Joint replacement (arthroplasty) replaces damaged joint surfaces with metal, polyethylene, or ceramic components. The goals are pain relief, restored function, and correction of deformity.

Indications

• End-stage osteoarthritis (most common), rheumatoid arthritis, avascular necrosis, post-traumatic arthritis
• Displaced femoral neck fracture in older adults (hemiarthroplasty or total hip arthroplasty)
• Pain and disability not controlled by conservative therapy

Total hip arthroplasty (THA) replaces the femoral head and acetabulum. Total knee arthroplasty (TKA) resurfaces the distal femur, proximal tibia, and often the patella. Components may be cemented (immediately stable) or press-fit (bone grows into the surface).

Surgical approach matters for hip precautions

Dislocation risk is highest in the first 6–12 weeks, before the capsule and muscles heal. Evidence now shows that strict hip precautions add little protection for many clients, and many surgeons no longer prescribe them after anterior-approach THA. Always follow the surgeon's specific protocol, and know the classic posterior precautions because they remain widely used and tested.

Risk factors for poor outcomes: obesity, diabetes with poor glucose control, smoking, malnutrition, anemia, immunosuppression, active infection anywhere in the body (including teeth, skin, urine), and cognitive impairment.

Preoperative

• Pain, function, range of motion, gait, use of assistive devices
• Skin over the surgical site (no breaks or infection), dental status, urinary symptoms
• Medications: anticoagulants, antiplatelets, NSAIDs, immunosuppressants, diabetes drugs; history of VTE
• Home environment: stairs, toilet height, bathtub, rugs, support person

Postoperative

• Neurovascular status of the operative leg compared with the other leg: color, warmth, capillary refill, pedal and posterior tibial pulses, sensation, active movement of the foot and toes (dorsiflexion and plantar flexion). THA can injure the sciatic nerve (foot drop); TKA can injure the peroneal nerve
• Dressing and drain output; hemoglobin
• Pain, sedation level, respiratory status
• Signs of hip dislocation: sudden severe pain, a "pop," shortening of the leg, abnormal rotation (internal rotation with posterior dislocation, external rotation with anterior dislocation), inability to bear weight
• Calves for swelling or tenderness; skin over heels and sacrum
• Temperature, incision redness, and drainage

Preoperative optimization

• Smoking cessation, glucose control, weight management, anemia correction, treatment of dental or skin infection
• Chlorhexidine bathing and nasal decolonization per protocol
• Prophylactic antibiotic (commonly cefazolin; vancomycin for MRSA risk or severe beta-lactam allergy) given within 60 minutes before incision (vancomycin within 120 minutes); usually stopped within 24 hours after surgery
• Tranexamic acid to reduce blood loss (use caution with active VTE or recent thrombosis)

Pain — multimodal and scheduled

• Regional anesthesia (spinal, peripheral nerve blocks such as adductor canal block), scheduled acetaminophen, NSAIDs or celecoxib if kidney function allows, and opioids only for breakthrough pain
• Scheduled dosing prevents pain peaks and allows early exercise
• Femoral nerve blocks weaken the quadriceps (fall risk); adductor canal blocks largely spare quadriceps strength, but fall precautions still apply

VTE prophylaxis (THA and TKA are high-risk surgeries)

• Pharmacologic options: aspirin (for many lower-risk clients) or an anticoagulant — LMWH (enoxaparin), direct oral anticoagulants (rivaroxaban, apixaban), or warfarin; when an anticoagulant is chosen, a DOAC is generally preferred over LMWH
• Duration: at least 10–14 days, often extended up to 35 days, especially after THA
• Mechanical prophylaxis: intermittent pneumatic compression devices while in bed, plus early ambulation
• Safety: bleeding (wound, urine, stool, gums), platelets (heparin-induced thrombocytopenia with heparins), kidney function (LMWH and DOACs accumulate in kidney impairment); neuraxial timing — anticoagulant dosing and epidural catheter removal must follow anesthesia protocol because of spinal hematoma risk; warfarin requires INR monitoring and consistent vitamin K intake; aspirin causes GI bleeding

Rehabilitation

• Mobilization on the day of surgery or postoperative day 1
• Weight bearing as tolerated for most cemented and many press-fit implants (surgeon specifies)
• Walker first, then cane; outpatient or home physical therapy
• Continuous passive motion (CPM) is no longer routinely recommended after TKA

Listed in priority order.

