The Journal of Arthroplasty Vol. 10 No.

2 1995

H e a l t h and Quality of Life Before and After Hip or K n e e A r t h r o p l a s t y
Pekka Rissanen, MA,* Seppo Aro,

MD, MSc, MA,-t- Pfir

Slfitis, MD$

MD,$

Harri Sintonen,

PhD, MSc,* and Pekka Paavolainen,

Abstract: The impact of hip and knee

arthroplasty based on the patients' own evaluations of their health, quality of life, and physical ability was assessed using a crosssectional study design. The eligibility criteria were a diagnosis of primary arthrosis, primary operation, and total joint arthroplasty. Preoperative hip and knee patient groups were compared with similar groups who underwent arthroplasty 2 or 5 years previously. Subjective health outcome was assessed with the Nottingham health profile and a 15-dimensional, health-related quality of life measure. Patients' physical ability was assessed using a measure of activities of daily living. Major improvements were observed for pain, sleep, range of motion, and physical ability. However, after surgery, patients were less healthy than the general population of the same age. The health status of patients operated on 2 or 5 years ago was similar, suggesting that health gains persist for several years. K e y words: quality of life, activities of daily living, hip joint surgery, knee joint surgery.

Total hip a r t h r o p l a s t y (THA) a n d total k n e e a r t h r o p l a s t y (TKA) are a m a j o r a d v a n c e in the t r e a t m e n t of p a t i e n t s w i t h chronic arthritis, a n d t h e i r success in r e d u c i n g p a i n a n d i m p r o v i n g m o b i l i t y is well established. 1,2 The f r e q u e n c y of these o p e r a t i o n s has i n c r e a s e d rapidly in Finland. According to a n a t i o n w i d e register, a b o u t 1,700 THAs w e r e c o n d u c t e d in Finland in 1983 a n d a b o u t 3,800 in 1991 (0.76 p e r 1,000). The n u m b e r of TKAs P e r f o r m e d was 430 in 1983 a n d 1,800 in 1991 (0.36 p e r 1,000). Artificial j o i n t a r t h r o p l a s t i e s p e r f o r m e d o n hips a n d k n e e s a c c o u n t for 9 6 % of all j o i n t arthroplasties in Finland. P r i m a r y arthrosis is the m a j o r cause of a r t h r o p l a s t y in a b o u t 65 % of cases. A b o u t 65 % of all p r i m a r y THAs a n d TKAs are p e r f o r m e d o n

From the *University of Kuopio, Kuopio, i-National Research and Development Centre for Welfare and Health (STAKES), and qflnvalid Foundation Hospital, Helsinki, Finland. Reprint requests: Pekka Rissanen, MA, University of Kuopio, PO Box 1627, 70211 Kuopio, Finland.

p a t i e n t s o v e r 65 years of age a n d a b o u t t w o thirds are w o m e n . The d e m a n d for THAs a n d TKAs is likely to continue. It is generally expected that these procedures will eventually rise to the rate of 1 per 1,000, a l t h o u g h there are no detailed analyses ot the d e m a n d for total joint arthroplasty. 3 In 1990, 7.5 per 1,000 people over the age of 65 w e r e operated on. The predicted g r o w t h of the elderly p o p u l a t i o n in Finland over the n e x t few decades will increase the d e m a n d tor p r i m a r y a r t h r o p l a s t y - - n o t to m e n tion revisions, w h i c h currently account for 14% of all THAs and 6 % Of all TKAs. If the d e m a n d for surgery remains constant, the frequency of p r i m a r y THAs and TKAs in the elderly p o p u l a t i o n (-> 65 years) will be 1.4 times higher t h a n it is n o w b y the year 2010. This m a y be an underestimation, h o w ever, since the rate of operations has b e e n growing m a r k e d l y faster t h a n the elderly population. There is a general consensus, f r o m b o t h a clinical a n d m a n a g e r i a l point of view, that patients' o w n e v a l u a t i o n s of their h e a l t h a n d h e a l t h - r e l a t e d

