- Surgical Considerations:
-
preoperative anticoagulants:
- if patients have a medical condition that requires preoperative anticoagulants, then consider using press fit femoral and acetabular components;
- a prerequisite for cementing femoral stems, is the ability to obtain relative intramedullary canal hemostasis (which may not be possible w/ anticoagulation);
-
ankylosed hips: (see
hip arthodesis)
- this patients may be at high risk for
heterotopic ossification;
- references:
-
Joint replacement for ankylosed hips
-
avascular necrosis:
- note that there is some evidence that patients with AVN may have clotting abnormalities, and therefore these patients may
require more aggressive postoperative anticoagulation;
- references:
-
Total hip arthroplasty in patients with avascular necrosis of the hip. Follow-up observations on cementless and cemented operations.
-
coxa vara
-
dyplasia
-
perthes dz
-
SCFE
-
protrusio:
-
cerebral palsy:
- references:
-
The treatment of the painful hip in cerebral palsy by total hip replacement or hip arthrodesis.
-
femoral neck fracture:
- references:
-
Treatment of femoral neck fractures with total hip replacement versus cemented and noncemented hemiarthroplasty.
-
Secondary total hip replacement after fractures of the femoral neck.
-
Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement.
-
Primary total hip replacement for displaced subcapital fractures of the femur.
-
Treatment of acute femoral neck fractures with total hip arthroplasty.
-
Total hip arthroplasty following failed internal fixation of hip fractures.
- converstion of hemiarthroplasty to THR:
-
intertrochanteric frx
- references:
- Total hip arthroplasty for complications of intertrochanteric fracture. A technical note.
BM Patterson et al. JBJS-Am. Jun 1990. Vol 72 (5) p 776-777.
-
Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients. Primary bipolar arthroplasty compared with internal fixation.
-
Hip Arthroplasty for Salvage of Failed Treatment of Intertrochanteric Hip Fractures.
-
acetabular fracture:
-
gaucher's disease
- references:
-
Total hip arthroplasty in Gaucher's disease. Long-term prognosis.
-
juvenile rheumatoid arthritis:
- references:
-
Total hip arthroplasty in juvenile rheumatoid arthritis. Two to eleven-year results.
-
Total hip and knee arthroplasty in juvenile rheumatoid arthritis.
-
Total hip arthroplasty in juvenile rheumatoid arthritis.
-
rheumatoid arthritis:
-
organ transplantation:
- total joint replacement following renal or liver transplantation carries a risk of joint infection of appoximately 19%;
- these patients will have a high relative mortality rate;
-
cyclosporine A is associated w/ high risk of infection;
- references:
-
Total joint arthroplasty for steroid-induced osteonecrosis in cardiac transplant patients.
-
Total hip replacement in the renal transplant recipient.
-
Total hip arthroplasty after renal transplantation. Long-term follow-up study and assessment of metabolic bone status.
-
renal failure:
- patients receiving dialysis tend to develop early loosening;
- these patients may also be at especially high risk for
infection;
- there is some evidence that press fit stems are less likely to develop a bacterial biofilm layer, and therefore will be less prone to infection;
- consider use of
antibiotic impregnated cement;
- ref:
Blood management experience: relationship between autologous blood donation and transfusion in orthopedic surgery.
-
obese patient:
- references:
-
Total Hip Arthroplasty without Cement in Obese Patients. A Minimum Two-Year Clinical and Radiographic Follow-up Study.
-
A comparison of the perioperative morbidity in total joint arthroplasty in the obese and nonobese patient.
-
previous pelvic irradiation:
- affects osteoblastic activity;
- damaging effects occur after 3000 centigray, and bone infarction can occur after 5000 centigray;
- radiographic changes in the femoral head include lytic and sclerotic patching, which can resemble a pagetoid or malignant lesion;
- associated with early loosening (40-50%) at 2 years;
-
sickle cell anemia:
- these patients will require a careful assessment by a hematologist prior to surgery;
- in some cases, exchange transfusion will be indicated;
- references:
-
Total hip arthroplasty in patients who have sickle-cell hemoglobinopathy.
-
systemic lupus erythematosus
- references:
-
Hip arthroplasty in patients with systemic lupus erythematosus.
