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Primary Cemented Total Hip Arthroplasty - An Indian Experience

*Manoj Todkar, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD.

Address for Correspondence
Manoj Todkar,
17 Girdlestone Close, Headington, Oxford, OX3 7NS
Tel: 07792404268


We report outcome of nine-year follow up of fifty Charnley Cemented Primary Arthroplasties in forty-seven patients performed between 1996 to 1999.The minimum follow up period was 5 years with a mean of seven years. All hip joints were thoroughly assessed preoperatively to document patients functional level and Harris Hip Score was calculated. All the patients were disabled because of pain in hip and forty-five (90%) had used walking aids. At follow up all patients were living. The radiographs of all patients were available for the entire follow up period. Of the fifty operated hips, only two patients (4%) complained of pain while rest all were pain free. Postoperatively only ten (20%) patients used support for walking. At follow up none of the hips were revised. Two patients (4%) had dislocation in postoperative period in which reduction was done under anesthesia. In one patient (2%) prosthesis and cement was removed because of deep infection. In two patients (4%) radiolucent clear zone was seen at bone cement interface on acetabular side and three (6%) patients had it on femoral component. None of the patients developed deep vein thrombosis or heterotopic bone. In post operative period the Harris Hip Score was calculated in each case and compared with the preoperative score to evaluate the outcome. Significant improvement was found in Harris Hip Score after surgery.

Key Words:
Charnley Low Friction Arthroplasty, Primary Cemented Hip Replacement, Harris Hip Score

J.Orthopaedics 2005;2(3)e2


Analysis of long-term results of any operative procedure is important for the establishment of the outcome of the procedure. This outcome then serves as a basis for comparison of the results of newer procedures and of non- operative treatment. Because the rates of survival of the implant and the outcomes associated with the various designs and procedure for total hip arthroplasty have changed over time, the long term follow up of series of patients is important to determine the durability and the functions of implant over time.

In the current study, a series of patients in whom Charnley total hip arthroplasty with cement had been performed were followed up for a minimum period of 5 years with a mean of seven years. The purpose of the study was to establish the long term durability of total hip replacement with cement using mechanically sound prosthetic design and a hand packing technique for application of cement. We believe a longer follow up with a large number of patients is required as a basis for comparison of outcomes of newer devices and techniques of total hip replacement.


Patients and method

Between years 1996 to 1999, forty-seven patients had fifty total hip replacements at Sassoon General Hospital, Pune. There were forty men and ten women in this series. The average age of patients at the time of index arthroplasty was sixty-five years (range fifty to eighty years). The pre- operative diagnosis was osteonecrosis of head of femur in 39 (78%) cases, rheumatoid arthritis in 5 (10%) cases, ankylosing spondylitis in 4 (8%) cases, post-traumatic arthritis of hip in one (2%) case and osteoarthritis in one (2%) case. The arthroplasties were equally distributed between left and right hips. The Harris Hip Score was calculated in each case preoperatively. It indicates function of the hip joint. The maximum score is of 100 points. Points are given for pain, functional capacity, range of movement and absence of deformity.

More the score better the function of the hip. This score was compared with the postoperative score to find the improvement after arthroplasty. The indication for the surgery was pain. All patients underwent total hip replacement only after conservative line of management in the form of analgesic drugs, weight reduction, use of support for walking failed to relieve pain. The Charnley hip prosthesis was used in all patients. A stainless steel stem with head diameter of 22 millimeter and an acetabular cup made of ultrahigh molecular weight polyethylene with 22 millimeter inner diameter and varying outer diameter were inserted with polymethyl methacrylate radio-opaque bone cement. All procedures were performed using posterolateral approach to the hip in lateral position without doing osteotomy of greater trochanter. After splitting the fibres of gluteus maximus the gluteus medius is retracted to expose short external rotator muscles of the hip. These are divided close to their insertion and an inverted T shaped incision is made on the joint capsule. Hip is dislocated and femoral neck is osteotomised with oscillating power saw. Retracting the osteotomised neck anteriorly exposes acetabulum. Exposed acetabulum is reamed using reamers of increasing size. Cement fixation holes are drilled in the acetabulum followed by saline irrigation and roller gauze packing. Femoral canal is gradually reamed with the rasps. Trial prosthesis is used to ensure fit. Trial reduction gives idea about the stability and range of movement. Acetabulum followed by femur is prepared for insertion of components using manual cementing technique. After reduction range of motion and stability are checked. Short external rotators are reattached to femur with drill holes. Closure is carried out over the drain.

Postoperatively intravenous antibiotics were given for one day and drain was removed after fortyeight hours. Aspirin was used as prophylaxis for deep vein thrombosis. Average duration of the surgery was two hours and average blood loss was 400 ml. Postoperative protocol was carried out as per the recommendations of Internal Publication No.27, Nov.1970 (John Charnley Writhington Hospital). The limb is kept in abduction over a pilow. The breathing exercises and static exercises of calves, quadriceps and gluteal muscles are taught to patients preoperatively and carried out from the first day. Patient stands out of bed twice daily from the second postoperative day. Patients walk with the help of walker from third postoperative day. Range of motion exercises – adduction, adduction, flexion are taught after 3 days.

The patient is discharged after complete rehabilitation. At the time of discharge radiograph of the hip –anteroposterior and lateral views are taken. Patient is followed monthly for three months, three monthly for a year and six monthly thereafter. At each follow-up visit patient is examined clinically to calculate Harris Hip Score and radio logically to find out aseptic loosening.

