%; p = 0.84).
Conclusion
In patients undergoing contralateral THA > 1 year apart, baseline PROMs were slightly worse before the first THA, and improvements were slightly greater compared with the second THA, although these differences were likely not clinically significant. Clinically meaningful improvements, based on MCID and PASS thresholds, were similar at 1 year for both THAs, yet 20% to 25% of patients reported inadequate pain relief after both surgeries. Healthcare utilization was also comparable between both procedures. Surgeons can use these findings to counsel patients on the likely similar outcomes following both their THAs. Future studies should explore factors contributing to inadequate pain relief and identify strategies to improve patient outcomes after both THAs.
Level of Evidenc e Level III, therapeutic study.
Background
Paper-based patient-reported outcome measures (PROMs) and patient education can assist in improving outcomes but is administratively burdensome. Mobile phone applications (‘apps’) can distribute extensive information and PROMs at relevant time points. This study aimed to assess the suitability of an app to guide postoperative management and record PROMs based on satisfaction and compliance.
Methods
Thirty-four patients who were scheduled for a total hip/knee arthroplasty were enrolled into the study. Automatic notifications were sent by the app to complete PROMs at the appropriate time points. Patients were reminded via phone call if PROMs were not completed. An app satisfaction questionnaire was also completed, where a high score represented satisfaction with the app.
Results
Patients remained satisfied with the app throughout the study with a mean score of 19.0 out of 25. 57% found the app to be helpful with completing surveys, with 63% preferring the app over paper handouts. Majority of the participants (68%) stated that they would use the app again. There was an overall mean compliance of 78% at all time points. Most patients (82%) required at least one phone call reminder, with 18% of patients completing their PROMs prompted by the app notification alone.
Conclusions
A mobile phone app can be useful for both distributing patient education and collecting PROMs. PROMs collected using a mobile phone app still caused some administrative burden with many participants requiring multiple reminders to complete their questionnaires. While paper-forms will still be required for some patients, most found the app preferable to paper-form.
Total hip arthroplasty (THA) is one of the most successful orthopedic procedures. With improvements in implants and surgical techniques, stable outcomes have been achieved from the early postoperative period to more than 10 years postoperatively. Recently, the importance of patients’ quality of life (QOL) and satisfaction with the procedure has become more important in the postoperative evaluation of THA.
» As healthcare systems shift to value-based models, patient-reported outcome measures (PROMs) are increasingly used to measure effectiveness, efficiency, and patient satisfaction.
» PROMs provide valuable insights into treatment efficacy from the patient's perspective and are increasingly essential in value-based healthcare models.
» A variety of both joint-specific PROMs (i.e., Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement [HOOS-JR]/Knee Injury and Osteoarthritis Outcome Score for Joint Replacement [KOOS-JR]) and general PROMs (i.e., Patient-Reported Outcomes Measurement Information System [PROMIS]) currently exist for utilization in TJA practices.
» We recommend collection of the PROMIS score, the HOOS-JR/KOOS-JR, and either the University of California Los Angeles activity score or Forgotten Joint Score within 3 months preoperatively and at 1, 3, 6, and 12 months postoperatively, with final collection between 10 and 14 months.
» Continued integration of PROM research and practice will enable orthopaedic surgeons to further improve patient outcomes and overall care in TJA.
Aims
The Single Assessment Numerical Evalution (SANE) score is a pragmatic alternative to longer patient-reported outcome measures (PROMs). The purpose of this study was to investigate the concurrent validity of the SANE and hip-specific PROMs in a generalized population of patients with hip pain at a single timepoint upon initial visit with an orthopaedic surgeon who is a hip preservation specialist. We hypothesized that SANE would have a strong correlation with the 12-question International Hip Outcome Tool (iHOT)-12, the Hip Outcome Score (HOS), and the Hip disability and Osteoarthritis Outcome Score (HOOS), providing evidence for concurrent validity of the SANE and hip-specific outcome measures in patients with hip pain.
Methods
This study was a cross-sectional retrospective database analysis at a single timepoint. Data were collected from 2,782 patients at initial evaluation with a hip preservation specialist using the iHOT-12, HOS, HOOS, and SANE. Outcome scores were retrospectively analyzed using Pearson correlation coefficients.
Results
Mean raw scores were iHOT-12 67.01 (SD 29.52), HOS 58.42 (SD 26.26), HOOS 86.85 (SD 32.94), and SANE 49.60 (SD 27.92). SANE was moderately correlated with the iHOT-12 ( r = -0.4; 95% CI -0.35 to -0.44; p < 0.001), HOS ( r = 0.57; 95% CI 0.53 to 0.60; p < 0.001), and HOOS ( r = -0.55; 95% CI -0.51 to -0.58; p < 0.001). The iHOT-12 and HOOS were recorded as a lower score, indicating better function, which accounts for the negative r values.
Conclusion
This study was the first to investigate the relationship between the SANE and the iHOT-12, HOS, and HOOS in a population of patients with hip pain at the initial evaluation with an orthopaedic surgeon, and found moderate correlation between SANE and the iHOT-12, HOS, and HOOS. The SANE may be a pragmatic alternative for clinical benchmarking in a general population of patients with hip pain. The construct validity of the SANE should be questioned compared to legacy measures whose content validity has been more rigorously investigated.
Cite this article: Bone Jt Open 2024;5(10):904–910.
Background
Value is defined as the ratio of patient outcomes to the cost of care. One method to assess value is through patient-level value analysis (PLVA). To our knowledge, this tool has not previously been implemented in the setting of total hip arthroplasty (THA). The purposes of this study were to perform PLVA for a 1-year episode of care among patients undergoing primary THA and to identify characteristics that affect value in a metropolitan health-care system.
Methods
The patient-reported outcome (PRO) measure database of the institution was queried for all primary THAs from 2018 to 2019. The PRO measure that was utilized was the Hip disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS-JR). Cost was evaluated with use of time-driven activity-based costing (TDABC) for a 1-year episode of care (consisting of the day of surgery, inpatient stay, discharge facility, postoperative appointments, and physical therapy). The primary outcome was the 1-year value quotient, or the ratio of the 1-year change in HOOS-JR to the cost of the episode of care (V HOOS ). The value quotient was compared among all included patients and evaluated for variables that may affect the overall value of the episode of care.
Results
In total, 480 patients were included in the analysis. The mean improvement in the HOOS-JR was +34.9 ± 16.1 (95% confidence interval [CI]: 33.5, 36.3). The mean cost was 3,471 (95% CI: 13,524, 14,146). The largest contributor to cost was implants (39.0%), followed by post-recovery care (i.e., inpatient stay and specialized nursing facilities; 24.1%). Change in the HOOS-JR was poorly correlated with the cost of care (r = −0.06; p = 0.19). THAs performed at an ambulatory surgery center (ASC) with discharge to home demonstrated higher value (V HOOS = 0.42) than THAs performed at a hospital with discharge to a rehabilitation facility (V HOOS = 0.15; analysis of variance F-test, p < 0.01).
Conclusions
Our study found that PROs did not correlate with costs in the setting of primary THA. Implants were the largest cost driver. Surgical setting (an ASC versus a hospital) and discharge destination influenced value as well. PLVA is a value measurement tool that can be utilized to optimize components of the care delivery pathway.
Level of Evidence
Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
Introduction
Iliopsoas tendinitis after total hip arthroplasty (THA) has become more prevalent with the increased use of large-diameter femoral heads impinging on native surrounding tissues. Anatomically contoured heads (ACH) are soft-tissue-friendly femoral heads created to minimise this issue. This retrospective study assesses iliopsoas tendinitis prevalence and re-operations in primary THAs with ACH, while determining the minimal clinically important difference (MCID) achievement and improvement with 5 patient-reported outcome measures (PROMs).
Methods
We conducted a retrospective analysis of 53 ACHs from January 2020 to July 2023. Patients who completed Hip Injury and Osteoarthritis Outcome Score–Physical Function Short Form (HOOS-PS), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF SF-10a), PROMIS Global Health (GH)-Mental, or PROMIS GH-Physical, and pain score questionnaires were identified. PROM scores were collected preoperatively and at 3-month and 1-year postoperative intervals. Comparisons using chi-square and ANOVA tests were applied.
Results
The rates of achieving MCID and improvement within the first year were (69.2 vs. 76.9%) for PROMIS GH-Physical, (38.5 vs. 46.2%) for PROMIS GH-Mental, (71.4 vs. 92.9%) for HOOS-PS, (80.0 vs. 80.0%) for PROMIS PF SF-10a, and (74.0 vs. 91.7%) for pain scores. PROM scores at 3 months and 1 year significantly varied across all categories, except for PROMIS GH-Mental. No patients had iliopsoas tendinitis, dislocations, or re-operations.
Discussion
ACH implants may alleviate anterior hip pain, while maintaining comparable strength and bio-compatibility to conventional femoral heads. This study underscores the early safety and potential of ACH implants in reducing iliopsoas tendinitis and impingement.
Adverse mental health status has been linked to less successful surgical outcomes across several orthopaedic subspecialties. Mental health represents a modifiable risk factor that can be optimized preoperatively to maximize outcomes for hip preservation surgery. This study examines the relationship between preoperative mental health status and preoperative and postoperative outcomes for adolescent and adult patients undergoing hip preservation surgery. A prospectively enrolled registry of patients undergoing periacetabular osteotomy or hip arthroscopy at a single institution between 2013 and 2021 was retrospectively reviewed to collect demographics and outcomes before and after surgery. We identified patients self-reporting anxiety/depression or no anxiety/depression preoperatively based on responses to the EuroQol-5D anxiety/depression dimension and compared their preoperative and postoperative Hip disability and Osteoarthritis Outcome Scores (HOOSs) using multivariable linear models and multivariable mixed effects models. Seventy-three patients were included, 40 patients with no anxiety/depression and 33 patients with anxiety/depression. Patients with anxiety/depression had worse preoperative HOOS pain (b = −12.5, P = .029), function in daily living (b = −12.0, P = .045), function in sports and recreational activities (b = −15.1, P = .030), and quality of life (b = −16.3, P = .005) as compared to patients with no anxiety/depression. Patients with anxiety/depression had worse postoperative HOOS compared to patients with no anxiety/depression, but these associations were not statistically significant after adjusting for preoperative HOOS. There were no significant differences between both groups for percent achieving minimal clinically important difference. Patients who reported anxiety/depression preoperatively had worse preoperative pain and function before hip preservation surgery, with both groups achieving similar levels of clinical effectiveness.
Background
The objectives of this study are to assess patient willingness to share smartphone generated health data with providers and to characterize patient populations who express hesitation around providing these data to providers.
Methods
Bivariate analysis involved unpaired t-test or analysis of variance for comparing continuous variables. An alpha value of 0.05 was used. A multivariable regression to investigate demographic factors associated with comfort with sharing health data was performed. Odds ratios compared participants by age group, educational attainment, and race.
Results
A total of 485 participants completed the survey, with an average age of 38 years old. Respondents were 65% male and 73% Caucasian. The majority (70%) of participants were comfortable answering questions about their health on their phone, as well as sending pictures of their health problems or wounds. Over half of participants were comfortable with passive social and physical activity information being sent to their doctor and would allow their doctors to download a data tracking application on their smartphone (55% and 59%, respectively). Younger participants (OR 2.0, P <0.05) and participants with increased education (OR 2.5, P < 0.01) were more likely to be comfortable in sharing their data. Privacy concerns were cited as the most common reason patients desired to refrain from sharing data.
Conclusion
Most study participants were comfortable sharing smartphone generated health data.
Background: Plain radiographs remain the standard for diagnosing osteoarthritis (OA). Total hip arthroplasty (THA) is generally offered only for advanced OA by plain radiographs. Advanced imaging is used as an adjunct to assess OA severity in cases of progressive symptoms with less advanced OA by plain radiographs. The objective of this study was to compare outcomes following THA in patients who have advanced OA visualized by plain radiographs to patients who have less severe OA visualized by plain radiographs.
Methods: From February 2016 to February 2020, 93 patients who had Kellgren-Lawrence (KL) grade 0 to 2 OA and underwent THA were identified. The median age was 65 years, and 55% were women. They were matched 1:3 to patients who underwent THA for KL 4 OA based on age, sex, body mass index, and Charlson Comorbidity Index. The primary outcome was achievement of the Hip Injury and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) minimum clinically important difference, substantial clinical benefit, and patient-acceptable symptom state at 1 year postoperatively.
Results: There was no difference between the KL 0 to 2 and KL 4 cohorts in the achievement of HOOS JR minimum clinically important difference (86 versus 85.6%, P = .922), substantial clinical benefit (81.7 versus 80.2%, P = .751), or patient-acceptable symptom state (89.2 versus 85.6%, P = .374). The KL 0 to 2 cohort had a similar improvement in their 2-year HOOS JR (42.5 versus 38.6, P = .019).
Conclusions: In this series, there was no difference in outcomes following primary THA between patients who have severe OA on plain radiographs (KL 4) compared to those who have less severe OA (KL 0 to 2). In the setting of severe symptoms and the absence of advanced OA on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from THA.
Keywords: Kellgren-Lawrence; magnetic resonance imaging; minimum clinically important difference; patient-acceptable symptom state; substantial clinical benefit; total hip arthroplasty.
Aims
Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocation. The aim of this study was to assess the risk for recurrent dislocation after revision THA for instability.
Methods
Between 2009 and 2019, 163 patients underwent revision THA for instability at Stanford University Medical Center. Of these, 33 (20.2%) required re-revision due to recurrent dislocation. Cox proportional hazard models, with death and re-revision surgery for periprosthetic infection as competing events, were used to analyze the risk factors, including the size and alignment of the components. Paired t -tests or Wilcoxon signed-rank tests were used to assess the outcome using the Veterans RAND 12 (VR-12) physical and VR-12 mental scores, the Harris Hip Score (HHS) pain and function, and the Hip disability and Osteoarthritis Outcome score for Joint Replacement (HOOS, JR).
Results
The median follow-up was 3.1 years (interquartile range 2.0 to 5.1). The one-year cumulative incidence of recurrent dislocation after revision was 8.7%, which increased to 18.8% at five years and 31.9% at ten years postoperatively. In multivariable analysis, a high American Society of Anesthesiologists (ASA) grade (hazard ratio (HR) 2.72 (95% confidence interval (CI) 1.13 to 6.60)), BMI between 25 and 30 kg/m ² (HR 4.31 (95% CI 1.52 to 12.27)), the use of specialized liners (HR 5.39 (95% CI 1.97 to 14.79) to 10.55 (95% CI 2.27 to 49.15)), lumbopelvic stiffness (HR 6.03 (95% CI 1.80 to 20.23)), and postoperative abductor weakness (HR 7.48 (95% CI 2.34 to 23.91)) were significant risk factors for recurrent dislocation. Increasing the size of the acetabular component by > 1 mm significantly decreased the risk of dislocation (HR 0.89 (95% CI 0.82 to 0.96)). The VR-12 physical and HHS (pain and function) scores improved significantly at mid term.
Conclusion
Patients requiring revision THA for instability are at risk of recurrent dislocation. Higher ASA grades, being overweight, a previous lumbopelvic fusion, the use of specialized liners, and postoperative abductor weakness are significant risk factors.
Cite this article: Bone Joint J 2024;106-B(5 Supple B):105–111.
