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 Table of Contents  
ORIGINAL ARTICLES
Year : 2022  |  Volume : 37  |  Issue : 2  |  Page : 76-79

Assessment of outcome of uncemented total hip arthroplasty


1 Department of Orthopedics, S.N. Medical College, Agra, Uttar Pradesh, India
2 Faculty of Orthopedics, District Hospital, Sant Kabir Nagar, Uttar Pradesh, India

Date of Submission03-Jul-2022
Date of Decision24-Aug-2022
Date of Acceptance14-Sep-2022
Date of Web Publication19-Oct-2022

Correspondence Address:
Jaydeep Patel
Department of Orthopedics, S.N. Medical College, Agra, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_11_22

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  Abstract 

Introduction: Uncemented total hip arthroplasty is a time-tested remarkable surgical procedure that provides mobility, stability, and better quality of life for thousands of patients, especially young patients throughout the world. Thus, uncemented total hip arthroplasty today has become the main mode of hip replacement, especially in young patients. However, uncemented total hip arthroplasty has its own drawbacks such as inadequate initial fixation, excessive wear, and periprosthetic bone loss due to particle-induced lysis. Materials and Methods: This prospective study was conducted between September 2018 and August 2020. A total of 30 patients were selected from patients attending emergency department and outpatient department of orthopedics. For all prospective cases, a detailed history regarding mode and mechanism of injury (in case of trauma) was taken followed by clinical examination, and the patient was documented. Follow-up visits were made at 3 months, 6 months, 1 year, and periodically thereafter. Results: In our study, functional outcomes after uncemented total hip replacement were excellent in 30% of cases, good in 53.33% of cases, fair in 13.33% of cases, and poor in 3.33% of cases by using Harris Hip Score. No patients showed any radiographic signs of loosening. No patients showed any complications during follow-up. Conclusion: In our study, the results are fair to poor in noncompliant young patients with high functional demands. The results are fair to poor in patients with bilateral affections such as chronic arthritis and avascular necrosis in which the patient undergoes only unilateral total hip arthroplasty.

Keywords: AVN, Harris Hip Score, uncemented total hip replacement


How to cite this article:
Shakunt RK, Sharma B, Sharma SS, Pal CP, Sadana A, Patel J. Assessment of outcome of uncemented total hip arthroplasty. J Bone Joint Dis 2022;37:76-9

How to cite this URL:
Shakunt RK, Sharma B, Sharma SS, Pal CP, Sadana A, Patel J. Assessment of outcome of uncemented total hip arthroplasty. J Bone Joint Dis [serial online] 2022 [cited 2022 Nov 29];37:76-9. Available from: http://www.jbjd.in/text.asp?2022/37/2/76/358791




  Introduction Top


Total hip replacement arthroplasty is a surgical procedure, which has relieved millions of people from incapacitating pain arising from the hip joint. At present, it is the most commonly performed adult reconstructive hip procedure. The success of total Hip replacement arthroplasty is its ability to relieve the pain associated with hip joint pathology while maintaining the mobility and stability of the hip joint.[1],[2]

Uncemented total hip arthroplasty is a time-tested remarkable surgical procedure that provides mobility, stability, and better quality of life for thousands of patients, especially young patients throughout the world. Adverse effects of bone cement led to the popularity of uncemented total hip arthroplasty. Here porous and hydroxy apatite coated components are used. This creates a biological interface called bone ingrowth (osteointegration). Instead of fatiguing and failing bone cement, this type of fixation continually grows stronger, remodeled, and becomes more permanent. The three criteria for bone ingrowth are pores >40 mm in diameter, absence of micromotion, and intimacy of porous surface with bone.[3],[4]

The uncemented total hip arthroplasty has its own drawbacks such as inadequate initial fixation, excessive wear, and periprosthetic bone loss due to particle-induced lysis.


  Materials and Methods Top


This prospective study was conducted at the Department of Orthopaedics of S.N. Medical College, Agra, Uttar Pradesh, India from September 2018 to August 2020. Patients were selected from patients attending emergency department and outpatient department (OPD) of orthopedics. The inclusion criteria of the study included any patient with hip pathology who has an indication of arthroplasty of the hip joint and patient willing and motivated for surgery and lifestyle changes required postoperatively.

