Ins and Outs of Total Hip

Replacements

Antonia F. Chen, MD/MBA

Director of Research, Arthroplasty Services
Orthopaedic Surgeon
Brigham and Women’s Hospital
Harvard Medical School
Hip Replacement
 Satisfaction

87-90%
satisfied
Mancuso et al. JBJS. 2009
Sep;91(9):2073-8.
Outline
• Indications for surgery
• Surgical approach
• Implant choices
• Perioperative pain protocol
• DVT prophylaxis
• Discharge instructions
Surgical Indications
• Persistent pain
• Limp
• Assistive walking devices
• Distance to ambulate
• Sitting
• Stiffness
• Affect activities of daily living
• Quality of life
 AAOS guidelines – OA hip
• Conservative therapy
– NSAIDs
– Cortisone injection
– Physical therapy
– Weight loss
• Not recommended
– Glucosamine
– Intraarticular hyaluronic acid
– Opioids
 Surgical Indication
• History and Physical Exam
– Duration of symptoms
– Limitation of daily activity
– Exhausted conservative therapy
• Imaging
– Radiographs
– MRI only necessary for Avascular Necrosis, NOT
for osteoarthritis
Poor Candidates for Surgery
Diabetes
• Surgical stress antagonizes insulin
– Predisposes patients to hyperglycemia
– Impairs ability of leukocytes to stop infection
– Hyperglycemia predisposes diabetic and
nondiabetic patients to infection (Richards JBJS 2012,
Stryker JBJS 2013)
Diabetes
Hemoglobin A1C
7.7%

GOALS:
HgbA1C < 7%
Maintain Glucose < 200
Poor Candidates for Surgery
Abdel et al. J Arthroplasty. 2014 Jul;29(7):1430-4.
Parvizi et al. CORR. 2014 Mar;472(3):903-12.

•  Operative time
•  Blood loss
•  Blood transfusions
•  DVT/PE
•  UTI, Pneumonia
•  Infections
• Malnutrition
 Patient Selection
- Strict BMI criteria (< 40 kg/m2)
- Require Preoperative Weight Reduction
- Nutritionist consult

Inacio et al. JOA. 2014

Anticoagulation prior to surgery
• CONTINUE NSAIDs
Medication Stop prior to surgery Restart after surgery
Plavix 5-7 days (depending on ASA 325 PO BID for 1
cardiologist) week, then restart Plavix
Pradaxa 5 days (3 days if < 65yo with normal 24hrs after surgery
kidney function)
Coumadin (Warfarin) 5 days (INR on the day of surgery), 24hrs after surgery
5mg evening prior to surgery
Fondaparinux (Arixtra) 4 days 24hrs after surgery

Xarelto (Rivaroxaban) 3 days 24hrs after surgery

Eliquis (Apixaban) 3 days 24hrs after surgery
Savaysa (Edoxaban) 3 days 24hrs after surgery
Bevyxxa (Betrixaban) 3 days 24hrs after surgery
LMWH (Lovenox) 24 hours 24hrs after surgery
 Surgical Approaches
• Direct Lateral
• Direct Anterior
• Posterior
• Anterior Muscle Based
Sparing approach
 Direct Lateral
• Other name: Modified
Hardinge approach
• Pros: good exposure,
uncommon dislocation
• Cons: abductor muscle
split – temporary limp
 Direct Anterior

• Other name: Modified Smith-Petersen

• Pros: more rapid initial recovery, no damage to the
abductor muscles
• Cons: anterior thigh numbness, potential damage to
the femoral nerve, increased bleeding
 Posterior
• Other name: Moore
or Southern approach
• Pros: good exposure,
no damage to the
abductor muscles
• Cons: increased
dislocation rate,
potential damage to
the sciatic nerve
Anterior Muscle Based Sparing approach

• Other name: Modified Watson-Jones

• Pros: more rapid initial recovery, no damage to the
abductor muscles
• Cons: anterior thigh numbness, potentially smaller
exposure
Removal of femoral head /
Femoral neck cut
Acetabular preparation
Femoral preparation
Completed hip replacement
Bearing Surfaces
 POLYETHYLENE
Implant choices - Not crosslinked
- Highly crosslinked
- Sterilization process
- Remelting
- Vitamin E

HEAD
- Metal
- Ceramic
- Oxinium

STEM
- Metaphyseal wedge
- Fit and fill
- Location of coating
- Short versus long
Implant choices
 Perioperative pain protocol

• Oral pain regimen

– Tylenol
– Pregabalin
– Celecoxib
– Ketorolac
– Narcotics as needed
• Intraarticular injection – variable
Discharge Instructions

• Home
• Weight bearing status
• Hip precautions (2-4 weeks)
– Posterior: Flexion, Adduction,
Internal rotation
– Anterior: Extension, Adduction,
External rotation
• Remove dressing after 7 days
DVT Prophylaxis

325 mg BID vs 81mg BID

3 weeks
DVT Prophylaxis
DVT Prophylaxis
• Everyone: once-daily oral rivaroxaban (10 mg)
until POD 5, randomly assigned to continue
rivaroxaban or switch to aspirin (81 mg daily)
– 9 days after total knee arthroplasty
– 30 days after total hip arthroplasty
• 90 day Endpoints: symptomatic venous
thromboembolism and bleeding complications
• 3424 patients  NO DIFFERENCE
LMWH vs Direct Oral Anticoag

• Direct Oral Anticoagulation agents = Lower VTE

• Potentially higher bleeding risk
Potential Complications - Intraoperative
• Bleeding
• Fracture
– Acetabulum
– Femur
Potential Complications - Postoperative
• Wound problems
• Dislocation
• Limb length discrepancy
• Periprosthetic fracture
• DVT/PE
• Periprosthetic joint infection
• Implant wear
• Implant failure
How long should a hip implant last?

• Δ Ceramic/X3
• 8mm Poly
• 0.04mm Linear Wear

200 Years!
Femoral Neck Fracture
• Total hip arthroplasty versus Hemiarthroplasty
 Patient considerations
• Age
• Comorbidities
– Parkinson’s
– Alcoholism
• Baseline ambulation
– Community versus
Household ambulator
– Assistive walking devices
• Expectations
 Conclusions
• Very successful procedure
• Ensure good patient selection
• Surgeon dependent surgical approach
• Any implants
• Oral pain protocol
• Not overaggressive DVT prophylaxis
• Discharge appropriately
• Monitor for complications
Thank You