Quality of Life Research

, Volume 24, Issue 12, pp 2917–2925 | Cite as

Clinical improvement and satisfaction after total joint replacement: a prospective 12-month evaluation on the patients’ perspective

  • Florian D. Naal
  • Franco M. Impellizzeri
  • Ulrich Lenze
  • Vanessa Wellauer
  • Rüdiger von Eisenhart-Rothe
  • Michael Leunig



To determine short-term improvements, satisfaction rates and the patient acceptable symptom state (PASS) after total joint replacement (TJR) for different patient-reported outcome measures (PROMs).


This prospective cohort study included 426 consecutive patients undergoing total hip (n = 193) or knee arthroplasty (n = 233). The following PROMs were completed before TJR, and at 3, 6 and 12 months after surgery, respectively: WOMAC, Oxford Hip or Knee Score, Lower Extremity Functional Scale, University of California at Los Angeles (UCLA) activity scale and EuroQol-5 dimension (EQ-5D). Satisfaction rates and the PASS thresholds were also assessed.


THA patients improved quicker and achieved higher outcome scores than TKA patients. Comorbidities according to the Sangha score were moderately correlated with all PROM values in an inverse direction at all time points (r = −0.27 to −0.47, p < 0.01) in both groups. Satisfaction with the result of surgery improved over time. At 12 months, more than 90 % of the patients were satisfied or very satisfied with the achieved result. The THA group showed a higher proportion of very satisfied patients than the TKA group at all time points. PASS thresholds increased over time for all PROMs except for the UCLA and the EQ-5D in TKA patients.


More than 90 % of the patients will be satisfied 1 year after TJR. THA patients recover faster than TKA patients, i.e., they achieve higher PROM values at earlier follow-up time points. Cutoff values defining a successful result in terms of the PASS could be defined for all PROMs at different time points and can serve as reference for future studies and patient-oriented follow-ups.


Total joint replacement Hip and knee arthroplasty Satisfaction PASS Patient-reported outcome 



The authors thank the Deutsche Arthrose-Hilfe e. V., Saarlouis, Germany, for funding this study.


