Regional or general anesthesia for fast-track hip and knee replacement - what is the evidence?

Henrik Kehlet, Eske Kvanner Aasvang, Henrik Kehlet, Eske Kvanner Aasvang

Abstract

Regional anesthesia for knee and hip arthroplasty may have favorable outcome effects compared with general anesthesia by effectively blocking afferent input, providing initial postoperative analgesia, reducing endocrine metabolic responses, and providing sympathetic blockade with reduced bleeding and less risk of thromboembolic complications but with undesirable effects on lower limb motor and urinary bladder function. Old randomized studies supported the use of regional anesthesia with fewer postoperative pulmonary and thromboembolic complications, and this has been supported by recent large non-randomized epidemiological database cohort studies. In contrast, the data from newer randomized trials are conflicting, and recent studies using modern general anesthetic techniques may potentially support the use of general versus spinal anesthesia. In summary, the lack of properly designed large randomized controlled trials comparing modern general anesthesia and spinal anesthesia for knee and hip arthroplasty prevents final recommendations and calls for prospective detailed studies in this clinically important field.

Keywords: Regional anesthesia; general anesthesia; hip replacement; knee replacement.

Conflict of interest statement

Competing interests: The authors declare that they have no competing interests.

No competing interests were disclosed.

References

    1. Rodgers A, Walker N, Schug S, et al. : Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;321(7275):1493. 10.1136/bmj.321.7275.1493
    1. Memtsoudis SG, Sun X, Chiu YL, et al. : Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology. 2013;118(5):1046–58. 10.1097/ALN.0b013e318286061d

    2. F1000 Recommendation

    1. Pugely AJ, Martin CT, Gao Y, et al. : Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. J Bone Joint Surg Am. 2013;95(3):193–9. 10.2106/JBJS.K.01682

    2. F1000 Recommendation

    1. Memtsoudis SG, Rasul R, Suzuki S, et al. : Does the impact of the type of anesthesia on outcomes differ by patient age and comorbidity burden? Reg Anesth Pain Med. 2014;39(2):112–9. 10.1097/AAP.0000000000000055

    2. F1000 Recommendation

    1. Helwani MA, Avidan MS, Ben Abdallah A, et al. : Effects of regional versus general anesthesia on outcomes after total hip arthroplasty: a retrospective propensity-matched cohort study. J Bone Joint Surg Am. 2015;97(3):186–93. 10.2106/JBJS.N.00612

    2. F1000 Recommendation

    1. Opperer M, Danninger T, Stundner O, et al. : Perioperative outcomes and type of anesthesia in hip surgical patients: An evidence based review. World J Orthop. 2014;5(3):336–43. 10.5312/wjo.v5.i3.336

    2. F1000 Recommendation

    1. Basques BA, Toy JO, Bohl DD, et al. : General compared with spinal anesthesia for total hip arthroplasty. J Bone Joint Surg Am. 2015;97(6):455–61. 10.2106/JBJS.N.00662

    2. F1000 Recommendation

    1. Kehlet H: Fast-track hip and knee arthroplasty. Lancet. 2013;381(9878):1600–2. 10.1016/S0140-6736(13)61003-X
    1. Macfarlane AJ, Prasad GA, Chan VW, et al. : Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review. Br J Anaesth. 2009;103(3):335–45. 10.1093/bja/aep208

    2. F1000 Recommendation

    1. Leslie K, Myles P, Devereaux P, et al. : Neuraxial block, death and serious cardiovascular morbidity in the POISE trial. Br J Anaesth. 2013;111(3):382–90. 10.1093/bja/aet120

