Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : August | Volume : 16 | Issue : 8 | Page : RC17 - RC20 Full Version

Does Cementing Influence CRP and ESR Levels after Total Hip Replacement in Early Postoperative Period? A Prospective Interventional Study


Published: August 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55984.16779
Anant Krishna, Vivek Vijayakumar, Tungish Bansal, Sudhir Kumar Garg, Sandeep Gupta, Gunjar Jain

1. Assistant Professor, Department of Orthopaedics, SGT Medical College Hospital and Research Institute, Gurugram, Haryana, India. 2. Senior Resident, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, Delhi, India. 3. Senior Resident, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, Delhi, India. 4. Professor and Head, Department of Orthopaedics, Government Medical College Hospital, Chandigarh, India. 5. Senior Consultant, Department of Orthopaedics, Fortis Hospital, Chandigarh, India. 6. Assistant Professor, Department of Orthopaedics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.

Correspondence Address :
Dr. Gunjar Jain,
Assistant Professor, Department of Orthopaedics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.
E-mail: drgunjarjain@gmail.com

Abstract

Introduction: The role of C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) in diagnosing delayed (>6 weeks) periprosthetic joint infection prior to performing a revision joint arthroplasty is well established.

Aim: To evaluate the effect of bone cement on C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) in the first 3 weeks after Total Hip Replacement (THR).

Materials and Methods: This prospective interventional study was conducted in Department of Orthopaedics at Government Medical College, Chandigarh, India, between June 2014 to December 2017. Sixteen patients who underwent an uncemented THR and 15 patients who underwent a hybrid THR were included in the study. Serum CRP and ESR were measured on the day before surgery and postoperatively on days 1, 2, 3, 7, 12, and at 3 weeks. Comparison of ESR and CRP values between the groups were performed using a Student’s t-test. A p-value <0.05 was considered statistically significant.

Results: There was no significant difference between the two groups with respect to age, gender, indication of surgery, co-morbidities, operative time and blood loss. CRP showed a peak at day two with a mean value of 203.74±46.15 mg/L in the uncemented group and a mean of 206.10±46.78 mg/L in the hybrid group, with normalisation by 3 weeks. ESR values showed a peak on day three with a mean of 94.28±5.97 mm/hour in the uncemented group and 92.15±6.86 mm/hour in the hybrid group and remained elevated even at 3 weeks. Statistically, no significant difference was observed in CRP and ESR values after the usage of cement in total hip arthroplasty (p-value >0.05 in all cases).

Conclusion: Bone cement does not affect CRP or ESR values significantly in the early phase after uncomplicated total hip arthroplasty.

Keywords

Bone cement, C-reactive protein, Erythrocyte sedimentation rate, Total hip arthroplasty

Serological inflammatory makers specifically C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) are often used as initial preliminary diagnostic as well as follow-up tools to rule out a suspicion of infection in joint arthroplasty (1). Factors that make ESR and CRP the markers of choice in monitoring the acute phase following surgery are that their values increase exponentially as compared to basal concentrations, have a relatively short lag time from the moment of stimulus, are inexpensive, non invasive and are widely and easily available tests (1),(2),(3),(4).

The role of CRP and ESR in diagnosing delayed (>6 weeks) periprosthetic joint infection prior to performing a revision joint arthroplasty is well established (5),(6),(7),(8),(9),(10),(11),(12),(13). But their role in diagnosing infection in the immediate postoperative period is still controversial and inconclusive. This is because CRP and ESR being acute phase reactants, show a normal physiological response curve in the immediate postoperative period due to surgery induced tissue damage, which in turn causes an elevation of these markers in the acute phase following surgery (14),(15),(16),(17),(18),(19). Therefore, before CRP and ESR could be used as effective markers of infection, it is essential to establish their baseline values in uncomplicated surgeries.

