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Duke Orthopaedics
Wheeless' Textbook of Orthopaedics

THR: Posterolateral Approach

- See: Total Hip Replacement Menu:

- PreOp:
    - Theory and Background:
    - Checklist for THR: and  Radiographs:

 - Initial Exposure:
    - positioning, prepping and antibiotics:  
    - posterolateral skin incision
    - incise thru iliotibial band:
    - split gluteus maximus
           - The course of the superior gluteal nerve in the lateral approach to the hip; 
    - identify the sciatic nerve 
    - measure leg lengths:
    - external rotators and the posterior capsule 
    - hip dislocation: technique:   
- Femoral Preparation:
    - femoral neck resection:
    - entry into femoral medullary canal:
    - femoral reaming:
    - broaching:
          - femoral broaching for press fit stems:

- Acetabulum: 
    - acetabular exposure and preparation for reaming:
    - acetabular reaming:
    - acetabular cup insertion:
          - acetabular cup position:
          - screw insertion
 - Femoral Stem Insertion:
    - insertion of cementless femoral stem:
    - insertion of cemented femoral stem: (cementing: preparation and technique):
    - trial reduction:

- Wound Closure:
    - Rush Betadine Lavage Protocol:
              - preparation of solution:
                      - scrub nurse draws up 17.5cc of 10% povidone-iodine with a syringe and mixes it with 500cc of sterile normal saline;
                      - this results in a dilution of 0.35% povidone-iodine for use prior to wound closure;
                      - following implantation of the prosthetic components, the wound is soaked with 500cc of the dilute betadine solution for three minutes,
                                followed by pulsatile lavage with 1L of normal saline without antibiotics;
                      - prior to final closure, betadine is applied to the skin surrounding the incision;
             - references:
                      - Dilute betadine lavage a simple, less expensive way to reduce postoperative TKA infection  
                      - Dilute Betadine Lavage in the Prevention of Postoperative Infection
                      - Dilute Betadine Lavage Before Closure for the Prevention of Acute Postoperative Deep Periprosthetic Joint Infection


 - Post Operative Care
    - anesthesia
           - Continuous Lumbar Plexus Block for Postoperative Pain Control After Total Hip Arthroplasty. A randomized controlled trial.
    - exam:
           - evaluate vascular and neurological status of both legs;
           - assess leg lengths (based on level of malleoli) to r/o dislocation
    - deep venous thrombosis
           - ref: Hypoxemia After Total Joint Arthroplasty: A Problem on the Rise
    - postop radiographs:
           - following THR in RR, x-rays must include the entire stem in two planes;
           - ap view: may reveal cement outside the cortex;
           - lateral view: may show the stem penetration of the cortex;
    - hip precautions:
           - patients need to hip limit flexion to 90 deg;
           - patients will require and elevated toilet seat, and instruments to help with putting on shoes and socks;
           - it is unclear whether patients need restricted wt bearing (see forces acting on hip joint); 
           - references:
                   - Hip revision with impacted morselized allografts: unrestricted weight-bearing and restricted weight-bearing have similar effect on migration. A radiostereometry analysis.
                   - Implant migration after early weightbearing in cementless hip replacement. 
    - postoperative dressing: 
           - modified vaccum assisted closure: 
                   - dramatic reduction of post op wound drainage can be obtained by applying gauze-fenestrated drain-gauze dressing covered by tegaderm which
                             is then hooked up to wall suction;
                   - references:
                             - Simplified wound care and earlier wound recovery without closed suction drainage in elective THA. A PRT trial in 100 operations 
                             - Blood loss after total hip replacement: a prospective randomized study between wound compression and drainage.
                             - Wound complications after hip surgery using a tapeless compressive support
                             - Suction dressings: a new surgical dressing technique.
                             - Suction dressings in total knee arthroplasty--an alternative to deep suction drainage.
                             - External suction drainage in primary total joint arthroplasties.  
                             - Incisional Vacuum-Assisted Closure Therapy
                             - Continuous high vacuum and primary skin closure in sternotomy wound infection 
                             - Role of Vacuum Assisted Closure (VAC) Device in Postoperative Management of Pelvic and Acetabular Fractures
                             - Incisional Wound Vac in Obese Patients
                             - Wound oozing after total hip arthroplasty.
                             - Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.   
                             - Is a fat stitch required when closing a hip hemiarthroplasty wound without a drain? 
                             - Blood loss after total hip replacement: a prospective randomized study between wound compression and drainage.
                             - Wound complications after hip surgery using a tapeless compressive support.

    - Post Op Fever:
            - references: 
                   - The Role of Blood Cultures in the Acute Evaluation of Postoperative Fever in Arthroplasty Patients
                   - Urinary-Bladder Management After Total Joint-Replacement Surgery
                   - Factors Associated with Prolonged Wound Drainage After Primary Total Hip and Knee Arthroplasty.
                   - Postoperative Ileus After Total Joint Arthroplasty (see prevention with chewing gum)
                   - Febrile response after knee and hip arthroplasty.   
                   - Evaluation of Postoperative Fever and Leukocytosis in Patients After Total Hip and Knee Arthroplasty

 Total Joint Arthroplasty: When Do Fatal or Near-Fatal Complications Occur?.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Clifford R. Wheeless, III, MD on Sunday, December 21, 2014 8:09 pm