Radiographic Evaluation :
Observations were based on anterioposterior radiographs of pelvis that had been made early postoperatively and at the latest follow up evaluation for all patients. In addition interval radiographs were used to determine the time that various radiographic changes had occurred. Loosening of the femoral component was defined according to criteria of Harris et al. It included subseidence of femoral component, fracture of cement or stem and presence of radioleucent line of greater than two millimeter that had not been seen on  the immediate postoperative radiograph at the interface of prosthesis and cement. Subsidence of femoral component was determined using the Loudon and Charnley method. The distance between tip of the trochanter and the tip of the stem was measured and compared with earlier radiographs to find out subsidence. Any bone loss in the periacetabular region that appeared cystic was recorded, as was any localized loss of endosteal cortex of femur. The position of the stem (varus, valgus or neutral) was recorded on each radiograph. Heterotopic bone when present was graded according to classification of Brooker et al. Radioleucent lines between cement and bone, as seen on anterioposterior radiograph were recorded on the basis of the three acetebular zones described by Delee and Charnley and the seven femoral zones described by Gruen et al.




At the follow up evaluation, the average age of the patient was seventy years (range fifty-seven to eighty-eight years). All patients were alive till latest follow up. The minimum follow up period was 5 years and the mean follow up was 7 years. A deep infection had developed in one (2%) of the fifty hips and two (4%) hips had dislocated at the time of latest follow up. None of the patients had undergone revision surgery. Before the index arthroplasty all patients had pain. All patients had excellent relief of pain after the total hip replacement and this was well maintained during the course of the follow up. Only two (4%) patients have moderate pain at the follow up. Preoperatively 45 (90%) patients used support for walking. Of these thirty (60%) patients used stick and fifteen (30%) used crutches. After surgery only ten (20%) patients use stick for walking. Deep vein thrombosis, heterotopic bone formation occurred in none of the cases. Radiolucent lines were seen at the bone cement interface on acetabular side in two (4%) cases and on femoral side in three (6%) cases. These were of less than two-millimeter width. But none of these patients complained of pain. Subsidence of cement prosthesis or

Table 1 (Sex distribution)











Table 2 (Indications )














Table 3 (Harris Hip Score )

Preoperative score

Postoperative score















Table 4 (Complications )







Acetabular radiolucency


Femoral radiolucency




Heterotopic ossification


fracture of cement or stem did not occur in any of the hips. The average preoperative Harris Hip Score in patients having osteonecrosis of head of femur was 43 and it went up to 88 postoperatively. In rheumatoid hips the score improved to 82 from a preoperative average value of 45. In cases of ankylosing spondylitis the average preoperative score was 49 and the postoperative score was 83. In cases of osteoarthrosis the average preoperative score was 47 and it improved to 87 after total hip replacement.



The present study was undertaken to know the vital role of cemented total hip replacement in cases of osteonecrosis of head of femur and arthritic hip joints. Osteonecrosis of head of femur (39 cases) was the major indication in this series followed by rheumatoid arthritis (5 cases) and ankylosing spondylitis (4 cases). The results obtained in this series are comparable to those obtained worldwide. In 1971,Eftekhar followed up 205 case for 8 years (1962-1970). The sepsis rate was 3.6% and 1.4% had loose sockets. In present study the sepsis rate is 2% and none of the patients have clinically significant loosening. In 1972, Charnley published the results in 338 cases (1962-1965) followed up for 5 years. Postoperative hip scores improved over the preoperative ones. The sepsis rate was 3.8% and 1% had loose sockets. In 1973, Cupic published follow up of 185 cases for 10 years (1962-1972).The scores improved and the sepsis rate was 5% and 2% had loosening. Wroblewski studied 15 –21 year follow up of Charnley Low Friction Arthroplasty in 93 patients. 85% were painfree. 29% showed subsidence of stem cement complex. 78% had full range of movement. 36 hips showed socket demarcation. It may be inferred that the results are similar to other studies and are highly encouraging. All the patients are very well adjusted to the changed life style required after total hip replacement. The patients were crippled because of the pain, loss of movements and inability to carry out day to day activities. All the patients have shown significant improvement in relief of pain, range of movement and deformities. Most of the patients have resumed their jobs and satisfied. Total hip arthroplasty is boon to the patients crippled because of arthritis of hip, as life is movement.


1.Charnley J: Internal publication No.27, November 1970, Centre for Hip Surgery.Wrightington Hospital
2.Charnley J : The long term results of low friction arthroplasty of the hip performed as a primary intervention. Journal of Bone and Joint Surgery, 54B: 61, 1972
3.Eftekhar NS, Stinchfielf FE: Experience with low friction arthroplasty a statistical review of early results and complications. Clinical Orthopaedics, 95: 60, 1973.
4.Harris WH: Traumatic arthritis of hip after dislocation and acetabular fractures – treatment by mold arthroplasty – An end result study using a new method of result evaluation. Journal of Bone and Joint Surgery, 51A: 4, 1969
5.Wroblewski BM, Siney PD: Charnley low friction arthroplasty of hip:
long term results. Clinical Orthopaedics, 292: 191, 1993.




 This is a peer reviewed paper 

Please cite as :Manoj Todkar:Primary Cemented Total Hip Arthroplasty - An Indian Experience
J.Orthopaedics 2005;2(3)e2





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