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Perioperative Care

Perioperative management for hip fracture and elective arthroplasty, focusing on ERAS protocols, comorbidity optimization, and mortality reduction.

Overview

Total hip and knee arthroplasty procedures benefit from structured, perioperative multidisciplinary enhanced patient care protocols informed by consensus-derived risk factors and interventions [1]. Such protocols are essential for delivering successful outcomes in complex populations, including solid organ transplant recipients [3] and patients with sickle cell disease, who face high complication risks [15]. Institutions must establish preoperative care pathways grounded in current evidence to prevent unnecessary testing and delays [4].

Preoperative management requires rigorous medical optimization. For patients with chronic obstructive pulmonary disease undergoing total hip arthroplasty, pulmonary evaluation is critical as many complications are medical in origin [5]. Preoperative optimization also reduces transfusion needs in lower extremity revision arthroplasty under restrictive blood management protocols [16]. Clinicians should utilize risk factors to tailor perioperative care and support for frail patients [10].

Intraoperative and postoperative strategies focus on safety and efficiency. Regional anesthesia should be utilized whenever feasible and without contraindications [7]. Postoperative care necessitates multimodal analgesia and close collaboration among the perioperative team to optimize outcomes [4]. Robust pre- and perioperative protocols enable safe same-day discharge for high-risk patients traditionally excluded by hard stop criteria [12]. Optimization of care delivery reduces broad variation in hospital readmissions after primary total hip arthroplasty [13]. Furthermore, the first-generation AAOS clinical guidelines for venous thromboembolic prophylaxis remain executable and effective when properly applied to minimize adverse outcomes [34].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Hip microinstability is characterized by abnormal femoral head micromotion within the acetabulum, leading to cartilage damage and osteoarthritis [60]. This condition is often associated with acetabular dysplasia or femoroacetabular impingement syndrome [60]. The ultimate goal of total hip arthroplasty is to restore normal hip biomechanics with adequate sizing, position, and fixation of prosthetic components while minimizing complications [35]. Robot-assisted total hip arthroplasty improves surgical accuracy compared to manual total hip arthroplasty without increasing surgical trauma [67]. Furthermore, robot-assisted total hip arthroplasty contributes to the restoration of the patient's original hip biomechanics [67]. Sitting lumbar-pelvic-femoral alignment following total hip arthroplasty may be driven by hip arthritis and/or spinal deformity [74].

Osseous Morphology and Classification

Osteoporosis is more aggravated in the lateral trochanter compared to the femoral neck with age [80]. Increased bone mass in the lateral trochanter may theoretically help lower the incidence of hip fractures [80]. Current classification of borderline hip dysplasia based solely on lateral center edge angle is insufficient [98]. The focus for borderline hip dysplasia must shift to assessing hip instability to better predict treatment outcomes and the need for bony realignment [98].

Classification

Multidisciplinary Protocol: A structured, perioperative enhanced patient care protocol for total hip and knee arthroplasty is informed by consensus-derived risk factors, perioperative interventions, and important outcomes [1]. Multidisciplinary collaboration and precise risk management techniques are important for perioperative patient care to impact periprosthetic joint infection and revision rates after total joint arthroplasty [2]. An ongoing multidisciplinary approach is required throughout the perioperative process and beyond to deliver successful outcomes in solid organ transplant patients undergoing total hip and knee arthroplasty [3]. Clinicians should use risk factors to optimize perioperative care and support for total hip and knee arthroplasty recipients as this patient population continues to increase [10].

ASA Physical Status: Patients identified as being at higher risk (ASA class 3 or 4) preoperatively should be closely managed medically so that perioperative medical complications can be managed and evolving medical issues can be addressed in a timely fashion [6]. The American Society of Anaesthesiologists (ASA) physical status classification system was evaluated for its predictive ability on health-related quality of life using eight EQ-5D-3L value sets across preoperative and postoperative periods up to 6 years after total hip replacement [46].

Glycemic and Nutritional Biomarkers: Admission hyperglycemia is a biomarker that can aid clinical assessment and perioperative management in geriatric patients with hip fractures [9]. Multiple HbA1c strata can be incorporated into preoperative risk-stratification models to stratify complication risk following total hip arthroplasty [47]. Preoperative hypoalbuminemia is associated with an increased risk of numerous types of complications, transfusion, unplanned reoperation, and mortality after total hip or knee arthroplasty [69].

Infection Risk Score: Infection risk can be objectively determined in a preoperative setting with a proposed surgical site infection (SSI) risk score for primary or revision knee and hip arthroplasty [66].

Other Considerations: Optimization of the delivery of care—both intraoperative and postoperative—is supported to reduce the broad variation in hospital readmissions after primary total hip arthroplasty [13]. Post-surgery interventions for hip fracture are heterogeneous in terms of type of interventions, settings, and outcome measures [18]. Standard comorbidity measures do not predict patient-reported outcomes 1 year after total hip arthroplasty; only knowing if the other hip is affected and whether the patient suffers from other joint pain or comorbidities affecting ambulation is needed to account for patient comorbidities [19]. Standardization of the definition of 'early' surgery and consistent reporting of 'time to surgery' would improve future evidence synthesis regarding the association between time to surgery and patient outcome after hip fracture [53].

