Total Hip Arthroplasty

• Use of ERAS programmes for those undergoing hip arthroplasty:
• Reduces length of stay, especially in healthier patients
• No increase in perioperative complications
• Reduces blood transfusion rates
• Reduces complication rate, including mortality
• Day-case arthroplasty programmes can improve healthcare efficiency by reducing cancellations due to lack of beds, though requires protocolised practice, strong MDT working and consistent communication throughout

• Pre-operative exercise programmes and education are recommended ('joint schools')
• Home-based prehabilitation programmes may improve perioperative pain and function, although not necessarily length of stay
• Educational components help manage patient's expectations; education about post-operative pain can reduce opioid consumption by half

• Even mild anaemia is associated with significantly increased risk of perioperative complications following total hip arthroplasty
• Severe anaemia doubles the risk of complications

• Smoking cessation for at least 4 weeks
• Alcohol cessation programme if history of abuse


• Reduce perioperative fasting time
• Use 'sip-to-send' policy
• Preoperative carbohydrate loading both the night before and the morning of surgery
• Bladder void immediately pre-theatre

• AAGBI monitoring
• If patient is positioned laterally, put cannula in operative side

• Neuraxial techniques are recommended for elective hip arthroplasty, as they are associated with:


Benefits of spinal anaesthesia for hip arthroplasty

↓ mortality (OR 0.67)

↓ pneumonia (OR 0.69)

↓ AKI (OR 0.69)

↓ DVT & PE (OR 0.61)

↓ Stroke (OR 0.37)

↓ POCD (OR 0.39)

↓ PONV

↓ Post-operative pain scores at up to 72hrs

↓ Post-operative opioid use

• The risk of MI is unchanged vs. GA
• The risk of urinary retention is higher following spinal techniques, especially if intrathecal opioids are used
• There is a risk of delayed early recovery because of syncopal symptoms/orthostatic intolerance due to prolonged vasomotor block
• Risk can be reduced by using short-acting agents such as prilocaine

• Spinal anaesthesia
• Bupivacaine (plain or heavy) and prilocaine are options; chloroprocaine may be too short-acting even for experienced surgical hands
• Aim to limit bupivacaine dose to 10mg i.e. 2ml 0.5% plain marcaine or 3-4ml 0.25% marcaine


• Intrathecal opioids
• Addition of intrathecal morphine (100μg) can improve post-operative analgesia vs. standard care for up to 16hrs post-op.
• Doses of 100μg or below are not associated with increased sedation or PONV
• Doses above 100μg may increase side-effects without providing additional analgesia
• Use of IT morphine is associated with higher rates of pruritus, urinary retention/catheterisation/UTI and sedation
• Overall not recommended, but may be useful in those having complex or revision hip arthroplasty, or those with complex pain syndromes


• Epidural/CSE is an option, especially for anticipated complex or revision cases


• ± procedural sedation
• E.g. propofol TCI
• Patient-controlled procedural sedation is associated with fewer sedation-associated adverse events than anaesthetist-led TCI (BJA, 2021)
• Avoid benzodiazepines where possible

• May be necessary in patients where neuraxial techniques are contraindicated, or have failed
• Requires alternative analgesia e.g. from regional techniques (see below) in addition to a standard multimodal analgesic regimen

• Tranexamic acid
• Usually 1g at induction, although there may be variable surgical requests regarding:
• Timing e.g. pre-tourniquet, prior to tourniquet release, further doses post-operatively
• Dosing e.g. 1g, 2g, 15mg/kg
• Route e.g. post-operative oral dosing
• NICE recommend IV TXA + 1-2g intra-articular TXA after the final washout


• Antibiotics as per local policy
• Intraosseous vancomycin may reduced perioperative joint infection


• VTE prophylaxis; typically 4 - 5 weeks of post-operative prophylaxis are required (LMWH, aspirin or DOAC)

• Patient's recovery trajectory may be impacted by:
• Surgical approach e.g. muscle-sparing anterior or posterior approaches
• Degree of deformity and stiffness, which will determine the extent of soft tissue release
• Whether implants are cemented or uncemented
• Robotic-assisted hip arthroplasty is associated with reduced early post-operative pain at the extent of prolonged surgical time during the learning curve

• Paracetamol
• NSAID (if no contraindication) - either IV or as part of orthopaedic infiltration


• Dexamethasone
• PROSPECT guidance recommends a single dose of 8-10mg
• Use is associated with reduced pain, opioid consumption, PONV, fatigue and length of stay
• A second IV dose 24hrs post-op. confers additional benefit over a single dose without increasing side-effects or complications


• Consider intra-operative adjuncts such as:
• Ketamine 0.1-0.3mg/kg IV
• Magnesium 50mg/kg IV over 30mins

• Patients are at risk of
1. Hyponatraemia, owing to a combination of dehydration, poor free water tolerance (age, SIADH, comorbid)
• 30% mild
• 1% severe
• 0.1 - 0.2% severe AND symptomatic


2. AKI (5%)


• If the patient is uncatheterised, give ~500ml in theatre and a further 500ml slowly on return to the ward
• If the patient is catheterised, aim to give closer to 2,000ml as this is associated with lower incidences of AKI and hyponatraemia

