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total hip arthroplasty/replacement (THA, THR)

This includes replacement of the head of the femur & the acetabulum. Also see hemiarthroplasty of hip. Classification: 1) metal-on-polyethylene implant (traditional) (metal femoral heads with polyethylene cups) result in 2) metal-on-metal implant (newer) [10]; out of favor [15] 3) ceramic-on-ceramic implants (newer) [10] Indications: - end-stage hip osteoarthritis - radiographic evidence of moderate-to-severe hip osteoarthritis [53] - moderate-to-severe pain, loss of function, or both [53] - no improvement with physical therapy or joint injection [53] - osteonecrosis of the femoral head - hip fracture - femoroacetabular impingement [38] * better option than hemiarthroplasty of hip for healthier potentially more mobile patients due to better walking ability & quality of life [44] * elective total hip arthroplasty has not been compared with nonsurgical management in randomized trials [46] * recommendations from [53] conditional, not strong Contraindications: - morbid obesity does NOT seem to be contraindication [7] - obesity regardless of BMI not a contraindication [53] - delay for poorly-controlled diabetes mellitus, but HgbA1c requirements are not defined [53] - delay for trial of smoking cessation [53] * recommendations from [53] conditional, not strong Complications: 1) hip movements that may lead to posterior dislocation: a) flexion b) adduction (most important) c) internal rotation past the neutral point 2) pneumonia 3) pressure ulcers 4) constipation 5) delirium (40%) [4] - poor preoperative performance on Mini-Cog test predicts postoperative delirium [33] - no difference in the rate of cognitive decline in individuals with vs without joint arthroplasty until 80 years of age [50] - no difference in the rate of memory decline in individuals with vs without joint arthroplasty at 3 & 5 years [55] 6) deep vein thrombosis a) 20% after unilateral THA, 60% of these proximal DVT [2] b) complete resolution of DVT in 6 months WITHOUT anticoagulation [2] c) NO pulmonary embolism WITHOUT anticoagulation [2] 7) peripheral nerve injuries 8) prosthesis infection 9) loosening of hardware 10) mean total blood loss 1500 mL of which 470 mL is hidden mean drop in hemoglobin is 3 g/dL [3] 11) ectopic bone formation in surrounding tissue [6] 12) metal-on-metal hip implants are not associated with an increased risk for cancer [13] 13) increased risk of myocardial infarction (25-fold at 2 weeks, returning to basline at 6 weeks) [16,28] 14) risk for revision: 10-year implant survival is 96%; 20-year implant survival is 85% [30] 15) overlapping surgery associated with an increased risk for surgical complications - increasing duration of operative overlap associated with an increasing risk for complications [34] 16) 30 day major postoperative complication rate is 5.0% [37] - if BMI >= 40 kg/m2 postoperative complication rate is 6.7% - 14 obese patients would need to be denied surgery to prevent 1 30-day major complication [37] 17) complications slightly more common with an anterior than with a lateral or posterior approach [43] Management: 1) general - do not delay for trials of physical therapy, NSAIDs, bracing, intra-articular glucocorticoid injections, or hyaluronic acid injections (conditional recommendation) [53] - frailty assessment [52] - routine placement of indwelling urinary catheter is unnecessary when patients undergo total hip replacement under spinal anesthesia [21] - perioperative antibiotic prophylaxis with cefazolin monotherapy - anticoagulation for 2-4 weeks, 4-5 weeks [5] - see prophylaxis for venous thromboembolism - ted hose & pneumatic compression device until ambulatory - enoxaparin 40 mg SQ QD - Active Care + SFT may be alternative to enoxaparin - advantage of warfarin or LMW heparin, compared with aspirin or mechanical prophylaxis not obvious [8] - LMW heparin for 10 days plus aspirin for 28 days as good as LMW heparin for 38 days [20] - rivaroxaban 10 mg QD for 14 days [36] - rivaroxaban 10 mg QD for 5 days followed by aspirin 81 mg QD for 9 days as effective as rivaroxaban for 14 days [36] - rivaroxaban for 38 days may be better - aspirin associated with lower 30-day mortality than other agents [41] - no difference in symptomatic pulmonary embolism or symptomatic proximal DVT, incidence of serious bleeding or death for enoxaparin 40 mg QD vs aspirin 100 mg QD for 35 days [48] - small difference in distal (below knee) DVT favoring enoxaparin - if prosthesis is cemented in