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    What Are Your Perioperative Protocols for Primary THA Patients?

    Dr. Antonia Chen, Dr. James Browne, and Dr. Jonathan Vigdorchik respond to questions from ICJR about perioperative management of primary total hip arthroplasty patients, including BMI cutoff, antibiotic prophylaxis, and the use of tranexamic acid.

    ICJR: Do you have a BMI cutoff when considering patients for primary THA? Is it a hard cutoff or a soft cutoff? If the patient’s BMI has decreased but is still above your cutoff, will you perform surgery?

    Antonia F. Chen, MD, MBA: The BMI cutoff in my practice is 40 kg/m2. I will work closely with patients to help them lose weight in a safe manner, including working with a nutritionist and recommending surgical intervention if warranted. I also check nutrition laboratory values to ensure that patients are not malnourished after weight loss.

    I monitor patients as they decrease their BMI and if they plateau with weight loss very close to the cutoff and are optimized, then I will consider primary THA (eg, BMI=41 kg/m2).

    James A. Browne, MD: The issue of obesity and BMI cutoffs is complex. I believe that this assessment must be done at the individual patient level and that BMI must be considered in the context of other patient risk factors when determining candidacy for THA. The potential benefit of surgery to the patient should also be assessed when balancing the risks of surgery.

    Patients with a BMI over 40 are typically asked to try to modify this risk factor prior to surgery. This is not a hard cutoff. We have had some success with dietary modification, exercise, and bariatric surgery, although admittedly the majority of patients struggle to lose weight.

    We do have a hard cutoff at 50, as research has clearly demonstrated that the risks become excessive and unacceptable at this level of obesity.

    Jonathan M. Vigdorchik, MD: Like Dr. Chen, my BMI cutoff is 40, but this is a soft cutoff. If patients have no other comorbidities and only the BMI is elevated, I will consider proceeding with the operation. Also, if the soft tissue envelope is smaller and most of the BMI is central obesity, I feel more comfortable that the wound complications may be less, although patients with a BMI of 40 may still be predisposed to medical complications.

    I want the patient to be a part of their care, meaning I explain to them the increased risks with an elevated BMI, mainly infection, and that by lowering the BMI, we can lower the risk. If they are motivated and make an attempt to lose weight, either on their own or through a nutritionist/dietary consult, I am more inclined to proceed if the BMI is still slightly elevated.

    ICJR: Do you operate on primary THA patients who are smokers, or do you require them to stop smoking before surgery? If smoking cessation is required, for how long before surgery? Do you do cotinine testing? If so, do you delay surgery if testing shows they’ve been smoking?

    Dr. Browne: As with other potentially modifiable risk factors, we try to make this assessment at the individual patient level and put smoking into the context of their other risk factors, as well as the potential benefits of THA.

    All smokers are counseled regarding the increased risks associated with smoking. We ask that smokers quit at least 6 weeks prior to surgery and not smoke for at least 6 weeks postoperatively. Patients deemed to be low risk without multiple comorbidities are not tested and we do not delay surgery. For high-risk patients with multiple risk factors, we will do cotinine testing and delay surgery if the test is positive.

    Dr. Vigdorchik: I require all current smokers to attempt to undergo smoking cessation therapy, either quitting on their own or going through a formalized program we have at the hospital. The reason they should quit is to help lower the risk of wound complications, pulmonary complications, and to avoid the use of a more potent DVT chemoprophylaxis (smoking is a risk factor for DVT).

    Patients should be smoke-free for 1 month prior to the operation. We verify with cotinine testing. If they continue to smoke but have made the effort to try to quit, we still proceed with surgery.

    Dr. Chen: I don’t operate on patients who are smokers. I require them to stop smoking 4 weeks prior to surgery, and then I test them for nicotine (since our hospital cannot test for cotinine). I will delay surgery if testing shows that they’ve been smoking.

    ICJR: Before performing primary THA, do you wean patients from any preoperative opioids they’d been taking to manage osteoarthritis (OA) pain? Do you change your pain management protocol to take into account their preoperative use of opioids?

    Dr. Vigdorchik: Patients on chronic preoperative opioids see the pain management specialist as part of their surgical optimization protocol and an attempt is made to wean down the opioid use preoperatively. However, if the patient continues to use opioids prior to surgery, we modify our pain management protocol to ensure they are not on a “narcotic-light” pathway, which has become our standard of care for opioid-naïve patients.

    Dr. Chen: I try to wean patients from preoperative opioid use prior to surgery, and I work with our acute pain colleagues for pain management in the perioperative period. They also assist with weaning patients from preoperative narcotics.