-
ankylosing spondylitis
-
THR in younger patients:
- as reported by Sochart and Martyn 1997, at 25 years survival of the femoral compartment was 75% to 89% (depending on the preoperative dx)
and the survival of the acetabular component was 58% to 79% depending on the preop dx;
- all of these patients underwent a formal Charnley type approach (trochanteric osteotomy w/ cemented acetabular and femoral components) and
all were less than 40 years old at the time of surgery;
- references:
- The long term results of Charnley Low Friction Arthroplasty in Young Patients who have Congenital Dislocation, DJD, or RA.
DH Sochart and ML Porter. JBJS Vol 79-A. No 11. Nov 1997. p 1599.
-
The fate of cemented total hip arthroplasty in young patients.
- Charnely total hip arthroplasty in patients less than fifty years old. A 20 to 25 year follow up note. JJ Callaghan et al. JBJS Vol 80-A. No 5. May 1998. p 704.
- Results of primary total hip arthroplasty in young patients. Callaghan. JBJS Vol 75-A. 1993. p 1728-1734.
- Total hip arthroplasties in patients less than 45 years old. LD Dorr et al. JBJS Vol 65-A. 1983. p 474-479.
- Total hip replacement in patients younger than 30 years old - a five year follow up study. HP Chandler et al. JBJS. Vol 63-A. 1981. p 1426-1434.
-
older patients:
- Total Hip Replacement in Patients Eighty Years of Age and Older
-
simultaneous bilateral total hip arthroplasty:
- Salvati et al (JBJS 1978) demonstrated that simultaneous bilateral total hip arthroplasty was no different than two
stage bilateral THA in terms of surgical technique, post-operative care, wound healing, or complications.
- in this study, the duration of anesthesia was greater than in a unilateral procedure by a factor less than two, but total
blood loss was about 1/3 more and the length of hospitalization was significantly longer;
- Agins, Salvati et al (Orthopaedic Clinics of North America, 1988) followed the first 122 consecutive patients having bilateral, cemented, simultaneous THA
for 9-15 years and felt that long-term clinical results for these patients are similar to those reported for unilateral procedures.
- the radiographic failure rate appeared to be greater in simultaneous bilateral hips performed for osteoarthritis, osteonecrosis, and rheumatoid arthritis.
- Ritter et al (J Arthroplasty 1995) demonstrated success using a cementless bilateral THA technique.
- 92 patients with 184 THAs were followed for 24-77 months.
- HHS scores averaged 94.6. X-ray assessment demonstrated 70% of the femoral components were optimally fixed, 26% were stable, and 4% had failed.
- 96% of acetabular components were optimally fixed with only 6 failures.
- early weight bearing did not appear to adversely affect initial stability and long-term bony ingrowth.
- even patients with stage 1 (no treatment) and 2 (treated with cerclage wires) proximal femur fractures did not
appear to have compromised clinical results.
- patients s/p bilateral uncemented THA may WBAT with crutches or walker immediately post-op without compromise of outcome.
- similar to unilateral THA, failure of femoral and acetabular components was caused by undersizing and malposition.
-
ankylosed hip:
- in the report by Moussa Hamadouche et al, the authors report the long-term results of THR following a hip fusion;
- 45 consecutive total hip arthroplasties were performed in 45 patients from 1969 through 1993;
- age of the patients at the time of the operation was 55.8 years (range, twenty-eight to eighty years);
- ankylosis of the hip had been spontaneous in twenty patients and postoperative in twenty-five patients;
- mean duration of the ankylosis had been thirty-six years (range, three to sixty-five years);
- mean duration of follow-up was 8.5 years (range, five to twenty-one years);
- hip function was considered to be satisfactory for forty-one (91%) of the 45 patients;
- only factor that was predictive of the final functional result with regard to walking ability was the intraoperative status of the gluteal muscles;
- cumulative survival rate at eight years, with revision as the end point, was 96.7% (95% confidence interval, 90.2% to 100%);
- ref: Total Hip Arthroplasty for the Treatment of Ankylosed Hips. A Five to Twenty-one-Year Follow-up Study
Moussa Hamadouche, MD. The Journal of Bone and Joint Surgery (American) 83:992-998 (2001)
