The hip is the second largest weight-bearing joint in the human body after the kneejoint.  It is a ball-and-socket type of synovial joint.  The rounded head of the femur forms the ball, which fits into the acetabulum (socket in the pelvis).  The bony surfaces are covered by articular cartilage and smooth tissue, which cushions the ends  of the bones and promotes joint motion.¹

Various conditions have been attributed to aetiological factor for avascular necrosis for femoral head. These include steroid therapy, autoimmune disease, hemoglobinopathies, hyper     coagulopathies, hyper-lipidemia, Gaucher’s disease, alcoholism, particularly trauma, and dislocation of hip.  All have a significant impact on the joint and cause pain and dysfunction.² The treatment of femoral head avascular necrosis ranges from conservative to invasive.³ In the early stages, conservative therapies   such   as   restricted   weight   bearing, physical therapy, termination    of    steroid    therapy, and    anti-inflammatory drugs are indicated.⁴           

Several pharmacological treatments, including bisphosphonates and statins, have demonstrated therapeutic efficacy in the early stages of avascular necrosis.⁵ The surgical treatment can be divided into two categories: those that preserve the femoral   head (core   decompression, osteotomy, non-vascularized    and    vascularized    bone    grafting, and autologous   bone   grating) and   those   that   partially   or completely replace the femoral head (hemiarthroplasty and total hip arthroplasty).⁶

The porous HA coated prosthesis   used   in   uncemented   total   hip   arthroplasty promotes healing which allows bone to grow into or onto the prosthesis has led to improved implant survival rate and supports their growing use.⁷ It was created to give an alternative   to   the   poor   results   associated   with   early cemented total hip replacements.⁸ The early outcomes for cementless total hip replacements were unsatisfactory because the smooth surface of the cementless prosthesis inhibited good adhesion to the bone, resulting in aseptic loosening a few years after surgery.⁹ The discovery of porous-coated materials in the 1980s permitted bone in growth   on   the   surface   of   prostheses, resulting   in enhanced adhesion and improved prognosis.¹⁰

Preliminary data suggest that nondemented total hip arthroplasties   have   relatively   low   revision   rate   and excellent prosthetic durability.  Evaluation of long-term outcomes of a procedure like total hip replacement is important to determine its durability.¹¹ It provides a means of   comparison   of   the   results   of   different   clinical interventions   that   may   lead   to   changes   in   operative technique and implant design over time. ^12-14

Several studies have evaluated the short and intermediate term follow-up results of uncemented THR in OA secondary to DDH. ^[14] However, there are only few studies until date, which have evaluated the long-term results of uncemented THR in OA secondary to sever grades of DDH. Hence, the purpose of this prospective study was to assess the mid-term clinical and radiological outcomes of uncemented total hip arthroplasty in OA of hip secondary to low and high-dislocated hips with mean follow-up of 8.8 years (range 2-13 years, 95% confidence interval [CI]).

This is a prospective study of clinical and radiological analysis of uncemented total hip arthroplasties performed for various hip disorders was carried out in Orthopaedics Department Tertiary Care Teaching Hospital.

Patients diagnosed with osteoarthritis of hip joint with stage III & stage IV, who underwent uncemented total hip replacement are included in our study. All the patients were explained about the procedure, necessity for follow up and written consent was taken. 35 patients in total who underwent uncemented total hip arthroplasty for osteoarthritis during the period were eligible for the study. Three patients who were not available for regular follow ups were excluded from the study. 32 patients who were available for minimum of 1 year follow up were included in our study. Total of 32 arthroplasties were performed in 32 patients.

Inclusion Criteria:

• Patients with significant disabling hip pain and moderate to severe functional limitation of activities of daily living due to osteoarthritis of the hip joint with any of the etiologies.
• Patients having a minimum period of 12 months of follow up were included in the study.

Exclusion Criteria:

• Total hip arthroplasties performed as revision for patients of post operative hemiarthroplasties or previous THRs were excluded.

     All patient data and clinical history were noted with reference to pain, range of motion, gait, activities or function (Harris Hip Score), pre operatively and at scheduled follow up visits. 

Statistical Analysis: Quantitative data is presented with the help of Mean, Range and Standard deviation. Paired T test and P- value is used to compare mean Harris hip scores at each visit with the pre operative score to see if the relation was statistically significant. P value less than 0.05 was considered as statistical significant. Data entry is done in Excel and analysis is done with the help of SPSS software version 26.

All 32 patients in the present study returned for clinical and radiological examinations subsequently. Patients were reviewed after six weeks, three months, six months and one year post operatively. Radiographs were reviewed at end of 3 months and 1year.

Observations in the form of tables, pie charts and bar diagrams are furnished.

Table. 1 : Age and Sex

The age ranges from 32-60 years with mean age of 48.31years. Most of the cases are between the age group of 51 to 60 years constituting 46.88% of study population

Table 2 : Sex Distribution

Of the 32 cases included in the study majority are male patients.22 patients are male constituting 68.75% of cases and the rest 10 are female patients constituting 31.25% of the cases.

Table 3 :- Etiology in the study group

Of the 16 cases with avascular necrosis 11 patients were male and 5 were female Of the 13 cases with primary osteoarthritis 9 patients were male and 4 were female Of the 3 cases with rheumatoid arthritis 2 were male and 1 case wase female

Table 4:- Side Involved:-

• A total number of 32 uncemented total hip replacements were done
• Right hip was involved in 12 cases
• Left hip was involved in 20 cases

Table 5:- Harris Hip Score at 1yr follow up

The average pre operative Harris hip score (HHS) was 44.69. The Harris hip score at most recent follow up (1yr) was 84.2. The result was excellent in 9 patients, Good in 17 patients, fair in 6 patients. Mean HHS at each follow up visit was compared with pre operative HHS using Paired T test and p values were calculated. P value was found to be significant with each comparison.

