journal of international academic research for … · 2014-11-06 · journal of international...

JOURNAL OF INTERNATIONAL ACADEMIC RESEARCH FOR MULTIDISCIPLINARY Impact Factor 1.625, ISSN: 2320-5083, Volume 2, Issue 10, November 2014

327 www.jiarm.com

FUNCTIONAL OUTCOME OF TOTAL HIP REPLACEMENT BY MOORES APPROACH

DR.LEELA PRASHANTH* DR. SANKAR MOHAN**

*M.S Orthopaedis, Mahatma Gandhi Medical College And Research Institute, Pondicherry, India **M.S Orthopaedis, Mahatma Gandhi Medical College And Research Institute, Pondicherry, India

ABSTRACT

Pain in the hip joint causes disability in human locomotion. Osteoarthrosis of the hip

is one of the oldest affliction of mankind. No race has been exempted from this disease. Total

hip arthroplasty has an operative history of over 100 years which has been reviewed and

improved over previous years making it the most successful operation of this generation. The

present study was conducted to study the functional outcome and complication of total hip

replacement by moore’s approach. In this study of 30 patients, with 33 diseased hip, aged

between 19 to 70 years were treated with total hip replacement in our institution and followed

up for a period of 24 months. Patients were evaluated functionally. The evaluation was done

by using Harris hip score(modified) showed excellent results in 18 hips, good in 10 hips, fair

in 3 hip. No poor results were noted. This study shows that total hip replacement by moores

approach is the best choice in younger individuals with good bone quality. With proper

patient selection, adequate planning and meticulous surgical technique, we have achieved

results which can be comparable to other authors. In a nutshell, our institute has performed

this procedure with technical precision which has provided us with very good clinical result.

Functional results are excellent and complications are minimal if done with care and

precision. As this is only a short term study, long term follow-up and evaluation is essential

to come out with a definitive conclusion.

KEYWORDS: Hip, Replacement, Moore’s, Arthroplasty, osteoarthritis

INTRODUCTION

Osteoarthrosis of the hip is one of the oldest afflictions of mankind. No race has been

exempted from the disease and the etiology of the condition has been the subject of

controversy and speculation1.

Pain in the hip joint is one of the most common causes in disabling human locomotion. Pain

in the hip may be due to various causes like intraarticular fractures of hip or arthritic changes.

Arthroplasty is an operation done to relive pain in the joint and improve function of

the muscles ligaments and other soft tissues structure included in the joint.


328 www.jiarm.com

Total hip arthroplasty has an operative history of over 100 years which has been

reviewed and improved over previous years making it one of the most successful operations

of this generation.

The goal of this operation is to relive pain and promote motion and stability of the

joint simultaneously correcting the deformity which in turn allows them lead a pain free and

normal life2.

Commonly indicated in older age group suffering from osteoarthritis, failed

conservative management and comparatively sedentary life style. It can also be done in a

younger age group who have multiple joint involvement caused due to Rheumatoid arthritis,

SLE or other systemic disorders3. Other indication being Avascular necrosis, metastatic

disease, ankylosing spondilitis.

Treatment for the pain for the above mentioned condition includes analgesics,

arthrodesis, excision arthroplasty, osteotomy and replacement arthroplasty, out of which

replacement arthroplasty provide best outcome and results4.

Total hip arthroplasty is a reconstructive hip procedure in which the degenerated,

destroyed head is replaced by artificial femoral head and acetabulum socket. This causes

immediate pain relief, mobile stable joint, it can be done using methylmethacrylate(bone

cement) or without cement. Usage of cement causes load of the body weight to be distributed

over a large area of bone, but loosening of the cement is a common complication.

So biological fixation emerged, but the overall results were not good enough. Finally

with the advent of porous coated implant, which allows the bone to penetrate the surface of

the prosthesis, complete fixation and better results are achieved5.

Therefore proving that the primary surgery has the highest success rate, it must be

done with technical precision other factors included for best results are proper patient

selection, implant selection and implantation.

We have decided to study the short-term follow up of functional results of total hip

arthroplasty by Moore’s approach, done in our institution.

Aims and Objectives

1. To study Functional Outcome of Total Hip Replacement by Moore’s Approach.

2. To study the complications associated with Total Hip Replacement by Moore’s approach


329 www.jiarm.com

REVIEW OF LITERATURE

HISTORY

The first surgery of the hip which had any resemblance to what is now known as

arthroplasty was performed by White of Westminster hospital in 1822. He excised the upper

end of femur in a 9 year old boy of sepsis and deformity6. Arthroplasty in the broadest sense

is a reconstructive procedure that alters the structure or function of a joint. Although major

surgical procedures occasionally were performed in early 1800s. It was not until the

introduction of general anaesthesia and aseptic techniques during the later half of the 19th

century. The idea and the procedure to implement had slowly and painstakingly evolved over

a period of about 155 years.

Rhea Barton in 1826 performed the first inter trochanteric osteotomy of femur with

an ankylosed hip in a sailor of 21 years age7.

Gluck and his successor Jules Emile Pean 1830 -1898 used rubber and platinum. The

earliest recorded attempts at hip replacement was noted in germany 1891 by Professor

Themistocles Gluck used ivory to replace femoral heads of patient whose hip joints has been

destroyed by Tuberculosis8.

Later surgeons experimented with “Interpositional Arthroplasty”in late 19th and early

20th century. They placed various tissues (fascia lata, skin, pigs bladder submucosa) between

the articulating hip surfaces. In 1902 Jones removed the femoral head and covered the neck

with gold foil. Baer in 1918 used chromicised submucosa of a pig's bladder that became

known as Baer's membrane. At the same time Dr Ban saw used hand made ivory component

for patients with femoral neck fractures in which 83% returned to sport and bicycle riding

within weeks post surgery 9.

