|Year : 2015 | Volume
| Issue : 1 | Page : 10-13
A study of 120 cases of total hip arthroplasty in avascular necrosis head of femur and degenerative diseases of the hip joint
Jaswinder Pal Singh Walia1, Avinash Chander Gupta1, Naveen Mittal1, Khushpreet Kaur2, Sargun Singh2
1 Department of Orthopaedics, Government Medical College, Patiala, Punjab, India
2 Department of Obstetrics and Gynaecology, Government Medical College, Patiala, Punjab, India
|Date of Web Publication||4-Mar-2015|
Dr. Jaswinder Pal Singh Walia
19, Phulkian Enclave, behind Mini Secretariat, Patiala, Punjab
Context: Hip arthroplasty has enabled patients with degenerative, developmental, and traumatic diseases of the hip joint to perform painless functional activities. Aims: To find the effectiveness of procedure using cemented techniques and complications in regards of loosening, limb length discrepancy, and dislocation. Settings and Design: 120 patients were assessed for the role of total hip arthroplasty (THA) in avascular necrosis (AVN) head of femur and degenerative diseases of the hip joint. Materials and Methods: We had 80 patients of AVN, 32 osteoarthritis (OA) patients, and 8 patients with rheumatoid arthritis (RA). The patients were in the 35-74 years age group with 80 male and 40 female patients. The results were evaluated using the Hospital for Special Surgery score. Statistical Analysis Used: Percentage, paired "t" test, and P value. Results: Excellent or good results were obtained in 100 out of 120 patients and fair results in 20 patients, which consisted of 64 of 80 patients in the AVN group, 28 of 32 in the OA group, and 8 of 8 in the RA group. There were no poor results. The most common complication was limb length discrepancy that was managed with a shoe raise. Conclusions: Cemented THA is a very useful cost-effective procedure with predictable sustained results in patients with stage 3 and stage 4 AVN (Ficat and Arlet staging), stage 4 OA (Kellgren and Lawrence), and advanced RA, taking into account meticulous cementing techniques. We furthermore establish AVN as the most common etiology for THA in the Indian population as against the western countries where OA is relatively more common.
Keywords: Avascular necrosis, cemented total hip arthroplasty, osteoarthritis, rheumatoid arthritis
|How to cite this article:|
Walia JS, Gupta AC, Mittal N, Kaur K, Singh S. A study of 120 cases of total hip arthroplasty in avascular necrosis head of femur and degenerative diseases of the hip joint. Trop J Med Res 2015;18:10-3
|How to cite this URL:|
Walia JS, Gupta AC, Mittal N, Kaur K, Singh S. A study of 120 cases of total hip arthroplasty in avascular necrosis head of femur and degenerative diseases of the hip joint. Trop J Med Res [serial online] 2015 [cited 2019 Oct 17];18:10-3. Available from: http://www.tjmrjournal.org/text.asp?2015/18/1/10/152544
| Introduction|| |
Total hip arthroplasty (THA) is indicated for the alleviation of incapacitating pain in the hip joint due to trauma or degenerative diseases of the hip joint.  There is a significant increase in number of younger patients undergoing joint replacement for various etiologies necessitating longevity of the implants. 
| Materials and Methods|| |
We undertook this study with particular attention to younger group and test results in inflammatory arthritis.
The review of literature shows no long-term study for evaluation of uncemented arthroplasty, whereas studies such as those of Kim et al.,  and Andrea et al.,  of cemented THR provide a benchmark for standardization of the time-tested cemented arthroplasty. Nath et al.,  published the results of cemented THA in Indian population, stressing that the needs of Indian patients vary. The pain tolerance is greater than that of western population and financial constraints are high. Thus, revision surgery among Indian-Asian patients is less compared to western yardsticks. Simon et al.,  evaluated the results of THR in patients less than 40 years old with avascular necrosis (AVN) of femoral head and showed that cemented polished tapered femoral component had an excellent survival.
The literature concerning rheumatoid arthritis (RA) is limited. The literature supports the use of cemented hip, but the quality of arthroplasty registries is not suited to deliver information on infection and dislocation rates, as shown by studies of Bongartz et al.,  Bernatsky et al.,  etc.
One hundred and twenty cases were enrolled in our study, including patients in the age group of 35-74 years. The decision to operate was taken on the basis of Hospital for Special Surgery  score (HSS) which takes into account pain, walking, function, and motion. Most of the patients pre-operatively had an average score of 9.8 (out of 40). Patients who did not show improvement with conservative measures were operated upon.
Cemented arthroplasty was done using posterior or southern approach in all cases.
The Hospital for Special Surgery score was used for evaluation, taking into account the presence of acetabular or femoral radiolucencies for loosening in addition to functional outcome.
| Results|| |
The maximum number of patients was in the 55-64 years age group with 24 patients of AVN and 12 patients of osteoarthrosis (OA) as shown in [Figure 1].
There were 80patients of AVN, 32 OA patients, and 8 RA patients; males were 80 and females were 40 in number.
In terms of deformities, 48 patients had flexion deformity of <15° and 16 patients had >15°. Adduction and external rotation deformities were present in 12 cases each (10%). However, adductors were tight in all patients.
In terms of results, excellent or good results were obtained in 100 patients and fair results in 20 patients. There were no poor results as shown in [Figure 2].
