How quickly should an adult patient with a history of hip arthritis prepare for a total hip replacement surgery scheduled in three weeks?

How to Prepare for Total Hip Replacement in Three Weeks

For a patient with hip arthritis scheduled for total hip replacement in three weeks, proceed with surgery without delay—no mandatory waiting period or additional conservative treatments are needed if nonoperative therapies have already been attempted. 1

General Surgical Readiness

The 2023 American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines explicitly state there should be no arbitrary 3-month "cool-down" period mandated before total joint arthroplasty (TJA). 1 Since patients indicated for surgery have already attempted nonoperative treatment for an extended period, further delays may lead to:

• Increased pain and loss of function 1
• Worsening medical comorbidities due to limited mobility 1
• Deterioration in quality of life 2

Risk Factor Optimization (If Applicable)

While surgery should not be delayed arbitrarily, the three-week window provides an opportunity to address modifiable risk factors through shared decision-making:

Diabetes Control

If the patient has poorly controlled diabetes, conditionally recommend delaying surgery to improve glycemic control. 1 This is the only condition where delay is specifically recommended, as poor glycemic control increases surgical and medical complications. 1

Nicotine Use

If the patient uses nicotine, conditionally recommend delaying for nicotine reduction or cessation. 1 Patients should be counseled on effective cessation methods and provided resources, though it's recognized not all patients have access to these resources. 1

Body Mass Index (BMI)

• For BMI ≥50,40-49, or 35-39: Proceed without delaying for weight reduction 1
• Weight loss should not be a barrier to surgery in this timeframe 1

Medication Management

Anticoagulation for VTE Prophylaxis

Low molecular weight heparin (LMWH) is the preferred prophylaxis method for elective hip replacement rather than warfarin, as it is more effective in preventing asymptomatic venous thromboembolism. 1 This will be initiated perioperatively by the surgical team.

Antirheumatic Medications (If Applicable)

If the patient takes disease-modifying antirheumatic drugs or biologics:

• Biologic agents: Plan surgery at the end of the dosing cycle (e.g., adalimumab dosed every 2 weeks—schedule surgery in week 3) 1
• JAK inhibitors (tofacitinib, baricitinib, upadacitinib): Withhold for at least 3 days prior to surgery 1
• Traditional DMARDs (methotrexate): Continue through the surgical period in most cases 1

What NOT to Do

Do not delay surgery for:

• Mandatory physical therapy trials 1
• Additional NSAID trials 1
• Intraarticular glucocorticoid or viscosupplementation injections 1
• Braces or ambulatory aids 1

These interventions provide limited benefit in patients already indicated for surgery and may cause harm through delayed definitive treatment. 1

Preoperative Information and Preparation

Providing comprehensive preparatory information improves physical recovery outcomes. 3 Patients should receive:

• Procedural information about the surgical process
• Sensory information about what to expect
• Coping strategies for the postoperative period
• Written materials to support verbal information 3

This preparation has been shown to reduce postoperative analgesic requirements, facilitate earlier mobilization, and shorten hospital stays by an average of 2 days. 3

Common Pitfalls to Avoid

• Avoid mandating arbitrary waiting periods: The evidence strongly opposes delaying surgery without specific medical indications 1
• Avoid intraarticular injections close to surgery: If glucocorticoid injections are considered, there is increased risk of joint infection if surgery occurs within 3 months 1
• Don't assume all patients can modify risk factors: Recognize that not all patients have the medical, financial, or social resources to address BMI, glycemic control, or nicotine dependence 1

Timeline for the Three-Week Period

• Week 1: Medical evaluation focusing on diabetes control and nicotine use; medication review and adjustment planning
• Week 2: Continue optimization of modifiable risk factors; provide comprehensive preoperative education
• Week 3: Final preoperative assessment; ensure appropriate timing of medication withholding if applicable

The emphasis should be on proceeding to surgery efficiently while addressing only those risk factors (diabetes, nicotine) where delay is conditionally recommended based on evidence. 1