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

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

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

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

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

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

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. 2002 Yes Harvey EJ, J Arthroplasty. 1997 No

The postoperative challenge !

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

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

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

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 ?

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

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

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

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

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

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

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

Functional Outcome after TKR: Any benefit from Regional analgesia ? D0 D3 1w 2-3 months 1year Colwell 1992 Munin 1998 Carli 2010 Kadic 2009

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

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% * * *

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

- 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

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

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

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% !!!

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 - 150 minutes de nursing time - 3000 $ par patient

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