Approach-Specific Hip Precautions and Dislocation Risk Documentation
- Total hip arthroplasty discharge instructions must specify the surgical approach used, because hip precautions differ substantially between the posterior approach and the anterior or anterolateral approaches. The posterior approach to THA requires a defined set of precautions to reduce dislocation risk during the healing period: avoiding hip flexion beyond 90 degrees, avoiding internal rotation of the operative extremity, and avoiding adduction of the operative leg across the midline. These precautions are typically maintained for 6 to 12 weeks post-operatively based on surgeon protocol, and the discharge instructions must state the specific duration of precautions required for the individual patient.
- Anterior approach THA is associated with a lower posterior dislocation rate than posterior approach THA, and many anterior approach protocols do not require the same hip flexion and rotation precautions. However, anterior approach THA carries a specific risk of anterior dislocation with extreme extension and external rotation of the operative extremity, and discharge instructions for anterior approach patients should address this distinct risk. The discharge instructions must document which approach was used and whether approach-specific precautions apply, rather than using a generic dislocation precautions template that may not correspond to the patient's actual surgical approach.
- Assistive device requirements at discharge must specify the prescribed device (walker, crutches, or cane), the expected sequence for progression to less restrictive devices, and the clinical criteria that determine when advancement is appropriate. For most THA patients, a standard two-wheeled walker is prescribed at discharge, with progression to a cane at the 4 to 6 week post-operative visit based on gait quality and pain control. Instructions must specify these milestones clearly and include guidance on contacting the provider if the patient is unable to make expected progress in ambulation, which may indicate a complication such as hardware instability, wound infection, or prosthetic component malposition.
- Dislocation recognition and management instructions are a required component of THA discharge documentation. Patients must be able to recognize the signs of hip dislocation, which typically include sudden severe pain at the hip following a movement that violated the prescribed precautions, the inability to bear weight on the operative extremity, shortening or external rotation of the operative limb, or visible deformity at the hip. Discharge instructions must specify that suspected THA dislocation requires emergency evaluation and that the patient should not attempt to reduce the joint or apply traction to the extremity before emergency evaluation. Prompt recognition and closed reduction of an early THA dislocation significantly reduces the need for open surgical revision.
DVT Prophylaxis and VTE Communication Requirements
- Anticoagulation prophylaxis documentation is a required element of THA discharge instructions and is subject to review during CMS conditions of participation surveys and Joint Commission accreditation reviews. The American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines recommend a minimum of 10 to 14 days of VTE prophylaxis following THA, with an extension to 35 days preferred for patients with elevated thrombotic risk. Approved pharmacologic prophylaxis agents for THA include aspirin, rivaroxaban, apixaban, enoxaparin, and warfarin, selected based on individual patient risk profile. Discharge instructions must document the specific agent, dose, frequency, and total duration of prophylaxis therapy.
- Aspirin-based VTE prophylaxis after THA has been endorsed by the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guideline on Preventing VTE in Patients Undergoing Elective Hip and Knee Arthroplasty as an option for patients at standard thrombotic risk. The AAOS guideline also acknowledges that the choice of prophylaxis agent should account for patient bleeding risk, as patients on concurrent antiplatelet therapy or with gastrointestinal bleeding history may have a higher aspirin-related bleeding risk. Discharge instructions for THA patients on aspirin prophylaxis should specify the dose (typically 81 mg or 325 mg twice daily depending on surgeon protocol), the duration, and the gastrointestinal symptoms that warrant dose adjustment or provider contact.
- DVT and pulmonary embolism symptom recognition must be included in THA discharge instructions with specific clinical descriptions rather than general references to clot symptoms. Patients should be instructed to contact the provider or seek emergency evaluation for lower extremity DVT symptoms including new calf tenderness, swelling, warmth, or erythema that increases beyond the operative extremity's expected post-operative swelling pattern. Pulmonary embolism symptoms requiring immediate emergency evaluation include sudden onset shortness of breath, chest pain, palpitations, or syncope. Instructions should note that the first 4 to 6 weeks after THA represent the highest-risk period for clinically significant VTE.
- Mechanical prophylaxis continuation instructions apply to THA patients discharged home with a portable sequential compression device (SCD) or graduated compression stockings as part of their VTE prophylaxis protocol. Instructions must specify the device type, the duration of daily use, and the procedure for cleaning and maintaining the device if applicable. For patients using both pharmacologic and mechanical prophylaxis, instructions should clarify that the mechanical device supplements rather than replaces pharmacologic therapy and that both components should be continued for the prescribed duration. Patients should be instructed to contact the provider if skin breakdown, pain, or circulation concerns develop under the compression device.
Wound Monitoring, Weight-Bearing Status, and Physical Therapy
- Wound monitoring documentation at THA discharge must specify the closure type used (staples, sutures, or absorbable closure), the expected timeline for closure device removal (typically 10 to 14 days for staples following THA), and criteria requiring provider evaluation before the scheduled removal date. Signs of wound complication requiring contact include increasing erythema beyond the immediate peri-incisional area, purulent or non-serous wound drainage, wound separation or dehiscence, progressive swelling at the wound site after the first 48 to 72 post-operative hours, or fever above 101.5 degrees Fahrenheit occurring after the initial post-operative period. Early identification of superficial wound complications reduces the risk of progression to periprosthetic joint infection.
- Weight-bearing status documentation must use standardized clinical terminology to avoid ambiguity: full weight-bearing (FWB), weight-bearing as tolerated (WBAT), partial weight-bearing (PWB) with the percentage of body weight specified, toe-touch weight-bearing (TTWB), or non-weight-bearing (NWB). Most contemporary THA protocols allow immediate full weight-bearing as tolerated in the post-operative period, but some complex primary THA cases, revision procedures, or cases with intraoperative bone quality concerns may require restricted weight-bearing. The discharge instructions must state the specific weight-bearing status prescribed for that patient, the assistive device required, and the timeline for advancing weight-bearing if a progression protocol has been established.
- Physical therapy initiation and milestone documentation are required components of THA discharge planning under Joint Commission standards and CMS conditions of participation for inpatient discharges. For outpatient THA, discharge instructions must specify the prescribed physical therapy modality (home physical therapy vs. outpatient physical therapy), the anticipated start date, and the initial therapy goals for the first 2 to 4 weeks of recovery. Standard THA physical therapy milestones include independent ambulation with a prescribed assistive device, the ability to negotiate stairs, range of motion goals at defined post-operative timepoints, and functional independence with activities of daily living. Patients without a confirmed physical therapy referral at discharge are at higher risk for functional decline and readmission.
- Follow-up appointment documentation must be included in THA discharge instructions with the specific date, time, and location of the scheduled appointment. Standard THA follow-up protocols typically include a wound evaluation and staple or suture removal at 10 to 14 days, a 6-week appointment with radiographic assessment of component positioning and alignment, and a 3-month appointment for functional outcome assessment using validated instruments such as the Hip Disability and Osteoarthritis Outcome Score (HOOS) or Oxford Hip Score. Patients who leave the hospital or ASC without a confirmed follow-up appointment are at statistically higher risk for delayed identification of wound complications and preventable hospital readmission.