Background: Total hip replacement (THR) is an established and highly successful surgical procedure for the management of end-stage hip disorders. The epidemiology of conditions requiring THR and the choice of implant fixation vary considerably across populations. In India, avascular necrosis (AVN) is a major indication for THR and frequently affects younger individuals, influencing implant selection and long-term management strategies. However, data regarding indications for THR and implant-selection patterns in rural and tribal populations remain limited.
Objective: To evaluate the spectrum of indications for total hip replacement and to assess the pattern of implant selection among patients undergoing THR in a rural tribal population of central India.
Methods: A prospective observational study was conducted in the Department of Orthopaedics, Raipur Institute of Medical Sciences, Raipur, Chhattisgarh, India, over a period of 18 months. A total of 79 patients undergoing primary THR were included. Demographic characteristics, indications for surgery, and implant fixation methods were recorded. The distribution of cemented and uncemented arthroplasty was analyzed using descriptive statistics.
Results: Seventy-nine patients underwent primary THR during the study period. The mean age of the study population was 44.16 ± 13.85 years, and males constituted 77.2% of the cohort. Avascular necrosis of the femoral head was the most common indication for THR, accounting for 49 cases (62.0%), followed by osteoarthritis (19.0%), fracture neck of femur (8.9%), failed hemiarthroplasty (5.1%), rheumatoid arthritis (2.5%), and ankylosing spondylitis (2.5%). Uncemented THR was performed in 71 patients (89.9%), whereas cemented THR was performed in 8 patients (10.1%). Patients undergoing cemented THR were older, with a mean age of 61.25 ± 8.34 years, compared with 42.24 ± 12.78 years among those receiving uncemented implants. The predominance of AVN and the younger age profile contributed to the overwhelming preference for uncemented fixation.
Conclusion: The epidemiological profile of THR in this rural tribal population differs substantially from that reported in Western populations. Avascular necrosis was the predominant indication for surgery, and patients undergoing THR were considerably younger than those reported in international registries. Uncemented fixation was the preferred implant choice, reflecting the younger age and better bone quality of the study population. These findings highlight the need for region-specific arthroplasty strategies and provide valuable insights into implant-selection patterns in rural and tribal populations of central India.
Total hip replacement is one of the most successful and widely performed reconstructive procedures in orthopaedic surgery, providing reliable pain relief, restoration of mobility, and significant improvement in quality of life for patients with end-stage hip disorders (1). Since its introduction by Sir John Charnley in the early 1960s, THR has evolved considerably through advances in implant design, biomaterials, fixation techniques, and surgical approaches, resulting in excellent long-term survivorship and patient satisfaction (2,3). Consequently, THR has become the treatment of choice for a variety of debilitating hip conditions, including osteoarthritis, avascular necrosis of the femoral head, fracture neck of femur, rheumatoid arthritis, ankylosing spondylitis, and failed hip reconstructive procedures (Aswal, Outcome of Patients Treated with Total Hip Arthroplasty for Various Disorders of Hip: A Retrospective Study, 2025).
The epidemiology of hip disorders requiring THR varies considerably across different geographical regions and populations (5). In developed countries, primary osteoarthritis is the predominant indication for THR and is largely observed in elderly individuals (6). In contrast, studies from India and other South Asian settings have consistently demonstrated that avascular necrosis of the femoral head represents a major indication for THR, often affecting younger and economically productive age groups (Jain, Sao, & Patond, Statistical analysis of total hip arthroplasty at rural hospital in Maharashtra under MJPJAY: a prospective study, 2024; Liu, Hu, Chan, & Sathappan, 2009; Aneja, Machaiah, & Shyam, 2025). This distinct disease pattern results in a lower mean age of patients undergoing THR compared with Western populations and has important implications for implant selection, long-term survivorship, and postoperative functional demands.
