Background

 

Hybrid THA

 

Indications

 

Disabling hip pain

Severe functional impairment

Failure non operative management

 

Etiology

 

Primary OA: 50%

Secondary OA: 50%

 

Secondary OA                                                        

 

Bilateral SUFEHip OA Perthes 2

SUFE                                                                                Perthes                                                                       

 

DDH Crowe 1Hip OA Coxa Vara 2

DDH                                                    Protrusio

 

Hip OA post Acetabular FractureHip OA post displaced Acetabular FractureHip OA Post NOF Fracture

Trauma       

                                                                                                                    

PagetsHIp OA Bilateral AVN

Paget's                                                                                           AVN     

                                                                                                                                                

Hip OA Post Sepsis

Sepsis

 

FAI OAFAI OA

FAI

 

Contraindications

 

Absolute

 

Active infection

Charcot

Flail / Neuromuscular impairment

Inadequate soft tissue cover

 

Relative

 

Young patient

Heavy demand

Obese

Poor compliance

Poor mental state

 

Complications

 

Informed consent

 

Infection

Dislocation

Intra-operative fracture

Bleeding / transfusion

Nerve injury

Vascular injury

Leg length discrepancy

DVT / PE

Heterotopic ossification

Loosening / revision

 

Issues

 

Simultaneous versus staged bilateral THA

Outpatient surgery

Infection prevention

TXA

Drains

Closure

DVT prophylaxis

Hip precautions

 

One- versus two-stage bilateral THA

 

Ramezani et al J Orthop Surg Res 2022

- meta-analysis

- 30,000 one stage bilateral THA

- 75,000 two stage bilateral THA

- one stage had lower DVT, complications, cost, hospital stay

- one stage had higher PE, and periprosthetic fracture

 

Shao et al J Arthroplasty 2017

- meta-analysis

- one stage bilateral lower major complications, DVT, hospital stay

- no difference in PE or cardiovascular complications

 

Partridge et al Arthroplasty 2020

- National database of 14,500 patients

- one stage bilateral THA increased PE, MI, renal failure, chest infection, and in-hospital death

- shorter hospital stay for one stage

 

Outpatient surgery

 

Goyal et al CORR 2017

- RCT of 220 patients

- < 75, no walker, no opioids, BMI < 40

- direct anterior under spinal

- 85/112 (76%) outpatient group discharged same day, 26/27 after 1 day

- 81/108 (75%) inpatient group discharged after overnight stay, 18/108 went home same day

- increased VAS pain scores first day with outpatient group

- no difference in complications, readmissions, emergency visits

 

Infection prevention

 

Antibiotics

 

Badge et al Bone Jt Open 2022

- prospective study of 2000 patients

- cephalosporin prior to skin incision lowers infection rate

 

Surgical helmet systems

 

Rahardja et al J Arthroplasty 2022

- 19,000 TKA

- surgical helmet use reduced risk of infection

 

Antibiotic impregnated bone cement

 

Zhang et al Medicine 2019

- systematic review of 10 studies and 14,000 patients

- antibiotic-impregnated cement decreased deep infection rates

 

Dilute Povidone-Iodine irrigation

 

Shohat et al J Arthroplasty 2022

- database of 31,000 cases of total joint arthroplasty

- irrigation with dilute povidone-iodine reduced infection rate compared with saline

 

Ebrahimzadeh et al BMC Musculoskeletal Disorder 2023

- systematic review of 13 studies and 64,000 total joint arthroplasty

- iodine irrigation reduces infection compared with saline

 

Vancomycin powder

 

Peng et al Orthop Traumatol Surg Res 2021

- systematic review of 9 studies and 4500 total joint arthroplasty

- vancomycin powder reduced rate of infection

 

Tranexamic acid (TXA)

 

TXA

 

Zhu et al Medicine 2017

- meta-analysis of 25 RCTs in THA

- TXA reduced blood loss, transfusion, and hospital stay

- no increase in DVT

 

IV versus topical TXA

 

Zhang et al Medicine 2016

- meta-analysis of 7 RCTs

- IV versus topical TXA

- no difference in blood loss, transfusion, and hospital stay

 

IV TXA versus IV + topical TXA

 

Zhang et al Medicine 2017

- meta-analysis of IV TXA versus IV TXA + topical TXA in THA

- IV + topical TXA superior in reducing blood loss and transfusion

 

Closed suction drains

 

Chen et al Eur J Orthop Surg Rehab 2014

- meta-analysis of 16 RCTs and 1600 patients undergoing THA

- drain versus no drains

- no difference in hematoma, infections

- increased transfusion with drains

 

Sutures versus staples

 

Liu et al J Orthop Surg Res 2021

- systematic review of 5 RCTs

- staples versus sutures

- increased superficial infection and prolonged discharge with staples

- increased time with sutures

 

DVT prophylaxis

 

Aspirin versus enoxeparin

 

CRISTAL study group JAMA 2022

- RCT of 100 mg of aspirin or 40 mg enoxeparin after THA / TKA
- 9000 patients

- 35 days in THA, 2 weeks TKA

- symptomatic VTE in aspirin group 3.5%

- symptomatic VTE in enoxeparin group 1.8% (p=0.007)

 

Sidhu et al CORR 2023

- subanalysis of CRISTAL study

- no increased wound drainage with enoxeparin (9%) versus aspirin (8%) with staple closure

- ? increased wound drainage with enoxeparin and subcuticular closure

- no increased reoperation rate

 

Rivaroxaban

 

Anderson et al N Eng J Med 2018

- RCT of 3500 patients undergoing THA / TKA

- 5 days of xarelto

- either xarelto or aspirin 81mg for 30 days THA / 9 days TKA

- VTE in 0.6% aspirin and 0.7% xarelto

 

Hip precautions

 

Korfitsen et al Acta Orthop 2023

- systematic review of 8,800 patients

- no evidence that hip precautions (flexion / adduction / internal rotation) decrease dislocation rates