Regional anesthesia in hip surgery

Morbidity and Mortality Following Total Hip and Knee Arthroplasty With Spinal Versus General Anesthesia: A Retrospective Analysis

BACKGROUND

The optimal anesthetic mode in total joint arthroplasty (TJA) has yet to be clearly identified. Patients undergoing TJA may recieve spinal anesthesia (SA) or general anesthesia (GA). While arthroplasty literature indicates differences in postoperative morbidity, hip fracture literature does not show clear superiority of SA or GA. The purpose of this study was to further investigate this relationship and determine if there is a significant difference in morbidity and mortality between GA and SA in patients undergoing primary total joint arthroplasty.

METHODS

Patients undergoing primary THA or TKA from February 2007 to February 2021 were retrospectively reviewed, creating four cohorts: THA/GA (n = 1,266), THA/SA (n = 1,084), TKA/GA (n = 882), and THA/SA (n = 2,067). Readmission within 90 days, mortality within 365 days, and thromboembolic events within 30 days postoperatively were compared using logistic regression, controlling for age, body mass index, and Charlson Comorbidity Index.

RESULTS

The odds of experiencing a deep venous thrombosis within 30 days postoperatively were elevated in the analysis of both the THA/GA (odds ratio (OR) = 3.1; 95% confidence interval (CI): 1.5 to 7.0; P = .004) and the TKA/GA (OR = 1.9; 95% CI: 1.2 to 3.0; P = .005) groups. Similarly, the risk of pulmonary embolism as higher in the THA/GA cohort (OR = 3.9; 95% CI: 1.2 to 17.3; P = .04). There were also higher odds of mortality within 365 days postoperatively in THA/GA patients (OR = 4.3; 95% CI: 1.7 to 13.0; P = .004). No other differences existed among TKA patients.

CONCLUSIONS

Based upon these data, both SA and GA are reasonable options for primary TKA with similar risk profiles. However, GA may be associated with higher rates of deep venous thrombosis in TJA and pulmonary embolism in THA. General anesthesia (GA) was also loosely associated with increased mortality within 1 year of THA, but this result should be considered with caution.

LEVEL OF EVIDENCE: 3

Evaluating Pain Management from Peripheral Nerve Block for Geriatric Patients following Bipolar Hemiarthroplasty for Displaced Femoral-Neck Fracture

INTRODUCTION

The purpose of this study was to evaluate peripheral nerve block (PNB) effectiveness in postoperative pain management and surgical outcomes for displaced femoral-neck fracture in geriatric patients (>70 years) who underwent bipolar hemiarthroplasty (BHA).

METHODS

From January 2017 to December 2021, 231 geriatric patients with displaced femoral-neck fracture who consecutively underwent BHA were retrospectively reviewed. Patients were divided into two groups: the patient-controlled analgesia (PCA) group (n = 132) who received only intravenous (IV) PCA for postoperative pain management, and all others who received PNB with IV PCA (PNB+PCA) such as femoral nerve block or fascia iliaca compartment block after surgery (n = 99). Primary outcomes were postoperative visual analog scale (VAS) at rest and during activity at 6, 24, and 48 h postoperatively. Secondary outcomes were postoperative complications, changes in hemoglobin, length of hospital stay, and total morphine usage after surgery.

RESULTS

Postoperative resting VAS at 6 h and 48 h was significantly lower in the PNB+PCA group compared with the PCA group (p = 0.075, p = 0.0318, respectively). However, there was no significant difference in either resting VAS at 24 h or active VAS. Complications of pneumonia and delirium until 1 month postoperative were significantly lower in the PNB + PCA group than the PCA group (p = 0.0022, p = 0.0055, respectively).

CONCLUSION

PNB with IV PCA seems to have a beneficial effect on geriatric femoral-neck patients who underwent BHA with postoperative analgesia for reducing postoperative resting pain and complications, especially pneumonia and delirium.

Comparative Evaluation of Analgesic Efficacy of Ultrasound-Guided Pericapsular Nerve Group Block and Femoral Nerve Block During Positioning of Patients With Hip Fractures for Spinal Anesthesia: A Prospective, Double-Blind, Randomized Controlled Study

INTRODUCTION

Hip fractures cause severe pain during positioning for spinal anesthesia (SA). Intravenous systemic analgesics can lead to various complications in elderly patients, hence peripheral nerve blocks are emerging as a standard of care in pain management for hip fractures, among which femoral nerve block (FNB) is widely known and practiced. Pericapsular nerve group (PENG) block is a recently described technique that blocks the articular nerves of the hip with motor-sparing effects and is used to manage positional pain in hip fractures. This study aims to evaluate the analgesic efficacy of PENG block over FNB in managing pain during positioning before SA in hip fractures.

MATERIALS AND METHODS

This was a prospective, randomized, double-blinded study. After ethical clearance, 70 patients undergoing hip fracture surgery under SA in a tertiary-care hospital were recruited and randomized to receive either ultrasound-guided PENG block or FNB with 20 ml of 0.25% bupivacaine before performing SA. We compared pain severity using the visual analog scale (VAS) 15 and 30 minutes after the block and during positioning. The sitting angle, requirement of rescue analgesia for positioning, and anesthesiologist and patient satisfaction scores were also analyzed. Continuous data were analyzed with an unpaired t-test while the chi-square test was used for categorical data.

RESULTS

There was a significant reduction in VAS scores after PENG block (PENG: 0.66 ± 1.05 and FNB: 1.94 ± 1.90; p = 0.001) with lesser requirement of rescue analgesia for positioning compared to FNB. The anesthesiologist and patient satisfaction scores were also significantly better in the PENG group.

CONCLUSION

PENG block offers better analgesia for positioning before SA than FNB without any significant side effects, and improves patient and anesthesiologist satisfaction, thus proving to be an effective analgesic alternative for painful hip fractures.

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review

The Enhanced Recovery After Surgery (ERAS) or Fast Track is defined as a multi-disciplinary, peri- and post-operative approach finalized to reduce surgical stress and simplify post-operative recovery. It has been introduced more than 20 years ago by Khelet to improve outcomes in general surgery. Fast Track is adapted to the patient's condition and improves traditional rehabilitation methods using evidence-based practices. Fast Track programs have been introduced into total hip arthroplasty (THA) surgery, with a reduction in post-operative length of stay, shorter convalescence, and rapid functional recovery without increased morbidity and mortality. We have divided Fast Track into three cores: pre-, intra-, and post-operative. For the first, we analyzed the standards of patient selection, for the second the anesthesiologic and intraoperative protocols, for the third the possible complications and the appropriate postoperative management. This narrative review aims to present the current status of THA Fast Track surgery research, implementation, and perspectives for further improvements. By implementing the ERAS protocol in the THA setting, an increase in patient satisfaction can be obtained while retaining safety and improving clinical outcomes.

Peripheral Nerve Block for Pain Management after Total Hip Arthroplasty: A Retrospective Study with Propensity Score Matching

This study aimed to evaluate the effect of a peripheral nerve block (PNB) on immediate postoperative analgesia and the early functional outcomes for patients who underwent total hip arthroplasty (THA). From January 2016 to August 2021, 353 patients who underwent THA were divided into two groups: the patient-controlled analgesia (PCA) group (n = 217) who received only intravenous (IV) analgesia, and others who received IV PCA and PNB (PCA + PNB group) (n = 136). After propensity score matching for age and sex, 136 patients from each group were included in the study. Primary outcomes were the visual analogue scale (VAS) at rest, activity status at postoperative 6, 24, 48 h. Secondary outcomes were functional scores by the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, Harris Hip Score (HHS) and rescue medications used. The postoperative VAS at 6, 24, 48 h at rest and 6 h at activity were significantly lower in the PCA + PNB group (p = 0.000, 0.001, 0.000, 0.004 in order). There was no significant difference for postoperative 3-month HHS (p = 0.218), except for 3-month WOMAC index (p = 0.001). There were no significant differences for VAS between the PNB methods except femoral nerve block (FNB) and fascia iliaca compartment block (FICB) at postoperative activity 48 h (p = 0.028). There was no significant difference in the total count and amount of rescue medication (p = 0.091, 0.069) and difference in the quadriceps weakness was not noted. Therefore, PNB is beneficial for patients who undergo THA as it provides sufficient postoperative analgesia, especially during immediate postoperative resting pain without quadriceps weakness.