Aims:
Periacetabular osteotomy (PAO) is the preferred treatment for symptomatic acetabular dysplasia in adolescents and young adults. There remains a lack of consensus regarding whether intra-articular procedures such as labral repair or improvement of femoral offset should be performed at the time of PAO or addressed subsequent to PAO if symptoms warrant. The purpose was to determine the rate of subsequent hip arthroscopy (HA) in a contemporary cohort of patients, who underwent PAO in isolation without any intra-articular procedures.
Methods:
From June 2012 to March 2022, 349 rectus-sparing PAOs were performed and followed for a minimum of one year (mean 6.2 years (1 to 11)). The mean age was 24 years (14 to 46) and 88.8% were female (n = 310). Patients were evaluated at final follow-up for patient-reported outcome measures (PROMs). Clinical records were reviewed for complications or subsequent surgery. Radiographs were reviewed for the following acetabular parameters: lateral centre-edge angle, anterior centre-edge angle, acetabular index, and the alpha-angle (AA). Patients were cross-referenced from the two largest hospital systems in our area to determine if subsequent HA was performed. Descriptive statistics were used to analyze risk factors for HA.
Results:
A total of 16 hips (15 patients; 4.6%) underwent subsequent HA with labral repair and femoral osteochondroplasty, the most common interventions. For those with a minimum of two years of follow-up, 5.3% (n = 14) underwent subsequent HA. No hips underwent total hip arthroplasty and one revision PAO was performed. Overall, 17 hips (4.9%) experienced a complication and 99 (26.9%) underwent hardware removal. All PROMs improved significantly postoperatively. Radiologically, 80% of hips (n = 279) reached the goal for acetabular correction (77% for acetbular index and 93% for LCEA), with no significant differences between those who underwent subsequent HA and those who did not.
Conclusion:
Rectus-sparing PAO is associated with a low rate of subsequent HA for intra-articular pathology at a mean of 6.2 years' follow-up (1 to 11). Acetabular correction alone may be sufficient as the primary intervention for the majority of patients with symptomatic acetabular dysplasia.
Background: Little is known about patients’ postoperative week-by-week progress after undergoing posterior approach total hip arthroplasty (THA) with regard to pain, function, return to work, and driving. Purpose: We sought to evaluate a large cohort of patients undergoing posterior approach THA with modified posterior hip precautions to better understand the trajectory of recovery. Methods: Patients at a single institution undergoing primary posterior approach THA by fellowship-trained arthroplasty surgeons were prospectively enrolled. Patient functional status and early rehabilitation recovery milestones were evaluated preoperatively and each week postoperatively for 6 weeks. Results: Of 312 patients who responded to weekly questionnaires, there were varying response rates per question. At 1 week after surgery, 15% (39/256) of respondents had returned to work, increasing to 57% (129/225) at week 6. At 6 weeks, 77% of patients (174/225) had returned to driving; 25% (56/225) were taking pain medication (including prescription opioids or nonsteroidal anti-inflammatory drugs); and 15% (34/225) were using assistive devices (down from 91%, 78%, 56%, 35%, and 27% at weeks 1, 2, 3, 4, and 5, respectively). Average postoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Lower Extremity Functional Scale scores were significantly higher than preoperative scores. Respondents reported significantly less pain at each week postoperatively than the previous week. Conclusion: These findings suggest that there may be an expected pathway for recovery after posterior THA using perioperative pain protocols, modified postoperative precautions, and physical therapy protocols to improve patient outcomes after THA, with most patients returning to normal at 4 weeks. Defining the expected recovery timeline may help surgeons in counseling patients preoperatively and guiding their recovery.
Aims
Professional dancers represent a unique patient population in the setting of hip arthroplasty, given the high degree of hip strength and mobility required by their profession. We sought to determine the clinical outcomes and ability to return to professional dance after total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA).
Methods
Active professional dancers who underwent primary THA or HRA at a single institution with minimum one-year follow-up were included in the study. Primary outcomes included the rate of return to professional dance, three patient-reported outcome measures (PROMs) (modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), and Lower Extremity Activity Scale (LEAS)), and postoperative complications.
Results
A total of 49 hips in 39 patients (mean age 56 years (SD 13); 80% female (n = 39)) were included. Mean follow-up was 4.9 years (SD 5.1). Of these 49 hips, 37 THAs and 12 HRAs were performed. In all, 96% of hips returned to professional dance activities postoperatively. With regard to PROMs, there were statistically significant improvements in mHHS, HOOS-JR, and LEAS from baseline to ≥ one year postoperatively. There were complications in 7/49 hips postoperatively (14%), five of which required revision surgery (10%). There were no revisions for instability after the index procedure. Two complications (5.4%) occurred in hips that underwent THA compared with five (42%) after HRA (p = 0.007), though the difference by procedure was not significantly different when including only contemporary implant designs (p = 0.334).
Conclusion
Active professional dancers experienced significant improvements in functional outcome scores after THA or HRA, with a 96% rate of return to professional dance. However, the revision rate at short- to mid-term follow-up highlights the challenges of performing hip arthroplasty in this demanding patient population. Further investigation is required to determine the results of THA versus HRA using contemporary implant designs in these patients.
Cite this article: Bone Joint J 2024;106-B(3 Supple A):17–23.
Predictive modeling promises to improve our understanding of what variables influence patient satisfaction following total knee arthroplasty (TKA). Questions remain regarding the most relevant inputs and outputs for modeling outcomes in this field. The aim was to identify the predictor strategies used for systematic data collection with the highest likelihood of success in predicting clinical outcomes. A PRISMA systematic review was conducted to identify all clinical studies that had used predictive models or that assessed predictive features for outcomes after TKA between 1996 and 2020. Preoperative predictive factors strongly associated with postoperative clinical outcomes were knee pain, knee-specific Patient-Reported Outcome Measure (PROM) scores, range of motion, the severity of osteoarthritis, and mental health scores. The outcome measures that correlated best with the predictive models were improvement of PROM scores, pain scores, and patient satisfaction. Several algorithms, based on PROM improvement, patient satisfaction, or pain after TKA, have been developed to improve decision-making regarding both indications for surgery and surgical strategy. Functional features such as preoperative pain and PROM scores were highly predictive for clinical outcomes following TKA. Some variables such as demographics data or knee alignment were less strongly correlated with TKA outcomes.
Background
Mental health characteristics such as negative mood, fear avoidance, unhelpful thoughts regarding pain, and low self-efficacy are associated with symptom intensity and capability among patients with hip and knee osteoarthritis (OA). Knowledge gaps remain regarding the conceptual and statistical overlap of these constructs and which of these are most strongly associated with capability in people with OA. Further study of these underlying factors can inform us which mental health assessments to prioritize and how to incorporate them into whole-person, psychologically informed care.
Questions/purposes
(1) What are the distinct underlying factors that can be identified using statistical grouping of responses to a multidimensional mental health survey administered to patients with OA? (2) What are the associations between these distinct underlying factors and capability in knee OA (measured using the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS JR]) and hip OA (measured using Hip Disability and Osteoarthritis Outcome Score, Joint Replacement [HOOS JR]), accounting for sociodemographic and clinical factors?
Methods
We performed a retrospective cross-sectional analysis of adult patients who were referred to our program with a primary complaint of hip or knee pain secondary to OA between October 2017 and December 2020. Of the 2006 patients in the database, 38% (760) were excluded because they did not have a diagnosis of primary osteoarthritis, and 23% (292 of 1246) were excluded owing to missing data, leaving 954 patients available for analysis. Seventy-three percent (697) were women, with a mean age of 61 ± 10 years; 65% (623) of patients were White, and 52% (498) were insured under a commercial plan or via their employer. We analyzed demographic data, patient-reported outcome measures, and a multidimensional mental health survey (the 10-item Optimal Screening for Prediction of Referral and Outcome-Yellow Flag [OSPRO-YF] assessment tool), which are routinely collected for all patients at their baseline new-patient visit. To answer our first question about identifying underlying mental health factors, we performed an exploratory factor analysis of the OSPRO-YF score estimates. This technique helped identify statistically distinct underlying factors for the entire cohort based on extracting the maximum common variance among the variables of the OSPRO-YF. The exploratory factor analysis established how strongly different mental health characteristics were intercorrelated. A scree plot technique was then applied to reduce these factor groupings (based on Eigenvalues above 1.0) into a set of distinct factors. Predicted factor scores of these latent variables were generated and were subsequently used as explanatory variables in the multivariable analysis that identified variables associated with HOOS JR and KOOS JR scores.
