This document provides an overview of anesthetic considerations for total hip and knee replacement surgeries. It discusses the anatomy of the hip and knee joints and their blood supply and innervation. It outlines common patient populations for these surgeries like the elderly and those with osteoarthritis or rheumatoid arthritis. It also discusses challenges like co-morbid conditions and decreased organ function. Finally, it provides details on preoperative optimization and considerations including screening for conditions like MRSA, assessing cardiopulmonary and musculoskeletal function, and managing comorbidities like diabetes, obesity, cardiovascular disease, anemia, malnutrition, tobacco use, and medications.

1. ANESTHETICIMPLICATIONSOFTOTALHIP
REPLACEMENTANDTOTALKNEE
REPLACEMENTSURGERIES
MODERATOR : DR. ARCHANA
SPEAKER : DR. FAROOQ

2. INTRODUCTION
◦ Joint replacement – is a very common and effective procedure for relief of disability due to severe joint pain and loss of function.
◦ Most common joints replaced are the hip, knee and shoulder.
◦ Most patients for it replacement have generalized degenerative joint disease (eg.OsteoArthritis).
◦ Other conditions necessitating joint replacement surgery include:
› rheumatoid arthritis
› osteoporosis and fracture
› metastatic lesions and pathological fractures
› avascular necrosis of the femoral head.
◦ Most patients are elderly, with associated problems such as HTN, IHD, COPD or renal disease.
◦ Younger pts presenting for jt replacement surgery often suffer from rheumatoid arthritis, severe osteoporosis or obesity.
◦ Presentation for revision of previous replacement is increasingly common.

3. CHALLENGES ASSOCIATED
DECREASED ORGAN FUNCTION AND RESERVE
CO-MORBID CONDITIONS
CONSEQUENCES OF POLYPHARMACY

4. ANATOMY OF HIP

6. BLOOD SUPPLY
The arterial supply to the hip joint is largely via the medial and lateral circumflex femoral arteries – branches of the profunda
femoris artery (deep femoral artery).
The MEDIAL circumflex femoral artery is responsible for the majority of the arterial supply.
The artery to head of femur and the superior/inferior gluteal arteries provide some additional supply.
INNERVATION
The hip joint is innervated primarily by the sciatic, femoral and obturator nerves.

7. ANATOMY OF THE KNEE

8. INNERVATION
1. This fine, subcu-taneous network of communicating nerve fibres over and around the patella is termed the peripatellar plexus -infrapatellar branch of
the saphenous nerve + branches of the medial and intermediate femoral cutaneous nerves + lateral femoral cutaneous nerve.
2. Infrapatellar branch of the saphenous nerve reaches the anterior aspect of the knee from the medial side.
3. Branches from the common fibular nerve and from the nerve to popliteus.
BLOOD SUPPLY
◦ genicular branches of the popliteal artery
◦ the descending genicular branch of the femoral artery,
◦ anterior recurrent branch of the anterior tibial artery
◦ mall contributions from muscular branches to vastus medialis and the posterior thigh muscles
- Cutaneous veins are tributaries of vessels that correspond to the named arteries.
LYMPHATIC DRAINAGE
◦ superficial inguinal nodes
◦ popliteal nodes
◦ deep inguinal nodes

9. GENERAL ASSESSMENT
◦ Problems in multiple systems are common because most patients are elderly.
◦ There are specific types of patients who are more likely to have orthopedic surgery and are more likely to have perioperative
complications.
 Geriatric patients
 Osteoarthritis
 Rheumatoid arthritis patients
 Ankylosing spondylitis patients

10. GERIATRIC PATIENTS
◦ Postmenopausal, age associated osteoporosis higher risk of fractures.
◦ Age associated osteoporosis may be due to increased circulating Parathyroid Hormone & decreased Vitamin D, Growth Hormone.
◦ With osteoporosis there is disproportionate loss of Trabecular (structural) bone – thus at high risk for stress fractures.
◦ Although all bones are at risk, thoracic and lumbar spine, proximal femur, proximal humerus, wrist bones are at highest risk.
◦ Frailty reflects a decrease in functional reserve capacity and an inability to respond to the physiological challenges presented by the
stress of surgery.
◦ It could predict surgical out-comes such as postoperative
complications, length of hospital stay,
and discharge to a skilled- or assisted-living facility.

