Total Hip Arthroplasty: Indications, Contraindications, Procedure

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Total hip arthroplasty
Authors: Greg A Erens, MD, Bill Walter, MBBS, FRACS, PhD, Marianna Crowley, MD
Section Editor: David Hunter, MD, PhD
Deputy Editors: Monica Ramirez Curtis, MD, MPH, Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2021. | This topic last updated: Nov 05, 2021.
INTRODUCTION
Total hip arthroplasty (THA) is one of the most successful orthopedic procedures performed today. For patients with hip pain due to a
variety of conditions, THA can relieve pain, restore function, and improve quality of life. Sir John Charnley, a British orthopedic surgeon,
developed the fundamental principles of the artificial hip and is credited as the father of THA. He designed a hip prosthesis in the midto late 1960s. Approximately 500,000 THAs are performed each year in the United States alone [1,2].
The evaluation and management of patients undergoing THA, as well as the conduct of the procedure, are reviewed here. The
complications of THA are presented in detail separately. (See "Complications of total hip arthroplasty".)
PREOPERATIVE CONSIDERATIONS
Indications — Total hip arthroplasty (THA) is indicated for patients who have failed conservative or previous surgical treatment options
for a deteriorated hip joint and who continue to have persistent, debilitating pain and a significant decrease in the activities of daily
living. Patients with significant deformity and limitation of motion may also be candidates if the disability that results is considerable,
even in the absence of pain. The decision to proceed with THA is made with an understanding of the potential benefits and risks. A
thorough understanding of the procedure and the anticipated outcome is an important part of the decision-making process.
The normal hip functions as a "ball-and-socket" joint. The femoral head (ball) articulates with the acetabulum (socket), allowing a
smooth range of motion in multiple planes. Any condition that affects either of these structures can lead to deterioration of the joint.
This, in turn, can lead to deformity, pain, and loss of function. The most common condition affecting the hip in this way is osteoarthritis.
Other conditions that may affect the hip adversely include inflammatory arthritides (eg, rheumatoid arthritis, psoriatic arthritis,
spondyloarthropathies), femoroacetabular impingement syndrome, developmental hip dysplasia, childhood hip disorders (eg, LeggCalvé-Perthes disease, slipped capital femoral epiphysis), trauma, neoplasms, and osteonecrosis.
Contraindications — THA should not be undertaken in a number of clinical settings, including:
●
Active infection (local or systemic)
●
Preexisting significant medical problems (eg, recent myocardial infarction, unstable angina, heart failure, severe anemia)
●
Skeletal immaturity
●
Quadriplegia
●
Permanent or irreversible muscle weakness in the absence of pain
Active infection is perhaps the most significant contraindication to THA. An infected THA can be a devastating and costly complication.
Infection and other complications of THA are discussed in detail elsewhere. (See "Complications of total hip arthroplasty".)
Relative contraindications include paraplegia, inability to ambulate that is not related to the hip disorder per se, absence of hip
abductor muscle function, progressive neurologic deficit, a neuropathic (Charcot) joint [3], and people with severe obesity.
Alternatives — THA is typically an elective procedure. Thus, a conservative approach aimed at treating the underlying disease should
be tried before THA. For patients with osteoarthritis, this usually includes nonoperative treatment measures, such as weight reduction,
physical therapy, nonsteroidal antiinflammatory drugs (NSAIDs), assistive devices (eg, a cane), and intraarticular glucocorticoid
injections. For patients with inflammatory arthritis of the hip (eg, rheumatoid arthritis or spondyloarthropathy), THA is offered to
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address the symptoms of advanced structural disease and not those of the underlying inflammatory disorder, which is treated
medically.
In selected cases, the suitability of surgical procedures other than THA such as hemiarthroplasty, hip resurfacing, arthrodesis, and hip
osteotomy may be discussed with the patient. (See "Overview of surgical therapy of knee and hip osteoarthritis", section on
'Alternatives to total hip arthroplasty'.)
PREOPERATIVE EVALUATION
A careful preoperative evaluation is essential to confirm hip pathology as the source of symptoms and disability and ensure the
appropriateness of surgery, as well as to assist with surgical planning. General issues in preoperative medical consultation and
management are presented elsewhere. (See "Preoperative medical evaluation of the healthy adult patient".)
History and physical examination — Most patients with deterioration of the hip joint present with pain. This is typically localized to
the anterior hip or groin. Pain may also be present in the posterior buttock and trochanteric region and can radiate to the thigh or
knee. Pain typically occurs with activity but can also be present at rest. The pain is often exacerbated by weightbearing and may be
worse with initial movement. Patients frequently describe "stiffness" or "tightness" of the hip, and loss of motion is often noted.
Disruption of sleep and difficulty walking, putting on shoes and socks, going up and down stairs, or getting into and out of a car are
common complaints. The patient may also need an assistive device (eg, cane).
A thorough musculoskeletal examination should be performed in every candidate for total hip arthroplasty (THA). A more detailed
description of hip anatomy, pain patterns, differential diagnosis, and physical examination of the hip, including special maneuvers, is
available elsewhere. (See "Approach to the adult with unspecified hip pain".)
Particular attention to the spine, pelvis, and knees is also essential to rule out radicular pathology, since hip pain may be the indirect
result of radicular pathology, as well as other concomitant diseases.
Prior to surgery, the following evaluations of the lower extremities are essential:
●
Inspection – Gait, previous incisions, abnormal swelling of hip or limb, abrasions, discolorations, and cutaneous infections should
be evaluated by inspection. Gait assessment should include an evaluation of any limp, use of assistive devices, and/or limb length
discrepancy. The presence or absence of a Trendelenburg gait should be noted. Any evidence of a "minor" infection (eg, infected
ingrown toenail) may require a delay in surgery until the infection has completely resolved.
