Hip arthroplasty

Hip arthroplasty

Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
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Total hip arthroplasty (THA) has become one of the most common orthopedic surgical procedures performed since 1960, and it is often one of the most successful. Indications for total hip arthroplasty include osteoarthritis, traumatic arthritis, avascular necrosis, post- proximal fracture arthrosis, and congenital hip dislocation. It is typically performed in patients ages 60 and over, but has been performed in patients of all ages depending on etiology. Older patients tend to require hip arthroplasty for indications like hip fracture and subsequent arthrosis/arthritis, osteoarthritis, while patients of all ages may require hip arthroplasty for indications such as traumatic arthritis and (juvenile) rheumatoid arthritis.

Preoperative management

Patient evaluation

System	Considerations
Neurologic	For RA patients, assess for cervical nerve root compression and antlanto-occipital instability. Imaging (lateral film XR) should be obtained, as well as physical examination performed, as this will alter airway and positioning plans. If regional anesthetic is planned, assess for presence of neurologic conditions (MS, neuropathies, existing nerve injuries) that may be relative contraindications to peripheral or neuraxial blocks.
Cardiovascular	Standard risk factor evaluation: more important for older patients with more cardiovascular risk factors. Often will need pharmacologic stress testing as pain and arthritis limit exercise capacity. In RA patients, consider increased risk for conduction abnormalities, valvular pathology (AR, valvular fibrosis), pericardial effusion.
Respiratory	Standard exercise capacity evaluation. In obese patients, evaluate for OSA and potential for resultant pHTN. In RA patients, consider pulmonary fibrosis, effusions, glottic narrowing. For all patients with arthritis, evaluate mouth opening (arthriticTMJ).
Gastrointestinal	Standard evaluation by H&P, testing as indicated.
Hematologic	Consider patient anticoagulation status and direct for proper holding of anticoagulation. Preoperative hemoglobin should be obtained, as well as type and screen. Consider preoperative blood order (especially if revision).
Renal	Preoperative kidney function (Cr, electrolytes) may be considered (effects on drug clearance; more important in geriatric populations).
Endocrine	Standard evaluation by H&P, testing as indicated.
Other	Consider home pain medication regimen; will help guide perioperative analgesic plan.

Labs and studies

Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P. At a minimum, all patients should have a preoperative hemoglobin and type and screen on file prior to case start. If procedure is to be a revision, strongly consider ordering preoperative packed red blood cells (PRBCs).

Operating room setup

Standard operating room setup. Airway setup, suction, IV setup, induction medications, emergency drugs, analgesic agents should be prepared and readily accessible.

Patient preparation and premedication

THA can be an extremely painful procedure for patients. It is often wise to consider a multimodal analgesic technique. Preoperative COX-2 inhbitors, gabapentin, and acetaminophen can be considered.

Regional and neuraxial techniques

Advantages to neuraxial and regional techniques include improved postoperative analgesia, decreased risk of DVT/PE, and decreased intraoperative blood loss. Neuraxial techniques (particularly spinal anesthesia) have been used with success in patients undergoing THA. Standard consideration of patient factors as they related to absolute/relative contraindications should be undertaken. Intrathecal long-acting morphine can be considered for postoperative pain control with an understanding that patient selection is important for administration of this medication given the risk for ongoing respiratory depression.

Peripheral regional nerve blocks are often used successfully

Intraoperative management

Monitoring and access

Standard ASA monitoring. Consider addition of intraoperative EEG monitoring.

2 large-bore PIV should be obtained. Arterial line for hemodynamic monitoring should be considered for revision procedures, cases with predicted significant blood loss, and for patients with significant cardiopulmonary disease.

Induction and airway management

Induction can be tailored to individual patient comorbidities and acuity. RSI induction is indicated for trauma patients or those without proper fasting per ASA guidelines. For patients with rheumatoid arthritis, special consideration should be given to the airway and potential for cervical (atlanto-occipital) instability. In these cases, videolaryngoscopy or fiberoptic intubation should be considered and utilized.

Induction and intubation on the preoperative bed prior to moving to the operating room table should be considered if possible for patients in whom it would cause significant pain (and resultant physiologic and emotional stress) to execute this move.

Positioning

If surgical approach is planned as anterior or anterolateral, supine positioning. If lateral or posterior surgical approach is planned, likely lateral decubitus positioning with the surgical side up. Can discuss with surgical team.

If lateral positioning, a beanbag and axillary roll are typically used. Additional blankets/pillows/foam will be needed for under the patients head (to ensure neutral positioning of cervical spine) and to cushion the upper extremities. Reassess padding of pressure points, eye/ear position, monitors, and PIV patency after positioning is complete and prior to case start.

Maintenance and surgical considerations

Standard maintenance. Neuromuscular blockade required if GA, as this facilitates good operating conditions and allows the surgical team to properly test and place the prostethic(s).

Emergence

Standard emergence. PONV prophylaxis dependent on patient risk factors, usually ondansetron 4mg IV.

Postoperative management

Disposition

Typically PACU. ICU disposition depending on acuity, comorbidities, and procedure planned (consider this especially with trauma patients or revision cases that have the potential for massive transfusion.

Pain management

Multimodal regimen, consider long-acting opioid agents if no contraindications or risk factors (pulmonary status). Ketamine bolus at induction or low-dose continuous infusion can act as analgesic adjunct. Consider supplementing with single shot peripheral nerve block (fascia iliaca, QL, lumbar plexus, femoral) if no contraindications and patient can tolerate positioning required for block.

Potential complications

• Bone Cement Implantation Syndrome (BCIS)--if pressurized insertion of bone cement (methylmethacrylate) is used. Signs can range from mild hypoxia and hypotension to full cardiovascular collapse. Pathophysiology is incompletely understood, but is likely multifactorial in nature consisting of microembolic showering (of air, fat, bone, cement), histamine release/hypersensitivity, complement activation. Treatment is supportive (fluids, vasopressor support, and ACLS in complete cardiovascular collapse), therefore immediate recognition and intervention is important.
• Venous Air Embolism (VAE)
• Blood Loss
• DVT
• Femoral Fracture

Procedure variants

• Depending upon surgical approach. Anterior/anterolateral approaches are performed supine, while lateral or posterior approaches are usually performed in lateral decubitus.

	Unipolar or Bipolar	Revision of THA
Unique considerations	unipolar: only femoral head replaced bipolar: femoral and acetabular side are both replaced	blood loss
Position	supine vs lateral decubitus (surgical side up)*	--
Surgical time	2-3hrs	3+ hours
EBL	250-750cc	>1000cc
Postoperative disposition	PACU	PACU vs ICU (depending on transfusion needs or acuity may need to remain intubated)
Pain management	multimodal	multimodal; if infected prosthetic, regional may be avoided depending on extent of infection, overlying infected tissue.
Potential complications	see above	see above