AVALIAÇÃO DA FUNÇÃO E QUALIDADE DE VIDA EM PACIENTES SUBMETIDOS A ARTROPLASTIA DE RESSECÇÃO TIPO GIRDLESTONE EVALUATION OF THE FUNCTION AND QUALITY OF LIFE OF PATIENTS SUBMITTED TO GIRDLESTONES RESECTION ARTHROPLASTY PRISCILA AKEMI YAMAMOTO1, GISELE LANDIM LAHOZ2, EDMILSON TAKEHIRO TAKATA3, DA

Citação: Yamamoto PA, Lahoz GL, Takata ET, Masiero D, Chamlian TR. Avaliação da função e qualidade de vida em pacientes submetidos a artroplastia de ressecção tipo girdlestone. Acta Ortop Bras. [periódico na Internet]. 2007; 15(4):214-217. Disponível em URL: http://www.scielo.br/aob. Citation: Yamamoto PA, Lahoz GL, Takata ET, Masiero D, Chamlian TR. Evaluation of the function and quality of life of patients submitted to girdlestones resectionarthroplasty. Acta Ortop Bras. [serial on the Internet]. 2007; 15(4): 214-217. Available from URL: http://www.scielo.br/aob. AVALIAÇÃO DA FUNÇÃO E QUALIDADE DE VIDA EM PACIENTES SUBMETIDOS A ARTROPLASTIA DE RESSECÇÃO TIPO GIRDLESTONE


SUMMARY
Objectives: To evaluate function and quality of life of patients submitted to Girdlestone's arthroplasty, and to compare outcomes between unilateral Girdlestone's group with the group with contralateral total hip prosthesis.Methods: Crosssectional study where 9 patients were evaluated with unilateral Girdlestone's and 3 with Girdlestone's in one hip and contralateral total hip prosthesis.The evaluation consisted in filling in a generic questionnaire on quality of life "SF-36" and a specific questionnaire for hip function "Harris Hip Score" (HHS).The comparison between groups was made by using the Student's t-test and the Fisher's test.Results: state that one of the major disadvantages of this procedure is the change imposed to these patients' lifestyles.The objective of this study is to assess function and quality of life of patients following Girdlestone's resection arthroplasty (GRA) and compare the results between the unilateral Girdlestone group with the group with contralateral HTP.

MATERIALS AND METHODS
The study was conducted at the Adult Hip Pathologies Group Outpatient Facility of Hospital São Paulo, Discipline of Orthopaedics, Department of Orthopaedics and Traumatology -UNIFESP -EPM, from May to December 2005, where 3 subjects diagnosed with GRA in one hip and contralateral hip total prosthesis and 9 with unilateral GRA were assessed.All the subjects enrolled in the study were informed about the nature of the research and their consents were recorded on a consent term.The average age of patients was 58.67 years, ranging from 27 to 89 years.The inclusion criterion was a diagnosis of Girdlestone's resection arthroplasty.Patients with primary GRA and presenting cognitive deficits were excluded from the study.At baseline, we counted on 37 patients, but 1 passed out and 8 could not be found, 5 were living in other cities, 9 were unwilling to take part of the study, and 2 patients else were excluded due to stroke resulting in total hearing loss (1 case) and to prosthesis replacement (1 case).Of the 12 subjects left, 8 were men and 4 were women.Regarding the involved side, 6 individuals were submitted to GRA on the right hip and the other 6 on the left side.All subjects were submitted to assessment, which constituted of applying a generic questionnaire on quality of life, the SF-36, and a functional questionnaire specific to hip joint -the "Harris Hip Score".The SF -36 is a multidimensional questionnaire comprised of 36 items, comprehending 8 domains: functional capacity, physical aspects, pain, overall health status, vitality, social and emotional aspects, mental health, as well as a question measuring current health status compared to the previous year's.This questionnaire assess both negative (pain) and positive (well-being and vitality) aspects (34) The functional questionnaire "Harris Hip Score" is constituted of 4 items: pain at the involved joint, presence or absence of deformity, and the range of motion of this joint.Function is assessed by questioning patients' daily life activities and gait, which includes the presence of limping, need of external support, and maximum walk distance (35) .Groups' comparison for SF-36 scores was made by using the Student's t test, and the comparison with categorical variables was made by using the Fisher's exact test.