Clinical Presentation

Perioperative care for hip and knee arthroplasty requires a structured, multidisciplinary enhanced patient care protocol informed by consensus-derived risk factors and interventions [1]. Multidisciplinary collaboration and precise risk management techniques are essential for perioperative patient care in total joint arthroplasty [2]. An ongoing multidisciplinary approach is required throughout the perioperative process to deliver successful outcomes in solid organ transplant patients undergoing total hip and knee arthroplasty [3]. Institutions should develop preoperative care pathways founded on sound and up-to-date evidence to avoid unnecessary testing and delays [4].

Preoperative management must address specific medical comorbidities and risk stratification. Pulmonary evaluation and medical optimization are critical steps in preoperative management for patients with chronic obstructive pulmonary disease undergoing total hip arthroplasty [5]. Patients identified as being at higher risk (ASA class 3 or 4) preoperatively should be closely managed medically to manage perioperative medical complications and address evolving medical issues in a timely fashion [6]. Awareness of risk factors can alert surgeons to patients who are potentially at risk and facilitate management during the preoperative and perioperative periods [8]. Clinicians should use risk factors such as frailty to optimize perioperative care and support for total hip and knee arthroplasty recipients [10].

Risk Stratification and Biomarkers: Admission hyperglycemia is associated with postoperative pneumonia in geriatric patients with hip fractures, serving as a biomarker to aid clinical assessment and perioperative management [9]. Risk factors for mortality following proximal femoral fractures in elderly patients include age ≥80 years, a >48-hour delay to surgery, and pre-operative ASA scores of 3–4 [11]. A predictive model incorporating variables such as malnutrition can facilitate early identification of high-risk patients with extended length of stay after total hip arthroplasty, optimizing preoperative management and improving clinical outcomes [24]. Patients with a recent COVID-19 diagnosis prior to total joint arthroplasty are at greater risk of postoperative complications including 30-day mortality [25].

Preoperative Optimization and Testing: Timely intervention for moderate and severe anemia at admission is recommended for elderly patients with hip fracture to reduce postoperative complications and mortality [31]. Preoperative vitamin D screening and potential supplementation strategies are important for patients receiving hip fracture surgery under general anesthesia who have vitamin D levels below 20 ng/mL [26]. Preoperative investigation for venous thromboembolism should be routinely considered for hip fracture patients in whom surgery is delayed for >24 hours [27]. The decision to obtain routine postoperative laboratory tests after primary total hip arthroplasty should be driven by patients' risk factors rather than routine necessity [30].

Postoperative Monitoring and Surgical Timing: Postoperative care requires multimodal analgesia and collaboration among the perioperative team to optimize outcomes [4]. Postoperative laboratory tests are required for patients with identified risk factors to identify abnormalities that need to be managed following hip hemiarthroplasty [22]. Routine postoperative laboratory tests are needed for patients with identified risk factors after high tibial osteotomy surgery [28]. Timing of surgery for total hip arthroplasty should consider patient age and pre-operative function [23]. Patients undergoing conversion total hip arthroplasty from free vascularized fibular grafting may be at an increased risk of perioperative complications, specifically associated with increased perioperative bleeding [29].

Investigations

Preoperative care pathways should be founded on sound and up-to-date evidence to avoid unnecessary testing and delays [4]. Awareness of risk factors can alert surgeons to potentially at-risk patients and facilitate management during the preoperative and perioperative periods [8]. For patients with osteoarthritis, preoperative function and radiological osteoarthritis should be focused on to decide when total hip replacement will be most effective [81].

Plain radiography: In total hip arthroplasty, X-rays taken immediately after surgery rarely reveal unknown complications [45]. Routine radiographs at the first postoperative visit after internal fixation of geriatric hip fractures do not change management and should only be obtained when indicated [86].

MRI: Routine preoperative magnetic resonance imaging for hip arthroscopy should be obtained at the discretion of the treating clinician based on specific clinical criteria rather than being mandated by insurers [43]. Standardised radiological imaging, with MRI to exclude overt tibiofemoral disease, should be part of the pre-operative assessment for femoro-patella Vialla joint replacement, especially for the non-dysplastic knee [56]. MRI offers the potential to identify patients with a higher risk of implant dislocation after posterior approach total hip arthroplasty by evaluating posterior capsular dehiscence [64].

Laboratory: Admission hyperglycemia is a biomarker that can aid clinical assessment and perioperative management in geriatric patients with hip fractures [9]. Preoperative echocardiography for hip fracture patients is associated with increased postoperative mortality at 90 days and one year, but not at 30 days [73].

