1. Regional Anesthesia for
Total Joint Arthroplasty
DAVID A. PROVENZANO, MD
Executive Director
Institute for Pain Diagnostics and Care
Ohio Valley General Hospital
McKees Rocks, Pennsylvania
EUGENE R. VISCUSI, MD
Director, Acute Pain Management
Department of Anesthesiology
Thomas Jefferson University
Philadelphia, Pennsylvania
Dr. Provenzano has consulted for Janssen Global
Services, LLC, and Medtronic, and received
honoraria from Cadence Pharmaceuticals.
Dr. Viscusi has received research funding from
AcelRx, Adolor/Cubist, Cumberland, and Salix;
consulted for AcelRx, Cadence, Cubist, Incline,
and Pacira; and received honoraria from Cadence
and Merck.
P
atients undergoing total joint arthroplasty (TJA) experience
high levels of pain after surgery that often interferes with
their functional recovery and sleep patterns in the postoperative
period.1
In one study, patients undergoing total hip arthroplasty (THA)
and total knee arthroplasty (TKA) reported mean worst pain severities of
7.6 and 8.1 on a 10-point scale, respectively.1
Numerous techniques have
been developed for anesthesia and analgesia in an effort to optimize
perioperative pain control, patient satisfaction, and functional recovery.
Because clinician preference strongly influences patient selection and
decision making, anesthesiologists and orthopedic surgeons must
understand the current literature and level of evidence for each technique.2
This article provides an updated review of the evidence for regional
anesthesia for TJA surgery with an emphasis on the risks and benefits of
each technique for intraoperative anesthesia and postoperative analgesia.
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2. TJA is performed with either a primary regional or
general anesthetic technique. Many methods exist for
continued perioperative pain control (Table 1). In some
cases, various modalities will be combined in an effort
to optimize pain management. Each method for pain
control is associated with specific benefits, risks, side
effects, economic implications, patient satisfaction lev-
els, and labor requirements for the health care team.
General Versus Regional Anesthesia for Total
Joint Arthroplasty
Several advantages have been suggested for the use
of neuraxial anesthesia for TJA surgery. These include
modification of the hypercoagulable surgical state,
improvements in regional blood flow, improvement in
pain control, and reduction in the surgical neuroendo-
crine stress response (Table 2). From the surgeon’s per-
spective, spinal anesthesia also provides ideal operating
conditions—profound muscle relaxation—moderate
hypotension, which reduces blood loss, and the poten-
tial for faster room turnover.
Recent systematic reviews have examined the influ-
ence of the anesthetic choice for TJA surgery on out-
comes. Reviews that included dates from 1966 onward
suggest that neuraxial anesthesia improves specific end-
organ outcomes and postoperative pain control. In a
meta-analysis specifically examining neuraxial regional
anesthesia for TJA, regional anesthesia was associated
with significant reductions in operating time, need for
transfusions, nausea and vomiting, and incidence of
thromboembolic disease including deep vein thrombosis
(DVT) and pulmonary embolism (PE).3
It is important to
note that many of the studies in this review that favored
regional anesthesia over general anesthesia in the reduc-
tion of vascular events were earlier trials that examined
individuals who were not receiving anticoagulation pro-
phylaxis. A review of general and regional anesthesia
for THA that contained research from 1966 to August
2005, suggested that neuraxial block decreased the inci-
dence of radiographically diagnosed DVT and PE, and
decreased operative time by 7.1 minutes and intraopera-
tive blood loss by 275 mL.4
Contemporary reviews that examined only papers
from 1990 onward have provided evidence for improve-
ment in pain control but do not always demonstrate
improvements in cardiovascular outcomes and mortal-
ity. One systematic review of studies published since
1990 found insufficient evidence from randomized con-
trolled trials to conclude that anesthetic technique
affected mortality, cardiovascular morbidity or inci-
dence of DVT and PE in patients undergoing THA.5
In addition, regional anesthesia did not reduce hospi-
tal length of stay or facilitate rehabilitation. In 2009, a
systematic review that examined contemporary litera-
ture on randomized controlled trials of TKA published
since 1990 found insufficient evidence to conclude that
anesthesia technique influenced mortality, cardiovascu-
lar morbidity, or incidence of DVT and PE when using
thromboprophylaxis.6
Anesthetic choice also has been shown to affect
other important outcomes, in addition to pain control,
including rates of surgical site infection (SSI) and med-
ical costs. In a retrospective review of more than 3,000
knee or hip arthroplasty surgeries, Chang and col-
leagues, demonstrated a significant reduction in 30-day
SSI rates—1.2% for epidural or spinal anesthesia versus
2.8% for general anesthesia.7
The odds of an SSI occur-
ring in a patient receiving general anesthesia were 2.2
times greater than when neuraxial anesthesia was used.
