What is the comprehensive approach to total hip replacement surgery?

Comprehensive Approach to Total Hip Replacement

Total hip arthroplasty (THA) should include pre-operative exercise and education, multimodal pain management with paracetamol and NSAIDs/COX-2 inhibitors, spinal or general anesthesia, intravenous dexamethasone 8-10mg, and appropriate regional analgesia techniques to optimize outcomes and facilitate early mobilization. 1

Pre-operative Phase

Patient Selection and Preparation

• Patients with advanced hip arthritis causing pain and functional limitation are primary candidates for THA 2
• Pre-operative exercise and education significantly improve postoperative outcomes and reduce pain (Grade A recommendation) 1
• Optimize medical comorbidities prior to surgery to reduce perioperative complications

Pain Management Planning

• Establish a multimodal analgesic regimen including:
  • Paracetamol (Grade A recommendation)
  • NSAIDs or COX-2 selective inhibitors (Grade A recommendation)
  • Dexamethasone 8-10 mg IV (Grade A recommendation) 1

Intra-operative Phase

Anesthetic Technique

• Both spinal and general anesthesia are recommended (Grade A recommendation) 1
• Regional anesthesia reduces the risk of pulmonary embolism compared to general anesthesia alone 1

Surgical Approach

• The posterior approach has shown a significantly lower overall complication rate (5.85%) compared to the anterior approach (8.5%) 3
• Most common complications include deep infection (22.8%), periprosthetic fracture (22.4%), and prolonged wound drainage (21.3%) 3
• Dislocation rates are comparable between posterior (0.84%) and anterior (1.28%) approaches 3

Pain Management During Surgery

• Administer IV dexamethasone 8-10 mg for its analgesic and anti-emetic effects 1
• Consider single-shot fascia iliaca block or local infiltration analgesia (Grade D recommendation) 1
• If using spinal anesthesia, intrathecal morphine 0.1 mg may be considered, though risks and side effects should be carefully weighed 1

Post-operative Phase

Immediate Pain Management

• Continue paracetamol and NSAIDs/COX-2 inhibitors postoperatively (Grade A recommendation) 1
• Reserve opioids for rescue analgesia only (Grade D recommendation) 1
• Avoid gabapentinoids as adverse effects outweigh benefits 1

Thromboprophylaxis

• All THA patients require thromboprophylaxis as they are at high risk for venous thromboembolism 1
• Options include:
  • LMWH starting 12-24 hours postoperatively (after removal of epidural catheter if present)
  • Aspirin may be considered in certain patients 1

Early Mobilization

• Implement early mobilization protocols as part of Enhanced Recovery After Surgery (ERAS) programs 4
• Begin physical therapy on the day of surgery or first postoperative day

Common Complications and Management

Pain-Related Complications

• Persistent postoperative pain requires thorough evaluation to differentiate between:
  • Intrinsic causes: infection, aseptic loosening, periprosthetic fracture
  • Extrinsic causes: referred pain from spine, vascular issues 5

Surgical Complications

• Deep infection (22.8% of complications)
• Periprosthetic fracture (22.4% of complications)
• Prolonged wound drainage (21.3% of complications)
• Dislocation (0.84-1.28% depending on approach) 3

Medical Complications

• Elderly patients are at higher risk for:
  • Pressure ulcers
  • Delirium
  • Deep venous thrombosis
  • Urinary retention and infection
  • Cardiac events 6

Special Considerations for Elderly Patients

• Age alone should not be a contraindication to THA 6
• Selection should be based on symptoms and overall health status
• Anticipate and implement preventive measures for common complications
• Team approach including orthopedic surgeon, primary care physician, nursing staff, and physical therapists is essential 6

Pitfalls and Caveats

• Avoid minimally invasive techniques if they compromise proper component positioning
• Do not rely solely on clinical assessment to determine thromboprophylaxis needs - all THA patients require it 1
• Recognize that extended duration prophylaxis (beyond 7-12 days) has shown effectiveness in preventing symptomatic VTE 1
• Be aware that the posterior approach, despite historical concerns about dislocation, has the lowest overall complication rate in recent studies 3