    Dr. Browne: We make an attempt to work with the patient and their primary medical team on weaning opioids whenever possible, particularly if the patient is taking an opioid medication for OA. It has become very rare for us to recommend elective THA for patients taking preoperative opioids for OA pain without first attempting to wean, which is a change in practice from a few years ago.

    We know that opioids, when compared with non-opioid medications, do not provide superior long-term pain relief in the treatment of hip OA. This is an opportunity for orthopaedic surgeons to do their part and respond to the opioid crisis.

    ICJR: Do you routinely screen primary THA patients for Staphylococcus infection preoperatively? If so, how far in advance of surgery? How do you treat those who are positive?

    Dr. Chen: I routinely screen patients for Staphyloccocus aureus within 30 days of surgery at preadmission testing. Those who are positive use mupirocin twice a day for 5 days and chlorhexidine body washes for 5 days. Patients who are positive for methicillin-resistant Staphylococcus aureus (MRSA) receive vancomycin and cefazolin, while patients who are positive for methicillin-sensitive Staphylococcus aureus receive cefazolin only.

    Dr. Browne: We do not screen. All patients receive nasal mupirocin and chlorhexidine scrubs preoperatively. We also routinely administer dual antibiotic prophylaxis so that all patients receive a single dose of vancomycin prior to incision. We follow our data closely and have not seen any renal concerns as a result of this dual antibiotic approach.

    Dr. Vigdorchik: Every patient undergoes MRSA nasal swab at the preop testing visit 2 to 3 weeks prior to surgery. In addition, every patient receives nasal povidone-iodine in the preop holding area immediately prior to surgery. Those with a positive MRSA nasal swab also receive intravenous (IV) vancomycin as their preoperative antibiotic instead of cefazolin.

    ICJR: What is your standard protocol of antibiotic prophylaxis in primary THA patients? What about for highrisk patients? What do you do when a patient reports a penicillin allergy?

    Dr. Vigdorchik: All patients receive weight-based cefazolin within 60 minutes prior to incision (80 kg receive 2 grams; >100 kg receive 3 grams). Patients allergic to penicillin also receive cefazolin unless they have true penicillin anaphylaxis as documented by allergy testing. Patients with MRSA-positive nasal swabs and a true penicillin allergy receive vancomycin preoperatively instead of cefazolin or clindamycin, with additional gram-negative coverage, as recent literature from Mayo Clinic shows an increased infection rate if clindamycin is used.

    Dr. Browne: Our standard protocol includes a weight-based dose of cephazolin in addition to a single dose of vancomycin prior to incision. Cephazolin is continued for 24 hours postoperatively.

    Based on recent evidence, we are increasingly attempting to refer patients with a reported penicillin allergy for testing preoperatively to determine if they have a true allergy. We are also pushing our anesthesiologists to test-dose patients who report a penicillin allergy with a first-generation cephalosporin, given the low incidence of cross-reactivity. Our goal is to use cephazolin as frequently as possible.

    Patients with a true penicillin allergy are relatively rare and receive perioperative clindamycin in addition to a single dose of vancomycin.

    Dr. Chen: My practice is similar. Patients routinely receive a weight-based dose of cefazolin preoperatively. Patients who are healthcare workers or screen positive for MRSA also receive vancomycin.

    For those who report a penicillin allergy, we assess the nature of the allergy first. If the allergy is a remote rash or similar minimal reaction, we administer cefazolin. If the allergy is an anaphylactic reaction, I give vancomycin and gentamicin. Patients with cephalosporin allergies also receive vancomycin and gentamicin.

    ICJR: What is your DVT prophylaxis protocol for primary THA patients – which drugs do you use and in which patients, and do you prescribe mechanical prophylaxis as well as chemoprophylaxis?

    Dr. Browne: Our institution is part of the multicenter PEPPER trial, which means those who enroll in the study are randomized to aspirin, warfarin, or rivaroxaban. Patients who decline to participate in the study are risk-stratified and the prophylaxis is chosen according to their individual risk profile. Low-risk patients receive aspirin 81 mg twice daily for 6 weeks. Historically, high-risk patients have received warfarin, but we are increasingly prescribing rivaroxaban instead given our experience using this chemoprophylaxis in the PEPPER trial. All patients receive foot pumps while in the hospital only.

    Dr. Vigdorchik: Our protocol is similar: Low-risk patients receive aspirin 81 mg twice daily for 4 weeks and high-risk patients – active malignancy, history of venous thromboembolism, active smokers, positive for human immunodeficiency virus – receive warfarin, enoxaparin (Lovenox), or rivaroxaban (Xarelto), depending on insurance coverage. All patients receive in-hospital mechanical prophylaxis.