Proposed mechanisms for possible reduction in surgical
site infections with neuraxial anesthesia include modu-
lation of the inflammatory response, vasodilation and
improvement in tissue oxygenation, and improvements
in postoperative analgesia.8
Spinal anesthesia has been shown to be more cost-
effective for TJA. Gonano and colleagues randomized
40 patients to receive either spinal anesthesia or gen-
eral anesthesia and examined the costs of drugs and
supplies for both the chosen anesthetic and associated
recovery.9
They found that spinal anesthesia was asso-
ciated with lower fixed and variable costs, resulting in
a 48% savings (excluding expenditures for personnel)
compared with general anesthesia.
Regional Techniques for Postoperative
Analgesia for Total Joint Arthroplasty
Several analgesic techniques exist for postoperative
pain management for TJA surgery. Each regional anes-
thetic technique has specific advantages and disadvan-
tages. Selection of the appropriate technique is best
Table 1. Methods of Postoperative
Pain Control for Total Joint
Arthroplasty
Intravenous opioids (IV-PCA)
Oral opioids
Nonopioid analgesics
Neuraxial anesthesia and analgesia
• Spinal–intrathecal opioids
• Epidural–continuous infusion
• Epidural–single-injection EREM
Single and continuous peripheral nerve blocks
• Femoral nerve block
• Sciatic nerve block
• Lumbar plexus block
EREM, extended-release epidural morphine;
PCA, patient-controlled analgesia
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3. guided through an understanding of the associated
risk–benefit profile of each technique and the pain man-
agement needs for the specific clinical situation.
INTRATHECAL OPIOIDS
One analgesic approach that requires only minor
modifications in the anesthetic plan is the addition of
intrathecal opioids to the spinal injection of local anes-
thetic. Typically, intrathecal morphine will be added in a
dose range from 0.2 to 0.3 mg. For THA and TKA, intra-
thecal morphine has been shown to improve patient
satisfaction compared with IV patient-controlled anal-
gesia (IV-PCA) with opioids. However, intrathecal mor-
phine only reduced the supplemental postoperative
PCA morphine requirements for the patients undergo-
ing THA.10
When intrathecal opioids are administered, additional
forms of pain control are needed to control “break-
through pain” and for pain that outlasts the duration
of the therapy. Respiratory monitoring also is required
when intrathecal opioids are administered.
EPIDURAL ANALGESIA
Epidural analgesia with a single injection of extended-
release epidural morphine (EREM) or continuous epi-
dural infusions with local anesthetics can be effective
methods of pain control in patients undergoing joint
surgery. When specifically examining the use of epidur-
als for TJA compared with IV-PCA, epidural analgesia
has been shown in high-quality studies to improve pain
relief and recovery time.11,12
A Cochrane Collaboration
review demonstrated that epidural analgesia for pain
relief following TJA in comparison to systemic analge-
sia was beneficial, but its effects may be limited only to
the early postoperative period, 4 to 6 hours.13
Use of EREM has been studied in patients undergo-
ing TKA and THA. Compared with IV-PCA, the patients
treated with EREM for TKA required significantly less
postoperative opioids and had reduced mean pain
intensity recall scores.14
For THA surgery, EREM demon-
strated improved pain control at rest to 48 hours post-
dose and improvement in pain control ratings15
; 25% of
THA patients who received EREM did not require sup-
plemental analgesia.
