Total hip arthroplasty (THA) can be broadly divided into those hips fixed with cement and those fixed without. Cemented THA uses polymethylmethacrylate (PMMA) to function as a grout, producing an interlocking fit between cancellous bone and prosthesis. Uncemented hips rely on biological fixation of bone to a surface coating on the prosthesis. Initial fixation is achieved by inserting a prosthesis slightly larger than the prepared bone-bed, generating compression hoop stresses, and obtaining a so-called “press-fit [1].

Moreover, since hip fracture prevalence increases exponentially with age [2], as populations age and longevity increases worldwide [3], these injuries are likely to occur at accelerated rates. This is important, because among those who sustain a hip fracture injury and survive, an increasing number continue to experience various degrees of subsequent disability, including the onset of painful disabling hip joint osteoarthritis, a high risk for falls, and further hip fracture injury. As a result, escalating and excessive monetary costs of care for this debilitating injury, which includes disability costs, nursing care, rehabilitation care, and surgical costs are predicted as well.

Shan et al. investigated mid-term HRQOL after THR in patients with osteoarthritis in a systemic review. They included 20 studies. Pooled response means of total Harris Hip Score (HHS) and combined pain and physical function domains of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and HHS improved markedly up to 7 years.Medical Outcomes Survey Short Form 36 shows physical functioning (PF), bodily pain (BP), role physical, role emotional, and social functioning (SF) were improved up to 7 years. General health (GH), mental health (MH), and vitality was similar. HRQOL was at least as good as reference populations in the first few years and subsequently plateaus or declines. Patient satisfaction and functional status was favorable.

There was significant heterogeneity amongst all studies, but publication bias was low in pooled analysis. They concluded that THR confers significant mid-term HRQOL benefits across a broad range of health domains. Further studies based on consistent guidelines provided in this review are required [4].

Aprato et al. evaluate and compare patient’s health-related quality of life after THA for osteoarthritis and femoral neck fracture. The postoperative outcome was retrospectively evaluated in patients who underwent THA with an intracapsular femoral neck fracture (Group A) or with an hip osteoarthritis (Group B). Length discrepancy was measured on postoperative X-rays. Study groups were compared as to age, results of WOMAC and SF-36 tests, limb length discrepancy (LLD) by independent group t-test. Correlations between LLD and results obtained at WOMAC test were performed. 117 patients were enrolled. The 2 groups were similar as to age, type of implanted stem and sex.Mean follow up was 2.4 years for group A and 2,3 years for group B. WOMAC score was found higher in group A in all items. Correlation tests did not indicate a statistically significant linear relationship between LLD and WOMAC score in both groups. They concluded that the patients who received THA for arthritis have better perception of quality of life than traumatologic patients. Although LLD should always be strongly considered by the surgeons performing a THA, LLD alone can’t be considered as an indicator of patient dissatisfaction or clinical bad result after a 2-year follow-up [5].

Dimitrou et al report the clinical outcomes, complication rate, mortality, and quality-adjusted life year (QALY) of THA in patients who already exceeded the average life expectancy. Patients treated with elective THA for debilitating hip osteoarthritis and already exceeded the average life expectancy in Switzerland (n= 100) were included. The complication rate, QALY, and 30-day, 1-year, and midterm mortality were assessed retrospectively. The overall complication rate was 12%. The 30-day and 1-year mortality was 3% and 6%, respectively. The Harris hip score increased significantly from an average of 50 preoperative to 93 points postoperative. Most of the patients (98%) had an improvement in the Harris hip score that was above the threshold for minimally significant change, whereas 75% reported an increase that exceeded the moderate improvement threshold. The average QALY was 4 years. They concluded that THA might be a safe and cost-effective procedure for improving pain, function, and quality of life with low mortality in selected elderly patients who already exceeded the average life expectancy. Hence, the arthroplasty surgeons should not hesitate to operate relatively active, independent, and cognitively intact elderly patients having debilitating hip osteoarthritis based only on the patient’s age. Nevertheless, careful patient selection, surgical indications, and aggressive perioperative optimization might be necessary to minimize the risk of preoperative complications [6].

