Total Hip Arthroplasty (THA)
Patient phenotype
Typically 60–80, OA or AVN, often obese, frequent comorbidities (HTN, DM, CAD). 'Geriatric' THA patients can be 80+ with hip fracture — very different risk profile.
Procedure
Posterior or anterior approach. Acetabular reaming + cementless cup, femoral canal preparation + cementless or cemented stem, head trial + reduction. 60–120 min. Lateral or supine position depending on approach.
Anesthetic plan
Spinal (bupivacaine 12-15 mg) for elective; GA for fracture or anatomic limitations. Fascia iliaca block or femoral nerve block for postop. Multimodal pain control. TXA 1 g IV pre-incision + closure.
Setup
- ·Standard ASA + temp
- ·Two PIVs
- ·A-line if cardiac concern (esp. cement use, geriatric hip fracture)
- ·Type & screen + cross 2 units
- ·Fascia iliaca block or FNB after spinal
- ·Position-specific: bean bag for lateral, padding for axillary brachial plexus
Biggest concerns by phase
Geriatric hip fracture — early surgery improves outcomes
Mortality + morbidity better with surgery within 24-48 h of fracture. Don't delay for 'optimization' that won't change. Continue antiplatelet (ASA), withhold anticoagulants per ASRA. Ensure cardiac evaluation but don't over-test.
Spinal vs. GA — outcome differences
Some evidence neuraxial > GA for: less DVT, less blood loss, less delirium in elderly. Spinal limited by anticoagulation, anatomy. Hyperbaric bupi 0.75% 12-15 mg lasts ~2 hr. CSE useful for longer cases.
Bone cement implantation syndrome — esp. femoral cementing
Cementing the femoral component (more so than acetabular) can cause: ↓BP, ↓SpO₂, arrhythmia, cardiac arrest. Especially in cardiac/pulmonary HTN/elderly. Communicate with surgeon BEFORE cementing — pre-position fluid + vasopressor.
Fat embolism — clinically significant 1-3%
Femoral reaming releases marrow fat. Triad: hypoxemia + petechiae + altered mental status (the latter masked under anesthesia). Most cases subclinical. Severe: ARDS pattern. Treatment supportive — O₂, hemodynamic support, sometimes ICU admit.
Blood loss + TXA reduces transfusion need 30-50%
Average loss 300-800 mL; cementless > cemented. TXA 10-20 mg/kg IV at incision + 1 g at closure. Topical TXA 1 g in joint also effective. Cell saver if anticipated > 1 L.
Postop: dislocation, DVT, delirium
Posterior approach has higher dislocation risk — abduction pillow, teach hip precautions. DVT prophylaxis per surgeon protocol (ASA + SCDs, LMWH, DOAC). Delirium 20-50% in elderly — minimize benzos + opioids, multimodal pain, early mobilization.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Your THA patient is 82, BMI 32, mild CAD, EF 50%. After cementing the femoral component, BP drops 130 → 70, SpO₂ falls 99 → 86, ETCO₂ rises 35 → 50. You're getting brief PVCs. What's happening and what do you do?
What an examiner probes for
- ▹Recognizes severe BCIS (grade 2-3)
- ▹100% O₂, fluid bolus, vasopressor (NE preferred over phenyl in elderly with possible RV dysfunction)
- ▹Communicates with surgeon — they may modify cementing technique
- ▹Anticipates ICU admission, postop CXR + ECG
Sources
- Miller's Ch 60
- AAOS Hip Fracture Guidelines
- ASRA Anticoagulation Guidelines
Anatomy reference
Sourced reference images. 4 matches for "hip femur joint pelvis".
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