CHAPTER 33 Revision Total Hip Arthroplasty Preoperative Planning John Manfredi, William J. Hozack CHAPTER OUTLINE History and Physical Examination 256 Radiographic Evaluation 257 Classification of Bone Deficiencies 258 Templating 258 Ordering Equipment and Parts 260 Summary 260 Revision total hip arthroplasty is a complex and demanding surgical procedure with an increased risk of perioperative complications and is frequently associated with unexpected intraoperative surgical findings. Preoperative planning is arguably the most critical part of the operative procedure. Preoperative planning should begin with taking a thorough patient history, performing a thorough physical examination, conducting appropriate radiographic evaluation, assessing bony deficiencies, performing accurate templating with the planned surgical components, and preparing for alternative methods of reconstruction. Thorough preoperative planning will help to identify most potential problems for any given patient, avoid intraoperative complications, minimize operative time, and optimize the clinical outcome. HISTORY AND PHYSICAL EXAMINATION The first step in planning for any surgical procedure is the taking of a detailed history and the performance of the physical examination. An accurate diagnosis cannot reliably be established without details about the patient’s history, review of symptoms, and physical examination findings. The history should begin with obtaining details of and hospital records from all prior surgical procedures and perioperative treatments. These records should contain information regarding implanted materials from previous operative notes. It is extremely helpful and efficient to request that the patient present these surgical records on his or her initial visit in order to provide the surgeon with valuable information regarding the prior procedure and the implants used. Initial history taking should begin with a discussion about the patient’s chief complaint. The location and nature of the patient’s pain can guide the surgeon to the proper diagnosis. Acetabular component loosening is often associated with groin pain, whereas startup pain (rising from a seated position) localized to the thigh is more indicative of femoral component loosening. Subluxation or dislocation may be indicated by a complaint of a sensation of hip “clicking” or “popping” rather than by a history of a documented frank dislocation. A thorough review of the patient’s medical history, along with a complete review of systems, will help the surgeon to identify any potential factors that may lead to perioperative complications and will allow the surgeon an opportunity to medically treat the patient or to optimize the patient’s condition before the planned operation. The cardiac and pulmonary history is of utmost importance, along with any history of thromboembolic disorders or endocrine abnormalities such as diabetes mellitus. Furthermore, sources of potential or concurrent infection need to be discovered, and proper evaluation and treatment should be performed well in advance of the surgical procedure. Studies have confirmed that the rate of postoperative deep infection is influenced by advanced age, obesity, metabolic disease, steroid therapy, depressed immune status, rheumatoid disease, previous hip surgery, and prolonged preoperative hospitalization. Men with prostate disease and women with recurrent urinary tract infections should be referred to a urologist in the preoperative period. Dental caries are also a potential source of infection, and a preoperative dental examination is helpful to avoid any potential seeding of the involved surgical site. A history of delayed wound healing, persistent drainage, and prolonged use of postoperative antibiotics should alert the surgeon to be suspicious for infection. If infection is suspected, routine laboratory testing should be ordered and should include a complete blood count (CBC) with differential, sedimentation rate, and a C-reactive protein level, along with a hip aspiration. It is important to note that negative hip aspirations do not completely rule out infection and should be followed by intraoperative tissue sampling with frozen sections; the appropriate pathology department personnel must be alerted before the planned surgical date. Patients with any history of chronic venous stasis ulcers, previous vascular bypass surgery, or absent distal pulses should be evaluated by a vascular surgeon. Patients with a history of cardiac bypass surgery, angioplasty, or coronary artery stenting should be evaluated by a cardiologist well in advance of the planned surgical date so that the need for any preoperative testing may be determined and so that the anesthesiologist may be alerted about any specific perioperative needs or postoperative intensive care monitoring requirements. The physical examination is an invaluable resource that should be used to confirm any impressions made during the collection of the patient’s history. The physical examination findings give the surgeon a baseline for the postoperative evaluation. The physical examination should begin with the analysis of the patient’s gait. Use of ambulatory assistive devices, presence of a limp, or presence of a deformity of the lower extremity should be noted. The antalgic gait is a result of pain in all phases of ambulation with weight bearing and is characterized by a shortened stance phase indicating hip-joint disease. The Trendelenburg gait or abductor lurch indicates either paralysis or loss of continuity of the abductor musculature and is identified by observing the shift of the patient’s center of gravity over the affected extremity during the stance phase of gait. Weakness of the gluteus maximus creates the characteristic extensor lurch gait, which occurs by the shifting of the weight of the thorax posteriorly during hip extension. Quadriceps weakness prevents full knee extension at heel strike, and a foot drop is usually present with tibialis anterior weakness. Inspection of previous surgical wounds should be routinely performed. Planning of the surgical incision is important in determining the approach for the surgical reconstruction, and although skin flap necrosis after hip surgery is rare, the maximum distance and angles used should be optimal to avoid this complication. Limb length measurements should be obtained in order to allow possible surgical correction during the revision procedure. We measure the medial malleoli, clinically a more useful measurement. It is important to properly inform the patient that stability is a priority over leg length equality and that all measurements will be taken to re-create leg length equality if possible. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: The Cementless Tapered Stem Femoroacetabular Osteoplasty Reconstruction of Acetabular Bone Deficiencies Using the Antiprotrusio Cage The Cemented Stem Revision Total Hip Replacement The Cemented Stem Stay updated, free articles. 