Veno-Arterial Extracorporeal Membrane Oxygenation Rescue in a Patient With Pulmonary Hypertension Presenting for Revision Total Hip Arthroplasty: A Case Report and Narrative Review

Patients with pulmonary hypertension (PH) are at an increased risk of perioperative morbidity and mortality when undergoing non-cardiac surgery. We present a case of a 57-year-old patient with severe PH, who developed cardiac arrest as the result of right heart failure, undergoing a revision total hip arthroplasty under combined spinal epidural anesthesia. Emergent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was undertaken as rescue therapy during the pulmonary hypertensive crisis and a temporizing measure to provide circulatory support in an intensive care unit (ICU). We present a narrative review on perioperative management for patients with PH undergoing non-cardiac surgery. The review goes through the updated hemodynamic definition, clinical classification of PH, perioperative morbidity, and mortality associated with PH in non-cardiac surgery. Pre-operative assessment evaluates the type of surgery, the severity of PH, and comorbidities. General anesthesia (GA) is discussed in detail for patients with PH regarding the benefits of and unsubstantiated arguments against GA in non-cardiac surgery. The literature on risks and benefits of regional anesthesia (RA) in terms of neuraxial, deep plexus, and peripheral nerve block with or without sedation in patients with PH undergoing non-cardiac surgery is reviewed. The choice of anesthesia technique depends on the type of surgery, right ventricle (RV) function, pulmonary artery (PA) pressure, and comorbidities. Given the differences in pathophysiology and mechanical circulatory support (MCS) between the RV and left ventricle (LV), the indications, goals, and contraindications of VA-ECMO as a rescue in cardiopulmonary arrest and pulmonary hypertensive crisis in patients with PH are discussed. Given the significant morbidity and mortality associated with PH, multidisciplinary teams including anesthesiologists, surgeons, cardiologists, pulmonologists, and psychological and social worker support should provide perioperative management.

Efficacy of Quadratus Lumborum Block for Pain Control in Patients Undergoing Hip Surgeries: A Systematic Review and Meta-Analysis

BACKGROUND

Several studies have reported the use of anterior, posterior and lateral quadratus lumborum block (QLB) for pain control in hip surgeries. However, high-quality evidence is lacking. The current review aimed to summarize data on the efficacy of QLB for pain control in patients undergoing hip surgeries.

METHODS

PubMed, Embase, and Google Scholar databases were searched up to August 5, 2021 for randomized controlled trials (RCTs) or non-RCTs assessing the efficacy of QLB for any type of hip surgery.

RESULTS

Thirteen studies were included (nine RCTs and four non-RCTs). On pooled analysis, there was a statistically significant reduction of 24-h total opioid consumption in patients receiving QLB as compared to the control group (MD: -9.92, 95% CI: -16.35, -3.48 I 2 = 99% p = 0.003). We noted a statistically significant reduction of pain scores in the QLB group as compared to control group at 2-4 h (MD: -0.57, 95% CI: -0.98, -0.17 I 2 = 61% p = 0.005), 6-8 h (MD: -1.45, 95% CI: -2.09, -0.81 I 2 = 86% p < 0.00001), 12 h (MD: -1.12, 95% CI: -1.89, -0.34 I 2 = 93% p = 0.005), 24 h (MD: -0.71, 95% CI: -1.27, -0.15 I 2 = 89% p = 0.01) and 48 h (MD: -0.76, 95% CI: -1.37, -0.16 I 2 = 85% p = 0.01) after the procedure. There was a statistically significant reduction in the risk of nausea/vomiting (RR: 0.40, 95% CI: 0.18, 0.88 I 2 = 62% p = 0.02) in patients receiving QLB but no difference in the risk of pruritis (RR: 0.46, 95% CI: 0.17, 1.24 I 2 = 16% p = 0.13) and urinary retention (RR: 0.44, 95% CI: 0.19, 1.02 I 2 = 0% p = 0.06).

CONCLUSION

QLB as a part of a multimodal analgesic regimen reduces opioid consumption and pain scores in patients undergoing hip surgeries. The certainty of evidence based on GRADE was moderate. Despite the statistically significant results, the clinical relevance of the analgesic efficacy of QLB is debatable due to the small effect size.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021267861.

Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.

Lumbar spine instrumented fusion surgery under spinal anaesthesia versus general anaesthesia-A retrospective study of 239 cases

OBJECTIVE

Conventionally spinal surgeries are done under general anaesthesia (GA). Plenty of literature is available on lumbar spine non-instrumented surgeries under spinal anaesthesia (SA) but handful of literature is there on lumbar spinal instrumented fusion surgeries under SA. We retrospectively analysed the data of 131 patients operated under SA and 108 patients under GA. Aim of the study was to evaluate the safety, advantages and disadvantages of doing lumbar spine instrumented fusion surgeries under SA.In time of COVID-19 pandemic, aerosol generating procedure like intubation, can be avoided if lumbar spine instrumented fusion surgeries are performed under SA.

METHODS

239 patients aged between 20 and 79 years operated from January 2014 to December 2019 were included in this study. Indications for surgery were lumbar canal stenosis, degenerative or lytic spondylolisthesis. They underwent L4-L5 or L5-S1 fusion surgeries either TLIF or pedicle screw fixation postero lateral fusion (PLF) and decompression. Out of 239 patients,131 were operated under SA and 108 patients under GA. Heart rate, mean arterial pressure (MAP), blood loss, operating room time, post-op pain relief and need of analgesics, cost of surgery and anaesthesia related complications were analysed.

RESULTS

The study found significantly less blood loss (p<.05), less OR time, better post-op analgesia and lesser incidence of nausea and vomiting in SA (8.4%) than GA (29.6%). We observed average 10% cost reduction in SA. This study did not find any prone position related complication in regional anaesthesia but one transient brachial plexus palsy and one post-op shoulder pain in GA group.

CONCLUSION

SA is a safe alternative to GA for lumbar spine instrumented fusion surgery with significant less blood loss, OR time, better post-op analgesia, average 10% overall cost reduction and no reported prone-position related complications.

Changing practice to increase rates of spinal anaesthesia for total joint replacement

BACKGROUND

Neuraxial anaesthesia for lower extremity total joint replacement surgery has several advantages over general anaesthesia; however, we encountered resistance to routine use of spinal anaesthesia and standardised analgesic regimens at our large, tertiary hospital. Our Perioperative Surgical Home led to multidisciplinary education and enhanced communication to change practice, with the purpose of increasing rates of neuraxial anaesthetics for these surgeries.

METHODS

Team members from anaesthesia, nursing and surgery participated in the development and adoption of the care pathway. After implementation, we performed a retrospective analysis to examine the impact of the pathway on primary anaesthetic choice. Data were analysed using Student's t-test and interrupted time series analysis.

RESULTS

The rate of neuraxial anaesthetics increased following implementation of the total joint pathway.

CONCLUSION

With multidisciplinary collaboration, we were able to change practice towards spinal anaesthesia, despite a large and diverse group of practitioners.

Comparison of pericapsular nerve group block versus fascia iliaca compartment block as postoperative pain management in hip fracture surgeries

Background and Objectives:

Methods:

Results:

Conclusion:

Local and Intra-articular Administration of Nonsteroidal Anti-inflammatory Drugs for Pain Management in Orthopedic Surgery

BACKGROUND

Although growing evidence demonstrates the benefits of locally administered nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain management, there is ongoing debate regarding NSAID use in orthopedic surgery.

AREAS OF UNCERTAINTY

Current data largely support a local site of NSAID action and suggest that effective pain control can be achieved with delivery of NSAIDs intra-articularly (IA) and/or locally at the site of injury, where they can block peripheral production of inflammatory mediators and may desensitize nociceptors. Improvements in postoperative pain control with locally administered NSAIDs have been widely reported in the total joint arthroplasty literature and may offer benefits in patient's undergoing arthroscopic procedures and those with osteoarthritis as well. The purpose of this review is to examine the available evidence in the literature regarding the efficacy and safety profile of the use of local and IA NSAIDs in orthopedic surgery.