Results
Two underlying mental health factors were identified using exploratory factor analysis and the scree plot; we labeled them “pain coping” and “mood.” For patients with knee OA, after accounting for confounders, worse mood and worse pain coping were associated with greater levels of incapability (KOOS JR) in separate models but when analyzed in a combined model, pain coping (regression coefficient -4.3 [95% confidence interval -5.4 to -3.2], partial R ² 0.076; p < 0.001) had the strongest relationship, and mood was no longer associated. Similarly, for hip OA, pain coping (regression coefficient -5.4 [95% CI -7.8 to -3.1], partial R ² 0.10; p < 0.001) had the strongest relationship, and mood was no longer associated.
Conclusion
This study simplifies the multitude of mental health assessments into two underlying factors: cognition (pain coping) and feelings (mood). When considered together, the association between capability and pain coping was dominant, signaling the importance of a mental health assessment in orthopaedic care to go beyond focusing on unhelpful feelings and mood (assessment of depression and anxiety) alone to include measures of pain coping, such as the Pain Catastrophizing Scale or Tampa Scale for Kinesiophobia, both of which have been used extensively in patients with musculoskeletal conditions.
Level of Evidence
Level III, prognostic study.
The Centers for Medicare & Medicaid Services (CMS) has finalized a landmark national policy to standardize and expand the collection and reporting of patient-reported outcome measures (PROMs) following total hip arthroplasty (THA) and total knee arthroplasty (TKA). This policy will be rolled out through phased implementation, beginning with voluntary reporting starting in 2023 and transitioning to mandatory reporting starting in 2025, which will be tied to hospital payment determinations in fiscal year 2028. The overarching goal of this policy is to gather meaningful pre- and postoperative PROM data directly from patients to enhance clinical care, shared decision-making, and quality measurement for these common elective procedures. This national initiative underscores the value of incorporating patient perspectives and priorities into assessments of surgical care quality. For orthopaedic surgeons and hospitals, participating in the initial voluntary reporting period provides an opportunity to integrate PROM collection into clinical workflows and to leverage these data to improve patient care. The achievement of robust PROM response rates and a strong performance on the underlying THA/TKA Patient-Reported Outcome-Based Performance Measure may have increasing relevance as payment models shift toward value-based care. The aim of the present forum was to provide an in-depth review of this new CMS policy and key details regarding required PROM instruments, data-collection time frames, and other specifications that surgical teams should understand as they prepare for implementation. The goal was to equip orthopaedic surgeons with actionable information as they embark on this new era of national PROM collection and reporting.
Background
The purpose of this study was to evaluate whether there were differences in patient-reported outcomes, operative times, satisfaction scores, and complications between patients undergoing total hip arthroplasty (THA) performed through a direct anterior approach on a specialized traction table or a regular operating room table.
Methods
Patients who underwent a direct anterior approach THA on a specialized table or a regular table with a minimum 1-year follow-up were included. Patient-reported outcome measures and THA satisfaction were recorded. Demographics, complications, and operative times (both in-room and surgical time) were evaluated. Three hundred twenty-two patients were included with 217 (67.4%) undergoing anterior THA on the specialized table and 105 (32.6%) on a regular table.
Results
Outcome measures were similar at 4 months and 1 year postoperatively. Average operative time was 87 minutes (range, 50-160) and 90 minutes (range, 35-197) for the specialized table and regular table groups (P = .314). Average total in room time was 123 minutes (range, 87-201) and 120 minutes (range, 62-255) for the specialized table and regular table groups (P = .564). Satisfaction rates between groups did not differ (P = .564). No differences were found in complication rates at 4 months (P = .814) or 1 year (P = .547).
Conclusions
This study shows that the direct anterior approach for THA can be safely and efficiently performed on either a specialized traction table or a regular table. Surgeons should continue to utilize the approach and set-up they are most comfortable with to achieve an optimal outcome for the patient.
Purpose: Hip fractures are common and serious injuries as they lead to high mortality and morbidity and have a significant effect on patients' lives. Additionally, these injuries have substantial socioeconomic consequences for patients' quality of life, their families, and healthcare systems. The aim of this study is to assess the quality of life (QoL) in patients after hip fracture surgery.
Methods: This study involved a cross-sectional survey between February 2016 and December 2019, with a sample of 199 patients who suffered a hip fracture and were treated at a tertiary care teaching hospital. The participants completed the EuroQol 5-Dimensions 5-Levels (EQ-5D-5L) questionnaire. Pearson's chi-squared test, independent sample t-test, and Pearson's correlation coefficient (r) were used in the analysis.
Results: We found that there is a statistically significant association between age and having problems with mobility (p=0.023), self-care (p<0.001), and usual activity (p=0.029). In addition, increased age was significantly associated with decreased EuroQol Visual Analog Scale (EQ-VAS) scores (r=-0.213, p=0.003). We also found a statistically significant association between gender and self-care, as males were more likely to report having problems with self-care when compared to females (OR: 3.63; CI 95%: 1.77-7.44; p<0.001).
Conclusion: Mobility, self-care, and usual activity were the most significantly affected quality of life measures and were more apparent in older age groups. Patients should be educated about the possibility of a decline in their QoL and the role of postoperative rehabilitation in improving patients' mobility. Periodic QoL screening should be done as early as possible to detect any further decrease. Future research should standardize postoperative interview intervals to improve QoL evaluation and include a control group.
Rating scales are employed as a means of extracting more information out of an item than would be obtained from a mere “yes/no”, “right/wrong” or other dichotomy. But does this additional information increase measurement accuracy and precision? Eight guidelines are suggested to aid the analyst in optimizing the manner in which rating scales categories cooperate in order to improve the utility of the resultant measures. Though these guidelines are presented within the context of Rasch analysis, they reflect aspects of rating scale functioning which impact all methods of analysis. The guidelines feature rating-scale-based data such as category frequency, ordering, rating-to-measure inferential coherence, and the quality of the scale from measurement and statistical perspectives. The manner in which the guidelines prompt recategorization or reconceptualization of the rating scale is indicated. Utilization of the guidelines is illustrated through their application to two published data sets.
https://www.winsteps.com/a/Linacre-optimizing-category.pdf
Patient reported outcome measures (PROMs) movement has largely been driven by the agenda of researchers or service payers and has failed to focus effectively on improving the quality of care from the patient’s perspective. We use two examples to show how the use of PROMs in everyday practice has the potential to narrow the gap between the clinician’s and patient’s view of clinical reality and help tailor treatment plans to meet the patient’s preferences and needs.
See www.winsteps.com/manuals.htm
Background:
A number of reconstructive procedures are available for the management of hip osteoarthritis. Hip resurfacing arthroplasty is now an accepted procedure, with implant survivorship comparable to THA at up to 10 years' followup in certain series. Most reports focus on implant survivorship, surgeon-derived results, or complications. Fewer data pertain to patient-reported results, including validated measures of quality of life (QoL) and satisfaction and baseline measures from which to determine magnitude of improvement. Validated patient-reported results are essential to guide patients and surgeons in the current era of informed and shared decision making.
Questions/purposes:
We determined whether patients reported improvement in disease-specific, joint-specific, and generic QoL after hip resurfacing arthroplasty; whether patients were satisfied with the results of the procedure; and latest activity level and return to sport.
