Hip Replacement Nursing Guide

Total Hip Arthroplasty (THA) Overview

Total hip replacement (THR/THA) replaces the arthritic femoral head and acetabulum with prosthetic components. It is one of the most successful surgical procedures for chronic pain relief and functional restoration.

Indications

Severe osteoarthritis of the hip — most common indication (80%)
Avascular necrosis (AVN) of the femoral head — common in GCC (sickle cell, corticosteroid use)
Rheumatoid arthritis with hip involvement
Femoral neck fracture — hemi-arthroplasty (older patients) or THR (younger, active patients)
Ankylosing spondylitis, developmental dysplasia of the hip

Surgical Approaches

Approach	Precautions Post-Op	Dislocation Risk
Posterior (most common)	Avoid hip flexion >90°, internal rotation, adduction	Higher (posterior capsule violated)
Anterior	Avoid hip hyperextension and external rotation	Lower (capsule-sparing)
Lateral (Hardinge)	Avoid internal rotation and adduction	Moderate

Nursing MUST know surgical approach to apply correct dislocation precautions. Check operative notes before mobilisation.

Pre-Operative Assessment and Preparation

Pre-Admission Assessment

Domain	Assessment
Medical optimisation	Cardiac clearance (METS >4), respiratory function, renal function (baseline creatinine), HbA1c <9% ideally
Anaemia	Pre-operative Hb >100 g/L target; iron supplementation if deficient; cell salvage planned for anticipated blood loss
Anticoagulation management	Warfarin stop 5 days; DOAC stop per renal function; bridging LMWH if high thrombotic risk
MRSA screening	Nasal swab; decolonisation with mupirocin nasal ointment + chlorhexidine body wash if positive
Dental clearance	Active dental infections → delay surgery (bacteraemia risk → prosthetic joint infection)
Skin integrity	Any skin infection over operative site → reschedule
Weight	BMI >40 → increased complication risk; consider bariatric surgery first in elective cases

Prehabilitation — Nursing Education

Teach post-operative exercises: ankle pumps, quadriceps sets, gluteal squeezes
Educate on hip dislocation precautions — hands-on demonstration with hip replica
Arrange home assessment: raised toilet seat, shower chair, grab rails
Demonstrate crutch/walking frame use pre-operatively
Smoking cessation — minimum 6 weeks pre-operatively (reduces infection, poor wound healing)
Consent for blood transfusion; autologous blood donation if eligible

Post-Operative Care

Immediate Post-Operative (0–24 hours)

Parameter	Frequency	Target / Alert
Vital signs (NEWS2)	15-min × 1 hr → hourly × 4 hrs → 4-hourly	Tachycardia + hypotension → bleeding/PE
Wound/drain	Hourly for first 4 hrs; then 4-hourly	>500 mL/2 hrs drain output → alert surgeon
Neurovascular observations	Every 1–2 hrs for 24 hrs	5 Ps: Pain, Pallor, Paraesthesia, Pulselessness, Paralysis
Urine output	Hourly (IDC in first 24 hrs)	Target ≥0.5 mL/kg/hr
Pain score	Every 2–4 hrs	Target NRS ≤3; multi-modal analgesia
Hip position	Continuous observation	Maintain precautions per surgical approach; abduction pillow between legs

Pain Management — Multi-Modal

Paracetamol 1 g QDS — baseline analgesic
Celecoxib (COX-2 inhibitor) 200 mg BD — if no renal/GI contraindication; reduces opioid requirement
Opioid: oxycodone IR or morphine for breakthrough; PCA first 24 hrs in high-opioid patients
Local infiltration analgesia (LIA): surgeon infiltrates ropivacaine + ketorolac + adrenaline at wound closure — dramatically reduces immediate post-op pain
Peripheral nerve block (PENG block): Pericapsular Nerve Group block — increasingly used in GCC centres; reduces opioid requirements significantly
Gabapentin/pregabalin: neuropathic component in chronic OA

VTE Prophylaxis

TED stockings applied in recovery before emergence from anaesthesia
Intermittent pneumatic compression (IPC) while in bed
LMWH (enoxaparin 40 mg SC OD) or DOAC (rivaroxaban 10 mg OD) starting 12–24 hrs post-op
Duration: 35 days (standard recommendation for THR — extended prophylaxis)
Aspiration of warfarin patients: bridging with LMWH until INR therapeutic

Enhanced Recovery After Surgery (ERAS)

Same-day or next-day mobilisation with physiotherapist — walk to toilet within 4–6 hrs of surgery
Regional anaesthesia preferred over general for ERAS (faster recovery, less nausea)
Early oral nutrition: clear fluids 2 hrs, solids 4 hrs post-op
Discharge planning from day of admission: target 2–3 day hospital stay

Hip Dislocation Precautions

Hip dislocation is the most common complication post-THR — occurs in 2–4% of cases. Posterior approach carries highest risk. Occurs most commonly in first 6–12 weeks while soft tissues heal.

