Surgzon

Background

The Centers for Medicare & Medicaid Services recently mandated reporting of patient-reported outcome measures following primary total hip arthroplasty (THA), with emphasis on the substantial clinical benefit (SCB) threshold for the Hip Disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR). The impact of preoperative back and/or contralateral hip pain on achieving SCB and other validated patient-reported outcome measure thresholds remains unclear.

Methods

We retrospectively analyzed a prospective cohort of 4,412 Medicare primary elective unilateral THAs (2016 to 2023). Patients were stratified by preoperative back and/or contralateral hip pain and severity. Outcomes included achievement of SCB (22-point improvement in HOOS-JR), minimal clinically important difference, patient-acceptable symptom state, and satisfaction at one year. Multivariable logistic regression was adjusted for demographic, clinical, and socioeconomic factors.

Results

Patients who had both back and contralateral hip pain had the highest odds of failing to achieve SCB (odds ratio (OR) 3.1, 95% confidence interval (CI) 2.4 to 4.1; P < 0.001), followed by isolated contralateral hip pain (OR 1.7, 95% CI 1.1 to 2.6; P = 0.01) and isolated back pain (OR 1.6, 95% CI 1.2 to 2.0; P = 0.002). Risk increased proportionally with pain severity (mild/moderate back pain: OR 1.7; severe back pain: OR 2.8; both P < 0.001). Similar, though less pronounced, patterns were observed for minimal clinically important difference and patient-acceptable symptom state thresholds across HOOS domains. Patients who have both pain sources also reported the highest risk of dissatisfaction (OR 2.1, 95% CI 1.5 to 3.0; P < 0.001).

Conclusions

Preoperative back and contralateral hip pain, particularly when severe or concurrent, strongly and independently reduce the likelihood of achieving SCB for HOOS-JR following primary THA. These findings underscore the need for risk adjustment under the Centers for Medicare & Medicaid Services patient-reported outcome performance measure framework and highlight the value of multidisciplinary management of comorbid pain to optimize outcomes and ensure equitable benchmarking in value-based care.

Level of evidence

II (Prospective).

Keywords

Hip Disability and Osteoarthritis Outcome Score–Joint Replacement, contralateral hip pain, low back pain, substantial clinical benefit, total hip arthroplasty

Preoperative Contralateral Joint And/Or Back Pain Impact on Achieving the Substantial Clinical Benefit for Hip Disability and Osteoarthritis Outcome Score-Joint Replacement.