Other Considerations: Pulmonary evaluation and medical optimization are critical steps in preoperative management for patients with chronic obstructive pulmonary disease undergoing total hip arthroplasty [5]. Preoperative consultation with a vascular surgeon is advocated in settings involving prosthetic hip resection for infection due to the risk of external iliac artery injury [82]. Fluoroscopy-based robotic-assisted total hip arthroplasty is associated with lower postoperative opioid use, including during the immediate perioperative period, compared to manual techniques [72]. The benefit of intraoperative fluoroscopy in hip arthroplasty might become more evident at an early phase of the learning curve, but its role has yet to be defined [84].

Treatment

Non-Operative

Nonsurgical management with pharmacologic agents has not proved to be effective for periprosthetic osteolysis [51]. Treatment options for hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors [77].

Operative

Indications: Perioperative patient care requires multidisciplinary collaboration and precise risk management techniques to impact periprosthetic joint infection and revision rates [2]. Patients identified as being at higher risk (ASA class 3 or 4) preoperatively should be closely managed medically so that perioperative medical complications can be managed and evolving medical issues can be addressed in a timely fashion [6]. Preoperative optimization of the health of patients is recommended to reduce the need for transfusion in lower extremity revision arthroplasty under a restrictive blood management protocol [16]. Optimizing preoperative hemoglobin levels may mitigate postoperative anemia and adverse outcomes in total joint arthroplasty [17]. Guidelines for the perioperative management of patients with sickle cell disease undergoing total hip arthroplasty have been proposed to address the high risk of complications in this population [15].

Surgical Approach / Technique: Perioperative care for hip and knee arthroplasty should involve a structured, multidisciplinary enhanced patient care protocol informed by consensus-derived risk factors and interventions [1]. An ongoing multidisciplinary approach is required throughout the perioperative process and beyond to deliver successful outcomes in solid organ transplant patients undergoing total hip and knee arthroplasty [3]. Institutions should develop preoperative care pathways founded on sound and up-to-date evidence to avoid unnecessary testing and delays [4]. Regional anesthesia should be utilized whenever feasible, and when no contraindications are present, for total joint arthroplasty [7]. Intravenous corticosteroids (dexamethasone) should be utilized during anesthesia induction for primary knee or hip arthroplasty, provided no contraindications are present [32]. The American Society of Anesthesiologists recommends withholding daily-dose GLP-1 receptor agonist therapy on the day of surgery and weekly-dose therapy for the week prior, with specific precautions for patients exhibiting gastrointestinal symptoms [33]. The AAOS guideline recommends discontinuing antiplatelet agents before surgery for elective hip and knee arthroplasty [79].

Implant Selection: Three differing methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence, but the risk of reoperation was much higher than expected [78].

Alignment / Balancing Strategy: Hip arthroscopy experts agree with non-experts on most aspects of patient care, but surgical expertise is associated with the performance of advanced techniques and recommendation of a longer period of restricted weight bearing following microfractures [21].

Pain Management: Postoperative care requires multimodal analgesia and collaboration among the perioperative team to optimize outcomes [4]. Both nonnarcotic and narcotic pain management protocols provided adequate pain control after total hip arthroplasty, but the nonnarcotic protocol resulted in significantly decreased opioid consumption and fewer adverse effects [48].

Adjuncts: Using tranexamic acid (TXA) alone remains a highly effective and practical approach for improving early postoperative outcomes in patients undergoing total hip arthroplasty [36]. The use of a single intravenous TXA dose was as efficacious as two doses, without an increase in postoperative complications, in total joint arthroplasty [38]. The blood conserving effect of TXA was not associated with improved postoperative recovery across the measures of pain and mobility, but may have a positive effect on reducing the duration of inpatient stays in hip arthroplasty [39]. The AAOS guideline recommends using pharmacologic agents and/or mechanical compressive devices for venous thromboembolic prophylaxis in low-risk patients undergoing elective hip and knee arthroplasty [79]. The AAOS guideline recommends against routine postoperative duplex ultrasonography screening for venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty [79].

Setting of Care: Robust pre- and perioperative protocols enabled safe same-day discharge for high-risk patients traditionally excluded by hard stop criteria [12]. Optimization of the delivery of care—both intraoperative and postoperative—is supported to reduce the broad variation in hospital readmissions after primary total hip arthroplasty [13]. Preoperative and postoperative risk factors predispose patients to nonroutine discharges after total hip arthroplasty [59]. Nonelective total hip arthroplasty patients without specific risk factors may be safely discharged to home [71].

Revision: Postoperative complications and mortality rates remain higher than age-matched control subjects in geriatric hip fracture patients despite advances in care [14]. Post-surgery interventions for hip fracture are heterogeneous in terms of type of interventions, settings, and outcome measures [18].