    2. F1000 Recommendation

    1. Khan SK, Malviya A, Muller SD, et al. : Reduced short-term complications and mortality following Enhanced Recovery primary hip and knee arthroplasty: results from 6,000 consecutive procedures. Acta Orthop. 2014;85(1):26–31. 10.3109/17453674.2013.874925
    1. den Hartog YM, Mathijssen NM, Vehmeijer SB: Reduced length of hospital stay after the introduction of a rapid recovery protocol for primary THA procedures. Acta Orthop. 2013;84(5):444–7. 10.3109/17453674.2013.838657
    1. Jorgensen CC, Knop J, Nordentoft M, et al. : Psychiatric disorders and psychopharmacologic treatment as risk factors in elective fast-track total hip and knee arthroplasty. Anesthesiology. 2015;123(6):1281–91. 10.1097/ALN.0000000000000632
    1. Harsten A, Kehlet H, Toksvig-Larsen S: Recovery after total intravenous general anaesthesia or spinal anaesthesia for total knee arthroplasty: a randomized trial. Br J Anaesth. 2013;111(3):391–9. 10.1093/bja/aet104

    2. F1000 Recommendation

    1. Harsten A, Kehlet H, Ljung P, et al. : Total intravenous general anaesthesia vs. spinal anaesthesia for total hip arthroplasty: a randomised, controlled trial. Acta Anaesthesiol Scand. 2015;59(3):298–309. 10.1111/aas.12456
    1. Andersen LØ, Kehlet H: Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review. Br J Anaesth. 2014;113(3):360–74. 10.1093/bja/aeu155
    1. Choi PT, Bhandari M, Scott J, et al. : Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev. 2003; (3): CD003071. 10.1002/14651858.CD003071
    1. Rawal N: Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med. 2012;37(3):310–7. 10.1097/AAP.0b013e31825735c6
    1. Fernandez MA, Karthikeyan S, Wyse M, et al. : The incidence of postoperative urinary retention in patients undergoing elective hip and knee arthroplasty. Ann R Coll Surg Engl. 2014;96(6):462–5. 10.1308/003588414X13946184902523

    2. F1000 Recommendation

    1. Essving P, Axelsson K, Åberg E, et al. : Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty: a randomized controlled trial. Anesth Analg. 2011;113(4):926–33. 10.1213/ANE.0b013e3182288deb

    2. F1000 Recommendation

    1. Awad IT, Cheung JJ, Al-Allaq Y, et al. : Low-dose spinal bupivacaine for total knee arthroplasty facilitates recovery room discharge: a randomized controlled trial. Can J Anaesth. 2013;60(3):259–65. 10.1007/s12630-012-9867-5

    2. F1000 Recommendation

    1. Pitkänen MT, Aromaa U, Cozanitis DA, et al. : Serious complications associated with spinal and epidural anaesthesia in Finland from 2000 to 2009. Acta Anaesthesiol Scand. 2013;57(5):553–64. 10.1111/aas.12064

    2. F1000 Recommendation

    1. Pumberger M, Memtsoudis SG, Stundner O, et al. : An analysis of the safety of epidural and spinal neuraxial anesthesia in more than 100,000 consecutive major lower extremity joint replacements. Reg Anesth Pain Med. 2013;38(6):515–9. 10.1097/AAP.0000000000000009

    2. F1000 Recommendation

    1. Rosencher N, Llau JV, Mueck W, et al. : Incidence of neuraxial haematoma after total hip or knee surgery: RECORD programme (rivaroxaban vs. enoxaparin). Acta Anaesthesiol Scand. 2013;57(5):565–72. 10.1111/aas.12069

    2. F1000 Recommendation

    1. Dwyer T, Drexler M, Chan VW, et al. : Neurological Complications Related to Elective Orthopedic Surgery: Part 2: Common Hip and Knee Procedures. Reg Anesth Pain Med. 2015;40(5):443–54. 10.1097/AAP.0000000000000183

    2. F1000 Recommendation

    1. Choi S, Mahon P, Awad IT: Neuraxial anesthesia and bladder dysfunction in the perioperative period: a systematic review. Can J Anaesth. 2012;59(7):681–703. 10.1007/s12630-012-9717-5

    2. F1000 Recommendation

    1. Balderi T, Carli F: Urinary retention after total hip and knee arthroplasty. Minerva Anestesiol. 2010;76(2):120–30.

    2. F1000 Recommendation

    1. Bjerregaard LS, Bagi P, Kehlet H: Postoperative urinary retention (POUR) in fast-track total hip and knee arthroplasty. Acta Orthop. 2014;85(1):8–10. 10.3109/17453674.2014.881683
    1. Hollman F, Wolterbeek N, Veen R: Risk Factors for Postoperative Urinary Retention in Men Undergoing Total Hip Arthroplasty. Orthopedics. 2015;38(6):e507–11. 10.3928/01477447-20150603-59

    2. F1000 Recommendation

    1. Karason S, Olafsson TA: Avoiding bladder catheterisation in total knee arthroplasty: patient selection criteria and low-dose spinal anaesthesia. Acta Anaesthesiol Scand. 2013;57(5):639–45. 10.1111/aas.12089
    1. Hartog YM, Mathijssen NM, Vehmeijer SB: Total hip arthroplasty in an outpatient setting in 27 selected patients. Acta Orthop. 2015;86(6):667–70. 10.3109/17453674.2015.1066211

    2. F1000 Recommendation

    1. Kort NP, Bemelmans YF, Schotanus MG: Outpatient surgery for unicompartmental knee arthroplasty is effective and safe. Knee Surg Sports Traumatol Arthrosc. 2015. 10.1007/s00167-015-3680-y

    2. F1000 Recommendation

    1. Thienpont E, Lavand'homme P, Kehlet H: The constraints on day-case total knee arthroplasty: the fastest fast track. Bone Joint J. 2015;97-B(10 Suppl A):40–4. 10.1302/0301-620X.97B10.36610
    1. Aasvang EK, Luna IE, Kehlet H: Challenges in postdischarge function and recovery: the case of fast-track hip and knee arthroplasty. Br J Anaesth. 2015;115(6):861–6. 10.1093/bja/aev257
    1. Højer Karlsen AP, Geisler A, Petersen PL, et al. : Postoperative pain treatment after total hip arthroplasty: a systematic review. Pain. 2015;156(1):8–30. 10.1016/j.pain.0000000000000003

    2. F1000 Recommendation

    1. YaDeau JT, Lin Y, Mayman DJ, et al. : Pregabalin and pain after total knee arthroplasty: a double-blind, randomized, placebo-controlled, multidose trial. Br J Anaesth. 2015;115(2):285–93. 10.1093/bja/aev217

    2. F1000 Recommendation

    1. Lunn TH, Husted H, Laursen MB, et al. : Analgesic and sedative effects of perioperative gabapentin in total knee arthroplasty: a randomized, double-blind, placebo-controlled dose-finding study. Pain. 2015;156(12):2438–48. 10.1097/j.pain.0000000000000309
    1. Lunn TH, Kristensen BB, Andersen LØ, et al. : Effect of high-dose preoperative methylprednisolone on pain and recovery after total knee arthroplasty: a randomized, placebo-controlled trial. Br J Anaesth. 2011;106(2):230–8. 10.1093/bja/aeq333

    2. F1000 Recommendation

    1. Lunn TH, Andersen LØ, Kristensen BB, et al. : Effect of high-dose preoperative methylprednisolone on recovery after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial. Br J Anaesth. 2013;110(1):66–73. 10.1093/bja/aes345

    2. F1000 Recommendation

    1. Jørgensen CC, Jacobsen MK, Soeballe K, et al. : Thromboprophylaxis only during hospitalisation in fast-track hip and knee arthroplasty, a prospective cohort study. BMJ Open. 2013;3(12):e003965. 10.1136/bmjopen-2013-003965
    1. McCartney CJ, Choi S: Does anaesthetic technique really matter for total knee arthroplasty? Br J Anaesth. 2013;111(3):331–3. 10.1093/bja/aet200

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere