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Regional Anesthesia in Total Joint Arthroplasty: What Is the Evidence?
The Journal of Arthroplasty 32 (2017) S74eS76
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
AAHKS Symposium
Regional Anesthesia in Total Joint Arthroplasty: What Is the Evidence? Dalia H. Elmofty, MD a, *, Asokumar Buvanendran, MD b a b
Department of Anesthesia & Critical Care, The University of Chicago, Chicago, Illinois Department of Anesthesia & Critical Care, Rush University Medical Center, Chicago, Illinois
a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 April 2017 Received in revised form 28 April 2017 Accepted 9 May 2017 Available online 18 May 2017
Total joint arthroplasty is one of the most common surgical procedures performed for end-stage osteoarthritis. The increasing demand for knee and hip arthroplasties along with the improvement in life expectancy has created a substantial medical and economic impact on the society. Effective planning of health care for these individuals is vital. The best method for providing anesthesia and analgesia for total joint arthroplasty has not been defined. Yet, emerging evidence suggests that the type of anesthesia can affect morbidity and mortality of patients undergoing these procedures. © 2017 Elsevier Inc. All rights reserved.
Keywords: total hip arthroplasty total knee arthroplasty peripheral nerve block neuraxial anesthesia morbidity mortality
Over 1 million total hip and knee arthroplasty surgeries are performed each year in the United States [1]. Total joint arthroplasty is becoming more common than treatments for other chronic diseases. The prevalence of joint disease is similar to that of stroke and myocardial infarction and greater than heart failure [2]. Total joint arthroplasty has been shown to improve long-term quality of life. With the aging of the “baby boomer” generation and the minimal progress being made toward the prevention and treatment of osteoarthritis, the demand for total joint arthroplasty is anticipated to rise and overburden health care economics. As the global population ages, the prevalence of cardiopulmonary comorbidities also increases. Older patients with poorer American Society of Anesthesiologists physical status classification have a higher incidence of perioperative complications [3]. Approximately 1.6%-2.1% of patients undergoing total knee arthroplasty will experience a major systemic complication [4]. Although a rare event, the 30-day mortality after total hip arthroplasty was estimated at 0.3% [5] and after total knee arthroplasty at 0.18% [4]. Early ambulation, reducing length of hospital stay, and minimizing
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.05.017. * Reprint requests: Dalia H. Elmofty, MD, Department of Anesthesia & Critical Care, The University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637. http://dx.doi.org/10.1016/j.arth.2017.05.017 0883-5403/© 2017 Elsevier Inc. All rights reserved.
perioperative complications is critical for improving outcomes in patients undergoing total joint arthroplasty. An abundance of literature exists describing the risk factors associated with increased morbidity and mortality after total joint arthroplasty: older age, male gender, bilateral joint surgery, diabetes, renal disease, metastatic cancer, and cerebrovascular or cardiopulmonary comorbidities [4,6e8]. In these large studies, however, the type of anesthesia for total joint arthroplasty was not reported. There is emerging evidence that type of anesthesia is strongly associated with perioperative outcomes. Anesthetic options for total joint arthroplasty are general and regional anesthesia or a combination of both. Perioperative regional anesthesia, with peripheral nerve blocks, is becoming more popular. The introduction of the ultrasound has facilitated the performance and accuracy of peripheral nerve blocks. Although some of the studies show that regional anesthesia is linked to a decrease in postoperative morbidity and mortality, it continues to be underutilized. In a review of data from 2006 to 2013, 64.4% of patients received general anesthesia, 22.8% received neuraxial anesthesia, and 12.8% received peripheral nerve blocks for total joint arthroplasty [9]. Regional Techniques for Total Joint Arthroplasty Neuraxial Anesthesia Neuraxial anesthesia is associated with improved outcomes in patients undergoing total joint arthroplasty. The exact mechanism is
D.H. Elmofty, A. Buvanendran / The Journal of Arthroplasty 32 (2017) S74eS76
