Comparative Study of Pre-operative, Operative, and Post-operative Parameters of Single and Staged Bilateral Total Hip Replacement

INTRODUCTION

Total hip replacement (THR) is one of the most successful and sought-after surgeries that can drastically change the quality of life of an arthritis patient. Patients generally have bilateral (B/L) hip involvement in cases like avascular necrosis (AVN) of the head of the femur that is one of the significant causes of developmental dysplasia, ankylosing spondylitis, and rheumatoid arthritis.^[1]

B/L hip arthritis can be operated in single or staged operation (i.e., two operations within a gap of few days). In 1971, Charnley first demonstrated the feasibility of simultaneous bilateral (B/L) THR.^[2] Operating bilaterally in a single operation theoretically has the advantage of single anesthesia, more rewarding to the surgeon, single rehabilitation program, more patient satisfaction, few hospital stays, and reduced cost. However, it may have disadvantages like increased surgical risk and higher incidence of post-operative complications like thromboembolic episodes. Studies conducted comparing unilateral to single B/L and staged B/L are of the view that in single Bilateral Total Hip Replacement (B/L THR), mortality and with mortality, and complications were similar to unilateral THR and even allowed better control of limb length;^[3] whereas other studies show concern about post-operative complications and increased risk with higher transfusion rate.^[4] Aghayev et al. have demonstrated that the possible intra and post-operative complications of single simultaneous B/L THR are equal to staged THR,^[5] whereas Berend et al. showed a higher rate of in-patient complications with increased blood transfusion and failure to reach physical therapy goals in single B/L THR.^[6] Hence, the choice of operation remains controversial. In the pursuit of finding an appropriate approach, comparative studies on B/L THR single or staged have been conducted, but they mainly comprise THR done on one side and then on the other after a few days or in a different set-up. Comparative data of B/L THR single and staged operation done in a single institution under a single surgeon is limited.

The aim of our study is to analyze the pre-operative, operative and post-operative parameters of bilateral operations done in a single and staged operation procedure in the same admission after a days gap of 6–7 days, and compare which is more suitable for the Indian setup.

MATERIAL AND METHODS

A retrospective cohort study was done for all the cases of B/L THR operated between 2017 and 2021 under a single surgeon in a tertiary care hospital. This study was approved by the Institutional Ethical Committee: IEC no. 797/Chairman-IEC, MKCG Medical College, Brahmapur-4.

Surgical method

All patients were operated on through a mini-invasive postero-lateral incision under a spinal block in a lateral position.^[8] The leg was positioned loosely in 30° hip flexion and 60° knee flexion. Sterile draping was applied. A line is drawn on the skin from the lateral femoral condyle to the tip of the greater trochanter, the middle of this line being the new landmark, and then joined proximally to the posterior superior iliac spine. On this line, a perpendicular was drawn to the axis of the femur from the tip of the trochanter, and the skin incision of 6–8 cm long was made along the oblique posterior iliac line 3–4 cm proximally and 3–4 cm distally to this point. The gluteus maximus muscle is divided, and underlying structures reached with the use of self-retaining retractor. Thus, the posterior part of the neck is reached through short external rotators, with the hip in internal rotation. The neck is cut, the head is delivered, then acetabular preparation is done, followed by femoral preparation; a trial implant was tried. Arthroplasty is completed with non-cemented acetabular and femoral components. The capsule with rotators was repaired back to the trochanter. The wound is closed over a drain.

In single B/L THR, an operation was done on both hips under single anesthesia [Figures 1a, 1b]. In staged B/L THR operation, the second operation was done in the same hospital admission in a similar manner after a span of 6–7 days, when the patient was found fit for surgery after stabilization of routine parameters [Figures 2a, 2b, 2c].

Close

Figure 1a:

Pre-operative X-ray (R-right side) of patient of Single B/L THR; B/L THR: Bilateral Total Hip Replacement.

Export to PPT

Close

Figure 1b:

Post-operative X-ray of Single B/L THR; B/L THR: Bilateral Total Hip Replacement (B/L THR).

Export to PPT

Close

Figure 2a:

Pre-operative X-ray (R-right side) of Staged B/L THR; B/L THR: Bilateral Total Hip Replacement.

Export to PPT

Close

Figure 2b:

Post-operative X-ray of Staged B/L THR operated on one side; B/L THR: Bilateral Total Hip Replacement.

Export to PPT

Close

Figure 2c:

Post-operative X-ray of Staged B/L THR operated on other side; B/L THR: Bilateral Total Hip Replacement (B/L THR).

Export to PPT

RESULTS

The present study included 97 cases of B/L THR operated in single (37 cases) or staged (60 cases) operation in a single hospital admission. The patients were assessed based on pre-operative, operative, and post-operative parameters.