●
Palpation – Anterior superior iliac spines, iliac crest, greater trochanter, posterior superior iliac spines, ischial tuberosity, and
sacroiliac joint should be evaluated by palpation. Palpation can help rule out nonarticular causes of "hip pain." For example, lateral
hip pain localized over the greater trochanter is usually not an indicator of hip joint pathology but may actually represent greater
trochanteric bursitis or greater trochanteric pain syndrome (from inflammation or tendinopathy of the gluteus medius and
minimus tendons). (See "Greater trochanteric pain syndrome (formerly trochanteric bursitis)", section on 'Clinical presentation'.)
●
Range of motion – Hip flexion/extension, abduction/adduction, and internal/external rotation should be recorded. Contractures
should be noted. Limitation of motion often develops as hip pathology progresses. Joint surface incongruity, muscle spasms, soft
tissue contracture, and/or mechanical block (eg, osteophytes or loose bodies) may all contribute to decreased motion.
●
Muscle testing – Motor strength and tone of the hip flexors, extensors, abductors, and adductors should be evaluated and
documented. In addition, muscle strength and tone of the distal limb should also be tested.
●
Nerve and vascular status – Preoperatively, it is imperative to evaluate and document nerve and vascular status. Sciatic and
peroneal nerve function testing, assessment of arterial pulses, and a sensory examination should be performed and documented
for both limbs. In addition, venous insufficiency should be noted. Severe vascular disease should be evaluated by a vascular
surgeon prior to proceeding with surgery.
●
Special tests
• Leg length measurement – As part of preoperative planning, leg lengths must be evaluated. There are two types of leg length
discrepancy:
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- "Apparent" leg length discrepancy is the result of compensation in response to pathology or contracture rather than an
actual difference in leg lengths (eg, presence of scoliosis or pelvic obliquity).
- True leg length discrepancy is the result of an anatomic or structural change in the lower limb (eg, tibia fracture). Typically,
a deteriorated hip joint will cause a decrease in true leg length.
To measure leg length, the patient should lie supine with the lower limbs in comparable positions with the legs slightly apart
and parallel. A tape measure can be used to record the length between the anterior superior iliac spine and the medial
malleolus for each limb. Another useful method of identifying a true leg length discrepancy is by using blocks of varying
height. The patient is asked to stand, and blocks of varying height are placed under the shorter limb. When the iliac crests are
at the same level, the block height represents a good approximation of the true leg length discrepancy.
• Trendelenburg sign – This test assesses the strength and function of the hip abductors. The sign is elicited by asking the
patient to stand on the involved leg. Normally, the pelvis on the opposite side rises. However, if the pelvis on the opposite side
drops, this test is positive. A positive test indicates that the hip abductors of the involved limb are weak or are relatively
inhibited.
• Straight leg raise – When this test is performed against resistance, groin pain is typically elicited if significant hip pathology is
present (eg, Stinchfield test). In addition, when this test is performed passively by the examiner, radiating pain from the back
or posterior hip into the lower leg suggests a radicular pathology.
Medical risk assessment — The patient undergoing THA must be able to tolerate anesthesia, associated operative stress, and
perioperative blood loss, as well as the rehabilitation process involved following THA. Since many patients who undergo THA are older,
specific attention should be paid to the patient's comorbid medical problems and symptoms that may reflect underlying comorbidities
that need to be considered prior to undergoing THA.
A more detailed discussion of the medical risk assessment prior to THA, which is similar to that for total knee arthroplasty (TKA), can be
found elsewhere (see "Total knee arthroplasty", section on 'Medical risk assessment'). A more general preoperative medical evaluation
is also reviewed separately. (See "Preoperative medical evaluation of the healthy adult patient" and "Evaluation of cardiac risk prior to
noncardiac surgery" and "Evaluation of perioperative pulmonary risk" and "Preoperative evaluation and perioperative management of
patients with rheumatic diseases".)
The overall success and longevity of the implant may depend on several patient-related factors that are associated with increased wear,
including younger age, high activity level, and obesity [4]. (See 'Longevity of implant' below.)
Laboratory studies — Baseline laboratory tests should include a complete blood count (CBC), prothrombin time (PT), international
normalized ratio (INR), activated partial thromboplastin time (aPTT), blood type/screen, and basic chemistries. An electrocardiogram
(ECG) is often performed. Urinalysis should be obtained in patient with urinary symptoms. Any identified urinary tract infection
(>100,000 colony-forming units [CFU]) should be treated with antibiotics prior to surgery [5]. Other laboratory tests can be ordered, as
needed, to assess abnormalities found during the preoperative examination.
Imaging studies — Plain radiographs of the hip and pelvis confirm the diagnosis and help with preoperative planning for THA.
Preoperative films should include a weightbearing anteroposterior (AP) pelvis, as well as AP and lateral views of the affected hip. Care
should be taken to ensure that the entire proximal femur is visualized so that any deformity can be identified. In addition to plain
radiographs, magnetic resonance imaging (MRI) may be necessary to evaluate certain hip disorders such as osteonecrosis. If significant
lumbar disease or history of lumbar spine surgery is noted, separate lumbar spine films may be obtained for further evaluation.
Standing and sitting lateral films from the first lumbar vertebra to the pelvis may help in evaluation of the spine-pelvis-hip relationship.
A discussion of imaging techniques and modalities for evaluation of hip pain is presented separately. (See "Approach to the adult with
unspecified hip pain".)