In 1919 Belbet used rubber prosthesis to replace head of femur2

In 1925 Marius Smith Peterson created the “First Mould Arthroplasty” out of glass10.

It consisted of hallow hemisphere which was fitted over the femoral head and provided a new

smooth surface for movement, but it failed as it couldn’t with stand the force going through

the hip joint and shattered.

The result which provided a reasonable range of movement and comparative

stability. In 1923 and 1925, Lorenz performed osteotomy of upper femoral shaft7

Hey Groove 1933 modified and reviewed the methods for reliving pain in the hip

joint. He indicated the requirement of osteotomy in patient with varus deformity11.


330 www.jiarm.com

Mc Murray 1935 created a method called Lorenz procedure in which “osteotomy”

Above the level of lesser trochanter with medial displacement of femoral shaft was done for

the treatment of unilateral osteoarthritis12.

Malkin 1936 described a simple trochantric osteotomy in which the femur is divided

at the level or just below the lesser trochanter13.

If deformity is adduction bone divided in a plane slightly oblique from downwards

and inwards. when the deformity is external rotation the division of the bone is transverse

with no obliquity of the shaft, then rotated required amount.

In 1940 Bohlmann and Neones from America used a stainless steel metal prosthesis

which was a major step forwarded for future development

Later Marius Smith Peterson along with Philip Wiles went on to try the current

material of choice stainless steel and filled it using bolts and screws creating the first Total

Hip Replceament14.

In 1952 Thompson and Moore described their long stemmed metal prosthesis,

however it caused erosion of the pelvis, that bought light on resurfacing the acetabulum15.

In 1953 the first person to use metal on metal prosthesis on regular bases was English

surgeon Ge0rge McKee and Watson Farrar modified Thompson stem (Cemented

Hemiarthroplasty) used for neck of femur fracture treatment with one new piece cobalt-

chrome socket as the new acetabulum16. The survival rate of this prosthesis was 74%. It lost

popularity due to the local effects of metal particles seen during revision surgery for

prosthetic failure.

Sir John Charnley who worked at the Manchester Royal Infirmary is considered as

“Father of Modern Total Hip Replacemet”17.

He designed a low frictional arthroplasty in early 1960 which is very similar to the

prosthesis used today. It consists of 3 parts metal femoral stem , a polyethylene acetabular

component, acrylic bone cement which he borrowed from dentist. It was called Low friction

arthroplasty due to the use of small femoral head reduces wear due to its smaller surface.

He divided his work in total hip arthroplasty in 6 phases of development18:

Phase 1:Basic research into lubrication of normal animal joints

Phase 2:Use of Polytetra fluroethylene, Teflon

Phase 3:Low friction arthroplastyas a principal

Phase 4 :Bonding of implant to the living bone using acrylic cement

Phase 5:High density polyethylene


331 www.jiarm.com

Phase 6:Control of infection and thromboembolism

Charnely work was followed by Muller with his own modification to the desigin of

cemented Total hip prosthesis19

Uncemented metal prosthesis was introduced in 1960, the initial ring prosthesis

consisted of a metallic acetabular component screwed in to the pelvis.

In 1960, Tronzo modified the Acetabular screw with 1 large and 3 smaller prongs,

which were driven into the acetabulum preventing rotation.

Method used for cementless fixation of implants are press fit fixation, macro interlock

fixation(steps,ribs, threads,fluts) and bone ingrowth. Cementless fixation is more preferred

for young patients in whom revision surgery may be necessary at a later date. In the late

1960’s and early 1970’s the first reports of biological fixation with porous metals came. Both

cobalt-chrome alloys and commercially pure titanium were shown to allow bone ingrowth if

the surface was porous20 or textured with sintered fiber metal21

Metal on polyethylene was most widely used in total hip arthroplasty. Early success

of Charnley prosthesis in 1970 polyethylene based implants almost completely displaced all

other bearing surfaces22. The main concern being PE debris which creates periprosthetic

osteolysis by the release of cytokines and proteolytic enzymes-leading to implant failure23.

Metal on Metal is next in row which caused metallosis, which had a carcinogenic risk,

hypersensitivity reaction and loosening. The wear in metal on metal is 60 times less than that

metal on PE24. On long term metal on metal liberates metal ions with cobalt and chromium

which are increased3-5 times in blood than compared to metal on PE.

In 1970 a French surgeon Pierre Boutin used ceramic head for the first time in central

europe25,26. The benefits of this being high level of hardness, scratch resistance, the inert

nature of debris compared to metal or PE.27.

In 1970 Charnely used cement taken from dentist for improving the grout rather than

gluing the prosthesis28, but the cement failed so there emerged the idea of cementless

prosthesis.

The cementless prosthesis have a specialized coating, hydroxyapatite, that allows in

growth of the bone and thus the fixation of the prosthesis. it also allows easier planning of

revision surgery, particularly in younger patients, with greater preservation of bone tissue.

cementless has got better short term outcome with no radiological difference29.

In recent year minimally invasive surgery is gaining popularity as it provide soft

tissue sparing, bone conservation option, reduced intra op blood loss, shorter hospital stay,


332 www.jiarm.com

faster rehabilitation and good cosmetic result while not compromising the complications30,31.

The disadvantages being limited visibility of anatomical landmarks and vital structures32.

Entering the second decade of use, computer-assisted total hip replacement utilizes

the digital image system to map the position of surgical instrument with relation to

anatomical landmarks, helping to obtain reproducible and accurate placement of implants.

Disadvantages being In actuality navigation leads to increase surgical time, elevated cost and

operation complexity30.

Some discussions regarding the use of computer assisted with minimally invasive

improves the outcome is yet to wait and see.