Selection of an appropriate implant fixation method remains an important determinant of surgical outcome following THR (10). The two principal fixation techniques include cemented and uncemented arthroplasty (11). Cemented THR utilizes polymethylmethacrylate bone cement to achieve immediate fixation between the prosthesis and host bone, whereas uncemented THR relies on biological fixation through bone ingrowth and osteointegration (12). Both techniques have demonstrated favorable long-term outcomes; however, implant selection is influenced by several factors including patient age, bone quality, activity level, underlying pathology, surgeon preference, and implant availability (13,14).
Younger patients with good bone stock are generally considered ideal candidates for uncemented fixation because of the potential for long-term biological integration and preservation of bone stock (11,15). Conversely, cemented fixation is often preferred in elderly individuals and patients with osteoporosis or compromised bone quality (14,15). Understanding patterns of implant selection in different populations is important for evaluating contemporary arthroplasty practices and optimizing treatment strategies. Furthermore, the distribution of indications for THR may significantly influence implant preference, particularly in populations where AVN predominates over degenerative osteoarthritis.
Rural and tribal populations represent a unique demographic group that remains underrepresented in arthroplasty literature (16,17). These populations frequently experience delayed healthcare access, limited availability of specialist services, and greater occupational dependence on physically demanding activities (18,19). Such factors may influence both the spectrum of hip disorders requiring THR and the choice of implant fixation. Despite the increasing utilization of THR in India, there is limited evidence describing indications for surgery and implant-selection patterns among rural and tribal populations.
Most available studies evaluating indications for THR and implant-selection patterns have been conducted in urban tertiary-care centres (20) and may not accurately reflect the epidemiological profile of patients from rural and tribal regions (Mishra, Singh, & Gupta, 2022; Jain, Sao, & Patond, Statistical analysis of total hip arthroplasty at rural hospital in Maharashtra under MJPJAY: a prospective study, 2024). Understanding the common indications for THR and factors influencing the choice between cemented and uncemented fixation is essential for planning arthroplasty services, optimizing resource allocation, and improving patient outcomes in these populations (19). Therefore, the present study was undertaken to evaluate the spectrum of indications for THR and the pattern of implant selection in a rural tribal population of central India.
The present study was undertaken to determine the common indications for total hip replacement and to evaluate the pattern of implant selection among patients undergoing THR in a rural tribal population. Additionally, the study aimed to assess the distribution of cemented and uncemented arthroplasty and to identify the predominant clinical conditions necessitating total hip replacement in this setting.
METHODS
Study Design and Setting
A prospective observational study was conducted at the Department of Orthopaedics, Raipur Institute of Medical Sciences, Raipur, Chhattisgarh, India, over 18 months. The institution serves a predominantly rural and tribal population from central India.
Study Population
All eligible patients undergoing primary THR during the study period were enrolled after obtaining informed consent. A total of 79 patients were included in the final analysis.
Data Collection
Demographic details including age and sex were recorded. Clinical indications leading to THR were documented and categorized as avascular necrosis, osteoarthritis, fracture neck of femur, failed hemiarthroplasty, rheumatoid arthritis, and other indications.
Implant Selection
The type of prosthesis used (cemented or uncemented THR) was recorded for each patient. Implant selection was made by the treating surgeon based on patient characteristics, bone quality, age, and clinical considerations.
Outcome Measures
The primary outcomes were the distribution of indications for THR and the proportion of patients undergoing cemented versus uncemented THR. Secondary analyses evaluated demographic characteristics associated with various indications and implant choices.
Statistical Analysis
Categorical variables were summarized as frequencies and percentages, while continuous variables were expressed as mean ± standard deviation. The commonest indication for THR and the distribution of implant choices were determined using descriptive statistics.
Ethical Approval
The study received approval from the Institutional Ethics Committee of Raipur Institute of Medical Sciences, Raipur, Chhattisgarh. Written informed consent was obtained from all patients before inclusion in the study.
RESULTS
Demographic Characteristics
A total of 79 patients undergoing primary total hip replacement (THR) were included in the study. The mean age of the study population was 44.16 ± 13.85 years. Males constituted the majority of patients (77.2%), while females accounted for 22.8%.