not completely understood but may be associated with sympathectomy, which may improve tissue perfusion; decrease in the stress response that improves hemodynamics and reduces blood pressure fluctuation; and better pain control. Reducing complications after total joint arthroplasty is an important public health concern. In one large nationwide study of the effect of anesthetic techniques on perioperative outcomes for primary total joint arthroplasty, neuraxial, or combined neuraxial-general vs general anesthesia alone was associated with improved outcomes, and the addition of neuraxial anesthesia was a positive modifier [10]. Complication rates for pulmonary embolism, pulmonary compromise, pneumonia, and acute renal failure were reduced in the neuraxial and combined neuraxialgeneral anesthesia group. The 30-day mortality rate was higher in the general anesthesia group [10]. In another retrospective study, the effects of neuraxial vs general anesthesia in populations of various ages and comorbidities were reviewed. Neuraxial anesthesia was associated with several reductions: complications, intensive care utilization, and length of hospital stay across all age groups. Neuraxial anesthesia also had a positive effect on elderly patients with significant cardiopulmonary comorbidities [11]. In spite of the growing evidence that neuraxial anesthesia is linked to improved outcomes, the American College of Surgeons National Surgical Quality Improvement Program reports that general anesthesia continues to be the main choice for patients undergoing total hip arthroplasty [12]. A retrospective propensitymatched cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program database found that after total hip arthroplasty, deep surgical site infections were reduced in patients receiving regional anesthesia, epidural, or spinal, vs those undergoing general anesthesia [12]. Spinal anesthesia was associated with a lower incidence of death within 30 days and major blood loss, shorter operating room time, and hospital stay than general anesthesia for total joint arthroplasty [13]. A multicenter prospective comparison of shortterm (within 30 days) complications between spinal and general anesthesia for patients who underwent total knee arthroplasty revealed that patients who had spinal anesthesia had a lower unadjusted frequency of superficial wound infections, blood transfusions, and overall complications. The length of surgery and hospital stay was shorter. Patients with multiple comorbidities would seem to benefit most from spinal anesthesia [14]. There is controversy regarding the association between regional anesthesia and inpatient falls. Inpatient falls negatively impact outcomes and can lead to greater use of critical care services and to overall morbidity and mortality. In one study of inpatient falls after total knee arthroplasty, advanced age and a higher comorbidity burden were independent risk factors for falls and the use of neuraxial over general anesthesia was associated with reduced risk [15]. Neuraxial anesthesia is effective for pain control but is associated with a higher incidence of neurologic and hemorrhagic complications. Elderly patients may have spinal stenosis, predisposing them to neurologic injuries [16]. Patients undergoing total joint arthroplasty have a high risk for deep vein thrombosis. Thromboprophylaxis is mandatory in this patient population but can be associated with a higher risk of hemorrhagic complications such as neuraxial hematoma. The risk has been underestimated in the past and varies based on the cohort: epidurals for orthopedic surgery 1:4000, epidurals for other surgical procedures 1:10,000-20,000, and for labor 1:200,000 [17]. In general, epidural anesthesia in the nonobstetric population produced a higher incidence of neuraxial hematoma [18]. Although the risks for epidural hematomas are multifactorial, certain anatomic factors [19] and anticoagulation therapy [20] increase risk. When trends in the use of regional anesthesia in 2006-2007 were compared with trends in 2012-2013, the use of neuraxial
S75