  1. 1.
    Ethgen, O., Bruyere, O., Richy, F., Dardenne, C., & Reginster, J. Y. (2004). Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. Journal of Bone and Joint Surgery, 86, 963–974.PubMedGoogle Scholar
  2. 2.
    Kozma, C. M., Slaton, T., Paris, A., & Edgell, E. T. (2013). Cost and utilization of healthcare services for hip and knee replacement. Journal of Medical Economics, 16, 888–896.CrossRefPubMedGoogle Scholar
  3. 3.
    Kurtz, S., Ong, K., Lau, E., Mowat, F., & Halpern, M. (2007). Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. Journal of Bone and Joint Surgery, 89, 780–785.CrossRefPubMedGoogle Scholar
  4. 4.
    Pabinger, C., & Geissler, A. (2014). Utilization rates of hip arthroplasty in OECD countries. Osteoarthritis Cartilage, 22, 734–741.CrossRefPubMedGoogle Scholar
  5. 5.
    Duwelius, P. J., Moller, H. S., Burkhart, R. L., Waller, F., Wu, Y., & Grunkemeier, G. L. (2011). The economic impact of minimally invasive total hip arthroplasty. Journal of Arthroplasty, 26, 883–885.CrossRefPubMedGoogle Scholar
  6. 6.
    Goebel, S., Steinert, A. F., Schillinger, J., Eulert, J., Broscheit, J., Rudert, M., et al. (2012). Reduced postoperative pain in total hip arthroplasty after minimal-invasive anterior approach. International Orthopaedics, 36, 491–498.PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    King, J. C., Manner, P. A., Stamper, D. L., Schaad, D. C., & Leopold, S. S. (2011). Is minimally invasive total knee arthroplasty associated with lower costs than traditional TKA? Clinical Orthopaedics and Related Research, 469, 1716–1720.PubMedCentralCrossRefPubMedGoogle Scholar
  8. 8.
    Devane, P., Horne, G., & Gehling, D. J. (2013). Oxford hip scores at 6 months and 5 years are associated with total hip revision within the subsequent 2 years. Clinical Orthopaedics and Related Research, 471, 3870–3874.PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Tubach, F., Ravaud, P., Baron, G., Falissard, B., Logeart, I., Bellamy, N., et al. (2005). Evaluation of clinically relevant states in patient reported outcomes in knee and hip osteoarthritis: The patient acceptable symptom state. Annals of the Rheumatic Diseases, 64, 34–37.PubMedCentralCrossRefPubMedGoogle Scholar
  10. 10.
    Kvien, T. K., Heiberg, T., & Hagen, K. B. (2007). Minimal clinically important improvement/difference (MCII/MCID) and patient acceptable symptom state (PASS): What do these concepts mean? Annals of the Rheumatic Diseases, 66(Suppl 3), iii40–iii41.Google Scholar
  11. 11.
    Wells, G., Beaton, D., Shea, B., Boers, M., Simon, L., Strand, V., et al. (2001). Minimal clinically important differences: Review of methods. Journal of Rheumatology, 28, 406–412.PubMedGoogle Scholar
  12. 12.
    Stucki, G., Meier, D., Stucki, S., Michel, B. A., Tyndall, A. G., Dick, W., et al. (1996). Evaluation of a German version of WOMAC (Western Ontario and McMaster Universities) Arthrosis Index. Zeitschrift fur Rheumatologie, 1996(55), 40–49.Google Scholar
  13. 13.
    Naal, F. D., Impellizzeri, F. M., Sieverding, M., Loibl, M., von Knoch, F., Mannion, A. F., et al. (2009). The 12-item Oxford Knee Score: Cross-cultural adaptation into German and assessment of its psychometric properties in patients with osteoarthritis of the knee. Osteoarthritis Cartilage, 17, 49–52.CrossRefPubMedGoogle Scholar
  14. 14.
    Naal, F. D., Sieverding, M., Impellizzeri, F. M., von Knoch, F., Mannion, A. F., & Leunig, M. (2009). Reliability and validity of the cross-culturally adapted German Oxford hip score. Clinical Orthopaedics and Related Research, 467, 952–957.PubMedCentralCrossRefPubMedGoogle Scholar
  15. 15.
    Naal, F. D., Impellizzeri, F. M., Torka, S., Wellauer, V., Leunig, M., & von Eisenhart-Rothe, R. (2015). The German Lower Extremity Functional Scale (LEFS) is reliable, valid and responsive in patients undergoing hip or knee replacement. Quality of Life Research, 24, 405–410.CrossRefPubMedGoogle Scholar
  16. 16.