• Use of peripheral nerve block is associated with a significant reduction in complications, including:
• Respiratory failure
• Surgical site infection
• Post-operative delirium
• It is recommended in guidelines focused on perioperative pain, although the degree of motor block and consequent impact on post-operative mobility must be considered

• Benefits from being available even if regional anaesthetic techniques aren't available
• May improve pain scores, reduce opioid requirements and reduce LOS

• Provides clinically beneficial analgesia without increasing risk of complications such as falls
• More effective than femoral nerve block and lumbar plexus block, with fewer risks
• In theory causes motor block therefore impairs mobilisation after surgery, which may make it unsuitable especially in day-case arthroplasty
• However, a supra-inguinal approach has been shown to be non-inferior to PENG block with regards to walking capacity post-operatively
• Inferior to intrathecal morphine with respect to post-operative opioid consumption

• Inferior to local anaesthetic infiltration over the first 24hrs with respect to pain scores and opioid consumption
• Causes quadriceps motor block, impairing post-operative mobilisation

• Most reliable technique for blocking the femoral, obturator and lateral cutaneous nerves
• Good analgesic effect for up to eight hours ± longer if catheter technique used
• A deep block which is technically difficult
• Associated with serious complications including psoas abscess, psoas haemorrhage and renal injury

• Similar to lumbar plexus block, is a deep block whose use if confounded by technical difficulty and risk of significant complications

• Avoids motor block
• May not cover full extent of cutaneous excision depending on surgical approach
• Marginal analgesic benefit

• Inconsistent results for hip analgesia although some suggestion it reduces pain scores at 24hrs and opioid requirements up to 48hrs post-operatively
• Mechanism of action unclear; probably via spread of LA to the lumbar plexus
• Suffers from higher technical requirements and potential risks

• Targets the proximal articular branches of the femoral, obturator and accessory obturator nerves as they pass over the iliopubic ramus
• Other theoretical mechanisms:
• Absorption into iliopsoas and reduced muscle spasm
• Systemic absorption causing analgesia as with other fascial plane blocks


• Maximum effective volume in 90% of cases is 13ml
• Involves injection of local anaesthetic deep to iliopsoas, in theory sparing the motor branches of the femoral nerve
• However in 45% of patients there is motor weakness at 3hrs and 25% at 6hrs post-block
• The degree of motor weakness is comparable to LIA techniques


• Reduces pain scores, opioid consumption and time to ambulation when used in conjunction with LIA and GA
• Superior to infra-inguinal fascia iliaca blocks with regards to opioid consumption, but not supra-inguinal FICB
• In patients receiving plain spinal anaesthesia, PENG block was inferior to LIA in terms of static and dynamic pain scores
• Non-inferior to LIA in patients who receive a spinal with intrathecal morphine
• Does not provide cutaneous anaesthesia so not suitable as a sole block; e.g. requires addition of lateral cutaneous femoral nerve block

• May be relatively motor-sparing vs. FICB
• Lumbar ESP catheters non-inferior to FICB catheters with regard to pain scores
• Does not improve analgesia over a standard multimodal analgesia regimen + LIA
• Insufficient evidence to support routine use for hip surgery

• The iliopsoas plane lies between the iliofemoral ligament and the iliopsoas muscle, lateral to rectus femoris and medial to the iliopsoas tendon
• The plane may be challenging to identify in patients with pericapsular haematoma or soft tissue oedema
• Catches articular branches of the femoral nerve, although there may be secondary spread of local anaesthetic to sensory and motor branches if the iliopectineal bursa is injected
• The block occurs more distally than a PENG block
• Benefits include:
• Reduced early post-operative opioid consumption
• Less motor block vs. femoral nerve block
• Comparable 48hr analgesia and patient satisfaction to femoral nerve block

• Aims to target posterior articular innervation from the sacral plexus
• Covers the posterior innervation of the hip capsule as well as the posterior femoral cutaneous nerve

• Early mobilisation is encouraged
• Restart carbohydrate energy drinks as early as recovery

• Regular paracetamol 1g Q6H
• Reduces post-operative opioid consumption by 16-26% (NNT 3.6)
• NSAID with PPI cover if not contraindicated
• E.g. ibuprofen 400mg Q8H, celecoxib 200mg TDS
• Avoid in the first 48hrs if eGFR<60/CKD3
• Avoid entirely if eGFR<30/CKD4
• Avoid diclofenac or -coxibs in those with cardiovascular disease
• Consider nefopam in those not able to have NSAIDs
• Reserve opioids for rescue analgesia
• Avoid morphine-based opioids in renal failure; use oxycodone instead

• Consider early bladder scanning to identify urinary retension in patients who lack bladder sensation due to spinal anaesthesia
• Use in/out catheter for patients with symptomatic retention, bladder volume >600ml who have failed to void in 1hr or >800ml at any time
• Limit oral free water intake to 20ml/kg to reduce risk of hyponatraemia
• Slow sodium 20mmol QDS to reduce risk of hyopnatraemia

• Regular senna
• Regular macrogol
• PRN ondanestron