Table 1. Baseline Demographic Characteristics of Patients Undergoing THR (N = 79)
|
Variable |
Value |
|
Age (years), Mean ± SD |
44.16 ± 13.85 |
|
Male, n (%) |
61 (77.2) |
|
Female, n (%) |
18 (22.8) |
Indications for Total Hip Replacement
Avascular necrosis (AVN) of the femoral head was the most common indication for THR, accounting for the majority of cases. Other indications included osteoarthritis, fracture neck of femur, failed hemiarthroplasty, rheumatoid arthritis, and ankylosing spondylitis.
Table 2. Indications for Total Hip Replacement
|
Indication |
Number of Patients (n) |
Percentage (%) |
|
Avascular necrosis |
49 |
62.0 |
|
Osteoarthritis |
15 |
19.0 |
|
Fracture neck of femur |
7 |
8.9 |
|
Failed hemiarthroplasty |
4 |
5.1 |
|
Rheumatoid arthritis |
2 |
2.5 |
|
Ankylosing spondylitis |
2 |
2.5 |
|
Total |
79 |
100.0 |
AVN emerged as the predominant indication for THR, accounting for nearly two-thirds of all procedures performed in the study population.
Implant Selection Pattern
Among the 79 patients, uncemented THR was performed in the majority of cases. Cemented fixation was utilized in a smaller proportion of patients, primarily based on age, bone quality, and surgeon preference.
Table 3. Distribution of Cemented and Uncemented Total Hip Replacement
|
Type of THR |
Number of Patients (n) |
Percentage (%) |
|
Uncemented THR |
71 |
89.9 |
|
Cemented THR |
8 |
10.1 |
|
Total |
79 |
100.0 |
Uncemented fixation was the preferred method of implantation, accounting for approximately 90% of all procedures.
Relationship Between Age and Implant Choice
Patients undergoing cemented THR were generally older than those receiving uncemented implants. Uncemented prostheses were predominantly utilized in younger patients with good bone stock, whereas cemented fixation was reserved for selected elderly patients and those with compromised bone quality.
Table 4. Age Distribution According to Implant Type
|
Implant Type |
Mean Age (Years) ± SD |
|
Cemented THR |
61.25 ± 8.34 |
|
Uncemented THR |
42.24 ± 12.78 |
Epidemiological Profile of THR in a Rural Tribal Population
The present study demonstrated a distinctive epidemiological pattern of THR in a rural tribal population. Unlike Western populations where primary osteoarthritis is the leading indication for THR, avascular necrosis represented the predominant indication in this cohort. Additionally, the relatively young mean age of patients undergoing THR reflects the burden of AVN among economically productive age groups. The overwhelming preference for uncemented implants further reflects the younger patient demographic and the need for durable biological fixation in physically active individuals.
Overall, avascular necrosis was the commonest indication for THR, and uncemented fixation was the preferred implant choice in this rural tribal population.
DISCUSSION
The present study provides a detailed evaluation of the indications and implant selection patterns for total hip replacement in a rural tribal population of central India. Our findings reveal a distinct epidemiological and clinical profile compared to Western populations and even some urban Indian cohorts. The most striking observations include the overwhelming predominance of avascular necrosis as the primary indication for surgery (62%), the significantly younger mean age of the cohort (44.16 years), and the strong preference for uncemented fixation (89.9%).
Avascular necrosis was the leading indication for THR in our study, accounting for 62% of all cases, while primary osteoarthritis followed at a much lower frequency of 19%. This distribution stands in sharp contrast to Western registries, such as the UK National Joint Registry and Norwegian registers, where primary OA is the predominant indication, often exceeding 90% (6,21). While studies from urban Indian tertiary centers also recognize AVN as a major indication, some still report OA as the leading cause (70%) in older cohorts (20). However, our data aligns more closely with contemporary Indian semi-urban and rural reports and the Indian Joint Registry, which highlight AVN as a primary driver for THR in the Indian subcontinent (Aneja, Machaiah, & Shyam, 2025; Aswal, Outcome of Patients Treated with Total Hip Arthroplasty for Various Disorders of Hip: A Retrospective Study, 2025). The high prevalence of AVN in this tribal population may be attributed to regional factors such as the high incidence of sickle cell disease, alcohol consumption, and potentially late-stage presentations of secondary hip pathologies (20).
