Study of Results of Difficult total hip Arthroplasty According to Modified harris hip score

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1 ORIGINAL ARTICLE Study of Results of Difficult total hip Arthroplasty According to Modified harris hip score Dhrumil M. Patel 1*, Sanjay Soni 2, Hemant H. Mathur 3, Gaurang M. Patel 4, Hardik Tailor 5, Marishka Mehta 6 1,2,5 Resident Doctor, 3 Professor & Head, 4 Assistant Professor, Department Of Orthopaedics, S.S.G. Hospital And Medical College, Baroda. 6 B.Sc. Biomedical Science, Queen Mary, University of London.(P.T.O) ABSTRACT BACKGROUND: Indian surgeons annually perform more than 150,000 total hip arthroplasties (THAs), 90% of which are primary procedures. Improved surgical technique and instrumentation have expanded the clinical indications for THA to include those difficult hip patients who previously would not have been considered eligible for this procedure and so it is important to study the results of the same. Aim: To study the results of Total Hip Arthroplasty in difficult hip. MATERIALS AND METHODS: All the patients were evaluated clinically (according to Modified Harris Hip Score) and radiologically at 6 months post operatively. RESULTS: The patients operated in our study had an average Modified Harris Hip Score. DISCUSSION: Compare the preoperative and postoperative modified harris hip score CONCLUSION: Results of total hip arthroplasty in difficult hip are good and satisfactory. Keywords: Difficult hip arthroplasty, Modified Harris Hip Score. INTRODUCTION We, in our institute began Total Hip Arthroplasty as a form of treatment for various hip pathologies, about two decades ago. The experience gained over these years has helped us to slowly expand the indications by including more challenging and difficult cases like Rheumatoid Arthritis, Ankylosing Spondilitis, Failed cemented total hip arthroplasties,dysplastic hip, Ankylosed hip, Failed operated hip fracture, Protrusio acetabuli, skeletal dysplasia, and previous bony procedures around the hip., etc. The surgery has gained popularity gradually amongst the patient population reporting at our institute. The problems faced with Difficult Total Hip Arthroplasties included exposure to the hip, implant extraction, rebuilding of the bone stock, management of periprosthetic fracture, limb length correction, offset correction and *Corresponding Author Dr. Dhrumil Patel Department of Orthopaedics, S.S.G. Hospital and, Medical College, Baroda - mail.dhrumil1988@gmail.com mail.dhrumil@yahoo.com soft tissue balancing, cement removal and management of osteolysis when used as a form of definitive treatment in young active patients. Also, these varieties of arthroplasties required rigorous life style modifications such as avoiding squatting, cross legged sitting, etc often rendering the patient incapable of earning a daily livelihood. This work is the story of evolution of Difficult Total Hip Arthroplasties in our institute, from conventional techniques to recent advances in this field and their results. MATERIALS AND METHODS This prospective study was carried out at Orthopaedic Department of Shree SayajiRao Gaekwad Hospital, Baroda. The study was approved by the Ethical and Scientific committee of our University, and informed consent was taken from all patients. All patients were informed and explained about the treatment plan. Study design: Prospective Observational Study. Sample size: 50 Study population: Patients admitted in wards in the Department of Orthopaedics, Medical College and S.S.G.Hospital, Vadodara. Investigations: X-ray, Routine blood Ix 54 Int J Res Med. 2014; 3(4);54-60 e ISSN: p ISSN:

2 Period of Data Collection: April 2012 to April 2014 Outcome parameters Periodic assessment clinically according to Modified Harris Hip Scoring system and radiologically according to X rays at 6weeks, 3months,6 months follow up. Inclusion Criteria: Difficult Hip Exclusion Criteria: Medically unfit patient, Unwilling patient Method of treatment: All the patients were operated using Modified Gibbson s Approach to the hip joint in lateral position on a straight table. Pre-operative Assesment Routine blood investigations- CBC, ESR, CRP, RA, PTINR, Sickling, RBS, Urea, Creatinine, Urine-R and M Radiological assessment- Patient s Xray of pelvis both AP and Frog-leg view were taken. Templating was done to measure the expected size of prosthesis and the limb-length discrepancy. After the patient