DATA SOURCES

Narrative literature review using keywords, expert opinion, either during or from live conference.

THERAPEUTIC ADVANCES

Local and IA administration of NSAIDs for pain management in orthopedic surgery.

CONCLUSION

There is convincing evidence that NSAIDs administered locally in and around the joint reduce postoperative pain scores and opioid consumption in patients undergoing total joint arthroplasty, yet further research is required regarding the risks of potential chondrotoxicity and the inhibition of bone and soft-tissue healing with locally administered NSAIDs.

A comparative study evaluating the role of adductor canal block catheter versus intraarticular analgesic infusion on knee pain and range of motion in the immediate postoperative period: a prospective multicenter trial

Postoperative pain after total knee arthroplasty (TKA) is an important determinant of hospital stay and rehabilitation and thereby functional outcome. Adductor canal block (ACB) and intraarticular analgesic infiltration through catheters (IAC) are techniques of multimodal analgesia which have shown to control postoperative pain satisfactorily. The aim of this study is to evaluate the efficacy of ACB versus IAC in reducing immediate postoperative pain and thereby allow early rehabilitation. A multicenter quasi-experimental study was conducted on 511 patients undergoing unilateral primary TKA from March 2016 to April 2017 who either received ACB with catheter (Group I, n = 350 patients) or IAC (Group II, n = 172 patients) for postoperative pain control. All the patients were assessed for severity of pain by Visual Analogue Scale at 8, 24, 48, 72 h postoperatively and knee range of motion (ROM) on the day of discharge. There was no significant difference in pain scores on postoperative day (POD) 0 (1.09 ± 0.30 vs. 0.98 ± 0.46, p = 0.45) and POD 1 (1.21 ± 0.45 vs. 1.00 ± 0.00, p = 0.11) and in mean ROM on the day of discharge between ACB and IAC (88.40° ± 7.96° vs. 88.34° ± 5.74°; p = 0.93) groups. This study shows that both ACB and IAC provide satisfactory postoperative analgesia with sparing of quadriceps function and good knee ROM leading to early rehabilitation and reduced hospital with no advantage of one technique over another.

Assessing Preoperative Pain Sensitivity Predicts the Postoperative Analgesic Requirement and Recovery after Total Knee Arthroplasty: A Prospective Study of 178 Patients

BACKGROUND

The aim of this article is to study the correlation between preoperative pain sensitivity and postoperative pain and analgesic requirements for patients undergoing primary total knee arthroplasty.

METHODS

Between December 2018 and April 2019, the pain sensitivity of 178 consecutive patients undergoing primary total knee arthroplasty was assessed preoperatively with a digital algometer. The patients reported the VAS (visual analog scale) score at 3 instances of needle prick (phlebotomy, glucometer blood sugar, intradermal antibiotic test dose), during the range of movements and completed the Depression Anxiety Stress Scale score. Postoperative VAS score, analgesic requirement, and physiotherapy milestones were recorded in all these patients on day 0 to day 4.

RESULTS

The average age of the patients was 64.13 years and 69.1% were females. Females had lower mean algometry values (56.12 ± 12.77 [standard deviation]) compared to males (71.09 ± 18.78 [standard deviation]) (P < .001). Higher Depression Anxiety Stress Scale correlated with lower algometry values (P < .001). The postoperative VAS score was 2.54 ± 0.59 on the day of surgery which increased to 3.27 ± 0.69 on day 1 after mobilization (P < .001) and reduced to 1.67 ± 0.62 on day 4. Low algometer score correlated with higher postoperative VAS score (P < .05), increased analgesic requirement, and opioid utilization (P < .001), delay in achieving an optimum range of movements (P < .001) and independent ambulation (P < .001).

CONCLUSION

Preoperative assessment of pain sensitivity predicts postoperative analgesic requirements and recovery. Patients with a lower pain threshold should be counseled preoperatively and also receive a better titration of analgesics perioperatively and prolonged physiotherapy.

Awake minimally invasive transforaminal lumbar interbody fusion with a pedicle-based retraction system

OBJECTIVE

Recently there has been increasing interest in the use of regional anesthesia for minimally-invasive transforaminal lumbar interbody fusion (TLIF) and laminectomy, with the goal of reducing the side effects and risks associated with general anesthesia and also to improve patient satisfaction. The goal of this technical note is to describe important perioperative aspects to safely perform an awake spine surgery and to describe a novel technique to preform minimally-invasive TLIF using a pedicle-based retraction system.

METHODS

We report our patient selection criteria, perioperative anesthesia protocol and surgical technique for awake TLIF with the Maximum Access Surgery (MAS) TLIF Retraction System. We describe an illustrative case of a 66-year-old female that presented with leg pain, lumbar MRI revealed a grade one spondylolisthesis at L4-5 with severe canal stenosis. She underwent a L4-5 Awake MIS TLIF using the MAS TLIF Retraction System.

RESULTS

The first 10 awake TLIF we performed with the MAS TLIF Retraction System had a mean procedure time of 117.3 min with a standard deviation (SD) of 13, and a mean total OR time of 151 min, SD 14.5. No surgery was converted under general anesthesia. No intraoperative complications were reported. Average length of stay was 1.3 ± 0.46 days.

CONCLUSION

Awake MAS TLIF is a safe and effective technique, with the advantage of reducing the risk and side effect of general anesthesia and the approach-associated damage to soft tissues and morbidity. The pedicle-based distraction allows easier access to the intervertebral disc space for both disc preparation and cage placement.

Should Preoperative Fascia Iliaca Block Be Used for Hip Arthroscopic Labral Repair and Femoroacetabular Impingement Treatment? A Prospective Single Blinded Randomized Study

PURPOSE

To evaluate the analgesic effect of preoperative fascia iliaca block on postoperative morphine equivalent dose, pain level, and patient satisfaction for patients electing to undergo primary hip arthroscopic labral repair with osteochondroplasty.

METHODS

This prospective study included 60 patients (fascia iliaca block group: n = 27; control group: n = 33) undergoing elective arthroscopic hip surgery by a single board-certified orthopedic surgeon, fellowship trained in hip arthroscopy. Participants for the study included patients older than 10 years of age and younger than 85 years of age, American Society of Anesthesiologists classifications I to III, diagnosed with symptomatic femoroacetabular impingement, and/or hip labral tear, and/or cartilage damage, and electing to undergo arthroscopic hip surgery. Patients were randomized by surgical date to receive preoperative fascia iliaca block or control (no fascia iliaca block). Preoperative fascia iliaca block was administered by 1 of 4 board certified anesthesiologists using identical anesthetic (35-40 mL ropivacaine 0.35%). Postoperative morphine equivalent dose, self-reported pain level (visual analog scale) and patient satisfaction were measure postoperatively.

RESULTS

There were no significant differences between the control group and the fascia iliaca block group in sex, age, height, weight, or body mass index. There was a significant difference between the 2 groups in distribution of American Society of Anesthesiologists classification (p = .031). There were no significant differences in postoperative morphine equivalent dose for patients receiving fascia iliaca block compared with the control group. There were no significant differences in self-reported visual analog scale pain and patient satisfaction between the 2 groups at any of the measured time points following surgery.

CONCLUSIONS

Based on the results of this study, routine preoperative fascia iliaca block for elective hip arthroscopic labral repair and treatment of femoroacetabular impingement is not recommended.

LEVEL OF EVIDENCE

Level II, prospective single blinded randomized study.

Is Spinal Anesthesia Safer than General Anesthesia for Patients Undergoing Revision THA? Analysis of the ACS-NSQIP Database

BACKGROUND

The incidence of revision THA continues to increase and there is a need to identify risk factors contributing to postoperative complications. Anesthesia type has been shown to be associated with complication rates in patients who undergo primary THA, but it is not clear whether the same is true among patients undergoing revision THA.

QUESTIONS/PURPOSES

(1) After controlling for confounding variables, in the setting of a large-database analysis, is spinal anesthesia associated with a lower risk of death, readmission, reoperation, postoperative transfusion, thromboembolic events, surgical site infection (SSI), and re-intubation among patients undergoing revision THA?