1. Airway, breathing, circulation, and bleeding
   • Vital signs, SpO₂, sedation level (opioids, nerve blocks)
   • Brisk bright-red drainage from the drain or dressing: take vital signs and notify the provider immediately; do not clamp or remove the drain
   • Monitor hemoglobin, urine output, and signs of hypovolemia
2. Neurovascular checks of the operative limb (circulation, sensation, movement) per protocol — often every 1–2 hours initially
3. Prevent dislocation (THA)
   • Posterior approach: keep the hip abducted with an abduction pillow or pillow between the legs; avoid flexion beyond 90°, crossing legs, or turning the operative leg inward; use raised toilet seats and chairs with arms
   • Anterior approach: avoid hyperextension and outward turning of the foot as instructed
   • Report sudden pain, leg shortening, or rotation — do not attempt to reposition; keep the client still and notify the provider
4. VTE prevention
   • Ankle pumps and quadriceps sets every hour while awake; compression devices while in bed; early walking
   • Give prophylaxis on time; watch for calf pain or swelling and sudden dyspnea or chest pain (pulmonary embolism)
5. Pain management — scheduled analgesia; give a dose before physical therapy; ice and elevation for swelling
6. Infection prevention
   • Aseptic wound care; monitor temperature and incision
   • Fever with increasing wound drainage, foul odor, or redness = possible surgical site infection — report promptly; low-grade fever in the first 1–2 days is often inflammatory, but do not assume
7. Knee range of motion (TKA)
   • Full extension: no pillow under the knee (causes flexion contracture); place a rolled towel under the ankle ("heel prop"); quadriceps sets, straight-leg raises
   • Flexion: heel slides, seated knee bending
8. Fall prevention and safe transfers
   • Sit on the side of the bed first before standing (orthostatic hypotension); non-slip footwear; call bell within reach
   • Use a walker; lead with the stronger leg going up stairs and the operative leg going down
9. Skin, bowel, and bladder: heel protection, repositioning, stool softeners with opioids, monitor for urinary retention after spinal anesthesia

Hip replacement (posterior precautions unless the surgeon says otherwise)

• Do not bend the hip beyond 90°: no low chairs, low sofas, or low toilets; use a raised toilet seat and a firm chair with armrests
• Do not cross the legs or bring the knees together; keep a pillow between the legs when lying on the side
• Do not turn the operative leg or foot inward
• Use long-handled aids: reacher, sock aid, long shoehorn, elastic laces; do not bend to put on shoes and socks
• Shower instead of tub bathing until cleared; use a shower chair
• Get into a car by sitting first, then swinging both legs in together

Knee replacement

• Daily exercises for both extension and flexion; do not rest with a pillow under the knee
• Elevate the whole leg above heart level with support under the calf and heel, keeping the knee straight, and use cold packs to reduce swelling
• Expect swelling to last weeks; use a stationary bike when approved

Both procedures

• Fall prevention at home: remove loose rugs and cords, add night lights and grab bars, wear low-heeled non-slip shoes, rise slowly (sit first, then stand), avoid walking while distracted
• Cane in the hand opposite the operative leg
• Take VTE prophylaxis for the full prescribed period; report calf pain, leg swelling, chest pain, or shortness of breath immediately
• Report fever, wound redness, drainage, or increasing pain — infection can occur months or years later
• Tell every dentist and provider about the implant; follow the surgeon's advice about antibiotics before dental procedures (routine prophylaxis is no longer recommended for most clients)
• Stay active with low-impact exercise (walking, swimming, cycling); avoid high-impact sports and jumping

• Posterior THA precautions: no hip flexion beyond 90°, no crossing legs (adduction), no internal rotation; abduction pillow between legs
• Anterior THA: avoid hyperextension and external rotation; many surgeons prescribe no strict precautions — follow the surgeon
• Dislocation: sudden pain, leg shortening, abnormal rotation — keep still and notify
• VTE prophylaxis: aspirin or anticoagulant for at least 10–14 days, up to 35 days; plus ankle pumps and compression devices
• Brisk bright-red drainage: vital signs and notify the provider
• Scheduled multimodal analgesia before therapy
• Fever with purulent, foul drainage = infection until proven otherwise
• TKA: no pillow under the knee; extension exercises (heel prop, quadriceps sets) and flexion exercises (heel slides)
• Cane in the opposite hand; walker first
• Raised toilet seat, chairs with arms, reacher and sock aid after THA
• Rise slowly and sit before standing to prevent falls
• Antibiotic prophylaxis within 60 minutes before incision