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Tchonda E.1,3*, Dione M.D.1, Azanmasso H.1, Diagne N.S.1, S. Larhalbli S.1, Ahyaoui H.2, Guinhouya K.M.2, Belo M.2, Lmidmani F.1, El Fatimi A.1, Rafai M2
1Department of Physical Medicine and Rehabilitation, Ibn Rochd, Casablanca, Morocco
2Department of Traumatology, Ibn Rochd, Casablanca, Morocco 
3Department of Neurology, CHU SO, Lome, Togo 

Corresponding author: Tchonda Essohouna 
Address
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Email address:  HYPERLINK "mailto:ngorsidediagne@yahoo.fr"stchonda79@yahoo.fr (TCHONDA E.)

Abstract: Introduction: The hip arthroplasty has become a very common practice. It concerns young population. The osteoarthritis is the most common indication for total hip prosthesis. Moroccans patients with osteoarthritis often related an alteration of their prayer and are worried about this. Nevertheless, the hip arthroplasty allows restoration. Objectives: The proposal of our studies is to determine what becomes moroccans patients with total hip prosthesis. Methodology: A cross-sectional, prospective study has been conducted at the Department of Physical Medicine and Rehabilitation in collaboration with the Department of Traumatology of University Hospital, Ibn Rochd, Casablanca, Morocco. Patients who took advantage of rehabilitation sessions before and after total hip prosthesis have been included. Patients with secondary prosthesis, post traumatic total hip prosthesis or cognitive impairment have been excluded. The socio demographic characteristics, the prosthesis indications, and complications have been gathered using a questionnaire. Patients mentioned their style of prayer. The style of prayer has been classified in three groups: non difficult standard prayer, difficult standard prayer and impossible (prayer is done at sit position on a chair). An assessment has been carried out before and six months after total hip replacement. For mobility assessment, passive hip movements have been performed and measured with the universal goniometer. Current pain intensity has been assessed using an 101-point numerical rating scale ranging from 0 (non pain) to 100 (the worst imaginable pain). Disability has been assessed using the Western Ontario and Mac Master (WOMAC) Universities Arthritis Index, the Postel-Merle and Aubign�  Index (PMA). Results: 79 patients have been included. Average age was 47.7 years. Sex ratio was 0.61. Eighty-two percent (82%) patients were manual laborers against 18% of office workers. All patients were muslims. The main causes of hip disease were ankylosing spondylitis (25.3%), rheumatoid arthritis (19%), infection (7.6%), hip osteoarthritis (27.8%), and aseptic osteonecrosis (6.3 %). All the operations have been performed through the posterior lateral approach. The total hip replacement has improved pain (p = 0.0004), mobility (p <0.05), function (p = 0.006). Before the prosthesis, the prayer was impossible in 48.4% and difficult in 31.6% of cases. Eleven point four percent patients after total hip prosthesis could not perform the prayer. Discussion: Total hip prosthesis is a successful surgical procedure for relieving pain, improving function and mobility. In Moroccan patients, total hip prosthesis restored style of prayer and improved the functional capacity. Conclusion: The hip arthropalsty helps improve the quality of life which is strongly influenced by prayer style. Thus, the indication for total hip prosthesis in Morocco must consider the aspect of prayer.
Keywords: patient outcomes, prayer, muslim,  total hip prosthesis.  
1. Introduction
The total hip prosthesis (THP) is an internal articular device that aims to replace the hip joint [1]. Total hip prosthesis is one of the most frequently performed orthopedic procedures worldwide [2] and is increased every year especially in obesity patients [3]. The main reasons of high frequency of hip prosthesis are the increasing life expectancy of the population who wish an active life style and the progressive extended of hip prosthesis in young patients [4,5,6,7] . The aim of this successful surgical procedure is to relieve pain and improve function [8,9]. The indications are different depend on country. These variations are based on the life style, daily activities, study population and technological advancement. Total hip prosthesis is considered an effective treatment for patients with end-stage osteoarthritis [2]. Pain, presence of radiographic osteoatrhitis and disability are generally accepted as indications of THP [10, 11,12,13]. In Morocco all the population is muslim. Muslim prayer remains a religious obligation during which the articulation of the hip is permanently needed in various positions (standing, leaning forward, forehead against floor). During prayer hip flexion is between 110 and 130 degree. The duration of the prayer is four minutes and five prayers per day are obligatory. Moroccan patients who can't pray in the above mentioned positions, do so by sitting on the chair. This aspect is often related to Moroccan patients with osteoarthritis and makes patients anxious.  After hip prosthesis, Moroccan patient are satisfied of results only if they found a previous mode of prayer. The proposal of our studies was to consider the style of prayer, to determine what becomes moroccans patients with total hip prosthesis. 
