CORRELATIVE STUDY OF PMA SCORING IN A GROUP OF ROMANIAN PATIENTS SUBMITTED TO TOTAL HIP REPLACEMENT

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1 Rev. Med. Chir. Soc. Med. Nat., Iaşi 2012 vol. 116, no. 3 SURGERY ORIGINAL PAPERS CORRELATIVE STUDY OF PMA SCORING IN A GROUP OF ROMANIAN PATIENTS SUBMITTED TO TOTAL HIP REPLACEMENT Carmen Grierosu 1, P. Botez 2,3 1. Ph. D. student at University of Medicine and Pharmacy Grigore T. Popa - Iași University of Medicine and Pharmacy Grigore T. Popa - Iași School of Medicine 2. Discipline of Orthopedics-Traumatology Rehabilitation Hospital, Iasi 3. Orthopedic Clinic CORRELATIVE STUDY OF PMA SCORING IN A GROUP OF ROMANIAN PATIENTS SUBMITTED TO TOTAL HIP REPLACEMENT (Abstract): Elective hip and knee prosthetic surgery represent the ultimate treatment option for pain and disabilities caused by arthr o- sis with these particular localizations. Material and methods: We conducted a preliminary retrospective study on a series of 47 patients investigated and operated at the Orthopedic Clinic of the Iasi Rehabilitation Hospital in the interval March 1, March 1, Results: A good correlation between the general preoperative and 3 month-postoperative PMA scores (r=0.746) was found, even though the correlations between individual parameters were only moderate. Conclusions: The obtained results show that mean preoperative PMA scores statistically differ from the scores recorded 3 months after surgery. Key words: TO- TAL HIP REPLACEMENT, PMA SCORE, CORRELATION, QUALITY OF LIFE. Elective hip and knee prosthetic surgery represent the ultimate treatment option for pain and disabilities caused by the arthrosis with these particular localizations (1). The prevalence of both diseases continues to increase mainly in economically developed countries due to surgical techniques improvement and general population ageing. This trend led to increased expenses for health services, and also to longer waiting lists and implicitly waiting time for the required elective surgery. Clear and objective criteria must be defined for the selection of patients accepted or directed to these waiting lists; also, standard diagnostic tools should be defined to determine the priorities on these lists, and to accurately assess the true emergencies and optimal benefit for the patient. Chronologic criterion should not be considered alone, but in relation with the clinical and social impact of delayed surgery effects. In 1994, in USA, about 124,000 total hip replacements were performed as compared to 119,000 interventions in While the frequency of surgical interventions increased by 4% from 1990, the mean hospital stay decreased by 33.3%, from 10.8 to 7.2 days on average. Also, during the same interval, the number of total knee replacements increased by 62% from 129,000 to 209,000, while mean hospital stay decreased by 35%, from 10.5 to 6.8 days (2-4). Even though this information is useful to evaluate 823

2 Carmen Grierosu, P. Botez the money spent for health services, these are enough. More specific info is required mainly regarding changes in preoperative and postoperative patient health status in order to determine how much health we can buy for the spent money. Large joint replacement (hip, knee) is efficient in most patients, being one of the most cost-effective interventions in all surgical domains. However, some problems may occur mainly in young patients and long-term results (5, 6). The need for hip functional assessment by a numerical score came from the declared purpose to obtain accurate data regarding operative indications and postoperative results (7). Some scores are excessively detailed and complex, thus being difficult to use. As an example, the Harris Hip Score, a hip-specific instrument, evaluates pain, function, activity, and motion on a scale (where 100 is the best). It allows easy data collection and electronic assessment, but its main drawback consists in the fact that only 5 points are awarded for mobility; thus, a bilateral, not painful ankylosis in extension is scored 50 to 100 points, while following arthroplasty a 60 degrees flexion with 2 Canadian crutches, slight pain in sitting position will determine a score of only 32 of 100 points. Postel