Abstract
Background
Primary osteoarthritis of hip has been widely reported to be the leading cause for total hip replacement (THR) in the world. The other common causes are avascular necrosis of hip, inflammatory diseases and trauma sequelae. We report the prevalence of these disease as studied retrospectively at a tertiary healthcare centre and discuss the common age groups and sex ratios of these patients as compared to the West. Additionally, we compare the outcomes of these surgeries based on the aetiologies for which they were done.
Methodology
Patients who underwent primary THR in our institute within six years were called and retrospectively analysed. Revision cases were excluded. All the surgeries were done by a single experienced arthroplasty surgeon. On follow ups, functional scores were assessed using standard Harris hip score (HHS) and quality of life scores were assessed using the Short musculoskeletal functional assessment (SMFA) score.
Results
118 hips in 99 patients (M:F- 3.2:1) with a mean age group of 43.22 years, were operated over a period of six years. Non traumatic avascular necrosis (AVN) of hip topped the list in our study with 42.4% of cases, followed by post-traumatic sequelae (30.5%). These were followed subsequently by primary osteoarthritis (OA) (14.4%) and the remaining were inflammatory pathologies (IA). The HHS of patients with non traumatic AVN hip, traumatic sequelae and primary osteoarthritis were significantly superior to inflammatory arthritis with a p value of 0.001, 0.001 and 0.016 respectively. Additionally the short musculoskeletal functional assessment score was also significantly higher in IA than AVN, OA and post trauma groups (p = 0.001, 0.037 and 0.002 respectively); where a higher score denotes inferior outcomes.
Conclusion
In our part of the world, non traumatic AVN hip is the commonest indication for primary hip arthroplasty, followed by traumatic sequelae. The frequency of males undergoing hip arthroplasty is much more than females and at a younger age as compared to the West. Additionally, the functional outcomes in cases of inflammatory arthritis are inferior as compared to the other indications, probably because of associated contractures, deformity and spinal issues.
Keywords: Arthroplasty, Avascular necrosis, AVN, Epidemiology, Indications, Inflammatory arthritis, THR, Total hip replacement, Traumat sequelae
1. Introduction
Total hip replacement (THR) is one of the most successful surgeries since its advent and remains the treatment of choice for long-term functional restoration for patients with variety of hip conditions.1,2 The common indications for THR in western countries are Primary osteoarthritis (OA), Ankylosing spondylitis (AS), Avascular necrosis (AVN), Rheumatoid arthritis (RA) and trauma.3,4
Different etiologies create different biomechanics for hip arthroplasty. While AVN hip is a disease of relatively younger patients with healthy musculature, patients of primary OA may have wasted musculature because of advanced age. Hips with post traumatic sequelae could have physical defects, following primary effect of trauma or any primary surgeries done thereof. With such varied and vivid indications for a standard procedure, whether or not the indication itself, has an effect on the outcome is a valid question, that needs an answer.
In India there is paucity of literature even regarding the epidemiology of primary THR cases. Lack of regional or national arthroplasty registers is a major cause of this inadequacy.
The present study was conceptualised to determine the cross sectional prevalence of conditions requiring THR in a tertiary care hospital in North India, and their outcomes. In India, a relative younger population lives with a different lifestyle as compared to the western world, so the epidemiological and demographical profile of THR cases should be different as well. The present study tries to assess these profiles and provide some clarity in this aspect. Additionally the functional outcomes and quality of life were assessed and compared among the etiological groups.
2. Materials and methods
It was a retrospective study where in, patients who underwent total hip arthroplasty at our tertiary centre, by a senior arthroplasty surgeon between 2008 and 2013 were called to the outpatient department. Detailed history of each patient was taken for the aetiology of the primary disease and their previous hospital admission records were checked to complete the preoperative details. All 99 patients with 118 affected hips treated with total hip arthroplasty included in the study, were divided into four groups of IA, non traumatic AVN, Primary OA and sequelae of trauma like fracture acetabulum, fracture neck of femur and Pipkin's fracture.
3. Statistical analysis
2. Normally distributed continuous data were analysed with Analysis of Variance (ANOVA), followed by Tukey's test; the data was presented with descriptive statistics with Mean ± SD and their range of minimum and maximum values. After removing the confounding factors of age and sex, univariate analysis of data was done. A p-value of less than 0.05 was considered statistically significant.
4. Results
Out of the total of 118 hips, there were 50 cases of non traumatic AVN, 36 post traumatic sequelae, 17 primary OA and 15 cases of IA. 19 cases were bilateral and 80 were unilateral. The average follow up was 1.6 years.