The exclusion criteria of the study included age less than 20 years, preexisting neurological disorder, preexisting musculoskeletal disorder, bleeding disorders, and comorbid conditions contraindicating for surgery.

For all prospective cases, a detailed history regarding the mode and mechanism of injury (in case of trauma) was taken, followed by a clinical examination.


  Preoperative Assessment Top


Preoperatively patients were kept on ski /skeletal traction in case of trauma to relieve pain and to correct the deformity. Patients were educated on quadriceps exercise, active finger movement, and breathing exercises. Aspirin and other anti-inflammatory drugs are discontinued 7–10 days before surgery.

  • Soft tissues about the hip were inspected for any inflammation or scarring


  • Strength of the abductors is determined by the Trendelenburg test. Any limb length discrepancy and fixed deformity are assessed.


  • When both hip and knee are arthritic usually the hip should be operated on first.


  • Status of the hip is rated preoperatively by modified Harris Hip Scoring.



  •   Preoperative Assessment of X-rays Top


    The objectives of preoperative assessment of X-ray are to determine the correct stem size, optimal stem positioning in the medullary canal, the correct size of acetabular cup, and to maintain equal leg length. The planning is done by using plastic overlay templates. The templating aims in detection of the type of implant, neck length required, and to determine the femoral offset. Anterio-posterior view of a pelvis showing proximal femur and lateral view of the hip with proximal femur are the minimum views required. In special cases, X-rays of the spine and knee are required.
    Table 1: Comparison between male and female population on the basis of Harris Hip Score

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    Table 2: Pre- and postoperative comparison of outcome

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    Prophylactic antibiotics

    The antibiotics are administered in the night before operation theater, in the operative room 15–30 min before the skin incision, and 2 h after the operative procedure.

    Postoperative care

    Ideally rehabilitation should begin before the operation. A patient who was motivated and informed and has appropriate goals is a better participant in the rehabilitation process. A preoperative session was used to teach the appropriate mechanism for transfers, the use of supportive devices, and dislocation precautions.

    Hip extension exercises are encouraged, especially if there has been a preexisting flexion deformity. The patient should spend time in the supine position each day and a pillow beneath the knee is discouraged. The hip flexors can be stretched early by flexing the opposite hip and maintaining the operated limb flat on the bed (Thomas Test).

    Partial weight bearing was done after 3 days postoperatively in cemented total hip replacement. In cementless total hip replacement weight bearing is allowed after 45 days. Quadriceps exercises were mostly initiated second postoperative day, whereas knee bending is done on 6–8 postoperative days. Skin stitches were removed after 12 days.

    Activities such as squatting, cross legs sitting, and other positions that produce repetitive impact loading or extremes of the positioning of the hip are unwise and the patient should be warned that such activities can increase the risk of failure of arthroplasty.

    Postoperative antibiotics were given. In the immediate postoperative period, the hip is positioned at approximately 15° of abduction while the patient is recovering from anesthetic. We use a triangular pillow to maintain abduction and prevent extremes of flexion.

    Follow-up

    Patients were asked to attend OPD for exercises and regular follow-up. The mean follow-up period was 12 months. Clinical and functional evaluation was done using Harris Hip Score and radiologically at 2 weeks and thereafter 4 weekly. A detailed clinical analysis was carried out in terms of function, mobility, walking, pain, and complications at the time of each follow-up.


      Result Top


    In our study, a total of 30 patients were studied; of which, 18 (60%) were males, and the rest 12 (40%) were females. Indications were out of 30 hips studied, 1 (3.33%) hip of chronic osteoarthritis, 20 (66.66%) hips of avascular necrosis (AVN) of the head of the femur, 1 (3.33%) hip of fracture neck of the femur with nonunion, 5 (16.67%) hips of fracture neck of the femur with implant failure, and 3 (10.00%) hips of the tubercular hip. Of 30 hips studied, 11 (36.67%) cases were between 20 and 30 years, 9 (30%) cases were between 31 and 40 years, 3 (10%) cases were between 41 and 50 years, 7 (23.34%) cases were between 51 and 60 years, and no cases were more than 60 years. Of 26 cases studied, 10 (38.46%) cases operated right side, 12 (46.15%) cases operated left side, and 4 (15.38%) cases operated on both sides.


      Sex-Wise Pre- and Postop Harris Hip Score Top


    In our study, the sex-wise distribution of preop Harris Hip Score and postop Harris Hip Score is given below.

    In our study, radiological assessment of the position of the acetabular cup was the optimal position in 24 cases and in 6 cases it was not in the optimal position. In our study, radiological assessment of the position of the femoral stem was the neutral position in 22 cases, in 6 cases it was valgus, and in 2 cases it was varus in position.

    In our study, functional outcomes after uncemented total hip replacement were excellent in 30% of cases, good in 53.33% of cases, fair in 13.33% of cases, and poor in 3.33% of cases [Tables 1 and 2].


      Discussion Top


    This prospective study was conducted to analyze the radiological, clinical, and functional outcomes of uncemented total hip arthroplasty done in younger individuals. The results of the study are compared with the known similar studies given in the western literature. The mean age group in our study was 36 years. The mean age group in other studies are as follows: in Schramm and Keck[5] the mean age was 47 years, in Aldinger et al.[6] the mean age was 51 years, the mean age was 55 years, and in Alexander et al.[7] the mean age was 54 years. In our study, it primarily involved younger age group in comparison with western literature. It shows that in our country younger people are more affected due to quack and steroid abuse and go for an operation to adopt a healthy lifestyle. The sex distribution in our study was 60% in males and 40% in females. It shows the male dominance and more working population is male like in western countries. In Alexander et al.’s study, there were 61% males and 38% females. In western literature, the males were also more involved. The most common indication in our study was AVN head of femur (67%). The other indications were fracture neck of the femur (20%), tubercular hip (10%), and chronic arthritis (3%). In Alexander et al.’s[7] study, the most common indication was chronic arthritis. The other indications were AVN head of femur and fracture neck of femur. In our study, the most common indication was AVN hip; however, in western literature, it was chronic arthritis. It shows that AVN is more common in the young population due to steroid abuse as compared with other countries. In our country, tuberculosis is also common, which leads to tubercular hip because poverty and malnutrition are more common. The older population with chronic arthritis is neglected and not easily goes for operative procedures in India.[8],[9],[10]

    The radiological parameters in our study is studies is optimal position of femoral stem in our study is neutral to valgus >90% which is comparable to Bourne et al.’s[5] study. Position of acetabular component optimal position in 80% cases. There were no implant and procedure-related complications in our study, whereas the reason for some complications in our study is the noncompliance of the patient with respect to postoperative counselling. The immediate success of total hip arthroplasty is determined by the ability of the patient to return to maximum possible level of functional activity. Thus, maximum points are given to the pain and mobility of patients. Patients with chronic arthritis are incapacitated by pain and restricted motion and thus the relief of these two factors greatly determines the satisfactory outcome of the surgery. Restoration of the biomechanics of the hip is important for the good outcome and longevity of the prosthesis. In all our cases, we tried to restore the center of rotation, limb length, and medial and vertical offset. We believed that maintaining considerable activity is important for bone remodeling and osteointegration. Only those activities that do not produce considerable joint loads such as swimming, cycling, and walking are recommended. The activities that increase the joint load are cross-legged sitting, squatting for toilet purposes, and any strenuous physical activity.[11],[12],[13]

    In most of the western studies, Harris Hip Score was used to assess the functional outcome and considered as the best mean of objective evaluation of result of total hip arthroplasty.

    The functional outcome was assessed in our study by using the modified Harris Hip Score. The postoperative Harris Hip Score at the end of follow-up study is excellent or good (83%), fair (13%), and poor (3%) outcomes found in our study. The follow-up outcomes of Harris Hip Score in other studies are as follows: good or excellent (84%), fair discussion (14%), and poor (2%); and good or excellent (79%) and fair or poor (20%). In our study, none of the patients had any recognized risk factors for Heterotropic Ossification and none of the patients had any pharmacological or radiotherapeutic prophylaxis against Heterotropic Ossification. We also noted a negative correlation between the prevalence of Heterotropic Ossification and postoperative Harris Hip Score. However, in Schreiner et al. study the incidence of Heterotropic Ossification is 5.7%.[14],[15]


      Conclusion Top


    Uncemented total hip arthroplasty is mainly indicated in young patients with adequate bone stock.