PERIOPERATIVE CARE
Antimicrobial prophylaxis — All patients undergoing total hip arthroplasty (THA) should receive prophylactic antibiotics (
table 1).
Prophylactic regimens are discussed in detail elsewhere. (See "Prevention of prosthetic joint and other types of orthopedic hardware
infection", section on 'During hardware placement'.)
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Thromboprophylaxis — Thromboprophylaxis (pharmacologic, mechanical) is indicated for patients undergoing THA because they are
at moderate-to-high risk for thromboembolism. A discussion on the incidence of venous thromboembolism after THA can be found
elsewhere. (See "Complications of total hip arthroplasty", section on 'Venous thromboembolism'.)
Our practice is generally consistent with guidelines from the American College of Chest Physicians (ACCP), the American Society of
Hematology (ASH), and the American Academy of Orthopaedic Surgeons (AAOS). The approach to prevent thromboembolic disease in
patients undergoing THA is discussed in detail separately. (See "Prevention of venous thromboembolism in adult orthopedic surgical
patients".)
Anesthetic considerations — THA may be performed with general anesthesia, regional anesthesia, or neuraxial anesthesia (ie, spinal,
epidural, or combined spinal epidural). The choice of anesthetic technique is based on patient comorbidities and patient choice.
General anesthesia is used for patients with contraindications to neuraxial anesthesia and for some patients with potential difficulty
with airway management. In practice, many patients receive some elements of both types of anesthesia. During neuraxial anesthesia,
most patients receive heavy sedation, and patients who receive general anesthesia for THA may also have epidural analgesia for
postoperative pain control.
Comparisons of general and neuraxial anesthesia for THA show some differences for some, but not all, outcomes. In one meta-analysis
that includes patients undergoing total hip or knee arthroplasty, length of hospital stay was reduced for those undergoing neuraxial
anesthesia (weighted mean difference -0.4 days [-0.76 to -0.03]) [6]. However, there were no significant differences in mortality, chest
infection, or thromboembolism. Blood loss and transfusion were not evaluated because of the low quality of studies.
For uncomplicated primary THA, single injection spinal anesthesia is a commonly used technique. Epidural or combined spinal-epidural
are used for procedures that are expected to last more than approximately two hours and if postoperative epidural analgesia is
planned. Any plans for ongoing use of antithrombotic therapies (antiplatelet agents, anticoagulants) should be discussed with the
surgeon before finalizing plans for regional anesthesia techniques, either used intraoperatively or postoperatively. (See "Neuraxial
anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication".)
Perioperative pain control — A multimodal strategy for control of pain control after THA may include regional anesthesia,
acetaminophen, and nonsteroidal antiinflammatory drugs (NSAIDs), which are often used to reduce the need for opioids. (See
"Management of acute perioperative pain".)
●
Lumbar epidural analgesia – Postoperative continuous epidural analgesia can be used if epidural or combined spinal-epidural
anesthesia is used for surgery. (See "Management of acute perioperative pain", section on 'Epidural analgesia with local
anesthetics and opioids'.)
●
Peripheral nerve block – Sensory innervation of the hip joint includes femoral, sciatic, and obturator nerves. Therefore, no single
nerve block can be used to provide complete analgesia after THA. Lumbar plexus block may provide adequate postoperative
analgesia after THA but can be technically challenging and carries risks including neuraxial spread of local anesthetic, neuraxial
hematoma, and retroperitoneal hematoma. It can be considered as part of a multimodal pain control strategy for patients with
chronic pain, opioid tolerance, or sensitivity to opioids. (See "Lower extremity nerve blocks: Techniques", section on 'Lumbar
plexus (psoas compartment) block'.)
TOTAL HIP ARTHROPLASTY PROCEDURE
Total hip arthroplasty implant design — All total hip arthroplasties (THAs) consist of a femoral component, an acetabular component,
and a bearing surface. Most systems are modular with a separate femoral stem, femoral head, acetabular liner, and acetabular shell.
This modularity gives the operating surgeon tremendous flexibility in dealing with any intraoperative situation or anatomic variation.
There are a number of femoral and acetabular implants available for use in THA. The choices reflect different philosophies regarding
the type of fixation, design features, and materials.
Fixation of the prosthetic components to host bone can be achieved with one of two techniques. The more common approach in the
United States achieves fixation without the use of cement and relies on bony ingrowth into or onto the porous implant surface that has
been either "press-fit" or "interference-fit" into the surrounding bone. Alternatively, methylmethacrylate cement can be used to fix the
femoral and/or acetabular component in patients with poor bone quality.
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Acetabular component — While there are many options for acetabular components in primary THA, the majority of acetabular
components inserted today are cementless, porous, and modular. Typically, a hemispheric porous metal shell is inserted into the
acetabulum, and a modular liner is then placed within the shell. The acetabular liner, typically made of highly crosslinked polyethylene,
is designed to articulate with a highly polished femoral head (ball). The porous surface of the implant varies from manufacturer to
manufacturer and may have a surface coating (such as hydroxyapatite) that promotes bony ingrowth or ongrowth. Many designs allow
for the insertion of screws for supplementary fixation of the shell.
The alternative to a cementless acetabular component is an acetabular component fixed to the acetabulum with cement. This type of
acetabular implant has fallen out of favor in the United States due to studies showing a higher overall loosening rate than with
uncemented implants. However, some surgeons advocate the use of an all-polyethylene cemented acetabular implant for older
patients with poor bone quality [7].
