Total Hip Arthroplasty in the Obese Patient: Tips and Tricks and Review of the Literature.

Abstract

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. 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. 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. Postoperatively, difficult extubation should be anticipated with ITU/HDU beds available. Epidural anaesthetics for postoperative pain management require higher nursing vigilance. Chemical prophylaxis is recommended. Despite being technically more difficult with higher risks, functional outcomes are comparable with patients with a normal BMI.