Complications

Infection (PJI): Postoperative surgical site infection is a serious complication responsible for prolonged hospital stays, increased mortality, and greater healthcare costs after primary hip hemiarthroplasty [40]. Perioperative multidisciplinary collaboration and precise risk management techniques are important for managing periprosthetic joint infection and revision rates after total joint arthroplasty [2]. An ongoing multidisciplinary approach is required throughout the perioperative process to deliver successful outcomes in solid organ transplant patients undergoing total hip and knee arthroplasty [3].

Medical Complications: Chronic obstructive pulmonary disease is associated with short-term complications following total hip arthroplasty [5]. Many complications following total hip arthroplasty in patients with chronic obstructive pulmonary disease are medical, making pulmonary evaluation and medical optimization critical steps in preoperative management [5]. Increasing age and history of cardiac disease increases the risk of cardiac complication after total hip arthroplasty and total knee arthroplasty [44]. Patients with a history of coronary artery bypass graft may have an increased risk of adverse cardiovascular events following total joint arthroplasty, necessitating more intensive postoperative cardiovascular monitoring and care [37].

Mortality and Risk Stratification: General complications and pre-operative comorbidities are the basic predictors of mortality at any time interval following fracture of the hip [20]. Risk factors for mortality following proximal femoral fractures in elderly patients include age ≥80 years, a >48-hour delay to surgery, and pre-operative ASA scores of 3–4 [11]. Patients identified as being at higher risk (ASA class 3 or 4) preoperatively should be closely managed medically so that perioperative medical complications can be managed and evolving medical issues can be addressed in a timely fashion [6]. Awareness of risk factors can alert surgeons to patients who are potentially at risk and facilitate management during the preoperative and perioperative periods [8]. Postoperative complications and mortality rates remain higher than age-matched control subjects in geriatric hip fracture patients despite advances in care [14].

Other Considerations: Robust pre- and perioperative protocols enabled safe same-day discharge for high-risk patients traditionally excluded by hard stop criteria, with no differences in postoperative short-term complications or 2-year revision rates compared to inpatient care [12, 42]. Optimizing preoperative hemoglobin levels may mitigate postoperative anemia and adverse outcomes in total joint arthroplasty [17]. Optimal vs suboptimal glycemic control had no effect on the length of stay, hospital costs, or rate of short-term postoperative complications in total joint arthroplasty patients [49]. Factors such as patient medical history and diabetes control should be considered when evaluating insulin-dependent patients for surgery, rather than establishing strict BMI cutoffs, as diabetes status affects odds of body mass index–dependent adverse outcomes after total hip arthroplasty [61]. Crohn’s disease is associated with longer in-hospital lengths of stay and higher rates of complications and costs after primary total hip arthroplasty [41].

Recovery

Light activity (weeks): Early recovery is supported by the direct superior approach, which facilitates earlier mobilization compared to the posterolateral approach [58]. The direct anterior approach also demonstrates superior short-term functional gains in elderly individuals with femoral neck fractures undergoing total hip arthroplasty [70]. For patients undergoing total hip arthroplasty, regional anesthesia should be utilized whenever feasible, provided no contraindications are present [7].

Full activity (months): Mid- to long-term follow-up reveals that the direct superior approach yields better functional outcomes than the posterolateral approach [58]. In elderly patients with femoral neck fractures, the direct anterior approach provides similar long-term outcomes to the posterolateral approach despite superior short-term gains [70]. Total hip arthroplasty in patients aged 20 years and younger using modern implants exhibits excellent clinical outcome scores and survivorship at mid- to long-term follow-up [54].

Complete recovery / outcome plateau (months): Long-term functional outcomes stabilize with the approaches described above, though further studies are needed to determine if the grafted area maintains structural and functional integrity after autologous matrix-induced chondrogenesis for focal cartilage defects in the knee [52]. Additionally, further studies are required to assess the long-term effects of conventional versus lateral fasciotomy for preventing lateral femoral cutaneous nerve injury in total hip arthroplasty with the direct anterior approach [55]. Overlapping surgery is associated with satisfactory short-term revision rates, but prolonged follow-up is required to assess medium-term and long-term outcomes [57].

Rehabilitation protocol: More focus on the period after hospital discharge may improve recovery, patient satisfaction, and functional outcome in fast-track programs for elective joint replacement [68].

Functional milestones: Functionally dependent patients undergoing total hip arthroplasty are at higher risk of mortality, adverse perioperative outcomes, and complications [50]. Awareness of risk factors facilitates management during the preoperative and perioperative periods for elective total hip arthroplasty [8].

Other Considerations: Risk factors for mortality in elderly patients with proximal femoral fractures include age ≥80 years, a >48-hour delay to surgery, and pre-operative ASA scores of 3–4 [11]. Postoperative complications and mortality rates for geriatric hip fracture patients remain higher than age-matched control subjects [14]. General complications and pre-operative comorbidities are basic predictors of mortality at any time interval following hip fracture [20]. A higher Charlson comorbidity index correlates with worse patient function and higher long-term risk of death in elderly patients with femoral neck fractures [62].