Tilbury et al. assessed whether preoperative radiographic severity of OA is related to improvements in functioning, pain, and health-related quality of life (HRQoL) 1 year after THA or TKA. This prospective cohort study included 302 THA patients and 271 TKA patients with hip or knee OA. In the THA patients, preoperatively 26% had mild OA and 74% had severe OA, in the TKA patients, preoperatively 27% had mild OA and 73% had severe OA. Radiographic severity was determined according to the Kellgren and Lawrence (KL) classification. Clinical assessments preoperatively and 1 year postoperatively included socio-demographic characteristics and patient-reported outcomes (PROMs) like Oxford hip/knee score, hip/knee injury and osteoarthritis outcome score (HOOS/KOOS), SF36, and EQ5D. Change scores of PROMs were compared with mild OA (KL 0–2) and severe OA (KL 3–4) using a multivariate linear regression model. The decrease in pain and improvement  in function in THA patients, but not in TKA patients, was positively associated with the preoperative radiographic severity of OA [7].

Kjærgaard et al. defined the thresholds to distinguish patients with a satisfactory or unsatisfactory outcome after total hip replacement (THR) based on patient-reported outcome measures (PROMs) including the Oxford Hip Score (OHS), and using patient satisfaction and patient-perceived function as global transition items. The thresholds are intended to be used as a tool in the process of determining which patients are in need of postoperative outpatient evaluation. One hundred and three THR patients who had completed a preoperative questionnaire containing the OHS questionnaire were invited to complete the same questionnaire and supplementary questions at a mean of 6 (4–9) months after surgery. Significant correlations were found between outcome measures and anchors. Thresholds were determined for outcome measures coupled with satisfaction, patient perceived function and a combination thereof using a cutoff of 50 and 70. They established a set of thresholds for Oxford scores that may help determine which THR patients are in need of postoperative evaluation. These thresholds can be implemented in clinical practice [8].

Świtoń A et al. conducted in a group of 189 patients who had undergone unilateral total hip arthroplasty. Goniometry was used to determine the range of motion of both hip joints. Patients' physical ability and pain severity were assessed based on the Harris Hip Score (HHS) questionnaire. The examination of the range of motion in the lower extremities revealed statistically significant diffe-rences in flexion (p = 0.01), abduction (p = 0.01), adduction (p = 0.01) and external rotation (p=0.01) between the operated and the healthy extremity. The greatest limitation of motion was demonstrated for external rotation (14°). Approximately 14% of the patients were not able to perform this motion in their healthy hip joint, while 17.5% of them could not do so in the affected hip joint. Analysis of HHS results (mean = 79 pts) revealed that more than 50% of the patients described their functional ability and quality of life as good and excellent. It was demonstrated that 54% of patients did not suffer from pain, whereas minor or mild pain was noted in 35%.A subjective clinical assessment of patients after total hip arthroplasty showed that their quality of life had improved. They suggested that it was necessary to perform physiotherapy after total hip arthroplasty, on both the operated and healthy side. Exacerbation of pain and impaired activity in patients after total hip arthroplasty were associated with the female sex to a considerable extent [9].

Verdugo-Meza et al. conducted a study with an objective to determine the claudication, quality of life and functional results of THA through minimal invasive approach in patients with primary coxarthrosis. It was a prospective longitudinal study in patients with unilateral primary coxarthrosis postop of THA with minimally invasive approach. Each patient was analyzed for the quality of Life instrument (WOMAC), Functional test for coxarthrosis (HHS) and functional test in patients with hip surgery (OHS) with follow-up of one year. They included 21 patients, 17 female and 4 males corresponding to 80.95% and 19.05% respectively, average age of 59.95 years (ED = 9.64), with excellent functional results to one year according to HHS and OHS, quality of life high in 100% of cases according to WOMAC, with claudication rate of 4.76%. In the end, they concluded that the minimal invasive approach was a reproducible surgical technique, with excellent functional results, low claudication rate and high quality of life in postoperative patients of primary ATC at only one year of follow-up [10].

Ray S et al. conducted a study to assess whether improvements in quality of life between the preoperative and 1-year postoperative period were associated with patient satisfaction. Data was extracted for 69,083 THR operations with complete data reported to the Swedish Hip Arthroplasty Register (SHAR) between 2008 and 2015. Health-related quality of life and patient satisfaction were captured using the Euro-Qol-5D (EQ-5D) and visual analogue scale (VAS), respectively. Multivariable analysis was performed to assess associations between the changes in pre- and postoperative EQ5D and patient satisfaction. In patients reporting severe or moderate problems with mobility preoperatively, improvement to no problems was associated with numerically higher patient satisfaction (coefficient -18 (95% CI -22 to -14) and -18 (-18 to -17)). Improvement in the self-care dimension from severe or moderate problems to no problems was associated with numerically higher patient satisfaction (-15 (-16 to -14) and -13 (-15 to -11)). Improvement from severe problems with the ability to perform usual activities to no problems was associated with numerically higher patient satisfaction (-18 (-19 to -17)). This association was also found for improvement in pain/discomfort and anxiety/depression (-16 (-17 to -15) and -15 (-16 to -14)).Their results indicated that satisfaction with the operated hip was a valid patient-reported outcome reflecting the changes in different EQ-5D dimensions and should be included in the follow-up of patients after THR surgery [11].