It is important to realise that a single reading holds very limited value and that a trend must be established in order to effectively diagnose joint infection. It is imperative that baseline values of CRP and ESR be established before diagnosing prosthetic joint infection. Identifying other factors that can alter the values of these markers hence becomes important. There are several known factors that can affect CRP and ESR values in arthroplasty. These factors can be divided into patient dependent and procedure dependent (20),(21),(22),(23),(24),(25). Some patient dependent factors include the Body Mass Index (BMI) of the patient, gender of the patient (females are known to have a higher baseline values of ESR), age of the patient and the presence of any pre-existing inflammatory pathologies such as rheumatoid arthritis (20),(21),(22). Procedure dependent factors that can affect CRP and ESR values include the amount of surgical dissection performed, and the duration of surgery (23),(24),(25).

Bone cement is commonly used in arthroplasty procedures and cementing during arthroplasty is known to have systemic effects (26),(27). However, it’s role as a variable that can affect the local inflammatory response, is a topic, still untouched by current literature so far. Therefore, it is possible that cemented and uncemented arthroplasties have varying natural response curves of ESR and CRP levels. The present study was conducted to compare the early postoperative trend of ESR and CRP in uncemented and hybrid Total Hip Replacement (THR) patients. The present work was done as a pilot study, as to the best of author’s knowledge, there is no similar study in the literature evaluating the role of cement on CRP and ESR in Total Hip Replacement (THR) surgeries. It was hypothesised that hybrid THR patients (uncemented cup and a cemented femoral stem) will have higher postoperative values of ESR and CRP as compared to uncemented THR patients.

Material and Methods

This prospective interventional study was conducted in Department of Orthopaedics at Government Medical College, Chandigarh, India, between June 2014 to December 2017. The ethical approval was obtained from Institutional Ethical Committee approval (Ref No.5680).All investigations were conducted in conformity with ethical principles of research and an informed written consent was obtained from each patient.

A total of 31 patients who were matched in terms of their co-morbidities (using the Charlson Co-morbidity Index) were enrolled for this study and evaluated preoperatively and postoperatively. Charlson Co-morbidity Index is a tool used to measure the 1 year mortality risk and burden of disease. The index has been extensively used in clinical research and practice to address the confounding influence of co-morbidities and predict outcomes (28).

Inclusion criteria: All patients undergoing hip replacement surgery during the study period, who met the inclusion criteria were enrolled for the study. The patients who had a wide femoral canal (Dorr type C) were selected for the hybrid group and others were included in the uncemented group. The study included patients who presented with primary or secondary osteoarthritis of the hip.

Exclusion criteria: Patients presenting with symptoms of rheumatoid arthritis viz pain in small joints of hand, morning stiffness for more than 30 minutes with deformities of hand and wrist along with elevated levels of ESR and CRP were excluded from the study. Similarly patients presenting with back pain, reduced chest expansion of less than 2.5 cm, a positive Schobers test and elevated inflammatory markers pointing towards ankylosing spondylitis were also excluded from the study. Patients previously operated on the hip for any pathology and those with abnormal baseline value of ESR (>30 mm/hour) and CRP (>5 mg/L) also fell into the exclusion criterion of our study.

Out of the 31 patients,
• Uncemented THR: This group included 16 patients
• Hybrid THR: This group included 15 patients

Thus a total of five patients, of which one patient with symptoms of rheumatoid arthritis, one patient with ankylosing spondylitis and three patients with abnormal preoperative values of CRP and ESR were excluded from the present study. Initially 36 patients were recruited out of which five patients were excluded due to the above mentioned criteria. All uncemented and hybrid THR surgeries were performed using a modified Gibson posterior approach to hip by two separate senior Orthopaedic Surgeons (29).

Data collection: Blood samples for CRP and ESR were obtained one day before the surgery and on 1st, 2nd, 3rd, and 7th postoperative day. Further samples were drawn at the time of suture removal on the 12th day and the time of first follow-up after 3 weeks from the day of surgery. A 2 mL of blood sample for CRP analysis and 2 mL for ESR analysis were collected in plain and Ethylenediaminetetraacetic Acid (EDTA) vials respectively and sent for analysis. Quantitative CRP analysis was done by employing a testing kit which was based on the principle of immunoassay with a normal reference range of 5 mg/L. The ESR was estimated using the Wintrobes method with a normal reference range of 30 mm/hour. A complete haemogram renal and liver function tests, urine routine microscopy and chest X-ray were sent before the surgery and 3 days after the surgery for all postoperative cases to make sure the surgeries were uncomplicated.

