Rhind John-Henry, Baker Camilla, Roberts Philip John
Robert Jones Agnes Hunt hospital, Gobowen, UK.
Chelsea & Westminster Hospital, London, UK.
Indian J Orthop. 2020 Jun 10;54(6):776-783. doi: 10.1007/s43465-020-00164-w. eCollection 2020 Nov.
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.
POST-OPERATIVE CONSIDERATIONS: 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.
肥胖患者初次髋关节置换术的最佳方法缺乏共识且证据有限。本文基于作者的经验以及文献综述提出了一系列考量因素。
在术前阶段，建议进行知情同意程序。根据英国国民健康服务体系（NHS）英格兰地区的指南，建议进行体重减轻，并应考虑身体体型。在进行模板测量时，应采取措施避免高估植入物尺寸。
在手术过程中，使用专门的肥胖症治疗设备：肥胖症病床、额外支撑、气垫床垫、更长的手术刀、电刀、血液回收机和微创手术设备。与麻醉师和手术团队进行沟通以做好准备至关重要。如有需要，应考虑术中尺寸测量和成像。预防静脉血栓栓塞症（VTE）时，气动足泵更佳。由于技术难度，区域麻醉更为可取。建议使用静脉注射抗生素和氨甲环酸。最常使用前侧和后侧手术入路；我们主张后侧入路。切口应具有扩展性，术中应考虑更高的偏心距，以及双动型和限制性衬垫以降低脱位风险。关闭伤口时，应考虑使用查尔尼纽扣和海绵以及负压伤口敷料（iNPWTd）和引流管。
术后，应预料到拔管困难，需准备重症监护病房（ITU）/高依赖病房（HDU）病床。用于术后疼痛管理的硬膜外麻醉需要更高的护理警惕性。建议进行化学预防。
尽管技术上难度更大且风险更高，但功能结果与体重指数（BMI）正常的患者相当。
