European Journal of Cardiovascular Medicine

This investigation on THR in patients with femoral head avascular necrosis-induced hip arthritis was inspired by commonly reported instances across the globe. A severe condition known as AVN of the femoral head usually results in hip osteoarthritis in very young people (mean age at presentation: 38 years). Although the disease's prevalence is unknown, estimates place the number of new cases identified in the US each year between 10,000 and 20,000.^[1,2] Avascular necrosis is a disease in which bone components die (necrosis) as a result of a disruption in the blood supply.^[3,4] It is also referred to as osteonecrosis, bone infarction, aseptic necrosis, ischemic bone necrosis, and AVN.^[5] Bone crumbles because bone tissue dies in the absence of blood. When avascular necrosis damages a joint's bone structure, it often leads to the articular surfaces of the joint deteriorating and hip secondary osteoarthritis developing as a result. Munro first reported osteonecrosis of the femoral head in 1738. Around 1835, a blood flow halt caused morphologic changes to the femoral head, as Cruveilhier demonstrated. There have been progressively more cases reported of AVN since Mankin identified 27 cases in 1962. It is still unclear how common osteonecrosis is. Between 10,000 and 20,000 new cases are predicted to be diagnosed in the US each year.^[6] with osteonecrosis accounting for 10% of all hip replacements. The coexisting comorbidities affect the male-to-female ratio. Men are more likely than women to get osteonecrosis connected to alcohol, while women are more likely to develop osteonecrosis brought on by SLE (Systemic Lupus Erythematosus). Depending on comorbidities, the average age at diagnosis varies; however, it is typically under 40. Usually, lengthy bones with clinical avascular necrosis affect their ends (epiphysis), such as the head of the femur. The scaphoid, talus, tip of the humerus, and jaw bones are additional frequent locations. One bone, many bones at once, or numerous bones at separate times might all be affected by the illness.

Hip joint secondary arthritis is more frequently caused by avascular necrosis, which is more common at the head of the femur. Many techniques are currently used to treat avascular necrosis, with THR (Total Hip Replacement) being the most common. Five to twelve percent of patients undergoing total hip replacements had AVN of the femoral head. It is debatable what the appropriate course of action is for patients who have femoral head collapse and significant discomfort. Although the outcomes of osteotomies, which transfer healthy femoral head surface regions for weight bearing, are a legitimate therapeutic alternative, they are not always predictable. Although the incidence of bilaterality in non-traumatic AVN has been reported to range between 40 and 70%, arthrodesis may be explored for unilateral disease; nevertheless, its utility is limited. The only reliable and efficient treatment for AVN of the femoral head is complete hip replacement when the disease reaches Ficat and Arlet stages III and IV.^[7,8] According to J. P. Garino and M. E. Steinberg, total hip arthroplasty may be the best option when reconstructive surgery is necessary since it can produce exceptional results in young patients with AVN when using cutting-edge cement methods and components. For advanced femoral head osteonecrosis, cementless total hip arthroplasty remains a viable therapeutic option, despite the fact that wear on the bearing surface continues to limit long-term success.

Aims and Objectives

• To investigate the rate of patient recovery from avascular necrosis of the femoral head in 30 sample cases after cemented or uncemented total hip arthroplasty.
• To examine the clinical and functional results of both cemented and uncemented total hip replacements in individuals suffering from femoral head avascular necrosis.

This was a 17-month study that took place in a hospital setting and involved 30 patients with hip joint arthritis brought on by avascular necrosis of the femoral head. The patients gave written informed consent, and the approval of the institutional ethics committee was obtained before being referred to the Department of Orthopedics at the Princes Esra Hospital/Deccan College of Medical Sciences, Hyderabad, Telangana, India

Inclusion Criteria

• Patients with femoral head avascular necrosis.
• Patients between the ages of 30 and 75.
• Patients prepared to provide informed consent.

Exclusion Criteria

• Patients under the age of 30.
• Individuals with both local and systemic illnesses.
• Individuals who do not meet the requirements for surgery.

Statistical Methods

Both descriptive and inferential statistical analysis were used in this investigation. Categorical measurements are given as numbers (%), and continuous values are presented as mean ± SD (min-max). The 5% level of significance is used to determine significance.

The research group's age distribution. The average age of the study's subjects was 42.30±11.43 years. 43.3% of the patients with avascular necrosis in the research group were between the ages of 31 and 40. Individuals in the age ranges of > 60 (3.3%), 21–30 (13.3%), 51–60 (20.0%), and 41–50 (20.0%).

According to the study group's gender breakdown, there were approximately 23.3% female patients and 76.7% male patients.

Prior to surgery, the average pain score was 10.13±1.96; following surgery, it was 42.13±2.03. There was a statistically significant difference in pain levels before and after surgery. Prior to surgery, the average functional gait score was 10.53±6.96. The postoperative mean difference was 30.33±2.31, with a t-value of -14.588 and a p-value of less than 0.001**. A statistically significant difference between the preoperative and postoperative scores was shown by a p-value of less than 0.05. Prior to surgery, the functional activity score was 5.17±1.62, and following surgery, it was 11.40±1.07. The study group's preoperative and postoperative scores showed statistically significant variation.

The majority of the patients had no serious abnormalities prior to surgery, as evidenced by the lack of a statistically significant difference in scores for the measure of absence of deformity postoperatively. The study group's mean range of motion (ROM) score was 2.40±1.25 prior to surgery, and it was 4.63±0.49 following surgery. In the preoperative and postoperative phases, there was a statistically significant difference in ROM evaluations.

Prior to surgery, the average total score was 32.27±8.11, and following surgery, it was 92.60±3.16). Scores before and after surgery varied in a statistically significant way.

Significant Figures

+ Suggestive significance (p-value: 0.05<p<0.10).

* Moderately significant (p-value: 0.01<p≤ 0.05).

** Strongly significant (p-value: p ≤ 0.01).

Eighty percent of trial participants had excellent results from a total hip replacement. Of the trial group, about 20.0% had successful results.

There was no evidence of postoperative limb shortening in 86.7% of both research groups. Sixth of the patients, or one patient with a 1.5 cm shortening, one patient in the stryker group (4.5%), and two patients in the link group (25.0%), had a 1 cm shortening

Avascular necrosis is a disease in which bone components die (necrosis) as a result of a disruption in the blood supply. It is also referred to as osteonecrosis, bone infarction, aseptic necrosis, ischemic bone necrosis, and AVN.^[5] Bone crumbles because bone tissue dies in the absence of blood.^[4] When avascular necrosis damages a joint's bone structure, it often leads to the articular surfaces of the joint deteriorating and hip secondary osteoarthritis developing as a result. There are many theories on the etiology of avascular necrosis. Among the suggested risk factors are radiation damage, bisphosphonates (especially those for the mandible), sickle cell anemia, vascular compression, hypertension, alcoholism, excessive steroid use, post-traumatic stress disorder, caisson disease (decompression sickness), and Gaucher's disease. There are situations where the cause is unknown. Both lupus and rheumatoid arthritis are frequent causes of AVN. The precise correlation between the AVN and repetitive, extended exposure to high pressures (as encountered by military and commercial divers) is uncertain, but there has been evidence of a relationship. Avascular necrosis can occur in any bone; however, the shoulder and hip joints are the most commonly affected; approximately half of cases involve several sites of injury. The head of the femur, the talus neck, and the scaphoids waist are the classical sites. Clinical avascular necrosis primarily affects the ends (epiphyses) of long bones, such as the femur (the bone that connects the hip and knee joints). The jaw, shoulders, ankles, and humerus are other common sites.^[9]

The illness may affect one bone, many bones at once, or numerous bones at separate times. In the United States, avascular necrosis of the head of the femur affects between 10,000 and 20,000 people annually; most cases occur in those between the ages of 30 and 50. Currently, there are several ways to treat avascular necrosis; total hip replacement (THR) is the most common method. One proven surgical procedure is total hip replacement.^[10] AVN-induced moderate to severe hip arthritis patients experience less pain and functional dysfunction, leading to an overall improvement in their quality of life.^[11]

A prospective study was conducted with thirty patients who had either cemented or uncemented total hip replacements at the Orthopaedic Department, Princes Esra Hospital/Deccan College of Medical Sciences, Hyderabad, Telangana, India

Age and Sex

According to the study, the patients' average age was 42.30±11.43 years. Between the ages of 31 and 40, avascular necrosis affected about 43.3% of the research participants. A multivariate analysis showed, in contrast to these results, a low age at which avascular necrosis develops.^[12]

According to the study group's sex distribution, there were roughly 76.7% male patients and 23.3% female patients. Similar findings were obtained by other researchers, including Tofferi JK and Gilliland W.^[13]

Etiology

After conducting a patient examination to determine the etiology of AVN, the results revealed that 70.0% of patients experienced AVN of the hip joint due to unknown causes (idiopathic), while 16.7% of patients developed AVN due to corticosteroids. Similar to this study, a study by Koo KH, Kim R, Kim YS, et al.^[14] discovered that 13.3% of patients had AVN of the hip joint, with 65% of cases resulting from idiopathic causes and 10% to 30% from corticosteroid therapy.