Regional Techniques for Postoperative
Analgesia for Total Hip Arthroplasty
THA is associated with a high level of postopera-
tive pain, although perhaps less than TKA. Many tech-
niques for administering regional anesthesia have been
explored for THA to improve pain control.16
These
include neuraxial analgesia, peripheral nerve blocks
(PMBs), and EREM. Singelyn and colleagues compared
IV-PCA with morphine, continuous epidural analgesia,
and continuous femoral nerve sheath block for post-
operative analgesia in THA.17
The authors found no
difference in quality of pain relief, postoperative hip
rehabilitation, and duration of hospital stay for any of
these approaches. The continuous femoral block was
associated with a lower incidence of side effects, includ-
ing nausea and vomiting, urinary retention, and arte-
rial hypotension. Single and continuous lumbar plexus
blocks also have been employed for postoperative
analgesia. A lumbar plexus block is performed with the
goal of anesthetizing additional nerve branches (lateral
femoral cutaneous, femoral, and obturator nerves) that
innervate the surgical area. A continuous lumbar plexus
block was found to be superior to IV-PCA for pain man-
agement, with a reduction in morphine consumption,
improvement in pain control, and patient satisfaction.18
Although the lumbar plexus nerve block provides
effective analgesia, recently published guidelines from
the American Society of Regional Anesthesia and Pain
Medicine for patients receiving antithrombotic therapy
circumscribe its use.19
The new guidelines state that the
same precautions should be applied to deep periph-
eral nerve catheters as neuraxial techniques. Alterna-
tives to the lumbar plexus block have been investigated,
including a continuous femoral nerve block (CFNB). In
one study, Ilfeld and colleagues compared a continuous
posterior lumbar plexus nerve block with a CFNB.20
The
femoral nerve-stimulating catheter was advanced up to
15 cm beyond the tip with the goal of obtaining cov-
erage of the obturator and lateral femoral cutaneous
nerves. Pain control was equivalent for these 2 meth-
ods. The CFNB was associated with shorter ambulation
distances the morning after surgery, suggesting greater
impairment in the quadriceps femoris muscle.
Regional Anesthesia for Total Knee
Arthroplasty
PERIPHERAL NERVE BLOCKS
PNBs, including single-injection and continuous PNB
catheters (CPNBC), have received substantial atten-
tion as alternatives to neuraxial analgesia and systemic
opioids for TKA. Some of the emphasis on PNBs arises
from concerns about concurrent anticoagulation and
Table 2. Physiologic Sequelae of the
Neuroendocrine Stress Response
Hyperactivity of the autonomic nervous system
Increased cardiovascular stress
Dysfunction in respiratory mechanics
Decreased muscle protein synthesis
Elevated metabolic rate with an associated pro-
tein catabolic state
Increased formation of blood clots
Slower return of bowel function
Impaired immune function
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4. neuraxial anesthesia. The employment of low-molecu-
lar-weight heparin for DVT prophylaxis has limited the
use of epidurals for postoperative analgesia. Although
CPNBCs have been advocated as a means of prolong-
ing the duration of action of single-injection nerve
blocks, debate still continues on their advantages and
disadvantages compared with single-injection blocks.
FEMORAL AND SCIATIC NERVE BLOCKS
The most commonly used PNBs for TKA are femo-
ral and sciatic (Figure). In 2010, Paul et al performed a
meta-analysis of randomized controlled trials that com-
pared a femoral block with or without a sciatic nerve
block with PCA or epidural analgesia.21
Compared with
PCA alone, a femoral block reduced morphine con-
sumption at 24 and 48 hours, pain scores with activity
(but not at rest) at 24 and 48 hours, and the incidence
of nausea. No further improvements were found with
the addition of a CFNB. Although the femoral nerve
does not innervate the posterior portion of the knee, in
this meta-analysis a single-jnjection sciatic nerve block
did not offer a pain control advantage.
In a recent trial comparing a single-injection femo-
ral block to CFNB for TKA, pain-intensity ratings were
improved during the first and second days after sur-
gery.22
Opioid consumption and pain-intensity ratings
during physical therapy also were significantly lower
with a CFNB.
Although a femoral block does improve postopera-
tive pain control for TKA, 60% to 80% of patients still
will complain of clinically significant pain. In an attempt
to improve pain control, single and continuous sciatic
nerve blocks can be administered. Evidence is mixed
for the analgesic benefits of adding a single-injection
or continuous catheter sciatic nerve block to a femoral
nerve block technique. In addition, no consensus has
been reached on whether a sciatic nerve block should
be performed for all TKA cases in which a femoral nerve
block also is performed.23
Neither a single-injection nor
a continuous catheter sciatic nerve block is without the-
oretical risks and possible disadvantages, including the
prevention of the early detection of compartment syn-
drome or neurologic injury resulting from surgery and
the further impairment of motor function, thus imped-
ing physical therapy during its duration of action. Some
of the hesitation to perform sciatic nerve blocks is
related to the risk profile of the procedure and the sur-
gical vulnerability of the nerve. Sciatic nerve injury after
TKA, not related to regional anesthetic technique, is a
known complication.
