Hip Int 2014; 24 ( 5): 480-484

DOI: 10.5301/hipint.5000152


Developing a sustainable hip service in Cambodia Jacquelyn A. Holt, James J. Aird, James G. Gollogly, Ou C. Ngiep, Sohrab Gollogly Children’s Surgical Centre, Phnom Penh - Cambodia

Objective: Initial report on establishment of a hip service in Phnom Penh, Cambodia at Children’s Surgical Centre. We describe indications for total hip replacement (THR) and initial results. Methods: A database was established to collect data and track patients for follow up. Initial data collected included; diagnosis, implant used, post-operative complications. As the service developed, pre- and postoperative Harris hip scores were included. Results: High rate of avascular necrosis (AVN) as the initial diagnosis. Five years post initiation of the hip service, 95 patients have received 116 THRs; including 10 revisions, 12 bilateral procedures. Complications/failures requiring revision involved four prosthetic femoral neck fractures, two aseptic acetabular component, two late infections, one instability. One failure, a periprosthetic acetabular fracture, required removal of all prosthetics. Complications not requiring revision, included three post-op foot drops, three superficial wound infections, one Vancouver B1 periprosthetic femur fracture. Average age was 41. Overall implant survival is 85% at three years. Discussion: AVN was the most common indication for THR: many patients had a history of hip trauma, and/or prolonged steroids from traditional healers for pain. Problems with specific implants were addressed by the company. A different stem is now routinely used, no further fractures have been reported. Acetabular loosening, thought to be due to poor technique, has been addressed by focused training. Infection rate is monitored, and microbiology resources are improving. Conclusion: Developing an affordable hip arthroplasty service in a country like Cambodia is challenging. Developing a local registry has helped to identify complications and modify techniques. Keywords: Cambodia, Arthroplasty, Hip, Registy, Prosthesis Accepted: March 31, 2014

INTRODUCTION Severe hip arthritis is a disabling condition, which leads to continuous pain, immobility, and dependence. Treatment options include analgesia, lifestyle modification, arthroplasty, and fusion. Cambodia has very limited surgical provision especially for poor patients, and long-term analgesia can be expensive to obtain. Many patients with painful hips therefore seek the help of traditional healers. Traditional healers will often provide patients with a variety of remedies, frequently including steroids. These steroids may be taken for prolonged periods. Prior to five years ago, there were no hospitals capable of offering total hip 480

replacements in Cambodia, and limited centres that could do hip fusions. Whilst the wealthy few in Cambodia can afford to travel abroad for surgery, the majority of middle- and low-income patients are unable to afford such treatment. Travelling to other contries in the area such as Vietnam cost at least $2,000 and more elsewhere in SE Asia. Children’s Surgical Centre (CSC) was established in 1998 to provide free orthopaedic, maxillofacial, plastic, and ophthalmic surgery to poor Cambodians in the National Rehabilitation Centre, Kien Khleang, Phnom Penh. CSC is staffed principally by local Khmer doctors, and trains local surgeons with the help of a variety of regularly visiting international surgeons.

© 2014 Wichtig Publishing - ISSN 1120-7000

Holt et al

In an effort to maintain senior local staff, a private clinic was established in association with CSC, allowing local staff to start a private practice whilst maintaining clinical input into CSC. The lack of provision for total hip replacements for anyone in the country, led CSC to develop a service that could afford to provide such replacements. This service would be free of charge to the poor, and at an affordable cost to those with middle incomes. The service was initiated in 2007, during a two-week visit from an American hip surgeon, Sorhab Gollogly. As local expertise has improved, senior Cambodian surgeons are now regularly performing THRs independently. A simple database was set up by CSC physicians to detect early complications. The database has been recently updated to look at longer term outcomes. There are only a few other reports of arthroplasty regi­sters in developing countries (such as in Malawi (1)), but none following this model of care and financial constraints. We therefore feel it important to share our early experience. This paper analyses the early outcome of the first 95 patients to undergo THR in Cambodia and be included in the database. New patients at CSC and the private hospital are continually added to the database in order for CSC to follow not only the short-term but also long-term outcomes of total hip replacements. The model of care and financial system continue to operate as described in this paper.