DISCUSSION

THR is one of the most satisfying and successful remedies for the arthritis of the hip and its sequelae. The number of patients in India opting for replacement in general and THR in particular is now rising. This is because of the introduction of various schemes and insurance packages, due to which even the poorest of poor patients who earlier were reluctant or could not afford, now opt for this procedure. Patients come from remote places seeking surgery; hence, early management and disposal of these cases remain an objective. Many cases present bilateral involvement, which can be operated in a single or staged operation. With the number of cases of THR increasing, the feasibility of single-stage THR remains a non-practicable thought because of the risk of complications.^[11] Earlier studies on single and staged THR have analyzed results on parameters like a hospital stay, cost, and blood loss; thromboembolic events like DVT and pulmonary embolism, dislocations, sciatic nerve palsy, trochanteric fracture, hematoma, wound infection, etc.; and have published opposite extremes of results. Staged B/L THR done in two sessions increases cumulative surgery time increasing in anesthesia time that also increases the risk of infection, venous thromboembolism, neurologic deficit, revision, intra-operative blood loss, transfusion, and other adverse effects. However, there is scanty literature on data obtained from single institutions and single admission THR surgeries. Hence, our study comparing B/L single THR and staged THR (same admission) compared complications like intra-operative and post-operative blood loss, pre and post-operative Hb%, pain (reaching baseline 3 on VAS), Harris Hip score, infection, DVT, dislocation and duration of hospital stay was undertaken. Patients with comorbid conditions or major systemic complications like cardiovascular failure, pulmonary failure, or stroke requiring an extended hospital stay and Intensive Care Unit setup were not included in our present study.

In our study, age, sex, and BMI-matched patients were grouped as per the operation procedure, i.e., single B/L THR and Staged B/L THR. The pre-operative Harris Hip Score and Hb level were equal in both groups and statistically insignificant.

In comparison to the intra-operative parameters, the blood loss during surgery was measured from markings on the suction canister. We affirm the readings as we did not use diluents like normal saline. The results from both groups were not statistically significant in our study. However, in Single THR, 21 cases (56.75%) showed blood loss of 50–100 ml, whereas in Staged B/L THR, 36 cases (60%) showed >100 ml blood loss. As 90% of blood loss occurs between skin closure and the first post-operative 24 hours^[12] the post-operative blood loss was estimated in both cases. This was found to be statistically not significant in our study; however, 22 cases (59.45%) showed blood loss of 300–500 ml in Single B/L THR, whereas 38 cases (63.33%) had >500 ml blood loss in staged B/L THR. These findings are similar to studies done by Bhan S et al.^[10] and Salvati EA et al.^[13] and a systemic review and meta-analysis done by Ramezani A et al.^[14], which showed that single B/L THR had lower blood loss. However, some studies like Berend et al.^[15] have proposed an increased requirement for blood transfusion after Single B/L THR.

The pain gradually decreased postoperatively during the hospital stay but aggravated with mobilization and physiotherapy. The pain was assessed as the number of days reaching baseline 3 on the visual pain analog score.^[16] Pain was found to be 5.92 ± 0.493 days in Single B/L THR and 10.50 ± 0.701 days in Staged B/L THR, which was statistically significant. This increase in number of days in Staged B/L THR can be explained on the basis of the injury being inflicted by two different surgeries on two different occasions in Staged B/L THR compared to a single surgery in Single B/L THR.

On comparing the post-operative DVT, 1 (one) case of Single B/L THR and three cases of Staged B/L THR were observed. Lower hospital stay, early mobilization, early initiation, and better compliance to weight-bearing and physiotherapy in Single B/L THR resulted in a lower incidence of DVT than in Staged B/L THR. This is a consistent study done by Ramezani et al.^[14] that showed decreased risk of DVT in Single B/L THR. However, a study done by Bhan et al.^[10] found a similar incidence of DVT in both groups. Despite pulmonary embolism being a common complication in THR,^[17] we have not encountered it in our study which can be attributed to anticoagulation therapy and early post-operative mobilization in both groups.

Another complication found in our study is infection in one case of both Single B/L THR and Staged B/L THR. The infection was superficial, with an indurated skin margin with normal baseline hematological parameters. The infection healed without any further intervention at the time of stitch removal.

There were no dislocations reported in our study that may be attributed to meticulous posterior structure (i.e. posterior capsule and short rotators) repair intra-operatively.

To assess hip functionality, the Harris Hip score is a standard functional score compared to pre- and post-operatively (after three months) in both groups. We have observed a regaining of the function of both hips without showing any correlation to the time of operation, as observed by no statistical significance between Single B/L THR and Staged B/L THR. This is in accordance with Wykman and Olsson,^[18] who stated that optimal functions are regained with both hips replaced in B/L hip disease. However, our study observed that 56.7% (21 cases) of Single B/L THR showed Hip score improvement to 90–100 compared to 46.6% (28 cases) of Staged B/L THR. This finding of better functional outcome is similar to a study by Kim et al.^[12], who argued that the accuracy of surgery, earlier starting rehabilitation for both operated hips, and reduced time lost from work resulted in better functional outcome in Single B/L THR.

Another factor for consideration in THR cases is the duration of hospital stay. This was found to be on 5.32 ± 0.747 days in Single B/L THR compared to 9.32 ± 0.701 days in Staged B/L THR that is statistically significant. Duration of hospital stay is a major driving factor in the cost of surgery. Thus, two surgeries in single admission (i.e., Staged THR) are costlier than Single B/L THR. Similar findings have been observed by various studies.^[10] Hence, economically, B/L Single THR imparts a positive result to patients and society.

CONCLUSION

Single B/L THR is feasible, safe, and economically convenient than Staged B/L THR. This also possesses a great advantage for those who come for surgery from remote places. The intra and post-operative blood loss, risk of DVT, dislocation, and infection are not increased in Single B/L THR. The functional outcome, as observed, is identical in both Single B/L THR and Staged B/L THR but the pain persists for more days in Staged B/L THR, thereby returning to society is earlier in Single B/L THR. The length of hospital stay is decreased in Single B/L THR; hence, it is cost-effective and bears a less burden to the person in particular and society in general. Therefore, tertiary care centers should encourage Single B/L THR.