This document discusses anesthesia considerations for total hip replacement (THR) and total knee replacement (TKR) surgeries. It covers preoperative evaluation and optimization of comorbidities. Regional anesthesia techniques like spinal, epidural and peripheral nerve blocks are preferred due to advantages like less blood loss, better pain control and early mobility. General anesthesia is an option as well. Intraoperative monitoring, fluid management and prevention of complications like venous thromboembolism and cement implantation syndrome are discussed. Early mobilization and multimodal analgesia are emphasized for postoperative care.

1. ANESTHESIA FOR THR & TKR
Aftab HussainAftab Hussain

2. Case Scenario
• Mr. X is 83yr old retired bank manager, who
had osteoarthritis of his right hip requiring
total hip replacement.
• Prior to surgery he had difficulty in walking
and was in constant pain, requiring chronic
pain management.
• He has history of HTN and renal insufficiency.

3. He was operated under regional anaesthesia
and was uneventful. Post op pain was
controlled by epidural top up injections.
He has b/l sequential compression stockings
applied to his lower legs post operatively.

4. • Total knee replacement (TKR) and hip
fracture coming for replacement are the
two most common surgical procedures
after the sixth decade of life.
Introduction

5. • What are the conditions requiring hip/knee
replacement ?

6. • Most of the patients have degenerative
joint disease, commonly osteoarthritis
(OA).

7. Other conditions requiring knee or hip
replacement are -
• injury to the neck of femur or knee joint,
• knee deformity,
• rheumatoid arthritis
• Gout
• Hemophilia

8. Joint replacement is performed to relieve -
• pain and
• morbidity.

9. • What are the challenges associated with
THR/TKR patients ?

10. The challenge….
• Decreased organ function and reserve
• Co-morbid conditions
• Consequences of polypharmacy

11. • What are the preoperative preparation ?

12. Preoperative Preparation
Evaluation of the functional cardiovascular
reserves
• Simple steps (e.g., auscultation, ECG, and
chest x-ray) can detect acute
decompensation.

13. • Echocardiography if feasible at the bedside.
• Evaluation of electrolytes and blood count is
required
Renal Function – may be impaired d/t age, HTN
or chronic use of NSAIDS.

14. • What are the implication of musculoskeletal
examination in these patients ?

15. Musculoskeletal system -
• other joint involvement is common which
have implications for positioning for regional
anaesthesia & surgery.
• Rheumatoid Arthritis –
cervical spine involvement
TMJ involvement

16. Atlantoaxial Subluxation
Cord compression or vertebral artery
compression on excessive movement of neck
Neck stabilisation or awake intubation

17. TMJ involvement
Restricted mouth opening
Difficult Intubation
Regional Anaesthesia is better option

18. H/o Drugs –
. If patient is taking warfarin,
aspirin, clopidogrel
More chances of hematoma formation in
regional anaesthesia
. Beta blockers – can be continued

19. • What are the investigations required ?

20. Investigations - Blood Counts
Renal function test
ECG
Blood Grouping
Coagulation Profile
Chest X-ray

21. The choice of anaesthesia is determined by:
i) surgical factors
ii) Patients factors
iii) Estimates of risk associated with
anaesthesia techniques
Choice Of AnaesthesiaChoice Of Anaesthesia

22. • Name anaesthetic techniques for THR ?

23. • THR – 1. Regional Epidural
Combined
spinal epidural
2. General Anaesthesia
Spinal

24. • Name anaesthetic techniques for TKR ?

25.  TKR –
1. GA with femoral & sciatic nerve block
2. Femoral & sciatic n. block alone
3. General Anaesthesia
4. Spinal
5. Epidural
6. Combined Spinal Epidural

26. Anaesthesia
SPINAL
 If no contraindication
 Preload with IV fluid before performing
spinal.
 In TKR Avoid excessive preload before
performing spinal

27. • For a single shot spinal use 2.5 – 3.0 mls of 0.5%
bupivacaine depending on patient size.

28. • Adjuvants added to prolong effect of spinal
anaesthesia ?

