Surgical approaches to the hip, postoperative cour

Surgical approaches to the hip, postoperative course and complications

The operation can be performed via a posterior approach, a trochanteric osteotomy , an anterolateral or Hardinge approach or an anterior approach ( Table 39.8 ). Each approach has its own advantages and disadvantages. Minimally invasive Kevin Hardinge , b. 1939, orthopaedic surgeon, Wrightington Hospital, UK, described the direct lateral approach to the hip in 1982. surgery has been described that shortens the size of the incision and attempts to lessen soft-tissue damage. As access can be restricted, specialised instruments have been developed to facilitate this. Although the concept is attractive, no long - term benefits have been conclusiv ely shown in minimally inva - sive hip surgery over the conventional technique. Eventually , whichever approach is used, it is essential to be able to implant - a prosthesis so as to reproduce the patient’s anatomy such that the implant has the correct o ff set, is at the correct centre of rotation with the correct component orientation, restores leg length and carries minimal risk of complications. The postoperative course generally involves a 2- to 3-day stay in hospital but day case hip replacements are being per - formed in a select group of patients in some centres. The physiotherapist encourages the patient to mobilise safely and inde pendently , avoiding any movements that might lead to a dislocation ( Figure 39.10 ). Postopera tive plain radiographs are essential to ensure that implants are in correct alignment and orientation, and rule out any iatrogenic fracture. Prior to dis - charge, the occupational therapist assesses the patient’s home circumstances and arranges for any modifications that may be

Disadvantages Current use Favourable in older age group >70 Comparatively high friction; high years wear rates; wear particles excite an in /f_l ammatory response that leads to osteolysis Expensive; ceramic fracture can be Preferrable in younger patients a problem <70 years. Newer polyethylene – UHMWPE – has low wear rate Only a select group of patients – Problem with metal ion release young male. Use head size larger leading to adverse reaction to than 48 /uni00A0 mm metal debris and severe osteolysis. Published examples of failure requiring early revision; implant recalls; expensive Very expensive; ceramic can High-functioning young patients fracture; squeaking Disadvantages Cement polymerisation is exothermic with possibility of thermal injury; fragments may cause third-body wear and stimulate aseptic loosening; dif /f_i cult to remove at revision Higher shear forces leading to failure Risk of fracture; /f_i t must be perfect; osseous integration may not be established; expensive Improper technique can lead to acetabular fracture

required to assist the patient, e.g. a raised toilet seat. For the first 6 weeks patients are advised to avoid movements that make the THR prone to dislocation. Outpatient follow-up visits are arranged at 6 weeks and at 1 year post surgery . Although THR is generally a successful and safe procedure, it does have asso ciated complications. A comprehensive list of complications is provided in Table 39.9 . Perioperative administration of vention of infection antibiotics is a very important part in pre in addition to adequate aseptic precautions in the operating theatre. V enous thromboembolism is a risk following THR and deep vein thrombosis (DVT) is relatively common if no precautions are taken to reduce this risk. DVT can lead to pul monary embolism (PE), which can be fatal. Hence steps need to be taken to minimise the risk for both DVT and PE, includ ing adequate hydration, the use of regional anaesthesia and early postoperative mobilisation. In addition, both mechani rent [TED] stockings, foot cal device (thromboembolic deter pumps or intermittent pneumatic calf compression devices) hemical thromboprophylaxis (low-molecular-weight hep and c arin, warfarin or oral anticoagulants) are commonly prescribed 4–6 weeks after surgery to reduce the risk of for a period of DVT (this depends on local and national guidelines). /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Figure 39.10 Anteroposterior radiograph showing dislocation of a left hybrid total hip replacement (cemented femoral stem and unce mented acetabular component). TABLE 39.8 Surgical approaches to the hip. Surgical approach Anatomical interval and muscle Posterior Along the /f_i bres of the gluteus maximus, and dividing the short external rotators Trochanteric A trochanteric osteotomy is required Anterolateral/ Parts of the gluteus medius and minimus are Hardinge re /f_l ected off the greater trochanter Anterior The interval is developed between the sartorius and tensor fascia lata super /f_i cially and rectus femoris and gluteus medius deeply Intraoperative Nerve injury – sciatic, femoral and complications obturator nerves Vascular injury – femoral vein and artery Femoral or acetabular fracture Fragments of cement left in joint Postoperative Infection complications Deep vein thrombosis and pulmonary embolism Leg length inequality Dislocation Heterotopic ossi /f_i cation Septic/aseptic loosening Implant breakage/failure