Bearing surface — In the past, the standard bearing surface consisted of a metallic (cobalt-chromium) femoral head, which
articulated with a smooth, high-density polyethylene acetabular liner. Due to osteolysis (bone loss and destruction) caused by wear and
resultant particle debris, this combination is used less commonly. The most widely used combination is a ceramic femoral head with an
acetabular liner made of highly crosslinked polyethylene. Laboratory results show superior wear performance of highly crosslinked
polyethylene compared with conventional high-density polyethylene [8,9]. Furthermore, clinical results have shown superior longevity
of highly crosslinked polyethylene compared with conventional high-density polyethylene in vivo [10-12]. Ceramic femoral heads avoid
the risk of taper corrosion that can occur with a metal head on metal trunnion (mixed-metal taper junction).
Other bearing surfaces used in the hip include ceramic-on-ceramic and metal-on-metal. While these have both demonstrated reduced
wear as compared with standard metal-on-polyethylene, other potential complications have limited their widespread use. Ceramic-onceramic bearing surfaces have rarely shown catastrophic breakages as well as minor chips and cracks. With newer ceramic technology,
this occurs much less frequently. Another complication of a ceramic-on-ceramic bearing surface is an audible squeak.
Metal-on-metal bearing surfaces were introduced because they were thought to offer advantages over other materials, including less
wear and lower risk of dislocation because of the ability to use larger head ball sizes. However, subsequent studies showed that metalon-metal THA did not confer a clinical advantage over other bearing surfaces and resulted in higher rates of revision [13-17]. The lack of
evidence as a superior bearing surface along with adverse local tissue reactions have limited the use of metal-on-metal bearing
surfaces in conventional THA. This is in contrast to metal-on-metal resurfacing procedures, where the results in select patient cohorts
have been equal to or better than conventional THA in terms of implant survival, patient mortality, and function [18-20]. However,
adverse local tissue reactions have been described for metal-on-metal resurfacings as well. It should be noted that metal-on-metal
bearing surfaces are contraindicated in patients with compromised kidney function as well as women of childbearing age due to
unknown effects of metal ions on the unborn fetus. Complications from metal-on-metal wear is discussed separately. (See
"Complications of total hip arthroplasty", section on 'Sequelae from metal-on-metal wear debris'.)
Femoral component — Femoral components can be classified as either cementless or cemented. A cementless femoral component is
the implant of choice for younger patients and any patient with good bone stock (particularly those with thick femoral cortices and with
smaller diameter femoral canals). However, in older patients and those with osteoporosis, it may be more difficult to get good initial
stability with a cementless component and there is a higher risk of periprosthetic femoral fracture. In addition, a larger (and necessarily
stiffer) implant would be required. Therefore, a cemented implant is an appropriate choice in the older, low-demand patient with poor
bone stock (thin cortices and larger canal diameter).
Cementless implants are typically porous-coated to increase surface area for bone ingrowth. In addition, the roughened surface helps
to achieve initial stability of the implant, which is critical for the long-term success of the implant. The porous coating may be limited to
the proximal portion of the femoral implant or may extend over the entire length of the implant. This varies depending upon the
philosophy of the design. Proximally porous coated implants rely on the metaphysis or metadiaphyseal junction for fixation and
stability. Extensively porous-coated implants rely more on diaphyseal fixation. Cementless implant designs use a circumferential porous
coating, which has been shown to help prevent access of wear particles from the articulating surface down along the implant-bone
interface.
The use of bone cement during arthroplasty can rarely cause bone cement implantation syndrome (BCIS), which is a poorly understood
condition that can cause hypoxia and hypotension, and may result in cardiac arrest. Measures to prevent BCIS include pulse lavage of
the femoral canal, slow introduction of the stem, providing a vent hole in the bone for long-stem component insertion, and minimal
pressurization of cement. (See "Complications of total hip arthroplasty".)
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Femoral head — The femoral head in any THA must match the acetabular bearing surface. Almost all THAs performed today utilize a
highly polished ceramic or cobalt chrome femoral head. Due to increased awareness and prevalence of trunnionosis (wear at the
femoral head-neck interface), there has been a shift towards greater use of ceramic as the femoral head material of choice. Different
diameters are available ranging from 22 mm up to 40 mm (or greater). The key considerations regarding head size are range of motion,
stability, and propensity for wear. In general, increasing head size is correlated with increased range of motion and decreased
dislocation rate but also with increased volumetric wear and generation of particle debris. Therefore, a compromise must be made. The
introductions of more durable acetabular liners (eg, highly crosslinked polyethylene) and alternative bearing surfaces have led most
surgeons towards the use of a larger head size than the prior standard of 28 mm typically used in primary THA. The larger prosthetic
head allows for improved range of motion and decreased risk of dislocation.
Arthroplasty technique — The surgical technique for THA has evolved since it was first introduced, with a variety of surgical
approaches described.
THA is carried out in a stepwise fashion (
figure 1):
●
Surgical incision
●
The hip joint is exposed
●
The femoral neck is cut (with or without dislocation of the femoral head) and the femoral head is removed
●
The acetabulum is prepared and a cup is placed
●
The femur is prepared and a stem is placed
●
A head ball is then placed onto the stem
●
The hip is reduced and the surgical wound is closed
Incision and exposure — THA can be approached using a posterolateral, direct lateral, or anterior approach. These surgical
approaches all provide excellent exposure of the hip joint. A good result can be achieved through any of these approaches, and the
best approach is that with which the surgeon is most comfortable. The surgical approach can impact the type and incidence of certain
complications as noted the sections below [21].
Posterolateral approach — The posterolateral approach, also called the Kocher-Langenbeck approach, gains exposure to the hip
through a posterior incision. The gluteus maximus muscle is split and the short external rotators are dissected off the posterior aspect
of the hip. The joint is entered posteriorly through the capsule. The gluteus medius is left intact. This approach is usually performed
with the patient in the lateral decubitus position. Variations of this approach preserve some or all of the short external rotators. A
piriformis sparing approach accesses the hip joint below the piriformis tendon and a superior variation of the posterior approach
accesses the hip above the short external rotators.
