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Total Hip Arthroplasty in a Low-Income Country

Ten-Year Outcomes from the National Joint Registry of the Malawi Orthopaedic Association

Graham, Simon Matthew MBChB, MRCS, MSc(Res), FRCS1,2,3; Howard, Nicholas MBChB, MRCS, MSc, FRCS3; Moffat, Chipiliro4; Lubega, Nicholas MBChB, MMed(Ortho), FCS(ECSA), MBA4; Mkandawire, Nyengo BMBS, FRCS, MCh(Orth), FCS(ECSA)4; Harrison, William J. MA(Oxon), FRCS(Tr&Orth)5

Author Information
doi: 10.2106/JBJS.OA.19.00027
  • Open
  • Disclosures


Total joint arthroplasty (TJA) is increasingly performed in low-income countries, such as Malawi in sub-Saharan Africa1-3. The reasons for this include, among other factors, greater surgical resources and longer life expectancy2. However, many of these countries do not have adequate resources to offer this form of service to all potential patients who require or will benefit from it4. Indications for surgery and the age of the patient can be considerably different than in high-income settings, with a larger proportion of patients with human immunodeficiency virus (HIV)1. The training of surgeons and allied health professionals, available facilities, and resources can also differ substantially2. To our knowledge, long-term outcomes and survivorship of TJA performed in low-income countries have not previously been reported.

Beit CURE International Hospital (BCIH), where the majority of the procedures recorded in the National Joint Registry of the Malawi Orthopaedic Association (NJRMOA) take place, is an example of a health-care system in which the hospital provides scheduled hip and knee arthroplasty services that, in turn, fund other health-care services that are provided for free. The NJRMOA was set up in 2005 to ensure that patients undergoing TJA received follow-up and that surgical and functional outcomes were accurately recorded for the purposes of both clinical governance and research. The registry includes every patient who has undergone TJA at Beit CURE.

Our primary objective was to describe what we believe to be the first study of total hip arthroplasty (THA) in a low-income country to assess complications, patient-reported outcomes, and survivorship data extending over 10 years. Our hope is that our findings will provide a benchmark against which other hospitals and registries based in similar jurisdictions can compare their outcomes.

Materials and Methods

All patients who underwent THA during the period of January 2005 to February 2008 were identified from the NJRMOA and included in the study. All data were derived from the registry, which was set up with ethical approval from the Research and Ethics Committee of the College of Medicine of the University of Malawi.

THA was performed on 83 hips in 70 patients (40 male and 30 female) with a mean age of 52 years (range, 18 to 77 years); bilateral THA was performed in 13 patients. The main indications for surgery in the cohort as a whole were osteonecrosis (n = 41 hips) and osteoarthritis (n = 26 hips) (Table I). The cohort included 24 HIV-positive patients (14 male and 10 female) with a mean age of 52 years (range, 35 to 78 years) who underwent THA primarily because of osteonecrosis (Table II).

TABLE I - Demographic and Surgical Data of Patients in the Malawi National Joint Registry Who Underwent THA During the Study Period
Demographic and Surgical Data No. of Patients (Hips)
Entered in registry 70 (83)
Lost to follow-up 10
10-yr follow-up in registry 46
Died 14
HIV-positive 24
HIV-negative 46
Indication for surgery
  Osteonecrosis (41)
  Osteoarthritis (26)
  Previous infection (9)
  Fractured neck of femur (2)
  Failure of internal fixation (1)
  Other (4)
Type of implant
  Charnley (61)
  Stanmore (22)

TABLE II - Demographic and Surgical Data of HIV-Positive Patients in the Malawi National Joint Registry Who Underwent THA During the Study Period
Demographic and Surgical Data No. of Patients
Entered in registry 24
Lost to follow-up 0
10-yr follow-up in registry 24
Indication for surgery
  Osteonecrosis 16
  Osteoarthritis 3
  Previous infection 3
  Other 2
Type of implant
  Charnley 14
  Stanmore 10

The procedures were performed by 6 surgeons at 3 institutions, with most procedures (66, 80%) performed at BCIH. No operating theater had a laminar flow system. Two different all-cemented prostheses with well-established good long-term survivorship were used5-7: a Charnley prosthesis (DePuy Orthopaedics) with either a flanged or round-backed femoral stem and a standard long posterior wall or an Ogee acetabular component (DePuy) in 61 (73%) of the procedures, and a Stanmore implant with modular stems and 28-mm cobalt-chromium head (Biomet) in 22 (27%) of the procedures. Implants were secured using SMARTSET GHV cement with gentamicin (DePuy). At the start of surgery, patients also received a single dose of cefuroxime intravenous antibiotic, replaced by gentamicin in those allergic to penicillin. HIV-positive patients were administered antibiotic prophylaxis along with co-trimoxazole (trimethoprim-sulfamethoxazole) (960 mg), in accordance with Malawi national policy and World Health Organization guidelines8.

