Las Variables Cuantitativas en la evaluación de Créditos

Patients having total joint arthroplasty are sometimes studied together with the assumption that the experience of having total hip and knee arthroplasty is the same. This may be because their 30-plus-year history, outcomes, course of rehabilitation, hospital lengths of stay, and costs are similar (Rothman, Moriarty, Rothman, Silver,

O’Connor and Agvas, 1994). Harris and Sledge (1990b) report that total knee

arthroplasty appears to be very similar to total hip arthroplasty in terms of the predictability of good or excellent results, the infrequency of complications, and the ability to correct most complications to produce an eventually satisfactory result. These

26

Table 1.5

Summary of References Relating to Pain and Functional Outcome Following Knee Arthroplasty: 1978-1986

Author Year Patients Duration of

Follow-Up

Fain Relief

Functional Improvement including activities of daily living

N Range

Years Mean Years Ewald, Thomas, Foss, Scott and

Sledge

1978 167 NS 2.5 94% NS

Sledge, Stem, Thomas, Ewald, Foss and Scott

1978 123 2-4 2.5 90% 40% good to excellent function

Sheehan 1979 131 NS NS 97% 81.7% good ambulation

Cracchiolo, Benson, Finerman, Horacek and Amstutz

1979 175 2 NS 85% 80% good walking ability

Laskin 1981 117 2 NS 86% 78% good ambulation

Insall, Hood, Flawn and Sullivan 1983 100 1-5 NS NS No meaningful change in flexion

Schurman, Parker, and Omstein 1985 71 2 NS NS Flexion maintained but not changed.

Roush 1985 11 6 - 35

months 18 months

NS 8 patients reported no change in function; 3 improved function

Insall and Kelly 1986 32 10 NS NS 87.5% functioning ‘satisfactorily’.

Liang, Cullen, Larson, Thompson, Schwartz, Fossel, Roberts and Sledge

1986 23 6

months

NS NS Significant improvement in global health and functional

scores

Faget, Jensen, Ruchlin, Godbold, Kroll, Otis, Lee, Sculco and Christian 1986 327 6 months 1 NS NS Improved 1st 6 months

Fatigue, tension-anxiety and depression improved over 1st 6 months then levelled off. Improved function (N=50 tested). Most improvement occurred by 6 months.

Table 1.6

Summary of References Relating to Pain and Functional Outcome Following Knee Arthroplasty: 1990-1993

Author Year Patients Duration of

Follow-Up

Fain Relief Functional Improvement including activities of daily living

N Range

Years Mean Years Wright, Ewald, Walker,

Thomas, Foss and Sledge

1990 192 5-9 NS 91-98%

Dependent on activity

83% could ascend and descend stairs without aids. 50% could ascend and descend stairs normally. 65% > 1 1 0 ° flexion; flexion in^)roved to 2°.

Harris and Sledge 1990b 192 6 NS 84%

rheumatoid 94% osteoarthritis

83% able to walk 4-6 blocks. 80% climb stairs without support, and 50% could climb stairs in a normal fashion. 65% had > 110° flexion with an average > in flexion of 5°.

Bowman, Guyer and Bos 1991 256 1-17 NS NS Scoring on the Hospital for Special Surgery Score lower

by 5-10 points than other studies.

Patel, Aichroth and Wand 1991 118 2-7 3.5 76% 86% excellent or good function

Lichtenstein, Semaan and M armar 1993 126 96 6 months 1 NS NS NS NS

58% independent functioning and 76% good health 69% independent functioning and 76% good health. 77% back to their normal life.

Levitsky, Harris, McManus and Scott

1993 66 2.4-

15.5

7.5 NS M ean Knee Society Score > 23.2 to 89.9 and function score improved from 58.4 to 90.0. 89.5% satisfaction with surgery.

M allon and Callaghan 1993 83 3-NS 4.7 65% No

ache after playing golf

Active golfers reported a significant rise in handicap, and a decrease in the length o f their drive.

27 Introduction Chapter 1

Table 1.7

Summary of References Relating to Pain and Functional Outcome Following Knee Arthroplasty: 1994-1996

Author Year Patients Duration of Follow-

Up

Pain Relief Functional Improvement including activities of daily living

N Range

Years

Mean Years Swann, Thomas, Bridle and

Dean

1994 40 1-23 11 100% "Useful" range of movement obtained in all

cases. Kirwan, Currey, Freeman,

Snow and Young

1994 130 Annual

intervals to 5 years

NS 89% 89% showed improvement in pain and function

at 1 years, maintained for 3 years. 11 % deteriorated. Overall > pain relief < reduction in disability

Noble, Monsall, Obeid and M ehtar

1994 50 NS 5.8 70% no

pain 24% slight to mild

93% delight to very pleased with the outcome with Hospital for Special Surgery Score = 70% good or excellent. M ean flexion was 99°.

Adam and Noble 1994 51 > 7 5

56 < 7 5 years

2-10.5 5.5

5.8

NS Pain relief, knee stability, range of motion residual degree of flexion contracture, and extension lag equal to younger age group, but mobility not as good. Satisfaction equal to the younger group.