12. OSTEOARTHRITIS
◦ Osteoarthritis (OA) is the most common joint disorder, is one of the most common chronic diseases in the elderly, and is a leading
cause of disability.
◦ Most common type of arthritis - involves loss of articular cartilage due to intense inflammation.
◦ Obesity is the most significant independent predictor of both incidence and progression of OA as well as the need for surgery.
◦ The risk for development of OA is increased by high-impact repetitive activities, smoking, and osteoporosis.
◦ Clinical manifestations include pain, crepitance, reduced mobility, and deformity of involved joints.
◦ Hands – spurring, swelling of the Distal InterPhalyngeal joints (Heberden's nodes) and Proximal InterPhalyngeal joints
(Bouchard's nodes).
◦ Since there are no obvious systemic manifestations of osteoarthritis – the anesthesiologist should be aware of previous orthopedic
surgeries/ joint replacements / joints which are painful / limited mobility.

13. RHEUMATOID ARTHRITIS
◦ Rheumatoid arthritis (RA) is a chronic multisystem disease with inflammatory polyarthritis of symmetric distribution affecting the
peripheral joints of the hands (sparing DIP joints), feet, wrists, elbows, shoulders, hips, knees, and ankles.
◦ The cervical spine is generally the only axial skeleton affected by RA.
◦ Rheumatoid arthritis manifests in constitutional symptoms of fatigue, low-grade fever, weight loss, and morning stiffness.
Synovitis (inflammation of the synovium) is the hallmark of RA. It produces pain, swelling, and tenderness of the joints.
◦ RA is characterized by a waxing-and-waning course with relapses and remissions.
◦ Pain in RA is multifactorial. In the early stages, it is secondary to inflammation. At later stages, the damaging effects of erosion
of cartilage and bone also cause pain.

15. ◦ TMJ synovitis limits mandibular motion & mouth opening.
◦ Arthritic damage to cricoarytenoid joints diminished movement of Vocal Cords , narrowed glottic opening; preop as hoarseness
and stridor.
◦ During DIRECT Laryngoscopy, Vocal Cords may appear erythematous /edematous, reduced glottic opening may interfere with
passage of ETT.
◦ Increased risk of cricoarytenoid dislocation with traumatic intubations.
◦ Arthritis of Cervical spine (atlantoaxial subluxation, Flexion of head, displacement of odontoid process into cervical spine and
medulla compression of vertebral arteries precipitate quadriparesis, spinal shock, and death).
◦ Preop cervical flexion-extension radiographs required to plan for awake fiberoptic tracheal intubation, C-spine should be protected
with collar.

16. ANKYLOSING SPONDYLITIS
◦ Chronic inflammatory arthritic disease that results in fusion of the axial skeleton.
◦ Ossification of axial ligaments progressing from sacral lumbar region cranially, resulting in a significant loss of spinal mobility.
◦ Significant challenge to us with regard to airway reduced movement of their C - spines & TMJs.
◦ In most cases, awake fiberoptic endotracheal intubation is required for GA.
◦ Increased rigidity of the thoracic spine in most cases also necessitates intraoperative controlled mechanical ventilation.
◦ Although neuraxial anesthesia is better alternative to GA, ossification of spinal ligaments closes intervertebral spaces, blocking
access to epidural space.

17. EXTRASKELETAL MANIFESTATIONS
1. Aortic insufficiency
2. Cardiac conduction abnormalities
3. Iritis
4. Upper lobe fibro-bullous disease, Pleural effusions
5. Strict attention to positioning to avoid fracture of the fused spine with concomitant spinal cord trauma.

