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De overordnede formål for denne afhandling er at undersøge prognostiske faktorer for hoftealloplastik hos patienter med hofte artrose og billeddiagnostiske fund som effekt modifikatorer for ikke-kirurgisk behandling hos patienter med knæ og hofte artrose. Afhandlingen omfatter en systematisk litteraturgennemgang der afdækker, hvorvidt billeddiagnostiske fund har betydning for behandlingseffekten ved forskellige ikke-kirurgiske interventioner, og et reliabilitetsstudie af diagnostisk ultralydsskanning af artrose forandringer i hoften og et registerstudie der undersøger hyppighed af total hoftealloplastik hos patienter med hofte artrose samt prognostiske faktorer for dette.I den systematiske litteratur gennemgang (studie I) inkluderede vi subgruppe analyser fra randomiserede studier, der undersøgte effekt af anbefalede ikke-kirurgiske behandlingsmetoder til knæ og hofte artrose. Vi vurderede studierne med fokus på om billeddiagnostiske fund på røntgen, CT, MR eller ultralydsskanning modificerede effekten af den undersøgte behandling. Formålet var at undersøge om billeddiagnostiske fund kan identificere patientgrupper, der adskiller sig ved at have en særlig effekt af en given behandling. Vi gennemgik de tre største databaser for medicinsk litteratur (MEDLINE, EMBASE og Cochrane Central Register of Controlled Trials) og identificerede syv studier, der angiveligt undersøgte dette. Kun to af studierne opfyldte de metodologiske kvalitetskriterier for subgruppe analyse. Således fandt vi at litteraturen på dette område er meget begrænset. Studiet belyser desuden typiske begrænsninger i subgruppeanalyser og disse metodemæssige begrænsninger betyder, at vi ikke kan konkludere, hvorvidt billeddiagnostiske fund modificerer effekten af ikke-kirurgiske behandlinger for knæ og hofte artrose. Der er simpelthen meget begrænset viden om subgruppe effekter hos både knæ og hofte artrose patienter.I reliabilitets studiet var formålet at vurdere pålidelighed (reliabilitet) af ultralydsfund mellem to erfarne ultralydsundersøgere samt overensstemmelsen mellem fund på ultralydsskanning og røntgenbilleder hos patienter med hofte artrose. Så vidt vi ved, er dette den første undersøgelse vedrørende ultralydsskanning af hoften, der i vurderingen af pålidelighed mellem to undersøgere inkluderer forskelle i undersøgelsesprocedure. Vi fandt meget høj inter-bedømmer-pålidelighed af ultralydsfund relateret til hofte ansamling/synovitis og væsentlig inter-bedømmer-pålidelighed ved de almindeligste ultralydsfund relateret til hofte artrose. Overensstemmelsen mellem røntgenfund og sværhedsgraden af radiologisk artrose vurderet på henholdsvis ultralydsskanning og røntgenbilleder var moderat, hvilket formentligt skyldes, at det kun i nogen grad er de samme forandringer der vurderes på de to undersøgelser. Overordnet set finder vi at ultralydsskanning er et pålideligt værktøj til vurdering af strukturelle forandringer ved hofte artrose. Resultatet danner grundlag for yderligere forskning i den prognostiske og diagnostiske værdi af ultralydsfund hos hofte artrose patienter.I registerstudiet (studie III) anvendte vi data fra patienter med hoftesmerter, der deltog i det landsdækkende uddannelses- og træningsterapiprogram 'Godt liv med Artrose i Danmark' (GLA:D®) samt data fra nationale registre. Formålet var at beskrive hyppigheden af total hoftealloplastik (THA), i de første to år efter patientens start i programmet, samt undersøge prognostiske faktorer for THA. Evidensen på dette område er begrænset og undersøgelsen bidrager således med betydelig ny viden. De potentielle prognostiske faktorer vi undersøgte omfattede demografiske og sygdomsspecifikke baseline karakteristika og forskellige mål for fysisk aktivitet og livskvalitet. Vi fandt at 30% af deltagere med hofte artrose gennemgik THA inden for to år. Ud af 22 potentielle prognostiske baseline karakteristika var 14 statistisk signifikante for THA. Raten af THA var signifikant højere blandt personer med højere smertescore, dårligere hofterelateret livskvalitet, dem med tidligere alloplastik i et andet led (knæ eller den anden hofte), dem der allerede var på venteliste til THA, og dem med selvrapporteret radiologisk artrose. Overraskende nok havde 40 % af dem der stod på venteliste til THA ved opstart i GLA:D, ikke modtaget en THA efter to år, hvilket tyder på, at selv deltagere med fremskredet artrose, der er kirurgiske kandidater, kan ændre deres forløb og måske klare sig uden THA. The overall aims