anesthesia decreased slightly from 21.7% to 19.7% for hip arthroplasty and 24.7% to 21.3% for knee arthroplasty, possibly from concerns about neuraxial hematoma [9]. Peripheral nerve blocks can prevent many of the disadvantages of neuraxial blocks and may have a more favorable safety profile. Blocks performed by an experienced physician under ultrasound guidance can greatly reduce the risk of vascular injury in anticoagulated patients. In one study, ultrasound-guided peripheral nerve blocks correlated with fewer needle passes and vascular puncture [21]. Case reports have described successful blocks in patients receiving anticoagulation therapy without hemorrhagic complications [22]. A prospective observational study enrolled 540 patients who had a femoral nerve catheter inserted before surgery that remained in place 36-48 hours postoperatively. Patients were given rivaroxaban 10 mg daily and were assessed for complications, hematoma causing neurovascular compromise, or ecchymosis at the femoral catheter site. No hematomas were identified but ecchymosis was found in the groin or thigh [23]. Peripheral Nerve Blocks Peripheral nerve blocks also can be associated with neurologic and hemorrhagic injuries, but their consequences may not be as serious as those associated with neuraxial blockade. Previously published data have associated peripheral nerve blocks with a higher risk of inpatient falls [24], but results from a recent, large, national database review found no association between the two [15]. The integration of peripheral nerve blocks into the perioperative anesthetic plan may improve perioperative outcomes for patients undergoing total joint arthroplasty. Common nerve blocks performed for total joint arthroplasty are femoral, adductor, sciatic, lumbar plexus, and fascia iliaca compartment. There has been an increase in the utilization of peripheral nerve blocks for hip arthroplasty from 6.5% to 8.7% and for knee arthroplasty from 10.3% to 20.4% when data from 2006 to 2007 were compared with data from 2012 to 2013 [9]. Peripheral nerve blocks also can influence outcomes in patients undergoing total joint arthroplasty. Peripheral nerve blocks may offer the same favorable physiological effects as neuraxial anesthesia: sympathectomy, decreased stress response, and improved pain control. A meta-analysis comparing epidural analgesia vs peripheral nerve blockade for total knee arthroplasty found no considerable difference in scores on visual analog scale at 0-48 hours. Epidural anesthesia was associated with more nausea, vomiting, postoperative hypotension, and urinary retention compared with peripheral nerve blocks [25]. A retrospective review investigated the relationship between peripheral nerve blocks and outcome measures such as complications (cardiac, pulmonary, gastrointestinal, renal, cerebrovascular, infections, thromboembolic, inpatient falls, and mortality) and resource utilization (blood transfusions, intensive care unit admission, opioid consumption, cost, and length of stay). Peripheral nerve blocks were associated with lower odds for most complications, decreased opioid consumption, and length of stay, and minor reduction in costs for patients undergoing total hip arthroplasty. There were similar benefits for patients undergoing total knee arthroplasty with significantly lower odds for pulmonary complications [26]. Femoral nerve blocks, which are commonly performed for patients undergoing total knee arthroplasty, target both sensory and motor innervation of the knee joint. Femoral nerve blocks were found superior to intravenous patient-controlled analgesia (PCA) and equivalent to epidural analgesia for pain control [27]. With femoral nerve blocks, knee flexion was better than PCA, and opioid-related side-effects were reduced compared with PCA or epidural analgesia.
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D.H. Elmofty, A. Buvanendran / The Journal of Arthroplasty 32 (2017) S74eS76
The adductor canal block is emerging as a substitute for the femoral nerve block because it blocks the sensory branches of the femoral nerve and minimizes motor impairment to the knee. When a meta-analysis compared adductor canal blocks to femoral nerve blocks, there was no significant difference in the visual analog scale scores at 24 hours and at 48 hours [25]. In another systematic review, adductor canal block was as effective in controlling pain as femoral nerve block and facilitated earlier mobilization [28]. In one meta-analysis, equivalent analgesic benefit was found with adductor canal and femoral nerve blocks. The effect on quadriceps muscle strength could not be assessed because of the inconsistency among the studies in outcome measurements [29]. If the adductor canal is reliably defined (mid-thigh vs proximal one-third), concerns about the type of block and separation of motor fibers from the sensory fibers could be determined. A recent prospective, randomized, controlled study compared the analgesic effectiveness of combined adductor canal block with periarticular infiltration