Bahardoust et al. evaluated the Heealth –related quality of life (HRQoL) of the patient after THA, for the first time in the Iranian population. In a case-control study, HRQoL was assessed in 217 patients after THA and compared with a matched reference population. The 36-item short-form health survey (SF-36) was used for the evaluation of HRQoL. A multiple linear regression model was used to investigate the influence of sociodemographic and clinical characteristics of the patients on the HRQOL. The mean follow-up of the patients was 27±18 months. The mean total SF-36 score was 41.4±22.2 in the case and 67.3±26.6 in the control group (p = 0.001). The mean physical component score, but not the mental component score, was significantly lower in the patient group (p = 0.001). Except for the vitality and emotional role, all other SF-36 subscales were significantly lower in the case group. Male sex (B = 4.52, p = 0.023), number of comorbidities (p = 0.011), body mass index (p = 0.044), number of post-operative complications (p = 0.001), and adherence to physiotherapy protocol (p = 0.014) were associated with HRQoL after THA. Although THA is considered as one of the most successful orthopedic practices, it is associated with remarkable reduced HRQoL in Iranian population when compared with the reference population [12]. 

1. Maggs, J. and M. Wilson. “The Relative Merits of Cemented and Uncemented Prostheses in Total Hip Arthroplasty.” Indian Journal of Orthopaedics, vol. 51, no. 4, 2017, pp. 377–385.

2. Samelson, E.J. et al. “Effect of Birth Cohort on Risk of Hip Fracture: Age-Specific Incidence Rates in the Framingham Study.” American Journal of Public Health, vol. 92, 2002, pp. 858–862.

3. Wilson, R.T. and R.B. Wallace. “Trends in Hip Fracture Incidence in Young and Older Adults.” American Journal of Public Health, vol. 97, 2007, pp. 1734–1735.

4. Shan, L. et al. “Total Hip Replacement: A Systematic Review and Meta-Analysis on Mid-Term Quality of Life.” Osteoarthritis and Cartilage, vol. 22, no. 3, 2014, pp. 389–406.

5. Aprato, A. et al. “Patient-Perceived Quality of Life after Total Hip Arthroplasty: Elective versus Traumatological Surgery.” ISRN Orthopedics, vol. 2011, 2011, pp. 910392.

6. Dimitriou, D. et al. “Total Hip Arthroplasty Improves the Quality-Adjusted Life Years in Patients Who Exceeded the Estimated Life Expectancy.” The Journal of Arthroplasty, 2018.

7. Tilbury, C. et al. “Outcome of Total Hip Arthroplasty, but Not of Total Knee Arthroplasty, Is Related to the Preoperative Radiographic Severity of Osteoarthritis: A Prospective Cohort Study of 573 Patients.” Acta Orthopaedica, vol. 87, no. 1, 2016, pp. 67–71.

8. Kjærgaard, N. et al. “Thresholds for the Oxford Hip Score after Total Hip Replacement Surgery: A Novel Approach to Postoperative Evaluation.” Journal of Orthopaedics and Traumatology, vol. 18, no. 4, 2017, pp. 401–406.

9. Świtoń, A. et al. “Activity and Quality of Life after Total Hip Arthroplasty.” Ortopedia Traumatologia Rehabilitacja, vol. 19, no. 5, October 2017, pp. 441–450.

10. Verdugo-Meza, R.A. et al. “Claudication, Functional Outcomes and Quality of Life in Primary Total Hip Arthroplasty with Minimally Invasive Anterolateral Approach.” Acta Ortopédica Mexicana, vol. 33, no. 1, January–February 2019, pp. 8–12.

11. Ray, G.S. et al. “Changes in Health-Related Quality of Life Are Associated with Patient Satisfaction Following Total Hip Replacement: An Analysis of 69,083 Patients in the Swedish Hip Arthroplasty Register.” Acta Orthopaedica, vol. 91, no. 1, February 2020, pp. 48–52.

12. Bahardoust, M. et al. “Evaluation of Health-Related Quality of Life after Total Hip Arthroplasty: A Case-Control Study in the Iranian Population.” BMC Musculoskeletal Disorders, vol. 20, no. 1, January 2019, pp. 46.