Out of the unilateral cases, 49 patients had right hip involvement and remaining 31 had left hip pathologies. Uncemented THR was done more commonly in 75% of cases. Cemented techniques were mostly used in patients with trauma sequelae with deficient acetabulum and poor bone stock. Such cases also required usage of mesh, cages or rings in addition.
The average age of all the patients was 43.2 years, with IA patients belonging to the lowest age group and primary OA to the oldest. AVN group had 12 females and 38 males, primary OA group had 7 females and 10 males, IA group had 6 females and 9 males and post traumatic group had 31 males and 4 females [Table 1].
Table 1.
Epidemiological data of the THR patients and their outcomes.
| No. of patients | No. of Hips | Age (years) | Sex (M:F) | Side (R; L,; B/L) | Cemented/Uncemented | HHS | SMFA | |
|---|---|---|---|---|---|---|---|---|
| Atraumatic AVN | 38 | 50 | 39.32 | 3.2:1 | 18; 8;12 | 3/47 | 87.04 | 11.50 |
| TRAUMA sequelae | 36 | 36 | 46.08 | 8:1 | 23; 13; 0 | 23/13 | 84.25 | 13.02 |
| OA | 15 | 17 | 55.53 | 1.4:1 | 4; 9; 2 | 1/16 | 78.12 | 18.22 |
| IA | 10 | 15 | 37.53 | 1.5:1 | 4; 1; 5 | 3/12 | 76.25 | 26.7 |
| TOTAL/Mean | 99 | 118 | 43.20 | 3.1:1 | 49: 31; 19 | 30/88 | 81.41 | 17.36 |
THR: Total hip replacement; AVN: Avascular Necrosis; OA: Primary Osteoarthritis; IA: Inflammatory Arthritis; R: right; L: left; B/L: bilateral; HHS: Harris hip score; SMFA: short musculoskeletal functional assessment.
The mean standard Harris Hip Scores was highest in non traumatic causes of AVN (87.04) and lowest in inflammatory arthritis (76.25). After omitting confounding factors of age and sex the HHS was found to be significantly worse in the IA group as compared to AVN, OA and post trauma sequelae groups (p < 0.05). [Table 2].
Table 2.
Comparison of HHS among the groups.
| Diagnosis Versus | Diagnosis | Sig. |
|---|---|---|
| IA | AVN | .001 |
| OA | .016 | |
| Post-trauma | .001 | |
| AVN | IA | .001 |
| OA | 1.000 | |
| Post-trauma | 1.000 | |
| OA | IA | .016 |
| AVN | 1.000 | |
| Post-trauma | 1.000 | |
| Post-trauma | IA | .001 |
| AVN | 1.000 | |
| OA | 1.000 | |
AVN: Avascular Necrosis; OA: Primary Osteoarthritis; IA: Inflammatory Arthritis; HHS: Harris hip score.
The mean SMFA score was significantly highest for IA group (26.7) [Table 3]. A higher SMFA denotes inferior outcomes.
Table 3.
Comparison of SMFA among the groups.
| Diagnosis versus | Diagnosis | Sig. |
|---|---|---|
| IA | AVN | .001 |
| OA | .037 | |
| Post-trauma | .002 | |
| AVN | IA | .001 |
| OA | 1.000 | |
| Post-trauma | 1.000 | |
| OA | IA | .037 |
| AVN | 1.000 | |
| Post-trauma | 1.000 | |
| Post-trauma | IA | .002 |
| AVN | 1.000 | |
| OA | 1.000 | |
AVN: Avascular Necrosis; OA: Primary Osteoarthritis; IA: Inflammatory Arthritis; SMFA: short musculoskeletal functional assessment.
5. Discussion
THR remains the treatment of choice for restoration of hip function in patients with diseased or damaged hips. The common indications for THR are arthritis due to avascular necrosis, primary osteoarthritis, inflammatory arthritis and trauma.3,4 The functional outcomes of THR depends on various factors; patients’ profile, the surgical technique and the surgical implants; all these have roles to play in the ultimate quality of life the patient achieves.
