THR: Posterolateral Approach

  
- See: Total Hip Replacement Menu:

- PreOp:
    - Theory and Background:
    - Checklist for THR: and  Radiographs:

 

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 - Initial Exposure:
    - positioning, prepping and antibiotics:  
    - posterolateral skin incision: 
    - incise thru iliotibial band:
    - split gluteus maximus: 
           - The course of the superior gluteal nerve in the lateral approach to the hip; 
    - identify the sciatic nerve 
    - measure leg lengths:
    - external rotators and the posterior capsule 
    - hip dislocation: technique:   
    - references:
          - Surgical approaches for primary THR. A prospective comparison of the Marcy modification of the Gibson and Watson-Jones approaches.
          - The trochanteric approach to the hip for prosthetic replacement.
          - The direct lateral approach to the hip for arthroplasty. Advantages and complications.
          - Comparison of heterotopic bone after anterolateral, transtrochanteric, and posterior approaches for total hip arthroplasty.
          - The transgluteal approach to the hip joint.    R Bauer et al.  Arch Orthop Trauma Surg. Vol 95. 1979 p 47-49.
          - Comparison of the transtrochanteric and posterior approaches for THR. RP Robinson et al.  CORR. Vol 147. p 143-147. 1980. 
          - Comparison of complications after transtrochanteric and posterolateral approaches for primary total hip arthroplasty. 
          - Comparison of Primary Total Hip Replacements Performed with a Standard Incision or a Mini-Incision. 

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- Femoral Preparation:
    - femoral neck resection:
    - entry into femoral medullary canal:
    - femoral reaming:
    - broaching:
          - femoral broaching for press fit stems:

- Acetabulum:
    - acetabular exposure and preparation for reaming:
    - acetabular reaming:
    - acetabular cup insertion:
          - acetabular cup position:
          - screw insertion: 
    

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 - Femoral Stem Insertion:
    - insertion of cementless femoral stem:
    - insertion of cemented femoral stem: (cementing: preparation and technique):
    - trial reduction:

- Wound Closure: 

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- Post Operative Care: 
    - anesthesia
           - Continuous Lumbar Plexus Block for Postoperative Pain Control After Total Hip Arthroplasty
    - exam:
           - evaluate vascular and neurological status of both legs;
           - assess leg lengths (based on level of malleoli) to r/o dislocation; 
           - ref: Hypoxemia After Total Joint Arthroplasty: A Problem on the Rise
    - deep venous thrombosis
    - postop radiographs:
           - following THR in RR, x-rays must include the entire stem in two planes;
           - ap view: may reveal cement outside the cortex;
           - lateral view: may show the stem penetration of the cortex;
    - hip precautions:
           - patients need to hip limit flexion to 90 deg;
           - patients will require and elevated toilet seat, and instruments to help with putting on shoes and socks;
           - it is unclear whether patients need restricted wt bearing (see forces acting on hip joint); 
           - references:
                   - Hip revision with impacted morselized allografts: unrestricted wt-bearing and restricted wt-bearing have similar effect on migration.
                   - Implant migration after early weightbearing in cementless hip replacement. 
    - postoperative dressing: 
           - modified vaccum assisted closure: 
                   - dramatic reduction of post op wound drainage can be obtained by applying gauze-fenestrated drain-gauze dressing covered by tegaderm which
                             is then hooked up to wall suction;
                   - references:
                             - Simplified wound care and earlier wound recovery without closed suction drainage in elective THR. A prospective randomized trial in 100 operations 
                             - Blood loss after total hip replacement: a prospective randomized study between wound compression and drainage.
                             - Wound complications after hip surgery using a tapeless compressive support
                             - Suction dressings: a new surgical dressing technique.
                             - Suction dressings in total knee arthroplasty--an alternative to deep suction drainage.
                             - External suction drainage in primary total joint arthroplasties.  (full text article)
                             - Incisional Vacuum-Assisted Closure Therapy
                             - Continuous high vacuum and primary skin closure in sternotomy wound infection 
                             - Role of Vacuum Assisted Closure (VAC) Device in Postoperative Management of Pelvic and Acetabular Fractures
                             - Incisional Wound Vac in Obese Patients
                             - Wound oozing after total hip arthroplasty.
                             - Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty.   
                             - Is a fat stitch required when closing a hip hemiarthroplasty wound without a drain? 
                             - Blood loss after total hip replacement: a prospective randomized study between wound compression and drainage.
                             - Wound complications after hip surgery using a tapeless compressive support.

    - references: 
                   - The Role of Blood Cultures in the Acute Evaluation of Postoperative Fever in Arthroplasty Patients
                   - Urinary-Bladder Management After Total Joint-Replacement Surgery. 
                   - Factors Associated with Prolonged Wound Drainage After Primary Total Hip and Knee Arthroplasty.
                   - Postoperative Ileus After Total Joint Arthroplasty
                   - Febrile response after knee and hip arthroplasty.   
                   

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Total Joint Arthroplasty: When Do Fatal or Near-Fatal Complications Occur?.

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