• whether the pain is sufficient to justify a major elective
• 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
• Is the patient’s general condition good enough to
tolerate a major operation, during which a significant
amount of blood may be lost?
• Comorbidities known to be inherent to elderly patients
should be considered
• cardiopulmonary disease
• A thorough general medical evaluation, including
• 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
• 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
• 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).
• 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
●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
●Venous thromboembolism (VTE) within the previous 12 weeks
●Recent coronary stenting
●Previous thromboembolism during interruption of chronic
• 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
• ●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
• Pyogenic skin lesions should be eradicated.
• Urinary retention due to prostatic or bladder disease
and dental problems should be addressed before
• 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
• if bone has been resorbed around an internal fixation device.
• 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
• 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.
• The lengths of the lower extremities
should be compared, and any fixed deformity should be
• Adduction contracture of the hip
• produce apparent shortening of the limb despite equally measured leg
• 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
• When the hip and the knee are both severely arthritic:
• the hip should be operated on first.
• Hip arthroplasty may alter knee alignment and
• knee arthroplasty is technically more difficult when the
hip is stiff, and rehabilitation would be hampered.
• 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
• Arthritic pain usually is worse with activity and
improves to some degree with rest and limited weight
• 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
• 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
• 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
• Pain, ability to walk, function, mobility, and radiographic
changes are recorded.
• As yet, no particular hip rating system has been uniformly
• The Harris system is the most frequently used
• 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.
• 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
• More intensive intraoperative monitoring, including an
arterial line, pulmonary artery catheter, and urinary
catheter, is recommended.
• 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
• 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
• 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.
• 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
• If excessive bowing or a rotational deformity is present, femoral
osteotomy may be required before or in addition to the