METHODS

The American College of Surgeons-National Surgical Quality Improvement (ACS-NSQIP) database was queried for patients undergoing aseptic, revision THA with either spinal or general anesthesia. Coarsened exact matching was used to match patients based on several baseline characteristics, including age, sex, body mass index, surgery type (Current Procedural Terminology code), and the modified Frailty Index score. Coarsened exact matching is a statistical method of exact matching that matches on chosen characteristics, in which continuous variables may be temporarily coarsened (such as, into discrete categorical variables) to facilitate matching. This method is an alternate to and requires less estimation than traditional propensity score matching. Then, using a model controlling for baseline patient characteristics and operative time, we performed multivariate logistic and linear regression analyses of matched cohorts to examine differences in mortality, readmission, reoperation, thromboembolic events, transfusion, SSI, and re-intubation.

RESULTS

After statistical matching and controlling for baseline demographic variables, surgery type (one- or two-component revision), surgical time and modified Frailty Index we found that patients receiving general anesthesia had higher odds of mortality (OR 3.72 [95% CI 1.31 to 10.50]; p = 0.013), readmission (OR 1.49 [95% CI 1.24 to 1.80]; p < 0.001), reoperation (OR 1.40 [95% CI 1.13 to 1.73]; p = 0.002), thromboembolic events (OR 2.57 [95% CI 1.37 to 4.84]; p = 0.003), SSI (OR 1.32 [95% CI 1.01 to 1.72]; p = 0.046), postoperative transfusion (OR 1.57 [95%CI 1.39 to 1.78]; p < 0.001) and unplanned intubation or failure to wean off intubation (OR 5.95 [95% CI 1.43 to 24.72]; p = 0.014).

CONCLUSIONS

In patients undergoing revision THA, spinal anesthesia is associated with a decreased risk of several complications. The current investigation suggests that, when practical (such as when long surgical times or changes to the surgical plan are not anticipated), spinal anesthesia should be considered for use during revision THA.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A Survey on the Short-term Outcome of Microlumbar Discectomy with General versus Spinal Anesthesia

Background

Surgery on the lower thoracic and lumbosacral spine is possible with both general and spinal anesthesia, but most spine surgeons are reluctant to perform the surgery with spinal anesthesia. We aimed to conduct a survey on the short-term outcome of microlumbar discectomy in the patients who had been treated under general or spinal anesthesia.

Methods

In this prospective study, we performed a survey on 72 patients who underwent microlumbar discectomy under general anesthesia (group A) or spinal anesthesia (group B). Demographic characteristics, American Society of Anesthesiologists physical status, duration of operation, blood loss, and complications were all documented. Preoperative and early postoperative (at the time of discharge) disability and pain were assessed by using Japanese Orthopedic Association (JOA) scoring system and a visual analog scale questionnaire.

Results

The two groups were homogenous preoperatively. The mean intraoperative blood loss was less and the mean operating time was shorter in group A than in group B, but there was no statistically significant difference between groups. The rate of postoperative improvement in JOA score and improvement in pain were similar between groups. Anesthetic complications were unremarkable.

Conclusions

Simple lumbar disc operations in the otherwise healthy patients can be safely performed under either spinal or general anesthesia. Both anesthetic methods led to comparable outcomes with minimal complications.

Preemptive Analgesia With Oxycodone Is Associated With More Pain Following Total Joint Arthroplasty

BACKGROUND

Preemptive multimodal analgesia (PMA) is a commonly used technique to control pain following total joint arthroplasty. PMA protocols use multiple analgesics immediately preoperatively to prevent central sensitization and amplification of pain during surgery. While benefits of some individual components of a PMA protocol have been established, there are little data to support inclusion or exclusion of opioids in this context.

METHODS

This is a retrospective cohort study of 550 patients undergoing elective, primary total joint arthroplasty at a single institution using a standardized preoperative perioperative protocol. Two hundred seventy-five patients received oxycodone in addition to a standard multimodal preoperative analgesia regimen just before surgery and were compared to a matched cohort of 275 patients who received the standard regimen alone. Outcome measures included inpatient visual analog scale pain scores, inpatient opioid consumption, length of stay, and ambulation distance with physical therapy.

RESULTS

Patients who received opioids in preoperative holding reported significantly greater visual analog scale pain scores on postoperative day 1 (3.7 vs 3.1; P = .01), when compared to those who did not. These patients also walked shorter distances on postoperative day 0 (59.5' vs 125.7'; P < .001) and consumed greater morphine equivalents per hospital day over the course of their hospital stay (52.2 vs 37.2 mg; P < .001). These differences remained significant when stratified by procedure, total knee arthroplasty or total hip arthroplasty. Differences in pain and function between groups were more pronounced in patients undergoing total hip arthroplasty than those undergoing total knee arthroplasty.

CONCLUSION

Total joint patients who were given preemptive opioids immediately before surgery experienced more pain, consumed more postoperative opioids, and exhibited impaired early function as compared to those who were not given preemptive opioids. Orthopedic surgeons should reconsider routine use of preemptive opioids in this context.

Oral Multimodal Analgesia for Total Joint Arthroplasty

BACKGROUND

Oral multimodal analgesia for hip and knee arthroplasty is increasingly used as part of enhanced recovery protocols designed to minimize early postoperative pain and to facilitate early discharge, while minimizing undesirable side effects related to single-agent opioid administration.

METHODS

This article is a review of previously published data evaluating the use of various oral medications in the management of postoperative pain after lower extremity arthroplasty and was presented as part of a symposium at the November 2016 AAHKS Annual Meeting.

RESULTS

Multimodal analgesia has been shown to reduce opioid consumption and side effects, with a positive effect on both early and longer term outcomes for hip and knee arthroplasty patients. Medications directed at multiple points on the pain cascade minimize pain by different mechanisms. Suggested dosing regimens are proposed.

CONCLUSION

Oral multimodal analgesia incorporating a combination of opioid and nonopioid analgesics, selective and nonselective anti-inflammatory drugs, acetaminophen, and gabapentinoids are recommended as a part of a pre-emptive approach to pain management in patients undergoing hip or knee arthroplasty. Reduction of opioid consumption and minimization of side effects are primary outcomes, and prevention of chronic pain can positively affect long-term results.

Efficacy and Safety of 3 Different Anesthesia Techniques Used in Total Hip Arthroplasty

Background

This study compared the efficacy and safety of 3 different anesthesia techniques used in total hip arthroplasty (THA).

Material/Methods

We allocated 198 patients preparing to undertake THA into 3 groups: general anesthesia group (GA group, n=66), caudal epidural anesthesia group (CEA group, n=66), and spinal-epidural anesthesia group (SEA group, n=66). We compared postoperative adverse effects occurring in patients of the 3 anesthesia groups. The Visual Analog Scale (VAS) score, Minimum Mental State Examination (MMSE) score, and β-amyloid (Aβ) expression were calculated to determine the effects of different anesthesia on the postoperative pain and cognitive dysfunction of patients.

Results

The CEA and SEA groups had lower rates of perioperative adverse effects than in the GA group. Patients in the GA group required significantly higher administration of analgesics after the surgery than those in CEA and SEA groups. Higher Aβ expression levels and VAS scores, as well as lower MMSE scores, were also seen in the GA group compared with the other 2 groups.

Conclusions

CEA and SEA were more effective than GA in THA, and CEA seemed to be a better anesthesia technique than SEA.

Comparison of Short-Term Complications of General and Spinal Anesthesia for Primary Unilateral Total Knee Arthroplasty

Purpose

To compare the occurrences of perioperative complications of two anesthetic techniques (general anesthesia [GA] and spinal anesthesia [SA] in patients undergoing primary unilateral total knee arthroplasty (TKA).

Materials and Methods

Patients who underwent unilateral primary TKA due to osteoarthritis from January 2005 to January 2014 were retrospectively reviewed. They were divided into two groups: GA (n=490) and SA (n=746). The operation duration, length of perioperative stay in the operation room and occurrences of adverse events in postoperative 30 days (mean, 29.7±3.1 days) were compared. Before multivariate linear or logistic regression analysis, different baseline characteristics were adjusted in the statistical models.