Patients were mobilized on the first postoperative day and used thromboembolism-deterrent graduated-compression stockings along with low-dose aspirin for the following 6 weeks.

Postoperatively, at 6 weeks, 3 and 6 months, and annually thereafter, a senior research nurse in partnership with a senior surgeon evaluated all patients for pain, postoperative complications, and function. Outcome measures include the Oxford Hip Score (OHS) and the Harris hip score (HHS)9. However, use of the OHS as a patient-reported outcome was introduced after 2013, and therefore, preoperative scores are not available for comparison. Furthermore, although the HHS was collected preoperatively as of 12 months following the commencement of the registry, the data are incomplete and preoperative values are not reported in this study.

Surgical wounds were assessed in the first 6 weeks using the ASEPSIS system (Additional treatment, the presence of Serous discharge, Erythema, Purulent exudate, and Separation of the deep tissues, the Isolation of bacteria, and the duration of inpatient Stay), which assigns a total possible score of 70 on the basis of appearance and any additional treatment required10. For the purpose of the present study, we considered a score of >10 as indicative of early surgical site infection, a threshold approved by the National Institute for Health and Care Excellence in the U.K11. Late wound infection was diagnosed if there was wound breakdown or sinus formation >6 weeks postoperatively, or unexplained late pain with associated radiographic changes consistent with periprosthetic joint infection or microbiological confirmation following revision surgery, irrigation, or aspiration.

Anteroposterior and lateral radiographs of the hip were made at each follow-up appointment. The most recent radiographs were reviewed by the first author (S.M.G.), who had not been involved in the surgical procedures and who assessed the images for signs of loosening. For all HIV-positive patients, antiretroviral therapy was administered according to national guidelines.


Of the 70 patients who underwent primary THA, 24 were unavailable at the most recent follow-up and were excluded from analysis. Of these 24 patients, 14 (20% of the original cohort) had died, including 4 HIV-positive patients, before the most recent follow-up and 10 (14%) were lost to follow-up, leaving 46 patients (66%; 59 THAs) included in the final analysis of 10-year outcomes after primary THA. No accurate recorded information was available for reporting the outcomes of the patients who had died; however, none are thought to have died as a result of their procedure or from complications of their procedure.

All patients were seen at 6 weeks postoperatively. There were no early complications, including deep vein thrombosis, pulmonary embolism, or surgical site infection. This was reflected by the fact that no patient had an ASEPSIS score of >10.

Overall, 5 revision procedures (5 of 59 THAs, 8%) were performed, for aseptic loosening (n = 4) and a periprosthetic fracture (n = 1); the latter patient underwent successful revision in India following the fracture, which occurred 5 years after the primary procedure. All 5 patients who had revision surgery, including 2 HIV-positive patients, are alive and are currently being followed >10 years after the primary procedure. No revision procedures had been performed among the patients who died or were lost to follow-up.

Of the 4 revision procedures carried out for aseptic loosening, 1 patient had a single-component acetabular revision 9 years postoperatively, 2 patients had both components revised for loosening 9 years after the primary procedure, and the fourth patient, who had undergone THA for trauma, had revision of both components 5 years after the primary procedure because of loosening and a re-revision for loosening 7 years after the primary procedure. Samples from both of these procedures were taken, but no organism was grown on culture to suggest low-grade infection. There were no revision procedures for periprosthetic joint infection and no evidence of infection in any of the patients who underwent revision. There were also no revision procedures performed for instability or dislocation and no signs of loosening on radiographs in the patients without revision.

Hip scores were recorded for 36 and 46 patients at 5 and 10 years of follow-up, respectively. Additional OHS and HHS data were available in the registry for 18 patients (26% of the original cohort) who had >10 years of follow-up (Table III). There was a decline seen in the HHS at 10 and >10 years and in the OHS at >10 years. The scores were comparable with those of other series at the same time points from high-income settings and are above the scores correlating with the suggested need for revision surgery12-14.

TABLE III - Postoperative Harris Hip Score (HHS) and Oxford Hip Score (OHS) Results
Follow-up (yr) No. of Patients Mean (Range)
2 16 86 (44-91) 46 (32-48)
5 36 97 (36-91) 47 (36-48)
10 46 88 (41-91) 46 (25-48)
>10* 18 75 (44-91) 40 (9-48)
Mean follow-up, 10.9 years.


