Minimally invasive total knee arthroplasty (TKA) (MIS or quad sparing) may discharge earlier.

Continuous passive motion (CPM) machine is sometimes used.

Most primary (and some revision) TKAs are weight bearing as tolerated (WBAT).

Common issues to TKAs and total hip arthroplasties (THAs): See below.

More blood loss may occur postoperatively than intraoperatively.

Patients will be taught “hip precautions”—avoidance of flexion/rotation, avoidance of deep flexion, and others—to minimize the likelihood of dislocation of the hip prosthesis.

Patients who have undergone minimally invasive approach may go home on POD 1–2.

Most primary (first-time) THAs are WBAT, but many revision THAs will be partial or protected weight bearing.

Both depression and use of narcotics prior to joint replacement are associated with clinical dissatisfaction after surgery. Consider minimizing narcotics to lowest tolerable dose in advance of elective surgery and working to assure depression is reasonably controlled.

Patients with comorbidities, complications, or persistent drainage may have longer hospital courses.

Revisions typically are more complex, take longer, and have more intraoperative blood loss.

Hypotension is common on the night of surgery (POD 0), especially if insufficient volume is given intraoperatively or if indwelling epidural catheters are used; IV fluid boluses in appropriate patients typically support patients through this. For this reason, it is particularly important to write holding parameters for antihypertensive medications.

Avoid 1/2 normal saline for IVF maintenance immediately postoperatively, which may contribute to hyponatremia in a patient who is slightly under-resuscitated; rather, normal saline or Lactated Ringers are appropriate.

Commonly used drains include hemovac (round cylinder, uses springs to provide suction) and autovac (hemovac autotransfusion system—filters and reinfuses drained blood).

Prophylactic antibiotics should be discontinued by 24 h postoperatively, unless otherwise indicated.

Some centers use multimodal analgesic approaches (including long-acting oral analgesics, NSAIDs, and prophylactic antiemetics); use caution when introducing new medications, especially long-acting narcotics, in narcotic-naïve and older patients.

Deep vein thrombosis (DVT) prophylaxis is typically the surgeon’s choice, though good to engage in conversation with surgeons if the patient’s risk for DVT deviates from the norm. Know that there are differences between the American Academy of Orthopedic Surgeons (AAOS) and American College of Chest Physicians (ACCP) guidelines. Common agents are low-molecular-weight heparins, warfarin, and aspirin (in addition to TEDs and SCDs).

Be aware of hip precautions when examining patients—they may be prohibited from crossing legs initially. Check with the orthopedic surgeon if you need to move the patient for an examination.

There are various options for operative repair, including intramedullary nail, dynamic hip screw, and hemi- or total arthroplasty.

Preoperative evaluation should include cardiovascular risk stratification, assessment for the presence of medical factors contributing to fracture (e.g., seizure or syncope), and recommendations for perioperative medication management.

Surgery should not be delayed for minor medical conditions (e.g., poorly controlled hypertension without hypertensive urgency or emergency).

If surgery is to be delayed, VTE prophylaxis should be encouraged, as there is risk of VTE from the fracture itself even without surgery.

Pharmacologic VTE prophylaxis is not used if patients are ambulating.

Postoperative bleeding/hemarthrosis is not uncommon after total shoulder arthroplasty (TSA). In patients who are on therapeutic anticoagulation (for atrial fibrillation, heart valve, history of VTE, others), work closely with the patient’s surgeon and primary cardiologist (if applicable) to determine the best time to resume therapeutic anticoagulation. Ideally, avoid anticoagulation in the first several days postoperatively unless the risk of clot is exceedingly high (e.g., mitral valve prosthesis).

If a scalene block is used, adverse effects include hypotension, bradycardia, Horner’s syndrome, and phrenic nerve involvement, causing diaphragmatic paralysis and sudden onset of pain late in the night or early morning as block wears off.

These are high-risk operations due to their blood loss and duration.

EBL can reach as much as 10 L.

Often operations are accomplished in 2–3 stages.

Patients are at risk for multiple complications including venous thromboembolic events (VTE), myocardial infarction, pneumonia, disseminated intravascular coagulation, dilutional coagulopathy, posterior ischemic optic neuropathy (blindness—rare, but devastating), dural leak, cerebrospinal fluid leak (may be difficult to detect), hematoma, secondary meningitis (can be subtle—may present with confusion, low-grade fever, headache), facial/airway edema from prone position, and ileus.

Occasionally patients receive pulse-dose steroids.

Rehab/skilled nursing facility is a common disposition.

Spine precautions—patients commonly require a brace.

C-spine decompressions often have a shorter stay, e.g., 24–48 h.

Microdecompressions are typically limited-stay procedures.

Generally intermediate-risk operations, but can be of high risk depending on duration and blood loss.

Tumors are often highly vascular, contributing to higher EBLs and drain output.

Sudden increase in drain output after pelvic surgery may be a sign of ureter disruption.

Surgery service may be reluctant to initiate heparin-based VTE prophylaxis due to wound drainage—discuss with primary team.