Distribution of patients according to diagnostic category of results in shown in [Figure 3].
|Figure 3: Distribution of patients according to diagnostic category for result|
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Sixty-four of 80 patients in the AVN group, 28 out of 32 in the OA group, and 8 of 8 in the RA group had excellent or good results. Fair results were obtained in 16 patients of AVN group and 4 patients of OA group.
Distribution of patients according to Charnley category for results in shown in [Figure 4].
|Figure 4: Distribution of patients according to functional category for result|
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Excellent or good results were obtained in 60 of 72 patients in Charnley category A, 32 of 40 patients in category B, and 8 out of 8 patients in category C.
In 72 patients, indigenously manufactured prosthesis was used and in 48, internationally manufactured type was used. The P value in terms of total pre-operative, post-operative, and final post-operative (clinical and radiological) values was >0.05, signifying no statistical significance with all patients doing well.
In terms of improvement in clinical outcome according to HSS score, pain pre-op average was 2 (constant, but bearable; uses strong medication occasionally) and post-op average was 8 (occasional and slight). For walking, pre-op score was 4 (uses no support, house-bound) and post-op score was 8 (uses no support, limps). For function, pre-op score was 2 (partially dependent) and post-op score was 6 (does most of the house work, shops freely, can do desk type work). For motion, pre-op score was 2 (muscle power, poor to fair; arc of flexion less than 60°) and post-op score was 6 (muscle power, good or normal; arc of flexion more than 90°).
We had our share of complications. Fifteen patients had limb length discrepancy of an average of 1.34 cm which was managed with a shoe raise. Four patients each developed tenotomy site infection, urinary tract infection, and bronchopneumonia which were managed. Of the twelve patients with infection, there were six of RA.
Twelve patients had circumferential radiolucency of <2 mm on actebular radiographs, which is a high risk for subsequent loosening.
| Discussion|| |
Since its introduction in 1961 by Sir John Charnley, THA has withstood the test of time. A number of hip rating systems have been designed to assess the hip function (Merle d'Aubinge and Postel 1954, Larson 1963, Harris 1969, Wilson et al., 1972, Mayo, Iowa, AAOS, etc.). A comparison of five different hip rating systems by Callaghan et al., proved that the HSS rating was the most optimistic.
In the present study, 80 (66.6%) patients had AVN of femoral head, 32 (26.6%) had OA, and 8 (0.67%) had RA. In 2005, Dhaon et al., reported that in Indian population, AVN is the most common (66.6%) while OA was reported only in 4.76% cases. In 2010, Nath et al., reported AVN in 50%, OA in 0.67%, and RA in 16.67% of patients.
Studies in the west report OA as the most common diagnosis (63% by Harris et al., 77% by Berger et al., and 97% by Slack et al.). AVN was the second most common (10% by Harris et al., 7% by Berger et al., and 2.23% by Slack et al.).
The mean age of patients was 54.23 years. Maximum number of patients was in the age group of 55-64 years.
Thus, the present study are comparable with that of Siwach et al. as shown in the above table. However, the number of younger patients undergoing hip arthroplasty is on the rise due to changes in patient selection and increased awareness among people.
In a study by Chidambram and Cobb, only 8% of patients were under 60 years of age in 1993 which increased to 23% in 2005. Between 2000 and 2005, this figure was at or above 20%.
The mean pre-operative Hospital for Special Surgery score was 11 and the mean post-operative score was 43.46 which were better compared to those in the study of Lo  who reported a pre-operative score of 17 and a post-operative score of 32. Jarrett et al., reported pre-operative and post-operative scores of 19 and 38.4, respectively.
The complication of limb length discrepancy developed in 20 patients (16.67%) with an average of 1.34 cm. Williamson and Reckling found limb lengthening of average 1.6 cm in 144 out of 150 (96%) patients. In Nath et al.,  study, limb discrepancy was found in 9 of 30 (30%) patients.
Thus, cemented THA is a very useful procedure with predictable sustained results in patients with end-stage disease due to AVN, OA, and RA of the hip joint. The cemented procedure does stay longer, but the steps are logical and relatively straightforward.
The point of big debate in patients with RA has been the incidence of infection, dislocation, and aseptic loosening. We believe that in light of the relatively frequent reports of increased infection in combination with the potential under-registration of infection rates, RA patients have a mildly increased risk of post-operative infection after THA, in comparison with OA and AVN patients. There has been reported no increased risk of dislocation in these patients. Although there used to be an increased risk of aseptic loosening, the success rate has improved over the years and there is no evidence to show the increased risk among RA patients. Thus, these patients do well and THA offers a dramatic change in the lifestyle of the debilitated patients.
Studies in the west have always recommended squatting and sitting cross - legged to be avoided, but the needs and culture of the Indian set-up are different. Most of the patients do squat against the precautions and there has been no increased risk of dislocation. Thus, we support squatting at least 1 year after the index procedure.
The pain tolerance and financial restraints of Indian population are different. Most of the patients can barely support one operation. It is almost impossible to convince them for a revision. They can tolerate some pain. Thus, none of the procedures has been revised, although increased risk of loosening was seen in some.
Thus, we support the use of cemented all polyethylene acetabular components and polished tapered collarless cemented stems as a cost-effective procedure for the low socio-economic strata of the society as they offer tremendous improvement in the quality of life, who otherwise would have been left stranded.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]