was fit for surgery medically and anaesthetically, we posted the patient for surgery. Type of Anaesthesia: Spinal Anaesthesia plus Epidural Anaesthesia After anaesthesia, the patient was shifted on the plain O.T.table in lateral position. Local parts (including same side lower limb) were prepared, painted and draped. First dose of intravenous antibiotic was given half hour before incision. And if surgery was prolonged for more than 2 hours, then second dose was repeated. Approach and Incision: Modified Gibson s Approach was used in all patients. The gluteus maximus was bluntly split proximally in the direction of its fibers. The knee was flexed and the extended hip was internally rotated to place the short external rotators under tension. The sciatic nerve was palpated. The short external rotators including at least the proximal half of the quadratus femoris were divided at their insertion on the femur. Now the entire exposed portion of the capsule along its attachment to the femur was divided. Then, the hip was dislocated posteriorly. If the hip could not be easily dislocated, the femur was never forcibly internally rotated, since this could cause a spiral fracture of the shaft. Instead, it was ensured that the superior and inferior portions of the capsule had been released as far anteriorly as possible. If the hip still could not be dislocated without undue force, the femoral neck was divided with an oscillating saw at the appropriate level and subsequently the femoral head segment was removed. After dislocation of the hip, the femoral neck osteotomy was carried out with an oscillating or reciprocating power saw. Exposure and Preparation of Acetabulum and Femoral Canal: The anterior capsule was isolated, the excision of the labrum was completed. The bony margins of the rim of the acetabulum were exposed around its entire circumference by using an osteotome to remove any osteophytes that protrude beyond the bony limits of the true acetabulum to facilitate the proper placement of the acetabular components. Now the bony preparation of the acetabulum was preceded with reaming of the acetabulum with bone-conserving Mira-type reamers at an inclination of 45 0 to the sagittal plane of the body with an anteversion of Reaming was complete when all cartilage had been removed. Now a bleeding subchondral bone bed was exposed by maintaining as much of the subchondral bone plate as possible. In cases with protrusio acetabulum and subchondral bone cyst, the cavities were filled with morselized cancellous bone obtained from the patient's femoral head and impacted with a small punch. Before the insertion of the acetabular component, it was ensured that the patient remained in the true lateral position.the system used had trial acetabular components that could be inserted before final implant selection to determine the adequacy of fit, the presence of circumferential bone contact, and the adequacy of the bony coverage of the component. Once a proper positioning of the acetabulum was ascertained, depending upon the type of implant selected, the component was either press-fitted into the prepared cavity or multiple cancellous screws were used to secure the fixation and subsequent femoral fixation was carried out. The femoral canal was prepared using graduated broaches inserted in approximately 15 of anteversion in relation to 55 Int J Res Med. 2014; 3(4);54-60 e ISSN: p ISSN:

3 the axis of the flexed tibia. The templated neck length was selected and a trial component was assessed. A trial reduction was carried out with appropriate trial size femoral head fitted on to stem so as to determine limb length, range of motion, tissue tension and stability of the arthroplasty. Once adequate stable reduction and correct limb length was achieved, the appropriate sized femoral stem was hammered into the femoral canal maintaining the neutral position and appropriate anteversion and ensuring proper seating of the collar of implant over resected medial part of the femoral neck. Then, the appropriate sized head as concluded from the trial reduction manoeuvre was fitted on the stem. The implanted femoral stem was then reduced into the newly constructed acetabulum by gentle traction along the long axis of femur and external rotation. Following reduction, on table stability of the new hip system was assessed, along with the range of motion. Repair of the posterior soft tissue envelope was done. The capsule which was