2. Methodology 
We have carried out a study from January 2009 to September 2013. This study was conducted at the department of physical medicine and rehabilitation of university hospital in collaboration with traumatology department. Patients took advantage of a total hip prosthesis and rehabilitation sessions before and after total hip prosthesis were included. Patients with secondary prosthesis, post traumatic total hip prosthesis or cognitive impairment have been excluded. All patients have been operated by the same surgical team at the department of traumatology, Ibn Rochd Hospital coordinated by a highly experienced surgeon (R. M). The preoperative rehabilitation included transcutaneous electrical nerve stimulation (TENS), passive and active mobilization, postures, strength training and proprioceptive entrainment. The post operative rehabilitation was begun at first day after surgery. The patients were verticalized 48 hour after hip prosthesis with two crutches. An additional preoperative rehabilitation comprised teaching on the prevention of dislocated movement, cryotherapy, isometric quadriceps strengthening, stretching muscle, passive and assisted active mobilization and proprioceptive training. Postures were done in resistant stiffness. Strength training was done progressively. It had begin with Kabat methods rehabilitation and followed with active mobilization using the gravity or not. Walking have been carried out on leveled and erratic ground. Climbing up and down stairs have been equally done. The rehabilitation protocol was subject to changes with patients who presented complications. Patients with secondary prosthesis, post traumatic total hip prosthesis or cognitive impairment have been excluded. The socio-demographic characteristics, the prosthesis indications and complications have been gathered using a questionnaire. Patients answered about their prayer style. The prayer style have been classified in three groups: non difficult standard prayer, difficult standard prayer and impossible (prayer is done at sit position on a chair). An assessment was carried out before and six months after total hip replacement. For mobility assessment, passive hip movements have been performed and measured with the universal goniometer. Current pain intensity has been assessed using an 101-point numerical rating scale ranging from 0 (non pain) to 100 (the worst imaginable pain). Disability has been assessed using the Western Ontario and Mac Master (WOMAC) Universities Arthritis Index, the Postel-Merle and Aubign�  Index (PMA). We have used the Moroccan version of WOMAC which has been proven to be reliable and valid [14]. The data was analyzed with SPSS 16.0 software. Statistical tests were performed with Chi2 methods and p with Fisher methods. The significance level was set to 5%. 
3. Results
3.1 Sociodemographic characteristics
We recruited 79 patients. The average age was 47.7 years (20-75). The sex ratio was 0,61. In 76% of cases, patients were married and 18.9% of patients were single. Widows represented 5.1% of cases. Eighty two percent (82%) of patients were manual laborers against 18% office workers. All patients were muslims. 
3.2 Causes of hip disease
The main causes of hip disease were ankylosing spondylitis (25.3%), rheumatoid arthritis (19%), infection (7.6%), hip osteoarthritis (27.8%), and aseptic osteonecrosis (6.3 %). The other causes have been noted in 14% of cases. They were dominated by tumors. 
3.3 Surgical approach and complications
All patients had a posterolateral approach. In 70.5% of cases prosthesis were cemented and 29.5 % was not cemented. The complications have been noted in 32% of cases. The inequality of length has been found in 15.18% of cases. It was lower than 10 millimeters among 3 patients. The tendinitis and the deficit of the gluteus medius have been noted in 8.86% of cases and the paralysis of the sciatic nerve in 6.3% cases. The paralysis of the sciatic nerve resulted in a partial deficit of the lifters muscles in all patients. This deficit has been associated to hypoesthesia at the external face of the leg (two cases) and at the side section of the back of the foot (one case). It was a neuropraxia in all patients. Hematoma was represented in 3 patients (3.7%). 
3.3 Prayer style
Before hip prosthesis, twenty per cent (20%) of patients had non difficult standard prayers against 31.6% with difficult prayer.  Standard prayer was impossible in 48.4% of cases.  After arthroplasty, prayer has been made possible in 88.60% of cases and remained impossible in 11%. Those patients had mechanical knee pain associated with related arthritis. The figure below shows the impact of hip prosthesis on prayer. 

figure 1: prayer style and hip prosthesis
3.4 Pain
The average score of pain before the total hip prosthesis was 67/100.  The average score of pain after hip prosthesis increased to 12/100 (p=0.0004). 
3.5. Joint mobility
Before the total hip prosthesis, the average hip flexion was 71.8 degrees and the extension was less than 22.3 degrees. The average hip flexion (p=0.001) also increased (105.94 degree) and the extension (p=0.002) to minus 3 degrees after surgical intervention. The best extension progress was found in patients with inflammatory disease (p=0.015). 