Methods:
We retrospectively reviewed 127 patients (100 men, 27 women) who underwent 143 hip resurfacing procedures between 2002 and 2006. Mean patient age was 52 years. Patients completed the WOMAC, Oxford Hip Score, and SF-12 at baseline and again at minimum 2-year followup (mean, 2.5 years; range, 2-6 years). At latest followup, patients completed a validated satisfaction questionnaire and UCLA activity score.
Results:
All QoL scores improved (normalized to a 0-100 scale, where 100 = best health state). WOMAC improved from 46 to 95, Oxford Hip Score from 42 to 95, SF-12 (physical) from 34 to 54, and SF-12 (mental) from 46 to 56. Patient satisfaction score was 96. UCLA activity score was 8.
Conclusions:
The majority of patients reported improvement in QoL, were very satisfied with their outcome, and returned to a high level of activity after hip resurfacing arthroplasty.
Level of evidence:
Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
Rating scales are employed as a means of extracting more information out of an item than would be obtained from a mere "yes/no", "right/wrong" or other dichotomy. But does this additional information increase measurement accuracy and precision? Eight guidelines are suggested to aid the analyst in optimizing the manner in which rating scales categories cooperate in order to improve the utility of the resultant measures. Though these guidelines are presented within the context of Rasch analysis, they reflect aspects of rating scale functioning which impact all methods of analysis. The guidelines feature rating-scale-based data such as category frequency, ordering, rating-to-measure inferential coherence, and the quality of the scale from measurement and statistical perspectives. The manner in which the guidelines prompt recategorization or reconceptualization of the rating scale is indicated. Utilization of the guidelines is illustrated through their application to two published data sets.
The aim of the study was to evaluate if physical functions usually associated with a younger population were of importance for an older population, and to construct an outcome measure for hip osteoarthritis with improved responsiveness compared to the Western Ontario McMaster osteoarthritis score (WOMAC LK 3.0).
A 40 item questionnaire (hip disability and osteoarthritis outcome score, HOOS) was constructed to assess patient-relevant outcomes in five separate subscales (pain, symptoms, activity of daily living, sport and recreation function and hip related quality of life). The HOOS contains all WOMAC LK 3.0 questions in unchanged form. The HOOS was distributed to 90 patients with primary hip osteoarthritis (mean age 71.5, range 49-85, 41 females) assigned for total hip replacement for osteoarthritis preoperatively and at six months follow-up.
The HOOS met set criteria of validity and responsiveness. It was more responsive than WOMAC regarding the subscales pain (SRM 2.11 vs. 1.83) and other symptoms (SRM 1.83 vs. 1.28). The responsiveness (SRM) for the two added subscales sport and recreation and quality of life were 1.29 and 1.65, respectively. Patients <or= 66 years of age (range 49-66) reported higher responsiveness in all five subscales than patients >66 years of age (range 67-85) (Pain SRM 2.60 vs. 1.97, other symptoms SRM 3.0 vs. 1.60, activity of daily living SRM 2.51 vs. 1.52, sport and recreation function SRM 1.53 vs. 1.21 and hip related quality of life SRM 1.95 vs. 1.57).
The HOOS 2.0 appears to be useful for the evaluation of patient-relevant outcome after THR and is more responsive than the WOMAC LK 3.0. The added subscales sport and recreation function and hip related quality of life were highly responsive for this group of patients, with the responsiveness being highest for those younger than 66.
Our aim was to define the minimum set of patient-reported outcome measures which are required to assess health status after total hip replacement (THR). In 114 patients, we compared the pre-operative characteristics and sensitivity to change of the Oxford hip score (OHS), the Western Ontario and McMaster Universities osteoarthritis index (WOMAC), the SF-36, the SF-12 (derived from the SF-36), and the Euroqol questionnaire (EQ-5D).
At one year after operation, very large effect sizes were found for the disease-specific measures, the physical domains of the SF-12, SF-36 and the EQ-5D index (1.3 to 3.0). Patients in Charnley class A showed more change in the OHS, WOMAC pain and function, the physical domains of the SF-36 and the EQ-5D vas (p < 0.05) compared with those in the Charnley B and C group. In this group, the effect size for the OHS more than doubled the effect sizes of WOMAC pain and physical function. We found high correlations and correlations of change between the OHS, the WOMAC, the physical domains of the SF-12 and the SF-36 and EQ-5D index . The SF-36 and EQ-5D scores at one year after operation approached those of the general population. Furthermore, we found a binomial distribution of the pre-operative EQ-5D index score and a pre-operative discrepancy and post-operative agreement between the EQ-5D vas and EQ-5D index .
We recommend the use of the OHS and SF-12 in the assessment of THR. The SF-36 may be used in circumstances when smaller changes in health status are investigated, for example in the follow-up of THR. The EQ-5D is useful in situations in which utility values are needed in order to calculate cost-effectiveness or quality-adjusted life years (QALYs), such as in the assessment of new techniques in THR.
The Edinburgh Postnatal Depression Scale (EPDS) is a 10 item self-rating post-natal depression scale which has seen widespread use in epidemiological and clinical studies. Concern has been raised over the validity of the EPDS as a single summed scale, with suggestions that it measures two separate aspects, one of depressive feelings, the other of anxiety.
As part of a larger cross-sectional study conducted in Melbourne, Australia, a community sample (324 women, ranging in age from 18 to 44 years: mean = 32 yrs, SD = 4.6), was obtained by inviting primiparous women to participate voluntarily in this study. Data from the EPDS were fitted to the Rasch measurement model and tested for appropriate category ordering, for item bias through Differential Item Functioning (DIF) analysis, and for unidimensionality through tests of the assumption of local independence.
Rasch analysis of the data from the ten item scale initially demonstrated a lack of fit to the model with a significant Item-Trait Interaction total chi-square (chi Square = 82.8, df = 40; p < .001). Removal of two items (items 7 and 8) resulted in a non-significant Item-Trait Interaction total chi-square with a residual mean value for items of -0.467 with a standard deviation of 0.850, showing fit to the model. No DIF existed in the final 8-item scale (EPDS-8) and all items showed fit to model expectations. Principal Components Analysis of the residuals supported the local independence assumption, and unidimensionality of the revised EPDS-8 scale. Revised cut points were identified for EPDS-8 to maintain the case identification of the original scale.
The results of this study suggest that EPDS, in its original 10 item form, is not a viable scale for the unidimensional measurement of depression. Rasch analysis suggests that a revised eight item version (EPDS-8) would provide a more psychometrically robust scale. The revised cut points of 7/8 and 9/10 for the EPDS-8 show high levels of agreement with the original case identification for the EPDS-10.
Previous research on educational data has demonstrated that Rasch fit statistics (mean squares and t-statistics) are highly susceptible to sample size variation for dichotomously scored rating data, although little is known about this relationship for polytomous data. These statistics help inform researchers about how well items fit to a unidimensional latent trait, and are an important adjunct to modern psychometrics. Given the increasing use of Rasch models in health research the purpose of this study was therefore to explore the relationship between fit statistics and sample size for polytomous data.
Data were collated from a heterogeneous sample of cancer patients (n = 4072) who had completed both the Patient Health Questionnaire - 9 and the Hospital Anxiety and Depression Scale. Ten samples were drawn with replacement for each of eight sample sizes (n = 25 to n = 3200). The Rating and Partial Credit Models were applied and the mean square and t-fit statistics (infit/outfit) derived for each model.
The results demonstrated that t-statistics were highly sensitive to sample size, whereas mean square statistics remained relatively stable for polytomous data.
It was concluded that mean square statistics were relatively independent of sample size for polytomous data and that misfit to the model could be identified using published recommended ranges.
We studied the validity and reliability of the Foot and Ankle Outcome Score (FAOS) when used to evaluate the outcome of 213 patients (mean age 40 years, 85 females) who underwent anatomical reconstruction of the lateral ankle ligaments with an average postoperative follow-up of 12 years (range, three to 24 years). The FAOS is a 42-item questionnaire assessing patient-relevant outcomes in five separate subscales (Pain, Other Symptoms, Activities of Daily Living, Sport and Recreation Function, Foot- and Ankle-Related Quality of Life). The FAOS met set criteria of validity and reliability. The FAOS appears to be useful for the evaluation of patient-relevant outcomes related to ankle reconstruction.
