A Comprehensive Anesthesia Protocol That Emphasizes Peripheral Nerve Blockade for Total Knee and Total Hip Arthroplasty

Abstract

R ecently, advances in radiographic imaging and surgical instrumentation have allowed experienced orthopaedic surgeons to perform total hip and total knee replacement surgery with surgical exposures that are less extensive than those associated with traditional techniques1,2. Commonly referred to as “minimally invasive total hip and total knee arthroplasty,” these techniques are now being touted as important surgical advancements. The introduction of minimally invasive total hip and total knee techniques has been accompanied by substantial concomitant changes in perioperative anesthetic techniques, rapid rehabilitation protocols, and changes in patient education and expectations. However, the specific contribution of each of these changes to observed improvements after contemporary total hip and total knee arthroplasty remains unclear. Tremendous strides in anesthesiology and perioperative pain management have been made with regard to the understanding of pain mechanisms and the importance of perioperative analgesia. The consequences of uncontrolled pain and medication-related side effects include the inability to actively participate in rehabilitation, delayed recovery, poor or suboptimal surgical outcome, prolonged hospitalization, and greater use of health-care resources3. Traditionally, the administration of intravenous opioids has been the mainstay for postoperative analgesia following total hip or total knee arthroplasty. However, parenteral opioids are commonly associated with inadequate pain relief, generalized sedation, and adverse side effects such as nausea, vomiting, gastrointestinal ileus, and pruritus. In response, some anesthesiologists have embraced the concept of “preemptive multimodal perioperative analgesia.” Preemptive analgesia involves the administration of analgesics prior to painful stimuli in order to prevent central sensitization and thus the amplification of pain4. Multimodal analgesia refers to the use of combined analgesic regimens for the treatment of postoperative pain. For example, low-dose opioids, local anesthetic infiltration, peripheral nerve blockade, nonsteroidal anti-inflammatory drugs, corticosteroids, clonidine, and cryotherapy all have been used in various combinations to manage postoperative …