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.
Before Incision
- Consent, site marking, and imaging verified; implants and rep confirmed.
- Antibiotic confirmed in within 60 min of incision (cefazolin 2 g / 3 g > 120 kg).
- TXA given (oral 1–2 g 2 h pre-op or IV 1 g pre-incision) unless held for CrCl < 30 or VTE < 12 months.
- Hair clipped only if needed, incision area only — never a razor.
- TKA: no tourniquet by default when TXA is on board (or brief, cementation-only, per surgeon).
Intra-Op Tasks
- PAI cocktail mixed (TKA & THA; shoulder relies on the interscalene block) — 100 mL total, same recipe: 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.
- IO vancomycin 500 mg in injectable saline — TKA: proximal tibia (in 100–150 mL); THA: greater trochanter; shoulder: proximal humerus. This is in addition to IV cefazolin.
- Topical TXA 2 g in 50 mL injectable saline into the joint before closure.
- Dilute povidone-iodine (0.25–0.35%) lavage before closure.
- No drain.
- Closure: watertight barbed capsular repair; subcuticular / 2-octyl-cyanoacrylate + mesh for skin.
- Waterproof silver dressing — stays on, patient showers with it from POD 1–2, off at 5–7 days.
Post-Op Orders (the three-drug backbone + VTE)
- Dexamethasone 16 mg PO on POD 1 — in addition to the induction dose; given in hospital, or sent home with same-day discharges.
- Acetaminophen 1,000 mg PO q8h scheduled (not PRN).
- Celecoxib 200 mg PO BID scheduled — OTC naproxen or ibuprofen may substitute by patient preference (add GI protection; separate from aspirin).
- Aspirin 81 mg PO BID starting the evening of POD 0 — 2 weeks TKA & shoulder / 4 weeks THA. Elevated VTE risk: DOAC instead (rivaroxaban 10 mg daily or apixaban 2.5 mg BID). IPCDs while in-house; no TED hose.
- Senna-docusate + PEG PRN while on opioids; hold for diarrhea.
- Ondansetron 4 mg PO q8h PRN.
- Oxycodone 5 mg PO q4–6h PRN, breakthrough only — small quantity (≈10–20 tabs).
- Tamsulosin 0.4 mg daily for at-risk men; bladder scan protocol, straight-cath > 400 mL or retention.
- No routine post-op labs, radiographs, or duplex ultrasound.
Discharge & Follow-Up
- Mobilize the day of surgery; full weight-bearing (routine cementless per surgeon).
- Milestone-based discharge: pain controlled on orals, safe ambulation and transfers, voiding, tolerating intake, support at home.
- Nurse call POD 1 and POD 2; 24/7 line staffed; in-person visit at 2 weeks.