Steffen Jacobsen

Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: Fast-track experience in 712 patients

Background and purposeu2003Very few studies have focused on patient characteristics that influence length of stay (LOS) in fast-track total hip (THR) and knee arthroplasty (TKR). The aim of this prospective study was to identify patient characteristics associated with LOS and patient satisfaction after total hip and knee replacement surgery. Patients and methodsu2003Between September 2003 and December 2005, 712 consecutive, unselected patients (440 women) with a mean age of 69 (31–91) years were admitted for hip and knee replacement surgery at our specialized fast-track joint replacement unit. Epidemiological, physical, and perioperative parameters were registered and correlated to LOS and patient satisfaction. Resultsu200392% of the patients were discharged directly to their homes within 5 days, and 41% were discharged within 3 days. Age, sex, marital status, co-morbidity, preoperative use of walking aids, pre- and postoperative hemoglobin levels, the need for blood transfusion, ASA score, and time between surgery and mobilization, were all found to influence postoperative outcome in general, and LOS and patient satisfaction in particular. Interpretationu2003We identified several patient characteristics that influence postoperative outcome, LOS, and patient satisfaction in our series of consecutive fast-track joint replacement patients, enabling further attention to be paid to certain aspects of surgery and rehabilitation.

Prevalence of malformations of the hip joint and their relationship to sex, groin pain, and risk of osteoarthritis: a population-based survey.

BACKGROUNDnAlthough the clinical consequences of femoroacetabular impingement have been well described, little is known about the prevalence of the anatomical malformations associated with this condition in the general population, the natural history of the condition, and the risk estimates for the development of osteoarthritis.nnnMETHODSnThe study material was derived from a cross-sectional population-based radiographic and questionnaire database of 4151 individuals from the Copenhagen Osteoarthritis Substudy cohort between 1991 and 1994. The subjects were primarily white, and all were from the county of Østerbro, Copenhagen, Denmark. The inclusion criteria for this study were met by 1332 men and 2288 women. On the basis of radiographic criteria, the hips were categorized as being without malformations or as having an abnormality consisting of a deep acetabular socket, a pistol grip deformity, or a combination of a deep acetabular socket and a pistol grip deformity. Hip osteoarthritis was defined radiographically as a minimum joint-space width of <or=2 mm.nnnRESULTSnThe male and female prevalences of hip joint malformations in the 3620 study subjects were 4.3% and 3.6%, respectively, for acetabular dysplasia; 15.2% and 19.4% for a deep acetabular socket; 19.6% and 5.2% for a pistol grip deformity; and 2.9% and 0.9% for a combination of a deep acetabular socket and pistol grip deformity. The male and female prevalences of a normal acetabular roof were 80.5% and 77.0%. We found no significantly increased prevalence of groin pain in subjects whose radiographs showed these hip joint malformations (all p > 0.13). A deep acetabular socket was a significant risk factor for the development of osteoarthritis (risk ratio, 2.4), as was a pistol grip deformity (risk ratio, 2.2). Acetabular dysplasia and the subjects sex were not found to be significant risk factors for the development of hip osteoarthritis (p = 0.053 and p = 0.063, respectively). The prevalence of hip osteoarthritis was 9.5% in men and 11.2% in women. The prevalence of concomitant malformations was 71.0% in men with hip osteoarthritis and 36.6% in women with hip osteoarthritis.nnnCONCLUSIONSnIn our study population, a deep acetabular socket and a pistol grip deformity were common radiographic findings and were associated with an increased risk of hip osteoarthritis. The high prevalence of osteoarthritis in association with malformations of the hip joint suggests that an increased focus on early identification of malformations should be considered.

The prevalence of cam-type deformity of the hip joint: a survey of 4151 subjects of the copenhagen osteoarthritis study:

Background: Cam deformity is a preosteoarthritic malformation causing premature hip-joint degeneration. While the pathogenetic pathway from deformity to osteoarthrosis (OA) has been well established, almost nothing is known of the malformations epidemiology. Purpose: To determine the distribution of cam deformity in a large, unselected cohort from standardized anteroposterior (AP) pelvic radiographs. Material and Methods: The distribution of cam deformity was assessed in 3202 (1184 male, 2018 female) standardized AP pelvic radiographs using the triangular index (TI) and the α angle. The relationships between cam malformation and self-reported hip pain were evaluated, and the relative importance of known risk factors for cam malformation estimated. Results: We found a pronounced sex-related difference in cam-deformity distribution. The overall prevalence of cam deformity was approximately 17% in men and 4% in women. The distribution of cam deformity was unaltered in subjects with normal joint-space width or other features of hip-joint degeneration. We found no significant association with self-reported hip pain, nor did we find any relative importance of possible risk factors for hip deformity, such as body-mass index (BMI), occupational exposure to heavy workloads, or concomitant acetabular dysplasia. Conclusion:The results lend support to the thesis that cam deformity represents a silent slipped capital epiphysis, predominantly in men, and that it is a far from uncommon deformity in subjects with no apparent evidence of hip-joint osteoarthritis.