Background: 'Patient-based outcome measure' is a short-hand term referring to the array of questionnaires, interview schedules and other related methods of assessing health, illness and benefits of health care interventions from the patient's perspective. Patient-based outcome measures, addressing constructs such as health-related quality of life, subjective health status, functional status, are increasingly used as primary or secondary end-points in clinical trials. Objectives: To describe the diversity and reasons for diversity of available patient-based outcome measures. To make clear that criteria investigators should have in mind when they select patient-based outcome measures for use in a clinical trial. Methods: Data sources: Literature was identified by a combination of electronic searches of databases, handsearching of selected journals and retrieval of references cited in available literature. Databases used included MEDLINE, EMBASE, CINAHL, PsychLIT and Sociofile. Study selection: A set of explicit criteria were used for selection of literature. Articles were included if they focused on any methodological aspect of patient-based outcome measures (for example, methods of evaluating such measures, psychometric evaluation of measures, comparative studies of measures, studies reporting validation of measures). Studies were excluded if they only reported use of a measure without evaluation, focused only on cross-cultural issues, focused only on clinician-based outcome measures or discussed economic utility theory only without considering measurement. A total of 5621 abstracts and articles were identified by initial searches as potentially relevant. However, after assessment, 391 key references were selected as useful to the objectives of the review. A further 22 references were incorporated into the final version as a result of comments from external experts and referees. Data synthesis: A first draft synthesising the evidence was produced by the first author of this review (RF) and extensively critiqued by the other three authors. A revised version was then submitted for evaluation to a panel of ten experts recruited to represent a wide range of areas of expertise (including clinical medicine, clinical trials, health economics, health services research, social sciences and statistics). Feedback from this panel was read and discussed by the authors of the review and a third version of the review drafted. The final version is a quasi- consensus view from individuals with a wide range of expertise. Results: Diversity of patient-based outcome measures: Seven major types of instrument can be identified in the literature: disease-specific, site-specific, dimension-specific, generic, summary item, individualised, utility. Concepts, definitions and theories of what such instruments measure are generally not clearly or consistently used. For example, there is little consistency of use or agreement as to the meaning of key terms such 'quality of life' and 'health-related quality of life'. The intended purpose and content of types of instruments vary. There are advantages and disadvantages to each of the different type of instrument when used in a particular clinical trial. Criteria for selecting patient-based outcome measures: There are eight criteria that investigators should apply to evaluate candidate patient-based outcome measures for any specific clinical trial: appropriateness, reliability, validity, responsiveness, precision, interpretability, acceptability, feasibility. These criteria are not consistently defined and the literature associated with the criteria cannot be summarised in clear, explicit and unambiguous terms. It is not possible from available evidence to rank order the relative importance of the eight criteria in relation to decisions about selection of measures to include in a trial. Appropriateness requires that investigators consider the match of an instrument to the specific purpose and questions of a trial. Reliability requires that an instrument is reproducible and internally consistent. Validity is involved in judging whether an instrument measures what it purports to measure. Responsiveness in this context addresses whether an instrument is sensitive to changes of importance to patients. Precision is concerned with the number and accuracy of distinctions made by an instrument. Interpretability is concerned with how meaningful are the scores from an instrument. Acceptability addresses how acceptable is an instrument for respondents to complete. Feasibility is concerned with the extent of effort, burden and disruption to staff and clinical care arising from use of an instrument. Conclusions and recommendations: Investigators need to make their choice of patient-based outcome measures for trials in terms of the criteria identified in this review. Developers of instruments need to make evidence available under the same headings. By means of the above criteria, further primary research and consensus-type processes should be used to evaluate leading instruments in the different fields and specialties of health care to improve use of patient-based outcome measures in research. Primary research is needed either in the form of methodological additions to substantive clinical trials (for example comparing the performance of two or more measures) or studies of leading measures with methodology as the primary rationale.
We believe it can; now we should put it to the test
The Patient-Centered Outcomes Research Trust Fund (PCORTF) was established in 2009 to support research that is funded, designed, carried out, and put into practice within a culture of patient centeredness.1 A legislatively mandated review in 2017 of the “adequacy and use of funding” will be used to determine whether PCORTF funding levels should be continued or adjusted after its authorization runs out in autumn 2019. As 2017 approaches, researchers ought to begin taking stock of our work in patient centered outcomes research: how well are we are doing and what might we do better?
In the linked paper (doi:10.1136/bmj.h3786), Xian and colleagues present a solid example of how to refocus research on questions, outcomes, and approaches that could help patients and clinicians to make better healthcare decisions. The team studied prescribing of warfarin for patients with ischemic stroke who were discharged from hospital between 2009 and 2011 with persistent or paroxysmal atrial fibrillation or flutter.2 This study was funded by the Patient-Centered Outcomes Research Institute (PCORI) in 2013.
This team’s preliminary work with patients resulted in prioritization …
Clinicians and those in health sciences are frequently called upon to measure subjective states such as attitudes, feelings, quality of life, educational achievement and aptitude, and learning style in their patients. This fifth edition of Health Measurement Scales enables these groups to both develop scales to measure non-tangible health outcomes, and better evaluate and differentiate between existing tools.
Health Measurement Scales is the ultimate guide to developing and validating measurement scales that are to be used in the health sciences. The book covers how the individual items are developed; various biases that can affect responses (e.g. social desirability, yea-saying, framing); various response options; how to select the best items in the set; how to combine them into a scale; and finally how to determine the reliability and validity of the scale. It concludes with a discussion of ethical issues that may be encountered, and guidelines for reporting the results of the scale development process. Appendices include a comprehensive guide to finding existing scales, and a brief introduction to exploratory and confirmatory factor analysis, making this book a must-read for any practitioner dealing with this kind of data.
This commentary serves as an introduction to an upcoming series of articles about orthopaedic registries, in general, with an emphasis on lessons learned from the evolving U.S. and international total joint replacement registries. This paper provides an overview of total joint replacement registries and the current expansion of data collection beyond implant attributes and survival to include postoperative complications and patient-reported outcomes.
Osteoarthritis is the most common cause of physical disability in the U.S.1. The combination of osteoarthritis prevalence and the success of total joint replacement in relieving pain and improving function in patients with advanced osteoarthritis has resulted in total joint replacement becoming the most common and costly inpatient procedure among Medicare beneficiaries. Moreover, the fastest growing subgroup of patients undergoing total joint replacement consists of those less than sixty-five years of age2. More than one million total joint replacements are performed annually in the U.S., making measurement of total joint replacement outcomes a public health priority. To measure and monitor the outcomes of total joint replacement, state and national total joint replacement registries are emerging that incorporate lessons learned from long-standing international implant registries as well as integrate new methods to quantify perioperative quality and patient-reported outcomes.
International total joint replacement registries have traditionally focused on implant revision rates and tracked the length of time between the initial total joint replacement and implant removal. In this model, national registries incorporate large numbers of arthroplasties to identify relatively low annual failure rates and the focus is on device longevity. However, today’s total joint replacement registries are broadening their focus to include perioperative complications and patient-reported outcomes following surgery. While the implant revision rate remains an important outcome, implant materials and technology have matured and patients and insurers want to understand the quality of care of …
The Oxford hip and knee scores (OHS and OKS) are validated patient-reported outcome measures used in patients undergoing total hip replacement (THR), hip resurfacing (HR), total knee replacement (TKR) and unicompartmental knee replacement (UKR). We analysed the absolute OHS and OKS and change in scores following THR, HR, TKR, and UKR performed at one specialist centre. All patients undergoing and completing at least one Oxford score were eligible for inclusion in the study which included 27 950 OHS and 19 750 OKS in 13 682 patients. Data were analysed using non-linear quantile regression. The median absolute Oxford scores for THR, HR, TKR and UKR were pre-operative 68.8% (15.0/48), 58.3% (20.0/48), 66.7% (16.0/48), 60.4% (19.0/48) respectively: and post-operative asymptote was 14.6% (41.0/48), 5.8% (45.2/48), 31.2% (33.0/48), 29.2% (34.0/48). The median asymptotic change from the pre-operative score for THR, HR, TKR and UKR were 47.9% (23.0/48), 47.9% (23.0/48), 33.3% (16.0/48) and 32.4% (15.5/48), respectively. The median time at which no further appreciable change in score was achieved post-operatively was 0.7 years for THR, 1.1 years for HR, 0.9 years for TKR and 1.1 years for UKR.
