Patrick NARCHI, MD
Centre Clinical
16800- Soyaux
France

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

Anesthetic technique ?
• GA ? Why not?
– 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 anesthesiainduced hypotension in the elderly hypotension
Cristalloids
500 ml
62
Buggy D, A&A 1997
Colloid
500 ml control P =
39 46 0.1
% vasopressors 45 29 39 0.4
Ephedrine (mg) 6.4
5.9
6.8
0.4
Nausea/vomiting 7 14 7 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
1
0
3
2
5
4
2,3 regional anesthesia other anesthesia
2,1
Major bleeding

TKR: tourniquet or not ?
• Any effect on bleeding?
– Hersekli MA,
NO
Int Orthop. 2004
– Schuh A,
– Tetro AM,
Zentralbl Chir. 2003
Can J Surg. 2001
– Jorn LP, Acta Orthop Scand. 1999
• Any effect on venous thrombosis?
– Wauke K, Arch Orthop Trauma Surg. 2002
– Harvey EJ, J Arthroplasty. 1997
Yes
No

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

• 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:
• Side effects:
PNB

Epid
PNB < Epid
• Major Complications: PNB < Epid

Spinal anesthesia
Sciatic 15 ml levoB
Psoas Catheter:
- bolus 25 ml levoB
- perfusion
* placebo
* L-Bupi
PCA iv (morphine)
Watson M.W, RAPM 2005

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

Pham Dang C, RAPM 2005
• PCA Morphine (mg)
23 mg vs 4 mg *
• Vomiting
43% vs 14% *

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

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
• PNB
37 days
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
– Femoral catheter no benefit no benefit

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

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
Oxycodone (mg) D1
Able to hold quadriceps D1
5
100
50%
3
83
80%
*
* *
* * *

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

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

80
60
40
20
0
EARLIEST FUNCTIONAL OUTCOME
IMPORTANCE OF ANALGESIA TECHNIQUE
EVIDENCE
Discharge Critera : adequate analgesia independence from iv analgesics ambulation of at least 30 meters
Day 5
Discharge
1 month
3 month
A
60
80
90
125
B
80
90
95
125
C
85
90
105
130
25 h
71 h
1
2
Ilfeld BM Anesthesiology 2008
Knee flexion depends on analgesia technique

Continuous blockade of the lumbar plexus after knee surgery
Dahl JB, Anaesthesia 1988
• TKR under GA & femoral catheter

Bladder management after total joint arthroplasty
Knight RM, J Arthroplasty
1996
174 patients
ECBU (+)
Foley intermittent p =
8%
Resondage > J3 16%
12%
25%
NS
**
Economie - 150 minutes de nursing time
- 3000 $ par patient

FEMORAL NERVE BLOCK
IDEAL TECHNIQUE
EVIDENCE
E FFECTIVE
L ESS SIDE EFFECTS
F AST FUNCTIONNAL RECUPERATION