Hip dysplasia and osteoarthrosis: A survey of 4 151 subjects from the osteoarthrosis substudy of the Copenhagen city heart study

Introduction Hip dysplasia (HD) is assumed to be an etiological factor in the development of premature hip osteoarthrosis (OA). We established the prevalences of HD and OA in adults according to qualified radiographic discriminators, and investigated the relationship between HD and OA. Methods Wiberg′s CE angle (CE), Sharp′s angle, the femoral head extrusion index, the acetabular depth ratio (ADR), the radiographic OA discriminators of Croft, and of Kellgren and Lawrence, and also minimum joint space width (JSW) ≤ 2 mm were applied to the standing, standardized pelvic radiographs of 1 429 men (22-93 years), and 2 430 women (22-92 years). Results The 4 HD discriminators were interrelated. A negligible sex-related difference in acetabular morphology was found, male acetabulae being slightly more dysplastic than female acetabulae. However, differences between the sexes for right and left CE angles were within 1.0°, and within 1.4° for right and left Sharp′s angles. There were no cases of hip subluxation (breakage of Shenton′s line ≥ 5 mm). Average CE angle was 34° in men (SD 7.3°), and 35° in women (SD 7.6°). Applying a CE cut-off value of 20° for designation of definite hip dysplasia, we found a prevalence of hip dysplasia of 3.4%. Approximately 2% of cases were unilateral and 1.4% of cases were bilateral. We found significant relationships between radiographic OA discriminators and the CE angle, femoral head extrusion index and ADR. Odds ratios ranged from 1.0 to 6.2. Compared to subjects with OA in morphologically normal hips, a trend towards younger age in subjects with HD and OA was noted, but this was not strictly significant. Interpretation We found that HD is not uncommon in the general population. The assumption that HD is an etiological factor in the development of hip OA was confirmed.

Radiographic case definitions and prevalence of osteoarthrosis of the hip: a survey of 4 151 subjects in the Osteoarthritis Substudy of the Copenhagen City Heart Study.

Background The diagnosis of osteoarthrosis (OA) is founded on radiographic evidence of joint degeneration and characteristic subjective symptoms. Due to the lack of consensus radiographic case definitions, the prevalence and incidence of OA reported in the literature varies. The aims of the current study were to establish an accurate and workable radiographic definition of OA in hip joints and to examine the association of OA (thus defined) with self-reported pain. Methods Radiographic features of hip OA were classified in pelvic radiographs of 3 807 subjects (1 448 males and 2 359 females) according to the OA classifications of Kellgren and Lawrence (1957) and Croft (1990), and according to minimum joint space width (JSW) of 2.0 mm regardless of other radiographic features of OA. The relationships between these radiographic discriminators and self-reported hip pain were investigated. Results Formation of cysts, osteophytes and subchondral sclerosis was significantly more frequent in men. Average minimum JSW was narrower in women than in men (pu2009<u20090.001). In both sexes, minimum JSW decreased after the fourth decade of life, but progressively more so in women. Women reported hip pain more frequently than men (pu2009<u20090.001). When the cut-off JSW value of 2.0 mm was applied regardless of other radiographic features of OA, prevalences of hip OA ranged from 4.4% to 5.3% in subjectsu2009≥u200960 years of age. The radiographic discriminator with the strongest association with self-reported hip pain in men and womenu2009≥u200960 years of age was minimum JSWu2009≤u20092.0 mm; OR =u20093.3 (95% CI 1.9u2009−u20095.7) for men, and ORu2009=u20093.2 (95% CI 1.9u2009−u20095.2) for women. Interpretation We found that minimum JSWu2009≤u20092.0 mm was the radiographic criterion having the closest association with self-reported hip pain. Using composite OA scores emphasizing the relatively inconsequential formation of cysts, osteophytes and subchondral sclerosis runs the risk of over-inflating the prevalence of hip OA in men and of underestimating hip OA prevalence in women.