place, immediate weight-bearing as tolerated - non-cemented components rely on ingrowth of bone for stabilization of joint; limit weight-bearing for 6 weeks - active assisted range-of-motion exercises immediately postoperative - delay full range of motion exercises to prevent dislocation - muscle stengthening, resistive exercises 6-8 weeks postoperatively - out of bed on 1st post-operative day - ambulation with physical therapy assistance on 2nd post-operative day - bisphosphonate use is associated with a lower rate of revision after hip arthroplasty & knee arthroplasty & longer implant survival [9] - threshold for urinary catheterization of 800 mL rather than 500 mL may prevent unnecessary catheterization [29] 2) anesthesia & analgesia - regional anesthesia relative to general anesthesia is associated with: [27] - fewer surgical site infections (3 per 1000) - fewer cardiovascular complications (5 per 1000) - fewer respiratory complications (4 per 1000) - fewer prolonged hospital stays (5% vs 7% for >= 7 days) - no difference in 30 day mortality [27] - spinal anesthesia associated with less pain, less opioid use & fewer intensive care unit admissions than general anesthesia [49] - transcutaneous electrical acupoint stimulation significantly reduces pain & improves cognitive function in patients undergoing hip replacement surgery [56] - acetaminophen 1000 mg + ibuprofen 400 mg 1 hour before surgery & every 6 hours afterward for 24 hours reduces need for PRN morphine [39] - acetaminophen 1000 mg + ibuprofen 400 mg TID & dexamethasone 24 mg QD superior to acetaminophen + ibuprofen [54] - morphine 15-24 mg for breakthrough pain - perioperative gabapentinoids associated with excess pulmonary complications & do not spare opioid use [42] 3) posterior approach - adduction splint placed between the legs when the patient is in bed if patient unable to comply with positioning instructions - a raised toilet seat to minimize hip flexion - limit time in a seated position to no more than 30 minutes at a time to prevent hip dislocation & joint flexion contracture 4) Goals of rehabilitation: - maintain full joint range of motion - prevent joint contracture - strengthen periarticular musculature - restore gait - prevent dislocation of artificial joint - unsupervised home exercises are as effective as formal post-hospitalization physical therapy for selected patients with good home support [31] 5) exercise interventions: - supervised preoperative & postoperative exercise interventions not associated with improved self-reported physical function [45] - preoperative exercise for obese patients can improve postoperative functional mobility & increase the likelihood of discharge home [25] 6) patients with rheumatic diseases - DMARDs methotrexate, leflunomide, hydroxychloroquine, sulfasalazine may be continued during the perioperative period [32] - biologics (adalimumab, etanercept ..) - withhold for one dosing schedule before elective surgery - resume with evidence of wound healing (minimum of 14 days) - no increase in infections when infliximab given within 4 weeks of hip replacement or knee replacement [35] 7) metformin reduces need for THA/THR 30% in patients with type 2 diabetes [51] 8) RED FLAGS - sudden or steady increase in pain - infection - loosening of hardware Notes: 1) revision arthroplasty higher for newer metal on metal & ceramic-on-ceramic implants than traditional metal-on-polyethylene implants [10] 2) failure rates for the metal on metal implants, especially among women are > 10% [11]; 6% [12] 3) cobalt-chromium surfaces of metal-metal implants can wear down, leading to the release of Co+2 at levels in excess of workplace-exposure limits of 5.0 ug/L in the blood [11] 4) metal-on-metal implants with 5-year failure rates resulting in revision rate 3-fold higher than other bearing types, ~ 6% vs 2% - larger metal-on-metal head sizes were most prone to failure [12] 5) ceramic-on-ceramic prostheses have better performance with larger head size [12] 6) women & obese most at risk for metal-on-metal implant failure [15] 7) ~8% of hip arthroplasties in the U.K. performed using new devices without evidence of effectiveness [22] 8) ceramic-on-ceramic bearings, modular femoral necks, & high-flexion implants associated with higher rates of revision [26] 9) 89%, 70%, & 58% of total hip replacements lasted 15, 20, & 25 years, respectively [40]

Related

hemiarthroplasty of hip prophylaxis for venous thromboembolism (VTE)

General

arthroplasty

References

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