Psychological, Sexually and Social Consequences of Osteoarthritis Treatment With THA or TKA and Joint Preserving Surgery
Condition: Osteoarthritis; Depression; Hip Dysplasia
MeSH terms: Osteoarthritis; Hip Dislocation; Developmental Dysplasia of the Hip; Hip Dislocation, Congenital
Study type: Observational

Summary: 
      The project runs as a Ph.d. project at the Faculty of Health Sciences- University of
      Copenhagen.

      In Denmark the investigators operate around 16.000 artificial hips and knees yearly, mainly
      due to osteoarthritis. The numbers has increased with 13,9% for hips and 50,7% for knees in
      the period 2004 to 2007. In 10% of the cases, or approximately 1.600 patients, the patient is
      younger than 50 years - mid-life, working, socially active and sexually active. The
      investigators have a tendency within in the orthopedic society to mainly focus on the
      technological aspects of the procedure and tend to forget that this is a key event for the
      patient with widespread consequences for the patient and his future life.

      Hip- and knee arthroplasties is without no doubt two of the most important and successfully
      surgical procedures ever introduced. The economical cost for osteoarthritis treatment has
      exploded in the developed world over the last decade, with a yearly growth on 8%.

      Because of the limited lifetime for an artificial hip or knee, this treatment can be
      unfortunate for the young patient. This has over the last years led to an increased interest
      for joint preserving surgery. Over the last twenty years it has been tried to delay the time
      for total hip arthroplasties for patients with hip dysplasia with the aid of Ganz osteotomy.
      Since this technique was introduced back in 1988, the research on the topic has had its main
      focus on optimizing the operation technique. So as with surgery with artificial hip or knee
      the investigators have a lack of knowledge regarding the social, work related, psychological
      and sexual aspects of this treatment.

      Purpose The consequences of an artificial hip or knee joint regarding patients' social-life,
      work, psychological and sexual aspects gain very little attention international. The
      investigators apply most of our research funds exclusively to research and development of the
      surgical track and procedure, new prosthesis designs or coatings. The investigators find this
      study highly relevant because this kind of studies has been preformed for several chronic
      diseases but not osteoarthritis and its treatment.

      With this study the investigators wish to examine the social, work related, psychological and
      sexual aspects of end stage osteoarthritis. This will lead the way for improved information
      to the patient and improve the surgeons' possibilities for chosen the correct time for
      surgery.
    

Detailed description: 
      In Denmark approximately 16.000 artificial hips or knees are inserted yearly. A increasing
      number that probably will continue to increase due to demographic factors and the populations
      rising demands on a active life in the old age. However of the 16.000 artificial joints
      approximately 10% are inserted in patients under fifty years(1;2). This group of patients is
      mid-life and thereby for most parts working and socially- and sexually active.

      Total hip arthroplasty(THA) or total knee arthroplasty(TKA) is unquestionably one of the most
      successfully operations there has been introduced, and is capable of relieving pain,
      optimizing the function of the joint and optimizing the quality of life(3;4). In the resent
      years the main focus has been on optimizing the surgical track, whereby most of the patient
      today are only admitted to the hospital in 1-2 days. This progress has had a tremendous
      impact on patients, the departments and the health care system. Joint replacement surgery
      with THA or TKA is a key event for the patient and can recreate the patient's mobility but as
      well has widespread (but still undocumented) consequences for the patient and his future
      life.

      In the preoperative treatment and planning of the correct time of surgery, it is imported to
      know, how the patient is affected of a disabling joint disease like end-stage
      osteoarthritis(OA) and which consequences it has to the patient to have an artificial joint.
      It is known, that patients with OA has a two-fold increased risk of depression(8-13).

      These aspects of the treatment has so far not had the desirable attention, neither national
      or international At Hvidovre Hospital, Frederiksberg Hospital and Køge Hospital the
      Orthopaedic departments has many years of experience with joint replacement surgery at
      specialist level. The structures of the departments are based on modern fast-track
      principals, with clearly defined goals for preoperative information, pre- and postoperative
      regimes and discharged criteria. Thereby insuring a smooth course, short rekonvalens and a
      minimizing of complications.

      Because of the limited lifetime for an artificial hip or knee, this treatment can be
      unfortunate for the young patient. This has over the last years led to an increased interest
      for joint preserving surgery. Over the last twenty years it has been tried to delay the time
      for total hip arthroplasties for patients with hip dysplasia with the aid of Peri Acetabular
      Osteotomy(PAO). Hip dysplasia is seen equally in both sexes. However it is more often
      symptomatic in females(14). In Denmark PAO is performed at Copenhagen University Hospital,
      Odense University Hospital and Aarhus University Hospital. The procedure is preformed on
      symptomatic (mainly sharp groin pain) patients in hope of delaying the development of OA.
      Femoroacetabular impingement (FAI) is believed to be the pathology, where repeated trauma to
      the acetabular labrum and adjacent chondral structures can result in labral tears and
      chondral delamination, leading to groin pain and over time OA. However there are only a few
      minor studies concerning which impact this procedure has on the young patients life in term
      of psychological, sexually and social wellbeing.