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quality of life should be used as one criterion in medical decision making. The effects of THA and TKA on health and health-related outcomes have been assessed in a n u m b e r of studies. These have mainly concerned economic benefits 4,5 changes in pain, mobility, and activities of daily life, 6,7 and sick leave, work disability, or occupation. 1,s,9 A few studies have also assessed the effects of TEIA and TKA in terms of quality of life. 1°-~4 In only one report were changes in the quality of life after THA and TKA assessed a n d compared. 12 In two studies, widely e m p l o y e d and well-validated measures of health-related quality of life were used.~2,I3 The main purpose of this study is to assess the impact of THA and TKA on patients' subjective evaluations of their general health, quality of life, and physical ability using well-established measures. The study design was cross-sectional, that is, preoperative patient groups were compared with postoperative groups. By interviewing patients w h o had surgery either 2 or 5 years ago, a relatively long postoperative period could be scrutinized. An additional comparison of hip and knee patients with the general population of the same age was also performed.

Materials and Methods
Data were collected from three groups of Finnish patients with primary hip and knee arthroses: a preoperative group waiting for operation, a group operated on 2 years ago, and a group operated on 5 years ago. Health outcomes, quality of life, and functional ability were assessed. Eligibility criteria for all groups were a diagnosis of primary arthrosis, primary operation, and total joint arthroplasty. Preoperative patients were consecutively recruited at seven university-level orthopedic departments in Finland. All patients admitted between March 1991 and June 1991 and w h o met the eligibility criteria e n t e r e d the study. These patients c o m p l e t e d self-administered questionnaires after admission to the hospital. The postoperative THA patients had been operated on either between January 1986 and April 1986 or between January I989 and April 1989, while the postoperative TKA patients had had surgery either between January 1986 and May 1986 or between January 1989 and May 1989. All operations were conducted at the Invalid Foundation Hospital in Helsinki, consecutive hip and knee patients with primary arthrosis were entered into the study until each group had 50 cases. A self-administered questionnaire was mailed to these patients.

Health o u t c o m e was assessed with the Nottingham health profile (NHP) 15 and a 15-dimensional, h e a l t h - r e l a t e d quality of life m e a s u r e (15D).16 Patients' physical ability was assessed with a measure of activities of daily living (ADL). 17 The NHP is a widely used and w e l l - d o c u m e n t e d health measure. 15 It is composed of 38 assertions (yes/no) from which six dimensions of health can be derived. Items are weighted and each dimension yields a value b e t w e e n 0 and i00 on an interval scale, with the worst state being 100 and the best state being 0. However, the dimensions are usually not aggregated to produce a single overall estimate of general health. Consequently, NHP is a profile of health dimensions rather t h a n a single health measure. In this study, the items were weighted using scores derived from a Finnish population sample, is The 15D is composed of 15 dimensions relating to health (Fig. 1). For each dimension, the respondent has to choose one of four or five levels that best describes his/her present health status. A relative importance weight has b e e n derived for each dimension, from a Finnish population sample, as well as a relative weight (value) for all levels within each dimension. Multiplying these two weights and aggregating over all dimensions produce a continuous variable (15D score) yielding values b e t w e e n 0 and 1. An index value of 1 represents the best (health related) quality of life and 0 the worst (patient death). 16 The I5D measure can be used to produce either a single estimate of the overall quality of life or a profile of the m e a n levels of the different dimensions (where the m i n i m u m or best value = i; the m a x i m u m or worst value = 4 for seeing, hearing, sleeping, communicating, eliminating, and pain; and the m a x i m u m value = 5 for the other 9 dimensions). The o u t c o m e measure for the physical ability of patients was a 14 item score of ADL. Each item yielded values from 0 (no problems) to 3 (unable to manage). The items were: walking outdoors, negotiating stairs, walking at least 400 m, carrying h e a v y items, such as a 5 kg shopping bag for I00 m, p e r f o r m i n g h e a v y h o u s e w o r k , w a s h i n g and bathing oneself, cooking for oneself, cutting toenails, p e r f o r m i n g light h o u s e w o r k , walking b e t w e e n rooms, use of the lavatory, dressing and undressing, getting in and out of bed, and feeding oneself. Physical ability was classified into three groups (good, moderate, or poor) o n the basis of the values of the ADL items using a procedure described by Jylh/i et al. 17 Differences in subjective health status and physical ability b e t w e e n the pre- and postoperative groups were used to express the effects of joint

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Moving Seeing Hearing Breathing Sleeping Eating Communicating Eliminating Working Social participation Mental functioning Pain / ache Depression Distress ( a n g s t ) l ~ - ~ - - : ~ y- ~ ............. Perceived health '~-'-" ~...................... ~ ~-..................................'... i .. ................. : 0 0.5 1 1.5 2 2.5 Age and sex adjusted means

Fig. 1. Health-related quality of life in pre- .and postoperative THA patients and in the general population, as well as the 15-dimensional measure. Age- and sex-adjusted means of single dimensions.

Before operation After operation General population aged 64-70

arthroplasty. Statistical significance of the means of the two groups was analyzed using either analysis of variance, t-test, or chi-square test. Regression and covariance analyses were applied for age and sex adjustment. For comparison of the two measures of health-related quality of life, the NHP and 15D, p r o d u c t - m o m e n t correlation coefficients were used. For calculating the correlations, the NHP dimensions were pooled to produce a single estimate, the NHP score. All preoperative patients responded to the questionnaire (Table 1). The response rate of the postoperative groups was 87%. The main reason for failure to complete the questionnaire was that Swedish-speaking patients had difficulties answering the Finnish-language questionnaire (about 6% of the Finnish population is Swedish speaking). Some

of the respondents f o u n d it impossible to complete the questionnaire. Three of the postoperative patients died before the survey was completed. Response rates and patient characteristics are s h o w n in Table 1. The m e a n age of the patient groups varied between 64 and 70 years. The patients were mainly w o m e n (65%), married (55%), and retired (90%) (Table 1). Only 7% were employed. The general age of entitlem e n t for pension in Finland is 65 years.

Results Health Status and Quality of Life
The overall quality of life (15D) score was significantly higher (0.89) in the postoperative THA

Table 1. P a t i e n t D a t a a n d R e s p o n s e R a t e By T i m e a n d Type o f O p e r a t i o n
THA Groups Postoperative Preoperative No. of responses Response rate (%) Mean age (years) Age range (years) Women (%) Married (%) Widowed (%) Retired (%) I20 100.0 66 55-85 57.1 55.8 24.2 83.2 Two-year 47 90.4 64 53-72 51.1 66.0 17.0 89.4 Five-year 45 84.0 65 55-75 61.4 62.8 18.6 88.4 Preoperative 63 100.0 67 55-82 82.5 45.2 30.6 92.1 TKA Groups Postoperative Two-year 42 93.8 68 57-76 72.5 56.4 23.1 100.0 Five-year 38 80.9 70 61-81 71.1 50.0 30.6 97.3

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groups compared with the preoperative THA group (0.82) (P < .05). Among the general population, the mean score was 0.92 (Rissanen P, Sintonen H, Pekurinen M, unpublished data, 1992). Postoperative TKA (P < .001) and THA (P = .07) patients had significantly lower scores than the general population. The NHP dimensions showed a substantial decrease in pain and improvement in physical mobility, and the postoperative patients reported less problems with sleep and higher energy levels than the preoperative patients (Table 2}. In Figure 1, single dimensions of the 15D are compared between pre- and postoperative hip patients and the general population of the same age. The 2- and 5-year postoperative groups were pooled, since none of the differences between them were statistically significant at P <. 10. Postoperative hip patients had better scores for mobility, working, social participation, pain, and perceived health than the preoperative patients, although these were worse than the respective scores for the general population. The same comparison among TKA patients showed similar, though smaller, differences in health and quality of life measures (Table 3). The largest variations in the NHP dimensions were observed for pain and physical mobility. The comparison of single 15D dimensions showed major differences in mobility, working, social participation, pain, and perceived health (Fig. 2). Again, the general population had fewer problems in many of these areas than the postoperative knee patients. The two methods of measuring health and quality of life gave rather similar results. The NHP and 15D scores correlated strongly in the hip and knee postoperative groups (r = .82 in THA patients and r = .81 in TKA patients; absolute values, P < .001 in both groups). The correlations between the two measures

were slightly weaker in the preoperative hip and knee groups (r = .69 in THA patients and r = .55 in TKA patients, absolute values, P < .001).

Physical Ability
In TKA and THA patients, there were substantial differences in the ADL score between the pre- and postoperative groups. The ADL score was classified as good in only 1-3% of the preoperative patients; 63-80% were classified as poor. After surgery, 20-25% of the patients had good ADL scores and 25-35% had poor ADL scores. The differences between the pre- and postoperative groups were statistically significant (P < .001) (Table 4). Physical ability was significantly improved in the postoperative groups, although the ADL scores of both hip and knee patients were more problematic than those of the general population of corresponding age (Table 4).

Discussion
In this study, the outcome of THA and TICA was assessed by measures of health-related quality of life and physical ability. The aim of this study was to obtain an overview of the impact of joint arthroplasty on the patients' well being. Three patient groups with different time intervals from operation to follow-up evaluation (1 preoperative 2 postoperative) were compared. The cross-sectional study effects of operations conducted a relatively long time ago can be assessed. However, this design reduces the statistical power of the analysis compared to a person-based prospective study. Additionally, there are some considerations relating to patient selection and case mix, as follows.

T a b l e 2. H e a l t h a n d Quality of Life i n P r e o p e r a t i v e THA Patients, P o s t o p e r a t i v e THA Patients, a n d t h e G e n e r a l P o p u l a t i o n (95% C o n f i d e n c e Intervals) Postoperative Group (mean _+ SD) Preoperative Group (mean _+ SD) Fifteen-dimensional score]NHP dimensions$ Energy Sleep Pain Emotional reaction Socialisolation Physical mobility 0.82 _+ 37.90 43.46 62.76 15.62 8.15 57.58 + _+ _+ _+ _+ _+ .02 5.58 6.81 5.33 3.77 3.40 4.93 TWo-year 0.89 + 24.35 17.23 21.76 14.83 12.66 31.05 .03§ Five-year 0.89 +_ .03§ General Population (65-70 years)* (mean -+ SD) 0.92 -+ ,02

+ 9.87§ ± 8.16§ ± 6.96§ + 7.17 + 8.02 ± 7.79§

23.02_+10.51§ 19.62 _+ 7.61§ 17.99 _+ 7.29§ 10.21 _+ 5.73 2.11 _+ 1.77§11 23.20 +_ 6.59§

*Rissanen E Sintonen H, Pekurinen M, unpublished data (1992). J-l, best health-related quality of life; 0, worst health-related quality of life (patient death). $0, best health state; 100, worst health state, §P < .05 for independent samples, t-test for comparing differences between the pre- and postoperative groups, lIP < .05 for independent samples, t-test for comparing differences between postoperative groups. NHE Nottingham health profile.

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Table 3. Health and Quality of Life in Preoperative TKA Patients, Postoperative TKA Patients, and the General Population (95% Confidence Intervals)
Preoperative G r o u p ( m e a n ± SD) Fifteen-dimensional score+ NHP dimensions~c Energy Sleep Pain E m o t i o n a l reaction Socialisolation Physical mobility 0.83 _+ .02 38.05 31.73 56.57 16.05 8.86 48.66 -+ ± + ± ± -+ 8.75 8.10 8.08 3.99 4.10 5.55 P o s t o p e r a t i v e ~G r o u p ( m e a n ± SD) Two-year Five-year 0.87 ± 25.45 28.28 25.42 20.04 9.70 28.56 .03§ 0.86 ± 34.36 31.48 25.75 19.16 14.87 29.54 .03 General P o p u l a t i o n (65-70 years)* ( m e a n ± SD) 0.92 + .02

± 10.64 ± 10.85 ± 9.66§ ± 7.65 _+ 6.29 _+ 8.64§

_+ 12.62 ± 11.00 ±11.01§ ± 9.35 _+ 8.14 + 10.61§

*Rissanen P, S i n t o n e n H, P e k u r i n e n M, u n p u b l i s h e d data (1992). J-i, best health-related quality of life; 0, worst health-related quality of life (patient death). ~:0, best h e a l t h state; 100, worst h e a l t h state, §P < .05 for i n d e p e n d e n t samples, t-test for c o m p a r i n g differences b e t w e e n t h e pre- a n d postoperative groups. NHP, N o t t i n g h a m h e a l t h profile.

First, all postoperative patients came from the Invalid Foundation Hospital, which serves the whole country, has the most experience with joint arthroplasty, and the largest annual n u m b e r of discharges in Finland. The preoperative patients, however, came from seven Finnish hospitals, although the proportion of t h e m subsequently operated on at the Invalid Foundation Hospital was only 21%. We have made the assumption that the average quality of care at these seven university-level hospitals is similar to the quafity of care at the Invalid Foundation Hospital. However, due to the small n u m b e r of patients iri each of the seven hospitals (preoperative patients), we could not make the appropriate between-hospital comparisons to verify this assumption. Second, the age range and structure of the preand postoperative groups were almost identical, and so age is unlikely to cause confounding. We did not have detailed information on comorbidities. However, a comparison of those 15D items that are supposed to be unaffected by the arthroplasty was very similar in the pre- and postoperative groups. This suggests that differences in comorbidities are unlikely to cause any further confounding. Third, postoperative mortality among these joint arthroplasty patients was assumed to be no higher

than among the general population. In general, the death rate is lower in arthroplasty than in most other elective operations. 19 Indeed, the mortality among THA patients is found to be lower than among the general population? ° Therefore, a sample selection of "the fittest patients" should not have had any significant influence on the comparison of outcomes. Fourth, the rate of operations has increased t h r o u g h o u t the 1980s. F r o m 1986 (start year of operation for the 5-year postoperative group) to 1991, the n u m b e r of joint arthroplasties p e r f o r m e d increased by 10% annually. This m a y indicate that the selection criteria for operation had b e c o m e broader, suggesting that less severe cases~were operated on in 199{ t h a n ~ 5 . y e a r s earlier. If this were so, the differences iri h e a l t h o u t c o m e b e t w e e n the pre- and postoperative groups w o u l d tend to be smaller t h a n expected in an equal case-~nix situation. In s u m m a r y , the case mix b e t w e e n hosp!tals and pre- and postoperative patients should be comparable e n o u g h to cause n o serious bias. The NHP and 15D gave essentially similar profiles. Major i m p r o v e m e n t s were observed for pain, sleep, and mobility. Activities:of daily living were substantially e n h a n c e d a f t e r operation. The com~
t, Ez • ~ .

