What is the process for undergoing hip replacement at a clinic?

Hip Replacement at a Clinic: Process and Key Considerations

Patient Selection and Timing

For elective hip replacement, patients with moderate-to-severe radiographic osteoarthritis or advanced osteonecrosis who have failed ≥1 trial of appropriate nonoperative therapy (physical therapy, NSAIDs, intraarticular injections) should proceed to surgery without arbitrary delay rather than waiting an additional 3 months. 1

• The 2023 ACR/AAHKS guidelines conditionally recommend proceeding to total joint arthroplasty (TJA) without delay over delaying arthroplasty 3 months in patients who have already attempted nonoperative treatment for an extended period 1
• There should be no mandate for an arbitrary "cool-down period" before surgery 1
• Joint replacement must be considered in patients with radiographic evidence of hip osteoarthritis who have refractory pain and disability 1

Pre-operative Assessment and Optimization

Patients require multidisciplinary evaluation involving orthopedic surgeons, anesthesiologists, and orthogeriatricians to identify and treat co-morbidities without unnecessarily delaying surgery. 1

Critical Risk Factor Modification:

• BMI optimization: Patients should be educated on increased surgical complication risks and provided resources for weight loss 1
• Glycemic control: Diabetic patients require optimization before surgery 1
• Nicotine cessation: Patients must be counseled on effective cessation methods and provided resources 1
• Cardiac evaluation: Echocardiography is indicated if the patient is breathless at rest/low-level exertion or if significant aortic stenosis is suspected 1

Pre-operative Protocols Must Include:

• Monitoring: pulse oximetry, respiratory rate, ECG, non-invasive blood pressure, core temperature, and pain scores 1
• Intravenous fluid therapy and cannulation 1
• Analgesia protocols with regular paracetamol and cautious opioid use (particularly with renal dysfunction) 1
• Femoral or fascia iliaca nerve blocks for pain control 1

Surgical Procedure

For displaced femoral neck fractures in elderly patients, arthroplasty is the treatment of choice, with cemented femoral stems strongly recommended. 2

Anesthesia Selection:

• Either spinal or general anesthesia is acceptable, though spinal anesthesia may reduce postoperative confusion in elderly patients 3
• Multimodal analgesia incorporating preoperative femoral nerve block provides optimal pain control 3

Critical Intraoperative Steps:

• Tranexamic acid must be administered at surgery start to reduce blood loss and transfusion requirements 2, 3
• The surgeon must verbally announce to the anesthesiologist before instrumenting the femoral canal 3
• Maintain systolic blood pressure within 20% of pre-induction values using vasopressors and/or fluids 3
• Use pressurized lavage to clean the endosteal bone of fat and marrow 3
• Insert cement in retrograde fashion; avoid excessive manual pressurization in patients at higher cardiovascular risk 3

Surgical Team Requirements:

• Patients should be operated on by appropriately experienced surgeons to minimize operative time, blood loss, and complication rates 1
• A core group of consultants with relevant experience should provide the majority of the service rather than randomly-allocated consultants 1
• The minimum theatre team consists of an operating department practitioner, two scrub practitioners, and a circulator 1

Postoperative Management

Immediate weight-bearing as tolerated is recommended after surgery, with VTE prophylaxis continued for 4 weeks postoperatively. 2

Essential Postoperative Elements:

• Allow immediate weight-bearing as tolerated (limited strength option) 2
• Continue VTE prophylaxis for 4 weeks with enoxaparin or equivalent 2
• Refer patients to Fracture Liaison Service or Bone Health Clinic for osteoporosis evaluation and secondary fracture prevention 2
• Implement interdisciplinary care with orthogeriatric comanagement to decrease complications 2

Expected Outcomes and Complications

Total hip replacement achieves pain-free status in 43-84% of patients, with revision rates of 0.18-2.04 per 100 person-years. 1

Common Complications to Monitor:

• Infection, loosening, dislocation 4
• Phlebothrombosis and embolism 4
• Neurovascular deficits 4
• Bone cement implantation syndrome (occurs in ~20% of cemented cases, particularly in elderly males with cardiopulmonary disease) 3
• Up to 27% of patients experience some discomfort, with 6% experiencing severe chronic pain 5

Critical Caveat:

The evidence base for many common orthopedic procedures, including total hip replacement, is limited and of low quality, with most recommendations being conditional rather than strong 1. However, the procedure remains highly successful with appropriate patient selection and perioperative management 6.