METHODS A database has been developed, by CSC, to monitor the outcomes and complications of THRs preformed at CSC and the private hospital. Initially preoperative data collection was done variably, however as time progressed a more standardized data collection system has been implemented. This now includes pre- and postoperative Harris hip scores (HHS), which have been used in similar studies (2). Alternative patient reported hip scores were considered, however we could not find evidence of validation in south east Asia, and the Harris hip scores allowed comparison with data from Malawi (1). A prere­quisite for receiving treatment at CSC was consent for data to be entered into the registry.

Surgery Preoperative work-up includes CBC, ESR and CRP as well as HIV tests on all patients. There is a blood bank on

site, and all patients are obliged to donate two units of autologous blood preoperatively, at three weeks and one week before surgery. All arthroplasty surgery was done in the Private clinic, which was deemed to have the most sterile environment, although it did not have laminar flow. Prophylactic preoperative antibiotics (ceforixime) are given to all patients, along with two postoperative doses. A posterior approach is used in the majority of patients. The cemented implants usually used were bought from, and manufactured in, India and are copies of either a C-stem or Muller type design. Occasionally, donations of American prostheses became available with visiting surgeons, and were used as uncemented implants. Due to the challenge of obtaining consumables, a cement gun was not used and the cement was inserted antegrade, without a cement restrictor or centraliser, much as in the original Charnley procedure. Seventy percent of the operations were performed by two local surgeons, in the other 30% of operations, they were assisted by either of two visiting foreign specialists. Postoperatively, the patients stay in CSC for seven to 10 days, during which they are encouraged to start immediate ambulation by the physical therapists. Once discharged, patients are asked to return for three-month, one-year, and five-year follow-ups. Patients are assessed with the Harris hip score at each follow up visit, and also have their hips x-rayed to look for signs of failure. About 5% of patients chose to be treated privately and were charged $1400 for the procedure and subsequent follow-up.

RESULTS Between November 2007 and October 2012, 95 patients have been entered in the database, and 116 total operations have been documented. Of these 10 were revisions (one revision was removal of all implants), and 12 patients had bilateral operations on different occasions. Fifty-five patients were men, and 40 patients were women. The average age of the patients at the time of operation was 41 years (range 18–74). The average weight of the patients was 57 kg. The total hip replacement service started in 2007, and was initially limited to biannual visits from one surgeon. However, as local expertise increased and other visiting surgeons also assisted in training, numbers increased as shown in Figure 1.

© 2014 Wichtig Publishing - ISSN 1120-7000


Developing a sustainable hip service in Cambodia

Fig. 1 - Number of hip replacements preformed per 6th month period.



Avascular Necrosis


Primary Osteoarthritis


Arthritis post trauma


Arthritis post CDH


Chronic traumatic Dislocation


Femoral neck fracture


Ankylosing spondylitis


Tubercular Arthritis


Rheumatoid Arthritis




Fifteen patients were lost early to follow-up. In survival analysis, these implants were assumed to have survived to the date of most recent follow-up. As there are no other centres currently offering a hip replacement service it is likely that if they had significant problems they would return to CSC. Of the remaining patients the average follow-up is one year. The indications for surgery are listed in Table I. The most common indication for hip replacement was AVN, all of which were post trauma. One patient had recently finished being treated for tuberculosis infection of the hip. Most of the prosthetic components used were obtained commercially from India. They were all designed to be cemented in place, and consisted of a polyethylene acetabulum and a femoral stem supplemented by a 28 mm head 482

Fig. 2 - Survival curves of implants, excluding dislocations requiring closed reduction.

