Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature.

Background: Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.

Methods: A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.

The Effect of Hypotensive Anesthesia on Hemoglobin Levels during Total Knee Arthroplasty.

Introduction: Hypotensive epidural anesthesia (HEA) is used in total joint arthroplasty as a safe and effective blood-saving modality. In order to maintain the blood pressure and heart rate patients, receive 1000 to 1500 mL of lactated Ringer's solution during surgery. While HEA reduces the intraoperative blood loss, the effect of intravenous fluid loading on hemoglobin levels is not fully understood.

Multimodal prophylaxis in patients with a history of venous thromboembolism undergoing primary elective hip arthroplasty.

Aims: We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient's risk of VTE.

Methods: Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution.

Changes in the augmentation index and postoperative orthostatic intolerance in orthopedic surgery: a prospective cohort study.

Background: Postoperative orthostatic intolerance (OI) can be a major obstacle to early ambulation and its determinants are poorly understood. We aimed to study postoperative changes in vascular tone and their potential association with OI in various orthopedic surgical settings.

Methods: In this prospective cohort study, 350 patients undergoing total joint arthroplasty under neuraxial anesthesia or spine surgery under general anesthesia were enrolled.

Changes in Markers of Thrombin Generation and Interleukin-6 During Unicondylar Knee and Total Knee Arthroplasty.

Background: Total knee arthroplasty (TKA) is associated with a risk of thromboembolism requiring routine thromboprophylaxis, but there is debate about the risk with unicondylar knee arthroplasty (UKA) as it is a more minor procedure. We sought to investigate the relative risk of thromboembolism with UKA compared to TKA and one-staged bilateral TKA (BTKA) by measuring the increase in circulating biochemical markers of thrombin generation during the procedures. Degree of surgical trauma was also assessed by measuring interleukin-6, a marker of metabolic injury.

The Clinical Severity of Patients Diagnosed With an In-Hospital Pulmonary Embolism Following Modern, Elective Joint Arthroplasty Is Unrelated to the Location of Emboli in the Pulmonary Vasculature.

Background: In the event of a postoperative pulmonary embolism (PE), it is generally believed that patients with centrally located emboli will have worse clinical symptoms than those with segmental or subsegmental ones. We studied if a relationship exists between the clinical severity at the time of PE diagnosis and the location of the emboli within the pulmonary vasculature.

Methods: All 269 patients who developed an in-hospital, computed tomography pulmonary angiography-proved, PE following elective total hip arthroplasty or total knee arthroplasty in our institution were studied.

An Observational Study of Cerebral Blood Flow Velocity During Hypotensive Epidural Anesthesia.

Background: Hypotensive epidural anesthesia (HEA), as practiced at our institution, uses sympathetic blockade to achieve mean arterial blood pressure (MAP) of ≤50 mm Hg while administering epinephrine by infusion to support the circulation. HEA has not been associated with gross adverse effects on neurologic outcome or cognitive function in the postoperative period, suggesting adequate cerebral blood flow (CBF). However, the use of MAPs well below the commonly accepted lower limit of CBF autoregulation suggests that CBF should be significantly reduced below normal levels.

Lateralizing epidural catheter placement as evidenced by electrical stimulation.

Background: Epidural steroids are more effective if administered in the anterolateral epidural space. It follows that the ability to administer local anesthetics in the ipsilateral anterolateral epidural space should likewise improve their efficacy for postoperative epidural analgesia.

Questions/purposes: We determined whether epidural catheters can be reliably placed in the ipsilateral anterolateral epidural space using the paramedian approach.

Perioperative comparative effectiveness of anesthetic technique in orthopedic patients.

Background: The impact of anesthetic technique on perioperative outcomes remains controversial. We studied a large national sample of primary joint arthroplasty recipients and hypothesized that neuraxial anesthesia favorably influences perioperative outcomes.

Methods: Data from approximately 400 hospitals between 2006 and 2010 were accessed.

Pulmonary circulatory changes after bilateral total knee arthroplasty during regional anesthesia.

Study Objective: To monitor the pulmonary hemodynamics of patients undergoing bilateral total knee arthroplasty (BTKA) intraoperatively and up to 24 hours following surgery.

Design: Prospective observational study.

Setting: University-affiliated teaching hospital.

Markers of thrombin generation during resurfacing and noncemented total hip arthroplasty: a pilot study.

Background: Hip resurfacing arthroplasty (HRA) could be associated with an increased risk of deep vein thrombosis (DVT) compared to traditional noncemented THA because it involves greater dissection, increased kinking and distortion of the femoral vessels, takes longer to perform, and involves insertion of some cement into the femur.

Questions/purposes: Does HRA lead to greater risk of thromboembolism compared with noncemented THA?

Methods: We prospectively studied 20 patients receiving HRA and 20 receiving THA. All patients were younger than 67 years old and were similar in height, weight, American Society of Anesthesiologists status, and gender mix.

Perioperative pulmonary circulatory changes during bilateral total hip arthroplasty under regional anesthesia.

