Hip arthroplasty

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Hip arthroplasty
Anesthesia type

General or spinal ± Regional


ETT if general

Lines and access

Large bore IV ± Arterial line


Standard ± ABP

Primary anesthetic considerations

Risk for bone cement implantation syndrome (BCIS)


Multimodal analgesia

Article quality
Editor rating
User likes

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 RA pts: assess for cervical nerve root compression and antlanto-occipital instability. Imaging (lateral film XR) and exam performed as this will alter airway and positioning plans.

If regional planned: assess for presence of neurologic conditions (MS, neuropathies, existing nerve injuries) that may be relative contraindications

Cardiovascular Standard evaluation: more important for older patients with more cardiovascular risk factors. Often will need pharmacologic stress testing as pain and arthritis limit exercise capacity.

RA patients, consider increased risk for conduction abnormalities, valvular pathology (AR, valvular fibrosis), pericardial effusion.

Pulmonary 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 including NPO status
Hematologic Consider patient anticoagulation status and direct for proper holding of anticoagulation, particularly as regional is used often in these cases. 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, blood sugar control important for postoperative wound healing
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.

Tranexamic acid prior to incision and at closure being used in greater frequency for blood loss control[1][2]

Antibiotics considerations: Beta-lactam (cefazolin) +/- glycopeptide (vancomycin)

Patient preparation and premedication

  • Multimodal analgesic technique recommended.
  • Preoperative COX-2 inhibitors, gabapentin, and acetaminophen can be considered.
  • Enhanced recovery protocols[3] are using PO multimodal medications with greater frequency

Regional and neuraxial techniques

Advantages to neuraxial and regional techniques:

  • improved postoperative pain control
  • decreased risk of DVT/PE
  • decreased intraoperative blood loss.

Neuraxial techniques (particularly spinal anesthesia) have been used with success in patients undergoing THA and especially beneficial in patients who may have a complicated or difficult airway. See discussion on drug choice.

Drug Conc. Baricity Dose Duration*




Bupivicaine[4][5] 0.75% Hyperbaric 12-16mg 90-120
Bupivicaine[4][5] 0.5% Isobaric 12-16mg 90-120
Lidocaine[4][6][7] 1-2%




60-80mg 60-90 TNS (7%)
Mepivicaine[8][9][10][11] 1.5% Isobaric 50-80mg 100-120 TNS (7%)
Chloroprocaine[12][13][14][15] 2% Hyperbaric 30-60mg 30-50 (2-level regression)

60-90 (motor)

100-130 (ambulation)

Flu-like symptoms

and back ache with

epinephrine addition

Ropivacaine[16] 0.75% Isobaric 15-22.5 mg 120 (motor)

170 (sensory)

Standard consideration of patient factors as they related to absolute/relative contraindications should be undertaken. Additional considerations for post operative mobilization. Some surgical teams and fast tracking joint replacement centers may mobilize patients as early as 2-4 hours postoperatively to help prevent DVT. [17]

Time of procedure should also be considered, as spinal anesthesia has a limited duration of action (typically 2-3 hours, depending on agents used).

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 respiratory depression and long duration of action.

Single shot peripheral regional nerve blocks can be used to improve postoperative analgesia, but are not sufficient as a primary anesthetic. Patients must be able to assume the position required to place these blocks. Blocks can help reduce postoperative opiate requirements. Blocks used include:

  • femoral
  • lumbar plexus
  • quadratus lumborum (QL)
  • fascia iliaca
  • lumbar ESP (Erector spinae plane) block
  • PENG Block (Pericapsular Nerve Group Block/Hip Block)

Intraoperative management

Monitoring and access

Standard ASA monitoring. Consider addition of intraoperative EEG monitoring (BIS or similar).

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.


Surgical Approach Lateral Posterior Anterior/Anterolateral
Position Lateral decubitus Lateral decubitus Supine
Special Equipment Axillary roll/bean bag Axillary roll/bean bag Hana Table

Traction boots attachment to Hana table

Positioning Concerns Brachial plexus injury

Neck positioning

Check PIV flow

Brachial plexus injury

Neck positioning

Check PIV flow

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.

