What is the criteria and procedure for a total hip replacement?

Total Hip Replacement: Criteria and Procedure

Indications for Total Hip Replacement

Total hip arthroplasty is indicated for end-stage hip osteoarthritis with persistent, severe pain and functional limitation when conservative treatment has failed and the patient desires surgical intervention. 1, 2

Patient Selection Criteria

• Primary indication: Symptomatic osteoarthritis causing high degree of persistent suffering despite conservative management 2, 3
• Age consideration: Typically patients 50 years or older, though age alone is not an absolute criterion 3, 4
• Clinical triad required: Concordant medical history, clinical examination findings, and radiographic evidence of end-stage arthritis 3
• Patient factors: Realistic expectations about outcomes and understanding of risks/benefits are essential predictive factors for good subjective outcomes 3
• Functional goals: Patient desires pain relief and improved mobility/quality of life that conservative therapy cannot provide 1

Common Comorbidities to Assess

The typical THR patient is elderly with significant comorbid conditions that affect perioperative management 1:

• Hypertension 1
• Ischaemic heart disease 1
• Renal dysfunction 1
• Obstructive pulmonary disease 1
• Vascular diseases 1
• Diabetes mellitus 1
• Obesity 1

Surgical Procedure Overview

The procedure involves replacement of the damaged hip joint with an artificial prosthesis, with cemented components using polyethylene-on-ceramic articulation being the most cost-effective option across all age groups. 5

Prosthesis Selection

• Most cost-effective: Cemented components with polyethylene-on-ceramic articulation (Category E) demonstrated lower costs and higher quality-adjusted life-years across all age and sex groups 5
• Alternative for older patients: Cemented components with polyethylene-on-metal articulation (Category A) may be more cost-effective in older age groups specifically 5
• Avoid: Hip resurfacing arthroplasty has higher revision rates, higher costs, and lower QALYs compared to THR and is dominated by THR in cost-effectiveness analyses 5

Technical Considerations

• Larger femoral head sizes confer benefit 5
• Cemented cup fixation preferred over cementless 5
• Cross-linked polyethylene cup liner preferred over traditional polyethylene 5
• Ceramic-on-ceramic articulation shows advantages over metal-on-polyethylene 5

Anesthetic and Analgesic Management

Preoperative and Intraoperative Analgesia

Multimodal analgesia with paracetamol plus NSAIDs/COX-2 inhibitors combined with intravenous dexamethasone 8-10mg should be administered preoperatively. 6

• Basic analgesia: Paracetamol (acetaminophen) 1g every 6 hours (maximum 4g daily) plus NSAIDs or COX-2 selective inhibitors 6, 7
• Corticosteroid: Intravenous dexamethasone 8-10mg 6
• Regional anesthesia: Fascia iliaca block or local infiltration analgesia (moderate to high quality evidence) 6
• Primary anesthetic technique: Either general anesthesia combined with peripheral nerve block continued postoperatively OR intrathecal (spinal) injection of local anesthetic and opioid 1

Postoperative Pain Management

Continue paracetamol and NSAIDs/COX-2 inhibitors postoperatively with opioids reserved strictly for rescue only, never scheduled dosing. 6, 7

• Scheduled medications: Continue paracetamol and NSAIDs/COX-2 inhibitors regularly for optimal anti-inflammatory effect 6, 7
• Opioids: Grade D recommendation—rescue analgesia only, not scheduled 6, 7
• Step-down approach: Paracetamol plus NSAIDs with strong or weak opioids as required 1

Techniques to AVOID

Do not use femoral nerve blocks, lumbar plexus blocks, or epidural analgesia for postoperative pain management as adverse effects outweigh benefits. 6, 7

• These techniques have moderate quality evidence showing harm exceeds benefit 6
• Femoral nerve blocks increase risk of falls and delay mobilization 6

Rehabilitation and Recovery

Early Mobilization Protocol

Early mobilization should begin immediately, facilitated by optimal multimodal analgesia (Grade A recommendation). 6

• Preoperative preparation: Preoperative exercise and patient education (Grade A recommendation, high quality evidence) 6
• Physical therapy options: Either formal physical therapy or unsupervised home exercise are equally acceptable after THR 7
• Goal: Timely mobility to optimize functional recovery and decrease postoperative morbidity and mortality 1

Expected Outcomes

Total hip replacement results in clinically important, superior reduction in hip pain and improved function at 6 months compared to resistance training, with mean improvement of 15.9 points on the Oxford Hip Score. 4

• THR showed 11.4-point greater improvement than resistance training (95% CI: 8.9 to 14.0; P<0.001) 4
• Revision rates for modern THR are low (1.6% to 3.5% at 9 years) 5
• Serious adverse events are primarily known complications of THR surgery 4

Critical Pitfalls to Avoid

• Do not assume treatment failure without proper medication optimization: Scheduled acetaminophen and NSAIDs should minimize or eliminate opioid requirements 7
• Avoid NSAIDs in patients with colon or rectal anastomoses due to potential correlation with dehiscence 7
• Do not use gabapentinoids routinely for hip arthroplasty due to side effects without proven benefit 7
• Use acetaminophen cautiously in liver disease and never exceed 4g daily 7