Norman-Taylor, Palmer and Villar

1996 31 1 NS NS All patients increased their quality o f life score.

32% achieved complete normality

N ote: NS = not specified

Table 1.8

Summary of Combined Studies of Pain and functional Outcome Following Arthroplasty: 1985-1996

Author Hips Knees

Roush (1985) N = 32

31% reported an improvement, 59.5% no change and 9.5% a loss of function

N = 11

27% (3) reported an improvement, 73% (8) reported no change in function.

Liang, Cullen, Larson, Thompson, Schwartz, Fossel, Roberts and Sledge (1986)

N = 22 at 6 months. Significant improvement in global health and functional scores.

N = 23 at 6 months. Significant improvement in global health and functional scores.

Albert, Cohn, Rothman, Springstead, Rothman and Booth, Jr. (1991)

Com bined N = 94 first few days postoperatively hip patients had significantly lower pain observation scores.

C om bined N = 94 first days postoperatively knee patients had significantly higher pain scores

Lichtenstein, Semaan and M armar (1993)

N = 86 at 6 months 40% assessed their function favourably; 87% good health.

N = 79 at 1 year 70% assessed their function favourably; 86% good health and 86% back to their normal life

N = 126 at 6 months 58% independent functioning and 76% good health.

N = 96 at 1 year 69% independent functioning and 76% good health. 7% back to their normal life.

Kirwan, Currey, Freeman, Snow and Young (1994)

N = 205 at 1 year. Mean proportional improvement for both pain and disability was slightly greater for hip patients.

N = 130 at 1 year. Mean proportional improvements in both pain and disability was slightly less.

Norman-Taylor, Palmer and Villar (1996)

N = 41 at 1 year all patients increased their quality of life score. 39% achieved complete normality.

N = 31 at 1 year all patients increased their quality of life score. 32% achieved complete normality.

28 Introduction Chapter 1

comments relate to medical outcomes and may not necessarily apply to all dimensions of recovery. Table 1.8 shows combined studies of pain and functional recovery following arthroplasty separately for hip and knee patients for easy comparison.

Some research has shown little difference in recovery between groups. In a study of 45 patients, 22 undergoing total hip replacement and 23 total knee replacements, Liang Cullen, Larson, Thompson, Schwartz, Fossel, Roberts and Sledge (1986) report statistically significant improvement in global health scores and functional scores, six months after discharge, with no significant difference between hip and knee patients. Although pain was measured prior to surgery, with no significant difference reported between groups, it is not reported at the postoperative assessment, a surprising omission considering pain reduction is one of the main indicators for arthroplasty.

Patient-perceived functional outcomes in activities of daily living were surveyed in 43 arthroplasty patients, 32 undergoing hip replacement and 11 having knee replacement, in a study by Roush, (1985). Patients were sent a questionnaire by mail, a mean of 18 months, (range 6 to 35 months), following surgery, where they were required to evaluate their ability to perform 22 activities, both before and after surgery, including personal care items such as bathing, dressing and tying shoe-laces; housework and yard work such as walking up stairs, cooking, washing dishes, maintaining a garden; recreation and social activities such as sitting watching television, caring for a pet, going out and driving a car.

Results were categorised into three groups, ‘No change’, ‘Function Improved’, and ‘Function Lost’. When all 22 of the surveyed activities were considered collectively, 65 percent of the subjects reported that the surgery did not change functional ability. Nineteen hip patients (60%) reported no change, and three (9%), a loss of function, with

29 Introduction Chapter 1

only ten (31%) reporting an improvement; eight knee patients (73%), reported no change, with the remaining three (27%) reporting functional improvement. There was no significant difference between the functional score of hip and knee patients.

A total of 293 patients having 205 hip and 130 knee arthroplasties were assessed for overall pain and disability prior to, and following their operation, at annual intervals for up to five years by Kirwan, Currey, Freeman, Snow and Young (1994). The mean age of patients was 62.7 years (SD 12.0) with more women than men undergoing surgery. Fourteen patients showed a deterioration in pain and function one year after surgery, but the remainder showed improvements, which took one year or more to reach maximum, and were maintained for at least three years. Overall pain relief was reported as "quite large" and remained "fairly constant" over the three years after operation. The mean proportional improvements obtained for both pain and disability was "slightly greater" for hip than for knee replacement.

Despite the perceived similarity, there seems to be a danger in assuming recovery is the same and assessing the recovery of hip and knee arthroplasty patients together. There is need for caution in interpreting combined results, particularly in the early stages of recovery, as there is some evidence to suggest that knee arthroplasty patients experience more complications in the early postoperative period (Rothman, Moriarty, Rothman, Silver, O’Connor and Agvas, 1994), longer hospital stays (Phillips, 1992), as well as greater pain in the first few days following surgery, and greater disability at one year (Albert, Cohn, Rothman, Springstead, Rothman, and Booth, 1991; Kirwan, Currey, Freeman, Snow and Young, 1994). One of the aims of the studies reported in this thesis is to assess hip and knee patients separately to examine whether there are any differences between them both preoperatively, and during their postoperative recovery.

30 Introduction Chapter 1