Neuraxial vs General Anesthesia

Observations studies have suggested improved outcomes if neuraxial (particularly spinal) anesthesia is utilized as primary anesthetic over general anesthesia. A recent randomized trial out of NEJM with 1600 patients age >50 compared spinal anesthesia vs general anesthesia (GA) and found:

  • Death or inability to walk independently at 60 days: 18.5% in spinal vs 18.0% in GA (RR 1.03, 95%CI .84-1.27, P=.83)
  • Death by day 60: 3.9% in spinal vs 4.1% in GA (RR 0.97, 95%CI .59-1.57)
  • Inability to walk at day 60: 15.2% in spinal vs 14.4% in GA (RR 1.06, 95%CI .82-1.36)
  • New onset delirium: 20.5% in spinal vs 19.7% in GA (RR 1.04, 95%CI .84-1.30)
  • Median time to discharge in US: 3 days in spinal vs 3 days in GA (RR 1.06, 95%CI .96-1.16)

In general according to this study, spinal anesthesia was not superior to general anesthesia with respect to 60 day survival and ambulation. Additional postoperative delirium was similar between spinal and GA. [18]

Evidence for TXA

Tranexamic acid (TXA) is an antifibrinolytic agent often used in cardiac and trauma surgery to reduce clot breakdown and subsequent bleeding. TXA has been introduced into procedures with bleeding risk and has been shown to help decrease transfusions and overall blood loss.

Meta analysis of TXA use in total hip arthroplasty reveled strong evidence to reduce blood loss and risk of transfusion.[19] When compared with placebo, IV administration of TXA reduced blood loss by 504 mL and decreased the number of units transfused per patient by 1.43 units. In this meta-analysis, 14 of 15 studies used low doses (10 to 50 mg/kg) of TXA, and the remaining study used a high-dose (150 mg/kg) regimen.[20]

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).


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

Postoperative management


Typically PACU.

Specialty centers are conducting same-day discharge[21][22] for pre-screened populations[23] with low-comorbidities and with adequate home support structure

ICU disposition depending on acuity, co-morbidities, 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 ( while hammering of femoral head into acetabulum). 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)
  • Venous Fat Embolism
  • 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 Anterior Approach
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 Femoral artery injury

during dissection between vastus lateralis and sartorius

Enhanced Recovery after Surgery (ERAS):


  1. Rajesparan, K.; Biant, L. C.; Ahmad, M.; Field, R. E. (2009-06). "The effect of an intravenous bolus of tranexamic acid on blood loss in total hip replacement". The Journal of Bone and Joint Surgery. British Volume. 91 (6): 776–783. doi:10.1302/0301-620X.91B6.22393. ISSN 2044-5377. PMID 19483232. Check date values in: |date= (help)
  2. Peng Zhang, M. M.; Jifeng Li, M. M.; Xiao Wang, M. M. (2017-07). "Combined versus single application of tranexamic acid in total knee and hip arthroplasty: A meta-analysis of randomized controlled trials". International Journal of Surgery (London, England). 43: 171–180. doi:10.1016/j.ijsu.2017.05.065. ISSN 1743-9159. PMID 28602763. Check date values in: |date= (help)
  3. Wainwright, Thomas W.; Gill, Mike; McDonald, David A.; Middleton, Robert G.; Reed, Mike; Sahota, Opinder; Yates, Piers; Ljungqvist, Olle (2020-01-02). "Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations". Acta Orthopaedica. 91 (1): 3–19. doi:10.1080/17453674.2019.1683790. ISSN 1745-3674. PMC 7006728. PMID 31663402.CS1 maint: PMC format (link)
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  6. Liam, B. L.; Yim, C. F.; Chong, J. L. (1998-07). "Dose response study of lidocaine 1% for spinal anaesthesia for lower limb and perineal surgery". Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie. 45 (7): 645–650. doi:10.1007/BF03012094. ISSN 0832-610X. PMID 9717596. Check date values in: |date= (help)
  7. Pawlowski, Julius; Orr, Kevin; Kim, Ku-Mie; Pappas, Ana Lucia; Sukhani, Radha; Jellish, W. Scott (2012-03). "Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures". Journal of Clinical Anesthesia. 24 (2): 109–115. doi:10.1016/j.jclinane.2011.06.014. ISSN 1873-4529. PMID 22342508. Check date values in: |date= (help)
  8. Pawlowski, Julius; Orr, Kevin; Kim, Ku-Mie; Pappas, Ana Lucia; Sukhani, Radha; Jellish, W. Scott (2012-03). "Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures". Journal of Clinical Anesthesia. 24 (2): 109–115. doi:10.1016/j.jclinane.2011.06.014. ISSN 1873-4529. PMID 22342508. Check date values in: |date= (help)
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  11. Schwenk, Eric S.; Kasper, Vincent P.; Smoker, Jordan D.; Mendelson, Andrew M.; Austin, Matthew S.; Brown, Scot A.; Hozack, William J.; Cohen, Alexa J.; Li, Jonathan J.; Wahal, Christopher S.; Baratta, Jaime L. (2020-10-01). "Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation". Anesthesiology. 133 (4): 801–811. doi:10.1097/ALN.0000000000003480. ISSN 1528-1175. PMID 32852904.
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