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Per op. in tha


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preoperative planning of THA for orthopaedic hip surgeons

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Per op. in tha

  1. 1. M. Dehnokhalaji
  2. 2. • whether the pain is sufficient to justify a major elective operation • Is the patient’s life expectancy reasonable? • would he or she be bedridden or confined to a wheelchair after surgery because of some other incurable disease? • Is the patient’s general condition good enough to tolerate a major operation, during which a significant amount of blood may be lost?
  3. 3. • Comorbidities known to be inherent to elderly patients should be considered • cardiopulmonary disease • Infections • thromboembolism. • A thorough general medical evaluation, including laboratory tests
  4. 4. • Aspirin and other antiinflammatory and antiplatelet medications should be discontinued 7 to 10 days before surgery • oral anticoagulants such as warfarin should be discontinued in sufficient time for coagulation studies to return to normal. • A bridging program with a short-acting anticoagulant such as enoxaparin may be required when discontinuing warfarin. • Many herbal medications and nutritional supplements may cause increased perioperative blood loss • recommend that these medications be discontinued preoperatively.
  5. 5. • we typically discontinue warfarin five days before elective surgery (ie, last dose of warfarin is given on day minus 6) and, when possible, check the PT/INR on the day before surgery . If the INR is >1.5, we administer low dose oral vitamin K (eg, 1 to 2 mg) to hasten normalization of the PT/INR and recheck the following day. We proceed with surgery when the INR is ≤1.4. An INR in the normal range is especially important in patients undergoing surgery associated with a high bleeding risk (eg, intracranial, spinal, urologic) or if neuraxial anesthesia is to be used
  6. 6. • Use of bridging preoperatively – We generally reserve bridging for individuals considered at very high or high risk of thromboembolism (eg, recent stroke, mechanical heart valve, CHADS2 score of 5 or 6) if they require interruption of warfarin. In these cases, the bridging agent (eg, therapeutic dose subcutaneous low molecular weight [LMW] heparin) is started three days before surgery. • A bridging agent may also be appropriate if there is a prolonged period during which the patient cannot take oral medications (eg, postoperative ileus).
  7. 7. • We suggest the use of bridging in individuals taking warfarin for one of the following conditions: ●Embolic stroke or systemic embolic event within the previous 12 weeks ●Mechanical mitral valve ●Mechanical aortic valve and additional stroke risk factors ●Atrial fibrillation and very high risk of stroke (eg, CHADS2 score of 5 or 6, stroke or systemic embolism within the previous 12 weeks) ●Venous thromboembolism (VTE) within the previous 12 weeks ●Recent coronary stenting ●Previous thromboembolism during interruption of chronic anticoagulation
  8. 8. • Preoperative timing of bridging — We generally initiate heparin bridging three days before a planned procedure (ie, two days after stopping warfarin), when thePT/INR has started to drop below the therapeutic range. • ●LMW heparin – We discontinue LMW heparin 24 hours before the planned surgery or procedure, based on a biologic half-life of most subcutaneous LMW heparins of approximately three to five hours . • If a twice-daily LMW heparin regimen is given, the evening dose the night before surgery is omitted, whereas if a once-daily regimen is given (eg, dalteparin 200 international units/kg), one-half of the total daily dose is given on the morning of the day before surgery.
  9. 9. • Pyogenic skin lesions should be eradicated. • Urinary retention due to prostatic or bladder disease and dental problems should be addressed before surgery.
  10. 10. • history of previous surgery, • purulent drainage from the hip, • other indications of ongoing infection: • laboratory investigation • ESR, CRP • nuclear scans • a culture and sensitivity determination of an aspirate of the hip • suspection to Infection • if part of the subchondral bone of the acetabulum or femoral head is eroded • if bone has been resorbed around an internal fixation device.
  11. 11. • the spine and the upper and lower extremities. • The soft tissues around the hip should be inspected for any inflammation or scarring where the incision is to be made. • Gentle palpation of the hip and thigh may reveal areas of point tenderness or a soft tissue mass. • The strength of the abductor musculature should be determined by the Trendelenburg test.
  12. 12. • The lengths of the lower extremities should be compared, and any fixed deformity should be noted. • Adduction contracture of the hip • produce apparent shortening of the limb despite equally measured leg lengths. • Abduction contracture • conversely produces apparent lengthening. • Fixed flexion deformity of the hip • forces the lumbar spine into lordosis on assuming an upright posture and may aggravate lower back pain symptoms. • fixed lumbar spine deformity from scoliosis or AS
  13. 13. • When the hip and the knee are both severely arthritic: • the hip should be operated on first. • Hip arthroplasty may alter knee alignment and mechanics. • knee arthroplasty is technically more difficult when the hip is stiff, and rehabilitation would be hampered.
  14. 14. • An alternative or additional diagnosis • The complaint of “hip pain” can be brought about by a variety of afflictions, and arthritis of the hip joint is one of the less common ones. • True hip joint pain usually is perceived in the groin, sometimes in the anterior thigh, and occasionally in the knee. • Arthritic pain usually is worse with activity and improves to some degree with rest and limited weight bearing.
  15. 15. • Pain in atypical locations and of atypical character should prompt a search for other problems. • Pain isolated to the buttock or posterior pelvis often is referred from the lumbar spine, sacrum, or sacroiliac joint. • Arthritis often in the hip and lumbar spine. • A THA done to relieve symptoms predominantly referred from the lumbar spine would do little to improve the patient’s condition. • Likewise, surgical intervention in the face of mild hip arthritis when the pain actually is caused by unrecognized vascular claudication, trochanteric bursitis, pubic ramus fracture, or an intraabdominal problem subjects the patient to needless risk
  16. 16. • The Harris, Iowa (Larson), Judet, Andersson, and d’Aubigné and Postel systems for recording the status of the hip before surgery are useful for evaluating postoperative results. • Pain, ability to walk, function, mobility, and radiographic changes are recorded. • As yet, no particular hip rating system has been uniformly adopted. • The Harris system is the most frequently used
  17. 17. • substantially increase local or general complications compared with staged procedures • Costs may be reduced by 30%. • The major indication •a medically fit patient • with bilateral severe involvement •with stiffness or fixed flexion deformity •because rehabilitation may be difficult if surgery is done on one side only.
  18. 18. • Elderly patients with other comorbidities, such as heart disease, pulmonary insufficiency, or diabetes are not suitable candidates for such a procedure. • A documented patent ductus arteriosus or septal defect is an absolute contraindication. • More intensive intraoperative monitoring, including an arterial line, pulmonary artery catheter, and urinary catheter, is recommended.
  19. 19. • the minimal views required • An anteroposterior view of the pelvis showing the proximal Femur • a lateral view of the hip and proximal femur • evaluate the structural integrity of the acetabulum • estimate the size of the implant required • how much reaming would be necessary • Determine whether bone grafting would be required
  20. 20. • Significant protrusion or periacetabular osteophyte formation may make dislocation of the hip difficult • In patients with developmental dysplasia, the pelvis should be evaluated with special care to determine the amount of bone stock present for fixation of the cup. • With old fracture-dislocations, obturator and iliac oblique views are obtained because a significant defect may be present in the posterior wall. • A three-dimensional CT scan also is helpful in evaluating the acetabulum in these complex cases.
  21. 21. • The width of the medullary canal • it may be narrow, especially in young patients, patients with dysplasia, and dwarfs. • a femoral component with a straight stem or a specially made small stem may be needed. • In Paget disease, old fractures of the femoral shaft, or congenital abnormalities, a lateral radiograph of the proximal femur may reveal a significant anterior bowing that may make preparation of the canal more difficult. • If excessive bowing or a rotational deformity is present, femoral osteotomy may be required before or in addition to the arthroplasty.