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Indications for total hip arthroplasty

  • Persistent symptoms of  pain from the hip with limited ambulation, night pain, severe quality of life limitation despite conservative therapy

  • Conservative options tried first are weight loss, NSAIDS, walking stick in contralateral hand

  • Used in: OA (primary or secondary), inflammatory arthritis, Osteonecrosis, Fractures, failed reconstructions, tumours

 

Contraindications

  • Absolute:

    • Active infection

  • Relative:

    • Preexisting medical problems which have not been optimised

    • Skeletally immature

    • Non ambulators

    • Neurotrophic joint

    • Abductor muscle loss

    • Progressive neurological disease

 

Preop assessment

  • Ensure that pain is from the hip, not referred from the back etc

  • Medical evaluation

  • Dental evaluation

  • FBC, U+Es, MSU

  • Consider preop donation of blood (see blood transfusion) , or Xmatch

  • Nasal and perineal swabs for MRSA

  • Preop Xrays, AP pelvis, AP view centred at the hip, with leg internally rotated to 15 degrees (allows templating by eliminating femoral anteversion). Lateral film

  • Planning of surgical approach and templating

Consent:

Informed Consent to include:

Local Risks:

  1. Leg length inequality possible (15%)

  2. Dislocation - 3%

  3. Infection - 2%

  4. Loosening - at about 10 - 15 years

  5. 1% of patients are not satisfied 

Systemic Risks:

  1. Urinary tract (& chest) infection - 10%

  2. Clinical DVT - 2%

  3. Non-fatal PE - 1%

  4. Fatal PE - < 0.5%

  5. Mortality - < 0.5%

Prevention of infection

  •  Shave at the last minute

  • Intravenous antibiotic, 1.5g IV cefuroxime, to be continued for 24-48 hrs post op

  • Wilson Aglietti and Salvati found reduction of infection from 11% to 1%.

  • Lidwell et al found reduction of infection to 0.1% with combination of clean air sytems, body exhaust suits and antibiotics. The antibiotics decreased the risk of sepsis to the greatest extent

 

Surgical approach

  • Mainly a matter of personal preference and training

  • Each approach has advantages and disadvantages

 

Surgical anatomy of the superior gluteal nerve & ... the direct lateral approach to the hip

  • Bos JC. Stoeckart R et al. - Surgical & Radiologic Anatomy. 16(3):253-8, 1994.

  • In view of the increasing popularity of the direct lateral approach to the hip joint for hemi- or total hip arthroplasty, the location of the superior gluteal nerve (SGN) was studied. This nerve is in danger when using a transgluteal incision. In 20 embalmed specimens the relation of the SGN to the tip of the greater trochanter (TT) was studied as well as the relation to the iliac crest. For this purpose macroscopy, microscopy and CT were used. In 13 hips a so-called most inferior branch was found at an average of 1 cm distal to the inferior branch, the main trunk of the nerve. There was substantial variation in the course of both the inferior and the most inferior branch of the SGN. In order to prevent nerve damage, proximal extension of the transgluteal incision should be limited to 3 cm cranial to TT. Furthermore the incision has to be confined to the distal one third of the distance TT-iliac crest. In tall people extra care should be taken.



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