Table 4. Physical Ability in the Pre- and Postoperative Groups as Compared to the Geileral Population*
T H A G r o u p s (%) Physical Ability Good Moderate Poor Preoperative (n = 116) 3.4 16.4 80.2 Postoperative TWo-year Five-year (n = 45) (n = 43) 13.3 55.6 31.1 27.9 53.5 18.6 T K A G r o u p s (%) Preoperative (n = 62) 1.6 35.5 62.9 Postoperative TWo-year Five-year (n = 39) (n = 35) 30.8 35.9 33.3 20.0 42.9 37.1 General Population (65-69 years*) Women Men (n = 90) (n = 91) 61 32 7 52 42' 6

c h i - s q u a r e = 67.6 (P < .0001)

chi-square = 20.7(P = .0004)

df= 4
*Jylhfi M, Jokela J, Tolvanen E et al. 17

df= 4

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Moving Seeing Hearing Breathing Sleeping Fig. 2. Health-related quality of life in pre- and postoperative TKA patients and in the general population, as well as the 15-dimensional measure. Age- and sex-adjusted means of single dimensions. Eating Communicating Eliminating Working Social participation Mental functioning Pain / ache Depression Distress (angst) Perceived health [ 0
I i i i it~'n
4 l

Before operation After operation General population aged 64-/O

0.5

1

1.5

2

2.5

A g e and sex adjusted means

parison of patients w h o had surgery 2 versus 5 years ago suggests that gains in health and physical abiIity persist for several years. Nevertheless, postoperative patients w e r e less h e a l t h y t h a n the general p o p u l a t i o n of the same age. Contrary to the general Pattern of health differences, b o t h g r o u p s of h i p ' a n d k n e e patients h a d worse scores for breathing (ie, shortness of b r e a t h w h e n quickening one's pace) t h a n the preoperative groups. This m a y be due to greater d e m a n d placed o n the cardiorespiratory system after the i m p r o v e m e n t in mobility, a n d thus is interpreted as a sign of successful t r e a t m e n t . Our results are similar to earlier studies that e m p l o y e d different m e a s u r e s of o u t c o m e . 1°-14 In a tollow-up study, NHP was used to assess quality of life before a n d after THA. 13 in that study, the NHP d i m e n s i o n s yielded considerably higher values before surgery and lower values atter surgery, a n d consequently, the changes in NHP dimensions w e r e greater t h a n in our study. Liang a n d co-workers ~2 f o u n d significant i m p r o v e m e n t s in the Bush index of well being a n d in a c o m b i n e d m e a s u r e of mobility, physical a n d social activity, a n d a m a r k e d r e d u c t i o n o f s y m p t o m s after THA a n d TKA. Contrary to o u r study, they did not find differences in the o u t c o m e s b e t w e e n hip and k n e e patients. In summary, this study s h o w e d that the technolology of THA and TKA is well developed in terms of its ability to i m p r o v e patient well being for m a n y

years. A prospective study of THA and TKA is needed to validate the above resuks. Detailed patient-based analyses of changes in health, quality of life and ADL, cost data on operations, other health and rehabilitation services, disability days, and other relevant factors are needed to assess further the relative merits and effidency of joint operations in different patient groups and in relation to other conditions. Our study group has started such a prospective study and its findings will be available in the n e a r future.

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16. Sintonen H, Pekurinen M: A fifteen-dimensional measure of health related quality of life (15D) and its applications. In Walker SR, Rosser RM (eds): Quality of life assessment: key issues in the 1990s. Kluwer Academic Publishers, London, I993 17. Jylh~ M, Jokela J, Tolvanen E et al: The Tampere longitudinal study on ageing: description of the study. Basic results on health and functional ability. Scand J Soc Med 20 (suppl 47):1, 1992 18. Koivukangas E Koivukangas J, Ohinmaa A e t al: NttP: el~mfinlaadun mittari terveydenhuollon arviontitutkimuksiin: sosiaalilfia~ketieteellinen aikakauslehti (NI-IP: a method for measuring health related quality of life in health services evaluation). J Soc Med Finland 29:229, 1992 19. Daellenbach HG, Gillespie WJ, Crosbie E Daellenbach US: Economic appraisal of new technology in the absence of survival data: the case of total hip replacement. Soc Sci Med 31:1287, 1990 20. Holmberg S: Life expectancy after total hip arthroplasty. J Arthroplasty 7:183, 1992