Surgical Technique

In both groups, a modified Gibson’s approach to hip was followed. Patients were positioned laterally and a straight incision measuring 10-15 cms in length beginning in the mid-lateral thigh was made. The incision was then extended toward the tip of the greater trochanter and then proximally to the level of the iliac crest. After superficial dissection, the plane between the posterior border of gluteus medius and anterior border of gluteus maximus was identified and subsequent deep dissection was followed as per the Kocher-Langenback approach (29).

In the uncemented THR group, a polar stem with R 3 cup (Smith and Nephew) was used, whereas for hybrid THR group, a CPT stem with multi hole Triology cup (Zimmer Biomet) was employed. A 3rd generation cementing technique with vacuum mixing of a Simplex P bone cement (Stryker) was done and used for fixing of the cup in hybrid THR. The average operating time was 1.5 hour and on an average a single unit of blood transfusion was required in the postoperative period for patients in both these groups. Prophylactic antibiotic therapy (3rd generation cephalosporin) was instituted on the morning of surgery and continued 72 hour after surgery. Aspirin 150 mg OD was started from day 1 of the surgery and continued till 6 weeks postoperatively. Patients were mobilised with full weight bearing 24 hour after the surgery with the help of walker. Because of the author’s aggressive postoperative physiotherapy regimen and the judicious use of chemical thrombopropholaxis, authors did not encounter any case of deep vein thrombosis in any of the operated patients.

Statistical Analysis

Data was tabulated on an excel spreadsheet and mean and standard deviation were calculated for normally distributed continuous variables. Comparison of ESR and CRP between uncemented and hybrid groups were done using the Student’s t-test. A p-value <0.05 was considered statistically significant. The data was tabulated in excel sheets and statistical analyses were conducted using Statistical Package for Social Sciences (SPSS) version 20.0 software.

Results

The study consisted of 22 (71%) male patients and 9 (29%) females patients. The average age of patients undergoing THR was 41.5 years. The comparison between the uncemented and hybrid THR groups is represented in (Table/Fig 1). There was no significant difference between the two groups with respect to age, gender, indication of surgery, co-morbidities, operative time and blood loss (p-value >0.05 for all comparisons).

The CRP values in both the uncemented and hybrid groups followed a parallel curve with peak values seen at day two and normalisation at three weeks. The CRP curve showed a peak at day two with a mean of 203.74±46.15 mg/L in uncemented group and a mean of 206.10±46.78 mg/L in the hybrid group. The decreasing trend started after day 3 of surgery. Though the absolute and peak values of mean CRP (mg/L) in the hybrid group were more than that of the uncemented group on days 1, 2 and 3, no statistically significant differences were found between these two groups (Table/Fig 2).

The ESR pattern in the uncemented and hybrid groups also followed a parallel curve with mean peak values at day three which continued to remain elevated at three weeks. ESR reached a peak at day three with a mean of 94.28±5.97 mm/hour in the uncemented group and 92.15±6.86 mm/hour in the hybrid group. Though a decreasing trend in ESR values were observed after day three the value of ESR remained elevated at three weeks (Table/Fig 3). Although mean ESR values (mm/hour) in the uncemented group were marginally higher than hybrid group, no statistically significant difference was found between these two, suggesting that the use of cement had no impact on CRP and ESR levels, post total hip arthroplasty in the acute phase.