Side of THR

The majority of patients (50.0%) had total hip replacements on their left, 26.7% had total hip replacements on their right, and 23.3% had total hip replacements on both sides, according to an examination of the patients' surgical sites. These results were similar to what Jacobs B. found.^[15]

Type of Arthroplasty

While 13.3% of patients underwent hybrid arthroplasty, the bulk of patients (86.7%) underwent cemented arthroplasty. Compared to earlier designs of prostheses implanted without cement, the new generation of uncemented prostheses showed improved clinical and radiological outcomes.

Pain Relief

Prior to surgery, the average pain score was 10.13±1.96; following surgery, it was 42.13±2.03. According to Sochart et al., every patient who survived saw a notable improvement in function and pain relief. 96% of patients had great pain scores, according to Joshi et al research^[16] whereas 29.2% had normal or nearly normal function scores.

Functional Gait and Activity

The mean functional gait score was 10.53±6.96 before surgery, and it was 30.33±2.31 after surgery. Prior to surgery, the functional activity score was 5.17±1.62, and following surgery, it was 11.40±1.07. Most patients in a study by Katz JN et al. showed improvements in their ability to walk and function.^[17]

Range of Movement Score

The study group's mean ROM (Range Of Motion) was 2.40±1.25 before surgery and 4.63±0.49 afterward. In the preoperative and postoperative phases, there was a statistically significant difference in ROM evaluations. A study by Katz JN and Phillips CB found that while preoperative sum total range of motion was maintained or improved in hips with a painful arc of movement, it improved in individuals with avascular necrosis of the femoral head.^[18] They also discovered that idiopathic cases account for the majority of restricted mobility cases in avascular necrosis patients.

Complications of THR

In the trial group, the majority of patients (93.3%) had no issues. With two individuals affected and making up 6.7% of the trial group, foot drop was the most common issue. 4.3% of hips had intraoperative fractures, 1.1% had sciatic nerve palsy, and 14% of patients had revisions due to aseptic loosening, according to a research by Meek RM and Garbuz DS.^[19] 8.6% of patients had periprosthetic fractures, according to a Learmonth ID study.^[20]

Limb Shortening

Ninety-three percent of the study group did not have postoperative limb shortening. Leg shortening of one or two centimeters occurred in about 6.7% of the study group. A lengthened limb is not as socially acceptable as over-lengthening, which is more prevalent than legs that are still shorter. Longer limbs were linked to lower clinical hip scores, as found by Konyves and Bannister. Poor preoperative patient evaluation and intraoperative technical issues, such as the level of femoral neck resection, the length of the prosthetic neck, or the inability to correct offset, can also result in a limb-length mismatch.

Type of Implant

26.7% of the study group utilized a link implant, compared to 73.3% who used a Stryker implant. In 75% of the patients in the link group, the total hip replacement result was good; two patients (25%) had a satisfactory outcome. Patients in the Stryer group had excellent outcomes following surgery in 81.8 percent of cases, compared to 18.2 percent following THR.

Outcome of THR

Eighty percent of trial participants had excellent results from a total hip replacement. Of the trial group, about 20.0% had successful results. According to the Harris hip score, 70% of the outcomes in earlier research by Sharp et al. were rated as outstanding or good, which is in line with the results of this investigation.

Hip joints and the axial skeleton are the main areas affected by avascular necrosis (AVN). A number of other joints, such as the jaw, shoulders, ankles, and humerus, may also be affected. Avascular necrosis patients are usually young, active individuals who experience problems relating to function; men are more likely to be impacted than women. The most common types of osteonecrosis are idiopathic, steroid-induced, and post-traumatic.

One proven surgical procedure is total hip replacement. AVN-induced moderate to severe hip arthritis patients experience reduced pain and functional dysfunction, leading to an overall improvement in their quality of life. Many factors affect the outcome of total hip replacement in AVN of the hip joint, including surgical technique, patient selection, and component design.

Long-term studies are required to assess the procedure's overall impact. This study demonstrates that the present generation of uncemented implants used in total hip replacement for hip joint arthritis caused by AVN delivers good clinical and radiological outcomes at an intermediate follow-up time. The overall functional and clinical outcomes have been satisfactory to outstanding, notwithstanding some issues with the treatment.

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