Posterior Approach Precautions (Most Common)

NO hip flexion >90° — do not bend forward past 90°; use long-handled aids for shoes/socks
NO internal rotation — do not cross midline; do not turn foot inward
NO adduction — do not cross legs; abduction pillow in bed
Raised toilet seat — standard toilet seat requires >90° hip flexion; raised seat prevents this
Bed height — bed raised to avoid deep hip flexion getting up
Sitting: Sit in chairs with arms; avoid low sofas
Sleeping: Pillow between legs; do not roll onto operative side initially

Recognising Hip Dislocation

Signs: Sudden severe hip pain, shortened and externally rotated leg (posterior dislocation), inability to weight-bear, palpable femoral head in buttock.

Nursing action: Keep patient still, call surgeon immediately, NBM (reduction may require sedation/anaesthesia), morphine for pain, urgent X-ray
Closed reduction: Performed under sedation — do NOT attempt any reduction without surgeon
CT post-reduction: Confirm component position
Revision surgery: Required if dislocation recurrent or reduction fails

GCC-Specific Context

Hip Arthroplasty in GCC

Avascular necrosis (AVN) rates: Higher in GCC due to sickle cell disease (especially in Bahrain, Eastern Saudi Arabia, Oman), high-dose corticosteroid use for nephrotic syndrome, SLE, IBD, and alcohol use in expatriate populations. AVN is a major indication for THR in younger GCC patients
High BMI: Obesity epidemic in GCC → increased periprosthetic complications, longer surgeries, higher infection risk. BMI >40 significantly increases revision rates
Traditional sitting positions: Cross-legged floor sitting (common in GCC/Islamic culture) must be avoided post-THR. Patient education in Arabic is critical. Family members must be educated as they often assist with rehabilitation
Prayer positions: Kneeling (sujood) and bending (ruku) in Islamic prayer — physiotherapy and religious guidance coordination. Many patients can gradually return to modified prayer positions at 3–6 months with physiotherapy guidance
Hajj planning: Patients who undergo THR should delay Hajj/Umrah pilgrimage (extensive walking, crowding) for minimum 6–12 months post-operatively

Exam Tips

Posterior approach precautions: no flexion >90°, no internal rotation, no adduction
Dislocation signs: shortened externally rotated leg, severe pain
VTE prophylaxis: 35 days for THR
Neurovascular checks: 5 Ps (Pain, Pallor, Paraesthesia, Pulselessness, Paralysis)
MRSA screening before elective arthroplasty
Active dental infection → delay surgery (prosthetic joint infection risk)

Exam MCQs — DHA / SCFHS / QCHP

Q1. A patient had a posterior approach total hip replacement 2 days ago. Which activity instruction is CORRECT?

A) Cross legs when sitting for comfort B) Use a raised toilet seat and avoid bending the hip beyond 90° C) Sit on low chairs to promote hip flexion exercises D) Sleep on the operative side to avoid pressure on the other hip

✅ B — Posterior approach precautions: NO hip flexion >90°, NO adduction (crossing legs), NO internal rotation. A raised toilet seat prevents excessive hip flexion. Low chairs force >90° flexion and must be avoided.

Q2. A nurse is performing post-operative neurovascular observations on a patient's right leg after THR. Which finding requires IMMEDIATE escalation?

A) Mild swelling and bruising around wound site B)Capillary refill 2 seconds in right toes C) Absent dorsalis pedis pulse, cold pale foot, severe pain in right leg D> Moderate pain at wound site rated 5/10

✅ C — Absent pulse + cold, pale foot + severe pain = vascular emergency. This could indicate femoral artery injury, arterial thrombosis or compartment syndrome. Call vascular surgery immediately. The 5 Ps (Pulselessness, Pallor, Pain, Paraesthesia, Paralysis) indicate limb-threatening emergency.

Q3. A patient 6 hours post-THR suddenly reports severe left hip pain. On assessment, the left leg appears shorter than the right and is externally rotated. What is the MOST LIKELY complication?

A) Deep vein thrombosis B) Periprosthetic fracture C) Hip dislocation — posterior D) Wound haematoma

✅ C — Classic signs of posterior hip dislocation: sudden severe hip pain, shortened leg, external rotation. Do NOT attempt repositioning — keep patient still, administer analgesia, call surgeon urgently, keep NBM for likely procedural sedation for closed reduction, arrange urgent X-ray.

Q4. How long should VTE prophylaxis be continued after total hip replacement?

A) 7 days post-operatively B) Until discharge only C) 35 days post-operatively D) 90 days post-operatively

✅ C — NICE and most international guidelines recommend 35 days (5 weeks) of extended VTE prophylaxis after THR. This is longer than knee replacement (14 days). Rivaroxaban 10 mg OD or LMWH (enoxaparin 40 mg OD) are commonly used agents for extended prophylaxis.

🦴 Total Hip Replacement Nursing