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CHAPTER 33 Revision Total Hip Arthroplasty Preoperative Planning John Manfredi, William J. Hozack CHAPTER OUTLINE History and Physical Examination 256 Radiographic Evaluation 257 Classification of Bone Deficiencies 258 Templating 258 Ordering Equipment and Parts 260 Summary 260 Revision total hip arthroplasty is a complex and demanding surgical procedure with an increased risk of perioperative complications and is frequently associated with unexpected intraoperative surgical findings. Preoperative planning is arguably the most critical part of the operative procedure. Preoperative planning should begin with taking a thorough patient history, performing a thorough physical examination, conducting appropriate radiographic evaluation, assessing bony deficiencies, performing accurate templating with the planned surgical components, and preparing for alternative methods of reconstruction. Thorough preoperative planning will help to identify most potential problems for any given patient, avoid intraoperative complications, minimize operative time, and optimize the clinical outcome. HISTORY AND PHYSICAL EXAMINATION The first step in planning for any surgical procedure is the taking of a detailed history and the performance of the physical examination. An accurate diagnosis cannot reliably be established without details about the patient’s history, review of symptoms, and physical examination findings. The history should begin with obtaining details of and hospital records from all prior surgical procedures and perioperative treatments. These records should contain information regarding implanted materials from previous operative notes. It is extremely helpful and efficient to request that the patient present these surgical records on his or her initial visit in order to provide the surgeon with valuable information regarding the prior procedure and the implants used. Initial history taking should begin with a discussion about the patient’s chief complaint. The location and nature of the patient’s pain can guide the surgeon to the proper diagnosis. Acetabular component loosening is often associated with groin pain, whereas startup pain (rising from a seated position) localized to the thigh is more indicative of femoral component loosening. Subluxation or dislocation may be indicated by a complaint of a sensation of hip “clicking” or “popping” rather than by a history of a documented frank dislocation. A thorough review of the patient’s medical history, along with a complete review of systems, will help the surgeon to identify any potential factors that may lead to perioperative complications and will allow the surgeon an opportunity to medically treat the patient or to optimize the patient’s condition before the planned operation. The cardiac and pulmonary history is of utmost importance, along with any history of thromboembolic disorders or endocrine abnormalities such as diabetes mellitus. Furthermore, sources of potential or concurrent infection need to be discovered, and proper evaluation and treatment should be performed well in advance of the surgical procedure. Studies have confirmed that the rate of postoperative deep infection is influenced by advanced age, obesity, metabolic disease, steroid therapy, depressed immune status, rheumatoid disease, previous hip surgery, and prolonged preoperative hospitalization. Men with prostate disease and women with recurrent urinary tract infections should be referred to a urologist in the preoperative period. Dental caries are also a potential source of infection, and a preoperative dental examination is helpful to avoid any potential seeding of the involved surgical site. A history of delayed wound healing, persistent drainage, and prolonged use of postoperative antibiotics should alert the surgeon to be suspicious for infection. If infection is suspected, routine laboratory testing should be ordered and should include a complete blood count (CBC) with differential, sedimentation rate, and a C-reactive protein level, along with a hip aspiration. It is important to note that negative hip aspirations do not completely rule out infection and should be followed by intraoperative tissue sampling with frozen sections; the appropriate pathology department personnel must be alerted before the planned surgical date. Patients with any history of chronic venous stasis ulcers, previous vascular bypass surgery, or absent distal pulses should be evaluated by a vascular surgeon. Patients with a history of cardiac bypass surgery, angioplasty, or coronary artery stenting should be evaluated by a cardiologist well in advance of the planned surgical date so that the need for any preoperative testing may be determined and so that the anesthesiologist may be alerted about any specific perioperative needs or postoperative intensive care monitoring requirements. The physical examination is an invaluable resource that should be used to confirm any impressions made during the collection of the patient’s history. The physical examination findings give the surgeon a baseline for the postoperative evaluation. The physical examination should begin with the analysis of the patient’s gait. Use of ambulatory assistive devices, presence of a limp, or presence of a deformity of the lower extremity should be noted. The antalgic gait is a result of pain in all phases of ambulation with weight bearing and is characterized by a shortened stance phase indicating hip-joint disease. The Trendelenburg gait or abductor lurch indicates either paralysis or loss of continuity of the abductor musculature and is identified by observing the shift of the patient’s center of gravity over the affected extremity during the stance phase of gait. Weakness of the gluteus maximus creates the characteristic extensor lurch gait, which occurs by the shifting of the weight of the thorax posteriorly during hip extension. Quadriceps weakness prevents full knee extension at heel strike, and a foot drop is usually present with tibialis anterior weakness. Inspection of previous surgical wounds should be routinely performed. Planning of the surgical incision is important in determining the approach for the surgical reconstruction, and although skin flap necrosis after hip surgery is rare, the maximum distance and angles used should be optimal to avoid this complication. Limb length measurements should be obtained in order to allow possible surgical correction during the revision procedure. We measure the medial malleoli, clinically a more useful measurement. It is important to properly inform the patient that stability is a priority over leg length equality and that all measurements will be taken to re-create leg length equality if possible. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: The Cementless Tapered Stem Femoroacetabular Osteoplasty Reconstruction of Acetabular Bone Deficiencies Using the Antiprotrusio Cage The Cemented Stem Revision Total Hip Replacement The Cemented Stem Stay updated, free articles. Join our Telegram channel Join Tags: Replacement, Surgical Treatment of Hip Arthritis Reconstruction Mar 10, 2016 | Posted by admin in Reconstructive surgery | Comments Off on Revision Total Hip Arthroplasty Full access? Get Clinical Tree