Despite of over 100 years history in total hip arthroplasty, a technique and material to

suit all patient characteristics is not yet a reality.

Corten et al reported the long term results in which cemented and uncemented was

compared in 250 patients, in which 126 were uncemented and 124 were cemented, the mean

duration was 20 years. The survivorship of uncemented stem was 100% and cup was 79%.33

Kim et al reported on the result patients less than 50 years of age and compared 157

patients, 79 uncemented and 78 cemented, mean follow up was 18.4 years. There was no

difference between the groups in terms of haris hip score, the cup and stem survival rates

were similar, there was high prevalence of anterior thigh pain in uncemented group.34

J. palan et al, multicenter prospective nonrandomized study in 1089 patient who

underwent total hip arthroplasty, 699 were treated by antero-lateral approach and 390 by

posterior approach, follow up being 5 years, there was no difference in post op oxford hip

score, the outcome in first 3 months and one year was better in posterior approach, there was

no difference in terms of complication and revision rates.35

Finally the most important modern advancement in arthroplasty surgery has been the

establishment of the joint registries; they provide data on survival, complication and can help

to establish standards for practice. American join replacement registry(AJRR) is currently in

process of being formalised.

SUBJECTS AND METHODS

This is a prospective study conducted at Department of Orthopaedics, Mahatma Gandhi

Medical College & research institute during the period from May 2011 to March 2013. We

had done 30 total hip replacement surgeries for a variety of indications.


333 www.jiarm.com

INCLUSION CRITERIA

Age >18 years

Degenerative joint diseases

1) Primary

2) Secondary

-Rheumatoid arthritis

-Ankylosing spondylitis

- -Septic arthritis

-Tubercular arthritis

-Developmental dysplasia of hip

-Tumours-involving proximal femur and

acetabulum

-Achondroplasia.

EXCLUSION CRITERIA

Sepsis - Any localized or distal septic focus is an absolute

contraindication

Progressive Neurologic and musculoskeletal disorders

Revision surgery

Peri- prosthetic fracture

Total hip replacement done in other approaches

DATA COLLECTION

All data was entered into data collection Proforma sheet (Appendix 1) and were

entered in to the excel (M S Excel 2011). The Sheet had a visual map for marking and

divided into indication for both genders. Other biographical details were also collected

including age, sex, side effected.

STATISTICAL METHODS

Table 1 An evaluation of HHS score pre post operative in patient study

HHS

SCORE Min-Max Mean ± SD difference t value P value

Pre op 16.00-73.00 33.70±14.84 - - -

Post op 78.00-96.00 88.79±5.29 54.827 19.880 <0.001**


334 www.jiarm.com

Student t test

Statistical Methods: Descriptive and inferential statistical analysis has been carried

out in the present study. Results on continuous measurements are presented on Mean SD

(Min-Max) and results on categorical measurements are presented in Number (%).

Significance is assessed at 5 % level of significance. The following assumptions on data is

made

ASSUMPTIONS:

1.Dependent variables should be normally distributed.

2.Samples drawn from the population should be random, Cases of the samples should be

independent

Student t test (Paired) has been used to find the significance of HHS score

SIGNIFICANT FIGURES

+ Suggestive significance (P value: 0.05<P<0.10).

* Moderately significant ( P value:0.01<P 0.05)

** Strongly significant (P value : P0.01)

Statistical software: The Statistical software namely SAS 9.2, SPSS 15.0, Stata 10.1,

MedCalc 9.0.1 ,Systat 12.0 and R environment ver.2.11.1 were used for the analysis of the

data and Microsoft word and Excel have been used to generate graphs, tables etc.

RESULTS

In this study we analysed 30 patients with 33 diseased hips treated with total hip

replacement between May 2011 to March 2013 in Mahatma Gandhi medical college &

research institute, Pondicherry.

All patients were evaluated clinically, preoperatively and at various follow up periods.

All the patients were analysed using Harris Hip Score evaluation, preoperatively and post

operatively.

AGE DISTRIBUTION

Out of 30 patients, 10 patients (33.3%) belonged to the age group between 31-40

years of age. 6 patients (20.1%) belonged to age group between 51-6o years of age and 4

patients (13.3%) were in the age group between 21-30 years of age. The youngest patient was


335 www.jiarm.com

19 years old and the oldest patient was 68 years old. The mean age of our study was

41.43years.

Table 2 : Age distribution

Age in years Patients %

18-20 3 10.0

21-30 4 13.3

31-40 10 33.3

41-50 4 13.3

51-60 6 20.1

61-70 3 10.0

Total 30 100.0

0

2

4

6

8

10

12

18‐20 21‐30 31‐40 41‐50

Figure1:Age of patients

SEX DISTRIBUTION Out of 30 Patients 19 (63.3%) were male and 11 (36.7) were females, thus showing male preponderance.

Table 3:Sex Distribution

SEX PATIENTS DISTRIBUTION

MALE 19 63.3% FEMALE 11 36.7%

MALE63%

FEMALE37%

0%0%

PATIENTS

Figure2:Sex Distribution


336 www.jiarm.com

PIE CHART SHOWING SEX DISTRIBUTION SIDE EFFECTED In our study 16(53%) had left side, 11 (37%) had right and 3 (10%) had bilateral hip joint

affection. All the 3 cases of bilateral hip got operated on both sides in our institution.

Table 4:Side Affected SIDE EFFECTED PATIENTS DISTRIBUTION

LEFT 16 53% RIGHT 11 37%

BILATERAL 3 10%

37%

53%

10%

Side affected

Right ‐11 Left ‐16 Bilateral ‐3

Figure3:Side affected

PIE CHART SHOWING SIDE AFFECTED INDICATIONS

The most common indication for surgery in our study was Avascular necrosis of the femoral

head with number of patients being 16 (54%). The other causes were secondary osteoarthritis

4 (13%), non union neck of femur 4 (14%) patients, post traumatic arthritis we had 4(13.3%)

patients, TB hip 1 (3.3%) patient and 1 patient with idiopathic chondrolysis.