preserved was repaired with heavy, absorbable sutures and, the previously tagged tendons of the short external rotator muscles were reattached to the posterior aspect of the greater trochanter, followed by closure of the subcutaneous layer with interrupted, absorbable sutures. The skin was closed in routine fashion either with stainless steel skin staplers or nonabsorbable suture material. Post-operative Management: Prophylactic antibiotics (intravenous as well as oral) were continued for 5-14 days postoperatively depending upon the status of the dressings, approximately 5-7 days of intravenous antibiotics followed by oral antibiotics till the sutures were removed. Negative suction drain was removed 48 hours after surgery, depending upon the drain output. X-ray was done usually on the third post-operative day (before weight bearing) when the patient was more comfortable. Sutures were removed on 10 th - 14 th day after surgery routinely depending on the status of the dressing and the local part. All patients under this study received prophylaxis to prevent deep vein thrombosis and pulmonary embolism with Tablet Rivaroxaban(10 mg) once at night for 15 days from the day of surgery. Under normal circumstances, with the patient being stable postoperatively, static and active quadriceps exercises were begun on the same evening within the limits of comfort followed by high sitting on the day of drain removal. This was followed by non weight bearing crutch walking of the patient with the help of a walker for a period of three weeks. The patients were advised to start partial weight bearing at three weeks as per pain tolerance and on table stability of the implant. Full weight bearing without any support was started at 6-8 weeks post-operatively in uncomplicated cases after clinical and radiological assesment. Patients were instructed not to squat, sit cross-legged or to indulge in active sports. They were advised to use western style toilets. Follow up: Patients were followed up at 6 weeks, 3months and 6 months.the patients were assessed at each follow-up with proper clinical and roentogenic evaluation as per guidelines discussed elsewhere in this study. RESULTS In our series, age varied from 17 to 83 years, with a mean age of years. There was male predominance. Male: Female ratio was 2.5:1 Majority of our patients were labourers by occupation. 31 (62 %) operated hips had moderate to high physically active life style. The main indication of surgery was - avascular necrosis of hip (48%). 20% patients had Sickle cell disease, 18% patients had AVN with implant in situ, 16% patients had aseptic loosening of bipolar prosthesis, 12% had old infective hip, 12% had Rheumatoid Arthritis as a cause of AVN, 8% had Ankylosing Spondylitis and 4% had associated acetabulum fracture, 4% had old slipped capital femoral epiphysis, and 4% had periprosthetic fractures, 2% had old dislocated bipolar prosthesis. 19 patients were operated on left side and 17 on right side. 7 Patients were operated for total hip replacement on both sides. Intra-Operatively, no complications were encountered in any patient. Average blood transfusion for each surgery was 1.5 units. 56 Int J Res Med. 2014; 3(4);54-60 e ISSN: p ISSN:

4 Post-Operatively out of 50 patients, 1 patient had sciatic nerve palsy, 1 had local infection, 1 had post-op dislocation, 1 had pulmonary embolism, 1 had late infection and 1 patient had heterotropic ossification(grade 1) as a late complication. 6% patients had Diabetes mellitus, 10% had hypertension and 2% had HIV as associated systemic disease. On final follow-up, 30% patients had excellent result, 56% had good, 10% fair, and 4% had poor result. Preoperative mean modified harris hip score was compared to postoperative score of Fig: 1 final modified harris hip score Fig.: 5 pre op Fig.: 6 Pre-op xray No. of Cases Fig.: 7 post-op xray Fig.: 2 final modified harris hip score 100 Modified Harris Hip Score 50 Modified Fig.: 8 Post op 0 Fig.: 3 pre op xray Fig.: 4 post op xray DISCUSSION AND ANALYSIS Our study consisted of 50 Difficult total hip arthroplasties operated in Department of Orthopaedics, Sir Sayajirao Gaekwad General Hospital, Vadodara with an average follow up period of 6 months between April 2012 to April Maximum number of our patients were in the middle-aged group (4 th to 6 th decade). The young patients in our series showed good short and medium term results. We had treated the complications of cemented total hip arthroplasties such as osteolysis, bone loss, periprosthetic fractures, etc in young as well as old patients with revision cementless total hip arthroplasties and these patients had also shown 57 Int J Res Med. 2014; 3(4);54-60 e ISSN: p ISSN:

