Hip arthroplasty
Anesthesia type GA vs Neuraxial (spinal)
Airway ETT
Lines and access large bore PIV x2, +/- arterial line
Monitors Standard ASA
Primary anesthetic considerations
Preoperative Standard
Intraoperative Risk for bone cement implantation syndrome (BCIS)
Postoperative Multimodal analgesia

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.

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
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
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.

  • Two level regression
Drug Conc. Baricity Dose Duration*

(min)

Unique

Side-Effects

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%

5%

Isobaric;

hyperbaric

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

Standard consideration of patient factors as they related to absolute/relative contraindications should be undertaken.

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 used include:

  • femoral
  • lumbar plexus
  • quadratus lumborum (QL)
  • fascia iliaca

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

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.

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.

Specialty centers are conducting same-day discharge[16][17] for pre-screened populations[18] 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):

References

  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)
  4. 4.0 4.1 4.2 Frey, K.; Holman, S.; Mikat-Stevens, M.; Vazquez, J.; White, L.; Pedicini, E.; Sheikh, T.; Kao, T. C.; Kleinman, B.; Stevens, R. A. (1998-03). "The recovery profile of hyperbaric spinal anesthesia with lidocaine, tetracaine, and bupivacaine". Regional Anesthesia and Pain Medicine. 23 (2): 159–163. doi:10.1097/00115550-199823020-00008. ISSN 1098-7339. PMID 9570604. Check date values in: |date= (help)
  5. 5.0 5.1 Malinovsky, J. M.; Charles, F.; Kick, O.; Lepage, J. Y.; Malinge, M.; Cozian, A.; Bouchot, O.; Pinaud, M. (2000-12). "Intrathecal anesthesia: ropivacaine versus bupivacaine". Anesthesia and Analgesia. 91 (6): 1457–1460. doi:10.1097/00000539-200012000-00030. ISSN 0003-2999. PMID 11094000. Check date values in: |date= (help)
  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)
  9. Pawlowski, J.; Sukhani, R.; Pappas, A. L.; Kim, K. M.; Lurie, J.; Gunnerson, H.; Corsino, A.; Frey, K.; Tonino, P. (2000-09). "The anesthetic and recovery profile of two doses (60 and 80 mg) of plain mepivacaine for ambulatory spinal anesthesia". Anesthesia and Analgesia. 91 (3): 580–584. doi:10.1097/00000539-200009000-00015. ISSN 0003-2999. PMID 10960380. Check date values in: |date= (help)
  10. Zayas, V. M.; Liguori, G. A.; Chisholm, M. F.; Susman, M. H.; Gordon, M. A. (1999-11). "Dose response relationships for isobaric spinal mepivacaine using the combined spinal epidural technique". Anesthesia and Analgesia. 89 (5): 1167–1171. ISSN 0003-2999. PMID 10553828. Check date values in: |date= (help)
  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.
  12. Goldblum, E.; Atchabahian, A. (2013-05). "The use of 2-chloroprocaine for spinal anaesthesia: Chloroprocaine for spinal anaesthesia". Acta Anaesthesiologica Scandinavica. 57 (5): 545–552. doi:10.1111/aas.12071. Check date values in: |date= (help)
  13. Lacasse, Marie-Andrée; Roy, Jean-Denis; Forget, Josée; Vandenbroucke, Franck; Seal, Robert F.; Beaulieu, Danielle; McCormack, Michael; Massicotte, Luc (2011-04). "Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: a double-blind randomized trial". Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 58 (4): 384–391. doi:10.1007/s12630-010-9450-x. ISSN 0832-610X. Check date values in: |date= (help)
  14. Kouri, Mary E.; Kopacz, Dan J. (2004-01). "Spinal 2-Chloroprocaine: A Comparison with Lidocaine in Volunteers:". Anesthesia & Analgesia: 75–80. doi:10.1213/01.ANE.0000093228.61443.EE. ISSN 0003-2999. Check date values in: |date= (help)
  15. Smith, Kristin N.; Kopacz, Dan J.; McDonald, Susan B. (2004-01). "Spinal 2-chloroprocaine: a dose-ranging study and the effect of added epinephrine". Anesthesia and Analgesia. 98 (1): 81–88, table of contents. doi:10.1213/01.ane.0000093361.48458.6e. ISSN 0003-2999. PMID 14693591. Check date values in: |date= (help)
  16. Amundson, Adam W.; Panchamia, Jason K.; Jacob, Adam K. (2019-06). "Anesthesia for Same-Day Total Joint Replacement". Anesthesiology Clinics. 37 (2): 251–264. doi:10.1016/j.anclin.2019.01.006. Check date values in: |date= (help)
  17. Li, Jinlei; Rubin, Lee E.; Mariano, Edward R. (2019-10). "Essential elements of an outpatient total joint replacement programme". Current Opinion in Anaesthesiology. 32 (5): 643–648. doi:10.1097/ACO.0000000000000774. ISSN 0952-7907. Check date values in: |date= (help)
  18. Ziemba-Davis, Mary; Caccavallo, Peter; Meneghini, R. Michael (2019-07). "Outpatient Joint Arthroplasty—Patient Selection: Update on the Outpatient Arthroplasty Risk Assessment Score". The Journal of Arthroplasty. 34 (7): S40–S43. doi:10.1016/j.arth.2019.01.007. Check date values in: |date= (help)