Table 5: Indications

Diagnosis Patients %

AVN 16 54

Fracture neck 4 14

OA 4 13

Post-traumatic arthritis 4 13

Tb hip 1 3

Idiopathic chondrolysis 1 3

Total 30 100.0


337 www.jiarm.com

54%

14%

13%

13%

3%3%

Indications AVN‐16

Non union neck of femur‐4

Secondary osteoarthritis‐5

Post traumatic arthritis‐4

Tb Hip‐1

Idiopathic chondrolysis

Figure4:PIE CHART SHOWING INDICATIONS

The preoperative hip score ranging from 16 to 56, with an average of 34 in our study.

In our study, post op Harris hip score(modified) showed 18 (60%) cases showed excellent

results, 10 (33.3%) cases showed good results, 1 (3.3%) case had fair results and no poor

results.

Table 6:Pre and Post op HHS

Outcome Pre op Post op % change

Excellent 0 18(60%) +60%

Good 0(0.0%) 10(33.3%) +33.3%

Fair 0(0.0%) 1(3.3%) +3.3%

Poor 30(100%) 0 -

All the patients were analyzed by using Harris hip score38

Based on the Harris Hip Score (HHS), the results were divided into excellent, good, fair and

poor as below:

Excellent : > 90 points

Good : 80-89 points

Fair : 70-79 points

Poor : <70 points


338 www.jiarm.com

0

5

10

15

20

Excellent Good Fair Poor

Harris hip score

Figure5:Harris hip score

COMPLICATIONS:

In our study, the following complications were noted.

Dislocation

We had 2 cases (6.7%) of posterior dislocations in our study. One case got dislocated

on the 2th post – operative day while the patient was trying to sleep on the lateral position in

the bed and the other patient the head size was small and caused dislocation, one cases was

managed by closed reduction following Allis’ technique and skeletal traction for a period of 3

weeks. The other patient we revised the surgery and changed the head size to +2mm. The

patients were then discharged and regularly followed- up. No further episodes of re-

dislocation were noted.

Sciatic Nerve palsy:

One patient (3.3%) had sciatic nerve palsy since the immediate post operative period.

This was due to traction injury. The patient is using foot drop splint.

Death:

1 Patient(3.3%) had death postoperatively due to “DIC” (disseminated intravascular

coagulation)

6.7

3.3 3.3

0

2

4

6

8

10

Dislocation Expired Foot drop

Percentages

Complications

Figure6:Complications


339 www.jiarm.com

DISCUSSION

Total hip replacement is a permanent method of relieving pain in the hip due to various

conditions. The aim of the surgery is to relieve pain, at the same time to preserve motion and

stability of the joint.

Cemented total hip replacement has some limitations like the long term complications

associated with the cementing technique mainly aseptic loosening and difficult revision

surgeries. The challenge comes when patients of younger age group are to be operated

because, then every technical detail must be used and followed so that the patient has a

reasonable chance of 20 of more years of trouble free activity and survival.

Uncemented total hip replacement is the procedure of choice for younger individuals in

whom total hip replacement is contemplated. The first generation cementless implants were

associated with a high incidence of thigh pain, aseptic loosening, stress shielding and

osteolysis. With the advancement and refining of implant designs and materials, the new

generation cementless implants, which are commonly porous coated, are associated with less

incidence of complications and provide better results.

Y.H. Kim et al., from the Ewha Womans University College of Medicine, Seoul, Korea,

prospectively analysed the long term results of the cementless porous-coated anatomic total

hip prosthesis in 119 patients (131 hips), surgeries done between January 1984 and January

1986.60

Jeremy et al., from the university of Utah, USA analysed retrospective review in 40 total hip

with a follow up for 5 years , surgery was done in between 1996-2008.61

Siwach et al., from department of orthopaedic, PGIMS, Haryana, India made a retrospective

study in 100 patients, where surgery was done in between 1993 to 2003. There were 52 males

and 48 females.62

Since the materials and methods used for the analysis were similar to our study, these studies

was chosen for the comparison of results of our study.

M.J. Bryant, W.G. Kernohan, J.R. Nixon and R.A.B. Mollan from Musgrave Park Hospital,

Belfast of Northern Ireland, analysed 13 methods of hip scoring systems in the postoperative

assessment of 47 hip arthroplasties. They concluded that three essential variables for

measurement appear to the walking distance, hip flexion and pain, and these three variables

should be recorded separately.63


340 www.jiarm.com

Since Harris Hip score system includes all the essential criteria with adequate weightage for

functional assessment, it is widely accepted as a good scoring system and we have also used

this in our study.

Table 7: mean follow up

Study Follow up Kim et al 2years

Jeremy et al 5 years Siwach et al 3 years Our study 2 years

The follow up period in average in Kim et al was 2 years, Jeremy et al had a mean

follow up for 65 months (range 24-151) Siwach et al had mean follow up for 3 years (range 2

to 8) since our study is short term study we included the above study.

Table 8:Age Study Age Mean

Kim et al 19 to 69 48.4 Jeremy et al 15 to 39 22.3 Siwach et al 35 to 70 52.4 Our study 19 to 70 41.4

In the study of Kim et al the mean age was 48.4 years (range, 19 to 69) Jeremy et al

22.3 years (15 to 39) and Siwach et al was 52.4(35 to 70) and was compared to our study

which was 41.4 years (range, 19 to 70) in our study.

