Total Hip Arthroplasty
By Ellen Salazar
San Joaquin Valley College
Total Hip Arthroplasty
The hip is a ball-and-socket joint formed at the junction of the femur and the pelvis bone. The unit known as the ball of this joint is formed by the femoral head, at the superior end of the femur. The large part of the pelvic bone, known as the acetabulum, forms the socket portion of the hip. Articular cartilage covers the areas of both of these bones where they meet. This cartilage enables the bones to move easily and cushions them to prevent pain when moving. Another tissue that covers these bones is known as the synovial membrane, which secretes a small amount of fluid to lubricate the cartilage. This secretion has the effect of eliminating nearly all friction when the joint is moving. Ligaments provide stability to the entire joint, connecting the ball and socket.
Indications for Total Hip Arthroplasty
Chronic pain and impaired functionality of the hip are indications for total hip arthroplasty. This can be caused by a number of factors, including wearing down of cartilage and inflamed synovial membrane.
Arthritis is the most common cause of joint pain in the hip. There are different types of arthritis, each with a different effect. Osteoarthritis occurs when the cartilage between the two bones is worn away. This usually occurs in older patients above the age of fifty due to normal wear and tear, and in patients who have a family history of the disease. Rheumatoid arthritis describes when the synovial membrane becomes thickened and inflamed, which damages the cartilage and causes chronic pain and discomfort. When the cartilage is damaged due to a fracture or other injury, a diagnosis of post-traumatic arthritis is given. This also causes pain. There are other, less common factors that can cause damage and pain to the hip area. These include ankylosing spondylitis, avascular necrosis of the hip joint, alcoholism, degenerative joint disease, systemic lupus erythematosus, nonunion of trochanteric fracture, nonunion of femoral neck, tuberculosis, congenital subluxation, congenital luxation, and bone tumor of proximal femur or acetabulum. When symptoms caused by any of these diseases are serious enough, a patient is a candidate for total hip arthroplasty.
If a patient is experiencing chronic hip pain that impairs their ability to function normally, doctors will usually try exploring other options before recommending a total hip arthroplasty. These include anti-inflammatory drugs, walking supports, and/or physical therapy.
Many extensive tests must be performed to conclude that a total hip arthroplasty is the best option for an individual. A full medical history and physical exam is the first step in this process. This determines if a patient’s ability to function is hampered significantly and if there is a history of osteoarthritis or rheumatoid arthritis in the patient’s family. This increases the chances of a total hip arthroplasty being recommended. X-rays are also used. These can show if there is damage to any part of the joint, especially the cartilage, and the surgeon may use these images to plan details of the surgery using plastic overlay templates. Other tests may be used, depending on the individual patient. A doctor may determine an MRI scan or CT scan is needed to further view the damaged tissue and potentially plan aspects of the surgery.
A total hip arthroplasty involves the removal of the hip joint, including the ball and socket portions. Therefore, the femoral head and the acetabulum are both removed and replaced with components made of metal or ceramic.
There are five common approaches to total hip arthroplasty: Smith-Peterson (also known as anterior), Watson-Jones (also known as anterolateral), Hardinge (also known as direct lateral), transtrochanteric, and posterolateral. The orthopedic surgeon will determine which is to be used based on factors concerning the patient as well as personal preference. Posterolateral is the most common approach, so this paper will be primarily describing this method.
Positioning will vary based on which approach is to be used. Supine positioning is utilized in the anterior, anterolateral, and direct lateral approaches. If the transtrochanteric or posterolateral approach is to be used, however, the patient will be placed in lateral position with the operative side up. In lateral position, the pelvis will need to be secured in a neutral position to minimize the risk of patient displacement and injury. The patient’s arms may be extended on armboards and secured. Pillows should be placed to avoid injury and bruising.
Skin of the surgical area will be prepped in a circular motion starting at the hip, as close to the incision site as possible. The circular motion will continue up the lateral midline of the abdomen until the level of the umbilicus is reached, and then will move as far laterally in that area as possible. Once the abdominal area is covered, the entirety of the leg and foot will IV.Surgical intervention (procedural steps). Please include:
B.Prep solution and area prepped
C.SuppliesD.DrapingE.IncisionF.Equipment and what it was used for
G.Suture (Type, size, needle, and usage)
H.Instruments (spend time on the instruments used for the substantive part of the
procedure, not opening and closing)
I.Procedure steps (detailed anatomy)
J.Counts (what was counted and when)
KSpecimen and how it was cared for
L.Drains and dressings
Special considerations (include the patient aspects, as well as case and physician specific