Results

There were significant intergroup differences in mean age (GA, 68.4±7.2 years; SA, 70.7±7.5 years; p<0.001) and mCCI (GA, 3±1.4; SA, 3.2±1.5; p<0.001). The GA group required longer preoperative room time (+9.4 minutes; p<0.001), postoperative room time (+12.7 minutes; p<0.001), and postoperative hospital stay (+2.5 days; p=0.001) and had more surgical site infections (5 [1%] vs. 0 [0%]; p=0.005) and blood transfusion (205 [41.8%] vs. 262 [35.1%]; p=0.01). No differences in operative duration and other adverse events were identified.

Conclusions

We should cautiously consider that GA may be associated with slightly increased preoperative and postoperative room times, postoperative hospital stay, transfusion and surgical site infection rates in primary unilateral TKA.

Fears and Perceptions Associated with Regional Anesthesia: A Study from a Tertiary Care Hospital in South India

AIMS

To assess the patients' fears and their perception about regional anesthesia and to study the correlation between fears and perception and demographic profile.

DESIGN

A prospective cross-sectional survey on 150 patients scheduled for surgery under regional anesthesia (RA).

MATERIALS AND METHODS

The structured questionnaires composed of patients' demographic data and questions regarding patients' fears about RA. Questionnaires along with consent forms were sequentially distributed to patients. American Society of Anesthesiologists physical status Classes I and II patients aged between 18 and 80 years scheduled for surgery under RA at the preanesthesia clinics were included in the study.

STATISTICAL ANALYSIS

Statistical analysis was done by calculating percentages using Chi-square test.

RESULTS

One hundred and fifty participants were studied, and their responses were analyzed. Overall, 75.3% (n = 113) patients had preoperative fear. Fear of pain during surgery, i.e., 49.3% (n = 56) and fear of needles 48.7% (n = 55) were the most common fears that were observed in the study population. Patients had less fear regarding nausea, vomiting, and headache. Patients' demographic details did not have a significant correlation with their fears except for gender, with women being more afraid (86.3% vs. 67.7% of men, P = 0.01). Six patients (4%) revealed dissatisfaction and 10 patients were neutral with RA. Ten patients (6.7%) opted for GA in the future and one patient opted for RA with sedation.

CONCLUSION

There is a significant prevalence of fear for RA and its procedures which can affect the patients' decision and postoperative anxiety. The study replicated the high prevalence of anxiety and fear and has clinical implication of improving the education and specifically targeting the fears and anxiety to help the patients' better cope during and after the surgical procedure.

A nomogram for predicting the need for sciatic nerve block after total knee arthroplasty

PURPOSE

Sciatic nerve block (SNB) is commonly performed in combination with femoral nerve block (FNB) for postoperative analgesia following total knee arthroplasty (TKA). Despite the fact that 10-20 % of TKA patients require SNB for postoperative posterior knee pain, there are no existing studies that suggest a model to predict the need for SNB. The aim of our study was to develop a prediction tool to measure the likelihood of patients undergoing TKA surgery requiring a postoperative SNB.

METHODS

With institutional review board approval, we obtained data from the electronic medical record of patients who underwent TKA at the Cleveland Clinic. A multivariable logistic regression was used to estimate the probability of requiring a postoperative SNB. Clinicians selected potential predictors to create a model, and the potential nonlinear association between continuous predictors and SNB was assessed using the restricted cubic spline model.

RESULTS

In total 6279 TKA cases involving 2329 patients with complete datasets were used for building the prediction model, including 276 (12 %) patients who received a postoperative SNB and 2053 (88 %) patients who did not. The estimated C statistic of the prediction model was 0.64. The nomogram is used by first locating the patient position on each predictor variable scale, which has corresponding prognostic points. The cut-off of 11.6 % jointly maximizes the sensitivity and specificity.

CONCLUSION

This is the first study to be published on SNB prediction after TKA. Our nomogram may prove to be a useful tool for guiding physicians in terms of their decisions regarding SNB.

Anesthesia for hip arthroscopy: a narrative review

PURPOSE

Hip arthroscopy is a minimally invasive surgical procedure indicated for the treatment of specific hip disorders. In this narrative review, we aim to examine the key components in providing anesthesia for this procedure.

SOURCE

MEDLINE(®), PubMed, and EMBASE™ databases were searched for peer-reviewed articles discussing the anesthetic management of patients undergoing hip arthroscopy.

PRINCIPAL FINDINGS

The primary anesthetic regimen used for hip arthroscopy should balance patient factors, preferences of the surgeon, and the demands of the procedure itself. Both general and neuraxial anesthetic techniques are well suited for this mostly ambulatory surgical procedure. There is a lack of current literature specifically comparing the benefits and risks of the two techniques in this setting. Postoperative pain management consists mainly of intravenous and oral opioids; however, a variety of regional anesthesia techniques, such as lumbar plexus block and fascia iliaca block, can be performed pre- or postoperatively. Overall, hip arthroscopy is safe, although positioning-related difficulties, extravasation of irrigation fluid, hypothermia, infections, and thromboembolic events are potential perioperative complications that warrant specific monitoring and prompt treatment.

CONCLUSIONS

Until now, the anesthetic technique for hip arthroscopy has not been well studied. Thus, increasing emphasis should be directed towards examining relevant clinical outcomes that can better inform evidence-based decision-making in the anesthetic management of hip arthroscopy patients. In the meantime, awareness of potential complications and vigilant monitoring are paramount in providing safe anesthetic care for patients undergoing hip arthroscopy.

Perioperative Pain Management in Total Hip Arthroplasty: Korean Hip Society Guidelines

Effective perioperative pain management techniques and accelerated rehabilitation programs can improve health-related quality of life and functional status of patients after total hip arthroplasty. Traditionally, postoperative analgesia following arthroplasty was provided by intravenous patient-controlled analgesia or epidural analgesia. Recently, peripheral nerve blockade has emerged alternative analgesic approach. Multimodal analgesia strategy combines analgesics with different mechanisms of action to improve pain management. Intraoperative periarticular injection of multimodal drugs is one of the most important procedures in perioperative pain control for total hip arthroplasty. The goal of this review article is to provide a concise overview of the principles of multimodal pain management regimens as a practical guide for the perioperative pain management for total hip arthroplasty.

Patient refusal for regional anesthesia in elderly orthopedic population: A cross-sectional survey at a tertiary care hospital

Background and Aims:

Improvements in pain management techniques in the last decade have had a major impact on the practice of orthopedic surgeries, for example, total hip arthroplasty and total knee arthroplasty. Although there are a number of treatment options for postoperative pain, a gold standard has not been established. In our institution, both general anesthesia and regional anesthesia (RA), are being offered to the elderly orthopedic population but RA is not frequently accepted by elderly population. The objective of this study was to determine the frequency of various reasons for refusal of RA in elderly patients undergoing orthopedic surgeries.

Material and Methods:

A prospective study conducted over a period of 1 year, had 549 patients with ages above 60 years who underwent different types of elective orthopedic procedures 182 patients who refused RA were interviewed according to a structured questionnaire designed to assess the reasons of refusal.

Results:

Most common reason for the refusal of RA was surgeon's choice (38.5%), whereas 20.3% of the patients were unaware about the RA. There was a significant association between female gender and refusing RA due to backache (17.2%) and fear of being awake during the operation (24.1%) respectively.

Conclusion:

This survey showed that the main reasons among elderly female population were the fear of remaining awake and backache. However, overall it was the surgeon's choice which made patients refuse RA, and the anesthesiologists were the main source of information.

Management of acute pain in patients on treatment with opioids

The use of opioids for both benign and cancer-related chronic pain has increased exponentially over the last few years. For this reason, increasing numbers of such patients are presenting for surgery. It is known that continuous use of opioids is associated with an increase in postoperative analgesic requirements. This is believed to be mediated by the development of tolerance and opioid-induced hyperalgesia. Patients treated with opioids have special needs in the perioperative setting and it is the anesthesiologist's responsibility to manage these needs optimally. The aim of the present paper is to briefly orient the reader in the management of postoperative pain in patients chronically treated with licit opioids.