Because the posterolateral approach disrupts the posterior soft tissue of the hip, it has historically been associated with having a
higher rate of dislocation compared with the direct lateral approach. Additional information regarding the risk of dislocation is
presented separately. (See "Complications of total hip arthroplasty", section on 'Dislocation'.)
Direct lateral approach — The direct lateral approach, also called the Hardinge or modified Hardinge approach, gains exposure
to the hip through a lateral incision. The anterior portion of the gluteus medius muscle is split and elevated off of the femur. This
provides access to the hip through the anterior hip capsule. Typically, this approach is performed with the patient in the lateral position.
However, the direct lateral approach may be performed with the patient supine or in a semilateral position. Once the THA is completed,
the gluteus medius muscle insertion is repaired (by the tendon itself or with a portion of detached bone).
The direct lateral approach has a low risk of dislocation [22] but higher risk for postoperative limp and heterotopic ossification due to
disruption of the abductor muscles [23,24]. Additional information regarding heterotopic ossification is presented separately. (See
"Complications of total hip arthroplasty", section on 'Heterotopic ossification' and 'Prophylaxis for heterotopic ossification in selected
patients' below.)
Anterior approach — The anterior approach, also called the Smith-Petersen or Hueter approach, gains exposure to the hip
anteriorly without the need to detach any of the surrounding muscles. A space is created between the tensor fascia lata and the
sartorius muscles. Access to the hip is provided through the anterior hip capsule. A variation of the anterior approach, the anterolateral
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approach (or Watson-Jones approach), accesses the hip through the space posterior to the tensor fascia lata. Anterior approaches are
performed with the patient supine but can also be performed with the patient in a lateral position. A special operating table and the
assistance of fluoroscopy are often used, but a regular operating table ("off-table") can also be used. (See "Patient positioning for
surgery and anesthesia in adults".)
Complications associated with the anterior approach include intraoperative femoral fracture (due to a more challenging femoral
exposure), ankle fracture (from positioning or traction issues when using a specialized operating table), and damage to the lateral
femoral cutaneous nerve or femoral nerve (as branches of this nerve sit very close to the surgical field). Because the muscles around
the hip are not detached during the procedure, many surgeons who use the anterior approach tell their patients that dislocation
precautions are not necessary. There appears to be a lower risk of dislocation with the direct anterior approach as compared with the
posterior approach, but the direct lateral approach has the lowest dislocation rate [22]. There is also some preliminary evidence that
the anterior approach is associated with a more rapid early recovery [25,26]. However, speed of recovery depends upon many variables,
and a good rapid recovery can be achieved with any of the approaches with the right anesthetic regimen, patient education, and
postoperative assistance.
Surgical navigation and robotic surgical assistance — Surgical navigation in THA is also being developed. Navigation involves realtime tracking of bones and surgical instruments during surgery. The potential benefits of navigation in THA are improved accuracy of
implant position (particularly the acetabular component) [27]. Similarly, a surgical robot, which can assist the surgeon in bone
preparation and implant positioning, may also be used. The disadvantages of navigation systems or robotic assistance are increased
operative time, the need for image acquisition preoperatively or intraoperatively, and increased expense. Navigation is used in very few
hip replacements, but there is now accumulating evidence that use of this technology may help reduce the risk of dislocation and
reduce the need for revision of the acetabular component [28-30].
Minimizing blood loss — THA may involve substantial intraoperative and perioperative blood loss. In one study, the estimated blood
loss following THA was almost 1000 mL [31]. This places some patients at increased risk for myocardial infarction, angina, transient
ischemic attack, stroke, and seizure (especially in patients with significant systemic illness), as well as the need for blood transfusions.
Tranexamic acid, an antifibrinolytic agent, is increasingly used for joint arthroplasty to help minimize blood loss. For most patients
undergoing THA, tranexamic acid is administered to decrease blood loss and the need for blood transfusion. For patients with a high
baseline risk of VTE, the decision should be individualized as there is insufficient data regarding its use in this patient population.
The optimal regimen for administration of tranexamic acid is still uncertain, since various doses and routes of administration (ie, oral,
topical, and intravenous) are available [32-41]. A common regimen is to give 1 gram of tranexamic acid intravenously before incision
and 1 gram of tranexamic acid intravenously during closure. Tranexamic acid can also be given in the postoperative period as needed.
This practice is consistent with the guideline regarding tranexamic acid that has been published and endorsed by the American
Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic
Surgeons, Hip Society, and Knee Society [42].
The efficacy and safety of tranexamic acid has been evaluated in randomized trials [43-45] and meta-analyses [46-49]. In one of the
largest meta-analyses, the administration of either topical or intravenous tranexamic acid during THA was associated with less total
blood loss, lower transfusion rates, and shorter hospitalization duration compared with controls [46]. Although there was no increased
risk of deep vein thrombosis, the outcome of pulmonary embolism or other vascular complications was not included in the analysis.
A general discussion of preoperative and intraoperative blood conservation techniques is presented separately. (See "Perioperative
blood management: Strategies to minimize transfusions", section on 'Preoperative strategies' and "Perioperative blood management:
Strategies to minimize transfusions", section on 'Intraoperative strategies'.)
Managing limb length discrepancy — As noted previously, a deteriorated hip joint may cause a decrease in leg length. In most
patients, it is desired to achieve equal leg lengths postoperatively. Sometimes, however, surgeons may desire to lengthen a leg beyond
the pre-arthritic length to improve stability of the hip. Tensioning the soft tissues around the hip (hip capsule and abductors) may help
reduce the risk of dislocation. Ultimately, hip stability is more important than leg length discrepancy. Most surgeons would accept a
small leg length inequality in exchange for a hip that is more stable and less likely to dislocate.
Intraoperatively, there are many techniques to determine limb length. These range from special devices that measure from a fixed
point on the pelvis to a simple comparison of intraoperative knee and heel positions. Intraoperative radiographs or fluoroscopy may
also be very useful. Some method is required for measuring limb length, and redundancy is desirable.
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POSTOPERATIVE CARE AND FOLLOW-UP
The hospital length of stay following total hip arthroplasty (THA) is typically one to three days. However, there are a growing number of
surgeons who are now safely performing this procedure as outpatient [50-52].
Postoperative management includes pain management, prophylaxis against venous thromboembolism, appropriate attention to
medical comorbidities, and physical therapy. (See 'Perioperative care' above.)
Rehabilitation — Many patients can be discharged home after surgery, but some may require a temporary inpatient rehabilitation or
nursing facility stay. Mobilization and physical therapy are initiated as soon as possible to facilitate recovery of function and to help
prevent deep vein thrombosis (DVT). Rapid recovery protocols are becoming more widespread. Exercises to restore normal hip motion
and strength and a gradual return to everyday activities are initiated in the hospital and continued upon discharge [53]. This may
involve 20 to 30 minutes of exercises two or three times daily during early recovery. Typically, weightbearing as tolerated is allowed,
and an assistive device is used to help with balance and stability. Walking aids are weaned as strength, balance, and comfort improve.
Depending on the surgical approach and surgeon's protocol, some patients may need to follow certain dislocation precautions. As an
example, patients given posterior hip dislocation precautions may be asked to avoid low chairs, not to bend their hip beyond 90
degrees, and to avoid crossing their legs. Some surgeons may also recommend formal outpatient therapy, but this is often
individualized based on the surgeon's preferences and the patient's needs [54].
Time to full recovery varies widely, but patients are typically doing quite well with minimal pain by three months postoperatively. There
may be further improvement noted even up to one year following surgery.
Follow-up and activity level — Follow-up visits with the surgeon are scheduled at routine intervals, but may vary from surgeon to
surgeon. Most patients may resume regular, non-impact activities such as walking, stair-climbing, swimming, golf, light tennis, and
biking. These activities can be resumed once comfort and strength allows. High-impact activities such as manual labor, heavy lifting,
and high-intensity sports (eg, running, jogging) should be avoided. Other activities such as yoga and Pilates may be allowed if care is
taken to avoid extremes in range of motion to avoid dislocation. Long-term follow-up is recommended to evaluate for wear of the
bearing surface or other implant-related issues.
Prophylaxis for heterotopic ossification in selected patients — For patients at high risk of heterotopic ossification (HO), we suggest
administering prophylactic nonsteroidal antiinflammatory drugs (NSAIDs). External beam radiation (typically given as a single dose
perioperatively) is a reasonable alternative for patients who cannot tolerate NSAIDs or for whom NSAIDs are contraindicated. However,
the decision for which method of prophylaxis to use is typically surgeon dependent. Both methods have been shown to decrease the
incidence of HO in high-risk patients. A previous history of HO is one of the strongest risk factors for HO after THA [55]. Other factors
placing patients at higher risk for HO include male sex, cemented implant, bilateral surgery, ankylosing spondylitis, and the direct
lateral surgical approach [56,57]. A detailed description of the incidence and presenting symptoms of HO after THA is presented
separately. (See "Complications of total hip arthroplasty".)
Indomethacin is the most commonly used NSAID for HO prophylaxis, although other NSAIDs have demonstrated effectiveness [57].
The usual dose of indomethacin is 75 to 100 mg/day. It is typically initiated within 24 to 48 hours for surgery, and then continued for 7
to 14 days postoperatively. The efficacy for NSAIDs in reducing the incidence of postoperative HO is supported by randomized trials
and meta-analyses [57-60]. In one of the largest meta-analyses including both randomized trials and observational studies, both
selective and nonselective NSAIDs decreased the risk of forming HO after THA when compared with placebo (odds ratio [OR] -1.35, CI
-1.83 to -0.86 and OR -1.58, CI -2.41 to -0.75, respectively) [57]. Bleeding complications are more frequent in patients receiving NSAIDs
in conjunction with anticoagulation for thromboembolic prophylaxis [61,62]. Careful monitoring should be implemented [61].
Prophylactic use of a proton pump inhibitor may reduce the risk of NSAID-induced gastroduodenal damage and subsequent
gastrointestinal bleeding (see "NSAIDs (including aspirin): Secondary prevention of gastroduodenal toxicity"). While indomethacin is
relatively inexpensive and readily available, some patients are not able to tolerate the medication due to gastrointestinal side effects.
Kidney issues (such as chronic renal insufficiency) may also make indomethacin a poor choice for prophylaxis. These patients may be
more appropriate for external beam radiation.
External beam radiation has also demonstrated efficacy in preventing HO after THA [63]. When used, it is typically administered as a
single-dose regimen of 700 or 800 centigray. Radiation may be administered preoperatively (within 24 hours) or postoperatively (within
72 hours) [64-67]. Malignant transformation following this type of single-dose radiation has been reported but is very rare [68,69]. A
meta-analysis that included seven randomized trials that compared radiation with NSAIDs concluded that radiotherapy is more
effective, but the absolute difference in the rates of clinically significant HO were quite small, and on the order of 1 percent [70].