Time to surgery presents conflicting evidence regarding its impact on outcomes. Total delay exceeding 48 hours is associated with increased three-day and one-year mortality, while hospital delay exceeding 24 hours is associated with more intraoperative medical complications in hip fracture patients [93]. An operative delay of more than two calendar days after admission is an important predictor of mortality within one year for elderly patients with hip fracture who are cognitively intact, able to walk, and living at home before the fracture [100]. However, time to surgery is not an independent risk factor for mortality or functional outcomes in delayed primary hip arthroplasty for geriatric low-energy femoral neck fracture when controlling for patient-specific factors [76]. Time to surgery was not associated with adverse outcomes in nonagenarians undergoing operative fixation of hip fractures, suggesting the 48-hour operative window may not be critical for this population [89]. No association was found between time to surgery and 30-day mortality rates or postoperative length of hospital stay in elderly hip fracture patients [96]. Warfarin therapy at the time of injury is associated with increased time to surgery, length of stay, and decreased survival after hip fracture, even after controlling for multiple prognostic factors [85]. Evaluating operative time as a cause of adverse events is difficult due to potential unmeasured confounders and lack of orthopedic-specific outcome data, requiring additional research to clarify causality [92].

There were no clinically relevant differences in early postoperative mortality between simultaneous and staged bilateral primary total hip arthroplasty in healthy patients [101].

