SEMINAR ON ANESTHETIC MANAGEMENT OF TOTAL HIP REPLACEMENT SURGERY.

1.  Presented By: Moderated By
 Dr.Debashish Mondal Dr.I.Begum
 1st year PGT Associate Professor
 Dept. of Anesthesiology and Critical care
 Silchar Medical College and Hospital

2.  Hip replacement is also known as “ARTHROPLASTY”.
 ARTHROPLASTY-it is a reconstructive surgery to
restore the joint motion and function and to relieve
pain.It generally involve the replacement of bony joint
structure by a prosthesis.
 It is the most common orthopaedic surgery.
 Hip replacement surgery can be performed as :
 1.Total hip replacement-it consist of replacing both
femoral head and acetabulam.
 2.half(hemi) replacement-it consist of replacing
femoral head in general.

3.  CHARNELEY(1979)-revolutionized the management
 Of the arthiritic hip with development of low friction
arthroplasty.
 His 3 major contribution to the evolution of hip
replacement were:
 1.the concept of low friction torque arthroplasty.
 2.the use of acrylic cement to fix the components.
 3.the introduction of high density polyethylene as a
bearing material.

9.  Attached to hip joint is a strong,loose,fibrous
capsule which permits free movement of hip
joint.
 It attaches proximally to acetabulam and
transverse acetabular ligament.
 Some parts of fibrous capsule are thicker
than other and are called ligaments.

14.  Femoral nerve
 Obturator nerve
 Superior gluteal nerve
 Nerve to quadratus femoris.

15.  For patients with unremitting pain and irreversibily
damaged joints as in 1.severe osteoarthiritis.
 2.rheumatoid arthiritis.
 Selected fracture-femoral neck fracture.
 Failure of previous reconstructive surgeries(osteotomy,cup
arthroplasty,femoral neck fracture complications-non
union,avascular necrosis)
 Congenital hip disease.
 Pathologic fracture from metastatic cancer.
 Joint instability

16.  1.osteoarthiritis-60%
 2.rheumatoid arthiritis-7%
 3.fracture/dislocations-11%
 4.aseptic bone necrosis-7%
 5.revision arthroplasty-6%
 6.other-9%.

18.  Common in weight bearing joints like hip and knee jts.Also seen in spine
and hand.
 Both male and female affected but commoner in post menopausal
women as there is loss of oestrogenic support.
 Osteoarthiritis can be primary and secondary.
 Primary-cause is unknown,more commoner than secondary.common in
elders where there is no previous pathology.it may be due to wear and
tear occuring in old age in wt. bearing joint.
 Secondary-due to predisposing cause like injury,previous
infection,RA,CDH,deformity,obesity,hyperparathroidism.
 Pathology-non inflammatory degenaration of articular cartilage with
exposure of bone surface which becomes hard and polished called
eburnation of bones,there is osteophyte formation at the margin of
articular cartilage which projects into the joint.

20.  Pain in affected joint aggravated by
movement(most common symptom)
 Morning stiffness more than 1hrs.
 Relative incidence of joint involvement in RA:-
 Mcp and pip joints of hand ,mtp of feet-90%
 Knees,ankles ,wrist-80%
 Elbows-50%
 TMJ,Acromioclavicular joint-30%

21.  HEART-
pericarditis,endocarditis,LVF,valvulitis,atherosclero
sis leading to MI.
 LUNGS-Pleural
effusion,pneumonitis,pleuropulmonary nodules ,ild
 CNS-
 Peripheral neuropathy,cord compression from
atlantoaxial/midcervical spine
sublaxation,entrapment neuropathies.
 HEMATOLOGICAL-normocytic normochromic
anaemia,leucocytosis/leucopaenia,thrombocytosis.

22.  Feltys syndrome-chronic nodular Rheumatoid
arthiritis+splenomegaly+neutropenia.
 Most common extraarticular manifestation is
constituitional symptoms followed by rheumatoid
nodules.
 Pts likely to get extraarticular manifestation shows
following:
 1.high titres of RF/ANTI-CCP
 2.HLA DR4+
 3.male gender
 4.early onset disability
 5. history of smocking

24.  Absolute:1.pt. with unstable medical illness that
would significantly increase the risk of morbidity
and mortality.
 2.active infection of hip joint or anywhere
else in the body.
 Relative:1.any process that is rapidly destroying
bone eg-neuropathic joint,generalized progressive
osteopenia.
 2.insufficiency of abductor musculature.
 3.progressive neurological disorder.