18. PERIOPERATIVE RISKS INVOLVED IN RESPECT TO OLD AGE
Ischemic Heart Disease:
Elderly patients invariably have atheromatous plaques in their vessels and there are high chances of having them in their coronary
vessels.
The overall perioperative risk should take in to account the physical status of the patient, site and duration of the procedure.
Hypertension:
It is the most common disease with serious potential consequences.
The degree (mild, moderate or severe), the duration (recent or chronic), whether primary (essential) or secondary, end-organ
changes, whether the patient is at increased perioperative risk, will lowering the blood pressure preoperatively lower risk and how long
should the patient be treated before surgery.
If the surgical condition permits, treatment should be optimized until the patient is normotensive on follow-up for 3–4 weeks, to
allow for the normalization of some of the hypertensive vascular changes, including LV hypertrophy.

19. Diabetes:
The preoperative evaluation can be distinctly divided into two parts, viz. the evaluation of the diabetic status per se and
associated end organ disease in a diabetic which includes the cardiac status, hypertension, the renal status, peripheral vascular
disease, autonomic neuropathy and ocular changes.
The principal involvement of the heart in diabetes is in the form of: atherosclerotic CAD, cardiomyopathy, autonomic nervous
system dysfunction, silent MI – (incidence 25%), increased risk of CHF, blunted response to stress all of which increase risk of
sudden unexplained death.
Cerebrovascular Accidents/Insufficiency (CVA):
Higher Systolic BP and LVH are the strongest predictors of stroke in the elderly.
Cardiac impairment like Chronic heart disease, cardiac failure, atrial fibrillation, valvular problems increase stroke risk at any level of
BP.
Intraoperative hypotension, hypertension and arrhythmias can increase the risk of stroke.
Cognitive Dysfunction:
Impaired memory and concentration, mild personality changes, and emotional instability, are commonly referred to as postoperative
cognitive dysfunction (POCD).
Etiologic mechanisms behind POCD have been suggested which include cerebral hypoxia caused by arterial hypoxemia or low flow,
residual concentrations of drugs such as benzodiazepines that have also active metabolites, long-lasting effect of general
anaesthestics on cholinergic or glutaminergic neurotransmission and psychological factors related to illness and environment during
hospitalization.

20. PREOPERATIVE CONSIDERATIONS
◦ Preoperative optimization is mandatory as the chances of serious complications within 30 days of joint replacement surgery is
high.
◦ The IDEAL timeline for the optimization protocol screening is 4-6 weeks before the surgery date, to allow time for risk
modification interventions before surgery. Not always practical.
◦ The goal is to identify possible risk factors that increase the risk of complications postoperatively
◦ The objective of the optimization protocol is to standardize clinical decision-making and ensure that patients proceed to surgery
only after their modifiable risk factors have been optimized.
◦ In addition to established protocol for age and co morbidities, an elaborate pre-anesthetic check up should include the following:

21. CARDIOPULMONARY RESERVE
Estimated by assessment of exercise tolerance. May be inaccurate due to limited exercise capacity.
In such circumstances the following may be used:
1. PFTs, ABG, Room Air SPO2
2. Resting ECG (silent ischaemia / previous MI)
3. 2D Echo (LV function, WMA and valvular abnormality) limited relevance information only about function of rested, rather
than stressed, cardiopulmonary systems.
4. Dobutamine Stress Tests provide information about cardiac function under stress but they are not readily available.
SCREENING FOR METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)
1. Preoperative testing of nasal swabs for MRSA can be considered a routine.
2. Studies have found that nasal screening and decolonization with Nasal Mupirocin twice daily for 5 days prior to surgery resulted
in a 4-fold decrease in Staph. aureus surgical site infections.