Discussion

Erythrocyte sedimentation rate and C-reactive protein levels are commonly used postoperatively by arthroplasty surgeons for diagnosing prosthetic joint infection. However, the purpose of the present study was not to establish the threshold of CRP or ESR levels to determine Prosthetic Joint Infection (PJI) but to study the natural kinetics and establish baseline values of CRP and ESR in uncemented and cemented hip arthroplasty patients. The authors through this study have attempted to establish the normal baseline levels and kinetics of ESR and CRP after a normal uncomplicated hip arthroplasty, so that it may be used by surgeons as a guide to determine whether subclinical infection is developing or not. This could help alert the surgeon to warrant additional blood investigations and other laboratory tests to rule out infection or could help decide the duration of prophylactic antibiotics at the time of discharge.

The other purpose of the present study was to analyse the effect of cement on the local inflammatory response after a total hip arthroplasty. Cementing is known to have many systemic effects in joint replacement surgery (26),(27). However, its role as a variable that can have a bearing on the local inflammatory response (as measured by postoperative CRP and ESR values) is still debatable. In the study by Szypula J et al., done on a Caucasian subpopulation, comparison of biocompatibility of cemented vs uncemented hip joint endoprosthesis based on postoperative evaluation of proinflammatory cytokine levels were performed. The study showed a higher CRP and Interleukin-6 (IL-6) levels in cemented hip endoprosthesis as compared to uncemented, a finding that stands in contrast to the results of the present study (30). The contrasting results could be due to the different demographic and geographic factors of the present study as they are known to affect the baseline levels of the inflammatory markers (31),(32).

The present study was conducted to compare the early postoperative trends of ESR and CRP in uncemented and hybrid THR patients. The authors hypothesised that a cemented hip arthroplasty could induce a significantly raised inflammatory response and would thereby result in higher mean values of CRP and ESR in the postoperative period. This stemmed primarily from the notion that the heat of polymerisation of cement would have a bearing on the inflammatory process after a hip replacement surgery. However, the results of the study were contrary to our hypothesis, and a similar and comparable postoperative trend of CRP and ESR were observed after uncemented and hybrid THR, thus highlighting the fact that cementing does not seem to have any significant effect on the local inflammatory process after an arthroplasty procedure.

The current study also confirms and highlights the facts previously recorded in literature (1),(2),(3),(4),(5),(6),(7), that CRP correlates with higher degree of inflammatory activity with a more rapid increase and a faster return to normal than ESR at three weeks postoperatively. Serum CRP and ESR differ in their normal temporal patterns of postoperative levels after THR. The temporal changes of CRP values were faster and greater than those of ESR. CRP levels rapidly reached a peak at day two and thereafter the levels decreased in a biphasic pattern. The first phase occurred after day three when CRP levels decreased rapidly and the second phase came after day seven with a gradual decrease until normalisation at three weeks. In contrast, the ESR levels peaked on the third day after surgery and gradually decreased and remained elevated above the normal reference level (30 mm/hour) at three weeks postoperative. CRP shows a more predictable response with less atypical patterns and appears to be a better indicator of acute-phase response than ESR. Further elaborative studies in this regard would conclusively substantiate the evidence highlighted in this study.

Limitation(s)

This was a single-institution study done on a subset of the Asian population. The sample size of the study population was small with a short follow-up period of three weeks. However, it must be noted that period of 3 weeks was kept to take into account only the acute phase response of CRP and ESR. Though CRP normalised by three weeks, ESR did not. However, it was not followed longer than 3 weeks to see when it was normalised. Only uncomplicated cases were included in the present study to establish the baseline value of ESR and CRP in the Asian population.

Conclusion

Bone cement does not affect CRP or ESR values significantly in early postoperative phase after uncomplicated total hip arthroplasty. Hence, it may be used as a reliable marker of infection, both in cemented and uncemented hip arthroplasty. However, further research is required in this field to conclusively provide evidence regarding this.

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DOI and Others

DOI: 10.7860/JCDR/2022/55984.16779

Date of Submission: Feb 28, 2022
Date of Peer Review: May 03, 2022
Date of Acceptance: Jun 13, 2022
Date of Publishing: Aug 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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• iThenticate Software: Jul 05, 2022 (21%)

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