Table 9:Etiology

Study Etiology Mean Kim et al AVN 62 hips(47%) Jeremy et al Paediatric hip disease 21 hips (52.5%) Siwach et al AVN 26 hips(31%) Our study AVN 16 hips(53.3%) The common indications for the surgery in Kim et al were avascular necrosis of femoral head

in 62 hips (47%), arthritis in 33 hips (25%) and fractures of neck of femur in 27 hips (21%).

In the study of Jeremy et al, the most common cause was paediatric hips disease in 21

hips(52.5%), following avascular necrosis of femoral head in 30%, 3 patients(7.5%) had

inflammatory arthritis.

In the study of Siwach et al, avascular necrosis of femoral head in 26

patient(31%),Rheumatoid in 17 patients(21%), fractures of neck of femur 10 patients(22%)

and osteoarthritis in 16 patient(19%).


341 www.jiarm.com

In our study, the common indications were following avascular necrosis in 16 patient

(53.4%), arthritis in 5 patient (16.7%), fractures of neck of femur in 4 patient (13.3%),Post

traumatic arthritis in 4 patient(13.3%) and TBhip(3.3%).

Table 10:Pre and Post HHS

Study Pre op HHS AVG Post op HHS AVG Kim et al 12 to 74 55 75 to 100 95

Jeremy et al 57 to 68 62 92 to 97 94 Siwach et al 30 to 50 44 62 to 96 83 Our study 16 to 56 34 78 to 96 88

In Kim et al., study, the preoperative hip score ranged from 12 to 74 with an average of 55.

In Jermey et al study, the preoperative hip score ranged from 57 to 68 with an average of 62.

In Siwach et al study, the preoperative hip score ranged from 30 to 50 with an average of 44.

In compared to the preoperative hip score ranging from 16 to 56, with an average of 34 in our

study. The lesser preoperative Harris hip score in our study may be due to the fact that Indian

patients go in for Joint replacement surgery only after advanced changes in the joint.

Table 11:Outcome in all studies Study Excellent Good Fair Poor

Kim et al 75% 19% 6% 0 Jermey et al 76% 16% 8% 3% Siwach et al 0 75% 33.3% 7% Our Study 60% 19% 3.3% 0

After 2 years of follow up Kim et al of 128 hips, the results were excellent in 96 hips (75%),

good in 24 hips (19%), fair in 8 hips (6%) and poor in none of the hips (0%), with the mean

postoperative Harris hip score of 95 (range, 75 to 100).

After 5 year of follow up in Jeremy et al of 34 patients , the results were excellent in 19

hips(76%),good in 9 hip (16%),5 hip (8%) fair with no poor results, with post operative

Harris hip score of 94(range,92 to 97).

After 3 year of follow up in Siwach et al of 100 patients, the results 75% good results,18%

fair and 7% poor, with postoperative Harris hip score 83(range,62 to 96)

In our study, after 11.3 months of mean followup, the results were excellent in 18hips (60%),

good in 10 hips (33.3%), fair in 1 hips (3.3%) and no poor results, with the mean post

operative Harris hip score of 88 (range, 78 to 96).

After 19.4 years of followup (in Kim et al., study), the results were excellent in 64 hips

(58%), good in 8 hips (7%), fair in 6 hips (6%) and poor in 32 hips (29%), with the mean hip


342 www.jiarm.com

score of 85 (range, 45 to 100). In most cases, this could be attributed to age – related

deterioration in function.

Kim et al., (1987) treated 38 cases of tuberculous arthritis with total hip replacement

with quiescent period ranging from 3months to 45 years. Intraoperative culture was positive

in 4 cases64. No reactivation of disease was seen in these cases. He recommended anti –

tuberculous chemotherapy for 3 weeks preoperatively and for 6 to 9 months postoperatively.

Teak Rim Yoon, Sung Man Rowe, Iwan Budiwan Anwar and Jae Yoon Chung treated

tuberculous hips with one stage total hip replacement and anti-tuberculous chemotherapy. No

signs of reactivation was seen after mean follow up of 3 years65

In our study, we had operated a case of tuberculous arthritis under anti-tuberculous

chemotherapy cover, and no reactivation or infection was seen.

Total hip arthroplasty appears to be a safe procedure for patients who have quiescent

as well as active tuberculosis of the hip when there is no gross evidence of infection.

Robert et al, had study on rapid progressive disease of hip treated with total hip

replacement showed good results on harris hip score66

In our study, we had a case of Idiopathic chondrolysis treared with total hip

replacement.

With his study, Kim et al., suggested that uncemented acetabular components with

polyethylene of better quality and a better capturing mechanism, or with alternative bearing

surfaces such as ceramic - on - ceramic, may provide longer lasting results.

In our study most of the patient were young age group falling between 31 to 40

years, hence uncemented total hip replacement was done using porous coated stems.

The approach used was posterior approach and advantages being preservation of

abductor mechanism, excellent exposure of acetabulum, the complication associated with this

approach was Posterior dislocation.

In Jeremy et al61 used posterior approach in 30(75%) in which 4(10%)hips had

dislocation.

Amstutz67 et al. in their study have reported a 3% incidence of dislocation of hip in

first week. In our study, 1 of the 2 cases (5%) had dislocation in the 1st week.

Fackler CD68 et al. in their study have reported a 2% incidence of dislocation after

primary hip arthroplasty.

In our series, dislocation of the hip occurred in Two case(6.7%). One patient while

patient was trying to sleep in lateral position, other due to smaller size head, which was


343 www.jiarm.com

treated with revision and increasing the head size, the other patient closed reduction was

performed, skeletal traction was applied for period of 3 weeks.

Although wear of the bearing surface continues to limit the long - term success rate of

arthroplasty, there is a predictable long term stability of the bone implant interface achieved

with cementless fixation.