      Patients included are both men and women from twenty to sixty years old who are admitted to
      undergo primary uni- or bilateral THA or TKA at Hvidovre Hospital, Frederiksberg Hospital or
      Køge Hospital as a result of end-stage OA, rheumatoid arthritis or another joint disease
      diagnosed by one of the departments doctors with specialty in joint replacement surgery. The
      included patients in the PAO study has all had PAO at Aarhus University Hospital between
      1999-2002 and were at the age of fifteen or more at the time of surgery. To avoid
      co-morbidity confounders the joint disease has to be the only main disease.

      The goal of the study is to investigate:

        1. What are the Health-Related-Quality-Of-Life(HRQoL) consequences of end-stage hip or knee
           OA? The investigators will examine this with SF-36, a standardized and validated
           questionnaire that explores HRQOL.

        2. What is the relation between the pre- and postoperative joint function and the patients
           HRQoL, and do this relation reflects the patient's social class and attachment to the
           workforce.

        3. Which preoperative parameters have the strongest relation on the postoperative out-come?
           The highly nuanced picture the investigators get of the patients pre- and postoperative
           condition will enable us to answer this question.

        4. How is the patient's relation to the workforce-affected by the patient's joint disease
           and operation? Are the investigators able to operate the patient back in work? Do the
           patient lose he's job because of the operation? Do the patient's with a job preoperative
           keep their job will those without a job preoperative do not recover their working
           ability because of the operation?

        5. It is known that patients with OA has a two fold increased risk of depression. Is the
           depression due to the patients underlying disease? Or is the depression due to
           modulations in pain perception which lead to a lower pain threshold that again leads to
           the increased prevalence of symptomatic OA? If the THA or TKA is curative for the
           patient's depression, the investigators may assume that the depression is due to the
           patients disabling disease and vice versa.

        6. It is known that patients with hip OA experience sexual-problems. How is this affected
           by joint replacement surgery? A Danish study has shown that older men -average age 70
           years- who receives a THA has a highly increased risk of postoperative impotence -26%
           compared to the expected 3% for an age matched group. Other studies have shown that
           females experience an improvement of there sexual-life after THA. Unfortunately, there
           are only quite few and small studies concerning these subjects. The investigators wish
           to explore these subjects and the similar subjects for TKA, this has not previously been
           explored.

        7. Over the last three decades there has been an increasing focus on joint preserving
           surgery, mainly in the form of PAO. This procedure is preformed on public hospitals in
           Aarhus University Hospital, Odense University Hospital and Copenhagen University
           Hospital. Aarhus University Hospital holds the leading experience in Denmark and
           performs approximately 75 procedures a year. However there is now documentation on how
           this procedure affects the patients HRQoL or sexual-life.

      The main part of this study runs as a prospective questionnaire based study of the patients,
      which are having a THA or TKA at Hvidovre University Hospital, Frederiksberg University
      Hospital and Køge Hospital. A smaller part of the study is a retrospective questionnaire
      based study of the patients, which in the period 1999-2002 underwent PAO at Aarhus University
      Prior to planned surgery with THA or TKA the patient receive a questionnaire. This will be
      followed by a questionnaire 3, 6 and 12 months postoperative. Twelve months postoperative the
      patient will have and ambulatory control.

      The patients who underwent PAO at Aarhus University Hospital in the period 1999-2002 are
      posted a questionnaire.

      The inclusions of patients started April 2010 and runs at least to the summer of 2011 or when
      at least 250 patients are included.

      The results are expected to be published in international English language journals and the
      research and findings will be defended as a PhD ad the Faculty of Health Sciences- University
      of Copenhagen.

      Purposes of the study:

      Primary purpose:

      To investigate how end-stage OA and joint replacement surgery affects the patients HRQoL and
      herby which impact this procedure has on the young patients life in term of psychological,
      sexually and social wellbeing. Next the investigators wish to investigate how the patients'
      attachment to the workforce is affected bye end-stage OA and joint replacement surgery

      Secondary purpose:

      To investigate how patients with other disabling joint diseases with need for joint
      replacement surgery is affected as described above.

      Tertiary purpose:

      Edification of a database to reveal complications over years for this well-defined young
      patient population, who has a higher demand to there prosthesis and as a consequence put them
      to a higher stress.

      Other purposes:

      To investigate which impact PAO has on the young patients life in term of HRQoL,
      psychological, sexually and social wellbeing.
    

Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Young adults undergoing TKA/THA/PAO with now other major health complications.
      
Keywords: Total knee arthroplasty; Total hip arthroplasty; Peri acetabular osteotomy; Social class; Health related quality of life