THR: Wound Closure

    - place leg on padded Mayo stand in 10 deg of abduction to relieve tension on leg;
    - deep soft tissue repair:
           - repair of posterior capsule and reattachment of the external rotators (which may help to decrease posterior dislocation);
           - there is some evidence to suggest that external rotator muscle repair is doomed to failure;
           - references:
                  - Failure of reinserted short external rotator muscles after total hip arthroplasty
                  - Hip Mechanics After Posterior Structure Repair in Total Hip Arthroplasty.
                  - Failure of Capsular Enhanced Short External Rotator Repair After Total Hip Replacement. 
    - superficial closure:
           - references:
               - Should we still stitch the subcutaneous fat layer A clinical and ultrasound assessment in 50 hip operations.
               - Comparative study of skin closure in hip surgery.
               - Is a fat stitch required when closing a hip hemiarthroplasty wound without a drain? 
               - Inverted running interlocking suture (IRIS): a technique for rapid closure of wounds.
               - Delayed wound healing and nutritional deficiencies after total hip arthroplasty. 
               - Comparing wound complication rates following closure of hip wounds with metallic skin staples or subQ vicryl suture: a prospective randomised trial.
    - wheel vac:
           - inorder to address wound complications that may arise from aggressive CPM activity, consider an inexpensive vaccum suction device;
           - technique:
               - apply several layers of gauze over the incision;
               - apply a "hemovac" type drain over gauze (multi holed tube is positioned over gauze) with the non-fenestrated portion of the tubing exiting outside gauze;
               - "tegaderm" is applied over the gauze and the tubing;
               - hook the tubing upto the hospital suction at 125 mm HG; 
    - need to drain THR is controversial:
           - some surgeons place one drain deep to fascia, and if the patient is obese, then one drain superficial;
           - references:
               - Closed wound drainage in total hip or total knee replacement. A prospective, randomized study.
               - The effect of suction drains after total hip replacement.
               - The use of postoperative suction drainage in total hip arthroplasty.
               - The efficacy of suction drains after routine total joint arthroplasty
               - Why use drains
               - The effect of suction drains after total hip replacement.
               - Closed Suction Drainage for Hip and Knee Arthroplasty. A Meta-Analysis.
               - A prospective, randomised, controlled trial of the use of drains in total hip arthroplasty.
               - Simplified wound care and earlier wound recovery without closed suction drainage in elective total hip arthroplasty. A prospective randomized trial in 100 operations.