The strength of this study is that all hips were primary uncemented arthroplasties, All

were done using a uniform technique, done by same surgeon and no patient lost for follow -

up. The limitation of the study is that the sample size is small and the follow-up duration is

not very long so as to demonstrate the long term complications of this procedure.

CONCLUSION

Based on the results and the methodology employed, we have concluded that: The

total hip arthroplasty is the best choice of surgery for hip diseases in younger individuals with

good bone quality. The learning curve for the total hip arthroplasty to produce better results

of this surgery is fairly big.

Since the first total hip arthroplasty in 1891, research has developed from perfecting surgical

technique to advances in technology (with respects to both prosthesis design and materials) in

order to provide a reproducible technique that provides a good range of motion, stability and

most importantly adequate life span.

The use of porous coated implants had better primary stability and also later with bone in

growth, superior bond strength at the implant interface in comparison to cemented implants.

The preferred surgical approach is by Posterior Moores approach and the position is lateral

position, especially for the surgeons in the learning curve, since the surgeon will have better

three-dimensional orientation with no damage to the abductor mechanism of the hip and less

extensive tissue dissection.

The success of hip arthroplasty is predicted on proper patient selection, use of well designed

implants and skilled technical execution of the procedure.

In summary, total hip arthroplasty is a highly successful procedure in decreasing pain and

improving activity across all age groups, gender and geographical region. However the

controversies continue regarding the ideal prosthesis, bearing surfaces, method of fixation

and surgical approach.

As this is only a short term study, further long term follow up is necessary to study

the late complications and to prove the efficacy of the implants and procedure.


344 www.jiarm.com

1.1 MASTER CHART 1 A 38 M Business AVN L NIL 21 Poor 85 Good DISLOCA

2 B 59 F Housewif AVN B/L Diabet 23 Poor 80 Good Nil

3 C 37 M Farmer AVN B/L Nil 16 Poor 91 Excl Nil

4 D 55 M Business OA L Nil 23 Poor 92 Excl Nil

5 E 31 M Business OA L Nil 31 Poor 91 Excl Nil

6 F 65 F Housewif Tb hip L Diabet 20 Poor 80 Good nil

7 G 55 M housewif PTA R Nil 61 Poor 78 Fair Footdrop

8 H 26 M Business PTA R Nil 24 Poor 92 Excl Nil

9 I 35 F Farmer AVN L Nil 19 Poor 86 Good Nil

10 J 60 M Farmer PTA R Htn 26 Poor ‐ ‐ expired

11 K 68 M Shopkeep AVN L Nil 23 Poor 92 Excl Nil

12 L 60 F Housewif NFN L Nil 24 Poor 91 Excl Nil

13 M 39 M Business AVN B/L Nil 18 Poor 90 Excl DISLOCA

14 N 29 M Engineer NFN R Nil 23 Poor 86 Good Nil

15 O 36 M business AVN L Nil 56 Poor 90 Excl Nil

16 P 40 F Housewif AVN R Nil 20 Poor 80 Good Nil17 Q 45 F Housewif AVN L Nil 23 Poor 88 Good Nil

18 R 60 F Housewif NFN L Nil 30 Poor 90 Excl Nil

19 S 31 F Business AVN L Nil 73 Poor 92 Excl Nil

20 T 19 F Student AVN L Nil 30 Poor 80 Good Nil

21 U 19 M Student IC L NIL 56 Poor 94 Excl Nil

22 V 32 M Business OA L NIL 56 Poor 96 Excl Nil

23 W 39 M Agricultur AVN L Nil 46 Poor 94 Excl Nil

24 X 42 M Business AVN L Nil 35 Poor 92 Excl Nil

25 Y 63 M Agricultur OA L Nil 40 Poor 90 Excl Nil

26 Z 22 M Business AVN L NIL 32 Poor 95 Excl Nil

27 A1 49 F Housewif OA R NIL 38 Poor 96 Excl Nil

28 B1 20 M Student AVN L NIL 36 Poor 94 Excl Nil

29 C1 32 M Business AVN R NIL 42 Poor 86 Good Nil

30 C2 42 F housewif NFN R NIL 46 Poor 84 Good Nil

CLINICAL & RADIOLOGICAL PHOTOGRAPHS

A: AVN– EXCELLENT RESULT


345 www.jiarm.com

Pre Op Post Op

1 Year Post op

Scar Flexion


346 www.jiarm.com

Abduction Adduction

Internal Rotation External Rotation

COMPLICATIONS

Case1-Dislocation Case 2- Dislocation

Case 3-Foot drop


347 www.jiarm.com

REFERENCES 1. Nicoll EA, Holden NT. Displacement osteotomy in the treatment of osteoarthritis of the hip. J Bone

Joint Surg Br 1961; 43 B:50-60. 2. Pachore JA, Jhunjhunwala HR. Total Hip Arthroplasty. In: GS Kulkarni, editor. Textbook of

Orthopaedics and Trauma, 2nd ed. New Delhi: Jaypee; 2008. p.3675-3738. 3. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet.

2007 Oct 27; 370(9597):1508-19. 4. Wroblewski BM, Siney PD, Fleming PA. The Charnley LFA: The Wrightington Hospital. In: Finerman

GAM, Dorey FJ, Grigoris P, Mckellop HA, editors. Total Hip Arthroplasty Outcomes. New York: Churchill livingstone; 1998. p.15-29.

5. Helsinki et al - Results of total hip arthroplasty in young and active individuals-JBJS, Vol. 86-B, 2004, by Helsinki (EFORT).