of this PhD thesis are to investigate prognostic factors for total joint replacement in hip OA and imaging findings as effect modifiers of non-surgical treatment in knee and hip OA. The thesis includes a systematic literature review on whether imaging findings are modifiers of treatment effect in non-surgical knee and hip OA interventions, a reliability study on diagnostic ultrasound imaging in hip osteoarthritis, and a registry study on prognostic factors for total hip replacement.The systematic review of subgroup analyses from randomized controlled trials (study I) appraises the literature on diagnostic imaging findings as treatment effect modifiers for non-surgical knee and hip osteoarthritis treatment. The aim was to assess if baseline diagnostic imaging findings on radiographs, CT, MRI, and ultrasound identifies subgroups of patients with knee or hip osteoarthritis who respond better (or less) to various non-surgical interventions. Seven studies investigating treatment effect modifiers in knee or hip osteoarthritis were identified, and only two fulfilled the methodological criteria for subgroup analysis. In one study, participants with moderate to severe radiographic knee OA (Kellgren-Lawrence 3-4) had additional symptomatic benefits of wearing unloading shoes compared to conventional walking shoes compared to those with mild OA (KellgrenLawrence 2), indicating that radiographic severity potentially modifies the effect of unloading shoes in knee osteoarthritis. However, the methodological limitations in the included studies, the limited number of suitable studies, and the heterogeneity between them did not permit conclusions about imaging findings as treatment effect modifiers in people living with knee and hip osteoarthritis. In conclusion, the review identified a knowledge gap and frequently occurring subgroup analysis limitations.In the reliability study (study II), the objectives were to assess the inter-and intra-rater reliability of ultrasound imaging in patients with hip osteoarthritis between two experienced ultrasound operators and the agreement between findings on ultrasound and radiographs. To our knowledge, this is the first reliability study on hip ultrasound to include differences in the scanning technique between the two operators. The study demonstrated excellent inter-rater reliability of ultrasound findings related to hip effusion/synovitis and substantial to almost perfect inter-rater reliability on the most common ultrasound findings related to hip osteoarthritis. Intra-rater reliability was similar or higher. The agreement between the severity of different radiographic findings and osteoarthritis graded with diagnostic ultrasound and on radiographs using Kellgren-Lawrence grading was fair to moderate, indicating that radiographs and ultrasound scorings only assign similar gradings to some extent. In conclusion, the study supports ultrasound imaging as a reliable tool in assessing hip osteoarthritis. These results form the basis for further research on the prognostic and diagnostic value of ultrasound findings in hip osteoarthritis patients.The registry study (study III) used data from the ongoing nationwide initiative ‘Good Life with osteoArthritis in Denmark’ (GLA:D®) and national registers. The aim was to describe the total hip replacement rate and prognostic factors for total hip replacement in participants with hip osteoarthritis in a large cohort of patients with hip osteoarthritis. The study is relevant because it provides insight into a population where the evidence on prognostic factors is conflicting. Potential prognostic factors included demographic and disease-specific baseline characteristics and measures of physical activity and quality of life. Within two years, 30% received a total hip replacement. Of 22 baseline candidate prognostic factors, 14 were statistically significant for total hip replacement. The rate of total hip replacement was significantly greater among individuals with higher pain scores, lower hip-related quality of life, better general health, previous total joint replacement in another joint, those wait-listed for total hip replacement, and those with self-reported radiographic osteoarthritis. Interestingly, 40% of those already wait-listed for total hip replacement,when enrolled in the program, had not received a total hip replacement after two years, suggesting that even those eligible for surgery can change the course towards total hip replacement.
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