Pelvic orientation and assessment of hip dysplasia in adults

Background The study was performed to qualify the source material of 4 151 pelvic radiographs for the research into the relationship between unrecognised childhood hip disorders and the development of hip osteoarthrosis, and to investigate the effect of varying degrees of pelvic tilt and rotation on the measurements of radiographic indices of hip dysplasia. Material and methods We investigated the effect of varying pelvic orientation on radiographic measurements of acetabular dysplasia using a cadaver model. Results from the cadaver study were used to validate the radiographic assessments of acetabular dysplasia in the longitudinal survey cohort of the Copenhagen City Heart Study (CCHS; Osteoarthrosis Sub-study). 1) Cadaver pelvises and proximal femurs from a male and a female donor were mounted anatomically in holding devices allowing independent inclination/reclination and rotation. An AP pelvic radiograph was recorded at each 3° increment. The most widely used radiographic parameters of hip dysplasia were assessed. 2) Critical limits of acceptable rotation and inclination/reclination of pelvises were determined on 4 151 standing, standardised pelvic radiographs of the CCHS cohort. Results Wibergs CE angle, Sharps angle, the xcoordinate of Goodmans Cartesian coordinate system, and the acetabular depth ratio were significantly affected by varying rotation and inclination/reclination of the cadaver pelvises. Femoral head extrusion index was not significantly affected within the applied rotation and inclination/reclination of the cadaver study. Application of the corresponding critical limits of Tönnis’ foramen obturator index of 0.7–1.8 meant that 188 of 4 151 (4.5%) of the CCHS-III pelvic radiographs had to be omitted from further studies. Interpretation To ensure a neutral starting point and reproducible readings, especially in epidemiological and clinical studies, and when performing preoperative planning and follow-up of patients undergoing redirectional pelvic osteotomies, it is important that all aspects of the radiographic examination are controlled and reproducible. Furthermore, we found that studies of acetabular dysplasia based on supine urograms or colon radiographs without information about pelvic orientation, centering of the X-ray beam and tube to film distance, run a serious risk of erroneous measurements.

Degeneration in dysplastic hips. A computer tomography study.

BackgroundHip dysplasia is considered pre-osteoarthritic, causing degeneration in young individuals.ObjectiveTo determine the pattern of degenerative change in moderate to severely dysplastic hips in young patients.Design and patientsOne hundred and ninety-three consecutively-referred younger patients with hip pain believed to be caused by hip dysplasia constituted the study cohort. The average age was 35.5 years (range, 15–61 years). They were examined by close-cut transverse pelvic and knee computed tomography and antero-posterior radiographs (CT). We identified 197 hips with moderate to severe dysplasia, and 78 hips with normal morphology in the study cohort, whilst 111 hip joints were borderline dysplastic according to preset definitions. Comparative analyses of anatomy and distribution of degeneration between dysplastic and normal hips in the study cohort were performed.ResultsIn dysplastic hips the anterior acetabular sector angle was significantly and inversely associated to femoral anteversion (p<0.001). The center-edge (CE) angle, the acetabular angle (AA), and the acetabular depth ratio (ADR) were significantly interrelated (p<0.001; correlation coefficients ranging from −0.8 to 0.7). Fifty-one hips were subluxated (24R/27L). There were no cases of complete dislocation. The formation of subchondral cysts or osteophytes in dysplastic hips was significantly associated with reduced minimum joint space width (p ranging from 0.005 to 0.02). However, in 67 hips with acetabular cysts, only 6 hips had minimum joint space widths =2.0xa0mm (8.9%) in the coronal plane. In 96 cases with acetabular cysts found in the sagittal plane, 43 cases had minimum joint space widths =2.0xa0mm (44.7%). Bony rim detachment at the site of labral insertion was recorded in 30 hips. Twenty-three of these were dysplastic (p=0.01).ConclusionsDegeneration was most often found in the anterolateral part of the dysplastic hip joints. Most cysts were located above the transition zone between the bony and the fibrocartilaginous acetabulum, and we found a significantly- increased number of cases with avulsed bony fragments at the antero-lateral labral insertion in dysplastic hips compared to normal hips. It seems likely that the early degenerative process in dysplastic hips originates at the watershed zone between the acetabular labrum and the acetabular cartilage in response to subluxation and femoroacetabular impingement.

Case definitions of knee osteoarthritis in 4,151 unselected subjects: relevance for epidemiological studies: the Copenhagen Osteoarthritis Study.

IntroductionThe aims of the present study were threefold: to examine the distribution of knee joint osteoarthritis in a large, standardized radiological study; to examine the relationships between self reported knee pain and radiological OA; and to examine the natural history of radio-morphological change over age in individuals without radiological features of OA.Materials and MethodsThe Copenhagen Osteoarthritis Study – COS is a substudy of the Copenhagen City Heart Study, a longitudinal regional health survey. From the third inclusion of the CCHS (1992–1994) 4,151 subjects were selected for subsequent standardized radiography of the pelvis, the knees, the hands, the wrists, and the lumbar spine. Images were analyzed and knee joint osteoarthritis (OA) was classified according to the radiographic atlas of Kellgren and Lawrence. Joint space width (JSW) was measured at three sites within both the medial and the lateral compartment.ResultsFor the entire cohort the prevalence of radiological knee joint OA of all grades was 38.7% for men and 44.2% for women. Age stratification documented increasing knee joint OA both in regard to prevalence and morphological severity. Knee pain was universally correlated to the Kellgren and Lawrence severity of OA. In a subgroup with no features of radiological OA, a significant and linear decline in JSW with increasing age was found.ConclusionWe found a clear relationship between self-reported knee pain and radiological osteoarthritis. Pain was proportionally related to the severity of change. We also demonstrated a significant diminishing of joint space width with increasing age in individuals without apparent radiological degeneration.