A prospective randomized comparative study of postoperative pain control using an epidural catheter in patients undergoing posterior lumbar interbody fusion

PURPOSE

To assess the efficacy of continuous epidural infusion analgesia (ED) with 0.2 % Ropivacaine versus IV PCA (Fentanyl) in spinal fusion surgery patients.

METHOD

A prospective randomized comparative clinical trial. Patients were randomized into one of two groups-the epidural group (ED-51 patients) and the IV PCA group (IV-43 patients). The epidural catheter tip was placed one level cephalad to the level of the PLIF in patients in the ED group. Patients were assessed by determining the pain score, cumulative opioid requirement, adverse effects, and satisfaction.

RESULTS

Pain score comparisons between the ED group and the IV group, respectively, were as follows: immediate postoperative status: 2.1 ± 1.5 vs. 7.2 ± 2.1, p = 0.01; postoperative day 1: 2.3 ± 1.9 vs. 6.8 ± 2.3, p = 0.02; postoperative day 2: 1.9 ± 1.8 vs. 5.4 ± 2.1, p = 0.02; postoperative day 3: 1.5 ± 1.6 vs. 3.9 ± 1.9, p = 0.03; postoperative day 4: 3.8 ± 2.1 vs. 3.1 ± 1.9, p = 0.4. Lower levels of opioids were required in the ED group, and fewer opioid-related complications developed in the patients in this group. Complications related to the use of epidural catheters were comparable between the two groups. Patient satisfaction with postoperative pain control was higher in the ED group.

CONCLUSION

In comparison with the use of IV PCA only, continuous epidural infusion of Ropivacaine resulted in lower pain scores and opioid consumption and higher patient satisfaction levels after posterior lumbar interbody fusion.

Combined Lumbar-Sacral Plexus Block in High Surgical Risk Geriatric Patients undergoing Early Hip Fracture Surgery

Objective: To evaluate the postoperative outcome after using combined lumbar and sacral plexus block (CLSB), as a sole anesthetic method in hip fracture (HF) surgery in highrisk geriatric patients.

Materials and Methods: A single-center retrospective study was conducted, between 2010 and 2012, on 70 elderly HF patients with American Society of Anesthesiologists grading III-IV who underwent early surgical intervention with our CLSB protocol. Perioperative data, outcome, and complications were recorded.

Results: Forty-eight patients (69%) had ongoing anticoagulant medication. Postoperatively, all patients were hemodynamically stable and awake. None of them required general anesthesia conversion. Minor anesthetic-related complications were found in nine patients. One patient (1%) died from sepsis due to pneumonia. Patients’ satisfactions were all rated as very good or excellent.

Conclusion: CLSB is an interesting anesthetic option in HF surgery, especially in high surgical risk geriatric patients. This method offers an excellent clinical efficiency and high patients’ satisfaction without serious complications.

Protocol-Based Arthroplasty: Less Is More

As a result of reading this article, physicians should be able to: 1. State an argument for, and background information on, patient-centered arthroplasty protocols. 2. Describe specific recommendations for designing a simplified arthroplasty care pathway that is reproducible in other institutions. 3. Discuss cost-effectiveness research on the latest value-delivering protocols. 4. Recognize areas of continued research and opportunities for future improvement in protocol development. Total joint arthroplasty is a successful orthopedic procedure that is performed in high volume in the United States and internationally. As economic pressures continue to mount in the US health care system, it will become increasingly important to minimize cost and improve quality and value. At the authors' institution, a protocol-based arthroplasty model is used, in many ways based on simplification of the patient care pathway. The largely evidence-based protocol has its foundation in eliminating unnecessary dogmatic practices, enhancing the patient experience, and achieving cost-effectiveness. The authors believe that a model like this can be applied to joint arthroplasty practices across the country in the future to maximize the value delivered to patients.

Comparative study of systemically and perineurally administered tramadol as an adjunct for supraclavicular brachial plexus block

Background and Aims:

The study was designed to compare the effects of tramadol administered as an adjunct to bupivacaine in supraclavicular block to that of systemic administration, on postoperative analgesia and rescue analgesic requirement following upper limb surgeries.

Material and Methods:

A prospective, randomized, controlled, double-blind study was undertaken in patients scheduled for upper limb surgeries under supraclavicular block. All the three group patients received either of the following drugs mixtures: Group A — bupivacaine 0.5%-18 ml + normal saline-7 ml for block and normal saline-10 ml intravenously. Group B — bupivacaine 0.5%-18 ml + normal saline-7 ml mixture for block and tramadol (100 mg) diluted to 10 ml — intravenously. Group C — bupivacaine 0.5%-18 ml + tramadol (100 mg) + normal saline-5 ml mixture and normal saline 10 ml intravenously. The patients were observed for sensory, motor onset along with the duration of sensory and motor block. Patients were monitored for sedation and hemodynamic parameters during intra-operative and postoperative period. Pain-free period and demand for rescue analgesia was noted in all the patients.

Results:

The study demonstrates that the mixture of tramadol and bupivacaine injected perineurally for supraclavicular brachial plexus block hastens the onset of sensory block, motor block and provides a longer duration of motor blockade and demand for rescue analgesia as compared to other two groups.

Conclusions:

In conclusion, the addition of tramadol to bupivacaine mixtures as an adjunct for supraclavicular brachial plexus block provide better postoperative analgesia for orthopedic upper extremity surgery in comparison to control or systemic tramadol group without any side effects.

General compared with spinal anesthesia for total hip arthroplasty

BACKGROUND

Total hip arthroplasty may be performed under general or spinal anesthesia. The purpose of the current study was to compare perioperative outcomes between anesthetic types for patients undergoing primary elective total hip arthroplasty.

METHODS

Patients who had undergone primary elective total hip arthroplasty from 2010 to 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Operating room times, length of stay, thirty-day adverse events, and readmission were compared between patients who had received general anesthesia and those who had received spinal anesthesia. Propensity-adjusted multivariate analysis was used to control for selection bias and baseline patient characteristics.

RESULTS

A total of 20,936 patients who had undergone total hip arthroplasty met inclusion criteria for this study. Of these, 12,752 patients (60.9%) had received general anesthesia and 8184 patients (39.1%) had received spinal anesthesia. On propensity-adjusted multivariate analyses, general anesthesia for total hip arthroplasty was associated with increased operative time (+12 minutes [95% confidence interval, +11 to +13 minutes]; p < 0.001) and postoperative room time (+5 minutes [95% confidence interval, +4 to +6 minutes]; p < 0.001). General anesthesia was also associated with the occurrence of any adverse event (odds ratio, 1.31 [95% confidence interval, 1.23 to 1.41]; p < 0.001), prolonged postoperative ventilator use (odds ratio, 5.81 [95% confidence interval, 1.35 to 25.06]; p = 0.018), unplanned intubation (odds ratio, 2.17 [95% confidence interval, 1.11 to 4.29]; p = 0.024), stroke (odds ratio, 2.51 [95% confidence interval, 1.02 to 6.20]; p = 0.046), cardiac arrest (odds ratio, 5.04 [95% confidence interval, 1.15 to 22.07]; p = 0.032), any minor adverse event (odds ratio, 1.35 [95% confidence interval, 1.25 to 1.45]; p = 0.001), and blood transfusion (odds ratio, 1.34 [95% confidence interval, 1.25 to 1.45]; p < 0.001). General anesthesia was not associated with any difference in preoperative room time, postoperative length of stay, or readmission.

CONCLUSIONS

General anesthesia was associated with an increased rate of adverse events and mildly increased operating room times.

Continuous spinal anaesthesia versus ultrasound-guided combined psoas compartment-sciatic nerve block for hip replacement surgery in elderly high-risk patients: a prospective randomised study

Background

Our aim is to compare the hemodynamic effects of combined psoas compartment-sciatic nerve block (PCSNB) with continuous spinal anaesthesia (CSA) in elderly high-risk patients undergoing hip replacement surgery.