22. MUSCULOSKELETAL - other joint involvement is common.
1. Range of limb and neck movements should be noted.
2. Obesity may be a cause or consequence of degenerative joint disease.
3. Assessment for positioning on table and for regional blockade should be made.
4. Other joint involvement is common which have implications for positioning for regional anaesthesia & surgery.
ROUTINE INVESTIGATIONS
1. Blood Counts
2. Renal function test
3. ECG
4. Blood Grouping
5. Coagulation Profile
6. Chest X-ray

23. DIABETES
1. Screening patients with hyperglycemia with HbA1C testing
2. HbA1C > 6.7 is associated with an increased risk of wound complications
3. Exact HbA1C target (roughly <8) varies by anesthesiologist and hospital
4. HbA1C >7 = Higher risk for Stroke, PE, Infection, Transfusion requirements, Prolonged length of stay and Mortality.
OBESITY
1. Consistently shown to increase the risk of postoperative complications
2. acute kidney failure, Cardiovascular complications, wound complications, infection
3. BMI >40 has been used in many studies as having an increased risk of complications, and is associated with DVT/PE, Infection,
Readmissions and Post-op mortality.
4. Weight loss of >5% may be needed to decrease risk in morbidly obese patients
5. Bariatric surgery may have a role in such cases.

24.  CARDIOVASCULAR DISEASE
1. Preoperative cardiovascular disease and older age are major risk factors for postoperative cardiovascular events
2. Delay elective surgery in patients whose dual antiplatelet therapy will be stopped within
- 30 days after bare-metal stent (BMS)
- 12 months /365 days after drug-elution stent (DES)
3. Clopidogrel management should be discussed with a cardiologist and restarted as soon as possible
- Stopping 7 days preop can lower bleeding events and the need for transfusion without increasing perioperative cardiovascular events.
 ANAEMIA
1. Increased risk of infection in patients with preoperative Hb < 10 g/dl
2. Perioperative blood transfusions are associated with higher rates of postoperative complications
3. Pre-operative anaemia is associated with an increased risk of PJI, longer LOS, allogeneic transfusion and cardiovascular complications after THA
and TKA
 RENAL FUNCTION
1. Nephrology consultation if creatinine > 1.5 mg/dl or creatinine clearance < 100 ml/min.
2. Patients on dialysis at time of THA or TKA have a 10-20 times increased risk of complications
3. May be impaired owing to age, HTN or chronic use of NSAIDs.

25. MALNUTRITION
Albumin <3.5 g/dL Lymphocytes < 1200 cells/mm3 Transferrin <200 mg/dL
◦ Malnutrition has been shown to increase the risk of medical and surgical complications following arthroplasty, including
periprosthetic joint infection, revision surgery and 90-day mortality.
Malnutrition
1. Impairs wound healing
2. Hinders fibroblast proliferation
3. Decreases collagen synthesis
4. Prolongs inflammation
Decreased lymphocyte count <1200 cells/ mm3 and transferring levels
1. Impairs body’s ability to fight infection
2. Increased risk of pneumonia.

26. TOBACCO/ALCOHOL ABUSE
1. Increased risk of postoperative complications and infection
2. 6 weeks of cessation
3. Smoking increases the risk of post-operative pneumonia, CVA, PJI, revision and one-year mortality following THA and TKA.
ILLICIT DRUG USE
1. History of substance abuse/misuse have a 5x increase risk of mortality
2. Increased risk of infectious and non-infectious complications as well
3. Higher risk of mortality, readmission, and reoperation in patients who failed a toxicology screen
4. Studies have shown longer length of stay (LOS), lower patient-reported outcome measures, prolonged post-operative opioid use
and higher revision rates in this patient group.

27. DRUGS
◦ Dual antiplatelet therapy ( Aspirin and Clopidogrel (Plavix):
STOP 7 days before surgery
Post case only after obtaining proper cardiology review
◦ NSAIDs:
7 days before surgery STOP taking all NSAIDs such as naproxen , ibuprofen.
◦ Stress-dose steroids (SDS) for patients on steroids
If <7.5 mg/day or any dose for <3 weeks, only use typical daily dose perioperatively
If > 7.5 mg/day, then consider review by the physician.
◦ Methotrexate
Considered safe to continue in the perioperative period*
-Reasonable to hold for 2-4 weeks preoperatively if patient can tolerate withdrawal of methotrexate therapy
◦ Other disease-modifying antirheumatic drugs
Hydroxychloroquine considered safe to continue in perioperative period
Leflunomide, sulfasalazine, and azathioprine generally held until normal renal function ensues postoperatively

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