6. Barton JR. On the treatment of anchylosis by the formation of artificial joints. North Am Med Surg J 1827; 3:279-292.

7. Lorenz, Aloenz, A. (1923): A New Method of Treatment of Irreducible, Acquired or Congenital Hip Dislocations. New York Medical Journal, 117, 130.. (1923): A New Method of Treatment of Irreducible, Acquired or Congenital Hip Dislocations. New York Medical Journal, 117, 130.

8. Gluck T.Autoplastic-Transplantation-Implantation von Fremdkorpern. Klin Wochenschr 1890; 27: 421. 9. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet

2007;370:1508-19. 10. Nygaard Smith-Petersen M,Zerahan B, Bruce C, Soballe K, Borgwardth A. Early perprosthetic

femoralbone remodelling using different bearing material combination in total hip arthroplasties: a prospective randomised study, Eur Cell Master 2004;31(8): 65-73

11. Groves, E. W. Hey (1933): The Surgical Treatment of Osteo-arthritis of the Hip. British Medica/Journal, i, 3.

12. McMurray, T. P. (1935): Osteo-arthritis of the Hip-Joint. British Journal of Surgerr, 22, 716. 13. Malkin, S. A. S. (1936): Femoral Osteotomy in Treatment of Osteo-arthritis of the Hip. British Medical

Journal i, 304. 14. Wiles P W. The surgery of the osteoarthritic hip. Br J Surg 1958; 45: 488 15. Moore A T. The self-locking metal hip prosthesis. J Bone Joint Surg (Am) 1957; 39: 811-27 16. McKnee G K, Watson-Farrar J. Replacement of arthritic hip by the McKee-Farrar prosthesis, J Bone

Joint Surg 1966 (Br); 48: 254. 17. 17)Charnely J. Low friction arthroplasty of the hip. Theory and practice.1979, Springer-Verlag, Berlin:

3 18. Charnley J. Total hip replacement by low friction arthroplasty. Clin Orthop 1970; 72:7-21. 19. Charnley J. Anchorage of the femoral head prosthesis to the shaft of the femur. J Bone Joint Surg Br

1960; 42 B:28-30. 20. Pilliar R M, Cameron H U, Macnab I. Porous surface layered prosthetic devices. Biomed Eng 1975; 10

(4): 126-31. 21. Galante J O, Rostoker W, Lueck R, Ray R D. Sintered fiber metal composites as a basis for attachment

of implants to bone. J Bone Joint Surg (Am) 1971; 53 (1): 101-14. 22. Amstutz HC, Grigoris P. Metal on metal bearings in hip arthroplasty. Clin Orthop Relat Res

1996;329:S11-34 23. Bizot P, Nizard R, Hamadouche M et al. Preventation of wear and osteolysis: alumina-on-alumina

bearing.Clin Orthop Relat Res 2001;393:85-93 24. Cuckler JM. The rational for metal-on-metal total hip arthroplasty. Clin Orthop Relat Res

2005;441:132-6 25. Sandhu HS, Middleton RG. Controversial topic in orthopaedic: ceramic-on-ceramic. Ann R Coll Surg

Engl 2005;87:415-6 26. Boutin P. Total arthroplasty of the hip by fritted aluminium prosthesis. Experimental study and 1st

clinical applications. Rev Chir Orthop Reparatrice Appar Mot 1972;58:229-46 27. Bierbaum BE , Nairus J, Kuesis D et al Ceramic-on-ceramic bearing in total hip arthroplasty. Clin

Orthop Relat Res 2002:405:158-63. 28. Charnley J . Arthroplasty of the hip: a new operation. Lancet 1961;1:1129- 32. 29. Ni GX, Lu WW, Chinu KY, Fong DYT. Review article: Cemented or uncemented femoral component

in primary total hip replacement? A review from clinical and radiological perspective. J Orthop Surg 2005;13:96-105.

30. Reininga IH,Zijlstra W, Wagenmakers R et al. Minimally invasive and computer navigated total hip arthroplasty: a qualitative and systemic review of literature BMC Musculoskeletal Disorder 2010;11:92.


348 www.jiarm.com

31. Berry DJ,Berger RA, Callaghan JJ, et al, Minimally invasive total hip arthroplasty:development, early results and a critical analysis- presented at the annual meeting of American Orthopaedic Association,Charleston,South Carolina, USA, June 14, 2003. J Bone Joint Surg Am 2003;85A:2235-46.

32. Callaghan J. Skeptical perspective on minimally invasive total hip arthroplasty. J Bone Joint Surg Am 2006;85:2242-3.

33. Corten K, Bourne RB,Charron KD, AU K, Rorabeck CH. Comparison of total hip arthroplasty performed with and without cement: a randomized trail. A concise followup, at twenty years, of previous report. J Bone Joint Surg Am. 2011 jul 20;93(14):1335-8.

34. Kim YH, Kim JS, Park JW, Joo JH. Comparision of total hip replacement with and without cement in patients younger than 50 year of age: the results at 18 years. J Bone Joint Surg Br. 2011 Apr;93(4):449-55.

35. Palan J, Beard DJ, D.Phil, Murray DW,F.R.C.S.(Orth), Andrew JG,FRCS (O, Nolan J. Which Approach for Total Hip Arthroplasty: Anterolateral or Posterior? Clin Orthop 2009 02;467(2):473-7.'

36. Mahadevan V. Pelvic Girdle and Lower Limb. In: Standring S, editor. Gray’s Anatomy. The Anatomical Basis of Clinical Practice, 40th ed. London: Elsevier Churchill Livingstone; 2008. p.1349-1392.

37. Turek SL. The Hip. In: Orthopaedics: Principles and their Application, 4th ed. Philadelphia: Lipincott-Raven; 2006. p.1109- 1268

38. Harkess JW, Crockarell JR Jr. Arthroplasty of the Hip. In: Canale ST and Beaty JH, editors. Campbell’s Operative Orthopaedics, 11th ed. Philadelphia: Mosby; 2008. p.312-482.