29. • Opiate may be added for more prolonged
analgesia and to cover longer surgery (up to 3
hours).
Opioid Dose
Duration of action
Diamorphine 250 mcg 10-20 hrs
Morphine 100-200mcg 8-24 hrs
Fentanyl 25mcg 1-4 hrs
Butorphenol 50-100 mcg 2-3 hrs

30. • Light sedation using increments of midazolam
0.5mg or low dose target controlled infusion
of propofol may be used.
• For long cases – Epidural &
combined spinal epidural

31. PERIPHERAL NERVE BLOCKS
• Peripheral nerve blocks employing long-acting
anesthetics or catheters may provide
excellent intraoperative anesthesia and
superior postoperative analgesia.

32. • Why is peripheral nerve block technically
difficult to perform in THR ?

33. Peripheral nerve blocks for total hip
replacement
 The hip joint is innervated by the femoral, gluteal
and obturator nerves with skin and superficial tissues
receiving branches from the lower thoracic nerves.
Consequently no single peripheral nerve block is
sufficient for hip replacement.
 Lumbar plexus block provides effective analgesia
which extends into the postoperative period.
 The femoral 3 in 1 block, technically easier

34. • Peripheral nerve block for TKR ?

35. Peripheral nerve blocks for TKR
• Femoral (3 in 1) blocks have become popular
and provide good analgesia in the first 12-24
hrs.
• They avoid the need for a urinary catheter in
most patients and allow mobility in bed.
• They need 30 minutes to become effective
and do not provide surgical anaesthesia.

36. • Femoral 3 in 1 block … ?

37. • Historically femoral nerve block was
thought to block femoral, lateral femoral
cutaneous nerve and obturator nerve.
• Most of the time obturator nerve is not
blocked.

38. • What are the advantages of regional
anaesthesia ?

39. Regional Anesthesia -AdvantagesRegional Anesthesia -Advantages
 Stress response to surgeryStress response to surgery
 Intraoperative blood lossIntraoperative blood loss
 Post-operative hypoxiaPost-operative hypoxia
 PONVPONV
 DVT- early mobilizationDVT- early mobilization

40. GENERAL ANAESTHESIA
• Spontaneous ventilation via LMA
• Ventilation via endotracheal tube

41. • What are the advantages of general
anaesthesia ?

42. General Anaesthesia -
Advantages
• Better for patients who are unable to lie flat.
• Safer for patients with fixed cardiac output
states such as aortic stenosis.
• Patient preference.
• Less likely to require urinary catheterisation.

43. • Monitoring requirement ?

44. Perioperative…
Monitoring – NIBP
ECG
PULSE OXIMETER
CAPNOGRAPH
URINE OUTPUT

45. Difficulties associated with positioning in…
• THR ?
• TKR ?

46. Position –
• In THR position is lateral. There is a
risk of excessive lateral neck flexion
and pressure in the dependent limb.
• In TKR patient is supine & airway
control can be a problem if sedation
is used.

47. • What is the use of tourniquet in TKR and
morbidity associated with it ?
• Risks associated with tourniquet deflation ?

48. Tourniquet -
 Used in TKR so perioperative blood loss is
not a problem until its release.
 Tourniquet pain occur after about 1 hr
causing increased
HR & BP (GA) and it can occur even with
regional anaesthesia.
Tt – deepen anaesthesia
opioids

49. Tourniquet deflation
• After deflation of the tourniquet a short-
lived reperfusion event commonly occurs.
• Acidic products of metabolism are washed
out of the limb causing peripheral
vasodilatation and reduced cardiac
contractility, both of which result in a
drop in blood pressure.

50. • End-tidal CO2 rises and a fall in oxygen
saturation is often seen.
• Prevention involves fluid loading before and
during tourniquet release. Additional oxygen
and vasopressors may be required.

51. • Fluid balance –after release of the tourniquet
most blood loss occurs in the recovery area.
Careful fluid balance is essential as
hypovolaemia is poorly tolerated in elderly
patients.
• Check haemoglobin 24 hours postoperatively
and treat with iron as necessary. Blood
transfusion is required only rarely.

