Krishnan S.P*, Zaghloul A
M*, Carrington R.W.Jж, Jeffery R. M.ж, Garlick N.ж
*Watford General Hospital, London,
UK.
ж Royal Free Hospital,
London, UK.
Address for Correspondence
Dr. Ahmed Zaghloul
Orthopaedic Surgery
Department, Watford General Hospital
Watford, WD18 0HB,
UK
Tel:
07810898664
Email:
drahmedz@hotmail.com
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Abstract
Fifty patients were
randomly selected from a cohort of 400 patients who had
unilateral cemented primary CPT total hip replacements (Zimmer
UK) atleast 12 months previously using the Hardinge approach.
All surgeries were
performed by one surgeon. Patients were grouped according to
whether the
offset had been accurately reconstructed, increased or
decreased. Their functional
outcomes were evaluated using the Harris scoring system and
the delayed
Trendelenburg test.
While 52% (26) patients had their offset reconstructed
accurately, those with an increased and decreased offset
reconstruction were 28% (14) and 20 % (10) respectively. The
variation in offset ranged from +20 mm to -15mm.There was no
significant difference between the three groups in their mean
Harris hip scores (p =0.57) and their delayed Trendelenburg
test (1, 0 and 1 respectively) at a
mean follow-up of 38 months (range: 12 to 78 months).
Reconstruction of the hip using a standard cemented CPT
prosthesis produced
considerable variation in the reconstructed hip offset. This
resulted in no significant
difference in
the functional outcome at 38 months. Accurate reconstruction
of the hip
joint offset in total hip
arthroplasty may therefore not be important in the functional
outcome.
J.Orthopaedics 2007;4(1)e9
Introduction:
Numerous authors
have independently analysed the implications of offset
reconstruction on various factors in hip arthroplasty
including range of motion1,
abductor
muscle strength, polyethylene wear, medial cement mantle
strain2, post
operative hip
dislocation, trochanteric prominence3,limp and bony
impingement2.
Many surgeons
reconstruct offset using preoperative radiographic planning,
intraoperative assessment of stability of the hip, the soft
tissue tension and leg length
assessment while using standard prostheses . This may result
in either accurate
reconstruction of the offset, increased or decreased offset
reconstruction when
compared
to the contra-lateral normal hip. Bourne etal reported a 40%
incidence of under correction of offset following hip
arthroplasty4. To the best of our knowledge, the effect of
offset on the functional outcome has never been studied in the
past. Although many authors believe that an increased offset
reconstruction may be more
desirable
than a normal offset reconstruction, such a reconstruction has
its own potential disadvantages3 such as trochanteric
prominence, bursitis and pain and possibly increased stress on
the proximal medial cement mantle and the stem5.
McGrory
et al.1 demonstrated an increase in range of motion and
abductor muscle
strength with
increased offset reconstructions. Whether this added range of
motion
and abductor
strength could be important in the functional outcome warrant
further
evaluation.
This
study was an attempt to assess the significance of varying
degrees of offset reconstruction on the final functional
outcome after primary total hip arthroplasty.
Material and Methods :
Fifty
consecutive patients were selected from a cohort of four
hundred patients based
on the
following criteria:
-
All underwent
primary cemented total hip replacements with no previous
operations on their hip joint and had a normal
contra-lateral hip.
-
Minimum post
operative follow-up of 1 year at the time of evaluation.
-
No significant
co-morbid conditions which might affect their functional
outcome.
-
No
post-operative infection or loosening.
-
The surgery
was performed using the standard CPT femoral stem prosthesis
(Zimmer
UK) and using the Hardinge approach.
Patients were
functionally assessed using the Harris hip scoring system6
and the
delayed
Trendelenburg test 7. Measurements were taken from
standardised post-operative anteroposterior radiographs of the
pelvis centred on the symphysis pubis,
with the
patient lying supine and the great toes touching to maintain
consistent femoral rotation. The medial offsets on the operated
side and the contra- lateral
normal side
were measured on the radiographs. Medial offset was measured as
the
perpendicular
distance from the centre line of the proximal femur (mid –
diaphyseal
axis) to the
centre of rotation of the femoral head (fig 1) 8. The
centre of the femoral
head was
identified using templates of concentric circles.
The
patients were divided into three different groups based on the
study by Dolhein
et al 8:
-
The normal
offset group:
The
reconstructed offset was within +/-4mm of the offset measured
on the contra-lateral
normal hip9.
-
The increased
offset group:The reconstructed offset was 4mm or more than the
contra-lateral normal hip.
-
The decreased
offset group
The
reconstructed offset less than 4mm compared to that of the
contra-lateral normal
hip.
All the patients
had a diagnosis of osteoarthritis affecting only one hip with
preservation of anatomy of the contra-lateral hip joint. All
total hip replacements were
performed
by one experienced hip surgeon (N.G). Intra-observer and
inter-observer variations were determined from ten randomly
selected sets of radiographs measured initially and after three
weeks by the same author and also by independent assessment of
another author.Intra class correlation was then measured and was
evaluated using the grouping recommended by J R Landis etal for
the kappa statistics10. Scores between 0.61 and 0.8
represented substantial agreement and those greater than 0.81
almost perfect agreements.
Results :
Inter- and
intra-observer variability showed almost perfect agreement while measuring femoral
offset. (Table I)
Table I: reproducibility
of measurements.
|
Femoral offset |
Intra- observer
error:
Intra-class
correlation
|
0.98
|
Inter- observer
error:
Intra-class
correlation
|
0.83
|
The mean age group of
patients in this study was 71.1 years ranging from 45 to 87 years. The mean follow
up at the time of evaluation was 38 months ranging from 12 to 78 months. Of the
fifty patients studied, 26 patients (52%) were found to have had their hip offset
accurately reconstructed (normal offset group); 14 patients
(28%) had their hip offset
increased (increased offset group) and 10 patients (20%) had
their hip offset decreased
(decreased offset group) (Table II). The variation in offset
ranged from +20 mm to -15mm.
Table II: Summary of
findings.
Offset group
|
No. of patients in each group
|
Mean Harris Hip score
(range)
[ P=0.57 ]
|
No. of patients with
+ve Trendelenburg
test
|
Normal offset
|
26
|
92.01
(68.86-100)
|
1
|
Increased offset
|
14
|
90.25
(72.8-99.8)
|
Nil
|
Decreased offset
|
10
|
91.50
(90.8-100)
|
1
|
The mean Harris hip
scores for patients with normal offset, increased offset and decreased offset were
92.01(range: 68.86-100), 90.25(range:72.8-99.8) and 91.50(range: 90.8-100)
respectively. Harris hip scores were compared between the three groups using the
Kruskal-Wallis analysis of variance, as it could not be assumed that the scores would
follow a normal distribution (Fig 3). The p-value was 0.57, indicating no evidence
of a difference in scores between the groups. Of the fifty patients
studied the delayed Trendelenburg test could be performed in 43. Of these, 21 patients
were from the normal offset group, 14 from the increased offset group and 8 from the
decreased offset group. The number of patients who were found to be positive was 1, 0
and 1 in the normal offset reconstruction group, increased offset reconstruction
group and the decreased offset reconstruction group
respectively.
Box and whisker plot to
compare the distribution of the Harris hip scores among the three offset groups.
Thick horizontal lines represent median hip score, the box represents the inter
quartile range and whiskers represent the full range.
Discussion:
Increased offset
reconstruction has been shown to increase the range of motion of
the reconstructed hip and
the abductor muscle strength1. Vaz et al found that
although the hip abductor muscle
strength is related to its function, isometric measurements of strength should not be
relied upon as the sole predictor of function in patients who have undergone total hip
arthoplasty 11. Although an increased offset may
increase the isometric abductor
muscle strength as suggested by Mcgregory et al1; our
study did not show any
significant difference in the functional scores among patients
with higher offset reconstruction.
Decreased offset shortens the moment arm of the abductor
musculature and results in increased joint reaction
force. This may in turn lead to bony impingement, limp and increased polyethylene
wear 12. Decreased offset also causes reduction in
the soft tissue tension whereas
and an increase in offset may result in increased stress with in the stem and the
proximal medial cement mantle 13,8,14. Major
overcorrection of the femoral offset may also
lead to soft tissue problems such as pain resulting from trochanteric prominence
and from bursitis 3. Whether the reconstructed offset
should be equivalent to that of
the contra-lateral normal hip (if the contra-lateral hip joint
is available for
preoperative planning) or whether it should be deliberately
increased remains unclear. Harris pointed out that
extreme ranges of motion at the hip might not determine the functional outcome as
they are not important for normal daily activities. Pain and functional capacity are
the two basic considerations in the functional assessment using the Harris hip scoring
system6.They constitute the indications for surgery
in the vast majority of patients
with hip problems and hence receive the heaviest weighting on hip scoring. In specific
cases, correction of deformity or restoration of motion may be of prime importance but
such cases are uncommon. This study supports
these ideas and shows that even though an increased offset may produce an additional
increase in the replaced hip’s range of motion1; such
an increase does not
determine the functional score of the patient as extreme ranges
of motion are not important
in normal daily activities. In conclusion, no
significant difference was found in the mean hip scores and the delayed
Trendelenburg tests between the three groups of patients in this pilot study regardless
of the offset at the hip. A larger size study would be required
to confirm these results.
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