Managing Difficult Hip Patients with the DAA
The ideal patient for a surgeon who is in the learning curve for total hip arthroplasty (THA) through the direct anterior approach (DAA) is a thin, valgus female with soft, pliable muscles and no other pathology.
The reality is that few patients meet this ideal.
In the US, the prevalence of obesity has doubled in the last 25 years. By 2030, 50% of the 78 million baby boomers in this country are projected to have osteoarthritis; more than 33% of them are projected to be obese, defined as a BMI greater than 30.
Obese patients aren’t the only patients who are more difficult for the surgeon who is in the learning curve for the DAA. At the International Congress for Joint Reconstruction’s 4th Annual Anterior Hip Course last year, Tyler D. Goldberg, MD, from Texas Orthopedics in Austin identified other difficult patients:
- Short varus neck
- Protrusio hip (ankylosis)
- Previous hardware
- Severe anatomic deformities
Although difficult, these patients can undergo THA through the DAA, but there are risks, particularly with patients who are obese. Dr. Goldberg reminded attendees that obese THA and total knee arthroplasty patients have increased risk for complications:
- BMI > 40: 3.2 times greater risk for infection
- BMI > 50: 18.3 times greater risk for infection
Of greatest concern in these patients is whether they have metabolic syndrome – a combination of diabetes (A1C > 7.0), hypertension (blood pressure >140/90), dyslipidemia (total serum cholesterol >200), and obesity (BMI >30) – which can increase the rate of complications by as much as 50% if the metabolic syndrome is uncontrolled. Before recommending arthroplasty, Dr. Goldberg said, the patient should be optimized medically, including reducing the BMI.
Careful attention to logistics during surgery can make for a well-executed and successful THA in obese patients, Dr. Goldberg said. He recommends the following:
- Tape up the pannus to achieve a clean groin crease
- Swab the groin crease with alcohol
- Make the incision out of the groin crease; it should be more lateral and oblique
- Perform generous femoral releases, particularly with the pubofemoral and ischiofemoral ligaments
Click on the image above to hear more tips from Dr. Goldberg on THA through the DAA in difficult patients.