Merle d Aubigne (PMA) score, first published in 1946 by Robert Merle d Aubigné and Michel Postel (8), is a simple scoring system, three aspects of hip function being scored 0 to 6; thus, this score was adopted world-wide. In 1990, PMA score was modified, form used by us in the present study. The main changes consist in the introduction of two new elements without changing the original principle. Practically, the incidence is determined by the level of pain, and stability is dependent on walking quality, that is separate scores for each hip. This new PMA scoring system includes 3 items scored 0 to 6: pain, mobility and stability (with unilateral load bearing, including walking) for each hip. MATERIAL AND METHODS We conducted a preliminary retrospective study on a series of 47 patients investigated and operated between March 1, 2009 and March 1, 2010 at the Orthopedic Clinic of the Iasi Rehabilitation Hospital. Statistical analysis was made with the help of SPSS17 software. Statistical analysis was based on the total numerical score of each parameter and not on the clinical staging. We performed a descriptive statistical analysis together with a correlative study were carried out in order to evaluate the relation between preoperative and 3 month-postoperative PMA scores. In this patient series we have applied the PMA scores pre- and postoperatively in order to evaluate the results and the followup in total hip replacement surgery. The mean patient age was of years. Most patients were from rural areas (70.21%). All patients were retired, this not being an absolute rule but a limitation of our study group. The mean body mass index in our study group was of 27.1, indicating that most of our patients were overweight. The body mass index may be an essential indicator in preoperative, immediate or late postoperative assessment. Continuous variables (interval) were characterized by calculating the main statistical indicators (mean and confidence interval 95%, median, standard deviation, dispersion). RESULTS In our study group there was an even gender distribution of the cases (23 males 824

3 Correlative study of PMA scoring in a group of Romanian patients 48.94% and 24 females 51.06%), standard deviation (SD) of Gender distribution is important to define the allowed post-surgery activities. Age-group distribution is also important in the evaluation using PMA scores. In our patients mean age was of years, with a standard deviation of for a confidence interval of 95%. The youngest patient was 49 years-old, while the oldest was 81 years-old; the true mean age varied between and years and median age was of 65 years. Most patients belonged to the years age group. The follow-up of quality of life parameters depends directly on gender, activity, occupation, and social integration level of each particular patient. Rural-urban distribution of patients is an important factor to be considered as, at least in Romania, it may directly influence the level of individual activity and also the type of the activity to be developed. In our study group a Pearson correlation index of was obtained, suggesting a direct powerful correlation, as this result is very close to value 1. Sig. corresponding value is equal to that is we have obtained a significant correlation coefficient of 0.01, meaning that there are less than 1% chances to be wrong if we claim that between the two variables there is a significant correlation. Thus we may assert that there is a powerful correlation between preoperative and 3 month-postoperative PMA scores. Therefore, the lower the preoperative PMA score, the lower the chances for postoperative PMA score to get closer to 18 (meaning excellent results). However, some debatable aspects should be considered, such as the techniques and implants available in 2009 and other subjective factors that may influence the outcome. We have also calculated the Spearman correlation coefficient on total and partial PMA scores of the 47 study patients. Spearman correlation scores were interpreted according to the following scale (9): low correlation (rho < 0.3); moderate correlation (0.3 < rho < 0.6); good correlation (0.6 < rho < 0.8); excellent correlation (rho > 0.8) Analysis of the