vs adductor canal or periarticular infiltration alone. The combined method was superior to either alone [30]. The fascia iliaca compartment block can treat acute postoperative pain from total hip arthroplasty. It provides an indirect proximal approach to the lumbar plexus. In a prospective, randomized trial, fascia iliaca block was compared with periarticular liposomal bupivacaine injection. Both treatments effectively reduced pain intensity compared with pain in a retrospective control group for total hip arthroplasty. Opioid use was reduced in the fascia iliaca block group compared with the control [31]. A noninferiority trial compared the fascia iliaca block to spinal morphine for analgesia in the first 24 hours postoperatively in patients undergoing total hip arthroplasty and found spinal morphine superior to the block [32]. Conclusion The anesthesia practice for orthopedic surgery continues to evolve. Recent changes in the health care system have impacted the choice of anesthesia with the goal of delivering cost-effective, excellent health care. The use of regional anesthesia for total joint arthroplasty remains under-utilized. It provides adequate anesthesia and analgesia that may promote early ambulation, fewer days in the hospital, and overall recovery. Because the current literature on the topic is primarily retrospective, a causal link cannot be fully determined. Additional research is needed in the form of large, multicenter, prospectively, randomized trials to clarify the potential benefits and effect on perioperative morbidity and mortality. References [1] Stiener C, Andrews R, Barrett M, Weiss A. HCUP projections: mobility/orthopedic procedures 2003 to 2012. HCUP Projections Report # 2012-03. U.S. Agency for Healthcare Research and Quality; 2012. https://hcup-us.ahrq.gov/ reports/projections/2012-03.pdf [accessed 28.03.17]. [2] Kremers HM, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, et al. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am 2015;97:1386e97. [3] Fu KMG, Smith JS, Polly Jr DW, Ames CP, Berven SH, Perra JH, et al. Scoliosis research society morbidity and mortality committee. Correlation of higher preoperative American Society of Anesthesiology grade and increased morbidity and mortality rates in patients undergoing spine surgery. J Neurosurg Spine 2011;14:470e4. [4] Belmont P, Goodman G, Waterman B, Bader J, Schoenfeld A. Thirty-day postoperative complications and mortality following total knee arthroplasty. J Bone Joint Surg Am 2014;96:20e6. [5] Berstock J, Beswick A, Lenguerrand E, Whitehouse M, Blom A. Mortality after total hip replacement surgery: a systematic review. Bone Joint Res 2014;3:175e82. [6] Memtsoudis SG, Ma Y, Chiu YL, Poultsides L, Gonzalez Della Valle A, Mazumdar M. Bilateral total knee arthroplasty: risk factors for major morbidity and mortality. Anesth Analg 2011;113:784e90.
[7] Memtsoudis SG, Ma Y, Chiu YL, Walz JM, Voswinckel R, Mazumdar M. Perioperative mortality in patient with pulmonary hypertension undergoing major joint replacement. Anesth Analg 2010;111:1110e6. [8] Bozic K, Lau E, Kurtz S, Ong K, Rubash H, Vail TP, et al. Patient-related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients. J Bone Joint Surg Am 2012;94: 794e800. [9] Cozowicz C, Poeran J, Zubizarreta N, Mazumdar M, Memtsoudis SG. Trends in the use of regional anesthesia. Reg Anesth Pain Med 2016;41:43e9. [10] Memtsoudis SG, Sun X, Chiu YL, Stundner O, Liu SS, Banerjee S, et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology 2013;118:1046e58. [11] Memtsoudis SG, Rasul R, Suzuki S, Poeran J, Danninger T, C W, et al. Does the impact of the type of anesthesia on outcomes differ by patient age and comorbidity burden? Reg Anesth Pain Med 2014;39:112e9. [12] Helwani MA, Avidan MS, Abdallah AB, Kaiser DJ, Clohisy JC, Hall BL, et al. Effects of regional versus general anesthesia on outcomes after total hip arthroplasty. J Bone Joint Surg Am 2015;97:186e93. [13] Perlas A, Chan V, Beattie S. Anesthesia technique and mortality after total hip or knee arthroplasty. Anesthesiology 2016;125:724e31. [14] Pugely AJ, Martin CT, Gao Y, Mandoza-Lattes S, Callaghan JJ. Difference in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. J Bone Joint Surg Am 2013;95:193e9. [15] Memtsoudis SG, Danninger T, Rasul R, Poeran J, Gerner P, Stundner O, et al. Inpatient falls after total knee arthroplasty. Anesthesiology 2014;120:551e63. [16] Hebl JR, Horlocker TT, Kopp SL, Schroder DR. Neuraxial blockade in patients with preexisting spinal stenosis, lumbar disk disease, or prior spine