The curves produced from this analysis could be used to educate patients, and to audit the performance of a surgeon and an institution. The time to achieve a stable improvement in outcome varied between different types of joint replacement, which may have implications for the timing of post-operative review.
Cite this article: Bone Joint J 2014; 96-B:928–35.
Differential item functioning (DIF) assessment attempts to identify items or item types for which subpopulations of examinees exhibit performance differentials that are not consistent with the performance differentials typically seen for those subpopulations on collections of items that purport to measure a common construct. DIF assessment requires a rule for scoring items and a matching variable on which different subpopulations can be viewed as comparable for purposes of assessing their performance on items. Typically, DIF is operationally defined as a difference in item performance between subpopulations, e.g., Blacks and Whites, that exists after members of the different subpopulations have been matched on some total score. Constructed-response items move beyond traditional multiple-choice items, for which DIF methodology is well-defined, towards item types involving selection or identification, reordering or rearrangement, substitution or correction, completion, construction, and performance or presentation. This paper defines DIF, describes two standard procedures for measuring DIF and indicates how DIF might be assessed for certain constructed-response item types. The description of DIF assessment presented in this paper is applicable to computer-delivered constructed-response items as well as paper and pencil delivered items.
Background:
Good orthopaedic care requires a knowledge of the patient's history of musculoskeletal pain and associated limitations in daily function. Standardized measures of patient-reported outcomes (PROs) can provide this information. Integrating PROs into routine orthopaedic patient visits can provide key information to monitor changes in symptom severity over time, support shared clinical care decisions, and assess treatment effectiveness for quality initiatives and value-based reimbursement. WHERE ARE WE NOW?: Although standardized, validated PRO surveys are routinely used in clinical and comparative effectiveness research, they are not consistently or efficiently collected in clinical practice. WHERE DO WE NEED TO GO?: Ideally, PROs need to be collected directly from patients before their surgeon visit so the data are readily available to the surgeon and patient at the time of the office visit. In addition, PROs should be integrated in the electronic health record to monitor patient status over time. HOW DO WE GET THERE?: PRO integration in clinical practice requires minor modifications to the office flow, some additional staff to facilitate collection, and the technical infrastructure to score, process, and store the responses. We document successful office procedures for collecting PROs in one busy orthopaedic clinic and some suggested methods to extend this model to the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) consortium of 121 surgeons where the process is centralized and staff obtained consent to send the PRO directly to the patient's home. Both methods are options for the broader adoption of office-based PROs.
Background:
Total joint arthroplasty (TJA) registries traditionally have focused on implant longevity and rates of revision surgery. Registries would benefit from the addition of standardized patient-reported outcomes (PROs) such as pain relief and improved physical function. However, PROs have not been routinely adopted, and their incorporation into TJA registries presents challenges.
Questions/purposes:
We review current PRO use by existing national registries, challenges to integrating PROs in national registries, lessons from national registries that have integrated PROs, and suggestions to guide future adoption of PROs.
Methods:
We conducted a literature search of papers addressing PRO use in national knee and hip arthroplasty registries, resulting in 15 articles. These publications were supplemented by discussions with thought leaders from international registries. WHERE ARE WE NOW?: Some national TJA registries are collecting PROs and valuable research is emerging. However, challenges exist, such as selecting suitable PROs, selection bias in countries without government-mandated participation for all hospitals, and challenges with missing data. WHERE DO WE NEED TO GO?: The ideal system will incorporate PROs into TJA registries. In so doing, it will be important to choose suitable PROs and develop innovative methods to collect PROs to ensure complete data and sustainability. HOW DO WE GET THERE?: New methods are required to meet the challenges related to registry design, logistics of PRO collection, and registry cost and sustainability. Modifications to the traditional hospital- and implant-centric design and new procedures to collect complete data from both patients and clinicians may be necessary. For instance, England and Wales, New Zealand, and Sweden developed methods to collect PROs after TJA directly from patients and a US TJA registry collects PROs as the primary outcome. Finally, to assure long-term sustainability, PRO data must be valuable to multiple stakeholders, including patients, clinicians, researchers, and policy makers.
Routine use of patient reported outcome measures (PROMs) has the potential to help transform healthcare, says Nick Black. Not only can PROMs help patients and clinicians make better decisions, but they can also enable comparisons of providers' performances to stimulate improvements in services Patient reported outcome measures (PROMs) can drive the changes in how healthcare is organised and delivered. Key to this will be to link doctors' use of PROMs in the treatment of their patients with collection and aggregation of the data for assessing and comparing the performance of providers-all to improve healthcare quality.
Discusses the Function and Outcomes Research for Comparative Effectiveness in TJR (FORCE-TJR) research program for total joint replacement funded by the Agency for Healthcare Research and Quality. Led by a team of researchers at the University of Massachusetts Medical School in cooperation with a national network of surgeons, FORCE-TJR assembled a consortium of orthopedic practices to serve as a research laboratory to generate comparative effectiveness research to guide surgeon and patient decisions. The FORCE-TJR has a national scope, is representative of US practices, includes longitudinal patient-reported outcomes, and has the ability to measure implant failure as well as important clinical outcomes and complications.
Outcome measures included in this review are the Harris Hip Score, the Hip Disability and Osteoarthritis Outcome Score, the Oxford Hip Score, the Lequesne Index of Sever- ity for Osteoarthritis of the Hip, and the American Acad- emy of Orthopedic Surgeons Hip and Knee Questionnaire.The outcome measures chosen are the most common ones in the literature concerning hip function and symp- toms. Most of them are patient-reported. The selected mea- sures meet the basic requirements for an outcome mea- surement, although there are shortcomings in a few of them.
The standardization approach to comprehensive differential item functioning (Cdif) is described and contrasted with the log-linear approach to differential distractor functioning explicated by Green, Crone, and Folk (1989) and with the IRT-based approach to differential alternative functioning explicated by Thissen, Steinberg, and Wainer (1992). This descriptive approach is used routinely as an adjunct to Mantel-Haenszel differential item functioning (DIP) detection (Dorans & Holland, 1992) in many operational testing programs at the Educational Testing Service. Data from an edition of the SAT are used to illustrate how the standardization approach to Cdif could be used to uncover differential speededness. Speculations about the sources of differential speededness for Black examinees and Hispanic examinees are offered, and some implications of the existence of differential speededness for DIP detection are mentioned.
It is observed that many sorts of difficulties may preclude the uneventful construction of tests by a computerized algorithm, such as those currently in favor in Computerized Adaptive Testing (CAT). In this essay we discuss a number of these problems, as well as some possible avenues of solution. We conclude with the development of the “testlet,” a bundle of items that can be arranged either hierarchically or linearly, thus maintaining the efficiency of an adaptive test while keeping the quality control of test construction that is possible currently only with careful expert scrutiny. Performance on the separate testlets is aggregated to yield ability estimates.
