· Web viewImpact of comorbidities on outcome after total hip arthroplasty. Loth FL., M.Sc....

Impact of comorbidities on outcome after total hip arthroplasty

1. Loth FL., M.Sc. ([email protected])1,

2. Giesinger JM., Ph.D. ([email protected])2,

3. Giesinger K., M.D. ([email protected])3,

4. MacDonald DJ., B.A. ([email protected])4,

5. Simpson AHRW., Professor DPhil. ([email protected])4,

6. Howie CR., Professor FRCS(Ed) ([email protected])4,

7. Hamilton DF., Ph.D. ([email protected])4

1 Faculty of Psychology and Sport Science, University of Innsbruck, Austria2 Innsbruck Institute of Patient-centered Outcomes (IIPCOR), Austria3 Department of Orthopaedics and Traumatology, Kantonspital St. Gallen, Switzerland4 Department of Orthopaedics and Trauma, University of Edinburgh, United Kingdom

Correspondence toDr. David Hamilton

Chancellors Building

49 Little France Crescent

EH16 4SB Edinburgh

[email protected]

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mailto:[email protected]

Impact of comorbidities on outcome after total hip arthroplasty

ABSTRACT

Background. Patient-reported outcome (PRO) scores gain increasing importance in

quantifying clinical success and procedure remuneration. Our aim was to evaluate the impact

of comorbidity on joint-specific outcome and general health in patients undergoing elective

total hip arthroplasty (THA).

Methods. Longitudinal data on THA procedures was used to evaluate the association

between comorbidity and surgical outcome in terms of joint-specific measures and general

health (Forgotten Joint Score-12 (FJS-12), Oxford Hip Score (OHS), Short-form 12 (SF-12)

at 1-year follow-up. Comorbidities comprised the Charlson Comorbidity Index (CCI) low

back pain (LBP), pain from other joints (POJ) and Body Mass index.

Results. We analysed data from 251 THA patients (age: 67.7±11.8 years; 58.2% female).

Most common conditions were POJ (75.9%), LBP (55.1%), connective tissue disease

(12.1%), and diabetes (5.6%).

With regard to post-operative improvement we did not find statistically significant

differences between patients with or without CCI comorbidities (FJS-12 +38.7 vs +43.2

p=0.370; OHS +15.6 vs +19.9 p=0.100) or POJ (FJS-12 +39.9 vs +45.1 p=0.325; OHS +17.3

vs +16.6 p=0.645). Patients with LBP showed less improvement on the FJS-12 than those

without LBP (+35.6 vs +49.1, p=0.002), whereas no difference was found for the OHS

(+17.9 vs +16.5; p=0.266).

Conclusion. Patients with comorbid conditions report lower pre- and post-operative outcome

scores compared to patients with no such conditions; however, there was no statistically

significant association of CCI comorbidities and POJ with post-operative improvement in

joint-specific outcomes. LBP was found to have a negative impact on post-operative

improvement in terms of joint awareness.

Keywords: Arthroplasty, Oxford Hip Score, Forgotten Joint Score-12, Comorbidity, Outcome

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INTRODUCTION

Total Hip Arthroplasty (THA) provides pain relief and improves physical function in patients

with end-stage osteoarthritis (OA) [1-4]. As such, surgical volumes of THA have increased

greatly [5], with approx. 400,000 procedures carried out in the US [6, 7] and 100,000 in the

UK [8] annually. High levels of patient satisfaction are typically reported [1, 9]. Concurrent

with this increase in procedure volume, has been a drive to gather greater patient level data in

joint replacement registries, to evaluate outcomes and investigate characteristics that may

influence these [10-13].

The ‘health’ of the patient undergoing surgery is one such consideration.

A case-control study of general practice consulters in the UK showed that patients suffering

from OA were more than twice as likely to have high numbers of comorbid diseases than

patients without degenerative joint disease [14]. Most common problems of patients with OA

of the hip include back pain, pain from other joints, hypertension, osteoporosis, and type II

diabetes mellitus [14-16]. Comorbidities result in increased length of hospital stays, a higher

probability of readmission following THA and of undergoing revision surgery [15, 17, 18].

Further findings associate comorbidity burden in THA patients with poorer quality of life,

including psychological factors such as higher levels of fatigue, depression, or anxiety [19-

21]. THA patients with comorbidities show significantly lower physical functioning and

higher pain levels preoperatively than those without [15, 20-23]. In addition, THA patients

reporting (severe) back pain or pain from other joints have worse outcomes scores at baseline

and during follow-up [15, 20, 21, 24].

While a number of studies have correlated comorbidity with pre-operative predictors of

length of stay or postoperative levels of pain and function, there has been scant consideration

as to differences in postoperative improvement in outcome parameters between patients with

and without comorbidity, nor the ability of different scoring systems to capture any such

differences. Thus the objective of this study was to evaluate differences in improvement

following hip arthroplasty in patients with and without comorbidities using a variety of

outcome assessment tools.

PATIENTS AND METHODS

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Sample

Data was accessed for patients who underwent primary THA for a diagnosis of osteoarthritis

at a single high volume arthroplasty unit in the UK between January and June 2014. Our

retrospective analysis included patients with available comorbidity data and patient reported

outcome data pre-surgery and at 12-month follow-up.

Patients were assessed prior to surgery and at 12 months following surgery with two joint-

specific PRO instruments, the Oxford Hip Score (OHS) and the Forgotten Joint Score-12

(FJS-12). In addition, the SF-12 was administered at 12-month follow-up to measure patients’

general health. Comorbidity was assessed at pre-surgery using the Charlson Comorbidity

Index (CCI) and two additional questions on low back pain and pain from other joints.

Ethical approval for this study was obtained from the institutional review board

(11/AL/0079).

Assessment instruments

Oxford Hip Score

The Oxford Hip Score (OHS) is a widely used measure for the assessment of pain and

function in patients undergoing hip surgery [25]. The questionnaire consists of 12 questions

using a 5-point response format from which a total score ranging from 0 to 48 points is

calculated. A higher score indicates better outcome.

Forgotten Joint Score - 12

The Forgotten Joint Score FJS-12 assesses joint awareness in patients with pathologies of the

hip or knee [26]. It consists of 12 questions using a 5-point Likert response format. The total

score calculated from these items ranges from 0 to 100, with high scores indicating a good

outcome, i.e. a high level of forgetting about the joint in everyday life.

SF-12

The SF-12 is a general health questionnaire that provides a physical component summary

score (PCS) and a mental component summary score (MCS) [27]. The SF-12 consists of 12

items, it is a brief measure that is commonly used in large population health surveys or in

national registers. While lower scores indicate poor health, higher scores indicate a good

health status.

Charlson Comorbidity Index (CCI)

The Charlson Comorbidity Index (CCI) allows the standardised assessment of comorbidity. It

consists of 19 medical conditions assigned with different scores depending on the associated

mortality risk of the condition. The following conditions are covered by the CCI: myocardial

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infarction, congestive heart failure, peripheral disease, cerebrovascular disease:

cerebrovascular accident (CVA) with mild or no residua or Transient ischemic attack (TIA),

dementia, chronic pulmonary disease, connective tissue disease, peptic ulcer disease, mild

liver disease, and diabetes without end-organ damage, hemiplegia, moderate or severe renal

disease, diabetes with end-organ damage, tumour without metastasis, leukaemia and

lymphoma, moderate or severe liver disease, metastatic solid tumour, and AIDS.

For more comprehensive comorbidity assessment we additionally assessed low back pain

(LBP), pain from other joints (POJ) and Body Mass Index (BMI).

Statistical analysis

Sample characteristics are given as means or percentages, standard deviations, ranges, and

frequencies. In our analysis we compared the following comorbidity groups: Low back pain

(yes vs no), pain from other joints (yes vs no), and number of comorbidities listed in the CCI

(0 vs 1 or more). BMI was dichotomised at 30 kg/m², resulting in an obese and a non-obese

patient group in line with the WHO classification for obesity REFERENCE.

Comparison of FJS-12 and OHS outcomes between comorbidity groups and over time was

based on mixed linear models. We used comorbidity group and time point as fixed factor,

with a random baseline term and with a first-order autocorrelation covariance matrix to adjust

for correlation between repeated assessments. Age was added to the model as a covariate

where significant. The group-by-time interaction in this model indicates a difference in

postoperative change between the comorbidity groups. To identify differences in SF-12

scores between comorbidity groups at 1 year follow-up, we conducted t-tests for independent

samples.

RESULTS

Patient characteristics

We analysed data for 251 patients who had comorbidity and PRO data recorded pre-surgery

and linked 12-month PRO follow-up data. The mean age of the patients included in this study

was 67.7 (SD 11.8) years with a 58/42 female to male split. The most common comorbid

conditions were pain from other joints (75.9%), low back pain (55.1%), connective tissue

disease (12.1%), diabetes (5.6%), and myocardial infarction (4.1%). 27.1% of the patients

suffered at least from one CCI comorbidity. Mean BMI was 28.6 (SD 7.5).

Further clinical and sociodemographic data are presented in table 1.

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PLEASE INSERT TABLE 1

Impact of comorbidity burden covered by the CCI on THA outcome

The impact of comorbidities on THA outcomes was assessed by evaluating OHS and FJS-12

scores of patients with no CCI comorbidity and with one or more comorbidity. Patients not

suffering comorbid conditions reported a mean OHS of 22.0 points prior to surgery and 39.9

points one year following surgery. Patients with one or more CCI comorbidities reported a

mean OHS of 19.3 points pre-operatively and 34.8 points at one year. As such, the mean

improvement between baseline assessment and follow-up was 17.9 points for patients without

comorbidities and 15.6 points for patients with comorbid conditions. Overall, both groups

improved significantly from pre-surgery to one year (p<0.001) and patients with and without

a CCI comorbidity differed significantly pre-op and at one year (p<0.001). However, the

between group difference in pre-op to post-op change in OHS was not statistically significant

(p=0.100).

The mean FJS-12 score for patients with no CCI comorbidities was 13.2 prior to surgery and

56.4 points at one year. Patients with one or more CCI comorbidity reported a mean FJS-12

score of 10.4 points pre-op and 49.2 points post-op. The mean change between baseline

assessment and follow-up was 43.2 points for patients without comorbidities and 38.7 points

for patients with comorbidity burden. While the total sample improved significantly from

pre-surgery to one year follow-up (p<0.001), differences between groups (p=0.078) and

differences in change over time (p=0.370) were not statistically significant. In this model age

did not have a significant impact on FJS-12 (p=0.052) or OHS (p=0.403). For further details

see table 2 and figure 1.

PLEASE INSERT

FIGURE 1: CCI comorbidities and postoperative improvement on the FJS-12 and OHS


Impact of low back pain on THA outcome

Patients without LBP reported a mean OHS of 24.1 at pre-surgery and 42.0 points at one year

(table 3, Figure 2). Patients who did suffer from LBP reported a mean OHS of 18.9 points

pre-surgery and 35.4 points at one year. Difference between baseline assessment and follow-

up was 17.9 points for patients without LBP and 16.5 points for patients suffering from LBP.

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While this difference in change was not statistically significant (p=0.266), the total sample

did improve significantly from pre-surgery to follow-up (p<0.001), with patients with and

without LBP also differing significantly (p<0.001). Table 3 shows detailed results on the

impact of LBP.

Mean baseline FJS-12 score was 9.8 points for patients reporting LBP and 16.0 points for

those without (table 3). One year after surgery patients’ scores increased to a mean FJS-12 of

45.3 points for the LBP subsample and 65.2 points for patients without low back pain. These

resulted in mean differences of 49.1 points for patients without LBP and 35.6 points for LBP.

Interaction analysis for the LBP sample showed, that differences in change were statistically

significant (p=0.002). We also observed a significant improvement from pre-surgery to

follow-up (p<0.001), and statistically significant differences between the two patient groups

(p<0.001). Age did not have a significant impact on FJS-12 (p=0.076) or OHS (p=0.673) in

this model. For further details see table 3 and figure 2.

PLEASE INSERT

FIGURE 2: Lower back pain and postoperative improvement on the FJS-12 and OHS


Impact of pain from other joints on THA outcome

Patients who did not suffer from POJ reported a mean OHS of 23.7 points and 40.3 points

one year after surgery (table 4, Figure 3). Patients with POJ reported a mean OHS of 20.3

points pre-op and an OHS of 37.3 points one year after surgery. OHS improved by 16.6

points for those who did not report POJ and 17.3 points in those who did. There was a

significant change in mean scores from pre-surgery to one year follow-up (p<0.001) and

differences between patient groups were also statistically significant (p=0.011). The group

difference in change over time was not statistically significant (p=0.645).

At baseline, mean FJS-12 score for patients with pain from other joints was 10.8 points,

increasing to a mean score of 50.7 points one year after surgery. Patients without additional

joint pain started with a mean score of 17.7 points and increased up to 62.7 points at 12-

month follow-up. Differences in change over time between the two groups were not

statistically significant (p=0.325). Patients improved significantly from baseline to follow-up

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(p<0.001). Age did not significantly impact FJS-12 (p=0.108) or OHS (p=0.980) scores. For

further details see table 4 and figure 3.

PLEASE INSERT

FIGURE 3: Pain from other joints and postoperative improvement on the FJS-12 and

OHS


Impact of Body Mass Index on THA outcome

Non-obese patients reported a mean OHS of 22.1 points before surgery and a mean OHS of

39.2 points 12 months after surgery (Table 5). Patients with a BMI above 29 had a

preoperative mean score of 19.3 points on the OHS and a mean of 36.6 points at 1-year

follow-up. This means that the mean OHS improves 17.2 points in non-obese patients and

17.3 points in obese ones.

In the total sample change in mean scores from pre-surgery to 12 months follow-up was

significant (=<0.001), but there was neither a significant group difference (p=0.078), nor a

statistically significant group difference in change over time (p=0.370).

For the FJS-12 patients with a BMI below 30 had a mean score of 13.1 points at baseline and

a mean score of 54.1 points at 1-year follow-up (mean change: 41.0 points). Obese patients

started with a mean FJS-12 score of 9.8 points and baseline and ended with a mean score of

52.8 points 12 months after (mean change: 43.0 points). Again the change between the pre-

surgery and post-surgery assessment was statistically significant (p=0.001), but there was no

significant difference between the compared BMI groups (p=0.405), and no group difference

for change over time (p=0.685). Age did not significant impact FJS-12 (p=0.081) or OHS

(p=0.683) scores in this model. Further details are reported in Table 5.


Impact of comorbidity burden on general health

General health was measured with the SF-12 one year after surgery. Patients with one or

more CCI comorbidity reported poorer physical health than patients with no CCI comorbidity

(mean: 39.1 vs 44.9, p<0.001), but did not differ with regard to mental health (46.5 vs 48.6,

p=0.057). For LBP we found differences between patients with and without this condition for

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both, physical health (39.2 vs 50.0, p<0.001) and mental health (46.8 vs 49.4, p=0.008).

Patients with POJ differed from those without POJ in physical health (42.0 vs 46.8, p=0.002),

but not in mental health (47.8 vs 48.7, p=0.465).

We did not find statistically significant differences between obese and non-obese patients

with regard to physical health (41.2 vs 44.1, p=0.083) or mental health (47.2 vs 48.2,

p=0.399). Further details are given in table 6.


DISCUSSION

Our study highlights high levels of co-existing conditions in patients undergoing hip

replacement for osteoarthritis. Three out of four THA patients suffered from pain from other

joints and one in two from low back pain. Comorbidities covered by the CCI were less

frequent, with around 30% of patients reporting at least 1 condition. These prevalence rates

are in line with findings from comparable studies [8, 15, 16, 19].

Outcome scores were lower pre-operatively and at post-operative review in patients with 1 or

more CCI comorbidity and pain from other joints compared to those without; however

changes between pre- and post-operative scores were essentially the same. Interestingly,

differences in joint-specific improvement in patients with or without concomitant LBP were

observed. The improvement expressed in outcome scores was more limited in the patient

group with LBP.

There are a multitude of potential outcome metrics available with which to contextualise the

outcomes of THA. Huge variation has been noted in the in outcome measures used in THA

clinical trials; with Riddle et al. [28] noting 20 differing metrics (measuring various

constructs) in 82 trials reported between 2000 and 2007. As such it is important to understand

how confounding variables, such as patient comorbidities, influence different outcome

domains and therefore outcome scores.

Studies also differ in the way they analyse the impact of comorbidity on joint function before

and after THA [15, 21, 29]. A number of studies analysed the impact of comorbidity

separately at pre-surgery and/or post-surgery. These studies showed that THA patients’

comorbidity count is related to more functional impairment before surgery [20, 22, 29-31],

and lower functional status after surgery [15, 22]. Davis et al. [32] showed that baseline

comorbidity count is a stronger predictor of 2-year pain than complications or pre-operative

pain levels.

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Pain from other joints was associated with higher levels of pain in general, reduced function,

health-related quality of life [15, 16, 21]. Back pain was shown to have an important impact

on THA outcome, with patients having worse PRO scores before surgery [20, 21, 24] as well

as during follow-up [15, 19, 23]. The significant impact of low back pain on the mental SF-

12 scores reflects the well-known association between (low back) pain and psychological

well-being [33-35]. Whereas these studies show the strong association between comorbidity

and commonly assessed parameters such as function and pain, they did not analyse if

comorbidity also impacts the postoperative improvement, i.e. the score change from pre- to

post-surgery. Judge et al. [36] showed that POJ resulted in a lower likelihood of achieving

clinically meaningful post-operative improvement. In line with the findings of current

studies, we were able to show, that patients show less improvement after THA, if also

suffering from LBP [19, 23]. However, while improvement of joint outcomes may be worse,

THA may on the other hand reduce LBP and improve spinal function [24, 37]. BMI was not

associated with post-operative improvement from pre-surgery to 1-year follow-up, a finding

well in line with the results from Andrew et al. who also found no difference in change from

pre-surgery to 5-year follow-up.

The comorbidities assessed in our study were found to have a substantial impact on joint-

specific functional limitations and pain measured with the OHS, on joint awareness measured

with the FJS-12 and on general physical function measured with the SF-12. Patients with low

back pain were also found to have poorer mental health at 1-year follow-up and additionally

showed significantly less post-surgical improvement with regard to joint awareness than

patients without back pain. Patients reporting pain from other joints and CCI comorbidities

did not differ significantly from those without such conditions in terms of postoperative

improvement measured with the OHS and FJS-12.

The CCI is typically employed to investigate patients’ overall health status in relation to

surgical risks and complications. When applied to short term clinical outcomes (1 year PRO

scores) worse absolute outcome scores are observed with increased comorbidity, but the pre-

to-post operative improvement is the same in each group, suggesting that the comorbid

conditions captured by the CCI do not directly interact with the improvement after THA. In

contrast, LBP and guarding from fear of LBP cause a significant reduction in lumbar range of

motion [38, 39] which may directly influence patient-reported function.

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By using data from a large teaching hospital in the UK we could analyse a relatively large

and heterogeneous sample with various types of comorbidity burden. A further strength of

this analysis is that this is the first evaluation of the impact of comorbidity on joint awareness

in THA patients. There are however some limitations to our study. We were only able to

assess comorbidities prior to surgery. Whereas the assessed comorbidities were mostly

chronic conditions, it is possible that there might have been a change in comorbidity burden

between the assessment pre-surgery and the one year evaluation. In particular, low back pain

at 12-months follow-up might have been influenced by better function of the operated hip

[24, 37]. A more detailed assessment of LBP or POJ using a validated metric would have

strengthened our analysis. Due to the low prevalence of specific comorbidities covered by the

CCI we could not analyse these comorbidities separately but relied on the aggregate measure

of CCI comorbidity; yes vs no. However, relying on categorising number of CCI

comorbidities is in line with comparable literature [30, 31, 40].