Surgical approaches to the hip, postoperative course and complications

The operation can be performed via a posterior approach, a trochanteric osteotomy , an anterolateral or Hardinge approach or an anterior approach ( Table 39.8 ). Each approach has its own advantages and disadvantages. Minimally invasive Kevin Hardinge , b. 1939, orthopaedic surgeon, Wrightington Hospital, UK, described the direct lateral approach to the hip in 1982. surgery has been described that shortens the size of the incision and attempts to lessen soft-tissue damage. As access can be restricted, specialised instruments have been developed to facilitate this. Although the concept is attractive, no long - term benefits have been conclusiv ely shown in minimally inva - sive hip surgery over the conventional technique. Eventually , whichever approach is used, it is essential to be able to implant - a prosthesis so as to reproduce the patient’s anatomy such that the implant has the correct o ff set, is at the correct centre of rotation with the correct component orientation, restores leg length and carries minimal risk of complications. The postoperative course generally involves a 2- to 3-day stay in hospital but day case hip replacements are being per - formed in a select group of patients in some centres. The physiotherapist encourages the patient to mobilise safely and inde pendently , avoiding any movements that might lead to a dislocation ( Figure 39.10 ). Postopera tive plain radiographs are essential to ensure that implants are in correct alignment and orientation, and rule out any iatrogenic fracture. Prior to dis - charge, the occupational therapist assesses the patient’s home circumstances and arranges for any modifications that may be

Disadvantages Current use Favourable in older age group >70 Comparatively high friction; high years wear rates; wear particles excite an in /f_l ammatory response that leads to osteolysis Expensive; ceramic fracture can be Preferrable in younger patients a problem <70 years. Newer polyethylene – UHMWPE – has low wear rate Only a select group of patients – Problem with metal ion release young male. Use head size larger leading to adverse reaction to than 48 /uni00A0 mm metal debris and severe osteolysis. Published examples of failure requiring early revision; implant recalls; expensive Very expensive; ceramic can High-functioning young patients fracture; squeaking Disadvantages Cement polymerisation is exothermic with possibility of thermal injury; fragments may cause third-body wear and stimulate aseptic loosening; dif /f_i cult to remove at revision Higher shear forces leading to failure Risk of fracture; /f_i t must be perfect; osseous integration may not be established; expensive Improper technique can lead to acetabular fracture

required to assist the patient, e.g. a raised toilet seat. For the first 6 weeks patients are advised to avoid movements that make the THR prone to dislocation. Outpatient follow-up visits are arranged at 6 weeks and at 1 year post surgery . Although THR is generally a successful and safe procedure, it does have asso ciated complications. A comprehensive list of complications is provided in Table 39.9 . Perioperative administration of vention of infection antibiotics is a very important part in pre in addition to adequate aseptic precautions in the operating theatre. V enous thromboembolism is a risk following THR and deep vein thrombosis (DVT) is relatively common if no precautions are taken to reduce this risk. DVT can lead to pul monary embolism (PE), which can be fatal. Hence steps need to be taken to minimise the risk for both DVT and PE, includ ing adequate hydration, the use of regional anaesthesia and early postoperative mobilisation. In addition, both mechani rent [TED] stockings, foot cal device (thromboembolic deter pumps or intermittent pneumatic calf compression devices) hemical thromboprophylaxis (low-molecular-weight hep and c arin, warfarin or oral anticoagulants) are commonly prescribed 4–6 weeks after surgery to reduce the risk of for a period of DVT (this depends on local and national guidelines). /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Figure 39.10 Anteroposterior radiograph showing dislocation of a left hybrid total hip replacement (cemented femoral stem and unce mented acetabular component). TABLE 39.8 Surgical approaches to the hip. Surgical approach Anatomical interval and muscle Posterior Along the /f_i bres of the gluteus maximus, and dividing the short external rotators Trochanteric A trochanteric osteotomy is required Anterolateral/ Parts of the gluteus medius and minimus are Hardinge re /f_l ected off the greater trochanter Anterior The interval is developed between the sartorius and tensor fascia lata super /f_i cially and rectus femoris and gluteus medius deeply Intraoperative Nerve injury – sciatic, femoral and complications obturator nerves Vascular injury – femoral vein and artery Femoral or acetabular fracture Fragments of cement left in joint Postoperative Infection complications Deep vein thrombosis and pulmonary embolism Leg length inequality Dislocation Heterotopic ossi /f_i cation Septic/aseptic loosening Implant breakage/failure