on a short, medium or long neck. Of the femoral stems used 50% were labeled by the manufacturer as small, 34% as medium, and 16% as large. The visiting specialists however, sometimes received donations of prostheses from orthopaedic equipment companies in the USA. Twenty patients received those implants donated by USA orthopaedic companies, which were inserted without cement. All of the implants were inserted using a posterior approach. For implant survival analysis, prosthetic failures were considered to be any complication that required removal and/ or replacement of any component of the prosthesis. Figure 2 demonstrates implant survival until time of most recent follow-up, when three dislocations requiring closed reductions were not included as failures. Ten patients required removal or replacement of the prosthetic component, including four cases in which the neck of the femoral stem broke a year or more after operation, as noted in Table II. The four prosthetic femoral neck fractures occurred in cemented C-stem designs copied from the West, and once recognised, that model of femoral component was changed to Muller-type stems in subsequent operations, none of which have broken. We are continuing to observe patients with the C stem type design implants to see if more fractures occur. Two acetabular components loosened shortly after operation, due to poor cement mantle thickness, and had to be revised. The late pelvic fracture

© 2014 Wichtig Publishing - ISSN 1120-7000

Holt et al


Number of Prosthesis

Femoral implant breakage


Acetabular loosening requiring revision


Hip dislocation acetabular revision


Periprosthetic acetabular fracture


Late infection


occurred in a patient who continued to take steroids from a traditional healther post-operatively (3). Two years and nine months post-op, this patient fell, broke her pelvis and the acetabular cup prolapsed into the pelvis. The patient was treated with removal of all prosthetic components leaving her with a Girdlestone arthoplasty. One patient developed a late infection 20 months post primary operation. The infection was cultured and grew staphylococcus aureus. The patient had removal of implants and insertion of antibiotic spacer. He has not yet had a 2nd stage procedure. One patient had an early dislocation, which was unstable post reduction. The acetabular component was felt to be mal-positioned so acetabular revision was undertaken, the patient had no further problems. Three years post-op, 85% of the implants are still in place and without complications. Three patients developed superficial wound infections which resolved with antibiotic treatment. One patient developed a deep infection. The patient had been treated for TB preoperatively and developed a sinus postoperatively, and a flare-up of his TB was determined to be the cause. He was re-treated with a wider spectrum of anti-TB medications. His prostheses show the development of circumferential lucent lines, and he is scheduled for a conversion to a hip fusion once the disease is quiescent. Postoperative foot drop was observed in three patients, all of whom had preoperative chronic dislocation of the hip, and which improved in all three during the postoperative period. It was not possible to confirm whether the foot drop was present preoperatively but the foot drop did improve postoperatively in all patients, suggesting an intraoperative neuropraxia. One patient had a spiral fracture of the femur, involving the distal cement mantle. The implant however remained stable, and the fracture healed with conservative management.

Four hips in three patients had evidence of a lucent line in Delee and Charnley zones 1 and 2 on initial post operative radiographs, however this had not shown signs of progression at follow-up. The mean preoperative Harris hip score for those 33 patients on whom it was assessed, was 61. Postoperatively 25 patients were evaluated in the clinic with an average postoperative score of 81. Eight patients were assessed by telephone interview with an average postoperative Harris hip score of 85, and the postoperative score was 82, leading us to confirm patients’ reports of a reduction of pain and increase in mobility at their follow-up.

DISCUSSION The average age of patients is low (41 years, range 18–74) in comparison to UK national joint registry 67 years (2). The average is also 10 years younger than the study conducted in Malawi (1). Both Malawi and Cambodia have very young populations, with low life expectancy in comparison to the UK. The young age remains a concern, as this may lead to high revision rates in the future. The current life expectancy reported by the World Health Organization is 64 for men and 66 for women (4). This highlights the need for an effective registry to detect problems early and provision to be made for revision surgery. Initial diagnosis was often difficult as arthritis was very far advanced, and it was hard to determine what the original cause was. Several times, an initial diagnosis of osteoarthritis had to be reclassified into tuberculosis arthritis, sometimes on the operating table before the prostheses were implanted, leading to abandonment of the operation. However, avascular necrosis turned out to be the most common indication for THR: similar to that seen in the Malawi joint registry, where it was thought to be due to the high background rates of HIV (1). In Cambodia, however, HIV is relatively rare with prevalence rates estimated at 0.8% (2). Nearly all patients in Cambodia will initially utilize traditional healers for bone and joint pain and will receive locally made medicines, which commonly contain large doses of steroids. Many patients will be unaware that they have taken steroids, but often present with facial oedema and central obesity, which slowly resolve on stopping the traditional medicine. This may influence the rates of avascular necrosis (5). The most disturbing feature of our results was the breakage of four femoral stems, which were all of the same