Key Evidence

  • [L5] The consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. (10.1186/s12891-018-2062-2)
  • [L3] These results highlight how important it is for perioperative patient care to have multidisciplinary collaboration and precise risk management techniques. (10.1016/j.arth.2025.08.020)
  • [L5] An ongoing multidisciplinary approach is required throughout the perioperative process and beyond to deliver successful outcomes. (10.5435/jaaos-d-22-00370)
  • [L3] Many of these complications are medical, and pulmonary evaluation and medical optimization are a critical step in preoperative management for these patients. (10.1016/j.arth.2017.12.043)
  • [L2] Patients identified as being at higher risk (in ASA class 3 or 4) preoperatively should be closely managed medically so that perioperative medical complications can be managed and evolving medical issues can be addressed in a timely fashion. (10.2106/jbjs.i.00571)
  • [L2] Regional anesthesia should be utilized whenever feasible, and when no contraindications are present. (10.1016/j.arth.2024.10.082)
  • [L3] Awareness of these factors can alert the surgeon to patients who are potentially at risk and facilitate management, particularly during the preoperative and perioperative periods. (10.2106/00004623-200110000-00010)
  • [L3] This biomarker can aid clinical assessment and perioperative management. (10.1186/s12891-023-06829-5)
  • [L3] Clinicians should use these risk factors to optimize perioperative care and support as this patient population continues to increase. (10.5435/jaaos-d-22-00642)
  • [L3] Risk factors for mortality include age ≥80 years, a >48-hour delay to surgery, and pre-operative ASA scores of 3–4. (10.1186/s12891-023-06825-9)
  • [L3] Robust pre- and perioperative protocols enabled safe same-day discharge for high-risk patients traditionally excluded by hard stop criteria. (10.1016/j.arth.2025.05.054)
  • [L3] These findings support further optimization of the delivery of care—both intraoperative and postoperative—to reduce the broad variation in hospital readmissions. (10.1016/j.arth.2016.03.041)
  • [L5] Despite advances in care, postoperative complications and mortality rates remain higher than age-matched control subjects. (10.5435/jaaos-d-22-00815)
  • [L4] This review proposes guidelines for the perioperative management of patients with sickle cell disease undergoing total hip arthroplasty, informed by the clinical expertise of the authors and available literature to address the high risk of complications in this population. (10.1302/2058-5241.5.190073)
  • [L3] The authors recommend preoperative optimization of the health of these patients to reduce the need for transfusion. (10.5435/jaaos-d-20-00185)
  • [L4] Optimizing preoperative hemoglobin levels may mitigate postoperative anemia and adverse outcomes. (10.2106/jbjs.20.01766)
  • [L1] The identified RCTs regarding post-surgery interventions were heterogeneous in terms of type of interventions, settings and outcome measures. (10.1186/s12891-023-06512-9)
  • [L5] Only knowing if the other hip is affected and whether the patient suffers from other joint pain or comorbidities affecting ambulation is needed to account for patient comorbidities. (10.1007/s11999-015-4252-7)
  • [L2] General complications and pre-operative comorbidities are the basic predictors of mortality at any time interval. (10.1302/0301-620x.97b3.34504)
  • [L5] Hip arthroscopy experts agree with non-experts on most aspects of patient care, but surgical expertise is associated with the performance of advanced techniques and recommendation of a longer period of restricted weight bearing following microfractures. (10.1007/s00167-018-5289-4)
  • [L3] Nevertheless, for patients with identified risk factors, postoperative laboratory tests are still required to identify the abnormalities that need to be managed. (10.1186/s12891-021-04698-4)
  • [L2] Timing of surgery should consider patient age and pre-operative function. (10.1186/1749-799x-7-13)
  • [L3] A predictive model incorporating other variables demonstrated the highest diagnostic value, and the application of this model for the early identification of high-risk patients who have extended length of stay may facilitate targeted interventions, optimize preoperative management, and improve clinical outcomes. (10.1016/j.arth.2025.09.047)
  • [L3] Patients with a recent COVID-19 diagnosis prior to TJA are at greater risk of postoperative complications including 30-day mortality. (10.2106/jbjs.22.01317)
  • [L2] These findings highlight the importance of preoperative vitamin D screening and potential supplementation strategies for patients who have vitamin D levels below 20 ng/mL. (10.1016/j.arth.2025.04.080)
  • [L4] Therefore, preoperative investigation for VTE should be routinely considered for patients in whom surgery is delayed for >24 hours. (10.2106/jbjs.15.01329)
  • [L3] However, for patients with identified risk factors, routine postoperative laboratory tests are still needed. (10.1186/s12891-021-04608-8)
  • [L3] These patients should be counseled that they may be at an increased risk of perioperative complications, specifically associated with increased perioperative bleeding. (10.1016/j.arth.2018.09.041)
  • [L3] Instead, the decision to obtain laboratory tests after surgery should be driven by patients' risk factors. (10.1016/j.arth.2018.11.037)
  • [L3] For patients with moderate and severe anemia at admission, timely intervention is recommended to reduce postoperative complications and mortality. (10.1186/s12891-024-08252-w)
  • [L1] The authors recommend utilizing intravenous corticosteroids (dexamethasone) during anesthesia induction, provided no contraindications are present. (10.1016/j.arth.2024.10.078)
  • [L5] The American Society of Anesthesiologists recommends withholding daily-dose therapy on the day of surgery and weekly-dose therapy for the week prior, with specific precautions for patients exhibiting gastrointestinal symptoms. (10.2106/jbjs.24.01287)
  • [L4] When properly used in these patients, the guidelines to minimize adverse outcomes are executable and effective. (10.2106/jbjs.m.00503)
  • [L3] Using TXA alone remains a highly effective and practical approach for improving early postoperative outcomes in patients undergoing THA. (10.1186/s42836-025-00320-3)
  • [L3] Patients who have a history of CABG may have an increased risk of adverse cardiovascular events following total joint arthroplasty, necessitating more intensive postoperative cardiovascular monitoring and care. (10.1016/j.arth.2025.04.069)
  • [L3] The use of a single intravenous TXA dose was as efficacious as two doses, without an increase in postoperative complications. (10.5435/jaaos-d-20-00658)
  • [L1] The blood conserving effect of TXA was not associated with improved postoperative recovery across the measures of pain and mobility, but may have a positive effect on reducing the duration of inpatient stays. (10.1016/j.arth.2016.11.045)
  • [L3] Postoperative SSI is a serious complication that is responsible for prolonged hospital stays, increased mortality, and greater healthcare costs. (10.1186/s42836-022-00155-2)
  • [L3] This study may aid physicians to perform appropriate risk adjustment for adverse outcomes and to educate these patients about potential postoperative complications. (10.1016/j.arth.2021.02.002)
  • [L3] We found no differences regarding postoperative short-term complications or 2-year revision rates, and no differences in unplanned office visits or readmissions. (10.1186/s13018-020-01871-8)
  • [L5] The author concludes that MRI should be obtained at the discretion of the treating clinician based on specific clinical criteria rather than being mandated by insurers. (10.1016/j.arthro.2022.04.009)
  • [L1] Increasing age and history of cardiac disease increases the risk of cardiac complication after total hip arthroplasty and total knee arthroplasty. (10.1186/s13018-018-1058-9)
  • [L3] In total hip arthroplasty, X-rays taken immediately after surgery rarely reveal unknown complications. (10.1186/s42836-022-00148-1)
