THR

Total Hip Replacement

Indications

  • Persistent symptoms of  pain from the hip with limited ambulation, night pain, severe quality of life limitation despite conservative therapy
  • Conservative options tried first are weight loss, NSAIDS, walking stick in contralateral hand
  • Used in: OA (primary or secondary), inflammatory arthritis, Osteonecrosis, #s, failed reconstructions, tumours

  Contraindications

  • Absolute:
    • Active infection
  • Relative:
    • Preexisting medical problems which have not been optimised
    • Skeletally immature
    • Non ambulators
    • Neurotrophic joint
    • Abductor muscle loss
    • Progressive neurological disease

Preoperative assessment

  • Ensure that pain is from the hip, not referred from the back etc
  • Medical evaluation
  • Dental evaluation
  • FBC, U+Es, MSU
  • Consider preop donation of blood (see blood transfusion) , or Xmatch
  • Nasal and perineal swabs for MRSA
  • Preop Xrays, AP pelvis, AP view centred at the hip, with leg internally rotated to 15 degrees (allows templating by eliminating femoral anteversion). Lateral film
  • Planning of surgical approach and templating

Consent

Local Risks:

  1. Leg length inequality possible (15%)
  2. Dislocation – 3%
  3. Infection – 2%
  4. Loosening – at about 10 – 15 years
  5. 1% of patients are not satisfied

Systemic Risks:

  1. Urinary tract (& chest) infection – 10%
  2. Clinical DVT – 2%
  3. Non-fatal PE – 1%
  4. Fatal PE – < 0.5%
  5. Mortality – < 0.5%

Prevention of infection

  •  Shave at the last minute
  • Intravenous antibiotic, 1.5g IV cefuroxime, to be continued for 24-48 hrs post op
  • Wilson Aglietti and Salvati found reduction of infection from 11% to 1%.
  • Lidwell et al found reduction of infection to 0.1% with combination of clean air sytems, body exhaust suits and antibiotics. The antibiotics decreased the risk of sepsis to the greatest extent

Surgical approach

Charnley approach

Hardinge direct lateral approach

Posterolateral approach (Moore  or Southern)

Anterolateral approach of Watson-Jones