52. • Antibiotic prophylaxis .. When ?

53. Antibiotic Prophylaxis
Infection is one of the most common
complication after THR & TKR. So all
patients should receive antibiotic
prophylaxis.
Administered within 1 hr prior to skin
incision.
If tourniquet is to be used, should be
given prior to tourniquet inflation.

54. • Post op care ?

55. Immediate postoperative care to support
 oxygenation,
 controlling pain, and
 early mobilisation
Post-operative carePost-operative care

56. • Effective post op analgesia is essential
for early physical rehabilitation to
maximize postoperative range of motion
and prevent joint adhesions.
• Patients usually undertake passive
exercises in the operated leg within 24
hours and are mobilized at 48 hours.

57. • Postoperative pain therapy is best a
multimodal approach.
• regular paracetamol and a NSAID.
• Parenteral opioid may be administered to
supplement peripheral nerve blocks as
necessary.

58. • Oxygen therapy for 24 hours is
advisable in most patients, continued
up to 72 hours in those at high risk of
myocardial ischaemia.

59. • What are the complications associated with
THR/TKR ?

60. COMPLICATIONS
• Blood loss –
• In THR The average loss is 300-500mls
(reduced by centroneuraxial techniques). A
similar amount may be lost in the drain and
tissues postoperatively.
• In TKR Blood loss may be brisk after deflation
of the tourniquet, and if it exceeds 500 mls
the surgeon may clamp the drain for a period.

61. Venous Thromboembolism
• More common in TKR than THR
• Clinical DVT occurs in 10% of patients
without prophylaxis and fatal pulmonary
embolism in 0.4% of patients.

62. • Strategies to prevent Venous
thromboembolism ?

63. • Strategies to minimise risk include -
.avoiding dehydration,
.early mobilisation,
.regional anaesthesia,
.intermittent leg-compression devices,
.graduated compression stockings.

64. • Prophylaxis for DVT ?

65. Prophylaxis against DVT
• Low dose heparin, low molecular weight heparin
(LMWH), warfarin, or the selective factor Xa
inhibitor, fondaparinux are effective in reducing
DVT.
• concern about possible bleeding complications
• Recommendations allow a 12 hour interval between
low molecular weight heparin and epidural/spinal
injection. This also applies to removal of an epidural
catheter.

66. • What is cement reaction (BCIS)?

67. Cement Rxn - BCIS
• More common in THR
• Use of cement to fix the prostheses in place
may lead to bone cement implantation
syndrome(BCIS).
• Methylmethacrylate is an acrylic polymer.
• Its use is associated with the potential for
hypoxia, hypotension and cardiovascular
collapse including cardiac arrest.
• The most likely cause is fat embolization

68. FAT EMBOLISM
• The high incidence of fat embolism with
femoral neck fracture repair and cemented
endoprosthesis may contribute to pulmonary
dysfunction.

69. • Strategies for prevention and treatment of
BCIS ?

70. Prevention and treatment
• Increased inspired oxygen concentration
prior to cementing
• Measure blood pressure frequently at this
time
• Ensure adequate blood volume prior to
cementing
• Stop N2O
• Alpha agonists (epinephrine) to treat
hypotension
• In case of severe cardiac disease use of
cement should be avoided.

71. • High pressure pulsatile lavage of femoral
canal.
• Drilling a vent hole in the femur before
prosthesis insertion.

72. • SBTKR ?
• Advantages and disadvantages?

73. • SBTKR -- Simulataneous B/l, TKR
• Advantages and disadvantages?

74. • Advantages:
One anaesthetic exposure
Postop pain course
Reduced rehabilitation
Earlier return of baseline function
• Disadvantages
Increased perioperative complications
More blood transfusions
Risk of ICU admissions.

75. Conclusion
• Geriatric patients for joint replacement
surgeries offer a great challenge to the
anaesthesiologists.
• A careful preoperative examination,
preoperative optimization, safe
intraoperative anaesthetic techniques,
good postoperative pain relief, good
postoperative followup with rehabilitation
would aid in decreasing the morbidity in
these patients.

76. THANK YOU