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Modiﬁcation of the Harris Hip Score in acetabularfracture treatment

Stein Ovre

*, Leiv Sandvik

, Jan Erik Madsen

, Olav Roise

Department of Orthopaedic Surgery, Ulleval University Hospital, Oslo, Norway

Department of Biostatistics, University of Oslo, Oslo, Norway

Accepted 24 April 2006

Introduction

The demand for documentation of the quality andeffectiveness of treatment steadily increases. Col-lecting and evaluating results is a prerequisite forcontinuousprofessionalimprovement.Thequalityof outcome scores should satisfy different demands

such as reliability and validity. Scores should bereproducible, consistent and responsive, and shouldaccurately evaluate the focused clinical area.Outcome scores are based on elements of speciﬁcmeasures and generic questionnaires. The self-administered generic questionnaire, the MedicalOutcomesStudy 36-item Short Form Health Survey(SF-36)

9,14

,isoneofthemostfrequentlyusedhealthstatus measures. The disease-speciﬁc Harris HipScore is an outcome measureof hip arthroplasty,and was introduced in 1969.

It is an extensivelyused hip questionnaire and has shown high validityand reliability in a study comparing SF-36 withWOMAC.

Thus, the Harris Hip Score should be asuitable instrument for documentation of qualityand effectiveness of treatment.In a previous study, however, we demonstratedthat the Harris Hip Score has a skewed distribution,with a considerable ceiling effect, which limited itsclinical use in acetabular fracture treatment. The50th percentile showed 95% of maximum score anddid notcapture differences in the upper end of thescale.

We therefore question the discriminativequalities of the score as an outcome measure inacetabular fracture treatment. Does it adequatelyrecognise minor differences in patient outcome of

Injury, Int. J. Care Injured (2007)

, 344—349www.elsevier.com/locate/injury

KEYWORDS

Modiﬁed Harris HipScore;Harris Hip Score;Ulleval Hip Score;Acetabulum;Fracture

Summary

The aim of this study was to adjust the Harris Hip Score for evaluation of acetabular fracture treatment. The discriminating quality of the score was assessed.As there was low discriminating capacity at the upper end of the scale, with a highceiling effect and the 60th percentile showing top points, the score was modified andre-evaluated. The discrimination of the modified score was improved, with the 90thpercentile giving top points. Differences in treatment outcome of acetabular frac-tures will be easier to detect with the modified score.

* Corresponding author. Tel.: +47 22119540

E-mail address:

stovre@broadpark.no(S. Ovre).0020–1383/$ — see front matter

acetabular fractures, even though it correlates wellwith the SF-36 and WOMAC? The aim of the presentstudy was to assess the discriminative characteris-tics of the Harris Hip Score in the treatment of acetabular fractures. If necessary, we wished toimprove these characteristics by modifying thescore and evaluating the modiﬁed version.

Methods

The study population was a 10-year cohort of 450consecutive patients with acetabular fracturesrecorded from 1993. For the whole population,the age was median 44.1 (12—92) years, but 53patients died because of the initial trauma or duringfollow up. Fractures weretreatedoperatively in 223and non-operatively in 227 cases. Of these, 23patients were excluded because of total hip repla-cement surgery; 31 observations were excludedbecause the hip score was inﬂuenced by other con-ditions (e.g., leg fractures with impaired functiondue to other illness), leaving a total of 1122 obser-vations for analysis. Outcome instruments wereadministered at 6 and 12 months and at 2, 5, 7, 8and 10 years post-fracture.The discriminative characteristics were assessedfor the ﬁrst 100 consecutive follow-up observationswiththeHarrisHipScoreastheoutcomeinstrument.Thisisastaff-administeredevaluationscorecompris-ing the domains of Pain, Function, Absence of Defor-mity, and Range of Movement (ROM).

It is a disease-specific instrument assessing hip disabilities, origin-ally worked out as an outcome score after mouldarthroplasties. The maximum score is 100 points, of which the Pain domain contributes 44, Function 47,ROM5andAbsenceofDeformity4points.FunctionissubdividedintoGaitandActivitiesofDailyLiving.Thedesign of the score makes it possible to compare andanalyse the total score as well as the domains andsplit elements within the domains.Because of the high ceiling effect and low dis-criminating capacity, the Harris Hip Score was mod-ified and assessed for the next 100 consecutivefollow-up observations. One of our concerns wasthe discrepancy between self-reported pain in theoutpatient clinic and the score recorded in the Paindomain. The Pain domain was then modified toinclude a visual analogue scale (VAS) of pain atnight, at rest and walking. No pain at night yielded20 points, intolerable pain 0 points, pain at restduring the day 17 points and pain at gait 13 points.Additionally, the Pain domain was supplementedwith the use of analgesics (Table 1).The elements describing Activities of Daily Livingwere not changed except for entering public trans-portation and use of shoes and socks, which wereerased.GaitSupportwasreducedfromseventofourgrades.The domain Absence of Deformity was erased andreplacedbyRelativeStrength,ashipmusclestrengthis related to functional outcome.