surgery: efficacy and neurologic complications. Anesth Analg 2010;111:1511e9. [17] Moen V. Scandinavian guidelines for neuraxial block and disturbed haemostasis: replacing wishful thinking with evidence based caution. Acta Anaesthesiol Scand 2010;54:6e8. [18] Volk T, Wolf A, Van Aken H, Burke H, Wiebalck A, Steinfeldt T. Incidence of spinal hematoma after epidural puncture: analysis from the German network for safety in regional anesthesia. Eur Anaesthesiol 2012;29:170e6. [19] Narouze S, Benzon HT, Provenzano D, Buvanendran A, De Andres J, Deer TR, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med 2015;40:182e212. [20] Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidencebased guidelines (third edition). Reg Anesth Pain Med 2010;35:64e101. [21] Warman P, Nicholls B. Ultrasound-guided nerve blocks: efficacy and safety. Best Pract Res Clin Anaesthesiol 2009;23:313e26. [22] Ferraro LHC, Tardelli MA, Yamashita AM, Cardone JDB, Kishi JM. Ultrasoundguided femoral and sciatic nerve blocks in an anticoagulated patient. Case reports. Rev Bras Anestesiol 2010;60:422e8. [23] Idestrup C, Sawhney M, Nix C, Kiss A. The incidence of hematoma formation in patients with continuous femoral nerve catheters following total knee arthroplasty while receiving rivaroxaban as thromboprophylaxis: an observational study. Reg Anesth Pain Med 2014;39:414e7. [24] Johnson RL, Kopp SL, Hebl JR, Erwin PJ, Mantilla CB. Falls and major orthopedic surgery with peripheral nerve blockade: a systematic review and metaanalysis. Br J Anaesth 2013;110:518e28. [25] Gerrad AD, Brooks B, Asaad P, Hajibandeh S. Meta-analysis of epidural analgesia versus peripheral nerve blockade after total knee replacement. Eur J Orthop Surg Traumatol 2017;27:61e72. [26] Memtsoudis SG, Poeran J, Cozowicz C, Zubizarreta N, Ozbek U. The impact of peripheral nerve blocks on perioperative outcome in hip and knee arthroplasty-a population-based study. Pain 2016;157:2341e9. [27] Chan EY, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after total knee arthroplasty. Cochrane Database Syst Rev 2014;5:CD009941. [28] Gao F, Ma J, Sun W, Guo W, Li Z, Wang W. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty; a systematic review and meta-analysis. Clin J Pain 2017;33:356e68. [29] Hussain N, Ferreri TG, Prusick PJ, Banfield L, Long B, Prusick VR, et al. Adductor canal block versus femoral canal block for total knee arthroplasty: a meta-analysis. What does the evidence suggest? Reg Anesth Pain Med 2016;41:314e20. [30] Sawhney M, Mehdian H, Kashin B, Ip G, Bent M, Choy J, et al. Pain after unilateral total knee arthroplasty; a prospective randomized controlled trial examining the analgesic effectiveness of a combined adductor canal peripheral nerve block with periarticular infiltration versus adductor canal nerve bock alone versus periarticular infiltration alone. Anesth Analg 2016;122:2040e6. [31] McGraw-Tatum MA, Grover MT, George NE, Urse JS, Heh V. A prospective, randomized trial comparing liposomal bupivacaine vs. fascia iliaca compartment block for postoperative control in total hip arthroplasty. J Arthroplasty 2017;32:2181e5. [32] Kearns R, Macfarlane A, Grant A, Puxty K, Harrison P, Shaw M, et al. A randomized, controlled, double-blinded, non-inferiority trial of ultrasoundguided fascia iliaca block vs. spinal morphine for analgesia after primary hip arthroplasty. Anaesthesia 2016;71:1431e40.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
AAHKS Symposium
Regional Anesthesia in Total Joint Arthroplasty: What Is the Evidence? Dalia H. Elmofty, MD a, *, Asokumar Buvanendran, MD b a b
Department of Anesthesia & Critical Care, The University of Chicago, Chicago, Illinois Department of Anesthesia & Critical Care, Rush University Medical Center, Chicago, Illinois
a r t i c l e i n f o
a b s t r a c t
Article history: Received 14 April 2017 Received in revised form 28 April 2017 Accepted 9 May 2017 Available online 18 May 2017
Total joint arthroplasty is one of the most common surgical procedures performed for end-stage osteoarthritis. The increasing demand for knee and hip arthroplasties along with the improvement in life expectancy has created a substantial medical and economic impact on the society. Effective planning of health care for these individuals is vital. The best method for providing anesthesia and analgesia for total joint arthroplasty has not been defined. Yet, emerging evidence suggests that the type of anesthesia can affect morbidity and mortality of patients undergoing these procedures. © 2017 Elsevier Inc. All rights reserved.