39. Crowninshield RD, Johnston RC, Brand RA, Pederson DR, Wilson MA, Tolbert JR. An engineering analysis of the total hip component design. Orthop Rev 1983; 12:33-45.

40. Davey JR, O’Connor DO, Burke DW, Harris WH. Femoral component offset. Its effect on strain in bone-cement. J Arthroplasty 1993; 8:23-26.

41. Davey JR, O’Connor DO, Burke DW, Harris WH. Femoral component offset. Its effect on strain in bone-cement. J Arthroplasty 1993; 8:23-26.

42. Charnley J, Ferreira A. Transplantation of the greater trochanter in arthroplasty of the hip. J Bone Joint Surg Br 1964; 46 B:191-197.

43. Thompson RC Jr, Culver JE. The role of trochanteric osteotomy in total hip replacement. Clin Orthop 1975; 106:102-106.

44. Coventry MB. The surgical technique of total hip arthroplasty, modified from Charnley, as done at the Mayo clinic. Orthop Clin North Am 1973; 4:473-482.

45. Steinberg B, Harris WH. The “offset” problem in total hip arthroplasty. Contemp Orthop 1992; 24:556-562.

46. Muller ME. Total hip prostheses. Clin orthop 1970; 72:46-68. 47. Amstutz HC, Lodwig RM, Schurman DJ, Hodgson AG. Range of motion studies for total hip

replacements. A comparative study with a new experimental apparatus. Clin Orthop 1975; 111:124-130.

48. Livermore J, Ilstrup D, Morrey B. Effect of femoral head size on wear of the polyethylene acetabular component. J Bone Joint Surg Am 1990; 72:518-528.

49. Charnley J. The long term results of low friction arthroplasty of the hip performed as a primary intervention. J Bone Joint Surg Br 1972; 54 B:61-76.

50. Walker PS, Bullough PG. The effects of friction and wear in artificial joints. Orthop Clin North Am 1973; 4:275-293.

51. Daniel AU, Harkess JW. Introduction and Overview. In: Canale ST, Daughtery K, Jones L, editors. Campbell’s Operative Orthopaedics, 10th ed. Philadelphia: Mosby; 2003. p.223-242.

52. Ducheyne P. Biological fixation of implants. In: Ducheyne P, Hastings GW, editors. Functional behaviour of orthopaedic materials. Boca Raton, FL: CRC Press; 1984. p.163-199

53. Dunn MG, Maxian SH. Biomaterials used in orthopaedic surgery. In: Greco RS, editor. Implantation Biology: the host response and biomedical devices. Boca Raton, FL: CRC Press; 1994. p.229-252.

54. Bragdon CR, O’Connor DO, Muratoglu OK et al. A new polyethylene with undetectable wear at 12 million cycles. In: 24th Annual Meeting of the Society of Biomaterials. San Diego, CA; April 22-26 1998. p.2.

55. Uchida A, Nade SM, McCartney ER, Ching W. The use of ceramics for bone replacement. A comparative study of three different porous ceramics. J Bone Joint Surg Br 1984; 66 B:269-275

56. Charnley J. Characterisitics of self-curing acrylic cement. In: Acrylic Cement in Orthopaedic Surgery. Edinburg and London: Churchill livingstone; 1972. p.23-32.

57. Krause WR, Krug W, Eng B, Miller J. Strength of cement-bone interface. Clin Orthop 1982; 163:290-299


349 www.jiarm.com

58. Tarr RR, Clarke IC, Gruen TA et al. Total hip femoral component design: stem characterization, experimental studies and analytical modelling for the orthopaedic surgeon. Orthop Rev 1982; 11:23-36.

59. Oh I, Sander TW, Treharne RW. Total hip acetabular cup flange design and its effect on cement fixation. Clin orthop 1985; 195:304-309.

60. Y. H. Kim. . In: 2005 British editorial society of bone and joint surgery (eds.)Long-term of the cementless porous-coated anatomic total hip prosthesis. 1st ed. Seoul,Korea: J Bone Joint Surg [Br] 2005;87-B:; 2004. p623-7

61. Jeremy M Gililland. Mean 5 year clinican and Radiographic out comes of Cementless total hip arthroplasty in patients under the age of 30. Hindawi Publishing Corporation.2013;volume 2013(10.1155/2013/649506):7.

62. Siwach R C, Kadyan VS, Sangwan S S. Guota R. A retrospective study of total hip arthroplasty. Indian J Orthop 2007;41:62-6.

63. A Statistical analysis of hip scores, By Bryant MJ, Kernohan WG, Nixon JR and Mollan RA; Journal of Bone and joint Surgery(British) 1993 sep; 75(5): 705-9.

64. Zhang Y, M.D., Zhang H, M.D. One-stage Total Joint Arthroplasty for Patients With Active Tuberculosis. Orthopedics (Online) 2013 05;36(5):328-30.

65. Active Tuberculosis of the hip treated with early total hip replacement-a report of 3 cases; Taek Rim Yoon,Sung Man Rowe, Iwan Budiwan Anwar and Jae Yoon Chung; Acta Orthop Scand 2001; 72(4); 419-421.

66. Pivec R, Johnson AJ, Mont MA. Results of total hip arthroplasty in patients who have rapidly progressive hip disease: a systematic review of the literature. Expert Review of Medical Devices 2012 05;9(3):257-262.

67. Amstutz HC. Complications of total hip replacement .I. skeletal fixation and loosening of total hip replacements. Instr course lect 1974; 23:201.

68. Fackler CD, Poss R. Dislocation in total hip arthroplasties. Clin Orthop 1980; 151:169-178.

journal of international academic research for … · 2014-11-06 · journal of international...

Documents