One page, in case order, covering hip, knee, and shoulder arthroplasty. Every item traces to the Arthroplasty Protocol Quick Reference and the Shoulder Arthroplasty Protocol Sheet — see them for rationale and the companion Reference & Evidence document for studies. Joint-specific items are flagged inline.
Pre-Op / Holding
- Patient ID, site, and consent verified.
- Povidone-iodine 5% nasal swab to both nares within 2 h of incision.
- Chlorhexidine or ChloraPrep skin wipe done.
- Forced-air warming blanket on + warmed IV fluids — patient arrives in the room warm (core ≥ 36 °C).
- Antibiotic timing confirmed with anesthesia — cefazolin within 60 min of incision; note the time for redosing (q3–4 h).
- Diabetics: glucose checked; target < 200 mg/dL.
Room Setup
- Clippers available — clip only if needed, incision area only, never a razor.
- TKA: tourniquet available but not applied by default when TXA is used (brief, cementation-only, per surgeon).
- Vancomycin 500 mg in injectable saline prepared for intraosseous use (TKA: 100–150 mL for proximal tibia; THA: greater trochanter; shoulder: proximal humerus).
- PAI ingredients pulled and drawn up (TKA & THA): bupivacaine 0.25%, ketorolac 30 mg, epinephrine 1:1,000, methylprednisolone 40 mg, injectable normal saline (100 mL total mix).
- Topical TXA drawn: 2 g in 50 mL injectable saline for the joint before closure.
- Dilute povidone-iodine irrigation prepared (0.25–0.35%) for pre-closure lavage.
- Waterproof silver dressing on the field. No drain expected.
- No intrawound vancomycin powder — it is off-protocol.
During the Case
- Keep door openings to a minimum; traffic control throughout.
- Monitor and chart core temperature — normothermia ≥ 36 °C for the whole case.
- Prompt anesthesia for cefazolin redosing at 3–4 h.
- Counts per policy; document PAI, IO vancomycin, topical TXA, and irrigation times.
Hand-Off to PACU
- Report what was given: induction dexamethasone, TXA (route), PAI, IO vancomycin, ketorolac (or not — PACU gives it IV if missed).
- Report block type and expected regression (spinal / adductor canal / interscalene).
- Dressing: waterproof silver — stays on; patient may shower with it from POD 1–2.
- Plan: mobilize the day of surgery — PACU should expect PT the same day.