Keywords: total hip arthroplasty total knee arthroplasty peripheral nerve block neuraxial anesthesia morbidity mortality
Over 1 million total hip and knee arthroplasty surgeries are performed each year in the United States [1]. Total joint arthroplasty is becoming more common than treatments for other chronic diseases. The prevalence of joint disease is similar to that of stroke and myocardial infarction and greater than heart failure [2]. Total joint arthroplasty has been shown to improve long-term quality of life. With the aging of the “baby boomer” generation and the minimal progress being made toward the prevention and treatment of osteoarthritis, the demand for total joint arthroplasty is anticipated to rise and overburden health care economics. As the global population ages, the prevalence of cardiopulmonary comorbidities also increases. Older patients with poorer American Society of Anesthesiologists physical status classification have a higher incidence of perioperative complications [3]. Approximately 1.6%-2.1% of patients undergoing total knee arthroplasty will experience a major systemic complication [4]. Although a rare event, the 30-day mortality after total hip arthroplasty was estimated at 0.3% [5] and after total knee arthroplasty at 0.18% [4]. Early ambulation, reducing length of hospital stay, and minimizing
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.05.017. * Reprint requests: Dalia H. Elmofty, MD, Department of Anesthesia & Critical Care, The University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637. http://dx.doi.org/10.1016/j.arth.2017.05.017 0883-5403/© 2017 Elsevier Inc. All rights reserved.
perioperative complications is critical for improving outcomes in patients undergoing total joint arthroplasty. An abundance of literature exists describing the risk factors associated with increased morbidity and mortality after total joint arthroplasty: older age, male gender, bilateral joint surgery, diabetes, renal disease, metastatic cancer, and cerebrovascular or cardiopulmonary comorbidities [4,6e8]. In these large studies, however, the type of anesthesia for total joint arthroplasty was not reported. There is emerging evidence that type of anesthesia is strongly associated with perioperative outcomes. Anesthetic options for total joint arthroplasty are general and regional anesthesia or a combination of both. Perioperative regional anesthesia, with peripheral nerve blocks, is becoming more popular. The introduction of the ultrasound has facilitated the performance and accuracy of peripheral nerve blocks. Although some of the studies show that regional anesthesia is linked to a decrease in postoperative morbidity and mortality, it continues to be underutilized. In a review of data from 2006 to 2013, 64.4% of patients received general anesthesia, 22.8% received neuraxial anesthesia, and 12.8% received peripheral nerve blocks for total joint arthroplasty [9]. Regional Techniques for Total Joint Arthroplasty Neuraxial Anesthesia Neuraxial anesthesia is associated with improved outcomes in patients undergoing total joint arthroplasty. The exact mechanism is
D.H. Elmofty, A. Buvanendran / The Journal of Arthroplasty 32 (2017) S74eS76
not completely understood but may be associated with sympathectomy, which may improve tissue perfusion; decrease in the stress response that improves hemodynamics and reduces blood pressure fluctuation; and better pain control. Reducing complications after total joint arthroplasty is an important public health concern. In one large nationwide study of the effect of anesthetic techniques on perioperative outcomes for primary total joint arthroplasty, neuraxial, or combined neuraxial-general vs general anesthesia alone was associated with improved outcomes, and the addition of neuraxial anesthesia was a positive modifier [10]. Complication rates for pulmonary embolism, pulmonary compromise, pneumonia, and acute renal failure were reduced in the neuraxial and combined neuraxialgeneral anesthesia group. The 30-day mortality rate was higher in the general anesthesia group [10]. In another retrospective study, the effects of neuraxial vs general anesthesia in populations of various ages and comorbidities were reviewed. Neuraxial anesthesia was associated with several reductions: complications, intensive care utilization, and length of hospital stay across all age groups. Neuraxial anesthesia also had a positive effect on elderly patients with significant cardiopulmonary comorbidities [11]. In spite of the growing evidence that neuraxial anesthesia is linked to improved outcomes, the American College of Surgeons National Surgical Quality Improvement Program reports that general anesthesia continues to be the main choice for patients undergoing total hip arthroplasty [12]. A retrospective propensitymatched cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program database found that after total hip arthroplasty, deep surgical site infections were reduced in patients receiving regional anesthesia, epidural, or spinal, vs those undergoing general anesthesia [12]. Spinal anesthesia was associated with a lower incidence of death within 30 days and major blood loss, shorter operating room time, and hospital stay than general anesthesia for total joint arthroplasty [13]. A multicenter prospective comparison of shortterm (within 30 days) complications between spinal and general anesthesia for patients who underwent total knee arthroplasty revealed that patients who had spinal anesthesia had a lower unadjusted frequency of superficial