My advice is based on clinical reasoning (Engebretsen et al 2015; “Unpacking the process of interpretation in evidence-based decision making“) taking the BPS model (Waddell et al 1987) into consideration and using the CLINICAL REASONING REFLECTION SHORT FORM fra Mark Jones book “Clinical Reasoning for Manual Therapists“ to break down my reasoning into boxes before I make my decisions based on Ian Shier 3-STEP RETURN TO PLAY DECISION MAKING MODEL
- Obesity: Pasient with obesity has an increase risk of dislocation, revision and early stem loosening. (Lie 2004; Flugsrud et al., 2007; Munger et al., 2006; Sadr et al., 2008).
- Age: Literature states that patients of young age < 60 years had increased risk of revision (Havelin et al., 2000; Espehaug et al., 2006; Santaguida et al., 2008) and suffering early stem loosening (Munger et al., 2006). In the latter research the risk for stem loosening increased linearly with decreasing age. Patients operated at the age of 50, had 50% increased risk compared to those operated by the age of 70. An increased activity level, as seen in young patients (Flugsrud et al., 2007; Munger et al., 2006) and those with unrestricted mobility, may be an important factor for the increased incidence of stem loosening. Age older than 80 years, is associated with deteriorating physical condition, and poorer wound healing (MacWilliam et al., 1996).The frequency of complication occurring after THR (HIP NOT Knee..) in patients over age of 80 years varies from 24% to 42.5% compared to 8% in the general population (De TE et al 2009). Early postoperative mortality is also higher in older patients (Lie et al 2004; Santaguida et al.,2008).
- Sex: Males have in several studies been indicated as having increased risk for complications following THA/TKR. . As found in younger age, male sex is also associated with increased physical activity and thus revision due to aseptic loosening. There is a tendency that men get a THA/TKA earlier than women. Women are more likely to have pre-operative physical therapy intervention compared to men: 57% vs. 38% respectively the year before surgery. Thus the risk increases further when you have the combination: young age and male sex (Lie et al., 2004; Havelin et al.2000; Flugsrud et al., 2007; Munger et al., 2006).
- Diabetes: DM predisposes for increased length of stay, higher hospital charge and more surgical and systemic complications (Marchant MH et al., 2009). Infection rates and overall complication rates are also increased for DM patients (Bolognesi et al., 2008)
- Smoking: Smoking leads to increased risk for decreased wound healing cardiovascular complications, the need for intensive care and revision (Moller et al., 2001; Moller et al.,2003) Post operation days at hospital have been reduced among smoking patients who quit smoking 6-8 weeks prior to surgery. Former heavy smokers were found to have 2.6 times higher risk for early revision compared to people that has never smoked (Havelin et al.,2000).
- DVT: DVT and PE are complication risks that are always present after surgery, a potential lethal complication as a result of immobilization. Mortality rate for patients undergoing THA/TKR is increased in the first 60 days, compared to the normal population and is due to thrombolytic disease and cardiovascular disease (CVD) (Lie et al., 2004)
- The prevalence of thromboembolism during hospital stay is approximately 60% of patients undergoing THA (HIP!) . This is due to increased coagulant activity at the end of the first- postoperative week, and reduced blood flow in lower limbs for several weeks. Late venous thromboembolism is thus a risk factor for patients that are discharged from hospital after a week without continued thromboprophylaxis.