Duke Orthopaedics
presents
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 
           - ref: The change in position of the sciatic nerve during the posterior approach to the hip
    - 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 and determination of  neck length (offset):

- 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, wound is soaked w/ 500cc of dilute betadine solution for 3 min,
                                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.
           - Surgeon delivered psoas compartment block in total hip arthroplasty.
           - A cadaveric study of injectate spread in the psoas compartment with a direct iliopsoas injection suggested for use during surgery.
           - TENS stimulation on acupoints reduces fentanyl requirement for postop pain relief after THR in elderly patients

    - 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 total hip arthroplasty. A prospective randomized 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.
    - Urinary Management:
             - references:
                   - Risk Factors for Postoperative Urinary Retention in Men Undergoing Total Hip Arthroplasty     
                   - Urinary-Bladder Management After Total Joint-Replacement Surgery

    - Post Op Fever:
            - references: 
                   - The Role of Blood Cultures in the Acute Evaluation of Postoperative Fever in Arthroplasty Patients
                   - 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


- Misc Complications:
       - Total Joint Arthroplasty: When Do Fatal or Near-Fatal Complications Occur?.
       - Acute abdominal complications following hip surgery.




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

Last updated by Data Trace Staff on Thursday, May 19, 2016 10:17 am

© 2016 - Data Trace Internet Publishing, LLC - All rights reserved.