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OUTCOMES
Longevity of implant — Published results of total hip arthroplasty (THA) demonstrate excellent clinical and functional results. These
results vary depending upon the implant, surgical technique, the type of fixation, biomaterials, the patient's age, preoperative function,
and a myriad of other factors including the hospital/clinician's surgical volume [4,71-73]. THA may be performed successfully in patients
ranging from young [74-76] to older adults (over 80 years of age) [77]. With modern bearing materials, the risk of revision is as low as
0.5 percent per year for the first 20 years where data are available. This is true for younger and older patients with only slight increases
in risk in younger, more active patients [78]. Patient satisfaction following the procedure is also typically high [79].
In general, over 90 percent of patients are working successfully after THA, are pain-free, and are without complication 15 years
postoperatively [80]. A large meta-analysis including data from national registries estimated that almost 60 percent of hip replacements
last 25 years [81].
Most studies show an increased risk of early revision due to infection in patients with obesity [82,83]. This effect increases with
increasing obesity, particularly with a body mass index (BMI) over 35 kg/m2. Despite the increased risk of revision in patients with
obesity, the risk remains low, and such patients do have significant improvement in postoperative pain, function, and satisfaction. A
study from Canada noted that patients with severe obesity can experience substantial benefit, despite a very small but statistically
significant increase in the need for revision due to septic complications [84]. Other studies have emphasized the increased risk of both
superficial and deep infections and have described an increased risk of dislocation in such patients [85-87]. (See "Complications of total
hip arthroplasty".)
Morbidity and mortality — Postoperative mortality after THA is overall low, with estimates citing a 30- or 90-day mortality rate of less
than 1 percent [88-90]:
●
Reductions in mortality rates between 1991 and 2008 were shown in an analysis of over 1.4 million Medicare beneficiaries in the
United States who underwent elective primary THA during this period [89]. The 30-day mortality decreased during this interval
from 0.7 to 0.4 percent, despite a mean increase of one year in age and despite a mean increase from one to two in the number of
comorbid medical conditions.
●
A retrospective analysis from the United Kingdom assessed mortality within 90 days of hip replacement from 2003 to 2011, and
included 409,096 primary hip replacements for osteoarthritis [90]. During the eight years of follow-up, there was a significant
decrease in mortality from 0.56 to 0.29 percent, even after adjusting for age, sex, and comorbidity.
A number of factors are associated with the risk of death after THA. As an example, mortality rates are higher in patients who have THA
in the setting of hip fracture management when compared with those who have elective surgery for other indications [91]. In addition,
improved survival has been noted in patients administered spinal anesthesia as well as mechanical or chemical thromboprophylaxis
[90]. (See 'Perioperative care' above.)
Complications following THA include those that may occur with any major surgery, such as those related to anesthesia, blood loss, or
transfusion reactions. Complications that are specific to the hip arthroplasty procedure are discussed in detail separately. (See
"Complications of total hip arthroplasty".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces
are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to
12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients.
(You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●
Basics topics (see "Patient education: Hip replacement (The Basics)")
●
Beyond the Basics topics (see "Patient education: Total hip replacement (Beyond the Basics)")
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SUMMARY AND RECOMMENDATIONS
●
Total hip arthroplasty (THA), also known as total hip replacement, consists of resection of the diseased articular surfaces of the
hip, followed by replacement with prosthetic hip components. For the properly selected patient, the procedure results in
significant pain relief, as well as improved function and quality of life. In spite of the potential benefits of THA, it is typically an
elective procedure and should only be considered after a thorough discussion of the risks, benefits, and alternatives. (See
'Introduction' above and 'Preoperative considerations' above.)
●
The most common indication for THA is for the relief of pain associated with osteoarthritis of the hip in patients who have failed
nonoperative treatments. Other conditions that cause pain and loss of function that may result in the need for THA include
inflammatory arthritides (eg, rheumatoid arthritis, psoriatic arthritis, spondyloarthropathies), femoroacetabular impingement
syndrome, developmental hip dysplasia, childhood hip disorders (eg, Legg-Calvé-Perthes disease, slipped capital femoral
epiphysis), trauma, neoplasms, and osteonecrosis. (See 'Indications' above.)
●
Active infection is perhaps the most significant contraindication to THA. Other contraindications include preexisting or significant
medical problems (eg, recent myocardial infarction, unstable angina, heart failure, severe anemia), skeletal immaturity,
quadriplegia, or permanent or irreversible muscle weakness in the absence of pain. Relative contraindications include paraplegia,
inability to ambulate that is not related to the hip disorder per se, absence of hip abductor muscle function, progressive
neurologic deficit, a neuropathic (Charcot) joint, and patents with severe obesity. (See 'Contraindications' above.)
●
A careful preoperative evaluation must be performed to confirm hip pathology as the source of symptoms and disability and
ensure the appropriateness of surgery as well as to assist with surgical planning. The evaluation includes particular elements of
the history, a physical examination, imaging and laboratory studies, a review of treatment alternatives, and discussions of the
benefits and risks of the procedure. (See 'Preoperative evaluation' above.)
●
Prophylactic antibiotics are given preoperatively to reduce the risk for surgical site infection and prosthetic joint infection.
Postoperative thromboprophylaxis should also be administered in patients undergoing THA. Prophylactic antibiotic regimens and
the approach to thromboprophylaxis in adult orthopedic surgery are discussed in detail separately. (See "Prevention of prosthetic
joint and other types of orthopedic hardware infection", section on 'During hardware placement' and "Prevention of venous
thromboembolism in adult orthopedic surgical patients".)
