The prevalence of Parkinson’s disease and the incidence of hip fractures mirror an ageing population living longer [
The aim of the study was to compare the short- to mid-term clinical outcomes following elective and traumatic total hip arthroplasty in patients with Parkinson’s disease focusing on the assessment of risks and benefits of surgery.
All patients with a confirmed diagnosis of Parkinson’s disease having total hip arthroplasty at our institution between January 2005 and December 2012 were enrolled in a retrospective analysis. In total, 24 total hip arthroplasties were implanted in 23 patients, 8 men (35%) and 15 women (65%). The primary indication for surgery was osteoarthritis for 10 hips; these 10 patients comprise the “elective group” with a mean age at operation 74 years (65 to 82). Thirteen patients underwent total hip arthroplasty for proximal femoral fracture (one patient had hip fracture subsequently on both sides); they comprise the “hip fracture group” with a mean age at operation 76 years (67 to 83) (Table
Demographics of patients included in the study.
Elective group | Hip fracture group | |
---|---|---|
Number of patients | 10 | 13 |
Number of hips | 10 | 14 |
Mean age in years (range) | 74 (65–82) | 76 (67–83) |
Gender | ||
Female | 8 | 7 |
Male | 2 | 6 |
Right side | 5 | 5 |
Left side | 5 | 9 |
ASA score, average | 2.50 | 2.62 |
Hoehn-Yahr scale, average | 2.30 | 2.31 |
All the procedures were performed via a standard anterolateral Watson-Jones approach to the hip joint. In order to maximize sample size in the elective and hip fracture groups, implant design was not a controlled variable. The details of components with regard to stability of the implanted nonconstrained total hip arthroplasty are depicted in Table
Details of implants used in the study.
Elective group | Hip fracture group | |
---|---|---|
Acetabular component | ||
Cemented | 8 | 13 |
Cementless | 2 | 1 |
Acetabular liner | ||
Standard | 7 | 8 |
With elevated rim/lipped | 3 | 6 |
Femoral stem | ||
Cemented | 9 | 12 |
Cementless | 1 | 2 |
Head diameter | ||
28 mm | 7 | 13 |
32 mm | 3 | 1 |
Outcome measure analysed in the study included Charnley’s modified Merle d’Aubigné and Postel scoring system [ Maintained independent ability to walk: being able to walk without support from another person (with aids if necessary). Not maintained: support from another person or use of a wheelchair required.
Complications were recorded throughout the follow-up period. All patients were followed up prospectively before surgery, at 6 months and 36 months postoperatively, and at the time of the latest follow-up.
In the elective group consisting of 10 hips, the mean follow-up was 82 (33–143) months. One patient in the elective group died at 33 months postoperatively from causes unrelated to the surgery (pulmonary tumor). For 14 hips in the hip fracture group, the mean follow-up was 54 (1–143) months. Five patients in the hip fracture group died during follow-up at 1, 3, 4, 11, and 30 months postoperatively.
Measurement data were processed and statistically evaluated with the help of MS Excel 2013 (Microsoft Corp, Redmond WA, USA) and NCSS 2007 (Hintze, J. (2007). NCSS 2007. NCSS LLC, Kaysville, Utah, USA.
The statistically significant difference between the medians of Merle d’Aubigné and Postel score in the elective and hip fracture group was recorded preoperatively, at 6 and 36 months after total hip arthroplasty. There was no statistically significant difference between the two groups during the last follow-up (Figure
Line graph of Merle d’Aubigné and Postel scores by time in the elective and hip fracture group. Comparison of the progress of the medians of Merle d’Aubigné and Postel score during follow-up. The asterisk (
The elective group had preoperatively significantly higher pain score when compared with the hip fracture group. There was no statistically significant difference between the two groups during the 6 months, 36 months, and the last follow-up (Figure
Line graph of pain scores by time in the elective and hip fracture group. Comparison of the progress of the medians of pain score during follow-up. The asterisk (
Despite the improvement in Merle d’Aubigné and Postel and pain scores, disability related to Parkinson’s disease increased during the follow-up; neurological progression was noted in 83% of all our patients. At the time of latest follow-up 57% of all the patients had progressed to functional stage IV or V (Table
Details of patients included in the study.