wound infections, blood transfusions, and overall complications. The length of surgery and hospital stay was shorter. Patients with multiple comorbidities would seem to benefit most from spinal anesthesia [14]. There is controversy regarding the association between regional anesthesia and inpatient falls. Inpatient falls negatively impact outcomes and can lead to greater use of critical care services and to overall morbidity and mortality. In one study of inpatient falls after total knee arthroplasty, advanced age and a higher comorbidity burden were independent risk factors for falls and the use of neuraxial over general anesthesia was associated with reduced risk [15]. Neuraxial anesthesia is effective for pain control but is associated with a higher incidence of neurologic and hemorrhagic complications. Elderly patients may have spinal stenosis, predisposing them to neurologic injuries [16]. Patients undergoing total joint arthroplasty have a high risk for deep vein thrombosis. Thromboprophylaxis is mandatory in this patient population but can be associated with a higher risk of hemorrhagic complications such as neuraxial hematoma. The risk has been underestimated in the past and varies based on the cohort: epidurals for orthopedic surgery 1:4000, epidurals for other surgical procedures 1:10,000-20,000, and for labor 1:200,000 [17]. In general, epidural anesthesia in the nonobstetric population produced a higher incidence of neuraxial hematoma [18]. Although the risks for epidural hematomas are multifactorial, certain anatomic factors [19] and anticoagulation therapy [20] increase risk. When trends in the use of regional anesthesia in 2006-2007 were compared with trends in 2012-2013, the use of neuraxial
S75
anesthesia decreased slightly from 21.7% to 19.7% for hip arthroplasty and 24.7% to 21.3% for knee arthroplasty, possibly from concerns about neuraxial hematoma [9]. Peripheral nerve blocks can prevent many of the disadvantages of neuraxial blocks and may have a more favorable safety profile. Blocks performed by an experienced physician under ultrasound guidance can greatly reduce the risk of vascular injury in anticoagulated patients. In one study, ultrasound-guided peripheral nerve blocks correlated with fewer needle passes and vascular puncture [21]. Case reports have described successful blocks in patients receiving anticoagulation therapy without hemorrhagic complications [22]. A prospective observational study enrolled 540 patients who had a femoral nerve catheter inserted before surgery that remained in place 36-48 hours postoperatively. Patients were given rivaroxaban 10 mg daily and were assessed for complications, hematoma causing neurovascular compromise, or ecchymosis at the femoral catheter site. No hematomas were identified but ecchymosis was found in the groin or thigh [23]. Peripheral Nerve Blocks Peripheral nerve blocks also can be associated with neurologic and hemorrhagic injuries, but their consequences may not be as serious as those associated with neuraxial blockade. Previously published data have associated peripheral nerve blocks with a higher risk of inpatient falls [24], but results from a recent, large, national database review found no association between the two [15]. The integration of peripheral nerve blocks into the perioperative anesthetic plan may improve perioperative outcomes for patients undergoing total joint arthroplasty. Common nerve blocks performed for total joint arthroplasty are femoral, adductor, sciatic, lumbar plexus, and fascia iliaca compartment. There has been an increase in the utilization of peripheral nerve blocks for hip arthroplasty from 6.5% to 8.7% and for knee arthroplasty from 10.3% to 20.4% when data from 2006 to 2007 were compared with data from 2012 to 2013 [9]. Peripheral nerve blocks also can influence outcomes in patients undergoing total joint arthroplasty. Peripheral nerve blocks may offer the same favorable physiological effects as neuraxial anesthesia: sympathectomy, decreased stress response, and improved pain control. A meta-analysis comparing epidural analgesia vs peripheral nerve blockade for total knee arthroplasty found no considerable difference in scores on visual analog scale at 0-48 hours. Epidural anesthesia was associated with more nausea, vomiting, postoperative hypotension, and urinary retention compared with peripheral nerve blocks [25]. A retrospective review investigated the relationship between peripheral nerve blocks and outcome measures such as complications (cardiac, pulmonary, gastrointestinal, renal, cerebrovascular, infections, thromboembolic, inpatient falls, and mortality) and resource utilization (blood transfusions, intensive care unit admission, opioid consumption, cost, and length of stay). Peripheral nerve blocks were associated with lower odds for most complications, decreased opioid consumption, and length of stay, and minor reduction in costs for patients undergoing total hip arthroplasty. There were similar benefits for patients undergoing total knee arthroplasty with significantly lower odds for pulmonary complications [26]. Femoral nerve blocks, which are commonly performed for patients undergoing total knee arthroplasty, target both sensory and motor innervation of the knee joint. Femoral nerve blocks were found superior to intravenous patient-controlled analgesia (PCA) and equivalent to epidural analgesia for pain control [27]. With femoral nerve blocks, knee flexion was better than PCA, and opioid-related side-effects were reduced compared with PCA or epidural analgesia.