    1. Careful patient selection along with preop and postop evaluation of both patients and radiographs is essential for the success of total hip arthroplasty.


    2. Failure of the patients to follow postop instructions regarding lifestyle changes is one of the reasons for fair-to-poor results in our study.


    3. In our study, the results are fair to poor in noncompliant young patients with high functional demands.


    4. The results are far better in young patients with low functional demands.


    5. The results are fair to poor in patients with bilateral affections such as chronic arthritis and AVN in which the patient undergoes only unilateral total hip arthroplasty.


    6. The dislocation rate is higher in large cups with overhanging margins in abnormal version and inclination.


    7. The complications such as pneumonia, fatal pulmonary embolism, deep vein thrombosis, sciatic nerve palsy, and periprosthetic femoral stem fracture are not seen in our study.


    8. In the preoperative and postoperative assessment, modified Harris Hip Score is very useful to evaluate the functional outcome.


    Financial support and sponsorship

    Not applicable.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    McKee GK, Watson-Farrar J Replacement of arthritic hips by the Mckee–Farrar prosthesis. J Bone Joint Surg Br 1966;48: 245-59.  Back to cited text no. 1
        
    2.
    Ring PA Complete replacement arthroplasty of the hip by the ring prosthesis. J Bone Joint Surg Br 1968;50:720-31.  Back to cited text no. 2
        
    3.
    Charnley J Total hip replacement by low friction arthroplasty. Clin Orthop Relat Res 1970;72:7-21.  Back to cited text no. 3
        
    4.
    Charnley J Low Friction Arthroplasty of the Hip: Theory and Practice. Berlin: Springer-Verlag; 1979.  Back to cited text no. 4
        
    5.
    Schramm M, Keck F, Hohmann D, Pitto RP. Total hip arthroplasty using uncemented femoral component with taper design outcome of 10 year follow up. Arch Orthop Trauma Surg 2000;120:407-12.  Back to cited text no. 5
        
    6.
    Aldinger PR, Thomsen M, Mau H, Ewerbeck V, Breusch SJ. Cementless Spotorno tapered titanium stems. Acta Orthop Scand 2003;74:253-8.  Back to cited text no. 6
        
    7.
    Bufford A, Goswami T Review of wear mechanisms in hip implants: Paper I – general. Mater Design 2004;25:385-93.  Back to cited text no. 7
        
    8.
    Roy Chowdhury SK, Mishra A, Pradhan B, Saha D, Wear characteristic and biocompatibility of some polymer composite acetabular cups. Wear 2004;256:1026-36.  Back to cited text no. 8
        
    9.
    Pyburn E, Goswami T Finite element analysis of femoral components paper III – hip joints. Mater Design 2004;25:705-13.  Back to cited text no. 9
        
    10.
    Latham B, Goswami T Effect of geometric parameters in the design of hip implants paper IV. Mater Design 2004;25:715-22.  Back to cited text no. 10
        
    11.
    Hindocha S Atraumatic fracture neck of femur in Marfan’s syndrome. Inj Extra 2007;38:343-5.  Back to cited text no. 11
        
    12.
    Ling RSM, Charity J, Lee AJC, Whitehouse SL, Timperley AJ, Gie GA The long-term results of the original Exeter polished cemented femoral component. J Arthroplasty 2009;24:511-7.  Back to cited text no. 12
        
    13.
    Loures FB, Cost-effectiveness of surgical treatment for hip fractures among the elderly in Brazil. Orthop Traumatol Surg Res 2010;96:44-8.  Back to cited text no. 13
        
    14.
    Baker RP A medium-term comparison of hybrid hip replacement and Birmingham hip resurfacing in active young patients. J Bone Joint Surg Br 2011;93:158-63.  Back to cited text no. 14
        
    15.
    Peck CN Leg length discrepancy in cementless total hip arthroplasty. Surg Sci 2011;2:183-7.  Back to cited text no. 15
        



     
     
        Tables

      [Table 1], [Table 2]



     

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