The mean age of our study population was 44.16 ± 13.85 years, which is substantially lower than the mean age of approximately 69.2 years reported in Western THR registries (21). This age gap of nearly 25 years has profound implications for long-term surgical outcomes and implant durability. Patients in our cohort are in their most economically productive years and often engage in high-demand physical labor common in rural tribal settings (19). The lower mean age reflects the underlying pathology, as AVN typically affects younger individuals compared to the degenerative nature of primary OA seen in elderly Western patients (Liu, Hu, Chan, & Sathappan, 2009; Jain, Sao, & Patond, Statistical analysis of total hip arthroplasty at rural hospital in Maharashtra under MJPJAY: a prospective study, 2024).
In response to the younger demographic and high physical demands, uncemented fixation was utilized in 89.9% of our cases. The preference for biological fixation via uncemented components is clinically justified in younger patients with good bone stock, as it facilitates bone ingrowth and osseointegration, potentially offering better long-term resistance to aseptic loosening compared to cemented stems in active individuals (11,22). While cemented THR has a long history of success—pioneered by Sir John Charnley (1,2)—its use in our study (10.1%) was primarily reserved for older patients (mean age 61.25 years) or those with compromised bone quality. Modern literature supports this trend, suggesting that uncemented THA is more conducive to the higher activity levels and longer life expectancy of younger patients, even allowing for easier future revision surgeries if required (23,24).
The findings of this study underscore the unique challenges of providing arthroplasty services in a rural tribal region. Tribal populations in India often face significant barriers to healthcare, including geographical isolation and limited infrastructure (18,25). These impediments often lead to delayed healthcare-seeking behavior; many patients only seek specialist care months after the onset of symptoms (26). By the time these patients reach a tertiary center like ours, hip disorders such as AVN or post-traumatic conditions have often progressed to end-stage destruction, necessitating THR rather than joint-preserving procedures. Furthermore, the reliance on physically demanding activities in tribal communities necessitates the selection of implants that can withstand high mechanical stress, further justifying the shift toward uncemented biological fixation (13,27).
This study has several limitations that should be acknowledged. First, the sample size (N=79) is relatively small, which may limit the generalizability of the findings to the entire tribal population of India. Second, the single-center, prospective observational design may reflect the specific referral patterns and surgeon preferences of our institution rather than a broader regional trend. Additionally, the study focuses on indications and implant selection without long-term functional follow-up or survival analysis. Future multi-center studies with larger cohorts and long-term outcome data are essential to further optimize arthroplasty practices for this unique demographic.
CONCLUSION
This study demonstrates that total hip replacement in the rural tribal population of central India presents a distinct clinical and epidemiological profile compared to global standards. Avascular necrosis was identified as the predominant indication for surgery, accounting for 62% of the cases, which aligns with regional patterns but contrasts sharply with the osteoarthritis-dominant profiles seen in Western registries (Saoji, Gupta, Chavan, Gawande, & Jain, 2022; Aswal, Outcome of Patients Treated with Total Hip Arthroplasty for Various Disorders of Hip: A Retrospective Study, 2025). The mean age of the cohort (44.16 years) is significantly younger than the mean age of approximately 69.2 years reported in Western cohorts (21). To meet the high physical demands and longer life expectancy of this younger demographic, there was a strong preference for uncemented fixation (89.9%), which provides the biological stability necessary for active individuals (23,24,27).
These findings underscore the critical necessity for specialized arthroplasty strategies and tailored orthopaedic care that account for the unique socioeconomic and geographical challenges of rural tribal regions (25,26). While the results are promising for this specific demographic, future large-scale, multi-center research is essential to validate long-term functional outcomes and implant survival in this underserved population.
REFERENCES
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