We believe that our study is the first to present long-term follow-up data of patients who have undergone primary THA in a low-income country. Our aim was to provide a benchmark for use by other hospitals and registries in similar settings when evaluating their own data. In particular, our study is the first, to our knowledge, to report 10-year follow-up data of a cohort of HIV-positive patients who have undergone THA, with most reports for this population focusing on perioperative complications and infections15-17. The perioperative mortality rate was 0%, and there were no early complications at 6 weeks. An overall revision rate of 8% at 10 years and functional scores that were good at 5 years and fair at 10 years indicate good long-term survivorship9.

Two-thirds of the world’s population is estimated to live in lower-middle and low-income countries, and arthritis ranks as the eleventh highest contributor to global disability3. Arthroplasty, in some form, is becoming increasingly available in most African countries, with reported results from South Africa, Senegal, Kenya, Malawi, Zambia, Botswana, Burkina Faso, and the Maghreb1,2,15,18-20, most of which are defined as middle-income countries21. There is, however, a paucity of literature from low-income countries, with studies of small cohorts focusing on perioperative and short-term complications.

Of 6 identified reports on THAs performed in low-income countries15,18,22-25, 1 was a case series from Burkina Faso that included 136 patients who underwent THA after an arthroplasty service was initiated by a visiting surgical program; a high intraoperative complication rate of 51% and a perioperative complication rate of 16% were reported22. Only 1 paper, from Senegal, had follow-up of >18 months: 38 patients were followed for a maximum of 5 years after THA for sickle cell disease; the complication rate was 19%24. To our knowledge, no country other than Malawi has produced results beyond 5 years. Our longest follow-up duration previously reported from Malawi was a mean of 3.5 years15.

Both the population and indications for THA differ from those in higher-income countries: our registry showed that 58% of the procedures were performed in men, and the average age was 52 years, compared with 40% men, average age of 68 years, in the U.K. This may well have implications on results, with national registries showing higher revision rates among younger patients26. The indications for THA are also poorly reported in low-income countries. Osteoarthritis is responsible for 92% of all hip replacements in the U.K. compared with 31% in Malawi, where osteonecrosis is the leading indication, at 49%. Fractures account for 2% of procedures in Malawi and 5% in the U.K27.

Our study showed promising results, with outcomes comparable with those of the national joint registries of high-income countries27. Ten-year mortality was 20% compared with 25% in the U.K., no doubt reflecting the younger cohort in the Malawi registry, although life expectancy is notably less than the U.K28. Overall revision rates are similar: 8% at 10 years compared with 5% in the U.K., a figure that climbs to 8% among those <55 years of age, matching the younger Malawi cohort27. One might expect infection and dislocation to represent notable complications in the short and long term for THA in low-income countries; however, in our study, neither of these complications was recorded. The mean HHS of 75 and OHS of 40 at >10 years in our cohort compare favorably with functional outcomes in high-income countries29. Functional scores were even better in the HIV-positive cohort, with a mean HHS of 88 (range, 76 to 91) at >10 years. Reasons for this are not clear, but possible explanations from our experience are the younger, more active population seen in the Malawian cohort.

The main limitations of our study were the relatively small number of patients included and the loss to follow-up. Follow-up of patients in this environment can be challenging. Our hospital is 1 of only 3 in the country at which TJA is performed. Therefore, patients commonly live long distances from the hospital, making follow-up challenging and costly for the patient. Furthermore, since there is a lack of arthroplasty services in neighboring countries, some of our patients do not live in Malawi, again resulting in challenges with follow-up. In addition, despite the small number of patients reported as having ≥10 years of follow-up, we believe that this is the largest study of this type with this length of follow-up from a low-income country in Africa. Our institute provides only a private, elective hip and knee arthroplasty service, which subsequently funds free orthopaedic health care for children. Therefore, this limits the number of arthroplasty procedures performed each year because the services are only available through private or insurance funding.

Our 10-year experience of THA within a controlled hospital environment in a low-income setting has demonstrated that our encouraging early results can be sustained in the long term. We previously called for other institutes and low-income countries in our region to establish joint registries30. Comparative registries will highlight strengths and weaknesses in different forms of arthroplasty services. They can also help to focus training or adjustment of clinical practice, and thus optimize good clinical governance for TJA in the region. Furthermore, pooling the data may allow conclusions about long-term outcomes to be derived earlier.


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