28.  The prosthetic implant must be durable.
 They must permit extraordinary low friction movement at
the articulation.
 They must be firmly fixed to skeleton.
 They must be inert and not provoke any unwanted reaction
in tissue.
 The prosthesis are of various designs and may be fixed to
the remaining bone by cement,pressfit or bone ingrowth.
 Selection of prosthesis and fixation technique depends on
patients bone structure,joint stability,other individual
characteristics -age,weight,activity level.

29.  Bone cement-methylmethacrylate is an acrylic polymer
that has been used extensively in orthopaedic
surgeries for approx,30 yrs.
 Its use is associated with potential for
hypoxia,hypotension and cardiovascular collapse
including cardiac arrest.
 The most likely cause is fat embolisation resulting from
raised intramedullary pressure due to cement
expanding as it hardens.
 Direct toxic effect of cement is also possible.

30.  Problem typically occur soon after cement implantation
but maynot occur until the end of operation when the
hip is relocated and emboli are dislodged from a
previously obstructed femoral vein.
 PREVENTION AND TREATMENT
 1.suction applied to bone cavity to evacuate air and fat
during cement insertion dramatically reduces the
incidence of complications.
 2.measure blood pressure frequently during this time.
 3.ensure adequate blood volume prior to cementing.
 4.increase the inspired o2 conc. Prior to cementing.
 5.stop N2O (nitrous oxide).
 6.alpha agonist(eg.methoxamine) to treat hypotension.

32.  Pts are usually elderly has associated systemic illness such
as HTN,IHD,COPD,Renal impairment, therefore careful
history taking and risk assessment is vital.
 Cardiopulmonary reserve is difficult to assess in such
patients as exercise tolerance is usually limited by hip
disease in such paients.
 Impaired renal function due to age,htn or chronic use of
NSAIDS.
 Musculoskeletal involvement-in RA pts cervical spine and
TMJ may be involved-this may be significant enough to
impair GA if required.regional anesthesia is usually best in
such cases.

33.  Drugs-pts may be taking drugs which have
implications for regional anesthesia such as
warfarin/aspirin/clopidogrel.cvs drugs such as b-
blockers,ace-inhibitors.beta blockers should be
continued perioperatively,ACE inhibitors may be
stopped if a regional technique selected.
 General examination-important factors which may
influence choice of anesthesia-pt weight,shape of
back,spinal deformity if any(scoliosis/kyphosis).

34.  INVESTIGATIONS –all patients should have the
following investigations done:
 1.Full blood count
 2.serum urea,creatinine
 3.serum electrolytes(Na+,k+,ca2+,cl-)
 4.ECG
 5.Chest x ray
 6.coagulation profile.
 7.blood groping/save or crossmatched 2 units of
whole blood or packed rbcs.
 8.Random blood sugar.
 Special invectigation- echocardiography in pt.
above 60yrs or in case of clinical indication.

35.  Total hip replacement can be performed under
general,spinal,epidural anesthesia and often a
combination of techniques used.
 There is no evidence of difference in mortality
between techiques.however REGIONAL ANESTHESIA
has significant advantage over GENERAL
ANESTHESIA.
 Advantages of RA-1.reduce blood loss during
surgery,thus reducing need for blood transfusion.

36.  2.decreases bleeding at operative site,improves
cement bonding and shortens surgical time.
 3.reduces incidenc of DVT and PE (Pulmonary
embolism).
 4.avoids effect of general anesthesia on pulmonary
function.
 5.provides good early postoperative analgesia.
 6.cost effective.
 N.b-the reduced blood loss in SA as compared to
GA is due to reduction in arterial and venous
pressure resulting from sympathetic
blockade,which give rise to less arterial ,notably
less venous oozing from surgical site.

37.  1.Monitoring-all patient should be monitored with blood
pressure,ecg,pulseoximetry.

 Capnography,inspired oxygen,volatile agent analysis and airway
pressure monitoring are indicated for general anesthetic.
 2. I.v access-16-18 g cannula.For patient undergoing surgery in
lateral position placement of cannula in lower arm has the
advantage of keeping upper arm free for blood pressure cuff.
 3.temperature maintenance-keep pt warm by forced warm air or
by warmed I v fluids/covering exposed area if possible.actively
warming the pt. reduces intraoperative blood loss, hypothermia
can lead to poor wound healing,infection and cardiovascular
dysfunction.

38.  4.positioning of patient-most surgery takes place
in lateral position.there is a risk of excessive lateral
neck flexion and pressure in dependant limbs.
 Also care must be taken to ensure that anterior
stabilising post used to hold the patient in lateral
 position does not compress the femoral triangle.
 5.ensure adequate blood pressure being
maintained,hypotension contraindicated.
 6.ensure adeqaute volume filling prior to
cementing.
 7.antibiotic prophylaxis is required.

39.  1.spinal anesthesia in hip replacement surgery-
ensure adequate hydration prior to performing
spinal anesthesia and cementing.
 2.for single shot spinal anesthesia-3ml bupivcaine
0.5% depending on patients size.opiates may be
added for more prolonged analgesia and to cover
longer surgery time(upto 3 hrs).
Opioid Dose
Duration of
action
Diamorphine 250 mcg 10-20 hrs
Morphine (preservative
free)
100-200mcg 8-24 hrs
Fentanyl 25mcg 1-4 hrs

40.  Sedation is often desirable due to length of
operation,intraoperative noise,and pt.request
 Pt in lateral position may become restless and
uncomfortable because of pain in dependant
shoulder.
 Drug used for sedation-intermittent doses of
midazolam/tci(target controlled infusion) of
propofol with supplemental
oxygenation.Buprenorphine,ruffy also used with
spinal anesthetic as analgesic and to cover the
duration of surgery.
 2.general anesthesia in HRA-occasional, for supine
position consider LMA with light general anesthesia

41.  Advantages of general anesthesia in HRA:
 1.safer for patient with fixed cardiac output conditions
such as aortic stenosis.
 2.patients preference
 3.less likely to require urinary catheterisation.
 N.b-spontaneous ventilation with a LMA or ventilation
via ET –TUBE is appropriate during GA.
 Analgesia may be supplemented by peripheral nerve
block enabling reduced use of opiods.
 Epidural analgesia may be considered for longer,more
complex surgery but is not usually required for
postoperative analgesic requirement in an
uncomplicated hip replacement surgery.For longer
surgeries a combined spinal-epidural technique can be
applied.

42.  The hip joint is innervated by femoral,sciatic,obtur
 ator nerves with skin and superficial tissues receiving
branches from lower thoracic nerves.
 Consequently no single peripheral nerve block is
sufficient for hip replacement.
 A femoral 3 in 1 block or a psoas lumbar plexus block
may be performed if central neuraxial blockade is
contraindicated.A 3 in one block is used to block
femoral nerve,lateral femoral cutaneous
nerve,obturator nerve.
 .
 These techniques provides comparable analgesia and
can be used to supplement GA.

43.  1.Patient on bed in supine position with legs abducted using a pillow to
prevent dislocation of prosthesis.
 2.Anti thrombolytic prophylaxis is important as DVT is the most common
serious post op complication usually effecting calf muscles and
responsible for 50% post op mortality within 3 months of surgery. It can
be prevented by early mobilization,pneumatic compression
boots/stockings,pharmacologic prophylaxis with low dose
heparin,aspirin,warfarin,dextran.Early detection is essential and
diagnosed by duplex doppler ultrasound.
 Fatal pulmonary embolism can be seen in 2% cases.
 3.Oxygen therapy for upto 24 hr is advisable in most patients.
 4.haemoglobin should be checked 24 hr postop and treated with either
blood transfusion /iron supplementation as indicated.
 5.For analgesia-Simple IM opiods with regular paracetamol or NSAIDS is
sufficient.If an epidural has been inserted a postop infusion is rarely
necessary and needs to cease prior to mobilisation.

44.  Blood loss varies significantly on an avg-300-
500ml.It is also sffected by anesthetic technique.
 The decision to transfuse is multifactorial and
includes general finess,continous surgical losses
and local practice.
 The benefits of epidural analgesia may be limited
to early postop period only(upto 6 hr).
 Use of bone cement is associated with 3 times
higher risk of PE.
 Use of unfractionated heparin is associated with 6
fold higher risk for DVT compared with LMWH.

45.  Early complications:
 1.nerve injury(sciatic,femoral,peroneal nerve may
get injured from direct surgical
trauma,traction,pressure from retractors,thermal
or pressure injury from bone cementing).
 2.Haemathrosis/vascular injury.
 3.Thromboembolism.
 4.Bladder injuries and uti.

46.  Late complcations: 1.loosening of prosthesis.
 2.osteolysis.
 3.heterotrophic calcification.
 4.component failure.
 COMPLICATIONS INDEPENDENT OF TIME:
 1.Infection
 2.dislocation
 3.trochanteric non union
 4.femoral fracture
 5.limb length discrepency


47.  Geriatric patient for joint replacement surgeries
offer a great challenge to anesthesiologist.
 A careful preoperative examination,preoperative
optimization,safe intraoperative anesthetic
technique,good post operative pain relief,good
post operative follow up with rehabilitation would
aid in decresing morbidity in these patients.