Methods

Seventy patients over the age of 60 with ASA III or IV physical status were randomly allocated to two groups: In the PCSNB group, ultrasound-guided psoas compartment block was performed with modified Winnie technique using 30 mL of 0.25% bupivacaine with 1:200.000 epinephrine (5 μgr/mL) and iliac crest block was performed using the same local anaesthetic solution (5 mL). All patients in the PCSNB group needed continuing infusion of propofol (2 mg/kg/h) during operation. In the CSA group, CSA was performed in the L₃-L₄ interspaced with the patient in lateral decubitus position using 2.5 mg of isobaric bupivacaine 0.5%. When sensory block was not reached to the level of T₁₂ within 10 minutes in the CSA group, additional 2.5 mg of isobaric bupivacaine 0.5% was administered through the catheter at 5-min intervals by limiting the total dose of 15 mg until a T₁₂ level of the sensory block was achieved.

Results

The PCSNB group had significantly higher mean arterial blood pressure values at the beginning of surgery and at 5^th, 10^th and 20^th minutes of surgery compared to the CSA group (P =0.038, P =0.029, P =0.012, P =0.009 respectively). There were no significant differences between groups in terms of heart rate and peripheral oxygen saturation values during surgery and the postoperative period (P >0.05). Arterial hypotension required ephedrine was observed in 13 patients in the CSA and 4 patients in the PCSNB group (P =0.012).

Conclusions

CSA and PCSNB produce satisfactory quality of anaesthesia in elderly high-risk patients with fewer hemodynamic changes in PCSNB cases compared with CSA cases.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12614000658617, Registered 24 June 2014.

Continuous Spinal Anaesthesia for Hip Fracture Surgery in a High-Risk Patient

Elderly patients have increased risk for perioperative mortality and morbidity due to additional comorbidities, such as cardiac diseases. Regional anaesthesia techniques are usually preferred in high-risk patients due to some advantages, such as the maintenance of cardiovascular stability and early postoperative mobilisation. This case presents the anaesthetic approach in a 55-year-old male patient with low ejection fraction that underwent hip fracture surgery. In this present case, continuous spinal anaesthesia with low-dose hyperbaric bupivacaine provided safe and effective anaesthesia during surgery with minimal haemodynamic changes and adequate analgesia during the first 24 hours after surgery.

Comparison of 2 Methods of Local Anesthetic-Based Injection as Part of a Multimodal Approach to Pain Management After Total Knee Arthroplasty

BACKGROUND

It is estimated that up to 50% of patients undergoing total knee arthroplasty (TKA) receive suboptimal postoperative pain management.

METHODS

In a retrospective study, 224 patients who underwent TKA between January 1, 2011, and September 30, 2012, were identified by surgical records for 2 surgeons at Community Medical Center in Missoula, Montana. Patient records were reviewed and data collected for patient hospital length of stay (LOS), postoperative opioid use, opioid-associated adverse events, and nonopioid analgesic use. Data were analyzed for differences in outcomes between patients who received an intraoperative intra-articular (IOIA) injection followed by a postoperative infusion (0.25%-0.5% bupivacaine) or an intraoperative periarticular (IOPA) injection (ropivacaine, ketorolac, epinephrine, and clonidine) for sustained analgesia after TKA.

RESULTS

Patients who received an IOPA injection had a statistically significant decrease in hospital LOS (67.0 vs 75.9 hours; P = .027) and postoperative nausea and vomiting (39.3% vs 54.9%; P = .023) when compared to patients who received an IOIA infusion. The incidence of having either oversedation or pruritus did not differ between groups (9.8% vs 9.8%; P = 1.00).

CONCLUSION

The use of IOPA injections containing ropivacaine, epinephrine, ketorolac, and clonidine during TKA offered some benefit over IOIA infusions containing 0.25% to 0.5% bupivacaine at our institution.

Comparison of venous thromboembolism after total hip arthroplasty between ankylosing spondylitis and osteoarthritis

Objective. Ankylosing spondylitis (AS), an inflammatory rheumatic disease, will gradually lead to severe hip joint dysfunction. Total hip arthroplasty is a useful method to improve patients' quality of life. The aim of this study was to compare the incidence and risk factors of deep vein thrombosis (DVT) between AS and hip osteoarthritis. Methods. In a retrospective study, a total of 149 subjects who underwent cementless THA were studied. Clinical data, biochemical data, and surgery-related data were measured between AS and OA groups. Results. The incidence of DVT in AS group was lower than that of OA group, although no significant difference was detected (P = 0.89). The patients of AS group were much younger (P < 0.0001) and thinner (P = 0.018) compared with those of OA group. AS patients had higher ejection fraction (EF) (P = 0.016), higher platelet counts (P < 0.0001), and lower hypertension rate (P = 0.0004). The values of APTT, PT, and INR in AS patients were higher than those in OA patients (all P < 0.0001). The values of D-dimer and APTT were both significantly higher in DVT subjects than those in non-DVT subjects. Conclusion. AS patients potentially had a lower incidence of DVT compared with OA patients.

Multimodal pain management in total knee arthroplasty: a prospective randomized controlled trial

We analyze the effects of a multimodal analgesic regimen on postoperative pain, function, adverse effects and satisfaction compared to patient-controlled analgesia (PCA). Thirty-six patients undergoing TKA were randomized to receive either (1) periarticular injection before wound closure (30cc 0.5% bupivacaine, 10mg MSO4, 15 mg ketorolac) and multimodal analgesics (oxycodone, tramadol, ketorolac; narcotics as needed) or (2) hydromorphone PCA. Preoperative and postoperative data were collected for VAS pain scores, time to physical therapy milestones, hospital stay length, patient satisfaction, narcotic consumption and medication-related adverse effects. The multimodal group had lower VAS scores, fewer adverse effects, lower narcotic usage, higher satisfaction scores and earlier times to physical therapy milestones. Multimodal pain management protocol decreases narcotic usage, improves pain scores, increases satisfaction and enhances early recovery.

Comparison between spinal and general anesthesia in percutaneous nephrolithotomy

Background

Hemodynamic stability and blood loss reduction are subjects to further consideration in patients undergoing percutaneous nephrolithotomy (PNCL).

Objectives

This study compared the preference of spinal anaesthesia (SA) or general anaesthesia (GA) in respect to mentioned concerns.

Patients and Methods

In this randomized clinical trial, 59 patients who underwent PCNL divided into SA and GA groups. 15-20 mg from intra-thecal bupivacaine 0.5%, and premedication of 0.01-0.02 mg from midazolam, were given to patients in SA group (n = 29). Patients in GA group (n = 30) received premedication of 1-2 µg/kg from fentanyl and 0.01-0.02 mg/kg from midazolam, and intravenously anaesthetized with 100 µg/kg/min of propofol and 0.5 mg/kg of atracurium, given by continuous infusion and N₂O/O₂ 50%. Mean arterial pressure (MAP) and heart rate were recorded intra-operatively and during recovery.

Results

MAP and heart rate show no significant differences at designated time points between two groups (P > 0.05). Surgery time, anesthesia time, bleeding volume, and analgesic intake were significantly reduced in SA group (P < 0.05).

Conclusions

It seems that, in patients undergoing PNCL, SA is as effective and safe as GA. Patients who undergo PNCL under SA require smaller amounts of analgesic dose and show hemodynamic stability during surgery and recovery time. Also, SA technique provides decreased blood loss and shortened surgery as well as anesthesia times compared to GA.

Preoperative L1 and L2 paravertebral block is an effective postoperative analgesia for hip arthroscopy in a multimodal analgesic regimen

We describe the case of a 30-year-old woman with chronic hip pain secondary to avascular necrosis. She received preoperative L1-L2 paravertebral block for postoperative pain control after arthroscopic hip surgery. Preoperative paravertebral block at the level of L1-L2 provided an effective postoperative analgesia for hip arthroscopy when used in a multimodal approach.

Guidelines for the management of postoperative pain after total knee arthroplasty

This clinical practice guideline was approved by Korean Knee Society on February 28, 2012. It is based on a systematic review of published studies on the management of postoperative pain after total knee arthroplasty and was developed to include the overall pain management modalities. The purpose of the guideline is to help improve treatment based on current best evidence. Eleven recommendations have been developed based on a systematic review of research evidence and the consensus opinions of a multidisciplinary working group of experts. These recommendations will be revised regularly following systematic review of new research evidence as this becomes available.