Background:
Patient-reported outcome (PRO) instruments are used to evaluate the effect of medical products on how patients feel or function. This article presents the results of an ISPOR task force convened to address good clinical research practices for the use of existing or modified PRO instruments to support medical product labeling claims. The focus of the article is on content validity, with specific reference to existing or modified PRO instruments, because of the importance of content validity in selecting or modifying an existing PRO instrument and the lack of consensus in the research community regarding best practices for establishing and documenting this measurement property.
Methods:
Topics addressed in the article include: definition and general description of content validity; PRO concept identification as the important first step in establishing content validity; instrument identification and the initial review process; key issues in qualitative methodology; and potential threats to content validity, with three case examples used to illustrate types of threats and how they might be resolved. A table of steps used to identify and evaluate an existing PRO instrument is provided, and figures are used to illustrate the meaning of content validity in relationship to instrument development and evaluation. RESULTS & RECOMMENDATIONS: Four important threats to content validity are identified: unclear conceptual match between the PRO instrument and the intended claim, lack of direct patient input into PRO item content from the target population in which the claim is desired, no evidence that the most relevant and important item content is contained in the instrument, and lack of documentation to support modifications to the PRO instrument. In some cases, careful review of the threats to content validity in a specific application may be reduced through additional well documented qualitative studies that specifically address the issue of concern.
Conclusion:
Published evidence of the content validity of a PRO instrument for an intended application is often limited. Such evidence is, however, important to evaluating the adequacy of a PRO instrument for the intended application. This article provides an overview of key issues involved in assessing and documenting content validity as it relates to using existing instruments in the drug approval process.
Hip arthroplasty (total hip replacement) is a common orthopaedic procedure that can greatly improve patients' quality of life. This article discusses the pathophysiology of hip dysfunction, the assessment and pre-operative screening of patients with hip pain, and some of the post-operative nursing considerations following hip arthroplasty. Multidisciplinary care of patients undergoing hip arthroplasty is essential to provide optimal care and an efficient service.
A unidimensional latent trait model for responses scored in two or more ordered categories is developed. This “Partial Credit”
model is a member of the family of latent trait models which share the property of parameter separability and so permit “specifically
objective” comparisons of persons and items. The model can be viewed as an extension of Andrich's Rating Scale model to situations
in which ordered response alternatives are free to vary in number and structure from item to item. The difference between
the parameters in this model and the “category boundaries” in Samejima's Graded Response model is demonstrated. An unconditional
maximum likelihood procedure for estimating the model parameters is developed.
This study represents a long-term effort to find optimal techniques for evaluating outcome in patients who have undergone total joint arthroplasty. Sensitivity of five health status questionnaires was studied in a longitudinal evaluation of orthopedic surgery. The questionnaires (Arthritis Impact Measurement Scales [AIMS], Functional Status Index [FSI], Health Assessment Questionnaire [HAQ], Index of Well Being [IWB], and Sickness Impact Profile [SIP]) were administered to 38 patients with end-stage arthritis at three points in time: two weeks before hip or knee arthroplasty, and at three-month and 12- to 15-month follow-up. Response values (i.e., changes within patients) were calculated on four scales: global health, pain, mobility, and social function. By the three-month follow-up, most instruments detected large mean responses in global health, pain scores, and mobility. Smaller changes on these scales were found between three and 12 to 15 months. Social function showed small to modest gains at successive follow-ups. Standardized response means were calculated to assess sensitivity to detect change. Confidence intervals for these indices were constructed using a jackknife procedure, and significance tests were performed by pairing selected indices. Finally, the study projected sample sizes required to assess a new therapy, using each response. These statistical tools facilitated comparisons among instruments and may prove useful in other settings.
Maximizing the response rate of self-administered questionnaires is key in survey research. We aimed to evaluate the effects of lottery incentive and length of questionnaire on health survey response rates when used in isolation or combined. A random sample of 440 residents in Western Sydney, Australia was randomly allocated to four equal groups to receive or not receive an instant lottery ticket and a long (seven page) or short (one page) questionnaire. The overall response rate was 71.8%. The final response rates were higher among those receiving the short, rather than the long, questionnaire (75.6% versus 68.2%) (P = 0.08); and among those receiving the lottery incentive compared with those not receiving the incentive (75% versus 68.2%) (P = 0.09). By logistic regression analysis, the success of obtaining a completed questionnaire without any follow-up reminders was significantly associated with the lottery incentive but not the questionnaire length (P = 0.03 and P = 0.54, respectively). The difference between lottery and no lottery groups decreased gradually during the follow-up. A lottery incentive is associated with an increased response after the first mailing. A small up-front cost for a lottery ticket may be worthwhile, since it can save further costs by obviating the need for repeated follow-ups.
We studied the validity and reliability of the Foot and Ankle Outcome Score (FAOS) when used to evaluate the outcome of 213 patients (mean age 40 years, 85 females) who underwent anatomical reconstruction of the lateral ankle ligaments with an average postoperative follow-up of 12 years (range, three to 24 years). The FAOS is a 42-item questionnaire assessing patient-relevant outcomes in five separate subscales (Pain, Other Symptoms, Activities of Daily Living, Sport and Recreation Function, Foot- and Ankle-Related Quality of Life). The FAOS met set criteria of validity and reliability. The FAOS appears to be useful for the evaluation of patient-relevant outcomes related to ankle reconstruction.
There has been an increasing need for the sensitive and reproducible measurement of the outcome after hip surgery. Numerous hip scoring systems, varying in their complexity and disease specificity, have been designed to achieve a measure of outcome-some rely ultimately on the judgement of the surgeon, whereas others rely on the patients' perceptions. The Oxford hip score (OHS) has been found to be easier to administer and achieves a much higher follow-up rate than that of the Harris hip score (HHS). Unfortunately, with the availability of numerous scoring systems and the publication of data in these systems, it has been difficult to compare results. Our aim was to compare the more widely used HHS to the shorter OHS. We followed 200 consecutive primary total hip arthroplasties (196 patients between January 1994 and May 1995) for an average of 5 years. All patients had a preoperative HHS recorded. At the 5-year review, assessment was made using OHS and the HHS. There were 115 hips that had full OHS and HHS available. The mean OHS was 19.1 (range 12-52, SD 9.5), and HHS was 89.4 (range 47-100, SD 13.3) at follow-up. The Spearman correlation showed good negative correlation between the 2 results (Spearman rank -0.712, P < .0001). The HHS vs OHS shows good correlation at 5 years. This is the first study to confirm that correlation persists for the OHS in the medium term. We include a classification of OHS of excellent (<19), good (19-26), fair (27-33), and poor (>33) outcomes which correlate well with the HHS. This study enables the case for the Oxford data with its easier analysis and higher compliance rate to be used more directly to compare studies that use the HHS.
To derive a cross-culturally valid, short measure of physical function using function subscales (daily living and sports and recreation) of the Hip disability and Osteoarthritis Outcome Score (HOOS).
Rasch analysis was conducted on data from individuals from multiple countries who had hip osteoarthritis (OA). Fit of the data to the Rasch model was evaluated by model chi(2) and item fit statistics (chi(2), size of residual, and F-test). Differential item functioning was evaluated by gender, age and country. Unidimensionality was evaluated by factor analysis of residuals. Individual data sets were analyzed and data pooled and re-analyzed for fit to the model. Regression modeling was conducted to derive a nomogram converting raw summed scores to Rasch derived interval scores.
Seven data sets were included (n=2991), ages 19-96 years, male/female ratio was 1:1.23. The final model included five HOOS items. From the easiest to most difficult, the items (logit) were as follows: sitting (1.832), descending stairs (0.729), getting in/out of bath or shower (0.255), twisting/pivoting on loaded leg (-0.221) and running (-2.595). The separation index was 0.80.
The daily activity and sports and recreational items of the HOOS were reduced to five items achieving a feasible, short measure of physical function with interval level properties. This tool has potential for use as the function component of an OA severity scoring system. Further testing of this measure is warranted.
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Assessing unidimensionality for Rasch measurement
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Short-form THA Outcomes Survey