The GSB III elbow prosthesis in rheumatoid arthritis: A 2- to 9-year follow-up

Backgroundu2003The optimal design of an elbow prosthesis for badly damaged elbows is unkown. We evaluated 23 GSB III semi-constrained (sloppy-hinged) total elbow arthroplasties in 16 consecutive patients with rheumatoid arthritis. Patients and methodsu2003After a mean follow-up period of 5 (2–9) years, we assessed quality of the cementing technique, signs of aseptic loosening, patient satisfaction, range of movement, and determined the Hospital for Special Surgery (HSS) elbow score. 3 patients had died before follow-up; thus, 20 replacements in 16 patients were available for clinical and radiographic study. All patients had endstage rheumatoid arthritis (RA) of the elbow joint. Resultsu2003In 2 patients, humeral components were revised due to malorientation. 1 arthroplasty was revised due to aseptic loosening of the humeral component. There were 4 cases of intraoperative fracture which healed uneventfully. The total rate of complications was thus one-third. In 17 of 40 components, the cementing technique was rated as marginal or inadequate. We found no association between cementing technique and loosening. The arc of extension/flexion increased by 19° (0–80), and the range of pronation/supination increased by 31° (0–130). There were no cases of infection or ulnar nerve dysfunction. At the latest follow-up, the HSS elbow score was 84 (40–100) points. 11 of 20 elbows were rated as excellent, 4 elbows were rated as good, 2 elbows were rated as fair, and 3 elbows were rated as poor. 14 of 16 patients were satisfied with the result and the 2 patients who were not satisfied had persistent pain. Interpretationu2003Despite the inherent problems of cementing in small-calibre medullary cavities, the clinical outcome of the GSB III arthroplasty was encouraging for patients with-end stage RA. The rate of overall complications compared favorably with other studies of semiconstrained elbow arthroplasty for end-stage RA. Most complications of the series were minor and did not necessitate revision.u2003▪

Lumbar spondylolysis: a life long dynamic condition? A cross sectional survey of 4.151 adults

Lumbar spondylolysis (LS) has been the subject of several studies focusing on adolescent athletes. Few, if any, studies have examined LS in the general population. Lysis of the pars interarticularis of the vertebra may be associated with slipping (olisthesis), or it may be stable. In the present survey of lumbar radiographs and general epidemiological data recorded from the Copenhagen Osteoarthritis Study cohort of 4.151 subjects (age range, 22–93xa0years), we identified the distribution and individual risk factors for LS-development. Men were significantly more at risk of L5 spondylolysis (Pxa0=xa00.002). There were no sex-specific significant differences regarding LS-incidence at the L4 level. We found no significant differences of risk of LS between nulliparous or multiparous women (L4 Pxa0=xa00.54/L5 Pxa0=xa00.35). Furthermore, we found no significant relationship between age at menopause and LS-development. Increased lumbar lordosis was associated to L4/L5 spondylolysis in men (L4 Pxa0<xa00.001/L5 Pxa0=xa00.008). In women increased lumbar lordosis had a significant association with L5 spondylolysis (Pxa0<xa00.001). Increased pelvic inclination was associated with L5 spondylolysis in both men and women (Pxa0<xa00.001). There were no sex-specific differences regarding the occurrence of simultaneous slips/non-slips. In men, no individual risk factors for L4 slips with concomitant LS were found. In women slipped LS of L4 were significantly associated to aging (Pxa0<xa00.001) and with decreased pelvic inclination (Pxa0=xa00.001). In men slipped LS of L5 was significantly associated to increased BMI (Pxa0=xa00.002), but not to aging (Pxa0=xa00.10). In women, slips of L5 LS were significantly correlated to aging (Pxa0=xa00.005), to BMI recorded at the time of radiographic examination (Pxa0=xa00.006), and BMI measured 17xa0years before radiographic index examination (Pxa0=xa00.004). The present study contrasts with commonly held views regarding lumbar spondylolysis. The prevalence of LS increases throughout life and is apparently not a condition restricted to adolescence. Although the cross-sectional nature of the present study prevents an exact estimate of the age at onset; future, sequential studies of the cohort may provide us with some important answers on this topic. Apart from aging–obesity, lordotic angle and pelvic inclination were found to be individual risk factors for LS.