●
THA can be performed with general anesthesia, regional anesthesia, or neuraxial (ie, spinal, epidural, or combined spinal epidural)
anesthesia. The choice of anesthetic technique is based on patient comorbidities and patient choice. (See 'Anesthetic
considerations' above.)
●
For most patients undergoing THA, tranexamic acid is used to decrease blood loss and the need for blood transfusion. The
optimal regimen for administration of tranexamic acid is still uncertain, as various doses and routes of administration (ie, oral,
topical, and intravenous) are available. (See 'Minimizing blood loss' above.)
●
THA is carried in stepwise fashion (
figure 1). THA can be performed using a posterolateral, direct lateral, or anterior approach.
(See 'Arthroplasty technique' above and 'Incision and exposure' above.)
●
Total hip prostheses consist of a femoral component, an acetabular component, and a bearing surface. There are a number of
femoral and acetabular implants available for use. The choices reflect different philosophies regarding the type of fixation, design
features, and materials. (See 'Total hip arthroplasty implant design' above.)
●
Postoperative care includes pain management and venous thromboembolism (VTE) prophylaxis, as well as appropriate physical
therapy to achieve the best possible hip motion and return to full function as quickly and safely as possible. (See
'Thromboprophylaxis' above and 'Perioperative pain control' above and 'Rehabilitation' above and 'Follow-up and activity level'
above.)
●
For patients at high risk of heterotopic ossification (HO), we suggest administering prophylactic nonsteroidal antiinflammatory
drugs (NSAIDs) (Grade 2C). External beam radiation is a reasonable alternative for patients who cannot tolerate NSAIDs or for
whom NSAIDs are contraindicated. Indomethacin is the most commonly used NSAID for HO prophylaxis, although other NSAIDs
are also effective. The usual dose of indomethacin is 75 to 100 mg/day and should be continued for 7 to 14 days postoperatively.
Measures aimed at preventing HO should be administered before the fifth postoperative day, optimally within 24 to 48 hours. (See
'Prophylaxis for heterotopic ossification in selected patients' above.)
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●
Total hip arthroplasty - UpToDate
THA typically results in excellent clinical and functional outcomes. Mortality following THA is overall low, with estimates citing a 30or 90-day mortality of less than 1 percent, and is primarily related to preexisting medical comorbidities. (See 'Longevity of implant'
above and 'Morbidity and mortality' above.)
●
Complications specific to THA are discussed in detail separately. (See "Complications of total hip arthroplasty".)
ACKNOWLEDGMENTS
The UpToDate editorial staff acknowledges Thomas Thornhill, MD, and Jeffrey Katz, MD, MSc, who contributed to an earlier version of
this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
Topic 7972 Version 35.0
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GRAPHICS
Antimicrobial prophylaxis for orthopedic surgery in adults
Nature of operation
Common pathogens
Clean operation involving
hand, knee, or foot with no
–
Recommended
antimicrobials
Usual adult dose*
Redose interval¶
–
–
None
implantation of foreign
material
Spinal procedures
Hip fracture
Staphylococcus aureus,
Staphylococcus epidermidis
CefazolinΔ
<120 kg: 2 g IV
4 hours
≥120 kg: 3 g IV
Internal fixation
Total joint replacement
Removal of orthopedic
hardware used for
treatment of lower
extremity fractures§
OR vancomycinΔ◊
15 mg/kg IV (max 2 g)
N/A
OR clindamycin
900 mg IV
6 hours
IV: intravenous; N/A: not applicable; MRSA: methicillin-resistant Staphylococcus aureus.
* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. If vancomycin is used, the
infusion should be started within 60 to 120 minutes before the initial incision to have adequate tissue levels at the time of incision and to minimize
the possibility of an infusion reaction close to the time of induction of anesthesia.
¶ For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive burns, additional intraoperative doses should be
given at intervals one to two times the half-life of the drug for the duration of the procedure in patients with normal renal function.
Δ If a tourniquet is to be used in the procedure, the entire dose of antibiotic must be infused prior to its inflation.
◊ Use of vancomycin is appropriate in hospitals in which MRSA and Staphylococcus epidermidis are a frequent cause of postoperative wound
infection, in patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may
cause hypotension, which could be especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension
may occur; treatment with diphenhydramine and further slowing of the infusion rate may be helpful. Some experts would give 15 mg/kg of
vancomycin to patients weighing more than 75 kg, up to a maximum of 1.5 g, with a slower infusion rate (90 minutes for 1.5 g).
​ The role of antimicrobial prophylaxis prior to removal of orthopedic hardware used for treatment of lower extremity factures is controversial.
§
According to the guidelines issued by the United States Centers for Disease Control and Prevention, this is considered a "clean" surgical procedure
(ie, without skin contamination or local infection), for which preoperative antibiotic prophylaxis is not routinely recommended. However, relatively
high rates of surgical site infection have been reported for this procedure; therefore, we favor administration of preoperative antimicrobial
prophylaxis. Refer to the text for further discussion.
Adapted from:
1. Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73.
Graphic 87204 Version 19.0
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Total hip replacement
The figures illustrate total hip replacement. An incision is made across the hip joint
(A), the location of which depends upon the selected approach (anterior, lateral,
posterior). Once exposed, the femoral neck is transected (with or without
dislocation of the hip) and the femoral head is removed (B). The acetabulum is
prepared and the cup of the prosthesis is placed (C). The femur is prepared and the
stem of the prosthesis is placed and a head ball is placed onto the stem (D). The
hip is reduced and the proper functioning of the completed hip replacement is
checked (E). The incision is then closed and the hip incision is dressed.
THA: total hip arthroplasty.
Graphic 121269 Version 1.0
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