Avascular necrosis of hip is bone death caused by poor blood supply to the femoral head that may eventually lead to its collapse, resulting in secondary osteoarthritis. It commonly occurs in middle aged males with recognised risk factors like alcohol, steroids, smoking, coagulation disorders etc. THR is generally required for advanced stages (ARCO stage 4b, 4c, 5, 6).4
Inflammatory arthritis consisted of AS and RA in our study. AS is a spondyloarthropathy affecting young men commonly involving the sacroiliac joints, vertebrae, pelvis and hip joints besides the extra articular involvement like restrictive lung disease, uveitis etc.5 Rheumatoid arthritis is a long-term autoimmune disease that causes inflammation of joints and the surrounding tissues most commonly in females. Typical symptoms include morning stiffness, symmetrical joint pains: usually bilateral and small joints are more often affected. Hip is commonly involved too and the disease process leads to joint destruction and secondary osteoarthritis.6
Post traumatic patients are a significant group for which THR is regularly performed. The spectrum of such patients includes fractures of neck of femur, fracture inter-trochanteric femur and acetabulum fractures, which managed either conservatively or operatively tends to present later with secondary joint degeneration, that would require THR.1
In the western world primary OA (69%) and trauma (13%) are two most common diseases reported, for which THR is done, followed by other diseases.3,7,8 In the present study however, etiological distribution favoured AVN (41%) and post fractures sequelae (29.5%).. This difference in Indian scenario could be due to the geographical variance, lower life expectancy and different lifestyle of Indian patients.3,9 The demography of India includes majority of people in younger, productive age groups. Thereby it could be the reason for AVN and increased road traffic trauma.
The average age of patients undergoing THR in the west is 60–70 years, that is a higher age profile compared to the Indian patients.3,10,11 In the present study it is highlighted, that the average age at which THR is done is relatively on the younger side. The older age groups of THR patients in the West could be due to the fact, that the life span in their population is comparatively more than Indians and hence patients generally present at a higher age group.
In the Western countries, for THR, the male female sex ratio is almost equal.3,8,10,11 In the present study though, males are shown to undergo much more number of hip replacements than females akin to the other Indian studies.12,13 The males dominate the cohort with a ratio of 3.1:1. The higher incidence of male population undergoing THR could be due to the high incidence of AVN and post trauma cases in our study, consisting mainly of post acetabulum fractures due to road traffic accidents.
AVN has a significant etiological relation with alcohol intake and smoking. In India, due to the social traditions and customs, it is the male population that predominantly consumes alcohol and smokes. Also, road traffic accidents could be higher in the male population, probably due to the trend of them travelling more, for livelihood, while non urban females generally take care of their homes; this makes the former, more susceptible to accidents.1
The technique of THR broadly involves usage of cement or otherwise. The newer designs of uncemented stems, that act by press-fit technique, theoretically have advantages of easier surgical procedure and lesser duration of surgery, but also are known to possess risks of periprosthetic fractures and thigh pain with implant loosening due to poor osteointegration, specially in osteoporotic bone.14,15The widespread trend of increased usage of uncemented stems is reflected in our study, specially in cases like AVN, which occur in younger patients with good bone quality, and does not require cement.
THR provides optimal functional outcomes and quality of life to the patients. However in the present study, inflammatory arthritis is shown to be an etiological factor that causes relatively inferior results when compared to other pathologies. This could be due to the fact that it involves multiple joints with or without severe destruction and is more disabling. Associated spinal issues, knee OA and hands or feet deformities could be the reasons for inferior quality of lives in these patients.12 Therefore although the prevalence of these patients requiring THR is lower than the more common AVN or trauma sequelae, IA is a very important diagnosis and requires optimal intervention and post operative rehabilitation.
The present study is retrospective and hence has its limitations. Surgeries done by a single surgeon were assessed and so it does not give the actual incidence of the aetiologies. We only get an idea of proportional prevalence of the causes for which we do THR in a developing country like ours. Additionally, there are limitations of lack of preoperative scores, and different types of prosthesis used. Therefore to get a clearer picture, large scale national data should be imbibed and assessed. Preferably, we recommend that a National arthroplasty registry should be initiated and maintained where entries from all over the country should be inked, to get the detailed and precise epidemiological data. Adequate screening and treatment strategies should be included in the National health programmes to screen them early and initiate adequate treatment at earlier stages, specially in AVN hips. Prospective multi centric studies evaluating both preoperative and post-operative scores will further add to the evidence.
6. Conclusion
Total hip arthroplasty is a routinely done surgery despite its costs and constraints, even in the developing parts of the world. Avascular necrosis and fracture sequelae form the main indications and the average age of these patients is relatively on the younger side. The overall functional outcomes and quality of lives after these surgeries are good, however Inflammatory arthritis patients have inferior outcomes and require prolonged rehabilitation.
Author declaration
The authors declare no conflict of interest and nil funding source.
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