In conclusion, we found a substantial impact of comorbidities covered by the CCI, of pain

from other joints and of low back pain on general physical function joint-specific function,

pain and joint awareness pre- and 1-year post-operatively. Postoperative improvement (pain,

function) did not differ significantly between patients with and without comorbidities, with

the exception of less reduction of joint awareness in patients with low back pain. These

findings indicate that the choice of outcome domains and PRO measures and their specific

measurement properties can influence the results.

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18. Paxton EW, Inacio MC, Singh JA, Love R, Bini SA, Namba RS. Are There Modifiable Risk Factors for Hospital Readmission After Total Hip Arthroplasty in a US Healthcare System? Clinical orthopaedics and related research 473(11): 3446, 201519. Hernandez C, Diaz-Heredia J, Berraquero ML, Crespo P, Loza E, Ruiz Iban MA. Pre-operative Predictive Factors of Post-operative Pain in Patients With Hip or Knee Arthroplasty: A Systematic Review. Reumatologia clinica 11(6): 361, 201520. Wolfe F. Determinants of WOMAC function, pain and stiffness scores: evidence for the role of low back pain, symptom counts, fatigue and depression in osteoarthritis, rheumatoid arthritis and fibromyalgia. Rheumatology (Oxford) 38(4): 355, 199921. Hoogeboom TJ, den Broeder AA, Swierstra BA, de Bie RA, van den Ende CH. Joint-pain comorbidity, health status, and medication use in hip and knee osteoarthritis: a cross-sectional study. Arthritis care & research 64(1): 54, 201222. Kadam UT, Croft PR. Clinical comorbidity in osteoarthritis: associations with physical function in older patients in family practice. The Journal of rheumatology 34(9): 1899, 200723. Hawker GA, Badley EM, Borkhoff CM, Croxford R, Davis AM, Dunn S, Gignac MA, Jaglal SB, Kreder HJ, Sale JE. Which patients are most likely to benefit from total joint arthroplasty? Arthritis and rheumatism 65(5): 1243, 201324. Ben-Galim P, Ben-Galim T, Rand N, Haim A, Hipp J, Dekel S, Floman Y. Hip-spine syndrome: the effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip. Spine 32(19): 2099, 200725. Murray DW, Fitzpatrick R, Rogers K, Pandit H, Beard DJ, Carr AJ, Dawson J. The use of the Oxford hip and knee scores. J Bone Joint Surg Br 89(8): 1010, 200726. Behrend H, Giesinger K, Giesinger JM, Kuster MS. The "forgotten joint" as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure. The Journal of arthroplasty 27(3): 430, 201227. Ware J, Jr., Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical care 34(3): 220, 199628. Riddle DL, Stratford PW, Bowman DH. Findings of extensive variation in the types of outcome measures used in hip and knee replacement clinical trials: a systematic review. Arthritis and rheumatism 59(6): 876, 200829. van Dijk GM, Veenhof C, Lankhorst GJ, Dekker J. Limitations in activities in patients with osteoarthritis of the hip or knee: the relationship with body functions, comorbidity and cognitive functioning. Disability and rehabilitation 31(20): 1685, 200930. Marks R, Allegrante JP. Comorbid disease profiles of adults with end-stage hip osteoarthritis. Medical science monitor : international medical journal of experimental and clinical research 8(4): CR305, 200231. van Dijk GM, Veenhof C, Schellevis F, Hulsmans H, Bakker JP, Arwert H, Dekker JH, Lankhorst GJ, Dekker J. Comorbidity, limitations in activities and pain in patients with osteoarthritis of the hip or knee. BMC musculoskeletal disorders 9: 95, 200832. Davis AM, Agnidis Z, Badley E, Kiss A, Waddell JP, Gross AE. Predictors of functional outcome two years following revision hip arthroplasty. The Journal of bone and joint surgery American volume 88(4): 685, 200633. Froud R, Patterson S, Eldridge S, Seale C, Pincus T, Rajendran D, Fossum C, Underwood M. A systematic review and meta-synthesis of the impact of low back pain on people's lives. BMC musculoskeletal disorders 15: 50, 201434. Moore JE. Chronic low back pain and psychosocial issues. Physical medicine and rehabilitation clinics of North America 21(4): 801, 201035. Trivedi MH. The link between depression and physical symptoms. Primary care companion to the Journal of clinical psychiatry 6(Suppl 1): 12, 200436. Judge A, Javaid MK, Arden NK, Cushnaghan J, Reading I, Croft P, Dieppe PA, Cooper C. Clinical tool to identify patients who are most likely to achieve long-term improvement in physical function after total hip arthroplasty. Arthritis care & research 64(6): 881, 201237. Parvizi J, Pour AE, Hillibrand A, Goldberg G, Sharkey PF, Rothman RH. Back pain and total hip arthroplasty: a prospective natural history study. Clinical orthopaedics and related research 468(5): 1325, 2010

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38. Esola MA, McClure PW, Fitzgerald GK, Siegler S. Analysis of lumbar spine and hip motion during forward bending in subjects with and without a history of low back pain. Spine 21(1): 71, 199639. Blizzard DJ, Nickel BT, Seyler TM, Bolognesi MP. The Impact of Lumbar Spine Disease and Deformity on Total Hip Arthroplasty Outcomes. The Orthopedic clinics of North America 47(1): 19, 201640. Ong KL, Lau E, Suggs J, Kurtz SM, Manley MT. Risk of subsequent revision after primary and revision total joint arthroplasty. Clinical orthopaedics and related research 468(11): 3070, 2010

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Table 1 Patient characteristics (N = 251)

female sex, N (%) 146 (58.2)

Age, years (SD) 67.7 (11.8)

left side, N (%) 130 (52.6)

CCI, N (%)

Myocardial infarction 10 (4.1)

Congestive heart failure 1 (0.4)

Peripheral vascular disease 4 (1.7)

Cerebrovascular disease 0

Dementia 3 (1.2)

COPD 9 (3.8)

Connective tissue disease 29 (12.1)

Peptic ulcer 1 (0.4)

Mild liver disease 8 (3.2)

Diabetes with or without endstage damage 14 (5.6)

Hemiplegia 8 (3.2)

Moderate or severe renal disease 6 (2.4)

Tumor with or without metastasis 3 (1.2)

Leukemia (acute or chronic) 0

Lymphoma 0

Moderate or severe liver disease 8 (3.2)

AIDS 2 (0.8)

Pain, N (%) Low back pain 135 (55.1)

Pain from other joints 180 (75.9)

BMI, N (%) Non-obese (BMI<30) 141 (65.0%)

Obese (BMI>=30) 76 (35.0%)

Missing 34

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Table 2: Impact of CCI comorbidities on FJS-12 and OHS outcomes

OHS FJS-12

Pre-surgery 1-Year Follow-up Change over time Pre-surgery 1-Year Follow-up

Mean (95%CI) Mean (95%CI) Mean (95%CI) Mean (95%CI) Mean (95%CI)

CCI comorbidity

no 22.0 (20.7 to 23.3) 39.9 (38.6 to 41.3) 17.9 (16.5 to 19.4) 13.2 (10.9 to 15.6) 56.4 (51.6 to 61.2)

yes 19.3 (17.1 to 21.4) 34.8 (32.6 to 37.0) 15.6 (13.1 to 18.0) 10.4 (6.4 to 14.5) 49.2 (41.1 to 57.2)

Group difference:

mean (95%CI) -2.7 (-5.3 to -0.2) -5.1 (-7.7 to -2.5) -2.8 (-7.5 to 1.8) -7.2 ( -16.7 to 2.2)

Factor: Time Factor: GroupInteraction

GroupXTime Factor: Time Factor: Group

F- statistic 549.031 12.984 2.723 274.894 3.123

p- value <0.001 <0.001 0.100 <0.001 0.078

CCI = Charlson Comorbidity Index

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Table 3 Impact of Low Back Pain on FJS-12 and OHS outcomes