obtained PMA scores showed a good correlation (r = 0,746) between preoperative and 3-month-postoperative scores. This shows that the used method can evaluate with good accuracy specific aspects of life quality in total hip replacement patient. Nevertheless, some technical aspects remain difficult to separate during scoring evaluation, according to this scoring system. Next step was to perform individual correlations between the pre and postoperative PMA scores for pain, mobility, and stability. For the pain score, correlation analysis showed the following results: preoperative PMA scoring showed a mean of 3.45 (scale 0-6), with a standard deviation (SD) = 0.686; postoperative PMA scoring showed a mean of 5.81, with a standard deviation (SD) = 0.398; preoperative pain showed a mean score of 3.45 (min=2, max=5) with a SD=0.686; postoperative pain showed a mean score of 5.81 (min=5, max=6) with a SD=0.398 A high symmetry of Spearman score (rho = 0.541) and Pearson (0.560) index was found. A moderate correlation between the scores for preoperative and 3-monthpostoperative pain was noted. Thus, pain, as a subjective but relevant factor that may influence patient s quality of life requires detailed and further attention. Individual results illustrate a main subjective component in evaluating this score, while at 3 months postoperatively most patients show good pain scores. The lack of correlation between pre and postoperative scores 825

4 Carmen Grierosu, P. Botez shows a random evaluation of preoperative pain and a uniform positive evaluation of the postoperative pain (mild to no pain). For the range of motion (ROM) score, correlation analysis showed that: preoperative PMA scoring showed a mean of 4.11 (range 3-6), with a standard deviation SD = 0.890; postoperative PMA scoring showed a mean of 5.60, with a standard deviation SD = 0.496; preoperative ROM scoring showed a mean of 4.11 (min=3, max=6) with a SD=0.890; postoperative ROM scoring showed a mean of 5.81 (min=5, max=6) with a SD=0.496 We may observe a high uniformity for Spearman (rho = 0.493) and Pearson coefficients (0.496). As for the pain, there was a moderate correlation between the obtained scores for pre and 3-monthpostoperative ROM. ROM should also be considered for further detailed evaluation with special references to surgical technique and/or implant type. As to the functional score (walking/stability), the correlation analysis provided the following results: preoperative PMA scoring showed a mean of 4.00 (range 3-6), with a standard deviation SD = 0.834; postoperative PMA scoring showed a mean of 5.43, with a standard deviation SD = 0.5; preoperative functionality recorded a score of 4 (min=3, max=6) with a SD=0.834; Postoperative functionality recorded a score of 5.81 (min=5, max=6) with a SD=0.5. We may observe a high uniformity for Spearman (rho = 0.446) and Pearson (0.496) indices. As for the pain, there is a moderate correlation between the scores for pre and 3 month-postoperative functionality. DISCUSSION AND CONCLUSIONS A good correlation between the general PMA scores applied pre and 3 monthpostoperatively (r=0.746), even if the correlations between individual parameters were only moderate. The results obtained in the evaluation of our patient group show that the mean preoperative PMA scores statistically differ from the scores recorded 3 months after surgery. Thus, applying PMA questionnaires may be useful for a functional evaluation, but cannot highlight the importance of a specific implant or surgical technique. We have noticed that this questionnaire cannot make the difference between different prosthesis types and various surgical techniques that may represent important impact factors on patient s quality of life, mainly long-time after surgery. The used prosthesis influences the dynamic articular behavior and the indices for different scoring systems (PMA, Harris, AAOS). Study groups should be organized so to include prospective and retrospective studies and further detailed statistical analysis will show the flaws of classic scoring systems. REFERENCES 1. Montin L, Suominen T, Haaranen E, Katajisto J, Lepisto J, Leino-Kilpi H. The changes in healthrelated quality of life and related factors during the process of total hip arthroplasty. Int J Nurs Pract. 2011; 17(1): Howell J, Xu M, Duncan CP, Masri BA, Garbuz DS. A comparison between patient recall and concurrent measurement of preoperative quality of life outcome in total hip arthroplasty. J Arthroplasty 2008; 23(6): Xu M, Garbuz DS, Kuramoto L, Sobolev B. Classifying health-related quality of life outcomes of total hip arthroplasty. BMC Musculoskelet Disord. 2005; 6:

5 Correlative study of PMA scoring in a group of Romanian patients 4. Bayle B, Kemoun G, Migaud H, Thevenon A. Comparison of two modes of administration of a personalized quality of life scale in a longitudinal study of total hip arthroplasty. Joint Bone Spine 2000; 67(2): Goetzen N, Lampe F, Nassut R, Morlock MM. Load-shift--numerical evaluation of a new design philosophy for uncemented hip prostheses. J Biomechanics 2005; 38: Botez P, Simion L, Sargu. Evaluarea rezultatului funcţional şi a "calităţii vieţii" în chirurgia ortopedică modernă. Endoprotezarea articulară. Rev Rom Bioetica 2007; 5(4): NOUTĂȚI NEWS O ENZIMĂ ÎNDELUNG IGNORATĂ SE DOVEDEŞTE A FI CHEIA PENTRU A UCIDE BACTERIILE PATOGENE Noi cercetări arată că o enzimă care a fost mult timp considerată relativ inutilă răspunsului imun are un rol important în determinarea celulelor sistemului imunitar să ucidă bacteriile care cauzează infecţii. Cercetătorii de la Ohio State University au stabilit că această enzimă, numită caspase-11 la şoareci, permite componentelor celulare ale sistemului imunitar să fuzioneze şi să degradeze bacteriile care cauzează un tip de pneumonie numită boala legionarilor. Fără formarea fagolizosomului, aceste bacterii pot provoca boala. Nu se ştie dacă efectul este acelaşi şi contra altor bacterii. La om, enzima similară este o combinaţie de caspases 4 şi 5. Cercetătorii au stabilit că bacteria Legionella pneumophila suprimă activarea acestor două enzime din celulele umane. Dar, în cazul în care enzimele au fost reintroduse în celulele sistemului imunitar, au apărut aceleaşi evenimente de fuziune - observate şi la şoareci - care vor ucide bacteriile. Rezultatele ar putea duce la dezvoltarea de medicamente non-antibiotice concepute pentru a lupta împotriva anumitor infecţii bacteriene prin activarea acestor enzime. Cei mai vulnerabili la boala legionarilor sunt fumătorii, vârstnicii, persoanele cu boli cronice sau compromise imunitar, inclusiv pacienţii cu cancer şi SIDA. Majoritatea studiilor publicate până în prezent susţineau că fagocitoza era iniţiată de o enzimă diferită, caspase 1, iar caspase- 11 era necesară doar pentru activarea caspase- 1. Această concluzie se explică prin faptul că testele s-au făcut pe şoareci modificaţi genetic care nu aveau caspase- 1 dar nici caspase- 11 deoarece genele care codifică cele două enzime sunt situate foarte aproape una de alta. Datorită acestor studii, caspase-1 a fost considerată o ţintă atractivă pentru tratament. Dar activarea caspase- 1 poate determina ca reacţie adversă, o inflamaţie extinsă care nu apare la activarea caspase - 11, făcând din cea din urmă o ţinta terapeutică mai dorită de companiile farmaceutice. Pentru noile studii, cercetătorii au utilizat culturi de celule umane şi şoareci modificaţi genetic, astfel încât aceştia să nu producă caspase-11. Ei au demonstrat că formarea fagolizosomului este activată de către caspase- 11 prin fosforilarea unei proteine ţintă numită actin iar în celulele umane, bacteria Legionella a suprimat activarea caspases 4 şi 5, dar când au adăugat cele două enzime înapoi la culturile de celule imune ce conţin bacterii Legionella, bacteriile nu au mai supravieţuit. Act i- varea fagocitozei de către aceste enzime nu s-a produs în cazul altei bacterii patogene (Salmonella) ceea ce sugerează ca poate exista o diferenţiere a acestor enzime funcţie de tipul de ba c- terie (Anwari Akhter, Kyle Caution, Arwa Abu Khweek et al. Caspase-11 Promotes the Fusion of Phagosomes Harboring Pathogenic Bacteria with Lysosomes by Modulating Actin Polymerization. Immunity, 2012; DOI: /j.immuni Ohio State University (2012, June 11; Long-ignored enzyme turns out to be key to killing infectious bacteria. ScienceDaily. Retrieved June 16, 2012, from /releases/2012/06/ htm). Cătălina Luca 827