Pain management after total knee arthroplasty using a multimodal approach

Improvements in pain management techniques over the past decade have had a significant impact on the outcomes of total knee arthroplasty. Of these techniques, multimodal approaches have shown potential. The purpose of this study was to compare the results of periarticular injection (PAI) to a combination of patient-controlled epidural analgesia and femoral nerve block (PCEA/FNB). Ninety patients undergoing primary unilateral total knee arthroplasty between June 2010 and March 2011 were randomized into 2 groups. The first group received the PCEA/FNB protocol, whereas the second group received the PAI. Mean patient age was 66.1 ± 8.7 years. All patients were operated on using a similar standard medial parapatellar approach, and all received preemptive analgesia and postoperative pain protocols. All patients were interviewed twice daily for the first 3 days postoperatively, once on day 7, and once in month 6. The 2 groups had similar readiness for discharge (PCEA/FNB group, 3.3 ± 1.2 days; PAI group, 3.2 ± 1.9 days). The results indicated no statistical difference between the 2 groups in 3 of 4 categories (rest in the morning, rest in the evening, and ambulation in the morning). Pain on ambulation was the only category that was statistically lower in the PCEA/FNB group than in the PAI group.Although the study demonstrates similar results between the 2 groups, PAI can play a major role in postoperative pain control in institutions that may not have appropriately trained individuals, equipment, and resources for PCEA/FNB. It also reduces many of the side effects and complications associated with regional anesthesia.

Does supplemental epidural anesthesia improve outcomes of acetabular fracture surgery?

OBJECTIVE

Addition of epidural anesthesia to general anesthesia is theorized to reduce hospital length of stay, improve postoperative pain control, reduce time to mobilization, and reduce intraoperative blood loss for operative treatment of acetabular fractures. Our hypothesis was that epidural anesthesia would result in improvement in short-term outcomes and therefore justify any associated increases in anesthesia induction time, treatment costs, or risks.

DESIGN

Retrospective case-control.

SETTING

Academic trauma center.

PATIENTS

We identified 163 patients who underwent open reduction and internal fixation of posterior wall acetabular fractures from 2002 through 2007. We excluded patients who were intubated before the procedure (n = 20) and patients with incomplete intraoperative anesthesia records (n = 5). Patients were divided into two groups: Group 1 received combined epidural plus general anesthesia (CEGA) (n = 64) and Group 2 received general anesthesia alone (GA) (n = 74). No differences were observed between the two groups in terms of age, gender, Injury Severity Score, head Abbreviated Injury Score, mechanism of injury, number of associated fractures, number of comorbidities, or delay between injury and day of surgery.

INTERVENTION

General anesthesia with or without epidural anesthesia.

MAIN OUTCOME MEASUREMENTS

Length of stay, postanesthesia care unit initial and discharge pain scores, time to mobilization with physical therapy, estimated blood loss, and anesthesia time.

RESULTS

: No significant differences were shown between the two groups for length of stay (CEGA, 6.2 days; GA, 5.9 days; P = 0.62; 80% power to detect a difference of 1.3 days), postanesthesia care unit initial pain scores (CEGA, 3.5; GA, 3.4; P = 0.92), postanesthesia care unit discharge pain scores (CEGA, 2.5; GA, 3.3; P = 0.13), or time to mobilization with physical therapy (CEGA, 1.5 days; GA, 1.7 days; P = 0.43). Intraoperative blood loss was less in the CEGA group (CEGA, 458 mL; GA, 543 mL; P = 0.05). Mean anesthesia time was longer for the CEGA group (CEGA, 85 minutes; GA, 66 minutes; P < 0.01).

CONCLUSIONS

Although addition of epidural anesthesia added an average of 19 minutes to the anesthesia time (P < 0.01), we found no advantage to CEGA regarding length of stay, pain scores, or time to rehabilitation. Mean decrease of blood loss of less than 100 mL in the CEGA group is unlikely to be of clinical significance. Our results contrast findings in support of CEGA in the hip arthroplasty literature and question the use of CEGA for posterior wall acetabular fractures.

The efficacy of multimodal high-volume wound infiltration in primary total hip replacement

Multimodal wound infiltration with local anesthetics, adrenaline, and nonsteroidal anti-inflammatory agents can lower the opiate intake, reduce the length of stay, and enhance early mobilization after total hip arthroplasty (THA). A retrospective review of 204 patients undergoing primary THA was undertaken. One hundred two patients had their wounds infiltrated with ropivacaine, adrenaline, and ketorolac by the operating surgeon intraoperatively. Subsequently, a 19-gauge wound catheter was inserted percutaneously into the hip joint. Patients received 2 further top-up doses of 20 mL of ropivacaine (7.5 mg/mL) at 10 and 20 hours postoperatively. These patients were compared to a control group of 102 patients who received no local infiltration. Both groups were comparable in terms of body mass index and age. Opiate consumption in the first 48 hours after surgery and length of hospital stay were recorded. The mean consumption of morphine in the treatment group was 42.3 mg (standard deviation [SD], 31.2 mg) compared to 60.9 mg (SD, 33.8 mg) in the control group (P<.0001). The mean length of stay was significantly reduced from 5.2 days (SD, 1.6 days) in the control group to 4 days (SD, 1.3 days) in the treatment group (P<.0001). The time needed by the patients to walk for 3 meters after surgery was significantly reduced in the treatment group (median, 25 vs 46.1 hours; interquartile range, 20.7- 45.1 vs 27.2- 50.9; P<.0001). This is the largest series to demonstrate that a multimodal perioperative wound infiltration technique in primary THA surgery leads to early attainment of immediate postoperative rehabilitation milestones and reduced length of stay along with reduction in postoperative opiate consumption.

[Postoperative pain management for patients who are long-term users of opioid]

Pain is one of the most common reasons for seeking medical care and the frequency of prescription of opioid analgesics by both primary care physicians and specialists has increased. It is therefore unsurprising that many patients with chronic pain who must undergo scheduled or emergency surgery will be on long-term medication, including opioids. Managing postoperative pain, even with high doses of drugs, seems to be more difficult in regular users of such analgesics, possibly because of an apparent association of opioid use with increased tolerance and hyperalgesia. Postoperative pain relief should be carefully tailored in these cases by means of a management plan worked out along with the patient. Adjuvants may be particularly useful; the most thoroughly studied adjuvants are nonsteroidal anti-inflammatory drugs and ketamine. Regional anesthesia offers a particularly attractive approach when long-term users of opioids must undergo surgery.

The efficacy of periarticular multimodal drug infiltration in total hip arthroplasty

BACKGROUND

Patient-controlled analgesia is a widely used and effective method of controlling pain after THA. This method is associated with substantial undesirable side effects. Local infiltration has been introduced in an attempt to reduce opioid requirements postoperatively, but its ability to reduce pain without complications is still questioned.

QUESTIONS/PURPOSES

We evaluated patient-controlled analgesia use, pain and satisfaction scores, complication rates, and ropivacaine levels associated with the use of periarticular multimodal drug infiltration in THA.

PATIENTS AND METHODS

We randomized 64 patients undergoing THA to receive a periarticular intraoperative multimodal drug injection or to receive no injection. All patients received patient-controlled analgesia for 24 hours after surgery. The final assessment was at 6 weeks.

RESULTS

Patients receiving the periarticular injection used less patient-controlled analgesia 6 hours postoperatively. The 24-hour patient-controlled analgesia requirement postsurgery also was less. The visual analog scale score for pain on activity in the postanesthetic care unit was less for patients who received an injection. The visual analog scale satisfaction score was similar in the two groups throughout the followup period. Recorded unbound ropivacaine levels were 2.5 times lower than toxic levels.

CONCLUSIONS

Periarticular intraoperative injection with multimodal drugs can reduce postoperative patient-controlled analgesia requirements and pain on activity in patients undergoing THA with no apparent increase in risk.

LEVEL OF EVIDENCE

Level I, therapeutic study. See the guidelines online for a complete description of level of evidence.