© 2014 Wichtig Publishing - ISSN 1120-7000


Developing a sustainable hip service in Cambodia

design, and all broke in the same place. These stems were all Indian produced copies of the C stem. This is not a problem that has been reported with this design of prosthesis in the past and therefore is likely to be related to the metallurgy of the Indian copied implant. This highlights the problem of obtaining high quality affordable regionally sourced implants. CSC is now using an alternative design and has had no further breakages. It also emphasises the need of some form of registry to identify complications, especially if patients may go to other providers if complications occur. The acetabular component failures were due to technical errors with cementing which has been improved by focused training. The three postoperative foot drops are suspected to be intraoperative neuropraxia, as they all improve postoperatively. All had previous dislocations of the hip. We are concerned about our two major postoperative infections, one with Staphylococcus aureus and one with TB. The deep infection rate remains relatively low at 2%. We have improved our microbiology input, and have access to advanced culture techniques and PCR if required. We monitor local antibiotic resistance, and have noted high rates of MRSA in hospital acquired infections – we have rationalised our antibiotic prescribing based on this. Postoperative Harris hip scores would suggest that patients are getting good clinical results from their prostheses. Initially only a small portion of patients have elected to be treated privately for a small fee. As the service grows we expect to increase the number of private patients. Currently CSC continues to fund the service. Since the creation of the service the number of patients seen by CSC physicians for hip replacement has steadily increased.




1. Ministry of Health. NCHADS. HIV/AIDS Program Annual Report 2008. Phnom Penh, Cambodia: National Center for HIV/AIDS, Dermatology and STD Control; 2009. 2. Annual Report National Joint Registry for England and Wales (2012). 3. Lubega N, Mkandawire NC, Sibande GC, Norrish AR, Harrison WJ. Joint replacement in Malawi: establishment of a National Joint Registry. J Bone Joint Surg Br. 2009;91(3):341-343.


Delivering an effective service for THR in the developing world is challenging. There is little governance of surgical practice and little regulation regarding what operations surgeons can perform. The nature of arthroplasty failure, with a lag time of 5–20 years means that surgeons may be unaware of their results, and morbidity and the financial cost of revision need to be assessed when deciding how to implement a service. This paper highlights some of the issues faced when trying to deliver a service in a financially constrained and consumable-limited environment. The use of arthroplasty surgery in this type of environment is becoming more common. Open discussions on how to improve outcomes without unduly negative criticism of current practices and inadequacies is important in helping the healthcare systems in these countries develop. This study shows the benefit of a registry in detecting complications and modifying practice. Financial Support: None.

Conflict of Interest: None.

Address for correspondence: James Aird Specialist Trainee Severn Deanery Orthopaedics Bristol Royal Hospital For Children Upper Maudlin Street Bristol, BS2 8BJ, UK [email protected]



Osteoporosis causes and risk factors. In DynaMed (database online). EBSCO Information Services. Available at: http://search.ebscohost.com.offcampus.lib.washington. edu/login.aspx?direct=true&site=DynaMed&id=113862. Updated March 09, 2010. Accessed August 6, 2013. Organization WH. Global health observatory data repository. Cambodia: Country Statistics. Available at: http://apps.who. int/ghodata, 2011. Accessed August 6, 2013. Weinstein RS. Glucocorticoid-induced osteonecrosis. Endocrine. 2012;41(2):183-190.

© 2014 Wichtig Publishing - ISSN 1120-7000

Copyright of Hip International is the property of Wichtig Editore and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Developing a sustainable hip service in Cambodia.

Initial report on establishment of a hip service in Phnom Penh, Cambodia at Children's Surgical Centre. We describe indications for total hip replacem...
89KB Sizes 23 Downloads 4 Views