Evidence-based perioperative pathway for primary, unilateral total knee and total hip arthroplasty. This is the at-a-glance summary; see the companion Reference & Evidence document for rationale and studies. Detailed therapy progression lives in the TKA "Quiet Knee" and THA (posterior) rehabilitation protocols.
1 · Patient Selection & Preoperative Optimization
Candidates: primary, unilateral TKA / THA (or UKA). Optimize every modifiable risk factor in clinic ≥4 weeks before surgery.
| Target | Threshold / action |
|---|---|
| Glycemic control | HbA1c < 7% for elective surgery; perioperative glucose < 200 mg/dL |
| Nutrition — albumin | ≥ 3.5 g/dL. < 3.0 → delay, dietitian, repletion. Protein 1.2–1.5 g/kg/day |
| Anemia / iron | Hb ≥ 13 (M) / ≥ 12 (F). IV iron if deficient and < 4 wk to surgery |
| Vitamin D | Empiric supplement for all — D3 4,000 IU/day pre-op; no routine testing |
| Smoking | Cessation ≥ 4 wk (NRT/varenicline); do not make surgery contingent on full quit |
| BMI | < 36 for candidacy; shared decision / optimization above |
| S. aureus | Universal decolonization (see §2) — no routine MRSA screen |
| Dental | No mandatory clearance. Refer only for active/suspected oral infection or elevated risk; finish invasive work ≥ 2 wk pre-op (extractions ≥ 3 wk) |
Site of Surgery — Outpatient · Inpatient · Tertiary Referral
Outpatient (same-day / ASC) — ALL must be met: primary unilateral TKA/THA · ASA I–II (or optimized III) · BMI < 36 · age < 75 · HbA1c < 7 · Hb ≥ 12 · insulin-dependent DM OK if optimized · independent ADLs · willing/able to have spinal · 24-h caregiver for the first 24–72 h · lives ≤ 30–60 min from a hospital · pre-op education completed.
Inpatient (hospital) — deliberately only slightly more lenient than outpatient; acceptable ONLY as follows: age 75–82 · stable, optimized ASA III · BMI 36–39 · HbA1c 7–7.4 (≥ 7.5: delay & optimize) · Hb 11–11.9 after an IV-iron attempt (< 11: delay & optimize) · not independent in ADLs (start discharge planning pre-op) · unable to have spinal (general OK) · no 24-h caregiver or > 60 min from hospital (extended-stay / swing-bed plan) · untreated OSA (continuous monitoring; stays inpatient until off narcotics) · prior post-op delirium (precautions) · therapeutic anticoagulation (stable, with bridging plan) · chronic opioids ≤ 90 MME with a written pain plan. Pacemaker-dependence: individualized decision with Anesthesia and Cardiology.
Refer to a tertiary facility: ASA IV (or ASA III that cannot be stabilized) · age > 82 · BMI ≥ 40 · CHF · cirrhosis · ESRD/dialysis · unstable arrhythmia · symptomatic aortic stenosis · severe pulmonary hypertension · recent MI or coronary stent (< 6 months / on DAPT) · recent VTE (< 3 months) · opioid dependence needing specialty pain management (> 90 MME or on buprenorphine/methadone).
May still go outpatient after optimization or added monitoring: stable CAD · COPD · treated OSA on CPAP · active smoking · BPH/urinary-retention history (tamsulosin) · depression/anxiety. Prior contralateral TJA is favorable. Not meeting outpatient criteria never cancels surgery — it directs the case to the right setting.
2 · Decolonization & Education (start 5 days before)
| Step | Regimen |
|---|---|
| Nasal | Povidone-iodine 5% to both nares BID × 5 d (preferred; avoids mupirocin resistance) — or mupirocin 2% BID × 5 d |
| Skin | Chlorhexidine 2% cloths or 4% wash, full body, daily × 5 d (min 2 d) |
| Day of surgery | Povidone-iodine nasal swab to both nares within 2 h of incision |
| Education | Standardized session: pain expectations, multimodal plan, opioid-counseling video, PT exercises |
3 · Day of Surgery — Pre-op Orders
| Order | Detail |
|---|---|
| NPO / carb load | NPO per ASA; Ensure Pre-Surgery Clear Carbohydrate Drink — 1 bottle the evening before + 1 bottle up to 2 h before arrival (non-diabetic). Patient buys it (Amazon/Walmart); if unavailable, skip the drink entirely — no substitutes. |
| Hair | Clip only if needed, incision area only — NEVER razor |
| Skin | Chlorhexidine or ChloraPrep wipe |
| Warming | Forced-air warming blanket + warmed IV fluids in pre-op holding (normothermia ≥ 36 °C) |
| Antibiotic | Cefazolin 2 g IV (3 g if > 120 kg) within 60 min of incision; redose q3–4 h. Non-anaphylactic PCN allergy → still cefazolin; severe/anaphylactic → clindamycin 900 mg. Do NOT add IV vancomycin routinely |
| TXA | Oral 1–2 g 2 h pre-op OR IV 1 g pre-incision. Hold: CrCl < 30, TXA allergy, VTE < 12 mo |
| Analgesia (PO) | Acetaminophen 1,000 mg + celecoxib 200 mg (pregabalin 75 mg optional/selective) |
| Dexamethasone | 10 mg IV at induction (pain, PONV, LOS). Give even in diabetics with HbA1c < 8% |
| Urinary (at-risk males) | Tamsulosin 0.4 mg starting ~3 days pre-op |
4 · Anesthesia & Regional
- Spinal anesthesia is the default (lower mortality, pulmonary complications, DVT, SSI, transfusion). Low-dose agent for ASC.
