Total hip replacement (THR) is traditionally performed in tertiary hospitals with full intensive care unit (ICU) support to manage potential perioperative complications. However, with the evolution of minimally invasive anesthesia and surgical techniques, performing major joint arthroplasties in peripheral settings has become increasingly feasible. We present the case of a 60-year-old male with primary osteoarthritis of the left hip, classified as American Society of Anesthesiologists (ASA) grade II, who successfully underwent THR at a zonal hospital lacking dedicated ICU facilities.

Preoperative assessment revealed no significant comorbidities. Routine investigations, including electrocardiogram, chest radiograph, and basic metabolic panel, were within normal limits. Echocardiography confirmed normal left ventricular function, and pulmonary function testing was unremarkable. The patient was carefully counseled regarding the limitations of the facility, including the absence of ICU backup, and provided informed consent.

Anesthetic management focused on ensuring maximum stability with minimum physiological disturbance. A combined spinal-epidural technique was selected, utilizing 2.8 mL of 0.5% heavy bupivacaine with 25 micrograms of fentanyl intrathecally. An epidural catheter was inserted at the L2–L3 level to enable postoperative analgesia if required. Sedation was maintained intraoperatively with intravenous midazolam and fentanyl. Standard ASA monitoring, including non-invasive blood pressure, pulse oximetry, and ECG, was used throughout the procedure.   A defibrillator and emergency airway equipment were readily available. Blood was prearranged and crossmatched, anticipating potential haemorrhage.

Figure 1: Pre-operative X-ray                                       

The surgical procedure was conducted via a posterolateral approach to the hip with careful patient positioning utilizing boards and clamps. An uncemented THR was performed using standard techniques. The operation lasted approximately 90 minutes, with an estimated blood loss of 400 mL. There were no intraoperative hemodynamic instabilities or adverse events.

Postoperatively, the patient was observed in a high-dependency area for four hours and then transferred to the general orthopedic ward. Analgesia was maintained using paracetamol and tramadol. Deep vein thrombosis (DVT) prophylaxis was administered with low molecular weight heparin (Enoxaparin). The patient was mobilized on postoperative Day 1 under physiotherapy supervision. He remained hemodynamically stable, pain was well-controlled, and he was discharged on postoperative Day 5, ambulating independently without complications.

This case exemplifies that total hip arthroplasty can be safely conducted in a peripheral hospital setting without ICU backup, provided appropriate measures are taken. Proper patient selection is critical, excluding individuals with significant cardiac, respiratory, or systemic comorbidities that might require postoperative critical care support [1,2]. Regional anesthesia techniques such as spinal or combined spinal-epidural anesthesia offer distinct advantages over general anesthesia in resource-constrained environments, reducing the risk of postoperative respiratory depression, thromboembolic events, and major cardiovascular complications [3,4].

The benefits of regional anesthesia in lower limb arthroplasty include decreased blood loss, improved postoperative analgesia, reduced opioid consumption, and earlier mobilization [5]. Fast-track surgical protocols, involving multimodal pain management and early mobilization strategies, have significantly improved recovery rates after THR even in non-tertiary centers [6]. Furthermore, appropriate perioperative preparation, including prearranging blood products, maintaining emergency equipment readiness, and adhering to standardized monitoring protocols, plays a vital role in enhancing safety [7]

Figure 2: Post-operative X-ray

It is important to recognize the limitations of peripheral setups. Surgeons and anesthetists must be prepared for immediate escalation, with protocols in place for emergency transfers should complications arise. Nevertheless, evidence increasingly supports the decentralization of joint replacement surgeries to well-prepared secondary care facilities, promoting broader access to surgical care while maintaining high safety standards [8].

Total hip replacement can be safely performed in peripheral hospitals without ICU backup through careful case selection, regional anesthesia application, vigilant intraoperative monitoring, and proactive postoperative management. Expansion of such services can enhance access to orthopedic care in resource-limited areas without compromising patient safety.

1. Chatterji, U. et al. "The role of spinal anaesthesia in day-case total hip arthroplasty." Journal of Bone and Joint Surgery - British Volume, vol. 87, no. 8, 2005, pp. 1032–1035.

2. Kehlet, H., and Wilmore, D. W. "Evidence-based surgical care and the evolution of fast-track surgery." Annals of Surgery, vol. 248, no. 2, 2008, pp. 189–198.

3. Parvizi, J. et al. "Total joint arthroplasty: when do fatal or near-fatal complications occur?" Journal of Bone and Joint Surgery - American Volume, vol. 89, no. 1, 2007, pp. 27–32.

4. Pugely, A. J. et al. "Incidence of and risk factors for 30-day readmission after total hip arthroplasty: a statewide analysis." Journal of Arthroplasty, vol. 28, no. 3, 2013, pp. 511–514.

5. Memtsoudis, S. G. et al. "Perioperative comparative effectiveness of anesthetic technique in orthopedic patients." Anesthesiology, vol. 118, no. 5, 2013, pp. 1046–1058.

6. Berend, K. R., Lombardi, A. V. Jr, and Mallory, T. H. "Rapid recovery protocol for THA: a safe and efficient method." Clinical Orthopaedics and Related Research, no. 429, 2004, pp. 215–225.

7. Boylan, M. R. et al. "Initiation of a regional anesthesia program reduces blood loss in hip and knee arthroplasty." Journal of Arthroplasty, vol. 32, no. 12, 2017, pp. 3763–3767.

8. Boni, L. et al. "Emergency surgery and ICU resource utilization: managing high-risk patients without backup." World Journal of Emergency Surgery, vol. 7, no. 1, 2012, p. 11.