What is the recommended treatment and management for patients undergoing partial hip arthroplasty?

Management of Patients Undergoing Partial Hip Arthroplasty

Patients undergoing partial hip arthroplasty should receive neuraxial anesthesia rather than general anesthesia when possible, with careful perioperative monitoring for cardiorespiratory compromise during cement application, and appropriate pain management including multimodal analgesia with acetaminophen and NSAIDs as baseline therapy. 1

Preoperative Management

Anesthetic Considerations

• Neuraxial anesthesia (spinal or epidural) is preferred over general anesthesia due to lower rates of pulmonary complications and potentially reduced mortality 1
• For patients with significant cardiac disease, an ECG is required, and those with heart murmurs should be evaluated for aortic stenosis 1
• Patients on anticoagulation therapy require special consideration:
  • Warfarin should be managed to achieve INR <2 for surgery and <1.5 for neuraxial anesthesia 1
  • Aspirin may be withheld during inpatient stay unless specifically indicated 1
  • Clopidogrel is generally not stopped, but may lead to increased blood loss 1

Medication Management

• For patients with rheumatic diseases:
  • Continue glucocorticoids at current daily dose rather than administering "stress dosing" if dose is ≤16 mg/day prednisone equivalent 1
  • Consider withholding DMARDs and biologic agents according to their specific half-lives 1
• Preoperative carbohydrate loading may reduce postoperative pain for the first 20 hours 1
• Preoperative exercise and education are beneficial in reducing postoperative pain and improving functional outcomes 1

Intraoperative Management

Cement-Related Considerations

• For cemented hemiarthroplasty, implement a three-stage process to reduce complications:
  1. Maintain vigilance for cardiorespiratory compromise using arterial line or automated BP monitoring on "stat" mode 1
  2. Aim for systolic blood pressure within 20% of pre-induction value 1
  3. Prepare vasopressors in case of cardiovascular collapse 1

Specific Team Roles

• Surgeon responsibilities:

  • Inform anesthetist before cement insertion 1
  • Thoroughly wash and dry the femoral canal 1
  • Apply cement in retrograde fashion using cement gun with suction catheter and intramedullary plug 1
  • Avoid vigorous pressurization in high-risk patients 1

• Anesthetist responsibilities:

  • Ensure adequate resuscitation pre- and intra-operatively 1
  • Confirm awareness when surgeon is about to prepare/apply cement 1
  • Monitor for sudden drop in systolic pressure or end-tidal CO2, which may indicate right heart failure 1

Postoperative Management

Pain Management

• Implement multimodal analgesia including:
  • Paracetamol (acetaminophen) as baseline therapy 1, 2
  • NSAIDs or COX-2 selective inhibitors unless contraindicated 1, 2
  • Opioids for rescue analgesia only 1, 2
  • Consider dexamethasone 8-10 mg IV for additional analgesia 1

Special Considerations

• For patients with diabetes, follow hospital guidelines for perioperative management; hyperglycemia alone is not a reason to delay surgery unless the patient is ketotic/dehydrated 1
• For patients with chest infections, provide prompt antibiotic therapy, supplemental oxygen, IV fluids, and physiotherapy 1
• For patients on dialysis, surgery should be tailored around dialysis schedule when possible 1

Common Pitfalls and Caveats

• Bone Cement Implantation Syndrome: Can occur during preparation of femoral canal, insertion of cement, and/or prosthesis placement. Vigilant monitoring is essential as this can lead to significant cardiovascular compromise 1

• Anticoagulation Management: Balancing the risks of thrombosis versus bleeding requires careful consideration of patient-specific factors and medication timing 1

• Infection Prevention: Patients with rheumatic diseases have higher rates of infection following arthroplasty. Careful perioperative management of immunosuppressive medications is crucial 1

• Periprosthetic Joint Infection: Early recognition and appropriate management are essential. Revision arthroplasty may be more effective than debridement, antibiotics, and implant retention (DAIR) for treating periprosthetic hip infections 3

• Postoperative Mobilization: Early mobilization should be encouraged to improve functional outcomes and reduce complications, with appropriate pain management to facilitate this 1