TABLE 6:- Statistics Of Pre Op & Post Op HHS Comparison

TABLE 7:- Paired Samples Statistics

Ours is a prospective study comprising of 32 patients with 32 uncemented total hip arthroplasties. Of the 32 cases included in the study majority are male patients.22 patients are male constituting 68.75% of cases and the rest 10 are female patients constituting 31.25% of the cases

Male preponderance of osteonecrosis has been noticed in our study which was similar to most other studies. The mean age of patients in the group is 48.31 yrs (range 32 to 60 years), which is comparable to the study done by KimYH et al¹⁵ who reported the results in 98 patients mean age of 47.3 yrs and with Rahman WA et al¹⁶ study who reported 31 patients with mean age of 47. Garino and Steinberg¹⁷ studied 85 patients with an average age of 45 years.

The average pre operative Harris Hip score in our study is 44.69 which are similar to the pre operative average Harris hip score in the studies done by Garino and Steinberg.¹⁷ They studied 123 total hip arthroplasties with average Harris Hip Score of 45. Chiu KH et al¹⁸ studied 36 patients of osteonecrosis of femoral head with average Harris Hip Score of 36.8. In our study, the average pre operative Harris Hip Score of 44.69 improved to 84.2 at the end of 12 months follow up. The post op Harris Hip Score observed in our study is comparable to that in the study conducted by Garino and Steinberg¹⁷ who reported increase in the Harris Hip Score from 45 to 92. It is also comparable to the study of Chiu KH et al¹⁸ who reported improvement from 36.8 to 83.5. Though Chiu et al ^[18] study group had patients with worse pre operative score than our study group the end result was similar. This result shows that total hip replacement is effective even in case of worse pre operative status of the patients.

In our study, excellent results were obtained in 28.13% of the cases, good in 53.13% and fair in 18.75%. 30/32 (93.75%) patients could walk unlimited distance. 96.88% patients walked without support. 93.75% patients could use public transport. All of the patients who were employed prior to the arthroplasty returned to work. 84.38% of the patients were completely pain free and 15.63% complained of slight pain which they almost ignored. Kantor SG et al ^[19] reported 79% excellent, 4% good and 4% fair results. Hartley WT et al²⁰ reported that 93% had few or no functional limitation, 79%could walk unlimited distance, 86% had no pain, and 79% were employed. Chiu KH et al¹⁸ reported 77.8% excellent or good results.

One patient in our study developed superficial infection (3.13%). Kim YH et al¹⁵ reported incidence of infection in their study as 2%. Christophe N et al²¹ reported deep infection in 1 hip of the 122 cemented arthroplasties.

Kantor SG et al¹⁹ reported that 12.5% of cases came for revision for loosening at 10 years. Hartley WT et al²⁰ reported 20.8% required revision but none of them were due to aseptic failure of femoral component. Christophe N et al ²¹ reported socket loosening in 6 hips. In our study, no loosening observed in any of the 32 uncemented total hip arthroplasties during the follow up of an average period of 16.8 months (maximum follow up of 27 months). Our result could not be compared with the other studies which had a longer follow up period. Kakaria BHL et al²² had similar results to ours which had a similar shorter follow up.

The patients in our study were followed up for an average period of 16.8months (minimum of 12 months and maximum of 27 months). In the period that we followed up the patients we did not encounter any sign of loosening, or heterotopic ossification. Only one cases had significant limb length discrepancy (1.5cm). He required heel rise for comfortable walking. Those who had the discrepancy of less than 1 cm were not affected by it.

Chiu KH et al¹⁸ in their follow up of 36 arthroplasties for osteonecrosis and 36 for osteoarthritis for 6 years concluded that patients with alcohol and steroid induced cases of osteonecrosis showed poorer results compared to other causes. Those arthroplasties done in cases of posttraumatic, idiopathic osteonecrosis were better and comparable to the results of arthroplasties done for non osteonecrotic cases.

In our study Idiopathic osteonecrosis was most common etiology accounting for 50% of cases.41% of cases are due to primary osteoarthritis and 9% of cases are due to rheumatoid arthritis.

Brown SR et al²² in their follow up of 20 patients had Harris hip scores improved from a mean of 43 to postoperative score of 89. We have similar scores with improvement of Harris hip scores average preoperative harris hip score from 44.7 to post operative harris hip score of 84.2. Graphic comparison of some similar studies in terms of age, pre operative and post operative HHS is given below.

Uncemented replacement of the hip as a primary procedure can give a good clinical result which is comparable with the totally cemented joint. Although in some patients there are minor residual symptoms which do not limit activity. Although the operation can often be performed more rapidly, it requires a high standard of bone preparation and in the attempt to produce a tight interference fit. On the acetabular side there is a positive gain in the augmentation of pelvic bone stock. with or without grafting, and. in most systems. failure on the acetabular side is uncommon. On the femoral side there appear to be both theoretical and practical advantages in methods of enhanced fixation.

This study has shown that the outcome of uncemented total hip arthroplasty has excellent results in terms of pain relief, increased walking distance, and functional capabilities in patients. Patients are satisfied with the results and most of them resumed their normal activities and are pursuing their jobs. Patient had significant improvement in range of motion at hip. Complications encountered in our short term follow up did not affect the outcome at the end. Neither the complications like aseptic loosening and wear requiring revision have not been found in our study, nor analysis regarding survivorship and longevity of the arthroplasty have been dealt with. Long term follow up is mandatory to analyze these aspects.

Our study supports the usage of uncemented THR in osteoarthritis in both young and elderly. The current trend, research and advent of new implants support uncemented THR in patients suffering from this crippling hip arthritis and avascular necrosis.

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