    Naal, F. D., Impellizzeri, F. M., & Leunig, M. (2009). Which is the best activity rating scale for patients undergoing total joint arthroplasty. Clinical Orthopaedics and Related Research, 467, 958–965.PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    Greiner, W., Claes, C., Busschbach, J. J., & von der Schulenburg, J. M. (2005). Validating the EQ-5D with time trade off for the German population. The European Journal of Health Economics, 6, 124–130.CrossRefPubMedGoogle Scholar
  18. 18.
    Dawson, J., Fitzpatrick, R., Carr, A., & Murray, D. (1996). Questionnaire on the perceptions of patients about total hip replacement. Journal of Bone and Joint Surgery, 78, 185–190.PubMedGoogle Scholar
  19. 19.
    Dawson, J., Fitzpatrick, R., Murray, D., & Carr, A. (1998). Questionnaire on the perceptions of patients about total knee replacement. Journal of Bone and Joint Surgery, 80, 63–69.CrossRefPubMedGoogle Scholar
  20. 20.
    Impellizzeri, F. M., Mannion, A. F., Leunig, M., Bizzini, M., & Naal, F. D. (2011). Comparison of the reliability, responsiveness, and construct validity of 4 different questionnaires for evaluating outcomes after total knee arthroplasty. Journal of Arthroplasty, 26, 861–869.CrossRefPubMedGoogle Scholar
  21. 21.
    Pua, Y. H., Cowan, S. M., Wrigley, T. V., & Bennell, K. L. (2009). The Lower Extremity Functional Scale could be an alternative to the Western Ontario and McMaster Universities Osteoarthritis Index physical function scale. Journal of Clinical Epidemiology, 62, 1103–1111.CrossRefPubMedGoogle Scholar
  22. 22.
    Ostendorf, M., van Stel, H. F., Buskens, E., Schrijvers, A. J., Marting, L. N., Verbout, A. J., & Dhert, W. J. (2004). Patient-reported outcome in total hip replacement. A comparison of five instruments of health status. Journal of Bone and Joint Surgery, 86, 801–808.CrossRefPubMedGoogle Scholar
  23. 23.
    Conner-Spady, B. L., Marshall, D. A., Bohm, E., Dunbar, M. J., Loucks, L., Khudairy, A. A., et al. (2015). Reliability and validity of the EQ-5D-5L compared to the EQ-5D-3L in patients with osteoarthritis referred for hip and knee replacement. Quality of Life Research. doi:  10.1007/s11136-014-0910-6.
  24. 24.
    Dakin, H., Gray, A., & Murray, D. (2013). Mapping analyses to estimate EQ-5D utilities and responses based on Oxford Knee Score. Quality of Life Research, 22, 683–694.PubMedCentralCrossRefPubMedGoogle Scholar
  25. 25.
    Pinedo-Villanueva, R. A., Turner, D., Judge, A., Raftery, J. P., & Arden, N. K. (2013). Mapping the Oxford hip score onto the EQ-5D utility index. Quality of Life Research, 22, 665–675.CrossRefPubMedGoogle Scholar
  26. 26.
    Murray, D. W., Fitzpatrick, R., Rogers, K., Pandit, H., Beard, D. J., Carr, A. J., & Dawson, J. (2007). The use of the Oxford hip and knee scores. Journal of Bone and Joint Surgery, 89, 1010–1014.CrossRefPubMedGoogle Scholar
  27. 27.
    Prieto, L., & Sacristan, J. A. (2004). What is the value of social values? The uselessness of assessing health-related quality of life through preference measures. BMC Medical Research Methodology, 4, 10.PubMedCentralCrossRefPubMedGoogle Scholar
  28. 28.
    Sangha, O., Stucki, G., Liang, M. H., Fossel, A. H., & Katz, J. N. (2003). The Self-Administered Comorbidity Questionnaire: A new method to assess comorbidity for clinical and health services research. Arthritis and Rheumatism, 49, 156–163.CrossRefPubMedGoogle Scholar
  29. 29.
    Youden, W. J. (1950). Index for rating diagnostic tests. Cancer, 3, 32–35.CrossRefPubMedGoogle Scholar
  30. 30.
    Casartelli, N. C., Item-Glatthorn, J. F., Bizzini, M., Leunig, M., & Maffiuletti, N. A. (2013). Differences in gait characteristics between total hip, knee, and ankle arthroplasty patients: A six-month postoperative comparison. BMC Musculoskelet Disord, 14, 176.PubMedCentralCrossRefPubMedGoogle Scholar
  31. 31.
    Bachmeier, C. J., March, L. M., Cross, M. J., Lapsley, H. M., Tribe, K. L., Courtenay, B. G., et al. (2001). A comparison of outcomes in osteoarthritis patients undergoing total hip and knee replacement surgery. Osteoarthritis Cartilage, 9, 137–146.CrossRefPubMedGoogle Scholar
  32. 32.
    Hamilton, D., Henderson, G. R., Gaston, P., MacDonald, D., Howie, C., & Simpson, A. H. (2012). Comparative outcomes of total hip and knee arthroplasty: A prospective cohort study. Postgraduate Medical Journal, 88, 627–631.CrossRefPubMedGoogle Scholar
  33. 33.
    Escobar, A., Gonzalez, M., Quintana, J. M., Vrotsou, K., Bilbao, A., Herrera-Espiñeira, C., et al. (2012). Patient acceptable symptom state and OMERACT-OARSI set of responder criteria in joint replacement. Identification of Cut-Off Values Osteoarthritis Cartilage, 20, 87–92.CrossRefPubMedGoogle Scholar
  34. 34.
    Liebs, T. R., Herzberg, W., Roth-Kroeger, M., Rüther, W., & Hassenpflug, J. (2011). Women recover faster than men after standard knee arthroplasty. Clinical Orthopaedics and Related Research, 469, 2855–2865.PubMedCentralCrossRefPubMedGoogle Scholar
  35. 35.
    Papakostidou, I., Dailiana, Z. H., Papapolychroniou, T., Liaropoulos, L., Zintzaras, E., Karachalios, T. S., et al. (2012). Factors affecting the quality of life after total knee arthroplasties: A prospective study. BMC Musculoskelet Disord, 13, 116.PubMedCentralCrossRefPubMedGoogle Scholar
  36. 36.
    Hooper, G. J., Rothwell, A. G., Hooper, N. M., & Frampton, C. (2012). The relationship between the American Society Of Anesthesiologists physical rating and outcome following total hip and knee arthroplasty: An analysis of the New Zealand Joint Registry. Journal of Bone and Joint Surgery, 94, 1065–1070.CrossRefPubMedGoogle Scholar
  37. 37.
    Keurentjes, J. C., Van Tol, F. R., Fiocco, M., So-Osman, C., Onstenk, R., Koopman-Van Gemert, A. W., et al. (2014). Patient acceptable symptom states after total hip or knee replacement at mid-term follow-up: Thresholds of the Oxford hip and knee scores. Bone and Joint Research, 3, 7–13.PubMedCentralCrossRefPubMedGoogle Scholar
  38. 38.
    Jämsen, E., Peltola, M., Eskelinen, A., & Lehto, M. U. (2013). Comorbid diseases as predictors of survival of primary total hip and knee replacements: A nationwide register-based study of 96 754 operations on patients with primary osteoarthritis. Annals of the Rheumatic Diseases, 72, 1975–1982.PubMedCentralCrossRefPubMedGoogle Scholar
  39. 39.
    Judge, A., Arden, N. K., Kiran, A., Price, A., Javaid, M. K., Beard, D., et al. (2012). Interpretation of patient-reported outcomes for hip and knee replacement surgery. Journal of Bone and Joint Surgery, 94, 412–418.CrossRefPubMedGoogle Scholar
  40. 40.
    Williams, D. P., O’Brien, S., Doran, E., Price, A. J., Beard, D. J., Murray, D. W., et al. (2013). Early postoperative predictors of satisfaction following total knee arthroplasty. Knee, 20, 442–446.CrossRefPubMedGoogle Scholar
  41. 41.
    Escobar, A., & Riddle, D. L. (2014). Concordance between important change and acceptable symptom state following knee arthroplasty: The role of baseline scores. Osteoarthritis Cartilage, 22, 1107–1110.CrossRefPubMedGoogle Scholar
  42. 42.
    Quintana, J. M., Aguirre, U., Barrio, I., Orive, M., Garcia, S., & Escobar, A. (2012). Outcomes after total hip replacement based on patients’ baseline status: What results can be expected? Arthritis Care & Research, 64, 563–572.CrossRefGoogle Scholar
  43. 43.
    Vogl, M., Wilkesmann, R., Lausmann, C., Hunger, M., & Plötz, W. (2014). The impact of preoperative patient characteristic on health states after total hip replacement and related satisfaction thresholds: A cohort study. Health and Quality of Life Outcomes, 12, 108.PubMedCentralCrossRefPubMedGoogle Scholar
  44. 44.
    Paulsen, A., Roos, E. M., Pedersen, A. B., & Overgaard, S. (2014). Minimal clinically important improvement (MCII) and patient-acceptable symptom state (PASS) in total hip arthroplasty (THA) patients 1 year postoperatively. Acta Orthopaedica, 85, 39–48.PubMedCentralCrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  • Florian D. Naal
    • 1
    • 2
  • Franco M. Impellizzeri
    • 3
  • Ulrich Lenze
    • 1
  • Vanessa Wellauer
    • 3
  • Rüdiger von Eisenhart-Rothe
    • 1
  • Michael Leunig
    • 2
  1. 1.Department of Orthopaedic Surgery, Klinikum rechts der IsarTechnical University of MunichMunichGermany
  2. 2.Department of Orthopaedic SurgerySchulthess ClinicZurichSwitzerland
  3. 3.Department of Research and DevelopmentSchulthess ClinicZurichSwitzerland

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