Elective group
Case | A | B | C | D | E | F | G | H | I | J |
---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 75 | 2 | 33 | 3/4 | 1/2 | 1 + 4 | 70/80 | 30/20 | 7 + 4 |
2 | 2 | 71 | 2 | 123 | 2/5 | 1/2 | 1 + 5 | 70/100 | 0/30 | 6 + 8 |
3 | 1 | 66 | 3 | 143 | 2/3 | 1/1 | 2 + 4 | 95/90 | 35/40 | 10 + 3 |
4 | 1 | 77 | 3 | 99 | 2/2 | 1/1 | 1 + 5 | 90/95 | 20/20 | 8 + 6 |
5 | 2 | 70 | 3 | 132 | 2/4 | 1/2 | 1 + 5 | 70/90 | 30/30 | 8 + 7 |
6 | 2 | 82 | 2 | 60 | 2/2 | 1/1 | 1 + 5 | 60/90 | 15/30 | 6 + 8 |
7 | 2 | 77 | 3 | 72 | 3/3 | 1/1 | 2 + 4 | 120/90 | 30/40 | 9 + 4 |
8 | 2 | 82 | 2 | 52 | 2/3 | 1/1 | 2 + 3 | 95/90 | 30/30 | 12 + 0 |
9 | 2 | 65 | 2 | 53 | 3/4 | 1/1 | 1 + 5 | 80/90 | 25/30 | 7 + 6 |
10 | 2 | 74 | 3 | 48 | 2/3 | 1/2 | 2 + 4 | 85/120 | 20/30 | 10 + 4 |
Hip fracture group
Case | A | B | C | D | E | F | G | H | I | J |
---|---|---|---|---|---|---|---|---|---|---|
1 | 1 | 70 | 3 | 1 | 3/5 | 1/2 | 1 + |
|
|
3 + |
2 | 1 | 75 | 3 | 4 | 3/5 | 1/2 | 1 + |
|
|
3 + |
3 | 2 | 80 | 3 | 143 | 2/3 | 1/1 | 1 + 5 |
|
|
3 + 12 |
4 | 2 | 73 | 2 | 93 | 2/5 | 1/2 | 1 + 5 |
|
|
3 + 9 |
5 left | 2 | 80 | 3 | 53 | 3/3 | 1/1 | 1 + 5 |
|
|
3 + 9 |
5 right | 2 | 80 | 3 | 53 | 3/3 | 1/1 | 1 + 4 |
|
|
3 + 8 |
6 | 2 | 78 | 2 | 85 | 2/4 | 1/2 | 1 + 5 |
|
|
3 + 10 |
7 | 2 | 67 | 3 | 82 | 2/5 | 1/2 | 1 + 5 |
|
|
3 + 9 |
8 | 1 | 83 | 3 | 87 | 3/5 | 1/2 | 1 + 5 |
|
|
3 + 10 |
9 | 1 | 77 | 3 | 11 | 2/5 | 1/2 | 1 + 5 |
|
|
3 + 9 |
10 | 2 | 75 | 2 | 3 | 2/5 | 1/2 | 1 + |
|
|
3 + |
11 | 1 | 75 | 2 | 61 | 2/3 | 1/1 | 1 + 5 |
|
|
3 + 9 |
12 | 2 | 74 | 2 | 45 | 1/2 | 1/1 | 1 + 5 |
|
|
3 + 9 |
13 | 1 | 82 | 3 | 30 | 3/4 | 1/2 | 1 + 5 |
|
|
3 + 9 |
A: gender: 1: male; 2: female; B: age at total hip arthroplasty (years); C: ASA score; D: follow-up (months); E: Hoehn and Yahr functional stage preoperatively/at the time of latest follow-up; F: functional status preoperatively/at the time of latest follow-up: 1: maintained independent ability to walk; 2: not maintained independent ability to walk; G: preoperative pain score ± the postoperative increase at 6 months postoperatively (points);
All patients in both groups were able to walk independently before surgery and functional status deteriorated over time as seen in Figure
Distribution of independent and reliant patients in the elective and hip fracture groups during follow-up.
The complications are listed in Table
Complications.
Complication | Elective group (10 hips; 10 patients) | Hip fracture group (14 hips; 13 patients) |
---|---|---|
Dislocation | 1 | 1 |
Periprosthetic fracture | 1 | 1 |
Periprosthetic infection | 0 | 1 |
Cerebrovascular accident | 0 | 1 |
Postoperative confusion | 0 | 2 |
Urinary tract infection | 0 | 9 |
Pneumonia | 0 | 4 |
Vulvovaginitis | 1 | 0 |
Pressure sores | 1 | 2 |
Decompensation of diabetes mellitus | 1 | 0 |
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Six patients (five in the hip fracture group) had two complications each. Two patients in the hip fracture group had four complications.
Four patients in the hip fracture group died during first year after surgery: three of pneumonia and one of cerebrovascular accident. The overall 1-year mortality for the hip fracture group was 28.6%.
Total hip arthroplasty is one of the major successes of modern medicine [
Our study demonstrates a clear improvement in hip pain following total hip arthroplasty in patients with Parkinson’s disease as supported by improved Merle d’Aubigné and Postel and pain scores. This improvement was maintained from 6 months after surgery to the latest follow-up in the elective and hip fracture group. Although the functional status of Parkinson’s disease patients deteriorated over time, we observed that patients in the elective group benefited from excellent pain relief and were able to walk without support of another person at 36 months after total hip arthroplasty which was indicated for osteoarthritis with severe hip joint pain preventing activities of daily living. Ten of living patients from both groups (43%) were still able to walk without support of another person at the time of the latest follow-up.
Although variable mortality following hip fracture in Parkinson’s disease patients has been reported, we found it comparable with 1-year mortality published in non-Parkinson’s disease patients [
Obstructive respiratory pattern due to neuromuscular dysfunction predisposes to retained secretion, atelectasis, and pulmonary infection [
The musculoskeletal manifestation of Parkinson’s disease include tremor, rigidity, contractures, bradykinesia, dystonia, and postural instability which theoretically predispose patients to dislocation of the hip [
Recently Parkinson’s disease patients had an approximately twofold risk of hip dislocation [
Despite early mobilization started on the first postoperative day, intensive postoperative rehabilitation, and patient’s care, the dislocation rate of nonconstrained total hip arthroplasty in our study (8.3%) is comparable with recently reported rate in nationwide registry-based case-controlled study (6.1%) [
Most Parkinson’s disease patients experience falls as a result of disease symptoms and many have recurrent episodes [
With increasing prevalence of Parkinson’s disease, falls and fractures are anticipated to have a major impact on health care systems in the coming decades [
This retrospective study is limited by the small patient numbers and short duration of follow-up. Nevertheless the follow-up was sufficient to reveal a clinical outcome following elective and traumatic total hip arthroplasty in patients with Parkinson’s disease. Total hip arthroplasty is a viable alternative for these patients if the surgery is individualized and carefully planned. A multidisciplinary team comprised of health professionals, including the neurologist, geriatrician, and physiotherapist, should be involved to maximize patient outcome [
In conclusion, total hip arthroplasty in patients with Parkinson’s disease is challenging due to higher risk of medical complications which were seen mainly in patients with hip fracture. Excellent pain relief with preserved walking ability without support of another person and acceptable complication profile was observed in Parkinson’s disease patients at 36 months after elective total hip arthroplasty. Elective total hip arthroplasty may be indicated in patients with Parkinson’s disease after careful and individualized planning.
The authors declare that there are no conflicts of interest regarding the publication of this paper.
This study was supported by the Program PROGRES Q40/04.