3.6 Functional capacity
 The function of the patients have been weathered with a score of WOMAC 89 and PMA 7.2 at start. At the end of the study, the average WOMAC score was 36 (p= 0.006) and PMA score 14.8 (p= 0.005). The PMA score was excellent in 22% of cases, very good (27%), good (19%), average (16%) and mediocre (16%). The functional progress according to the PMA was the best in patients with degenerative hip disease (p=0.018).  
.4. Discussion
The prosthetic hip surgery is still increasing. It concerns active young population [5, 6, 7,15]. The small number of the focused people concerning our study within 4 years, suggests otherwise in Morocco. By the way the prosthetic surgery is frequently done at the department of traumatology, University Hospital Ibn Rochd. As result, patients are not systematically sent for rehabilitation. According to the recommendations of Barrois and Ribinik, only are sent to rehabilitation after arthroplasty, patients who presented altered preoperative comorbidities associated with functional capacity and those with postoperative complications [16,17]. This could justify our results. Total hip replacement is at mostly realized on women [18]. This could be explained by life expectancy which is more important among women. Our data means the following. Indications about total hip replacements vary according to the country [5]. It vary according to the standard of livingand the jobs of patients, the focused people research, technologic discoveries of the country and the etiologies of hip disease [5]. Those indications are showed by the pain, functional impotence, x ray results and failure of conservatory treatment [5]. Morocco is an Islamic country. Muslim prayer remains an obligation in which the hip and knees are needed in various positions. The impossibiliy to make this prayer in appropriate way is Moroccans essential preoccupation and contributes to the deterioration of their life standard. The total hip replacement in our patients allowed to recover that function except the patients with knee osteoarthritis associated. Our results suggest that muslim prayer request more stability and mobility than strength. In our study, rehabilitation protocol was most focused on analgesic physiotherapy, joint mobility, stability and explained why results are the best in components pain and mobility. Others rehabilitation protocols are proved efficient after hip prosthesis. Marco M and al, found that task oriented exercises associated with early full weight-bearing is superior to a program of traditional exercises associated with partial weight-bearing in term of reducing disability, pain, improving daily activity of life and quality of life [8]. Gilbeys and al, have mentioned the interest of the reconditioning effort associated to the classic method of joints amplitude recovery [19]. It was attractive to evaluate Body Mass Index (BMI), radiographic osteoarthritis for our patients who aren�t recovered standard style of prayer [20] but our study was analytical and descriptive. It shall be completed in order to determinate risk factors of poorer outcomes in Moroccan patients after hip prosthesis. The relatively young average age of our patients is due to the predominance of inflammatory coxitis in our study [21]. In fact, the use of anti-TNF is not as regular in Morocco as in many developing countries. This can be explain by their cost. It makes the deterioration of joints very easier and explains the frequency of inflammatory hip disease in our research. Very rare nerve complications are noticed after hip replacement [22]. The topography of injury is variable depending on the chirurgical approach. In our research, these complications are more frequent. It would be surely due to the first posterolateral approach in our patients [23, 22,24]. The unequal length of the lower limbs is a fairly common complication after hip replacement. Its frequency is between 14 and 15% [25, 26]. The total hip replacement reduced significantly hip pain [25,27,28]. The severity of pain after hip replacement is less than 2.1/10 [61,75]. The hip prosthesis provides 90o of flexion and flexion-extension ratio ranging between 23.1o and 40.7o [29,27,30]. After hip prosthesis, studies mentioned an improvement of the function. Marco and al, have mentioned a benefice of rehabilitation, interesting all of the WOMAC dimensions in hip prosthesis population. The results were best in physical function [8]. Physical activity after hip prosthesis is better in patients with degenerative hip disease and is inversely proportional to the postoperative period [27]. Birgit and al shows that progressive resting training improved muscle strength, functional capacity and self reported function after hip prosthesis [21]. The interest of preoperative progressive resistance training is poor investigate [21].  However, significant improvements in functional capacity, pain and self reported function are found before the post total hip arthroplasty intervention in patients who are beneficed at preoperative rehabilitation [28,21, 31]. In our study, hip prosthesis are improved the function of patients. 
5. Conclusion: 
The hip arthroplasty has become a very common practice. It concerns patients increasingly young and active. This allows an improvement in pain, joint mobility, hip function and quality of life. The latter is strongly influenced by the ability to perform or not adequately muslim prayer in Morocco. Thus, the indication for total hip prosthesis in Morocco should take into account the aspect of prayer.
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