4,5

In both hips thestrength of hip ﬂexion, extension and abduction wasscaledandallottedthefollowingpoints:5,normal;4,Modiﬁcation of the Harris Hip Score in acetabular fracture treatment 345

Table 1

The Pain domain in the modiﬁed Harris Hip Score (a)

(a)Noanalgesicuse,additional10points;infrequentuse,5points;dailyuse,0points;(b)nopainatrestisweighted85%ofnopainatnight. Pain at gait is weighted 65%.

movingagainstresistance;3,movingagainstgravity;2, moving, but not against gravity; 1, trace of con-traction; and 0, paralysed limb.

The index pointswere then added and relative strength of theaffected hip was calculated. Relative strength of more than 95% of the strength of the normal hipyielded 10 points; 86—95%, 7 points; 66—85%, 4points;51—65%,2points;andlessthan51%,0points.The ROM domain was altered to Relative ROM.Flexion, extension, abduction, adduction and inter-nal and external rotation in flexion were measuredin both hips. Total ROM of more than 95% of thecontralateral normal hip attracted 8 points; 86—95%, 5 points; 66—85%, 2 points; 51—65%, 1 point;and less than 51%, 0 points. Synopses of the mod-ifications are shown inTable 2.Both the original and modified Harris Hip Scoreswere evaluated for the following 922 observations.The outcome instruments were compared usingNCSS Statistical Software for Windows (version2004). Descriptive statistical analyses were per-formedontheoutcomefortheoriginalandmodifiedHarris Hip Scores as well as the domains. The dis-tribution was described with skewness and percen-tiles. Because of proven skewness, Spearman’s rhowas used as correlation coefficient. The coefficientswere interpreted as follows: poor correlation(

0.3); moderate correlation (0.3

0.6);good correlation (0.6

0.8); and excellent cor-relation (

0.8).

A linear relationship betweenoutcomes in the original and modiﬁed Harris HipScoreswasexpected.Kappa agreementanalysis wasevaluated as follows: poor agreement (kappa value

0.20); fair (0.21—0.40); moderate (0.41—0.60);good (0.61—0.80); and very good (0.81—1.00).

The patient information was selected and storedaccording to guidelines issued by the hospital andofﬁcial authorities, and the Data Inspectorate andtheRegionalCommitteeofEthicsapprovedthestudy.

Results

Of the first 100 observations, 79 were made inoperatively and 21 in conservatively treatedpatients. Their mean Harris Hip Score was 88.1(46—100; S.D. 14.2). The 25th and 50th percentilesfor the total numeric score were 80 and 94 points,respectively. The 65th percentile had a ceiling valueof 100 points. The Pain domain in the Harris HipScoreshowedameanvalueof39.3(20—44;S.D.6.1)points with the 60th percentile showing the ceilingvalue of44points. Themean oftheFunctiondomainwas 40.3 (11—47; S.D. 8.7) with the 25th percentileshowing 35 points. The 60th percentile showed themaximum 47 points. The Absence of Deformitydomain showed a mean 3.7 (0—4; S.D. 1.1) andthe 10th percentile showed the top value of 4.The mean in the ROM domain was 4.9 (4—5; S.D.0.3) and the 15th percentile reached the ceilingvalue of 5.The modified score was applied to the next 100observations, in 63 operatively and 37 conserva-tively treated patients. The mean modified HarrisHip Score was 104.9 points (54—120; S.D. 14.9) andthe 25th, 50th and 75th percentiles were 98, 110and 117 points, respectively. The 90th percentilehad a ceiling value of 120 points. The mean in thePain domain (VAS score and Analgesics) was 51.9(32—60; S.D. 8.0) and the 25th and 50th percentileswere 45 and 56 points, respectively. The 75th per-centileshowedaceilingvalueof60.Themeanvaluein the Function domain was 38.4 (10—42; S.D. 6.6),the 25th percentile showed 38 points and the 45thpercentile reached the top 42 points. The mean inthe Relative Strength domain was 8.6 (0—10; S.D.2.7), the 25th percentile was 7 points and the 30thpercentile showed the ceiling value of 10 points.346 S. Ovre et al.

Figure 1

(A and B): Histograms of the original andmodiﬁed Harris Hip Score in 461 pair of observations.The modiﬁed score has wider distribution and the ceilingeffect is less pronounced. Note the differences in numberof observations on the vertical axis.