Two randomized controlled trials24,25
and a recent
systematic review26
have attempted to address whether
blocking the sciatic nerve is advantageous for post-
operative pain control and other related clinical out-
comes following TKA. In one trial, patients undergoing
TKA were randomized to 1 of 3 groups: a femoral nerve
catheter, a femoral catheter combined with a single
injection, or a femoral catheter plus a continuous sci-
atic nerve block.25
The addition of a single-injection
sciatic nerve block to the CFNB reduced postopera-
tive pain on the day of surgery. The continuous sciatic
nerve block reduced moderate pain during mobilization
on the first 2 postoperative days. A sciatic nerve block
did not influence time to discharge readiness. In a sec-
ond study, Pham Dang and colleagues demonstrated
improvements in pain control with a continuous sciatic
nerve block during the first 36 postoperative hours.24
A recent systematic review, examining 4 interme-
diate-quality randomized and 3 observational studies,
established that there is inadequate evidence to define
the role of adding a sciatic nerve block, and could not
demonstrate a benefit in analgesia beyond 24 hours.26
Unlike a CFNB, continuous sciatic nerve blocks have
not been shown to improve functional outcomes or
decrease time until discharge readiness.23,25
With the current level of evidence for a sciatic nerve
block, one method to determine its implementation
could be to observe the patient during early recovery
to see if he or she is experiencing significant pain from
the posterior aspect of the knee that is not relieved by
the femoral nerve block. If so, the analgesia could be
augmented with a single-injection sciatic nerve block.
Complications
Other factors that must be incorporated into deci-
sion making for the anesthetic and analgesic technique
for TJA include complications and adverse events. All
Figure. An ultrasound-guided right-
sided femoral nerve block. The red
arrows delineate the placed needle.
The triangle-shaped femoral nerve is
lateral to the femoral artery (FA).
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5. the regional anesthetic techniques described above
have the following risks, including but not limited to
bleeding, nerve damage, vascular injury, block failure,
and infection. Neuraxial techniques and deep peripheral
nerve catheters have been associated with devastating
bleeding complications. When opioids are incorporated
into neuraxial anesthesia, respiratory depression may
occur. Other opioid-related side effects also may result,
including sedation, pruritus, urinary retention, and post-
operative nausea and vomiting.27
The risks and compli-
cations specifically associated with CPNBCs are shown
in Table 3.
Although bacterial colonization may be common
with certain catheters, the overall risk for infection is
low. In one study, the incidence of bacterial colonization
for femoral catheters was reported to be as high as 57%
when catheters were removed at 48 hours.28
Although
3 cases of transitory bacteremia likely related to the
femoral catheters were reported, no patients developed
an abscess or cellulitis.
Abscesses, cellulitis, and transient bacteremia have
been reported with CPNBCs. The presence of diabetes
mellitus may increase the risk for infection. Appropri-
ate steps to reduce the risk for infection include lim-
iting the duration of catheter use and following strict
aseptic guidelines. Another potential hazard of CPN-
BCs that has received significant recent attention is
the association between lower-extremity blocks and
patient falls.29-31
Continuous PNBs are associated with
muscle weakness that may lead to falls or that can delay
rehabilitation. Lower-extremity nerve blocks have been
shown to impair the maintenance of limb stiffness, alter
proprioception, and decrease lateral stability.32
Post-
operative protocols should be in place to safely and
appropriately manage quadriceps weakness associated
with femoral nerve blocks in the postoperative period.
In addition, the selected postoperative pain manage-
ment technique should be tailored to allow for early
rehabilitation following TJA. Early intensive rehabili-
tation following TKA (ie, starting rehabilitation within
24 hours) has been shown to improve muscle strength,
range of motion, and pain by the time of discharge from
the hospital.33
Conclusion
TJA is associated with significant levels of postop-
erative pain. An appropriately selected anesthetic and
analgesic plan will positively influence pain levels and
function after the procedure. To obtain optimal results
with regional anesthetic and analgesic techniques,
these therapies should comprise one facet of a multi-
modal perioperative treatment plan that includes non-
opioid analgesics and the inclusion of a structured
rehabilitation program. A massive increase in the num-
ber of patients undergoing TJA surgery in the United
States is expected to occur over the next 2 decades;
by 2030, it is estimated that nearly 3.5 million primary
TKA surgeries alone will be performed in this coun-
try.34
Research must continue to define and refine the
selection of perioperative pain treatment based on effi-
cacy, safety, and patient satisfaction. The economic
implications and labor requirements of each technique
also should be further explored.
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