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Planning for THR: Considerations for Specific Diseases

- Surgical Considerations:



    - preoperative anticoagulants:
           - consider use of cell saver;
           - 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);
    - 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;
           - reference:
                  - 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:
           - reference:
                  - 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.
                  - 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
           - reference:
                  - 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:
           - may be at higher risk of infection
           - 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;
           - references:
                  - Septic arthritis of the hip joint in cervical cancer patients after radiotherapy: three case reports
                  - Septic arthritis of hip after radiotherapy for carcinoma of cervix
                  - Septic arthritis of the hip as a late complication of radiation therapy: a case report and review 

    - sickle cell anemia:
           - these patients will require a careful assessment by a hematologist prior to surgery;
           - in some cases, exchange transfusion will be indicated;
           - reference:
                   - Total hip arthroplasty in patients who have sickle-cell hemoglobinopathy.
    - systemic lupus erythematosus
           - reference:
                   - Hip arthroplasty in patients with systemic lupus erythematosus.
    - ankylosing spondylitis
    - young patients:
           - as reported by Sochart and Porter (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, degenerative osteoarthritis, or rheumatoid arthritis.
                  - The fate of cemented total hip arthroplasty in young patients.
                  - Charnely total hip arthroplasty in patients less than fifty years old.  A twenty to twenty five-year follow-up note
                  - Results of primary total hip arthroplasty in young patients.  
                  - Total hip arthroplasties in patients less than forty-five years old
                  - Total hip replacement in patients younger than 30 years old - a five year follow up study
     - older patients:
            -
Total Hip Replacement in Patients Eighty Years of Age and Older    
     - simultaneous bilateral total hip arthroplasty:
           - Salvati et al (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, et al (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 (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. 
           - references
                  - Bilateral total hip-replacement arthroplasty in one stage.
                  - The nine- to fifteen-year follow-up of one-stage bilateral total hip arthroplasty.
                  - Single-stage, bilateral, cementless total hip arthroplasty.
     - ankylosed hip:  (see hip arthodesis)
             - these patients may be at high risk for heterotopic ossification;
             - in the report by Hamadouche M, 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;
                    - 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%);
             - references:
                    - Total Hip Arthroplasty for the Treatment of Ankylosed Hips. A five to twenty one-year follow-up study
                    - Joint replacement for ankylosed hips