Current Guidelines for Total Hip Arthroplasty
Pain Management Protocol
The current standard for THA pain management is multimodal analgesia with paracetamol plus NSAIDs or COX-2 inhibitors as the foundation, combined with intravenous dexamethasone 8-10mg, while avoiding routine opioids and neuraxial blocks. 1, 2
Preoperative and Intraoperative Interventions
Paracetamol (acetaminophen) should be administered preoperatively and continued postoperatively at 1g every 6 hours, not exceeding 4g daily (Grade A recommendation) 1, 2, 3
NSAIDs or COX-2 selective inhibitors must be given regularly for optimal anti-inflammatory effect, not as-needed dosing (Grade A recommendation) 1, 2
Dexamethasone 8-10mg intravenous is recommended as a single intraoperative dose (Grade A recommendation) 1, 2
Preoperative exercise and patient education significantly reduce postoperative pain and improve functional outcomes (Grade A recommendation) 1, 2
Regional anesthesia options include single-shot fascia iliaca block or local infiltration analgesia (Grade D recommendation) 1, 2
Postoperative Management
Continue paracetamol and NSAIDs/COX-2 inhibitors as scheduled medications, not as-needed (Grade A recommendation) 1, 2, 3
Opioids should be reserved strictly for rescue analgesia only, never as scheduled dosing (Grade D recommendation) 1, 2, 3
Early mobilization should begin immediately, facilitated by optimal multimodal analgesia 2, 3
Critical Techniques to Avoid
Do not use femoral nerve blocks, lumbar plexus blocks, or epidural analgesia as adverse effects outweigh benefits and these techniques delay mobilization 2, 3
Intrathecal morphine remains controversial - while it provides analgesia, it causes significant nausea, vomiting, pruritus, delayed ambulation, and requires 24-hour monitoring, making it incompatible with modern early rehabilitation protocols 1
Gabapentinoids should not be used routinely due to side effects without proven benefit 3
Biomaterials and Implant Longevity Updates
Highly cross-linked polyethylene (HXLPE) has become the gold standard acetabular bearing material, demonstrating exceptional wear resistance with mean linear wear of only 0.04-0.05 mm/year at 15+ years follow-up. 4, 5
Polyethylene Advances
HXLPE shows dramatically reduced wear compared to conventional polyethylene (0.05 mm/year versus 0.26 mm/year) with volumetric wear of only 6.22 mm³/year at 15-17 year follow-up 4, 5
No osteolysis or mechanical loosening has been observed in large cohorts of patients aged ≤50 years at minimum 15-year follow-up using HXLPE 4
Second-generation improved polyethylenes with antioxidant additives and free radical scavengers are now available, showing further improvements in oxidation resistance 6, 7
Antioxidant-doped polyethylene liners represent the latest evolution, addressing the historical problem of oxidative degradation 1, 6
Bearing Surface Options
Metal-on-highly cross-linked polyethylene remains the most reliable combination with proven long-term durability 1, 4, 7
Ceramic-on-polyethylene and ceramic-on-ceramic articulations are alternative options with low wear characteristics 1, 7
Metal-on-metal prostheses should be avoided due to high short-term failure rates, adverse local tissue reactions (ALTR), metallosis, pseudotumor formation, and recalls 1, 7
Fixation and Design
Cementless fixation with osseointegration is the predominant technique for younger, active patients 4, 7
Median head size of 28mm has shown excellent long-term results, though larger heads are used in specific instability scenarios 4
Constrained liners should be reserved for severe ligamentous instability or neuropathic joints, not used routinely 8
Expected Implant Survivorship
HXLPE in patients ≤50 years old demonstrates excellent clinical outcomes with Harris Hip Scores improving from mean 52.8 preoperatively to 94.8 postoperatively at 15+ years 4
Overall THA survivorship exceeds 85% at 15 years across different patient populations, surgeons, and designs 6
Primary causes of revision (2012-2019) are infection/inflammatory reaction (19.3%), instability (17.4%), and aseptic loosening (15.8%), with wear/osteolysis accounting for only 7.5% 1
Imaging Surveillance
Routine radiographs remain the primary surveillance tool for uncomplicated primary hip prostheses 1
Metal artifact reduction sequences (MARS-MRI) enable assessment of soft tissues, pseudocapsule, tendons, and neurovascular structures around prosthetic hips without artifact interference 1
Ultrasound can assess superficial soft tissues adjacent to hip arthroplasties without prosthetic artifacts, though limited for deep structures 1
Common Pitfalls to Avoid
Do not assume treatment failure without proper medication optimization - scheduled paracetamol plus NSAIDs should minimize or eliminate opioid requirements 3
Avoid NSAIDs in patients with gastrointestinal anastomoses due to potential correlation with dehiscence 3
Do not delay THA in patients with severe ligamentous instability or neuropathic joints as this increases technical difficulty, bone loss, and deformity without improving outcomes 8
Monitor for metal-on-metal complications in patients with older prostheses, including ALTR, pseudotumors, and metallosis 1, 7