    Dr. Chen: I used to prescribe aspirin 81 mg twice daily in primary THA patients and mechanical prophylaxis in the hospital but not at discharge or at home. A patient who was on anticoagulation prior to surgery, such as warfarin or apixaban (Eliquis), will continue on that medication. We are currently enrolling patients in the PEPPER trial, so our protocol is the same as Dr. Browne’s protocol.

    ICJR: Do you use tranexamic acid (TXA) routinely in your primary THA patients? Do you have any exclusions? What is your standard dosage – route and amount? Have you had pushback from your anesthesiologists over IV TXA, particularly with patients on an anticoagulant, and how have you overcome it? What is your transfusions rate and how has it changed since using TXA?

    Dr. Chen: I use TXA in as many patients as possible, 1 gram IV preoperatively and 1 g IV at closure. We constantly get pushback from the anesthesiologists about IV TXA, though, and we’ve excluded it in patients with:

    • History of or active arterial or venous thromboembolic disease
    • Congenital or acquired thrombophilia
    • Coronary stent placed within 1 year
    • History of severe ischemic heart disease or myocardial infarction
    • Renal impairment (serum creatinine greater than 1.5 times the upper limit of normal)
    • Hepatic impairment (at least 1 of the following: total bilirubin above 2 mg/dL, albumin below 3.5 g/L, INR above 1.4, ascites, or hepatic encephalopathy)
    • Subacrachoid hemorrhage
    • Cerebrovascular accident or transient ischemic attack within 1 year
    • Acquired disturbances of color vision
    • Upper urinary tract bleeding or history of clot

    Intravenous TXA is also contraindicated in pregnant and breastfeeding patients, patients with an allergy to TXA, and patients on chronic anticoagulation for any reason.

    In addition, IV TXA is used cautiously in patients with:

    • High risk of clotting
    • History of seizures
    • History of ischemic heart disease requiring coronary stent(s) and/or bypass surgery
    • History of cerebrovascular accident(s)

    We also use IV TXA cautiously in patients taking oral contraceptives.

    Patients who have exclusions for IV TXA – except those with an allergy, pregnancy, breastfeeding, or disturbances of color vision – typically receive topical TXA at 3 g per 100 mL of saline.

    I have used TXA in my entire practice, so I do not have a transfusion comparison group.

    Dr. Browne: With rare exceptions, our primary THA patients routinely receive IV TXA. Our anesthesiologists have gotten more comfortable administering TXA as the data continue to accumulate. The position statement from AAHKS has helped us here as well.

    However, we continue to get pushback on select patients deemed to be higher risk for clotting complications (history of venous thromboembolism or recent stent, for example), and we will forgo IV administration and administer TXA topically.

    Our primary THA transfusion rate for healthy patients with a normal preoperative hemoglobin level is very close to zero at this point, which is likely a result of both routine TXA use and restrictive transfusion triggers.

    Dr. Vigdorchik: All patients receive 1 gram of IV TXA prior to incision and at closure except where contraindicated (TXA allergy). Those with stents, history of myocardial infarction/cerebrovascular accident, venous thromboembolism, or atrial fibrillation do not receive a second dose of IV TXA but do receive the first dose. This protocol is based on a multidisciplinary team analysis (pharmacy, medical ICU, anesthesia, surgeons) which showed systemic absorption of topical TXA was similar to 1 dose of IV TXA, so any patient indicated for topical TXA may instead receive 1 IV dose.

    Transfusions rates are currently less than 1% for primary THA and have decreased since the implementation of the TXA protocol.

    Author Information

    Antonia F. Chen, MD, MBA, is Associate Professor at Harvard Medical School and the Director of Research for the Division of Adult Reconstruction and Total Joint Arthroplasty in the Department of Orthopaedic Surgery at Brigham and Women’s Hospital, Boston, Massachusetts.

    James A. Browne, MD, is Associate Professor in the Division of Joint Replacement and Adult Reconstructive Surgery, Department of Orthopaedic Surgery, at the University of Virginia Health System in Charlottesville.

    Jonathan Vigdorchik, MD, is Assistant Attending Orthopedic Surgeon at Hospital for Special Surgery, Assistant Professor of Orthopedic Surgery at Weill Cornell Medical College, and Assistant Attending Orthopedic Surgeon at NewYork-Prebysterian Hospital, all in New York, New York.

    Disclosures: Dr. Chen, Dr. Browne, and Dr. Vigdorchik have no disclosures relevant to this article.