  • [L3] The study utilized data from the Swedish Hip Arthroplasty Register to evaluate the predictive ability of the ASA physical status classification system on health-related quality of life using eight EQ-5D-3L value sets across preoperative and postoperative periods up to 6 years. (10.1186/s12891-020-03399-8)
  • [L3] Our results support the use of multiple HbA1c strata that can be incorporated into preoperative risk-stratification models. (10.1016/j.arth.2023.10.024)
  • [L2] Both protocols provided adequate pain control after total hip arthroplasty; the nonnarcotic pain management protocol resulted in significantly decreased opioid consumption and fewer adverse effects. (10.1016/j.arth.2010.01.003)
  • [L3] Optimal vs suboptimal glycemic control in these patients also had no effect on the length of stay, hospital costs, or rate of short-term postoperative complications. (10.1016/j.arth.2016.07.002)
  • [L3] Functionally dependent patients undergoing THA are at higher risk of mortality, adverse perioperative outcomes, and complications. (10.1016/j.arth.2018.12.037)
  • [L5] Nonsurgical management with pharmacologic agents has not proved to be effective. (10.5435/00124635-200800001-00006)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L1] Standardization of the definition of 'early' surgery and consistent reporting of 'time to surgery' would improve future evidence synthesis. (10.1302/0301-620x.108b1.bjj-2025-0035.r1)
  • [L4] In patients 20 years old and younger, THAs performed with use of modern implants exhibit excellent clinical outcome scores and survivorship at mid- to long-term follow-up. (10.2106/jbjs.19.00699)
  • [L1] Further studies are needed to assess the longterm effects of these approaches. (10.1302/0301-620x.105b12.bjj-2023-0375.r1)
  • [L4] Standardised radiological imaging, with MRI to exclude overt tibiofemoral disease should be part of the pre-operative assessment, especially for the non-dysplastic knee. (10.1302/0301-620x.95b6.31355)
  • [L1] Although overlapping surgery is associated with satisfactory short-term revision rates, prolonged follow-up is required to further assess medium-term and long-term outcomes. (10.5435/jaaos-d-20-01130)
  • [L1] These advantages support the use of DSA for promoting early recovery and better mid-term functional outcomes. (10.1186/s12891-024-08271-7)
  • [L3] This study identifies both preoperative and postoperative risk factors that predispose patients to nonroutine discharges after THA. (10.5435/jaaos-d-19-00272)
  • [L3] These findings suggest that factors such as patient medical history and diabetes control should be considered when evaluating insulin-dependent patients for surgery, rather than establishing strict BMI cutoffs. (10.5435/jaaos-d-20-00028)
  • [L3] The higher the CCI, the worse the patient's function and the higher the long-term risk of death. (10.1186/s12891-024-07814-2)
  • [L3] MRI offers the potential to identify patients with a higher risk of implant dislocation. (10.5435/jaaos-d-18-00655)
  • [L3] We believe that infection risk can be objectively determined in a preoperative setting with the proposed SSI risk score. (10.2106/jbjs.15.00988)
  • [L1] Compared to manual THA, R-THA improves surgical accuracy without increasing surgical trauma, contributing to the restoration of the patient's original hip biomechanics. (10.1016/j.arth.2025.07.029)
  • [L4] More focus on the period after hospital discharge may improve recovery, patient satisfaction, and functional outcome. (10.1186/s13018-019-1232-8)
  • [L1] Preoperative hypoalbuminemia is associated with an increased risk of numerous types of complications, transfusion, unplanned reoperation, and mortality after THA or TKA. (10.1530/eor-2025-0170)
  • [L3] DAA demonstrated superior short-term functional gains and similar long-term outcomes compared with the posterolateral approach. (10.1186/s13018-025-05941-7)
  • [L3] Nonelective total hip arthroplasty patients without these risk factors may be safely discharged to home. (10.1016/j.arth.2017.03.042)
  • [L3] Fluoroscopy-based RA-THA is associated with lower postoperative opioid use, including during the immediate perioperative period, when compared to manual techniques. (10.1186/s42836-023-00211-5)
  • [L3] Preoperative echocardiography for hip fracture patients is associated with increased postoperative mortality at 90 days and one year but not at 30 days. (10.1302/0301-620x.103b2.bjj-2020-1011.r1)
  • [L3] Sitting lumbar-pelvic-femoral alignment following THA may be driven by hip arthritis and/or spinal deformity. (10.1302/0301-620x.100b10.bjj-2017-1336.r2)
  • [L3] The study found that time to surgery was not an independent risk factor for mortality or functional outcomes when controlling for patient-specific factors. (10.1016/j.arth.2025.05.099)
  • [L5] Treatment options range from non-operative measures to various surgical procedures including cheilectomy, arthroplasty, and arthrodesis, with selection depending on disease stage and patient factors. (10.2106/00004623-199806000-00015)
  • [L3] The three described methods of managing intraoperative nondisplaced calcar fractures demonstrated little radiographic stem subsidence; however, the risk of reoperation was much higher than expected. (10.1016/j.arth.2024.03.049)
  • [L5] The AAOS guideline recommends discontinuing antiplatelet agents before surgery, using pharmacologic agents and/or mechanical compressive devices for prophylaxis in low-risk patients, and recommends against routine postoperative duplex ultrasonography screening. (10.5435/00124635-201112000-00008)
  • [Paper] All devices which may increase bone mass in the lateral trochanter, theoretically, may be helpful in lowering the incidence of hip fractures. (10.1016/j.injury.2009.05.028)
  • [L2] Results suggest to focus on preoperative function and radiological osteoarthritis to decide when THA will be most effective. (10.1186/s12891-016-1070-3)
  • [L4] We advocate preoperative consultation with a vascular surgeon in this setting. (10.1016/j.arth.2009.03.006)
  • [L1] The benefit of intraoperative fluoroscopy might become more evident at an early phase of the learning curve for this procedure, therefore its role has yet to be defined. (10.1186/s42836-023-00173-8)
  • [L3] After controlling for multiple prognostic factors, warfarin therapy at the time of injury is associated with increased time to surgery, length of stay, and decreased survival. (10.1007/s11999-016-5056-0)
  • [L4] Routine radiographs at the first postoperative visit after internal fixation of geriatric hip fractures do not change management and should only be obtained when indicated. (10.5435/jaaos-d-24-00036)
  • [L3] Since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. (10.1016/j.arth.2020.06.005)
  • [L5] Evaluating operative time as a cause of adverse events is difficult due to potential unmeasured confounders and lack of orthopedic-specific outcome data; additional research is needed to better clarify the causality of observed associations. (10.1016/j.arth.2018.04.029)
  • [L2] Total delay exceeding 48 hours was associated with increased three-day and one-year mortality, while hospital delay exceeding 24 hours was associated with more intraoperative medical complications. (10.1302/0301-620x.101b9.bjj-2019-0295.r1)
  • [L3] No association was found between time to surgery and 30-day mortality rates or postoperative length of hospital stay. (10.1302/0301-620x.104b12.bjj-2022-0172.r2)
  • [L5] The authors argue that current classification of borderline hip dysplasia based solely on lateral center edge angle is insufficient and that the focus must shift to assessing hip instability to better predict treatment outcomes and the need for bony realignment. (10.1016/j.arthro.2023.10.023)
  • [L2] An operative delay of more than two calendar days after admission is an important predictor of mortality within one year for elderly patients who have a fracture of the hip and who are cognitively intact, able to walk, and living at home before the fracture. (10.2106/00004623-199510000-00010)
  • [L3] There were no clinically relevant differences in early postoperative mortality between simultaneous and staged bilateral surgery in healthy patients. (10.1186/s12891-015-0535-0)

