What are the differences between anterior and posterior total hip replacement (THR) approaches in a 93-year-old patient with a history of coronary artery disease (CAD)?

From the Guidelines

For a 93-year-old patient with coronary artery disease (CAD) requiring total hip replacement (THR), a posterior approach is generally preferred over an anterior approach. This preference is based on the need to minimize surgical duration and physiological stress in elderly patients with significant comorbidities like CAD. The posterior approach typically offers better visualization of the surgical field and reduced operative time, which can lead to less physiological stress during surgery, a critical consideration for a patient of advanced age with cardiac disease 1.

When considering the approach for THR in this patient, several factors come into play:

• The patient's advanced age and history of CAD increase the risk of perioperative cardiac complications.
• The need for careful anesthesia management to minimize cardiovascular stress, with consideration for regional anesthesia techniques when possible.
• The importance of preoperative cardiac risk stratification, including optimization of cardiac medications and possibly a cardiology consultation.
• The benefits of early mobilization postoperatively, balanced with careful attention to vital signs and symptoms of cardiac distress.

Given these considerations, the posterior approach may offer a safer profile for this high-risk patient by potentially reducing the risk of intraoperative complications and minimizing physiological stress. While the anterior approach has its benefits, such as faster early recovery and lower dislocation rates, these may be outweighed by the increased surgical complexity and longer operative time associated with this approach in elderly patients with comorbidities like CAD. Therefore, prioritizing a approach that minimizes risk and stress is crucial in this scenario.

From the Research

Anterior vs Posterior THR in a 93yo with History CAD

• The choice between anterior and posterior total hip replacement (THR) in a 93-year-old patient with a history of coronary artery disease (CAD) should be based on various factors, including the patient's overall health, surgical risks, and potential benefits of each approach.
• According to 2, patients over 80 years old with CAD are at high risk of perioperative cardiac complications (PCCs) when undergoing noncardiac surgery, including THR.
• The study by 2 identified independent risk factors for PCCs, including age ≥85 years, body mass index ≥30 kg/m2, history of angina within 6 months, and preoperative ST-T segment abnormality.
• In terms of antithrombotic therapy, 3 recommends aspirin and clopidogrel for patients with CAD, while 4 suggests that dual antiplatelet therapy should be continued for a period of 4 weeks to 12 months after coronary stenting.
• However, the management of anticoagulant and antiplatelet therapy in patients with atrial fibrillation after coronary stenting or acute coronary syndrome is complex, and the optimal balance between reducing ischemic risk and minimizing bleeding risk is challenging 5.
• Combining antiplatelet and anticoagulant therapies can increase the risk of bleeding, and the use of triple antithrombotic therapy (a dual antiplatelet regimen plus warfarin) requires careful consideration of the benefits and risks 6.
• Ultimately, the decision between anterior and posterior THR in a 93-year-old patient with a history of CAD should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.

Considerations for THR in Elderly Patients with CAD

• Elderly patients with CAD are at high risk of perioperative cardiac complications, and careful preoperative evaluation and monitoring are essential to minimize this risk.
• The choice of surgical approach (anterior or posterior) should be based on the patient's individual needs and the surgeon's expertise.
• Antithrombotic therapy should be managed carefully to balance the risk of thromboembolism and bleeding.
• Close collaboration between the surgical team, cardiologist, and anesthesiologist is crucial to ensure optimal care for elderly patients with CAD undergoing THR.