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The adductor canal block is emerging as a substitute for the femoral nerve block because it blocks the sensory branches of the femoral nerve and minimizes motor impairment to the knee. When a meta-analysis compared adductor canal blocks to femoral nerve blocks, there was no significant difference in the visual analog scale scores at 24 hours and at 48 hours [25]. In another systematic review, adductor canal block was as effective in controlling pain as femoral nerve block and facilitated earlier mobilization [28]. In one meta-analysis, equivalent analgesic benefit was found with adductor canal and femoral nerve blocks. The effect on quadriceps muscle strength could not be assessed because of the inconsistency among the studies in outcome measurements [29]. If the adductor canal is reliably defined (mid-thigh vs proximal one-third), concerns about the type of block and separation of motor fibers from the sensory fibers could be determined. A recent prospective, randomized, controlled study compared the analgesic effectiveness of combined adductor canal block with periarticular infiltration vs adductor canal or periarticular infiltration alone. The combined method was superior to either alone [30]. The fascia iliaca compartment block can treat acute postoperative pain from total hip arthroplasty. It provides an indirect proximal approach to the lumbar plexus. In a prospective, randomized trial, fascia iliaca block was compared with periarticular liposomal bupivacaine injection. Both treatments effectively reduced pain intensity compared with pain in a retrospective control group for total hip arthroplasty. Opioid use was reduced in the fascia iliaca block group compared with the control [31]. A noninferiority trial compared the fascia iliaca block to spinal morphine for analgesia in the first 24 hours postoperatively in patients undergoing total hip arthroplasty and found spinal morphine superior to the block [32]. Conclusion The anesthesia practice for orthopedic surgery continues to evolve. Recent changes in the health care system have impacted the choice of anesthesia with the goal of delivering cost-effective, excellent health care. The use of regional anesthesia for total joint arthroplasty remains under-utilized. It provides adequate anesthesia and analgesia that may promote early ambulation, fewer days in the hospital, and overall recovery. Because the current literature on the topic is primarily retrospective, a causal link cannot be fully determined. Additional research is needed in the form of large, multicenter, prospectively, randomized trials to clarify the potential benefits and effect on perioperative morbidity and mortality. References [1] Stiener C, Andrews R, Barrett M, Weiss A. HCUP projections: mobility/orthopedic procedures 2003 to 2012. HCUP Projections Report # 2012-03. U.S. Agency for Healthcare Research and Quality; 2012. https://hcup-us.ahrq.gov/ reports/projections/2012-03.pdf [accessed 28.03.17]. [2] Kremers HM, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, et al. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am 2015;97:1386e97. [3] Fu KMG, Smith JS, Polly Jr DW, Ames CP, Berven SH, Perra JH, et al. Scoliosis research society morbidity and mortality committee. Correlation of higher preoperative American Society of Anesthesiology grade and increased morbidity and mortality rates in patients undergoing spine surgery. J Neurosurg Spine 2011;14:470e4. [4] Belmont P, Goodman G, Waterman B, Bader J, Schoenfeld A. Thirty-day postoperative complications and mortality following total knee arthroplasty. J Bone Joint Surg Am 2014;96:20e6. [5] Berstock J, Beswick A, Lenguerrand E, Whitehouse M, Blom A. Mortality after total hip replacement surgery: a systematic review. Bone Joint Res 2014;3:175e82. [6] Memtsoudis SG, Ma Y, Chiu YL, Poultsides L, Gonzalez Della Valle A, Mazumdar M. Bilateral total knee arthroplasty: risk factors for major morbidity and mortality. Anesth Analg 2011;113:784e90.
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