What are the key considerations and protocols for a total hip arthroplasty (THA) procedure?

Key Considerations for Total Hip Arthroplasty (THA)

For optimal outcomes in total hip arthroplasty, implement a comprehensive protocol that includes preoperative education, appropriate perioperative medication management, multimodal pain control, and structured rehabilitation.

Preoperative Considerations

Patient Education and Preparation

• Provide preoperative exercise and education to reduce postoperative pain and improve functional outcomes (Grade A evidence) 1
• Educate patients on movement restrictions, proper use of assistive devices, expected recovery timeline, and pain management strategies 1

Medication Management

For patients with rheumatic diseases:

• Continue conventional DMARDs through surgery (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, apremilast) 2
• Withhold biologics prior to surgery and plan surgery after the next dose is due 2
• Withhold JAK inhibitors (tofacitinib, baricitinib, upadacitinib) for at least 3 days prior to surgery 2
• For SLE patients (not severe), withhold mycophenolate mofetil, azathioprine, cyclosporine, tacrolimus 1 week prior to surgery 2
• For severe SLE patients, continue immunosuppressants through surgery 2
• Continue current glucocorticoid doses rather than administering supraphysiologic doses on the day of surgery 2

Intraoperative Considerations

Anesthesia

• Either spinal or general anesthesia is recommended (Grade A) 2
• If using spinal anesthesia, intrathecal morphine 0.1mg could be considered for postoperative pain management 2, 1

Antibiotic Prophylaxis

• Administer antibiotic prophylaxis both systemically and in bone cement for cemented implants 3
• Optimal systemic antibiotic regimen: administer 4 times on the day of surgery rather than 1-3 times 3
• First-generation cephalosporins are most commonly used 4

Pain Management

• Administer preoperative or intraoperative paracetamol and NSAIDs/COX-2 inhibitors 2, 1
• Administer single intraoperative dose of IV dexamethasone 8-10mg for analgesic and anti-emetic effects 2, 1
• Perform single-shot fascia iliaca block or local infiltration analgesia 2, 1

Postoperative Considerations

Pain Management

• Continue paracetamol and NSAIDs/COX-2 inhibitors postoperatively 2, 1
• Reserve opioids as rescue analgesics only for breakthrough pain 2, 1

Medication Resumption

• Restart antirheumatic medications once the wound shows evidence of healing (typically ~14 days), when sutures/staples are removed, and there is no significant swelling, erythema, drainage, or ongoing infection 2

Rehabilitation Protocol

1. Days 1-3:

   • Ankle pumps, gluteal sets, assisted sitting
   • Weight-bearing as tolerated with walker/crutches
   • Basic bed mobility exercises, standing transfers
   • Short distance ambulation, gentle hip ROM exercises 1

2. Days 4-14:

   • Progress ambulation distance
   • Stair training
   • Continue ROM exercises
   • Begin gentle strengthening exercises 1

3. Weeks 2-4:

   • Progress from walker to crutches or cane
   • Increase walking distance
   • Add functional exercises
   • Begin light resistance exercises for hip muscles 1

4. Weeks 4-6:

   • Progress to single cane
   • Increase resistance in strengthening exercises
   • Begin balance exercises
   • Focus on normalizing gait pattern 1

5. Weeks 6-12:

   • Transition to walking without assistive devices
   • Progress to more functional strengthening
   • Increase endurance activities
   • Address any remaining gait abnormalities 1

Movement Precautions

• Avoid hip flexion beyond 90 degrees for 6-12 weeks (depending on surgical approach)
• Avoid crossing legs, internal rotation, and twisting movements at the hip
• Use elevated toilet seats and chair cushions 1

Infection Prevention

• Implement evidence-based perioperative infection prevention protocols 5
• Consider extended oral antibiotic prophylaxis (7 days post-discharge) for high-risk patients, which can reduce 90-day infection rates by approximately 4-5 times 6
• High-risk patients include those with diabetes, obesity, immunosuppression, prior surgery, or revision procedures 6

Outcome Assessment

• Regularly assess pain levels using validated instruments (VAS or numerical rating)
• Evaluate functional outcomes using validated tools (Harris Hip Score, WOMAC, SF-36)
• Monitor for complications such as infection, dislocation, or venous thromboembolism 1

Common Pitfalls to Avoid

1. Inadequate preoperative education leading to unrealistic expectations
2. Improper medication management in patients with rheumatic diseases
3. Insufficient pain control leading to delayed mobilization
4. Failure to identify high-risk patients who may benefit from extended antibiotic prophylaxis
5. Premature discontinuation of movement precautions leading to dislocation

By following these evidence-based recommendations, you can optimize outcomes and minimize complications in patients undergoing total hip arthroplasty.