Total Hip Arthroplasty in the Obese Patient: Tips and Tricks and Review of the Literature
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REVIEW ARTICLE
Total Hip Arthroplasty in the Obese Patient: Tips and Tricks and Review of the Literature John‑Henry Rhind1 · Camilla Baker2 · Philip John Roberts3 Received: 21 April 2020 / Accepted: 1 June 2020 © Indian Orthopaedics Association 2020
Abstract Aim There is a lack of consensus on the optimal method of performing primary hip arthroplasty in obese patients and limited evidence. This article presents a series of considerations based on the authors’ experiences as well as a review of the literature. Preoperative Care In the preoperative phase, an informed consent process is recommended. Weight loss is recommended according to NHS England guidelines, and body habitus should be taken into account. When templating, steps are taken to avoid overestimating the implant size. Surgical Procedure During the surgical procedure, specialist bariatric equipment is utilised: bariatric beds, extra supports, hover mattresses, longer scalpels, diathermy, cell saver and minimally invasive surgery equipment. Communication with the anaesthetist and surgical team to anticipate is vital. Intraoperative sizing and imaging, if required, should be considered. Pneumatic foot pumps are preferable for VTE prophylaxis. Regional anaesthesia is preferred due to technical difficulty. IV antibiotics and tranexamic acid are recommended. The anterior and posterior surgical approaches are most frequently used; we advocate posterior. Incisions are extensile and a higher offset is considered intraoperatively, as well as dual mobility and constrained liners to reduce dislocation risk. When closing the wound, Charnely button and sponge should be considered as well as negative pressure wound dressings (iNPWTd) and drains. Post‑operative Considerations Postoperatively, difficult extubation should be anticipated with ITU/HDU beds avail‑ able. Epidural anaesthetics for postoperative pain management require higher nursing vigilance. Chemical prophylaxis is recommended. Conclusion Despite being technically more difficult with higher risks, functional outcomes are comparable with patients with a normal BMI. Keywords Hip arthroplasty · Obesity · Total hip replacement · Technical · Tips tricks
Introduction 28.7% of adults in England are classified as obese [1]. This statistic has increased dramatically from 15 per cent in 1993 and is set to continue at an alarming rate throughout the * John‑Henry Rhind [email protected] Camilla Baker [email protected] Philip John Roberts [email protected] 1
Robert Jones Agnes Hunt hospital, Gobowen, UK
2
Chelsea & Westminster Hospital, London, UK
3
Royal Stoke University Hospital, Stoke‑on‑Trent, UK
U.K and worldwide. Obesity is defined as BMI ≥ 30 kg/m2, and subdivided into class I (30 to 34.9 kg/m2), class II (35 to 39.9 kg/m2) and class III (≥ 40 kg/m2), the latter termed ‘morbid obesity’. This poses unique challenges to the ortho‑ paedic surgeon conducting total hip arthroplasty. Obesity has been shown to be directly linked to earlier age onset osteoarthritis leading to an inc
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