Functional outcome, disability and quality of life after primary total hip arthroplasty: a prospective cohort study from North India

INTRODUCTION

Total hip arthroplasty (THA) is one of the most successful orthopedic procedures for end-stage hip diseases including osteoarthritis, avascular necrosis (AVN), and fracture neck of the femur, relieving millions of people from incapacitating pain arising from the hip joint.¹ The first total hip replacement is thought to have been done in London by Phillip Wiles in 1938.² The procedure was further developed in the 1950s by McKee and Farrar which was later developed by Sir John Charnley in the late 1960s.^3-5 Estimates of the lifetime risk of undergoing THA have been found to vary by country, with rates ranging from 8.7% to 15.9% in women and 6.3% to 8.6% in men.^6,7 In India, a nation with a population exceeding 1.4 billion, hip arthritis imposes a substantial burden, compounded by AVN and femoral neck fractures, particularly in younger patients due to trauma.

Beyond pain relief and mobility restoration, contemporary outcome assessment emphasizes patient-reported outcome measures (PROMs) that evaluate disability and quality of life, in addition to functional recovery.

Although several studies have reported functional outcomes following THA, limited Indian literature simultaneously evaluates functional status, disability, and quality of life using validated instruments in a prospective design. Therefore, the present study was undertaken to comprehensively assess these parameters in a North Indian population.

METHODS

Study design

Prospective open cohort study conducted at Dr Rajendra Prasad Government Medical college Kangra, Himachal Pradesh, India.

The sample size was calculated based on an expected mean improvement of 20 points in HHS with a standard deviation of 25, at 80% power and 5% alpha error, yielding a minimum required sample size of 48. Considering a 10% loss to follow-up, 56 patients were finally included in the study.

Study period

The study period was between January 2022 to October 2023.

Study centre

The study was conducted at Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India.

Follow-up

Follow-up was minimum 6 months.

Inclusion criteria

Inclusion criteria included individual aged >18 years, primary THR for osteoarthritis, AVN, or fracture neck femur and willing for follow-up.

Exclusion criteria

Exclusion criteria included individual with revision THR, active infection and neuromuscular gait disorders

Outcome measures

Harris hip score (HHS)

It evaluates pain, function, deformity, and range of motion. Scores range from 0 to 100, with higher scores indicating better outcomes.

WHO disability assessment schedule 2.0 (WHODAS 2.0)

A standardized tool for evaluating activity limitations and participation across six domains.

WHOQOL-BREF

Quality of life was evaluated using the questionnaire, which measures quality of life across four domains: physical, psychological, social, and environmental factors.

Statistical analysis

Data analyzed using statistical package for the social sciences (SPSS) version (IBM SPSS 28). Continuous variables expressed as mean±SD. Pre- and post-operative scores compared using paired t-test. Confidence intervals calculated where applicable.

Surgical procedure

All procedures were performed by experienced orthopedic surgeons at the same institution using the posterolateral approach to the hip. The choice of implant (cemented or uncemented) was determined by the operating surgeon based on the patient’s characteristics and bone quality.

Rehabilitation

Standard rehabilitation protocols were followed in all patients except those with complications requiring a patient-specific approach.

RESULTS

The study included 56 participants who were assessed preoperatively and post operatively on OPD basis to evaluate the functional outcome using Harris hip score, satisfaction through WHO-disability schedule 2.0, and quality of life using WHOQOL-BREF scoring system.

Mean age was 50.30 years. Gender distribution included males 80.4% and females 19.6%. Functional outcome showed that HHS improved significantly from 48.25 to ~90 (p<0.001). Disability WHODAS score reduced from 37.6 to 5.58 (p<0.001) (Tables 1-3).

Quality of life showed significant improvements in the physical, psychological, social, and environmental domains.

Subgroup analysis comparing AVN and fracture neck of femur demonstrated comparable improvements in HHS at the final follow-up (Table 4). The overall complication rate was 5.4%, including one superficial infection, one septic loosening, and one stem perforation. No mortality was observed in this study (Table 5).

DISCUSSION

This study demonstrated significant and sustained improvements in hip function, disability reduction, and quality of life enhancement following primary THA. The improvements were evident as early as the second postoperative week and continued progressively up to 1.5 years of follow-up, indicating both early and durable benefits of the procedure. The use of three validated instruments provided a comprehensive assessment.

The mean age of the study participants in our study was 50.30 years, whereas the mean age of patients in the study by Engelbert and his colleagues among 134 patients was 59.2 years (range 25 to 85 years) mainly due to improvement in health facilities and earlier diagnosis. In our study, AVN was the most common cause of hip replacement (64.3%), followed by fracture neck of femur (17.9%).⁸ Most studies have reported AVN as the most common indication for hip replacement.⁹ The inclusion of three scores for the evaluation of results, assessment of disability, and quality of life makes this study novel. The mean preoperative HHS was 48.25, reflecting substantial functional limitations which improved to 89.82 at the final follow-up, representing a clinically meaningful gain. These findings are comparable to previously reported improvements in functional outcomes after THA by Vinjamuri in the Indian population, demonstrating consistency in results among regional cohorts.¹⁰ Likewise, Li et al observed in their study that there was a significant improvement in the functional outcome of their study participants having necrosis of femoral head using modified Harris hip score after THA.¹¹ This is comparable to the study conducted by Peters et al, who reported an improvement from 54 points preoperatively to 84 points at the time of the last follow-up. All these studies are comparable to our study. In addition to functional recovery, we also assessed the disability score of our study participants using the WHO disability assessment schedule 2.0 both pre-and postoperatively at various follow-ups, which showed a great decline in disability, thus making the individual free from incapacitating pain and allowing reintegration into daily life. There is a dearth of literature estimating the satisfaction level of patients after THR. Therefore, this study is novel in its own kind in that it suggests that THA benefits extend beyond pain relief and mobility restoration to meaningful improvement in independence and societal participation. Lastly, we also assessed the quality of life using the WHO-BREF scoring system, which considers four domains: physical health, psychological health, social relationships, and environmental scores that encompass every possible aspect of a patient’s being, to evaluate the ultimate outcome of any intervention for a disease. It has shown cultural adaptability and validity in certain interventions, such as surgeries for acetabular and hip fractures.¹² We used three types of prosthesis in our study participants viz cemented, uncemented and hybrid, of which uncemented prosthesis was used most commonly because the mean age of study participants was 50.30 i.e. comparatively younger age group with good bone stock. Abdulkarim et al in their study concluded that cemented vs uncemented THR gave similar results.¹³ The better results in the three domains could be explained by the fact that these surgeries are mostly performed when the hips are increasingly damaged and the patients are debilitated to an extent where they cease to have a fruitful social and environmental life, along with psychological deficits. Therefore, once their pain and debility diminish post THRs, they report significantly high mental and social improvements. In our study there is a marked improvement in domain 1 and domain 4 i.e. physical status and environmental which can be explained by the fact that pain decrease after THR and the study being done in hilly area the need for environmental security as well as transportation is a priority.

Strengths

The strength of the study was that it utilizes a prospective design and validated outcome tools.

Limitations

Limitations were modest sample size, single-center design, and short follow-up duration.

CONCLUSION

Primary THR significantly improves function, reduces disability, and enhances quality of life.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

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