Persistently High Hip Circumference after Bariatric Surgery Is a Major Hurdle to Successful Hip Replacement

Table 1

Modifications to consider for hip arthroplasty with high hip circumference.

Challenge	Standard procedure	Modifications to consider
Preoperative workup	Hip and pelvis radiographs	Waist and hip circumferences*; Preoperative range of motion/flexibility assessment; Axial supine and lateral decubitus CT (Figure 2 is presented as an example)
Preoperative setup in surgical suite	“Bean bag” with usual time and staffing	Schedule for oversized 1000-pound table, lateral positioners, oversized instruments, and retractors, and additional staff and operating time and resources
Position on operative table	Approach as per surgeon’s preference	Anterolateral approach
Evaluation of tunnel depth	Direct inspection	Intraoperative direct measurements
Visualization	Direct inspection	Improved illumination and retraction
Illumination	Quartz halogen, LED, focused high intensity lighting	Supplemental headlamps, flashlights
Tissue exposure	“Charnley,” Weitlander, angled, and reverse retractors	Oversized “Charnleys,” Burkhalters, and Beckman’s oversized angled retractors and oversized instruments
Tissue compression	Careful soft tissue handling	Broad retractor blades, wider exposure, releasing tension in intervals
Tissue reflection	Careful soft tissue handling	Accommodation for hard immobile adipose tissues
Delivering the femur	One surgical assistant	Multiple surgical assistants and soft tissue releases
Alignment	Guidance rods and skeletal landmarks	More deliberate use of “bone hooks,” retractors, and computer assisted guides

∗http://www.cdc.gov/nchs/nhanes/nhanes3/anthropometric_videos.htm.