Background And Objectives: The transient and rarely clinically relevant effect of bone and cement embolization during unilateral joint arthroplasty is a known phenomenon. However, available studies do not address events surrounding bilateral total hip arthroplasties, during which embolic load is presumably doubled. To elucidate events surrounding this increasingly used procedure and assess the effect on the pulmonary hemodynamics in the intraoperative and postoperative periods, we studied 24 subjects undergoing cemented bilateral total hip arthroplasty during the same anesthetic session.

Relationship between perioperative urinary tract infection and deep infection after joint arthroplasty.

Unlabelled: Surgical wound infection is a serious and potentially catastrophic complication after joint arthroplasty. Urinary tract infection is a common infection that creates a potential reservoir of resistant pathogens and increases patient morbidity. We asked whether treated preoperative and postoperative urinary tract infections are risk factors for deep joint infection.

Venous thromboembolic disease after total hip and knee arthroplasty: current perspectives in a regulated environment.

Venous thromboembolic disease is the single most common reason for readmission to the hospital following total hip and total knee arthroplasty and remains a genuine threat to the life of the patient. Nevertheless, advances in surgical procedure, anesthetic management, and postoperative convalescence have altered the risks of venous thromboembolism after total joint arthroplasty in the lower extremity. Regional anesthetic techniques reduce the prevalence of venographic thrombosis by approximately 50%, and intraoperative monitoring has identified preparation of the femoral canal as the sentinel event that activates the coagulation cascade by the intravasation of marrow fat into the systemic circulation.

Hypotensive epidural anesthesia in patients with aortic stenosis undergoing total hip replacement.

Background And Objectives: The use of conduction anesthesia and induced hypotension are traditionally contraindicated in patients with aortic stenosis. This hypothesis-generating observational pilot study details the clinical outcomes in patients with aortic stenosis undergoing hypotensive epidural anesthesia for total hip replacement.

Methods: From a database of 1,947 consecutive patients undergoing total hip replacement under hypotensive epidural anesthesia performed from 1994 to 2005, 22 patients were identified with aortic stenosis.

Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty.

Anticoagulation for thromboprophylaxis after THA and TKA has not been confirmed to diminish all-cause mortality. We determined whether the incidence of all-cause mortality and pulmonary embolism in patients undergoing total joint arthroplasty differs with currently used thromboprophylaxis protocols. We reviewed articles published from 1998 to 2007 that included 6-week or 3-month incidence of all-cause mortality and symptomatic, nonfatal pulmonary embolism.

Symptomatic thromboembolism after one-stage bilateral THA with a multimodal prophylaxis protocol.

To determine the incidence of thromboembolism after one-stage bilateral total hip arthroplasty and the role of two different chemoprophylaxis agents, we retrospectively studied 644 consecutive patients who underwent one-stage bilateral total hip arthroplasties. All patients received a similar multimodal prophylaxis protocol, which differed only in the postoperative chemoprophylaxis: 292 patients received warfarin (Group 1) and 352 received aspirin (Group 2). All patients were followed for a minimum of 3 months.

The 2007 ABJS Nicolas Andry Award: three decades of clinical, basic, and applied research on thromboembolic disease after THA: rationale and clinical results of a multimodal prophylaxis protocol.

Total hip arthroplasty is an operation with a high risk for venous thromboembolism. Three decades of research conducted at the Hospital for Special Surgery identified the exact timing of the thrombogenic stimulus during surgery, defined the role of magnetic resonance venography, and established the role of certain genetic and acquired predispositions. Based on these studies, we implemented a multimodal prophylaxis consisting of a series of safe preventive measures applied before, during, and immediately after surgery to reduce the risk of venous thromboembolism.

Venous thromboembolism is rare with a multimodal prophylaxis protocol after total hip arthroplasty.

Unlabelled: We evaluated the safety and efficacy of a multimodal approach for prophylaxis of thromboembolism after total hip arthroplasty, which includes preoperative discontinuation of procoagulant medication; autologous blood donation; hypotensive epidural anesthesia; intravenous administration of heparin during surgery and before femoral preparation; aspiration of intramedullary contents; pneumatic compression; knee-high elastic stockings; and early mobilization and chemoprophylaxis for 4 to 6 weeks (aspirin 83%; warfarin 17%). One thousand nine hundred forty-seven consecutive, nonselected patients (2032 total hip arthroplasties) who received this multimodal prophylaxis were observed prospectively for 3 months. The incidence of asymptomatic deep vein thrombosis assessed by ultrasound in the first 171 patients was 6.

Decreases in pulmonary artery oxygen saturation during total hip arthroplasty variations using 2 leg positioning techniques.

When the femoral component is being inserted during total hip arthroplasty, venous obstruction occurs because of twisting and kinking of the femoral vein. Relocation of the hip joint is associated with an acute reduction in pulmonary artery oxygen saturation (s(v)O(2)). To determine whether changes in leg positioning could influence femoral venous occlusion, 19 patients undergoing 1-stage bilateral total hip arthroplasty were studied using a randomized crossover study design of 2 leg positioning maneuvers.

The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty.

Either epidural analgesia or femoral nerve blockade improves analgesia and rehabilitation after total knee arthroplasty. No study has evaluated the combination of femoral nerve blockade and epidural analgesia. In this prospective, randomized, blinded study we investigated combining femoral nerve blockade with epidural analgesia.