OHS FJS-12


Mean (95%CI) Mean (95%CI)Mean

(95%CI) Mean (95%CI) Mean (95%CI)

LBP

no 24.1 (22.5 to 25.7) 42.0 (40.4 to 43.7) 17.9 (16.0 to 19.8) 16.0 (13.0 to 19.0) 65.2 (59.1 to 71.3)

yes 18.9 (17.5 to 20.4) 35.4 (33.9 to 36.9) 16.5 (14.8 to 18.2) 9.8 (7.1 to 12.4) 45.3 (40.0 to 50.6)

Group difference:

mean (95%CI) -5.2 (-7.4 to -3.0) -6.6 (-8.9 to -4.4) -6.3 (-10.3 to -2.2) -19.9 (-27.9 to -11.8)



F-statistic 701.578 41.008 1.245 385.466 29.324

p-value <0.001 <0.001 0.266 <0.001 <0.001

LBP = Low Back Pain

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Table 4 Impact of Pain from other joints on FJS-12 and OHS outcomes

OHS



POJ

no 23.7 (21.3 to 26.0) 40.3 (37.8 to 42.8) 16.6 (14.0 to 19.3) 17.7 (13.6 to 21.8) 62.7 (53.9 to 71.6)

yes 20.3 (19.0 to 21.6) 37.7 (36.3 to 39.0) 17.3 (15.9 to 18.8) 10.8 (8.5 to 13.1) 50.7 (45.9 to 55.4)

Group difference:

mean (95%CI) -3.3 (-6.0 to -0.7) -2.6 (-5.5 to 0.2) -6.9 (-11.6 to -2.2) 12.1 (-22.1 to -2.0)

Factor: Time Factor: GroupInteraction GroupXTime Factor: Time Factor: Group

F-statistic 492.384 6.507 0.213 260.460

p-value <0.001 0.011 0.645 <0.001

POJ = Pain from other joints

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Table 5 Impact of BMI on FJS-12 and OHS outcomes

OHS FJS-12



BMI

BMI <30

22.1 (20.6 to

23.5)39.2 (37.6 to 40.8)

17.2 (15.5 to 18.3) 13.1 (10.6 to 15.6) 54.1 (48.5 to

BMI ≥30

19.3 (17.4 to

21.3)36.6 (34.5 to 38.8)

17.3 (15.0 to 19.6) 9.8 ( 6.4 to 13.2) 52.8 (45.2 to 60.4)

Group difference:

Mean (95%CI) -2.7 (-5.2 to -0.3) -2.6 (-5.3 to 0.1) -3.3 (-7.5 to 0.9) -1.3 (-10.8 to 8.2)



F-statistic 274.894 3.123 0.807 287.786 0.696

p-value <0.001 0.078 0.370 0.001 0.405

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Table 6 Impact of Comorbidity (CCI), low back pain, pain from other Joints and BMI on SF-12 outcomes at 1-year follow-up

Comorbidty (CCI) Low back pain Pain from other joints

no yes no yes no yes

SF-12 PCSMean

(95% CI)

44.9

(43.4 to 46.5)

39.1

(36.4 to 41.9)

50.0

(46.3 to 49.6)

39.2

(37.4 to 41.1)

46.8

(44.3 to 49.2)

42.0

4(0.3 to 43.6) (42.4 to 45.8)

T-statistic; p-value 3.778; <0.001 6.848; <0.001 3.149; 0.002

SF-12 MCS

Mean

(95% CI)

48.6

(47.5 to 49.7)

46.5

(44.5 to 48.5)

49.4

(48.1 to 50.7)

46.8

(45.4 to 48.2)

48.7

(46.7 to 50.6)

47.8

(46.6 to 48.9) (46.9 to 49.4)

T-statistic; p-value 1.909; 0.057 2.677; 0.008 0.732; 0.465

PCS=Physical Component Score; MCS=Mental Component Score

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Figures

Figure 1

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Figure 2

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Figure 3

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