- TKA: single-shot adductor canal block + periarticular injection (PAI — cocktail recipe in Section 5). iPACK only if PAI not used or difficult pain expected. No femoral nerve block.
- THA: no routine block — the PAI alone is a defensible stand-alone regimen for THA; blocks (fascia iliaca / PENG) are optional adjuncts, not required. THA evidence (in contrast to TKA) consistently shows PAI/LIA performing at least as well as regional blocks.
- Ketamine (intra-op): low-dose 0.25–0.5 mg/kg bolus + 0.1–0.25 mg/kg/h infusion, stop near closure; especially opioid-tolerant patients.
- PONV prophylaxis: dexamethasone (above) + ondansetron.
5 · Intraoperative Bundle
| Element | Standard |
|---|---|
| Skin prep | Alcohol-based — chlorhexidine-alcohol or povidone-iodine-alcohol |
| Tourniquet (TKA) | None by default when TXA used (or brief, cementation-only) |
| IO vancomycin | 500 mg in injectable saline — TKA: proximal tibia (in 100 mL); THA: greater trochanter. In addition to IV cefazolin |
| PAI cocktail | 100 mL total — same for TKA & THA: bupivacaine 0.25% 100 mg = 40 mL + ketorolac 30 mg = 1 mL + epinephrine 1:1,000 0.5 mg = 0.5 mL + methylprednisolone 40 mg = 1 mL, then injectable normal saline to 100 mL. Layered infiltration. Not liposomal, not morphine |
| Topical TXA | 2 g in 50 mL injectable saline into joint before closure |
| Irrigation | Dilute povidone-iodine (0.25–0.35%) lavage before closure |
| Drain | None |
| Closure | Watertight barbed capsular repair; subcuticular / 2-octyl-cyanoacrylate + mesh skin |
| Bundle | Normothermia (active prewarming + warm IV fluids) · glucose < 200 · clippers only |
Do Not (intraop adjuncts without benefit)
Intrawound vancomycin powder · reliance on laminar airflow · metal-on-metal bearings.
PACU — Meds & Discharge
Meds: scheduled acetaminophen + celecoxib; ketorolac 15–30 mg IV if not given intra-op; ondansetron 4 mg IV PRN (rescue a different class); rescue opioid PRN; aspirin 81 mg (evening POD 0). Normothermia ≥ 36 °C; mechanical VTE; mobilize day of surgery.
Leave PACU when: stable vitals · pain ≤ 4 on oral meds · nausea controlled · neuraxial block regressing (motor returning, can protect limb) · not over-sedated · void or bladder plan.
6 · Postoperative Orders
| Order | Detail |
|---|---|
| Mobilize | Out of bed / PT the day of surgery; full weight-bearing (routine cementless per surgeon) |
| Analgesia | Scheduled acetaminophen 1,000 mg q6h + celecoxib; dexamethasone 16 mg PO on POD 1; oral TXA 1 g q6h × ~24 h; opioids rescue only, small discharge quantity |
| VTE | Aspirin 81 mg BID (standard) + IPCD; no TED hose. High-risk → DOAC (rivaroxaban 10 mg daily / apixaban 2.5 mg BID). Duration: 2 wk TKA · 4 wk THA |
| Bowel | Senna + PEG scheduled; hold for diarrhea |
| Bladder | No routine indwelling catheter; scan protocol; straight-cath > 400 mL / retention; tamsulosin |
| Comfort | Ice/cryotherapy + elevation. No CPM |
| Dressing | Silver dressing (most) — waterproof, shower POD 1–2, leave 5–7 d. High-risk → closed-incision NPWT (e.g., PICO) |
| Testing | No routine post-op labs or radiographs; no routine duplex US |
Post-op Timeline & Follow-up
POD 0–4: dexamethasone 16 mg PO on POD 1; scheduled acetaminophen + celecoxib 200 BID (OTC naproxen or ibuprofen may substitute by patient preference — add GI protection, separate from aspirin) + aspirin 81 BID; bowel regimen; opioid PRN only; dressing stays on, shower POD 1–2.
POD 4–14: continue acetaminophen + celecoxib; opioids off by ~POD 5–7; aspirin through 2 wk (TKA) / 4 wk (THA); dressing / NPWT off ~POD 5–7; sutures/staples out ~POD 12–14.
Staff follow-up: nurse call POD 1 and POD 2; 24/7 line × 72 h; in-person 2-week visit.
7 · Discharge & Rehab
- Milestone-based discharge (pain controlled PO, safe ambulation/transfers, voiding, tolerating intake, support). Target POD 0–1; same-day for appropriate candidates.
- No mandatory 90° knee-flexion criterion. No routine hip precautions after posterior THA with capsular repair — avoid only extreme flexion + adduction + internal rotation early.
- Home-based rehab is first-line; telerehabilitation is acceptable and lower-cost. Stratify to formal PT by 2-week criteria.
- Therapy detail: TKA "Quiet Knee" and THA (posterior) minimal-restriction protocols.
8 · Practices to Abandon
Surgical drains · CPM machines · routine indwelling urinary catheter · routine post-op labs · routine post-op radiographs · pre-op asymptomatic-bacteriuria screening · antibiotics > 24 h · reliance on laminar airflow · razor hair removal · compression stockings alone (use IPCD) · liposomal bupivacaine · mandatory/universal pre-op dental clearance (refer selectively) · routine dental antibiotic prophylaxis · routine ICU admission · intrawound vancomycin powder.