RESULTS
By analyzing each individual score in this very questionnaire, we can see that, in unilateral Girdlestone group, they were shown to be good for pain, emotional and social aspects, overall health status (OHS) and mental health.A moderate score was given to vitality criterion, and low scores have been given to functional capacity and physical aspects.In the Girdlestone with contralateral HTP group, good scores were only seen for 3 items: pain, emotional aspects, and mental health (Table 1).Chart 1 gives us the descriptive level of each of the eight domains of the SF-36 when comparing the mean scores achieved between both groups.We found that in the end result of the HHS functional questionnaire, only one patient achieved a score regarded as good, and that patient belonged to the GRA with contralateral HTP group, while the remainder ranged from moderate to poor.About 77.8% of the individuals of unilateral Girdlestone group showed poor functional outcomes.As previously mentioned in the methods, one of the requirements of the HHS to assess patients' function is gait.Of the 12 studied patients, 11 showed limping gait of mild to severe magnitude for the 1st group, and mild to moderate for the 2nd group.All subjects of the group with contralateral HTP required external support to ambulate.In the group with unilateral Girdlestone, only one patient was able to ambulate without support, but showing severe limping.Also in that group, 1 patient became wheelchair- dependent secondarily to the procedure, 1 walked with the aid of crutches, 1 with one crutch and 2 else used only a cane for short distances (Chart 2).Both groups showed discrepant lower limbs, in an average of 5.5.cm for the group with unilateral GRA (4.0 -10.0 cm) and 7.0 cm for the group with contralateral HTP (3.5 -9.5 cm).The Trendelenburg's test was positive for all patients, and, of the 12 assessed patients, only 7 used special shoes.Among the remaining 5 patients, 2 reported that they had not received prescriptions for special shoes, and the other 3 reported not using special shoes because they couldn't adjust to them due to excessive weight and to aesthetic reasons.Due to the results achieved in the HHS, other additional factors were considered, such as hospital-based or outpatientbased physical therapy postoperatively (PO) (Table 2), pain in another joint and site (Table 3) and the real magnitude of pain in Girdlestone hip (Table 4).By comparing these categorical variables of interest (Chart 1), we can see that the only ones that would potentially present significant difference should the sample was larger would be postoperative hospital-or outpatient-based physical therapy and HHS.
No article mentioned physical therapy, but a number of these stated that this kind of salvage surgery is functionally poor (1,8,12,14,15,17,18,21,22,(25)(26)(27) .As our overall results confirmed that, we decided to check if the subjects of this study had been submitted to hospital-or outpatient-based physical therapy postoperatively and found that of the 9 subjects of the unilateral GRA group, 6 had undergone both kinds of physical therapy and none of the subjects belonging to group with contralateral HTP was submitted to hospital-and outpatient-based physical therapy postoperatively.Patients submitted to physical therapy were unable to inform its time and frequency, as well as the approach employed.Once the sample is small, the accuracy of estimates is severely compromised.Thus, this result is only indicative that if the sample was larger, there would be potential to differences between groups submitted to physical therapy and those not submitted to it.We noticed that, of the 12 assessed subjects, 5 presented with no pain at all on Girdlestone hip and only 1 showed it severely, which leads us to think that the overall poor functional result obtained with the HHS is due to the involvement of another joint following GRA, because, of the 12 patients, 8 complained of pain in other regions, with contralateral hip being the most frequently involved one.Many articles report the presence of signs and symptoms of multiple joints involvement after GRA, such as contralateral hip and/ or knees (5,7,15,21,23,36) , stating that these are the major responsible for these patients' functional disability and daily life restraints (5,49) .A number of studies mentioned functional results of patients after GRA (1,5,(7)(8)(9)(10)12,14,15,(17)(18)(19)(21)(22)(23)25,(27)(28)(29)31) ; however, only one article was found reporting that, in some cases, this procedure can be the last resource to assure a goof QoL for patients with hip pathologies (12) . Although no article  mentioned ndividuals submitted to GRA in one hip and contralateral HTP, our population (37 patients) was composed of 14 unilateral GRAs and 23 contralateral HTP; therefore, we decided to check for differences between QoL and function in both groups.By assessing SF-36 results, we noticed that the patients submitted to unilateral procedure showed a higher number of highly scored criteria than the other group; however, sample is small and the only item that seems to present a significant difference when comparing both groups is social aspects.Regarding function, as assessed by us with the HHS, if the sample was bigger, there might be difference between groups; however, we cannot regard this study as completed, because its results are only indicative of its variables' behavior.

CONCLUSIONS
1. Overall, the subjects from unilateral Girdlestone group showed a higher number of SF-36 domains with scores rated as high than the individuals of the contralateral HTP group, although both groups had been scored poorly in the functional capacity item.2. Of the 12 assessed patients, only one showed an end HHS score that was regarded as good.This patient belonged to contralateral HTP group.The remainder ranged from moderate to poor, with most of the individuals in the unilateral Girdlestone group showing poor scores.
3. Since this sample is small, the accuracy of estimates was severely compromised.Thus, the results described hereon are only indicative of the study variables' behavior and cannot be regarded as finished.

Table 1 -
Individual scores and descriptive measures of SF-36 domains, per group.

Table 2 -
Distribution of Girdlestone groups for PO outpatient-and hospital-based physical therapy variable

Table 3 -
Distribution of Girdlestone groups for pain in other joint else and pain site variables