Guidelines for Total Hip Replacement (THR)
Anesthesia and Primary Analgesic Technique
For primary total hip replacement, use either general anesthesia combined with a peripheral nerve block (continued postoperatively) OR intrathecal (spinal) injection of local anesthetic and opioid. 1
Preoperative and Intraoperative Analgesia
- Administer paracetamol plus NSAIDs or COX-2 selective inhibitors preoperatively and intraoperatively 2
- Give intravenous dexamethasone 8-10mg 2
- Perform fascia iliaca block or local infiltration analgesia as part of the regional anesthetic approach 2
Regional Anesthesia Considerations
- Avoid femoral nerve blocks, lumbar plexus blocks, and epidural analgesia due to adverse effects outweighing benefits, particularly motor blockade that delays mobilization 2
- The evidence supporting avoidance of these techniques is moderate quality but clinically significant given the impact on early rehabilitation 2
Postoperative Pain Management
Implement a multimodal step-down analgesic approach combining paracetamol plus conventional NSAIDs, with opioids reserved for rescue only. 1, 2
Analgesic Hierarchy
- First-line: Continue paracetamol and NSAIDs/COX-2 inhibitors postoperatively 2
- Second-line: Add weak opioids only if inadequate pain control 1
- Third-line: Strong opioids as rescue medication when necessary 1
Rationale for Step-Down Approach
- This strategy minimizes opioid-related side effects (nausea, sedation, respiratory depression) that can impair early mobilization 1
- Effective pain control with minimal side effects is critical for timely mobility and optimal functional recovery, particularly in elderly patients with comorbidities 1
Patient Selection and Preoperative Optimization
Indications for Surgery
- Radiologically demonstrated advanced hip osteoarthritis (Kellgren and Lawrence grade 3 or 4) 3
- At least three months of failed conservative treatment 3
- High subjective distress from hip joint symptoms 3
Contraindications
Preoperative Optimization Requirements
- Smoking cessation: Stop at least one month before surgery 3
- Diabetes control: Achieve HbA1c below 8% preoperatively 3
- Weight reduction: Target BMI below 30 kg/m² when possible 3
- Preoperative exercise and education: Implement structured programs (Grade A recommendation) 2
Critical Caveat
- Worse preoperative condition correlates with poorer surgical outcomes, emphasizing the importance of optimization 3
Postoperative Rehabilitation
Facilitate early mobilization through optimal multimodal analgesia starting immediately postoperatively. 2
- Early mobilization is a Grade A recommendation with high-quality evidence supporting improved functional outcomes 2
- The analgesic regimen must be designed specifically to avoid motor blockade that would impede mobilization 2
Special Population Considerations
Elderly Patients with Comorbidities
- THR patients are typically elderly with significant comorbidities including hypertension, ischemic heart disease, renal dysfunction, obstructive pulmonary disease, vascular diseases, diabetes mellitus, and obesity 1
- These conditions adversely affect perioperative management and increase the importance of choosing analgesic regimens with minimal side effects 1
- The goal is to decrease postoperative morbidity and mortality through effective pain control that enables early mobilization 1
Evidence Quality Note
The most recent PROSPECT guideline from 2021 1 represents an update of earlier 2005 1 and 2010 recommendations, incorporating literature through December 2019 and using refined methodology that balances procedure-specific efficacy against general risks and invasiveness 1. The 2025 Praxis Medical Insights summary 2 consolidates recommendations from major societies including the American Society of Anesthesiologists, American Pain Society, and American College of Sports Medicine, providing the most current evidence-based approach.