References

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[28] Re-evaluating the necessity of routine laboratory tests after high tibial osteotomy surgery. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04608-8

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[31] Risk factors and characteristics of preoperative heart failure in elderly patients with hip fracture and the influence of anemia on prognosis. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08252-w

[32] Should Intravenous Corticosteroids Be Administered Routinely During Primary Knee or Hip Arthroplasty to Impart Analgesic and Anti-Inflammatory Properties?. The Journal of Arthroplasty. 2025. DOI: 10.1016/j.arth.2024.10.078

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[35] Chapter 44 Primary Hip Arthroplasty. 2019.

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[38] One Dose Versus Two Doses of Intravenous Tranexamic Acid in Total Joint Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00658

[39] OBTAIN A: Outcome Benefits of Tranexamic Acid in Hip Arthroplasty. A Randomized Double-Blinded Controlled Trial. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2016.11.045

[40] Incidence and risk factors for surgical site infection (SSI) after primary hip hemiarthroplasty: an analysis of the ACS-NSQIP hip fracture procedure targeted database. Arthroplasty. 2023. DOI: 10.1186/s42836-022-00155-2

[41] Crohn’s Disease is Associated with Longer In-Hospital Lengths of Stay and Higher Rates of Complications and Costs after Primary Total Hip Arthroplasty. The Journal of Arthroplasty. 2021. DOI: 10.1016/j.arth.2021.02.002

[42] Outpatient vs. inpatient hip arthroplasty: a matched case-control study on a 90-day complication rate and 2-year patient-reported outcomes. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01871-8

[43] Editorial Commentary: Routine Preoperative Magnetic Resonance Imaging for Hip Arthroscopy Is Wasting Health Care Dollars and Delaying Surgical Intervention: Decision Making Should Be at the Discretion of the Health Care Provider Not Mandated by Health Care Insurers. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.04.009

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[49] Preoperative Glycemic Control on Total Joint Arthroplasty Patient-Perceived Outcomes and Hospital Costs. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2016.07.002

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[57] Outcomes and Patient Safety in Overlapping vs. Nonoverlapping Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-01130

[58] Direct superior approach versus posterolateral approach in mid-term clinical outcomes of total hip arthroplasty: a prospective randomized controlled study. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-024-08271-7

[59] Which Patients Require Unexpected Admission to Postacute Care Facilities After Total Hip Arthroplasty?. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-19-00272

[60] Chapter 12 Hip Microinstability. 2019.

[61] Diabetes Status Affects Odds of Body Mass Index–dependent Adverse Outcomes After Total Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00028

[62] Correlation between Charlson comorbidity index and surgical prognosis in elderly patients with femoral neck fractures: a retrospective study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07814-2

[64] MRI Evaluation of Posterior Capsular Dehiscence After Posterior Approach Total Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-18-00655

[66] Development and Validation of a Preoperative Surgical Site Infection Risk Score for Primary or Revision Knee and Hip Arthroplasty. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.15.00988

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[71] Nonelective Primary Total Hip Arthroplasty: The Effect of Discharge Destination on Postdischarge Outcomes. The Journal of Arthroplasty. 2017. DOI: 10.1016/j.arth.2017.03.042

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iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.