What are the approaches for hemiarthroplasty?

Approaches for Hemiarthroplasty

The posterior approach should be avoided for hip hemiarthroplasty due to higher rates of dislocation and reoperation compared to lateral and anterior approaches. 1

Common Surgical Approaches for Hemiarthroplasty

Hemiarthroplasty is commonly performed using several different surgical approaches, each with distinct advantages and disadvantages:

1. Anterior Approach

   • Provides direct access to the hip joint
   • Associated with faster early discharge (patients more likely to be discharged by postoperative day 3) 2
   • May have higher overall complication rates (8.5%) compared to posterior approach 3
   • Lower dislocation rates compared to posterior approach 1

2. Anterolateral Approach

   • Good exposure of the hip joint
   • Lower dislocation rates compared to posterior approach 1
   • May be associated with greater blood loss and longer operative time 4

3. Direct Lateral Approach

   • Provides good stability
   • Lower dislocation rates compared to posterior approach 1
   • May have slightly lower patient-reported health-related quality of life compared to posterior approach, though this difference disappears when adjusting for patient factors 5

4. Posterior Approach

   • Has the lowest overall complication rate (5.85%) 3
   • Higher dislocation rates compared to anterior and lateral approaches 1
   • Should be avoided for hemiarthroplasty procedures due to higher reoperation rates 1

Considerations for Approach Selection

When selecting an approach for hemiarthroplasty, the following factors should be considered:

• Risk of dislocation: Posterior approaches have higher dislocation rates 1
• Patient factors: Age, comorbidities, and bone quality
• Surgeon experience: The approach with which the surgeon is most familiar often yields the best results 4
• Implant considerations: Cemented femoral stems are strongly recommended regardless of approach 6

Implant Selection for Hemiarthroplasty

The American Academy of Orthopaedic Surgeons (AAOS) provides the following recommendations for implant selection:

• Unipolar vs. Bipolar: Both unipolar and bipolar hemiarthroplasty can be equally beneficial (moderate strength recommendation) 6
• Cemented vs. Uncemented: Cemented femoral stems are strongly recommended (strong recommendation) 6
• Cementation technique: Proper cement technique is crucial to reduce the risk of bone cement implantation syndrome 6

Perioperative Considerations

Anesthesia

• Either spinal or general anesthesia is appropriate (strong recommendation) 6

Bone Cement Implantation Syndrome Prevention

When using cemented implants, the following precautions should be taken:

1. Preoperative:

   • Identify high-risk patients (elderly, male, significant cardiopulmonary disease, diuretic use) 6
   • Ensure adequate hydration 6

2. Intraoperative:

   • Clear communication between surgeon and anesthesiologist before cementing 6
   • Thorough preparation, washing, and drying of the femoral canal 6
   • Use of pressurized lavage system to clean endosteal bone 6
   • Use of distal suction catheter with intramedullary plug 6
   • Retrograde cement insertion using a cement gun 6
   • Avoid excessive manual pressurization in high-risk patients 6
   • Maintain systolic blood pressure within 20% of pre-induction values 6
   • Have vasopressors ready in case of cardiovascular collapse 6

Postoperative Care

For optimal outcomes following hemiarthroplasty:

• Implement multimodal analgesia incorporating preoperative nerve blocks (strong recommendation) 6
• Consider tranexamic acid administration to reduce blood loss and transfusion requirements (strong recommendation) 6
• Utilize interdisciplinary care programs to decrease complications and improve outcomes (strong recommendation) 6

Common Pitfalls and Complications

• Dislocation: More common with posterior approach (0.84-1.28%) 3, 1
• Periprosthetic fracture: One of the most common complications (22.4%) 3
• Deep infection: A significant complication (22.8% of all complications) 3
• Bone cement implantation syndrome: Can occur in approximately 20% of cemented cases 6

By carefully selecting the surgical approach and following evidence-based recommendations for implant selection and perioperative management, surgeons can optimize outcomes and minimize complications in patients undergoing hemiarthroplasty.