5 excellent short-term and medium-term followup outcomes. The male to female ratio in our series was approximately 2.5:1. In our series, this disproportionate representation of males and females in total hip arthroplasties probably is due to higher incidence of Avascular necrosis of femoral head in males, and the fact that our series involved maximum number of patients of avascular necrosis of hip. Most of our patients, being middle-aged, were occupied into moderate physical activity. Majority of them were able to carry out their occupations without any hindrance postoperatively after recovery. Even the highly active patients were fully satisfied with the performance of their hip joints. Two patients in the series had poor result. One of which developed aspiration pneumonia as an immediate complication and was admitted in ICCU for 7 days. Patient was bed-ridden for one month and could not bear weight for upto 3 months. The other patient developed stroke and suffered paralysis in the same limb, so she could not bear weight on the same limb. Early and late infection was treated with debridement and antibiotics. Our series revealed longstanding avascular necrosis of hip joint with arthritis and deformities to be the prime indicator of difficult total hip arthroplasty in all the age groups. Most of the patients operated had sickle cell disease. However, rheumatoid arthritis and ankylosing spondylitis were also found to be a significant cause of avascular necrosis in our series. Avascular necrosis of the femoral head with implant in situ also formed a significant proportion of the cases. We have had good results even in patients with arthritic hips with implant failure in proximal femur. Many of the patients in our series suffered from one or more systemic illness ranging from diabetes mellitus, hypertension and sickle cell disease. Thus total hip arthroplasty, though a major surgery can be performed safely and effectively in patients with systemic diseases. All the patients in our institute were treated by Modified Gibson's approach. The same had been followed by Chandler et al. Posterior dislocation was found only in one of our patients. Similar observation had been made by Charnley, Lawrence et al. Though no comparison with any other approach could be made in our series (because all the cases were done with modified Gibson's approach) the ease and reliability of this approach was well established. All cases were operated with acetabular as well as femoral prosthesis, most commonly the Corail with Duraloc hip system. In revision cementless total hip arthroplasties, the problem of bone loss was managed with femoral head allograft and cortico cancellous bone graft from iliac crest. In cases of periprosthetic fractures, cementless total hip systems with long femoral stems such as the Solution revision hip systems or the Reef modular hip systems were used with control cable and SS wire loop. Fig.: 9 Pre op Fig.: 10 Post op Our study did not reveal any aseptic loosening of either the femoral or the acetabular components on the short or medium term follow-up of these patients. However, these cases would require a longer follow-up study to evaluate their result with respect to aseptic loosening. One patient operated in our study had evidence of early infection and one had evidence of late infection. Our series noted incidence of dislocation to be 2%. Some patients in whom compliance was doubtful were immobilized in abduction pillow for periods of 3-6 weeks. 1 patient developed 58 Int J Res Med. 2014; 3(4);54-60 e ISSN: p ISSN:

6 Grade 1 heterotropic ossification. Incidence of sciatic nerve palsy was 0% in our series. None of our patients developed cardiopulmonary complications during surgery or anaesthesia so as to require prolonged monitoring / ventilatory support. We found 72% of femoral components to be in neutral and 4% to be in valgus and 24% to be in varus. Although 24% of the femoral stems were in varus,on final follow-up their overall functional outcome was excellent even at an average 6 months follow-up. All the acetabular comoponents were placed in normal anteversion and inclination; the better placement of acetabular and femoral components could have been a reason for only one incidence of dislocation in our series. At 6 months follow up, the average flexion at hip was upto 90, abduction was 30, adduction was 20, external rotation 30 and internal rotation was 10. Overall, our results are similar to previously published series in the literature. However, we would like to highlight a number of factors evident in our experience which we would consider useful when considering these procedures. We found preoperative planning to be of value in considering selection of implant, requirement of bone grafts, offset and leg length inequality. We believe that accurate reconstruction of the axes gives the previously weak abductor musculature the best chance of strengthening. Leg length correction has to be limited due to the potential risk of damage to the sciatic nerve. Maximum length that can be gained with safety at the time of total hip replacement should be no more than 4 cm. We found a modular prosthesis to be useful in the versatility it provided to correct version, offset and limb-length. We felt that prophylactic measures to prevent heterotopic ossification should be made. We recommend nonsteroidal anti- inflammatory drugs for ease of use. Finally careful patient communication is important. Patients must be aware of higher complication rates compared with primary arthroplasty and the requirement of lifestyle modification for better outcome and longevity of the hip. CONCLUSION Though patients with difficult hip are at increased risk during total hip arthroplasty and during early post-operative period, the results are good and satisfactory. A multi-disciplinary approach involving physician, anaesthetist and orthopaedic surgeon should be used to reduce the incidence and severity of complications. Most complications are preventable by proper preoperative planning, attention to surgical detail, anticipating the intraoperative challenges and careful postoperative care. Acknowledgement We specially thank Dr. Rajiv Daveshwar,M.S Ortho, Professor & Superintendent, Medical college & SSG Hospital, Vadodara for his valuable support to carry out and fulfill this research. REFERENCES 1. Bruce D. Shepherd, Warwick Bruce, William Walter, Eugene Sherry-Sydney, Australia; Hugh U. Cameron-Toronto, Canada; Timothy McTighe-Stamford, Connecticut, USA; Difficult Hip Replacement Surgery: Problems and Solutions ; a scientific exhibit at the 1989 aacis meeting las vegas, nevada. 2. Sathappan S. Sathappan, MD, Eric J. Strauss, MD, Daniel Ginat, BS, Vidyadhar Upasani, BS, and Paul E. Di Cesare, MD. ) Surgical Challenges in Complex Primary Total Hip Arthroplasty. Am J Orthop. 2007;36(10): Copyright Quadrant HealthCom Inc M.B. Howard, W.J.M. Bruce, W. Walsh, J.A. Goldberg Concord Repatriation General Hospital, Concord, Australia. Total hip arthroplasty for arthrodesed hips Journal of Orthopaedic Surgery 2002, 10(1): Nilesh Patil, MD; Katherine Hwang, MS; Stuart B. Goodman, MD, PhD Cancellous Impaction Bone Grafting of Acetabular Defects in Complex Primary and Revision Total Hip Arthroplasty. 5. Wong HC*, Ho ST. Department of Orthopaedics and Traumatology. Acetabuloplasty technique in primary total hip arthroplasty for the dysplastic hip. Pb Journal of Orthopaedics Vol-XII, No.1, 2011CaritasMedical Centre, Hong Kong. 59 Int J Res Med. 2014; 3(4);54-60 e ISSN: p ISSN:

7 6. N. P. Badhe, P. W. Howard From Derbyshire Royal Infirmary, Derby, England. A stemmed acetabular component in the management of severe acetabular deficiency. 7. Paprosky WG, Perona PG, Lawrence JM. J Arthroplasty. Acetabular defect classification and surgical reconstruction in revision arthroplasty. A 6-year follow-up evaluation. 1994; 9(1): Tetsunori Okamoto, Shigenori Inao, Eiji Gotoh, Mifumi Ando. Primary Charnley Total Hip Athroplasty for Congenital Dysplasia- effect of improved techniques of cementing. A 8-year follow-up evaluation. J Bone Joint Surg(Br) 1997;79-B: Adnan Faraj, MRCS; Wright P, FRCS. Total Hip Replacement in the Dysplastic Hip: The Use of Cementless Acetabular Components. Malaysian orthopaedic journal, 2011, vol.5,no J. M. Harley, J. A. Wilkinson, Hip replacement for adults with unreduced congenital dislocation- A new surgical technique, Lord Mayor Treloar Hospital, Alton, J Bone surg (Br) Campbell s Operative Orthopaedics (12th edition) 16. Rockwood and Green s Fractures in Adults (7 th edition) 60 Int J Res Med. 2014; 3(4);54-60 e ISSN: p ISSN: