1. Patrick NARCHI, MD Centre Clinical 16800- Soyaux France
- Anesthesia and Analgesia after Total knee replacement- « State of the Art »
Patrick NARCHI, MD
Centre Clinical
Soyaux
France

2. TKR: surgical characteristics
Surgical risk moderate
Surgical duration 60 – 240 minutes !!!
Bleeding
intraoperative +
Postoperative +++
Postoperative pain related to flessum

3. Anesthetic technique ? GA ? Why not? Spinal anesthesia Nerve blocks
Preoperative epidural or femoral catheter
Spinal anesthesia
Combined Spinal-epidural
Femoral catheter
Nerve blocks
Psoas block (catheter) + sciatic block
Intraoperative sedation or TIVA

4. Prevention of Spinal anesthesia- induced hypotension in the elderly Buggy D, A&A 1997
Cristalloids
500 ml
Colloid
control
P =
hypotension 62 39 46
0.1
% vasopressors 45 29
0.4
Ephedrine (mg)
6.4
5.9
6.8
Nausea/vomiting 7 14
0.7

5. Mortality / Morbidity: RA – GA : No difference
Operating time
Mortality
Cardiovascular morbidity
DVT / Pulmonary embolism
Intra-operative blood loss

6. Bleeding after major orthopedic surgery GA = Reg Anesth
% major bleeding
READ SLIDE

7. TKR: tourniquet or not ? Any effect on bleeding? NO
Hersekli MA, Int Orthop. 2004
Schuh A, Zentralbl Chir. 2003
Tetro AM, Can J Surg. 2001
Jorn LP, Acta Orthop Scand. 1999
Any effect on venous thrombosis?
Wauke K, Arch Orthop Trauma Surg Yes
Harvey EJ, J Arthroplasty No

8. The postoperative challenge !

9. Why Regional Analgesia ?
Superior to iv PCA (opioids)
Excellent “dynamic analgesia”… 72h
Avoids opioid-side effects
nausea-vomiting +++
sedation

10. Total knee replacement
Epidural analgesia ?
Psoas, femoral block, iliofascial block ?
Is an obturator nerve block really useful ?
Sciatic block ?
Single shot or catheter?
Infiltration ?

11. Peripheral nerve catheters > Epidural
Efficacy: PNB  Epid
Side effects: PNB < Epid
Major Complications: PNB < Epid
* Epidural abcess * Epidural hematoma

12. Is a femoral catheter really indicated ?
Watson M.W, RAPM 2005
Spinal anesthesia
Sciatic 15 ml levoB
Psoas Catheter:
- bolus 25 ml levoB
- perfusion
* placebo
* L-Bupi
PCA iv (morphine)
Is a femoral catheter really indicated ?

13. Is the catheter really necessary ? Prolonged analgesia
similar 3 months outcome
Functional Outcome
Resting and Peak VAS Pain
Systemic analgesic requirement

14. Sciatic nerve block for total-knee replacement: is it really necessary in all patients ?
Levesque S, Delbos A, RAPM 2005
200 TKR patients
N= 25 (12.5%) needed a single sciatic block in PACU
Predictive risk factors of pain
1- Flessum
2- important preoperative pain

15. Is the femoral catheter enough is a sciatic block necessary ? or
Pham Dang C, RAPM 2005
PCA Morphine (mg)
23 mg vs 4 mg *
Vomiting
43% vs 14% *
Is the femoral catheter enough
is a sciatic block necessary ? or

16. What about 0,3mg spinal morphine ?
Effective
Adverse effects: PONV– Pruritus

17. Total knee replacement is the femoral catheter enough ?
(D0- D1): pain anterior & posterior !
The catheter is not enough
- Sciatic block (Allen, Weber, Mansour)
- morphine: iv PCA, spinal, s/cut …
(D2- D4): physiotherapy ….
the femoral catheter is sufficient

18. Total knee replacment … Regional analgesia >> PCA morphine
Quality of analgesia
Quality of early physiotherapy: KINETEC
Discharge criteria: Knee Flexion at 90
Duration of physiotherapy +++
PCA 50 days
Epidural 37 days
PNB 40 days

19. Femoral Nerve Block Improves Analgesia Outcomes after Total Knee Arthroplasty A Meta-analysis of Randomized Controlled Trials (JE Paul, Anesthesiology 2010)
Single shot FNB >> iv PCA till 48h
Compared to a single shot FNB:
Addition of Sciatic block no benefit
Femoral catheter no benefit

20. Functional Outcome after TKR: Any benefit from Regional analgesia ?
D0 D w months 1year
Colwell 1992
Munin 1998
Carli 2010
Kadic 2009

21. Total knee replacement Regional Analgesia > PCA morphine But …
The final functional result of the operated knee is not related to any analgesia technique or drug …
Colwell 1992, Munin JAMA 1998

23. Infiltration + intraarticular analgesia vs femoral nerve catheter after TKR Toftdahl K, Acta Orthopaedica 2007
80 TKR, spinal anesthesia
Femoral catheter
Infiltr at the end of surg + Intraarticular catheter 2 inj
femoral
Infilt + artic
statistics
Worst pain score during physical therapy D1 5 3 *
Oxycodone (mg) D1
100 83
* *
Able to hold quadriceps D1
50%
80%
* * *

24. INFILTRATION : EFFECTIVE EVIDENCE INFILTRATION VS OPIODS
Better analgesia
Less consumption of opiods

25. - Catheter: no efficacy
Andersen LO, Acta Anaesth Scand 2010
150ml Ropi 0,2%
Capsule, muscles, S/cut
Subcutan Catheter
Infiltration
- Bolus effective
- Catheter: no efficacy

26. Total Knee Replacement The Past ... The Present ... And the Future !
Anesthesia GA = Spinal = Blocks
Postoperative Regional Analgesia
Femoral block is the standard today
Femoral catheter … longer analgesia
Obturator block … weak interest
Sciatic block … for the first 24h
LIA … promising but requires larger surveys

27. EARLIEST FUNCTIONAL OUTCOME IMPORTANCE OF ANALGESIA TECHNIQUE
EVIDENCE
Discharge Critera :
adequate analgesia
independence from iv analgesics
ambulation of at least 30 meters A B C
Day 5
Discharge
1 month
3 month 60 80 90
125 95 85
105
130
25 h
71 h
Ilfeld BM Anesthesiology 2008
Knee flexion depends on
analgesia technique

28. Urgent urinary drainage : 20% !!!
Continuous blockade of the lumbar plexus after knee surgery Dahl JB, Anaesthesia 1988
TKR under GA & femoral catheter
Urgent urinary drainage : 20% !!!

29. Bladder management after total joint arthroplasty Knight RM, J Arthroplasty 1996
174 patients
Foley
intermittent
p =
ECBU (+) 8%
12% NS
Resondage > J3
16%
25% **
Economie minutes de nursing time
$ par patient

30. FEMORAL NERVE BLOCK IDEAL TECHNIQUE
EVIDENCE
Effective
Less side effects
Fast functionnal recuperation