Preoperative Planning and Templating for Primary Total Hip Arthroplasty

Timothy B. Alton

Daniel J. Berry

Introduction

Preoperative planning allows the surgeon to predict intraoperative needs and challenges and to work out an operative plan and to prepare for contingencies in advance of surgery. This, in turn, helps the surgeon execute the operation accurately and efficiently.
Preoperative planning helps ensure the optimal instruments and implants will be available at surgery.
Successful total hip arthroplasty (THA) requires precise positioning of femoral and acetabular components, appropriately sized for the patient’s femoral and pelvic anatomy, to minimize complications and optimize biomechanical function and implant longevity. Preoperative planning and careful templating helps the surgeon accomplish optimal restoration of hip biomechanics.
Digital templating allows fast, precise, calibrated measurements and digital storage in the electronic medical record for access and review at the time of surgery.

History

Careful documentation of symptoms
- Pain location, duration, alleviating and aggravating interventions, etc
Prior non-operative treatment
- Injections, physical therapy, weight loss, nonsteroidal anti-inflammatory drugs (NSAIDs), etc
Detailed medical history to identify modifiable and nonmodifiable risk factors
- Lumbar spine issues, hernias, diabetes, myocardial infarction, blood clots, patient or family clotting disorders, dental problems, etc
- Send for preoperative medical clearance as indicated
Detailed surgical history focused on the operative hip and limb
- Prior arthroscopy, infections, osteotomies, trauma, etc

Physical Examination

Observe patient standing and walking
- Identify/document gait abnormalities, coronal plane deformities, foot drop, etc
Examination of the operative hip
- Leg length evaluation with detailed preoperative documentation of differences
  - Note scoliosis and pelvic tilt issues that can contribute to actual and perceived leg length discrepancies.
  - Different methods exist to measure true and apparent leg length. The authors usually use apparent leg length measured in the supine position. However, when major deformities or contractures exist, true leg length measurement may be used. Blocks to test the leg length that levels the patient’s pelvis and feels comfortable to the patient are helpful.
- Evaluate range of motion
  - Flexion, extension (can flex contralateral hip to isolate operative hip), internal and external rotation
- Careful examination and documentation of distal motor/sensory function
- Palpate for dorsalis pedis and posterior tibial pulses
- Careful examination of the skin for open sores and prior scars, plan accordingly.

Radiographs

Three views
- Standing AP pelvis, AP hip, and true lateral hip radiographs
  - When previous femoral trauma or deformity is present, make sure radiographs are available showing the entire femur that will be instrumented.
  - True lateral hip radiographs can be valuable in identifying predominantly anterior or posterior hip arthritis.
  - Note prior lumbar fusion and pelvic obliquity and plan accordingly.