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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 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: