International tips and pearls offered for performing a total hip arthroplasty

The following panel discussion was taken directly from the podium at the Current Concepts in Joint Replacement 25th Annual Winter meeting in December 2008. The goal is to consider the key decisions that surgeons make when performing a standard primary hip replacement.

We have four excellent panelists and our aim is to get a snapshot of what they are doing at the present time. We will highlight areas where there is consensus as well as areas where there is a diversity of approach. These participants represent three countries on two continents and they provide an outstanding discussion.

Daniel J. Berry, MD
Moderator

Daniel J. Berry, MD: What is your standard procedure for preoperative blood management? Do you do autologous blood donation, erythropoietin, or none of these?

Edwin P. Su, MD: I tell the patients about the risk of bleeding and give them the option to donate one pint of autologous blood, but I do not routinely mandate that. Most of the time patients opt to do this.

Arun B. Mullaji, MD, FRCS (Ed), MS: I do none of the things that you mentioned. I use blood only when it is really needed. For most primaries, we do not use blood.

Keith R. Berend, MD: We do not do any of the things that you mention.

Michael J. Dunbar, MD, FRCSC, PhD: I do none of the things you mentioned, with the exception of erythropoietin if the patient has low hemoglobin preoperatively.

Berry: In terms of antibiotics, what do you do if a patient is allergic to penicillin?

Dunbar: I prefer vancomycin, but if we don’t have time, because it takes an hour to infuse it, I use clindamycin. If vancomycin was started, I make sure the entire dose is administered before I begin surgery.

Berend: We prefer vancomycin if we have the time, if not we give clindamycin. I give patients with either a family history of Methicillin-resistant Staphylococcus aureus (MRSA) or patients who work in the health care industry vancomycin, if they are penicillin allergic.

Mullaji: If the patient is penicillin allergic, then I give them vancomycin an hour in advance.

Su: We usually use a first generation cephalosporin. Our anesthesiologists are pretty liberal and will give a test-dose even if there is a history of a non-anaphylactic type penicillin allergy. If the patient is truly penicillin allergic, I will use vancomycin.

Berry: What is your preferred anesthetic?

Su: I use a combined spinal-epidural.

Mullaji: For a straightforward THA: spinal; for others a combined spinal epidural.

Berend: I use a spinal with an intrathecal narcotic.

Dunbar: I use a spinal.

Berry: Does anyone medicate patients preoperatively with long-acting oral medications to reduce postoperative pain?

Su: We give a single dose of a nonsteroidal anti-inflammatory medicine preoperatively.

Mullaji: We give a single dose of a COX-2 inhibitor the evening before surgery.

Berend: I give a COX-2 inhibitor the morning of surgery, the intrathecal narcotic and, if they are young, I give a long-acting oral narcotic. One of the keystones in our environment right now is a delirium protocol, so we don’t give long-acting oral narcotics to the older patients.

Dunbar: I give acetaminophen, an anti-inflammatory, and pregabalin.

Berry: What is your preferred standard operative approach?

Su: I use a posterior approach for everyone.

Mullaji: I use the anterolateral approach for all except for those with specific indications like a posterior acetabular rim fracture or if there is an implant that has to be removed.

Berend: I use the direct anterior supine approach in more than 90% and the anterolateral approach for the others.

Dunbar: I use the direct lateral, which you may also call the anterolateral, or the modified Hardinge.

Berry: Are you trying to shorten the length of your incisions compared to 10 years ago?

Dunbar: I am doing shorter incisions, but not tiny.

Berend: The anterior incisions end up being pretty small because you don’t need the skin exposure – you don’t need to get the subcutaneous tissue out of the way. When you use the direct lateral or the modified Hardinge, the incision tends to be larger. For our anterior approaches, we use a standard OR table, that is jackknifed with mounted a femoral elevating hook.

Mullaji: I use shorter incisions, but not tiny.

Su: When I first started to practice, there was a tremendous focus upon a shorter incision. Now, less attention is being given to incision length and I find my incisions have gotten longer.

Berry: How do you get the cup into the right position?

Dunbar: Patient positioning is very critical in placing the acetabular cup. It is important to get the patient stable and to have their shoulders properly oriented. You have to be cognizant of men vs. women because of the differences in the ratio between the shoulders and the pelvis. Intraoperatively, the look of the acetabulum varies depending on the pathology. One of the consistent landmarks is probably the transverse acetabular ligament.

Berend: I do the same thing for the direct lateral. For the supine anterior approach cases, I use fluoroscopy.

Mullaji: I use the lateral position and make sure that the patient is perfectly positioned, ensure good exposure, then use anatomic landmarks—mainly the transverse acetabular ligament.

Su: I agree with Mike. I think that component position is highly variable depending on the patient position. I use a Charnley face checker which gives the anteversion angle. I point it behind the shoulder.

Berry: For femoral components, what is the percentage breakdown between your use of cemented and uncemented stems?

Dunbar: I use about 90% cemented and that number is slowly drifting down.

Berend: I use 99% + cementless. I may occasionally cement a patient with Paget’s disease, radiation exposure or tumor.

Mullaji: I use 90% uncemented and 10% cemented. I use cemented mainly for the older and low-demand patients because of cost issues.

Su: I use 95% uncemented.

Berry: Do you perform hip resurfacing, and if so, in whom?

Su: Yes, mainly in men younger than 60 years. Resurfacing is probably 60% of my practice. I have concerns about using it in women, so my indications are tightening up a little.

Mullaji: In India we don’t see much primary osteoarthritis, most of our patients have avascular necrosis or rheumatoid arthritis, and therefore I almost never do resurfacing.

Berend: I do resurfacing mostly in men younger than the age of 50 and occasionally in women if they are active and know what they are getting into. Overall, we started with pretty strict indications — in the beginning we did about 8% resurfacings — now our indications are even tighter and we do about 4%.

Dunbar: My read on the literature is that in the young group, resurfacing is at best equivalent to total hip arthroplasty; otherwise I can’t see any advantages. Patients who want resurfacing are such a pre-selected group that I would rather pass them along to my colleagues.

Berry: How would you treat each of these case scenarios in terms of fixation on the acetabular and femoral components?

Case 1: A 45-year-old man with high femoral offset (Figure 1).

Dunbar: I would use a hybrid cemented component on the femoral side and an uncemented acetabular cup. To manage the offset issue, I would consider a lateralized acetabular liner.

Berend: I would consider a resurfacing depending on the patient factors; otherwise it would be cementless on both sides.

Mullaji: I would use cementless on both sides.

Su: I would resurface him, especially because of the high offset. To really recreate that anatomy, I think resurfacing would be best.

Berry: Case 2: An active 65 year-old man, with a narrow femoral canal (Figure 2).

Su: I would use cementless socket and a cementless stem.

Mullaji: I would also use a cementless socket and stem.

Berend: A cementless socket and stem.

Dunbar: I would use a hybrid.

Berry: Case 3: A 65 year-old woman (Figure 3).

Su: I would use a cementless cup and stem.

Mullaji: I would probably cement both sides. I don’t do hybrids, so if I cement, I cement both sides.

Berend: I would use cementless on both sides.

Dunbar: I would use a hybrid.

Berry: Case 4: A 78 year-old woman with a wide femoral canal and an old healed femoral neck fracture (Figure 4).

Dunbar: I would cement the stem and use an uncemented cup.

Berend: I would do both sides cementless, using as big a stem as required to get it tight.

Mullaji: I would cement both sides.

Su: I would do cementless.

Berry: How do you decide when to use a high offset femoral component?

Dunbar: Templating is important, but it is not everything. Intraoperatively, I use a device that Robert Bourne, MD, showed me in London, which is fixed to the pelvis and uses an outrigger over the greater trochanter. It gives you a rough approximation of the offset. I aim for the offset the patient had prior to surgery, maybe a little less.

Berend: One of the advantages of doing a direct anterior approach in the supine position with fluoroscopy is you can measure the normal side, then look at the offset with hip rotation, and compare that to the X-ray of the opposite side. I also use preoperative templating.

Mullaji: I use a template of the opposite side, if it is normal. However, we have the opposite problem in our country where we are looking for smaller offsets, not higher offsets because our patients are smaller.

Su: I agree with everything that has been said.

Berry: What is your routine acetabular liner configuration of choice?

Su: I routinely use a flat liner. The only time I deviate from that is if, when trialing, I find an elevated rim improves stability.

Mullaji: I use a 10° elevated rim for all of the cementless prostheses and I use the long posterior wall-type cup for the cemented sockets. I position the elevation posterolaterally.

Berend: Data is coming out that impingement is one of the leading culprits in terms of accelerated wear. And with the crosslinked polyethylenes, impingement may be a risk factor for catastrophic failure, so I have switched in the last few years from routinely using an elevated rim on everyone to routinely using a flat liner on everyone.

Lateralization of the liner is not as good for wear characteristics as is femoral offset, so I really try to avoid a lateralized liner. Unfortunately, many of the manufacturers only offer lateralized liners in some of their sizes because of the thinness of the crosslinked polyethylene.

Dunbar: I always use flat. I worry about impingement. I use a lateralized liner when I am trying to build up offset and I haven’t been able to get it with the femoral component.

Berry: How do you get the leg length right?

Dunbar: I use a combination of templating, preoperative assessment, knee-to-knee and heel-to-heel measurement, soft tissue tension, and the leg-length offset device. Using that confluence of technologies you can usually get it right.

I tell every patient that I may have to make them longer to get the stability.

Berend: I use all the same things.

Mullaji: I agree with using all the methods that have been mentioned. If is a particularly difficult hip, in some cases, I will put a pin in the superior part of the pelvis and use that to measure.

Su: I agree with all that have been mentioned so far. I also hang my hat on measuring the distance from the lesser trochanter to head center distance intraoperatively.

Berry: What head size and type of head do you use with a polyethylene bearing?

Dunbar: I use a 32-mm metal head on crosslinked polyethylene.

Berend: I use a 32-mm ceramic head in younger patients and metal heads in older patients. I use as big a head as possible, as long as the polyethylene is not thin.

Mullaji: I use 28-mm heads in most of our patients. Our patients are mostly small, so we rarely need a 32- or 36-mm head. I mostly use metal heads, but will use ceramic in the very young.

Su: Mostly, I use 32-mm head. If the cup is 56 mm or larger I’ll go to a 36-mm head. I usually use cobalt chrome heads, but occasionally ceramic.

Berry: What is your bearing surface head and size of choice for a 40 year-old male with stage IV avascular necrosis?

Su: I would use metal-on-metal with a large diameter, anatomic-sized head.

Mullaji: I would do a total hip with a ceramic head and a highly crosslinked polyethylene cup.

Berend: Most likely I would use a ceramic head with a crosslinked polyethylene cup. In this young age category I am hanging my hat on the modularity and the ease of changing the polyethylene liner 20 or 30 years down the road.

I think there are a lot of unknowns with metal-on-metal right now. I think in a 40 year-old male, if we use cross-linked polyethylene we can watch for the wear, we know how to deal with it, and I can change the liner out if it fails.

Dunbar: I would use metal-on-crosslinked polyethylene. I have no indications for metal-on-metal in my practice.

Berry: Which bearing surface would you use in a 60 year-old male with osteoarthritis?

Dunbar: Metal-on-crosslinked polyethylene.

Berend: Ceramic-on-crosslinked polyethylene.

Mullaji: Ceramic-on-crosslinked polyethylene.

Su: Ceramic-on-crosslinked polyethylene.

Berry: Do any of you use ceramic-on-ceramic in your young female patients of childbearing age?

Su: Yes.

Mullaji: No.

Berend: No. Squeaking is a very popular media item in the Midwest right now.

Dunbar: No.

Berry: Do you routinely use drains?

Su: No, not unless the wound is very wet at closure.

Mullaji: I use one subcutaneous drain which is removed after 24 hours.

Berend: I drain all the supine anterior approach patients and none of the direct lateral approach patients.

Dunbar: No.

Berry: For venous thromboembolism prophylaxis, what is your standard go-to agent and for what duration?

Dunbar: Low-molecular-weight heparin for a 10-day total course.

Berend: Perioperative risk stratification, and multi-modal prophylaxis with aspirin for most patients. We assess the deep venous thrombosis (DVT) risk of the patient preoperatively to avoid giving the low-DVT-risk patients a high risk of bleeding. The low-DVT-risk patients will get aspirin, the high-DVT-risk something injectable.

Mullaji: All of the patients get a calf pump and aspirin. The high-DVT-risk cases receive low-molecular-weight heparin for 5 days.

Su: I use aspirin for 1 month with intermittent pneumatic compression.

Berry: What is your standard form of postoperative pain management?

Su: We use an indwelling epidural for 24 hours, and a PCA. We also give a nonsteroidal anti-inflammatory agent and an oral narcotic.

Mullaji: Most of the patients have a spinal and receive oral narcotics. If we expect severe pain, then we use an indwelling epidural catheter.

Berend: A single-shot spinal with narcotic and then oral narcotics. Postoperatively, we use non-steroidals and acetaminophen.

Dunbar: We use acetaminophen and a subcutaneous narcotic and an NSAID. PCA pumps have been taken away from us due to medicolegal issues at the hospital.

Berry: Do you use a heterotopic ossification prophylaxis?

Dunbar: I do in people who have formed heterotopic ossification before or big muscular males who get a direct lateral approach.

Berend: I agree with Mike for the most part. For someone who is very high-risk, I give a preoperative dose of radiation. Anti-inflammatories are hard to take postoperatively.

Mullaji: I only give HO prophylaxis to patients with anklyosing spondylitis, who are already used to taking NSAIDs. I continue that for 3 weeks postoperatively.

Su: All my patients get aspirin, so that provides some level of HO protection.

Berry: What is your postoperative weight-bearing standard protocol?

Su: As tolerated, started with the walker and then a cane after a day or so, using the cane until they feel safe.

Mullaji: For those with cemented implants: full weight-bearing right after surgery. For those with uncemented implants: I tell them to use a walker for 2 to 4 weeks and weight-bearing as tolerated.

Berend: I say weight-bearing as tolerated and get rid of the support device when you feel up to it.

Dunbar: Weight-bearing as tolerated and support at the discretion of the therapist.

For more information:

• Daniel J Berry, MD, can be reached at 200 1st St. SW, Rochester, MN 55905; 507-284-4204; e-mail: mundt.norma@mayo.edu. He is a consultant for and receives remuneration for intellectual property rights from DePuy, a Johnson & Johnson Company.
• Keith R. Berend, MD, can be reached at 7277 Smith’s Mill Road, Suite 200,New Albany, OH 43054; 614-221-6331; e-mail: BerendKR@joint-surgeons.com. He is a consultant for and receives speaking and speaking remuneration and intellectual property rights from Biomet Orthopedics.
• Michael J. Dunbar, MD, FRCSC, PhD, associate professor, Department of Surgery, Division of Orthopaedics, and clinical research scholar, Dalhousie University, can be reached at 902-473-7337; e-mail: michael.dunbar@dal.ca. He is a consultant for Stryker.
• Arun Mullaji, MD, FRCS (Ed), MS, can be reached at Breach Candy Hospital, 60 A Bhulabhai Desai Road, Mumbai 400 026, India; 91-22-23671888; e-mail: arunmullaji@hotmail.com. He is a consultant for DePuy, a Johnson & Johnson Company.
• Edwin P. Su, MD, can be reached at Hospital for Special Surgery, 535 East 70th Street New York, NY 10021; 212-606-1128; e-mail: sue@hss.edu. He is a consultant for Smith & Nephew, which also provides research support to his institution.

Reference:

• Berry DJ. Performing a primary hip arthroplasty. Paper #15. Presented at the 25th Annual Current Concepts in Joint Replacement Winter Meeting. Dec. 11-13, 2008. Orlando, Fla.